LTC Claims Advisory Toolbox —Section 2
Suspect Claim Activity
A. Suspect LTC Claim Activity - Introduction
Suspect Long Term Care Insurance claim activity can result in the overpayment of
Long Term Care Insurance benefits to an insured or a care provider.
This activity can be committed by both an insured or a care provider. Insured activity
includes intentionally overstating a disability, altering claim forms, and submitting bills
or invoices for care, services or treatment not received. Care provider activity
includes claims submitted by bogus care providers, billing for care, services or
treatment not rendered, and providing care, services or treatment while under
suspension or when license to provide the care has been revoked.
B. Identifying and Managing Suspect Claim Activity – Scenarios, Red
Flags and Tools
There are a number of suspect claim activity scenarios that have been identified
through experience from Long Term Care Insurance carriers. In addition, a number
of ‘red flags’ have been documented which can assist a Claims associate in
identifying suspect claim activity and finally tools which can be used to manage such
activity.
The following sections provide further detail for the three key areas in
detecting suspect claim activity.
C. Suspect Claim Scenarios
Suspect Claim
Scenario
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2
Scenario
Description
Scenario
Identifiers/
Triggers
Ineligibility of
the Insured.
Insured's health
and/or level of
disability has been
intentionally
overstated.
Insured, attending
physicians and other
care providers,
assessors, 'tipsters',
family members and
others
Misstatement
of dates of
service.
Dates of services are
reported as beginning
earlier than actual
start date in order to
begin an eligibility
period sooner.
Insured, attending
physicians and other
care providers,
assessors, family
members and others
LTC Claims Advisory Toolbox 2007
Revealing
Claim
Documentation
Insured's statements,
attending physician
statements and
narratives, medical
records, care notes,
assessment results,
telephone
conversations,
bills/invoices
Insured's statements,
attending physician
statements and
narratives, medical
records, care notes,
assessment results,
telephone
conversations,
bills/invoices
Possible
Investigative
Tools
IME, Assessment,
medical records,
surveillance,
insured and/or
caregiver
interviews
Contact
insured/caregiver
to confirm dates,
obtain medical or
facility records,
request proof of
payment
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LTC Claims Advisory Toolbox —Section 2
Suspect Claim Activity
Bills/Invoices
for care,
services,
treatment or
items not
provided or
received.
Entire or portions of
bills received are for
care, services and
treatment that were
never provided to the
Insured. Or, bills
received include
expenses for items
not purchased or
rented by the
Insured. Or, bills
received are 'padded'
in order to seek more
policy benefits than
are actually payable.
Or, bills are for care,
services, treatment or
items that may not be
billed for in the
absence of insurance.
Insured, attending
physicians and other
care providers,
assessors, 'tipsters',
billing companies,
family members and
others
Insured's statements,
attending physician
statements and
narratives, medical
records, care notes,
assessment results,
telephone
conversations,
bills/invoices
Contact
insured/provider to
confirm amounts
billed, obtain
medical or facility
records, request
proof of payment
4
Unnecessary
care, services,
treatment or
items provided
or received.
Care, services,
treatment or items
provided to or
received by the
Insured appear
inappropriate for
diagnoses and/or
prognoses.
Insured, attending
physicians and other
care providers,
assessors, 'tipsters',
family members and
others
Insured's statements,
attending physician
statements and
narratives, medical
records, care notes,
assessment results,
telephone
conversations,
bills/invoices
Contact
insured/provider,
obtain medical or
facility records to
determine services
and need, request
proof of payment
5
Use of higher
service code
than is
warranted by
the services
actually
provided
Bills/invoices for care,
services, treatment or
items reflect an
inaccurate service
code in order to seek
more policy benefits
than actually payable.
Insured, attending
physicians and other
care providers,
assessors, 'tipsters',
billing companies,
family members and
others
Attending physician
statements and
narratives, medical
records, care notes,
telephone
conversations,
bills/invoices
6
Use of several
service codes
to bill
separately for
services rather
than one
applicable code
`
Insured, attending
physicians and other
care providers,
assessors, 'tipsters',
billing companies,
family members and
others
Attending physician
statements and
narratives, medical
records, care notes,
telephone
conversations,
bills/invoices
Use of
unlicensed
practitioners
Use of unlicensed
practitioners in order
to receive benefits
reserved for licensed
services or higher
grades of service.
