Adult foster care owner files fraudulent claims

The sharp-eyed daughter of an elderly Blue Cross Blue Shield of Michigan subscriber called the Anti-Fraud Hotline after her mother died. While reviewing her mother's Explanation of Benefit Payments statements, she discovered that the adult foster care facility that was caring for her mother had filed claims for psychiatric services with Blue Cross Blue Shield of Michigan and Medicare. The daughter said her mother had not received psychiatric services while at the adult foster care center, nor had they been authorized. 

Upon investigation, our Corporate Fraud and Investigations unit discovered that the owner of the adult foster care center, who had a master's degree in social work, was submitting psychiatric claims for her assisted living clients. There was no evidence of necessity for these services, and a review of patient records showed no indication that these services were provided. In addition, the services hadn't been contracted or authorized by the members, and the owner continued to file claims for these services even though these residents moved to different facilities or had died. As a result of this investigation, the owner was charged with multiple counts of health care fraud - false claims.

The owner pleaded no contest and has been sentenced. Investigations related to her social work and adult foster care facility licenses are being conducted by the appropriate state agencies.

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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