Question

Case Study 1. Locate and research a Case Study for Long Term Care Insurance Fraud. Summarize the case study. Which party committed the fraud and explain with specific facts why it may or may not have been fraudulent? Describe the consequences either party endured due to the fraudulent act. You can start your research using the following websites:

http://www.irs.gov

http://library.cw.edu/

The report should be of 2 pages and submit your document in a Word format.

Answer 1

SESSION OVERVIEW- KEY CONCEPTS.

1.Undiscoverd clamins froud costs the industry millions each year.

2.Claims organization necesairy need to drive efficiecy which means you cant get every piece of document medical record vist or care notes surveli every claiment 24/7 etc.

3.Each organizatoin needs to make choice about what tools and techniques are in place to meet the often conflicting goals of processing efficiency vs identification of policy abuse or fraud.

4.This season will discuss and review one case study which resulted in substantial for the LTC carrier.

5.With 20/20 hindsight we have analyzed these cases and will suggest things we could earlier in the claims process to identify the froud before it causd a big loss to the company.

CASE STUDY SENENARIO:

1. "The Accident Claimant" Claiment accessing policy benefits after a motar vehicle accident.

CLAIMS AND UNDERWRITING

Clamins case study

FACTS OF CASE

1.Augest 2008 policy issued at insured age 54

-LIFETIME BENIFIT

-HIGH DAILY LIMIT

-INDEXING

FACTS OF CASWE CONT"D

1.The indepandent provider is a no relation

2.Reimbursementdemanded every thusday

INVESTIGATIVE APPROACH

1.Performed through claim and medical review

2.Database research

3.Conducted in home interview

4.Observed activity

OUTCOME

1.Claim closed

2.Demanded returnn of benefit paid

3.State froud reorting

4.state of investing

5.Current status

HINDSIGHT IN 20/20

1.Shoud the policyhave been issued

2.obtain medical records

3.verefication of hours worked and care provided