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PIP Insurance Fraud Dennis Handley Special Agent March 20 & 21, 2015.

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1 PIP Insurance Fraud Dennis Handley Special Agent March 20 & 21, 2015

2 About NICB The National Insurance Crime Bureau (NICB) is a not-for-profit organization that receives support from nearly 1,100 property and casualty insurance companies and self-insured organizations. The NICB partners with insurers and law enforcement agencies to facilitate the identification, detection and prosecution of insurance criminals. The vision of the NICB is to be the preeminent organization fighting insurance fraud and crime.

3 NICB Mission Lead a united effort of insurers, law enforcement agencies and representatives of the public to prevent and combat insurance fraud and crime through data analytics, investigations, training, legislative advocacy and public awareness.

4 NICB Disciplines Investigations Data Analytics Training
Legislative Advocacy Public Awareness

5

6 Questionable Claims Insurance professional identifies questionable claims Makes NICB aware of the claim Provides multiple benefits

7 NICB Questionable Claims
Single, most important tool in identifying fraudulent claims Allows cross referencing on single claims Builds intelligence, to identify patterns and trends Used to initiate major cases Used to increase public awareness regarding insurance fraud and vehicle crimes

8 Investigative Resources
Special Agents Investigative Assistants 24/7 Hot Line 1-800-TEL-NICB Text Keyword “Fraud” to TIP411 Via Tip app (iPhone, iPad, iPod touch compatible)

9 PIP Claims and Insurance Fraud
These materials are NICB work products and as such, any reproduction, distribution and/or additions or deletions must be approved by the NICB Training Department. Introduce yourself. Give a brief background to establish your credibility with the topic of the class. If the class is informal, let the attendees know they can ask questions at any time. If the class structure is more formal, let them know you’ll be happy to answer questions at the end of the session. Provide a brief synopsis of what the class will cover and how it will benefit them. We’re here today to talk about questionable PIP claims. In other words, PIP claims you think may contain insurance fraud. It’s important to realize that insurance fraud in PIP claims is the same type of fraud found in non PIP claims. It’s still medical billing fraud or a faked injury or an attorney/provider scheme or all of the above. What’s different in PIP claims are the characteristics concerning PIP itself. So, after you determine the PIP claim is questionable, the action steps to determine if it is a meritorious claim or not, are the same ones you would take with any questionable claim. For that reason, this PIP course is normally given in tandem with another FraudSmart class specific to the type of fraud you are looking at. For example, the CPT code FS, or the Medical/Legal Aspects of BI Claims, or Staged Auto Accidents FS. Let’s look at what we are going to accomplish with this PIP FraudSmart Course. Instructor: Please mention that there is a website to determine what services a CPT code is supposed to represent. It is free and it could serve as a quick reference guide. Go to Click on the Healthcare Cost link in left hand menu bar Click on the Consumer Healthcare Information logo in left hand menu bar Click on the Benchmark Fees link on main screen Click on the Physician Procedures logo on main screen Enter CPT code in field and click on submit March 20 & 21, 2015

10 What are we talking about?
What is: PERSONAL INJURY PROTECTION (PIP) While there are differences between states, generally PIP exists in no fault states where the right to sue, and recover expenses, is limited. PIP coverage pays benefits without regard to fault to persons injured in auto accidents. Payments include reimbursement for medical expenses, lost wages, funeral expenses and the cost of rehabilitation and replacement services necessitated by the injury. PIP is designed to reduce the litigation often arising from minor auto accidents in order to recover costs and expenses for the “not at fault driver”. By protecting the victim with PIP there is no need to sue. This will reduce courtroom crowding, insurance costs and aid the public at large. This is why PIP was created. However, sometimes, PIP or no PIP, there is negligence involved in the accident and the victim should not be denied their legal rights to sue for some type of financial settlement. To accommodate this, these no fault states have no fault laws containing “tort thresholds” defining in terms of medical expense, days of disability or severity of injury, that determine when an injury qualifies for a liability claim or a lawsuit against the “at fault” driver. There are monetary thresholds and verbal thresholds.

