Personal injury law firm’s PSA alerts to crash soliciting

Rarely do you associate trial attorneys with anti-fraud efforts, but a law firm in Florida is doing just that with a new public service video warning consumers about door-to-door scammers looking to sign up auto accident victims.

“If you’ve been in an accident and a stranger knocks on your door to get you to sign up for a doctor or lawyer, they’re breaking the law. Some of these criminals even have the nerve to walk into your hospital room. They may even text you to get your case. They probably illegally obtained your police report…These people are not only annoying, they’re trying to steal from you. Don’t sign anything. Instead call the insurance fraud hotline. You could be entitled to a reward.”

The video then flashes the fraud hotline number of the Florida Division of Insurance Fraud.

Soliciting accident victims within 60 days of a crash is a crime in the state, thanks to a law enacted a few years ago that was pushed by fraud fighters in Florida and the Coalition.

Illegal soliciting still occurs, although much less frequently.

So what’s the motivation behind the Rubenstein Law firm in sponsoring this PSA? Are they trying to cut the crooked lawyers out of the action to gain more clients for themselves? Or perhaps they truly do care that solicitation scams hurt consumers.

Whatever their motivation, we commend the law firm for supporting anti-fraud efforts in the Sunshine State.

Humble and brazen health claims

$100,000 for ear wax removal? $46,000 to remove a bunion? Those are some of the outrageous charges cited this week by a judge who awarded Aetna $51.4 million from a Houston surgical hospital.

In a two-year period, Humble Surgical Hospital in Houston, Tex. billed the insurer more than $68 million. Humble billings these are not.

The five-bed surgical center, created by 10 doctors in 2010, charged patients in-network rates but billed the insurer at out-of-network rates. Some bills were as high as ten times what other hospitals charge.

Why did the insurer paid $41 million before challenging Humble’s bills? Aetna isn’t known for throwing money at medical providers, and it sponsors a good SIU team. (Full disclosure: Aetna provides health insurance for Coalition staff.)

Perhaps part of the problem is prompt-pay laws in many states that encourage insurers to “pay and chase” suspect claims. Some states grant delays in paying claims when fraud is suspected. Others do not.

The Humble claims spanned 2010 to 2012. Since then, new technologies such as predictive modeling have been developed to help insurers detect claim anomalies quicker and better. Another new development is the sharing of suspect claims information through the Healthcare Fraud Prevention Partnership.

As someone who pays a hefty monthly premium for health insurance, I hope Aetna and other health insurers use all the anti-fraud tools at their disposal to keep such brazen claims practices in check.

About the author: Dennis Jay is executive director of the Coalition Against Insurance Fraud.

Examining examinations under oath

A valued and effective anti-fraud tool that benefits consumers would be hobbled under a misguided bill in Washington State. It’s called the examination under oath, or EUO.

Insurers interview claimants, who are legally bound to answer questions truthfully. Thoughtful questioning by trained investigators can expose lies and mistruths by claimants trying to hide suspected scams. Telltale clues often can be uncovered only by EUOs. This is why they’re crucial to exposing often well-hidden crimes.

Many fraudsters don’t even bother showing up for an EUO, which helps insurers halt suspected claim payments and close out bad claims.

Under the Washington bill, the statute of limitations for using EUOs would begin when a suspected scam happens, instead of when an insurer discovers it. This strict time limit imposes arbitrary legal handcuffs, regardless of the actual crime-fighting need.

The bill’s stated goal is to protect consumers from supposed insurer fishing expeditions — though where’s the proof of fishing trips? We’ve seen no evidence.

“This would set up a system where insurers would be forced to pay suspect claims before they could adequately decide whether the claim is legitimate,” the Coalition wrote the chair of a subcommittee that’s vetting the measure.

Insurers use EUOs judiciously, only when clear red flags of possible fraud are uncovered first. Companies have neither the time nor budgets to conduct large volumes of EUOs on all claims.

The Washington bill thus would backfire. Insurers would be forced to pay suspicious claims because they wouldn’t have time to fully investigate for warning signals. More bogus claims means more crime and higher premiums for honest insurance consumers in Washington.

If an insurer is abusing the privilege of compelling claimants to appear at EUOs to answer questions, regulators and existing law have existing remedies to punish them. Curtailing this important tool across the board is not in the best interest of public policy.

The Coalition will publish a white paper on EUOs later this year. We will shed more light on how EUOs work, and why we need them to work effectively as anti-fraud tools.

