Health insurers face wave of questionable claims for overseas injuries
Prosecutors in Boston have filed a criminal complaint accusing six people of health care fraud.
Employers and their benefits professionals may have to look even harder at requests for reimbursement for care that health plan members said they received while outside the United States.
Prosecutors in Boston last week accused five Massachusetts residents and a New York resident of conspiring to file fraudulent claims for reimbursement for care allegedly received overseas.
The defendants said they had suffered traumatic injuries, such as stabbings and gunshot wounds, while traveling and had paid for care out of their own pockets. They asked the insurers to pay them back, according to a complaint the U.S. attorney’s office filed July 10 with the U.S. District Court for the District of Massachusetts.
Prosecutors maintain that the documentation for the reimbursement requests was fabricated.
The prosecutors did not name the payers involved but described them as “private insurers.”
The defendants named in the complaint are Brendon Ashe, Aqiyla Atherton, Darline Cobbler, Darline Ezeonyido, Ariel Lambert and Chinenye Nwodim.
Oscar Cruz Jr., Atherton’s lawyer, declined to comment.
The other defendants could not immediately be reached for comment.
Questionable claim examples: A carrier identified only as “Insurance Company A” attracted investigators’ attention Insurance by telling them a policyholder had provided what appeared to be fabricated records to support an international reimbursement claim, according to an affidavit by Gregory Gerlach, a Federal Bureau of Investigation special agent, that was filed along with the complaint.
Insurance Company A found that one woman had asked for reimbursement for international care in 2019, 2020 and 2021, for a total of $191,908 in overseas medical bills. One of the requests involved for care for an appendectomy, one for a stabbing and one for a shooting.
U.S. Customs and Border Protection records showed that the woman with the large overseas medical bills in 2019, 2020 and 2021 has not traveled internationally since 2014.
Insurance Company A also reported receiving two reimbursement claims for $234,243 for care related to a shooting in Namibia and a hit-and-run accident in Namibia.
Investigators found that insureds had submitted nearly identical medical records in support of apparently unrelated reimbursement claims sent to different insurers.
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One medical record template popular with the reimbursement seekers comes from a private hospital in Botswana.
The record shows the same patient number and vital signs figures, such as an oxygen saturation level of 92% and a blood pressure reading of 80 over 55, for different patients, according to copies of different defendants’ versions of the record included in the affidavit.