Special Investigations Unit (SIU)
Arrests of fraudulent Claimants, Medical Providers and other service providers in California are up across the State. Contributing to this is Berkshire Hathaway Homestate Companies' (BHHC's) Special Investigations Unit (SIU). This internal program has two goals: to fight fraud aggressively and minimize the exposure on suspect claims. Both goals are of equal importance to the SIU department and BHHC.
The BHHC SIU is made up of former law enforcement and senior workers' compensation claims professionals. This creates a unit that is diverse in knowledge and experience and allows each professional to utilize their skills together to minimize exposure where abuse is present and to combat fraud effectively. The reality is the claims handler and the law enforcement professionals have distinctly different realms to work in. To bridge the gap, BHHC has focused on training and communication for all employees so that smart, effective and timely referrals are made to the SIU department.
It is important to recognize potential fraud at the beginning of a claim. A proactive approach of vigilance and administration minimizes exposure. Additionally, timely specific reporting of suspicious behavior improves our probability of cost containment and fighting fraud. The SIU REACT program incorporates claims handling and the SIU function together to include:
- Reviewing each new claim file set-up for "red flags"
- Explore "red flag" indicators with appropriate investigation
- Assign investigators and litigation specialists as necessary
- Coordinate between SIU, Claims Examiner, Investigators and Legal Representatives
- Track the claim and make sound referrals to law enforcement agencies
- An effective SIU program recognizes the difference between abuse and fraud and utilizes its resources for cost containment and criminal litigation effectively. Abuse resembles fraud, but there are important legal differences between these concepts. Abuse is addressed within the Workers Compensation arena and occurs more frequently than fraud. It includes such instances as disputes concerning the nature and extent of an injury. Fraud, on the other hand, is handled in the criminal arena and occurs only when a lie has been knowingly told for material gain.
Insurance fraud is prosecuted by the District Attorney and is often difficult to prove to a judge and jury. In the Criminal arena, the threshold for the burden of proof is beyond a reasonable doubt. The involvement of the insured can be the definitive factor in proving fraud. Consequently, insured communication is highly encouraged and BHHC has developed two ways for insureds to communicate the information:
- Direct e-mail access reportfraud@bhhc.com.
- Toll-free direct access number to report information 1-800-300-JAIL (5245).
With your help we can put criminals behind bars.