Insurance Department nabs trio for billing fraud

The California Department of Insurance arrested three individuals including a registered qualified medical evaluator (QME) in a scheme to defraud health insurers by artificially inflating bills. The three face charges of conspiracy to submit at least $380,000 in fraudulent bills for laboratory services.

Arrested were Dr. Edward Albert G. Balbas, chiropractor Jon Brunelle, and Alejandra Brunelle. The three jointly own Corona Physical Medicine clinic. Balbas is registered as a QME with the Division of Workers’ Compensation for pain medicine and physical medicine and rehabilitation.
The insurance department says the defendants cooked up a scheme to inflate the cost of its bills for laboratory tests. CDI says the three paid an out-of-state laboratory between $312 and $625 for tests but billed the health insurers $4,256 for the tests. Investigators say the suspects told carriers that they processed and analyzed the blood tests in-house.

Riverside County’s District Attorney’s office is handling the prosecution.

Compline suggests that brokers’ who are reviewing clients’ loss runs may want to determine if charges from this clinic appear as part of the paid medical and take appropriate action which may include directing the carrier to provide information to the DA and to adjust under the fraud provisions its loss reporting for X-Mod purposes.