DAY 1 – Insurance Fraud Expo Presentations
September 08, 2008 - 01:00 pm to 02:30 pm
Regulating Chiropractors: The Role of Licensing Boards
S. Steven Baker DC, DABCO, FACO, DABFP, DABCC
American Chiropractic Association/Rincon Chiropractic
State chiropractic boards have a specific role legally, ethically, and professionally when it comes to regulating the chiropractic profession and a responsibility to society to protect the consumer, whether that is the patient, an insurer , or another entity affected by a physician’s actions. This presentation will help to define the role of a chiropractic licensing board, the powers with which it is vested, the process of filing a complaint, and how the board proceeds once a complaint has been filed. Included will be a discussion of common complaints and the most common findings of the Arizona board.
DATELINE SIU: Recent Trends
Audrey Parr and Jacques Parenteau
Parr & Parenteau, PC
Come and participate in this highly interactive workshop regarding the most recent Court decisions rendered nationwide since last year’s IASIU conference in 2007. Learn about the latest legal opinions affecting the handling of SIU claims involving bad faith, 1st and 3rd party claims for Bodily Injury, PIP/Medical Payments, Auto Theft, Workers’ Compensation, Homeowners, Commercial General Liability and more. Discuss the facts of the cases and the bases for the Courts’ decisions on issues such as misrepresentation in the application, defamation, stalking, arson, life and disability claims. Bring your own personal experiences to the group as we discuss coverage and exclusion issues dealt with on a daily basis by SIU investigators and managers. Gain valuable insight from your peers while analyzing local and national Court opinions that will assist you in the future handling of your company’s claims.
The “Perfect Storm” of Insurance fraud: The Nexus of Medical ID Theft and Medical Provider Fraud
Mike McKee, NICB
Kolby Bates, Travelers Investigative Services
This presentation utilizes two recent investigations as case studies. These two investigations neutralized 48 "Phantom Diagnostic Centers" which fraudulently billed for tens of millions of dollars through medical ID theft. These "phantom" diagnostic centers were created and run by professional criminal rings. This new criminal technique was designed to counter the current "red flags" utilized to spot insurance fraud by the insurance industry. Learn how these rings and other criminals are using this technique to defraud your company. Learn how to spot this newest trend in insurance fraud in your claim files. This new fraud activity is known to be targeting casualty, but mainly worker compensation and health care carriers.
Los Angeles County Metropolitan Transportation Authority presents Analysis of Metro's Special Investigations Unit
Cliff Ladage, Metro Special Investigations Unit
The Los Angeles County Metropolitan Transportation Authority Special Investigations Unit has been responsible for a steady decrease in the number of Workers’ Compensation claims filed since 2000. The 4 person unit consists of a SIU Manager, 2 SIU Investigators and an Administrative Analyst. This presentation will provide those in attendance an overview of how Metro’s SIU created a change of culture within the Metro system which has resulted in several successful fraudulent Workers’ Compensation prosecutions and employee terminations. The presentation will also cover how Metro’s Special Investigations Unit presents cases to the District Attorneys Office and overviews of several cases Metro’s SIU investigators have successfully submitted for prosecution.
Trucking Security, Cargo Theft and Its Impact on Insurance Fraud
Level: Advanced/Special
Jeff Lieberman and Tom Hansen
Sentry Insurance
This presentation will provide an overview of the trucking transportation industry and the challenges faced by SIU when investigating cargo thefts. We will focus on current trends and patterns affecting the industry from organized rings to driver involvement. You will learn about the trucking industry in general – why the tremendous increase in this type of crime and the current national strategies implemented by the American Truckers Association Security Council. You will learn proactive cutting-edge techniques to implement within your organization to reduce your exposure.
Vacancy and Unoccupancy Issues: The SIU Investigation. The Many Faces of the Vacancy and Unoccupancy Defense
Peter Schoonmaker, Condon & Cook, L.L.C.
Patrick Burke, Metlife Auto & Home
This presentation will focus upon the most typical vacancy and unocupancy exclusions and will provide an overview of cases throughout the United States which have construed and enforced the provisions. The presentation will then illustrate the use of the vacancy and unoccupancy exclusions through case studies exemplifying the most typical types of losses which can be defeated utilizing the exclusions. It is designed to stimulate creative thinking and alternative approaches to traditional SIU Investigations. Successful use and implementation of these policy exclusions also offers the SIU unit an opportunity to expand into areas traditionally deemed to be coverage issues, as opposed to fraud issues.
