Submitting false claims
A plan member enrolled in a group benefit plan and proceeded to submit multiple fraudulent claims over a short period of time for services not received.
Approach
The member was identified by our analytics team. The member’s ability to submit claims online was suspended. We also contacted the providers, who confirmed that they did not provide the services to the member. Finally, we contacted the member for an explanation but did not receive a response.
Results
The plan member’s benefit plan was terminated. The case has been reported to the member’s employer, who has since terminated the employee. We have issued a criminal complaint and law enforcement have begun their investigation. We contacted the member requesting repayment, but because there was no response, we have taken legal action to recover the $38,000 overpaid in funds.
Plan terminated
Employment terminated
Criminal complaint filed
$38,000 recovered in funds
Conclusion
This case is an example of the consequences plan members could face if they knowingly submit false claims. We have enhanced our review process to act on risky claims and members more quickly and through more frequent projects.
The information on this page is based on data provided by our private book of business.