Case Study – Clinic investigation

Concern: Massaging the Invoice

A nationwide insurance company was receiving exorbitant invoices from a rehabilitation facility that specialized in massage therapy. Said bills often exceeded the hours under which this rehabilitation facility operated. Ergo, the nationwide insurance company decided to pursue criminal charges for PIP fraud. Ethos Risk Services was asked to conduct a clinic investigation to aid in said pursuit.

Actions Taken:

1. Ethos tasked investigators with conducting five days of surveillance beginning before the rehab facility opened and discontinuing after the facility closed.

2. Field investigators documented all subjects who arrived at and departed from the facility including patients and employees.

3. Tag numbers of all vehicles that arrived at the facility were run to determine registrants and registered addresses.

4. The rehabilitation facility’s opening and closing times were verified during surveillance efforts to aid the insurance company in future endeavors in this case.

Bottom Line: Ethos investigators determined that customer traffic at this facility was not as extensive as the rehabilitation facility invoices indicated.

Positive Outcome:  Ethos greatly assisted this insurance company in its pursuit of criminal charges against a provider for PIP fraud. Thanks to documentation obtained during surveillance, this insurance company was able to intelligently compare the surveillance results against the invoice from its rehabilitation facility. More over, the insurance company could determine if the patients for which specific forms were filed were actually treated. All this allowed the insurance company to pursue action against the rehabilitation facility.

Case Exposure: $300,278 (bill from physical rehab facility)

Ethos case investigation resulted in: $265,500 savings (case exposure – case investment = Savings)

Submit a Comment

Your email address will not be published. Required fields are marked *