Insured, attending
physicians and other
care providers including
the unlicensed
practitioner, assessors,
'tipsters', billing
companies, family
members and others
Attending physician
statements and
narratives, medical
records, care notes,
telephone
conversations,
bills/invoices
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LTC Claims Advisory Toolbox 2007
Contact
insured/provider,
obtain medical or
facility records to
determine services
and appropriate
service code,
request proof of
payment
Contact
insured/provider,
obtain proof of
payment, medical
or facility records
to determine
services and
appropriate service
codes
Request license
from
insured/provider,
check state
websites for license
information
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LTC Claims Advisory Toolbox —Section 2
Suspect Claim Activity
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Kickbacks
between care
or service
providers and
Insureds
9
Non-covered
care, services,
treatment or
items
presented as
covered care,
services,
treatment or
items.
10
Early
submission of a
claim.
Agreements made
between a care or
service provider and
the Insured wherein
the Insured receives
a percentage of the
policy benefits paid to
the care provider for
having made the
benefits payable in
the first place.
Bills/invoices for care,
services, treatment or
items reflect
inaccurate
descriptions of actual
care, services or
treatment received or
items provided in
order to seek policy
benefits for noncovered care,
services, treatment or
items.
Claim is filed by the
Insured within a short
period of time
following the policy's
effective date or
within a short period
of time following the
contestable period.
Insured, attending
physicians and other
care providers,
assessors, 'tipsters',
billing companies,
family members and
others
Telephone
conversations,
bills/invoices, proof of
payment
Contact
insured/provider,
request proof of
payment
Insured, attending
physicians and other
care providers including
the unlicensed
practitioner, assessors,
'tipsters', billing
companies, family
members and others
Attending physician
statements and
narratives, medical
records, care notes,
telephone
conversations,
bills/invoices
Contact
insured/provider,
request proof of
payment and
documentation of
goods/services
Insured, Insured's legal
representative,
Insured's family
members or agent
Insured's statements,
attending physician
statements and
narratives, medical
records, care notes,
assessment results,
telephone
conversations,
bills/invoices
Prescription check,
medical records,
insured and/or
agent interview,
other insurance
including disability
and worker's comp
D. Red Flags In Suspect Claim Activity
Suspect
Claim
Activity
Red Flag
Red Flag Description
Possible Scenarios
1
Documentation does not support care,
services, or treatment provided or
items purchased or rented such as
equipment.
Insured/family may be overstating/misreporting
needs
2
Discrepancy in medical records.
Insured/family/MD may have altered records or
incorrect information is being reported
3
Inconsistent diagnoses and/or
prognoses.
Insured may be overstating/misreporting needs
LTC Claims Advisory Toolbox 2007
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LTC Claims Advisory Toolbox —Section 2
Suspect Claim Activity
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5
6
7
High incidence of routine examinations
or assessments.
Reluctance to submit complete claim
documentation.
Altered or missing documentation such
as medical records, care notes,
treatment or care plans.
Care or service provider will not
provide acceptable evidence of stated
license/credentials.
Insured may be attempting to document need for
care or services
Insured/family may not want to document
possible mis-representations
Insured/family/provider may have altered forms
Provider may not be licensed
8
Misused or misspelled medical and/or
industry terminology.
Insured/family may be completing forms
9
Documents submitted contain 'white
out' erasures, or small lines around
sections of medical records that
appear to have been made as a result
of 'cut, paste, and copy' activities.
Insured/family may have changed documents
10
Requests received for policy benefit
payments to be mailed to a Post Office
box versus a street address.
Insured may not want to provide physical
address to avoid possible contact
11
Insured and/or Insured's legal
representative shows uncanny
familiarity with the claim adjudication
process.
Insured/family may have prior personal or
professional experience and are using that
knowledge for their gain
Pressure is received by the Claims
associate to pay a claim quickly.
Insured or Insured's legal
representative demands a quick
settlement. Insured appears
extremely eager to know the results of
the claim investigation, calls
repeatedly, uses threatening
language, etc.
Claims associate receives a direct or
indirect threat of legal action by the
Insured, Insured's legal
representative, care provider, or
agent.
Large benefit payments are requested
in the absence of Assignment of
Benefits.
Insured/family requesting direct payment of
benefits as rates have been exaggerated or no
charges were incurred.
15
Care, services or treatment received
by the Insured do not match the
provider's specialty.
Provider may not have provided services and
may be involved or insured/family has altered the
information
16
Similarities in handwriting between the
Insured or Insured's legal
representative and the care provider.
