Feds to snoop in private payroll data for disability cheats

New law could threaten privacy and be a headache for businesses

Congress recently passed legislation to shore up the funds dispersed to Social Security disability recipients. Included is a four-page bill allowing the feds to check private payroll data and see if people on the disability rolls are double dipping by collecting while working.

The provision is a sound fraud-detection tool that also would deter ineligible people from stealing benefits.

But concern is emerging about potential unintended consequences. Privacy advocates question whether giving the Social Security Administration the power to datamine private payroll might lead to fishing expeditions and abuse.

Business groups worry that requirements might impose a burden on employers to provide the data. Plus, they’re concerned about lawsuits filed by workers for sharing confidential payroll information.

The devil will be in the details when the SSA drafts regulations to implement the new law. The Coalition will review the regs when published. We’ll encourage regulators to balance the potential anti-fraud benefits against concerns by those that may be affected negatively.

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

Comp systems may miss boat in sticking with ICD-9

Uniform medical codes can help detect fraud across insurance providers

Come October 1, medical providers and health plans across America will be using a new medical coding system — ICD 10. The codes are much more detailed for billing for specific treatments and procedures. The new system will help perfect reimbursement, aid medical research and could improve medical outcomes.

The new codes also should help better detect scams once medical billers, insurer data systems and fraud fighters learn to effectively use thousands of new codes.

Unfortunately, half of state workers comp systems plan to stick with its predecessor — ICD-9. A big reason likely is the large cost of updating to ICD-10. But in the longterm, it may be pound-foolish not to switch over. They won’t be able to share claims data as easily with other systems to help track fraud trends and pinpoint treatment areas vulnerable to fraud.

The Healthcare Fraud Prevention Partnership recently conducted a study using code combinations from Medicare, health plans and property/casualty insurers. The data analysis resulted in significant savings for all. Each could focus on specific treatment areas that previously failed to appear on anyone’s radar. Fraud was detected more easily and false claims were refused.

Workers comp in the 26 states sticking with ICD-9 should reconsider. Sooner or later, they’ll have to make the upgrade. Might as well bite the bullet now and and join the rest of the medical and insurance communities — and reap the benefits.

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

Let’s armor instead of oppose electronic health records

Rising technology can better catch shysters who find gaps in the system

A recent column by syndicated conservative columnist Charles Krauthammer mourns the federal requiring of electronic health records. Doctors are leaving the profession because they can’t keep up with record-keeping requirements, he says.

“Virtually every doctor and doctors’ group I speak to cites the same litany, with particular bitterness about the EHR mandate,” writes Krauthammer .

Besides, the electronic data highway makes it easier to commit fraud by cutting and pasting false info into data fields, the columnist writes.

Reminds me of the same futile complaints when desktop computers started replacing typewriters back in the early 1980s. The strange new technology would ruin the efficient manual record-keeping of office staffers using their trusty IBM Selectrics, the cry went out in many circles.

Doctors also have complained about paperwork ever since large medical groups began buying up small practices and implementing streamlined software and tighter procedures to make their practices more efficient and protect against scamming.

There may be at least some grain of truth to the complaints. But hardly enough to stop the inevitable march of progress. The best doctors will adapt. The best crooks also will find gaps in the electronic networks; that’s what they do well.

High-gear technology such as predictive and predictive analysis increasingly also is arming fraud fighters with tools to better uproot the best-hidden crimes. Investigators are poised for a potential revolution in how they uncover medical and health-insurance schemes. This is especially true of long-abused Medicare, which is connected to the electronic-record highway like Siamese twins.

So instead of taking the Luddite path of decrying the electronic highway, let’s continue armoring the system against insurance shysters. We make progress by, well, making progress work for us.

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

Technology coming of age as anti-fraud weapon

More insurers are using advanced tools, but success still relies on investigator instincts

Insurer use of anti-fraud technology has rapidly moved forward in the last few years. Time and time again, these weapons have proven to be game-changing tools for investigations of all kinds.

This is especially true of large and complex rings such as no-fault medical mills that pile up expensive and false crash-injury claims against auto insurers.

Tech software can quickly churn through imposingly large amounts of evidence and expose the structure and inner workings of often well-insulated fraud cartels. The door thus is opened to major busts, devastating prosecutions, and large-dollar savings that help control premiums for honest policyholders.

The maturation of technology use by insurers was confirmed by a study released this week by the Coalition, with assistance from the business analytics firm SAS.

Nearly all insurers (95 percent) said they use anti-fraud technology, compared to 88 percent when the study was first conducted in 2012.

Suspicious activity has increased, the responding insurers say. So the need for technological wingmen is stronger than ever.

