This three-part series of articles examines the problem of insurance fraud, including its pervasiveness and general characteristics in the United States, the United Kingdom and the world. Insurance fraud is a widespread problem that requires real solutions and is often difficult to detect and combat.<\/p>\n
Part One of the series, \u201cWhat is Insurance Fraud,\u201d<\/a> provides an introduction to a topic that is important for any business leader, insurance professional, compliance agent or fraud investigator. Part Two, \u201cHow do Companies Detect Insurance Fraud,\u201d<\/a> details red flags of insurance fraud that help tip off investigators to possible illegal behaviour. Part Three, \u201cAnatomy of an Insurance Fraud Investigation,\u201d provides a look at case studies and reveals key tips for handling a successful investigation. To receive the next series subscribe to our monthly newsletter here<\/a>!<\/p>\n Taken as a whole, this series is the perfect primer for any insurance fraud professional and companies looking to avoid becoming victims of insurance fraud claims. It provides the tools and knowledge needed to effectively combat insurance fraud.<\/p>\n The insurance fraud epidemic is of serious concern to businesses, insurance providers and consumers worldwide. In Part One<\/a> of this three-part series, we examined the scope of the problem, and discussed a few cases that illustrate the magnitude of insurance fraud. In Part Two<\/a>, we looked at how companies can detect insurance fraud, including how to recognise the red flags that represent potential criminal behaviour.<\/p>\n In this final Part Three, we\u2019ll examine the elements of an insurance fraud investigation, beginning with a case study that illustrates how CRI Group\u2122\u2019s insurance fraud investigator<\/a>s exposed fraud schemes \u2013 saving its clients thousands of dollars.<\/p>\n <\/p>\n A CRI Group client requested an investigation of a health insurance claim filed by one of their employees, \u201cMr. Jones.\u201d Mr. Jones claimed that while on an official visit to UAE from the U.S., he felt sudden abdominal pain with nausea and vomiting lasting 18 hours. He was admitted to a clinic and stayed under observation for two days, which cost him around $4,000 (US).According to the claim, Mr. Jones (name changed) was discharged from the clinic, but then felt the return of his sickness, so he was admitted to another clinic for two more days. During this time, he was kept under observation. For this second clinic visit, he was charged nearly $1,000.<\/p>\n As part of CRI Group\u2122\u2019s \u201cexperts in a field\u201d approach, a local investigator visited both of the clinics involved in the claim. One clinic was located in Dubai, while the other was in Abu Dhabi. When he arrived at the Dubai clinic, CRI Group\u2019s local expert immediately learned that the clinic deals specifically in cosmetic surgery for women. In fact, as advertised on the outside of the clinic, its services are only for women. The clinic\u2019s administrator confirmed that the clinic is only in the business of providing cosmetic surgery for women.<\/p>\n CRI Group\u2122\u2019s local investigator then visited the clinic in Abu Dhabi. This clinic also appeared to be in the business of providing cosmetic surgery for women. When the local expert tried to contact the doctor who was named as the treating physician for Mr. Jones, the doctor was hesitant to meet the expert. CRI Group\u2122\u2019s expert showed the report to the doctor, and though it was on the official letterhead of the clinic, the doctor first denied involvement in the case.<\/p>\n Later, the doctor told CRI Group\u2122\u2019s expert that while \u201cwe don\u2019t treat that kind of illness,\u201d the patient \u201cwas in such bad condition that we treated him on a humanitarian basis.\u201d Yet the doctor was hesitant to accept that the bills came from his clinic (the expert had already learned that the doctor in question was also the owner of the clinic). Regardless, CRI Group\u2122 successfully secured the evidence that the health insurance invoices were fake and Mr. Jones was making false claims to get money from his employer.