# InsuranceFraud.org > Generated by All in One SEO Pro v5.0.3, this is an llms-full.txt file, used by LLMs to index the site. ## Posts ### [Lorem Ipsum](https://insurancefraud.org/lorem-ipsum/) **Published:** June 2, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Lorem ipsum dolor sit amet, consectetur adipiscing elit, sed do eiusmod tempor incididunt ut labore et dolore magna aliqua. Ut enim ad minim veniam, quis nostrud exercitation ullamco laboris nisi ut aliquip ex ea commodo consequat. Duis aute irure dolor in reprehenderit in voluptate velit esse cillum dolore eu fugiat nulla pariatur. Excepteur sint occaecat cupidatat non proident, sunt in culpa qui officia deserunt mollit anim id est laborum. **Categories:** Blog --- ### [Sed do eiusmod tempor incididunt](https://insurancefraud.org/sed-do-eiusmod-tempor-incididunt/) **Published:** June 2, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Lorem ipsum dolor sit amet, consectetur adipiscing elit, sed do eiusmod tempor incididunt ut labore et dolore magna aliqua. Ut enim ad minim veniam, quis nostrud exercitation ullamco laboris nisi ut aliquip ex ea commodo consequat. Duis aute irure dolor in reprehenderit in voluptate velit esse cillum dolore eu fugiat nulla pariatur. Excepteur sint occaecat cupidatat non proident, sunt in culpa qui officia deserunt mollit anim id est laborum.” **Categories:** Blog --- ### [Duis aute irure dolor in reprehenderit](https://insurancefraud.org/duis-aute-irure-dolor-in-reprehenderit/) **Published:** June 2, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Lorem ipsum dolor sit amet, consectetur adipiscing elit, sed do eiusmod tempor incididunt ut labore et dolore magna aliqua. Ut enim ad minim veniam, quis nostrud exercitation ullamco laboris nisi ut aliquip ex ea commodo consequat. Duis aute irure dolor in reprehenderit in voluptate velit esse cillum dolore eu fugiat nulla pariatur. Excepteur sint occaecat cupidatat non proident, sunt in culpa qui officia deserunt mollit anim id est laborum. **Categories:** Blog --- ## Pages ### [Homepage](https://insurancefraud.org/) **Published:** February 10, 2020 **Author:** Coalition Against Insurance Fraud **Content:** ![](https://insurancefraud.org/wp-content/uploads/IMPORTANT-NOTICE-Chrome-Website-Label.png) *The Coalition Against Insurance Fraud unites and empowers private and public groups to fight insurance fraud through outreach, advocacy and research. Insurance fraud is generally described as the intentional providing of false or is misleading information, or withholding of material information, as part of an insurance transaction.* [Join us](https://insurancefraud.org/join-us) [About Us](https://insurancefraud.org/about-us/) Follow Us On Social Media: - [ ](https://www.facebook.com/profile.php?id=61579225779934) - [ ](https://twitter.com/Insurance_Fraud) - [ ](https://www.youtube.com/user/stopinsurancefraud) - [ ](https://www.linkedin.com/company/coalition-against-insurance-fraud) - [ ](https://www.instagram.com/stopinsurancefraud/) [Join us](https://insurancefraud.org/join-us) [About Us](https://insurancefraud.org/about-us/) Follow Us On Social Media: - [ ](https://www.facebook.com/profile.php?id=61579225779934) - [ ](https://twitter.com/Insurance_Fraud) - [ ](https://www.youtube.com/user/stopinsurancefraud) - [ ](https://www.linkedin.com/company/coalition-against-insurance-fraud) - [ ](https://www.instagram.com/stopinsurancefraud/) [ Previous ](#home-slider) [ Next ](#home-slider) [Scroll down](#next-section) [advanced search](/advanced-search/) ### Have you been scammed? [Report fraud](https://insurancefraud.org/report-fraud/) ## On the radar **2026 Annual Meeting in Washington, D.C.** - Members please join us December 7-8 for the Coalition Against Insurance Fraud’s 2026 Annual Meeting at the Hilton Alexandria Mark Center. The Coalition Against Insurance Fraud’s Annual Meeting brings together insurers, regulators, consumer groups, legal experts, and other groups that serve the fraud-fighting community so we can collectively tackle emerging schemes and share real-time intelligence. **Registration opens September 1.** **Next-Gen Voices Drive Phase Two of Insurance Fraud Awareness on Social Media!** - The Coalition Against Insurance Fraud is proud to continue its Social Media Competition in partnership with [Wayne State University](https://wayne.edu/), and [Carpe Data](https://carpe.io/), who is sponsoring phase two of this education and outreach initiative. In Phase Two, Wayne State marketing students have been transforming weekly educational themes into creative, peer-focused posts on the Coalition’s Instagram page, @stopinsurancefraud. They began by highlighting the per-person cost of insurance fraud, challenging audiences to consider what they could do with an extra $932 each year. Students then created attention-grabbing reels explaining the legal consequences of committing insurance fraud, and in the coming weeks will introduce content showing how insurers are increasingly using artificial intelligence to detect fraud schemes. By engaging young adults where they already spend their time online, the campaign is turning awareness into engagement as they’ve already achieved more than 14,000 views in their first 30 days! To check out their posts, share their creativity and amplify their messages, follow: [\#StopInsuranceFraud](https://www.instagram.com/stopinsurancefraud/) **Have An Idea For A Presentation Or Webinar?** - We invite our members to submit topics for review and help shape our upcoming educational programs. Whether you can share insight on an emerging fraud trend, a regulatory update, a case study, or a proven strategy, your expertise can benefit the entire community. Click the link to submit your presentation or webinar idea. We look forward to highlighting the knowledge and leadership within our membership. Click this link –> [I have an idea](https://s.surveyplanet.com/bj1sw6en). [ ![](https://insurancefraud.org/wp-content/uploads/Webinar-Image-for-Website.jpg) ### Webinar Library Welcome, Coalition members, to our Webinar Library. Explore a curated collection of webinars featuring industry leaders and fellow members who are actively driving change across the fraud prevention landscape. Gain valuable perspectives through real-world insights, innovative strategies, and practical approaches shared directly from the front lines. Each webinar is carefully designed to keep you informed and inspired by impactful work by our members. ](https://insurancefraud.org/podcasts-videos/) [ ![](https://insurancefraud.org/wp-content/uploads/legislationxs-img.jpg) ### Legislative Interactive Map Track Insurance Fraud Legislation. Get updates on new fraud bills, regulations, and model acts as they develop. We monitor state-level changes and industry developments so you can stay informed on the legislation that matters to your work. Simple updates. Clear insights. Always current. Stay ahead of policy changes that impact investigations, compliance, and enforcement. Know what lawmakers are proposing before it affects your organization. ](https://insurancefraud.org/government-law/) [ ![](https://insurancefraud.org/wp-content/uploads/Steve-final.png) ### PSA’s & Infographics The Coalition has curated a library of insurance fraud awareness videos exclusively for use by our member organizations. These professionally produced videos are designed to support your fraud prevention campaigns and can be customized with your organization’s logo, which will appear at the end of the selected video. This resource is available to Coalition members only and aims to enhance outreach and education on the dangers of insurance fraud. ](https://insurancefraud.org/videos-infographics/) [ Previous ](#carousel__posts) [ Next ](#carousel__posts) ## Fraud Stats Stats reveal fraud trends. How big is fraud? … How much damage … Progress we’re making — or not … What scams are happening, and why. Find the fraud facts — across all lines of insurance. The Coalition’s study shows that $308.6B is stolen every yearDid you know that $308.6B can… • Stretch to the moon and back 16 times! • Purchase approx. 771, 500 homes! • Fund approx. 3,086,000 four-year college degrees! • Cost approx. $932 per person each year! • Cost approx. $3,750 per family each year! • Buy 81 billion school lunches! Insurance companies are convinced that insurance fraud is growingInsurance companies report that fraud is increasing or remaining steady, underscoring a growing concern within the industry. In response, the Coalition Against Insurance Fraud, a national alliance of over 300 organizations, including insurers, consumer groups, and government agencies, is intensifying its efforts to combat this pervasive issue. Through collaboration, research, and public education, the Coalition aims to protect consumers and reduce the financial impact of fraudulent activities. Consumers are concerned A significant majority of consumers express concern about insurance fraud and its detrimental effects on both the economy and individuals. This widespread apprehension underscores public awareness of the financial burden that fraudulent activities impose, including increased premiums and eroded trust in the insurance system. In response, the Coalition Against Insurance Fraud is actively collaborating with its diverse stakeholders to foster a more secure and trustworthy environment for all. By uniting these groups, the Coalition aims to effectively combat the ever-evolving landscape of insurance fraud. --- ### [Officers, Directors & Board](https://insurancefraud.org/officers-directors-board/) **Published:** July 23, 2020 **Author:** Coalition Against Insurance Fraud **Content:** ## Officers ![](https://insurancefraud.org/wp-content/uploads/Steve-Piper-2.png) [ Read More ](#t-steve-piper-co-chair)### Steve Piper, Co-Chair CNA – Vice President – Technical Claims, Shared Services – TERM ENDS 2028 ![](https://insurancefraud.org/wp-content/uploads/Tony-DiPaolo-Headshot-500x500-1.png) [ Read More ](#t-tony-dipaolo-public-interest-co-chair)### Tony DiPaolo, Public Interest Co-Chair Insurance Fraud Bureau (IFB) of Massachusetts – Executive Director – TERM ENDS 2026 ![](https://insurancefraud.org/wp-content/uploads/SOKIT-JON-02-scaled.jpg) [ Read More ](#t-john-sokit-treasurer)### John Sokit, Treasurer Nationwide Mutual Insurance Company – AVP Special Investigations and Recovery Operations – TERM ENDS 2028 ![](https://insurancefraud.org/wp-content/uploads/Website-Headshot-500-x-500_0010_Brenda-C.-New-2022-Headshot.jpg) [ Read More ](#t-brenda-j-cude-ph-d-secretary)### Brenda J. Cude, Ph.D., Secretary American Council on Consumer Interests – Professor Emerita – TERM ENDS 2026 Steve Piper, Co-Chair ![](https://insurancefraud.org/wp-content/uploads/Steve-Piper-2.png) CNA – Vice President – Technical Claims, Shared Services – TERM ENDS 2028 Tony DiPaolo, Public Interest Co-Chair ![](https://insurancefraud.org/wp-content/uploads/Tony-DiPaolo-Headshot-500x500-1.png) Insurance Fraud Bureau (IFB) of Massachusetts – Executive Director – TERM ENDS 2026 John Sokit, Treasurer ![](https://insurancefraud.org/wp-content/uploads/SOKIT-JON-02-scaled.jpg) Nationwide Mutual Insurance Company – AVP Special Investigations and Recovery Operations – TERM ENDS 2028 Brenda J. Cude, Ph.D., Secretary ![](https://insurancefraud.org/wp-content/uploads/Website-Headshot-500-x-500_0010_Brenda-C.-New-2022-Headshot.jpg) American Council on Consumer Interests – Professor Emerita – TERM ENDS 2026 ## Executive Committee Members ![](https://insurancefraud.org/wp-content/uploads/Roberta-Baca-2.png) Read More ### Roberta Baca New Mexico Office of the Superintendent of Insurance (OSI) – Director, Insurance Fraud Law Enforcement Division – TERM ENDS 2028 ![](https://insurancefraud.org/wp-content/uploads/Eric-Charlick-e1736445175382.png) Read More ### Eric Charlick California Department of Insurance – Enforcement Branch – Deputy Commissioner – TERM ENDS 2028 ![](https://insurancefraud.org/wp-content/uploads/ANNA-Flores-1.png) Read More ### Anna Flores Consumer Action – Executive Director – TERM ENDS 2029 ![](https://insurancefraud.org/wp-content/uploads/DOUG-HELLER-500-x-500-New-Photo-2023.png) Read More ### Douglas Heller Consumer Federation of America – Director of Insurance – TERM ENDS 2028 ![](https://insurancefraud.org/wp-content/uploads/SJ-Headshot2-e1736371242288.jpg) Read More ### Steve Jarrett Westfield Insurance – National Director, Special Investigations – TERM ENDS 2028 ![](https://insurancefraud.org/wp-content/uploads/Arteniece-Lee.jpg) Read More ### Arteniece Lee Horace Mann Educators Corporation – Assistant Vice President, Business Area Compliance – TERM ENDS 2028 ![](https://insurancefraud.org/wp-content/uploads/Pranay-Mittal.png) Read More ### Pranay Mittal Travelers – Vice President, Investigative Services – TERM ENDS 2028 ![](https://insurancefraud.org/wp-content/uploads/Dave-Rioux-2022.jpg) Read More ### David Rioux Erie Insurance – Vice President, Investigations & Internal Controls – TERM ENDS 2029 ![Michelle Rafeld](https://insurancefraud.org/wp-content/uploads/Michelle_Rafeld2.jpg) Read More ### Michelle Rafeld Coalition Against Insurance Fraud – Executive Director ![](https://insurancefraud.org/wp-content/uploads/Aimee-Stidham.png) Read More ### Aimee Stidham, Advisor International Association of Special Investigation Units (IASIU) – President ![](https://insurancefraud.org/wp-content/uploads/David-Glawe-2.jpg) Read More ### David Glawe, Advisor National Insurance Crime Bureau (NICB) – President & CEO ![](https://insurancefraud.org/wp-content/uploads/Frank-Sztuk-with-glasses-1-scaled.jpg) Read More ### Frank X. Sztuk, Advisor Delta Group – Senior Vice President Investigative Services ## Board of Directors [**AIG** ](http://www.aig.com/)Paul Sylvester, Regional Head of Fraud & Recovery – North America General Insurance Jacqueline Nguyen, SIU Manager [**Allstate Insurance Company**](http://www.allstate.com/) Ramine Poureshmenantalemy, SIU Operations Manager Al Capparella, SIU Design Sr Manager **[American Council on Consumer Interests](http://consumerinterests.org/)**Brenda J. Cude, Ph.D, Professor Emerita Jennifer Breitenbach, Assistant to the Editor [**American Family Insurance**](http://www.amfam.com/) Betsy Gabbei, Senior Manager, SIU Josh Moe, Manager – Special Investigations [**American Fidelity Assurance Company**](https://americanfidelity.com/)Tina Marshall, Special Investigation Unit Manager Jennifer Herron, Director of Internal Audit **[American Property Casualty Insurance Association (APCIA)](https://www.apci.org/)**[](http://www.pciaa.net/pciwebsite/cms/content/viewpage?sitePageId=54463)Michael Richmond-Crum, Senior Director, Personal Lines & Council Robert C. Passmore, Vice President, Personal Lines **[Assurant](https://www.assurant.com/)[](http://www.pciaa.net/pciwebsite/cms/content/viewpage?sitePageId=54463)**Mariela M. Pennock, AVP SIU, Fraud Compliance, & Subrogation Alan Haskins, VP Global Fraud Risk [**Blue Cross Blue Shield Association**](https://www.bcbs.com/) Cuno Q. Andersen Jr., Fraud Investigations Consultant **[California Department of Insurance](https://www.insurance.ca.gov/)** Eric Charlick, Deputy Commissioner Enforcement Branch Andrew Gulcher, Chief, Investigations Division [**CNA**](http://www.cna.com/)**\*\*** Steve Piper, Vice President – Claims Technical, Shared Services Steve Walden, AVP, Special Investigations Unit **[Consumer Action](http://www.consumer-action.org/)** Anna Flores, Executive Director Ruth Susswein, Director of Consumer Protection [**Consumer Federation of America**](http://www.consumerfed.org/)**\*\*** Douglas Heller, Director of Insurance Michael DeLong, Research and Advocacy Associate [**Erie Insurance**](http://www.erieinsurance.com/) David Rioux, VP – Investigations & Internal Controls Ronald Bryant, Investigative Services Manager [**Farmers Insurance**](https://www.farmers.com/) Sarah Bowman, SIU National Director Michael Marks, East Zone Manager **[Florida Department of Financial Services, Bureau of Insurance Fraud](https://www.myfloridacfo.com/)** Luis Negrete, Colonel Evangelina James, Assistant Director/Lt. Colonel [**Horace Mann Educators Corporation**](https://www.horacemann.com/) Arteniece Lee, Assistant Vice President, Business Area Compliance Charles Dougherty, Director in Enterprise Compliance & Ethics [**Insurance Fraud Bureau (IFB) of Massachusetts**](https://www.ifb.org/) Tony DiPaolo, Executive Director Kate Mulligan, Chief of Investigations [**International Association of Special Investigation Units (IASIU)** ](https://www.iasiu.org/)Joe Rosario, Executive Director Aimee Stidham, President **[Intact Insurance](http://www.onebeacon.com/)** Brian Lynch, Sr. Manager, Fraud Prevention Mike Guerra, SIU Analyst [**John Hancock**](http://www.johnhancock.com/) Charles B. Ziegenbein, Assistant Vice President Kristina Mulholland, Senior Director [**Katten Muchin Rosenman LLP**](https://katten.com/)Ross Silverman, Senior Counsel Jonathan Marks, Partner [**Liberty Mutual Insurance**](http://libertymutual.com/) Alina Wilkinson, Vice President of Claims Processes for Medical, WC, SIU and QI Steve Friedman, Claims Manager III [**Louisiana State Police**](http://www.lsp.org/) Leander Journee, Lieutenant in Insurance Fraud Auto Theft Unit Daniel Graff, Sergeant [**Massachusetts Mutual Life Insurance Company**](http://www.massmutual.com/) Cindy Belmore, Head of Investigations Anthony Bundy, Investigative Consultant [**MetLife**](https://www.metlife.com/) Matthew Griffin, Senior Special Investigator, Global Investigations Unit Tiffanie Drayton, Associate Manager, Investigations, Group Claims FWA [**National Association of Insurance Commissioners (NAIC)**](http://www.naic.org/)**\*\*** Greg Welker, Antifraud Coordinator/Market Regulation Specialist II Tim Mullen, Director, Market Regulation **[National Association of Public Insurance Adjusters (NAPIA)](https://www.napia.com/)**Brian Goodman, Esq. General Counsel Gjergj Ndoja, Executive Director [**National Council of Insurance Legislators (NCOIL)**](http://www.ncoil.org/) Pat Gilbert, Director of Policy, Administration & Member Services Cindy McLavish, Office Manager [**National Insurance Crime Bureau (NICB)**](http://www.nicb.org/)**\*\*** David J. Glawe, President & CEO Richard DiZinno, Senior Vice President and General Counsel Dan Abbott, Vice President, Partner Engagement and Member Services [**Nationwide Mutual Insurance Company**](http://www.nationwide.com/) John Sokit, AVP Special Investigations and Recovery Operations Steve Ferguson, Vice President **[New Mexico Office of the Superintendent of Insurance (OSI)](https://www.osi.state.nm.us/)** Roberta Baca, Criminal Division Director Devin H. Chapman, Prosecutor/NMATPA Exec. Dir. **[New York Life Insurance](https://www.newyorklife.com/)** Paulina Lee, Corporate Vice President – Fraud Risk Management Tom Schreck, Corporate Vice President, Risk Management **[Northwestern Mutual](https://www.northwesternmutual.com/)** Adam Kawa, Assistant Director – SIU Chris Amidzich, Fraud Risk Management Lead [**Pennsylvania Insurance Fraud Prevention Authority (IFPA)**](http://www.helpstopfraud.org/) Christopher Sloan, Executive Director Joan Dockery, Associate Executive Director [**Pennsylvania Office of Attorney General**](https://www.attorneygeneral.gov/get-help/) Robert G. LaBar, Senior Deputy Attorney General Eric Norman, Section Director [**Progressive Insurance** ](http://www.progressive.com/)Jeff Moore, Business Leader-Claims Process Jim Wheeler, Claims Attorney IV [**Prudential Insurance**](http://www.prudential.com/) Frederick Ransom, Vice President, Head of Corporate Investigations Lesley Ligas, Corporate Investigations Division, ERISA Law, Regulatory Law [**San Diego County District Attorney (CA)**](http://www.sdcda.org/) Victor Ou, Deputy District Attorney; Chief of Insurance Fraud and Workplace Justice Tamara Martin, Deputy District Attorney, Director of Insurance Fraud Grants **[Senior Medicare Patrol (SMP) National Resource Center](https://www.smpresource.org/)** Nicole Liebau, Strategic Partnership and Engagement Director Brandy Bauer, Joint Center Director [**Sentry Insurance**](http://www.sentry.com/) Timothy Hopper, Special Investigations Major Case Manager [**State Farm**](http://statefarm.com/)**\*\*** Mike Horan, Claims Manager-P&C Tiphanie DeWitt, Claim Consultant **[Swiss RE](https://www.swissre.com/)** Kimberly Beaudreau, Global SIU Counter Fraud Expert Aidan Brennan, Global SIU Lead [**The American Policyholders Association**](https://apassociation.org/)Doug Quinn, Executive Director John Wood [**The Hanover Insurance Group**](http://www.allmerica.com/) Tessa Phillips, SIU Senior Manager William Toner, SIU Assistant Vice President [**The Hartford**](http://www.thehartford.com/)**\*\*** Matt Murphy, Vice President – Special Investigations, Claim & Underwriting Anti-Fraud Solutions Matthew Huls, Assistant Vice President – SIU Anti-Fraud Solutions [**The Standard**](https://www.standard.com/)Mark Hesse, SIU Director Jonathan Ayers, Investigator [**Travelers**](http://www.travelers.com/) Pranay Mittal, Vice President Luke LaRosa, Assistant Vice President [**United Policyholders (UP)**](https://uphelp.org/) Sandra Moriarty, Insurance Claims Consultant Amy Bach, Esq., Executive Director **[USAA](https://www.usaa.com/)** Michael Yates, Assistant Vice President, SIU Jeffrey Schmersahl, SIU Director **[Verisk](https://www.verisk.com/)** John Trovinger, AVP, Client Success [**Westfield Insurance**](https://www.westfieldinsurance.com/) Steve Jarrett, Claims Strategy & Transformation/National Director-Special Investigations Chris Lueder, Unit Manager-Special Investigations **[Zurich Insurance Group](https://www.zurichna.com/)** Delpha DiGiacomo, Vice President, Investigative Services Daniel Krueger, Senior Manager – Claims Fraud and Investigations \*\* Charter members --- ### [Members](https://insurancefraud.org/coalition-members/) **Published:** December 21, 2023 **Author:** Coalition Against Insurance Fraud **Content:** *\*Coalition Board Members are shown in bold.* #### **Academic** Colorado State University Global Campus Franklin University Indiana University of Pennsylvania Marshall University, Center for Business & Economic Research Southern Utah University University of Wisconsin-Oshkosh #### **Associate** 4WARN Advantage Investigations Agero Allied Universal Becker & Company Carpe Data Carpenters/Contractors Cooperation Committee, Inc CCC Intelligent Solutions CDI Canvassing Center for Contract Compliance (CCC) Charlee.ai Clearspeed Command Investigations Contego CostFirst Corp. CoventBridge Delta Group Demotech, Inc. Diligence International Group, LLC Equifax Ethos Risk Evadata ForMotiv Frasco Investigative Services FRISS Fuzion HealthSherpa Hodson P.I. Investigative Solutions IDI Data illumifin Insurance Care Direct INTERTEL ISG Lemieux & Associates LexisNexis Risk Solutions North American Training Group PhotoFax Pilotbird PwC Quantexa Rockholt & Associates Search Pros, Inc. Sedgwick Claims Management Services, Inc. Shift Technology Skopenow Snapsheet Social Discovery Sphere Investigations Uber VRC Investigations **Verisk** Watchpoint Whooster #### **Association** **American Property Casualty Insurance Association (APCIA)** AHIP **Blue Cross Blue Shield Association** **International Association of Special Investigation Units (IASIU)** International Association of Arson Investigators (IAAI) National Association of Mutual Insurance Companies (NAMIC) **National Association of Public Insurance Adjusters (NAPIA)** National Health Care Anti-Fraud Association **National Insurance Crime Bureau** **(NICB)** South Carolina Wind and Hail Underwriting Association United Brotherhood of Carpenters & Joiners of America (UBC) #### **Government** Alabama State Fire Marshal’s Office Alaska Division of Insurance Arizona Department of Administration (ADOA) Arizona Department of Insurance and Financial Institutions Arizona Attorney General’s Office Arkansas Insurance Department Criminal Investigation Division (CID) Bucks County District Attorney’s Office (PA) **California Department of Insurance – Enforcement Branch** California Insurance Guarantee Association (CIGA) California Labor Commissioner’s Office Cape May County Prosecutor’s Office (NJ) Citizens Property Insurance Corporation of Florida City of Concord (NC) City of Erie Police Department (PA) Colorado Attorney General’s Office Colorado Department of Regulatory Agencies Connecticut Insurance Department County of Fresno District Attorney (CA) Delaware Department of Insurance District of Columbia Department of Insurance, Securities & Banking District of Columbia Fire & EMS Department District of Columbia Office of Risk Management Federal Bureau of Investigation (FBI) **Florida Department of Financial Services, Bureau of Insurance Fraud** Florida Division of Investigative and Forensic Services Florida Highway Patrol Florida Office of Insurance Regulation Florida Workers’ Compensation Joint Underwriting Association, Inc. Floyd County Fire Territory Hawaii Department of Commerce and Consumer Affairs (DCCA) Insurance Fraud Investigations Branch Idaho Department of Insurance Illinois Department of Insurance Indiana Department of Insurance **Insurance Fraud Bureau (IFB) of Massachusetts** Iowa Insurance Fraud Bureau Kansas Department of Insurance Kentucky Department of Insurance Kern County District Attorney’s Office (CA) Los Angeles County District Attorney’s Office (CA) Louisiana Department of Insurance Louisiana Office of State Fire Marshal **Louisiana State Police** Maine Bureau of Insurance Marin County District Attorney Office (CA) Maryland Auto Insurance Maryland Insurance Administration Massachusetts Department of Industrial Accidents Michigan Department of Insurance and Financial Services Michigan Department of the Attorney General Minnesota Bureau of Criminal Apprehension Mississippi Insurance Department Missouri Department of Commerce and Insurance (DCI) Missouri Department of Labor and Industrial Relations – Division of Workers’ Compensation Montana Commissioner of Securities and Insurance Monterey County District Attorney’s Office (CA) Nassau County District Attorney’s Office (NY) **National Association of Insurance Commissioners (NAIC)** National Conference of State Legislatures (NCSL) **National Council of Insurance Legislators** **(NCOIL)** Nebraska Department of Insurance Nevada Attorney General’s Office Nevada Division of Insurance New Hampshire Insurance Department New Jersey Department of Banking and Insurance New Jersey Office of Insurance Fraud Prosecutor (OIFP) New Jersey Property-Liability Insurance Guaranty Association **New Mexico Office of the Superintendent of Insurance** **(OSI)** New Mexico Workers’ Compensation Administration New York City Police Department (NYPD) New York Offices of the Inspector General New York State Department of Financial Services New York State Insurance Fund (NYSIF) North Carolina Department of Insurance North Dakota Insurance Department Office of the Alameda County District Attorney Office of Insurance and Safety Fire Commissioner (GA) Office of the Medicaid Inspector General (OMIG) (NY) Ohio Bureau of Workers’ Compensation Ohio Department of Insurance Oklahoma Insurance Department Oklahoma Office of the Attorney General Orange County District Attorney’s Office (CA) Orange County Sheriff’s Department (CA) Oregon Division of Financial Regulation Palm Beach County Fire Rescue (FL) Paragould Fire Department (AR) Pennsylvania Insurance Department **Pennsylvania Insurance Fraud Prevention Authority** **(IFPA)** **Pennsylvania Office of Attorney General** Pennsylvania State Police Riverside County Office of the District Attorney (CA) San Bernardino County District Attorney’s Office (CA) **San Diego County District Attorney (CA)** San Francisco County District Attorney’s Office (CA) San Joaquin County District Attorney’s Office (CA) San Mateo County District Attorney’s Office (CA) Santa Clara County District Attorney’s Office (CA) Sedona Fire District (AZ) Shasta County DA’s Office (CA) Solano County District Attorney’s Office (CA) Sonoma County District Attorney’s Office (CA) South Carolina Department of Insurance South Carolina Attorney General’s Office South Dakota Division of Insurance State of Rhode Island – Department of Business Regulation State of Rhode Island Department of Labor and Training Sussex County Prosecutor’s Office (NJ) Tennessee Department of Commerce and Insurance Texas Department of Insurance – Fraud Unit Tuscaloosa Arson and Fire Prevention Unit U.S. Department of Labor U.S. DHHS OIG Office of Investigations Utah Department of Insurance – Fraud Division Ventura County District Attorney’s Office (CA) Vermont Department of Financial Regulation Virginia Bureau of Insurance – State Corporation Commission Virginia State Police Washington Metropolitan Area Transit Authority (WMATA) Washington State Department of Labor and Industries Washington State Office of the Insurance Commissioner West Virginia Offices of the Insurance Commissioner West Virginia Securities Commission Wisconsin Department of Health Services Wisconsin Office of the Commissioner of Insurance Wyoming Department of Insurance #### **Insurer** AAA Life Insurance Company Accident Fund Acuity Insurance **AIG** Allianz Life Insurance Company of North America Allied Trust Insurance Company **Allstate Insurance Company** **American Family Insurance** **American Fidelity Assurance Company** American Modern American National Insurance Company Amica AmTrust Financial Arch Insurance Company **Assurant** AuguStar Financial Auto-Owners Insurance Berkshire Hathaway Homestate Companies Canal Insurance Central Insurance Chesapeake Employers Insurance Chubb Cincinnati Insurance Companies **CNA** Core Speciality COUNTRY Financial Crum & Forster Insurance Donegal Insurance Group EMC Insurance Employers Enterprise Mobility ERAC, a heritage GE company **Erie Insurance** Everest Group Farm Bureau Insurance of Tennessee **Farmers Insurance** FCCI Insurance Group FFVA Mutual Insurance Company Frankenmuth Insurance Frontline Insurance Genworth Financial Goodville Mutual Casualty Company Grange Insurance Great American Insurance Group Grinnell Mutual Reinsurance Company Group 1001 Hawaii Employers’ Mutual Insurance Company (HEMIC) Homesite Group **Horace Mann** **Educators Corporation** ICW Group Insurance Companies **Intact Insurance** Interinsurance Exchange of the Automobile Club (AAA) **John Hancock** Kemper Corporation Lemonade **Liberty Mutual Insurance** Markel Group **Massachusetts Mutual** **Life Insurance Company** Merchants Insurance Group **MetLife** Modern Woodmen of America National Indemnity Company (NICO) **Nationwide Mutual Insurance** **Company** New York Automobile Insurance Plan (AIPSO) **New York Life Insurance** NJM Insurance **Northwestern Mutual** NYCM Insurance Old Republic Commercial Risk (formerly PMA Companies) Physicians Mutual Pinnacol Assurance Plymouth Rock Assurance **Progressive Insurance** **Prudential Insurance** RGA Reinsurance Company Selective Insurance **Sentry Insurance** Shelter Insurance State Compensation Insurance Fund (SCIF) **State Farm** Stewart Title Guaranty Company Stillwater Insurance **Swiss Re** The General The Hagerty Group, LLC **The Hanover Insurance Group** **The Hartford** **The Standard** **Travelers** TruStage **USAA** WCF Insurance West Bend Insurance Company **Westfield Insurance** Windward Risk Managers Zenith Insurance Company **Zurich Insurance Group** #### **International Partner** ALFA City of London Police Larmtjänst #### **Law Firm** Bruno Gerbino Soriano & Aitken LLP Cozen O’Connor Faegre Drinker Biddle & Reath LLP GladstoneWeisberg ALC Greenberg Traurig, LLC **Katten Muchin Rosenman LLP** KPM Law Lewis Brisbois Bisgaard & Smith LLP Manning Kass Marshall Dennehey, P.C. Rivkin Radler, LLP #### **Public Interest** **American Council on Consumer Interests** Anti-Fraud Alliance (AFA) California Health Advocates Call for Action **Consumer Action Consumer Federation of America** Families USA Federal Association for Insurance Reform (FAIR) Federation of Manufactured Home Owners of Florida (FMO) Florida Office of the Insurance Consumer Advocate Global Insurance Fraud Summit Identity Theft Resource Center Institute4Education Jarrod’sLaw.org L.A. Care Health Plan **Senior Medicare Patrol (SMP) National Resource Center** State Health Insurance Programs National Technical Assistance Center **The American Policyholders Association** The Center for Advocacy for the Rights and Interests of the Elders (CARIE) **United Policyholders** **(UP)** --- ### [Staff](https://insurancefraud.org/staff/) **Published:** July 23, 2020 **Author:** Coalition Against Insurance Fraud **Content:** **For Media Inquiries – Please [click here](https://insurancefraud.org/media-request-form/).** ![Michelle Rafeld](https://insurancefraud.org/wp-content/uploads/Michelle_Rafeld2.jpg) Read More ### Michelle Rafeld Executive Director ![](https://insurancefraud.org/wp-content/uploads/Karen-Montgomery.png) Read More ### Karen Montgomery Head of Operations ![](https://insurancefraud.org/wp-content/uploads/Heidi-New-2023-Pic.png) Read More ### Heidi Krumenauer Director of Strategy, Transformation & Business Development ![](https://insurancefraud.org/wp-content/uploads/Brent-Walker-2024-2.png) Read More - ### Brent J. Walker Director of Government Relations ![](https://insurancefraud.org/wp-content/uploads/Lauren-Vitanye.jpg) Read More ### Lauren Vitanye Communications Lead ![](https://insurancefraud.org/wp-content/uploads/Celeste-Dodson.png) Read More ### Celeste Dodson, MBA, CPCU, FCLA Director of Member Relations and Initiatives ![](https://insurancefraud.org/wp-content/uploads/Website-Headshot-500-x-500_0002_IF-Conference-Headshots-By-Gedalia-Vera-38.jpg) Read More ### Kendra Smith Head of Member Services & Events ![](https://insurancefraud.org/wp-content/uploads/Kate-Gordon-e1723049849459.png) Read More ### Kate Gordon General Counsel X ![Michelle Rafeld](https://insurancefraud.org/wp-content/uploads/Michelle_Rafeld2.jpg) Executive Director ### Michelle Rafeld Michelle Rafeld is a seasoned insurance professional with over 30 years of experience in the industry, including extensive expertise in investigating insurance fraud across all lines of insurance.Michelle began her insurance career as an agent before transitioning to public service, where she spent 32 years with the State of Ohio. During her tenure as a public servant, Michelle held various roles with the Ohio Bureau of Workers’ Compensation (BWC) and gained invaluable experience in claims, auditing, investigations, and leadership. To expand her expertise beyond the workers’ compensation arena, Michelle joined the Fraud Enforcement Division of the Ohio Department of Insurance in 2005. While Michelle held various leadership roles within the division, she’s most notably known for serving as the agency’s Fraud Director, a position she held from 2007 until her retirement from state service in June 2023. Throughout her career, Michelle built strong relationships with insurers, law enforcement agencies, consumer protection groups, and regulators. She was actively involved with the National Association of Insurance Commissioners (NAIC) and served in advisory roles with the Healthcare Fraud Prevention Partnership, the National Insurance Crime Bureau’s Law Enforcement Advisory Committee, and the Executive Committee of the Coalition Against Insurance Fraud. In 2020, Michelle was appointed Public-Interest Co-Chair of the Coalition, and on January 1, 2024, she became the Coalition’s third Executive Director. In addition to her role as Executive Director of the Coalition, Michelle serves as an advisor to the International Association of Special Investigation Units (IASIU) and the National Insurance Crime Bureau (NICB). She is also a Board Member for the Anti-Fraud Alliance (AFA) and the New York Alliance Against Insurance Fraud. Michelle holds a Bachelor of Science in Business Administration from the University of Dayton and earned her Associate Professional in Insurance Regulation (APIR) and Professional in Insurance Regulation (PIR) designations from the NAIC. [![](https://insurancefraud.org/wp-content/uploads/iconfinder_phone_1608790-1.png) 202-393-7333](tel:202-393-7333) **\|** [![](https://insurancefraud.org/wp-content/uploads/iconfinder_aiga_mail_134146.png) michelle@insurancefraud.org](mailto:michelle@insurancefraud.org) X ![](https://insurancefraud.org/wp-content/uploads/Karen-Montgomery.png) Head of Operations ### Karen Montgomery Karen Montgomery is a business operations and continuous improvement professional with a proven track record of enhancing organizational efficiency through multifaceted strategic approaches. She brings over a decade of diverse experience spanning business operations, project management, and strategic leadership. Her methodologies encompass technological innovation, process optimization, and cultural transformation. Her most notable achievements include serving as Chief of Staff at Mantium, where she implemented a new employee onboarding initiative with a 95% satisfaction rate, and leading organizational change management efforts at the Public Utilities Commission of Ohio for a data collection system affecting over 1,700 regulated utilities. With a Lean Six Sigma Green Belt certification and expertise in change management, Karen combines academic preparation from Miami University and Capital University Law School with practical, results-driven professional experience. Her versatile skill set spans roles in legal support, customer service, and project coordination, enabling her to deliver strategic operational enhancements through a holistic approach that integrates technological solutions, human-centered design, and systematic process improvement. Karen’s comprehensive expertise demonstrates her consistent commitment to organizational excellence and meaningful workplace transformation. [![](https://insurancefraud.org/wp-content/uploads/iconfinder_aiga_mail_134146.png) karen@insurancefraud.org](mailto:karen@insurancefraud.org) X ![](https://insurancefraud.org/wp-content/uploads/Heidi-New-2023-Pic.png) Director of Strategy, Transformation & Business Development ### Heidi Krumenauer Heidi joined the Coalition staff in October 2024 after a 33-year career with American Family Insurance. There, she held director roles, driving strategic initiatives and enterprise transformation in the areas of Government Affairs, Optimizing Business Operations, Special Investigations, Planning, Analytics, Claims, Claims Legal, Business Technology, and Medical Services. For the past decade, Heidi has focused her energy on enterprise planning, portfolio management, operational efficiency, and strategic alignment. Her roles have emphasized staff development, executive communication, strategic planning, and operating model design. Heidi served on the Coalition’s Board of Directors from 2009 – 2024. She joined the Executive Committee in 2012 where she led efforts on technology adoption, mission and values development, succession planning, financial oversight, and held the Treasurer position for 9 years. She holds a degree in Technical Communications from the University of Wisconsin–Platteville and a master’s certificate in Executive Leadership from Notre Dame. A published author of 13 books and contributor to 18 more, Heidi has also penned more than 1,200 articles for national publications. She and her husband live in Wisconsin near their two grown sons. [![](https://insurancefraud.org/wp-content/uploads/iconfinder_phone_1608790-1.png) 202-393-7331](tel:202-393-7331) **\|** [![](https://insurancefraud.org/wp-content/uploads/iconfinder_aiga_mail_134146.png) heidi@insurancefraud.org](mailto:heidi@insurancefraud.org) X ![](https://insurancefraud.org/wp-content/uploads/Brent-Walker-2024-2.png) Director of Government Relations ### Brent J. Walker Brent Walker serves as the Director of Government Relations for the Coalition Against Insurance Fraud, where he leads the organization’s advocacy efforts nationwide. In this role, Brent also serves as the staff liaison for the Coalition’s Government Affairs, Legal Affairs, and Amicus Review Committees, along with the Property & Casualty Task Force. He also serves as the organization’s primary liaison to state and federal policymaking bodies, and regulatory associations, including having been appointed as a Consumer Representative to the National Association of Insurance Commissioners (NAIC). Brent brings nearly 30 years of combined experience in law enforcement, insurance fraud investigations, and nonprofit leadership. His career began as a police detective and evolved into senior roles within special investigation units (SIUs) at two major insurance carriers. He has served as a major case investigator, regional SIU manager, and anti-fraud compliance director. In addition, Brent believes in the value of collaboration in the fight against insurance fraud and has been very active in the larger antifraud community for over two decades. He has had the opportunity to serve on the board of the International Association of Special Investigation Units (IASIU), lead a local Texas chapter, chair numerous committees, get involved with advocacy in both regulatory and legislative arenas, plan antifraud educational events, manage a global publication, and participate in many other initiatives. Prior to joining the Coalition Against Insurance Fraud, Brent co-chaired its Government Affairs Committee. Brent received a bachelor’s degree from East Texas A&M University in organizational leadership and holds the Senior Claim Law Associate designation from the American Educational Institute. He has been married for over 30 years, has three children, and is a veteran of the United States Marine Corps. [![](https://insurancefraud.org/wp-content/uploads/iconfinder_phone_1608790-1.png) 301-821-6145](tel:301-821-6145) **\|** [![](https://insurancefraud.org/wp-content/uploads/iconfinder_aiga_mail_134146.png) brent@insurancefraud.org](mailto:brent@insurancefraud.org) X ![](https://insurancefraud.org/wp-content/uploads/Lauren-Vitanye.jpg) Communications Lead ### Lauren Vitanye Lauren Vitanye serves as Communications Lead, supporting the Coalition’s strategic priorities by developing and executing integrated communications that engage members, consumers and other key audiences. She brings more than 15 years of experience in corporate communications, public affairs and executive communications across insurance, healthcare and biotechnology. Previously, Lauren held senior communications roles at Exact Sciences, now part of Abbott, and American Family Insurance, partnering with business and executive leaders on strategic communications, organizational change and stakeholder engagement. She began her career in Washington, D.C., and holds a B.S. in Communication from Ohio University, with a minor in Business Administration. [![](https://insurancefraud.org/wp-content/uploads/iconfinder_phone_1608790-1.png) 202-393-7331](tel:202-250-3250) **\|** [![](https://insurancefraud.org/wp-content/uploads/iconfinder_aiga_mail_134146.png) lauren@insurancefraud.org](mailto:lauren@insurancefraud.org) X ![](https://insurancefraud.org/wp-content/uploads/Celeste-Dodson.png) Director of Member Relations and Initiatives ### Celeste Dodson, MBA, CPCU, FCLA As Director of Member Relations and Initiatives for the Coalition Against Insurance Fraud Celeste is focused on strengthening and growing the Coalition’s member relations, enhancing its presence, and expanding its influence within the insurance and fraud-fighting community. In addition she provides leadership and oversight of the Coalition’s numerous task forces and committees. Prior to joining the Coalition, Celeste worked within the P&C Insurance Industry for over 30 years. Celeste built and led regional and national Special Investigation Unit (SIU) operations, as well as directed claims, underwriting, and project management initiatives for one of the largest P&C carriers within the United States. Her career reflects a steadfast commitment to innovation, integrity, and excellence in combating insurance fraud and advancing operational effectiveness. Celeste is a recognized leader within the anti-fraud community, having served as President of the International Association of Special Investigation Units (IASIU), Vice President of the Global Insurance Fraud Summit (GIFS), and Secretary of the Pennsylvania Automobile Theft Prevention Authority (ATPA). She has also contributed her expertise as an advisor to the National Insurance Crime Bureau (NICB) Board of Governors and the Coalition Against Insurance Fraud’s Executive Board. A respected and engaging industry speaker, Celeste is frequently invited to share her insights on fraud prevention, leadership, and organizational strategy. She has earned the Chartered Property Casualty Underwriter (CPCU) and Fraud Claim Law Associate (FCLA) designations, holds a Bachelor of Science in Criminology from Florida State