Insurers also appear to be making a strong business case that technology returns a strong ROI. More case referrals, better ones and improved investigator efficiency were among the chief business benefits, large percentages of insurers asserted.

And more insurers are using advanced weaponry such as link analysis, predictive modeling and text mining.

Technology has moved miles ahead of the early days when it could only sift through basic clues for case leads. We’re now in the modern era. Advances in technology finally may be starting to get keep pace with America’s fraud wave, and possibly start getting ahead of the biggest offenders.

Measuring progress with precision is impossible. Nor is technology alone the solution. Insurers need to continue supporting the acquisition of modern tech pistons for their investigative units. Investigators, in turn, are challenged to keep making a strong business case for these tools.

Software developers must deliver viable tools — and make them as affordable as possible. The best weaponry must be within reach of as many insurers of all sizes and diverse investigative needs as possible.

Breaking open fraud crimes of all stripes still comes down to the keen instincts and training of investigators. They must properly interpret and doggedly track down the evidence that tech uncovers.

Human and digital boots on the ground can be an imposing team, one that more fraudsters will come to fear in the years ahead.

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

One way ACA may aid p/c insurers

New entity to validate efficacy of medical procedures may reduce costs

Why do property/casualty insurers sometimes pay for questionable medical procedures that Medicare and health plans routinely deny?

In part, auto, workers comp and liability carriers are subject to state laws that require them to reimburse medical providers for sketchy procedures. And in other cases, insurers don’t have enough evidence that such procedures are more for enriching doctors, clinics, hospitals and labs than for the health of the patient.

But thanks to the Affordable Care Act (ACA), insurers may have more evidence to deny costly and unnecessary treatment in the future.

The ACA helps fund an entity called the Patient-Centered Outcomes Research Institute (PCORI), whose mission is to find out what really works and what doesn’t in healthcare. With access to electronic medical records, PCORI will be able to analyze mountains of data and pinpoint ineffective procedures that do not lead to the best health outcomes.

As a Washington Post editorial Sunday asks, “Should you get surgery for your back pain or stick with physical therapy? When is heart surgery preferable to drug treatment? And which drugs should you take?”

Unneeded treatment, tests and drugs cost the healthcare system billions of dollars each year. PCORI has potential to bend the cost curve and reduce medical costs — for government, health plans and, yes, even property/casualty insurers. Carriers should follow PCORI’s work closely and see how it can potentially reduce loss costs, lower fraud and help keep property/casualty insurance affordable.

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

Software not soft on fraud

BLOG_mailAs crime increasingly becomes the domain of organized gangs, crime fighters of all stripes are deploying ever-more-powerful technology to discover and break down their shady operations.

Credit-card firms, for example, rely on software that’s extraordinarily skilled at mining vast piles of granular data for suspicious buying patterns. I was refueling my car at a gas station in Washington, D.C., where I live. The pump apparently refused my card because the gas station was located about half a mile outside of the cluster of stations I normally frequent.

The same card refused my purchase at an athletic-clothing store in downtown D.C. likely because I normally shop uptown. So it was no surprise that my alert credit-card company recently called me at my office in D.C. to ask whether I’d just purchased baby clothing in Riyadh, Saudi Arabia.

The software was remarkably sensitive at detecting minutely deviant buying patterns. And it caught those anomalies in real time, down to the second. Unreal.

Insurance fraud fighters are seeking the same technological edge. Insurers as a whole have yet to reach the remarkable sophistication of credit-card companies, but they’re working steadily in that direction.

They need to. Organized gangs are infiltrating the insurance fraudscape with growing force. I no longer blink when I read about a $50-million or $75-million Medicare scam. A staged-crash gang in New York allegedly tried to steal $400 million from auto insurers. Many of these same gangs are probably trying to work over credit-card companies, banks and other enterprises.

The encouraging part is that that nearly half of insurers use advanced fraud-catching software such as predictive analysis, text mining and datamining. The discouraging part is that nearly half of insurers don’t use these tools.

That’s one conclusion that can be drawn from a new study of insurer use of technology. It was conducted by the Coalition, with assistance from the business analytics company SAS.

Software of this high-impact ilk is capable of near-miraculous work by today’s standards. Predictive analysis in theory can catch suspicious insurance transactions in real time − instead of waiting until the insurer has paid the claim and the trail is growing cold. Text mining can pore through volumes of relatively mushy data such as an adjuster’s sketchy field notes.

The insurers who use these tools are better armoring themselves against false claims from serious criminal elements who are making a graduate-degree science of scamming. It’s a science that’s raising premiums for honest policyholders. These insurers have made an institutional decision that fraud is a significant enough drain on their and their policyholder resources to require this level of technology.