About the author: Howard Goldblatt is director of government affairs for the Coalition Against Insurance Fraud.

8 worst scammers of 2016 chosen

A home explodes … hundreds of setup car crashes churn fake whiplash claims … a helpless cerebral palsy patient starves to death.

All to steal insurance money.

The year’s extreme schemers are among the eight worst insurance criminals of 2016. They were elected to the Insurance Fraud Hall of Shame by the Coalition Against Insurance Fraud.

The Shamers reveal the year’s most brazen, bungling or vicious convicted insurance swindlers.

Insurance fraud is one of America’s largest financial crimes. Scams steal at least $80 billion annually, and many insurers say fraud is growing. Many consumers believe it’s ok to inflate claims, and they’re at risk of committing this crime, research reveals.

Victims are traumatized, maimed, lose their savings and have their credit ruined. Some die.

Exploding home. Two neighbors were incinerated and an Indianapolis subdivision nearly leveled when Bob Leonard helped accidentally blow up a house in a botched $300,000 home arson. “Oh well, they died,” Leonard said of the next-door couple. Sentence: life without parole.

Faulty no-fault con. Michael Danilovich masterminded a $279-million attempted looting of auto insurers with hundreds of staged car crashes in the New York City area. It was the largest no-fault auto scam in U.S. history. Crooked medical providers deluged insurers with fake whiplash claims. Sentence: 25 years.

Deer deception. Mob associate Ron Galati used deer parts and blood to gore up cars and claim the vehicles crashed into deer. Galati’s Philadelphia body shop made $5 million of inflated damage claims from phantom deer and other collisions. He even took a sledgehammer to cars, and plotted to have a witness shot. Sentence: up to 29 years.

Lawless libido. John Alfonzo Smiley was shot and paralyzed while arguing with a couple after he and his wife swapped sex with them at a San Francisco swingers club. Smiley claimed $4 million of workers comp money. The corrections officer contended — with a straight face — that a former inmate with a grudge shot him. Sentence: eight months.

Samaritan scam. Shannon Egeland had his son shotgun him in the legs to scam his disability policy. Egeland’s legs were shattered and a foot amputated. He claimed he was ambushed after stopping to help a stranded pregnant motorist near Caldwell, Idaho late one night. Sentence: awaiting jail term.

Killer caregiver. Makayla Norman was a cheerful 14-year old — and bedridden with cerebral palsy. The Dayton teen’s home caregiver Mollie Parsons starved her to death while making large Medicaid claims for supposedly steady care. Makayla weighed 28 pounds. Sentence: 10 years.

Baby murdered. Moussa Sissoko shook his infant son Shane to death for $750,000 of life insurance he took out on the baby. The Washington, D.C.-area man seemed like a caring father, yet plotted Shane’s death from the start. Sentence: 50 years.

Mental error. Dr. Fernando Mendez-Villamil made $60 million in false Medicare and Medicaid claims for mental-illness drugs. The Miami physician plied patients with powerful drugs whether or not they needed the meds. Insurance fraud bought him a mansion and art collection. Sentence: 12 years.

Fortunately, a small army of fraud fighters is committed to turning the corner on this crime. Most insurers have agile investigators, and so do most states. Technology even can predict some scams. And most Americans are honest.

Progress is being made. Yet the insurance money’s too good and attracts too many scammers for easy answers. As the Shamers show us, sometimes a cold jail cell is the best deterrent.

About the author: Jim Quiggle is director of communications for the Coalition Against Insurance Fraud.

Will election changes boost anti-fraud efforts?

The late David Bowie sang about “ch-ch-ch-ch-changes” in his memorable rock song. This theme could define anti-fraud legislation in 2017.

A new year always brings aspirations for success. Same with fraud fighters seeking new state laws clamping down on insurance swindlers.

Several statehouses are opening this week, and anti-fraud bills already are being docketed for debate. All amid many ch-ch-ch-ch-changes in leadership this big election year.

New state legislatures, governors and insurance commissioners have taken office. A new U.S. president and Congress could change the face of anti-fraud efforts. We’re watching closely for signals on how they’ll fund scam-busting programs for Obamacare, Medicare and Medicaid.

The anti-fraud community needs to help policymakers see that their constituents benefit greatly from robust, well-funded anti-fraud efforts.

