Patient's diligence uncovers chiropractor's fraud

A Detroit-area chiropractor's scheme to defraud Blue Cross Blue Shield of Michigan was foiled by an observant subscriber who wasn't afraid to speak up.

The subscriber noticed that her chiropractor had billed for more visits than she had received when she reviewed her Explanation of Benefits statement. When she asked the chiropractor about it, he said it had been a mistake, and it wouldn't happen again. He then sent her a gift basket.

In talking to some coworkers who went to the same chiropractor, the subscriber learned they too had noticed claims on their Explanation of Benefits statements for dates they didn't receive treatment.

The subscriber called the Blues Anti-Fraud Hotline to report her concerns. Our Corporate Fraud Investigations department launched an investigation that discovered the extra services had not been accidently billed, but the chiropractor had purposefully billed for numerous services that never occurred over the course of several years. One subscriber, whose wife and child were patients, had never been a patient of the chiropractor himself. Nonetheless, the chiropractor regularly sent claims to us as if the man were a patient. In several other instances, the chiropractor padded bills by adding on claims for X-rays which never occurred. Patients who only had two or three X-rays a year had claims submitted for X-rays once or twice a month.

The case was turned over to the Warren Police Department and Macomb County prosecutor for criminal prosecution. The chiropractor entered in a plea agreement where he pleaded no contest to a larceny charge and paid us back for the false claims. The chiropractor will be removed from our provider network and a referral will be made to the Michigan Department of Community Health for licensing action.

Members who suspect health care fraud are urged to call our Anti-Fraud Hotline at 1-800-482-3787, or report fraud through our website.

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