Insured/family/care provider may be completing
forms and not the appropriate person that should
be completing and signing the form
12
13
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LTC Claims Advisory Toolbox 2007
Insured/family may be trying to intimidate in
order to expedite processing and reduce claim
review process
Insured/family may be trying to intimidate in
order to expedite processing and reduce claim
review process
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LTC Claims Advisory Toolbox —Section 2
Suspect Claim Activity
17
Routinely submitting claims for policy
benefit payments equaling amounts
either just below or just above the
allotted benefit coverage in order to
receive maximum benefits.
Insured/family seeking to maximize benefit
payments, regardless of actual charges
18
Applicants (particularly young in age)
electing extremely rich benefit plans
with all peripheral services.
Insured/family may have knowledge of a medical
condition that was not disclosed or may be
seeking to defraud by submitting invoices for
high benefits for services not actually provided
19
Early claim (shortly after the
contestable period).
Insured/family waits until after the contestable
period expires to file claim thinking that insurer
has no recourse
20
21
22
23
Early claim (within short time of
effective date of policy). Claim was
submitted within the contestable
period and the medical records show
substantial and material unreported
health history.
Insured reports severe limitations of
ADL/IADL functioning without a clear
diagnoses that could have resulted in
such limitations.
Insured or Insured's legal
representative handles everything by
phone apparently avoiding the use of
mail services.
Family members (posing as unrelated
care providers) submit bills for home
care that they provide.
Insured may have intentionally withheld
information in order for policy to be issued
Insured may be overstating needs to support
claim
Insured/family may be trying to avoid mail fraud
penalties
Insured/family may be intentionally trying to
defraud by having excluded care providers
provide service
Insured may no longer be eligible, may be
working, out of town, etc. and therefore not
willing or able to have assessment
24
Reluctance by the Insured to have an
on-site assessment or is unavailable
25
Insured or Insured's legal
representative refuses to sign the
authorization or attempts to restrict
our ability to gather information that is
relevant to the claim.
Insured/family may be intentionally trying to limit
our ability to obtain pertinent information
26
Documents submitted contain 'white
out' erasures, or small lines around
sections of medical records that
appear to have been made as a result
of 'cut, paste, and copy' activities on
the bills.
Insured/family be intentionally trying to create or
conceal relevant information
27
28
Bills are received for home care
provided to an Insured during an
Insured's period of hospital
confinement.
The Insured or Insured's legal
representative are willing to accept
less in benefit payment than the
actual claim amount just to resolve the
claim quickly.
LTC Claims Advisory Toolbox 2007
Insured may be attempting to obtain payment for
non-covered services
Insured/family may be interested in resolving
claim before further investigation can be
conducted
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LTC Claims Advisory Toolbox —Section 2
Suspect Claim Activity
29
Care provider will not verify charges or
dates of service.
Care provider may not be willing to implicate
himself in potential fraud
30
Care provider will not provide care
notes or other acceptable evidence
that care was provided.
Care provider may not be willing to implicate
himself in potential fraud
31
Care provider and Insured share the
same last name.
Care provider and insured may be related.
32
Voluminous and overlapping dates of
service with other providers offering
same levels of care.
Care may not have been provided as
documented/may have been fabricated
33
Medical Records that are not
requested are presented with the
initial claim.
Insured may be eager to quickly resolve claim.
Records may have been altered.
34
Misspelled medical terminology on
attending physician's
statement/narrative and/or bills.
Physician may not have completed the
documentation
35
Home-made billing statements or
billing statements with no letterhead
or non-standard looking bills.
Insured may have created the billing statement
36
37
38
39
40
41
42
43
Excessive long term care provided to
an Insured with an acute diagnosis
(recovery expected within a short
period of time.)
Insured has had no change in
caregiver for an extraordinary period
of time.
Insured has had the same caregiver
for an extraordinary period of time
and there has been no break in the
care provided (no caregiver absences
such as vacation or sick time taken).
Bills received are for care in excessive
of 24 hours per day.
Insured age discrepancy between age
stated on application for coverage and
the age reflected in the claim
documents received.
Claim submitted by an Insured who is
young in age and particularly from
those same insureds who have
selected unlimited benefits and/or
high daily payment maximums.
Care provider is also the Insured's
POA or other form of legal
representative.
Care provider's address and the
Insured's address are spread apart by
20 or more miles.
LTC Claims Advisory Toolbox 2007
Insured may be overstating current condition
and needs in support of claim.
Documentation may not reflect actual
caregiver or schedule
Documentation may not reflect actual
caregiver or schedule
Documentation may not reflect actual
schedule
Insured may have under-reported age to
obtain a lower premium or coverage that
wouldn't have been available at actual age.