11 Personal Injury Protection
THRESHOLDS: VERBAL AND MONETARY Monetary thresholds are simply a dollar amount, usually from medical treatments, that has to be exceeded before a sue can be filed. Verbal thresholds generally state that when the injury has “far reaching disabling consequences” for the victim, a suit can be filed. Both have advantages and disadvantages. A disadvantage of monetary thresholds is that low (dollar amount) ones are easily met and lawsuits are filed anyway. The whole purpose of PIP is defeated. An advantage of a monetary threshold is that it is an objective concrete figure. It is either exceeded or it isn’t. There is no subjective judgment involved to determine if the person can sue or not. Naturally the higher the threshold, the less likely it will be met and the fewer lawsuits. An advantage to a verbal threshold is that although the dollar amount for medical bills may be low, the victim can still sue if the injury substantially changed their life. An example might be an amputated finger. The medical bills may be low relatively speaking, but the victim’s life is changed forever. A disadvantage of verbal thresholds is the subjectivity involved in determining “far reaching disabling consequences”. You basically have to take the doctor’s word for it.

12 Scope of the Benefits Lifetime Benefits for Injured Persons
Most generous medical-expense and patient care provisions of any No-Fault Act in the country Lifetime Medical Expenses Michigan Catastrophic Claims Attendant Care or Nursing Services Hire outside help or employ family members so the injured person can remain at home rather than be institutionalized Monetary thresholds are simply a dollar amount, usually from medical treatments, that has to be exceeded before a sue can be filed. Verbal thresholds generally state that when the injury has “far reaching disabling consequences” for the victim, a suit can be filed. Both have advantages and disadvantages. A disadvantage of monetary thresholds is that low (dollar amount) ones are easily met and lawsuits are filed anyway. The whole purpose of PIP is defeated. An advantage of a monetary threshold is that it is an objective concrete figure. It is either exceeded or it isn’t. There is no subjective judgment involved to determine if the person can sue or not. Naturally the higher the threshold, the less likely it will be met and the fewer lawsuits. An advantage to a verbal threshold is that although the dollar amount for medical bills may be low, the victim can still sue if the injury substantially changed their life. An example might be an amputated finger. The medical bills may be low relatively speaking, but the victim’s life is changed forever. A disadvantage of verbal thresholds is the subjectivity involved in determining “far reaching disabling consequences”. You basically have to take the doctor’s word for it.

13 Scope of the Benefits continued
Replacement Services Expense Benefits Maximum of three years Rehabilitation Physical Rehabilitation Vocational Rehabilitation Work Loss/Wage Loss Benefits Monthly maximum Replacement Services $20.00 per day $ per month Expenses incurred in having others perform reasonably necessary domestic-type services would have to perform for non-income-producing-purposes Benefit is payable for the first three years following an accident Rehabilitation Physical rehabilitation of injured person, unlimited reasonable expenses Vocational rehabilitation, job retraining and job placement. Courts have rejected that the no-fault insurer is only obligated to restore the injured person to his/her pre-accident status as opposed to elevating the victim to a higher functional level reasonably consistent with the person’s capabilities. Work Loss Benefit 85% of gross pay Up to 3 years Maximum monthly $ 5, indexed from year to year If filled, family would receive the wage loss for 3 years

14 Personal Injury Protection
So what happened? It was such a good idea! Why are we seeing so many questionable PIP claims? So, we’ve got this great idea to reduce the number of lawsuits, hold down insurance costs and still protect the victim of an accident. What went wrong? The answer is that people want more money than the accident/injury actually cost them out of their pocket. That’s not entirely without merit. You have all been through the inconvenience of missing work, arranging for transportation, trying to get babysitters, not being able to engage in your normal activities, getting behind on the job and on and on. People want to and in some cases deserve to be compensated financially for non-financial costs/losses. The problem is that all this sort of thing, right or wrong, falls under the heading of “general pain and suffering”. Under PIP a person can’t sue for these general damages until the threshold is met…… and there you have it. Fraudulently achieving the right to file a lawsuit for general pain and suffering is where the PIP concept gets abused.

