Index
Abuse, 144, 147, 148, 185, 211, 236, 237
Admissibility of evidence, 255–257
After-market parts. See Automobile glass replacement company, fraudulent insurance billing
Agency office, internal fraud
lessons learned, 73
prevention recommendations, 73, 74
prosecution and plea deal, 72, 73
Agents, fraud in soliciting medical insurance clients
lessons learned, 176
prevention recommendations, 176
Anti-fraud training and education, 28, 92, 168, 236
Antique automobile theft claims
lessons learned, 111
prevention recommendations, 111
prosecution, 111
Application misrepresentation, 39, 43, 44, 46, 202, 203, 205, 254. See also Antique automobile theft claims
Arson fraud
lessons learned, 46
prevention recommendations, 46
Attorney-client privilege, 79, 80
Audits
employee behavior during, 85
healthcare fraud, 183–186, 189
Medicare fraud, 180–183, 212–214
vendors, 168
Automobile glass replacement company, fraudulent insurance billing
criminal prosecution, 166, 167
lessons learned, 167
prevention recommendations, 168
Automobile insurance
antique automobiles. See Antique automobile theft claims
auto theft. See Automobile theft claims glass replacement. See Automobile glass replacement company, fraudulent insurance billing
and Mexican drug cartel intimidation. See Mexican drug cartels, fraudulent claims
personal injury protection (PIP) claims, 122. See also Medical clinic fraud
Automobile theft claims. See also Antique automobile theft claims
lessons learned, 102
prevention recommendations, 102
prosecution, 101
sting operation (Operation Give and Go), 95–101
Background checks
contractors, 20
employees, 28
importance of, 119
investigative tool, 24, 25, 105, 106, 119, 206
vendors, 28
Behavioral research, 256
Centers for Medicare and Medicaid Services (CMS), 185, 186, 215, 233
Chain of custody, 81, 82, 106, 145, 207, 244, 246
Checks and balances, 27, 38, 73, 74
Civil litigation
defense tactics, 80
Federal Civil False Claims Act, 7
Claims representative, internal fraud
lessons learned, 119
prevention recommendations, 120
prosecution, 119
Classification system for insurance fraud, xv
Commercial liability insurance
misappropriation and diversion of fiduciary funds. See Commercial liability insurance fraud
non-admitted insurance providers, 239
requirements, 239
Commercial liability insurance fraud
criminal prosecution, 245, 246
lessons learned, 246
online sales. See Online insurance sales fraud
prevention recommendations, 247
Department of Health and Human Services (DHHS), 186, 211, 237. See also Office of Inspector General (OIG)
Documents
management, 246
Durable medical equipment (DME) Medicare fraud
criminal prosecution, 214
lessons learned, 214
prevention recommendations, 215, 216
Employee leasing companies (professional employer organizations), 58–63
Employees
audits, behavior during, 85
background checks, 28
dishonest employee insurance claim, 72
former employees, blaming for fraud, 183
former employees, interviewing, 6, 125, 166, 186
hotlines, 27, 28, 85, 92, 132, 138, 164, 167, 227
retaliation, fear of in reporting fraud, 27, 28
whistleblowers. See Whistleblowers
workers' compensation insurance. See Workers' compensation insurance, claims fraud
Ethical business model (EBM), 27, 28
Ethics and fraud awareness training, 28, 92, 168, 236
Evidence
chain of custody, 81, 82, 106, 145, 207, 244, 246
physical, 9
Examinations under oath (EUO), 123, 125, 257, 263–266. See also Interviews
False Claims Act, 232
False disability and income continuation benefits claim
investigation and surveillance, 33–37
lessons learned, 37
prevention recommendations, 38
False medical insurance claims
prevention recommendations, 27, 28
Federal Civil False Claims Act, 7
Federal Rules of Criminal Procedure, 186
Financial elder abuse. See Variable indexed annuities, fraudulent practices in sale of
