Category Archives: Crime

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Identifying and Preventing Provider Fraud in Workers Comp Cases

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Claimant fraud and premium fraud are two of the most well-known types of workers compensation fraud. In these cases, a worker may intentionally fake an injury (claimant fraud) or a business owner may misrepresent their employee headcount or incorrectly classify employees to obtain lower insurance premiums. Now, a lesser-known type is occurring with greater frequency: provider fraud.

Provider fraud occurs when a professional other than the injured worker or employer accepts a bribe or illegal kick-back in exchange for patient or client referrals. The circle of potential culprits includes lawyers, translators, doctors, chiropractors, nurses, and telehealth professionals. Opportunity, incentive and rationalization—the “fraud triangle”—are key factors that go into a person’s decision to commit insurance fraud. These factors have been exacerbated in recent years, due in large part to the pressures presented by the global pandemic and the growing reliance upon remote services.

Most schemes involve knowingly billing for medical goods and medical and legal services that are unnecessary or not provided at all. A chiropractor, for example, conducted illegal medical evaluations and billed these evaluations, claiming that he was approved as a medical legal evaluator. In another example, an attorney named his daughter as the owner of a translation services company, while in reality he maintained ownership of the business. Each time the attorney was hired, the translation business was also engaged and billed its services. Provider fraud is increasingly prevalent in California and Florida due to each state’s workers comp rules. For instance, in California, a provider can file their own lien with the Workers’ Compensation Appeals Board, even if the bill was denied. California is the only state that allows providers to file their own adjudication. At a higher rate than in other states, healthcare providers in California and Florida are sometimes found billing for services that were never rendered, billing for more expensive services than were actually provided, ordering unnecessary tests or procedures, and providing kickbacks to referring physicians.

So, how can we pin down provider fraud?

  • Review Provider Invoices and Reports: Risk professionals can spot potential fraud cases and fraud trends by closely reviewing provider invoices and reports and scrutinizing those invoices that are close to, but not at the top of, typical billing charges. In the workers compensation system, there are typically five levels of a doctor evaluation: Level 1 is the cheapest while Level 5 is the most expensive. Fraud often occurs in Level 4 billings since Level 5 would be too obvious. Providers who consistently bill at Level 4 could be a red flag for fraud.
  • Shine a Spotlight on Supplementary Services: Insurers sometimes overlook that provider fraud can occur with supplementary services such as translation and transportation companies, copy services, medical equipment suppliers and pharmacies. It is not uncommon for insurers to discover that these schemes may involve a criminal enterprise (possibly a referral network) orchestrated by individuals who are not medical or legal professionals. While claimants can be complicit, often they are unwittingly involved and potentially subject to treatment that is unnecessary or even harmful. 
  • Consider Emerging Tech to Pinpoint Provider Fraud: Artificial intelligence and machine learning are game-changers for fraud investigations. Through the analysis of historical claims data and insurance adjuster notes, some technologies can help professionals discover fraudulent claims faster. For instance, AI can be particularly effective at the entity level when a doctor or hospital that is identified as fraudulent can be added to a “bad actors” list for review in future claims. If you do not have a fraud feedback loop, start gathering information now. As risk and insurance professionals, we rely on business rules and claims adjusters to catch all the details of a claim and then form a cohesive narrative to investigate. While business rules work, the fraud feedback loop is necessary to effectively train machine learning models to detect patterns and flag anomalies.

Workers compensation insurance provider fraud has become a multi-billion-dollar industry that is bad for business. It is costly for insurance companies to identify and prosecute, it inflates costs for goods and services that honest business owners rely on, and it stokes consumer apathy and distrust in the insurance system. Risk and insurance professionals need to be aware of the warning signs so they can work diligently to detect and prevent it.

Cyberrisk Management Tips for Businesses Amid the Russia-Ukraine War

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A wide range of risks are trickling down from Russia’s assault on Ukraine, from sanctions compliance to supply chain disruption to business interruption. Cyberrisk has also drawn considerable concern and the threat landscape continues to evolve rapidly, though the details of increased cyberattack activity are not yet fully known and may be largely unfolding below the surface right now. Attacks attributed to Russia have been launched against a range of targets in Ukraine, including new destructive malware campaigns, targeted information-gathering against a range of civilian and government targets, and attacks on critical infrastructure.

