Excellus BlueCross BlueShield Tackles Health Insurance Claim Fraud, Waste and Abuse With New Service From IBM

Excellus BlueCross BlueShield Tackles Health Insurance Claim Fraud, Waste and Abuse With New Service From IBM

Excellus BlueCross BlueShield has contracted to use the new Risk Identification Analysis Service from IBM (NYSE: IBM) to help combat health care insurance claim fraud, waste and abuse.
According to estimates from the federal government and issues-based groups such as the National Health Care Anti-Fraud Association, as much as 10 percent of all healthcare expenditures in the United States, or $170 billion, may be lost each year to fraud, waste and abuse. This results in a high cost to private and government insurance payors.

“Make no mistake about it — someone who knowingly commits insurance fraud is no different than any other person who steals,” said Flora Allen, Corporate Director, Special Investigations Unit, Excellus BlueCross BlueShield. “Fraud affects everyone’s bottom line, so we aggressively and proactively pursue recoveries and convictions because we are protecting our members’ premiums. Adding the Risk Identification Analysis Service from IBM to our existing investigative arsenal improves the analytical capabilities we need to find and identify the most egregious offenders.”

Excellus BCBS is a non-profit company that delivers health care coverage to two million people across upstate New York. The health plan initially will use the new service to review pharmacy-related claims to uncover complex schemes. Some of these schemes may include collusion, inappropriate billing practices, prescription forging, prescription pad theft and members who are “doctor shopping.”

In addition to pharmacy claims, the service can analyze approximately two dozen other specialties such as Cardiology, Home Health Care, Gastroenterology, and Durable Medical Equipment Suppliers.

Read the complete Press Release