The National Insurance Crime Bureau released its third quarter 2013 questionable claims (QC) referral reason analysis. The report examines six referral reason categories of claims – property, casualty, commercial, workers’ compensation, vehicle and miscellaneous – for the third quarters of 2011, 2012 and 2013.
Questionable claims are claims that NICB member insurance companies refer to NICB for closer review and investigation based on one or more indicators of possible fraud; A single claim may contain up to seven referral reasons. The volume of QC referrals can increase or decrease over a given period of time and may be caused by a number of factors, including better reporting by the industry and an increase or decrease in fraudulent activity, etc.
During the first three quarters of 2011, there were 74,944 QCs referred to NICB. During the first three quarters of 2012, that number increased to 87,684 and it increased again during the first three quarters of 2013 to 93,053. Overall, comparing the first three quarters of 2011 to the first three quarters of 2013, the numbers of QCs increased 24 percent
Although most categories of QCs saw increases in the third quarter, only one, the commercial category, posted a decrease. It was down 13 percent in the third quarter from the previous quarter; For a single referral reason, Medical Provider referrals in the Miscellaneous category had the largest increase in volume, as well as the highest percentage increase. Duplicate billing complaints were up 26%, unbundling/upcoding were up 20% and inflated billing referrals were up 17%.
Overall, Workers’ Compensation Questionable Claim referral reasons increased 4% when comparing the First 3 Quarters 2012 to the First 3 Quarters 2013. Disability and False SSN referrals topped the percentage increases with 58% and 40% respectively. Disability referrals had the highest increase of volume in the Workers’ Compensation category when comparing the First 3 Quarters 2012 to the First 3 Quarters 2013; while Claimant Fraud remains the largest Workers’ Compensation referral reason by over 2 ½ times the next highest referral reason.