Concerns about escalating cyber activity around the crisis are a vivid reminder of the importance of knowing your threat model and adjusting your risk management priorities accordingly. According to experts ranging from independent cybersecurity professionals to officials at the Cybersecurity and Infrastructure Security Agency (CISA), organizations at greatest risk right now include critical infrastructure, banks and other financial services firms, and of course key service providers in Ukraine or Russia.

Spill-over to other businesses is more likely with cyber conflict, however, particularly given Russia is one of the most advanced and aggressive nation-state cyber threat actors—remember the crippling global attack known as NotPetya that upended supply chains in 2017 resulted from a Russian cyberattack on Ukraine. That is not to say that there is necessarily cause for panic, simply that the effects of cyber conflict can be unexpected, widespread and potentially severe.

At this point, for most companies that are not in a high-risk position as a direct result of the war, the best course of action for risk professionals is to focus on ensuring your company has an updated and detailed incident response plan on hand and distributing it to relevant members of the organization, reviewing and potentially strengthening your general cybersecurity posture, and reminding employees about cyber hygiene.

For example, given the tragic events and breaking developments around the conflict, many may be glued to news or social media. Unfortunately malicious actors are known to take advantage of such situations by posting phishing links on social media with alleged news updates or email scams that purport to collect charity donations. Remind employees about these perils and offer refreshers on how to spot phishing scams and the need to exercise caution with links in emails or on social media.

“In addition to taking a fresh look at plans and other policies within an organization’s cybersecurity risk framework, businesses should consider a few common-sense tips to prepare for a potential cyber incident,” advised Annmarie Giblin, partner at Hinshaw & Culbertson and leader of the firm’s data privacy and cybersecurity practice. Giblin recommended risk professionals take the following steps to boost cyberrisk management efforts right now:

  1. Print out a hard copy of any necessary polices and plans, like the cyber incident response plan, the business’ cyber insurance policy and a contact list for the organization, so you have them available in the event you cannot access your system and need to communicate with employees through alternative methods.
  2. Remind your employees about common cyber scams and reiterate that there will be no retaliation for reporting a cybersecurity mistake, such as clicking on a bad link.
  3. Have key members of the executive team and incident response team set up a secure but alternate method of communication, such as sharing phone numbers or creating a different off system email address to communicate in the event the business’ systems are not available or not trusted.
  4. Keep track of the latest threats and get the research over to your IT team so they can update your firewall, and/or contact the business’ security services provider and make sure they are aware of and addressing these new malware strains.
  5. Evaluate and if possible, test your business continuity plans. Organizations should be asking themselves, “What does the work day look like without access to the business’ systems?” and “How can we still work without any technology support?”

Cyber insurance firm Coalition has put together a guide to basic cybersecurity measures to help organizations—policyholders and otherwise—proactively manage cyberrisk and reduce the likelihood of a cybersecurity incident. The guide provides 10 key steps to help improve cyberrisk management, highlighting the basics of each mitigation measure, tips on how to implement, and even some vendor suggestions for credible options, if desired. Coalition notes this may be particularly helpful for small and mid-sized businesses that do not necessarily have dedicated in-house information security experts, but it could also be worth a look for any risk professional who wants an overview of mitigations that should be in place or ways to fill those gaps. Check it out here: https://info.coalitioninc.com/rs/566-KWJ-784/images/DLC-2020-12-2021-Coalition-Cybersecurity-Guide.pdf

For more resources on cyberrisk management best practices, cyber incident response, cyber insurance considerations, and more, check out Risk Management Magazine’s extensive cyber coverage here. Some of the highlights below can help address key concerns that you—or your board—may have right now, and offer actionable strategies to strengthen your cyberrisk readiness and boost employee cyber hygiene:

A TechRisk/RiskTech Reading List from Risk Management Magazine

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Last week, the RIMS TechRisk/RiskTech virtual event featured two days of education content on some of the biggest challenges and opportunities in modern risk management, focusing extensively on cyberrisk as well as risktech—the latest technology tools and techniques for managing risk. As the presentations made clear, technology introduces some of the greatest risks to organizations, but also some of the most promising innovations to introduce or enhance risk management.

