The document discusses insurance fraud, outlining what constitutes insurance fraud, penalties for committing insurance fraud, partners in fighting insurance fraud like the Division of Insurance Fraud and National Insurance Crime Bureau, and responsibilities of claims adjusters to be aware of fraud indicators and consult special investigation units if fraud is suspected. Insurance fraud is a serious crime that costs consumers an estimated $80 billion annually, so combating fraud protects consumers and helps control insurance costs.

1. FRAUD AWARENESS
TRAINING
BY
THE SIU GROUP

2. INSURANCE FRAUD
What is Insurance Fraud?
Any action taken by an individual with the intent to
fraudulently obtain payment from an insurer is considered
insurance fraud.
 Insurance Fraud is not a victimless crime. It is estimated that
insurance fraud costs the US $80 billion dollars or more a year.
Those costs get passed down to consumers. The Coalition
Against Insurance Fraud (CAIF) estimates that cost to be
approximately $950 per family. (AS NOTED BY DFS/DIF)

3. INSURANCE FRAUD DEFINED
817.234 False and fraudulent insurance claims.—
(1)(a) A person commits insurance fraud punishable as provided in subsection (11) if that person, with the intent to
injure, defraud, or deceive any insurer:
1. Presents or causes to be presented any written or oral statement as part of, or in support of, a claim for payment or
other benefit pursuant to an insurance policy or a health maintenance organization subscriber or provider contract,
knowing that such statement contains any false, incomplete, or misleading information concerning any fact or thing
material to such claim;
2. Prepares or makes any written or oral statement that is intended to be presented to any insurer in connection with,
or in support of, any claim for payment or other benefit pursuant to an insurance policy or a health maintenance
organization subscriber or provider contract, knowing that such statement contains any false, incomplete, or misleading
information concerning any fact or thing material to such claim;

4. 3.a. Knowinglypresents,causestobepresented,orpreparesormakeswithknowledgeorbeliefthatitwillbe
presentedtoanyinsurer,purportedinsurer,servicingcorporation,insurancebroker,orinsuranceagent,orany
employeeoragentthereof,anyfalse,incomplete,ormisleadinginformationorwrittenororalstatementaspartof,or
insupportof,anapplicationfortheissuanceof,ortheratingof,anyinsurancepolicy,orahealthmaintenance
organizationsubscriberorprovidercontract;or
b. Knowinglyconcealsinformationconcerninganyfactmaterialtosuchapplication;or

5. 4. Knowinglypresents,causestobepresented,orpreparesormakeswithknowledgeorbeliefthatitwillbepresented
to anyinsureraclaimforpaymentorotherbenefitunderapersonalinjuryprotectioninsurancepolicyiftheperson
knowsthatthepayeeknowinglysubmittedafalse,misleading,orfraudulentapplicationorotherdocumentwhen
applyingforlicensureasahealthcareclinic,seekinganexemptionfromlicensureasahealthcareclinic,or
demonstratingcompliancewithpartXofchapter400.
(b) AllclaimsandapplicationformsmustcontainastatementthatisapprovedbytheOfficeof InsuranceRegulationof
theFinancialServicesCommissionwhichclearlystatesinsubstancethefollowing:“Anypersonwhoknowinglyandwith
intenttoinjure,defraud,ordeceiveanyinsurerfilesastatementofclaimoranapplicationcontaininganyfalse,
incomplete,ormisleadinginformationisguiltyofafelonyofthethirddegree.”Thisparagraphdoesnotapplyto
reinsurancecontracts,reinsuranceagreements,orreinsuranceclaimstransactions.

6. (2)(a) Any physician licensed under chapter 458, osteopathic physician licensed under chapter 459, chiropractic
physician licensed under chapter 460, or other practitioner licensed under the laws of this state who knowingly and
willfully assists, conspires with, or urges any insured party to fraudulently violate any of the provisions of this section or
part XI of chapter 627, or any person who, due to such assistance, conspiracy, or urging by said physician, osteopathic
physician, chiropractic physician, or practitioner, knowingly and willfully benefits from the proceeds derived from the
use of such fraud, commits insurance fraud, punishable as provided in subsection (11). In the event that a physician,
osteopathic physician, chiropractic physician, or practitioner is adjudicated guilty of a violation of this section, the Board
of Medicine as set forth in chapter 458, the Board of Osteopathic Medicine as set forth in chapter 459, the Board of
Chiropractic Medicine as set forth in chapter 460, or other appropriate licensing authority shall hold an administrative
hearing to consider the imposition of administrative sanctions as provided by law against said physician, osteopathic
physician, chiropractic physician, or practitioner.
(b) In addition to any other provision of law, systematic up-coding by a provider, as defined in s. 641.19(14), with the
intent to obtain reimbursement otherwise not due from an insurer is punishable as provided in s. 641.52(5).
ANY LICENSED HEALTH CARE PROVIDER; MEDICAL DOCTOR,
OSTEOPATH, AND CHIROPRATOR FOUND GUILTY OF FRAUD WILL
BE REVIEWED BY THEIR BOARD FOR POSSIBLE DISCIPLINARY
ACTION AGAINST THEIR LICENSE.

