Page 10 - midJersey Business - July/August 2015

News Desk

{Healthcare}

Healthy Savings

HOT

ON THE
BCBSNJ combats insurance fraud

TRAIL

tions Unit in 1983. Since 2005,
Horizon BCBSNJ’s anti-fraud
Fraud and abuse can
involve both healthcare eforts have saved members
providers and healthcare
$261 million.
consumers.
“Our SIU has progressively

Common examples enhanced Horizon’s analytics
include:
capabilities, which has al-
Providers:
lowed us to be more intuitive
Billing for a fraudulent in our anti-fraud eforts, and
■
diagnosis
better capable of detecting
Billing for services not and stopping fraud in its early
■
rendered
stages,” Douglas Falduto, vice
Billing for services not president, Administration
■
furnished as billed, also and Chief Security Oicer
known as “upcoding”
for Horizon BCBSNJ, says.

■ Inappropriate physi- “Through state-of-the art
cian/ancillary provider Hsoftware and smart detective

relationships resulting in work, we’re constantly im-
kickbacks
orizon Blue Cross Blue Shield of proving our ability to recognize and investigate

Consumers:
New Jersey (Horizon BCBSNJ) questionable claims and claim trends closer to
announced that its eforts to combat real time.”
Filing a false claim
■health insurance fraud resulted in In 2014, the SIU opened 1,318 new cases
■Using a false ID number $45.4 million in savings—identiied
of suspected fraudulent activity. Many inves-
Misrepresenting a depen-
■as a combination of monies recovered and losses tigations begin after tips are reported coni-
dent as eligible for policy avoided—in 2014. The $45.4 million represents dentially to the Horizon BCBSNJ Anti-Fraud
coverage
the highest recovery prevention total since hotline. The company received 2,450 calls to its
Horizon BCBSNJ created its Special Investiga-
hotline in 2014.

{}
In Their Words

“The legislation we are announcing will implement
t

modern technologies
to attract people

s from across the world to this state’s unique site
es

such as FirstEnergy Park, creating more jobs and

economic opportunities
.”

{STATE SENATOR ROBERT SINGER (R-30TH DISTRICT) ANNOUNCING SEVERAL NEW JOBS BILLS RECENTLY. }

8 midJersey business.com