Not all insurers routinely face a caliber of crime that requires the often-expensive investment in such software. But with several thousand insurers in the U.S., it takes little imagination to conclude that more than a few insurers could and should use these tools but have yet to reach that needed decision. That’s the discouraging part.

The Coalition’s study tells us other things about insurer mindsets regarding technology, and the crime it’s supposed to catch. A large swath of insurers are wide awake to the oncoming peril of organized crime: More than half say the chief benefit of technology is to catch such fraud rings.

Nearly all insurers use at least some form of anti-fraud software.

Predictive modeling and text mining are the top two areas in which insurers plan to invest in the future. But one of the thorniest barriers to fully investing in technology involves how to prove these tools are worth the investment, the insurers say. How do you quantify, for example, the value of dishonorable claims that are never made because some criminals don’t want to take on an insurer that’s known to be so well-defended?

Insurers as a whole may still be playing catchup with their brethren in the credit-card industry. They need, with growing urgency, to step up the pace. But the encouraging part is that more insurers appear to be taking those steps against a criminal underworld that grows more sophisticated and greedy with each passing month.

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

Stopping fraud with fun?

BLOG_viralvideoMost YouTube videographers dream of making videos that go viral. Advertisers strive to create spots that people remember and relate to.

In the anti-fraud world, the goal of advertising is to help consumers make more ethical decisions. A few successes attest to the viability of this endeavor. In a recent article in the Journal of Insurance Fraud in America, Ralph Burnham showed how advertising is key to prevention. Making people aware of fraud and its consequences led to a measured decline in fraud approval by some Pennsylvania consumers. In California, the District Attorney’s office in San Diego has found a direct link between anti-fraud outreach and decreasing workers comp fraud.

So advertising has had measured success in local markets, but what would it take to create a national campaign that sticks? A look at successful campaigns gives us some clues.

1. Get their attention. In this information-saturated era, the first challenge is for space. Creating a video that spreads by word of mouth is key. In online video, every second counts, an element of mystery can keep viewers watching through to the end.

2. Entertain. The difference between an ad that is spam, and one that gets shared by friends starts with entertainment.

3. Offer a new take on something personal. There are some things everyone can relate to. Father and sonsMothers and childrenunusual wedding proposals. What does insurance fraud have to do with normal citizens? We all pay for it. Our anti-fraud story could begin with tight finances.

4. Use Emotion. Try humor. Emotions guide many of our actions, joy, fear, hope, stress, excitement, inspiration. And humor? Pages and pages have been dedicated to to making people laugh. Some of the most-viewed YouTube videos just make people laugh. Can we present a serious topic with an element of humor and still have the desired impact?

Most ads that are broadcast on TV are posted on YouTube as well. Unlike TV ads that are in some way forced on viewers, ads on YouTube can be found by an audience that actually chooses to watch. So looking at what has been successful on YouTube can shed light on consumers’ interests.

Successful public service announcements, such as anti-drug campaigns or anti-smoking campaigns often deliver a serious message with shocking or memorable graphics. Though the point gets across, they seldom get shared or go viral as the more amusing ones do (Kony being one notable exception, successfully using emotion).

So we have a challenge in the fraud fight, if we are able to reach consumers to stop insurance fraud, how can we create a message everyone will want to watch and share?


About the author: Jennifer Tchinnosian is communications specialist for the Coalition Against Insurance Fraud.

6 mobile apps with fraud-fighting potential

BLOG_crashAppsA suspect vehicle suddenly swoops in front of you and jams on the brakes, causing a rear-end collision. Funny, you were going slow, and that car appeared out of nowhere. You think you’re being scammed, but what can you do? Having a smartphone may help. Not only do these devices make calls, track to-do lists, and help you find the nearest restaurant, a few recent apps may even help fight fraud. Some have been created for other purposes, but have fraud-fighting potential. Here we’ve chosen a few of our favorites.

1. iCarBlackBox 
What it is: This app turns your phone into a virtual black box. Using GPS, video, audio, and an impact sensor, iCar Black Box can record all the details of a crash as it takes place. Using the phoneʼs accelerometer, the app can tell when thereʼs been a sudden stop, and will verbally ask the user if they wish to save the footage of the incident. It only saves footage when instructed to do so, thereby conserving space. Users can check the speed of the moving vehicle, date and time, location, road conditions and more through audio/video.

Why it’s a fraud-buster: If you can show what really happened, you might have a better case of proving fraud.details of a crash as it takes place. Using the phone’s accelerometer, the app can tell when there’s been a sudden stop, and will verbally ask the user if they wish to save the footage of the incident. It only saves footage when instructed to do so, thereby conserving space. Users can check the speed of the moving vehicle, date and time, location, road conditions and more through audio/video.

