Case Study: Major Minnesota Health Plan Provider achieves chiropractor fraud conviction and restitution with Cotiviti FWA Solutions

How a major Minnesota health plan built a strong case leading to a chiropractor’s fraud conviction

Major Minnesota Health Plan Provider, which serves more than 2.5 million members and processes over 40 million claims annually, faced a suspected fraud tip about a chiropractor billing for services not rendered. The plan’s special investigative unit (SIU) — staffed with investigators and data analysts — relied on Cotiviti’s FWA Solutions (including Informant, Sentinel, and Commander) to rapidly analyze claims data, generate leads, and manage the investigation.

Using Cotiviti’s tools, the SIU broke down billing patterns with Informant’s calendaring features, flagged aberrant billing in Sentinel, and organized casework in Commander; analysis revealed the chiropractor had billed over $1.7 million overall and submitted more than $22,000 in charges for 156 patients on a single grand-opening day. The evidence supported an onsite audit and a law enforcement referral; the chiropractor pleaded guilty to wire fraud in January 2019, received a 27-month prison sentence, paid hundreds of thousands in restitution, and lost his license — outcomes the Major Minnesota Health Plan Provider attributes to the effectiveness of Cotiviti’s solutions.