Insurance Investigations

Health Insurance Fraud Investigations

Insurance fraud and health/benefits fraud cost insurance companies hundreds of millions of dollars each year. The Investigators Group works extensively with claim examiners, adjusters and legal specialists to help investigate and assess claims. Our services include investigation into fraud related to medical treatments, workers' compensation, life and health investigations, accident benefits investigations and property & casualty claims.

The Investigators Group's licensed private investigators are the most highly skilled in the industry. We have assisted clients with specialized investigations including undercover investigations and our professionals are adept at utilizing skilled investigation techniques including surveillance, video and photography evidence, witness interviews and statements. Our professionals are industry specialists who understand the need for integrity, confidentiality, and continuity within an investigation.

We have experience with complex investigations and those requiring multiple investigators. We are able to conduct background checks and have the ability to leverage multiple resources as needed.

IGI Uncovers Medical Services Fraud

Investigations to uncover organized insurance fraud requires the skills of experienced and skilled investigators. The Investigators Group assisted in one such investigation and our licensed private investigators were tasked with identifying fraudulent practices and illegal schemes at certain health care clinics. During the course of the investigation which spanned several months, our investigators uncovered kick-back and referral schemes of concern and unethical practices of the clinic, its staff and management. Ultimately, The Investigators Group helped to expose a fraud that netted the fraudsters over $1 million per year.

Insurance Investigations

In-Depth Fraud Investigation

From time to time, The Investigators Group is called upon to investigate organized fraud against insurers or their group clients. We have developed a methodology for such investigations that relies on our experience in Health Care Provider Audits, interview techniques and financial analysis to bring these types of investigations to a successful resolution. Our team of fraud investigators can prepare a case completely for civil and/ or criminal process.

Insurance Investigations

Employment Background

For IRB and other employment based claims, we verify the claimants stated employment through telephone and in person interviews with the claimants. We will view pay stubs, tax deductions and other documents to establish the validity of the claimant’s income. We will also research the employer themselves, conducting corporate searches where required, attendance at the employer’s address, documentation of the property and employer interview with a detailed description of the claimant’s duties. We will also review any apparent non-employment relationships between the claimant and the employer. For self-employed individuals, we are prepared to send in specialists to document earnings through a review of financial records.

Insurance Investigations

Living Arrangements / Neighbourhood Background

We send an investigator to attend at the claimant’s provided address, notation of accommodations, vehicles parked in the driveway documented to determine priority issues. We will interview Landlord, or Superintendent and neighbors to obtain current information regarding the subject’s current level of activity, length of residence and other persons who reside with the claimant. We will also conduct neighborhood background investigations to determine the claimant’s current level of activity

Insurance Investigations

Surveillance

The challenge of any surveillance operation is to accurately document with video, and contemporaneous notes, the activities of the claimant. The Investigators Group uses the latest technology, employs the finest surveillance specialists and provides incredible support to our surveillance team. Through experience and team support, our investigators are prepared for any eventuality that may occur in the field. "If you are too close you will be observed, if too far away, you will lose the claimant”. The eternal double edged sword for a surveillance investigator. How do we come out on top? The answer is preparation. We go into the field knowing more about the claimant then any other company. By doing so, we can more easily anticipate the actions of the claimant and provide the best “Investigative Solutions.”

Insurance Investigations

P&C Claims

Surveillance however, never stands alone. With the growing number of fraudulent claims, staged accidents, claim embellishment, over claimed caregiver costs, false residential addresses and employment information, we have changed our investigative objectives to address these ever changing trends in insurance fraud. Surveillance works hand in hand with in-depth background inquiries to further establish the validity of claims. Initially the surveillance provides the video and photographic evidence to determine the activity of the claimant or caregiver or other claimant-service provider. Then we employ a uniquely crafted questionnaire to obtain a statement from either claimants, caregivers, employer and involved third parties to identify any inconsistent information supplied in the accident benefit package and supplementary information. This information often provides assistance in mitigating the claim either in mediation, arbitration or litigation.

Insurance Investigations

Health Care Provider / Clinic Audits

The Investigators Group Inc. has a number of senior investigators trained in conducting Health Care Provider Audits and Clinic Inspections. Such investigations will determine the legitimacy of Medical / Chiropractic facilities, verify licence status, identify practices and treatments and verify the relationships between the clinic, it’s employees and it’s management.

During the course of this type of investigation, investigators will often uncover over utilization schemes, illegal treatment, unlicensed providers and illegal ownership. The Investigators Group is committed to providing the best “Investigative Solution” utilizing Audits and Inspections where billing for service not rendered, treating outside the scope of practice, and kick-back or referral schemes are of concern. Contact us to learn more about how Provider Audits and Clinic inspections can provide you with the “Best Evidence”.

Insurance Investigations

Accident Benefit & Bodily Injury Claims

Interview and statements of insured and other claimants
Third party interviews
Employment Verification and employer interviews, legitimacy of employer
Database analysis of staged accidents through analysis of commonality and other anomalies to prepare evidence package.
Analysis of rehab facilities and other medical service providers including attendance at facility to review documents and logs and photographs of premises
In cases where fraud is apparent, preparation of brief for presentation to Police
Liaison with Police as their investigation continues

Insurance Investigations

Original Statement of The Claimant

Property Casualty

At The Investigators Group Inc. we take an in-depth statement from the claimant, inclusive of over 200 questions relating to the accident, passengers, claimant injuries and any related expenses including housekeeper, caregiver and transportation. Included in this comprehensive statement, are questions regarding employment, other sources of income, tenancy and information about dependents. Also examined, are the claimant’s normal physical and social activities, information regarding previous accidents and AB, BI, long term and short term disability claims and pre-injury physical capabilities. The statement is designed to identify occasions when claimants are not truthful.

Life & Health

• Comprehensive Surveillance • Claimant Interviews • Death Claims • Accidental Death

The Investigators Group has developed an objective in-depth claimant statement including lifestyle determinant, and relevant psychological questions where applicable. The statement is signed to identify situations in which the claimant may not be truthful and may be used in comparison to any surveillance undertaken

Insurance Investigations

Interview and Statement of the Housekeeper/Caregiver

An in-depth interview of the caregiver and/or housekeeper, inclusive of over 100 questions. Included in this interview are questions regarding financial arrangements with the claimant, personal family situation and exact dates and times of apparent services, including the duration of the service. The interview is designed so as to elicit information regarding the authenticity of the work being performed including the caregivers knowledge of the claimant’s residence and other circumstances.

Insurance Investigations

Health Insurance Fraud Investigations

Investigative

Admissibility of Surveillance Evidence

Investigative

Surveillance by Employers

Investigative

Protecting your Business against Fraud