Fighting Fraud, Waste and/or Abuse

Every year analysts and investigators for Blue Cross and Blue Shield of Texas (BCBSTX) review claims data, industry trends and investigative results to identify potential areas of fraud, waste and/or abuse.

When billing issues are identified in this review, providers will receive letters explaining the concerns. The most recent letters focused on instances of potential billing abuse around COVID-19 testing and vaccinations. Future letters may identify upcoding, unbundling or other billing issues.

The letters will remind you to comply with BCBSTX’s policies and requirements.

For more information, please refer to the Provider Standards and Requirements on our website for additional information on policies.

If you encounter potential fraud, waste and/or abuse, please file a report online  or call our Fraud Hotline at 1-800-543-0867. All online reports and calls are confidential and you may remain anonymous. For more information, visit our Fraud and Abuse  page.

The above material is for informational purposes only and is not a substitute for the independent medical judgment of a physician or other health care provider, nor is the information presented intended to replace or supersede any requirements set forth in your contract with BCBSTX. Physicians and other health care providers are encouraged to use their own medical judgment based upon all available information and the condition of the patient in determining the appropriate course of treatment. The fact that a service or treatment is described in this material is not a guarantee that the service or treatment is a covered benefit and members should refer to their certificate of coverage for more details, including benefits, limitations and exclusions. Regardless of benefits, the final decision about any service or treatment is between the member and their health care provider.