Incorrect procedure codes
A provider submitted claims for ineligible services using the procedure code of an eligible service.
The provider was identified through a tip. We confirmed with the service provider that the procedure code claimed to Alberta Blue Cross® was not the service that they provided. The service provided to the patients was not an eligible service. However, the provider submitted claims using an eligible service code to receive payment.
The provider agreed to review their policies for procedures completed and claims submitted. The full amount overpaid has been recovered from the provider. We are continuing to monitor claims from this provider to ensure this does not occur again.
Identified through a tip
Service provided not eligible
Funds fully recovered
Provider is being monitored
Lessons learned for providers: this case is an example of the consequences to providers that knowingly submit false claims.
The information on this page is based on data provided by our private book of business.