How To Write A Reason For Submission

Transcription

1 Questionable Claim Reason for Submission Format Multiple state fraud bureaus require claims be submitted to them when there is a suspicion that fraud has been committed in the claim process. A critical feature of the submission is the description of the claim circumstances provided in the Reason for Submission field. To aid investigators in the efficient completion of this requirement and to enhance its effectiveness, NICB has developed (in conjunction with the International Association of Special Units) a standard format (with four areas of focus) for the Reason for Submission. In addition to streamlining the submission process for investigators, a standard, informative Reason for Submission quickly provides the fraud bureaus with critical information. This will assist them in their investigation and prosecution of insurance crime, thus benefiting the industry as a whole. In addition to the standard format the following suggestions concerning the Reason for Submission content should be considered: Avoid stating the claim was fraudulent unless the fraudulent activity was proven in court or admitted by the insured/claimant. Be as concise as possible while providing the necessary information. Provide specific intelligence (e.g. facts, data, identifiers) and actionable information concerning the claim (e.g. quality vs. quantity). As additional participants become known (e.g. medical providers, attorneys, body shops, etc.) the claim in ISO should be updated with the additional information. Include insurer contact information. Avoid using acronyms. Avoid typing the reason in all CAPS. Should not copy and paste reports of SIU activity as the reason for submission. Should avoid using For Information Only as the reason for the submission. It is recommended this type of compliance submission reference the appropriate regulatory guidance (e.g. In compliance with statute or As required by state law, etc.). Reason for Submission Format/Four Areas of Focus: Providing the nature of the submission, the questionable or fraudulent activity and a brief description of the claim circumstances providing the identifiers of any involved individuals (e.g. providers, witnesses) not identified in the claim documentation. If not in the claim documentation, the synopsis should provide the Who, When, Where, What, Why and How of the claim. The synopsis should also explain any unusual occurrences in the claim (e.g. the claim being submitted in one state but the loss and investigation is occurring in a different state and/or if any repeat or organized group activity is suspected). Providing a brief description of the investigation results detailing what indicators are present and what information was discovered. Providing information that the claim is pending or paid, mitigated, denied, closed without payment, withdrawn insured investigation, being investigated by the insurer, referred to a fraud bureau, etc. and/or being investigated by law enforcement. Providing any amount paid, reserves established and policy limits as appropriate. Include the current contact information of the claims adjuster or the SIU. 10/16/ P a g e

2 TABLE OF CONTENTS Reason for Submission Examples Provided Page Casualty Fraud: Slip and Fall 3 Medical Billing Fraud: Chiropractor 3 Medical Billing Fraud: Physical Therapy 4 Organized Activity: Staged Accident 4 Organized Activity: Caused Accident (Commercial) 5 Property Fraud: Arson for Profit 5 Property Fraud: Mysterious Jewelry Loss 6 Property Fraud: Home Repair 6 Property Fraud: Staged Theft 6 Vehicle Fraud: Owner Give Up 6 Vehicle Fraud: Owner Give Up 7 Vehicle Theft Fraud: Hit While Parked 7 Workers Compensation Fraud: False Documents 7 Vehicle Fraud: In compliance with statute submission 8 Workers Compensation Fraud: In compliance with statute submission 8 About This Document The following Reason for Submission examples contains the four areas of focus: Synopsis, Findings, Status and Exposure. Each focus will have a different font in order to clearly depict a complete Reason for Submission. The bolding, underscoring and italics are used as a means to easily identify the areas and are not meant to be part of actual text. Please see legend below. Normal font Bold Italics Underlined It is understood that insurers differ on permissible language and that different authors will have different writing styles. The following examples are not meant to dictate what words and style to use, they are only meant to demonstrate the standardized format. Language and style remain the choice of the author. Thus a variety of writing styles have been used in the examples. Several examples have been provided to depict a range of schemes and lines of business. 10/16/ P a g e

