2015 Annual Training Conference & Anti-Fraud Expo

Sessions Speakers Exhibitors Show Specials Floor Plan Buzz

Operation Cinco Castillos: New Physical Therapy and J Code Schemes Targeting Private Insurance Carriers (Room Seaport F)

This case study examines the investigation of a scheme to defraud privately insured health care plans, chiefly self-insured employers, who offered Administrative Services Only (ASO) insurance plans to their employees and out of state host plans. The discussion will focus on a group that recruited massage therapists to open physical therapy clinics. These individuals utilized medical director staffing companies to obtain and misappropriate the names and licensing information for numerous physicians. This information was then used to submit false and fraudulent physical therapy and injection claims to the private insurance plans. Owners paid kickbacks to recruiters to provide patients who would sign documents falsely and fraudulently representing that they had received medical services when, in fact, they had not received medical services. Owners also recruited uninsured individuals to enroll in private health insurance plans and would pay the monthly premium and additional kickbacks in exchange for billing under the complicit patients' names. In the span of one and one-half years, private insurance plans were billed over $130 million in false and fraudulent claims. As a result of this case study, participants will learn: new schemes targeting private insurance host and ASO plans; new JCodes used by fraudulent Physical Therapy clinics to defraud the insurers; new variations on kickback schemes; and methods by which private insurers may refer and charge private insurance cases to federal investigators under the federal health care fraud statutes.