15 Personal Injury Protection
GREED So, we’ve got this great idea to reduce the number of lawsuits, hold down insurance costs and still protect the victim of an accident. What went wrong? The answer is that people want more money than the accident/injury actually cost them out of their pocket. That’s not entirely without merit. You have all been through the inconvenience of missing work, arranging for transportation, trying to get babysitters, not being able to engage in your normal activities, getting behind on the job and on and on. People want to and in some cases deserve to be compensated financially for non-financial costs/losses. The problem is that all this sort of thing, right or wrong, falls under the heading of “general pain and suffering”. Under PIP a person can’t sue for these general damages until the threshold is met…… and there you have it. Fraudulently achieving the right to file a lawsuit for general pain and suffering is where the PIP concept gets abused.

16 PIP FRAUD Why? Not anymore Willie!
“Why do I rob banks? Because that’s where the money is” Attributed to bank robber Willie “the Actor” Banks, Not anymore Willie! CNNMoney Healthcare fraud costs $100 billion dollars per year Federal Bureau of Investigation FBI puts the figure at $80 billion dollars per year Durable Medical Equipment DME fraud could cost between $1.5 and $5 billion dollars per year

17 PIP Fraud WHAT IS FRAUD Webster:
Deceit, Trickery specifically : intentional perversion of truth in order to induce another to part with something of value or to surrender a legal right. Simple definition:  Fraud is a deceptive act intended to get a benefit to which a person is not entitled.

18 PIP Fraud Elements of fraud Material false statement
2. Knowledge that the statement was false 3. Victim must rely on the material false statement Victim must suffer damages due to their reliance on the false statement

19 PIP Fraud Schemes 10 common health care provider schemes
1. Billing for services not rendered 2. Billing for a non-covered service as a covered service 3. Misrepresenting dates of service 4. Misrepresenting locations of service Essentially, fraud in health care is just like in any other industry: Fraudsters with means and opportunity fake full advantage to unjustly profit. Health care crooks inside and outside the industry include patients, payers, employers, vendors and suppliers, and providers, include pharmacists. 5. Misrepresenting provider of services

20 PIP Fraud Schemes Continued
6. Waiving of deductibles and/or co-payments 7. Incorrect reporting of diagnoses or procedures (includes unbundling) 8. Overutilization of services 9. Corruption (kickbacks and bribery) 10. False or unnecessary issuance of prescription drugs

21 PIP Fraud: How It’s Done
Opportunistic/Professional Claimant Subjective Injuries Wants time off of work Wants Replacement Services Wants pain medications Knowledge of insurance/medical

22 PIP Fraud: How It’s Done
Solo Medical Provider Take advantage of liberal PIP payments Enhance extent of injuries Get claimant/patient off of work Get claimant/patient extra money

23 PIP Fraud: How It’s Done
Personal Injury Mill The Structure of the Scam Medical Providers Claimant Capper Attorney Loose Linked Organization- They may be driven by attorneys and/or providers that enlist “runners” to provide their client or patient population, but the individuals and companies are separate entities operating in concert Corrupt Attorneys Can initiate the scheme brom their own client base. Use cappers or runners to recruit legitimate or fake accident victims. The victims or their identities act as the fuel for the mill. Refer clients to medical providers who they know will participate Attorneys use the fraudulent diagnoses and treatments as basis for lawsuits.

