This occurs when a claims person purposely misrepresents the truth in order
to
either deny or support a claim; or offers or accepts any form of
consideration for
the referral or settlement of a claim.

Examples:
Accepting a gift, such as a television or trip to Hawaii, from a doctor’s
office in exchange
for an implied promise or patient referrals;
Knowingly referring cases for rehabilitation services that are not needed,
in exchange for a
rebate or other form of consideration;
Altering the evidence in a claim in order to support a denial.

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“Red Flags”:
Inconsistent application of cost-containment measures or agreement to pay
above the fee
schedule;
Sloppy observance of procedure for referrals to outside vendors, or
increase in the use of a particular vendor, to the exclusion of others;
Use of vendors outside the preapproved vendor panel;
Assignments made to vendors where the need for the assignment is
questionable;
Adjuster has social relationship with an applicant’s attorney or doctor;
Adjuster is overheard soliciting, or is observed receiving, tickets or
other gifts from
vendors.


Adjuster’s lifestyle grossly exceeds apparent income.

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