University, and a Master of Business Administration from Villanova University. [![](https://insurancefraud.org/wp-content/uploads/iconfinder_phone_1608790-1.png) 202-573-3435](tel:2025733435) **\|** [![](https://insurancefraud.org/wp-content/uploads/iconfinder_aiga_mail_134146.png) celeste@insurancefraud.org](mailto:celeste@insurancefraud.org) X ![](https://insurancefraud.org/wp-content/uploads/Website-Headshot-500-x-500_0002_IF-Conference-Headshots-By-Gedalia-Vera-38.jpg) Head of Member Services & Events ### Kendra Smith Kendra Smith serves as the Head of Member Services & Events. For nearly to two decades, Kendra has managed internal operations, member services and events for the Coalition. Her exceptional organizational skills ensure that the Midyear and Annual membership meetings, committee and task force meetings run efficiently and that our databases remain up-to-date. Kendra is dedicated to providing Coalition members with prompt and accurate responses to their inquiries. Prior to joining the Coalition in 2007, Kendra supported the President & CEO and senior staff at the [D.C. Chamber of Commerce](https://dcchamber.org/), where she also served as a liaison to the Mayor of the District of Columbia and city council member assistants. During her tenure at [Suited for Change](https://www.suitedforchange.org/), Kendra managed over 100 job-training programs aimed at assisting economically disadvantaged women. She provided mentoring, skill development and organized volunteers to assist women in search of employment and professional attire. At the Sanz School, Kendra arranged career expos, workshops and facilitated internships and employment opportunities for students. In 2008, Kendra completed her Bachelor of Arts in Business Administration and Associate of Arts in Criminal Justice at American InterContinental University. [![](https://insurancefraud.org/wp-content/uploads/iconfinder_phone_1608790-1.png) 202-393-7330](tel:2023937330) **\|** [![](https://insurancefraud.org/wp-content/uploads/iconfinder_aiga_mail_134146.png) Kendra@insurancefraud.org](mailto:Kendra@insurancefraud.org) X ![](https://insurancefraud.org/wp-content/uploads/Kate-Gordon-e1723049849459.png) General Counsel ### Kate Gordon Prior to coming to the Coalition, Kate was Associate General Counsel at American International Group (AIG) and was the principal legal support for Global Investigative Services of the Fraud and Recovery team. She managed a team of attorneys who supported the Claims and Operations Legal Group including Global Recovery matters, non-litigated bankruptcy issues, Regulatory inquiries and filings as well as contract drafting and interpretation. Prior to working at AIG, she was National Counsel for Special Investigations at Liberty Mutual Insurance Company overseeing a team of regional attorneys throughout the country. She worked collaboratively with investigators, attorneys and prosecutors to bring affirmative actions to recover funds and defend against claims if fraud was involved. She brings a wealth of knowledge on insurance fraud related matters as well as an extensive litigation background. Kate has been active with the Coalition as a Board member and most recently, Chair of the Government Affairs Committee. She was also a member of the APCIA fraud subcommittee and has presented at IASIU, RIMS and the Coalition on topics involving fraud matters. [![](https://insurancefraud.org/wp-content/uploads/iconfinder_phone_1608790-1.png) 202-384-7819](tel:202-384-7819) **\|** [![](https://insurancefraud.org/wp-content/uploads/iconfinder_aiga_mail_134146.png) Kate@insurancefraud.org](mailto:kate@insurancefraud.org) --- ### [Employment Infiltration Resources](https://insurancefraud.org/employment-infiltration-resources/) **Published:** September 2, 2026 **Author:** Coalition Against Insurance Fraud **Content:** Synthetic identities are breaking through hiring defenses. Using deepfakes and AI-generated personas, fraudsters are getting hired by insurance carriers under false pretenses. Once onboarded, these internal bad actors exploit gaps in verification to exfiltrate private customer data, commit internal fraud, or deploy malware across corporate systems. Protect your business. Learn more about how to avoid becoming the next victim. Members are encouraged to use these materials freely and are authorized to co-brand all materials provided below. For branding assistance, or questions related to the resources provided, please email <communications@insurancefraud.org>. ##### **2026 Employment Infiltration Alert** [![](https://insurancefraud.org/wp-content/uploads/Employment-Infiltration-Member-Alert-1024x980.jpg)](https://insurancefraud.org/wp-content/uploads/09-02-2026-Member-Alert_-Employment-Infiltration.pdf) View [2026 Employment Infiltration Member Alert](https://insurancefraud.org/wp-content/uploads/09-02-2026-Member-Alert_-Employment-Infiltration.pdf) Download [“Employment Infiltration: How Synthetic Identities and Deepfakes Are Threatening the Insurance Industry From Within”](https://insurancefraud.org/wp-content/uploads/08-2026-Employment-Infiltration_-How-synthetic-identities-and-deepfakes-are-threatening-the-insurance-industry-from-within.pdf) white paper ##### **2025 Employment Infiltration Alert** [![](https://insurancefraud.org/wp-content/uploads/2025-Employment-Infiltration-Alert-970x1024.jpg)](https://insurancefraud.org/wp-content/uploads/08-2025-Fraudsters-Are-Attempting-To-Infiltrate-Insurance-Companies-Through-Employment-Scams.pdf) Download [2025 Employment Infiltration Member Alert](https://insurancefraud.org/wp-content/uploads/08-2025-Fraudsters-Are-Attempting-To-Infiltrate-Insurance-Companies-Through-Employment-Scams.pdf) --- ##### Infographic [![](https://insurancefraud.org/wp-content/uploads/Employment-Infiltration-409x1024.png)](https://insurancefraud.org/wp-content/uploads/Employment-Infiltration-Infographic.pdf) [Download Infographic](https://insurancefraud.org/wp-content/uploads/Employment-Infiltration-Infographic.pdf) --- ### [Workers' Compensation Resources](https://insurancefraud.org/workers-comp-resources/) **Published:** August 15, 2025 **Author:** Coalition Against Insurance Fraud **Content:** Note: The Coalition provides a collection of resources to help members address workers’ compensation fraud. From case studies to investigative tools and best practices, these materials offer practical insights to support prevention and detection efforts. Members are free to use these tools, and if you would like any resource aside from the reports co-branded for your organization, please reach out to **<communications@insurancefraud.org>**. All resources have been centralized here for easy access. Please scroll down to view all information provided on this page. **Workers’ Compensation Claimant Fraud Resource for Investigators** [![](https://insurancefraud.org/wp-content/uploads/Workers-Comp-Fraud-Guide_Page_01-791x1024.jpg)](https://insurancefraud.org/wp-content/uploads/Workers-Comp-Fraud-Guide.pdf) **[Download](https://insurancefraud.org/wp-content/uploads/Workers-Comp-Fraud-Guide.pdf)** **WC Premium Fraud Job Aid – Investigative Steps** [![](https://insurancefraud.org/wp-content/uploads/Premium-Fraud-Investigative-Steps-791x1024.jpg)](https://insurancefraud.org/wp-content/uploads/Premium-Fraud-Investigative-Steps.pdf) --- #### Infographics [![](https://insurancefraud.org/wp-content/uploads/Workers_Comp_Premium_Fraud_Infographic-372x1024.png)](https://insurancefraud.org/wp-content/uploads/Workers_Comp_Premium_Fraud_Infographic.pdf) [Download infographic](https://insurancefraud.org/wp-content/uploads/Workers_Comp_Premium_Fraud_Infographic.pdf) [![](https://insurancefraud.org/wp-content/uploads/V2-WC-7-Red-Flags-Infographic-2025-307x1024.jpg)](https://insurancefraud.org/wp-content/uploads/V2-WC-7-Red-Flags-Infographic-2025-scaled.jpg)Workers’ Comp premium fraud **drains billions every year**, but knowing the warning signs can keep you one step ahead. Download this quick-reference infographic to spot common red flags. **[Download infographic](https://insurancefraud.org/wp-content/uploads/V2-WC-7-Red-Flags-Infographic-2025-scaled.jpg)** or **[Visit Infographics webpage to download](https://insurancefraud.org/videos-infographics/)** --- #### **Social Media Posts** [![](https://insurancefraud.org/wp-content/uploads/B.-Workerss-Comp-Report-2-25B-Social-Media-Post.png)](https://insurancefraud.org/wp-content/uploads/B.-Workerss-Comp-Report-2-25B-Social-Media-Post.pdf)[**Download**](https://insurancefraud.org/wp-content/uploads/B.-Workerss-Comp-Report-2-25B-Social-Media-Post.pdf) [![](https://insurancefraud.org/wp-content/uploads/A.-Workerss-Comp-Report-2-25B-Social-Media-Post.png)](https://insurancefraud.org/wp-content/uploads/A.-Workerss-Comp-Report-2-25B-Social-Media-Post.pdf)[**Download**](https://insurancefraud.org/wp-content/uploads/A.-Workerss-Comp-Report-2-25B-Social-Media-Post.pdf) [![](https://insurancefraud.org/wp-content/uploads/C.-Workerss-Comp-Report-2-25B-Social-Media-Post.png)](https://insurancefraud.org/wp-content/uploads/C.-Workerss-Comp-Report-2-25B-Social-Media-Post.pdf)[**Download**](https://insurancefraud.org/wp-content/uploads/C.-Workerss-Comp-Report-2-25B-Social-Media-Post.pdf) --- #### **Workers’ Compensation Reports** [![](https://insurancefraud.org/wp-content/uploads/10-2026-WC-Report-794x1024.png)](https://insurancefraud.org/wp-content/uploads/10-2026-From-Identifier-to-Investigative-Signal-How-the-NPI-Supports-Medical-Fraud-Detection.pdf) [![This image has an empty alt attribute; its file name is download-button-1.jpg](https://insurancefraud.org/wp-content/uploads/download-button-1.jpg)](https://insurancefraud.org/wp-content/uploads/10-2026-From-Identifier-to-Investigative-Signal-How-the-NPI-Supports-Medical-Fraud-Detection.pdf) [![](https://insurancefraud.org/wp-content/uploads/Coalition-Premium-Fraud-Report-8-2025-1-791x1024.jpg)](https://insurancefraud.org/wp-content/uploads/Coalition-Premium-Fraud-Report-8-2025-1.pdf)The Coalition’s new case study, **“When Employers Cheat the System,”** exposes how a Los Angeles business stole wages, hid millions in payroll, and defrauded insurers of $1.7 million. With **$25 billion** lost to workers’ comp premium fraud each year, this report highlights key red flags and strategies to stop fraud early.[![This image has an empty alt attribute; its file name is download-button-1.jpg](https://insurancefraud.org/wp-content/uploads/download-button-1.jpg)](https://insurancefraud.org/wp-content/uploads/Coalition-Premium-Fraud-Report-8-2025-1.pdf) [![](https://insurancefraud.org/wp-content/uploads/Workers-Comp-Report-March-2025-cover-791x1024.jpg)](https://insurancefraud.org/wp-content/uploads/Workers-Comp-Report-March-2025.pdf) [![This image has an empty alt attribute; its file name is download-button-1.jpg](https://insurancefraud.org/wp-content/uploads/download-button-1.jpg)](https://insurancefraud.org/wp-content/uploads/Workers-Comp-Report-March-2025.pdf) [![](https://insurancefraud.org/wp-content/uploads/Part-2-cover-WC-TaskFroce-Report-791x1024.png)](https://insurancefraud.org/wp-content/uploads/2023-Workers-Comp-report.pdf) [![This image has an empty alt attribute; its file name is download-button-1.jpg](https://insurancefraud.org/wp-content/uploads/download-button-1.jpg)](https://insurancefraud.org/wp-content/uploads/2023-Workers-Comp-report.pdf) [![](https://insurancefraud.org/wp-content/uploads/WC-Report-2022.png)](https://insurancefraud.org/wp-content/uploads/WORKERS-COMPENSATION-FRAUD-Report-FINAL.pdf) [![This image has an empty alt attribute; its file name is download-button-1.jpg](https://insurancefraud.org/wp-content/uploads/download-button-1.jpg)](https://insurancefraud.org/wp-content/uploads/WORKERS-COMPENSATION-FRAUD-Report-FINAL.pdf) --- #### **Workers’ Compensation Webinars** **[WC Premium Fraud and the Intersection to Auto Insurance Fraud and Other Crimes](https://vimeo.com/1128906376?fl=pl&fe=sh)** **[2025 Workers’ Compensation Claimant Fraud Case Study Webinar](https://vimeo.com/1086895081)** **[2024 Workers’ Compensation Provider Fraud Webinar](https://vimeo.com/928576472?share=copy)** **[2024 Workers’ Compensation Premium Fraud Webinar](https://vimeo.com/917554685?share=copy)** [**2024 Workers’ Compensation Claimant Fraud Webinar**](https://vimeo.com/910468904?share=copy) [**2023** ****Workers’ Compensation Fraud in America – Part 2****](https://vimeo.com/747787516) [**2022 Workers’ Compensation Webinar**](https://vimeo.com/747787516) --- ### [Advocacy Efforts](https://insurancefraud.org/advocacy-efforts/) **Published:** May 15, 2025 **Author:** Coalition Against Insurance Fraud **Content:** **The Coalition Against Insurance Fraud leads nationwide legislative and regulatory advocacy efforts to advance anti-fraud protections across all lines of insurance.** Guided by our annual [legislative priorities](https://insurancefraud.org/legislative-priorities/), the Coalition works with state and federal lawmakers, regulators, and stakeholders to support impactful [anti-fraud bills, laws and regulations](https://insurancefraud.org/government-law/). Our advocacy includes submitting letters of support or opposition, providing testimony, collaborating on model laws, and mobilizing grassroots campaigns. We also lend our anti-fraud expertise through judicial advocacy though the Coalition’s [amicus curiae program](https://insurancefraud.org/amicus-program/). These combined efforts aim to reduce insurance fraud, strengthen enforcement, and promote fair, consumer-focused insurance markets. #### **A list of recent Coalition advocacy efforts follows:** **Coalition urges Pennsylvania Senate to advance Public Adjuster Licensing Law** On October 9, 2026, the Coalition submitted a [letter support](https://insurancefraud.org/wp-content/uploads/10-9-2026-Coalition-Support-of-Pennsylvania-H1972.pdf) for House Bill 1972, which would strengthen public adjuster licensing requirements, restrict conflicts of interest, improve contract and disclosure protections, and strengthen enforcement to protect policyholders from fraud and misconduct. The letter urges Senate leadership to advance the bill during this legislative session. **Coalition supports California Senate Bill 536 to strengthen workers’ compensation premium fraud investigations.** California Senate Bill 536 would improve the detection and investigation of workers’ compensation premium fraud by allowing insurers, under strict privacy safeguards, to verify payroll tax information through the California Employment Development Department when fraud is suspected. - On June 8, 2026, the Coalition submitted a [letter of support](https://insurancefraud.org/wp-content/uploads/6-8-2026-Coalition-Support-of-California-SB-536.pdf "letter of support") to Senator Bob Archuleta, with a copy to Assembly Insurance Committee Chair Lisa Calderon, highlighting that the bill provides a balanced approach to strengthening premium fraud investigations while protecting confidential employer information and complying with federal privacy requirements. **Coalition balances consumer protection with antifraud capabilities as NAIC Privacy Protections Working Group advances its revision of privacy model.** The National Association of Insurance Commissioners (NAIC) Privacy Protections Working Group ([PPWG](https://content.naic.org/committees/h/privacy-protections-wg)) is reviewing the [Chair Draft of Model 672](https://content.naic.org/sites/default/files/call_materials/Chair%20Draft%20Amendments%20to%20%23672%208.5.24.pdf) (Privacy of Consumer Information Act) for possible revision. Coalition engagement has focused on preserving antifraud reporting capabilities in balance with responsible consumer privacy protections. That has included: - To meet a March 11, 2026 deadline for written comment, Brent Walker, Coalition director of government relations and NAIC appointed consumer representative, engaged with the drafting group and other key stakeholders to clarify proposed Article VII Section 25 and its relevance to online fraud reporting to NICB and NAIC, ensuring that the model’s language clearly preserved antifraud capabilities while maintaining a compliance requirement on responsible data use. - Then, on April 30, 2026, Walker further clarified on a Working Group virtual call that same section in the proposed model was to preserve antifraud exemptions supporting mandatory fraud reporting through the NAIC and NICB systems. - On August 13, 2026, Brent Walker, Coalition director of government relations and NAIC appointed consumer representative, testified before the Privacy Protections Working Group at the NAIC Summer National Meeting to thank the working group for the existing antifraud exceptions in the pending draft and signal the Coalition’s intent to submit further written comment to recommend additional antifraud safeguards. - On September 17, 2026, the Coalition submitted [comment](https://insurancefraud.org/wp-content/uploads/Coalition-Comments-9.17.2026-on-NAIC-Revised-MO672-Full-Exposure-Draft-7.24.26.pdf) on the proposed model, focused on the recommendation for additional antifraud exceptions to prevent new consumer rights proposed in Section 6 of the pending revisions from inadvertently revealing or compromising an ongoing fraud investigation and ensure proposed model language does not interfere with existing state requirements for fraud reporting, immunity and confidentiality (Section 29). - The final draft is planned to be ready for consideration at NAIC’s Fall National Meeting in November 2026. **Coalition continues to support New York Governor Hochul’s antifraud provisions in the Executive Budget during negotiations.** The New York Governor’s Executive Budget for fiscal year 2027 includes antifraud measures targeting staged accidents, workers’ compensation fraud, wage theft, and organized fraud activity, while increasing investigative and prosecutorial resources. The Coalition has been engaged and advocacy efforts include: - Initially, the Coalition was invited and Kate Gordon, Coalition general counsel, attended a New York press conference on January 22, 2026, with Governor Kathy Hochul highlighting the [Executive Budget for Fiscal Year 2027](https://www.governor.ny.gov/sites/default/files/2026-01/FY2027ExecutiveBudgetBook.pdf). - Previously, on February 24, 2026, the Coalition submitted [written support](https://insurancefraud.org/wp-content/uploads/Coalition-2-24-2026-Written-Support-of-Antifraud-Provisions-in-New-York-Executive-Budget.pdf) for the antifraud provisions in the Governor’s Executive Budget. These measures strengthen enforcement against staged accidents, workers’ compensation fraud, and wage theft, with additional funding to provide prosecutors and investigators the tools needed to protect consumers and stabilize insurance costs across New York. - On April 7, 2026, the Coalition submitted additional letters of support for the antifraud provisions in the Governor’s budget for fiscal year 2027, emphasizing the need for full funding of measures that strengthen workers’ compensation fraud units, expand auto insurance investigations, and enhance prosecution tools for organized and repeat fraud offenders. Letters were sent to the [Senate President](https://insurancefraud.org/wp-content/uploads/Coalition-Support-of-Antifraud-Provisions-in-New-York-Executive-Budget-4-7-2026-Senate-President.pdf), the [Senate Insurance Committee](https://insurancefraud.org/wp-content/uploads/Coalition-Support-of-Antifraud-Provisions-in-New-York-Executive-Budget-4-7-2026-Senate-Ins-Cmte.pdf), the [Speaker of the Assembly](https://insurancefraud.org/wp-content/uploads/Coalition-Support-of-Antifraud-Provisions-in-New-York-Executive-Budget-4-7-2026-Assembly-Speaker.pdf), and [Assembly Insurance Committee](https://insurancefraud.org/wp-content/uploads/Coalition-Support-of-Antifraud-Provisions-in-New-York-Executive-Budget-4-7-2026-Assembly-Ins-Cmte.pdf). Budget negotiations were still ongoing at the time these letters were sent. - On May 13, 2026, Kate Gordon, Coalition general counsel and Brent Walker, director of government relations attended a Legislative Action Day at the state capitol where there were able to answer lawmaker questions concerning fraud driven affordability challenges, the pending Governor’s budget, and support for antifraud measures targeting staged accidents, assignment of benefits abuse, fraudulent contractor activity, dedicated fraud prosecution funding, and modernized fraud reporting systems, while also highlighting Coalition research showing that more than half of Americans personally know someone who has committed insurance fraud. **Coalition supports Alaska airbag fraud bill to protect consumers and deter scams.** Alaska House Bill 74 would establish the crime of airbag fraud and prohibit the manufacture, sale, installation, or concealment of counterfeit or nonfunctioning airbags. - On May 21, 2026, the Coalition [urged](https://insurancefraud.org/wp-content/uploads/5-21-2026-Coalition-Support-of-Airbag-Fraud-Provisions-in-Alaska-HB-239.pdf) Governor Dunleavy to sign the airbag fraud provisions into law after that language was incorporated into a larger omnibus crime bill, HB 239. - On March 13, 2026, the Coalition submitted a [letter of support](https://insurancefraud.org/wp-content/uploads/3-13-2026-Coalition-Support-of-Alaska-HB-74.pdf) to the Alaska House Judiciary Committee urging passage of House Bill 74, highlighting that more than 30 states have enacted similar laws to strengthen protections and deter fraud involving counterfeit vehicle parts. **Coalition continues support for Kansas bill that would strengthen the Commissioner’s ability to fight insurance fraud.** Kansas House Bill 2323 expands civil enforcement authority, improves agent/adjuster licensing transparency involving fraud convictions, and addresses fraud-reporting gaps within the automobile assigned claims plan. The bill overwhelmingly passed the House in 2025 but did not advance in the Senate. Coalition efforts this year include: - In early 2026, collaboration with key stakeholders and conversations with the committee chair helped place the bill on the Senate committee’s agenda. - On March 9, 2026, the Coalition submitted a letter of support for Kansas [HB 2323](https://insurancefraud.org/wp-content/uploads/Coalition-3-9-2026-Support-of-HB-2323.pdf). - On March 10, 2026, the Coalition provided [remote testimony](https://www.youtube.com/watch?v=JLITmF7__S4) to the Kansas Senate Committee on Judiciary. - After amendment, this bill was signed by the Governor on April 6, 2026 and will become law. **Coalition testifies and submits written comments in support of Washington Senate and House bills to strengthen Insurance Fraud Program** Washington Senate Bill 6031 and House Bill 2394 were requested by the Insurance Commissioner and sought to elevate insurance fraud to a felony, expand prosecutorial powers, clarify venue and statute of limitations, and increase the Commissioner’s authority to share information. The bills also aimed to enhance the Criminal Investigations Unit by adding financial and digital specialists to address increasingly sophisticated fraud schemes. Coalition advocacy included: - On January 21, 2026, Coalition director of government relations Brent Walker [testified](https://app.leg.wa.gov/committeeschedules?eventID=2026011301#/Senate/29195/01-21-2026/01-21-2026/Schedule///Bill/) remotely before the Washington Senate Committee on Business, Trade & Economic Development in support of Senate Bill 6031. [Written comment](https://insurancefraud.org/wp-content/uploads/Coalition-Written-Testimony-in-Support-of-SB-6031.pdf) was also submitted. - On January 27, 2026, Brent Walker also submitted [written comment](https://insurancefraud.org/wp-content/uploads/Coalition-Written-Testimony-in-Support-of-HB-2394.pdf) in support of its companion, House Bill 2394. - Then on February 24, 2026, after Senate Bill 6031 advanced to the House, Brent Walker submitted a [letter of support](https://insurancefraud.org/wp-content/uploads/Coalition-2-23-2026-Support-of-SB-6031.pdf), urging the House committee to advance the bill. - Both bills failed to advance in the House. In addition to the above, the Coalition is also very active with both the National Council of Insurance Legislators (NCOIL) and the National Association of Insurance Commissioners (NAIC) where we were honored to participate, by appointment, in the NAIC [Consumer Participation Program](https://content.naic.org/consumer/consumer-participation-program). The Coalition attends both NCOIL and NAIC in-person national meetings, along with virtual participation in various committee, task force, and working group sessions. Often, the Coalition speaks or provides important anti-fraud updates at these venues. On occasion, the Coalition also provides anti-fraud input on model laws with both NCOIL and the NAIC. Recent examples include ongoing work within the NAIC [Privacy Protections (H) Working Group](https://content.naic.org/committees/h/privacy-protections-wg). #### C**oalition past advocacy efforts include:** **Coalition comments on Washington Office of Insurance Commissioner’s proposed amendments to Insurance Fraud Program for 2026** In a October 29, 2025 [letter](https://insurancefraud.org/wp-content/uploads/Coalition-10_29_2025-Comments-WA-OIC-Draft-RCW-48.135.pdf), the Coalition sent comments in support of the Washington Office of Insurance Commissioner’s (OIC) legislative requests for the 2026 session. The Coalition applauded the OIC’s attempt to strengthen and modernize that state’s ability to address the increasingly sophistication of insurance fraud and fraudsters to protect both the insurance system and consumers. **Coalition asked for New York Governor signature to pass bill that would establish a workers compensation fraud commission.** On September 24, 2025, the Coalition, by [letter](https://insurancefraud.org/wp-content/uploads/Coalition-Support-of-NY-S-7950.pdf), urged the New York Governor to pass SB 7950, thereby creating a workers compensation fraud assessment commission that would add resources to the investigation and prosecution of workers compensation fraud in that state. With that support also came a reminder that to be effective, those funds must be dedicated to its intended purpose, with the necessary oversight and accountability that it requires. *The Governor vetoed this bill but later included a similar measure in her 2026 Executive Budget.* **Coalition urges California Governor to sign bill to close workers compensation fraud prosecution loophole.** On September 22, 2025, the Coalition Against Insurance Fraud sent a [letter](https://insurancefraud.org/coalition-support-of-ca-ab-1398/) to the California Governor to pass AB 1398 by his signature. This bill would close a loophole that can limit law enforcement and prosecutors to misdemeanors, rather than felonies, for kickback schemes in the California workers compensation system. *This bill passed and will set precedent for cases moving forward.* **Coalition calls for tech giants to implement guardrails to prevent exploitation of AI systems to commit fraud**. In May, as a bold and proactive step to confront the growing misuse of generative artificial intelligence (AI) in insurance fraud schemes, the Coalition Against Insurance Fraud formally reached out to seven of the world’s leading AI companies, [Adobe](https://insurancefraud.org/wp-content/uploads/5-19-25-AI-Advocacy-Letter-Adobe.pdf), [Anthropic](https://insurancefraud.org/wp-content/uploads/5-19-25-AI-Advocacy-Letter-Anthropic-Final.pdf), [Canva](https://insurancefraud.org/wp-content/uploads/5-19-25-AI-Advocacy-Letter-Canva.pdf), [Google](https://insurancefraud.org/wp-content/uploads/5-19-25-AI-Advocacy-Letter-Google-DeepMind.pdf), [Meta](https://insurancefraud.org/wp-content/uploads/5-19-25-AI-Advocacy-Letter-Meta.pdf), [Microsoft](https://insurancefraud.org/wp-content/uploads/5-19-25-AI-Advocacy-Letter-Microsoft.pdf), and [OpenAI](https://insurancefraud.org/wp-content/uploads/5-19-25-AI-Advocacy-Letter-Open-AI-2.pdf), to call for immediate action and collaboration to prevent the exploitation of their platforms for fraudulent purposes. The Coalition urged AI companies to implement stronger guardrails and incorporate safeguards that prevent the creation of content that could facilitate fraudulent insurance claims. It also called on these companies to flag and warn users about the legal and ethical risks of misuse. Additionally, the Coalition is encouraging ongoing collaboration between the insurance industry and AI developers and has offered its expertise as a resource to help guide responsible innovation moving forward. **The Coalition wrote to the NAIC Antifraud Task Force to request the creation of a new fraud category for online reporting.** On June 2, 2025, the Coalition Against Insurance Fraud requested, in a [letter](https://insurancefraud.org/wp-content/uploads/6-2-25-NAIC-LTC-Letter.pdf "letter"), the addition of a dedicated Long Term Care (LTC) Insurance fraud category to the NAIC’s Online Fraud Reporting System (OFRS) in response to the rising use of LTC products and the corresponding increase in complex fraud schemes that are currently difficult to track under existing reporting categories. **The Coalition joins NICB and IASIU to support a bill that would make staging an accident with a commercial vehicle a Federal offense.** On May 30, 2025, the Coalition signed onto a joint [letter](https://insurancefraud.org/wp-content/uploads/Joint-Letter-Supporting-HR2662-May-30-2025-Final.pdf) with NICB and IASIU, supporting a US [HR 2662](https://www.congress.gov/bill/119th-congress/house-bill/2662/text), that would make staging an accident involving a commercial vehicle a Federal offense. This letter also highlights the bill’s authors requests for US Dept. of HLS to form a staged accident task force. **Coalition backs North Carolina bills targeting fraud in the bail bond system.** On April 16, 2025, the Coalition Against Insurance Fraud supported by letter, North Carolina [HB 718](https://insurancefraud.org/wp-content/uploads/Coalition-Support-of-North-Carolina-HB-718.pdf "HB 718") and [SB 251](https://insurancefraud.org/wp-content/uploads/Coalition-Support-of-North-Carolina-SB-251.pdf), which strengthen oversight of the bail bond system to protect consumers and surety companies from fraud. *These bills did not advance.* **The Coalition stood with Illinois stakeholders to support Chicago towing ordinance.** On April 7, 2025, the Coalition co-signed a [joint letter of support](https://insurancefraud.org/wp-content/uploads/Chicago-Rogue-Towing-2.0-Letter-04.07.2025.pdf) for a new Chicago towing ordinance that targets predatory practices like “wreck chasing” and inflated fees. *The Chicago City Council has since [passed](https://www.fox32chicago.com/news/chicago-rogue-towing-ordinance-vote) this [ordinance](https://chicityclerkelms.chicago.gov/Matter/?matterId=42684EBD-5674-EF11-A671-001DD809A88D) targeting predatory towing practices*, marking a major step forward in protecting accident victims and curbing insurance fraud risks tied to rogue operators. **The Coalition opposed a Texas Senate bill that could open the floodgates for insurance fraud.** On April 3, 2025, the Coalition opposed by letter, Texas [SB 1791](https://insurancefraud.org/wp-content/uploads/Coalition-OPPOSITION-to-Texas-SB-1791.pdf), which, if passed, would force insurers to pay auto liability claims if a policyholder doesn’t respond to the carrier after five contact attempts over 45 days. The bill risks enabling staged or fraudulent claims through intentional unresponsiveness, while unfairly penalizing consumers who may be unreachable for valid reasons like military service or hospitalization. *The bill has since been removed from the consent calendar.* **The** **Coalition-backed a bill to strengthen Kansas fraud laws**. On February 11, 2025, the Coalition sent a letter of support for Kansas [HB 2323](https://insurancefraud.org/wp-content/uploads/PRO.HB2323.Walker.02.12.25.Letter-of-Support.pdf). The bill passed the House onto the Senate, where it unfortunately did not advance. It would have expanded the Insurance Commissioner’s authority to pursue civil penalties for insurance fraud, enhanced licensing application transparency for agents and public adjusters with expunged fraud convictions, and closed fraud-reporting gaps in the automobile assigned claims plan, a known fraud risk in Kansas. *The bill overwhelmingly passed the House but did not advance in the Senate.* **Coalition urges action on Virginia towing legislation to protect consumers from predatory practices.** On January 23, 29 and 31, 2024, the Coalition joined the National Insurance Crime Bureau, American Property Casualty Insurance Association and National Association of Mutual Insurance Companies in comments on Virginia towing legislation. The organizations supported Senate Bill 94 and House Bill 1073, which would prohibit solicitation at accident scenes and help protect consumers from predatory towing practices. The organizations opposed House Bill 421, citing concerns about the proposed towing rate setting panel’s lack of representation from consumer, insurance and other affected stakeholders. **Coalition supports New York legislation strengthening protections against staged motor vehicle accidents.** On May 10, 2024, the Coalition submitted a memorandum supporting New York Senate Bill 7754 and Assembly Bill 6816, which would strengthen “Alice’s Law” and protections against staged motor vehicle accidents. The bills would expand criminal liability to those who direct, hire, request, encourage, orchestrate or invite others to participate in staged accidents, strengthening New York’s response to insurance fraud involving staged crashes. **Coalition continued with to balance consumer privacy and insurance fraud prevention in NAIC privacy model.** The Coalition engaged the National Association of Insurance Commissioners Privacy Protections Working Group in 2024 to emphasize that consumer privacy protections should remain consistent with effective fraud prevention, investigation and existing state antifraud requirements. - On July 9, 2024, the Coalition provided verbal comments during a Consumer Representatives call, emphasizing the importance of mandatory fraud reporting, good faith information sharing and the ability to detect, prevent and investigate suspected insurance fraud. - On July 24, 2024, the Coalition submitted follow up comments recommending a universal antifraud exception protecting the use, disclosure, confidentiality and retention of information involving suspected or actual insurance fraud or material misrepresentation, and ensuring privacy rights do not interfere with fraud investigations or evidence preservation. **Coalition urges NAIC to advance Antifraud Plan Repository to streamline compliance and strengthen antifraud efforts.** On August 13, 2024, the Coalition urged the National Association of Insurance Commissioners to allocate information technology resources to its Antifraud Plan Repository. The Coalition noted that the repository had been under development since 2019 and that regulators and industry had already completed significant groundwork. The Coalition urged the NAIC to move the project forward to streamline antifraud plan compliance, improve consistency and provide insurers and state insurance departments with a centralized platform for managing antifraud plan requirements. **Coalition urges California to strengthen insurance fraud enforcement workforce.** On September 5, 2024, the Coalition urged Gov. Gavin Newsom to sign Assembly Bill 2872, legislation addressing pay disparities affecting sworn investigators at the California Department of Insurance. The Coalition noted that recruitment and retention challenges have contributed to investigator vacancies and emphasized the importance of maintaining a strong investigative workforce to detect and combat insurance fraud and protect California consumers. **Coalition urges NCOIL to strengthen antifraud protections in third party litigation financing model.** On September 23, 2024, the Coalition submitted comments to the National Council of Insurance Legislators on its Transparency in Third Party Litigation Financing Model Act. The Coalition recommended applying key requirements and prohibitions to both consumer and commercial litigation funding companies, including restrictions on foreign financing, disclosure of protected information, registration and annual reporting. The Coalition also recommended stronger disclosure requirements and safeguards addressing fraud convictions and ownership interests. **Coalition urged NAIC to protect antifraud information sharing as **NAIC Privacy Protections Working Group**** **begins** **revisions on consumer data privacy model.** The National Association of Insurance Commissioners (NAIC) Privacy Protections Working Group ([PPWG](https://content.naic.org/committees/h/privacy-protections-wg)) began revisions on consumer data privacy model. Coalition involvement focused on preserving antifraud capabilities in balance with responsible consumer privacy protections. That has included: - On July 10, 2023, the Coalition submitted comments to the National Association of Insurance Commissioners on Draft Model #674, urging the Privacy Protections Working Group to preserve insurance fraud investigations. The Coalition recommended clarifying investigative consumer reports, adding fraud exceptions and disclosure limitations, and protecting existing state anti-fraud immunity laws. - On July 27, 2023, the Coalition submitted follow up comments on Version 1.2 of Draft Model #674, urging the Working Group to protect information sharing for fraud detection and investigation. The comments addressed anti-fraud immunity, reasonable suspicion of fraud, underwriting investigations and investigative consumer reports. **Coalition urged stronger consumer protections in revisions to NAIC Public Adjuster Licensing Model Act.** On November 10, 2023, the Coalition submitted comments to the National Association of Insurance Commissioners on revisions to the Public Adjuster Licensing Model Act #228, recommending stronger consumer protections and safeguards against conflicts of interest. The Coalition recommended prohibiting public adjusters from having financial interests in claims or repair services, removing provisions that could permit those interests through disclosure, strengthening restrictions on involvement in property repairs, and adding licensing safeguards and penalties for unlicensed activity. --- ### [Videos & Infographics](https://insurancefraud.org/videos-infographics/) **Published:** July 23, 2020 **Author:** Coalition Against Insurance Fraud **Content:** On this Page: - [Videos](https://insurancefraud.org/tools-resources/#videos) - [Infographics](https://insurancefraud.org/tools-resources/#infographics) - [Expert Speakers](https://insurancefraud.org/tools-resources/#expertspeakers) Related Content: - [Fraud: Why Care?](https://insurancefraud.org/fraud-why-care/) - [Fraud Stats](https://insurancefraud.org/fraud-stats/) - [Report Fraud](https://insurancefraud.org/report-fraud/) - [Anti-Fraud Events](https://insurancefraud.org/events/) The Coalition provides a complete “toolkit” to help members promote their anti-fraud message. Videos and infographics may even be customized with your logo and URL. Contact <info@insurancefraud.org>. ### Videos **True to Life** <https://insurancefraud.org/wp-content/uploads/IFPA-TrueToLife.mp4> **Know Your Tow Video – PA Insurance Fraud Prevention Authority** ****Steve Slip-and-Fall - Part 1**** ****Steve Video - Part 2**** https://vimeo.com/597494441/633cffc4bb ****Steve Vi**deo - Final** **Choices (30-second without subtitles)** **Choices (90-second with subtitles)** **Choices (20-second with subtitles)** ****Bad Day**** **Hitting the Roof** **Boyfriend** **Weekend Warrior** **Asking for Trouble** **Big Screen** **Lost and Found** **Permanent Record** ****Don't Be a But**** ****Weasy Money**** ******Weasily Embarrassed****** ********Ebenweaser Screwed******** ****Crash & Buy**** <https://insurancefraud.org/wp-content/uploads/crash-buy.mp4> ### Infographics Click image to view full infographic [![](https://insurancefraud.org/wp-content/uploads/Insurance-Fraud-Awareness-Flyer-455x1024.png)](https://insurancefraud.org/wp-content/uploads/Insurance-Fraud-Awareness_flyer.pdf) [![](https://insurancefraud.org/wp-content/uploads/Workers_Comp_Premium_Fraud_Infographic-372x1024.png)](https://insurancefraud.org/wp-content/uploads/Workers_Comp_Premium_Fraud_Infographic.pdf) [![](https://insurancefraud.org/wp-content/uploads/Protect-Your-Loved-One-Infographic-818x1024.jpg)](https://insurancefraud.org/wp-content/uploads/LTC-Protect-Your-Loved-One-Infographic.pdf)[Download LTC Protect Your Loved One Infographic Front & Back](https://insurancefraud.org/wp-content/uploads/LTC-Protect-Your-Loved-One-Infographic.pdf) [![](https://insurancefraud.org/wp-content/uploads/LTC-FRAUD-SCHEMES-Infogrpahics-818x1024.jpg)](https://insurancefraud.org/wp-content/uploads/LTC-Common-Fraud-Schemes-Infogrpahic.pdf)[Download LTC Fraud Schemes Infographic Front & Back](https://insurancefraud.org/wp-content/uploads/LTC-Common-Fraud-Schemes-Infogrpahic.pdf) **Money Laundering Red Flags** [![](https://insurancefraud.org/wp-content/uploads/Final-Red-Flag-410x1024.jpg)](https://insurancefraud.org/wp-content/uploads/Money-Laundering-Red-Flags-Infographic.pdf) **Money Laundering Risk Mitigation Strategies** [![](https://insurancefraud.org/wp-content/uploads/Final-Strategies-410x1024.jpg)](https://insurancefraud.org/wp-content/uploads/Money-Laundering-Risk-Mitigation-Strategies.pdf) **New Year's Resolution** [![](https://insurancefraud.org/wp-content/uploads/Make-A-New-Years-Resolution-That-Counts-Stop-Insurance-Fraud-410x1024.jpg)](https://insurancefraud.org/wp-content/uploads/Make-A-New-Years-Resolution-That-Counts-Stop-Insurance-Fraud-1.pdf) **Water Mitigation** [![](https://insurancefraud.org/wp-content/uploads/Water-Mitigation.jpg)](https://insurancefraud.org/wp-content/uploads/Water-Mitigation.pdf) **What Is Insurance Fraud?** [![](https://insurancefraud.org/wp-content/uploads/WHAT-IS-INSURANCE-FRAUD.png)](https://insurancefraud.org/wp-content/uploads/WHAT-IS-INSURANCE-FRAUD.pdf)**[Spanish version](https://insurancefraud.org/wp-content/uploads/WHAT-IS-INSURANCE-FRAUD-Spanish.pdf)** **Disability Insurance Fraud** [![](https://insurancefraud.org/wp-content/uploads/Disability--410x1024.jpg)](https://insurancefraud.org/wp-content/uploads/Disability-.pdf) **Life Insurance** **Fraud** [![](https://insurancefraud.org/wp-content/uploads/Life-Infographic-2023-scaled.png)](https://insurancefraud.org/wp-content/uploads/Life-Infographic-2023.pdf) ************Public Adjusters and Your Claim************ [![](https://insurancefraud.org/wp-content/uploads/Public-Adjuster.jpg)](https://insurancefraud.org/wp-content/uploads/Public-Adjuster.pdf)[**Spanish version**](https://insurancefraud.org/wp-content/uploads/Spanish-Public-Adjuster.pdf) ************Workers' Compensation Premium Fraud************ [![](https://insurancefraud.org/wp-content/uploads/Workers-Comp-Infographic-410x1024.jpg)](https://insurancefraud.org/wp-content/uploads/Workers-Comp-Infographic.pdf) **[Spanish version](https://insurancefraud.org/wp-content/uploads/Spanish-Workers-Comp-Infographics.pdf)** **********************************************************The Cost of Insurance Fraud********************************************************** [![](https://insurancefraud.org/wp-content/uploads/308.6-Infographic-410x1024.jpg)](https://insurancefraud.org/wp-content/uploads/308.6-Infographic.pdf) **[Spanish version](https://insurancefraud.org/wp-content/uploads/Spanish-308.6-Billion-Infographic.pdf)** **********Roofing Scams********** [![](https://insurancefraud.org/wp-content/uploads/Roofing-Scams-Infographic-scaled.jpg)](https://insurancefraud.org/wp-content/uploads/Roofing-Scams-Infographic.pdf)[**Spanish version**](https://insurancefraud.org/wp-content/uploads/Spanish-Roofing-Scams-Infographic.png) ************************************************Workers Comp Fraud************************************************ [![](https://insurancefraud.org/wp-content/uploads/Workers-Compensation-Infographic-2.png)](https://insurancefraud.org/wp-content/uploads/Workers-Compensation-Infographic-2.pdf) **************************************************************************************Healthcare Sharing Ministries************************************************************************************** [![](https://insurancefraud.org/wp-content/uploads/HCSM-infographic.png)](https://insurancefraud.org/wp-content/uploads/HCSM-infographic.pdf) ********************************************************************************************Cybercrime Scams******************************************************************************************** [![](https://insurancefraud.org/wp-content/uploads/Insurance-Scammers-Cybercrime.png)](https://insurancefraud.org/wp-content/uploads/Insurance-Scammers-Cybercrime-2.pdf) **************************************************************************************************Robocall Scams************************************************************************************************** [![](https://insurancefraud.org/wp-content/uploads/Phone-Scam-Infographic-1-569x1024.png)](https://insurancefraud.org/wp-content/uploads/Phone-Scam-Infographic-2.pdf) ********************************************************************************************************************************************************************************************Insurance Fraud: Why Care?