Member tips drive fraud investigations for BCBS Michigan

Hotline tips from members make up the majority of criminal fraud investigations at Blue Cross Blue Shield of Michigan (BCBSM), which are supplemented by a team made up of equal parts law enforcement and data analytics, according to an MI Blues Perspectives podcast.

In the podcast, Greg Anderson, vice president of corporate and financial investigations for BCBSM, Dan Crowell, director and investigator with the financial investigations team, and Wayne Pratt, chief of the healthcare fraud unit at the U.S. Attorney's Office in the Eastern District of Michigan, highlight the longstanding partnership between the insurer's fraud team and federal investigators. Both were instrumental in the case against Farid Fata, the Detroit oncologist that was sentenced to 45 years in prison for giving chemotherapy treatments to patients without cancer.

Anderson said hotline tips from members who notice discrepancies on their explanation of benefits serve as the "lifeblood" for identifying fraudulent schemes, making up 60-70 percent of the team's criminal investigations. However, beginning in 2015, predictive analytics has taken on a larger role, identifying billing outliers within each medical specialty. Throughout the industry, analytics have become critical to uncovering sophisticated fraud schemes.

"It's a tool," Crowell said in the podcast. "It doesn't mean they are absolutely committing fraud, but it will look at procedure codes--if they are monopolizing a specific procedure code based on their specialty."

Drug diversion, particularly amid rising overdose deaths, is emerging as a major concern for BCBSM fraud investigators who are intent on "interrupting diversion as early as possible," Anderson said. Investigating drug diversion often requires an undercover component that is familier to the 24 former law enforcement officials at BCBSM with experience in white-collar fraud investigations.

"Many of these cases could not be made if we didn't do the undercover cases because you cannot tell what that doctor does or what the interchange is with the patient," Anderson says.

To learn more:
- listen to the podcast

Related Articles:
How a broken leg set off the fraud investigation against Farid Fata
A healthcare fraud scheme that deserves a life sentence
Predictive analytics helps fraud fighters detect sophisticated schemes [Special Report]