24 PIP Fraud: How It’s Done
Personal Injury Mill The Structure of the Scam Continued Cappers, Runners or Chasers Are recruited by the mill operator. Can be tow truck operators, emergency room attendants, ambulance operators, or pros who recruit clients full-time. Are usually paid a flat fee for services. Recruit clients victims or auto accidents, people out of work….anyone. Refer clients to the attorneys or doctors, depending on the scheme. Claimants and/or Insureds Are often unwitting victims, unaware that the claim is being used fraudulently. Can be a knowing participant in the scheme, receiving payment for being involved. Acting as passengers in a car during a staged accident. Medical Practitioners Doctors or chiropractors fabricate diagnoses and reports, while preparing false bills. Can run the mill, hiring cappers to recruit victims or may have their own internal solicitation employees. Victims are then told they will need multiple visits or that they qualify for free visits. Set-up inflated billing schemes. They use claimants who pretend to be, or are represented to be more injured then they actually are or simply use strategic or creative billing. Billings are characterized by up-coding or unbundling charges and manufactured medical records to match the billings Attorney Mail Insurance Office

25 PIP Fraud: How It’s Done
Personal Injury Mill The Structure of the Scam Continued Attorney Medical Providers

26 PIP Fraud How It’s Done Vertical Integrated Billing Management
Companies Other Patients Referrals, Cappers, Runners, etc. Attorney Medical Clinic Diagnostic Tests Therapists Consultant M.D., D.O. Supply Company One or more individuals establish a billing management company Controls all aspects and facets on one or more medical clinics by: Controlling the day to day management of the clinic (s) Supplying the clinic (s) with a patient population Generating fraudulent bills for the clinic (s) Maintain all bank accounts Under such operations, by funneling monies from the medical clinic (s) under their control to their billing company to ultimately launder the funds to the principals. The BMC employs or purchases the right to use the names and license numbers of various doctors, therapists, chiropractors and specialists under which they bill for services never rendered or, if rendered, were minimal or medically unnecessary. Generally, the profile of the typical selling doctor or therapists that is not participating in the profits of the BMC scheme to defraud tend to be frail, elderly, cash-starved or heavily indebted individuals who can be easily manipulated. Billing Company Unlicensed Owner

27 Insurance Investigative Process
Claim Adjustors Insurance PIP claim investigations Develop Questionable claims

28 PIP Questionable Claims
Medical Bill Soap Notes Police Report Letters of Medical Necessity Compare to Claimant Statement DME Documents Therapy Worksheets Prescriptions Imaging Bills/Reports Vehicle Photos ER Reports Paramedic Reports Claimant Interviews

29 PIP Fraud Questionable Claims
What are the characteristics? Claim adjustor investigations Remember that PIP claim fraud is most often based in fraudulently exceeding the threshold so a lawsuit can be filed. Supporting indicators are those indicators that support the theory that some type of fraudulent activity was used to exceed the threshold limits. Let’s go over some of them. What is the difference between a “characteristic” of a questionable PIP claim and an “indicator” of a questionable PIP claim? Good question. Indicators are inconsistencies that you see in questionable claims all the time. Pretty standard. Characteristics are additional circumstances that you may not normally associate with a questionable claim or even look for. However in dealing with questionable PIP claims, there appears to be a correlation between these characteristics and a questionable PIP claim. It’s the combination of these characteristics and indicators that will help you decide if a PIP claim is questionable.

30 PIP Fraud Characteristics
Characteristics of a Questionable PIP Claim The threshold is exceeded Usually in a metropolitan area Early involvement of an attorney Appearance of “supporting “ indicators Obviously the threshold is exceeded. However, that may be legitimate. Unfortunately, bad things do happen to good people. So that alone is not enough. However, that is when you start paying attention. Most of the time questionable PIP claims are from a large city area. Why? Because this is where the prevalence of attorney’s is at. They advertise on TV all the time about fighting the big, bad insurance company and getting the money due them. They solicit PIP claimants and if the threshold isn’t met, somehow it gets met. Over the course of time, with enough attorneys, advertising and thresholds that almost encourage fraudulent activity, it becomes a way of life and part of the culture. For example the April 2001 IRC study reported that 39% of all PIP Claimants who hired counsel did so before reporting the injury to the insurer. Do you call your attorney first after you have an accident. In NYC the percentage is 49% That makes early attorney involvement a strong characteristic. 4. They are claiming a relatively low dollar cost. Why is that? In my opinion they are trying to stay in the “nuisance” claim range where it is “cheaper” for the carrier to pay the claim than it is to fight it in court. This low amount may also keep them off the “radar screen” of management & SIU. 5. Last, but not least you have the “supporting” indicators.