7. (3) Anyattorneywhoknowinglyandwillfullyassists,conspireswith,orurgesanyclaimanttofraudulentlyviolateany
oftheprovisionsofthissectionorpartXIofchapter627,oranypersonwho,duetosuchassistance,conspiracy,or
urgingonsuchattorney’spart,knowinglyandwillfullybenefitsfromtheproceedsderivedfromtheuseofsuchfraud,
commitsinsurancefraud,punishableasprovidedinsubsection(11).
ATTORNEYS AND THEIR EMPLOYEES ARE
SUBJECT TO THE FRAUD LAW AS WELL

8. (4) Any person or governmental unit licensed under chapter 395 to maintain or operate a hospital, and any
administrator or employee of any such hospital, who knowingly and willfully allows the use of the facilities of said
hospital by an insured party in a scheme or conspiracy to fraudulently violate any of the provisions of this section or part
XI of chapter 627 commits insurance fraud, punishable as provided in subsection (11). Any adjudication of guilt for a
violation of this subsection, or the use of business practices demonstrating a pattern indicating that the spirit of the law
set forth in this section or part XI of chapter 627 is not being followed, shall be grounds for suspension or revocation of
the license to operate the hospital or the imposition of an administrative penalty of up to $5,000 by the licensing
agency, as set forth in chapter 395.
HOSPITALS AND HEALTHCARE FACILITIES
LICENSED UNDER F.S. 395

9. (5) Anyinsurerdamagedasaresultofaviolationofanyprovisionofthissectionwhentherehasbeenacriminal
adjudicationofguiltshallhaveacauseofactiontorecovercompensatorydamages,plusallreasonableinvestigationand
litigationexpenses,includingattorneys’fees,atthetrialandappellatecourts.
RECOVERING DAMAGES

10. SOLICITATION
(8)(a) It is unlawful for any person intending to defraud any other person to solicit or cause to be solicited any business
from a person involved in a motor vehicle accident for the purpose of making, adjusting, or settling motor vehicle tort
claims or claims for personal injury protection benefits required by s. 627.736. Any person who violates the provisions of
this paragraph commits a felony of the second degree, punishable as provided in s. 775.082, s. 775.083, or s. 775.084. A
person who is convicted of a violation of this subsection shall be sentenced to a minimum term of imprisonment of 2
years.
(b) A person may not solicit or cause to be solicited any business from a person involved in a motor vehicle accident by
any means of communication other than advertising directed to the public for the purpose of making motor vehicle tort
claims or claims for personal injury protection benefits required by s. 627.736, within 60 days after the occurrence of the
motor vehicle accident. Any person who violates this paragraph commits a felony of the third degree, punishable as
provided in s. 775.082, s. 775.083, or s. 775.084.

11. PARTNERS IN FIGHTING INSURANCE FRAUD
* FLORIDA DEPARTMENT OF FINANCIAL SERVICES –
DIVISION OF INSURANCE FRAUD.
* COALITION AGAINST INSURANCE FRAUD.
* NATIONAL INSURANCE CRIME BUREAU.
* INSURANCE COMPANIES.
* SIU – SPECIAL INVESTIGATION UNITS.
* CLAIMS ADJUSTERS.
* PRIVATE INVESTIGATION AGENCIES CONTRACTED
BY INSURANCE COMPANIES.
* MANY PRIVATE SECTOR CONTRACT SERVICES

12. JEFF ATWATER, CHIEF FINANCIAL OFFICER
FLORIDA DEPARTMENT OF FINANCIAL SERVICES,
DIVISION OF INSURANCE FRAUD
_________________________________________
Established by the legislature in 1976, the Division of Insurance Fraud is the law
enforcement arm of the Department of Financial Services and is responsible for
investigating insurance fraud; crimes associated with personal injury protection (PIP)
insurance fraud, insurance premium fraud, workers' compensation claim fraud, workers'
compensation premium avoidance and diversions, insurer insolvency fraud, unauthorized
entity fraud and insurance agent crimes.

13. DIVISION OF INSURANCE FRAUD
ANNUAL REPORT 2010-11  2010/11 DIF REFERRALS
TOTAL 13,452
 PIP Fraud 50% at 6,699
 FOLLOWED BY:
 WORKERS’ COMP 11% AT 1,495
 VEHICLE FRAUD 7% AT 1,008

14. Record Setting First Quarter for Florida Division of
Insurance Fraud
 Florida Chief Financial Officer Jeff Atwater reported a record setting first quarter
for the Florida Department of Financial Services Division of Insurance Fraud
(DIF). With over 100 arrests each month so far in 2012, and the most arrests in
over 2 decades for a single month in March, DIF’s impact is being felt.
 According to the press release from the Chief Financial Officer’s office:
 Under CFO Atwater’s leadership, the division has made nearly 1,400 arrests
and recovered more than $150 million in court-ordered restitution.
 In addition to these arrests, the division’s investigations have led to the
shutting down of more than 50 medical clinics due to intensive Personal
Injury Protection (PIP) fraud investigations. PIP fraud constitutes the highest
number of referrals to the division, and is a high priority for CFO Atwater.
 According to the report, DIF investigations have resulted in over 1,400 arrests
and recovery of over $150 million in court ordered restitution.

15. With a 100-year heritage, the National Insurance Crime Bureau (NICB) is the nation's premier not-for-
profit organization dedicated exclusively to fighting insurance fraud and crime, and is the only
organization in the United States that convenes the collective resources needed to prevent, detect and deter
these crimes.