******************************************************************************************************************************************************************************************** [![](https://insurancefraud.org/wp-content/uploads/Insurance_Fraud_Why_Care_thumb.jpg)](https://149464873.v2.pressablecdn.com/wp-content/uploads/f3d80db2-8c41-41b5-a62e-07186ca155ff.jpg) **************************************************************************************************************************************************************************************************************Bandit towing - Hooked on fraud************************************************************************************************************************************************************************************************************** [![](https://insurancefraud.org/wp-content/uploads/bandit_towing_info_thumb.jpg)](https://149464873.v2.pressablecdn.com/wp-content/uploads/d26377d4-e667-4d5a-b44a-59d3f1bd8e2c.jpg) ************************************************************************************************************************************************************************************************************************************************Protect Against Home Repair Scams************************************************************************************************************************************************************************************************************************************************ [![](https://insurancefraud.org/wp-content/uploads/home_repair_info-thumb.jpg)](https://insurancefraud.org/wp-content/uploads/Home-Repair-Scams-infographic-1.pdf) --- ### [Model Acts](https://insurancefraud.org/model-acts/) **Published:** July 23, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Related Content: - [Government & Law](https://insurancefraud.org/government-law/) - [Amicus Program](https://insurancefraud.org/amicus-program/) The Coalition develops model acts to guide pursuing state laws to better shield consumers and insurers from scams. Dozens of states have adopted Coalition models in whole or part. Questions? [Email](mailto:brent@insurancefraud.org) Brent Walker or call 301-821-6145. **[Insurance Fraud Act](https://insurancefraud.org/wp-content/uploads/Insurance-fraud-model-act.pdf)** Most-inclusive state model insurance fraud law ever developed. Defines fraud — including attempted fraud, and fraud by insurer personnel. Also covers penalties, restitution, civil remedies, reporting immunity, and insurer regulatory requirements. Drafted with input from insurers, consumers, regulators and law enforcement. [Download](https://insurancefraud.org/wp-content/uploads/Insurance-fraud-model-act.pdf). **[Fraud Bureau Act](https://insurancefraud.org/wp-content/uploads/Fraud-bureau-model-bill.pdf)** States have a complete tool to create — or expand — an insurance fraud bureau. Defines terms, levels of authority, civil immunity for investigators, and referring cases for prosecution. Also covers fraud bureau funding, prosecution and fining authority. [Download](https://insurancefraud.org/wp-content/uploads/Fraud-bureau-model-bill.pdf). If you go to the FUNDING section of the model it says the [white paper](https://insurancefraud.org/wp-content/uploads/White_paper.pdf) follows the model act language. **[Anti-Runner Act](https://insurancefraud.org/wp-content/uploads/Model-anti-runners-bill.pdf)** Criminalizes recruiting for fraud schemes such as staged crashes, “runners” and medical rings. **Other model laws the Coalition supports include:** - [NAIC Model Insurance Fraud Act](https://content.naic.org/sites/default/files/model-law-680.pdf) - [NAIC Data Security Model Act](https://content.naic.org/sites/default/files/model-law-668.pdf) - [NCOIL Consumer Protection Model Towing Act](http://ncoil.org/wp-content/uploads/2018/07/Towing-Model-Final-7-16-18-1.pdf) - [NCOIL Model Act Regarding Auto Airbag Fraud](http://ncoil.org/wp-content/uploads/2018/07/Airbag-Fraud-Model-7-16-18-1.pdf) - [NCOIL Auto Insurance Fraud Model Act](http://ncoil.org/wp-content/uploads/2017/07/AutoFraudModel.pdf) - [NCOIL Model Anti-Runners Fraud Bill](https://ncoil.org/wp-content/uploads/2025/12/NCOIL-Anti-Runner-Model-Readopted-July-2023.pdf) - [NCOIL Storm Chaser Model Legislation](https://ncoil.org/wp-content/uploads/2026/02/NCOIL-Storm-Chaser-Model-November-2025.pdf) --- ### [Webinar Library](https://insurancefraud.org/webinars/) **Published:** July 24, 2020 **Author:** Coalition Against Insurance Fraud **Content:** #### 2026 Webinars [Preventing Cyber Incidents from Becoming Fraud Opportunities](https://vimeo.com/1232479523) [Download PowerPoint](https://insurancefraud.org/wp-content/uploads/10-1-26-Cyber-Incident-Webinar-Slides.pdf) [Brokers, Doctors and Dollars Webinar](https://vimeo.com/1228215750) [![](https://insurancefraud.org/wp-content/uploads/September-2026-webinar-1024x557.png)](https://vimeo.com/1228215750) [Download PowerPoint](https://insurancefraud.org/wp-content/uploads/9-17-26-Sober-Home-Webinar-Slides.pdf) [Account Takeover Risks Best Practices](https://vimeo.com/1220638443?share=copy&fl=sv&fe=ci) [![](https://insurancefraud.org/wp-content/uploads/8-20-26-Account-Takeover-Risks-Best-Practices-Webinar-1024x577.png)](https://vimeo.com/1220638443?share=copy&fl=sv&fe=ci) [**Best Practices for Reporting Suspected Insurance Fraud**](https://vimeo.com/1210880960?share=copy&fl=sv&fe=ci) [Download PowerPoint](https://insurancefraud.org/wp-content/uploads/From-Suspicion-to-Submission.pdf) [Download Fraud Referral Guide](https://insurancefraud.org/wp-content/uploads/Coalition-Fraud-Referral-Guide.pdf) [**Evadata – Five Fraud Trends Emerging With Life, Disability & Annuity Products**](https://vimeo.com/1205811603?fl=pl&fe=sh) [![](https://insurancefraud.org/wp-content/uploads/Evadata-Five-Fraud-Trends-Emerging-1024x576.png)](https://vimeo.com/1205811603?fl=pl&fe=sh) [Download PowerPoint](https://insurancefraud.org/wp-content/uploads/COPY-Evadata-Top-5-Fraud-Schemes-for-CAIF-6_2026.pdf) [**How Third-Party Funding May Be Fueling Insurance Fraud**](https://vimeo.com/1194846070?fl=pl&fe=sh) [![](https://insurancefraud.org/wp-content/uploads/4WARN-How-Third-Party-Funding-May-Be-Fueling-Insurance-Fraud-Webinar--1024x577.png)](https://vimeo.com/1194846070?fl=pl&fe=sh) [**The Human Trafficking – Insurance Fraud Connection**](https://vimeo.com/1168217544?fl=pl&fe=sh) [Download PowerPoint](https://insurancefraud.org/wp-content/uploads/Coalition-Webinar-PPT-Exploited-Lives-Exploited-Systems-2.11.2026.pdf) --- #### **2025 Webinars** **[Emerging Fraud Trends In P&C Insurance](https://vimeo.com/1148063455?fl=pl&fe=sh)** **[WC Premium Fraud ](https://vimeo.com/1128906376?fl=pl&fe=sh)** **[What Generations Of Investigators Can Teach Each Other Webinar](https://vimeo.com/1120149058?share=copy)** **[Generative AI And Insurance Fraud: Breaking Down the Data, Trends & Impact Webinar](https://vimeo.com/1112331290)** [Download PowerPoint](https://insurancefraud.org/wp-content/uploads/GenAI-Study-Final-Presentation-2025.pdf) **[Current Legal Issues Associated With Catastrophe Fraud Webinar](https://vimeo.com/1095051881?share=copy#t=0)** **[**[Workers’ Compensation Claimant Fraud Case Study Webinar](https://vimeo.com/1086895081)**](https://vimeo.com/1095051881?share=copy#t=0)** **[CDI Wildfires Webinar ](https://vimeo.com/1070329696)** **[State of Insurance Fraud Technology](https://vimeo.com/1059066821)** --- #### **2024 Webinars** **[ Trend Talk: Long Term Care Webinar](https://vimeo.com/1030772406)** **[Amicus Curiae Program](https://vimeo.com/1020736012)** [**Trend Talk: Water Mitigation**](https://vimeo.com/1008584480) **[Workers’ Compensation Provider Fraud Webinar](https://vimeo.com/928576472?share=copy)** **[Workers’ Compensation Premium Fraud Webinar](https://vimeo.com/917554685?share=copy)** [**Workers’ Compensation Claimant Fraud Webinar**](https://vimeo.com/910468904?share=copy) --- #### **2023 Webinars** **[California Department of Insurance Infonar](https://vimeo.com/884833888?share=copy)** [**Workers’ Compensation Fraud in America – Part 2**](https://vimeo.com/882553690?share=copy) **[Who Me? Who Commits Insurance Fraud and Why](https://vimeo.com/857908297?share=copy)** [**Litigation Funding: The Good, The Bad and The Ugly**](https://vimeo.com/847135899?share=copy) **[How Insurance Fraud Impacts Underserved Communities and How To Fight Back!](https://vimeo.com/871847514)** --- #### **2022 Webinars** **[The Ethical Use of Data to Fight Insurance Fraud Webinar](https://vimeo.com/766673611)** [**Workers’ Compensation Webinar**](https://vimeo.com/747787516) [**State of Insurance Fraud Technology Webinar**](https://vimeo.com/678384191) [**Impact of Insurance Fraud Webinar**](https://vimeo.com/742814346) --- --- ### [Fraud Scams](https://insurancefraud.org/scam-alerts/) **Published:** July 23, 2020 **Author:** Coalition Against Insurance Fraud **Content:** ## Agents & Insurers ## STOLEN PREMIUMS … FAKE COVERAGE … ![](https://insurancefraud.org/wp-content/uploads/Scam-alert-agent-and-insurer.jpg) Most insurance agents and insurers are ethical and trustworthy. But imagine you make a claim home only to find you have no coverage. What happened? **The scams** **• Stolen premiums.** An agent pockets your insurance premiums instead of buying promised coverage. **• Phony insurance.** An agent sells fake coverage from a phony insurer. You receive a forged policy or proof of insurance. Thousands of dollars are lost if you make a claim using a bogus policy. **• Coverage you don’t need.** The policy is expensive and unneeded, or your current policy already covers you. Buy the policy which is right for you needs. **• Churning.** Dishonest agents urge you to use the built-up value of your whole life policy to buy a “better” policy — even though your current coverage is fine. **• Sliding.** An agent or insurer secretly slips in extra coverage. Your premiums increase. Motor club memberships, accidental death coverage and guaranteed renewable life insurance are some examples. **• Twisting.** Urging you to switch policies by “twisting” the facts about your risk.. If you have an illness, injury or other medical condition, will your new health policy cover you despite a pre-existing medical condition? **Avoid the scams** - Verify the agent and insurer are licensed in your state — contact your [state insurance department](https://content.naic.org/state_web_map.htm). Check for any history of complaints. - Beware if the agent offers coverage priced suspiciously low. Shop around. - Pay premiums by check, credit card or money order — not cash. May payments to the insurance company. Get a receipt. - Pay for coverage only when all documents are filled out, and you know the coverage and cost. - Go slow if the agent or insurer seems evasive or tries to sell you coverage without “bothering” you with details. - Contact the insurer if you haven’t received a policy within 60 days after submitting your application. - Get a second opinion if an agent or insurer tries to sell you new or more expensive coverage. - Know what your policy covers and doesn’t . Get a detailed explanation in plain language. - Report scams. Notify your insurer, state insurance fraud bureau and police if you suspect a scam. ## Auto Scams ## DEFLATING AIRBAG SCHEMES ![](https://insurancefraud.org/wp-content/uploads/Scam-alert-airbag.jpg) You’re driving along. Another car careens across the lane and collides. Your airbags should protect you and your family. The airbags don’t deploy. They’re bogus. **The scams** **The pullout.** Body shops insert a cheap knockoff airbag in place of your deployed one. Your insurer is billed for the real thing. **The switch.** Body shop steal your un-deployed airbag to resell then insert a fake or even rags and trash to fill the void. **Used & salvaged vehicles.** Scammers install bogus or no airbags in used or salvaged vehicles after being totaled in a flood or crash. **You pay** **Lives & safety.** Lives are at stake without working airbags. Innocent drivers die in crashes with knockoff airbags. **Higher premiums.** Airbag swindles raise auto premiums for all drivers. **Fight back** **Dashboard light works?** When you start your vehicle, a dash light should flash if your airbag works. No light means a problem. **Invoice accurate.** Check invoices to verify the body shop bought the airbag from a legitimate manufacturer or dealer. **Used and salvaged vehicles.** Have a [certified mechanic](https://www.ase.com/Home.aspx) make sure the vehicle has working airbags — before you buy. **Avoid tampering.** Don’t open the airbag compartment yourself — it might explode. **Report scams.** Contact your auto insurer, law enforcement and state fraud bureau. ## AUTO REPAIRS ![](https://insurancefraud.org/wp-content/uploads/Scam-alert-auto-repair.jpg) Body shops keep your vehicle running well, fix damage, and your car safe for the road. Most are honest, but watch for scammers. **Padding.** Inflating repair bills beyond the original estimate or repairs for fake or unrelated damage. **Counterfeit parts.** Installing counterfeit, used or substandard parts, while charging for new parts. These parts may fail while you’re on the road. **Shoddy or no work.** Cutting corners or failing to do agreed to repairs.. **The price for fraud** **Safety.** You and others are in danger when you drive a poorly repaired vehicle. **Stress.** Avoid headaches and wasted time. Get it done right the first time. **Higher i premiums.** Inflated and unneeded repairs raise your auto premiums. **Stop fraud** **Find a trusted shop.** Ask for your insurer or others your trust to find a trusted body shop i. Are the technicians ASE-certified? **Written damage reports.** These provide more details of your repairs than basic written estimates. **Deductible waivers.** Refuse offers to recover or “waive” your insurance deductible. This is insurance fraud. **Bill higher than estimate?** Ask the shop to explain extra charges. All invoices should itemize work, parts, repairs and guarantees. **See a scam?** Notify the insurer covering the repairs, your state insurance fraud bureau and police if you suspect a scam. ## STAGED CRASHES: GIVE ME A “BRAKE” ![](https://insurancefraud.org/wp-content/uploads/Scam-alert-staged-accident.jpg) You’re driving minding your own business. A car darts in front and brakes. You rear-end the car. It’s a staged crash forever changing your life. **The scams** **Swoop & squat.** A vehicle swoops in front and jams on its brakes. You hit the rear. Passengers claim painful injuries. Your auto policy is falsely billed thousands. **Drive-down.** You’re merging or turning. A dishonest driver waves you forward, then deliberately crashes into your vehicle blaming you. Drivers also wave you out of a parking space, then dart into your path. **Go & Stop.** You’re stuck in traffic. The driver in front begins to move. You think traffic is finally going so you follow. Suddenly the car in front slams on the brakes. Shady helpers. A stranger approaches the crash scene, or phones you right after. They try to steer you to a medical clinic, body shop or lawyer. You’re being set up for bogus insurance claims. **You pay** **Premiums rise.** Setups raise your auto premiums, or cancel your policy. Crash schemes raise everyone’s premiums. **Victims.** Innocent drivers are terrorized, injured and even killed. **Life disrupted.** You spend months dealing with repairs, insurance claims, lawyers — all due to fraud. **Fight Fraud** - Never tailgate. Allow plenty of space between the vehicle in front. You have more time to stop safely. - Photograph the scene, vehicle damage and passengers. - Count passengers in the other vehicle. Get names, phone numbers and driver license. - How do they behave? Are they fine, even joking, but suddenly act injured when police arrive? - Get a police report — even for minor damage. - Only see medical and legal providers you know and trust. Ignore strangers who steer you. - Notify your insurer, police and state insurance fraud bureau if you suspect a setup scam. ## TOWING: DON’T GET HOOKED ![](https://insurancefraud.org/wp-content/uploads/Scam-alert-towing.jpg) A bandit tow truck arrives minutes after a crash? Know how to steer clear of towing cons. **The scams** **Patrol towing.** A tow-driver has a spotter who sees a car parked illegally. The driver takes your car to an impound lot. **Inflation.** Charging fees far above your auto policy limits. You’re forced to pay out of pocket. Watch for inflated and suspicious fees — inspections, photos,,, administrative. . **Steering.** You’re in a crash, and a tow mysteriously arrives. The driver be in cahoots with a dishonest body shop. **You pay for fraud** - Out of pocket for hundreds of dollars. - Retrieving your vehicle may take days of anxiety and effort. - Bogus repairs make your vehicle unsafe … and future bills you pay from your own pocket. **Fight Fraud** **Plan.** Know your auto insurer’s roadside program or join a reputable plan. They know reputable towing firms and repair shops. **Lurkers.** Never use a towing firm that just happens to show up. Ask police or your insurer for a reputable tow. **You Pick.** Never let the tow truck driver choose the shop. Call your insurer or others you trust. **Read.** Sign only the approval form authorizing your tow. The rest can wait. **Price.** Make sure the towing firm gives you a price list up front detailing all fees. **Document.** Insist the tow driver gives you a signed damage report at the accident scene.. **Credit.** Refuse to deal with a towing firm demanding cash. **Info.** Never give the tow driver your insurance or other personal information. **Report.** Notify your auto insurer, state insurance fraud bureau and police if you suspect a scam. ## Contractor Scams ## SHODDY REPAIRS … UNLICENSED … DISHONEST ![](https://insurancefraud.org/wp-content/uploads/Scam-alert-contractor.jpg) Hurricanes, tornados, floods, hail and fires cause damage every year.. You want to get things back quickly. Most contractors are honest, yet some want to line their pockets at your expense. **The scams** - Strangers appear after a storm, offering “affordable” repairs. They’re called storm chasers. - Lowball bids like “special post-disaster deals” or “limited time offers.” - Shoddy repairs, using substandard material. - Inflating the claim. You may lose all coverage. - Asking for large up-front payments — then disappearing while doing little or no work. - Convincing you to sign over your claim. The contractor may make inflated repair claims behind your back. **Fraud hurts** - Shoddy or incomplete repairs often take months of stress to correct - Your claim may be denied for fraud — leaving you to pay. **Stop fraud** **Hire local.** Use reputable contractors. Avoid strangers who go door-to-door, especially after a storm. They may be unlicensed and dishonest. **Get several bids.** Multiple bids help protect you. . **Licensed?** Ask to see a contractor’s licenses. Then confirm with the government licensing agency. **Insured?** Require proof of liability and workers-compensation insurance. **Signed contract.** Get a signed contract — before work begins. Don’t sign contracts with blanks. **Avoid advance payment.** Never pay a contractor in full before work begins. Normally 20 percent or less upfront is reasonable **Repairs insured?** Make sure your insurer will cover repairs — before work starts. Have your insurance adjuster estimate both damage and repair costs. **Coordinate with insurer.** Ask your insurer inspect the damage and agree to the repairs before work starts. **Report scams.** Contact your insurer, state insurance fraud bureau and police if you suspect a repair scam. ## Life Insurance Scams ## BEREAVEMENT … ![](https://insurancefraud.org/wp-content/uploads/Scam-alert-bereavement.jpg) **Preying on grief: the “gravest” fraud…** Scammers monitor obituaries for grieving victims who may let their guard down. They pitch surviving spouses with tempting deals. Grieving spouses are targets. **Life Scams** A scammer claiming to be a life-insurance agent says your deceased spouse bought a $1 million or more life policy but wanted to keep the policy secret. The catch…the final premium is owed before the payment will be released. Pay now so you can receive the $1 million. Just wire the money to a bank account, send gift cards or pay with your credit card. The policy is bogus. **Health Hoaxes** Your health policy is expiring, a caller says. Just pay with your credit card, money order or cash to keep your policy active. **Contractor Cons** Shady contractors demand pay for repairs the spouse supposedly signed for. Others try to offer special “deals” to do repairs or provide services after a loss. Promises insurance companies will reimburse for repairs are often false. **You pay** You’re robbed of hundreds or thousands of dollars. Your identity may be stolen. Plus unneeded emotional and financial stress. **Fight back** **Verify:** Contact the insurer, your attorney or financial advisor to verify the agent and policy are real. **Beware:** Pressuring for fast financial decisions under duress may signal a dishonest motive. Avoid repair deals, especially if you’re pressured. Contact your lawyer for advice. **Report:** If you feel you are being scammed notify law enforcement, your state department of insurance and your insurance carrier. ## Long Term Care Scams ## Common LTC Fraud Schemes Targeting Vulnerable Seniors ![](https://insurancefraud.org/wp-content/uploads/Old-Lady-LTC.jpg) Older adults who struggle to track benefits, manage complex paperwork, or advocate for themselves can become easy targets for exploitation. Unscrupulous caregivers, medical providers, and facilities may take advantage of these vulnerabilities, and engage in schemes such as: - **Billing for services or hours that never occurred** — counting on the patient not remembering or being able to verify what was provided. - **Charging for a higher level of care than actually delivered** — inflating claims to collect more money, without improving the patient’s care. - **Altering medical records, care logs, or timesheets** — hiding poor-quality care or justifying inflated charges. - **Pushing unnecessary treatments or equipment** — convincing patients or families to approve services that serve the provider’s profit, not the patient’s health. - **Insisting on handling all billing and communications** — keeping families “out of the loop” so fraudulent charges slip through. - **Pressuring patients to grant Power of Attorney (POA)** — convincing vulnerable seniors it’s in their best interest, often without informing or involving family members, to gain control over financial or medical decisions. [**To learn more about LTC Fraud click here to view the brochure.**](https://insurancefraud.org/wp-content/uploads/LTC-Fraud-Brochure.pdf) [![](https://insurancefraud.org/wp-content/uploads/LTC-Brochure-128x300.png)](https://insurancefraud.org/wp-content/uploads/LTC-Fraud-Brochure.pdf) ## Medical Scams ## DENTAL SCAMS ![](https://insurancefraud.org/wp-content/uploads/Scam-alert-dental-scams.jpg) Most dentists are ethical professionals. A small but disturbing number are dishonest. They exploit their position of authority to bilk trusting patients with useless and often painful treatment, and shady billing practices. **The scams** **Unneeded treatment.** Perform useless surgery on healthy patients to hike their insurance billings. The dentists remove healthy teeth, do root canals that aren’t needed, and drill for cavities that don’t exist. **Inflated billings.** Dentists do minor procedures such as routine tooth cleanings, but bill your insurance plan for costlier treatments. **Phantom treatment.** Dentists bill insurers for treatments they never perform. They send the insurer forged bills. **Unqualified employees.** Some dentists have unqualified staff perform treatments — yet bill as if the dentist performed the treatment. **The price you pay** **Painful, dangerous and disfiguring surgery.** Needless surgeries such as worthless root canals can be painful. Surgeries can become swollen and infected. **Your policy limits can max out.** False billing can exhaust your dental policy limits. You may have to pay expensive bills from your own pocket, or delay needed treatment. **Your dental premiums may rise.** Fraudulent claims can force your insurance premiums higher. **Fight back** **Verify you need the treatment.** A dentist may urge treatment that seems unneeded — such as eight cavity drillings. Get a second opinion to confirm you need the work. **Check out dentists.** Call your state insurance department and state dental board. Was the dentist disciplined for wrongdoing? Currently licensed? **Review your explanation of benefits.** Make sure your insurance plan is billed only for treatments and supplies you received. **Suspect a swindle?** Contact your insurer and [state insurance department](https://www.insurancefraud.org/fraud-bureaus-directory.htm). Contact [Medicare](https://www.medicare.gov/forms-help-resources/help-fight-medicare-fraud/how-report-medicare-fraud) or [Medicaid](https://www.cms.hhs.gov/states/fraud/default.asp) if you have these benefits. **Stay with your kids.** Some dentists perform unneeded surgery on kids — especially those covered by Medicaid. Ask to stay in the treatment room to ensure no excessive procedures are done. ## FAKE HEALTH PLANS: SICKENING ![](https://insurancefraud.org/wp-content/uploads/scam-alerts-couple.jpg) Fake and deceptive health plans promise full coverage, but deliver worthless or no benefits. Leaving large medical bills paid from your pocket. **The scams** **Phony benefits.** The plan promises full-benefits at low prices. Including pre-existing conditions, specialists and other essential benefits. Watch for cold callers, fake websites, email pitches and TV ads. **ACA-required.** Falsely claiming coverage is mandated by the Affordable Care Act, Medicare, Obamacare or even “Trumpcare.” **Pays little.** You receive a limited-benefit or discount plan paying few or no expenses. **Fake website.** Websites urge you to buy coverage online. They want your credit card. The website appears to be from a legitimate insurer, or an official Affordable Care Act signup portal. **Bogus association.** You have to join an “association” or “union” to buy coverage. Typically these groups are fake. **You pay** **Big Bills.** You’re forced to pay most or all medical bills yourself —sometimes tens of thousands of dollars. **Danger Delay.** Finding new health coverage after discovering your plan is fake may delay urgent medical treatment. **Fight Fraud** **Licensed?** Contact your [state insurance department](http://www.naic.org/state_web_map.htm%20Apply) to make sure the plan and agent are licensed. **Go slow.** Avoid signing up if you’re pressured to buy quickly— or the price seems too low. **Read.** Review the policy before buying. Have a qualified expert review. Does the policy deliver what the sales pitch promises? **Verify any “association” or “union.”** Does it have a website? Is the site vague about its activities and mostly hypes health coverage? **Notify your insurance department.** Contact your state fraud bureau if you think you’re dealing with a fake health plan. ## SURPRISE MEDICAL BILLINGS ![](https://insurancefraud.org/wp-content/uploads/Scam-alert-surprise-billing.jpg) Your health plan covered your surgery, or maybe childbirth. At least you thought. Then large bills pour in afterward. They’re uninsured, forcing you to pay from your pocket. Maybe for an extra surgeon or anesthesiologist. Surprise medical bills are increasingly common. Your medical facility used personnel who are out of your health plan’s network. Nor were you told in advance, or given a chance to shop around. **The scams** Surprise billings can be legal though unwelcome, unfair and financially draining. Out-of-network charges can be fraudulent. Maybe for a physician when a nurse should’ve been used. Or needless extra tests or medical equipment were ordered. Dishonest doctors illegally bribe colleagues to be included and billed in your surgery or other medical procedure. These are illegal kickbacks. **The price you pay** - You’re charged thousands of dollars in surprise medical bills. - Your credit can be damaged if you can’t pay the bills on time. - Resolving the problems can cost many hours of aggravation — when you’re healing from surgery or another procedure. **Fight back: before treatment** - If possible, ask your health insurer, doctor and hospital what bills you’ll have to pay. Also ask for the projected cost. Get a signed and written agreement. - Shop for the best deal that’s covered by your health policy. **Fight back: after treatment** - Appeal surprise bills to your insurer. Request that the insurer pay. - Contact the medical facility and your health insurer to review bills. Billed for treatments you didn’t receive? Unrequested out-of-network charges? - Some states protect you from certain surprise bills. This is especially true of medical emergencies. Check with your state insurance department. - Consider contacting a state-level [consumer advocate](http://www.familiesusa.org/health-action-network) for help. - Contact your state fraud bureau if you suspect fraud. ## DEFEND YOUR MEDICAL IDENTITY ![](https://insurancefraud.org/wp-content/uploads/Scam-alert-medical-ID-theft.jpg) Thieves steal your medical identity. They line their pockets with false health care claims. Malware, hacks, phishing, and robocall spoofs increase your danger. The scams Illegal and bogus treatment. Thieves bill your health plan for fake or inflated treatment. Organized rings sell your information on the Dark Web. Addictive drugs. Medical providers steal painkillers or other drugs using your name — they feed their addictions or sell for profit. Stealing treatment. Uninsured persons receive free medical treatment courtesy of your health policy. Often trusted friends or relatives stole your information. You pay Credit ruined. Unpaid medical bills wreck your credit. Regaining it takes months or years. While being turned down for needed loans or mortgages. Health coverage lost. Bogus claims max out your health policy. You’ll have less or no coverage when needed. . Health risks. False treatments go on your records. The wrong blood type, or medicine to which you’re allergic. Fight Fraud Digital defense Be careful Beware. Providers never text or email sensitive medical info. Use the provider’s secure portal or call Phishing. Bogus emails and calls claim to be a health insurer or government agency. Don’t share your health policy, credit card or SSN Never open unknown links. Avoid public wi-fi. Don’t log into your health accounts on public wi-fi. Thieves troll open wi-fi sites. Keep Healthy Verify. Review all explanation of health benefits statements to confirm treatments are valid. Defend your credit. Check your credit reports regularly for fraud. Medical records. If you suspect ID theft, notify your medical provider to correct medical record errors. Report. Report any identity scam to your health insurer, state department of insurance and police. You’re on record your information was stolen. ## Workers Comp Scams ## BOGUS INJURIES … FALSE MEDICAL CLAIMS … ![](https://insurancefraud.org/wp-content/uploads/Scam-alert-workers-compensation.jpg) Workers compensation protects job-injured employees. Medical bills, lost wages and other expenses are paid while a worker heals. Yet some game the system with bogus injuries. **Why fake an injury?** **Free money.** “Injured” workers secretly take a job or open a business. They claim lost wages from their workers comp policy — while illegally earning extra money. **Play.** Workers illegally collect insurance while doing personal activities. Like skydiving, playing soccer, weight lifting or fixing up their home. **The Scams** **Off the job.** Workers get injured off the job, but say they’re hurt at work so their workers comp policy covers the bills. **Inflate.** A minor job injury occurs but the claim is for far more. **Fake.** Invented injuries. Fake back and neck injuries. Think this is easy to get away with — wait until you are caught. **Malingering.** Pretend you’re still disabled — even though you’re healed and can return to work. **You pay** **Workers.** Caught! Lose your job, face jail plus fines and no future work. **Everyone.** Bogus injuries drive up premiums. Everyone pays. Higher costs may force layoffs and salary freezes. **Stop Fraud** **Workers:** **Your rights.** Seek treatment and benefits you deserve. Know your injured worker rights in your state. **Report.** Notify your supervisor immediately if you suspect fraud. **Beware.** Doctors may urge excessive tests or treatments. Avoid lawyers aggressively recruiting you to sign-up. **Employers:** **Safety First.** Create a safe workplace. Listen to complaints. Correct safety risks. Show you care. **Zero tolerance.** Inform employees this is a no-fraud zone. **Check.** Background checks for prior suspicious injury claims stop more fraud. **Proof.** Require reporting of job accidents immediately and document fully. **Report.** Encourage reporting of suspected fraud confidentially. Create a fraud reporting system. **Notify:** Suspect a scam? Contact your insurer, state insurance fraud bureau and police. ## Other Scams ## ATTORNEY SETTLEMENT SCHEMES … ![](https://insurancefraud.org/wp-content/uploads/Scam-alert-attorney-scams.jpg) An attorney may help you receive the insurance funds you deserve. Most attorneys are honest, yet watch for those who may steal your insurance payout. **The scams** Forwarding you a settlement check for less than you were awarded. Secretly depositing the rest in their account. Forging your signature on settlement checks. Not truthfully presenting your claim. **You pay** You may lose needed insurance funds when needed or all coverage if there is fraud. Home or auto repairs — even medical bills — go unpaid after a storm, fire or accident. You may have to pay large bills from your own pocket without full insurance funds. **Fight Fraud** Avoid attorneys who aggressively approach you immediately after an auto crash or calamity. Ask others you trust about attorneys they know. Check the attorney’s record with the local bar association. Insist on seeing and signing all insurance checks. Require a written settlement statement. Be suspicious of delays in responding. You deserve prompt responses and updates. Keep a phone log, all emails, paperwork and correspondence. Report suspected improper actions to your state fraud bureau and local bar association. If you attorney stole from you, contact your state’s Client Security Trust Fund to see if you’re eligible for compensation. ## SENIOR / ELDERLY SCAMS #### **![](https://insurancefraud.org/wp-content/uploads/Screenshot-2025-04-29-at-12.34.54 PM-300x186.png)** ### **Don’t Get Scammed. Stay Alert.** The Coalition is committed to protecting older adults by keeping them informed about scams that specifically target seniors. Through sharing education, alerts, and prevention tools, we aim to empower the elderly and their caregivers to recognize fraud and stay safe from financial exploitation. #### **“Emotional” Scams** Scammers pretend to be looking for love online. They’ll build a fake relationship over time, then start asking for money—usually for medical bills, travel expenses, or a supposed emergency. Many victims never meet the person in real life. **Protect yourself:** - Be skeptical of people who quickly declare love or ask for money. - Never send money or share financial info with someone you haven’t met. - Talk to family or friends before taking any action. #### **Fake Government Calls** You get a call from someone claiming to be from Medicare, Social Security, or the IRS. They may say you owe money, or that your benefits will stop unless you act now. Sometimes they even threaten arrest. **Protect yourself:** - Real agencies don’t call to threaten or demand immediate payment. - Hang up and call the agency directly using the number on their official website. - Never share your Social Security number or bank info with a caller. #### **Tech Trouble Tricks** Your screen goes blank, or a pop-up tells you to call for urgent computer help. It might look serious—but it’s a scam. If you call, a fake technician may ask for remote access to your computer and charge you for made-up problems. **Protect yourself:** - Don’t call numbers from pop-up alerts. - Only trust tech help from providers you know. - If unsure, ask someone you trust before doing anything. #### **Banking & Loan Scams** Scammers pretend to be from your bank or a financial company. They may say your account was hacked or offer better rates on a loan—then ask for your personal info or demand payment for a fake debt. **Protect yourself:** - Don’t click links or respond to emails/texts asking for account info. - Always contact your bank directly using verified contact info. - Watch for pressure tactics—they’re a red flag. #### **“Family” Scams** You get a call from someone claiming to be your grandchild or family member in trouble—they might say they’ve been arrested or had an accident. They’ll beg you not to tell anyone and ask for money urgently. Some even use AI to mimic your grandchild’s voice. **Protect yourself:** - Don’t guess who’s calling—ask questions only your grandchild would know. - Always double-check with another family member. - Never send money through gift cards, wire transfers, or with someone who shows up at your door. ### **Your Best Defense? Verify, verify and most importantly…verify!** Scammers count on fear and urgency. Pause before you act. Reach out to someone you trust. And remember—if something feels off, it probably is. If you or someone you know is or has been targeted please call… National Elder Fraud Hotline **1-833-FRAUD-11** (**833-372-8311**) 10 a.m. – 6 p.m. Eastern Time Monday – Friday Eldercare Locator helpline **1-800-677-1116** Their hotline is open Monday through Friday from 10:00 a.m. to 6:00 p.m. eastern time. **Sources:** National Council on Aging U.S. Department of Justice Department --- ### [Insurer Infiltration](https://insurancefraud.org/insurer-infiltration/) **Published:** August 19, 2025 **Author:** Coalition Against Insurance Fraud **Content:** Note: The Coalition provides a collection of resources to help members address workers’ compensation fraud. From case studies to investigative tools and best practices, these materials offer practical insights to support prevention and detection efforts. Members are free to use these tools, and if you would like any resource aside from the reports co-branded for your organization, please reach out to **[communications@insurancefrau](mailto:communications@insurancefraud.org)d.org**. All resources have been centralized here for easy access. Please scroll down to view all information provided on this page. **Workers’ Compensation Premium Report** The Coalition’s new case study, **“When Employers Cheat the System,”** exposes how a Los Angeles business stole wages, hid millions in payroll, and defrauded insurers of $1.7 million. With **$25 billion** lost to workers’ comp premium fraud each year, this report highlights key red flags and strategies to stop fraud early. [![](https://insurancefraud.org/wp-content/uploads/Coalition-Premium-Fraud-Report-8-2025-791x1024.jpg)](https://insurancefraud.org/wp-content/uploads/Coalition-Premium-Fraud-Report-8-2025.pdf)**[Download](https://insurancefraud.org/wp-content/uploads/Coalition-Premium-Fraud-Report-8-2025.pdf)** **WC Premium Fraud Job Aid – Investigative Steps** Workers’ comp premium fraud costs over **$25 billion each year**. Our step-by-step guide can be downloaded to help investigators spot red flags that may greatly enhance cases against deceptive employers. [![](https://insurancefraud.org/wp-content/uploads/Premium-Fraud-Investigative-Steps-791x1024.jpg)](https://insurancefraud.org/wp-content/uploads/Premium-Fraud-Investigative-Steps.pdf)**[Download](https://insurancefraud.org/wp-content/uploads/Premium-Fraud-Investigative-Steps.pdf "Download")** **Infographic** Workers’ Comp premium fraud **drains billions every year**, but knowing the warning signs can keep you one step ahead. Download this quick-reference infographic to spot common red flags. [![](https://insurancefraud.org/wp-content/uploads/V2-WC-7-Red-Flags-Infographic-2025-307x1024.jpg)](https://insurancefraud.org/wp-content/uploads/V2-WC-7-Red-Flags-Infographic-2025-scaled.jpg)[Download infographic](https://insurancefraud.org/wp-content/uploads/V2-WC-7-Red-Flags-Infographic-2025-scaled.jpg) or **[Visit Infographics webpage to download](https://insurancefraud.org/videos-infographics/)** ———————————————————————————– ALSO ————————————————————————— #### **Social Media Posts** ![](https://insurancefraud.org/wp-content/uploads/B.-Workerss-Comp-Report-2-25B-Social-Media-Post.png) ![](https://insurancefraud.org/wp-content/uploads/A.-Workerss-Comp-Report-2-25B-Social-Media-Post.png) ![](https://insurancefraud.org/wp-content/uploads/C.