DAY 3 – Insurance Fraud Expo Presentations
September 10, 2008 | 08:30 am to 11:45 am
National Rate Pusuit/Premium Evasion
Rob Bodoni, Metlife
Joey Cox, SCLA, CIFI, IRE, Abacus Research & Investigations
Premium fraud/rate evasion is a national concern which affects all lines of insurance. Monetary loss to this type of fraud is costing insurers millions of dollars in lost premium. In addition, due to the fact that false information is being presented at the time of application, insurers are basing their level of risk on false information. This program will examine the various schemes being run as well as how to prevent against them. Garaging issues, unlisted operators, business use of vehicle, fraudulent discounts and customary users are some of the types of schemes to be examined. This program applies to several levels of the insurance process. From point of sale, marketing, and underwriting stages as well as to claims. Related issues such as identity theft/fraud, fraudulent foreign license, OFAC Regulations and USA Patriot Act will all be examined. Information will be provided which will be useful in setting up a premium avoidance unit as well as how to best train investigators and underwriters in detecting this type of fraud. We will look at specific examples of cases investigated as the results. We will also examine how application misrepresentations are affected by jurisdiction, from the re-rating of policies, cancellation of policies, recissions as well as denial of claims.
Fighting Fraud with Biomechanics and Injuries Sustained in Low Speed Impacts - Fact or Fiction
Mike Markushewski and David Gushue
Do the alleged injuries fit the dynamics of the accident? Was there an injury mechanism present in this incident that could have caused this injury? SIU Investigators deal with bodily injury claims every day resulting from vehicle collisions, slips & falls and industrial accidents. In some cases, the description of loss does not account for the claimed injuries.
By conducting a Biomechanical analysis of the events and injuries, ARCCA’s biomechanical engineers will explore whether there was an injury mechanism present in the event that could have caused this injury.
Injuries Sustained in Low Speed Impacts – Fact or Fiction
The human body is more tolerant to impacts from the rear than any other direction. However, a disproportionate amount of injury claims as a result of rear-end collisions are reported. The potential for injury is partially related to occupant interaction with the design of the automobile, but also depends greatly on the force of the impact. While certain injuries are possible from these types of collisions, oftentimes the claimed injuries are unrelated to the crash.
Session I – Medical Provider Fraud and Abuse Pattern Detection
Roger Whiddon, Travelers Insurance
The current claim processing environment, with its emphasis on speed and high volume efficiency, is vulnerable to deliberate fraud and abuse by opportunistic medical providers. A proactive method of strategic analysis will be discussed that attempts to identify medical providers habitually abusing the claim processing system. This method uses the insurance company’’s own medical billing history to establish normal billing and treatment standards, and identify which medical providers are being abusive against these standards. This approach is flexible, self-adjusting, modular, and multi-dimensional in nature. Advantages and limitations of this approach will be discussed. Practical implementation issues will also be addressed.
Session II – Analytic Approach to the Identification of Stolen Vehicles with Altered Vehicle Identification Numbers (VINs)
Diann Williford, NICB
The altering of Vehicle Identification Numbers (VINs) to conceal a vehicle’’s true identity is a significant problem throughout the country. This presentation will discuss the VIN altering schemes and provide an overview of how the National Insurance Crime Bureau is utilizing analytics to assist with vehicle theft investigations.
Everything You Wanted to Know About Medical Fraud But Didn't Know to Ask
Eve Korff, Shaver, Korff & Castronovo
This is a comprehensive review of all aspects of medical fraud from issues concerning billing, treatment and diagnostic abuses. Detailed samples of all aspects are presented and discussed. The seminar is also updated yearly to discuss the most up-to-date fraud schemes and techniques.
