Insurance Fraud

The What, How and Why.

Fraud is a deliberately deceitful activity intended to result in financial or personal gain. It’s not just the worker that can commit fraud. The provider or even an employer can be found to have committed fraud.

Three components are typically needed to create the conditions that are conducive to fraud:

1. Financial pressures – these can affect anyone
2. Rationalization – they deserve it, the insurer can afford it, or it is not hurting anyone
3. Opportunity – “faceless” system with infrequent personal interaction, complex system with little accountability

Workers Compensation fraud can present itself in a variety of ways.

1. Worker Unreported Income – earned income, passive income, or concurrent unemployment benefits are just a few ways this could occur
2. Worker Malingering – when the worker exaggerates the injury to prolong benefits and delay return to work
3. Worker False Claims – when the injury was not work related or no injury occurred
4. Worker Forgery – this includes prescription receipts or expense reimbursements
5. Employer – false claims, failure to report claims, misrepresentation of payroll or class codes
6. Provider – billing for services not rendered, double billing, upcoding, unbundling, and false claims

What to Look For.

The desire to accomplish great things is commendable. But if you don’t have the right tools and know how to use them, it gets pretty difficult to get things done. PPI wants to help our clients and other investigative professionals improve their abilities to investigate insurance fraud.

Our Guide to Investigations is a powerful and effective Claims Management tool. This desktop resource provides a comprehensive manual that is written for both the Claims Manager and the Field Investigator. In it you will find investigative outlines on a myriad of workers compensation and liability claims. The Guide covers claims, motor vehicle accidents, and third-party investigations in detail.

Speaking engagements and more formal training seminars are another option for our clients. Using our vast and varied experience of insurance investigations, we can help instruct and train your staff to successfully obtain the information needed to make informed decisions.

Results at Your Fingertips.

Welcome to a new and effective way to reduce the paid costs on claims, eliminate high reserves and increase leverage for settlements. The current trend to subjectively review each claim for Fraud leads to inconsistent results. Responsible insurance professionals understand the important need to objectively review each claim based on consistent parameters. By consistently asking the right questions and reviewing the facts about each claim, you will streamline the process and better manage your caseloads and recover dollars lost to Fraud. This Guide to Investigations is an effective desktop tool to assist you in your efforts.

The Guide to Investigations is the most powerful and effective Claims Management tool on the market today. This desktop resource provides a comprehensive manual that is written for both the Claims Manager and the Field Investigator. In it you will find investigative outlines on a myriad of workers compensation and liability claims. The Guide covers claims, motor vehicle accidents, and third-party investigations in detail.

PPI Security is proud to offer this unique and innovative resource, used by insurance, investigative and claims management professionals nationwide. We believe it will help you better understand the variety of claims you have to deal with and how to run a thorough claims management process or investigation. Most importantly, it will make you more effective at your job whether that job is Claims Management or Field Investigations.

The Guide To Investigations – a new and effective way of doing business.

Knowledge is Power.

PPI is excited to partner with our clients to increase the success of obtaining quality information needed to make informed decisions. By offering speaking engagements, training, and other special programs, our experienced investigators will bring new insights and consistency to your staff’s work.

Some of the topics our seminars can address:

1. Convincing video evidence can refute or verify disabling conditions
2. Obtaining clear answers to your claim questions
3. Importance of detailed interviews that go away beyond canned questionnaires
4. Background investigation basics including pharmacy, medical records, court records, business records, assets, neighborhood canvasses, and social media searches.

By using our vast and varied experience of insurance investigations, we are dedicated to help instruct and train our clients to successfully obtain the information needed to make informed decisions.

Truth Well Told.

Details coming soon.

Experience + Technology = Success.

As claims adjusters are asked to process an ever increasing workload, it seems that claimants are becoming more proficient at malingering and a few at committing outright fraud. Meanwhile, many seasoned and experienced claims adjusters are nearing retirement, younger and freshly trained individuals are there in an attempt to fill their shoes. Unfortunately, as the acquired knowledge and years of experience leave, so does the seemingly innate ability to sense that something isn’t right with certain claims.

