Adjuster Fraud Investigation Checklist Essay

Published: 2021-06-29 01:52:38
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This occurs when a claims person purposely misrepresents the truth in ordertoeither deny or support a claim; or offers or accepts any form ofconsideration forthe referral or settlement of a claim. Examples:Accepting a gift, such as a television or trip to Hawaii, from a doctor’soffice in exchangefor an implied promise or patient referrals;Knowingly referring cases for rehabilitation services that are not needed,in exchange for arebate or other form of consideration;Altering the evidence in a claim in order to support a denial. “Red Flags”:Inconsistent application of cost-containment measures or agreement to payabove the feeschedule;Sloppy observance of procedure for referrals to outside vendors, orincrease in the use of a particular vendor, to the exclusion of others;Use of vendors outside the preapproved vendor panel;Assignments made to vendors where the need for the assignment isquestionable;Adjuster has social relationship with an applicant’s attorney or doctor;Adjuster is overheard soliciting, or is observed receiving, tickets orother gifts fromvendors. Adjuster’s lifestyle grossly exceeds apparent income.

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