SIU MISSION AND MEDICAL IDENTITY THEFT

1. Blue Cross and Blue Shield of Florida Special Investigation Unit SIU MISSION AND MEDICAL IDENTITY THEFT

2. INTRODUCTION • SIU Mission/Responsibilities. • What is Medical Identity Theft? • How can it be prevented? • What to do if it happens to you!

3. SIU Mission The Special Investigation Unit is dedicated to proactively and reactively identify and investigate allegations of fraud, waste and abuse, to protect the assets of the enterprise and to fulfill the customer promise.

4. Duties & Responsibilities Refer documented cases to law enforcement and/or regulatory agencies. Identify overpayments & initiate recoveries. Flag providers to prevent inappropriate claim payments. Refer cases of abuse to the appropriate area for further action. Initiate proactive investigations in high risk areas. 4

5. Duties & Responsibilities (cont’d) Maintain effective working relationships with law enforcement and other investigative/regulatory agencies. Stay current with the ever-changing data environment. Promote fraud awareness throughout the enterprise and external agencies. Identify and make recommendations for improvements of operational controls within the enterprise. 5

6. Areas of Responsibility Fraud Private Business • Providers – (All Business Lines) • Insured’s – (All Business Lines) • Agent Fraud • Employees • Stolen or Forged Checks • Medicare Advantage • Medicare Part D 6

7. MEDICAL IDENTITY THEFT • 2007 study by the Federal Trade Commission estimated that MEDICAL IDENTITY THEFTaffected 250,000 people in 2005. • Many thefts happen when a hospital, clinic or practice employee SELLS PATIENT INFORMATION to organized crime or gang leaders. • Information is used to conduct FAKE BILLING or obtain durable medical equipment such as wheelchairs etc. orprescriptions to sell on the black market. 7

8. MEDICAL IDENTITY THEFT • MEDICAL SERVICES OR DURABLE MEDICAL EQUIPMENT are obtained by using an individual’s identity such as insurance information or social security number without knowledge or consent of victim. • MONEY is obtained by using another person’s identity to falsify claims for medical services and falsifying medical records to support those claims. 8

9. MEDICAL IDENTITY THEFT • Frequently results in ERRONEOUS ENTRIES made to existing medical records and can involve creating FICTITIOUS MEDICAL RECORDS in a victim’s name. • As health care transitions from paper to electronic claims, this CRIME may become EASIER TO COMMIT and HARDER TO DETECT. • As medical errors are disseminated and re-disseminated through computer networks and information-sharing pathways, victims may find it MORE DIFFICULT TO RECOVER. 9

10. SERIOUS IMPACT • False Entries in Medical Records • False Histories of Diseases/Diagnosis • Incorrect Medical Treatments • Health Benefits Exhausted • Uninsurable for future health or life insurance • Loss of credit • Harassment by debt collectors 10

11. THEFT OR FRAUD • A fine line exists between: • HEALTH CARE FRAUD • MEDICAL IDENTITY THEFT • IDENTITY THEFT 11

12. THEFT OR FRAUD • HEALTH CARE FRAUD – An individual loans their health care ID card to a roommate who receives treatment at an emergency room. • MEDICAL IDENTITY THEFT –A roommate uses another individual’s health card ID card without the individual’s knowledge. This is alsoHEALTH CARE FRAUD. • IDENTITY THEFT –A laboratory technician uses your personal information in your medical chart to open up a credit card account in your name. 12

13. MEDICAL IDENTITY THEFT • EXAMPLE – A Boston area psychiatrist made false entries in the charts of individuals who were not his patients. He gave individuals diagnoses of drug addiction and abuse, severe depression and numerous psychiatric sessions that patients did not actually have, and then used their personal information to submit false bills to insurance companies. After learning of the crime, the victims had a difficult time getting the false information removed from their files. 13

14. MEDICAL IDENTITY THEFT • EXAMPLE – A doctor falsified medical records of patients claiming they received medical treatments but never did. • EXAMPLE – A woman gets surgery after presenting medical insurance information and an altered driver’s license using another persons identity. • EXAMPLE – A medical identity theft victim in Florida discovered an imposter had caused false entries on her medical file, including changes to her blood type. 14

15. MEDICAL IDENTITY THEFT • EXAMPLE – An Ohio woman, while working at a dental office, accessed protected patient information and used the information to phone in prescriptions for herself to local pharmacies. • EXAMPLE – An individual walks into an emergency room claiming to be someone else (without that person’s permission) so that they can receive emergency care. 15

