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 — Physician convicted and sentenced for distribution of controlled substances relating to the purchase, sale and delivery of narcotic pills.
  • Case File #2 — Pharmacist sentenced to 10 years in prison for conspiracy and distribution of controlled substances relating to the filling of “sham prescriptions” for Percocet, Xanax, and Lorcet in exchange for cash and other benefits.
  • Case File #3 — Owner/Operator of a Durable Medical Supply Company (DME Supplier) was convicted of 143 counts of healthcare fraud, mail fraud, and paying illegal kickbacks for Medicare referrals. The owner/operator was sentenced to 66 months in federal prison for defrauding Independence Blue Cross and Medicare.