...The presence of fraud in the insurance industry is not an unknown one. Health insurance seems to have large number of these fraud cases. A larger point of concern is that as per statistics, 90% of the insurance frauds come from health policies itself. Since the key motive for every fraud is financial profit, there are no exceptions to the people who are involved in it. The involvement of these people in these cases could range from the customer, to the agent, member of hospital in question, or even the employee of the insurance company itself. COMMON OCCURRING FRAUD IN THE INDUSTRY Health frauds can be broadly divided into hard frauds and soft frauds. Each of these categories consists of situations ranging from misinterpretation of facts, to fabrication of documents, and even situations including inflation of claims. Here are some of the malpractices that the industry comes across: * Misrepresentation of facts: This is one of the largest frauds; a case qualifies as misrepresentation when the applicant is completely aware of inaccuracy of the statement provided. The most commonly falsely stated details are regarding the details of medical condition, incorrect personal details such as name, age, identity or even information such as medical history, past claim information and so on. * Fabrication of documents: It is commonly noticed that it often acts as frequent form of fraud related activities that the industry is facing now a days. These documents range from those regarding...
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...Darlene Couture Lgl, Poli, Ethcl Dimns of Busn Professor: Louis Pearsall 01/19/2013 HB119 Personal Injury Protection (PIP) for Auto Insurance Fraud General Bill by Economic Affairs Committee and Insurance & Banking Subcommittee and Boyd (CO-SPONSORS) Albritton; Broxson; Costello; Horner; Tobia; Wood | Motor Vehicle Personal Injury Protection Insurance: Revises conditions for completing long-form traffic crash report; provides that certain entities exempt from licensure as health care clinic must nonetheless be licensed in order to receive reimbursement for provision of PIP benefits; requires that application for licensure, or exemption from licensure, as health care clinic include statement regarding insurance fraud; specifies additional unfair claim settlement practice; authorizes Division of Insurance Fraud of DFS to establish direct-support organization for purpose of prosecuting, investigating, & preventing motor vehicle insurance fraud; specifies effects of Florida Motor Vehicle No-Fault Law. | Effective Date: July 1, 2012 | Last Event: Chapter No. 2012-197; companion bill(s) passed, see CS/CS/HB 1101 (Ch. 2012-151) on Sunday, May 06, 2012 8:42 PM | Date Available for Final Passage: Tuesday, March 13, 2012 6:19 PMhttp://www.myfloridahouse.gov/Sections/Bills/billsdetail.aspx?BillId=47180 | 1. State the administrative agency which controls the regulation. Explain why this agency and your proposed regulation interest you (briefly). Will this proposed regulation...
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...to types of insurance that would be relevant to my professional future. The first site that I chose to research was “http://smallbusiness.findlaw.com/liability-and-insurance/businessliability.html”. This website deals with Business Liability, and within that are a plethora of areas so i’ll keep it simple and cover four. They are An Employer’s Liability for Employee’s Acts, Tortious Interference, Driving on Company Time, and Protecting Customer Data. An Employer’s Liability for Employer’s Acts- This category stood out to me because working in the food industry you will always find a big laminated poster of all of the employee’s rights and acts. In-fact I believe it is required by law that all businesses display an updated version. One of the most interesting facts that I read was that the Employer rather than the employee is responsible for the employees actions in the event there is an incident. Why you ask? Well there are two reasons why. First, plain and simple, “employer are seen as directing the behavior of their employees and accordingly, must share in the good as well as the bad.” This may sound brash but on the other hand, the employer reaps the rewards of an employees labor in the form of profit . The second reason is that when a workplace injury or incident occurs, the legal system wants to get as much compensation for the victim in the most effective way, and that is to go after the employer. Employers are more likely to have insurance coverage at...
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...his supervisor and the chief financial officer both were unhappy with it. After that Phil Bradley called Kevin Pfeiffer to go back to work and haul all the underground wire and the systems prior to the arrival of the insurance adjustor. If Kevin perform this task than it would be damage of more than $500,000 which is beyond the actual estimate damage of $15,00.Kevin refused to perform the task and Matt called up to perform this task for them. Antonio faced dilemma such as what to do in this situation. He has mainly two choices such as a) to take a lawful action or b) compromise with person ethics. Antonio Melendez not feels any confident regarding bypass the chief financial officer Roger. Antonio Melendez not sure about his decision because he knows well very that there are no mechanisms was in place to report wrong-doing internally, and no protections were available for whistle-blowers. He had knowledge about the Empress Luxury Lines successfully defraud the insurance company in the past. Antonio Melendez was concerned about whether or not he should just sweep the issue under the rug. He feels that t the person most likely to be penalized internally was the whistle blower. Before Antonio joined Empress, there were rumors that company successfully defrauded insurance companies and the upper level-management has condoned such practice. 2) Create and...