Formal, informal, and technology (FIT) controls, 27, 28
Former employees
blaming for fraud, 183
interviewing, 6, 125, 166, 186
Fraud, elements of, 142, 143, 147
Fraud, waste, and abuse (FWA), 185, 211, 236, 237
Friends, doing business with, 67–74
Health Care Fraud Prevention and Enforcement Teams (HEAT), 215
Healthcare fraud. See also Agents, fraud in soliciting medical insurance clients
experimental medical treatment, 2–7
false medical claims. See False medical insurance claims
investigation recommendations, 8, 9
kickbacks. See Kickbacks in Medicare fraud
lessons learned, 8
Medicaid. See Medicaid fraud
Medicare. See Medicare fraud
miscoding and false billing, 2–7
prosecution, 7
History of insurance business, xi–xiv
Hotlines, 27, 28, 85, 92, 132, 138, 164, 167, 227. See also Whistleblowers
Identity theft, 53, 132–138, 242, 243, 245
Identity theft based on system access
lessons learned, 54
prevention recommendations, 54
Information technology
controls, 28
identity theft based on system access, 47–54
Injury claim fraud
lessons learned, 20
prevention recommendations, 20
prosecution, 19
Insurance agency office, internal fraud
lessons learned, 73
prevention recommendations, 73, 74
prosecution and plea deal, 72, 73
Insurance agents, fraud in soliciting medical insurance clients
lessons learned, 176
prevention recommendations, 176
Insurance agents, online insurance sales fraud
disciplinary action, 206
prevention recommendations, 207
Insurance claims representative, internal fraud
lessons learned, 119
prevention recommendations, 120
prosecution, 119
Insurance Contract Act (Australia), 19
Insurance industry regulation, 61, 65, 153, 207, 239, 246–247
Insurance premiums, misappropriation and diversion of. See Commercial liability insurance fraud; Online insurance sales fraud
Internal auditors, role of, 26
Internal controls
formal controls, 27
internal auditors, role of, 26
Internal fraud
by claims representative, 113–120
insurance agency office, 67–74
Internet. See Online insurance sales fraud
Interviews. See also Examinations under oath (EUO)
employees, 6, 92, 125, 166, 186
informal, 257
preparing for, 4, 8, 9, 18, 24, 70
Intuition, 256
Investigative techniques, 9. See also Interviews
Jewelry store fraudulent theft claim (insufficient inventory for line of credit)
insurance claim for theft, 223–226
lessons learned, 227
prevention recommendations, 227
Jewelry store fraudulent theft claim (insufficient records to prove loss)
investigation recommendations, 267
lessons learned, 266
settlement, 266
Kickbacks in Medicare fraud
civil settlement and corporate integrity agreement, 234–236
lessons learned, 235
prevention recommendations, 236, 237
Licensing, 199, 202, 203, 206, 207, 239, 242, 243, 246, 247
Life insurance fraud. See also Pattern of insurance fraud
lessons learned, 138
prevention recommendations, 138
Lines of credit, 218, 219, 227. See also Jewelry store fraudulent theft claim (insufficient inventory for line of credit)
Litigation, civil. See Civil litigation
Long-term disability claims, 142, 143. See also False disability and income continuation benefits claim
Material misrepresentations, 45, 142, 143, 185, 188, 231, 234, 246
Medicaid comprehensive compliance program, 236, 237
Medicaid fraud
corporate integrity agreements (CIAs), 234–236
durable medical equipment billing. See Durable medical equipment (DME) Medicare fraud
medical billing by optometrist. See Medical billing fraud (optometry)
Medicaid Fraud Control Unit (MFCU), 180, 181, 186, 187
Medical billing fraud (optometry)
criminal prosecution, 188
lessons learned, 188
prevention recommendations, 189
Medical clinic fraud
lessons learned, 128
prevention recommendations, 129
Current Procedural Terminology (CPT), 232
International Classification of Diseases (ICD), 232
