Special Investigation Unit (SIU)

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


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.

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.

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

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

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:

  • The misrepresentation may be presented orally or by document.

  • 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.

  • The information must be presented with INTENT to defraud.

  • There must be a LIE which may be committed by an insured, Claimant, Witness, Party to a Claim, Insurer or Claims Handler.

  • The false information must have been presented KNOWINGLY.

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

Red Flag Indicators

  • Un-witnessed injury

  • Late reporting

  • Subjective complaints

  • Reporting after weekend

  • Short term employment

  • Prior claims history

  • Disciplinary problems

  • Personal problems

  • Medical diagnosis is not consistent with mechanism of injury

  • Witnesses in close proximity unable to substantiate allegations

  • Refusal to report employee claim

  • Sending employee to own doctor and submitting under own health insurance

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

  • Providing false facts to Claims Examiner

  • Providing payment or kickbacks to doctors for opinions

  • Altering medical documents

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

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