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Organizations that fail to identify and eliminate fraud are losing hundreds of thousands of dollarsand many dont even know it! Many claims professionals dont have the time or resources to spot the red flags that indicate a fraudulent workers compensation claim, and even if they stumble upon one by chance, they fail to conduct a comprehensive investigation. Mario S. Pecoraro, CEO of Alliance Worldwide Investigative Group, provides proactive strategies that will save you resources, money, and time investigating claims. The twenty best practices he explores will help you: hire the type of employee who wont file a claim in the first place; engage in preventative maintenance throughout the life of a claim; determine who should conduct an investigation when a claim is filed; carry out the investigative process using a variety of tools. Filled with case studies demonstrating where investigations went wrong (and where they went right), youll be equipped to apply best practices and avoid common mistakes. Start saving money, and get the right team in place with The Claim Game.
Book Synopsis The Claim Game by : Mario S. Pecoraro
Download or read book The Claim Game written by Mario S. Pecoraro and published by iUniverse. This book was released on 2015-10-08 with total page 104 pages. Available in PDF, EPUB and Kindle. Book excerpt: Organizations that fail to identify and eliminate fraud are losing hundreds of thousands of dollarsand many dont even know it! Many claims professionals dont have the time or resources to spot the red flags that indicate a fraudulent workers compensation claim, and even if they stumble upon one by chance, they fail to conduct a comprehensive investigation. Mario S. Pecoraro, CEO of Alliance Worldwide Investigative Group, provides proactive strategies that will save you resources, money, and time investigating claims. The twenty best practices he explores will help you: hire the type of employee who wont file a claim in the first place; engage in preventative maintenance throughout the life of a claim; determine who should conduct an investigation when a claim is filed; carry out the investigative process using a variety of tools. Filled with case studies demonstrating where investigations went wrong (and where they went right), youll be equipped to apply best practices and avoid common mistakes. Start saving money, and get the right team in place with The Claim Game.
Book Synopsis The Auto Policy and The Claim Investigation Process by : Hector Quiroga
Download or read book The Auto Policy and The Claim Investigation Process written by Hector Quiroga and published by Lulu.com. This book was released on with total page 187 pages. Available in PDF, EPUB and Kindle. Book excerpt:
The book is designed as a primer for claims investigators, health care managers, QA/QI personnel, in-house counsel, paralegals, personal injury attorneys, and others whose duties include the investigation of actual and potential medical malpractice lawsuits. It can be used as a desktop reference, self-study guide, or as part of a formal orientation program for risk managers and quality assurance personnel. The book contains a step-by-step description of the claims investigation. It also provides instruction on reviewing medical records; identifying adverse patient occurrences; selecting, locating and interviewing personnel involved in occurrences; analyzing investigative findings; and writing the investigation report.
Book Synopsis Medical Malpractice Claims Investigation by : Nancy Acerbo-Kozuchowski
Download or read book Medical Malpractice Claims Investigation written by Nancy Acerbo-Kozuchowski and published by Jones & Bartlett Learning. This book was released on 1997 with total page 298 pages. Available in PDF, EPUB and Kindle. Book excerpt: The book is designed as a primer for claims investigators, health care managers, QA/QI personnel, in-house counsel, paralegals, personal injury attorneys, and others whose duties include the investigation of actual and potential medical malpractice lawsuits. It can be used as a desktop reference, self-study guide, or as part of a formal orientation program for risk managers and quality assurance personnel. The book contains a step-by-step description of the claims investigation. It also provides instruction on reviewing medical records; identifying adverse patient occurrences; selecting, locating and interviewing personnel involved in occurrences; analyzing investigative findings; and writing the investigation report.
