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Anti-Fraud Case FilesCase File #1: Claims analysis results in guilty plea of psychotherapy business ownerThe Independence Blue Cross (IBC) Corporate & Financial Investigations Department (CFID) uses a sophisticated software data-mining tool to analyze all claims submitted by medical providers and pharmacies and compares them against member enrollment and overall provider information. Any trend, pattern, or aberrant billing practice is targeted for an in-depth audit or investigation. Utilizing the data-mining tool, CFID engaged in a proactive analysis. The analysis indicated excessive billing, at a high level, for psychotherapy visits. Psychiatric counseling and rehabilitation services were offered at both the individual and group level. The corporate owner filed false and fraudulent medical claims listing a licensed psychiatrist as the performing provider when, in fact, the psychiatrist had not seen the patients. CFID investigators determined that the psychiatrist was out of the country for most of the dates for which the claims were filed. The case was referred to the Federal Insurance Fraud Task Force. A Task Force officer conducting an undercover operation enrolled in yoga classes at the provider location. The owner filed claims to represent the yoga classes as treatment for mental and substance abuse. Because of the investigation, the owner pled guilty to health care fraud charges and faced a maximum sentence of 10 years imprisonment, three years to life of supervised release, and a $250,000 fine. He was sentenced to 30 months incarceration, 30 months probation, and was ordered by the court to make restitution to IBC in the amount of $1,080,755.63. |