Section 2698.39 Anti-Fraud Training

Requirements for training provided by and for the SIU shall include:

(a) The insurer shall establish and maintain an ongoing anti-fraud training program, planned and conducted to develop and improve the anti-fraud awareness skills of the integral anti-fraud personnel.

(b) The insurer shall designate an SIU staff person to be responsible for coordinating the ongoing anti-fraud training program.

(c) The anti-fraud training program shall consist of three (3) levels:

(1) All newly-hired employees shall receive an anti-fraud orientation within ninety (90) days of commencing assigned duties. The orientation shall provide information regarding:

(A) the function and purpose of the SIU;

(B) an overview of fraud detection and referral of suspected insurance fraud to the SIU for investigation;

(C) a review of the Fraud Division’s insurance fraud reporting requirements;

(D) an organization chart depicting the insurer’s SIU; and

(E) SIU contact telephone numbers and email addresses.

(2) Integral anti-fraud personnel shall receive annual anti-fraud in-service training, which shall include:

(A) review of the function and purpose of the SIU;

(B) introduction/review of the written procedures established by the SIU regarding the identification, documentation, and referral of incidents of suspected fraud to the SIU;

(C) identification and recognition of red flags or red flag events;

(D) any changes to current procedures for identifying, documenting, and referring incidents of suspected insurance fraud to the SIU;

(E) the Fraud Division’s insurance fraud reporting requirements; and

(F) introduction/review of existing and new, emerging insurance fraud trends.

(3) The SIU personnel shall receive at least five (5) hours of continuing anti-fraud training per calendar year. The training shall include instruction in one or more of the following topics:

(A) investigative techniques;

(B) communication with the Fraud Division and authorized governmental agencies;

(C) fraud indicators;

(D) emerging fraud trends; or

(E) legal and related issues.

(d) The training requirements stated in subdivision (c) of this Section 2698.39 shall not apply to persons retained to provide an expert opinion on a medical, technical, or scientific topic on behalf of the insurer and who do not participate in the claims handling or decision making function of the insurer.

(e) Training, instruction, or courses that may be used in order to satisfy the requirement stated in subdivision (c)(3) of this section shall include, without limitation: anti-fraud conferences; SIU roundtables hosted by the Fraud Division; anti-fraud association meetings and trainings; and insurer in-house trainings.

(f) Records of the anti-fraud training shall be prepared at the time training is provided and be maintained and available for inspection by the Department on request. The training records shall include:

(1) the title and date of the anti-fraud training, instruction, or course;

(2) the name, title, and contact information of the instructor(s), to the extent applicable;

(3) copies of the training, instruction, or course materials or, if the materials are unavailable, a description of the training, instruction, or course content;

(4) the length of the training, instruction, or course; and

(5) the name and job title(s) of participating personnel.

Note: Information last updated 10/6/2023. Please refer to the most current version online for compliance purposes.