The Department of Justice (DOJ) has accused five individuals of partaking in a multi-year scheme involving eight health insurance companies. Those charged in this case include a physician, office manager, insurance biller and former investigator for an anti-fraud unit within an insurance company. Each faces allegations of conspiracy to commit health care fraud and 13 counts of health care fraud.
Involvement of insurance investigator leads to additional accusations
The agency has accused the insurance investigator of providing the clinic with insurance billing codes that were most likely to go undetected in the event of an insurance fraud investigation. The DOJ also states the investigator worked to prevent insurance companies from detecting the alleged fraud and diverted attention of other investigators away from these clinics.
The group operated two clinics and allegedly worked with the investigator to offer patients “free” cosmetic procedures. These procedures included facials and Botox injections. In exchange for the procedures, patients would provide the clinics with insurance information. The group would then allegedly use this information to bill the insurance companies for procedures that were either never performed or unnecessary.
Altogether, the group is accused of submitting over $20 million in false insurance claims.
Government pushes for decade prison sentence and confiscation of assets
The government is pushing for serious penalties. Without a strong defense, these charges can come with a ten-year prison sentence. The government has also sought to pursue criminal forfeiture against the accused. If successful, this means the government will be able to confiscate funds from the accused by labeling these assets as “ill-gotten gains” connect to the alleged crime.