Former Anthem fraud investigator charged in $20M billing scheme

A former senior investigator for Anthem and a physician were among five people arrested May 22 for their alleged role in a multiyear billing scheme involving at least eight payers, according to the Justice Department.

Gary Jizmejian, who worked in Anthem's antifraud unit, allegedly provided confidential information to the owner, a physician and other employees of two San Fernando Valley, Calif.-based cosmetic clinics that helped them submit fraudulent claims to Anthem in 2012. Mr. Jizmejian provided the owner CPT codes he knew Anthem wouldn't detect as fraud, according to the indictment.

The prosecutors also accused the clinic owner and others of inducing patients to visit the clinic for "free" cosmetic procedures like facials and Botox injections. The indictment alleges the defendants obtained those patients' insurance information to fraudulently bill health insurers for medically unnecessary services or services that weren't provided.

The clinic owner and other defendants allegedly submitted at least $20 million in claims to Anthem and other insurance companies under the scheme. The insurers paid about $8 million on the claims, the indictment alleges.

Prosecutors claim other insurers affected by the scheme include the Federal Employees Health Benefits Program, which provides health insurance for federal employees, as well as the International Longshore and Warehouse Union's Pacific Maritime Association Benefit Plan. 

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