Uncovering Fraud in a Long-Term Care Claim

Case Overview

The insured claimed a medical condition which required 16 hours per day of home health care. The referring claim examiner stated that several red flags existed to include age of claimant not typically associated with the medical claim; cash payments were being made to the home health care provider and the receipts submitted with the claim, seem like duplicates.

Our Approach

The initial review of the referral led us to strategize with the claim examiner on how best to conduct this investigation.  It was determined that a Scoop report may provide valuable information on the claimant, their activity level and potential “friends”.  In addition , given the location and the length of daily home care coverage, we agreed  that eRemote surveillance would be the most effective surveillance approach.

Results

• The Scoop report uncovered some activity that was contrary to the stated disability.
• 3 days of eRemote surveillance provided video evidence that no home health aides were present for two of the three days. On the third day the aide was only there 4 hours.
• Upon review of the submitted billing on the days in question, there were 48 hours charged when the video surveillance showed only 4 hours of coverage.
• The claim was denied.
• Given the claimed medical condition, age of claimant and the policy language , reserves had been established at $100k. These were taken down after the claim denial.‍

Testimonial

We hadn’t used eRemote® before and had always relied on traditional surveillance.  This provided us with a much better understanding of the activity there and was less expensive than had we used a traditional surveillance investigator.

Key Takeaways

Utilizing red flags for this product line allowed the claim examiner to identify a claim that was suspicious.  With that suspicion and working closely with Delta Group allowed the client to take the appropriate action on the claim.