3 Casualty Fraud: Slip and Fall Suspicion of Slip and Fall fraud. Janine Taylor, of 110 Park Avenue, New York, New York appears to have staged a slip/fall at Original House of Pancakes located in the shopping center at Monroe and Bentley April 24, Taylor had knowledge of insurance terms and process and wanted early settlement. She immediately obtained an attorney, William Bain, and settlement demand letters were sent numerous times. The claimant is apparently in financial hardship as she was late paying her rent and subject to eviction. She has one prior fall at a Chili's Restaurant under similar circumstances. A video was obtained from the restaurant and her accident was closely examined. When Taylor and her attorney were notified of the video, they stopped with any further contact with claims and have not replied to phone calls or letters sent. The claim and investigation are pending waiting on their response. Claimant is demanding a settlement of $50,000 for pain and suffering and wages lost due to time off work. Assigned adjuster: John Smith, or jsmith@insurco.com. Status of claim, status (Italics) Medical Billing Fraud: Chiropractor Suspicion of medical billing fraud. Doctor Smith is suspected of upcoding modalities to procedures (e.g Contrast Bath to Aquatic Therapy) and is using unlicensed personnel (John Jones) to provide therapies. Over the last 12 months the aquatic therapy has been billed for 90% of Dr. Smith s patients in his clinic in Des Plaines, IL at 1111 E. Main Street and his clinic in Palos Hills, IL. A patient, Jane Doe, called the claim adjuster refuting the number of treatments her explanation of benefits reflected and during the discussion stated the aquatic therapy consisted of being in a whirlpool run by a John Jones who is a current college student. The SIU investigation consisted of interviewing multiple patients whose medical bills to us reflected the aquatic therapy procedure. In every instance the interview revealed the therapy was conducted in a whirlpool which does not qualify as the aquatic therapy procedure. Clinic inspections revealed the facilities do not have the necessary equipment (e.g. a pool) to conduct aquatic therapy. An interview was conducted with John Jones who acknowledged he has no prior medical training and was provided on the job training by Dr. Smith. It is suspected that Dr. Smith is upcoding other therapies repeatedly. All inappropriate bills will be denied based on the investigation determining his clinics do not have the proper equipment and an unlicensed person was conducting the procedures. The SIU investigation has been referred to our major case unit and to the fraud bureau.the amount paid on previous suspicious billings is being determined. Current claims totaling $ have been denied. As there is additional suspected fraud existing in multiple bills for multiple patients the overall exposure has not been determined but will probably be in the tens of thousands of dollars. Assigned SIU: John Jones, or jjones@insurco.com. 10/16/ P a g e

4 Medical Billing Fraud: Physical Therapy Suspicion of medical billing fraud. Reynolds Therapy submitted several bills for an auto accident injury on behalf of Bill Thorton, of Green Bay, Wisconsin, that he sustained on April 10, The bills and treatment provided seemed to be exceeding normal treatments per week as well as involving services not rendered. Various modalities and procedures were used, including Acupuncture, Aquatic Therapy, Bio Feedback training and Chiropractor adjustment. Several pieces of DME equipment was also prescribed and billed for. Several diagnostic tests were also being billed for. When Mr. Thorton was contacted and interviewed by the adjuster he stated that he did not receive some of the treatment that the clinic was billing for. He also stated that he only sustained minor cuts and bruises during the accident. However, according to the bills, medical treatment was provided over the course of 12 weeks for other non-identified injuries. The doctor, Medical Rehabilitation Center and another clinic are both associated with NICB questionable claims. The is on-going. Files, bills and databases that belong to Reynolds Therapy are currently being audited for possible additional fraud with other patients. Reynolds Therapy was paid nearly $25,000 on behalf of Mr. Thornton s injuries along with an additional potential loss of $15,000. Assigned adjuster: John Smith, or jsmith@insurco.com Status of claim, status (Italics) Organized Activity: Staged Accident Suspicion of staged accident fraud. Juanita Mendez of Sarasota, Michigan submitted a no fault claim on September 22, 2012 claiming that her sub-compact vehicle was side swiped injuring her and four other passengers. The other vehicle left the scene and could not be identified. It is suspected the participants are part of a staged accident ring. According to the police report, it was a very low speed impact and all injured parties refused immediate treatment at the scene of the accident. However, the medical bills for all five injured parties are extensive and are not consistent with the collision. All injured parties are being treated by the same clinic owned by Doctor Michael Smith who is named in multiple NICB questionable claims. Claimants cannot explain where they were going at the time of the accident and unable to describe medical treatment received. The vehicle has prior claims history. All names, addresses, phone numbers, SS#s, birthdates, etc have been searched through ISO and numerous matches were found. A questionable claim was submitted to the NICB and the Michigan Department of Insurance for additional assistance in investigation. Insurance company has paid out nearly $100,000 thus far in medical bills. Assigned SIU: John Jones, or jjones@insurco.com 10/16/ P a g e

