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A dishonest doctor or chiropractor will, for a fee, prepare fictitious medical reports, including invoices for several series of physiotherapy treatments. Sometimes the report of a legitimate accident victim changes only in the name, address and physical characteristics of the victim. In all other respects, the notifications are legitimate. They are not a report of the victim's actual injuries because the victim either did not exist or was not injured. Medical bills generated by such fiction amount to between $ 1200 and $ 3500. The numbers are kept small to avoid suspicion and entice insurers to make a quick settlement.
When I was a young adjuster I dealt with these taunts and paid fraudulent claims because I, like most young adjuster, was unaware of the amount of fraud being committed . Within a year, I learned and refused to pay for the suspected fraud and informed them that the insurance company I worked for would not pay anything and that they would sue. I was convinced that it was a scam when the lawsuit was never filed.
Due to the ease of use, an individual typewriter with word processors can prepare two hundred medical reports a day with doctors' laser printers that even generate their signature from a scanned image. The doctor, who is not involved in the procedure, receives $ 100 to $ 500 per report. The doctor is quite happy with his income because he does not have to see a patient or provide treatment.
This type of fraud operation can give hundreds of claims a month to individuals who were not injured or never injured. The claims could generate millions of dollars a year in net profits for lawyers, doctors and recruiters involved in the crime. By applying the maxims set out in the last chapter, these insurance criminals discovered that the person claimed to be injured, (that is, the lawyer's alleged client) will almost never be seen by an adjuster, investigator, or independent physician.
The criminals know that this is the case. as long as they keep the requirements small, no lawyer will have to take testimony from the person identified as injured. The criminals know that no one will go to the doctor's office to find out if they have really given the treatment requested. Since the insurance criminals keep their medical treatment down to a minimal level and the demands from the lawyer are always reasonable, the damages are resolved quickly. The adjuster wizard praises the adjuster for closing files. The adjuster is rewarded for keeping cost costs down. The insurer saved the cost of a lawyer. The fraud was a success.
Sometimes we read reports that the police or fraud agencies arrested a massive fraud. The grippers only touch the cream on top of the glass with milk. The rest remains. It is greed that makes the criminal's demands high enough to get the insurer to investigate the claim.
Insurance companies must realize that savings of cost dollars can, and almost always will, cost them more in compensation dollars.
New. database system enables insurers to obtain records of all claims supported by the skewed chiropractor, lawyer or physician. If the volume is too high, the information provided to an insurer from the Compensation Database, CLUE or other databases will give rise to suspicions of fraud that are sufficient to force a thorough fraud investigation.
© 2022 – Barry Zalma
Barry Zalma, Esq., CFE, now limits his practice to the position of insurance consultant specializing in insurance coverage, handling insurance claims, bad faith and insurance fraud almost equally for insurance fraudsters policyholder.
He practiced law in California for more than 44 years as an attorney for insurance coverage and claims management and more than 54 years in the insurance industry.
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