Healthcare fraud isn’t new, but it’s becoming increasingly sophisticated, targeted, and costly. The National Health Care Anti-Fraud Association estimates financial losses at tens of billions of dollars each year. Schemes are siphoning dollars away from patient care and driving up healthcare prices at a time when living expenses continue to skyrocket; we can do more to stop this.
Congress and the administration have wisely focused on tackling fraud, waste, and abuse, but we can make even more meaningful progress through greater coordination among health insurance companies, hospital systems, law enforcement, and regulators.
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Improved data and analytics have put health insurers on the front lines of this fight. Blue Cross and Blue Shield companies operate special investigative units — highly specialized teams of coders, fraud investigators, former law enforcement professionals, and audit experts trained to connect the dots others might miss. Using advanced analytics alongside deep, on-the-ground knowledge, they can flag billing patterns that don’t line up with patient needs or standard practice.
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Because fraud does not stop at state lines, the Blues work together to connect and build on local anti-fraud expertise, enabling BCBS companies to share intelligence the moment a scheme is identified. When one BCBS company spots a local fraud scheme, BCBS companies come together seamlessly to address the issue nationally, so that payments do not end up in the wrong hands.
Central to the work of this national hub is our partnership with law enforcement, which was foundational to Operation Gold Rush, one of the largest fraud schemes ever pursued by the Department of Justice. A BCBS company alerted the DOJ to an overseas operation that was greatly overbilling for items such as catheters and glucose monitors. This cooperation advanced the DOJ case, which involved $10 billion in fraudulent claims.
This approach from the Blues has made a significant dent in fraud: in just four years, more than 67,000 investigations helped prevent or recover more than $22 billion that would have otherwise been lost. Our coordination with law enforcement helps ensure scams are dismantled, not just paid and audited after the fact.
More can be done to strengthen fraud prevention across Medicare, Medicaid, and other federal health programs. BCBS recently responded to the Centers for Medicare & Medicaid Services’ Comprehensive Regulations to Uncover Suspicious Healthcare initiative’s request for input on how better to detect and stop fraud, waste, and abuse. Our message was straightforward: fraud prevention works best when health plans have access to timely, actionable information.
Too often today, action on credible fraud risks is slowed by limited real-time coordination and a lack of communication. With today’s technology, we know it’s possible to speed up information sharing to stop suspicious claims before dollars are spent.
One of our priorities is to ensure that when the federal government identifies a fraudulent provider and suspends payments, Medicare Advantage and Medicare Supplement plans should be notified immediately. That real-time visibility allows plans to act quickly, stopping payments and preventing bad actors from continuing to collect funds even after they’ve been flagged.
The same principle should work both ways. When plans detect fraud, they should have the authority to halt payments right away, protecting taxpayers’ dollars before losses pile up — not after, when recovery is harder, slower, and more costly.
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Smart, targeted fraud prevention protects access to care and keeps costs down. Health plans, CMS, and law enforcement are already stopping billions in fraud, and with coordinated, seamless information sharing, we can do even better.
Our goal isn’t more red tape, but smarter guardrails — earlier intervention, clearer accountability, and faster action that stops payment for fraudulent claims before costs escalate.
Monica Auciello is the chief legal officer for the Blue Cross Blue Shield Association. In her role, she oversees fraud prevention and detection work.