5 Organized Activity: Caused Accident (Commercial) Suspected staged accident and medical mill. Insured taxi cab driver Randy Watson works for Best in Town Taxi Company who is insured under a commercial policy. On January 15, 2012, Watson picked up a customer, Sarah Mahoney, from a hotel parking lot located on the corner of Congress & International Parkway. Watson pulled out of the hotel parking lot and the taxi struck a U-Haul truck as it exited a side street. The crash produced very little damage, resulting in a dent and broken headlight on the U- Haul and minor damage to Watson s taxi on the rear quarter panel. The taxi passenger and the two U-Haul passengers complained of neck and back injuries so the police called an ambulance who treated and released the injured parties. All parties were contacted and interviewed via telephone. The stories are consistent with the three injured parties saying the accident was the taxi s fault. However, the taxi cab driver provided a different story. All injured parties stated they didn t sustain any serious injuries. But a few weeks later, medical bills started coming in. All three injured parties were given the same treatment and went to the same doctors (The Feel Good Fast Chiropractic Clinic). When they were contacted again via telephone, we were told to contact their attorney and each one gladly provided the attorney s name and phone number (same attorney for all, John Smith, esq.). The attorney is submitting BI lawsuits for each party. ISO queries identified numerous claims involving the attorney and the clinic. Numerous variations of the claimants names were also identified and connected to the attorney and clinic. Commercial Policy limits of $1, are possible. Assigned SIU: John Jones, or jjones@insurco.com Status of claim, status (Italics) Property Fraud: Arson for Profit Suspected arson for profit. On Jan 1, 2010, Jane Doe obtained property coverage for her residence at 6565 Mocking Bird Lane, Miami, Florida for the period of Jan 1 st 2010 through Dec 31 th, On Apr 1, 2010, the property insured under the policy sustained a fire loss resulting in damages to the structure and personal contents. A claim was submitted to UpFront Insurance by Jane Doe on Apr 3 rd, On Apr 6 th, 2010, UpFront Insurance received a signed Proof of Loss from Jane Doe, advising that that fire was accidental and that her damages were in excess of $100,000. The fire was intentionally set. Due to all new business losses automatically being referred to SIU, an independent origin and cause investigation was completed by Joe Expert, who authored a report advising that the fire was incendiary. Samples taken from the scene revealed the presence of gasoline on the living room floor. A tape recorded interview was conducted with John Witness, the neighbor to Jane Doe, who advised that he witnessed Jane Doe exit her property shortly before noticing smoke. Fire Department officials responding to the home at the time of the fire, found the house to be secured. Jane Doe was experiencing financial strain at the time of the loss. Jane Doe is denying she intentionally set the fire. The investigation continues. This claim has been referred to the Department of Insurance. The investigation continues. To date, Jane Doe has received $50,000 in indemnity payments. $50,000 has been reserved. Additional payments have been suspended pending the outcome of the continuing investigation. Assigned SIU: John Jones, or jjones@insurco.com 10/16/ P a g e