“We all know that, ‘As fast as a business develops a strategy to protect their organization’s digital assets, cyber predators have already figured out their next move,’” said Patrick Sterling, vice president of legendary people and risk management at Texas Roadhouse Restaurants and 2022 president of RIMS. “So, risk professionals must do what risk professionals do best: We must adapt. And we must adapt quickly.”

“We can’t forget about the risks that preceded this pandemic, and top on that list stands technology,” Sterling added in his address during the event. “Cyber gets a bad rap—when we talk about risk, we must remember risk can lead to positive outcomes. While greater dependency on technology has opened the door to more threats, it also allows us to improve processes, keep employees safe, boost efficiencies and engage our customers in a whole new way.”

As a RIMS virtual event, the content from TechRisk/RiskTech will be available for attendees or new registrants to view on-demand for the next 60 days, and you can check out the sessions here.

Following the TechRisk/RiskTech event and last Friday’s international Data Privacy Day, risk professionals who want to learn more about cyberrisk and risktech topics can also check out a wealth of related articles from Risk Management Magazine. Whether you would like to keep up the education after attending TechRisk/Risktech or just want to catch up on topics like cyberrisk, ransomware, cyber insurance, risktech, artificial intelligence, the internet of things and connected devices, and other technology that can help manage risk, here’s a roundup of recent Risk Management articles on cyberrisk and risktech:

Tech Risk (Cyberrisk):

Risktech:

Detecting and Confronting Procurement Fraud

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Accountancy firm Crowe and credit rating company Experian have said that large enterprises and governments experienced 59% of procurement fraud in the United Kingdom, costing them $120 billion (£89 billion) collectively. It is estimated that over $2 trillion (£1.6 trillion) total is lost each year due to procurement fraud, or 4-8% percent of an organization’s procurement spending. This figure dwarfs other areas such as corporate tax avoidance, where HMRC estimates that $94 billion (£70 billion) was avoided between 2011 and 2015.

The main difference is that procurement fraud is so varied that it makes it virtually impossible to detect. More importantly, procurement fraud is difficult to detect because it is often embedded in a genuine expense. For example, when a construction contractor submits an invoice for 100 hours of work in a week, eight of those hours may be fraudulent. This may seem negligible, but when you consider that every purchase in an organization can include an element of fraud, the scale of the problem becomes clear. It is not just about the financial loss; there are many reputational issues too.

Why Procurement Fraud? 

There are two main reasons: greed and opportunity. In terms of motive, we see both individuals and groups committing acts of fraud because they want something for themselves. They might be looking for personal gain, or trying to get away from someone else, or simply seeking revenge on a competitor.

Several studies have shown that around 50% of fraudsters are motivated by either monetary reward or benefits gained by committing a crime. For example, in 2018, a Massachusetts Bay Transportation Authority (MBTA) procurement official was indicted for receiving over $300,000 in illegal bribes and gratuities from a construction company that performed work for MBTA.

Individuals may also notice a weakness in a business process, as trivial as a broken approval process, that allows for invoices to be paid to existing suppliers without checking the outstanding purchase order amount. The problem is that weaknesses can surface at virtually every step of the procurement lifecycle, across the entire supply chain. Additionally, fraud often occurs when suppliers become close with an individual with authority inside an organization that can provide undetected access. Fraudsters see an opportunity to profit from weaknesses and begin exploiting them.

What Can Be Done?

Here are three ways to help your business become less vulnerable to fraudulent activity:

1. Use data analytics tools: Data analytics tools give you access to information about how well suppliers perform against agreed standards. You can use this information to identify potential risks early on, which could save your company millions in wasted spending.

2. Choose suppliers carefully: The larger and more complex your supply chain, the greater the risk for procurement fraud. If you buy goods and services from many suppliers, you should try to choose suppliers based on quality rather than price. Quality is not always reflected in the cost, but this means you need to be wary of the cheapest option. Using data to draw definitive conclusions about a supplier’s performance is a good way to remain objective when selecting.

3. Create a robust process: It is important that have a robust supply chain management process in place. You should be able to trace back how a supplier was added to your supply chain, the selection criteria for any awarded contracts, their ongoing financial standing, and the people involved in managing the relationship.