Insured may be aware of significant medical
condition that wasn't disclosed, or insured
may be over-stating condition/needs
May be more to care provider relationship to
insured, such as Family Member.
Care provider may not be providing services
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LTC Claims Advisory Toolbox —Section 2
Suspect Claim Activity
44
Insured does not have a home
telephone number and provides on cell
phone number(s).
45
Insured is difficult to reach by
telephone.
46
High hourly rate for unskilled home
care providers.
47
Care providers are paid only in cash by
the Insured.
48
49
50
51
52
53
54
55
Insured has a history of legal or
financial issues such as lawsuits, liens,
criminal activity.
Attending physician’s credentials
are not documented and cannot be
verified.
Insured may not want to provide home
telephone number to avoid possible phone
contact or detection of physical address
Insured may be working or not home
receiving care
Care provider may not actually receive high
rate; may be split/shared with insured
Care provider may not be reporting income
or insured may attempting to conceal
information regarding actual pay
Insured may be more inclined to submit
suspect information
Attending physician may not exist
Physician's certification is vague or
appears inconsistent with diagnosis.
Certification may not have been completed
by physician
Insured advises that the rate
negotiated is different than the one
actually billed to the insurance
company.
Additional disabling conditions are
added to subsequent medical
documents.
Insured may be altering the bills
Claim submitted more than 60 days
after start of care.
Information may have been submitted late to
deter further investigation
Letter of legal representation
accompanies the initial submission of
claim.
90-day certification received from a
physician or other licensed health care
practitioner for a condition that usually
does not have a 90-day duration.
56
Insured’s care provider changes
frequently.
57
Insured requests withdrawal of the
claim shortly after it is submitted
especially when notified that a
contestable review is underway.
58
Insured's Plan of Care never changes
or is inconsistent and fluctuates widely
Insured may be attempting to bolster
reason(s) for claim
Insured may be trying to seek immediate
payment and intimidation
Practitioner may not have completed
documentation or may have an interest in
insured
Care provider may be unwilling to commit
fraud and quits or care providers may not
exist
Insured may have withdrawn claim with the
intention that the contestable review will
cease
Insured may not be accurately reporting
needs
E. Tools to Investigate Suspect Claim Activity
LTC Claims Advisory Toolbox 2007
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LTC Claims Advisory Toolbox —Section 2
Suspect Claim Activity
Insured Eligibility
Questions to Ask/Tips
Independent Medical
Examination
Conduct IME to determine
eligibility. May want to obtain
surveillance on day of IME and a
few other days close to IME date.
Onsite-assessment
Insured readily available to
schedule? Caregiver present?
Name and relationship of others
present at assessment?
Medical records
Any comments about work,
travel, names of insured's family
members?
Attending Physician Narrative
Compare physician's signature in
medical records to signature on
APN
"Google" insured
Any web information on insured
working, hobbies, etc.
Background check
Insured working? Family
members with different last
names providing care?
Pharmacy canvas
Doctors or medications not
disclosed on app?
Surveillance
Is insured's reported condition
consistent with surveillance
findings? Is caregiver working
the hours as reported?
Claim review
Is information consistent, any
gaps, oversights?
Caregiver Verification
Questions to Ask/Tips
Call caregiver at home and
conduct interview
Confirm services, payment, etc.
Conduct unannounced interview
at caregiver’s home
Confirm services, payment, etc.
Reverse phone number/address
check
Does phone number/address
match documentation provided?
Background check
Care provider related to insured?
Care provider address/phone
consistent with other
documentation?
Google care provider
Any information indicating
reported care provider may not
be a care provider?
Surveillance
Is caregiver working the hours
reported?
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LTC Claims Advisory Toolbox —Section 2
Suspect Claim Activity
Map Quest
Map distance between insured
and care providers
Proof of Payment Verification
Questions to Ask/Tips
Request front and back of
canceled checks used to pay
care providers
Properly endorsed? Signature
on check matches care providers
signature on other documents?
Insured pays in cash-request
bank statements documenting
cash payments, caregiver's bank
statement demonstrating
deposits,1099s, other verifiable
proof of payment
Do bank statements/withdrawals
reflect payments to care
providers?
Web Tools
Questions to Ask/Tips
www.Zillow.com
www.anywho.com
Address verification for
insured/care provider
Reverse phone and address info
www.google.com
Search insured, care provider,
agencies, etc.
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