Best Practice & Procedure for Conducting Difficult EUO’s
Roy A. Mura, Esw., Mura & Storm, PLLC
More and more insurers are having their special investigators conduct routine EUOs. In this presentation, participants will learn the practical "how to’s" of scheduling and conducting difficult EUOs. Designed to train the trainers, this will be a plug-and-play training presentation that SIU supervisors and managers can take back and present to their teams. Written materials will include samples of an EUO cover letter and notice with document requests, scheduling and rescheduling letters, no-show letters, standard opening and closing statements for an EUO, a transcript reading and signing letter, and scripted responses to certain objections and situations that frequently arise during EUOs. Participants will also receive and view videotaped vignettes of commonly occurring EUO scenarios such as handling documents, dealing with the obstructive or objecting insured’s attorney, what to do when a witness "takes the 5th", becomes aggressive, verbally abusive, won’t sit down, refuses to answer questions, feigns a lack of recollection, gets up to leave, etc. In addition to sample pre-EUO and post-EUO letters and question outlines, the written materials will include a survey of cases from state and federal jurisdictions on EUO practice and procedure for the attendees’ future reference.
September 10, 2008 | 01:00 pm to 04:15 pm
Updated Methods in Fighting Abuse Behind the Healthcare Madness
The Universal Claim Form – CMS 1500 Form is submitted to an insurance company for reimbursement, it is of paramount importance that every effort is made to produce a claim. This presentation will provide CRUCIAL information regarding:
REQUIREMENTS: NEW CMS-1500 Claim Form submission.
Clean Claim – A clean claim is defined as one that meets ALL the necessary requirements as defined by HCFA/CMS. "It is the responsibility of physicians to accurately report the level of type of service they provide to patients according to CPT coding guidelines and reimbursement rules of the payer." Resourse: AMA – Mastering the Reimbursement Process.
Evidence: Are You Managing It Properly
Joseph Toscano, Evidence Secure, Inc.
Guy E. "Sandy" Burnette, Guy E. Burnette, Jr. P.A.
"Physical Evidence", is the cornerstone of any case. Although there are rules and standards as well as consequences that address the proper and improper handling of physical evidence, few professionals treat or manage this issue with the level of importance it should receive during the investigative process. The presentation will discuss and illustrate common unacceptable practices utilized by some "professionals" today to document, collect, store and manage evidence in their custody and control. This course will discuss new techniques, technologies and approaches dealing with the retrieval, transportation, tracking, documentation, storage and management of "physical evidence". With "Spoliation" claims and rulings increasing every day, there is an equally increasing urgency that insurance professionals examine the protocols utilized by in-house as well as outsourced consultants retained to provide expert services that involves the collection and storage of evidence. Protect your case by protecting your evidence.
Link/Timeline Analysis & Visualization – Key tools for complex Investigations
Mike Woods & Lenny Angello
Gordian Analysis & Visualization, LLC
This presentation demonstrates the advantages of link and timeline analysis and innovative investigative techniques in a complex examination of large data sets from disparate sources. Specific analysis covers identifying questionable activities, uncovering relationships and activity patterns through questionable activities, uncovering relationships and activity patterns through examination of human resource and public source data, internal telephone and email communications, and the processing and payments of questionable invoices. Link Analysis and chart visualization is shown as a powerful tool to save time, sharpen the focus of an inquiry, uncover hidden relationships and patterns of activity, and communicate those complex and disparate findings to Law enforcement and/or litigation principles.
Workers Compensation Fraud and Investigative Techniques
Andris Berzins, Federated Mutual Insurance
Steve Fitzpatrick, Indianapolis Metropolitan Police Department
This presentation will provide the attendee with a step-by-step process for the training of their claims staff to refer quality suspected workers compensation fraud referrals, the development the fraud team and communication amongst the members, the enhancement of the investigative techniques used to develop information on the claimant, the assignment of surveillance as necessary, the various surveillance techniques and equipment that can be utilized, the techniques used to develop false statements on the part of the claimants including the use of surveillance results, the use of fraud evidence for the favorable disposition of the workers comp claims, and the evaluation and preparation of the case for prosecution.Email this page Print this page