Don’t fall for the false flag, fraud is pervasive

Here at Ethos, we are proud to be part of your team and to play a part in the fight against fraud. We all know the costs associated with fraudulent claims and we also understand the difficulty of making decisions without the necessary information. According to the FBI, the total cost of insurance fraud (non-health insurance) is estimated to be more than $40 billion per year. That means Insurance Fraud costs the average U.S. family between $400 and $700 per year in the form of increased premiums. We also understand the need to constantly update our knowledge and the tools we use to spot those exaggerated or bogus claims.

Fraud exists in every line of coverage and we all understand that dollars invested in the review of the right claims rewards us exponentially through mitigated losses or outright denials. According to the NICB, 10 percent or more of property-casualty insurance claims may be fraudulent. Knowing this, one of the first places to look for fraud is where you don’t see any. If your company has 5% fraudulent claims in most lines, but you see no fraud in a specialty line or for any specific coverage then it is time for a closer look. Occasionally, we make the mistake of thinking the lack of identified fraud equals the absence of fraud. Unfortunately, that is not the case and we need to review files in random audits and reexamine the red flags being utilized to identify the bad players in the adjusting process.

When we look at theft claims in the Property Casualty realm, for example, we find some carriers who believe that a specific market just doesn’t have a fraud problem. While it is certainly true that some areas are more likely to see a large number of false claims and organized crime than others (yes, Florida I’m looking at you, which is a great reason for Ethos to be headquartered in the state), it is not accurate that some areas don’t have fraud. It is there, we just have to look deeper and Ethos can help you with that. We are able to review files, handle inquiries/investigations, obtain documentation and statements for your SIU referrals and we can even assist your office with adjuster CE’s and expand your knowledge on red flags in the process.

Examining a “clean” market with the right lens can reveal fraud we were previously unaware of. In theft claims (renter’s or homeowner’s), we see insured’s who are a bit too eager for a quick settlement and don’t seem to fight for full compensation. Of course, we see the old stand-by of calls to check on coverage hypotheticals before a loss and addition of coverage (or brand-new coverage) shortly before a loss, but we also must be on the look out for financial issues, including separation or divorce just prior to the loss. Our digital investigations team is able to help identify those precursors. Perhaps you find a suspiciously convenient alibi when a mastermind burglar just happened to know how to find the fake book safe with a large amount of cash. This is not the “Italian Job,” most thieves are in an out quick and taking the obvious. They are certainly not taking the time to load up Grandma’s prize china set that Antique Roadshow would value at $20,000. Our job is to take the files where you identify red flags and help you find actionable information to mitigate or even deny the claim where fraud exists. .

Need background information? We have you covered. Need surveillance? No problem. Maybe you require a statement or a scene investigation in a remote area or another country? We can assist you globally. Looking for a partner in your SIU operations? Let us help. Contact Ethos today to learn how we can assist you and your team in 2018 with our full service of risk mitigation services.

Clinic Fraud: Costing All of Us

In recent years, clinic fraud has become a major concern, costing insurance companies and employers billions of dollars each year. That’s not exactly chump change and each and every one of us foots the bill for these unscrupulous activities through higher insurance premiums. It seems that not a day goes by without a news story or two about someone trying to make a quick buck by scamming the system.

So, how can you take action if you believe that one or more of your claimants is involved in clinic fraud? One proven method is to conduct a clinic investigation in order to document the activities taking place at a questionable facility. Even though the folks who are involved in clinic fraud think that they’re smarter than the rest of us, a well-executed clinic investigation can quickly dispel such notions.

Clinic investigations can help you get answers to the following questions:

* Is a claim valid or not?

* Does the clinic exist or is it a mail drop or store front?

* Is your claimant showing up at the appointments for which the clinic is invoicing you?

* Is your claimant being treated by a licensed physician, a licensed physician assistant, or possibly someone without a medical license?

* Are you being billed for the cost of a physician when an assistant or non-licensed employee is actually conducting the treatment?

* Is the clinic involved with “runners,” or unprincipled parties such as tow truck drivers, body shops, or attorneys who receive incentives to send patients to the clinic?

Regardless of the firm you choose to perform a clinic investigation, their game plan should include most, if not all, of the following:

* Verifying the clinic’s physical location and inspecting the facility.

* Verifying all medical licenses of healthcare workers and medical directors.

* Conducting surveillance to determine the number of individuals entering/exiting the clinic.

* Reviewing of medical files by expert adjusters.

* Interviewing the claimant, the insured, and all medical staff on premises.

* Conducting full background checks on the owners of the clinic.

* Determining if treatment is actually being conducted and whether or not the clinic has equipment for which they are billing.

* Investigating the process of the treatment and who is providing the treatment.

* Determining if there is fraud and/or potential for a criminal referral.

When choosing a firm to conduct your clinic investigation, be sure to ask for referrals and documentation of their experience in such investigations. It is critical that the firm you select has the experience and know-how to perform the investigation in a discreet manner as many of the folks who participate in clinic fraud are well trained to be on the lookout for surveillance.

Experienced investigators will scout the location in advance of the investigation and identify the best positions to prudently document every person and vehicle coming and going from the clinic without being noticed. The last thing you want is for your investigator(s) to be detected while on-site as this will likely compromise the integrity of the entire investigation.

At Ethos, we have performed numerous successful clinic investigations for our valued clients over the years. We’ve got the experience and expertise to perform highly effective clinic investigations in a discreet manner. If you suspect clinic fraud, contact Ethos today at 866-783-0525 to learn how you can fight back and protect your bottom line.