It’s all your fault…
This story from the field features a chiropractor who schemed to defraud our plan sponsors and their benefit plans but blamed it on his staff which was in fact, his wife. This involved billing for treatments that were never provided, so GreenShield paid for the full cost of his chiropractic treatments.
The benefit plan in this scenario did not cover the first 15 chiropractic treatments. After that, chiropractic treatments were reimbursed at $20 each. The clinic charged $40 per chiropractic treatment.
The clinic submitted false claims for plan members to “kickstart” their insurance coverage and then billed for two appointments for every one appointment attended by the patient so that the entire cost of their treatment would be covered by insurance. In some cases, if one family member reached the maximum limit for chiropractic treatment, the clinic would bill another family member who still had available coverage.
It's no surprise the clinic received several referrals because of information about the scheme spreading to other plan members.
This provider thought he was clever, but our Claim Watch team intervened.
Our Claim Watch Analyst sent out confirmation of service letters to several plan members, confirming our suspicions that false claims were being submitted by the provider.
During the investigation, the provider indicated that the false billing issue arose because patients needed more care than they could afford, and he wanted to help them. He believed GreenShield should pay for the full cost of his chiropractic treatments.
Our team filed a complaint to the College of Chiropractors of Ontario (CCO), and as a result, the provider’s certificate of registration was suspended for 12 months. He was also ordered to pay $15,000 to the CCO to partially cover the costs of the investigation, the hearing, and legal counsel.
The chiropractor blamed his wife as the one who concocted the scheme – if you ask her, she said it was all him.
Well done, Claim Watch team.
About Claim Watch
Claim Watch provides intelligence led, professionally aggressive fraud management strategies and solutions tailored to our partners. By employing cutting edge technology in data analytics, as well as proven investigational techniques, our team identifies and halts fraud and abuse quickly, thereby minimizing losses.
For further information, do not hesitate to contact us at 1-888-525-7587 or customer.service@greenshield.ca
