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SIU: Cracking Cases of Fraud and Abuse

Arkansas Blue Cross and Blue Shield’s Special Investigations Unit (SIU) might be able to match stories with TV’s top crime solvers.

This team of crack investigators and analysts works tirelessly to detect, prevent and eliminate potential fraud, waste and abuse.

Debbie Gunter, Special Investigations Unit (SIU)
Debbie Gunter

“Our focus is on protecting our members,” said Debbie Gunter, director of Performance Monitoring and Special Investigations. “By cutting out wasted dollars, we’re protecting the money our members pay in premiums.”

Between 2016 and 2018, the six investigators and five analysts in SIU handled 5,974 fraud reports and intercepted $47.9 million in fraudulent claims payments. Without their efforts, Arkansas Blue Cross would have been on the line for an estimated $98.7 million in fraudulent claims and related expenses.

The investigation process

When the SIU team receives a tip about possible fraud, analysts spring into action. If analysts find evidence that supports the fraud allegation, they escalate the complaint to an SIU investigator, who digs deeper.

“Investigators use many tools and resources and anything else that may assist the investigation,” Debbie said. If the SIU team finds questionable billing practices by a healthcare provider, they can attempt to settle with the provider or get law enforcement involved, depending on the severity of the allegation. “Our SIU investigators work with the FBI, the state Office of the Medicaid Inspector General, the federal Department of Health & Human Services (HHS) Office of Inspector General and other government agencies. When we get them involved, the work we hand over must be detailed and very clear.”

SIU in action

In 2017, the SIU learned of a scheme involving dubious drug rehabilitation facilities throughout the country.

The scheme targeted patients without insurance. These patients were fraudulently enrolled in health plans that had a low premium and good rehabilitation benefits. Also, the health plans accepted enrollment regardless of whether the patient actually lived in the state in which the plan was based. An Arkansas Blue Cross customer service representative received a call from one such out-of-state patient, and it aroused her suspicions. SIU was called in to investigate. They uncovered more than 100 such fraudulent policies and thwarted the scam at a potential savings of more than $11 million.

Fraud Hotline

If you suspect abuse or fraud, call the fraud hotline at 1-800-372- 8321.

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