The NICB "partners with insurers and law enforcement agencies to facilitate the identification, detection and prosecution of insurance criminals," according to its web site. The organization collects information on and tracks suspicious insurance claims in the property, casualty, commercial, workers' compensation, and vehicle arenas; referrals with no discernible category are placed in a miscellaneous column. For the first half of 2009, the NICB data showed increases in nearly all referral categories compared with the first half of 2008.
In its report, the group noted that it received 41,619 questionable claims in the first half of 2009, compared with 36,743 during the same period in 2008. These are claims that NICB member insurance companies refer to NICB for closer review and investigation based on one or more indicators of fraud. The full report is available at www.nicb.org.
"While there has been modest improvement within a few categories of referrals, the overall number of questionable claims for the first half of 2009 is 13 percent higher than it was at this time last year," NICB President and Chief Executive Officer Joe Wehrle said in a prepared release.
In the workers' compensation category, numbers varied widely. A chart in the NICB half-year report notes that duplicate billing accounted for the largest increase in workers' compensation referrals, with a 100 percent rise in that category when comparing the first halves of 2008 and 2009. Referrals indicating medical provider wrongdoing (duplicate billing and inflated medical billing) accounted for three percent of the total number of first-half 2009 workers' compensation referrals.
Conversely, there was a 100 percent decrease (from two reported incidents to zero), in the X-Mod Evasion workers' compensation subset. Overall, half of the workers' compensation referral reasons decreased in the first half of 2009 when compared to the same period in 2008; however, workers' compensation referrals showed an overall increase of two percent when comparing first-half 2008 to first-half 2009.
While the percentage changes in some subsets look dramatic, they must be viewed in the context of the sample size. For example, the 100 percent rise in duplicate billing is based on seven incidents in first-half 2008 rising to 14 incidents in first-half 2009.
"There is nothing earthshaking here," NICB's Director of Public Affairs Frank Scafidi concurred. "This entire universe of 41,000-plus is not a huge amount. We also need to remember that these are just first referrals, not proven cases of fraud."
Incidents categorized in the report as workers' compensation suspected abuses were:
WC Referral Reasons 1st Half 2008 1st Half 2009 % Change
Duplicate Billing 7 14 100%
False Loss Statements 106 164 55%
Disability 95 125 32%
Prior Injury/Not Related to Work 278 324 17%
Working While Collecting 238 262 10%
False Loss of Wages 99 106 7%
Material Misrepresentation -
(Fraud Warning Form) 15 16 7%
Claimant Fraud 1072 1030 -4%
Material Misrepresentation -
(Employment Application) 15 14 -7%
Premium Fraud 28 22 -21%
False SSN 125 91 -27%
False Mileage Reimbursement 6 4 -33%
Inflated Medical Billing 91 47 -48%
X-Mod Evasion 2 0 -100%
Total WC Referrals 2177 2219 2%
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