The NICB was formed in 1992 from a merger between the National Automobile Theft Bureau (NATB) and
the Insurance Crime Prevention Institute (ICPI), both of which were not-for-profit organizations. The NATB –
which managed vehicle theft investigations and developed vehicle theft databases for use by the insurance
industry – dates to the early 20th century, while the ICPI investigated insurance fraud for approximately 20
years before joining with the NATB to form the present National Insurance Crime Bureau.
Today, our membership includes more than 1,100 property and casualty insurance companies, self-insured
organizations, rental car companies, parking services providers, and transportation-related firms.
Beyond our membership, our 300+ employees work with law enforcement agencies, technology experts,
government officials, prosecutors, international crime-fighting organizations and the public to lead a united
effort to prevent and combat insurance fraud and crime.

16.  NICB Reports a 19 Percent Rise in Questionable Claims Since 2009
 In 2009, there were 84,407 QCs referred to NICB from its member
insurance companies. In 2010, that number increased to 91,797. In
2011, that number increased again to 100,450—a record level. This
represents a 9.4 percent increase from 2010 to 2011. Over the two
year timeframe from 2009 to 2011 there was a 19 percent increase.
Questionable claims are those claims that NICB member insurance
companies refer to NICB for closer review and investigation based on
one or more indicators of possible fraud. A single claim may contain up
to seven referral reasons.

18. The power of unity
Flash back to 1993. Spiraling insurance scams were driving everyone's premiums higher and higher. The nation was
struggling with a mounting crime wave, looking for answers.
Leaders of the anti-fraud fight realized America needed a catalyst to unite and ignite the power of many diverse groups
against rampant fraud. Only a long term commitment would work against such a deeply entrenched problem.
The vision of these charter members became the Coalition Against Insurance Fraud — the nation's only anti-fraud
watchdog that speaks for consumers, insurance companies, legislators, regulators and others.
Control everyone's costs
The coalition has become one of America's most trusted and credible anti-fraud forces, thanks to our remarkable diversity.
Together, our members are working to control everyone's insurance costs, protect the public safety, and bring this crime
wave to its knees.
Since its founding in 1993, the coalition has worked effectively to....
• enact tough new anti-fraud laws and regulations
• educate the public how to fight back, and
• serve as a national clearinghouse of fraud information.

19. STATEWIDE PIP FRAUD ARRESTS APRIL 2012
 PARTIAL LIST
 Geraldo Caroni Gomez, 40 – staged acct 04/03/09 (driver) $28,375 - E & B Rehabilitation Center / Franco’s Medical
Center (Progressive / State Farm) M
 Enrique Moreno, 64 – PIP patient - $787 – Vital Care Medical Center (Allstate) W
 Magdalas Mortimer, 38 – staged acct 01/07/09 (passenger) $46,781 – Michigan Health & Rehab (Avis/Budget / State
Farm) O
 Marilia Etienne-Lubin, 47 – staged acct 01/07/09 (passenger) $46,781 – Michigan Health & Rehab (Avis/Budget / State
Farm) O
 Isemona Pierre, 25 – staged acct 01/07/09 (recruiter) $46,781 – Michigan Health & Rehab (Avis/Budget / State Farm) O
 Vilnor Perou, 41 – staged acct 01/07/09 (passenger) $46,781 – Michigan Health & Rehab (Avis/Budget / State Farm) O
 LaShanda Kaye Pleas, 29 – staged acct 05/01/10 (driver) staged acct 05/27/10 (driver) $30,945 - x (Omni) O
 Lucson Dupervil, 27 – fake ins card (Geico) W
 Edwin Ramirez Montalvo, 39 – fake ins card (National) W
 Shenika Keaton, 18 – staged acct 05/01/10 (passenger) $30,945 - Bedford Medical Chiropractic / Central Florida
 Medical & Chiropractic Center / Laurel Rehabilitation Services (Omni) O
 Talitha Atkinson, 21 – staged acct 05/01/10 (passenger) $30,945 - Bedford Medical Chiropractic / Central Florida
 Medical & Chiropractic Center / Laurel Rehabilitation Services (Omni) O
 Andre Washington, 29 – staged acct 05/01/10 (passenger) $30,945 - Bedford Medical Chiropractic / Central Florida
 Medical & Chiropractic Center / Laurel Rehabilitation Services (Omni) O

20. CLAIMS ADJUSTER DUTIES AND RESPONSIBILITIES
REGARDING FRAUD
 Most claims are legitimate, and should be handled and processed as such. Acting or presenting
yourself in any other way to a claimant can imply that “you” and the “insurance Company” are acting in
“Bad Faith”, and as such exposed to civil and regulatory liability. Many claims though, are inflated or
fraudulent. Therefore, it is appropriate for the adjuster to review all claims for possible fraud.
 Why ? First of all Fraud is a crime. Second, by reducing paying fraudulent claims we help keep
“Premiums” down for all the other policy holders. Third, we are tasked and mandated to “Fight Fraud”
by State Laws, Rules, and guidelines. Then finally, but not least, It is the Right thing to do.

