Special Investigation Unit
Special Investigation Unit (SIU)
The purpose of a special investigative unit is to assure the effective implementation of a dedicated team to educate, train, protect, detect, and communicate with insurers and law enforcement agencies regarding possible fraudulent claims. In many states, the SIU department can be contracted to a third party to operate on behalf of the insurer. Our services include:
- Educating and training personnel in identifying patterns and trends of suspected fraudulent claims, effectively analyzing claim forms.
- Interviews and other investigative techniques.
- Prepare and submit district attorney insurance fraud referrals (packets).
Workers’ Compensation Fraud
EMPLOYEE FRAUD: An employee knowingly files a claim for injury that did not occur at all or did not occur in the course and scope of employment.
BILLING FRAUD: Medical provider bills for services NOT rendered, or intentionally inflate charges for services, or bills for services provided by non-licensed or unqualified personnel.
PREMIUM FRAUD: Committed by an employer who intentionally under reports the number of claims or under reports the number of employees on the payroll.
EMPLOYER FRAUD: Employer denies benefits to an employee by not reporting claim or encouraging employee not to report claim.
MEDICAL FRAUD: Medical industry use of runners, cappers, providing kickbacks or other illegal sources associated with obtaining cases/claims.
Insurance Fraud Defined
Each state has their own legal definition but each shares common elements:
The purpose of a special investigative unit is to assure the effective implementation of a dedicated team to educate, train, protect, detect, and communicate with insurers and law enforcement agencies regarding possible fraudulent claims. In many states, the SIU department can be contracted to a third party to operate on behalf of the insurer. Our services include:
- Educating and training personnel in identifying patterns and trends of suspected fraudulent claims, effectively analyzing claim forms.
- Interviews and other investigative techniques.
- Prepare and submit district attorney insurance fraud referrals (packets).
Red Flag Indicators
- Un-witnessed injury
- Late reporting
- Subjective complaints
- Reporting after weekend
- Short term employment
- Prior claims history
- Disciplinary problems
- Medical diagnosis is not consistent with mechanism of injury
- Witnesses in close proximity unable to substantiate allegations
- Refusal to report employee claim
- Sending employee to own doctor and submitting under own health insurance
- Altering dates or times of injury with intent to have claim denied
- Providing false facts to Claims Examiner
- Providing payment or kickbacks to doctors for opinions
- Altering medical documents
- Submitting claims that did not occur within course and scope of employment in attempt to allow employee some form of benefit