Copyright held by The John Cooke Fraud Report. Reprint rights are granted with attribution to The John Cooke Fraud Report with a link to this website.
By Eric Tackett, 1994
Published by Laser Tech
Finally, a neat, complete, well-written manual that walks the reader through the complicated world of medical auditing. Some of the information presented:
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Defines the purpose and the components of a medical audit;
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Explains the equipments/methods used in standard physical therapy;
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Provides definitions for the most common terms used in medical reports;
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Familiarizes the reader with
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medical fraud indicators and methodology
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applicable sections of the Chiropractic Act and the Medical Practice Act
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the Physical Therapy Service Requirements
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the intent of the Moscone-Knox Professional Corporations Act
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Tells just what to look for in a medical review;
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Provides the framework for determining if a clinic is operating legally and if a provider has proper licensing.
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This manual concisely explains that the purpose of the investigative medical audit is to obtain factual, documentary evidence that will assist in the determination of one or more of the following:
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whether treatment billed for was actually given
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whether or not the treatment was excessive
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whether or not treatment was proper
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whether or not providers are properly licensed
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whether the facility is operating legally, and
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whether the medical file matches the statement.
Although this manual is California specific, the vast majority of the information presented can be successfully utilized in any area of the country. The reader of this manual acquires one more highly effective tool to thoroughly understand and investigate claims involving medical treatments.
Purchase information is available by calling (714) 963-7915.
BILL KIZOREK’S BOOKS
Non-Fiction Training Books
As more and more insurance companies and self-insured businesses take aggressive action to fight workers’ compensation fraud, a need for anti-fraud education has emerged. What steps are necessary in the journey that begins with suspicion and ends, hopefully, with a court judgment to disallow or reduce a compensation award?
Bill Kizorek, president of Naperville, Illinois-based InPhoto Surveillance, has written five books on the various aspects of taking on a suspicious workers’ compensation claim and has just released his newest book in September. Topics include developing investigative units (SIUs), using video surveillance, testifying, organizing a special investigative unit and handling suspicious psychological claims.
As president of a firm specializing in the investigation and videotaping of insurance fraud suspects, Kizorek has become a leading author and speaker on the subject of insurance fraud and bodily injury claims. The success of his books is based on the practical information they provide and the “quick read” format in which they are written. Readers don’t have to spend a lot of time to learn valuable information and procedures for combating insurance fraud. To order any of the following books, call PSI Publications at (708) 955-0940.
CLAIMS DETECTIVE
The best selling of all Kizorek’s books, “Claims Detective” explains how some people try to take advantage of insurance companies and claim departments by exaggerating the extent of their injuries and disabilities. A touch of humor is thrown into his illustrations and into the actual investigations and court decisions he cites.
DISABILITY or DECEPTION
Using examples of actual cases, Kizorek provides different scenarios of how claimants have taken advantage of the system and what is being done with video equipment to ferret out bogus personal injury claims.
PSYCHOLOGICAL CLAIMS INVESTIGATION
The hottest new trends in the claims business are allegations of disability relating to the mind. “Psychological Claims Investigation” provides a plan of action incorporating psychological as well as video investigation.
FISHY CLAIMS EXPERT
(a coloring book)
Although claims handling is a very serious business, this book takes a lighthearted look at the daily operations of a claims department, from adjuster to vice president.
GREENHORN WITNESS
Kizorek’s latest publication, “Greenhorn Witness,” offers practical advice for those who must testify in legal proceedings. According to Kizorek, “This book will serve the interests of those who will be testifying for the first time, or need a refresher course in the fine art of testifying.” It is a 39-page paperback filled with pointers and techniques on interrogation, trick questions, what to say or not say, how to handle a deposition and much more.
SIU 101
(Co-authored by Scott Finger, InPhoto’s SIU Mgr.)
Developing, implementing and operating a special investigative unit is the primary focus of this book. “SIU 101” is an introductory guide in identifying and investigating fraud for special investigators and adjusters. The book contains guidelines for the investigation of various potentially fraudulent claim areas, lists of red flags used in identifying suspicious claims and “how to” sections on preparing for and testifying during legal proceedings.
The Kizorek books were reviewed by Susan Miura, Director of Public Affairs for the Alliance of American Insurers, headquartered in Schaumburg, Illinois.
HOW YOUR FRIENDS AND NEIGHBORS ARE SCREWING YOU
By Barry Zalma
Los Angeles, Claims School, Inc.
Copyright 1993
An entertaining collection of short stories authored by
Southern California Fraud Attorney Barry Zalma, “How Your Friends And Neighbors Are Screwing You” walks the tightrope between teaching the professional industry reader how to get away with a fraudulent claim and how to recognize a fraudulent claim. This book contains so many lessons, in fact, that it would be very unwise to leave/lose your copy on a bus bench in downtown Los Angeles. The lucky bus passenger who finds it, however, might very well be driving a 450 Mercedes SL, inadvertently funded by insurers, within the year.
