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Anti-Fraud Case FilesCase File #1: Chiropractor pleads guilty to insurance fraud and theft by deceptionAmeriHealth Corporate & Financial Investigations Department conducts independent fraud investigations as well as cooperating investigations with local, state, and federal law enforcement. Where indications of fraud are determined, referrals are readily made to the appropriate investigating agency. A doctor of chiropractic medicine falsified more than 40 precertification requests for further treatment of his patients by stating they had falls, suffering a new injury, thereby necessitating continuing chiropractic care. The Corporate & Financial Investigation Department investigators conducted interviews of patients disclosing that no falls had actually occurred. The investigation focused on two aspects of billing practices. The chiropractor routinely billed high consultation codes for all his patients in addition to the false precertification requests. He submitted false claims reflecting the high utilization coding more than 680 times during the period in question. The investigation was referred for criminal investigation and prosecution. The chiropractor was arrested and charged with insurance fraud, theft by deception, and violation of the Chiropractic Practice Act. He ultimately pled guilty and received two years probation and was ordered by the court to make restitution in the amount of $44,625. |