<\/p>\n <\/p>\n When red flags of fraud are uncovered, it\u2019s time to begin an investigation. As you can see from the examples above, CRI Group\u2019s investigations are based on a thorough approach that includes site visits and leaving no stone unturned. When you work with CRI Group, this is how the process will typically proceed. CRI Group will:<\/p>\n Working with an insurance fraud investigation company<\/a> like CRI Group provides the advantage of having an independent, impartial and unbiased third-party collecting the facts you need regarding any case that might involve potential fraud. CRI Group has been safeguarding businesses for more than 28 years, and you will be assured of the quality, professionalism and discreet nature of all investigations conducted by our experts.<\/p>\n Our global presence ensures that no matter how international your operations are, CRI Group\u2122\u2019s investigations<\/a> have the network needed to provide you all necessary support, wherever you happen to be. We take great care to ensure that our trained and licensed investigators are the best at what they do.<\/p>\n <\/p>\n \u201cSocial media is an absolute gold mine\u201d for insurance fraud investigations, according to\u00a0Kelly Riddle, founder of private investigation company Kelmar Global<\/a>. Many people think that setting high privacy settings on their social media accounts makes everything they post impossible to access. On the contrary, social media platforms usually hand over user information if they receive a subpoena for it.<\/p>\n Fraudsters often slip up online and post information revealing their fraud. For instance, someone receiving worker\u2019s compensation for an injured foot may post a video of themselves playing soccer with their kids. Or, someone else may unintentionally expose their scheme, as is the case if friends and family tag the claimant in an incriminating post.<\/p>\n Fraudsters who are proud of their work may boast about it on social media, thinking they will never get caught. Make sure to search for alternate accounts as well as the claimant\u2019s main social media pages to find as much of\u00a0this type of evidence<\/a>\u00a0as you can.<\/p>\n In order to learn everything you can about the claimant, you need to see where and how they live. Good old-fashioned surveillance of their home or workplace can provide evidence.\u00a0For example, someone who has claimed compensation for a shoulder injury leaving their home with a tennis racket, that is possible evidence for insurance fraud.<\/p>\n While you are in the claimant\u2019s neighbourhood, canvass others in the community. Even if the neighbours don\u2019t know the person well, they may have observed their lifestyle. Ask about the insured person\u2019s financial situation, which can indicate if they are in need of quick money.<\/p>\n In property insurance fraud investigations, be sure to also ask neighbours if they have seen or heard anything out of the ordinary around the time of the claim. This can include moving trucks or more comings and goings than usual from the claimant\u2019s home. They can also help you determine whether or not the claimant is actually living in their home.<\/p>\n Just because a claimant has included all of the relevant documents in their claim doesn\u2019t mean they aren\u2019t committing insurance fraud. In fact, fake documentation is a very common way to pull off a fraud. Signs of false documents include:<\/p>\n When studying accompanying documentation during an insurance fraud investigation, use a keen eye to\u00a0spot signs of editing<\/a>. Inconsistent lighting in photos and fonts that don\u2019t match the rest of the document are some common examples. Be sure to also review the claimant\u2019s history to see if they have claimed loss of the same items before.<\/p>\n <\/p>\n Nothing can derail your insurance fraud investigation quicker than finding out you have conducted it in violation of the law. Every jurisdiction is different, and privacy laws are the major consideration in these types of investigations. Understand the laws regarding filming or recording a subject or a witness, as doing it without their consent might be a violation of their rights. This is where it is helpful to engage the experts. At CRI Group, our investigators are trained and knowledgeable about local laws and the importance of proper evidence collection. Avoid trying to collect information by deceptive means, such as \u201cfriending\u201d a subject on social media.<\/p>\n It\u2019s important to gather the known facts of the case at the outset of your insurance fraud investigation: You need to have some idea of the who, what, when where, and how of the case. With your baseline facts in place, your investigation will proceed much more smoothly. Keep in mind that the subject of an insurance fraud investigation might work quickly to conceal or destroy evidence if they know they are under suspicion. You should make sure to immediately secure all documents and other evidence that you might need late in your investigation. If you are conducting the investigation for a client, make sure they follow proper security measures to keep evidence intact, especially when it comes to digital evidence.