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...Definition of Insurance Fraud Insurance fraud is a duplicitous action done with the intent of gaining or profiting from a claim or payment from an insurer. Insurance fraud is committed by a people coming from various walks of life. There are many cases of insurance fraud committed by doctors, layers, automobile insurers, salesman, and insurance agents and also by people in positions of trust. By law, any person who makes false claims and inflated claims in order to gain profit and benefit by mains of insurance can be prosecuted in the court of law. Types of Insurance Fraud In general terms, the law enforcing officers an lawyers distinguish insurance fraud in to two categories. They are: Hard Fraud: It is considered a serious crime than a soft fraud. A hard fraud is when a person purposefully fakes or sets up an accident, injury theft, arson or other loss to claim money by cheating the insurance companies. Hard frauds are usually committed by single individuals, but there has been an increase in the organized crime rings who setup large scale schemes to steal huge amounts of claim money. Soft Fraud: These are considered softer crimes and are usually not as serious as hard fraud. These types of crimes are characterized by "little white lies" to the insurance company, the purpose of these soft frauds is to get a change to file a claim or maximize the claim amount. Even though this is not considered harmful it is a crime. Lancaster man case A recent case of insurance fraud happened...
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...themselves or others in some way. Such misbehaviour infringes accepted societal norms. 2. Define compulsive consumer behaviour. Ans: it is the compulsion of buying which has serious consequences. 3. What is a consumer boycott and why would a consumer resort to this? Ans: rejection of a brand or company and the encouragement of the others to so not deal is known as consumer boycott. A consumer would resort to such kind of behaviour when he or she is not satisfied with the product and hence discourages other to buy it. 4. What is consumer misbehaviour related to products and services? Ans: Shop Lifting costs billions of pounds to retailers every year and consumers not only steal products but also engage in insurance fraud, hotel thefts and phone service fraud which also costs millions of pounds every year. 5. What is consumer misbehaviour related to price? Ans: If a consumer has standard rail ticket yet occupies a seat ina first class compartment. This is misused of a service but it is also an example of use without paying which in many guises is misbehaving over price. 6. What is consumer misbehaviour related to distribution? Ans: Boot legging is where illegal copies of dvd’s, videos etc are made and sold. It is considered as distribution misbehaviour as a pricy one. Counter fitting of brands is also distribution misbehaviour as well as pricing...
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...be non-payment of goods by the buyer or non-delivery of the goods by the seller. It is also difficult to judge the authenticity of buyers and sellers in advance, which creates a problem for eBay by having to verify the people involved in the transaction. Also, another problem would be transportation of goods from one place to another. eBay has no control on the delivery schedule of products as they have to rely on the transportation system the seller chooses. 3. How does eBay address these problems? eBay addresses these problems by insuring the buyers for non-delivery/damaged delivery of products. It also establishes in-house fraud prevention and escrow services to prevent fraudulent transactions. eBay also has one of the best payment mechanisms in the industry. Further, it blocks people for future transactions who have committed frauds on the website. 4. What are the contracting costs at eBay? The costs would be costs related to website maintenance, costs...
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...possibilities of loss or no loss,” and speculative risk is described as a “situation in which either profit or loss is possible” (Rejda, 2008, p. 6). Based on what you know about these types of risk, why do private insurers typically refuse to insure speculative risks? How does the law of large numbers affect speculative and pure risks? Discuss why personal, property, and liability risks are pure risks and provide examples in your response. Week 1 DQ 2 Recall that insurance creates benefits and costs for society. Review some of the benefits of insurance outlined in Ch. 2 (pp. 28–29) of the text. Compare those benefits with the costs of insurance described on the Web site for the Coalition Against Insurance Fraud at www.insurancefraud.org. Click on the Consumers button followed by the Useful Link and then click on the Learn About Fraud link. According to the Web site, how much does insurance fraud cost Americans each year? How are individuals and families impacted by insurance fraud? Why should the benefits and costs of insurance matter to you? In your opinion, do the benefits outweigh the costs or do the costs outweigh the benefits? For more Assignments visit:...
