Quick action on a tip, plus interagency cooperation, helped earn Regence BlueCross BlueShield recognition among Blue plans nationwide for a successful fraud investigation that can be duplicated across the country.
Tips from two Portland-area pharmacists in two days that a woman posing as a Regence member was seeking narcotics triggered red flags for the Regence Special Investigations Unit (SIU). The SIU worked with the health insurer’s membership and pharmacy teams to quickly uncover the facts.
Their proactive investigation took specific steps to protect members, find the culprit, prevent further abuse of Medicare funds and halt the illegal drug diversion:
Found the common link: the identification cards presented to pharmacies around Portland belonged to a Regence Medicare prescription plan specific to the Seattle area
Identified and called members with this specific plan whose accounts showed recently processed claims for prescription narcotic medication
Notified members that their ID might be compromised and issued them new IDs
Identified the common factor among these members, an eye clinic they all visited
Examined employee records of the eye clinic to develop a list of those who fit description of woman photographed passing narcotics prescriptions
Notified Health Integrity MEDIC, and later the U.S.Health and Human Services Office of the Inspector General (HHS-OIG) of this ongoing investigation, as required under federal law.
During the investigation, which started in September 2010, additional complaints were received regarding other member IDs used in attempts – most of them successful – to obtain narcotic prescriptions.
When an Oregon law enforcement agency arrested Alysse Burrell in October 2010, Regence immediately advised that she was a former eye clinic employee, and potentially subject to numerous criminal counts in addition to the incident that triggered her arrest.
The SIU’s extensive documentation was shared with the U.S. Attorney’s Office in Seattle, which conducted the prosecution. In May 2011, Alysse Burrell and her accomplice Horace Mitchell pled guilty to charges of aggravated identity theft, conspiracy to acquire controlled substances by fraud and to distribute controlled substances. They were sentenced to 60 months and 52 months confinement, respectively, plus 36 months supervised release. Regence estimates the street value of illegal narcotics they fraudulently obtained to be more than $200,000.
“Quick and coordinated response by Regence, plus the close relationship with law enforcement, helped mitigate further loss of stolen identifications and monetary damage,” said Jeanette Rogers, Regence vice president and deputy general counsel who oversees the SIU.
Regence employees recognized for their participation are Alex Johnson, SIU Director; John Lesmeister, Investigator III; Konnie Mastrovito, Investigator III; Patrick Guiton, Manager. This investigation offers a successful learning opportunity for other Blue Cross and Blue Shield Association plans to halt fraud and protect member premium dollars.
About Regence affiliated companies
The Regence affiliated companies serve more than two million members through Regence BlueShield of Idaho, Regence BlueCross BlueShield of Oregon, Regence BlueCross BlueShield of Utah and Regence BlueShield (selected counties in Washington). Each health plan is a nonprofit independent licensee of the Blue Cross and Blue Shield Association. The Regence affiliated companies are committed to improving the health of its members and communities and to transforming the health care system. For more information, please visit www.regence.com or follow us on Twitter.