Description
9. SIU Investigations and SIU procedures, NYIL §409(c)
Describe the SIU’s case management system.
Describe the procedures for case investigations.
How is the manual for investigators maintained? Hard copy or electronic?
Provide a list of databases used by investigators (e.g., ISO, DMV).
Describe the relationship of the SIU with law enforcement agencies and prosecutors required by NYIL
§409(c)(1), including:
a. Description of relationship between the SIU and the IFB.
b. Criteria for referral of a case to IFB and law enforcement.
c.
Name of the individual authorized to make referrals to the IFB. d. Description of the policy to avoid duplication (without notification) of concurrent referrals by SIU to more than one law enforcement agency,. Indicate the SIU’s compliance with NYIL §405(a) {emphasis added}: “(a) Any person licensed or registered pursuant to the provisions of this chapter… who has reason to believe that an insurance transaction or life settlement act may be fraudulent, or has knowledge that a fraudulent insurance transaction or fraudulent life settlement act is about to take place, or has taken place shall, within thirty days after determination by such person that the transaction appears to be fraudulent, send to the superintendent on a form prescribed by the superintendent, the information requested by the form and such additional information relative to the factual circumstances of the transaction and the parties involved as the superintendent may require. The superintendent shall accept reports of suspected fraudulent insurance transactions or fraudulent life settlement acts from any self insurer, including but not limited to self insurers providing health insurance coverage or those defined in section fifty of the workers' compensation law, and shall treat such reports as any other received pursuant to this section.” 10.
Restitution and Recoveries NYIL §409(c) The Plan must contain a provision that addresses savings and recoveries, including court-ordered restitution. NYIL §409(c)(4) states that the Plan shall provide for: “Coordination with other units of an insurer for the investigation and initiation of civil actions based upon information received by or through the special investigations unit.” 11. Internal/Employee Fraud The Plan should include a section to address employee fraud. Internal fraud should be reported to the DFS Criminal Investigations Unit per Section 405. 12.
Public Awareness Program - NYIL §409(c)(5) Has the insurer joined the National Health Care Anti-Fraud Association (NHCAA)? Has the insurer joined the New York Alliance Against Insurance Fraud (NYAAIF)? If developing an in-house program, provide the following: ï‚· Description of the media (e.g., radio, television, print, website, etc.). ï‚· Budget for the next year. ï‚· Target audience (must include general public). ï‚· Sample hard/electronic copies, 800 number, company website. 13. Fraud Data Reporting Requirement NYIL §409(c) NYIL §409(c)(2) requires that the Plan provide for the reporting of fraud data to a collection firm designated by the Department. Currently, no organization has been established; however, the Plan must contain a statement to comply with §409(c)(2). .
Name of the individual authorized to make referrals to the IFB. d. Description of the policy to avoid duplication (without notification) of concurrent referrals by SIU to more than one law enforcement agency,. Indicate the SIU’s compliance with NYIL §405(a) {emphasis added}: “(a) Any person licensed or registered pursuant to the provisions of this chapter… who has reason to believe that an insurance transaction or life settlement act may be fraudulent, or has knowledge that a fraudulent insurance transaction or fraudulent life settlement act is about to take place, or has taken place shall, within thirty days after determination by such person that the transaction appears to be fraudulent, send to the superintendent on a form prescribed by the superintendent, the information requested by the form and such additional information relative to the factual circumstances of the transaction and the parties involved as the superintendent may require. The superintendent shall accept reports of suspected fraudulent insurance transactions or fraudulent life settlement acts from any self insurer, including but not limited to self insurers providing health insurance coverage or those defined in section fifty of the workers' compensation law, and shall treat such reports as any other received pursuant to this section.” 10.
Restitution and Recoveries NYIL §409(c) The Plan must contain a provision that addresses savings and recoveries, including court-ordered restitution. NYIL §409(c)(4) states that the Plan shall provide for: “Coordination with other units of an insurer for the investigation and initiation of civil actions based upon information received by or through the special investigations unit.” 11. Internal/Employee Fraud The Plan should include a section to address employee fraud. Internal fraud should be reported to the DFS Criminal Investigations Unit per Section 405. 12.
Public Awareness Program - NYIL §409(c)(5) Has the insurer joined the National Health Care Anti-Fraud Association (NHCAA)? Has the insurer joined the New York Alliance Against Insurance Fraud (NYAAIF)? If developing an in-house program, provide the following: ï‚· Description of the media (e.g., radio, television, print, website, etc.). ï‚· Budget for the next year. ï‚· Target audience (must include general public). ï‚· Sample hard/electronic copies, 800 number, company website. 13. Fraud Data Reporting Requirement NYIL §409(c) NYIL §409(c)(2) requires that the Plan provide for the reporting of fraud data to a collection firm designated by the Department. Currently, no organization has been established; however, the Plan must contain a statement to comply with §409(c)(2). .
Economic Conditions Sub Categories
NYDFS
