Ohio Miscellaneous Regulatory Material
DEPARTMENT OF INSURANCE BULLETINS
Bulletin 96-1 Reporting suspected fraudulent insurance claims
Effective Date
July 2, 1996
July 2, 1996
|
Ohio Miscellaneous Regulatory Material Bulletin 96-1 Reporting suspected fraudulent insurance claims |
Effective Date
July 2, 1996 |
This Bulletin rescinds and supersedes existing Department of Insurance BULLETIN 93-6 dated November 19, 1993, entitled Reporting Suspected Fraudulent Property And Casualty Insurance Claims.
Ohio Administrative Code Rules 3901-1-54(G) and 3901-1-60(G) were enacted to establish minimum standards for the investigation and disposition of property/casualty and health claims arising under policies, certificates or contracts issued pursuant to Ohio Revised Code Titles 17 and 39.
These Rules require insurers to report to the Fraud Division, Ohio Department of Insurance, information regarding a claimant who has submitted a fraudulent insurance claim. The purpose of this Bulletin is to outline specific procedures to follow and appropriate forms to use when reporting insurance fraud. The documentation submitted will assist the Department with the prosecution of insurance fraud cases.
Ohio Administrative Code RULE 3901-1-54(G) establishes the following fraud reporting requirement for property/casualty claims:
If an insurer reasonably believes, based upon information obtained and documented within the claim file, that a claimant has fraudulently caused or contributed to the loss as represented by a properly executed and documented proof of loss, such information shall be presented to the Fraud Division of the Department within sixty days of receipt of the proof of loss. Any person making such report shall be afforded such immunity and the information submitted will be confidential as provided by sections 3901.44 and 3999.31 of the Revised Code.
Ohio Administrative Code RULE 3901-1-60(G) establishes the following fraud reporting requirement for health claims:
If a third-party payer reasonably believes, based upon information obtained and documented, that a claimant has fraudulently caused or contributed to the claim as represented by a properly executed and documented claim form or billing, such information shall be presented to the Fraud Division of the Department within sixty days of when the fraud becomes evident. Any person making such report shall be afforded such immunity and the information submitted shall be confidential as provided by sections 3901.44 and 3999.31 of the Revised Code.
If evidence of insurance fraud is indicated more than sixty days after receipt of the proof of loss (for property/casualty claims) or more than sixty days after the fraud becomes evident (for health claims), the information should be reported immediately to the Department.
Information regarding the fraudulent claim should be reported to the Fraud Division on the Fraud Reporting Form, INS 1100 REV 96 (see Attachment A). The Department will accept copies of this form.
Any insurer or third-party that is a member of the National Insurance Crime Bureau (NICB) may report appropriate information on the NICB Form #27 or report through a fraud reporting bureau's computer network if the Ohio Department of Insurance is provided access to such computer network.
Completion of the Fraud Reporting Form or other approved reporting method will satisfy the reporting requirement, unless requested by the Department, you are not required to submit copies of your claim file.
Once an insurer or other third-party has resolved or completed disposition of the claim that was previously reported to the Department as a fraudulent claim, a disposition report should be submitted to the Fraud Division of the Ohio Department of Insurance within ninety (90 days). The report should be submitted on the attached Final Disposition Reporting Form, INS 1102 (see Attachment B) or other appropriate and approved form(s) and should include the name of the insured/claimant and the claim/policy number.
Fraud Division
Ohio Department of Insurance
2100 Stella Court
Columbus, Ohio 43215-1067To satisfy the requirements of this Bulletin, all insurance fraud reporting information should be submitted to:
Phone: (614) 644-2671