21. The claims adjuster should be familiar with known “possible Fraud” Indicators.
These indicators, or fraud possibility factors, should help isolate those claims which merit closer scrutiny. No one
indicator by itself is necessarily suspicious or indicative of fraud. Even the presence of several indicators, while suggestive
of possible fraud, does not mean that a fraud has been committed. Indicators of possible fraud are not evidence that fraud
has occurred.
The indicators should prompt the claims adjuster to look closely at the file, considering possible fraud. Also, they
should consult their SIU, or contracted SIU, to at least look at the file as well, and be given a referral for their SIU
involvement in the claim.
All suspicious claims, though they may have to be paid for lack of conclusive evidence of fraud, should be referred to
NICB. There is no limit to the number of cases you may refer. No claim is too small for referral.
All claims that an element of fraud was detected should be referred to DFS, Division of Insurance Fraud.
*** When we all take these steps in handling claims we help provide a better product to the public.
BE AWARE AND DETECT “POSSIBLE FRAUD” INDICATORS

22. RED FLAGS FOR POSSIBLE WORKERS COMP FRAUD AND ABUSE
 The Injured Employee -
 Has injuries that are inconsistent with facts of the accident.
 Provides multiple versions of how the accident occurred.
 Refuses medical tests or examinations to confirm an injury.
 Stays out of work longer than the doctor prescribed.
 Protests excessively about a modified position or returning to work
and never seems to improve.
 Has a suspicious prior history of reporting subjective injuries.
 Has a questionable identity, residence or contact information
 Was experiencing financial difficulties prior to submission of a
claim and inquires about a quick claim settlement.
 Is retiring, on probation, involved in a labor dispute, disgruntled,
a poor job performer or subject to disciplinary action.
 Is a new employee, nomadic, a seasonal worker or on short-term
employment.
 Is never at home, does not answer telephone or avoids the use of
U.S. Mail.
 The Accident or Illness –
 Lacks witnesses.
 Occurs late on a Friday afternoon (especially if not
reported until Monday) or early on a Monday
morning.
 Is not associated with employee's job duties.
 Occurred in an area not frequented by employee.
 Is not reported to the employer in a timely way.
 Leads to rumors at work that the accident was
staged or illegitimate.

23. Indicators of Vehicle Theft FraudIndicators of Fraud Concerning the Insured
* Has lived at current address less than six months
* Has been with current employer less than six months
* Address is a post office box or mail drop
* Does not have a telephone
* Listed number is a mobile/cellular phone
* Is difficult to contact
* Frequently changes address and/or phone number
* Place of contact is a hotel, tavern, or other than employment or residence
* Handles all business in person, thus avoiding the use of mail
* Is unemployed
* Claims to be self-employed but is vague about the business details
* Has recent or current marital and/or financial problems
* Has a temporary, recently issued, or out-of-state driver’s license
* Driver’s license has recently been suspended
More indicators listed on the next slide -

24. Indicators of Fraud Concerning the Insured (Continued)
 Recently called to confirm and/or increase coverage
 Has an accumulation of parking tickets on vehicle
 Is unusually aggressive and pressures for quick settlement
 Offers inducement for quick settlement
 Is very knowledgeable of claims process and insurance terminology
 Income is not compatible with value of insured vehicle
 Claims expensive contents in vehicle at time of left
 Is employed with another insurance company
 Wants a friend or relative to pick up settlement check
 Is behind in loan payments on vehicle and/or other financial obligations
 Avoids meetings with investigators and/or claim adjusters
 Cancels scheduled appointments with claim adjusters for statements and/or
examination under oath
 Has a previous history of vehicle theft claims

25. Indicators of Fraud Related to the Vehicle
 Was purchased for cash with no bill of sale or proof of ownership
 Is a new or late model with no lien holder
 Was very recently purchased
 Was not seen for an extended period of time prior to reported theft
 Was purchased out of state
 Has a history of mechanical problems
 Is a "gas guzzler"
 Is customized, classic, and/or antique
 Displayed "for sale" signs prior to theft
 Was recovered clinically/carefully stripped
 Is parked on street although garage is available
 Was recovered stripped, but insured wants to retain salvage, and repair appears to be impractical
 Is recovered by the insured or a friend
 Purchase price was exceptionally high or low
 Was recovered with old or recent damage and coverage was high deductible or no collision
coverage
More indicators on the next slide -

26. Indicators of Fraud related to the vehicle – CONT’D
 Coverage is only on a binder
 Has an incorrect VIN (e.g. not originally manufactured, inconsistent with model)
 VIN is different than VIN appearing on the title
 VIN provided to police is incorrect
 Safety certification label is altered or missing
 Safety certification label displays different VIN than is displayed on vehicle
 Has theft and/or salvage history
 Is recovered with no ignition or with steering lock damage
 Is recovered with seized engine or blown transmission
 Was previously involved in a major collision
 Is late model with extremely high mileage (exceptions: taxi, police, utility vehicles)
 Is older model with exceptionally low mileage (i.e., odometer rollover/rollback)
 Is older or inexpensive model and insured indicates it was equipped with expensive accessories
which cannot be substantiated with receipts
 Is recovered stripped, burned, or has severe collision damage within a short duration of time after
loss allegedly occurred
 Leased vehicle with excessive mileage for which the insured would have been liable under the
mileage limitation agreement