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...Section 4 quiz Which of the following describes prior approval as a type of rating law? The insurer files policy rate information with the Department of Insurance. After filing, the insurer delivers evidence that the rates proposed are reasonable and fair. Then the insurer waits (30-60 days) for approval. A subsequent violation of a cease and desist would result in: license suspension Which one of the following is not one of the three principal parts to the privacy requirement of the Gramm-Leach-Bliley Act? Credit Reporting Which of the following is a responsibility of the Commissioner? To enforce the law of insurance. Which of the following statements about insolvency is TRUE? An insurer cannot escape the condition of insolvency by being able to provide for its liabilities and reinsurance of all outstanding risks. Rates shall remain in effect if they are: all of the following Which of the following is a penalty for violating the Insurance Information and Privacy Protection Act? $50,000 fine for violations committed with regularity showing they are a general business practice Who administers the California Administrative Code of Regulations? Commissioner Which of the following is NOT a type of rating law? Legal Competition What is the role of the Commissioner and the Department of Insurance in relation to consumers? The Commissioner and the DOI are responsible for regulating the conduct of agents and insurers. Which court case reversed the...
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...How to Submit the Required Documentation DO NOT FAX THIS PAGE Choose an option (Online or Fax) and follow the steps Online (Recommended) 1 Print, fill out and sign the Sworn Affidavit & Proof of Loss Statement. Found on page 2 of this document. 2 Scan or take pictures of both the completed affidavit and your valid photo ID. Acceptable forms of photo ID: valid driver’s license, passport, federally issued ID card or matricula consular ID. 3 Upload both documents at phoneclaim.com/verizon-uploader Fax 1 Print, fill out and sign the Sworn Affidavit & Proof of Loss Statement. 2 Photo copy your valid photo ID and handwrite your Claim ID number on the paper. 3 Fax both documents to 1-877-595-1399. How to prevent delays in processing your claim The document is marked with a barcode that is specific to your claim. Using a photocopy with an incorrect barcode will delay your claim Make sure you have a valid photo ID • Acceptable forms of photo ID: valid driver’s license, passport, federally issued ID card or matricula consular ID • Unacceptable forms of ID: student ID, work ID, birth certificate and Social Security card • Name on the ID must match name of the Verizon Account Owner/Account Manager who completes the Sworn Affidavit & Proof of Loss Statement • If name does not match, then you may need to provide additional documentation • The ID cannot be expired. If the ID appears altered, forged, illegitimate or unreadable, we will not be able to proceed with your claim Make sure...
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...Health care Fraud Health care fraud is a crime that has a significant effect on the private and public health care payment system. According to the Federal Bureau of Investigation, all health care programs are subject to fraud with Medicare and Medicaid being the most visible. It is estimated that fraudulent billings to both private and public health care programs are between 3 and 10 percent of total health care programs expenditures. The most recent Centers for Medicare and Medicaid (CMS) statistical estimates project that total health care expenditures are estimated to total $2.4 trillion, representing 14 percent of the gross domestic product. By the year 2016, CMS also estimates that by the year 2016, the total health care spending is to exceed $4.14 trillion, representing 19.6 percent of the GDP. As one can see, the tens of billions of dollars lost due to health care fraud is a serious financial issue that affects the healthcare system as a whole and affects patients, taxpayers, and government through higher health care costs, insurance premiums and taxes. Health care fraud is defined in Title 18, United States Code (U.S.C) s. 1347 as “whoever knowing and willfully executes or attempts to execute a scheme or artifice to defraud any health care benefit program or to obtain, by means of false or fraudulent pretenses, representations or promises, any money or property owned by or under the custody or control of, any health care benefit program.” In other words, it is intentional...