6 Property Fraud: Mysterious Jewelry Loss Suspicion of fraudulent theft claim. Insured Kim Morris of Los Angeles, California, alleged her home was broken into (no forced entry) and her five carat engagement ring, worth $32,000, from her ex-husband was stolen. Insured is now going through a divorce with the husband and struggling for money. The insured could not provide any info on when she last wore the ring or how it was stolen from her safe. Under the provisions of the policy it was vaulted (in a safe in the insured s basement). It is unlikely that the thieves would have the knowledge of the location of the ring inside the house. The ex-husband agreed to be interviewed and questioned about the mysterious ring theft. He informed us that they both have been struggling for money with the divorce and that she has repeatedly threatened how she was going sell the ring for money and not share it with him even though he purchased the ring. He stated that she refused to give the ring back to him after they split. The ex-husband showed us a picture on his facebook page when his ex-wife was wearing the ring after the claimed date of loss. Claim was denied and investigation closed. Claim is being referred for prosecution. The ring was covered in her policy and listed as scheduled jewelry. However, Ms. Morris was not paid out on her claim due to inconsistencies with the time of events and stories. Assigned SIU: John Jones, or jjones@insurco.com Status of claim, status (Italics) Property Fraud: Home Repair Fraudulent homeowner s claim. The insured submitted false invoices to support a window and roof damage claim. This claim was referred to the state s fraud bureau. Mr. DePalma was prosecuted and sentenced to two years probation and 150 hours of community service. Insurance claim value totaling $3, which was denied due to fraudulent activity proven. Assigned adjuster: John Smith, or jsmith@insurco.com Property Fraud: Staged Theft Fraudulent theft claim. The insured submitted fabricated receipts and appraisals in support of a theft claim. The police were notified and the insured was arrested, convicted, sentenced to one year supervised probation and ordered to pay restitution of 100% of the claim payment. This investigation is closed. Insured Claim value $20, was paid prior to the fraud being discovered, full restitution is expected. Assigned adjuster: John Smith, or jsmith@insurco.com Vehicle Fraud: Owner Give-Up Fraudulent vehicle theft claim. On , Tyrone Homes reported a theft of his 2011 Ford F150 from his residence located at 555 E. Western Avenue, Springfield, IL. Mr. Homes claimed he was at home sleeping and that the vehicle must have been stolen sometime in the middle of the night. Follow-up investigation revealed the vehicle crossed the border into Mexico on and has not returned. Invoices supplied by insured for property that was in vehicle were fraudulent. Insured behind on payments. Insured admitted involvement. The investigation is closed. Insured claim value of $20,000 was not paid. Assigned adjuster: John Smith, or jsmith@insurco.com 10/16/ P a g e

