Ineligible products
A provider dispensed ineligible products to patients and submitted claims using an eligible benefit code.
Approach
The provider was identified by our analytics team. We reviewed information supplied by the provider and compared the service provided to the service claimed. The service provided to the patients was not an eligible service. However, the provider submitted claims using an eligible benefit code. We also contacted the members, and they verified they received the ineligible service.
Results
The provider’s direct bill agreement was terminated, and the provider was delisted. This means that members who purchase services from this provider cannot submit claims or receive reimbursement for these purchases. We reported the provider to their regulatory body, and an investigation resulted in a resolution including a 3-month suspension, a fine and an order to repay the overpayment.
Identified through analytics team
Service provided not eligible
Provider has been delisted
Regulatory body disciplinary action
Conclusion
Lessons learned for providers: this case is an example of the consequences to providers that knowingly submit false claims—loss of direct bill agreements, being deemed an ineligible provider and regulatory body disciplinary action.
The information on this page is based on data provided by our private book of business.