31 PIP Fraud Supporting Indicators
What are they? Remember that PIP claim fraud is most often based in fraudulently exceeding the threshold so a lawsuit can be filed. Supporting indicators are those indicators that support the theory that some type of fraudulent activity was used to exceed the threshold limits. Let’s go over some of them. What is the difference between a “characteristic” of a questionable PIP claim and an “indicator” of a questionable PIP claim? Good question. Indicators are inconsistencies that you see in questionable claims all the time. Pretty standard. Characteristics are additional circumstances that you may not normally associate with a questionable claim or even look for. However in dealing with questionable PIP claims, there appears to be a correlation between these characteristics and a questionable PIP claim. It’s the combination of these characteristics and indicators that will help you decide if a PIP claim is questionable.

32 PIP Supporting Indicators
Injuries are subjective (e.g. pain, headaches, nausea, inability to sleep, depression, dizziness and soft tissue). Injuries are inconsistent with the collision (e.g. extensive injuries with very low speed impact) Extensive or unnecessary treatment for minor subjective injuries. A test or series of diagnostic imaging tests is given to all patients at a clinic or medical office regardless of injury. These are indicators that support the theory of fraudulently exceeding the threshold. Injuries are subjective (e.g. pain, headaches, nausea, inability to sleep, depression, dizziness and soft tissue) – used to inflate bills and treatment because they can’t be objectively disproved. Very standard fraud indicator. Injuries are inconsistent with the collision (e.g. extensive injuries with very low speed impact) - claimed injury not biomechanically possible (T-boned with a whiplash injury) or very low speed accident causing very long lasting soft tissue injury. Extensive or unnecessary treatment for minor subjective injuries - lasting weeks or months for injuries normally healed in a much shorter time. A test or series of diagnostic imaging test is given to all patients at a clinic or medical office regardless of injury - for a simple, straight forward sprain/strain.

33 PIP Supporting Indicators
Individuals travel across town to receive medical treatment. Individual initially wants to settle with insurer, but after retaining an attorney, complains of increased subjective injuries On-the-scene treatment is refused. Participants seek treatment from a hospital far away from their home or place of employment. Individuals travel across town to receive medical treatment - Significant delay before start of treatment – If the injury were that serious, wouldn’t the claimant seek treatment right away. Individual initially wants to settle with insurer, but after retaining an attorney, complains of increased subjective injuries – This is where the claimant goes to the lawyer and finds out they are hurt (joke). On-the-scene treatment is refused – You would think a accident resulting in an injury requiring prolonged treatment would have had an ambulance respond to the scene. Participants seek treatment from a hospital far away from their home or place of employment– If the injury is that bad and medical personnel didn’t come to them, why didn’t they go to medical personnel. These are all indicators that support the theory that fraudulent activity (fake or exaggerated medical conditions) is being used to exceed the threshold, with fraudulent medical bills, so a lawsuit can be filed. However in PIP claims you shouldn’t look at these alone.

34 Characteristics with Indictors
They should be looked at in combination with the “characteristics”. So What Now? Threshold exceeded. Metropolitan area. Early attorney involvement, $2 - $15 lost. One or more “supporting” indicators. It is when the supporting indicators are combined with the characteristics of a questionable PIP claim that you really need to be concerned. Obviously the first characteristic of the Threshold being exceeded is there or you wouldn’t be looking for the supporting indicators. Was it in a metropolitan area? Was the attorney in the game almost immediately? Is it a relatively small dollar amount? DO YOUR INDICATORS SUPPORT THE THEORY THE THRESHOLD WAS EXCEEDED BY FRAUDUENT MEANS? If these combinations exists, you have a right to be concerned. So now what?