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...Healthcare Fraud is when false information is promoted as the truth. The fraud could show in many forms, some as simple as billing for services that are not rendered. There are many types of fraud but some of the most common are billing for services not provided, billing for more expensive service not rendered, medically unnecessary services, misrepresenting services not covered by insurance to be medically necessary in order to receive insurance payments, falsifying a patients diagnosis to do unnecessary care or surgery, unbundling, and waving a co-pays or deductibles and overbilling the insurance company. No one really knows how much healthcare fraud is costing but the FBI estimates that it is around 80 billion a year and will continue to grow as healthcare cost rise. Healthcare fraud has become more prevalent with a lot of people. Health care fraud is not just committed by dishonest health care providers. “So enticing an invitation is our nation's ever-growing pool of health care money that in certain areas - Florida, for example - law enforcement agencies and health insurers have witnessed in recent years the migration of some criminals from illegal drug trafficking into the safer and far more lucrative business of perpetrating fraud schemes against Medicare, Medicaid and private health insurance companies.(NHCAA, Retrieved January 26,2014).” Healthcare fraud is not only being perpetrated by doctors, businesses but also many others such as drug dealers, and private citizens...
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...White Collar Crime Principles and Theory of Securities Management For: Professor Leiman By: Jaime Gwidt June 25th, 2016 Introduction This paper will cover the security crimes of credit card and health care fraud. It will discuss how these crimes are committed, their impacts on organizations and the tools a security professional has available to reduce opportunities for such crimes to occur. It will also cover an example of how credit card fraud was discovered and discuss possible measures that could have deterred those found guilty. Credit Card Fraud Credit card fraud occurs “when consumers give their credit card number to unfamiliar individuals, when cards are lost or stolen, when mail is diverted from the intended recipient and taken by criminals, or when employees of a business copy the cards or card numbers of a cardholder” (Chase, 2016). Credit card fraud is discovered by recognizing a break in spending patterns. An example would be if you live in one area of the US and you have charges happening in another part of the states, that may tip the scales in favor of possible fraud, and your credit card company might decline the charges and ask you to verify them. Businesses and organizations are negatively impacted by credit card fraud. Small business is most negatively impacted. Targets won’t be happy about the massive losses, but small businesspeople can get destroyed. If fraudsters charge up a storm on stolen card data with a given merchant, and that merchant...
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...Reporting Practices and Ethics Paper Jessy Dominique-Clark HCS/405 Health Care Financial Accounting September 24, 2013 Debra Brindley Reporting Practices and Ethics Paper The National Health Care Anti-Fraud Association assess that the economic damages cause by health care fraud is more than ten of billon dollars every year. Financial controlling is difficult, but by using the four fundamentals of monetary management correctly and following the generally accepted accounting principles, revealing the financial position of an organization is not difficult ("The Challenge of Health Care Fraud", 2012). The four fundamentals of monetary management are controlling, decision-making, organizing, and planning. Controlling entails ensuring that every area of the organization is adhering to the plans that have been established. The decision-making process entails making an educated choice. Organizing entails using the organizations resources to successfully carry out the plans that have been established. The process of planning is to compile goals of the organization and then to identify the steps necessary for achieving these goals. The financial management team is accountable for ensuring the reports are up-to-date, and they are accountable for reporting the funds with the principles set forth by the code of ethics and mission statement of the organization. Every organization has the obligation and wants the veracity to release the correct financial position to its stakeholders...
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...Insurance fraud occurs when any act is committed with the intent to fraudulently obtain some benefit or advantage to which they are not otherwise entitled to. Health insurance Fraud is becoming one of the top forms of fraud in America. Insurance fraud cost Americans billions of dollars every year as well as higher premiums. It is viewed as mostly a white-collar crime but it can come in many different forms. People who usually commit these kinds of frauds are motivated by greed for necessity or seeking wealth and luxury. There are several ways that healthcare companies are committing health insurance fraud. Examples of healthcare fraud include billing for services or supplies that were not provided, or billing Medicare for missed patient appointments, and altering CMS claim forms for higher payment amounts.. A successful prosecution of a health care provider that ends in a conviction can have serious consequences. The health care provider faces incarceration, fines, and possibly losing the right to practice in the medical industry. In Florida, it was reported that a physician was sentenced to 24 months incarceration and ordered to pay $727,000 in restitution fees for signing blank prescriptions and certificates of medical necessity for patients he never saw (Rudman, 2009). This is an example of the criminal liability that can result from healthcare fraud. In the case United States ex rel. Donigian v. St. Jude Medical agreed to pay $16 million to quiet allegations of paying...
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