(Ohio only)
1-800-686-1527
Fax: (614) 644-3327Harold T. Duryee
Superintendent of InsuranceATTACHMENT A
SUSPECTED FRAUDULENT CLAIM _____________________ DATE OF DISCOVERY _____
_______________________________ CLAIM NO _______________________________
NAME OF REPORTING CARRIER: _____________________________________________
ADDRESS: ______ CITY & STATE: __________________________________________
CONTACT PERSON: ______________________ TELEPHONE: ______________________A. DESCRIBE NATURE OF SUSPECTED FRAUDULENT ACTIVITY. (CHECK ALL THAT APPLY)
CLAIMANT MAY HAVE: MEDICAL PROVIDER MAY HAVE:
1. FAKED PROPERTY DAMAGE [] 13. PROVIDED AN INACCURATE/ []
INCOMPLETE HISTORY
2. INFLATED FINANCIAL LOSS [] 14. BILLED FOR SERVICES NOT []
PROVIDED
3. FAKED/EXAGGERATED INJURY [] 15. BILLED FOR EXCESSIVE OR []
EXTENDED TREATMENTS
4. STAGED ACCIDENT/INJURY [] 16. VIOLATED BUSINESS AND []
PROFESSIONS CODE/REG
5. BEEN KNOWN TO FILE SUSPECT [] 17. RECEIVED COMPENSATION FOR []
MEDICAL CLAIMS REFERRAL TO AND LEGAL
PROVIDERS
6. DEFRAUDED HEALTH CARE [] 18. HIRED OR PAID CAPPERS TO []
PROVIDER RECRUIT CLIENTS
19. OTHER (EXPLAIN): []LEGAL PROVIDER MAY HAVE: OTHER PERSON OR ENTITY MAY HAVE:
7. HIRED OR PAID CAPPERS/CHASERS [] 20. FABRICATED SERVICES []
TO RECRUIT CLIENTS
8. RECEIVED PAID COMPENSATION [] 21. CHARGED INCONSISTENT WITH []
FOR REFERRAL TO MEDICAL SERVICES PROVIDED
PROVIDER
9. CHARGED INCONSISTENT WITH [] 22. PROVIDED AN INACCURATE/ []
SERVICES PROVIDED INCOMPLETE HISTORY
10. BEEN KNOWN TO HANDLE SUSPECT [] 23. OPERATED WITHOUT A LICENSE []
CLAIMS
11. NEVER SEEN CLIENT. NON-LEGAL [] 24. RECEIVED PAID COMPENSATION []
STAFF HANDLES CASE FOR REFERRAL TO MEDICAL OR
LEGAL PROVIDER
12. OTHER (EXPLAIN): [] 25. OTHER (EXPLAIN): []SUMMARY OF SUSPECTED FRAUD _____________________________________________
________________________________________________________________________
________________________________________________________________________B. WHAT INFORMATION HAS BEEN DEVELOPED TO CONFIRM YOUR SUSPICION? (CHECK ALL THAT APPLY) (IF INFORMATION IS BEING DEVELOPED, PLEASE NOTE BELOW)
1. WITNESSES [] 5. VIDEOS (SUB-ROSA) [] 9. MULTIPLE CLAIMS FOR SAME []
LOSS
2. PHOTOGRAPHS [] 6. INVESTIGATIVE REPORTS [] 10. DEPOSITION/SWORN []
TESTIMONY
3. MEDICAL REPORTS [] 7. CORRESPONDENCE [] 11. CLAIMANT LIED UNDER OATH []
4. CONFLICTING [] 8. FALSIFIED DOCUMENTS [] 12. OTHER []
STATEMENTSINFORMATION BEING DEVELOPED ____________________________________________
C. DO YOU HAVE ANY REASON TO BELIEVE THIS INCIDENT IS RELATED TO OTHER FRAUDULENT ACTIVITY (CHECK ONE) YES NO IF YES, PLEASE DESCRIBE: ___
_____________________________________________________________________D. HAVE YOU REPORTED THIS MATTER TO OTHER ORGANIZATIONS? (INDICATE BELOW)
1. COUNTY PROSECUTOR'S OFFICE (COUNTY) _______________________________ _
2. OTHER LAW ENFORCEMENT _______________________________________________
4. NICB ______ 5. OTHER ________________________________________________(INS 1100. Rev. 96)
ATTACHMENT B
OHIO DEPARTMENT OF INSURANCE FINAL DISPOSITION REPORTING FORM
SIGNATURE NAME OF INSURANCE CO.
REFERRING PERSON ADDRESS
ADJUSTER/SIU NAME PHONE CITY/STATE/ZIP
CLAIM OR POLICY NO. INSURED/CLAIMANT
LOSS DATE (M/D/Y) FRAUD DIVISION'S FILE NO.
FINAL DEPOSITION:
CLAIM OR POLICY NO. INSURED/CLAIMANT
LOSS DATE (M/D/Y) FRAUD DIVISION'S FILE NO.
FINAL DISPOSITION:
CLAIM OR POLICY NO. INSURED/CLAIMANT
LOSS DATE (M/D/Y) FRAUD DIVISION'S FILE NO.
FINAL DISPOSITION:
CLAIM OR POLICY NO. INSURED/CLAIMANT
LOSS DATE (M/D/Y) FRAUD DIVISION'S FILE NO.
FINAL DISPOSITION:(INS 1102)
CROSS REFERENCE RULE 3901-1-54; RULE 3901-1-60
DATE NEW 1996
SUBJECT CATEGORY 060 - Health insurance / insurers
065 - Health service corporations
100 - Property and fire insurance / insurers
120 - Casualty and liability insurance / insurers
300 - The policy
360 - Filing and reporting requirements
700 - Trade practicesINDEX
Forms (documents) and Reporting requirements and Fraudulent claims
Health insurers and Reporting requirements and Fraudulent claims
Property insurers and Reporting requirements and Fraudulent claims
Casualty insurers and Reporting requirements and Fraudulent claims
Electronic filings and Reporting requirements and Fraudulent claims