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Anti-Fraud Training

 

Training the Global Life and/or Health Fraud Investigator as well as the Travel Claims Investigator and engaging the insurers’ Special Investigators and Claims Examiners!

 

This is the section in which we share specific knowledge or information on how the local Investigator can become a better professional by effectively investigating life, health and travel insurance claims and reporting on the findings. Effective investigation is one in which the Investigator covers every gamut of inquiries expected and conveys the findings in such a concise and succinct form that it communicates the salient aspects to the reader. The reader may be the Claims Examiner in the insurance office whether in the country or overseas in Africa, North/South America, Europe or Asia. The report should also be read and understood by the attorneys and the judge adjudicating a fraudulent claim litigated in the court.

 

Further, we intend in this column to engage our hordes of clients around the world by sharing our investigative experience with them.  

 

 

travel insurance fraud investigation

TRAINING / No. 7 GLOBAL - Health Insurance and Medical Expenses Claims

The Venezuela Challenge: Dual foreign exchange controls (up to

January 29, 2018)

 

VENEZUELA / GLOBAL – In the same vein, if the Claims Examiners in the United States are presented a bill indicating medical charges, BsF1,000,000.00, incurred say on September 6, 2017, then the amount payable is BsF1,000,000.00 divided by the erstwhile DICOM rate of BsF2640.00 applicable on that date. That equals US$378.79. If the bill is BsF2,000,000.00, the US dollar equivalent sum would be US$757.58. If the Claims Examiners unwittingly apply the wrong rate, the DIPRO rate, which is same as the online rate, they would be faced with the equivalent sums of US$100,000.00 and US$200,000.00 respectively.  

 


travel insurance fraud investigation

Training I No. 6 GLOBAL — Life Insurance and Accidental Death Claims Interviewing the family is a sine qua non to uncovering the fraud!

GLOBAL - Life Insurance & Accidental Death Claims

 

Interviewing the family is a sine qua non to uncovering the fraud!

 

The trend these days with life insurers’ Claims Examiners and Special Investigators is to instruct field Investigators not to conduct inquiries with the claimant’s family members. Often, the insurers are inundated with requests by claimants that they do not want their family to be contacted by the Investigators. The excuse they readily offer is that they do not want their family to know there was a life insurance on the deceased family member!


travel insurance fraud investigation

Training I No. 5 GLOBAL — Health Insurance and Medical Expenses Claims Indications of fraudulent foreign health insurance claims : Emergency Room (ER)

 

GLOBAL - Upon investigations it was noted that the facility was an out-patient medical clinic that consisted of two rooms. It opened or operated on specific hours, 8.00 a.m. to 8.00 p.m. every day. The two rooms were occupied as consulting rooms by the two physicians who are co-owners of the clinic. One of the physicians had an ECG in his room. Both rooms have Examination couch. There was practically none of the other items that constitute an Emergency Room seen in the rooms. There was not even a Suture Tray.


travel insurance fraud investigation

Training I No. 4 GLOBAL — Health Insurance and Medical Expenses Claims Taking photographs of the facility's contents and exterior


GLOBAL - In this course, we will dwell on what has become a difficult area for field Investigators. Investigators worldwide find it a challenge deciphering the relevant sections of a facility to take the photographs and how the photographs should be taken. By facility in health insurance investigations we refer to a medical clinic, hospital, independent paramedical establishments (laboratory, radiological center, physical therapy) pharmacy, dental center, and eye center.


travel insurance fraud investigation

Training I No. 3 GLOBAL - Certifications Professionalizing the Adjuster, the Special Investigator, the Private Investigator in international investigations...

GLOBAL - However, whether one is an Adjuster, an SI or a PI working foreign life, health and travel insurance claims, one positive step is to broaden one’s fraud horizon and become very fraud aware. In order to acquire fraud knowledge, you have to read widely and be open to new vistas developing in the field. Every field of study or profession is evolving and changing from time to time.


travel insurance fraud investigation

Training I No. 2 GLOBAL — Health Insurance and Medical Expenses Claims The typical investigative procedures — from drafting letters for physicians and providers to...


GLOBAL - This brief training program in the form of an article is to provide insights into factors taken into consideration by Investigators in drafting letters for physician providers; the psychological comportment of the Investigator when dealing with medical providers and the supporting documentation to seek. It reinforces the importance of seeking a Medical Consultant’s inputs in resolving knotty aspects of some claims.

 


travel insurance fraud investigation

Training I No. 1 GLOBAL — Health Insurance and Medical Expenses Claims Always speak with the No. 1 officer!


GLOBAL - The Investigator should make it a point on attending the place of inquiry, whether at a medical facility such as a clinic or hospital or the paramedical facility such as a laboratory, pharmacy, X-Ray center or in any other independent radiological center, to seek out the No. 1 officer at the facility rather than the person whose name appeared in the claim documents. The reason for this is that the official whose name appeared in the document may have colluded with the claimant in making the claim and thus communicating first with that individual may not augur well for you to obtain the facts of the case.