27. Indicators of Fraud Related to Coverage
 Loss occurs within one month of issue or expiration of the
policy
 Loss occurs after cancellation notice was sent to insured
 Insurance premium was paid in cash
 Coverage obtained via walk-in business to agent
 Coverage obtained from an agent not located in close
proximity to insured’s residence or work place
 Coverage is for minimum liability with full comprehensive
coverage on late model and/or expensive vehicle
 Coverage was recently increased

28. Indicators of Fraud Related to Reporting
 Police report has not been made by insured or has been delayed
 No report or claim is made to insurance carrier within one week after
theft
 Neighbors, friends, and family are not aware of loss
 License plate does not match vehicle and/or is not registered to insured
 Title is junk, salvage, out-of-state, photocopied, or duplicated
 Title history shows non-existent addresses
 Repair bills are consecutively numbered or dates show work
accomplished on weekends or holidays
 An individual, rather than a bank or financial institution, is named as
the lien holder

29. Other General Indicators of Vehicle Theft Fraud
 Vehicle is towed to isolated yard at owner’s request
 Salvage yard or repair garage takes unusual interest in
claim
 Information concerning prior owner is unavailable
 Prior owner cannot be located
 Vehicle is recovered totally burned after theft
 Fire damage is inconsistent with loss description
 VINs were removed prior to fire

30. Indicators of Casualty Fraud
CLAIMS ADJUSTER SHOULD CONSIDER THE FOLLOWING
 Most claims are legitimate, but many are inflated or fraudulent. Therefore, it is
appropriate for the adjuster to review all claims for possible fraud. Determining
the "fraud probability" of any claim is facilitated when the adjuster is familiar with
various fraud indicators.
 These indicators, or fraud possibility factors, should help isolate those claims
which merit closer scrutiny. No one indicator by itself is necessarily suspicious.
Even the presence of several indicators, while suggestive of possible fraud,
does not mean that a fraud has been committed. Indicators of possible fraud are
not evidence that fraud has occurred.
 All suspicious claims, though they may have to be paid for lack of conclusive
evidence of fraud, should be referred to NICB There is no limit to the number of
cases you may refer. No claim is too small for referral.

31. General Indicators of Insurance Fraud
 Claimant or insured is excessively eager to accept blame for an
accident, or is overly pushy or demanding of a quick, reduced
settlement.
 Claimant or insured is unusually familiar with insurance terms and
procedure, medical, or vehicle repair terminology.
 One or more claimants or insured list a post office box or hotel as
address.
 All transactions were conducted in person; claimant avoids using
the telephone or the mail.
 The kind of accident or type of vehicles involved arc not typical of those
seen on a regular basis.
 Claimant threatens to go to an attorney or physician if the claim is not
quickly settled.
 Claimant is a transient or out-of-towner on vacation.

32. Indicators of Automobile Accident Schemes
 Either no police report or an over-the-counter report for an accident resulting in
multiple injuries and/or extensive physical damage.
 Accident occurred shortly after one or more of the vehicles were purchased
or registered, or after the addition of comprehensive and collision coverage to
the policy.
 Insured has a history of accidents within a short period of time on one policy.
Index returns indicate an active claim history.
 Insured has no record of prior insurance coverage although damaged vehicle
was purchased much earlier than inception of policy and date of loss.
 Expensive, late model automobile was recently purchased with cash (no lien
holder).
 Attorney's lien or representation letter is dated the day of the accident or
soon after.

33. Indicators of Auto Physical Damage Fraud
 Serious accident with expensive physical damage claim but only minor,
subjectively diagnosed injuries, with little or no medical treatment.
 Despite expensive damage claims, the claimant vehicle remains
drivable. Often, there are no towing charges for removing vehicle from the
scene of the accident.
 Claimant vehicle was struck by a rental vehicle soon after the rental had
occurred.
 Claimant vehicle is not to be repaired locally, but driven or shipped out of
state for repair.
 All vehicles in a reported accident are taken to the same body shop.
 Claimant vehicles are not readily available for independent appraisal.
 Reported accident occurred on private property near residence of those
involved.

34. Indicators of Medical Fraud/Claim Inflation
 Three or more occupants in the claimant or "stuck vehicle"; all of them report similar injuries.
 All injuries are subjectively diagnosed, such as headaches, muscle spasms, traumas, and others.
 Medical claims are extensive, but collision is minor with little physical damage to vehicle.
 All of the claimants submit medical bills from the same doctor or medical facility.
 Medical bills submitted are photocopies of originals.
 Summary medical bills are submitted without dates and descriptions of office visits and treatments,
or treatment extends for a lengthy period without any interim bills.
 Vehicle driven by claimant is an old "clunker" with minimal coverage.
 Insured, even though legally liable for accident, is adamant that claimants were responsible for
accident, indicating that the insured may have been "targeted" by the claimants.

35. Indicators of Medical Fraud/Claim Inflation
 Claimants retain legal representation immediately after the
accident is reported.
 Minor accident produces major medical costs, lost wages and
unusually expensive demands for pain and suffering.
 Past experience demonstrates that the physician's bill and report,
regardless of the varying accident circumstances, is always the
same.
 Treatment prescribed for the various injuries resulting from differing
accidents is always the same in terms of duration and type of
therapy.
 Medical bills indicate routine treatment being provided on Sundays
and holidays.

