The Centers for Medicare and Medicaid Services (CMS) is concerned about health care fraud, waste and abuse. Generally, health care fraud is a material misstatement of fact knowingly made for the purpose of obtaining health care benefits, services, or other things of value from Medicare or other Government programs. Any attempts to commit health care fraud may constitute a crime even if there is no apparent loss to Medicare or Blue Cross and Blue Shield of Illinois.

False Claims Act
Health Plan Fraud Crimes
Anti-Kickback Statute
Penalties

False Claims Act
Knowing submission of:

• False information to obtain Federal funds
• False record or statement to get a false or fraudulent claim paid with Federal funds
• No specific intent to defraud required, but there must be
• Actual knowledge, or
• Deliberate ignorance or reckless disregard for the truth or falsity

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Health Plan Fraud Crimes
Knowingly and willfully, with respect to a public or private health plan:

• Embezzle, steal, convert, or misapply money or property
• Use false or fraudulent pretenses to obtain plan’s money or property
• Defraud plan in connection with delivery of or payment for benefits, items or services

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Anti-Kickback Statute

• Knowing and willful remuneration to induce or in return for referrals or business for which a Federal health care program may pay
• Violated if any purpose is inducement
• Applies to both parties to the arrangement

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Penalties
Specific penalties for violating the three laws listed previously are as follows:

False Claims Act penalties include:

• Civil Monetary Penalty of $5,500 to $11,000
• Three times or triple the false claim amount
• Possible Federal health care program exclusion

Self reporting mitigates penalties:

• Waives civil monetary penalty
• Reduces government’s damages from 3x to 2x claim amount

Health Plan Fraud Crimes penalties include:

• 5 years’ imprisonment
• The greater of individual’s gain or others’ losses or $250,000
• Possible Federal health care program exclusion

Anti-Kickback Statute penalties include:

• Criminal = 5 years + $25,000
• Civil = $50,000 + 3x loss
• Possible Federal health care program exclusion

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If you suspect any type of fraud, waste or abuse you must report it by contacting BCBSIL using any of the following methods:

• Call the Fraud Hotline at (800) 543-0867
• Complete an incident form online
• Contact us by mail: BCBSIL Special Investigations Department, 300 E. Randolph, 11th Floor, Chicago, IL 60601

If you report suspected fraud, waste or abuse, you must cooperate with any investigations, whether conducted by BCBSIL, the government, or law enforcement. Cooperation means providing all information, being available and making your staff available for interviews, promptly providing any requested documentation, and maintaining confidentiality.

Neither Blue Cross and Blue Shield of Illinois nor any of its employees will retaliate or bring retribution against any employee or other individual for reporting in good faith a possible violation or for participating in the investigation of an alleged violation. ("Other individual" refers to consultants, contractors, agency temporary employees, members, providers, vendors and producers and other entities with whom the Company does business.)