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Services not received

Two individual plan members enrolled in benefit plans with us. The two members used three different benefit plans to submit multiple claims for services they did not receive and submitted falsified documents to support their claims.

Approach

The members were quickly identified by our analytics team and further claims were immediately pended. We suspended the members’ ability to submit claims online, and we also contacted the providers. Some providers confirmed that the services claimed did not take place, and others indicated that the services they provided were based on forged documentation. When we contacted the members for an explanation, we did not receive a response.

Results

The members’ benefit plans were terminated. We filed a criminal complaint, and law enforcement have begun their investigation. We contacted the members requesting repayment, but because they did not respond, we have taken legal action to recover the $11,000 overpaid in funds.

Plan terminated

Criminal complaint filed

Ongoing investigation with law enforcement

$11,000 recovered in funds

Conclusion

This case is an example of the consequences plan members could face if they knowingly submit false claims and documentation. We have enhanced our continuous monitoring of member claims to identify risky claims and members more rapidly and with more accuracy.

The information on this page is based on data provided by our private book of business.