Anti-Fraud Case Files

The Independence Blue Cross (IBC) Corporate and Financial Investigations Department (CFID) uses a sophisticated software data-mining tool to analyze all claims submitted by medical providers, facilities, and pharmacies and compares them against member enrollment and benefits. Any trend, pattern, or aberrant billing practice is targeted for an in-depth audit or investigation.

Additionally, CFID works closely with state and federal law enforcement, regulatory agencies, and other insurance companies when the facts and evidence warrant it.

Health care fraud is a violation of state and/or federal law. Under federal law it is a felony offense (18 USC 1347), punishable by a fine of up to $250,000, and/or up to 10 years’ imprisonment. If the violation results in serious bodily injury, up to a 20-year prison term is possible.

Sample Cases of Successful Fraud Prosecution

• Case File #1 — A physician received 10 years in prison for illegally selling prescriptions for controlled substances.
• Case File #2 — Owners of an athletic club and rehabilitation facility, along with a co-defendant who was a chiropractor, were convicted of health care fraud and mail fraud.
• Case File #3 — A chiropractor was convicted of health care and mail fraud violations for submitting fraudulent medical bills to eight insurance companies, including IBC, for approximately $3 million. IBC was fraudulently billed $979,000.
• Case File #4 — A pharmacist was arrested and charged with fraud. Eventually the pharmacist pled guilty, admitting to defrauding IBC of $86,070.88 with fictitious prescription filings.