-Workerss-Comp-Report-2-25B-Social-Media-Post.png) --- ### [State Insurance Fraud Bureaus](https://insurancefraud.org/state-insurance-fraud-bureaus/) **Published:** September 2, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Related Content: - [Fraud: Why Care?](https://insurancefraud.org/fraud-why-care/) - [Fraud Stats](https://insurancefraud.org/fraud-stats/) - [Anti-Fraud Events](https://insurancefraud.org/events/) - [Tools & Resources](https://insurancefraud.org/tools-resources/) Fraud bureaus are state agencies that detect, investigate and prevent insurance scams. All bureaus invite citizens to phone in hot tips about suspected scams. Some bureaus also let you report scams from their websites. Most fraud bureaus deal with all kinds of insurance fraud, but some investigate only certain kinds, such as workers compensation or auto insurance. Scroll down to find the fraud bureau in your state. ### [**Alabama**](https://aldoi.gov/FraudUnitNew/About.aspx) Scott F. Pilgreen State Fire Marshal Insurance Fraud Unit - Investigators Alabama Fire Marshal's Office **Report fraud** [online](https://aldoi.gov/FraudUnitNew/ReportType.aspx) ### [**Alaska**](https://pfd.alaska.gov/Report-Fraud) Alex Romero Chief Investigator Alaska Division of Insurance 550 W. 7th Street, Suite 1560 Anchorage, AK 99501 **Report fraud:** 907-465-2654 ### [Arizona](https://difi.az.gov/fraud-00) Damas Salas Assistant Director, Fraud Investigations Division Arizona Department of Insurance and Financial Institutions 100 North 15th Avenue, Suite 261 Phoenix, AZ 85007 **Report fraud:** 602-364-2140 ### [Arkansas](https://www.insurance.arkansas.gov/consumer-services/criminal-investigation/) Russ Galbraith Chief Deputy Commissioner Arkansas Department of Insurance Criminal Investigation Division 1 Commerce Way, Bldg 4, Suite 502 Little Rock, AR 72202 **Report fraud:** 1-800-952-8248 ### [California](https://www.insurance.ca.gov/0300-fraud/reportingfraud.cfm) Eric Charlick Deputy Commissioner, Enforcement California Department of Insurance 2400 Del Paso Road, Suite 250 Sacramento, CA 95834 **Report fraud:** 916-854-5760 ### [Colorado](https://doi.colorado.gov/) Steven Giampaolo Director, Producer Licensing and Enforcement Colorado Division of Insurance 1560 Broadway, Suite 850 Denver, CO 80202 **Report fraud:** 303-894-7499 Sean Clifford First Assistant Attorney General Colorado Attorney General's Office 1300 Broadway, 9th Floor Denver, CO 80203 **Report fraud:** 720-508-6000 or [online](https://coag.gov/file-complaint/insurance-fraud/) ### [Connecticut](https://portal.ct.gov/cid/?language=en_US) Amy Stegall Manager, Fraud Investigations and Compliance Unit Connecticut Department of Insurance 280 Trumbull Street, 7th Floor Hartford, CT 06103 ### [Delaware](https://insurance.delaware.gov/reportfraud/) Gerald Pepper Director, Insurance Fraud Prevention Delaware Department of Insurance 1351 West North Street, Suite 101 Dover, DE 19904 **Report fraud:** 1-800-632-5154 ### [District of Columbia](https://disb.dc.gov/service/file-complaint-or-report-fraud) Brian Bressman Director, Enforcement & Investigation Bureau D.C. Department of Insurance, Securities and Banking 1050 First Street, NE Suite 801 Washington, D.C. 20002 **Report fraud:** 202-727-8000 ### [Florida](https://first.fldfs.com/) Col. Luis Negrete Director Florida Department of Financial Services - Fraud Division 200 E. Gaines Street, Larson Bldg. Tallahassee, FL 32399 **Report fraud:** 1-800-378-0445 ### [Georgia](https://oci.georgia.gov/report-suspected-fraud) Derek Lyman Director of Criminal Investigations Georgia Office of Insurance and Safety Fire Commissioner 2 Martin Luther King, Jr. Drive West Tower, Suite 704 Atlanta, GA 30334 **Report fraud:** 1-800-656-2298 ### [Hawaii](http://cca.hawaii.gov/ins/consumers/filing_a_complaint/mvif/) Colleen L. Chun Administrator, Insurance Fraud Investigation Unit Hawaii Department of Commerce and Consumer Affairs P.O. Box 3164 Honolulu, HI 96811 **Report fraud:** 1-808-587-7416 ### [Idaho](https://doi.idaho.gov/investigations/default) Dean L. Cameron Director of Insurance Idaho Department of Insurance 700 W. State Street, P.O. Box 83720 Boise, ID 83720 **Report fraud:** 1-866-939-7226 ### [Illinois](https://insurance.illinois.gov/Fraud/ContactFraudUnit.html) Justin Hammersmith Deputy Director, Enforcement and Investigations Illinois Department of Insurance Workers' Compensation Fraud Unit 122 South Michigan Avenue, 19th Floor Chicago, IL 60603 **Report fraud:** 877-923-8648 ### [Indiana](https://www.in.gov/idoi/2904.htm) Melissa Higgins Enforcement Director Indiana Department of Insurance 311 West Washington Street, Suite 103 Indianapolis, IN 46204 **Report fraud:** 1-800-835-6422 ### [Iowa](https://iid.iowa.gov/reporting-insurance-fraud) Jared Kirby Deputy Commissioner Iowa Insurance Fraud Bureau 1963 Bell Avenue, Suite 100 Des Moines, IA 50315 **Report fraud:** 515-281-5705 Matt Mortvedt Bureau Chief Iowa Insurance Division’s Fraud Bureau 1963 Bell Avenue, Suite 100 Des Moines, IA 50315 ### [Kansas](https://insurance.ks.gov/fight-fraud/how-to-report-fraud.php) John Eichkorn Director of Compliance, Enforcement and Antifraud Kansas Insurance Department 1300 SW Arrowhead Road Topeka, KS 66604 **Report fraud:** 1-800-432-2484 ### [Kentucky](https://insurance.ky.gov/ppc/newstatic_info.aspx?static_id=2) Juan D. Garrett Director, Insurance Fraud Investigation Division Kentucky Department of Insurance 500 Mero Street, 2 SE 11 Frankfort, KY 40601 **Report fraud:** 1-800-595-6053 ### [Louisiana](https://ldi.la.gov/consumers/insurance-fraud/report-insurance-fraud) Dominique Jones Deputy Commissioner, Fraud Louisiana Department of Insurance P.O. Box 94214 Baton Rouge, LA 70804 **Report fraud:** 1-800-259-5300 Jeffrey Zewe Director Louisiana Automobile Theft and Insurance Fraud Prevention Authority 7919 Independence Blvd. Baton Rouge, LA 70806 **Report fraud:** 225-925-3536 ### [Maine](https://www.maine.gov/pfr/insurance/home) Timothy N. Schmott Acting Superintendent Insurance Fraud Maine Bureau of Insurance 34 State House Station Augusta, ME 04333 **Report fraud:** 1-800-300-5000 ### [Maryland](https://insurance.maryland.gov/Consumer/Pages/InsuranceFraudConsumer.aspx) Robert Guynn Associate Commissioner for Insurance Fraud and Producer Enforcement Maryland Insurance Administration 200 St. Paul Place, Suite 2700 Baltimore, MD 21202 **Report fraud:** 1-800-846-4069 ### [Massachusetts](https://www.ifb.org/ContentPages/Public/Hotline.aspx) Anthony M. DiPaolo Executive Director Massachusetts Insurance Fraud Bureau 101 Arch Street Boston, MA 02110 **Report fraud:** 1-800-323-7283 ### [**Michigan**](https://www.michigan.gov/difs/0,5269,7-303--458352--,00.html) Jennifer Kinsey Manager, Fraud Investigation Unit Office of General Counsel Michigan Department of Insurance and Financial Services 530 W. Allegan, 7th Floor PO Box 30220 Lansing, MI 48933 **Report fraud:** 1-877-999-6442 Keisha L. Glenn Assistant Attorney General Auto Insurance Fraud Specialist Michigan Attorney General Office 3030 W. Grand Blvd., Suite 10-200 Detroit, MI 48202 ### [Minnesota](https://mn.gov/commerce/consumer/file-a-complaint/) Sara Payne Assistant Commissioner, Enforcement Division Minnesota Department of Commerce 85 7th Place East, Suite 280 St. Paul, MN 55101 **Report fraud:** 1-888-372-8366 ### [Mississippi](https://www.mid.ms.gov/consumers/fight-insurance-fraud.aspx#rif) John Bret Hornback Chief Investigator Mississippi Insurance Department P.O. Box 79 Jackson, MS 39205 **Report fraud:** 601-359-2474 Eric Wiginton Director, Criminal Investigations Mississippi Office of Attorney General Walter Sillers Building 550 High Street, Suite 1200 Jackson, MS 39201 **Report fraud:** 1-888-562-2957 ### [Missouri](https://insurance.mo.gov/industry/fraud.php) Marjorie Thompson Chief Investigator Missouri Department of Insurance P.O. Box 690 Jefferson City, MO 65102 **Report fraud:** 1-800-726-7390 Benjamin Qualls Acting Director, Division of Workers' Compensation Missouri Department of Labor and Industrial Relations P.O. Box 1009 Jefferson City, MO 65102 **Report fraud:** 1-800-775-2667 or [online](https://labor.mo.gov/report_fraud) ### [Montana](https://csimt.gov/insurance/) Ted Bidon Investigations Bureau Chief Montana Department of Insurance 840 Helena Avenue Helena, MT 59601 **Report fraud:** 1-800-332-6148 ### [Nebraska](https://doi.nebraska.gov/insurers/fraud) Kimberly Semler, SCLA, CIFI, AHFI Chief, Fraud Prevention Division Nebraska Department of Insurance Insurance Fraud Prevention Division 1135 M Street, Suite 300 PO Box 82089 Lincoln, NE 68501 **Report fraud:** 402-471-2201 ### [Nevada](https://doi.nv.gov/) Stephanie Canter Enforcement Chief Nevada Division of Insurance 3300 W. Sahara, Suite 275 Las Vegas, NV 89102 **Report fraud:** 1-888- 872-3234 Robert Giunta Director, Insurance Fraud Unit Nevada Attorney General's Office Grant Sawyer Buildling 555 E. Washington Avenue, Suite 3900 Las Vegas, NV 89101 **Report fraud:** Carson City Office: 775-684-1100 Las Vegas Office: 702-486-3420 Reno Office: 775-687-2100 ### [New Hampshire](https://www.nh.gov/insurance/) Heather Silverstein General Counsel, Insurance Fraud Division New Hampshire Department of Insurance 21 S. Fruit Street, Suite 14 Concord, NH 03301 **Report fraud:** 1-800-852-3416 ### [New Jersey](https://www.state.nj.us/dobi/index.html) George Wall Chief of Investigations New Jersey Department of Banking & Insurance P.O. Box 094 Trenton, NJ 08625 **Report fraud:** 1-800-466-7467 ### [New Mexico](https://www.osi.state.nm.us/) Alice Kane Superintendent of Insurance New Mexico Office of Superintendent of Insurance P.O. Box 1689 Santa Fe, NM 87504 **Report fraud:** 877-807-4010 Alexis Armijo Acting Director New Mexico Workers' Compensation Administration 2410 Centre Avenue SE Albuquerque, NM 87125 **Report fraud:** 1-866-967-5667 ### [New York](https://www.dfs.ny.gov/consumers/scams_schemes_frauds/insurance_fraud_avoid_becoming_a_victim) Eric Blachman Director of the Investigations & Intelligence Division NYS Department of Financial Services One State Street New York, NY 10004 **Report fraud:** 1-888-372-8369 ### [North Carolina](https://www.ncdoi.gov/fraud-control/report-insurance-fraud) Marty Sumner Senior Deputy Commissioner, Fraud Control Group North Carolina Department of Insurance Criminal Investigations Division 325 N. Salisbury Street Raleigh, NC 27603 **Report fraud:** 1-888-680-7684 ### [North Dakota](https://www.nd.gov/ndins/) Robyn Krile Director, Fraud Investigations Division North Dakota Department of Insurance 600 East Boulevard Avenue State Capital, Fifth Floor Bismarck, ND 58505 **Report fraud:** 1-800-247-0560 ### [Ohi](http://www.insurance.ohio.gov/)[o](https://insurance.ohio.gov/wps/portal/gov/odi/about-us/divisions/fraud-enforcement) David Barney Fraud and Enforcement-Enforcement Division Ohio Department of Insurance 50 West Town Street, Suite 300 Columbus, OH 43215 **Report fraud:** 1-800-686-1527 Jenn Cunningham Director of Special Investigations Ohio Bureau of Workers' Compensation 30 W. Spring Street Columbus, OH 43215 **Report fraud:** 833-658-0394 or [online](https://www.bwc.ohio.gov/bwccommon/forms/Fraud/default.aspx) ### [Oklahoma](https://www.oid.ok.gov/consumers/anti-fraud-unit/) Rick Wagnon Chief Investigator Oklahoma Insurance Department 400 NE 50th Street Oklahoma City, OK 73105 **Report fraud:** 1-800-522-0071 Jimmy Harmon Chief of the Criminal Division Fraud Prevention and Prosecution Division Oklahoma Office of Attorney General 313 NE 21st Street Oklahoma City, OK 73105 **Report fraud:** 405-521-3921 ### **[Oregon](https://www.oregon.gov/dcbs/consumer/Pages/consumer.aspx)** Dorothy Bean Chief of Enforcement Oregon Department of Consumer & Business Services 350 Winter Street NE Salem, OR 97301 **Report fraud:** 1-888-877-4894 ### **[Pennsylvania](https://www.insurance.pa.gov/Consumers/Pages/Report-Insurance-Fraud.aspx)** Michael Fissel Deputy Insurance Commissioner Pennsylvania Insurance Department 1326 Strawberry Square Harrisburg, Pennsylvania 17055 717-787-0272 **Report fraud:** 1-888-565-4372 Christopher Sloan Executive Director Insurance Fraud Prevention Authority 6 Kacey Court, Suite 101 Mechanicsburg, PA 17055 **Report fraud:** 1-888-565-4372 or [online](https://helpstopfraud.org/Reporting-Insurance-Fraud/What-You-Can-Do) Robert G. LaBar, Esq. Chief Deputy Attorney General Pennsylvania Office of the Attorney General Insurance Fraud Section 16th Floor, Strawberry Square Harrisburg PA 17120 **Report fraud:** 717-787-0272 or [online](https://www.attorneygeneral.gov/protect-yourself/insurance-fraud/) ### [Rhode Island](https://dlt.ri.gov/wc/reportfraud/) Elizabeth Kelleher Dwyer Director, Department of Business Regulation Rhode Island Department of Business Regulation; Division of Insurance 1511 Pontiac Avenue Cranston, RI 02920 **Report fraud:** 401-462-8100 ### [South Carolina](https://www.doi.sc.gov/FormCenter/Fraud-Division-16/SCDOI-Insurance-Fraud-Complain-Form-69) Michael Wise Director South Carolina Department of Insurance 1201 Main Street, Suite 1000 Columbia, SC 29201 **Report fraud:** 1-888-95-FRAUD LaRone Washington Assistant Attorney General South Carolina Office of Attorney General P.O. Box 11549 Columbia, SC 29201 **Report fraud:** 1-888-662-4328 ### [South Dakota](https://atg.sd.gov/Contact.aspx) Larry Deiter Director South Dakota Department of Labor and Regulation Division of Insurance Division of Criminal Investigations 124 S. Euclid Avenue 2nd Floor Pierre, SD 57501 **Report fraud:** 605-773-3563 South Dakota Attorney General’s Office Division of Criminal Investigations 1302 E. Hwy 14, Suite 5 Pierre, SD 57501-8501 **Report fraud:** 605-773-3331 ### [Tennessee](https://www.tn.gov/commerce/insurance/consumer-resources/fraud-investigation.html) Michele Stone Director, Fraud Investigations Tennessee Department of Commerce and Insurance Insurance Division Davy Crockett Tower, Twelfth Floor 500 James Robertson Parkway Nashville, TN 37243 **Report fraud:** 615-741-2241 ### [Texas](https://www.tdi.texas.gov/fraud/index.html) Leah Gillum Deputy Commissioner, Fraud and Enforcement Texas Department of Insurance P.O. Box 149104 Austin, TX 78714 **Report fraud:** 1-800-252-3439 Chris Davis Associate Commissioner, Fraud Unit Texas Department of Insurance P.O. Box 149104 Austin, TX 78714 **Report fraud:** 1-800-252-3439 ### [Utah](https://insurance.utah.gov/consumer/fraud/report-fraud) Armand Glick Director, Fraud Division Utah Insurance Department 1385 S. State Street, Suite 110 Salt Lake City, UT 84115 **Report fraud:** 1-844-373-0233 ### [Vermont](https://dfr.vermont.gov/avoid-scams-and-frauds#:~:text=If%20you%20think%20you%20have,or%20file%20your%20complaint%20online.) Vermont Department of Financial Regulation 89 Main Street Montpelier, VT 05620 **Report fraud:** 800-964-1784 ### [Vi](http://www.stampoutfraud.com/)[rginia](https://stampoutfraud.com/submit-a-tip/) Juan Rodriguez Chief, Agent Regulation Virginia Bureau of Insurance P.O. Box 1157 Richmond, VA 23218 Peter Lazear First Sergeant Virginia State Police Insurance Fraud Program P.O. Box 27472 Richmond, VA 23261 **Report fraud:** 1-877-623-7283 ### [Washington](https://www.insurance.wa.gov/report-insurance-fraud-washington-state) Dory Nicpon Chief Legal Officer for Criminal Investigations Washington State Office of Insurance Commissioner Criminal Investigations Unit P.O. Box 40255 Olympia, WA 98504 **Report fraud:** 1-800-562-6900 Elizabeth Smith L&I Deputy Director Fraud Prevention & Compliance Program Manager Washington State Department of Labor and Industries P.O. Box 44850 Olympia, WA 98504-4277 **Report fraud:** 1-888-811-5974 or [online](http://suspectfraud.wa.gov/report.html) ### [West Virginia](https://www.wvinsurance.gov/Divisions/Special-Investigations-Division) Kirby Stickler Insurance Inspector General West Virginia Office of the Insurance Commissioner Special Investigations Division P.O. Box 2901 Charleston, WV 25330 **Report fraud:** 304-558-5241 or Toll-Free 800-779-6853 ### [Wisconsin](https://oci.wi.gov/pages/homepage.aspx) Kelly Altschul Fraud Attorney Wisconsin Office of the Commissioner of Insurance 101 East Wilson Street Madison, WI 53703 **Report fraud:** <OCIFraud@wisconsin.gov> ### [Wyoming](http://doi.wyo.gov/) Jeff Rude Insurance Commissioner Wyoming Department of Insurance 106 East 6th Avenue Cheyenne, WY 82002 **Report fraud:** 307-777-7401 --- ### [Report Fraud](https://insurancefraud.org/report-fraud/) **Published:** July 23, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Related Content: - [Fraud: Why Care?](https://insurancefraud.org/fraud-why-care/) - [Fraud Stats](https://insurancefraud.org/fraud-stats/) - [Anti-Fraud Events](https://insurancefraud.org/events/) #### The Coalition Against Insurance Fraud does not accept reports of insurance fraud or scams directly. You can use this list of trusted organizations to report suspicious activity. These resources help you take action, which protects everyone. To report insurance fraud directly to a state fraud bureau, please click here to use the National Association of Insurance Commissioners [Online Fraud Reporting System](https://ofrs.naic.org). **STATE FRAUD BUREAU** Contact your [state fraud bureau](https://insurancefraud.org/state-insurance-fraud-bureaus/). Most states have fraud bureaus. **NATIONAL INSURANCE CRIME BUREAU** NICB investigates crimes against coverage such as auto, home, liability and workers compensation. TEL-NICB [1-800-835-6422](tel:18008356422) or [report scams online](https://www.nicb.org/how-we-help/report-fraud). **REPORT MEDICAL PROVIDERS** Contact state medical boards to report [scams by doctors](http://www.fsmb.org/state-medical-boards/contacts), [chiropractors](http://www.fclb.org/ChiropracticBoards/tabid/439/Default.aspx) and [dentists](https://www.ada.org/en/education-careers/licensure/licensure-dental-students/state-dental-boards). **MEDICARE** [1-800-MEDICARE](tel:180063342273) or [go online](https://www.medicare.gov/forms-help-resources/help-fight-medicare-fraud/how-report-medicare-fraud) to report scams. **MEDICAID** [1-800-HHS-TIPS](tel:18004478477) or [go online](https://www.cms.gov/medicare-medicaid-coordination/fraud-prevention/fraudabuseforconsumers/report_fraud_and_suspected_fraud.html). **NATIONAL FLOOD INSURANCE PROGRAM** [1-800-323-8603](tel:18004249121) or [go online](https://www.oig.dhs.gov/). **FEDERAL CROP INSURANCE PROGRAM** [1-800-424-9121](tel:18004249121) or [go online](https://www.usda.gov/oig/hotline). **TRICARE** [1-866-773-0404](tel:18667730404) or [go online](http://www.health.mil/Military-Health-Topics/Access-Cost-Quality-and-Safety/Quality-And-Safety-of-Healthcare/Program-Integrity/Reporting-Fraud-or-Abuse). **AFFORDABLE CARE ACT** [1-800-318-2596](tel:18003182596) or [go online](https://www.healthcare.gov/how-can-i-protect-myself-from-fraud-in-the-health-insurance-marketplace/). ##### **BE PREPARED** Include as much information as possible: - Full details of the suspected scam. - Dates, names, phone numbers, emails and URLs of suspected individuals and organizations. - Insurance companies that were defrauded - or did the defrauding. - Amount of money you believe was lost. - Records and other evidence. - Other information you think is helpful. --- ### [Fraud Stats](https://insurancefraud.org/fraud-stats/) **Published:** July 23, 2020 **Author:** Coalition Against Insurance Fraud **Content:** On this Page: - [Impact](https://insurancefraud.org/fraud-stats/#impact) - [By Category](https://insurancefraud.org/fraud-stats/#category) - [Stats](https://insurancefraud.org/fraud-stats/#stats) Related Content: - [Fraud: Why Care?](https://insurancefraud.org/fraud-why-care/) - [Report Fraud](https://insurancefraud.org/report-fraud/) - [Anti-Fraud Events](https://insurancefraud.org/events/) ### Impact - Insurance fraud steals at least $308.6B every year from American consumers. - Fraud occurs in about 10% of property-casualty insurance losses. ## By Category Consumer Attitudes78% say they are concerned about insurance fraud. State Laws48 states make insurance fraud a specific crime. ArsonIn 2020, 8,898 cars were intentionally set on fire in the U.S. Workers Compensation1.3 million-2.1 million workers were misclassified or doing cash-only work each month in 2020. Healthcare Fraud$3.1B in false and fraudulent claims in 2020. Technology21% of insurance companies plan to invest in AI in the next two years. ## Consumer Attitudes Most consumers are concerned about insurance fraud. Americans also show increasing tolerance for specific forms of unethical insurance behavior. Six of 10 Americans believe crime is higher than the year before, say 18 of 22 Gallup surveys between 1993 and 2018. Despite the generally downward trend in national violent and property crime rates during most of the same period. ([*Gallup surveys, 2019,*](https://news.gallup.com/poll/1603/crime.aspx)) - Consumers in their 20s and 30s are 25% more likely to report losing money to fraud than people 40 and over. - Millennials are 77% more likely than other age groups to say they lost money to a scam that started with an email. - Millennials are less likely to report losing money to scams starting with a phone call. ([*Federal Trade Commission, October 2019*](https://www.ftc.gov/news-events/blogs/data-spotlight/2019/10/not-what-you-think-millennials-fraud)) Older Americans exploited by fraud in recent years suffered an average loss of $34,200. Outside analysts looking at elder fraud have separately estimated losses of $2.9 billion-$36.5 billion a year. ([*Consumer Finance Protection Bureau, February 2019*](https://files.consumerfinance.gov/f/documents/cfpb_suspicious-activity-reports-elder-financial-exploitation_report.pdf)) ## State and Federal efforts to investigate and prosecute insurance fraud - 48 states make insurance fraud a specific crime. 30 states make insurer fraud a specific insurance crime. Oregon is the only state without an insurance fraud law of any kind. - 42 states and the District of Columbia have an insurance fraud bureau. Most deal with all lines of insurance. - 43 states and the District of Columbia require insurers to report suspected fraud to the state fraud bureau or other agency. - 22 states have enacted laws making counterfeit airbags a specific crime. ([*Coalition Against Insurance Fraud, March 2020*](https://www.insurancefraud.org/statutes.htm)) Fraud plots are getting more complex, often involving multiple industries rather than solely insurance. An insurance investigation, for instance, might reveal evidence of financial fraud. - 84 percent of insurance organizations say fraud cases they investigate involve more than one industry. - 76 percent of cross-industry fraud cases have a moderate to high impact on insurance organizations. - More than half say these cases (61 percent) have severe impacts on responding insurance organizations. ## Property Casualty fraud **Contractor fraud** Most contractors are ethical and honest. Yet unlicensed and dishonest operators try to [exploit](https://www.insurancefraud.org/scam-alerts-contractors.htm) often-traumatized homeowners after storms. Contractors may demand large cash down payments, then disappear without doing work. Shoddy workmanship with substandard materials are other problems. Contractor schemes can cost homeowners thousands of dollars in uninsured bills. **Auto fraud** Fraudsters convince drivers they need a windshield repair or replacement when they don’t. Some glass firms bill for phantom windshield replacements, or replace undamaged windshields. Dishonest glass firms also convince consumers to sign an assignment of benefits (AOB) form. This gives the glass firm the legal right to file claims, make repairs and collect insurance payments. Firms are exploiting AOBs to inflate repair claims. - 68% of consumers on average aren’t aware of various auto insurance fraud, from faulty windshield replacements to bandit tow truck - Nearly 1 in 3 people (32%) believe they’ve been a victim of insurance fraud - Auto insurance fraud is underreported, as 29% of those who say they were victims never reported their suspicions. - Auto insurance fraud is underreported, as 29% of those who say they were victims never reported their suspicions. Women are less likely to report suspected fraud than men (35% versus 24%). - 72% of alleged fraud victims say their auto insurance premiums increased as a result. Premium increases are most likely to affect millennials, 78% of whom saw higher costs after being victims of fraud. - Consumers need more education about the various types of auto insurance fraud to protect themselves and their wallets. For example, 78% haven’t heard about faulty windshield replacement scams, 77% haven’t heard about bandit tow trucks and 77% aren’t aware of faulty air bag replacement scams. - More than one-fifth of drivers lied to their insurer. 22% admit to lying to their auto insurer, most commonly by claiming damage to their vehicle but then pocketing the money intended for repairs, or by lying about their address or number of drivers to get a cheaper premium. [*ValuePenguin, Lending Tree (2021)*](https://www.valuepenguin.com/one-third-of-consumers-believe-they-have-been-insurance-fraud-victims) - Nevada is the worst state for auto-related fraud, with an average of 346 reported auto-related fraud cases per 1 million residents. - The 10 top states for auto-related fraud average 315 cases per one million residents - Many cases of auto-related fraud involve dishonest business practices scamming customers - The two leading businesses behind auto-related scams are auto maintenance shops and dealerships [*ClearSurance (2021)*](https://clearsurance.com/blog/worst-states-for-auto-related-fraud) - Michigan ranks 1st for the most expensive states for car insurance. [*Money.com (2020)*](https://money.com/car-insurance-costs-by-state/) - 10% of the nation’s auto glass claims were in Arizona between 2015 and 2019. - More auto-glass claims are filed in Arizona than California or Texas, with populations 5.5 and 4 times larger. - Auto glass claims have increased 26% over the last 5 years in Arizona. This suggests a possible spike in fraud. (*National Insurance Crime Bureau, February 2020*) Staged-crash rings injure or kill innocent victims and fleece auto insurers out of billions of dollars a year. Usually these are bogus soft-tissue injuries such as sore backs or whiplash involving billing for unneeded treatment of phantom injuries. Other frauds include false reporting of actual vehicle drivers, faking information on annual mileage driven, lying to get insurance coverage and claim vehicles are garaged in locations with cheaper insurance rates. **10 Worst States for Auto-Related Fraud** ([*Clearsurance, August 2021*](https://clearsurance.com/blog/worst-states-for-auto-related-fraud)) **Arson** - In 2020, a total of 8,898 motor vehicles were set on fire in the United States. - In total in that year, there were 39,851 arson offenses recorded in the United States, of which 15,079 were structure fires. *[Statista (2020) ](https://www.statista.com/statistics/252459/number-of-arson-offenses-in-the-united-states-by-type/)* - The increase in total fires was statistically significant. *National Fire Protection Association (NFPA) (2021)* - Arson increased nationally by 19.2 percent when compared with the first six months of 2019. - All four regions experienced more arson, with the West seeing the largest increase of 28 percent. - Arson grew the most in cities with populations over 1 million, rising by 52.1 percent. - However, nonmetropolitan counties saw arson increase by 13.7 percent, while metropolitan counties experienced a slightly smaller increase of 11.6 percent. *[FBI (2020)](https://www.fbi.gov/news/pressrel/press-releases/overview-of-preliminary-uniform-crime-report-january-june-2020) – first half of 2020* ## Healthcare - The National Health Care Anti-Fraud Association (NHCAA) estimates that the financial losses due to health care fraud are in the tens of billions of dollars each year. - A conservative estimate is 3% of total health care expenditures, while some government and law enforcement agencies place the loss as high as 10% of our annual health outlay, which could mean more than $300B. [*(NHCAA, 2021)*](https://www.nhcaa.org/tools-insights/about-health-care-fraud/the-challenge-of-health-care-fraud/) - HHS’ watchdog agency, the Office of Inspector General, recovered $3.1B in false and fraudulent claims in 2020, according to a July report. - OIG won or negotiated more than $1.8B in judgments and settlements in 2020, which, combined with efforts from previous years, led to 2020’s $3.1B recovery. Of the $3.1B, $2.1B was transferred to the Medicare Trust Fund, and $128.2M in Medicaid funds was transferred to the Treasury. - A total of 440 people were convicted of healthcare fraud and related crimes in 2020, the OIG said. The Department of Justice opened 1,148 healthcare fraud investigations in 2020, according to the report. [*HHS (2020)*](https://oig.hhs.gov/publications/docs/hcfac/FY2020-hcfac.pdf) **Medicare/Medicaid** - The Department of Justice obtained more than $2.2B in settlements and judgments from civil cases involving fraud and false claims against the government in the fiscal year ending Sept. 30, 2020, Acting Assistant Attorney General Jeffrey Bossert Clark of the Department of Justice’s Civil Division announced today. Recoveries since 1986, when Congress substantially strengthened the civil False Claims Act, now total more than $64B. - Of the more than $2.2B in settlements and judgments recovered by the Department of Justice this past fiscal year, over $1.8B relates to matters that involved the healthcare industry, including drug and medical device manufacturers, managed care providers, hospitals, pharmacies, hospice organizations, laboratories, and physicians. The amounts included in the $1.8B reflect only federal losses, and, in many of these cases, the department was instrumental in recovering additional tens of millions of dollars for state Medicaid programs. [*(DOJ, 2020)*](https://www.justice.gov/opa/pr/justice-department-recovers-over-22-billion-false-claims-act-cases-fiscal-year-2020) - The FY 2020 Medicare FFS estimated improper payment rate is 6.27 percent, representing $25.74B in improper payments. - This compares to the FY 2019 estimated improper payment rate of 7.25 percent, representing $28.91B in improper payments. - The decrease was driven by reductions in the improper payment rates for home health and skilled nursing facility claims. - Home Health – $5.90B decrease in estimated improper payments (2016 to 2020) due to corrective actions such as policy clarification and Targeted Probe and Educate (TPE) for home health agencies. - Skilled Nursing Facility – $1.00B decrease in estimated improper payments (2019 to 2020) due to a policy change related to the supporting information for physician certification and recertification for skilled nursing facility services and TPE for skilled nursing facility services. - The FY 2020 national Medicaid improper payment rate estimate is 21.36 percent, representing $86.49B in improper payments. - The FY 2020 national CHIP improper payment rate estimate is 27.00 percent, representing $4.78B in improper payments. [*CMS (2020)* ](https://www.cms.gov/newsroom/fact-sheets/2020-estimated-improper-payment-rates-centers-medicare-medicaid-services-cms-programs) - Analyzing data from 2015 to 2020, we found a total of 3,013 such scams reported to the BBB from across the U.S. - The worst state for health care, Medicare and Medicaid scams is Ohio, which is home to the 3 cities with the highest number of these types of scams: Vienna, Cleveland and Columbus. - The worst city in 2020 for coronavirus scams – by a considerable margin – was Memphis, Tennessee, with 56 reported COVID-19 scams. That’s nearly 3 times as many scams as were reported in New York City, despite having just 1/13th of the population. - In all, there were 9 cities that were in the top 20 worst cities for healthcare, Medicare and Medicaid scams and also for COVID-19 scams: - Memphis - New York - San Antonio - Los Angeles - Cleveland - Saint Louis - Columbus - Miami - Louisville [*Medicare Advantage (2020)*](https://www.medicareadvantage.com/news/health-care-and-senior-scams-report), Better Business Bureau Scam Tracker **Treatment by excluded medical providers** - Patients treated by healthcare professionals later excluded from the Medicare program for committing fraud and abuse are between 14%-17% more likely to die than patients treated by non-excluded physicians, nurses, and other professionals. - Patients treated by providers banned from Medicare for fraud and abuse are 11%-30% more likely to experience an emergency hospitalization. - Medical providers banned for fraud and abuse treat patients more likely to be low-income, non-white, and disabled. - Nearly one-quarter (23%) of patients seen by excluded providers are non-white while approximately 16.5% of patients treated by approved providers were non-white. *([Johns Hopkins Bloomberg School of Public Health, October 2019](https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2753426))* **Surprise medical bills** - Surprise medical bills impose large and often-unfair costs on patients for out-of-network expenses they thought their health plan covered. Surprise bills can border on fraudulently inflated. Out-of-network billing can also increase healthcare costs for patients who don’t receive balance bills. Many insurance plans require higher cost-sharing (deductibles, co-insurance, co-pays) for out-of-network care. - - More than 10% of commercial healthcare spending is attributable to services for which surprise billing is common: services by radiologists, anesthesiologists, pathologists, emergency physicians, emergency ground ambulances and emergency outpatient facilities. - Eliminating provider leverage stemming from the ability to surprise-bill could reduce commercial insurance premiums by as much as 5.1%, or $212 per member per year. This could reduce aggregate premiums by approximately $38 billion for the nation’s commercially insured population. *([American Journal of Managed Care, September 2020](https://www.ajmc.com/view/a-health-plan-showing-up-in-new-ways-amid-covid-19))* - 1 in 5 Americans who undergo elective surgery — or surgery they schedule in advance — incur unexpected out-of-network medical bills. - Patients who incurred surprise medical bills owe $2,011 more, on average. That’s in addition to the nearly $1,800 cost that average privately insured patients would owe to their insurer for elective surgery. *([Journal of the American Medical Association, February 2020](https://jamanetwork.com/journals/jama/fullarticle/2760735?guestAccessKey=9774a0bf-c1e7-45a4-b2a0-32f41c6fde66&utm_source=For_The_Media&utm_medium=referral&utm_campaign=ftm_links&utm_content=tfl&utm_term=021120))* ## Workers Compensation Some businesses illegally try to avoid paying state-required workers compensation premiums by misclassifying employees as independent contractors. Typically such workers are paid off the books to hide the evidence. Staff labor and payroll size are two key factors that workers-compensation insurers use to gauge premiums. Misclassifying employees in high-risk jobs as holding lower-risk jobs is another ruse. A dishonest roofing firm tells high-risk roofers are lower-risk sales staff or clerks. Misclassifying is especially widespread in dangerous professions such as construction, where risky work means high workers-comp premiums. Misclassifying illegally avoids taxes, wages and other expenses. Shady employers often prey on minority and immigrant communities especially. This crime gives employers an unfair advantage over competitors. - 1.3 million-2.1 million workers were misclassified or doing cash-only work each month. Hiring seasonal workers increases these rates during peak employment. - Payroll scams meant employers paid only $38.2-$43.7B — saving $11.7B and $6.2B, respectively. Specific states and regions may differ. *([United Brotherhood of Carpenters, March 2020](http://www.stoptaxfraud.net/wp-content/uploads/2020/03/National-Carpenters-Study-Methodology-for-Wage-and-Tax-Fraud-Report-FINAL.pdf))* --- ### [Long Term Care Fraud Resources](https://insurancefraud.org/long-term-care/) **Published:** October 23, 2025 **Author:** Coalition Against Insurance Fraud **Content:** As the demand for long-term care services continues to rise with an aging population, fraud schemes are evolving in both scale and sophistication. Long-term care (LTC) fraud is an emerging threat that jeopardizes care for some of society’s most vulnerable individuals. The impact extends beyond higher costs for insurers and policyholders. LTC fraud also erodes consumer benefits, which are capped by lifetime maximums. To help combat LTC Fraud, the Coalition, with the assistance of the members of the Long-Term Care Subcommittee, has created the resources to help educate both members and consumers about Long-Term Care insurance fraud. Members are encouraged to use these materials freely and are authorized to co-brand all materials provided below. For branding assistance, or questions related to the resources provided, please email <communications@insurancefraud.org>. ![](https://insurancefraud.org/wp-content/uploads/Screenshot-2026-04-28-at-9.08.59-AM-1024x575.png)[Click here to download the PPT](https://insurancefraud.org/wp-content/uploads/Coalition-Survey-Into-LTC-Fraud.pptx) ![Banner with Coalition Against Insurance Fraud logo and title 'A Survey into Long-Term Care Fraud Trends'; left dark blue panel, right shows an elderly woman with a walker being helped by a caregiver outdoors.](https://insurancefraud.org/wp-content/uploads/Screenshot-2026-04-28-at-9.08.59-AM-1-1024x575.png)[Click here to download the PDF](https://insurancefraud.org/wp-content/uploads/Coalition-Survey-Into-LTC-Fraud.pdf) **Long-Term Care Small Brochure** **11×8.5** [![](https://insurancefraud.org/wp-content/uploads/LTC-Brochure.png)](https://insurancefraud.org/wp-content/uploads/Coalition-LTC-Small-Brochure-Print-Specs.pdf) [Click here to download the 11×8.5 brochure and print specs](https://insurancefraud.org/wp-content/uploads/Coalition-LTC-Small-Brochure-Print-Specs.pdf) **Long-Term Care Brochure Large Brochure 12×9** [![](https://insurancefraud.org/wp-content/uploads/LTC-Brochure.png)](https://insurancefraud.org/wp-content/uploads/12x9-Long-Term-Care-Brochure-Specs.pdf) [Click here to download the 12×9 brochure and print specs](https://insurancefraud.org/wp-content/uploads/12x9-Long-Term-Care-Brochure-Specs.pdf) **Long-Term Care PowerPoint** [![](https://insurancefraud.org/wp-content/uploads/LTC-PPT-Cover-For-Website-1024x576.png)](https://insurancefraud.org/wp-content/uploads/Updated-Coalition-LTC-Fraud-Slides-.pptx) [Click here to download PPT](https://insurancefraud.org/wp-content/uploads/Updated-Coalition-LTC-Fraud-Slides-.pptx) **Social Media Graphics** [![](https://insurancefraud.org/wp-content/uploads/LTC-Blue-Social-Media-Messaging-2025-Recovered-1002x1024.jpg)](https://insurancefraud.org/wp-content/uploads/Updated-LTC-Blue-Social-Media-Messaging-2025-Recovered.pdf)[Click here to download](https://insurancefraud.org/wp-content/uploads/Updated-LTC-Blue-Social-Media-Messaging-2025-Recovered.pdf) [![](https://insurancefraud.org/wp-content/uploads/Updated-Report-Suspected-Fraud-LTC-Social-Media-Messaging-2025-928x1024.jpg)](https://insurancefraud.org/wp-content/uploads/Updated-PDF-Report-Suspected-Fraud-LTC-Social-Media-Messaging-2025.pdf)[Click here to download](https://insurancefraud.org/wp-content/uploads/Updated-PDF-Report-Suspected-Fraud-LTC-Social-Media-Messaging-2025.pdf) [![](https://insurancefraud.org/wp-content/uploads/Updated-Yellow-2-Protect-Your-Loved-One-LTC-Social-Media-Messaging-2025-928x1024.jpg)](https://insurancefraud.org/wp-content/uploads/Updated-Yellow-2-Protect-Your-Loved-One-LTC-Social-Media-Messaging-2025.pdf)[Click here to download](https://insurancefraud.org/wp-content/uploads/Updated-Yellow-2-Protect-Your-Loved-One-LTC-Social-Media-Messaging-2025.pdf) **Infographics** – Download Front & Back PDF’s [![](https://insurancefraud.org/wp-content/uploads/Protect-Your-Loved-One-Infographic-818x1024.jpg)](https://insurancefraud.org/wp-content/uploads/LTC-Protect-Your-Loved-One-Infographic.pdf)[Click here to download](https://insurancefraud.org/wp-content/uploads/LTC-Protect-Your-Loved-One-Infographic.pdf) [![](https://insurancefraud.org/wp-content/uploads/LTC-FRAUD-SCHEMES-Infogrpahics-818x1024.jpg)](https://insurancefraud.org/wp-content/uploads/LTC-Common-Fraud-Schemes-Infogrpahic.pdf)[Click here to download](https://insurancefraud.org/wp-content/uploads/LTC-Common-Fraud-Schemes-Infogrpahic.pdf) --- ### [Member Alerts](https://insurancefraud.org/member-alerts/) **Published:** August 26, 2026 **Author:** Coalition Against Insurance Fraud **Content:** **Stay Alert. Stay Informed.** Our latest member alerts highlight emerging insurance fraud trends, warning signs, and key developments to help you stay one step ahead. Take a look at the newest alerts and strengthen your awareness of the latest fraud risks. ##### 2026 [9/2/2026 – Employment Infiltration: How synthetic identities and deepfakes are threatening the insurance industry from within](https://insurancefraud.org/wp-content/uploads/09-02-2026-Member-Alert_-Employment-Infiltration.pdf) [8/26/2026 – Coalition and Shift Technology will Launch 2026 State of Technology Study in September](https://insurancefraud.org/wp-content/uploads/8-26-26-Member-Alert_-Coalition-and-Shift-Technology-Will-Launch-2026-State-of-Technology-Study-in-September.pdf) [8/26/2026 – California SIU Annual Report Training Scheduled for Sept. 2](https://insurancefraud.org/wp-content/uploads/08-26-2026-California-SIU-Annual-Report-training-scheduled-for-Sept.-2.pdf) [8/12/2026 – New Consumer Brochures Available To Help Combat Sober Home Fraud and Body Brokering](https://insurancefraud.org/wp-content/uploads/8-12-26-New-Consumer-Brochures-Available-To-Help-Combat-Sober-Home-Fraud-and-Body-Brokering.pdf) [8/12/2026 – Join the Coalition’s New Technology Task Force](https://insurancefraud.org/wp-content/uploads/8-12-26-Member-Alert_-Join-the-Coalitions-New-Technology-Task-Force.pdf) [8/5/2026 – Explore Our New Anti-Fraud Legislation Tracker](https://insurancefraud.org/wp-content/uploads/8-5-26-Explore-Our-New-Anti-Fraud-Legislation-Tracker.pdf) [8/5/2026 – Coalition Files Second Amicus Brief with Fifth Circuit to Defend Civil RICO Remedies](https://insurancefraud.org/wp-content/uploads/08-05-2026-Coalition-Files-Second-Amicus-Brief-with-Fifth-Circuit-to-Defend-Civil-RICO-Remedies.pdf) [7/22/2026 – Legal Alert – Allstate v Carteret Amicus](https://insurancefraud.org/wp-content/uploads/07-22-2026-Legal-Alert_-Amicus-Update-Allstate-v-Carteret-Amicus.pdf) [7/22/2026 – Government Affairs Alert – NCSL legislative databases](https://insurancefraud.org/wp-content/uploads/7-22-2026-Government-Affairs-Alert_NCSL-legislative-databases.pdf) [7/15/2026 – Indiana Fraud Reporting Requirement](https://insurancefraud.org/wp-content/uploads/7-15-26-Indiana-Fraud-Reporting-Requirement.pdf) [7/8/2026 – Collaboration At Work: 2026 Committee and Task Force Highlights](https://insurancefraud.org/wp-content/uploads/2026-Committee-and-Task-Force-Highlights.pdf) [6/10/2026 – Govt Affairs Alert – CT Repeal of Fraud Report](https://insurancefraud.org/wp-content/uploads/6-10-26-Govt-Affairs-Alert-CT-Repeal-of-Fraud-Report.pdf) [6/3/2026 – Emerging Transnational Organized Collision Fraud Scheme Expanding Across Multiple Markets](https://insurancefraud.org/wp-content/uploads/6.3.2026-Coalition-Member-Alert_-Transnational-Organized-Collision-Fraud-Scheme.pdf) [5/27/2026 – New financial exploitation laws enacted](https://insurancefraud.org/wp-content/uploads/5-27-26-Govt-Affairs-Alert_-Iowa-Nebraska-Senior-Exploitation-MLR-1.pdf) [5/13/2026 – The Prudential Insurance Company of America v. Carol Gardina et al.](https://insurancefraud.org/wp-content/uploads/05-13-2026-Legal-Alert_-Amicus_-Prudential-vs-Gardina-Announcement-1.pdf) [4/16/2026 – People v. Woods](https://insurancefraud.org/wp-content/uploads/04-15-2026-Legal-Alert_-Coalition-Files-Amicus-Brief-with-California-Supreme-Court-to-Preserve-Felony-Fraud-Prosecutions-1.pdf) [2/24/2026 – Social Media Competition Phase Two](https://insurancefraud.org/wp-content/uploads/Social-Media-Competition-Member-Alert.pdf) [2/4/2026 – United States v. Sebron D. Brown](https://insurancefraud.org/wp-content/uploads/Coalition-Legal-Alert-Federal-Appeals-Court-Affirms-Enhanced-Sentencing-In-Staged-Collision-Insurance-Fraud-Case.pdf) 2025 [9/15/2025 – Social Media Competition](https://insurancefraud.org/wp-content/uploads/Coalition-Social-Media-Competition-Member-Alert.pdf) [8/20/2025 – Employment Infiltration](https://insurancefraud.org/wp-content/uploads/08-2025-Fraudsters-Are-Attempting-To-Infiltrate-Insurance-Companies-Through-Employment-Scams.pdf) [7/23/2025 – AI Advocacy Alert](https://insurancefraud.org/wp-content/uploads/AI-Advocacy-Member-Alert-7-23-25.pdf) [6/20/2025 – Scattered Spider Alert](https://insurancefraud.org/wp-content/uploads/Insurer-Member-Alert-Scattered-Spider.pdf) [5/8/2025 – Money Laundering Alert](https://insurancefraud.org/money-laundering/) --- ### [International Fraud Awareness Week](https://insurancefraud.org/2025-international-fraud-awareness-week/) **Published:** October 14, 2025 **Author:** Coalition Against Insurance Fraud **Content:** In preparation for International Fraud Awareness Week, the Coalition is providing new downloadable resources to support member education and outreach. These include clear, accessible written materials and engaging, thought-provoking graphics for social media. Members are welcome to edit the Word documents as needed to align with their organization’s messaging and communication goals. ##### Download Word Documents [![](https://insurancefraud.org/wp-content/uploads/Why-Does-International-Awareness-Week-Matter-To-YOU_.png)](https://insurancefraud.org/wp-content/uploads/Why-Does-International-Fraud-Awareness-Week-Matter-to-YOU_.docx) [**What’s Fraud Awareness Week and Why Should You Care?