Book Synopsis The Investigation of Freight Claims by : George Henry Hunt
Download or read book The Investigation of Freight Claims written by George Henry Hunt and published by . This book was released on 1920 with total page 90 pages. Available in PDF, EPUB and Kindle. Book excerpt:
Book Synopsis The Claim Agent and His Work, Investigation and Settlement of Claims for Personal Injuries by : Smith Rufus Brittingham
Download or read book The Claim Agent and His Work, Investigation and Settlement of Claims for Personal Injuries written by Smith Rufus Brittingham and published by . This book was released on 1927 with total page 490 pages. Available in PDF, EPUB and Kindle. Book excerpt:
Book Synopsis The Investigation and Adjustment of Liability Insurance Claims and Workmen's Compensation Losses by : Walter Loane Clark
Download or read book The Investigation and Adjustment of Liability Insurance Claims and Workmen's Compensation Losses written by Walter Loane Clark and published by . This book was released on 1914 with total page 120 pages. Available in PDF, EPUB and Kindle. Book excerpt:
Download or read book Freight Claim Investigation written by and published by . This book was released on 1958 with total page 51 pages. Available in PDF, EPUB and Kindle. Book excerpt:
Some have estimated that healthcare fraud in the United States results in losses of approximately $80 billion a year. Although there are many books available that describe how to detect healthcare fraud, few address what must be done after the fraud is detected. Filling this need, Charles Piper‘s Healthcare Fraud Investigation Guidebook details not only how to detect healthcare fraud, but also how to investigate and prove the wrongdoing to increase the likelihood of successful prosecution in court.The book starts by covering the history of healthcare insurance and the various types of fraud schemes. It presents Charles Piper‘s unique approach to investigating (The Piper Method) which allows readers to conduct as many as 10 simultaneous investigations for each case. It emphasizes the importance of simultaneously searching for waste and abuse as well as systemic weaknesses and deficiencies that caused or contributed to the problem or wrongdoing under investigation and then make recommendations for improvement. It also provides:Questions to ask whistleblowers, complainants, employers, employees, and healthcare providers who are suspectsTips on investigative case planning, goals, and strategiesSample visual aids for use when briefing others about your investigative findingsGuidance on presenting information obtained from healthcare investigations and on how to testify in courtTechniques for uncovering previously undetected fraudThe book includes a sample case study that walks readers through a mock case from the time the case is received through the end. The case study demonstrates how to initiate, plan, and conduct a thorough and complete healthcare fraud investigation while incorporating Piper‘s proven methodology.Sharing insights gained through Charles Piper‘s decades o
Book Synopsis Healthcare Fraud Investigation Guidebook by : Charles E. Piper
Download or read book Healthcare Fraud Investigation Guidebook written by Charles E. Piper and published by Taylor & Francis. This book was released on 2017-07-27 with total page 172 pages. Available in PDF, EPUB and Kindle. Book excerpt: Some have estimated that healthcare fraud in the United States results in losses of approximately $80 billion a year. Although there are many books available that describe how to detect healthcare fraud, few address what must be done after the fraud is detected. Filling this need, Charles Piper‘s Healthcare Fraud Investigation Guidebook details not only how to detect healthcare fraud, but also how to investigate and prove the wrongdoing to increase the likelihood of successful prosecution in court.The book starts by covering the history of healthcare insurance and the various types of fraud schemes. It presents Charles Piper‘s unique approach to investigating (The Piper Method) which allows readers to conduct as many as 10 simultaneous investigations for each case. It emphasizes the importance of simultaneously searching for waste and abuse as well as systemic weaknesses and deficiencies that caused or contributed to the problem or wrongdoing under investigation and then make recommendations for improvement. It also provides:Questions to ask whistleblowers, complainants, employers, employees, and healthcare providers who are suspectsTips on investigative case planning, goals, and strategiesSample visual aids for use when briefing others about your investigative findingsGuidance on presenting information obtained from healthcare investigations and on how to testify in courtTechniques for uncovering previously undetected fraudThe book includes a sample case study that walks readers through a mock case from the time the case is received through the end. The case study demonstrates how to initiate, plan, and conduct a thorough and complete healthcare fraud investigation while incorporating Piper‘s proven methodology.Sharing insights gained through Charles Piper‘s decades o
Book Synopsis Insurance Claims Investigation and Agency Practice by : William Merrell
Download or read book Insurance Claims Investigation and Agency Practice written by William Merrell and published by . This book was released on 1998-06-01 with total page 201 pages. Available in PDF, EPUB and Kindle. Book excerpt:
