SERVICES

The purpose of a special investigative unit is to assure the effective implementation of a dedicated team to educate, train, protect, detect, and communicate with insurers and law enforcement agencies regarding possible fraudulent claims. In many states, the SIU department can be contracted to a third party to operate on behalf of the insurer. Our services include:

• Educating and training personnel in identifying patterns and trends of suspected fraudulent claims, effectively analyzing claim forms.

• Interviews and other investigative techniques.

• Prepare and submit district attorney insurance fraud referrals (packets).

Workers’ Compensation Fraud

1. EMPLOYEE FRAUD - An employee knowingly files a claim for injury that did not occur at all or did not occur in the course and scope of employment.

2. BILLING FRAUD - Medical provider bills for services NOT rendered, or intentionally inflate charges for services, or bills for services provided by non-licensed or unqualified personnel.

3. PREMIUM FRAUD - Committed by an employer who intentionally under reports the number of claims, or under reports the number of employees on the payroll.

4. EMPLOYER FRAUD - Employer denies benefits to an employee by not reporting claim or encouraging employee not to report claim.

5. MEDICAL FRAUD - Medical industry use of runners, cappers, providing kickbacks or other illegal sources associated with obtaining cases/claims. 

Insurance Fraud Defined

Each state has their own legal definition but each shares common elements . . .

1. The misrepresentation may be presented orally or by document.

2. The false information presented must be MATERIAL to the case. In other words, it would have altered, changed, or modified the manner the claim was handled, investigated, evaluated, or settled.

3. The information must be presented with INTENT to defraud.

4. There must be a LIE which may be committed by an insured, Claimant, witness, party to a claim, insurer or claims handler. 

5. The false information must have been presented KNOWINGLY.

6. Must be presented to prove, validate, affirm or deny a claim for injury or loss payment or to obtain insurance coverage.

Workers’ Compensation Red Flags

Employee Fraud

1. Un-witnessed Injury

2. Late reporting

3. Subjective complaints

4. Reporting after weekend

5. Short term employment

6. Prior claims history

7. Disciplinary problems

8. Personal problems

9. Medical diagnosis is not consistent with mechanism of injury

10. Witnesses in close proximity unable to substantiate allegations

11. Refusal to report employee claim

12. Sending employee to own doctor and submitting under own health insurance

13. Altering dates or times of injury with intent to have claim denied

14. Providing false facts to Claims Examiner

15. Providing payment or kickbacks to doctors for opinions

16. Altering medical documents

17. Submitting claims that did not occur within course and scope of employment in
    attempt to allow employee some form of benefit