16. MEDICAL IDENTITY THEFT • EXAMPLE – An insider was behind the theft of more than 1,100 Medicare beneficiaries’ medical identities at the Cleveland Clinic in Weston, Florida. A front desk clerk downloaded their names addresses and Social Security and Medicare numbers and sold the data to her cousin, who then made more than $2.8 million in false Medicare claims. The individual was caught because a co-worker reported to her supervisor that the clerk was acting suspiciously. 16

17. PROTECT YOURSELF • CLOSELY MONITOR "EXPLANATION OF BENEFITS"(EOB) BCBSF/FEP for: • Services you did not receive. • Charges for Office Visits you did not make. • Durable Medical EquipmentCharges you did not receive. • REVIEW INSURANCE STATEMENTS CAREFULLYA number of victims discover a problem by reviewing their statements. If anything appears wrong, raise questions with the insurer or the provider involved. Do not assume things are O.K. just because you don’t owe money. 17

18. PROTECT YOURSELF • REVIEW ONLINE / WEB-BASED CLAIM HISTORIES BCBSF and Federal Employees Benefits offer online access to claims history. These password protected web sites should be reviewed frequently for suspicious or questionable claims activity. These web sites will provide a complete overview of your personal claims activities. • www.bcbsfl.com • www.fepblue.org/ 18

19. IF YOU BECOME A VICTIM • CONTACT YOUR INSURANCE CARRIER immediately if you suspect you are the victim of fraudulent insurance claims. • Blue Cross and Blue Shield of Florida Fraud Hot Line1-800-678-8355 • Federal Employee Fraud Hotline (FEP)1-800-337-8440 • Blue Cross Blue Shield Association Fraud Hot Line1-877-327-Blue (2583) • REPORT THEFT OF YOUR IDENTITY to your local police or sheriff’s department as soon as possible. 19

20. IF YOU BECOME A VICTIM • IF YOU THINK YOU ARE A VICTIM of medical identity theft, obtaining a copy of your file from your doctor, hospital, pharmacy or laboratory is essential in determining theft and recovering from the crime • REQUEST A COPY OF YOUR MEDICAL FILES from each involved health care provider. • Ask your health care providers to INSPECT the medical file they maintain for you. 20

21. IF YOU BECOME A VICTIM • CORRECT ERRONEOUS AND FALSE INFORMATION IN YOUR FILE • Amending a health record can be a challenging process. • Separate requests in writing may need to be made to each provider of service. • Explain the reason for the amendment clearly to providers to justify the record amendment. 21

22. WHERE TO GET INFORMATION • USE THE INTERNET AS A RESOURCEfor valuable information about this growing problem • Use search engines such as Google, Yahoo, etc. to search for "Medical Identity Theft". • Useful Web Pages: • www.worldprivacyforum.org/medicalidentitytheft.html • www.idtheftcenter.org/index.html 22

23. FACTS • The FLORIDA ATTORNEY GENERAL’s OFFICE and the Florida Department of Law Enforcement (FDLE)have a website designed to serve as the State of Florida's official portal for IDENTITY THEFT INFORMATION. • www.myfloridalegal.com/identitytheft 23

24. FACTS • IDENTITY THEFT IS A THIRD DEGREE FELONY under Florida Statute §817.568. “Any person who willfully and without authorization fraudulently uses, or possesses with intent to fraudulently use, personal identification information concerning an individual without first obtaining that individual’s consent, commits the offense of fraudulent use of personal identification information, which is a felony of the third degree…” 24

25. FACTS • You are the front line of defense in protecting yourself from this growing problem. • Unlike financial identity theft, there is no straight forward process for challenging false medical claims or correcting inaccurate records. • For victims, the results can be thousands in unpaid charges, damaged credit and bogus, possibly dangerous details cluttering up their medical records for years. 25

26. CONCLUSION • MEDICAL IDENTITY THEFT is a complex growing problem that demands the attention of each of us. As consumers and patients, we each have a concern for documentation that may negatively impact us from both a financial and medical treatment perspective in the future. • BE ALERT • BE DILIGENT • DON’T BE AFRAID TO CHALLENGE INCORRECT INFORMATION 26

27. QUESTIONS AND ANSWERS 27

28. ON BEHALF OF THE SPECIAL INVESTIGATION UNIT … Thank You for Your Attention 28