hm anti-fraud training course

143 Pages·2015·2.23 MB·English

HM ANTI-FRAUD
TRAINING COURSE
Welcome!
This training is presented by the Special Investigations Unit (SIU) at HM
Insurance Group (HM).

The SIU investigates any claim or application for insurance that seems
to be suspicious or indicates that fraud is being committed.

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How Much is Lost to Fraud?
The National Health Care Anti-Fraud Association
estimates that 3% of the health care industry’s
expenditures in the United States are due to
fraudulent activities, amounting to a cost of about
$51 billion.1

Other estimates attribute as much as 10% of the
total health care spending in the United States to
fraud, or about $115 million.2

Sources: 1National Health Care Anti-Fraud Association. “The Problem of Health Care Fraud”; 2Hyman,
David A. “Health Care Fraud and Abuse.” p. 532

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Higher Premiums and Lost Jobs
Insurance fraud is not a victimless crime. It
affects everyone in the form of:
 Higher premiums  Job loss due to
which reduces your financial burdens placed
net income on employers as a
result of the increased
 Higher prices in and
cost of workers’
goods and services
compensation, property,
as the costs of
casualty and health
higher premiums are
insurance.
passed on to the
consumer.
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Why Fraud Training?
HM is licensed in 50 states, as well as in the District of Columbia.

Six (6) of these states (California, Florida, Kentucky, Maryland, New
Jersey and New York) have laws that mandate training.

According to state law, the training has to be at least two hours in
duration.

Since HM is licensed to conduct business in those states, we need to
adhere to their laws concerning fraud training.

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New Jersey Fraud Training
Since our covered lives exceed the
established threshold in New Jersey,
claims and underwriting are required
to take an additional two hours of
fraud related training every year.

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Course Objectives
Do you know how to recognize and combat fraud?
 A physician orders unnecessary lab tests and receives payment for
these services
 A pharmaceutical company offers free training or other benefits to a
doctor who prescribes their drug

After taking this training, you’ll be able to answer these
questions and determine the appropriate action to take to
help prevent fraud.
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Employee Fraud Scenario
Scenario: An employee who The answer: It’s fraud!
was injured at work has been
It is fraud. It’s fraud!
out of work collecting lost
It’s abuse!
time. Although he’s feeling
better, he’s been enjoying his
It’s both!
time off; so he tells his doctor
that he’s still in too much pain
It doesn’t affect me, so I don’t
in order to remain out of work care what it is.
for a longer period of time.

Is this fraud or abuse?

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Employee Fraud Scenario
Is this fraud or abuse? The answer: It’s fraud!
It is fraud. It’s fraud!
It’s fraud!

It’s abuse!
Do you know what type of
It’s both!
fraud it is?

It doesn’t affect me, so I don’t
care what it is.

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