Status works as a Special Investigations Unit (SIU) for our clients as needed. This type of work is often associated with cases of fraud.
Some of the key reasons for SIU investigations are:
- Suspicious Claims: Claims that have inconsistent or incomplete information, lack supporting evidence, involve multiple parties or policies, or deviate from the normal patterns of claims behavior.
- Fraud Indicators: Red flags that suggest possible fraud, such as staged accidents, exaggerated injuries, inflated bills, forged documents, false identities, or prior fraud history.
- Fraud Referrals: Tips or complaints from internal or external sources, such as employees, agents, customers, witnesses, law enforcement, or other insurers, that report suspected fraud activities or schemes.
- Fraud Audits: Systematic reviews of claims data, records, and processes to identify fraud trends, patterns, anomalies, or vulnerabilities.
We will work with you to determine the best use of a SIU investigation.
Status conducts different types of SIU fraud investigations to handle the different scope and natures of the fraud:
- Claim Investigation: This verifies the validity and accuracy of a claim and its supporting documents, such as medical records, invoices, receipts, police reports, etc. Claim investigation may involve interviews, surveillance, background checks, data analysis, or other methods to gather evidence and establish facts.
- Underwriting Investigation: This verifies the applicant's or policyholder's eligibility and risk profile for insurance coverage. Underwriting investigation may involve verifying personal information, financial status, medical history, driving record, criminal record, or other factors that affect the underwriting decision and premium calculation.
- Provider Investigation: This investigates the practices and conduct of a healthcare provider who is involved in an insurance claim. This type of investigation may involve reviewing billing records, medical records, treatment plans, prescriptions, referrals, or other documents to detect fraud schemes such as billing for services not rendered, upcoding, unbundling, kickbacks, or unnecessary treatments.
- Organized Fraud Investigation: This investigates a complex and coordinated fraud scheme that involves multiple parties, such as claimants, providers, attorneys, brokers, adjusters, or others. Organized fraud investigation may also involve uncovering the links and relationships among the participants, tracing the money flows and transactions, identifying the leaders and organizers, and exposing the modus operandi and objectives of the scheme.
Take a Closer Look at Status Investigative Group.
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