36. MEDICAL RECORDS
MEDICAL PROVIDER RECORDS
□Clinical notes not in usual sequential order
□All injuries are soft tissue
□Bills for medical services not actually performed
□Boilerplate medical reports
□Detailed report and scant handwritten notes
□No follow-up clinical notes supporting reports/billing statement
□Evidence of preexisting condition not reflected in doctor’s reports
□Extensive examination procedures/charges for apparent simple/routine injury/mild diagnosis
□Extensive or unnecessary treatments for minor subjective injuries
□Immediate referral for wide variety of psychiatric tests when original claim involved trauma only
□Incorrect facts within the medical report
□Inconsistencies between report and handwritten notes and claimant interview
□Findings not consistent with mechanics of accident
□Diagnosis not supported by documentation
□Injuries all subjective (headache, nausea, depression, sleep problems, tenderness, etc.)
□Multiple re-exams without necessity

37. MEDICAL RECORDS CONT’D
□No x-rays, or if x-rays taken, no radiological report
□Final report indicates fully recovered when x-rays show chronic condition that cannot be reversed
□Patient information sheet shows attorney obtained prior to first visit
□Patient information sheet indicates claimant unemployed at time of accident but was actually employed
□Referral for treatment/testing to facility close to referring facility
□□Referrals to several other providers who perform and bill for similar services
□Various injuries always receive same treatment
□Protracted treatment for extensive injuries for minor accident
□No final report
□No handwritten notes
□No patient information sheet for new patient
□No physical therapy progress reports
* Referrals to several other providers who perform and bill for similar services

38. Indicators of Lost Earnings Fraud
 Employment information is for an unknown business, often with a post
office box for address, or a street address in a residential area.
 Business telephone number is connected to an answering machine or
answering service.
 Lost earnings statement is handwritten or typed on blank paper, not
business letterhead.
 Claimant started employment shortly before accident occurred, or is
self-employed.
 One or more elements of claim is questionable: e.g. length of
absence, rate of pay, income incompatible with claimant's residence.
 Efforts to verify lost wage statement with employer raise doubts about
employer's legitimacy or about the actual employment of claimant.

39. FLORIDA STATUTES, CHAPTER 626 INSURANCE
FRAUDULENT PROOF OF LOSS - CRIMINAL VIOLATION
 The 2011 Florida Statutes Title XXXVII INSURANCE Chapter 626
INSURANCE FIELD REPRESENTATIVES AND OPERATIONS
 626.8797 Proof of loss; fraud statement.—All proof of loss
statements must prominently display the following statement:
 “Pursuant to s. 817.234, Florida Statutes, any person who, with the intent
to injure, defraud, or deceive any insurer or insured, prepares, presents, or
causes to be presented a proof of loss or estimate of cost or repair of
damaged property in support of a claim under an insurance policy knowing
that the proof of loss or estimate of claim or repairs contains any false,
incomplete, or misleading information concerning any fact or thing material
to the claim commits a felony of the third degree, punishable as provided in
s. 775.082, s. 775.083, or s.775.084, Florida Statutes.”

40. SIU DESIGNATE AND DIF
 Division of Insurance Fraud
 COMMUNICATION: Section 626.989(4)(d), F.S. provides that persons identified as designated employees whose responsibilities
include the investigation and disposition of claims relating to suspected fraudulent insurance acts may share information
relating to persons suspected of committing fraudulent insurance acts with other designated employees employed by the same or
other insurers whose responsibilities include the investigation and disposition of claims relating to fraudulent insurance acts, provided
the department has been given written notice of the names and job titles of such designated employees prior to such designated
employees sharing information. Unless the designated employees of the insurer act in bad faith or in reckless disregard for
the rights of any insured, neither the insurer nor its designated employees are civilly liable for libel, slander, or any other
relevant tort, and a civil action does not arise against the insurer or its designated employees.
 ADD or DELETE A DESIGNATED EMPLOYEE: Click on DIFSIUAdmin@MyFloridaCFO.com to provide the written notice of the
NAME and JOB TITLE of the “designated employee” whose responsibilities include the investigation and disposition of claims
relating to suspected fraudulent acts. The email request must also provide the insurer identifiers making the request
 Contact SIU Administrator:
 Denise Prather
Senior Management Analyst I
200 East Gaines Street
Tallahassee, Florida 32399-0324
DIFSIUAdmin@MyFloridaCFO.com

41. INSURANCE ANTI-FRAUD PLAN REPORTING
TO DFS - DIF
 Rule Chapter 69D-2, FAC was adopted September 15, 2006. Effective 20 days from this
date insurers and Health Maintenance Organizations (HMO) were required to file updated
SIU Descriptions or Anti-fraud plans pursuant to section 626.9891, Florida Statutes. The
type of filing will be differentiated by the insurer’s volume of Florida annual direct written
premium for calendar year 2006. Those insurers that write $10 million or more in annual
direct written premium are subject to Section 626.9891(1), F.S. and 69D-2.003, FAC and
those that write less than $10 million in annual direct written premium are subject to Section
626.9891(2), F.S. and 69D-2.004, FAC.
 Rule Chapter 69D-2, FAC requires that insurers and HMOs file the updated SIU
descriptions and anti-fraud plans on the division’s on-line, electronic database known
as IFPR (INSURANCE FRAUD PLAN REPORTING). Further, the rule stipulates that
insurers and HMOs must file the updated SIU descriptions AND/OR anti-fraud plans on
FORMS specified by the division. There are only two types of forms available. The
available forms are indicated below. An insurer or HMO will only make one filing, either the
SIU description or anti-fraud plan depending on their premium volume.
 Continued next slide -