7 Vehicle Fraud: Owner Give Up Fraudulent owner give-up claim. After the theft report, a forensic examination of the ignition was conducted by Jones Locksmith and it was determined that the vehicle had last been driven by use of a key. SIU investigation revealed insured was behind on his payments and that he had recently taken the vehicle to Smith Auto Repair for engine trouble. When confronted with this information the insured confessed to the owner give-up. This investigation has been closed. Chicago PD arrested the insured on June 30, 2012 for committing the fraud. He was found guilty, sentenced to 150 hours of community service, 2 years probation and ordered to pay back the $19,000 on the claim that was paid. Assigned SIU: John Jones, or jjones@insurco.com Status of claim, status (Italics) Vehicle Fraud: Hit While Parked Suspicion of fraudulent auto physical damage claim. Insured Ethan Ulysses, of San Juan, CA, reported damages to his vehicle when it was parked and unattended at the River Oak Shopping Center located at Burlington and LaGrange Ave. Insured is also claiming that the hit and run driver stole his front license plate. An inspection of the vehicle was conducted and it was determined that damages to left rear door, quarter panel and hubcap are straight even striations across the panels and not consistent with being hit by another vehicle. The front license plate being stolen at same time as part of the incident is not consistent with a hit and run claim. Due to the material misrepresentation concerning the cause of loss, the investigation has been closed and the claim denied. The claim is being referred for prosecution. Reserves of $15, had been established. Assigned adjuster: John Smith, or jsmith@insurco.com Workers Compensation Fraud: False Documents Fraudulent Workers Comp claim. The allegedly injured worker submitted fraudulent and altered photocopies of bills in support of her claim. Law Enforcement was notified and this investigation is closed and/or ongoing. Database has been flagged in system under her name, SS#, address, birth date and phone number. Donna was arrested and charged with the criminal act of fraudulently receiving over $13,000 in unemployment benefits and fraudulently receiving nearly $19,000 in workers compensation benefits. In addition, she was charged with submitting a fraudulent workers compensation claim. Assigned SIU: John Jones, or jjones@insurco.com 10/16/ P a g e

8 Vehicle Fraud: In compliance with statute submission In compliance with statute. Suspected Owner Give Up. Ben Price, of Charleston, South Carolina, filed an insurance claim on 03/23/2004, stating that his super duty custom 2002 Ford F-150 was stolen from his residence located at 444 Gator Alley in Charleston, South Carolina. Price filed a police report with Charleston PD. In the police report, Price stated he was not home at the time of the incident and that he was with a friend in their car miles away from the location of the theft. When asked what he and his friend were doing or where they were going, the story was not consistent when asked several times. When the Charleston PD asked about keys for the vehicle, Price replied he always left them over the visor in the truck. Price seemed overly pushy when dealing with the insurance company and was nearly demanding compensation for his stolen truck so he could quickly buy a new one. Police quickly discovered it only miles from his house, completely burned. Investigators spoke with the friend who verified the insured s story. The SIU Investigator did discover the owner was behind on his payments, had refinanced the truck twice and had lied about the debt when asked. In spite of the inconsistencies and false information this claim was paid. Mr. Price had a full coverage insurance policy on his vehicle which would cover him fully should anything happen to the vehicle including theft. Fraud is suspected but could not be proven. $42, was paid on the claim. Assigned SIU: John Jones, or jjones@insurco.com Status of claim, status (Italics) Workers Compensation Fraud: In compliance with statute submission In compliance with statute. Suspected fraudulent workers comp claim. Marla Cooper was an employee at Albert s Diner, located at 123 Mercott Avenue, Glendale, Georgia. Ms. Cooper claims she sustained a slip and fall injury, in the kitchen, while working at the diner on 03/14/13. Numerous medical bills have been submitted for soft tissue injuries to Ms. Cooper s lower back. There were no witnesses to the fall. The manager said he heard a yell and a thud and ran into the kitchen and found Ms. Cooper on the floor. She was holding her back and saying she was in extreme pain. The manager wanted to call an ambulance but Ms. Cooper insisted she be taken to her doctor. The manager drove her there. Treatment has been ongoing for several months without improvement or changes in treatment provided. An IME was inconclusive. ISO ClaimSearch matches show Ms. Cooper has two previous workers comp claims resulting from falls where she was employed. She had just started work at Albert s Diner the week prior to the alleged fall. ISO ClaimSearch also revealed her doctor, Thad Taylor D.C. has been identified in multiple questionable claims submitted to NICB and was Ms. Cooper s medical provider in her previous claims. Workers compensation payments are being made to Ms. Cooper and her medical bills are being paid. While fraud is suspected, our investigation has not been able to prove fraud on the part of Ms. Cooper or her doctor. $57,000 in workers comp and medical payments have been made with the potential for tens of thousands more. Assigned SIU: John Jones, or jjones@insurco.com 10/16/ P a g e