Fraud, Waste, and Abuse Concerns; Description of Laws and Penalties
As CMS is especially concerned about Fraud, Waste, and Abuse, these guidelines also serve to help eliminate practices that fall under these categories or violate laws that prohibit these actions. These laws include:

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

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 BCBSIL.

Here is a description of the three laws listed previously:

• False Claims Act—refers to:
  • 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
• Health Plan Fraud Crimes—refers to:
  • 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
• Anti-Kickback Statute—refers to:
  • 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

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
  • 3 times or triple the false claim amount
  • Possible Federal health care program exclusion
  • However, 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

If you suspect any type of fraud, waste and abuse you must report it by contacting BCBSIL using any of these methods:

• Fraud Hotline at 1-800-543-0867
• www.bcbsil.com/sid/reporting
• BCBSIL, Special Investigations Department
  300 E. Randolph, 11th Floor
  Chicago, IL 60601

If you report suspected Fraud, Waste and Abuse, you must then 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.)