You might be surprised to learn that not all insurance fraud is uncovered because of a personal injury investigation, workers compensation fraud investigation, product liability investigation or a long term disability insurance fraud investigation. No, it’s not always the “patient” who is being investigated. Sometimes it is the medical care provider!
Not every doctor, physical therapist or chiropractor is committing medical insurance fraud, but some are. Investigators were called in regarding insurance claims coming in from a specific chiropractor. The insurance company noticed that the number of claims had significantly increased from this particular service provider and the services were long-term and fairly extensive. It was the change in the claim history and types of claims that triggered one of those “red flags” for adjusters.
Insurance fraud investigations are usually triggered by a red flag of some sort. The insurance company adjusters become well versed in the usual number and types of claims and when something out of the ordinary surfaces, they often want to take a closer look – that’s why they call .
The patient whose claims were being paid to a chiropractor had been injured in a fall and was not getting disability benefits. If he knew he was being watched, he might have thought he was the subject of a slip and fall investigation. He was seeing the chiropractor three times a week. The claims were for services that indicated he was in the chiropractor’s office for an hour or more for each visit.
Insurance fraud investigators followed the patient from his home to the chiropractor’s office, videotaping the entire surveillance. Every frame in investigator’s footage is date and time-stamped so we are able to show how much time elapses on the recording. On many of the visits, the video showed that the patient entered and then left the chiropractor’s office within a 10 – 15 minute time frame. The bills being submitted were for services that would have required at least an hour.
In this instance, the patient was not even aware of the insurance fraud. It was the chiropractor who was committing medical provider fraud. Once fraudulent billings for this particular patient were uncovered, investigators were asked to confirm fraudulent billings for other patients.
In the end, the patients had to find another chiropractor.
-Brenda McGinley, CEO, All in Investigations, All in Investigations