Medical insurance
fraud in solicitation of customers. See Agents, fraud in soliciting medical insurance clients
Medicare fraud
durable medical equipment billing. See Durable medical equipment (DME) Medicare fraud
kickbacks. See Kickbacks in Medicare fraud
medical billing by optometrist. See Medical billing fraud (optometry)
national provider identifier (NPI) system, 214
Office of Inspector General (OIG), 211, 213, 214, 235–237
Operation Whack-A-Mole, 211, 212, 215
program safeguard contractors (zone program integrity contractors), 211, 212
Mexican drug cartels, fraudulent claims
insurance industry response, 195–197
lessons learned, 197
prevention recommendations, 198
Misappropriation and diversion of fiduciary funds. See Commercial liability insurance fraud; Online insurance sales fraud
Money laundering, 124, 127, 245, 246
National Association of Insurance Commissioners, 207
National Insurance Crime Bureau (NICB), 69, 124, 148
Office of Inspector General (OIG), 211, 213, 214, 235–237
Online insurance sales fraud
disciplinary action, 206
prevention recommendations, 207
Operation Whack-A-Mole, 211, 212, 215
Optometry services, fraudulent billing. See Medical billing fraud (optometry)
Original equipment manufacturer. See Automobile glass replacement company, fraudulent insurance billing
Pattern of insurance fraud
automobile theft claim, 254
civil lawsuits, 251
criminal prosecution, 255
homeowners' claim (property theft), 250–254
prevention recommendations, 257
Social Security fraud, 254
staged burglaries, 254
Predictive analytics and modeling, 182, 215
Premiums, misappropriation and diversion of. See Commercial liability insurance fraud; Online insurance sales fraud
Professional employer organizations (PEOs), 58–63
Property damage fraudulent claim
investigation recommendations, 82
lessons learned, 81
settlement, 81
Property theft, fraudulent insurance claim
lessons learned, 92
prevention recommendations, 92
prosecution and settlement, 90, 91
Property theft, fraudulent insurance claims by business owners
insufficient inventory to support line of credit, 217–227
insufficient records to prove loss, 259–267
Qui tam claims, 79
Regulatory agencies, working with, 69, 73, 202, 206, 247
Retaliation, fear of in reporting fraud, 27, 28
Search warrants, 63, 64, 110, 111, 166, 167, 179, 180, 243, 244, 254
Settlements
and cost of litigation, 81
Medicare fraud, civil settlement and corporate integrity agreement, 234–236
Shell corporations, 57, 58, 63, 244
Software
anti-fraud/fraud detection, 182, 189
forensic analysis, 207
Straw accounts, 69, 71, 72, 74
Subpoenas, 3, 6, 79–81, 108, 145, 164, 165, 186, 203, 204, 252, 257
Surveillance, 15–18, 33–38, 96, 97, 107–110, 141–145, 147, 155, 257
System access. See Identity theft based on system access
Theft
antique automobiles. See Antique automobile theft claims
automobile theft. See Automobile theft claims
of premiums. See Commercial liability insurance fraud
property theft. See Property theft, fraudulent insurance claim
property theft, fraudulent claim by business owner. See Jewelry store fraudulent theft claim (insufficient inventory for line of credit); Jewelry store fraudulent theft claim (insufficient records to prove loss)
Transaction analysis, 24
Variable indexed annuities, fraudulent practices in sale of
disciplinary action, 156
lessons learned, 156
prevention recommendations, 156
Vendors
audits, 168
background checks on, 28
fictitious vendors, payments to, 116–119
training, 138
Waste, 185
Weaknesses in internal controls, 114, 119
Whistleblowers. See also Hotlines
relator actions, 231
treatment of, 167
Workers' compensation insurance, claims fraud
background, 139
prevention recommendations, 147, 148
Workers' compensation insurance, coverage fraud
lessons learned, 65
prevention recommendations, 65