35 WHAT DO INVESTIGTORS DO NOW?
PIP Claim Fraud Investigators have the combination of characteristics and supporting indicators. WHAT DO INVESTIGTORS DO NOW? They take the action step of determining what kind of fraud it may be by looking for other indicators Instructor: Ask students for answer to question. Click for answer to appear. With the combination of characteristics and supporting indicators you are fairly certain you have some questionable activity going on….but what is it? Start looking for other indicators. If they are present, they’ll help identify the scheme being used. For example:

36 PIP Claim Fraud Other Indicators: Three or more passengers
Same injuries Same doctor Same attorney Here are some indicators you may not have noticed before or that you want to look for: A stuffed car. Most vehicles only have a single person in them. All hurt people have the same complaints unless they are all from the same family, it is odd they all have the same doctor Unless the attorney has group rates, it is unusual a car full of unrelated people would all have the same lawyer. What type of scheme would this point to? A staged accident ring. What you do in this case is covered in the Staged Accident FraudSmart course.

37 PIP Claim Fraud – Indicators
Numerous prior questionable claims from the same attorney. Attorney refuses to allow insured/claimant to appear for statements or IME. Attorney reports claim to insurance company. Physician is known for handling suspect claims (sometimes with same attorney. Here are some indicators you may not have noticed before or that you want to look for: Who is the attorney or firm? Are they “known’ in the office? Everything is done through the attorney? Basically, the attorney doesn’t want to give the “victim” the opportunity to mess up the scheme or story. When you had your last car accident, who did you call first? Your insurance agent or your lawyer? Not a normal practice for the lawyer to be the first contact with the carrier. Are the medical providers “known”? Do they do a lot of work with the “known” attorney. What type of scheme would this point to? This also could point to a staged accident ring or it could point to a medical mill where a capper or runner is showing up at the scene of actual accidents and recruiting victims for the medical provider and attorney. Then they start sending the victim back and forth to each other. The victim may be unwitting through the whole thing or they may be talked in to “going to the dark side” to make some money. What you do in this type of fraud is covered in the FraudSmart course - Medical/Legal Aspects of Fraud and/or the CPT code course.

38 PIP Claim Fraud - Indicators
Individual cannot identify other vehicle in “hit and run” injury loss. Vehicle or vehicles are not available for inspection (photos may be submitted in lieu of inspection). Individual is self-employed but vague about the business and actual responsibilities. Claimant started employment shortly before accident occurred. During statements, individuals appear to have “selective memories” on some facts, and cannot remember simple issues that would be common to remember. A phantom car. Nobody to refute his story. Doesn’t want his car looked at because he knows the damage won’t substantiate his story or claimed injuries. When the work is “all in the family” it is easy to falsify lost wage documents. Another way to get lost wages without having done any work is to just get hired right before the accident and claims lost future wages. Normal, honest claimants are very cooperative and give you everything you want to know so they get as much money as possible as fast as possible and why wouldn’t you be able to prove conclusively who you are? Pretty rare for a “normal” claimant to know more about the claims process than you do. What type of scheme would this point to? Professional claimants, perhaps a nomadic group of Gypsies or Travelers. What you do in this type of fraud is covered in portions of the FraudSmart course – Medical/Legal aspects and Staged Accidents. INSTRUCTOR: mention the interactive indicator guide that can be used for initial claim review through final disposition of the claim. This guide and all other indicators are available on the NICB Download Center site at Is unusually familiar with insurance terms or procedures.

39 PIP Fraud Questionable Claims
Here’s a $64,000 dollar question. What do you do if you suspect fraud in a PIP claim but the threshold isn’t met?

