Sources of PIP fraud:
- Staged accidents: Believe it or not, this is not uncommon. Organized fraud rings pay people to stage accidents and fake injuries so that the medical clinic can send medical bills to the carrier.
- Opportunistic billing: Have you ever been in a car crash in Miami? You may have been approached by multiple people prior to the police even arriving. These individuals invite accident victims to come to their medical clinic. When an injured person comes to the clinic, the medical clinic runs up the bill, sometimes doing work that is real but unnecessary and sometimes submitting bills for work that never took place. In many cases the claimant is “in on it,” receiving compensation for participating in the fraud.
- Fake office visits on unsuspecting claimants: People are injured in car crashes and seek medical help, but unknown to them, the medical clinic sends bills for many additional office visits that never occurred. When shown this information, the claimant is shocked to see what bills were sent on their behalf.
Our algorithms combine database operations with mathematical formulas and apply these to a carrier’s claims records. Our formulas could be marketed as “artificial intelligence,” but this overused phrase does not accurately reflect the thousands of hours of human thought put into developing our algorithms; there is nothing artificial about it. The results of our formulas have been evaluated by insurance professionals and proven in the real world. Our algorithms are revolutionary in that we are able to find fraud by combing through your data without any input from the carrier about past fraud situations.
For the PIP Radar to work, our algorithms need sufficient data to spot which fraud rings are targeting you. Necessary input includes medical bill data (Forms 1500 and 1450) in electronic format as well as a table of general claims files with information including first notice of loss, accident location, claimant home address, etc. Our proprietary process combines this information and connects it to prepared datasets.
What do the algorithms do?
- Connect the medical billing codes to our proprietary database.
- Connect the medical providers to our proprietary database.
- Evaluate the likelihood of certain aspects of the crashes.
- Evaluate the the probability of the sequence of events, from accident, to first notice of loss, to medical visits.
- Evaluate the likelihood that certain CPT codes should be applied to a given situation.
- Evaluate the plausibility of the provider completing the tasks stated in the medical bill.
- Indicate if the medical providers have already been flagged by other sources.
- Produce a score for the clinic, representing the probability the clinic is involved in fraud.
- Produce a score for individual claims, indicating their probability of fraudulence.
What should SIU do with the information?
We have built a web portal to which SIU members will have access. This portal shows claims sorted by their likelihood of fraudulence. The portal has multiple screens allowing the investigator to see the claim from different points of view and enabling the investigator to understand why the claim is suspicious. The various screens also allow the investigators to sort through the claims of different clinics to understand what type of claims come from those clinics and why a particular clinic may be considered suspicious.
What actions should be taken on suspicious claims?
It is up to the SIU department to determine how to deal with the information we provide from the tool. We recommend that when the tool is fully implemented it is run daily. We recommend immediately marking high ranking incoming claims for examinations under oath and/or surveillance. Our tool can be used to spot suspicious claims before you pay them.
Consistent use of our tool prevents fraud rings from future targeting of your company. When fraudsters realize that they cannot submit a bill without you noticing and taking appropriate action, they move on to softer targets. You will see noticeable reductions in incoming PIP claim counts and even bigger reductions in incoming PIP-related lawsuits.
How do I know it is working?
Prior to you making any purchase, we insist that we perform a demo on your data.
We have no interest in entering into a relationship with you if we cannot provide value. In our trial we ask that you use our secure connection to upload the data into our secure database in the cloud. After running our algorithms against your data, we are confident that they will identify fraud situations, some you may already know about and others that have been passing under your radar.
We encourage you to do due diligence on a sample of these flagged claims, such as:
a) comparing them to fraud you are already tracking and
b) performing a deep file review and/or surveillance of claims that we have flagged that were not already noticed by your claims/SIU teams.
We believe you will be pleased with the algorithm’s ability to spot claims that warrant attention by your SIU department. Assuming you agree that we have found valid SIU referrals and wish to proceed, we will enter into an agreement to update the results each night.
How much does it cost?
Our software agreement has no hidden fees. The PIP Radar is $5,000 per month, per state, with unlimited users. It can be cancelled at any time.