Insurance Fraud Investigation... Strategies

Learn about insurance fraud investigation protocols in the health, medical, auto, and life areas and the form of case report your attorney will require to ptotect your interests.

What The Insurance Fraud Investigator Pursues

Insurance fraud investigation is triggered when either the policy holder or the insurance firm suspects that contractual obligations have not been met by the opposite party.

* Health And Medical Insurance Foul Play. With rising costs and increasing complexity, health insurance fraud incidences in particular are rising. Medical insurance fraud in the mental health field represents a difficult area for investigation. In this mental health services area, insurance fraud can occur when the therapist fabricates client visits or enters fraudulent diagnostic information into the client's record.

* Spotting The "Smoking Gun" Of Fraud. How can the insurance firm spot a case of medical health insurance fraud? Well, for one, the insurance fraud forensic group works from a data base of demographic and client service history records. Their insurance fraud investigator team studies the pattern of billing from the practitioner, comparing the billing statements with data base records in order to spot a reporting anomaly.

Typically, the medical health insurance fraud investigation reveals that the practitioner has "cooked" his or her client service records, even falsifying visits or creating "phantom" family visits and consultations in order to raise per-visit revenues up to the so-called "market price". Let's look at some typical "numbers" for this form of medical health insurance fraud investigation.

The health practitioner "prices" his or her service at, say, $130 per hour; meanwhile, the insurance firm or HMO only "approves" a rate of, say, $45 per hour? Since the HMO controls the purse strings, the practitioner is now tempted to resort to medical health insurance fraud, by reporting bogus visits, padding the client's record in order to bring revenue up to $130 e.g. another 2 to 3 visits must be "recorded".

* Auto And Life Insurance Scams. Auto and life insurance fraud cases result in similar investigations. In the case of a car insurance fraud investigation, the insurance investigator looks to the crash report and damage estimate, and then compares these data with in-house data and records for similar accidents. The auto insurance fraud investigation case can narrow down its data for comparison purposes to the make and model of auto as well as the region where the crash occurred, creating an insurance fraud investigation report that can be used by their attorney when pursuing either the policy holder or the car repair facility.

* An Ounce Of Prevention...Internal Forensic Accounting. A preventive strategy to limit car and life insurance fraud investigation incidences has been to hire a professionally trained in-house group of accident investigators and cost evaluators. These field investigator teams utilize digital photography to record vehicle damage details as well as forensic insurance fraud investigation methods to trail all accounts related to repair.

In view of the sophisticated reporting and data base controls utilized by the insurance industry, cases requiring insurance fraud investigation should lower over time. However, the greed and temptation to get "easy money" sometimes lures people into contemplating insurance fraud. Auto insurance fraud investigations regularly show that "stolen" vehicles can become cases where organized crime syndicates target specific models for sale overseas, or where owners fabricate the theft in order to lay claim to the insurance payout benefits.

Bottom line, in order to avoid becoming the target of a medical health, life, or auto insurance fraud investigation, you need to play it straight, stick to your policy terms and conditions or the insurance fraud investigators will come knocking.


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