**](https://insurancefraud.org/wp-content/uploads/Why-Does-International-Fraud-Awareness-Week-Matter-to-YOU_.docx) [![](https://insurancefraud.org/wp-content/uploads/Insurance-Fraud-Warning-Signs-for-Consumers.png)](https://insurancefraud.org/wp-content/uploads/Insurance-Fraud-Red-Flags-for-Consumers.docx) [**Insurance Fraud Warning Signs**](https://insurancefraud.org/wp-content/uploads/Insurance-Fraud-Red-Flags-for-Consumers.docx) [![](https://insurancefraud.org/wp-content/uploads/How-to-Report-Insurance-Fraud.png)](https://insurancefraud.org/wp-content/uploads/How-to-Report-Insurance-Fraud.docx) [**How to Report Fraud**](https://insurancefraud.org/wp-content/uploads/How-to-Report-Insurance-Fraud.docx) [![](https://insurancefraud.org/wp-content/uploads/The-Future-of-Insurance-Fraud-is-Here.png)](https://insurancefraud.org/wp-content/uploads/The-Future-of-Fraud-is-Here_-Why-AI-and-Digital-Scams-Are-Your-Next-Big-Threat.docx) **[The Future of F](https://insurancefraud.org/wp-content/uploads/The-Future-of-Fraud-is-Here_-Why-AI-and-Digital-Scams-Are-Your-Next-Big-Threat.docx)[r](https://insurancefraud.org/wp-content/uploads/The-Future-of-Fraud-is-Here_-Why-AI-and-Digital-Scams-Are-Your-Next-Big-Threat.docx "r")[aud is Here: Why AI and Digital Scams Are Your Next Big Threat](https://insurancefraud.org/wp-content/uploads/The-Future-of-Fraud-is-Here_-Why-AI-and-Digital-Scams-Are-Your-Next-Big-Threat.docx)** [![](https://insurancefraud.org/wp-content/uploads/Insurance-Fraud-Awareness-Challenge.png)](https://insurancefraud.org/wp-content/uploads/Insurance-Fraud-Awareness-Challenge.docx) [**Test Your Knowledge**](https://insurancefraud.org/wp-content/uploads/Insurance-Fraud-Awareness-Challenge.docx) ##### Download PDFs [![](https://insurancefraud.org/wp-content/uploads/Why-Does-International-Awareness-Week-Matter-To-YOU_.png)](https://insurancefraud.org/wp-content/uploads/Why-Does-International-Fraud-Awareness-Week-Matter-to-YOU_.pdf) **[What’s Fraud Awareness Week and Why Should You Care?](https://insurancefraud.org/wp-content/uploads/Why-Does-International-Fraud-Awareness-Week-Matter-to-YOU_.pdf)** [![](https://insurancefraud.org/wp-content/uploads/Insurance-Fraud-Warning-Signs-for-Consumers.png)](https://insurancefraud.org/wp-content/uploads/Insurance-Fraud-Red-Flags-for-Consumers.pdf) [**Insurance Fraud Warning Signs**](https://insurancefraud.org/wp-content/uploads/Insurance-Fraud-Red-Flags-for-Consumers.pdf) [![](https://insurancefraud.org/wp-content/uploads/How-to-Report-Insurance-Fraud-1.png)](https://insurancefraud.org/wp-content/uploads/How-to-Report-Insurance-Fraud.pdf) **[How to Report Fraud](https://insurancefraud.org/wp-content/uploads/How-to-Report-Insurance-Fraud.pdf)** [![](https://insurancefraud.org/wp-content/uploads/The-Future-of-Insurance-Fraud-is-Here.png)](https://insurancefraud.org/wp-content/uploads/The-Future-of-Fraud-is-Here_-Why-AI-and-Digital-Scams-Are-Your-Next-Big-Threat.pdf) **[The Future of Fraud is Here: Why AI and Digital Scams Are Your Next Big Threat](https://insurancefraud.org/wp-content/uploads/The-Future-of-Fraud-is-Here_-Why-AI-and-Digital-Scams-Are-Your-Next-Big-Threat.pdf)** [![](https://insurancefraud.org/wp-content/uploads/Insurance-Fraud-Awareness-Challenge.png)](https://insurancefraud.org/wp-content/uploads/Insurance-Fraud-Awareness-Challenge.pdf) **[Test Your Knowledge](https://insurancefraud.org/wp-content/uploads/Insurance-Fraud-Awareness-Challenge.pdf)** ##### Download Videos **[Learn About Insurance Fraud](https://insurancefraud.org/wp-content/uploads/Learn-About-Insurance-Fraud.mp4)** **[Predatory Sales Tactics](https://insurancefraud.org/wp-content/uploads/Predatory-Sales-Tactics.mp4)** ##### Download **Podcast** **[A Deep Dive Into Insurance Fraud](https://insurancefraud.org/wp-content/uploads/A-Deep-Dive-Into-Insurance-Fraud.mp3)** [![](https://insurancefraud.org/wp-content/uploads/Podcast.png)](https://insurancefraud.org/wp-content/uploads/A-Deep-Dive-Into-Insurance-Fraud.mp3) --- ### [International Fraud Awareness Week Consumer Resources](https://insurancefraud.org/2025-international-fraud-awareness-week-resources/) **Published:** November 13, 2025 **Author:** Coalition Against Insurance Fraud **Content:** The Coalition is celebrating International Fraud Awareness Week by providing new downloadable resources to support your education and outreach. ##### Download PDFs [![](https://insurancefraud.org/wp-content/uploads/Why-Does-International-Awareness-Week-Matter-To-YOU_.png)](https://insurancefraud.org/wp-content/uploads/Why-Does-International-Fraud-Awareness-Week-Matter-to-YOU_.pdf) **[What’s Fraud Awareness Week and Why Should You Care?](https://insurancefraud.org/wp-content/uploads/Why-Does-International-Fraud-Awareness-Week-Matter-to-YOU_.pdf)** [![](https://insurancefraud.org/wp-content/uploads/Insurance-Fraud-Warning-Signs-for-Consumers.png)](https://insurancefraud.org/wp-content/uploads/Insurance-Fraud-Red-Flags-for-Consumers.pdf) [**Insurance Fraud Warning Signs**](https://insurancefraud.org/wp-content/uploads/Insurance-Fraud-Red-Flags-for-Consumers.pdf) [![](https://insurancefraud.org/wp-content/uploads/How-to-Report-Insurance-Fraud-1.png)](https://insurancefraud.org/wp-content/uploads/How-to-Report-Insurance-Fraud.pdf) **[How to Report Fraud](https://insurancefraud.org/wp-content/uploads/How-to-Report-Insurance-Fraud.pdf "download")** [![](https://insurancefraud.org/wp-content/uploads/The-Future-of-Insurance-Fraud-is-Here.png)](https://insurancefraud.org/wp-content/uploads/The-Future-of-Fraud-is-Here_-Why-AI-and-Digital-Scams-Are-Your-Next-Big-Threat.pdf) **[The Future of Fraud is Here: Why AI and Digital Scams Are Your Next Big Threat](https://insurancefraud.org/wp-content/uploads/The-Future-of-Fraud-is-Here_-Why-AI-and-Digital-Scams-Are-Your-Next-Big-Threat.pdf)** [![](https://insurancefraud.org/wp-content/uploads/Insurance-Fraud-Awareness-Challenge.png)](https://insurancefraud.org/wp-content/uploads/Insurance-Fraud-Awareness-Challenge.pdf) **[Test Your Knowledge](https://insurancefraud.org/wp-content/uploads/Insurance-Fraud-Awareness-Challenge.pdf)** [Insurance Fraud Awareness Challenge](https://insurancefraud.org/wp-content/uploads/Insurance-Fraud-Awareness-Challenge-1.pdf)[Download](https://insurancefraud.org/wp-content/uploads/Insurance-Fraud-Awareness-Challenge-1.pdf) --- ### [Sober Home & Body Brokering Resources](https://insurancefraud.org/sober-home-fraud-body-brokering-resources/) **Published:** August 5, 2026 **Author:** Coalition Against Insurance Fraud **Content:** **What is sober home fraud?** Sober home fraud happens when facility operators, treatment providers, or recruiters exploit people in recovery to collect illegal insurance payments. While legitimate sober homes support your recovery, fraudulent operations treat residents as revenue sources rather than patients. Common schemes include: - Paying recruiters, known as “body brokers,” to enroll insured individuals - Offering free rent, travel, gifts, or cash in exchange for insurance information - Billing for unnecessary drug tests, counseling, or other medical services - Billing for treatment never delivered or for residents who were not present - Shifting patients repeatedly between facilities to generate ongoing insurance claims - Exchanging kickbacks among sober homes, testing labs, and care providers - Falsifying a person’s medical condition or living arrangements to collect payments **Sober home fraud and body brokering** When you or your family search for addiction treatment, unscrupulous recruiters may target you to maximize insurance payouts. These “body brokers” earn fees by referring patients to specific facilities. They often offer free travel, housing, or cash, make unrealistic promises, and pressure you into programs that do not match your medical needs. The Coalition Against Insurance Fraud offers free downloadable brochures to help you spot warning signs, evaluate treatment options, and ask critical questions before accepting care. Download these resources to learn what to evaluate before traveling for treatment and how to report suspected fraud. ![](https://insurancefraud.org/wp-content/uploads/Coalition-Sober-Home-Brochure-Cover.jpg)[Click here to download the PDF](https://insurancefraud.org/wp-content/uploads/Coalition-Sober-Home-Brochure-family.pdf) ![](https://insurancefraud.org/wp-content/uploads/Coalition-Sober-Home-Brochure-Cover.jpg)[Click here to download the Print Ready Version](https://insurancefraud.org/wp-content/uploads/Coalition-Sober-Home-Brochure-familyPRESS.pdf) ![](https://insurancefraud.org/wp-content/uploads/Coalition-Body-Broker-Brochure-Cover.jpg)[Click here to download the PDF](https://insurancefraud.org/wp-content/uploads/Coalition-Sober-Home-Brochure-For-Individual.pdf) ![](https://insurancefraud.org/wp-content/uploads/Coalition-Body-Broker-Brochure-Cover.jpg)[Click here to download the Print Ready Version](https://insurancefraud.org/wp-content/uploads/Coalition-Sober-Home-Brochure-For-Individual-Print-Ready.pdf) **Infographic** ![](https://insurancefraud.org/wp-content/uploads/Infographic-Sober-Home-Red-Flag.png)[Click here to download the PDF](https://insurancefraud.org/wp-content/uploads/Infographic-Sober-Home-Red-Flag.pdf) --- ### [Contact us](https://insurancefraud.org/contact-us/) **Published:** July 23, 2020 **Author:** Coalition Against Insurance Fraud **Content:** ## Join the Coalition: Get Connected The Coalition is the national hub for the anti-fraud community. We unite diverse organizations to support the fraud fight … share data and trends … and expand vital fraud fighting connections. Insurers, consumer groups, government agencies and other partners know the Coalition is a valuable investment. More than [300 organizations](https://www.insurancefraud.org/member-list.htm) are members. Interested in becoming a member? ## Get involved Volunteering for Coalition committees and task forces is a valuable way to support the fraud fight. You’ll work on specific projects. Help develop strategy for legislation, regulation, research studies and public outreach programs. ### Join The Coalition has a long history of helping America become a less-friendly place for insurance fraud. Our members agree the Coalition provides tremendous value for their dues dollar. **Questions?** Email [Michelle Rafeld](mimailto:michelle@insurancefraud.org), Executive Director, or phone [202-393-7333](tel:2023937333). --- ### [Member Testimonials](https://insurancefraud.org/membertestimonials/) **Published:** October 11, 2023 **Author:** Coalition Against Insurance Fraud **Content:** Change the opening lines to say: The fight against insurance fraud requires strong, united partnerships. Explore firsthand accounts from our valued members detailing their experiences working alongside the Coalition. Their insights highlight the impact of our collective efforts and why organizations across the country trust us to lead the charge in outreach, advocacy, and research. Read their stories below to discover the tangible benefits of joining our anti-fraud alliance. If your organization would to join our roster of more than 320+ organizations, **[click here](https://insurancefraud.org/join-the-coalition/)** to submit an application. ![](https://insurancefraud.org/wp-content/uploads/1-1024x683.jpg) ![](https://insurancefraud.org/wp-content/uploads/3-1024x683.jpg) ![](https://insurancefraud.org/wp-content/uploads/2-1024x683.jpg) ![](https://insurancefraud.org/wp-content/uploads/4-2-1024x574.png) *I have had the privilege of being a Coalition Against Insurance Fraud member since 2021. I’ve been so impressed by the professionalism and commitment to fighting insurance fraud of the members and the Coalition. The industry expertise is truly unmatched. The clear communication and emphasis on a collaborative approach lead to meaningful results. The members of the task forces provide a deep understanding of the challenges we face on a state and national level. The innovative solutions have greatly benefited me in my role at the PA Insurance Fraud Prevention Authority. I wholeheartedly recommend joining the Coalition to anyone seeking a trusted partner in the fight against insurance fraud and the protection of insurance consumers. –* ***Christopher Sloan, CIFI, SCLA, Executive Director, PA Insurance Fraud Prevention Authority*** ![](https://insurancefraud.org/wp-content/uploads/IFPA.png) ![](https://insurancefraud.org/wp-content/uploads/Kentucky-DOI.png)*The Coalition Against Insurance Fraud has been a crucial partner and an essential resource for my career in the fight against insurance fraud. Their network of experts, educational materials, and advocacy efforts have been instrumental in staying well-informed on the latest insurance fraud schemes throughout the United States.* – ***Juan D. Garrett, Division Director, Kentucky Department of Insurance, Division of Insurance Fraud Investigation*** *I have had the privilege and pleasure of working with masters in the fraud field. The Coalition allows experts and dedicated personnel in the field to collaborate efforts in detecting, defeating and deterring insurance fraud. – **James Hailey, Partner, Lewis Brisbois Bisgaard & Smith LLP*** ![](https://insurancefraud.org/wp-content/uploads/Lewis-Brisbois-1.jpg) ![](https://insurancefraud.org/wp-content/uploads/GIFS-1.png)*As a member of the Coalition for over 30 years, I’ve seen firsthand the power of collaboration in the fight against insurance fraud. From co-chairing committees to contributing to global studies and events, the Coalition has been instrumental in my growth and impact. It’s a unique community where your voice matters and real change happens. For those thinking of joining — don’t wait. Get involved and be part of something truly meaningful.* *– **Dennis Toomey**, **President, Global Insurance Fraud Summit*** *I have valued the relationships through Coalition, knowledge sharing with Coalition carrier members & the associate members and the collaboration we have all participated in to continue to elevate the mission of Coalition and the fight against insurance fraud. – **Bob McConn**, **Sr. Director, Product Management Insurance Solutions, LexisNexis Risk Solutions*** ![](https://insurancefraud.org/wp-content/uploads/Lexis-Nexis-logo.png) ![](https://insurancefraud.org/wp-content/uploads/Del.-Commissioner-logo.png) *While my time as Insurance Commissioner only intersected with the Coalition’s long history of success for a short time, it has been an honor to work shoulder to shoulder with the Coalition …* ***– Delaware Commissioner Trinidad Navarro*** *Dennis Jay and I became fast friends as we wanted the same things out of our businesses… impact the industry as a whole in fighting fraud. Through the years I could always count on the Coalition for advice, the latest in industry news and global support. **– Mike Malone, Chairman & CEO***, ******Allied Universal Compliance & Investigations****** [![](https://insurancefraud.org/wp-content/uploads/Allied-Universal-formerly-G4S-1024x474.png)](https://www.aus.com/) [![](https://insurancefraud.org/wp-content/uploads/Delta-Group-logo.jpg)](https://www.deltagroup.net/) *I truly feel that I owe a lot of my career to the Coalition and look forward to continuing to be an active member of this great group. **– Frank Sztuk, Senior Vice President Investigative Services, Delta Group*** The Coalition has been, and will continue to be, NCOIL’s “go to” resource when dealing with insurance fraud issues. NCOIL looks forward to continuing its work with the Coalition in the years ahead. – ***William Melofchik, General Counsel, NCOIL*** [![](https://insurancefraud.org/wp-content/uploads/NCOIL.jpg)](https://ncoil.org/) [![](https://insurancefraud.org/wp-content/uploads/Kansas-DOI.png)](https://insurance.kansas.gov/) I used information provided by the Coalition when preparing presentations for local state groups and national conferences. Dennis Jay was a prominent figure on the National insurance fraud scene and I was pleased to serve with him on insurance fraud management panels and on other Boards. ***– Ted Clark, Anti-Fraud Division Director (Ret), Kansas Insurance Department*** During the two decades that I have been involved with the Coalition, I have seen the organization grow to one of the premier fraud fighting organizations in the world, providing a beacon of light and guidance to the entire fraud fighting community. – **J. Michael Skiba, MBA, PhD, “Dr. Fraud**“***, Colorado State University — Global Campus*** ![](https://insurancefraud.org/wp-content/uploads/Colorado_State_University–Global_Campus.png) [![](https://insurancefraud.org/wp-content/uploads/NJ-Chief-Of-Investigation-Department-of-Insurance.jpg)](https://www.nj.gov/dobi/division_insurance/bfd/enforcement.htm) I attended my first Coalition meeting. I remember being as excited as a five-year-old on their first trip to Disney World. Networking with fellow insurance fraud fighters nationwide and learning how they addressed new schemes and emerging insurance fraud trends was a turning point in my career. ***– John Butchko, Retired Chief Of Investigation, State of New Jersey, Department of Insurance, Bureau of Fraud Deterrence*** [![](https://insurancefraud.org/wp-content/uploads/Employers.png)](https://www.employers.com/) As I reflect on what makes the Coalition a premier organization, I think of what President Calvin Coolidge said, “no enterprise can exist for itself alone. It ministers to some great need, it performs some great service, not for itself, but for others; or failing therein it ceases to be profitable and ceases to exist”. – ***Michael R. Grenon, CIFI, FCLA, LPCS, Director, Special Investigations Unit, Employers*** The membership has given me the opportunity to work with other lawyers around the country on legal issues involved in insurance fraud investigation as a part of the Legal Affairs Committee. ***– Gene A. Weisberg, Co-President, GladstoneWeisberg*** [![](https://insurancefraud.org/wp-content/uploads/GladstoneWeisberg.png)](https://gladstoneweisberg.com/) ![](https://insurancefraud.org/wp-content/uploads/ethos-Horizontal-Logo_R-scaled.png) To me, the annual and mid-year meetings are like high school reunions, where I get the chance to reconnect with old friends and meet new friends. I am truly blessed by the number of friends and mentors I’ve met over the years as a member of the Coalition! – ***Tom Donahue, CIFI, FCLS, National Sales Director, Ethos*** The Coalition through the incredible work done over the last thirty years continues to uniquely provide awareness and unite in fighting the good fight against insurance fraud. – ***Steve Piper, Vice President – Technical Claims, Shared Services*** [![](https://insurancefraud.org/wp-content/uploads/CNA.png)](https://www.cna.com/web/guest/cna/home) ![](https://insurancefraud.org/wp-content/uploads/Katten_Blue_RGB-0_48_135-800x250px.jpg) *It is an amazing organization, and I am grateful to be associated with it and the fascinatingly diverse membership. **– Ross O. Silverman, Partner,*** ***Katten Muchin Rosenman LLP*** --- ### [Committees & Task Forces](https://insurancefraud.org/committees/) **Published:** October 23, 2020 **Author:** admcaif **Content:** Coalition committees and task forces include a diverse mix of insurers, government leaders, public interest groups, associations, associates, and law firms. Coalition members may join one or more of these groups to drive a positive impact in the fight against insurance fraud. To join a committee or task force, contact the liaison or member services at <memberservices@insurancefraud.org>. For more information or to find out how to join a committee, contact the staff liaison below. ###### Executive Committee Governs the Coalition’s overall direction, strategy, and operations. The Board of Directors elects the officers and members of this chief governing body. **Co-chairs:** [Anthony DiPaolo](mailto:adipaolo@ifb.org), Massachusetts Insurance Fraud Bureau [Steve Piper](mailto:Steven.Piper@cna.com), CNA **Staff liaison:** [Michelle Rafeld](mailto:michelle@insurancefraud.org) ###### Amicus Review Committee Identifies significant legal cases and submits amicus briefs in state and federal courts, providing arguments that help shape key rulings and establish broader precedents for the anti-fraud community. **Chair:** [John Doak](mailto:jdoak@insurancecaredirect.com), Insurance Care Direct **Staff liaison:** [Brent Walker](mailto:brent@insurancefraud.org) ###### Financial Review Committee Provides financial analysis and oversight of the Coalition’s budget. Ensures resources needed to provide programs and services to the community. **Co-chairs:** [Dave Rioux](mailto:david.rioux@erieinsurance.com), Erie Insurance [Tony DiPaolo](mailto:adipaolo@ifb.org), Insurance Fraud Bureau of Massachusetts **Staff liaison:** Michelle Rafeld ###### Government Affairs Committee Leads grassroots campaigns and supports updates to Coalition model legislative frameworks that states nationwide can use to combat fraud.You launch grassroots campaigns and help update Coalition model acts that states nationwide use to fight fraud. **Chair:** [Delpha DiGiacomo](mailto:%20delpha.digiacomo@zurichna.com), Zurich North America **Vice Chair:** [Breann Heininger](mailto:bheininger@deltagroup.net), Delta Group **Staff liaison:** [Brent Walker](mailto:brent@insurancefraud.org) ###### Legal Affairs Committee Tracks court decisions impacting insurance fraud and maintains the Coalition’s legal resources. Also identifies cases for potential amicus curiae participation to support member interests. Membership is by *invitation only*. **Chair:**[ Ross Silverman, Esq](mailto:ross.silverman@katten.com)., Katten Muchin Rosenmann LLP **Vice Chair:** [Jeffrey Rapattoni, Esq](mailto:%20jgrapattoni@mdwcg.com). Marshall Dennehey **Staff liaison:** [Brent Walker](mailto:brent@insurancefraud.org) ###### Public Information Committee Leads national outreach that empowers consumers to prevent and report fraud, promotes integrity across all insurance practices, and raises awareness of fraud’s widespread impact. **Co-chairs:** [Tom Donahue](mailto:thomas.donahue@ethosrisk.com), Ethos Risk [Chris Sloan](mailto:csloan@helpstopfraud.org), Pennsylvania Insurance Fraud Prevention Authority **Staff liaison:** [Celeste Dodson](mailto:celeste@insurancefraud.org) ###### Research Committee Conducts data-driven research to help members better understand and address emerging fraud challenges. Produces insights that inform decision-makers, highlight evolving trends, and support policy development at the national level. **Chair:** [David Rioux](mailto:david.rioux@erieinsurance.com), Erie Insurance **Vice Chair:** [Steve Jarrett](mailto:%20stevejarrett@westfieldgrp.com), Westfield Insurance **Staff liaison:** [Celeste Dodson](mailto:celeste@insurancefraud.org) --- ##### TASK FORCES ###### Associate Member Task Force Engages vendor partners, leveraging their deep expertise to support the Coalition’s mission. Ensures associate members remain informed, connected, and actively involved in advancing the Coalition’s strategy. **Co-chairs**: [Frank Sztuk](mailto:fsztuk@deltagroup.net), Delta Group [Dennis Toomey](mailto:%20dennis.toomey@pwc.com), PwC **Staff liaison:** [Celeste Dodson](mailto:celeste@insurancefraud.org) ###### Fraud Risk Management Task Force Collaborates with members to share best practices in enterprise fraud risk management, taking a holistic approach to fraud across the organization. Focuses on risk assessment, governance, and program oversight to strengthen protection and resilience. **Co-chairs:** [Arteniece Lee](mailto:Arteniece.Lee@horacemann.com), Horace Mann [Mariela Pennock](mariela.pennock@assurant.com), Assurant **Staff liaison:** [Celeste Dodson](mailto:celeste@insurancefraud.org) ###### Life & Disability Task Force Explores evolving fraud schemes and exposures within life and disability insurance. Collaborates to identify, understand, and create strategies to effectively combat fraud. **Life Co-chair:** [Cindy Belmore](mailto:%20cbelmore@massmutual.com), MassMutual **Disability Co-chair:** [Steve Pierson](mailto:%20steven.pierson@thehartford.com), The Hartford **Staff liaison:** [Celeste Dodson](mailto:celeste@insurancefraud.org) ###### Medical Fraud Task Force Addresses medical benefits and billing fraud. Creates strategies to increase awareness of current and emerging fraud trends. **Co-chairs:** [Craig Koerner](craig.koerner@verisk.com), Verisk [Robert McGinley](mailto:%20rob.mcginley@pwc.com), PwC **Staff liaison:** [Celeste Dodson](mailto:celeste@insurancefraud.org) ###### Property & Casualty Task Force Focuses on emerging fraud schemes in the property and casualty sector, strengthening public-private partnerships to enhance fraud detection and prevention efforts. ****Co-chairs:**** [Armand Glick](mailto:%20aglick@utah.gov), Utah Department of Insurance [Pranay Mittal](mailto:PMITTAL3@travelers.com), Travelers Insurance **Staff liaison:** [Celeste Dodson](mailto:celeste@insurancefraud.org) ###### State and Industry Fraud Task Force Brings together state insurance regulators and insurance company fraud directors to discuss key issues. This *invitation-only* group strengthens relationships and promotes collaboration between the public and private sectors. ****Co-chairs:**** [Anthony DiPaolo](mailto:adipaolo@ifb.org), Massachusetts Insurance Fraud Bureau [Steve Jarrett](mailto:stevejarrett@westfieldgrp.com), Westfield Insurance **Staff liaison:** [Celeste Dodson](mailto:celeste@insurancefraud.org) ###### Technology Task Force Provide a structured forum for members to collaborate, exchange perspectives, and share practical experiences to better understand how technology impacts insurance fraud. ****Co-chairs:**** [Julia Senn](mailto:julia.senn.gs3r@statefarm.com%20), State Farm Mutual Automobile Insurance Company [Alicia Holmes](mailto:alicia.holmes@shift-technology.com), Shift Technology **Staff liaison:** [Celeste Dodson](mailto:celeste@insurancefraud.org) ###### Workers’ Compensation Task Force Develops strategies to address emerging fraud trends and supports efforts to educate the industry while advancing improved approaches to related fraud issues. ****Co-chairs:**** [Jenn Cunningham](mailto:Jennifer.S.12@bwc.ohio.gov), Ohio Bureau of Workers’ Compensation [Dan Krueger](mailto:d.krueger@zurichna.com), Zurich Insurance **Staff liaison:** [Celeste Dodson](mailto:celeste@insurancefraud.org) --- ##### SUBCOMMITTEES ###### **Industry SIU Directors Subcommittee** Provides a forum for industry SIU Directors to discuss key issues related to their roles and responsibilities. **Staff liaison:** [Celeste Dodson](mailto:celeste@insurancefraud.org) ###### LTC Fraud Subcommittee Identifies emerging fraud trends in long-term care, helping to raise awareness within the industry, the public, and governmental agencies. Develops strategies to effectively combat insurance fraud, protect consumers, and preserve the integrity of the long-term care system. **Co-chairs:** [Jeff Ferrand](jeffferrand@illumifin.com), illumifin [Laurene A. Polignone](lpolignone@jhancock.com), John Hancock **Staff liaison:** [Celeste Dodson](mailto:celeste@insurancefraud.org) ###### Membership Subcommittee Promotes inclusion and representation across the Coalition while focusing on meeting member needs and expanding Coalition membership. Works to empower both public and private stakeholders to strengthen collaboration and achieve shared anti-fraud objectives. **Chair:** [Steve Piper,](mailto:Steven.Piper@cna.com) CNA **Staff liaison:** [Heidi Krumenauer](mailto:heidi@insurancefraud.org) ###### State Fraud Directors Subcommittee Discusses issues pertaining to the roles and responsibilities of state fraud directors. This group provides a platform for state leaders to align on anti-fraud strategies. ****Chair:**** [Anthony DiPaolo](mailto:adipaolo@ifb.org), Massachusetts Insurance Fraud Bureau **Staff liaison:** [Celeste Dodson](mailto:celeste@insurancefraud.org) --- ### [Amicus Program](https://insurancefraud.org/amicus-program/) **Published:** July 23, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Related Content: - [Government & Law](https://insurancefraud.org/government-law/) - [Model Acts](https://insurancefraud.org/model-acts/) ### The anti-fraud voice to America’s courts The Coalition files *amicus curiae* (“friend of the court”) briefs as a voice to federal and state courts on key anti-fraud issues. These decisions set national precedents. Important decisions greatly strengthen or damage how we combat fraud. Outcomes directly affect consumers and insurers alike. Over more than 20 years the Coalition remains a highly credible voice to courts. Coalition *amicus* briefs carry great weight and impact decisions. Our incisive briefs reflect our national leadership reputation — and the diverse voices of our members. Judges cite our arguments in landmark decisions supporting a stronger fraud fight. Courts listen when our nation’s anti-fraud leaders speak. ### Case Submissions Cases are reviewed by our Amicus Review Committee using the requirements below. Both civil and criminal cases are appropriate for amicus brief filings. Coalition amicus assistance is generally limited to state or federal courts of appeal or supreme courts. - **Summary:** Please provide a high-level summary of the original action and what triggered the request for amicus consideration. - **Judicial level:** What state or federal court has the matter been appealed to? - **Preservation:** Have the issues been preserved at the lower court level? - **Jurisdiction:** What is the court’s authority and significance, including the potential impact of the decision on the anti-fraud fight? - **Issues:** Are the facts and pleadings properly framed to address substantive anti-fraud issues? - **Position:** What position is the requesting party asking the Coalition to consider supporting? - **Status:** What is the current stage of the litigation, including pending actions, and anticipated next steps? - **Implications:** Does the case have national implications? Greater weight is given to cases where the decision will impact fraud laws nationally or in multiple states. - **Applicability:** Does the issue further the Coalition’s mission by advancing the interests of all constituents? - **Timing:** Sufficient research and drafting time are necessary to adequately prepare briefs for filing and the known or anticipated deadline for the amicus brief will need to be identified. Please provide all known or anticipated filing deadlines. - **Documents:** Please submit relevant case materials, including original filings and the most current ruling, opinion, or decision forming the basis of the amicus request. Please also provide documents related to relevant case law, prior amicus documents, or other related litigation. The Coalition’s Amicus Review Committee evaluates each request individually. Meeting any of these considerations does not guarantee amicus participation. The Coalition retains discretion to determine whether participation is appropriate based on the specific facts, legal issues, available resources, and strategic priorities of the organization. Submit the above to <governmentrelations@insurancefraud.org>. ### Coalition *amicus* briefs **[Allstate v. Innovo](https://insurancefraud.org/wp-content/uploads/7-29-2026-Coalition-Brief-of-Amicus-Curiae-Allstate-v-Innovo.pdf)** (United States Court of Appeals for the Fifth Circuit, 2026) • *Issue:* Allstate alleges a network of healthcare providers and related entities created fraudulent medical records and bills to inflate auto injury settlements. After the district court dismissed Allstate’s federal Racketeer Influenced and Corrupt Organizations Act (RICO) and Texas fraud claims, the Coalition’s amicus brief argues that the ruling conflicts with the Fifth Circuit’s recent *Allstate v. Bhagat* decision (see below). The Coalition contends insurers remain direct victims of organized fraud and that settlements based on fraudulent evidence do not bar recovery. The brief urges the Fifth Circuit to reverse. • *Outcome:* Pending **[Prudential v. Gardina](https://insurancefraud.org/wp-content/uploads/7_Motion-for-Leave-with-Prudential-v-Gardina-Amicus-Brief-Attached.pdf)** (United States Court of Appeals for the Eleventh Circuit, 2026) • *Issue:* In June 2023, Prudential sued a husband and wife for allegedly operating a long running long term care (LTC) fraud scheme that generated more than $1 million in payments over 20 years. A jury found the defendants liable for civil fraud and conspiracy involving LTC policies and awarded Prudential damages, including lost investment income and punitive damages. However, the trial court declined to void the policies because they lacked a “void for claim fraud” provision. Prudential appealed to the Eleventh Circuit. The Coalition argues that the District Court decision should be reversed, allowing insurers to void long term care policies upon findings of fraud. • *Outcome:* Pending **[People v. Woods](https://insurancefraud.org/wp-content/uploads/61339-20260326-RECEIVED-Stamped-CAIF-Amicus-Brief.pdf)** (California Supreme Court, 2026) • *Issue:* The Orange County District Attorney’s Office convicted a workers' compensation attorney of felony insurance fraud for participating in kickback schemes. The appellate court reversed these convictions, ruling that the attorney's conduct should have been prosecuted as a misdemeanor under a more specific Labor Code law rather than the general felony insurance fraud statute in the Penal Code. Subsequent to this ruling, the state of California closed this loophole with legislation. The Coalition contends that it was never the intent of legislature to weaken insurance fraud penalties by narrowing the Penal Code's application. • *Outcome:* Pending [**GEICO v. Mayzenberg**](https://insurancefraud.org/wp-content/uploads/GEICOvMayzenberg-amic-Coalition-brf.pdf) (New York Court of Appeals, 2025) • *Issue:* GEICO asserted that that paying for patient referrals (kickbacks) constitutes a licensing violation which renders a provider ineligible for reimbursement under the No-Fault Laws, thereby allowing for reimbursement on fraudulent bills for acupuncture services that were paid by GEICO as well as a declaratory judgment claim seeking to be relieved from responsibility on the unpaid claims. • *Outcome:* Unfavorable ruling. The New York Court of Appeals held that insurers cannot deny no fault reimbursement claims based solely on allegations that a provider engaged in improper referral payments or kickback schemes, even where such conduct may constitute professional misconduct (2025). **[Allstate v. Bhagat, et al](https://insurancefraud.org/wp-content/uploads/Coalition-Amicus-Brief-Allstate-v.-Bhagat-Case-FILE-STAMPED.pdf)** (United States Court of Appeals for the Fifth Circuit, 2025) • *Issue:* Allstate filed suit in July 2024 under the RICO statute (18 U.S.C. §§ 1962 and 1964) against several healthcare providers, alleging they engaged in a fraudulent scheme using a freestanding emergency care facility in Houston, Texas. The scheme allegedly involved unnecessary medical treatments, inflated charges, and improper attorney referrals to justify exaggerated personal injury claims. In addition to civil RICO, the lawsuit includes common law claims for fraud, conspiracy, and unjust enrichment. The Coalition contends that the trial court dismissed the case, erroneously requiring reliance to establish a RICO claim, contradicting Supreme Court and Fifth Circuit precedent, and also made factual determinations improper at the motion-to-dismiss stage. • *Outcome:* Favorable ruling. The Fifth Circuit reversed and remanded the district court’s dismissal of Allstate’s complaint in *Allstate v. Bhagat*, finding error in virtually every substantive holding reached by the lower court (2026). **[Allstate v. Carteret Comprehensive Medical Care](https://insurancefraud.org/wp-content/uploads/Allstate-v-Carteret-FILED-Amicus-Brief-with-Supporting-Documents.pdf)** (Supreme Court of New Jersey, 2024) • *Issue:* The issue under appeal centers around allegations of a complex insurance fraud conspiracy involving an illegal "doc-in-a-box" operation, with accusations of ongoing violations of the New Jersey Insurance Fraud Prevention Act (IFPA) and the state’s anti-racketeering statute. In a controversial decision, the case was remanded to New Jersey’s No-Fault arbitration system, which restricts subpoena issuance, offers minimal discovery opportunities, lacks authority to award damages or attorney’s fees, and severely curtails appeal rights. This outcome has the potential to significantly influence future fraud litigation strategies in New Jersey and other jurisdictions. The Coalition's brief argues that the trial court's decision threatens New Jersey consumers, insurers, and the State's ability to combat insurance fraud effectively. • *Outcome:* Favorable ruling. The New Jersey Appellate Division reversed the lower court’s decision, holding that claims under the Insurance Fraud Prevention Act (Fraud Act) and RICO are not subject to mandatory PIP arbitration in New Jersey (2025). Defendants appealed to the New Jersey Supreme Court, which affirmed the Appellate Division’s ruling (2026). [**State Farm Mut. Auto. Ins. Co. v. Michael LaRocca, D.C. et al.** ](https://insurancefraud.org/amicus-brief/ "State Farm Mut. Auto. Ins. Co. v. Michael LaRocca, D.C. et al. ")(United States Court of Appeals for the Eleventh Circuit, 2024) • *Issue:* The sole issue on appeal involves the statutory interpretation of Florida’s Health Care Clinic Act (“HCCA”), which states that if a clinic violates the HCCA, all charges of the clinic are unlawful, noncompensable, and subjects the owners and clinics to criminal penalties and disciplinary sanctions. The district court denied State Farm’s motion for summary judgment and barred it from advancing one of two theories. The jury returned a verdict for defendants on all claims. State Farm appealed and the Coalition's brief contends that the district court’s denial of summary judgment, and subsequent motion for reconsideration, should be reversed. After full briefing and oral argument, the Eleventh Circuit framed a question for the Florida Supreme Court concerning what it means to be “legally responsible” and a [second amicus brief](https://insurancefraud.org/wp-content/uploads/GT-Amicus-Curiae-Initial-Brief-6-30-2025.pdf "second amicus brief") was filed for the Coalition. • *Outcome:* Pending [**The Hanover Insurance Group, Inc. and Michael Arline, Jr. v. Luke Frazier** ](https://insurancefraud.org/wp-content/uploads/Hanover-v-Frazier.pdf)(Florida Second District Court of Appeal, 2023) • *Issue:* The principal issue is the application of statutory immunity from civil liability to insurance companies and SIU employees, arising from claims based on their reporting of suspected fraud to government entities, as required by law. The Coalition's brief highlights this statutory mechanism serves as a key tool in combating insurance fraud. • *Outcome:* The Florida Second District Court of Appeal agreed with the Coalition's amicus brief and reversed a lower court jury verdict to protect statutory immunity for insurance fraud reporting (2024). **[People ex rel. Allstate Ins. Co. et al. v. Discovery Radiology Physicians, P.C. et al.](https://insurancefraud.org/wp-content/uploads/2023.02.13-Amicus-Brief.pdf)** (California Court of Appeal for the Second District, 2023) • *Issue:* Allstate alleges the defendants committed insurance fraud by violating the corporate practice of medicine ban and operating a kickback scheme in contravention of California’s whistleblower statute, the Insurance Frauds Prevention Act (IFPA). The trial court dismissed the case, finding the corporate practice of medicine, and “structural fraud” more generally, are not viable theories of liability under the IFPA as a matter of law. Relying on the history of the IFPA and a wealth of case law, the Coalition’s brief contends the trial court’s holding was legally incorrect, and asks the Court of Appeal to reverse the trial court’s holding. • *Outcome:* The California Supreme Court denied the defendant's petition for review in People ex rel. Allstate Ins. Co. v. Discovery Radiology Physicians P.C. et al. and the Coalition-supported appellate decision stood (2023). [**State of California v. Encino Hospital Medical Center**](https://insurancefraud.org/wp-content/uploads/Encino-Hospital-Amicus-Brief.pdf) (Los Angeles County Superior Court, 2022) • *Issue:* Whether the California Insurance Fraud Prevention Act applies to fraudulent claims presented to HMOs and ERISA plans, which account for approximately 90% of the private health care market in California. The Coalition argues applying the IFPA to fraudulent claims made to HMOs and ERISA plans would be entirely consistent with the legislative purposes and public policies behind the law which is intended to combat all forms of insurance fraud including health care fraud, reduce the costs of insurance for consumers, and protect the fairness and integrity of the insurance system. [**Astellas Holdings v. Federal Insurance v. Federal Insurance Company** ](https://insurancefraud.org/wp-content/uploads/Astellas-Motion-and-Brief-Filed.pdf)(U.S. 7th Circuit Court of Appeals, 2022) • *Issue:* Decide whether insurers must indemnify a policyholder who agreed to a monetary settlement to resolve alleged federal False Claims Act violations. **[Taqueria El Primo LLC et al v. Farmers Group, Inc. et al.](https://insurancefraud.org/wp-content/uploads/Taqueria-El-Primo-LLC-et-al-v.-Farmers-Group-Inc.pdf)** (District Court of Minnesota, 2022) • *Issue:* Deciding whether Farmers Insurance anti-fraud efforts identifying medical providers they allege are committing PIP billing improprieties and then entering into “billing moratorium” agreements with those clinics to stop billing the company, violates the state’s no-fault law. • *Outcome:* The [Eighth Circuit Court of Appeals held](https://insurancefraud.org/wp-content/uploads/Taqueria-v-Farmers-appellate-decision.pdf) (2024) Farmers did not violate Minnesota’s No-Fault Act by entering into confidential, civil settlement agreements in which healthcare providers suspected of fraud agreed not to bill Farmers or its insureds for treatment (“no-bill agreements”). The appellate court then remanded the case to the district court to consider the impact of its decision on the plaintiffs’ claims for damages. **[Liberty Insurance v. Techdan](https://insurancefraud.org/wp-content/uploads/Amicus-Merits-Brief-Liberty-v.-Techdan.pdf) (Supreme Court of New Jersey, 2021) • *Issue:* Should those found liable for committing insurance fraud be subject to joint or several liability for awarded damages. **[S](https://insurancefraud.org/wp-content/uploads/Skillet-v-Allstate-Amicus-Brief-by-Coalition-Against-Insurance-Fraud-11.2.21.pdf)[killet v. Allstate](https://insurancefraud.org/wp-content/uploads/Skillet-v-Allstate-Amicus-Brief-by-Coalition-Against-Insurance-Fraud-11.2.21.pdf)** (U.S. District Court for the District of Colorado, 2021) • *Issue:* Personal liability in bad faith lawsuits. **[Keystone RX LLC v. Bureau of Workers' Compensation Fee Review **Hearing Office**](https://insurancefraud.org/wp-content/uploads/Keystone-Coalition_s-Amicus-Curiae-Brief-at-No.-27-EAP-2020-ts-134188272_1.pdf)** (Pennsylvania Supreme Court, 2020) • *Issue:* Right of providers to participate in review hearings/compound pharmaceutical fraud. **[Illinois v. Family Vision Care](https://insurancefraud.org/wp-content/uploads/Illinois_v_Family_Vision_Care_amicus.pdf)** (Illinois Supreme Court, 2020) • *Issue:* State financial loss on citizen whistleblower actions. [**Dr. Robert D. Haar, M.D. v. Nationwide Mutual** ](https://insurancefraud.org/wp-content/uploads/Haar-v-Nationwide.pdf)(New York Court of Appeals, 2019) • *Issue:* Immunity for good faith fraud reporting. **[Keodalah v. Allstate Insurance Company](https://insurancefraud.org/wp-content/uploads/Keodalalah_v_Allstate_amicus.pdf)** (Supreme Court of Washington State, 2019) • *Issue:* Personal liability in bad faith lawsuits. **[Restoration 1 of Port St. Lucie v. Ark Royal Insurance](https://insurancefraud.org/wp-content/uploads/Florida_Ark_Royal_Coalition_Amicus.pdf)** (Florida Supreme Court, 2019) • *Issue:* Assignment of benefits rights. **[Andrew Carothers, MD, PC v. Progressive Insurance](https://insurancefraud.org/wp-content/uploads/Carothers_Amicus-Brief.pdf)** (New York Court of Appeals, 2019) • *Issue:* Sham medical clinics. [**Allstate v. Rehab Alliance of Texas** ](https://insurancefraud.org/wp-content/uploads/Allstate_v_Rehab_Alliance_amicus.pdf)(Supreme Court of Texas, 2016) • *Issue:* Standards for pursuing recovery actions. **[State Farm Mutual Automobile v. Roniesha Adams](https://insurancefraud.org/wp-content/uploads/State_Farm_v_Adams_amicus.pdf)** (Supreme Court of Kentucky, 2016) • *Issue:* Examinations Under Oath. **[Jocelyn Zolna Pitts. v. ATI Holdings](https://insurancefraud.org/wp-content/uploads/CoalitionZolnaAmicusBrief.pdf)** (Appellate Court of Illinois, First Judicial District, 2014) • *Issue:* Application of state whistleblower fraud law. **[Hambarian vs. Orange County Superior Court](https://insurancefraud.org/wp-content/uploads/Hambarian_brief.pdf)** (California Supreme Court, 2001) *Issue:* victim participation in prosecution of insurance fraud [**Commonwealth of Massachusetts v. James N. Ellis, Sr.