The presentation is one of easy reading; stories run from two to seven pages. It’s the kind of a book that can be read piecemeal – but that you might be unwilling to put down once you begin the entertaining journey into the Land of Insurance Fraud.
From the lady who gave classroom type lessons on how to perpetrate auto fraud to the not-so-well-planned theft of Sweet Daddy’s Mercedes, “How Your Friends And Neighbors Are Screwing You “ is an entertaining and informative cover-to-cover read.
For a FREE SAMPLE of one of the stories, see page ___ of this issue of “The John Cooke Fraud Report.” To order the whole darn book, call Claimschool, Inc. at 310-390-1029 (Visa and MC accepted).
“H” IS FOR HOMICIDE
by Sue Grafton
New York, Henry Holt & Co.
1991, 202 p.
Fiction
Private Investigator Kensey Millhone seems to run into trouble alphabetically. Author Sue Grafton’s series has taken Millhone through adventures from “”A” is for Alibi” to “”K” is for Killer.”
As has been established in the earlier books, Millhone does investigative work for California Fidelity Insurance Company in addition to pursuing other cases. Unlike other books in the series, “”H” is for Homicide” uses the insurance company as a springboard for the mystery. In the opening pages, a claims adjuster for California Fidelity is found murdered in the office parking lot. Our detective is led into the plot through one of the dead man’s auto claims, submitted by one Bibianna Diaz.
Millhone easily discovers that Ms. Diaz is only a small-time operator. However, she’s also scared to death and running from her ex-fiance, Raymond Maldonado – the head of a multi-million dollar insurance fraud ring. Millhone goes undercover within Maldonado’s organization and receives a “crash” course in swoop and squat.
Grafton presents us with a well-crafted, balanced mystery – a finished story with all the loose ends tied neatly together. The action never quits, and more than a few times the reader wonders if Millhone will have time to catch her breath between flurries of action. Grafton presents the world of auto insurance scams in all its gritty detail. From the viewpoint of a passenger and then a driver, she describes the techniques used by drivers to engineer the accidents. Her main character Millhone gradually begins to see the victims of these scams through the eyes of the scam artist.
WHO KILLED MY DAUGHTER?
by Lois Duncan
New York, Dell
1994. Revised. 354 p.
Non-fiction
In this true story, Lois Duncan tells of the 1989 drive-by shooting death of her youngest daughter, Kaitlyn Arquette.
The Albuquerque, New Mexico, police originally considered Kaitlyn’s death a random accident. In the face of official indifference, Kaitlyn’s family took up the investigation ion and discovered that her death had probably been a result of her knowledge of the workings of a Vietnamese/Hispanic insurance scam ring. This book is a description of the family’s investigation and the often startling things they learned as they plunged deeper into organized automobile fraud.
Kaitlyn was 18 when she died – she had recently moved out of the family home and was living with her Vietnamese boyfriend, Dung Nguyen. As her parents later discovered, Nguyen was involved in an insurance scam ring. He had used Kaitlyn’s credit card on at least one occasion to rent a car which was later used in an “accident” in Los Angeles. Subsequent investigation revealed that the ring was also involved in the sale of illegal drugs. Kaitlyn was aware of Nguyen’s activities and had threatened to inform the authorities. On the day she died, she had told her parents that she was breaking up with Nguyen and demonstrated extreme reluctance to let him know her whereabouts.
Kaitlyn’s family cooperated with the police until, in their opinion, the police had become non-responsive to them. From that point, they conducted an investigation of their own with the assistance of private investigators, newspaper reporters, and psychics. In the process, the family received death threats as they got progressively closer to the answers they sought, and they were forced to move to safer accommodations. Duncan’s narrative is touching as it describes the crippling effect of Kaitlyn’s death on what was once a close family.
The most disturbing aspect of this book touches upon the inability (or unwillingness?) of the police and other authorities to do their mandated jobs. After initial enthusiasm, the Albuquerque Police Department exhibited reluctance to communicate with the family and indifference to the family’s questions and research. Two years after the murder, the state dropped a pending case against individuals the police department believed to be the killers. When this happened, the performance of the police in the case was criticized by the Albuquerque newspapers. After more than two years of research, and attempting to interest the authorities in their results, the family discovered that the local police had refused the assistance of the FBI in the official investigation.
Family members made broad use of psychics in their search for answers. Some of the psychic “revelations” may have been astounding coincidences, or perhaps the interpretations were influenced by the author’s grief and need for answers, but they play a critical part as the sad story unfolds.
This is a book that must be read with an open mind, and the evidence must be evaluated against the reader’s own knowledge and experience. Since the murder has not yet been solved – and the final chapter has not yet been written – we recommend this book to anyone in the insurance fraud-fighting industry. Perhaps the next reader will make a difference – add a new clue or puzzle piece to this case – and thus provide this family with their long sought answers.
“H” IS FOR HOMICIDE AND WHO KILLED MY DAUGHTER? were reviewed by Jean Cooper, a systems librarian at the University of Virginia. Jean also serves as the National Secretary for American Mensa, Ltd. and is a US representative to Mensa International.
© Copyright 1995 Alikim Media