<\/p>\n An effective investigation is one that is carefully planned. Failure to do so can cause problems from the outset, such as missing important details and evidence in the case, or running afoul of regulations such as reporting to FinCEN in the U.S. or FINTRAC in Canada.\u00a0Before you start the investigation, think about questions like:<\/p>\n Carefully document all the details and steps taken during the case to make sure your insurance fraud investigation stays on track.<\/p>\n When engaging with CRI Group\u2122, a fraud investigator will be allocated to your case. Read more about their skills and expertise in our article \u201cThe role of a FRAUD INVESTIGATOR.\u201d<\/a><\/p>\n This is where being an effective communicator comes into play. Most successful investigations include subject and witness interviews as a critical part of the evidence-gathering process:<\/p>\n During an insurance fraud investigation, and when reporting the results, an investigator should take care to separate his opinion from the facts of the case. The investigator should let the hard facts of evidence speak for itself in the case, rather than engaging in speculation or providing opinions on guilt or innocence. This is why proper evidence collecting and examination is so important. Files, documents and other evidence should be kept secure and chain-of-custody should be maintained. Never alter or mark up original documents or files with your own notes, even if they seem relevant. Keep copies for your files and make sure nothing slips through the cracks.<\/p>\n When your investigation has concluded, it\u2019s time to report the results. Prepare a thorough, facts-based report detailing the evidence and your findings. A good investigation report should include the following items:<\/p>\n Write your report in objective language, avoiding judgemental or inflammatory adjectives when describing details of the case. Use as many direct quotations as possible from interviewees or documents. Only include facts, not opinions or inferences, in your report.<\/p>\n This three-part series of articles is part of our “The Unseen Enemy: Insurance Fraud”<\/em> e-book. The e-book contains actionable advise on how to protect your business from insurance fraud and much more. Download the FREE e-book here!<\/strong><\/p>","protected":false},"excerpt":{"rendered":" This three-part series of articles examines the problem of insurance fraud, including its pervasiveness and general characteristics in the United States, the United Kingdom and the world. Insurance fraud is a widespread problem that requires real solutions and is often difficult to detect and combat. Part One of the series, \u201cWhat is Insurance Fraud,\u201d provides […]<\/p>","protected":false},"author":1,"featured_media":23452,"comment_status":"closed","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[48,111,43,146],"tags":[],"class_list":["post-8982","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-insurance","category-insurance-fraud-investigation","category-investigative-solution","category-resources"],"gutentor_comment":0,"yoast_head":"\n\n\n\n\n\n\n\n\n\n\n\n\n\n\t\n\t\n\n\n\n\n\t\nPart Three: Anatomy of an Insurance Fraud Investigation<\/span><\/strong><\/h2>\n
Case Study: Health Insurance Fraud<\/span><\/strong><\/h3>\n
When it\u2019s Time to Open an Investigation<\/span><\/strong><\/h3>\n
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3 types of insurance fraud investigations<\/span><\/strong><\/h3>\n
1.\u00a0\u00a0\u00a0\u00a0 Social Media Evidence<\/span><\/h4>\n
2.\u00a0\u00a0\u00a0\u00a0 Activity Check<\/span><\/h4>\n
3.\u00a0\u00a0\u00a0\u00a0 Fake Documentation of the Claim<\/span><\/h4>\n
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6 Keys to Successful Insurance Fraud Investigations<\/strong><\/span><\/h3>\n
1. Follow the Law<\/span><\/h4>\n
2. Conduct an Initial Assessment<\/span><\/h4>\n
3. Plan the Investigation Well<\/span><\/h4>\n
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4. Perform Great Interviews<\/span><\/h4>\n
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5. Understand Evidence<\/span><\/h4>\n
6. Report the Findings<\/span><\/h4>\n
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