Michigan Injury Fraud Training

1. Michigan Injury Fraud Training SIU & MCR Summit 12/2010

2. Special Investigation UnitInvestigates: • Medical Provider Fraud • Suspect Injury Fraud • Suspect Document Fraud • Wage Loss Claim Fraud • Household Services & Attendant Care Fraud • Surveillance

3. Special Investigation UnitDOES NOT Investigate: • Order of Priority Claims • Policy Fraud Please come talk to us if you are not clear. We also have suggestions for those types of investigations we do not handle.

4. Reasons to refer to Special Investigative Unit • Injury not consistent with Facts of Loss • Rear end accident with minimal property damage with a broken ankle. • Inured party alleges prospective employment through not employed at time of loss • Injured states had job offer but turned down due to injuries form this accident. • Questionable self-employment lost wage claim • Insured made living “under the table or refuses to provide tax returns. • Any claim party states accident did not occur • This should always be recorded under normal statement taking guidelines. • Duplicate or identical medical reports • All parties in vehicle suffered the same ailments and all treatment is the same.

5. Treatment not received or given by improper persons • Treatment preformed by a non licensed chiropractor or chiropractor assistance with out supervision of a licensed chiropractor • Suspect physical therapy • Pt should not be ordered for more than 30 days with a normal low impact accident. • Treatment not related to claim facts of loss • multiple diagnosis testing performed by treating doctor • no major complaints listed by the injures party to the doctor, yet the doctor orders a full battery of tests. • Phantom vehicles (hit and run) with injured occupants • Need to confirm proof of loss. • Suspect documentation • Disability slips not matching SOAP notes. • Jump in or ghost guest passenger

6. How to refer to Special Investigative Unit • Summarize the reason for SIU referral in the claim notes. • In ClaimStation (while viewing a claim), click SIU on the bottom left of screen. This will open the Transfer/Assist screen. • Enter the SIU Org. Code. • Tab to the left of each feature/exposure to be referred and enter "I" (Investigate). (Note: If you put an "A" or “T” here, it will be sent to the wrong area and will be rejected.) • After you have placed an "I" beside the feature/exposure you are referring, press the enter key and the claim will be referred to the SIU org. and will be assigned accordingly. • As always, if you are not sure please see your local SIU Investigator

7. How You can help…. • Always get a thorough detailed statement of the facts of loss, damages to vehicles, injuries and treatment. Make sure to use proper introduction with permission to record the conversation. • During initial statement, always obtain what Household chores they used to do before the accident, make sure to determine what the other household members did too. • Inspect both vehicles if the police did not come to scene, regardless if there is collision coverage or not. • Obtain cellular phone records of person who called 911 if police did not come to scene. This needs to be done ASAP as records are not always available after delayed time. • Get medical auth and wage loss forms as soon as possible. Faster have authorizations, the fast the records can be obtained.

8. Find employers contact information on your own. Do not relay on contact information given by the injured party. • When transportation is being listed as needed by the doctors. Make sure to confirm this is because the injured party cannot drive due to injuries and not due to lack of transportation. • When requesting tax returns, always have the injured party sign IRS form 4506 or 4506-T. Always request not only the previous year, but also the next 3 years since they can claim for the next 3 years. This will save time and money in the long run of the claim. • If its been 6 months with a subjective injury and only treating with Chiropractors and Physical Therapist, then a review for Independent Medical Exam should be done. Typical Whiplash should not take 6 months of 3-4 times per week of treatment. • Loss within days of policy inspection must have proof of loss. Obtain witness statements, vehicle inspections, ER notes, etc to collaborate the date of loss

9. Where you can find help.. • American Medical Association: • http://www.ama-assn.org/ama/home/index.shtml • Aetna IntelliHealth • http://www.intellihealth.com/IH/ihtIH • Quack Watch • http://www.quackwatch.org/ • Medicare • http://www.medicare.gov/fraudabuse/overview.asp • US Department of Health and Human Services • http://www.hhs.gov/ • National Insurance Crime Bureau • https://www.nicb.org// • Coalition against Insurance Fraud • http://www.insurancefraud.org/consortium.htm • National Health Care Anti-Fraud Association • http://www.nhcaa.org/eweb/StartPage.aspx

10. Quiz Question #1 • Edward is rear ended by another motor vehicle while riding in Emmett’s car. Both Edward and Emmett are injured. Edward does not immediately show he has his own vehicle or insurance. Do you refer this to SIU?

11. No. This is not SIU referral. Request the assistance of MRR and ISU Teams to resolve this file.

12. Quiz Question #2 • Esme is completely disabled with subjective injuries and claiming household services reimbursement. She is a mother of 4 young children and her husband works full-time. It is now 6 months post loss with no end in sight. Do you refer this to SIU?

13. Yes. This file appears to be a good candidate for surveillance.

14. Quiz Question #3 • Bella, Alice, Rosalie and Renesmee all are in the vehicle when it is hit by an unknown driver who leaves the scene. No one calls the police. The vehicle is drivable. Police report is a desk report. Their attorney calls in the claim 2 months after the accident and claims they have all been treating since the DOL. Do you refer this to SIU?

15. Yes. No proof of Loss. Phantom vehicle with injuries. Multiple unrelated guest passengers.

16. Quiz Question #4 • Jasper and Carlisle live on the same street. They claim not to know each other. Jasper rear ends Carlisle on the other side of town. No police to scene, both vehicles are drivable. No collision on either vehicle. They are both treating with the same medical provider. Do you refer this to SIU?

17. Yes. Appears to be a staged accident.

18. Quiz Question #5 • Jacob owns his own company selling scrap metal. He provides his tax returns for the year before the accident. He continues to renew his commercial auto insurance with full coverage even though the company is not working due to his disability. Do you refer this to SIU?

19. Yes. Appears to be a good candidate for surveillance.

20. If you are not sure on any file if it qualifies as an SIU referral,Please come see SIU.