40 PIP Fraud Questionable Claims
Possible indicators: Claimant’s recovery unduly long. Claimant’s injuries inconsistent with IME. Police report inconsistent with injuries. No emergency treatment. Injuries are soft tissue (sprain and strain). Two types of indicators missing: No indicators of previous similar claims So you have these standard indicators all over the place but the threshold isn’t met and there’s no lawsuit pending. What’s going on? Well, there’s two types of indicators missing. What are they? The first is no indicators of previous similar claims. This person probably hasn’t done this before. The second is no indicators of any kind of questionable activity by a medical provider or an attorney. What do you have here? You may have your garden variety opportunist. A person that was in an actual fender bender and is milking it. Taking advantage of the situation to make some extra money or to get extra time off of work or maybe both. What do you do here? Good luck. He’s telling the doctor he is hurt and in pain, the doctor has no reason to disagree. So unless you are able to get some surveillance going and catch him in the act, this is a tough nut to crack. Of course, if you question him hard, he may confess. No indicators of any kind of questionable activity by A medical provider or an attorney

41 PIP Fraud Questionable Claims
Okay the Claim Adjustor established a combination of “characteristics” and “supporting” indicators that makes the claim questionable and they identified the probable scheme. So where are we??? Typically the claims person does a “preliminary investigation” to resolve the inconsistencies of the indicators they have uncovered. Remember, while the indicators may make the PIP claim questionable, they don’t prove fraud. As we mentioned earlier, once the PIP claim is determined to be questionable, the means and methods to resolve a questionable PIP claim are the same ones you use to resolve a “normal” questionable B.I. Claim. The premise for all of this is good, sound claims handling practices. Some of the methods and techniques to resolve the indicators for each of the schemes we’ve mentioned are in the other FraudSmart courses we can go through. In any event, you follow your company’s procedure concerning questionable claims and referral to the SIU. Also make sure the questionable claim gets submitted to the NICB.

42 PIP Fraud Questionable Claims
Claim is transferred to: Special Investigation Unit SIU

43 PIP Questionable Claims
Medical Bill Soap Notes Police Report Letters of Medical Necessity Compare to Claimant Statement DME Documents Therapy Worksheets Prescriptions Imaging Bills/Reports Vehicle Photos ER Reports Paramedic Reports Claimant Interviews

44 PIP Fraud Questionable Claims
Special Investigation Unit SIU Action Steps More Informational Gathering Techniques Police reports (if available). Recorded interviews of involved party(s). Lots of photos of the vehicle involved. Action steps to confront these indicators would include: Police Reports (if available) Obtain police reports, if available, speak with the officer who wrote the report. Police reports can be helpful because the information is that of a disinterested party, an authority figure and documented. May contain other information that could be helpful, such as witnesses and other details not given by the claimant to the insurance company. Recorded interviews of involved party (s) Conduct recorded interviews with all involved parties, compare the information. Once the initial information has been documented, it is wise to connect with the claimant for an in-depth recorded interview about the events of the accident. This offers you an opportunity to obtain the details of the event from the claimant themselves and allows you to delve further into their explanation by asking open questions and clarifying information that is not immediately clear. Lots of photos of the vehicle involved. Take pictures from all eight angles. It has been said that a picture is worth a thousand words. This certainly is true when it comes to Auto Physical Damage. Take lots of pictures, from all of the obligatory angles as well as close ups of the damage, if needed. Take the pictures as soon after the accident as possible to eliminate the possibility of furthe

45 PIP Fraud Questionable Claims
Action Steps Cont. More Informational Gathering Techniques Background check for previous claim history. Background check on medical and attorney providers. Independent Medical Exams (IME”S). Surveillance. Action steps to confront these indicators would include: Background check for previous claim history. Run the information through ISO and the NICB QC database It is wise to conduct a background claims history on any claim that you may have of a suspicious nature. It is simply another source of information that will assist you in the end, in making an informed claims decision. The more information you have, the better the outcome for you and your company. Background check on medical and attorney providers. Again, run the medical providers and legal providers through NICB and ISO QC database. Like it or not, many times medical and legal providers can raise a few eyebrows regarding the nature of the claim. When these types of providers are involved, early on, it is wise to conduct a background check to see who you are dealing with. It will assist you in making the correct decisions regarding the nature of the claim and support (or not) any suspicions you may have regarding the compensability of the claim. Independent Medical Exams Utilizing your own doctor can at the very least give you a second opinion regarding the status of the claimant physically – the most important thing to remember is being certain that your doctor has the same, if not better, credentials than the treating physician. Documentation of events. For a number of reasons, it is extremely important to document all of the facts and information in your claim diary. Another saying is: The job is not completed until the paperwork is done. This holds very true especially for claims investigations. In order for you to make an informed decision, it is not enough just to get the facts, you must document them as well. At some point many days or months in the future, you may be asked for information regarding the claim. If you have not documented the facts accurately and simplistically, neither you or anyone of your colleagues will be able to make heads or tails from what you have (or have not) written in your diary. In the future, this could be a big problem. You never know who will want that information and, for what reason.