** ](https://insurancefraud.org/wp-content/uploads/Ellis_brief.pdf)(Massachusetts Supreme Court, 1998) • *Issue:* insurer funding of state fraud bureaus. --- ### [Legislative Priorities](https://insurancefraud.org/legislative-priorities/) **Published:** January 16, 2024 **Author:** Brent Walker **Content:** The Coalition Against Insurance Fraud develops legislative priorities, annually, through its Government Affairs Committee, in collaboration with other committees and member input. Approved by the Executive Committee and circulated to the membership, these priorities: - align with the Coalition’s goal to combat all forms of insurance fraud, - reduce costs for consumers and insurers, and - promote fairness and integrity in the insurance system. While this is a collaborative effort that strives for mutual consensus, individual members may hold differing views. The listed legislative priorities seek to encompass diverse perspectives within the Coalition, and active feedback and dialogue from members are encouraged, emphasizing the vital role of the Government Affairs Committee. **2026 Legislative Priorities** ### **Protecting Consumers from Insurance Fraud** - Advocating for strong laws to prevent scams that directly harm consumers, e.g., sober home fraud, corporate fraud, adjuster and agent fraud, contractor fraud, unlicensed public adjusting, towing/storage fraud, staged accidents, and others. - Supporting efforts to inform and educate consumers about legislative and regulatory efforts to reduce insurance fraud victimization. - Continuing to seek the criminalization of counterfeit and fraudulent airbags to protect consumer safety. - Engaging within the NAIC Consumer Representatives program to highlight emerging fraud schemes and promote stronger consumer safeguards. ### **Safeguarding the Insurance System Against Fraud** - Supporting the creation, funding, and modernization of state insurance fraud bureaus to ensure robust investigative and prosecutorial authority. - Advocating for stronger laws that address fraud schemes, global threats, organized crime, and other illegal activities that negatively impact the insurance industry and consumers. - Engaging with NAIC’s Antifraud (D) Task Force and NCOIL to modernize existing model laws or create new model laws to protect consumers and the industry. - Promoting antifraud immunity protections and improved information sharing among insurers, regulators, and law enforcement. - Supporting enhanced penalties for repeat offenders and schemes that inflate costs or erode consumer trust. ### **Navigating Emerging Antifraud Issues with Data, Technology, and Privacy** - Monitoring state and federal consumer data privacy initiatives to ensure antifraud exemptions are preserved. - Advocating for the responsible use of technology, including AI, and predictive analytics, in fraud detection. - Identifying legislative opportunities to prohibit criminal misuse of AI, deepfakes, synthetic identities, and other digital manipulation schemes. - Tracking evolving issues such as cyber-enabled fraud, and digital privacy concerns that can impact claims and investigations. [2026 Legislative Priorities](https://insurancefraud.org/wp-content/uploads/Coalition-2026-Legislative-Priorities.pdf) (download) [2026 Legislative Calendar](https://www.ncsl.org/about-state-legislatures/2026-state-legislative-session-calendar) [State Regulations & Statutes Map](https://insurancefraud.org/government-law/) [Legislation Map](https://insurancefraud.org/legislation) --- ### [Government & Law](https://insurancefraud.org/government-law/) **Published:** December 1, 2023 **Author:** Coalition Against Insurance Fraud **Content:** ## State Regulations and Statutes Browse anti-fraud regulations and statutes across the country. Looking for pending legislation? [View the Anti-Fraud Legislation Tracker →](/legislation) --- ### [Public Interest Members](https://insurancefraud.org/public-interest-members/) **Published:** September 17, 2024 **Author:** Coalition Against Insurance Fraud **Content:** To learn more about each of our Public Interest partners, click on the logos below. We value the ongoing support of our Coalition partners as we grow stronger together. **Please Note:** By clicking on a Public Interest Member logo link, you will be directed to a website outside of www.insurancefraud.org. Outside organizations may hold views or positions that differ from those of the Coalition. --- [ ![](https://insurancefraud.org/wp-content/uploads/ACCI-scaled.jpg) ](https://www.consumerinterests.org/) [ ![](https://insurancefraud.org/wp-content/uploads/American-Policyholders-Association.jpg) ](https://apassociation.org/) [ ![](https://insurancefraud.org/wp-content/uploads/AFA-3.png) ](https://antifraudalliance.org/) [ ![](https://insurancefraud.org/wp-content/uploads/California-Health-Advocates.png) ](https://cahealthadvocates.org/) [ ![](https://insurancefraud.org/wp-content/uploads/Call-for-Action.png) ](https://callforaction.org/) [ ![](https://insurancefraud.org/wp-content/uploads/CARIE.png) ](https://www.carie.org/) [ ![](https://insurancefraud.org/wp-content/uploads/Consumer-Action-1.png) ](https://www.consumer-action.org/) [ ![](https://insurancefraud.org/wp-content/uploads/Consumer-Federation-of-America.png) ](https://consumerfed.org/) [ ![](https://insurancefraud.org/wp-content/uploads/Families-USA.png) ](https://familiesusa.org/) [ ![](https://insurancefraud.org/wp-content/uploads/FAIR.png) ](https://www.federalinsurancereform.org/) [ ![](https://insurancefraud.org/wp-content/uploads/Federation-of-Manufactured-Home-Owners-of-Florida.png) ](https://www.fmo.org/) [ ![](https://insurancefraud.org/wp-content/uploads/Florida-Insurance-Consumer.png) ](https://www.myfloridacfo.com/division/ica) [ ![](https://insurancefraud.org/wp-content/uploads/GIFS-1.png) ](https://globalinsurancefraudsummit.org/) [ ![](https://insurancefraud.org/wp-content/uploads/Identity-Theft-Resource-Center.png) ](https://www.idtheftcenter.org/) [ ![](https://insurancefraud.org/wp-content/uploads/jarrodslaw.jpg) ](https://jarrodslaw.org/) [ ![](https://insurancefraud.org/wp-content/uploads/L.A.-Care.png) ](https://www.lacare.org/) [ ![](https://insurancefraud.org/wp-content/uploads/SMPLogoRGB.jpg) ](https://smpresource.org/) [ ![](https://insurancefraud.org/wp-content/uploads/SHIP.png) ](https://www.shiphelp.org/) [ ![](https://insurancefraud.org/wp-content/uploads/United-Policyholders.png) ](https://uphelp.org/) --- ### [2026 Midyear Membership Meeting](https://insurancefraud.org/2026-midyear-membership-meeting/) **Published:** July 1, 2026 **Author:** Joseph Matos **Content:** The Coalition extends sincere appreciation to all who attended and presented at the Midyear Meeting in June, helping to make it an outstanding success. Throughout the day, industry leaders, regulators, legal experts, and fraud-fighting professionals led sessions on some of the most pressing issues facing the insurance industry, including artificial intelligence, transnational organized crime, synthetic identity fraud, cyber-enabled fraud, title insurance fraud, account takeover risks, and emerging fraud trends. Resources from the Midyear Meeting are available to download. We encourage you to share these with your teams, leaders, and across organizational verticals where others may benefit from having a greater understanding of these topics and the Coalition’s mission to bring greater awareness to fighting insurance fraud. ![](https://insurancefraud.org/wp-content/uploads/New-Orleans-Artwork-1024x571.png)**[2026 Midyear Meeting Board Book](https://insurancefraud.org/wp-content/uploads/2026-June-Midyear-Meeting-Board-Book.pdf)** [2026 Midyear Meeting Coalition Accomplishments Video](https://insurancefraud.org/wp-content/uploads/Coalition-Video-Approved-New-Script-Version.-Faster-VO.mp4) [2026 Midyear Meeting Member Reception Video](https://insurancefraud.org/wp-content/uploads/2026-Midyear-Meeting-Member-Reception-Video.mp4) **Meeting Presentations** • [Shane Riedman – Verisk: 2026 State of Insurance Fraud Study](https://insurancefraud.org/wp-content/uploads/Shane-Riedman-Coalition-Against-Insurance-Fraud-Mid-Year-Meeting.pdf) • [Joel Norris – Pearson Professional Assessments: From Test to Theft: How Illicit Licensing May Be Fueling Insurance Fraud](https://insurancefraud.org/wp-content/uploads/Joel-Norris-Pearson-Professional-Assessments.pdf) • [Dave Smolensky- Resolute: When Cyber Incidents Become Fraud Opportunities](https://insurancefraud.org/wp-content/uploads/Dave-Smolensky-When-Cyber-Incidents-Become-Fraud-Opportunities.pdf) • [Brian Biggs – ICW/Anti-Fraud Alliance: The Power of Partnership Scaling Anti-Fraud Awareness Collaboratively](https://insurancefraud.org/wp-content/uploads/Brian-Biggs-The-Power-of-Partnership_-Scaling-Anti-Fraud-Awareness-Collaboratively.pdf) • [Brent Walker – Coalition’s Director of Government Relations: Advocacy in Action](https://insurancefraud.org/wp-content/uploads/Brent-Walker-2026-Midyear-Meeting-ADVOCACY-IN-ACTION.pdf) • [Steve Gottheim – American Land Title Association: Emerging Fraud Schemes Impacting the Industry](https://insurancefraud.org/wp-content/uploads/Steve-Gottheim_Mary-Thomas-Emerging-Fraud-Schemes-Impacting-the-Industry.pdf) --- ### [About the Coalition](https://insurancefraud.org/about-us/) **Published:** May 26, 2026 **Author:** Karen Montgomery **Content:** #### Our Mission The Coalition Against Insurance Fraud brings together and empowers both private and public partners to fight insurance fraud through outreach, advocacy, and research. The Coalition was built on the principle that insurance fraud cannot be solved by any one entity alone. By bringing together government agencies, regulators, insurers, and consumers, the Coalition creates a unified force dedicated to advancing meaningful, industry-wide change. --- #### Our Story Since our founding in 1993, we have grown from 16 charter organizations representing consumers, insurers, and government agencies into a network of more than 320 organizations, all united by a shared mission to combat insurance fraud and make a greater impact than any could achieve alone. Today, we lead the fight across four key areas: Legislative & Judicial Action, Public Awareness, Research, and Collaboration. Our strength lies in the diversity of our membership, uniting perspectives from consumers, government, academia, and industry to foster collaboration and advance the fight against insurance fraud. This unique partnership has earned lasting credibility and influence with legislators, regulators, the media, and the courts — and remains the cornerstone of our success. --- #### What We Do The Coalition drives progress across four areas: **Legislative & Judicial Action** — Advocating for strong anti-fraud laws and filing amicus briefs in pivotable court cases. **Public Awareness** — Educating consumers and the public on how to recognize and report insurance fraud. **Research** — Producing objective, credible research that informs policy and industry practice. **Collaboration** — Convening insurers, regulators, consumers, and government agencies to share intelligence and coordinate action. --- #### Explore the Coalition [Member Organizations Explore the diverse network of organizations united in the fight against insurance fraud. ](https://insurancefraud.org/coalition-members/) [Officers & Board of Directors Meet the leadership guiding the Coalition’s strategy, governance, and long-term direction. ](https://insurancefraud.org/officers-directors-board/) [Coalition Staff Meet the dedicated team driving our mission and supporting members in the fight against insurance fraud. ](https://insurancefraud.org/staff/) [Committees & Task Forces Learn about the working groups that tackle specific fraud issues and drive focused action. ](https://insurancefraud.org/committees/) [Bylaws Access the rules and procedures that govern how the Coalition is structured, led, and operated. ](https://insurancefraud.org/wp-content/uploads/Adopted-Coalition-Bylaws-Effective-December-10-2024.pdf) [Code of Conduct Review the ethical standards members uphold to keep meetings and events welcoming and productive. ](https://insurancefraud.org/wp-content/uploads/Member-Code-of-Conduct-2025.pdf) [Guiding Principles Review the shared values and commitments that define how Coalition members work together. ](https://insurancefraud.org/wp-content/uploads/Coalition-Guiding-Principles-2025.pdf) ## Interested in joining the Coalition? Membership is open to organizations committed to fighting insurance fraud. Learn about the benefits, requirements, and how to apply. [Explore Membership](https://insurancefraud.org/join-us/) --- ### [Join Us](https://insurancefraud.org/join-us/) **Published:** May 26, 2026 **Author:** Karen Montgomery **Content:** #### Join the 320+ Organizations Fighting Insurance Fraud Membership is open to organizations, not individuals. Ready to apply? Is your organization a [Coalition member](https://insurancefraud.org/coalition-members/)? Log in to access your benefits. [Apply Now](https://members.insurancefraud.org/page/member-application) [Member Login](https://members.insurancefraud.org/login.aspx) #### Who We Are Since 1993, the Coalition Against Insurance Fraud has united insurers, government agencies, consumers, and industry partners around one mission: fighting fraud through outreach, advocacy, and research. Today, more than 320 member organizations rely on the Coalition as their national hub for collaboration, intelligence, and impact. [Learn more about our history and mission.](https://insurancefraud.org/about-us/) #### Why Join ![](https://insurancefraud.org/wp-content/uploads/megaphone-thin.svg)Amplify your voice Add your voice to a national network of anti-fraud leaders. ![](https://insurancefraud.org/wp-content/uploads/magnifying-glass-thin.svg)Access tools Tap into research, fraud law, custom outreach materials, legal support, and more. ![](https://insurancefraud.org/wp-content/uploads/shield-thin.svg)Lead the fight Participate in committees, task forces, research, and events. #### What Members Say “The Coalition continues to uniquely provide awareness and unite in fighting the good fight against insurance fraud.” Steve Piper Global Head of Special Investigations, CNA Insurance “NCOIL’s ‘go to’ resource when dealing with insurance fraud issues.” William Melofchik General Counsel, NCOIL #### Benefits ● Network with insurance carriers and government entities ● Receive advocacy support on anti-fraud policy and legislative issues through our Government Relations efforts ● Access anti-fraud state laws, regulations, research studies, and member-only data ● Join one or more of our [committees and task forces](https://insurancefraud.org/committees/) ● Request legal support through our long-standing Amicus Curiae Program ● Attend the Coalition Midyear and Annual meetings, webinars, and events ● Partner with the Coalition on joint anti-fraud projects, including research and other initiatives #### Ready to join the fight against insurance fraud? Membership is open to organizations. Not sure if your organization qualifies? [View member types.](https://members.insurancefraud.org/page/membercategories) Apply today or contact us at <memberservices@insurancefraud.org> to learn more. [Apply Now](https://members.insurancefraud.org/page/member-application) --- ### [Association Members](https://insurancefraud.org/association-members/) **Published:** May 14, 2025 **Author:** Coalition Against Insurance Fraud **Content:** **Meet Our Association Members** Explore the organizations represented below. Each logo highlights a member making a meaningful contribution to combating insurance fraud. We are grateful for the dedicated support of our Association Members, whose commitment strengthens our collective efforts and progress. **Please Note:** Clicking on any of the logos will take you to an external website not affiliated with [www.insurancefraud.org](http://www.insurancefraud.org/). These organizations may express views or positions that do not necessarily reflect those of the Coalition. --- [ ![](https://insurancefraud.org/wp-content/uploads/APCIA.png) ](https://www.apci.org/) [ ![](https://insurancefraud.org/wp-content/uploads/AHIP.png) ](https://www.ahip.org/) [ ![](https://insurancefraud.org/wp-content/uploads/BlueCross.png) ](https://www.bcbs.com/) [ ![](https://insurancefraud.org/wp-content/uploads/IASIU-logo-1.png) ](https://www.iasiu.org/) [ ![](https://insurancefraud.org/wp-content/uploads/IAAI.png) ](https://www.firearson.com/) [ ![](https://insurancefraud.org/wp-content/uploads/NAMIC.png) ](https://www.namic.org/) [ ![](https://insurancefraud.org/wp-content/uploads/NAPIA-2.png) ](https://www.napia.com/) [ ![](https://insurancefraud.org/wp-content/uploads/NHCAA-2.png) ](https://www.nhcaa.org/) [ ![](https://insurancefraud.org/wp-content/uploads/NICB.png) ](https://www.nicb.org/) [ ![](https://insurancefraud.org/wp-content/uploads/South-Carolina-Wind-and-Hail-Underwriting-Association.png) ](https://www.scwind.com/) [ ![](https://insurancefraud.org/wp-content/uploads/united-brotherhood-carpenters-and-joiners-of-america.jpg) ](https://www.carpenters.org/) --- ### [Associate Members](https://insurancefraud.org/associatemembers/) **Published:** July 23, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Explore our Associate Members below, each logo offers a window into an organization making a real impact across the insurance fraud landscape. We deeply appreciate the steadfast support of our committed Associate Members, which fuels our collective growth. If you are inspired to join, please contact Associate Member Task Force Chair Frank Sztuk at fsztuk@deltagroup.net today! Please Note: By clicking on any of the Associate Member logos below, you will be redirected to a website outside of www.insurancefraud.org. Outside organizations may hold views or positions that differ from those of the Coalition. #### To view a comparison matrix of Associate Member services, [ click here.](https://insurancefraud.org/wp-content/uploads/Associate-Member-Service-Matrix-Survey.pdf) --- [ ![](https://insurancefraud.org/wp-content/uploads/4WARN.png) ](https://www.4warn.com/) [ ![](https://insurancefraud.org/wp-content/uploads/Advantage-Investigations-1.png) ](https://advantageinvestigations.com/) [ ![](https://insurancefraud.org/wp-content/uploads/Agero.png) ](https://www.agero.com/) [ ![](https://insurancefraud.org/wp-content/uploads/Allied-Universal-formerly-G4S.png) ](https://www.aus.com/) [ ![](https://insurancefraud.org/wp-content/uploads/Becker-Company.png) ](https://www.beckerpi.com/) [ ![](https://insurancefraud.org/wp-content/uploads/Carpe-Data.png) ](https://carpe.io/) [ ![](https://insurancefraud.org/wp-content/uploads/CarpentersContractors-Cooperation-Committee-Inc.png) ](https://www.quadc.org/) [ ![](https://insurancefraud.org/wp-content/uploads/CCC.jpg) ](https://cccis.com/) [ ![](https://insurancefraud.org/wp-content/uploads/CDI.png) ](https://www.cdicanvassing.com/) [ ![](https://insurancefraud.org/wp-content/uploads/CCC-1.png) ](https://socalccc.org/) [ ![](https://insurancefraud.org/wp-content/uploads/Charlee.ai-Inc.png) ](https://charlee.ai/) [ ![](https://insurancefraud.org/wp-content/uploads/Clearspeed-Logo-Blue-Gradient-1-1.png) ](https://www.clearspeed.com/) [ ![](https://insurancefraud.org/wp-content/uploads/Command-Investigations.png) ](https://gocommand.com/) [ ![](https://insurancefraud.org/wp-content/uploads/Contego-Investigative-Services-1.jpg) ](https://contegosiu.com/) [ ![](https://insurancefraud.org/wp-content/uploads/CostFirst-Corp.jpg) ](https://www.costfirst.com/) [ ![](https://insurancefraud.org/wp-content/uploads/CoventBridge-Group-Logo.png) ](https://www.youtube.com/watch?v=3Ei_J4kIpMM&feature=youtu.be) [ ![](https://insurancefraud.org/wp-content/uploads/Delta-Group-logo.jpg) ](https://www.deltagroup.net/) [ ![](https://insurancefraud.org/wp-content/uploads/Demotech-scaled.jpg) ](https://www.demotech.com/) [ ![](https://insurancefraud.org/wp-content/uploads/Diligence-1.png) ](https://digroup-us.com/) [ ![](https://insurancefraud.org/wp-content/uploads/Equifax.png) ](https://www.equifax.com/) [ ![](https://insurancefraud.org/wp-content/uploads/Ethos-Logo-2023-scaled.jpg) ](https://ethosrisk.com/) [ ![](https://insurancefraud.org/wp-content/uploads/Evadata.png) ](https://www.evadata.com/) [ ![](https://insurancefraud.org/wp-content/uploads/ForMotiv.png) ](https://formotiv.com/) [ ![](https://insurancefraud.org/wp-content/uploads/Frasco.jpg) ](https://frasco.com/) [ ![](https://insurancefraud.org/wp-content/uploads/FRISS.png) ](https://www.friss.com/about/) [ ![](https://insurancefraud.org/wp-content/uploads/Fuzion-logo-2c.webp) ](https://www.fuzionservices.com/) [ ![](https://insurancefraud.org/wp-content/uploads/healthsherpa_logo.png) ](https://www.healthsherpa.com/) [ ![](https://insurancefraud.org/wp-content/uploads/Hodson-PI.png) ](https://www.hodsonpi.com/) [ ![](https://insurancefraud.org/wp-content/uploads/IDI-Data.png) ](https://www.ididata.com/) [ ![](https://insurancefraud.org/wp-content/uploads/illiumifin-logo.png) ](https://www.illumifin.com/) [ ![](https://insurancefraud.org/wp-content/uploads/Insurance-Care-Direct.png) ](https://insurancecaredirect.com/) [ ![](https://insurancefraud.org/wp-content/uploads/Intertel.png) ](https://intertelinc.com/) [ ![](https://insurancefraud.org/wp-content/uploads/Screenshot-2026-03-11-at-2.23.59-PM.png) ](https://isgvalue.com/) [ ![](https://insurancefraud.org/wp-content/uploads/LEMIEUX-ASSOCIATES.png) ](https://www.lemieuxassociates.com/) [ ![](https://insurancefraud.org/wp-content/uploads/LexisNexis.jpg) ](https://www.lexisnexis.com/en-us/about-us/about-us.page) [ ![](https://insurancefraud.org/wp-content/uploads/North-American-Training-Group.png) ](https://fraudeducation.com/) [ ![](https://insurancefraud.org/wp-content/uploads/PhotoFax-Horizontal-logo-Navy-scaled.jpg) ](https://photofax.com/) [ ![](https://insurancefraud.org/wp-content/uploads/Pilotbird.png) ](https://www.pilotbird.com/) [ ![](https://insurancefraud.org/wp-content/uploads/pwc-logo-scaled.png) ](https://www.pwc.com/) [ ![](https://insurancefraud.org/wp-content/uploads/Quantexa.png) ](https://www.quantexa.com/) [ ![](https://insurancefraud.org/wp-content/uploads/RA-Logo-scaled.jpg) ](https://www.linkedin.com/company/rockholt-&-associates-llc) [ ![](https://insurancefraud.org/wp-content/uploads/Search-Pros-Inc.jpg) ](https://search-pros.com/) [ ![](https://insurancefraud.org/wp-content/uploads/Sedgwick-Claims-Management-Services-Inc.png) ](https://www.sedgwick.com/) [ ![](https://insurancefraud.org/wp-content/uploads/Shift-Technology-1.png) ](https://www.shift-technology.com/) [ ![](https://insurancefraud.org/wp-content/uploads/Skopenow-2.png) ](https://www.skopenow.com/) [ ![](https://insurancefraud.org/wp-content/uploads/Snapsheet.png) ](https://www.snapsheetclaims.com/) [ ![](https://insurancefraud.org/wp-content/uploads/Social-Discovery.png) ](https://www.socialdiscoverycorp.com/) [ ![](https://insurancefraud.org/wp-content/uploads/Sphere-Investigations.png) ](https://www.sphereinvestigations.com/) [ ![](https://insurancefraud.org/wp-content/uploads/Uber.png) ](https://www.uber.com/us/en/about/?uclick_id=d4d50894-be08-4599-9632-06124a3f8c5f) [ ![](https://insurancefraud.org/wp-content/uploads/VRC-LOGO.jpg) ](https://vrcinvestigations.com/) [ ![](https://insurancefraud.org/wp-content/uploads/Verisk-1.png) ](https://www.verisk.com/) [ ![](https://insurancefraud.org/wp-content/uploads/Watchpoint-1.png) ](https://watchpointsiu.com/) [ ![](https://insurancefraud.org/wp-content/uploads/Whooster-Powered-By-Owl-scaled.png) ](https://whooster.com/industries/insurance-financial-services/) --- ### [Government Affairs Network](https://insurancefraud.org/government-affairs-network/) **Published:** May 13, 2026 **Author:** Coalition Against Insurance Fraud **Content:** **Summary** The Coalition is working to strengthen its Government Affairs Network to support timely communication regarding legislative developments, advocacy initiatives, and other antifraud issues impacting the industry. To support that mission, the Government Affairs Committee has created a Government Affairs Engagement Survey to collect contact information for individuals within member organizations involved in government affairs, legislative, regulatory, or public policy activities related to insurance fraud. The survey should take less than five minutes to complete. Download the PDF and complete it by Friday, June 5. Return it to: <MemberServices@insurancefraud.org> Click on the links below to access the resources: ![](https://insurancefraud.org/wp-content/uploads/Access-Survey.png) [Survey Link](https://s.surveyplanet.com/0mfkcc1s) ![](https://insurancefraud.org/wp-content/uploads/Download-Survey.png) [Download](https://insurancefraud.org/wp-content/uploads/2026-Government-Relations-Survey.pdf) For more information or if you have questions, contact <memberservices@insurancefraud.org>. --- ### [Victim Impact Resources](https://insurancefraud.org/victim-impact-statement-program/) **Published:** January 31, 2026 **Author:** Coalition Against Insurance Fraud **Content:** **Summary** The Coalition Against Insurance Fraud’s Victim Impact resource equips victims of insurance fraud with the tools and resources needed to craft meaningful and effective victim impact letters. These letters help courts better understand the full financial, emotional, and societal consequences of insurance fraud, supporting more informed sentencing and stronger accountability. Through guidelines and sample resources, this empowers insurers and other victims to elevate their voice in the judicial process, strengthen fraud prosecution efforts, and promote fair, impactful outcomes that reflect the true cost of insurance fraud. **Victim Impact Resources:** - **Overview:** The problem summary and its key objectives. - **Guidelines:** Answers to general questions and how to utilize the resources. - **Letter of Intent Template:** A customizable template for informing the courts of your interest in a case and requesting case updates. - **Sample Impact Statement Letter Template:** A customizable template for providing the courts with case facts, restitution details, and sentencing requests. Click on the links below to access the resources: ![](https://insurancefraud.org/wp-content/uploads/program-overview-e1769884099945.png) [Download](https://insurancefraud.org/wp-content/uploads/Victim-Impact-Program-Overview-.pdf) ![](https://insurancefraud.org/wp-content/uploads/program-guidelines-e1769884220561.png) [Download](https://insurancefraud.org/wp-content/uploads/Guidelines-for-Victim-Impact-Statement-Program.pdf) ![](https://insurancefraud.org/wp-content/uploads/letter-of-intent-e1769883818376.png) [Download](https://insurancefraud.org/wp-content/uploads/Sample-Letter-of-Intent-for-Victim-Impact-Statement.docx) ![](https://insurancefraud.org/wp-content/uploads/sample-impact-victim-statement-letter-e1769884146624.png) [Download](https://insurancefraud.org/wp-content/uploads/Sample-Victim-Impact-Statement-Letter.docx) For more information or if you have questions, contact <Kate@insurancefraud.org>. --- ### [Fraud: Why Care?](https://insurancefraud.org/fraud-why-care/) **Published:** July 23, 2020 **Author:** Coalition Against Insurance Fraud **Content:** ### Fraud Impacts Everyone ##### Insurance fraud is one of the largest crimes in the U.S. It costs consumers at least $308.6 billion annually, according to the Coalition Against Insurance Fraud. These costs lead to higher insurance premiums for you and your family. ##### Beyond the financial impact, insurance fraud causes physical harm and destabilizes businesses. While some may view it as a victimless crime, the consequences are severe. Convicted fraudsters face jail time, significant fines, and a permanent criminal record. ##### Watch this three-part video series featuring Michelle Rafeld, executive director of the Coalition. She explains how insurance fraud works and how it affects your daily life. Part 1 of 3 – **A Glimpse Into The World Of Insurance Fraud** Part 2 of 3 – **The Coalition’s Role In Fighting Insurance Fraud** Part 3 of 3 – **Consumer Attitudes Are Changing** --- ### [State Laws Table](https://insurancefraud.org/government-law-2/key-state-laws/) **Published:** February 17, 2021 **Author:** Coalition Against Insurance Fraud **Content:** ### Key State Laws [Click here to print](https://insurancefraud.org/wp-content/uploads/Key-State-Laws-Against-Insurance-Fraud.pdf). --- ### [Law Firm Members](https://insurancefraud.org/law-firm-members/) **Published:** September 13, 2024 **Author:** Coalition Against Insurance Fraud **Content:** Explore our current Law Firm Members below, click on any logo to discover more about each organization. We sincerely appreciate the unwavering support of our elite Coalition Law Firm members, which fuels our growth and also the success of our Amicus Curiae program. **Please Note:** By clicking on any of the Law Firm logo links below, you will be directed to a website outside of www.insurancefraud.org. Outside organizations may hold views or positions that differ from those of the Coalition. --- [ ![](https://insurancefraud.org/wp-content/uploads/Bruno-Gerbino-1.png) ](https://bgslaw-ny.com/) [ ![](https://insurancefraud.org/wp-content/uploads/Cozen.png) ](https://www.cozen.com/) [ ![](https://insurancefraud.org/wp-content/uploads/Faegre-Drinker-Biddle-Reath-LLP.png) ](https://www.faegredrinker.com/en/) [ ![](https://insurancefraud.org/wp-content/uploads/GladstoneWeisberg.png) ](https://gladstoneweisberg.com/) [ ![](https://insurancefraud.org/wp-content/uploads/greenberg-traurig-logo.png) ](https://www.gtlaw.com/en/) [ ![](https://insurancefraud.org/wp-content/uploads/Katten.png) ](https://katten.com/) [ ![](https://insurancefraud.org/wp-content/uploads/KPM.png) ](https://www.kpmlaw.com/) [ ![](https://insurancefraud.org/wp-content/uploads/Lewis-Brisbois.jpg) ](https://lewisbrisbois.com/) [ ![](https://insurancefraud.org/wp-content/uploads/Manning-Kass.jpg) ](https://www.manningkass.com/#sthash.zknRtjjI.dpbs) [ ![](https://insurancefraud.org/wp-content/uploads/Marshall-Dennehey-1.jpg) ](https://marshalldennehey.com/) [ ![](https://insurancefraud.org/wp-content/uploads/Rivin.png) ](https://www.rivkinradler.com/) --- ### [2024 Midyear Membership Meeting](https://insurancefraud.org/2024-midyear-meeting-overview/) **Published:** July 27, 2023 **Author:** Coalition Against Insurance Fraud **Content:** We are absolutely thrilled to announce the successful conclusion of the 2024 Coalition Against Insurance Fraud event in Kansas City, MO! The event saw an outstanding turnout, with over 100 dedicated members and their organizations coming together to share their extensive expertise on insurance fraud matters. This gathering proved to be an incredible opportunity for professionals across the industry to engage in deep, meaningful discussions about the current landscape of insurance fraud and the innovative strategies needed to combat it. Throughout the event, participants delved into a wide range of pressing topics that are impacting the industry today. The conversations were not only insightful but also forward-thinking, providing invaluable perspectives on how fraudsters are evolving and the tactics they might employ in the future. These insights are crucial for our collective efforts to stay ahead of the curve and develop robust defenses against emerging threats. A special and heartfelt thank you goes out to our 25 elite presenters. These experts traveled from various parts of the country, and even from abroad, to share their knowledge and experiences. Our esteemed presenters included: 3. *Erik Charlick, California DOI* *1. Ross Silverman, Chair, Katten Muchin Rosenman LLP* 4. *Vince Gerbino, Bruno, Gerbino, Soriano & Aitken* 5. *Vince Albers, AON* 6. *Steve Jarrett, Westfield Insurance* 7. *Tim Hopper, Sentry Insurance* 8. *Mariela Pennock, Assurant* 9. *Lin Werkheiser, Command Investigations* 10. *Ryan Malone, Travelers SIU* 11. *Arteniece L. Lee, Horace Mann Insurance* 12. *Kevin Glasgow, Diligence International Group, LLC* 13. *Craig Koerner, Farmers Insurance Exchange* 14. *Richard Matarante, New York Life Insurance* 15. *Dominic Dugo, VP-Delta Group* 16. *Nikki Soriano, IASIU* 17. *Greg Welker, NAIC* 18. *Jay Bobrowsky, AFA* 19. *Ed Tobin, NICB* 20. *Chris Sloan, Pennsylvania IFPA* 21. *Brenda Cude, NAIC Consumer* 22. *Frank Sztuk, NYAAIF* 23. *Jeff Ferrand, illumifin* 24. *Micki Lockard, CNA* 25. *Nicholas Hamm, N.J. Property-Liability Insurance Guaranty Assoc.* 26. *Kathy Stokes, AARP* Here is some important information in case you were unable to attend the meeting. ![](https://insurancefraud.org/wp-content/uploads/2024-Midyear-Meeting-final.png) - [2024 Midyear Meeting Board Book](https://insurancefraud.org/wp-content/uploads/2024-Midyear-Meeting-Board-Book.pdf) - [Committee & Task Force Report Video](https://vimeo.com/986468527?share=copy) - **PowerPoint Presentations** - [Coalition Update](https://insurancefraud.org/wp-content/uploads/2024-Midyear-Meeting-Coalition-Update.pdf) – Michelle Rafeld, Executive Director - [Legal Affairs Committee Report ](https://insurancefraud.org/wp-content/uploads/Legal-Affairs-2024-Midyear-Slides.pdf)– Ross Silverman, Katten Muchin Rosenman LLP - [Litigation Funding “A Fist Full of Dollars”](https://insurancefraud.org/wp-content/uploads/2024-Midyear-Meeting-Litigation-Funding-.pdf) – Vince Gerbino, Bruno, Gerbino, Soriano & Aitken - [New Trends in Property Losses](https://insurancefraud.org/wp-content/uploads/2024-Midyear-Meeting-New-Trends.pdf) – Lin Werkheiser, Command Investigations - [Identity Theft Panel Discussion](https://insurancefraud.org/wp-content/uploads/2024-Midyear-Meeting-ID-Theft-Panel.pdf) – Arteniece Lee, *Horace Mann*, Moderator, Kevin Glasgow, *Diligence International*, Dominic Dugo, *Delta Group*, Craig Koerner, *Farmers Insurance* and Richard Matarante, *New York Life* - [Long-Term Care Fraud ](https://insurancefraud.org/wp-content/uploads/Long-Term-Care-Insurance-Fraud.pdf)– Jeff Ferrand, Illumfin and Micki Lockard, CNA - [The Need for a “Whole of Society” Approach to Fraud](https://insurancefraud.org/wp-content/uploads/2024-Midyear-Meeting-AARP.pdf) – Kathy Stokes, AARP - [Partners Updates](https://insurancefraud.org/wp-content/uploads/Partner-Updates-2024-MYM-Slides.pdf) – Nikki Soriano, *IASIU*, Jay Bobrowsky, *AFA*, Ed Tobin, *NICB*, Chris Sloan, *IFPA*, Brenda Cude, *NAIC Consumer Rep*, Frank Sztuk, *NYAAIF* - [Coalition Update](https://insurancefraud.org/wp-content/uploads/2024-Midyear-Meeting-Coalition-Update.pdf) – Michelle Rafeld, Executive Director - [Legal Affairs Committee Report ](https://insurancefraud.org/wp-content/uploads/Legal-Affairs-2024-Midyear-Slides.pdf)– Ross Silverman, Katten Muchin Rosenman LLP - [Litigation Funding “A Fist Full of Dollars”](https://insurancefraud.org/wp-content/uploads/2024-Midyear-Meeting-Litigation-Funding-.pdf) – Vince Gerbino, Bruno, Gerbino, Soriano & Aitken - [New Trends in Property Losses](https://insurancefraud.org/wp-content/uploads/2024-Midyear-Meeting-New-Trends.pdf) – Lin Werkheiser, Command Investigations - [Identity Theft Panel Discussion](https://insurancefraud.org/wp-content/uploads/2024-Midyear-Meeting-ID-Theft-Panel.pdf) – Arteniece Lee, *Horace Mann*, Moderator, Kevin Glasgow, *Diligence International*, Dominic Dugo, *Delta Group*, Craig Koerner, *Farmers Insurance* and Richard Matarante, *New York Life* - [Long-Term Care Fraud ](https://insurancefraud.org/wp-content/uploads/Long-Term-Care-Insurance-Fraud.pdf)– Jeff Ferrand, Illumfin and Micki Lockard, CNA - [The Need for a “Whole of Society” Approach to Fraud](https://insurancefraud.org/wp-content/uploads/2024-Midyear-Meeting-AARP.pdf) – Kathy Stokes, AARP - [Partners Updates](https://insurancefraud.org/wp-content/uploads/Partner-Updates-2024-MYM-Slides.pdf) – Nikki Soriano, *IASIU*, Jay Bobrowsky, *AFA*, Ed Tobin, *NICB*, Chris Sloan, *IFPA*, Brenda Cude, *NAIC Consumer Rep*, Frank Sztuk, *NYAAIF* - [Coalition Update](https://insurancefraud.org/wp-content/uploads/2024-Midyear-Meeting-Coalition-Update.pdf) – Michelle Rafeld, Executive Director - [Legal Affairs Committee Report ](https://insurancefraud.org/wp-content/uploads/Legal-Affairs-2024-Midyear-Slides.pdf)– Ross Silverman, Katten Muchin Rosenman LLP - [Litigation Funding “A Fist Full of Dollars”](https://insurancefraud.org/wp-content/uploads/2024-Midyear-Meeting-Litigation-Funding-.pdf) – Vince Gerbino, Bruno, Gerbino, Soriano & Aitken - [New Trends in Property Losses](https://insurancefraud.org/wp-content/uploads/2024-Midyear-Meeting-New-Trends.pdf) – Lin Werkheiser, Command Investigations - [Identity Theft Panel Discussion](https://insurancefraud.org/wp-content/uploads/2024-Midyear-Meeting-ID-Theft-Panel.pdf) – Arteniece Lee, *Horace Mann*, Moderator, Kevin Glasgow, *Diligence International*, Dominic Dugo, *Delta Group*, Craig Koerner, *Farmers Insurance* and Richard Matarante, *New York Life* - [Long-Term Care Fraud ](https://insurancefraud.org/wp-content/uploads/Long-Term-Care-Insurance-Fraud.pdf)– Jeff Ferrand, Illumfin and Micki Lockard, CNA - [The Need for a “Whole of Society” Approach to Fraud](https://insurancefraud.org/wp-content/uploads/2024-Midyear-Meeting-AARP.pdf) – Kathy Stokes, AARP - [Partners Updates](https://insurancefraud.org/wp-content/uploads/Partner-Updates-2024-MYM-Slides.pdf) – Nikki Soriano, *IASIU*, Jay Bobrowsky, *AFA*, Ed Tobin, *NICB*, Chris Sloan, *IFPA*, Brenda Cude, *NAIC Consumer Rep*, Frank Sztuk, *NYAAIF* --- ### [2024 Annual Membership Meeting](https://insurancefraud.org/2024-annual-membership-meeting/) **Published:** December 13, 2024 **Author:** Coalition Against Insurance Fraud **Content:** We are absolutely delighted to announce the successful conclusion of the 2024 Coalition Against Insurance Fraud Annual Meeting, held in the historic and vibrant Arlington, Virginia, at the Renaissance Arlington Capital View Hotel! This year’s event was nothing short of extraordinary, with an incredible 184 attendees representing 113 organizations, all united by a shared commitment to combating insurance fraud. This gathering was an unparalleled opportunity for professionals across the industry to engage in insightful discussions about the current landscape of insurance fraud and the innovative strategies needed to address it. Participants explored a wide range of critical topics, providing forward-thinking perspectives on the evolving tactics of fraudsters and the proactive measures necessary to stay ahead of emerging threats. We extend a great big thank you to our expert speakers who generously took time to join us and share their subject matter expertise. These individuals traveled from near and far, lending their invaluable insights and providing attendees with knowledge and strategies to tackle both current and emerging insurance fraud challenges ahead. Their contributions were central to the event’s success, sparking dynamic conversations and actionable takeaways for all in attendance. Thank you to everyone who made this event a remarkable success. Your dedication and collaboration are truly inspiring, and we look forward to building on this momentum as we continue the fight against insurance fraud! Here is some important information in case you were unable to attend the meeting. - [2024 Annual Meeting Board Book](https://insurancefraud.org/wp-content/uploads/2024-Annual-Meeting-Boardbook.pdf) - [2024 Year End Review Video](https://vimeo.com/1039027757?share=copy) - [2024 Annual Meeting Member Advertisements](https://vimeo.com/1039030403?share=copy) **PowerPoint Presentations** - Legal Affairs Committee Report - [Ross Silverman, Katten Muchin Rosenman LLP](https://insurancefraud.org/wp-content/uploads/Legal-Affairs.pdf) - [Vince Gerbino, Bruno, Gerbino, Soriano & Aitken LLP](https://insurancefraud.org/wp-content/uploads/Bruno-Gerbino.pdf) - [Results Of The Coalition Against Insurance Fraud 2024 Technology Study](https://insurancefraud.org/wp-content/uploads/SHIFT-State-of-Insurance-Fraud-Technology-Study.pdf) - Alicia Holmes, Shift Technology - Renee Moussa, Shift Technology - [Meet Your Cybercriminal](https://insurancefraud.org/wp-content/uploads/Phishing-for-Profit-FBI-Brief-SSA-K.-GALLAGHER.pdf) – SSA Kevin Gallagher, Federal Bureau of Investigation - [Healthcare Fraud Prevention Partnership](https://insurancefraud.org/wp-content/uploads/HFPP-Coalition-Presentation.pdf) – Dan Kreitman - [2024 Hall of Shame](https://vimeo.com/1039047020?share=copy) - [2024 Prosecutor of the Year](https://insurancefraud.org/wp-content/uploads/2024-POY.pdf) **Partner Updates** - [International Association of SIUs](https://insurancefraud.org/wp-content/uploads/IASIU-Presentation.pdf) – Celeste Dodson - [Anti-Fraud Alliance](https://insurancefraud.org/wp-content/uploads/Anti-Fraud-Alliance-AFA-.pdf) – Jay Bobrowsky - [Pennsylvania IFPA](https://insurancefraud.org/wp-content/uploads/IFPA-2024-Annual-Meeting.pdf) – Chris Sloan - [University of New Haven](https://insurancefraud.org/wp-content/uploads/University-of-New-Haven.pdf) – Patrick Malloy [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/148e02a8-7660-183e-155e-5761fb29e026.jpg)](https://insurancefraud.org/wp-content/uploads/V7-2024-Speakers.jpg) --- ### [2025 Midyear Membership Meeting](https://insurancefraud.org/2025-midyear-membership-meeting-2/) **Published:** June 13, 2025 **Author:** Coalition Against Insurance Fraud **Content:** **A Powerful Gathering at the 2025 Coalition Midyear Meeting in Chicago** Earlier this week, the Coalition Against Insurance Fraud hosted one of its most dynamic and well-attended Midyear Meetings in history, held June 9 and 10 at the iconic Palmer House Hotel in Chicago, IL. With the city’s historic backdrop adding to the energy, 158 members gathered in person, including an impressive 37 first-time attendees, to connect, collaborate, and recommit to the mission of fighting insurance fraud. The Coalition was honored to feature 25 expert presenters who shared groundbreaking insights, innovative strategies, and critical updates to help our ever-growing membership stay one step ahead of increasingly sophisticated fraud schemes. Their expertise and passion sparked lively discussions and reinforced the importance of cross-sector collaboration in our shared fight. A major highlight of the event was the premiere of the Coalition’s Committee and Task Force Update Video, a fast-paced, engaging recap of the incredible work underway across our committees and task forces. From legislative advocacy to tech-driven fraud detection, the video showcased the depth and diversity of efforts driving real impact over the past six months. The meeting also spotlighted a bold new initiative: the launch of the State and Industry Fraud Director Task Force, the first of its kind. Leaders of this pioneering group took the stage to share why this new collaboration is essential to unifying fraud-fighting strategies across jurisdictions and sectors. Their insights underscored just how vital innovation and coordination are in today’s evolving fraud landscape. From start to finish, the 2025 Midyear Meeting was more than just a gathering, it was a powerful demonstration of what’s possible when dedicated professionals unite around a common cause. The Coalition continues to strengthen its role as the leading hub for fraud-fighting collaboration, advocacy, and action. **Here’s to the work ahead and the momentum we’ve built together in Chicago!