42. 69D-2.003 Insurer SIUs
 (1) An insurer subject to Section 626.9891(1), F.S., shall file with the Division a detailed description of their SIU, and
shall submit the following information in the SIU description to satisfy this filing requirement:
 (a) The names of all personnel assigned to the SIU, and a description of each person’s work responsibilities relating to
the SIU’s anti-fraud efforts;
 (b) An acknowledgment that the SIU has established criteria that will be used to detect suspicious or fraudulent
activity during investigations relating to the different types of insurance offered by that insurer;
 (c) An acknowledgment that the SIU has established criteria that will be used for the investigation of acts of
suspected insurance fraud relating to the different types of insurance offered by that insurer.
 (d) An acknowledgment that the insurer or SIU shall report all suspected fraudulent insurance acts directly to the
Division electronically via Form DFS-L1-1691 (Eff. 10-5-06) “Suspected Fraud Referral Form,” or an electronic reporting
interface that is linked to such form, as provided on the Division’s website at www.myfloridacfo.com
 (e) An acknowledgment that all such reports of suspected insurance fraud shall contain information that clearly defines
and supports the allegation of suspicious activity.
 . Form DFS-L1-1691 (Eff. 10-5-06) Suspected Fraud Referral Form i

43. INSURANCE ANTI-FRAUD PLAN REPORTING
TO DFS - DIF
Continued from last slide -
Once the form is selected, the user will click on the form and “save” the form file to your computer files. You can
save it as the form number, but it may be better to rename it after the form has been completed. The insurer
or HMO should complete each of the component requirements (Questions) on the form. You can
click “Instructions for Filing SIU Descriptions and Anti-fraud plans to IFPR” for detailed instructions to make
the filing. For background, our division is seeking declaratory statements acknowledging the component
requirements of the rule in the form filing. The rule filing allows an insurer to acknowledge specific
component requirements without having to submit the detail of these requirements to the
division. However, FL OIR Market Investigations may conduct audits of insurers. The insurer must be
prepared to show that it has documented measures and plans in place that demonstrate the component
requirements are viable within the SIU or insurer organization.
We are only looking for acknowledgements of the component requirements as shown in the rule as
Florida has a broad public records law and the anti fraud plan and SIU descriptions are subject to
public record. However, it is important that your company develop viable investigative and detection
techniques for their anti fraud personnel and claim staff. The OIR will look at training documentation
records, referrals made to the division, claim files to be certain that adjusters have knowledge of “red flags”
to detect insurance fraud, and tracking the time frame from when the suspected fraud is detected to when
the suspected fraud is referred to the Division.

44. WORKERS COMP ANTI-FRAUD PLANS
FILING WITH DFS - DIF
 The Florida 2003 Legislature required all Workers Compensation carriers to submit a series of statistical and
narrative data on its experience and maintenance of its anti-fraud efforts. We created the Workers’ Compensation
Anti-Fraud (WCAF) Report filing system for WC carriers to report this data. The first thing you must do is activate a new
account. This must be done every year. We ask for basic identifying information, including an email address and a
password. You will receive an email that includes the account code and a link to the WCAF database. You will click on
the link to begin the WCAF report filing. It is a simple report to complete. We provide Frequently Asked Questions which
explains much of the process as well as provides definitions of the data required. Thank you for using this electronic
report filing system.
 Workers’ Compensation Annual Anti-Fraud Report Filing:
 Effective August 1, of every year, each insurer writing workers' compensation insurance in Florida shall report to the
Division of Insurance Fraud, Bureau of Workers’ Compensation Fraud its experience in implementing and maintaining an
anti-fraud special investigative unit (SIU) or an anti-fraud plan. DFS Informational Memorandum 04-002 describes the
statistical data required pursuant to 626.9891 (6), Florida Statutes.
 The time period for 2010 reporting is July 1, 2010 through June 30, 2011 (but carriers may use a calendar year period 1-1-
2010 through 12-31-2010 or any other annual period, but please advise what period is reported in the “Description of the
organization of the SIU or anti-fraud unit” section.
Continued on next slide -

45. WORKERS COMP ANTI-FRAUD PLAN FILING
WITH DFS - DIFContinued from previous slide
 The report filing requires:
 The dollar amount of recoveries and losses delineated by type of WC fraud.
 The number of referrals submitted to the Bureau of Workers’ Compensation Fraud delineated by type of WC fraud.
 A description of the organization of the SIU or anti-fraud unit including position titles and descriptions of staffing.
 The “rationale” for the level of staffing and resources being provided based on such criteria as the number of policies written for the
above referenced report data period, the number of claims received for the report data period, the number of suspected fraudulent claims
detected for the report data period, an assessment of optimal case load that can be handled by an SIU investigator for the report data period
and other factors that explain the level of staffing and resources.
 A description of education and training provided to underwriting and claims personnel to assist in identifying and evaluating instances of
suspected fraudulent acts in underwriting or claims activities.
 A description of a public awareness program focused on the costs and frequency of insurance fraud and methods by which the public can
prevent it.
 Please note that if an insurance carrier is licensed to insure workers’ compensation coverage, but did not write WC coverage during the
reporting period (7-1-2010 to 6-30-2011) the carrier will activate a new account, select the carrier and submit a “No Data to Submit” report filing.
 The electronic Workers’ Compensation Anti-Fraud (WCAF) report filing is accessible by July 1, 2011 and will be available until September 30,
2011. The WCAF report filing can be accessed via