Claim investigation is a fundamental part of an insurer's business. Queues form as claims accumulate and claims are investigated according to some queueing mechanism. The natural existence of queues in this context prompts the inclusion of a queue-based investigation mechanism to model features like congestion inherent in the claims handling process and further to assess their overall impact on an insurer's risk management program. This thesis explicitly models a queue-based claim investigation mechanism (CIM) in two classical models for insurance risk, namely, insurer surplus models (or risk models) and aggregate claim models (or loss models). Incorporating a queue-based CIM into surplus and aggregate claims models provides an additional degree of realism and as a result, can help insurers better characterize and manage risk. In surplus analysis, more accurate measures for ruin-related quantities of interest such as those relating to the time to ruin and the deficit at ruin can be developed. In aggregate claims models, more granular models of the claims handling process (e.g., by decomposing claims into those that are settled and those that have been reported but not yet settled) can help insurers target the source of inefficiencies in their processing systems and later mitigate their financial impact on the insurer. As a starting point, Chapter 2 proposes a simple CIM consisting of one server and no waiting places and superimposes this CIM onto the classical compound Poisson surplus process. An exponentially distributed investigation time is considered and then generalized to a combination of n exponentials. Standard techniques of conditioning on the first claim are used to derive a defective renewal equation (DRE) for the Gerber-Shiu discounted penalty function (or simply, the Gerber-Shiu function) m(u) and probabilistic interpretations for the DRE components are provided. The Gerber-Shiu function, introduced in Gerber and Shiu (1998), is a valuable analytical tool, serving as a unified means of risk analysis as it generates various ruin-related quantities of interest. Chapter 3 extends and generalizes the analysis in Chapter 2 by proposing a more complex CIM consisting of a single queue with n investigation units and a finite capacity of m claims. More precisely, we consider CIMs which admit a (spectrally negative) Markov Additive Process (MAP) formulation for the insurer's surplus and the analysis will heavily rely and benefit from recent developments in the fluctuation theory of MAPs. MAP formulations for four possible CIM generalizations are more specifically analyzed. Chapter 4 superimposes the more general CIM from Chapter 3 onto the aggregate claims process to obtain an "aggregate payment process". It is shown that this aggregate payment process has a Markovian Arrival Process formulation that is preserved under considerable generalizations to the CIM. A distributional analysis of the future payments due to reported but not settled claims ("RBNS payments") is then performed under various assumptions. Throughout the thesis, numerical analyses are used to illustrate the impact of variations in the CIM on the ruin probability (Chapters 2 and 3) and on the Value-at-Risk (VaR) and Tail-Value-at-Risk (TVaR) of RBNS payments (Chapter 4). Concluding remarks and avenues for further research are found in Chapter 5.
Book Synopsis Applications of Claim Investigation in Insurance Surplus and Claims Models by : Mirabelle Huynh
Download or read book Applications of Claim Investigation in Insurance Surplus and Claims Models written by Mirabelle Huynh and published by . This book was released on 2018 with total page 157 pages. Available in PDF, EPUB and Kindle. Book excerpt: Claim investigation is a fundamental part of an insurer's business. Queues form as claims accumulate and claims are investigated according to some queueing mechanism. The natural existence of queues in this context prompts the inclusion of a queue-based investigation mechanism to model features like congestion inherent in the claims handling process and further to assess their overall impact on an insurer's risk management program. This thesis explicitly models a queue-based claim investigation mechanism (CIM) in two classical models for insurance risk, namely, insurer surplus models (or risk models) and aggregate claim models (or loss models). Incorporating a queue-based CIM into surplus and aggregate claims models provides an additional degree of realism and as a result, can help insurers better characterize and manage risk. In surplus analysis, more accurate measures for ruin-related quantities of interest such as those relating to the time to ruin and the deficit at ruin can be developed. In aggregate claims models, more granular models of the claims handling process (e.g., by decomposing claims into those that are settled and those that have been reported but not yet settled) can help insurers target the source of inefficiencies in their processing systems and later mitigate their financial impact on the insurer. As a starting point, Chapter 2 proposes a simple CIM consisting of one server and no waiting places and superimposes this CIM onto the classical compound Poisson surplus process. An exponentially distributed investigation time is considered and then generalized to a combination of n exponentials. Standard techniques of conditioning on the first claim are used to derive a defective renewal equation (DRE) for the Gerber-Shiu discounted penalty function (or simply, the Gerber-Shiu function) m(u) and probabilistic interpretations for the DRE components are provided. The Gerber-Shiu function, introduced in Gerber and Shiu (1998), is a valuable analytical tool, serving as a unified means of risk analysis as it generates various ruin-related quantities of interest. Chapter 3 extends and generalizes the analysis in Chapter 2 by proposing a more complex CIM consisting of a single queue with n investigation units and a finite capacity of m claims. More precisely, we consider CIMs which admit a (spectrally negative) Markov Additive Process (MAP) formulation for the insurer's surplus and the analysis will heavily rely and benefit from recent developments in the fluctuation theory of MAPs. MAP formulations for four possible CIM generalizations are more specifically analyzed. Chapter 4 superimposes the more general CIM from Chapter 3 onto the aggregate claims process to obtain an "aggregate payment process". It is shown that this aggregate payment process has a Markovian Arrival Process formulation that is preserved under considerable generalizations to the CIM. A distributional analysis of the future payments due to reported but not settled claims ("RBNS payments") is then performed under various assumptions. Throughout the thesis, numerical analyses are used to illustrate the impact of variations in the CIM on the ruin probability (Chapters 2 and 3) and on the Value-at-Risk (VaR) and Tail-Value-at-Risk (TVaR) of RBNS payments (Chapter 4). Concluding remarks and avenues for further research are found in Chapter 5.