Patients and insurers victimized in alleged $176 million fraud scheme
SACRAMENTO, Calif. – California Department of Insurance detectives, assisted by multiple law enforcement agencies, arrested Chris Bathum and Kirsten Wallace on multiple felony counts of grand theft, and identity theft for allegedly conspiring to defraud patients and insurers out of more than $176 million through an elaborate conspiracy. Simultaneously, search warrants were also executed at 15 locations throughout Los Angeles and Orange County.
“Bathum and Wallace’s alleged conspiracy victimized hundreds of people addicted to drugs and alcohol by keeping them in a never-ending cycle of treatment, addiction, and fraud-all the while lining their pockets with millions of dollars from allegedly fraudulent insurance claims,” said Insurance Commissioner Dave Jones.
According to investigators, Bathum, the owner and CEO of Community Recovery of Los Angeles (CRLA) and Wallace, the CFO, are accused of luring vulnerable people addicted to drugs and alcohol to CRLA with a variety of treatment marketing schemes.
The Department of Insurance’s investigation revealed Bathum and Wallace conspired to steal patient identities and buy health insurance policies for patients without their knowledge. After completing treatment, Bathum continued to bill insurance companies for treatment services.
Bathum and Wallace billed health insurance companies more than $176 million in fraudulent claims. The insurers, including Anthem Blue Cross, Blue Shield, Cigna, Health Net and Humana paid approximately $44 million in total before discovering the suspected fraud and stopping claim payments to CRLA.
Bathum and Wallace are charged with multiple counts on the following felonies:
- Identity theft for submitting fraudulent health insurance applications without patients’ knowledge.
- Five counts of billing fraud for submitting claims for services not provided and duplicate billings.
- Five counts of grand theft by false representation for representing CRLA as a residential treatment facility, which it is not licensed to provide.
- Five counts of grand theft by false representation to insurers for filing fraudulent health insurance policy applications.
Additional charges include enhancements for losses greater than $500,000 and for losses greater than $3.2 million.
“This is likely the first wave of indictments and charges in an ongoing investigation into one of the largest health insurance fraud cases in California,” added Jones.
If convicted on all counts, Bathum and Wallace face more than 35 years in prison. Bail was requested at $2 million. Both are likely to be arraigned on November 14, 2016.
This case was investigated by the Department of Insurance and is being prosecuted by Los Angeles District Attorney Jackie Lacey. The Department of Insurance was assisted in the arrests and search warrants by the Los Angeles County District Attorney’s Bureau of Investigations; the Los Angeles County Sheriff’s Department; the Orange County District Attorney’s Bureau of Investigation; and the Department of Health Care Services accompanied detectives to ensure any patients in CRLA facilities are transferred to licensed treatment locations.
Editors note: Health Net of California cited excessive substance abuse claims experience as one of the reasons for such a large rate increase for 2017. https://www.calhealthnews.com/health-net-requests-23-rate-increase-for-2017-california-individual-and-family-plans/