46. FLORIDA STATUTES, CHAPTER 626, IMUNITY STATUTE –
Protection against Civil Liability for providing information regarding
suspected fraudulent insurance acts.
 626.989 Investigation by department or Division of Insurance Fraud; compliance; immunity; confidential information; reports to division; division
investigator’s power of arrest.—
 (c) In the absence of fraud or bad faith, a person is not subject to civil liability for libel, slander, or
any other relevant tort by virtue of filing reports, without malice, or furnishing other information, without
malice, required by this section or required by the department or division under the authority granted in
this section, and no civil cause of action of any nature shall arise against such person:1. For any
information relating to suspected fraudulent insurance acts or persons suspected of engaging in such
acts furnished to or received from law enforcement officials, their agents, or employees;
 2. For any information relating to suspected fraudulent insurance acts or persons suspected of
engaging in such acts furnished to or received from other persons subject to the provisions of this
chapter;
 3. For any such information furnished in reports to the department, the division, the National
Insurance Crime Bureau, the National Association of Insurance Commissioners, or any local, state, or
federal enforcement officials or their agents or employees; or
 4. For other actions taken in cooperation with any of the agencies or individuals specified in this
paragraph in the lawful investigation of suspected fraudulent insurance acts.

47. FLORIDA STATUTE CHAPTER 626 - DESIGNATED SIUs SHARING
INFORMATION WITH OTHER SIUs, CIVIL LIABILITY PROTECTION
F.S. 626.989(4)(d)
 (d) In addition to the immunity granted in paragraph (c), persons identified as designated
employees whose responsibilities include the investigation and disposition of claims relating to
suspected fraudulent insurance acts may share information relating to persons suspected of
committing fraudulent insurance acts with other designated employees employed by the same
or other insurers whose responsibilities include the investigation and disposition of claims relating
to fraudulent insurance acts, provided the department has been given written notice of the
names and job titles of such designated employees prior to such designated employees
sharing information. Unless the designated employees of the insurer act in bad faith or in
reckless disregard for the rights of any insured, neither the insurer nor its designated employees
are civilly liable for libel, slander, or any other relevant tort, and a civil action does not arise
against the insurer or its designated employees:
 1. For any information related to suspected fraudulent insurance acts provided to an
insurer; or
 2. For any information relating to suspected fraudulent insurance acts provided to the National
Insurance Crime Bureau or the National Association of Insurance Commissioners.

48. SIU INVOLVEMENT IN THE
INSURANCE CLAIM
Initiate SIU involvement by – the Claims Adjuster detecting at least one “Red Flag” or
possible “Fraud Indicators” and makes a Referral to SIU.
1. The SIU Investigator will meet with the claims adjuster personally, if possible.
2. SIU will review the claim for all elements of possible Fraud, as well as claims handling.
3. The SIU Investigator will then set an Action Plan for SIU tasks, and if necessary for the claims adjuster.
The SIU Investigator may do the following in their Action Plan;
A. Run background check on Claimant
B. Review tape of initial Loss Statement
C. Retrieve and review medical billing
D. SIU to go to the loss scene, photos, and canvass the area for witnesses, take statements
E. Go to the body shop, photos, interview shop repair person.
F. Order any specialty investigation, such as Cause & Origin, or accident reconstruction.
G. Consider ordering a surveillance
H. FWP Leads developed from initial investigation
I. Order and conduct an Examination Under Oath
J. Coordinate efforts with DIF, reporting suspicious claim to DIF
K. Participate in Claim File Conference

49. THE SIU GROUP
Fraud Investigations & Security Consultants, LLC
(904) 201-8321 (904) 463-5632 thesiugroup.com info@thesiugroup.com
WELCOME - THE SIU GROUP is a Florida based company,
Fraud Investigations & Security Consultants, LLC, located in
Jacksonville that provides SIU- Private Investigative Services in
the following areas; Orlando, Tampa, Ft. Lauderdale, West
Palm, SW Florida, and Jacksonville. These services include;
EUO, Loss Scene, Claimant/Witness Recorded Statements, and
Surveillance. Conducted by Florida licensed Private Investigators
with prior in-house SIU and Claims Adjuster experience.
************************************************************************
Our associates are experienced and trained SIU Investigators and
Claims Adjusters that provide Private Investigation services to
augment the Insurance Company Claims Department in their fight
against insurance fraud.
* Claim File Review ID Fraud Issues
• SIU Action Plan
• Loss scene investigation
• Recorded Statements
• Surveillance
• EUOs
• Claim File Conference
• Referrals to DFS – DIF
• File Fraud Plans
• Fraud Awareness Training