AASCIF - july-august-september

Lisa Coreless
Vice President of Claim Operations
Texas Mutual Insurance Company

The best crime fighters never work alone. Sherlock Holmes had Dr. Watson, The Lone Ranger had Tonto, Batman had Robin.

Fraud investigators and claim adjusters can follow the dynamic duo formula to stamp out fraud. In 2001, our adjusters referred an average of 134 cases per month to our claimant, healthcare and provider investigative units.

Working together, your adjusters and investigators can produce similar results.

Front-line defense
An adjuster’s primary job is to authorize timely, appropriate benefits. Because they are in close contact with injured workers, healthcare providers and employers, adjusters can also be your front-line defense against fraudulent claims.

For example, why was it so hard for a Texas Mutual adjuster to contact a paraplegic between scheduled doctor appointments? Why would a man who had just been awarded lifetime income benefits worth $559,000 act annoyed when the insurance adjuster finally was able to reach him to follow up on a couple of points about his claim?

In this case, the adjuster decided too many things about the claim didn’t add up, so he contacted our Special Investigations Division. The resulting investigation revealed that not only was the man able to walk, he was so confident in his ability to continue doing so that he had sold the wheelchair-accessible van that Texas Mutual Insurance Co. provided him.

The three Ds: document, document, document
We’re not all born with a nose for sniffing out fraud.

That’s why our investigators periodically train our adjusters on how to recognize the warning signs of fraud and know when to refer a case to SID.

During the three-hour training session, investigators stress the importance of asking the right questions, identifying suspicious responses and, most importantly, documenting the responses. All of this information goes into the detailed claim diaries our adjusters maintain for every claim they handle. These diaries can be crucial evidence in court.

We recently won a case in which our investigator uncovered evidence that an injured worker had returned to productive employment with another company while continuing to collect temporary income benefits. In Texas, however, this is not enough to prove fraud. The prosecution must also prove that the employee knowingly lied in order to continue receiving benefits.

Fortunately, our adjuster’s claim diary showed that she had asked the claimant more than once whether she had returned to work. Each time, the claimant said she had not. Introducing the claim diary in court made the difference between a court victory and what could have been an embarrassing court defeat.

Of course, you can’t expect adjusters to double as investigators. They can, however, prove useful during an investigation as well as at the beginning.

Operation Darkmed was a two-year undercover sting operation we conducted jointly with the FBI. The investigation started when we identified healthcare providers that were submitting inflated or totally false medical bills.

An FBI agent posing as a “broker” of phony claims spread the word that he had bribed a corrupt adjuster at Texas Mutual Insurance Company. We set up a bogus employer policy against which the providers billed their phony claims. Our adjuster authorized payment, and the providers gave the “broker” his cut.

Partners against crime
With fraud schemes getting increasingly complex, it is getting harder for investigators to keep up with those who try to cheat the system. Even the best investigators need all the help they can get.

That’s where your adjusters come in. Once they learn to recognize the warning signs of fraud, they can be an investigator’s most valuable partners in the fight against fraud.

Lisa Corless can be reached at LCorless@texasmutual.com or (512) 404-7268.

Claim adjusters partner with investigators to get results

Claim adjusters partner with investigators
to get results