When we study the knowledge and years of experience claims adjusters have in reviewing cases and flagging potential fraudulent activity, it is apparent that certain clues filter up to the top. By taking these clues and applying artificial intelligence, with massive amount of data, we can create a system that combines the best of the experienced adjuster and is now available to all adjusters.

When technology is applied to a specific problem, with input from experienced people, great things can happen.

We Make Sure They Get What They Deserve.

Compensability is the initial step in the processing of any Worker’s Compensation claim. It is the step that will lay the foundation for a claim’s legitimacy – or its denial. For our purposes, compensability is the gathering of information about the claimant, the circumstances, and the nature of the claim. A compensability statement that is properly and completely done should, in the event of a fraudulent claim, provide all the necessary information needed to deny and perhaps even prosecute the offender.

Field Investigators conduct the bulk of claims investigations. The investigation process typically will include employer interviews, taking of statements from witnesses, injured worker, and other parties. We seek to establish any information or fact which may be relevant to the claim including the history and background of the injured worker. Outside factors which may have an influence on the claim, or other credibility issues might also be explored.

An objective report, based on fact, and supported by documented evidence, provides you with pertinent information necessary to consider when making the determination on the claim. Supportive documentation gathered for you may include payroll, and attendance records, employment application, and other personnel records, as well as any company policies and procedures. Credibility issues may be supported by other external witness statements, such as past employers, friends, relatives or by other external witness statements, such as past employers, friends, relatives, or by other documents that might include items such as police or court records.

Field investigations are appropriate when there is visual need for in-person, on-site investigations to gather the information necessary for claim decision, or when in person interviews are indicated. Most attorney represented worker interviews are conducted by the field investigators. Field investigators frequently conduct activities checks and may locate worker or witnesses.

Consider an investigation when questions of compensability or responsibility arise, you find conflicting information in reports, there is questionable medical causation, or there may be third party potential.

Separating Fact From Fiction.

An Activity Check investigation should determine whether an individual’s level of activity is or is not consistent with their claimed condition and restrictions. The goal is to know more about the worker when you finish than you did when you started.

An investigation request may be initiated for any of several reasons, for example:

• Recovery time is longer than normally associated with type / severity of injury
• Leads / rumors indicate worker is active while on time loss
• Reports (medical / vocational / other) give indications of activity
• Lack of cooperation from worker (i.e. not attending medical appointments, not attending vocational training, not cooperating with ERTW efforts)
• Compensability decision depends on confirming rumored or alleged activity
• There are indications of home-based self-employment
• Confirmation of activity level for purposes of establishing accurate disability ratings

Good results depend on good case preparation. Know the history of the case and the issues to be resolved. Most importantly, know your subject before you go out. You need to know the type of injury, body part involved, current medical condition or diagnosis, physical limitation(s) or restriction (s) (use of cane / crutches, etc.), and have a good physical description of the worker.

Case preparation going out in the field should include:

• Contact adjuster if necessary
• Review medical reports if available, PCEs, IMEs, vocational reports
• Current work status; days / hours / limitations if on modified duty
• Treatment status; who / where / when / how often
• Contact employer or coworkers for physical description if unknown; also, for leads as to worker’s interests, and hobbies

Seeing is Believing.

Experience has shown us that some injured workers will prolong their return to work by malingering or their disabilities. Surveillance investigations should be initiated when you have good reason to believe the worker is misrepresenting their disability, and when visual evidence can be utilized in closing or managing the claim. In those instances, conducting covert surveillance and gathering video evidence of the injured workers disability and activity level is necessary to manage the claim effectively and avoid paying undeserved benefits.

Surveillance video may also be beneficial or necessary in some cases for establishing evidence that supports a fraud investigation and resulting in criminal prosecution. The goal in the fraud investigation is to determine whether fraudulent activity has occurred and to identify the course of action that should be pursued. That may lead to a recovery method that would include collection of monies owed, or civil / criminal prosecution.

There are three main categories of fraud investigations: worker, employer, and provider. You may recognize the indicators when dealing with the injured worker, but there are other red flags that may alert you to the need for further investigation or other types of possible fraud.

Effective surveillance reduces the paid costs on claims!

We’ll Take It From Here.

Coming Soon.