So here’s our bucket list for 2017:

  • Michigan finally creates a state insurance-fraud authority to go after widespread auto fraud rings in the state;
  • New York’s legislature sets aside turf wars to clamp down on staged-crash rings and shady contractors; and
  • Congress and the Administration properly fund the Healthcare Fraud Prevention Partnership. It has saved hundreds of millions of dollars by uncovering scams against private health insurers and taxpayer-funded health programs such as Medicare. And that’s just the beginning.

Other states will take up the call for stronger anti-fraud laws as well. The Coalition will work with our partners to get those laws onto the books.

We’re on board — will you be?

About the author: Howard Goldblatt is director of government affairs for the Coalition Against Insurance Fraud.

Study: Fraud spreading, tech helps apply brakes

tech_reportTechnology is a valued ally of insurers in combatting insurance fraud. And for good reason — this crime is growing.

These are two findings of the Coalition’s newest study of how insurers use tech to combat billions of dollars in fraud each year.

The study is one of the surest barometers of progress in how insurers wield technology against fraudsters. It’s also a window into scams that most concern property-casualty insurers, and how they’re responding.

Fraud is climbing, more than 60 percent of insurers say in the study. Cyber-fraud is a newer problem area that insurers are using tech tools to combat.

Technology is especially adept at helping uproot auto-insurance scams — long among the biggest losses inflicted on insurers. High auto premiums are an emotionally charged issue for many consumers. Analytics help keep auto premiums more in line by controlling bogus crash claims. This does a service to drivers who pay their premiums honestly.

Organized rings, crooked medical providers and drivers who falsely register vehicles in other locales to lower their auto premiums are priority schemes analytics play an important role in counting, the study shows.

Fraud-busting tech plays an ever-growing role for insurers. Tech seems to have turned the corner internally. Anti-fraud departments have done a good job of selling upper management on the business benefits of tech in helping stem large losses. Fraud fighters see less need to keep justifying tech, and fully one-third of insurers expect larger IT budgets in 2017.

Predictive analytics — which can forecast the likelihood of certain fraud crimes — continues rising as a star player. Powerful software also helps insurers automate detection of false claims, thus making fraud-busting faster and more-efficient than ever.

For all the gee-wiz headlines that cool tech breeds as a kind of new-era fraud-busting messiah, we should remember that tech tools are mostly buckets of code and data until humans make sense of the findings.

More to the point … fraud fighters also bring an unmatched 360-degree ability to size up fraud investigations from every angle — digital and street-level — to reach correct conclusions about claims. Nor am I aware of software programs grunting through a home’s blackened rubble for a possible insurance arson.

Analytics also are more than just hi-IQ data crunchers. Anti-fraud tech helps insurers serve the ultimate master: policyholders. Claims can get resolved faster and more accurately. Premiums are better controlled. Honest policyholders have a better experience, and fraudsters have a worse one. That’s what insurance should be all about.

About the author: Jim Quiggle is director of communications for the Coalition Against Insurance Fraud.

Angry consumers more likely to bilk insurers

angry_manFear and anger are two emotions that drive human behavior. But only one of them — anger — is more likely to cause people to cheat.

That’s the finding of a recent study that tested how people’s emotions can influence ethical behavior. When situations put people in fear, they are more likely to be honest, the study concluded. This seems obvious. The threat of jail or embarrassment keeps people from committing insurance fraud.

But the new revelation here is that anger tends to have the opposite effect. It emboldens consumers to defraud, especially against businesses, the researchers say. This is in line with a Coalition study from 2007. It found that consumers who had a positive claim experience in the past three years were much-less-tolerant of fraud than those who didn’t.

Insurers should take note and adopt more customer-service policies that are less likely to tick people off.

Everyone seems to have an insurance horror story, and many originated from the lack of understanding about insurance. The insurance industry just doesn’t do a good job of explaining coverage and the nuances of underwriting.

I was reminded of that this week when a boater friend relayed his horror story about relocating his vessel eight miles from southern Georgia to northern Florida. His annual premium went from $1,500 to more than $4,000. He was livid, especially since the insurer didn’t bother explaining the 100-percent-plus premium hike.

Whether it’s underwriting, claims handling, marketing or any contact insurers have with consumers, insurers could profit by making their customers a little less angry and a lot more informed.

About the author: Dennis Jay is executive director of the Coalition Against Insurance Fraud.

Defending against identity thieves

medical_ID_theft_11-16Is your organization equipped to fight identity fraud? Insurance fraud costs the property-casualty insurance industry an estimated $32 billion per year.

