Sandy Praeger. Ted Clark Anti-Fraud Division Director Kansas Insurance Department

Transcription

1 Sandy Praeger Kansas Insurance Commissioner Ted Clark Anti-Fraud Division Director Kansas Insurance Department

2 Viaticals What s Hot NAIC AFTF Activities

3 The AIDS Pandemic of the 1980s An AIDS patient came up with an idea to help other patients to buy expensive drugs Some AIDS victims had life insurance policies purchased long before diagnosis of the disease.

4 Investors or pools of investors were found to buy life insurance policies i from the AIDS patients This gave the patients quick access to money for treatment The investors paid the patients a percentage of the death benefit of the policy in exchange for becoming the owner and beneficiary of the life policy

5 The investors became the owner of the policy and made premium payments to keep the coverage in force The Viator and investors wager the insured will die before the percentage paid to the patient and total premiums paid reach the amount of the policy death benefit Agents represent patients to get them the best deal

6 The Insured wants to live The insurance company wants the insured to live The Viator and investors want to Insured to DIE and the sooner the better! DIE and the sooner the better!

7 The AIDS medications were effective and patients lived and are still living If the patient/insured lived beyond projections, the investor had to pay additional premiums to keep the policy in force

8 The AIDS patient market dries-up Some Viatical companies find a new pool of elderly insureds to market to investors Package investments with actuary opinions and doctor statements and doctor statements

9 Viatical Company uses questionable doctors to provide opinions i saying the insureds were much closer to death than in reality to artificially improve the appearance of the investment Viatical company sells over 100% of the investment to make more profit Agent shops for maximum commissions

10 Whatever it s called; who regulates it? Is it still an insurance product? Is it an investment instrument/security?

11 STOLI Stanger Originated Life Insurance STAT Stranger Originated Annuity Transaction

12 The Old and the New

13 Medical identity theft occurs when someone uses a person s s name and sometimes other parts of their identity (such as insurance information) without the person s knowledge or consent to obtain medical services or goods, or uses the person s identity information to make false claims for medical services or goods.

14 An individual id seeks treatment or Narcotic drugs by assuming the identity of someone else Use of someone s identity by a provider to bill for goods or services not provided Individual vs. Institutional Medical Identity Theft

15 Ruined Credit Legal Troubles Loss of health coverage or higher premiums FALSE MEDICAL HISTORY!!!

16 Theft of purses and billfolds Burglary of medical offices Placing a medical office employee to copy files Purchase of information from the Internet Information stolen from a friend or family member

17 Phishing, telephone and mail scams Fraudulent websites purporting to sell inexpensive coverage Door-to-door scammers pretending to represent Medicare or your insurance company

18 A Georgia physician who submitted tens of thousands of bogus Medicare and Medicaid claims for counseling sessions with dead patients pleaded guilty Monday in federal district court to two counts of health care fraud.

19 Examine EOBs Ask for a yearly summary of benefits paid by your insurance company Check your medical records Check your credit report, too

20 Never, Never, Never give out personal information to someone you don t know! Be wary of any offer that sounds too good to be true! Protect your medical information as you would your cash.

21 Demanding Upfront payment Signing checks directly over to the roofer Creating damage Acting as a public adjuster Power of Attorney

22 Stealing premium Licensed Stealing premium Unlicensed Forging signatures (upgrade & non-existent) Selling improper products Churning for commissions

23 Commercial liability Product Liability Arson fires False and inflated burglary claims Vehicle owner-give-ups Vehicle with preexisting damage

24 CHAIR COMMISSIONER SANDY K. PRAEGER of Kansas VICE CHAIR COMMISSIONER ROGER SEVIGNY of fnew Hampshire

25 FEDERAL AND INTERNATIONAL ENFORCEMENT COORDINATION WORKING GROUP GREG ELAM WEST VIRGINIA ANTI-FRAUD LIAISON WORKING GROUP STEVE PERRY- DC ANTI-FRAUD TRAINING AND SEMINAR WORKING GROUP MICHELLE BRUGH - OHIO INFORMATION SHARING AND TECHNOLOGY WORKING GROUP CINDY SCHMELL IOWA AGENT UNLAWFUL ACTIVITIES WORKING GROUP- DENNIS POMPA - TEXAS NAIC ENFORCEMENT COORDINATION WORKING GROUP BARBARA RICHARDSON NEW HAMPSHIRE

26 Enhanced Linking of NAIC OFRS to NICB/ISO Suspicious Claims Reporting System Studying how to obtain better quality reports Reporting is available to 43 States

27 LINKING NAIC OFRS WITH NHCAA-SIRIS SYSTEM IS UP AND RUNNING!! NHCAA, LexisNexis i and NAIC are working on ways to improve the interface so elements of cases are reported in a more user friendly fashion

28 Standardized Suspected Fraud Reporting Form Request from HHS Hope for the Future

29 Model Guidelines For Standardized Filings of Anti-Fraud Plans Recently Sent to D Committee

30 Joint Limited Medical Benefits Plans Working Group The Group is looking at many aspects of the plans that may be unethical, illegal or fraudulently marketed

31 Joint meetings with Title Insurance Task Force Looking at Mortgage Fraud and how to better Looking at Mortgage Fraud and how to better police the industry

32 Questions and Comments?