** - [2025 Midyear Meeting Recap Video](https://vimeo.com/manage/videos/1093128763) - [Thank You To The 2025 June Meeting Attendees & Presenters](https://vimeo.com/1093114596) - [2025 Midyear Meeting Board Book](https://insurancefraud.org/wp-content/uploads/2025-Midyear-meeting-Board-Book.pdf) - [2025 Committee & Taskforce Report Video](https://vimeo.com/manage/videos/1093165421) ![](https://insurancefraud.org/wp-content/uploads/Historic-Palmer.png) --- ### [2025 Annual Membership Meeting](https://insurancefraud.org/2025-annual-membership-meeting-2/) **Published:** December 11, 2025 **Author:** Coalition Against Insurance Fraud **Content:** We are pleased share that the 2025 Coalition Against Insurance Fraud Annual Meeting concluded successfully in Arlington, Virginia, at the Renaissance Arlington Capital View Hotel. Nearly **180 members** attended on December 2–3, including **37 first-time attendees** and **7 new members** since June, one of our strongest turnouts yet. The meeting provided a great opportunity for professionals across the industry to connect and discuss the current state of insurance fraud, along with the new strategies needed to address emerging challenges. Attendees covered a wide range of important topics, offering practical insights on how to keep pace with evolving fraud trends. We also want to extend a heartfelt thank-you to our speakers for sharing their time and expertise. Their contributions sparked valuable conversations and gave attendees useful takeaways for the work ahead. Thank you to everyone who helped make this event such a success. Your participation and support are truly appreciated. Explore and download these resources that were provided at the meeting. Please consider sharing the board book across your organization with others who may have an interest in the Coalition’s offerings. - [2025 Annual Meeting Board Book](https://insurancefraud.org/wp-content/uploads/Annual-Meeting-2025-FINAL-Boardbook.pdf) - [2025 Year End Review Video](https://insurancefraud.org/wp-content/uploads/2025-Year-In-Review.mp4) - [2025 Annual Meeting Member Advertisements](https://insurancefraud.org/wp-content/uploads/2025-Member-Commercial-Loop-Video.mp4) - [2025 Reception Video](https://insurancefraud.org/wp-content/uploads/2025-Annual-Meeting-Reception-Video.mp4) **PowerPoint Presentations** - **[Inside the Coalition’s Social Media Movement: How Students Took On Insurance Fraud One Post At A Time](https://insurancefraud.org/wp-content/uploads/Social-Media-Competition-Presentation.pptx)** – Nick Mattar, *Wayne State University* - **[2025 Hall of Shame](https://insurancefraud.org/wp-content/uploads/2025-HOS.mp4)** - **[How Third Party Funding May Be Fueling Insurance Fraud](https://insurancefraud.org/wp-content/uploads/How-Third-Party-Funding-May-Be-Fueling-Insurance-Fraud.pptx)** – Todd Kozikowski, *4Warn* - **[Unmasking Fraud and Corruption In Sober Homes: The Storytelling Power of Shuffle](https://insurancefraud.org/wp-content/uploads/SHUFFLE_CAIF.pptx)** – Benjamin Flaherty, Film Maker - **[Exploited Lives, Exploited Systems: The Human Trafficking–Insurance Fraud Connection](https://insurancefraud.org/wp-content/uploads/Mike-Skiba-12.2.2025.pptx)** – Dr. Michael Skiba, CSU Global - **[Ethical Public Adjusting As A Preventative Measure Against Insurance Fraud – A National Perspective](https://insurancefraud.org/wp-content/uploads/Ethical-Public-Adjusting-as-a-Preventive-Measure.pptx)** – Brian Goodman, *NAPIA* - **[2025 State Of The Insurance Industry](https://insurancefraud.org/wp-content/uploads/State-of-Insurance-Presentation.pptx)** – Micah Smith*, Ethos* - **[NICB Identity Crime Assessment](https://insurancefraud.org/wp-content/uploads/NICB-Identity-Crime-Assessment-2025.pptx)** – Raun Bass, *NICB* --- ### [Member Login](https://insurancefraud.org/login/) **Published:** July 31, 2020 **Author:** Coalition Against Insurance Fraud **Content:** [Logout](https://insurancefraud.org/wp-login.php?action=logout&_wpnonce=4c163ab5a4) If your company is a member of the Coalition, you have full access to all of our resources. To get started, simply[ create your profile](https://members.insurancefraud.org/general/pick_username.asp)—it only takes a few minutes. Once completed, you’ll unlock everything the Coalition has to offer. If you are not associated with a member company, you can still access the consumer resources at [insurancefraud.org](http://insurancefraud.org/). --- ### [Long Term Care Scams](https://insurancefraud.org/long-term-care-scams/) **Published:** November 7, 2025 **Author:** Joseph Matos **Content:** ## Long Term Care Fraud ## Common LTC Fraud Schemes Targeting Vulnerable Seniors ![](https://insurancefraud.org/wp-content/uploads/Old-Lady-LTC.jpg) Older adults who struggle to track benefits, manage complex paperwork, or advocate for themselves can become easy targets for exploitation. Unscrupulous caregivers, medical providers, and facilities may take advantage of these vulnerabilities, and engage in schemes such as: - **Billing for services or hours that never occurred** — counting on the patient not remembering or being able to verify what was provided. - **Charging for a higher level of care than actually delivered** — inflating claims to collect more money, without improving the patient’s care. - **Altering medical records, care logs, or timesheets** — hiding poor-quality care or justifying inflated charges. - **Pushing unnecessary treatments or equipment** — convincing patients or families to approve services that serve the provider’s profit, not the patient’s health. - **Insisting on handling all billing and communications** — keeping families “out of the loop” so fraudulent charges slip through. - **Pressuring patients to grant Power of Attorney (POA)** — convincing vulnerable seniors it’s in their best interest, often without informing or involving family members, to gain control over financial or medical decisions. [To learn more about LTC Fraud click here to view the brochure.](https://insurancefraud.org/wp-content/uploads/LTC-Fraud-Brochure.pdf) [![](https://insurancefraud.org/wp-content/uploads/LTC-Brochure-128x300.png)](https://insurancefraud.org/wp-content/uploads/LTC-Fraud-Brochure.pdf) --- ### [Media Request Form](https://insurancefraud.org/media-request-form/) **Published:** April 3, 2025 **Author:** Coalition Against Insurance Fraud **Content:** ![](https://insurancefraud.org/wp-content/uploads/Media-Request-1024x217.png) The Coalition Against Insurance Fraud welcomes media inquiries and takes great pride in serving as a resource for members of the media. **Areas of Expertise:** - Insurance fraud trends and statistics - Emerging fraud schemes and technologies - Anti-fraud and consumer protection best practices - Legislative and regulatory developments To protect the reputation of the organization and trust of its members, before granting an interview, the requesting party must acknowledge and agree to the following: **Interview Parameters:** - The Coalition will not comment on specific individuals, entities, cases, ongoing investigations, litigation of any kind or proposed legislation the organization has not reviewed - Interview questions must be submitted in advance - The interviewer agrees to provide the Coalition with a copy of the published story (print, online and/or video) upon request **Content Integrity:** - The Coalition will record all interviews to maintain a record of the information shared - Statements made by Coalition representatives are not to be taken out of context, edited to support unintended narratives, or used in a way that violates our Media Interview Policy - We reserve the right to request removal of our comments if used out of context **Request Process:** - To request an interview, please complete our media interview request form - The Coalition will evaluate requests within 1-2 business days of submission - For urgent inquiries, please contact communications@insurancefraud.org **Spokesperson Availability:** - Coalition representatives will conduct interviews Monday-Friday, between the hours of 9:00 AM – 5:00 PM EST - Virtual interviews are preferred; however, in-person requests will be considered with advance notice **Attribution & Branding:** - The organization must be referred to by its full name – Coalition Against Insurance Fraud - Quotes must contain the full name and title of the Coalition spokesperson - Use of the Coalition’s logo and organization description may be requested, but is not guaranteed Please [**click here**](https://insurancefraud.org/media-requests/) to complete the media interview request form. --- ### [2024 International Fraud Awareness Week](https://insurancefraud.org/international-fraud-awareness/) **Published:** November 22, 2024 **Author:** Coalition Against Insurance Fraud **Content:** ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/9e410acf-dd71-0576-3f90-bb5219b6011d.png) **Take A Glimpse Into The World Of Insurance Fraud –** Do you want the right words to explain insurance fraud to your family and friends? Share this! [A Glimpse Into The World Of Insurance Fraud – (Length: 5m:23s)](https://vimeo.com/1030793722) **Learn About Changing Consumer Attitudes –** As technology use for fraud schemes is ramping up, so are the consumer numbers who think that committing fraud is acceptable. [Consumer Attitudes Are Changing (Length: 6m:19s)](https://vimeo.com/1031292262?share=copy) **Find Out More About The Coalition’s Role In Fighting Insurance Fraud –** For 30+ years, the Coalition has brought insurers, consumers, and government agencies together to fight insurance fraud. Learn more about the Coalition, its 300+ members, and how the organization is fighting for you! [The Coalition’s Role In Fighting Insurance Fraud – (Length: 7m)](https://vimeo.com/1031294392?share=copy) ![](https://insurancefraud.org/wp-content/uploads/Infographics_Videos.png) [**View Videos and Infographics here**](https://insurancefraud.org/videos-infographics/) --- ### [Arrests and Convictions](https://insurancefraud.org/arrests-and-convictions/) **Published:** July 29, 2020 **Author:** Coalition Against Insurance Fraud --- ### [Research Studies & Reports](https://insurancefraud.org/research/) **Published:** October 6, 2020 **Author:** Coalition Against Insurance Fraud **Content:** On this Page: - [Videos](https://insurancefraud.org/tools-resources/#videos) - [Infographics](https://insurancefraud.org/tools-resources/#infographics) - [Expert Speakers](https://insurancefraud.org/tools-resources/#expertspeakers) Related Content: - [Fraud: Why Care?](https://insurancefraud.org/fraud-why-care/) - [Fraud Stats](https://insurancefraud.org/fraud-stats/) - [Report Fraud](https://insurancefraud.org/report-fraud/) - [Anti-Fraud Events](https://insurancefraud.org/events/) The Coalition is the nation’s leader in conducting research to measure the multiple important aspects of insurance fraud. Our research helps decision-makers and consumers better understand the extent of insurance fraud, its root causes, and how to better combat this crime. ![](https://insurancefraud.org/wp-content/uploads/AI-Study-Cover.png) [![This image has an empty alt attribute; its file name is download-button-1.jpg](https://insurancefraud.org/wp-content/uploads/download-button-1.jpg)](https://insurancefraud.org/wp-content/uploads/2025-Generative-AI-Study.pdf) [![](https://insurancefraud.org/wp-content/uploads/Coalition-Premium-Fraud-Report-8-2025-1-791x1024.jpg)](https://insurancefraud.org/wp-content/uploads/Coalition-Premium-Fraud-Report-8-2025-1.pdf)[![This image has an empty alt attribute; its file name is download-button-1.jpg](https://insurancefraud.org/wp-content/uploads/download-button-1.jpg)](https://insurancefraud.org/wp-content/uploads/Coalition-Premium-Fraud-Report-8-2025-1.pdf) [![](https://insurancefraud.org/wp-content/uploads/Workers-Comp-Report-March-2025-cover-791x1024.jpg)](https://insurancefraud.org/wp-content/uploads/Workers-Comp-Report-March-2025.pdf) [![This image has an empty alt attribute; its file name is download-button-1.jpg](https://insurancefraud.org/wp-content/uploads/download-button-1.jpg)](https://insurancefraud.org/wp-content/uploads/Workers-Comp-Report-March-2025.pdf) [![](https://insurancefraud.org/wp-content/uploads/2025-State-of-Technology-Study-791x1024.jpg)](https://insurancefraud.org/wp-content/uploads/2024-State-of-Technology-Study.pdf) [![This image has an empty alt attribute; its file name is download-button-1.jpg](https://insurancefraud.org/wp-content/uploads/download-button-1.jpg)](https://insurancefraud.org/wp-content/uploads/2024-State-of-Technology-Study.pdf) [![](https://insurancefraud.org/wp-content/uploads/2024-AON-Study-790x1024.png)](https://insurancefraud.org/wp-content/uploads/2024-Insurer-SIU-Benchmarking-Study.pdf) [![This image has an empty alt attribute; its file name is download-button-1.jpg](https://insurancefraud.org/wp-content/uploads/download-button-1.jpg)](https://insurancefraud.org/wp-content/uploads/2024-Insurer-SIU-Benchmarking-Study.pdf) [![](https://insurancefraud.org/wp-content/uploads/Coalition-Keys-Study-cover.jpg)](https://insurancefraud.org/wp-content/uploads/Coalition-Keys-Study.pdf) [![This image has an empty alt attribute; its file name is download-button-1.jpg](https://insurancefraud.org/wp-content/uploads/download-button-1.jpg)](https://insurancefraud.org/wp-content/uploads/Coalition-Keys-Study.pdf) [![](https://insurancefraud.org/wp-content/uploads/Part-2-cover-WC-TaskFroce-Report-791x1024.png)](https://insurancefraud.org/wp-content/uploads/2023-Workers-Comp-report.pdf) [![This image has an empty alt attribute; its file name is download-button-1.jpg](https://insurancefraud.org/wp-content/uploads/download-button-1.jpg)](https://insurancefraud.org/wp-content/uploads/2023-Workers-Comp-report.pdf) [![](https://insurancefraud.org/wp-content/uploads/./WHO_ME_STUDY_REPORT.jpg)](https://insurancefraud.org/wp-content/uploads/WHO_ME_STUDY_REPORT.pdf) [![This image has an empty alt attribute; its file name is download-button-1.jpg](https://insurancefraud.org/wp-content/uploads/download-button-1.jpg)](https://insurancefraud.org/wp-content/uploads/WHO_ME_STUDY_REPORT.pdf) [![](https://insurancefraud.org/wp-content/uploads/Ethical-Use-of-Data-Study-cover.jpg)](https://insurancefraud.org/wp-content/uploads/The-Ethical-Use-of-Data-to-Fight-Insurance-Fraud-Study—FV.pdf) [![This image has an empty alt attribute; its file name is download-button-1.jpg](https://insurancefraud.org/wp-content/uploads/download-button-1.jpg)](https://insurancefraud.org/wp-content/uploads/The-Ethical-Use-of-Data-to-Fight-Insurance-Fraud-Study—FV.pdf) [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/ef561388-1fd7-6fa1-89a6-1907964b7897.png)](https://insurancefraud.org/wp-content/uploads/WORKERS-COMPENSATION-FRAUD-Report-FINAL.pdf)[![This image has an empty alt attribute; its file name is download-button-1.jpg](https://insurancefraud.org/wp-content/uploads/download-button-1.jpg)](https://insurancefraud.org/wp-content/uploads/WORKERS-COMPENSATION-FRAUD-Report-FINAL.pdf) [![](https://insurancefraud.org/wp-content/uploads/Screen-Shot-2022-08-26-at-3.49.56-PM.png)](https://insurancefraud.org/wp-content/uploads/The-Impact-of-Insurance-Fraud-on-the-U.S.-Economy-Report-2022-8.26.2022-1.pdf) [![This image has an empty alt attribute; its file name is download-button-1.jpg](https://insurancefraud.org/wp-content/uploads/download-button-1.jpg)](https://insurancefraud.org/wp-content/uploads/The-Impact-of-Insurance-Fraud-on-the-U.S.-Economy-Report-2022-8.26.2022-1.pdf) [![This image has an empty alt attribute; its file name is 2022-Benchmarking-cover.png](https://insurancefraud.org/wp-content/uploads/2022-Benchmarking-cover.png)](https://insurancefraud.org/wp-content/uploads/2022-Insurer-SIU-Benchmarking-Study-updated-812022.pdf) [![This image has an empty alt attribute; its file name is download-button-1.jpg](https://insurancefraud.org/wp-content/uploads/download-button-1.jpg)](https://insurancefraud.org/wp-content/uploads/2022-Insurer-SIU-Benchmarking-Study-updated-812022.pdf) [![](https://insurancefraud.org/wp-content/uploads/Screen-Shot-2022-02-16-at-1.45.50-PM.png)](https://insurancefraud.org/wp-content/uploads/2021-Technology-Study-Report-Final-1.pdf) [![](https://insurancefraud.org/wp-content/uploads/download-button-1.jpg)](https://insurancefraud.org/wp-content/uploads/2021-Technology-Study-Report-Final-1.pdf) [![](https://insurancefraud.org/wp-content/uploads/Screen-Shot-2021-11-15-at-10.24.25-AM.png)](https://insurancefraud.org/wp-content/uploads/Globalization-of-Insurance-Fraud-report-Final-2.pdf)The Globalization of Insurance Fraud study is inaugural research that aims to gather information and develop insights that will help tackle globalized insurance fraud. [![](https://insurancefraud.org/wp-content/uploads/download-button-1.jpg)](https://insurancefraud.org/wp-content/uploads/Globalization-of-Insurance-Fraud-report-Final-2.pdf) [![](https://insurancefraud.org/wp-content/uploads/COVID-study-1024x725.png)](https://insurancefraud.org/wp-content/uploads/Updated-COVID-19-Insurance-Fraud.pdf)A trend analysis detailing the potential impact COVID-19 has had on fraudulent claim referrals. [![](https://insurancefraud.org/wp-content/uploads/download-button-1.jpg)](https://insurancefraud.org/wp-content/uploads/2024-Updated-COVID-19-Insurance-Fraud.pdf) [![](https://insurancefraud.org/wp-content/uploads/Screen-Shot-2020-10-06-at-4.38.30-PM.png)](https://insurancefraud.org/wp-content/uploads/Artificial-Intelligence-and-Insurance-Fraud-2020.pdf)AI is predicted to be the leading transformer in the fraud fight. Still, barriers must be addressed for consumer protections such as potential model bias. [![](https://insurancefraud.org/wp-content/uploads/download-button-1.jpg)](https://insurancefraud.org/wp-content/uploads/Artificial-Intelligence-and-Insurance-Fraud-2020.pdf) [![](https://insurancefraud.org/wp-content/uploads/Screen-Shot-2020-10-06-at-4.42.07-PM-645x1024.png)](https://insurancefraud.org/wp-content/uploads/Benchmarking-Study-Summary.pdf)Insurers are largely satisfied with their SIU operations. However, the percentage of insurer desk investigators is rapidly rising. [![](https://insurancefraud.org/wp-content/uploads/download-button-1.jpg)](https://insurancefraud.org/wp-content/uploads/Benchmarking-Study-Summary.pdf) [![](https://insurancefraud.org/wp-content/uploads/Screen-Shot-2020-10-06-at-5.17.47-PM-786x1024.png)](https://insurancefraud.org/wp-content/uploads/Fraud_tech_study_2019.pdf)Traditional anti-fraud technology tools are giving way to advanced analytics as insurance fraud rises, insurers say. [![](https://insurancefraud.org/wp-content/uploads/download-button-1.jpg)](https://insurancefraud.org/wp-content/uploads/Fraud_tech_study_2019.pdf) • **[2016 tech study](https://insurancefraud.org/wp-content/uploads/State_of_Insurance_Fraud_Technology2016.pdf)** •[ **2014 tech study**](https://insurancefraud.org/wp-content/uploads/technology_study-2014.pdf) • **[2012 tech study](https://insurancefraud.org/wp-content/uploads/techStudy_2012.pdf)** [![](https://insurancefraud.org/wp-content/uploads/Screen-Shot-2020-10-06-at-5.53.01-PM-794x1024.png)](https://insurancefraud.org/wp-content/uploads/fourfaces_2017.pdf)Nearly four of five consumers are concerned about insurance fraud. Even so, too many consumers still tolerate fraud.[![](https://insurancefraud.org/wp-content/uploads/download-button-1.jpg)](https://insurancefraud.org/wp-content/uploads/fourfaces_2017.pdf) • **[2007 Four Faces](https://insurancefraud.org/wp-content/uploads/Four_Faces_07.pdf)** • **[1997 Four Faces ](https://insurancefraud.org/wp-content/uploads/FourFaces.pdf)** [![](https://insurancefraud.org/wp-content/uploads/Screen-Shot-2020-10-07-at-10.14.48-AM-793x1024.png)](https://insurancefraud.org/wp-content/uploads/fraud-bureau-survey-2009.pdf)Bogus insurance claims by financially stressed consumers surged amid the nation’s financial meltdown in 2009.[![](https://insurancefraud.org/wp-content/uploads/download-button-1.jpg)](https://insurancefraud.org/wp-content/uploads/fraud-bureau-survey-2009.pdf) [![](https://insurancefraud.org/wp-content/uploads/Screen-Shot-2020-10-07-at-7.20.26-AM-788x1024.png)](https://insurancefraud.org/wp-content/uploads/drugDiversion.pdf)Insurance fraud is helping finance the rapid and illicit spread of painkillers and other opioids throughout America.[![](https://insurancefraud.org/wp-content/uploads/download-button-1.jpg)](https://insurancefraud.org/wp-content/uploads/drugDiversion.pdf) [![](https://insurancefraud.org/wp-content/uploads/Screen-Shot-2020-10-07-at-7.24.49-AM-789x1024.png)](https://insurancefraud.org/wp-content/uploads/unitedWeBrand.pdf)Outreach efforts to protect consumers against insurance fraud are fragmented. A unified national campaign is vital for turning the corner. [![](https://insurancefraud.org/wp-content/uploads/download-button-1.jpg)](https://insurancefraud.org/wp-content/uploads/unitedWeBrand.pdf) [![](https://insurancefraud.org/wp-content/uploads/2003-Study-cover.jpg)](https://insurancefraud.org/wp-content/uploads/Study-on-SIU-Performance-2003.pdf)[![](https://insurancefraud.org/wp-content/uploads/download-button-1.jpg)](https://insurancefraud.org/wp-content/uploads/Study-on-SIU-Performance-2003.pdf) The Coalition partners with leading fellow anti-fraud organizations and academic institutions to continually provide important research data. Proposals for future research projects may be submitted to [Michelle Rafeld.](mailto:%20michelle@insurancefraud.org) the Coalition’s Executive Director. --- ### [Key Word Search](https://insurancefraud.org/key-word-search/) **Published:** February 26, 2021 **Author:** admcaif **Content:** #### **Search insurance fraud state regulations, statutes, and pending legislation below.** --- ### [Upcoming Membership Meetings](https://insurancefraud.org/upcoming-membership-meetings/) **Published:** March 7, 2025 **Author:** Coalition Against Insurance Fraud **Content:** ![](https://insurancefraud.org/wp-content/uploads/December-2025-Meeting.png) **Registration Opens Early September – Official Date Will Be Announced In Fraud News Weekly in August.** --- ### [Money Laundering](https://insurancefraud.org/money-laundering/) **Published:** May 8, 2025 **Author:** Coalition Against Insurance Fraud **Content:** Note: Please scroll down to view all information provided on this page. ### **Money Laundering Through Insurance Products** [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/2f253a0d-5663-d6bc-e087-18b54104b19d.jpg)](https://insurancefraud.org/wp-content/uploads/Coalition-Member-ALERT-Money-Laundering-Alert.pdf) [![](https://mcusercontent.com/a440c5b647697de580a2fd586/_compresseds/a15245a1-47ae-0d9d-ab30-f2a2abacb760.jpg)](https://insurancefraud.org/wp-content/uploads/Insurer-Member-Alert.pdf) **What Is Money Laundering?** Money laundering is the process of making illegally obtained funds (dirty money) appear legal and legitimate (clean money). Criminals accomplish this by disguising the origins of where they got the funds, changing the form of the funds, or moving the funds to places where they’re less likely to attract attention. **How Do Criminals Launder Money Using Insurance Products?** Money laundering through insurance involves criminals using life insurance policies and annuity products to convert illegally obtained funds into what appears to be legitimate income. Unlike traditional bank-focused money laundering, insurance products offer unique features that make them attractive to criminals seeking to clean dirty money. [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/45e5632a-55ee-62c0-70f0-4cbb7dc1d9d7.png)](https://insurancefraud.org/videos-infographics/)**[Visit Infographics webpage to download](https://insurancefraud.org/videos-infographics/)** **Why Criminals Target Insurance Products** Life insurance and annuity products are attractive to money launderers for several reasons: - **Appearance of Legitimacy**: Insurance is a respected financial service used by millions of legitimate customers. - **Complex Products**: The technical nature of insurance makes suspicious transactions harder to detect. - **Conversion Opportunities**: Policies that can be quickly surrendered or borrowed against provide easy conversion of funds. - **Global Reach**: International insurance transactions can cross multiple jurisdictions, making the transactions harder to investigate. - **High-Value Transactions**: Large premium payments aren’t unusual in insurance, making large transfers less suspicious. **Common Money Laundering Schemes** **The Premium Payment Scheme** A criminal pays large premiums (using dirty money) for a policy, then quickly cancels it and receives a “clean” refund check from the respected insurance company. **The Loan Scheme** After purchasing a policy with illicit funds, the criminal takes out a policy loan, effectively receiving laundered money directly from the insurer. **The Beneficiary Scheme** Criminals purchase policies and name unrelated third parties or shell companies as beneficiaries, creating a future channel for transferring laundered funds. **The Immediate Annuity Scheme** Criminals use illicit funds to purchase an immediate annuity, converting a lump sum of dirty money into a stream of apparently legitimate “investment income.” **Red Flags For Insurers** - **Use of Synthetic IDs** to purchase policies - **Mismatched IP Addresses,** where online account activity or applications originate from locations different from the insured’s registered address - **Request For Excessive Coverage** that’s inconsistent with the buyer’s financial situation, occupation, or needs - **Large Cash Premium Payments** involving excessive or irregular cash premium payments - **Foreign or High-Risk Payment Sources,** such as premium payments originating from accounts in different countries or jurisdictions that vary from where the insured resides, especially from high-risk regions with weak anti-money laundering controls. - **Overpayment of Premiums** to immediately trigger a refund - **Rapid Purchase and Cancellation** of a policy - **Immediate Annuity Payouts** to convert illicit funds into legitimate income streams - **Surrenders, Withdrawals or Loans** initiated quickly after an initial premium payment or deposit of funds - **Naming of Questionable Beneficiaries**, such as a corporate entity or beneficiary with no clear relationship to the policyholder **Warning Signs for Consumers** While anti-money laundering compliance is primarily the responsibility of financial institutions, consumers should be aware of suspicious activities: - Someone offers you money to purchase an insurance policy in your name - You’re asked to name someone with no relation to you as a beneficiary - Someone offers to “invest” through insurance in a way that seems unusually complex or secretive - You’re pressured to purchase insurance with cash or unusual payment methods - Someone offers to buy your existing policy for more than its surrender value **Impact on Legitimate Insurance Customers** Money laundering through insurance has real consequences for honest consumers: - **Higher Premiums**: The costs of enhanced security and compliance are passed to customers - **More Complex Applications**: Increased verification requirements lead to longer application processes - **Additional Scrutiny**: Legitimate large transactions may face delays due to necessary verification steps **Industry Safeguards / Risk Mitigation Strategies** As the use of life and annuity products by criminals to launder money represents a serious threat to insurers, insurers are urged to consider the following risk mitigation strategies to bolster their anti-money laundering (AML) practices: - **Train Employees** to recognize and document red flags, ensuring they know when and how to escalate concerns - **Look To Enhance Know Your Customer (KYC) Protocols** by conducting thorough identity checks - **Verify The Source Of Funds** as part of the application process - **Conduct Periodic Reviews and Audits** of policyholder activities, focusing on high-risk customers and those exhibiting unusual transaction patterns. - **Use Technology and Data Analytics** to identify unusual patterns or activities and generate automated alerts related to suspicious activity - **Report Suspicious Transactions** to the Financial Crimes Enforcement Network (FinCEN) - **Continuously Evaluate AML Guidelines** to ensure emerging threats are regularly assessed **Report Suspicious Activity** If you suspect insurance-related money laundering: - Contact your state’s Department of Insurance - File a report with the Financial Crimes Enforcement Network (FinCEN) – www.FINCEN.gov **The Bigger Picture** Money laundering isn’t just a financial crime—it’s often associated with drug trafficking, organized crime, terrorism financing, and human trafficking. By understanding and helping combat money laundering through insurance, you’re contributing to the fight against these underlying crimes. --- ### [Scattered Spider Alert](https://insurancefraud.org/scattered-spider-alert/) **Published:** June 19, 2025 **Author:** Coalition Against Insurance Fraud **Content:** *This alert may extend beyond your immediate area of responsibility. As a heads-up, we strongly encourage you to share it with colleagues in technology, cybersecurity, staff training, and communications. Their involvement will be essential in helping your organization prepare for and respond to potential risks.* ### ****Scattered Spider Poses Growing Cyber Threat to Insurance Industry**** [![](https://insurancefraud.org/wp-content/uploads/Insurer-Member-Alert-Scattered-Spider-791x1024.jpg)](https://insurancefraud.org/wp-content/uploads/Insurer-Member-Alert-Scattered-Spider.pdf) *Insurance Business* and *Newsweek* magazines, along with several other information technology and security outlets, are reporting that the global insurance industry is the latest target of the hacker collective *Scattered Spider*, which has previously crippled U.S. casinos, telecom giants, and major U.K. retailers. Cybersecurity experts, including *Google’s Threat Intelligence Group*, report a rise in intrusions into U.S. insurance firms, prompting urgent calls for heightened awareness and defense. *Scattered Spider*, also known as UNC3944, has been linked to high-profile attacks on Marks & Spencer, Harrods, Caesars Entertainment, MGM Resorts, and financial institutions like PNC. Their tactics are especially effective against complex organizations like insurers, which often depend on distributed service centers and cloud-based infrastructure. The group’s hallmark is insider-level deception, using publicly available employee information to impersonate staff and manipulate help desks and IT administrators through social engineering. Recent cyber disruptions impacting several insurance carriers, while not yet formally tied to *Scattered Spider*, emphasize the urgent need for action. Now is an ideal time to strengthen enterprise-wide awareness, particularly among IT, administrative, and help desk staff. Educating employees on social engineering red flags is a proactive and effective step toward reducing risk. --- ### [Media Requests](https://insurancefraud.org/media-requests/) **Published:** April 2, 2025 **Author:** Coalition Against Insurance Fraud **Content:** ## Request For Interview Form Date(Required) Name of Reporter(Required) Reporter Email Address(Required) Reporter Phone Number(Required) Name Of Media Organization(Required) Interview Topic(s)(Required) Will any individual, entity, investigation or court case be referenced as part of the story?(Required) No Yes If you answered yes, please provide the names of all individuals, entities, investigations or court cases. Specific questions to be asked of Coalition representatives:(Required) Preferred format for Coalition response: (Check all that apply)(Required) Written Comments Virtual Interview In-Person Interview Time frame in which a response or interview is needed?(Required) What media format(s) will the interview be shared on? (Check all that apply)(Required) Television Print Social Media Radio Website Will any of the following be requested? (Check all that apply)(Required) High Resolution Coalition Logo Description Of The Coalition Do you agree to fully adhere to the Coalition's Media / Interview Policy, as outlined on our website?(Required) Yes No If you answered no, please indicate why you are unable to fully adhere to our media / interview policy? Any other details of factors you would like to provide about this request? Submit Δ --- ### [Upcoming Meetings](https://insurancefraud.org/upcoming-meetings/) **Published:** July 23, 2020 **Author:** Coalition Against Insurance Fraud **Content:** ![](https://insurancefraud.org/wp-content/uploads/June-2025.png) --- --- ### [Four Faces - 2017](https://insurancefraud.org/four-faces-2017/) **Published:** October 8, 2020 **Author:** admcaif **Content:** On this Page: - [Videos](https://insurancefraud.org/tools-resources/#videos) - [Infographics](https://insurancefraud.org/tools-resources/#infographics) - [Expert Speakers](https://insurancefraud.org/tools-resources/#expertspeakers) Related Content: - [Fraud: Why Care?](https://insurancefraud.org/fraud-why-care/) - [Fraud Stats](https://insurancefraud.org/fraud-stats/) - [Report Fraud](https://insurancefraud.org/report-fraud/) - [Anti-Fraud Events](https://insurancefraud.org/events/) #### *Consumer attitude study: **Americans concerned about fraud, yet ethics mixed*** ![](https://insurancefraud.org/wp-content/uploads/Four_faces1.jpg) Nearly four of five adult Americans say they’re concerned about insurance fraud to varying degrees, says *[Four Faces of Insurance Fraud](https://insurancefraud.org/wp-content/uploads/fourfaces_2017.pdf)*, the Coalition’s 2017 national survey of consumer attitudes. The survey of 2,733 consumers builds on *Four Faces studies in 1997 and 2007*. The study also places Americans into four groups based on their tolerance of insurance fraud: • **Moralists.** Have little tolerance for insurance fraud and view the issue as one of fundamental honesty. • **Realists.** Insurance fraud will always be there, even it is wrong. While they may not support committing fraud, it is a fact of life in the world of insurance. • **Conformists.** Accept that fraud occurs, and may be easily tempted to join in. • **Critics.** The critic is glad to see insurers fleeced. They welcome taking money from insurers, even via fraud. **Category findings** To the positive, the Critics group declined in size from 26% to 11% from 2007. While the Critics still are too numerous, a 15% drop suggests that public-awareness efforts to dissuade Americans from this crime are showing progress. ![](https://insurancefraud.org/wp-content/uploads/Four_faces2.jpg) On the other end of the spectrum, however, Moralists who do not tolerate this crime continued to decrease from both prior studies. Squeezed in the middle are Realists and Conformists. They recorded sharp increases over prior studies. **Overall findings** Despite the drop in general consumer concern about insurance fraud, Americans overall show increasing tolerance for specific unethical behavior: • 78% percent say they are concerned about insurance fraud • 88% say it’s unethical to misrepresent an incident to obtain payment for an uncovered loss, compared to 93% in 1997. • 84% say submitting an inflated claim is unethical, compared to 91% in 1997. Older Americans are less tolerant than younger consumers: • 81% of Americans over age 55 say premium evasion is unethical, compared to 68% of Americans under 35 years. How people justify insurance fraud: • Premiums are too high (70%). ![](https://insurancefraud.org/wp-content/uploads/Four_faces3.jpg) • Insurer profits are too high (63%). • Consumers want a fair return on the premiums they’ve paid (52%). • Everybody does it (49%) **Analysis** The rise of Millennials has been America’s largest demographic shift between 2007 and 2017. Millennials now outnumber all other generations in the workforce. Our 2017 findings, in turn, point to the major impact Millennials will have on insurance fraud. They are more accepting of lying and dishonesty than their Baby Boomer elders. Add in a widesrpread generational perception that big corporations are uncaring, and that CEO salaries unfairly dwarf the income of everyday workers. Pair that with the Coalition findings that many consumers belief fraud is committed in part in response to high perceived insurer profits and premiums. Thus younger Americans clearly will have a large impact on fraud for years to come. Fraud fighters must ensure our consumer-awareness messages resonate with a younger and more diverse generation. We encourage the anti-fraud community to consider the implications of *Four Faces* on anti-fraud efforts as we unite to develop anti-fraud strategies that meet the evolving challenges of today’s consumer attitudes and behaviors. --- ### [Fraud Tracker](https://insurancefraud.org/fraud-tracker/) **Published:** July 31, 2020 **Author:** Coalition Against Insurance Fraud **Content:** [Testing CSV](https://insurancefraud.org/testing-csv/) --- ### [YourMembership](https://insurancefraud.org/yourmembership/) **Published:** February 8, 2023 **Author:** Coalition Against Insurance Fraud **Content:** ![](https://insurancefraud.org/wp-content/uploads/Your-Membership-Graphic--1024x567.png)## **[<< Create your member profile today >>](https://members.insurancefraud.org/)** --- ### [DEI Statement](https://insurancefraud.org/dei-statement/) **Published:** February 1, 2023 **Author:** Coalition Against Insurance Fraud **Content:** ### **STATEMENT ON DIVERSITY, EQUITY AND INCLUSION** The Coalition recognizes both the profession and manner of fighting against insurance fraud have changed dramatically since our founding in 1993. We equally acknowledge and embrace the fact our nation continues to change as well. The Coalition is committed to being a leader in shaping and improving the fight against insurance fraud in the decades to come. In that spirit, the Coalition adopts this Statement on Diversity, Equity, and Inclusion. The Coalition is committed to creating a diverse, equitable, and inclusive environment for all members regardless of gender, race, ethnicity, national origin, age, sexual orientation or identity, education, or disability. We value and respect diverse life experiences and seek to ensure all voices are valued and heard. The Coalition and its members should model diversity, equity, and inclusion in the anti-fraud profession through our actions and our efforts. We urge all Coalition members to support these provisions in all ways in their efforts to combat insurance fraud and build for a stronger future: - We acknowledge diversity, equity and inclusion are connected to the anti-fraud mission and critical to ensuring the well-being of the professional and public communities we serve. - The Coalition, and its members, should affirmatively seek and encourage the hiring of more persons of color and diversity into the ranks of the fraud-fighting profession. This includes hiring for all positions, internships, scholarship programs, career education and recruitment efforts. This also applies to the promotion and career advancement tracks for persons of color and diversity so the future leadership of our profession better reflects the demographics and qualities of the communities and nation we serve. As a profession we will grow stronger, and believe our efforts to fight against insurance fraud will be enhanced, through greater inclusion and diversity in our collective ranks. - We urge members to undertake diversity and cultural training within their anti-fraud teams and management. We encourage listening, dialoguing and seeking education between culturally and ethnically diverse persons and communities. We recognize, for reasons far beyond the anti-fraud fight, systemic biases and prejudices have historically been, and continue to be, a part of our society, and as such, a part of our profession. We affirm to work to eliminate or minimize those biases to the best of our ability so the investigation of insurance fraud is conducted as free as possible from any form of cultural, racial, economic or any other form of bias or prejudice. - In addition to the individual and societal biases that may diminish the impartiality of anti-fraud efforts, we understand the potential risk bias in the development and application of technology-driven fraud fighting efforts. We call upon all technology developers and those utilizing such systems and data to remain vigilant to identify and protect against the risk of bias. We recognize such duties are ongoing in nature and require regular review, testing and analysis to prevent against the risk of potential bias. - The Coalition’s members seek to fight against all forms of insurance fraud and the harm it causes to consumers, insurers and businesses across our nation. We urge members to ensure fraud investigations are conducted in a fair and unbiased manner; for law enforcement to apply all laws fairly and impartially no matter the consequences; for legislators and regulators to oversee the investigation of insurance fraud with a recognition of the risk of systemic prejudice and bias and to undertake the reasonable oversight necessary to ensure such actions are not permitted as a part of the American insurance markets. - We recognize drafting and adopting this Statement is only a first step upon a necessary and extended journey. The Coalition Against Insurance Fraud through its members, board, executive committee and staff unequivocally commit to undertaking actions, both existing and new, with the goal of developing increased opportunities and seeking new pathways to make certain the words expressed herein today become actions for an improved future. The Board hereby directs and empowers the Executive Committee and Coalition staff to work toward identifying specific recommendations, efforts and programs designed to fulfill the goals set forth herein. Such actions may include, but are in no way limited to: - Encouraging Coalition partners to adopt this Statement, or a version of their own designed to achieve the same or similar goals and objectives. - Urging Coalition members to consider this Statement as an integral part of their anti-fraud and business programs. - Incorporating these goals into the primary missions of the Coalition in the areas of public outreach, legislative and judicial advocacy. - Undertaking specific research to analyze issues of diversity and inclusiveness in relation to its impact on the future of the anti-fraud profession, and the disparate impact of systemic bias and practices, as they relate to equity in fraud investigation referrals and decisions. - Encouraging developers and users of algorithmic and artificial intelligence based anti-fraud programs to work to ensure such programs are free of bias or prejudice. - Making certain the Coalition’s employment practices and work environment reflect these objectives and goals. - Working to ensure the Coalition’s committees, task forces and leadership reflect these goals and objectives - Reporting back regularly to the Executive Committee and the Board on progress made by the Coalition, our partners and our members to achieve the goals and objectives set out in this Statement. This Statement on Diversity, Equity and Inclusion is hereby adopted by vote of the Board of Directors of the Coalition Against Insurance Fraud this **7** day of **December 2022**. [**<< Click here to download this statement >>**](https://insurancefraud.org/wp-content/uploads/DIVERSITY-EQUITY-AND-INCLUSION-STATEMENT-Adopted-1272021.pdf) --- ### [regulations](https://insurancefraud.org/regulations/) **Published:** March 12, 2021 **Author:** Coalition Fraud --- ### [Advanced Search](https://insurancefraud.org/advanced-search/) **Published:** July 30, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Easily search the entire website for specific information about insurance fraud. Enter any or all of the fields below. Note that many information sources are available only to employees of member-organizations who are registered for special access. --- ### [Your Profile](https://insurancefraud.org/your-profile/) **Published:** July 31, 2020 **Author:** Coalition Against Insurance Fraud **Content:** \[pmpro\_member\_profile\_edit\] --- ## Legal Pages ### [Privacy Policy](https://insurancefraud.org/wpautoterms/online-privacy-policy/) **Published:** September 24, 2021 **Author:** Coalition Fraud **Content:** As part of our commitment to protecting your privacy, this statement is designed to provide you with information regarding how the Coalition Against Insurance Fraud may use — and process — the information you share when you use the Insurancefraud.org website. Information is also collected when you communicate with us or utilize any of our services. We use your personal data to provide and improve our services. By using the Service, You agree to the collection and use of information in accordance with this Privacy Policy. #### **Interpretation and Definitions** ##### **Interpretation** The words of which the initial letter is capitalized have meanings defined under the following conditions. The following definitions shall have the same meaning regardless of whether they appear in singular or in plural. ##### **Definitions** For the purposes of this Privacy Policy: - **You** means the individual accessing or using the Service, or the company, or other legal entity on behalf of which such individual is accessing or using the Service, as applicable. - **Organization** (referred to as either “the Organization”, “We”, “Us” or “Our” in this Agreement) refers to InsuranceFraud.org. - **Affiliate** means an entity that controls, is controlled by or is under common control with a party, where “control” means ownership of 50% or more of the shares, equity interest or other securities entitled to vote for election of directors or other managing authority. - **Account** means a unique account created for You to access our Service or parts of our Service. - **Website** refers to InsuranceFraud.org, accessible from https://insurancefraud.org - Service refers to the Website. - **Country** refers to: District of Columbia, United States - **Service Provider** means any natural or legal person who processes the data on behalf of the Organization. It refers to third-party companies or individuals employed by the Organization to facilitate the Service, to provide the Service on behalf of the Organization, to perform services related to the Service or to assist the Organization in analyzing how the Service is used. - **Third-party Social Media Service** refers to any website or any social network website through which a User can log in or create an account to use the Service. - **Personal Data** is any information that relates to an identified or identifiable individual.For the purposes of the CCPA, Personal Data means any information that identifies, relates to, describes or is capable of being associated with, or could reasonably be linked, directly or indirectly, with You. - Cookies are small files that are placed on Your computer, mobile device or any other device by a website, containing the details of Your browsing history on that website among its many uses. - **Device** means any device that can access the Service such as a computer, a cellphone or a digital tablet. - **Usage Data** refers to data collected automatically, either generated by the use of the Service or from the Service infrastructure itself (for example, the duration of a page visit). - **Business,** for the purpose of the CCPA (California Consumer Privacy Act), refers to the Organization as the legal entity that collects Consumers’ personal information and determines the purposes and means of the processing of Consumers’ personal information, or on behalf of which such information is collected and that alone, or jointly with others, determines the purposes and means of the processing of