It is unknown how much stems from identity-related crimes. But due to the shift of in-person agent interactions to a direct sales model, the risk of identity fraud has increased significantly.

Consider the nearly 75 percent of auto-insurance shoppers who obtained an auto quote online in 2015. Advances in technology have provided streamlined sales and claims, but also have opened customers to more identity-fraud risks.

One way this crime is perpetrated is when identities are stolen by organized crime rings to file fraudulent no-fault injury claims from staged crashes. A similar scheme is when stolen personal information is used to impersonate an insurance agent or policy applicant. This false or stolen identity information is then used on applications for auto or life insurance so the perpetrator can collect a commission on new policies.

These crimes should be a warning sign to insurers: Firm up your defenses against identity threats. You will protect your bottom line and ensure honest policyholders the safest insurance experience possible.

Use technology innovations to combat fraud: Mobile-device technology and capabilities, data and advanced analytics and linking tools all can quickly verify and confirm valid identities. They also can recognize anomalies through the driver license barcode imagery. And when mobile-device technology is used against fraud, it won’t slow policy application workflow.

Another way insurers can defend against identity fraud is by leveraging external data sets to gain a multi-dimensional view of policy applicants. This reduces dependence on self-reported information that may be false or inaccurate. These sources can include shared non-claims data from other industries that could shed light on investigations. Sources also can include public records data (name, phone number, address, SSN, and other “footprint” data such as bankruptcies, deceased files, watch lists and criminal records).

This week is Fraud Awareness Week 2016. LexisNexis Risk Solutions and the LexisNexis® Fraud Defense Network are partnering with the Coalition and several other leading fraud-fighting organizations to discuss the problems and solutions surrounding identity fraud. In recognition of this incredibly serious threat, this group is leading a global effort to minimize the impact of identity fraud. We encourage insurers to visit our microsite. It provides insights and actionable ideas for insurers to protect themselves and their customers from identity fraud.

We hope you join this important conversation all week. Stay up-to-date by following #StandUpToIDFraud and #FraudWeek.

Bill Brower is Vice President, Product Management, Claims for LexisNexis Risk Solutions. He leads the development of innovative products that help insurers achieve greater efficiency within their claims departments. With 30 years of P&C Insurance industry experience, Brower has held numerous leadership roles with top carriers such as Liberty Mutual and Nationwide Insurance Company. Most recently Brower served as Vice President and Manager of Strategic Partnerships for Liberty Mutual Personal Insurance. He led innovation efforts and managed vendor relationships across all claims disciplines. Brower earned his bachelor’s degree in Organizational Leadership from Franklin University and his MBA from Shorter University.

 

Election fallout ripples through anti-fraud world

election-falloutWhile the shock of the national elections continues to be felt, the Coalition is sizing up the likely impact on fraud-fighting.

The biggest concern is whether the Trump administration will continue the federal government’s aggressive stand in combating healthcare fraud. FBI investigations and Department of Justice prosecutions have helped set records for arrests, convictions and financial recoveries in the last eight years.

Another potential concern is whether repealing the Affordable Care Act will gut anti-fraud programs that were part of the original bill. Medicare has much more capacity and authority to crackdown and prevent healthcare fraud today. Its ability to shut down scams quickly and use the latest technology such as predictive modeling could be in jeopardy.

Republicans also likely will push for interstate sales of health insurance. We’ve repeatedly warned that such an unregulated system will spur scam artists to sell fake policies to unsuspecting consumers.

Another potential casualty could be the Healthcare Fraud Prevention Partnership, an alliance of more than 60 private insurers and public agencies.

The partnership’s data-sharing program has helped save more than $260 million for healthcare payers. It would be foolish not to continue, but the program operates at the whim of the administration and HHS secretary. That’s one reason we advocated writing the program into federal law, but it’s too late for that now.

As for state elections, Wayne Goodwin, the insurance commissioner in North Carolina, lost his election. He’s a strong supporter of anti-fraud measures. Goodwin sponsors an effective fraud bureau, and chairs the NAIC Anti-Fraud Task Force.

The change of governors and insurance commissioners in other states, such as Delaware, also may affect law-enforcement efforts to combat fraud.

We’ll continue analyzing the federal and state results. We’ll report developments as they emerge. In the meantime, the Coalition stands ready to work with the new office holders to advocate strong measures that effectively combat insurance fraud.

About the author: Dennis Jay is executive director of the Coalition Against Insurance Fraud.