Part Three: Anatomy of an Insurance Fraud Investigation
The insurance fraud epidemic is of serious concern to businesses, insurance providers and consumers worldwide. In Part One 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, we looked at how companies can detect insurance fraud, including how to recognize the red flags that represent potential criminal behavior.
In this final Part Three, we’ll examine the elements of an insurance fraud investigation, beginning with a case study that illustrates how CRI Group’s insurance fraud investigators exposed fraud schemes – saving its clients thousands of dollars.
Case Study: Health Insurance Fraud
A CRI Group client requested an investigation of a health insurance claim filed by one of their employees, “Mr. Jones.” 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.
As part of CRI Group’s “experts in a field” 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’s 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’s administrator confirmed that the clinic is only in the business of providing cosmetic surgery for women.
CRI Group’s 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’s 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.
Later, the doctor told CRI Group’s expert that while “we don’t treat that kind of illness,” the patient “was in such bad condition that we treated him on a humanitarian basis.” 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 successfully secured the evidence that the health insurance invoices were fake and Mr. Jones was making false claims to get money from his employer.
When it’s Time to Open an Investigation
When red flags of fraud are uncovered, it’s time to begin an investigation. As you can see from the examples above, CRI Group’s 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 assign the appropriate investigators with the right expertise in that area to investigate the claim.
- The investigators will contact the parties involved to gather all relevant details about the incident.
- CRI Group’s experts will use all resources available, including police reports, court filings, database records and other means to establish the truth in insurance fraud cases.
- The investigators will make site visits, speak to witnesses, take photos and establish timelines as needed to create a full, truthful story of the incident.
- CRI Group’s investigator(s) will uncover useful evidence, carefully documenting and preserving it in a way that is admissible in court.
- CRI Group will present its findings to the client, with recommendations on how to proceed. Sometimes, legal action is warranted.
Working with an insurance fraud investigation company 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.
Our global presence ensures that no matter how international your operations are, CRI Group’s investigations 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.