Kalamazoo social worker sentenced to prison

Blue Cross Blue Shield of Michigan's Corporate and Financial Investigations department received a referral from the Michigan Education Special Services Association about the questionable billing practices of a social worker who was operating a counseling service from her Kalamazoo-area residence.

Through an investigation by CFI and the Kalamazoo office of the Federal Bureau of Investigation, which consisted of research and numerous interviews, it was learned that this individual billed for services when she was out of the country or on vacation, as well as for an individual who had died.

From 2002 through 2007, the social worker engaged in fraudulent billing practices that included back-dating services to exhaust previous years' benefits and front-loading, or using up all the subscribers' benefits within the first few months by billing for false multiple daily sessions in a single week. She was also billing for services for an entire family when she only saw one or two family members, inflating her billing amounts to cover copays and billing for more hours than in a normal work day.

The social worker pled guilty to one count of health care fraud in U.S. District Court for the Western District of Michigan. On March 24, 2011, she was sentenced to 24 months incarceration with a 24-month supervised release period upon completion of her incarceration. She was also ordered to pay $276,794 in restitution to BCBSM, MESSA and four additional private insurers.

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.