46 PIP Fraud Questionable Claims
Action Steps Cont. More Informational Gathering Techniques Enhanced Interviewing Methods Accident Damage Analysis Medical Record Reviews Legal Support Additionally, SIU may get involved with some of the more enhanced investigative techniques that require more time than the claims staff can handle. Again, this is up to the claims manager and the protocols of your company. Accident Re-Constructionists and Bio Mechanical Experts can advise a claims representative the probability of an injury occurring or not based on the physics of the collision. Hiring a vendor to conduct surveillance can answer some questions regarding the actual physical abilities of the insured, as well. INSTRUCTOR: Before you start the test on slide 30: IF THERE ARE ANY TOPICS REMAINING (PER THE INTERACTIVE EXERCISE IN THE COURSE OBJECTIVE) THAT HAVE NOT BEEN DISCUSSED COVER THEM AT THIS TIME. Expert Support

47 PIP Fraud Questionable Claims
NICB Questionable Claims Data Base Single, most important tool in identifying fraudulent claims Allows cross referencing on single claims Builds intelligence, to identify patterns and trends Used to initiate major cases Used to increase public awareness regarding insurance fraud It is a critical element in the process of spotting “repeat claims” that cross insurance lines (e.g. workers’ compensation, health, property-casualty) They help identify trends and patterns of insurance fraud They can act as your submission to the appropriate fraud bureau (FBRP) Alerts other industry claims representatives to your concerns about the questionable nature of the claim thus encouraging them to be thorough in their claim review process Can help initiate investigations or contribute to an ongoing investigation Contributes to the questionable claims pool for subsequent investigative review and analysis for elements of insurance fraud. Increases public awareness regarding insurance fraud and vehicle crimes. Claim representatives are the first step in identifying a claim as “questionable”. Follow your company protocol. Most companies refer questionable claims to their SIU unit which, if the investigation warrants it, identifies the claim as questionable in ISO. Without you the questionable claims will not be identified. So why should you care if they are? What is identified today may help someone in your company tomorrow or next week or next year. Or it may help another company in our common effort of fighting fraud. The reverse is true as well. When other companies identify a claim as questionable, you are provided that information which helps you determine if the claim you are working is meritorious.

48 PIP Claim Fraud Possible Outcomes Claim denied Criminal Prosecution
Local State Federal Civil Lawsuits

49 Reporting Fraud NICB Hot Line 1-800-TEL-NICB
Text Keyword “Fraud” to TIP411 Via Tip app (iPhone, iPad, iPod touch compatible)

50 Reporting Fraud Medicare Medicaid HHS Office of Inspector General
Call TTY: Mail: HHS Tips Hotline P.O. Box 23489 Washington, DC OR Centers for Medicare & Medicaid Services Call: TTY: Mail: Medicare Beneficiary Contact Center P.O. Box 39 Lawrence, KS 66044

51 Blue Cross Blue Shield of Michigan (BCBSM)
Reporting Fraud Blue Cross Blue Shield of Michigan (BCBSM) BCBSM Call: Dedicated Medicare Anti-Fraud Hotline Call:

52 Contact Information Special Agent: Dennis Handley Address: P.O. Box 20127 Ferndale, MI 48220 Phone:


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