2. iWrecked
What it is: iWrecked allows users to log all the details of a crash, including unlimited pictures, other driver’s insurance information, police information, even witness data and weather conditions. It allows users to create crash diagrams. The app can then generate a pdf report detailing the accident, and send directly from the app to the user’s insurance company.

Why it’s a fraud-buster: Knowledge is power. The app’s reminder to get witnesses’ contact info, capture photos, and take down all the details of a crash may help provide a more comprehensive report.

3. NICB fraud tips

What it is: Reporting fraud just got way easier. This app allows users to anonymously report fraud from the convenience of their phones, on the go. Users can have a chat-style conversation to explain their circumstances, or send an anonymous email-like message including pictures and descriptions.

Why it’s a fraud-buster: Convenience is key, and users are can now snap pictures on their phones, or discuss a fraud tip without making a sound.

4. DBPR Mobile
What it is: Floridians who are approached by shady contractors after storms now have an instant licensing check on their phone. Consumers can verify whether businesses and professionals are licensed, searching by name or license number.

Why it’s a fraud-buster: It’s the first step in determining who to work with. Consumers are still advised to contact their insurer to get referrals on trusted contractors, but turning to this app can give an instant read on what contractors are being honest about licensing.

5. Oklahoma Insurance Department app
What it is: An Android-based app, this allows users to carry important insurance information with them. Consumers can report fraud, search for seasonal insurance topics, check licensing, nominate an insurance professional of the month, and contact the department directly.

Why it’s a fraud-buster: Users can check key fraud info, and can report fraud if they catch it.

6. Scam Detector
What it is: An app that allows users to verify telltale signs of scams to protect themselves from being defrauded. Detailing more than 525 scams, organized by industry, it’s updated in real time. The search function also lets users browse based on their circumstances. Auto scams, internet scams, financial scams, property scams and more.

Why it’s a fraud-buster: Knowing about a fraud can stop the crime in its tracks, and allow users to take action.

Are there any similar apps you are using that should be on this list?
Let us know in the comments.

Lie detection technology and fraud

liarEngland is a longtime user of voice-stress analysis, the system that’s touted to detect when someone strays from the truth. British insurers as well as government agencies have used the technology to question claimants: it detects changes in voice stress, supposedly a reliable indicator of lying.

The technology has its supporters — and critics — on both sides of the Atlantic. There has been little published data to indicate how well the technology works with insurance claimants.

One borough of London recently released data on the first 1,000 disability claimants on which the technology was tested. Of the 1,000 subjects, 43 — or 4.3 percent — were flagged by the system and all of these were found to have filed false claims or displayed a high potential for committing fraud.

Even more impressive: Another 281 claimants withdrew their claims after they learned about the use of the technology. The withdrawal rate is twice what it was before the technology was used.

So users now claim that voice-stress analysis is not only a detection tool, but a deterrent as well.

Officials say no claim is ever denied solely on the basis of voice-stress analysis, but it does help to direct investigators to claims that merit more scrutiny. It’s also said to help speed claims payments to truthful claimants.

So, is America ready for this technology? In an age when cameras catch red-light violators and the FBI can monitor phone calls and e-mail at will, perhaps Americans would accept this technology — if it helps to keep premiums in check.

I’d like to see the results of more thorough testing first.

Can MRIs really detect lies?

brain scanI have much faith in technology and believe someday scientists will develop a lie detection method that is nearly foolproof and practical for fraud fighters. Every few years a new method promises to be the holy grail of determining deception, but the hype rarely lives up to reality. We’ve seen everything from truth serum to polygraph to voice-stress analysis, but none has been deemed worthy enough to be accepted by courts as evidence in a criminal trial.

The latest method to create a buzz is the “No Lie MRI,” a system used to measure physiological changes in the brain, which when analyzed, can determine whether someone is lying, according to the owners of the system. In fact, they claim 90% accuracy in recent tests, and are now signing up MRI centers across the country to offer this new service.

The technology came to our attention after we learned an accused arsonist in South Carolina used the system to try to clear his name. Deli owner Nathan Harvey was accused of torching his business, and even though criminal charges had been dropped, his insurer refused to pay his claim. Harvey thought maybe the MRI scan results just might convince the insurer of his innocence. No word yet on whether his claim will be paid any time soon.

Nonetheless, the idea of this technology is intriguing, and if it works, could have widespread application from fraud to interrogating suspected terrorists. It also may pose opportunity since the technology is located in MRI centers. Perhaps insurers could ask their medical billers to undergo the tests to determine whether they are inflating their claims?