September 08, 2008 - 03:00 pm to 04:30 pm
Privacy Laws and SIU Investigations: SIU Investigations: How Far Can You Go?
Jodi Conners, John Curran and John Leslie
Smith and Brink, P.C.
The presentation will discuss the interplay of SIU investigations and privacy laws. More specifically, the presentation will discuss the balance between a claimant’s right to privacy and an insurer’s obligation to investigate and substantiate that a loss occurred which is covered under the terms of the insurance policy contract. An overview of recent case law will be presented focusing on an insurer’s rights and obligations in light of the advancement of surveillance technology, vs. an insured’s right to privacy.
Fraud in Losses Due to Sinkholes, Hurricanes, Floods and Other Natural Perils
Thomas A. Keller, Butler Pappas Weihmuller Katz Craig, LLP
The number of property claims due to the hurricanes of 2004 and 2005 allowed many questionable and fraudulent practices in claims presentation to flourish. These practices have spread to property claims due to other natural phenomena. The ability to ascertain whether fraud is being committed in a particular claim depends on an investigator’s knowledge of that type of claim and past experience. This presentation will provide an overview of different claims due to natural perils (sinkholes, hurricanes, floods, etc.) and examples of where questionable or fraudulent practices may arise in those claims.
Disability, Group v. Individual Claim Investigation
James Brooks and Mark Lanford
Metlife
An interactive discussion of Disability investigations involving both Group and Individual claims. The different nuances related to the policy and how the contract and/or policy play an important role in the investigative strategy. The use of surveillance and how the outcome may not always benefit the investigation.
Catching the Pharmacy Drug Diverter
Rick Germroth, Jay Loden and Alan Yee
Kaiser Permanente
This presentation provides actual investigative examples of subjects engaged in stealing prescription medications from Kaiser Permanente pharmacies. An investigative model will be presented which has been successfully employed by fraud detection investigators to address crimes involving the diversion of prescription drugs from pharmacies. The model utilized includes detecting drug inventory variances through data mining, techniques used to identify the party responsible for stealing drugs, the installation and utilization of covert and overt surveillance equipment, obtaining meaningful statements through interviews and the taking of signed statements and the successful preparation of an investigative report written for the benefit of law enforcement agencies and prosecutors. Actual footage of subjects engaged in the act of stealing prescription medications will be presented. The presentation concludes by offering specific prevention measures which can be implemented to avoid future losses.
2008 Important Updates: Event Data Recording Technology in Passenger Cars and Commercial Vehicles
R. Scott King, BSME
DJS Associates, Inc.
It’s been nearly ten years since the advent of the automotive "black box". Created for the seasoned SIU professional, as well those new to the industry, this seminar will provide a broad perspective of the use of Event Data Recording technology in passenger cars and commercial vehicles. Topics discussed include year, make and model of EDR-equipped vehicles; which vehicles record pre-crash vehicle speed and which don’t; and the conditions required for data recording. Focused attention will be given to the latest EDR’s within many newer Ford products, including those devices providing up to 25 second of pre-crash data, as well as the latest updates from Chrysler and Toyota products. Various state and federal legislative updates, including the important implications these laws have upon data access will be covered.
Investigative Intuition: The Foundation for Case Success
Daniel W. Draz, M.S., CFE
TransUnion
Insurance anti-fraud training often focuses on red flags, or the use of technology to analyze information and detect potentially fraudulent claims for further review. However, despite increased training and significant advances in technological tools, not all claims have red flags which are easily identifiable. In these cases, detecting fraud requires the expertise and experience of professionally trained investigators with well honed skills.
This unique training session, designed and presented by Daniel W. Draz, M.S.,CFE, focuses exclusively on the use of intuition and how great investigators use their intuitive skills to successfully identify and investigate fraudulent insurance claims. Intuition is rarely discussed in insurance industry anti-fraud training around the country and is a "must have" skill in any good insurance investigators toolbox.
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