consumers’ personal information, that does business in the State of California. - **Consumer,** for the purpose of the CCPA (California Consumer Privacy Act), means a natural person who is a California resident. A resident, as defined in the law, includes (1) every individual who is in the USA for other than a temporary or transitory purpose, and (2) every individual who is domiciled in the USA who is outside the USA for a temporary or transitory purpose. - **Sale**, for the purpose of the CCPA (California Consumer Privacy Act), means selling, renting, releasing, disclosing, disseminating, making available, transferring, or otherwise communicating orally, in writing, or by electronic or other means, a Consumer’s personal information to another business or a third party for monetary or other valuable consideration. #### **Collecting and Using Your Personal Data** ##### **Types of Data Collected** ###### **Personal Data** While using Our Service, We may ask You to provide Us with certain personally identifiable information that can be used to contact or identify You. Personally identifiable information may include, but is not limited to: - Email address - First name and last name - Phone number - Address, State, Province, ZIP/Postal code, City - Usage Data ###### **Usage Data** Usage Data is collected automatically when using the Service. Usage Data may include information such as Your Device’s Internet Protocol address (e.g. IP address), browser type, browser version, the pages of our Service that You visit, the time and date of Your visit, the time spent on those pages, unique device identifiers and other diagnostic data. When You access the Service by or through a mobile device, We may collect certain information automatically, including, but not limited to, the type of mobile device You use, Your mobile device unique ID, the IP address of Your mobile device, Your mobile operating system, the type of mobile Internet browser You use, unique device identifiers and other diagnostic data. We may also collect information that Your browser sends whenever You visit our Service or when You access the Service by or through a mobile device. ##### **Tracking Technologies and Cookies** We use Cookies and similar tracking technologies to track the activity on Our Service and store certain information. Tracking technologies used are beacons, tags, and scripts to collect and track information and to improve and analyze Our Service. The technologies We use may include: - Cookies or Browser Cookies. A cookie is a small file placed on Your Device. You can instruct Your browser to refuse all Cookies or to indicate when a Cookie is being sent. However, if You do not accept Cookies, You may not be able to use some parts of our Service. Unless you have adjusted Your browser setting so that it will refuse Cookies, our Service may use Cookies. - Flash Cookies. Certain features of our Service may use local stored objects (or Flash Cookies) to collect and store information about Your preferences or Your activity on our Service. Flash Cookies are not managed by the same browser settings as those used for Browser Cookies. For more information on how You can delete Flash Cookies, please read “Where can I change the settings for disabling, or deleting local shared objects?” available at [**https://helpx.adobe.com/flash-player/kb/disable-local-shared-objects-flash.html#main\_Where\_can\_I\_change\_the\_settings\_for\_disabling\_\_or\_deleting\_local\_shared\_objects\_**](https://helpx.adobe.com/flash-player/kb/disable-local-shared-objects-flash.html#main_Where_can_I_change_the_settings_for_disabling__or_deleting_local_shared_objects_) - Web Beacons. Certain sections of our Service and our emails may contain small electronic files known as web beacons (also referred to as clear gifs, pixel tags, and single-pixel gifs) that permit the Organization, for example, to count users who have visited those pages or opened an email and for other related website statistics (for example, recording the popularity of a certain section and verifying system and server integrity). Cookies can be “Persistent” or “Session” Cookies. Persistent Cookies remain on Your personal computer or mobile device when You go offline, while Session Cookies are deleted as soon as You close Your web browser. We use both Session and Persistent Cookies for the purposes set out below: - Necessary / Essential CookiesType: Session CookiesAdministered by: UsPurpose: These Cookies are essential to provide You with services available through the Website and to enable You to use some of its features. They help to authenticate users and prevent fraudulent use of user accounts. Without these Cookies, the services that You have asked for cannot be provided, and We only use these Cookies to provide You with those services. - Cookies Policy / Notice Acceptance CookiesType: Persistent CookiesAdministered by: UsPurpose: These Cookies identify if users have accepted the use of cookies on the Website. - Functionality Cookies Type: Persistent CookiesAdministered by: UsPurpose: These Cookies allow us to remember choices You make when You use the Website, such as remembering your login details or language preference. The purpose of these Cookies is to provide You with a more personal experience and to avoid You having to re-enter your preferences every time You use the Website. - Tracking and Performance CookiesType: Persistent CookiesAdministered by: Third-PartiesPurpose: These Cookies are used to track information about traffic to the Website and how users use the Website. The information gathered via these Cookies may directly or indirectly identify you as an individual visitor. This is because the information collected is typically linked to a pseudonymous identifier associated with the device you use to access the Website. We may also use these Cookies to test new pages, features or new functionality of the Website to see how our users react to them. ##### **Use of Your Personal Data** The Organization may use Personal Data for the following purposes: - To provide and maintain our Service, including to monitor the usage of our Service. - To manage Your Account: to manage Your registration as a user of the Service. The Personal Data You provide can give You access to different functionalities of the Service that are available to You as a registered user. - For the performance of a contract: the development, compliance and undertaking of the purchase contract for the products, items or services You have purchased or of any other contract with Us through the Service. - To contact You: To contact You by email, telephone calls, SMS, or other equivalent forms of electronic communication, such as a mobile application’s push notifications regarding updates or informative communications related to the functionalities, products or contracted services, including the security updates, when necessary or reasonable for their implementation. - To provide You with news, special offers and general information about other goods, services and events which we offer that are similar to those that you have already purchased or enquired about unless You have opted not to receive such information. - To manage Your requests: To attend and manage Your requests to Us. - For business transfers: We may use Your information to evaluate or conduct a merger, divestiture, restructuring, reorganization, dissolution, or other sale or transfer of some or all of Our assets, whether as a going concern or as part of bankruptcy, liquidation, or similar proceeding, in which Personal Data held by Us about our Service users is among the assets transferred. - For other purposes: We may use Your information for other purposes, such as data analysis, identifying usage trends, determining the effectiveness of our promotional campaigns and to evaluate and improve our Service, products, services, marketing and your experience. We may share Your personal information in the following situations: - With Service Providers: We may share Your personal information with Service Providers to monitor and analyze the use of our Service, to contact You. - For business transfers: We may share or transfer Your personal information in connection with, or during negotiations of, any merger, sale of Organization assets, financing, or acquisition of all or a portion of Our business to another company. - With Affiliates: We may share Your information with Our affiliates, in which case we will require those affiliates to honor this Privacy Policy. Affiliates include Our parent company and any other subsidiaries, joint venture partners or other companies that We control or that are under common control with Us. - With Our partners: We may share Your information with Our partners to offer You certain products, services or promotions. - With other users: when You share personal information or otherwise interact in the public areas with other users, such information may be viewed by all users and may be publicly distributed outside. If You interact with other users or register through a Third-Party Social Media Service, Your contacts on the Third-Party Social Media Service may see You name, profile, pictures and description of Your activity. Similarly, other users will be able to view descriptions of Your activity, communicate with You and view Your profile. - With Your consent: We may disclose Your personal information for any other purpose with Your consent. ##### **Retention of Your Personal Data** The Organization will retain Your Personal Data only for as long as is necessary for the purposes set out in this Privacy Policy. We will retain and use Your Personal Data to the extent necessary to comply with our legal obligations (for example, if we are required to retain your data to comply with applicable laws), resolve disputes, and enforce our legal agreements and policies. The Organization will also retain Usage Data for internal analysis purposes. Usage Data is generally retained for a shorter period of time, except when this data is used to strengthen the security or to improve the functionality of Our Service, or We are legally obligated to retain this data for longer time periods. ##### **Transfer of Your Personal Data** Your information, including Personal Data, is processed at the Organization’s operating offices and in any other places where the parties involved in the processing are located. It means that this information may be transferred to — and maintained on — computers located outside of Your state, province, country or other governmental jurisdiction where the data protection laws may differ than those from Your jurisdiction. Your consent to this Privacy Policy followed by Your submission of such information represents Your agreement to that transfer. The Organization will take all steps reasonably necessary to ensure that Your data is treated securely and in accordance with this Privacy Policy and no transfer of Your Personal Data will take place to an organization or a country unless there are adequate controls in place including the security of Your data and other personal information. #### **Disclosure of Your Personal Data** ##### **Business Transactions** If the Organization is involved in a merger, acquisition or asset sale, Your Personal Data may be transferred. We will provide notice before Your Personal Data is transferred and becomes subject to a different Privacy Policy. ##### **Law enforcement** Under certain circumstances, the Organization may be required to disclose Your Personal Data if required to do so by law or in response to valid requests by public authorities (e.g. a court or a government agency). ##### **Other legal requirements** The Organization may disclose Your Personal Data in the good faith belief that such action is necessary to: - Comply with a legal obligation - Protect and defend the rights or property of the Organization - Prevent or investigate possible wrongdoing in connection with the Service - Protect the personal safety of Users of the Service or the public - Protect against legal liability ##### **Security of Your Personal Data** The security of Your Personal Data is important to Us, but remember that no method of transmission over the Internet, or method of electronic storage is 100% secure. While We strive to use commercially acceptable means to protect Your Personal Data, We cannot guarantee its absolute security. ##### **Detailed Information on the Processing of Your Personal Data** The Service Providers We use may have access to Your Personal Data. These third-party vendors collect, store, use, process and transfer information about Your activity on Our Service in accordance with their Privacy Policies. #### **Analytics** We may use third-party Service providers to monitor and analyze the use of our Service. - Google AnalyticsGoogle Analytics is a web analytics service offered by Google that tracks and reports website traffic. Google uses the data collected to track and monitor the use of our Service. This data is shared with other Google services. Google may use the collected data to contextualise and personalise the ads of its own advertising network.You can opt-out of having made your activity on the Service available to Google Analytics by installing the Google Analytics opt-out browser add-on. The add-on prevents the Google Analytics JavaScript (ga.js, analytics.js and dc.js) from sharing information with Google Analytics about visits activity.For more information on the privacy practices of Google, please visit the Google Privacy & Terms web page: [**https://policies.google.com/privacy?hl=en**](https://policies.google.com/privacy?hl=en) #### **Email Marketing** We may use Your Personal Data to contact You with newsletters, marketing or promotional materials and other information that may be of interest to You. You may opt-out of receiving any, or all, of these communications from Us by following the unsubscribe link or instructions provided in any email We send or by contacting Us. We may use Email Marketing Service Providers to manage and send emails to You. - Mailchimp Mailchimp is an email marketing sending service provided by The Rocket Science Group LLC.For more information on the privacy practices of Mailchimp, please visit their Privacy policy: [**https://mailchimp.com/legal/privacy/**](https://mailchimp.com/legal/privacy/) #### **CCPA Privacy** This privacy notice section for California residents supplements the information contained in Our Privacy Policy and it applies solely to all visitors, users, and others who reside in the State of California. ##### **Categories of Personal Information Collected** We collect information that identifies, relates to, describes, references, is capable of being associated with, or could reasonably be linked, directly or indirectly, with a particular Consumer or Device. The following is a list of categories of personal information which we may collect or may have been collected from California residents within the last twelve (12) months. Please note that the categories and examples provided in the list below are those defined in the CCPA. This does not mean that all examples of that category of personal information were in fact collected by Us, but reflects our good faith belief to the best of our knowledge that some of that information from the applicable category may be and may have been collected. For example, certain categories of personal information would only be collected if You provided such personal information directly to Us. - Category A: Identifiers.Examples: A real name, alias, postal address, unique personal identifier, online identifier, Internet Protocol address, email address, account name, driver’s license number, passport number, or other similar identifiers.Collected: Yes. - Category B: Personal information categories listed in the California Customer Records statute (Cal. Civ. Code § 1798.80(e)).Examples: A name, signature, Social Security number, physical characteristics or description, address, telephone number, passport number, driver’s license or state identification card number, insurance policy number, education, employment, employment history, bank account number, credit card number, debit card number, or any other financial information, medical information, or health insurance information. Some personal information included in this category may overlap with other categories.Collected: Yes. - Category C: Protected classification characteristics under California or federal law.Examples: Age (40 years or older), race, color, ancestry, national origin, citizenship, religion or creed, marital status, medical condition, physical or mental disability, sex (including gender, gender identity, gender expression, pregnancy or childbirth and related medical conditions), sexual orientation, veteran or military status, genetic information (including familial genetic information).Collected: No. - Category D: Commercial information.Examples: Records and history of products or services purchased or considered.Collected: No. - Category E: Biometric information.Examples: Genetic, physiological, behavioral, and biological characteristics, or activity patterns used to extract a template or other identifier or identifying information, such as, fingerprints, faceprints, and voiceprints, iris or retina scans, keystroke, gait, or other physical patterns, and sleep, health, or exercise data.Collected: No. - Category F: Internet or other similar network activity.Examples: Interaction with our Service or advertisement.Collected: Yes. - Category G: Geolocation data.Examples: Approximate physical location.Collected: No. - Category H: Sensory data.Examples: Audio, electronic, visual, thermal, olfactory, or similar information.Collected: No. - Category I: Professional or employment-related information.Examples: Current or past job history or performance evaluations.Collected: No. - Category J: Non-public education information (per the Family Educational Rights and Privacy Act (20 U.S.C. Section 1232g, 34 C.F.R. Part 99)).Examples: Education records directly related to a student maintained by an educational institution or party acting on its behalf, such as grades, transcripts, class lists, student schedules, student identification codes, student financial information, or student disciplinary records.Collected: No. - Category K: Inferences drawn from other personal information.Examples: Profile reflecting a person’s preferences, characteristics, psychological trends, predispositions, behavior, attitudes, intelligence, abilities, and aptitudes.Collected: No. Under CCPA, personal information does not include: - Publicly available information from government records - Deidentified or aggregated consumer information - Information excluded from the CCPA’s scope, such as: - Health or medical information covered by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and the California Confidentiality of Medical Information Act (CMIA) or clinical trial data - Personal Information covered by certain sector-specific privacy laws, including the Fair Credit Reporting Act (FRCA), the Gramm-Leach-Bliley Act (GLBA) or California Financial Information Privacy Act (FIPA), and the Driver’s Privacy Protection Act of 1994 ##### **Sources of Personal Information** We obtain the categories of personal information listed above from the following categories of sources: - Directly from You. For example, from the forms You complete on our Service, preferences You express or provide through our Service. - Indirectly from You. For example, from observing Your activity on our Service. - Automatically from You. For example, through cookies We or our Service Providers set on Your Device as You navigate through our Service. - From Service Providers. For example, third-party vendors to monitor and analyze the use of our Service, or other third-party vendors that We use to provide the Service to You. ##### **Use of Personal Information for Business Purposes or Commercial Purposes** We may use or disclose personal information We collect for “business purposes” or “commercial purposes” (as defined under the CCPA), which may include the following examples: - To operate our Service and provide You with our Service. - To provide You with support and to respond to Your inquiries, including to investigate and address Your concerns and monitor and improve our Service. - To fulfill or meet the reason You provided the information. For example, if You share Your contact information to ask a question about our Service, We will use that personal information to respond to Your inquiry. - To respond to law enforcement requests and as required by applicable law, court order, or governmental regulations. - As described to You when collecting Your personal information or as otherwise set forth in the CCPA. - For internal administrative and auditing purposes. - To detect security incidents and protect against malicious, deceptive, fraudulent or illegal activity, including, when necessary, to prosecute those responsible for such activities. Please note that the examples provided above are illustrative and not intended to be exhaustive. For more details on how we use this information, please refer to the “Use of Your Personal Data” section. If We decide to collect additional categories of personal information or use the personal information We collected for materially different, unrelated, or incompatible purposes We will update this Privacy Policy. ##### **Disclosure of Personal Information for Business Purposes or Commercial Purposes** We may use or disclose and may have used or disclosed in the last twelve (12) months the following categories of personal information for business or commercial purposes: - Category A: Identifiers - Category B: Personal information categories listed in the California Customer Records statute (Cal. Civ. Code § 1798.80(e)) - Category F: Internet or other similar network activity Please note that the categories listed above are those defined in the CCPA. This does not mean that all examples of that category of personal information were in fact disclosed, but reflects our good faith belief to the best of our knowledge that some of that information from the applicable category may be and may have been disclosed. When We disclose personal information for a business purpose or a commercial purpose, We enter a contract that describes the purpose and requires the recipient to both keep that personal information confidential and not use it for any purpose except performing the contract. ##### **Sale of Personal Information** As defined in the CCPA, “sell” and “sale” mean selling, renting, releasing, disclosing, disseminating, making available, transferring, or otherwise communicating orally, in writing, or by electronic or other means, a consumer’s personal information by the business to a third party for valuable consideration. This means that We may have received some kind of benefit in return for sharing personal Iinformation, but not necessarily a monetary benefit. Please note that the categories listed below are those defined in the CCPA. This does not mean that all examples of that category of personal information were in fact sold, but reflects our good faith belief to the best of our knowledge that some of that information from the applicable category may be and may have been shared for value in return. We may sell and may have sold in the last twelve (12) months the following categories of personal information: - Category A: Identifiers - Category B: Personal information categories listed in the California Customer Records statute (Cal. Civ. Code § 1798.80(e)) - Category F: Internet or other similar network activity ##### **Share of Personal Information** We may share Your personal information identified in the above categories with the following categories of third parties: - Service Providers - Our affiliates - Our partners - Third party vendors to whom You or Your agents authorize Us to disclose Your personal information in connection with products or services We provide to You ##### **Sale of Personal Information of Minors Under 16 Years of Age** We do not sell the personal information of Consumers We actually know are less than 16 years of age, unless We receive affirmative authorization (the “right to opt-in”) from either the Consumer who is between 13 and 16 years of age, or the parent or guardian of a Consumer less than 13 years of age. Consumers who opt-in to the sale of personal information may opt-out of future sales at any time. To exercise the right to opt-out, You (or Your authorized representative) may submit a request to Us by contacting Us. If You have reason to believe that a child under the age of 13 (or 16) has provided Us with personal information, please contact Us with sufficient detail to enable Us to delete that information. ##### **Your Rights under the CCPA** The CCPA provides California residents with specific rights regarding their personal information. If You are a resident of California, You have the following rights: - The right to notice. You have the right to be notified which categories of Personal Data are being collected and the purposes for which the Personal Data is being used. - The right to request. Under CCPA, You have the right to request that We disclose information to You about Our collection, use, sale, disclosure for business purposes and share of personal information. Once We receive and confirm Your request, We will disclose to You: - The categories of personal information We collected about You - The categories of sources for the personal information We collected about You - Our business or commercial purpose for collecting or selling that personal information - The categories of third parties with whom We share that personal information - The specific pieces of personal information We collected about You - If we sold Your personal information or disclosed Your personal information for a business purpose, We will disclose to You: - The categories of personal information categories sold - The categories of personal information categories disclosed - The right to say no to the sale of Personal Data (opt-out). You have the right to direct Us to not sell Your personal information. To submit an opt-out request please contact Us. - The right to delete Personal Data. You have the right to request the deletion of Your Personal Data, subject to certain exceptions. Once We receive and confirm Your request, We will delete (and direct Our Service Providers to delete) Your personal information from our records, unless an exception applies. We may deny Your deletion request if retaining the information is necessary for Us or Our Service Providers to: - Complete the transaction for which We collected the personal information, provide a good or service that You requested, take actions reasonably anticipated within the context of our ongoing business relationship with You, or otherwise perform our contract with You. - Detect security incidents, protect against malicious, deceptive, fraudulent, or illegal activity, or prosecute those responsible for such activities. - Debug products to identify and repair errors that impair existing intended functionality. - Exercise free speech, ensure the right of another consumer to exercise their free speech rights, or exercise another right provided for by law. - Comply with the California Electronic Communications Privacy Act (Cal. Penal Code § 1546 et. seq.). - Engage in public or peer-reviewed scientific, historical, or statistical research in the public interest that adheres to all other applicable ethics and privacy laws, when the information’s deletion may likely render impossible or seriously impair the research’s achievement, if You previously provided informed consent. - Enable solely internal uses that are reasonably aligned with consumer expectations based on Your relationship with Us. - Comply with a legal obligation. - Make other internal and lawful uses of that information that are compatible with the context in which You provided it. - The right not to be discriminated against. You have the right not to be discriminated against for exercising any of Your consumer’s rights, including by: - Denying goods or services to You - Charging different prices or rates for goods or services, including the use of discounts or other benefits or imposing penalties - Providing a different level or quality of goods or services to You - Suggesting that You will receive a different price or rate for goods or services or a different level or quality of goods or services ##### **Exercising Your CCPA Data Protection Rights** In order to exercise any of Your rights under the CCPA, and if You are a California resident, You can contact Us: - By email: Info@insurancefraud.org Only You, or a person registered with the California Secretary of State that You authorize to act on Your behalf, may make a verifiable request related to Your personal information. Your request to Us must: - Provide sufficient information that allows Us to reasonably verify You are the person about whom We collected personal information or an authorized representative - Describe Your request with sufficient detail that allows Us to properly understand, evaluate, and respond to it We cannot respond to Your request or provide You with the required information if we cannot: - Verify Your identity or authority to make the request - And confirm that the personal information relates to You We will disclose and deliver the required information free of charge within 45 days of receiving Your verifiable request. The time period to provide the required information may be extended once by an additional 45 days when reasonable necessary and with prior notice. Any disclosures We provide will only cover the 12-month period preceding the verifiable request’s receipt. For data portability requests, We will select a format to provide Your personal information that is readily useable and should allow You to transmit the information from one entity to another entity without hindrance. ##### **Do Not Sell My Personal Information** You have the right to opt-out of the sale of Your personal information. Once We receive and confirm a verifiable consumer request from You, we will stop selling Your personal information. To exercise Your right to opt-out, please contact Us. The Service Providers we partner with (for example, our analytics or advertising partners) may use technology on the Service that sells personal information as defined by the CCPA law. If you wish to opt out of the use of Your personal information for interest-based advertising purposes and these potential sales as defined under CCPA law, you may do so by following the instructions below. Please note that any opt out is specific to the browser You use. You may need to opt out on every browser that You use. ##### **Website** You can opt out of receiving ads that are personalized as served by our Service Providers by following our instructions presented on the Service: - The NAI’s opt-out platform: [**http://www.networkadvertising.org/choices/**](https://www.networkadvertising.org/choices/) - The EDAA’s opt-out platform [**http://www.youronlinechoices.com/**](http://www.youronlinechoices.com/) - The DAA’s opt-out platform: [**http://optout.aboutads.info/?c=2&lang=EN**](http://optout.aboutads.info/?c=2&lang=EN) The opt out will place a cookie on Your computer that is unique to the browser You use to opt out. If you change browsers or delete the cookies saved by your browser, You will need to opt out again. ##### **Mobile Devices** Your mobile device may give you the ability to opt out of the use of information about the apps you use in order to serve you ads that are targeted to your interests: - “Opt out of Interest-Based Ads” or “Opt out of Ads Personalization” on Android devices - “Limit Ad Tracking” on iOS devices You can also stop the collection of location information from Your mobile device by changing the preferences on Your mobile device. ##### **“Do Not Track” Policy as Required by California Online Privacy Protection Act (CalOPPA)** Our Service does not respond to Do Not Track signals. However, some third party websites do keep track of You browsing activities. If You are visiting such websites, You can set Your preferences in Your web browser to inform websites that You do not want to be tracked. You can enable or disable DNT by visiting the preferences or settings page of Your web browser. ##### **Your California Privacy Rights (California’s Shine the Light law)** Under California Civil Code Section 1798 (California’s Shine the Light law), California residents with an established business relationship with us can request information once a year about sharing their Personal Data with third parties for the third parties’ direct marketing purposes. If you’d like to request more information under the California Shine the Light law, and if You are a California resident, You can contact Us using the contact information provided below. ##### **California Privacy Rights for Minor Users (California Business and Professions Code Section 22581)** California Business and Professions Code section 22581 allow California residents under the age of 18 who are registered users of online sites, services or applications to request and obtain removal of content or information they have publicly posted. To request removal of such data, and if You are a California resident, You can contact Us using the contact information provided below, and include the email address associated with Your account. Be aware that Your request does not guarantee complete or comprehensive removal of content or information posted online and that the law may not permit or require removal in certain circumstances. #### **Links to Other Websites** Our Service may contain links to other websites that are not operated by Us. If You click on a third party link, You will be directed to that third party’s site. We strongly advise You to review the Privacy Policy of every site You visit. We have no control over and assume no responsibility for the content, privacy policies or practices of any third party sites or services. #### **Changes to this Privacy Policy** We may update Our Privacy Policy from time to time. We will notify You of any changes by posting the new Privacy Policy on this page. We will let You know via email and/or a prominent notice on Our Service, prior to the change becoming effective and update the “Last updated” date at the top of this Privacy Policy. You are advised to review this Privacy Policy periodically for any changes. Changes to this Privacy Policy are effective when they are posted on this page. #### **Contact Us** If you have any questions about this Privacy Policy, You can contact us by email: Info@insurancefraud.org ###### **Effective date: September 24, 2021** --- ## Publications ### [Fraud News Weekly (FNW) Friday, October 16, 2026](https://insurancefraud.org/publications/fraud-news-weekly-fnw-friday-october-16-2026/) **Published:** October 16, 2026 **Author:** Coalition Against Insurance Fraud **Content:** Fraud News Weekly (FNW) Friday, October 16, 2026͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ | \| \| \| \| \| \| \| [View this email in your browser](https://mailchi.mp/3f867adb8da7/fraud-news-weekly-friday-may-1-10704982?e=%5BUNIQID%5D) \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| \| \| \| \| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a17387c7-1118-cd6a-54ab-8ba283e85ac6.jpeg) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/d2d67ba2-87f2-55d0-9155-f501649016f4.jpeg) \| \| \|:-:\| \| \| \| **Coalition urges Pennsylvania Senate to advance Public Adjuster Licensing Law.** On October 9, 2026, the Coalition submitted a [**letter of support**](https://insurancefraud.org/wp-content/uploads/10-9-2026-Coalition-Support-of-Pennsylvania-H1972.pdf) for Pennsylvania [House Bill 1972](https://www.palegis.us/legislation/bills/2025/hb1972), which would strengthen public adjuster licensing requirements, restrict conflicts of interest, improve contract and disclosure protections, and strengthen enforcement to protect policyholders from fraud and misconduct. The letter urges Senate leadership to advance the bill during this legislative session. [Read more](https://insurancefraud.org/wp-content/uploads/10-9-2026-Coalition-Support-of-Pennsylvania-H1972.pdf)… **Washington seeks to target insurance fraud and abusive assignment of benefits to strengthen consumer protections in 2027.** The Washington State Office of the Insurance Commissioner’s 2027 priorities include prohibiting post loss assignment of benefits (AOBs), which can transfer control of insurance claims from policyholders to third parties. The proposals would also expand the state’s definition of insurance fraud to cover identity theft, improper premium handling and billing for services or equipment never provided. Additional provisions would strengthen criminal penalties and extend the time prosecutors have to bring fraud charges. Commissioner Patty Kuderer told the Coalition, “*These two bills will modernize our state’s laws to protect consumers and ensure that Washingtonians don’t foot the bill for insurance fraud by paying higher premiums.*” [Read more](https://www.insurance.wa.gov/laws-rules/legislation-and-rulemaking/2027-legislative-priorities)… **New Hampshire adopts updated claim settlement rules with specific standards for suspected fraud.** New Hampshire adopted revisions to [Chapter Ins 1000, Claim Settlement](https://www.insurance.nh.gov/sites/g/files/ehbemt861/files/inline-documents/sonh/ins-1000-claims-settlement-final-proposal-annotated-text.pdf), effective Jan. 1, 2027. The rules update claims-handling standards across property and casualty, accident and health, and health insurance. For fraud professionals, the rules address how suspected fraud affects claim processing. Separate property and casualty provisions address fraud-related delays and denials, while health carriers may extend clean-claim deadlines when fraud, abuse or material misrepresentation is reasonably suspected. [Read more](https://www.insurance.nh.gov/sites/g/files/ehbemt861/files/inline-documents/sonh/ins-1000-claims-settlement-final-proposal-annotated-text.pdf)... **DOJ revises False Claims Act policies affecting federal insurance programs.** The U.S. Department of Justice (DOJ) updated its enforcement policies, including when it may seek to dismiss lawsuits brought by whistleblowers that do not serve the government’s interests. The changes also limit reliance on agency guidance that does not carry the force of law. For Special Investigation Unit (SIU) professionals, the policies may affect how suspected fraud involving federal programs, including Medicare Advantage, is investigated and pursued. Coalition member Greenberg Traurig recently explained the changes and what they mean for fraud cases. [Read more](https://www.gtlaw.com/en/insights/2026/10/doj-false-claims-act-enforcement-reforms-on-sub-regulatory-guidance-and-qui-tam-dismissals-highlight-new-defense-considerations)… \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/639dd51a-b5ce-1b6e-db24-25b13ce6cc3f.jpeg) \| \| \|:-:\| \| \| \| **District of Columbia attorney general secures $1.7 million settlement over construction payroll fraud.** District of Columbia Attorney General Brian Schwalb reached a $1.7 million consent order with Welch Mechanical Contractors to resolve illegal worker misclassification allegations. Misclassifying employees as independent contractors constitutes severe payroll fraud that evades workers’ compensation premiums, distorts insurance risk pools, and undercuts law-abiding businesses. District officials recovered $1 million in civil penalties and nearly $700,000 for 500 impacted workers. Coalition members should monitor these enforcement actions, as regulatory pressure on misclassification protects state compensation funds, strengthens fraud investigations, and advances fair market competition. [Read more…](https://oag.dc.gov/release/attorney-general-schwalb-secures-17-million) **Mississippi Insurance Department actions highlight growing enforcement against unlicensed practice and fraud.** The Mississippi Insurance Department recently escalated regulatory enforcement and consumer protection efforts by targeting unlicensed activity and fraudulent operations within the state. This regulatory crackdown underscores the critical need for robust fraud detection, enhanced SIU investigations, and coordinated reporting to protect consumers and maintain market integrity. For Coalition members, tracking state enforcement actions provides vital intelligence to strengthen fraud prevention strategies, informs legislative advocacy, and supports multi-jurisdictional fraud prosecution efforts across all insurance lines. [Read more…](https://www.mid.ms.gov/wp-content/uploads/2026/10/Pressrel101326.pdf) \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/df2df8da-5c89-a5b8-9eb9-788eeefd0017.jpeg) \| \| \|:-:\| \| \| \| *The arrest summaries in Fraud News Weekly are compiled from publicly available news sources. Individuals mentioned are presumed innocent until proven guilty in a court of law.* \| \| \|---\| \| \|---\| \| \| \| \| \|---\| \| \| \| **HEALTHCARE FRAUD** **October 8 – New York – Dobbs Ferry resident charged with $100K healthcare fraud scheme targeting two insurers** Jackie Crino was arrested and charged for submitting fraudulent invoices for unperformed medical services to UnitedHealthcare Company and Cigna Health and Life Insurance Company. The false claims yielded $103,007 in illicit reimbursements over a three-year period. Investigation by the Special Investigations Unit (SIU) uncovered… [Read more](https://www.westchesterda.net/october-2026/dobbs-ferry-woman-charged-with-defrauding-two-insurance-companies-of-over-100k) **AUTO / ARSON – FALSE CLAIM** **October 9 – Louisiana – Woman arrested for fraudulent car fire claim following State Fire Marshal investigation** Chastity Lewis was arrested after submitting a fraudulent claim for a burnt 2011 Nissan. Baton Rouge emergency crews originally responded to the vehicle fire along I-110 in April. The Louisiana Department of Insurance referred the case to the Louisiana State Fire Marshal, whose investigators discovered the fraud … [Read more](https://www.wbrz.com/news/woman-arrested-in-connection-with-insurance-fraud-investigation) **INSIDER – INSURER** **October 13 – Pennsylvania – Former claims adjuster charged in $949K insurance fraud scheme** Glenn Johnson was charged for using his position as a claims adjuster at Donegal Insurance to approve a fraudulent $949,639 accident claim. He created a fake law firm called Elite Injury Representatives and submitted fabricated medical records into the claim file. The insurer issued payment directly to his fictitious firm… [Read more](https://www.attorneygeneral.gov/taking-action/ag-sundays-insurance-fraud-section-charges-man-with-defrauding-lancaster-county-based-provider-of-nearly-1m-in-accident-claim-scheme/) **BUSINESS – PADDING/FAKING** **October 13 – Nevada – Las Vegas business owner pleads guilty in staged armed robbery scheme** Erwin Lanada, owner of CPR Cellphone Repair, pleaded guilty to mail fraud after hiring an accomplice to stage a gunpoint robbery at his electronic store. Lanada filed false claims for missing merchandise and income loss, tricking his carrier into issuing $88,611 in payout checks. The scheme unravelled when investigators discovered he supplied the weapon used in the staged crime… [Read more](https://www.insurancejournal.com/news/west/2026/10/13/888749.htm) **CONTRACTOR FRAUD** **October 12 – North Carolina – Roofing company employee charged with insurance fraud for intentionally damaging roof** Cameron Hammond was charged with insurance fraud after intentionally damaging residential roof shingles while working for Carolina Trophy Roofs. Hammond submitted false claims to North Carolina Farm Bureau and the North Carolina Joint Underwriters Association (NCJUA) for weather damage to collect insurance funds and a replacement commission. Hammond was released on a $5,000 bond pending a court date where he faces additional felony charges … [Read more](https://www.ncdoi.gov/news/press-releases/2026/10/12/craven-county-man-charged-insurance-fraud-roofing-scam) **HOMEOWNERS – FALSE CLAIM** **October 14 – New Jersey – West Deptford family charged in $138K homeowners insurance kickback scheme** Donald Feldman, Carolyn Feldman, and Brittany Feldman face charges for submitting fake property damage claims and invoices through Assurant Insurance Company. Working with a corrupt claims examiner, the group received $138,000 in payouts for unperformed work and unowned properties. The family paid the examiner 20% cash kickbacks on each approved payout after… [Read more](https://www.njoag.gov/three-family-members-indicted-in-insurance-fraud-and-commercial-bribery-schemes/) **AUTO – MEDICAL FALSE CLAIM** **Oct. 13 – South Carolina – Lexington County woman charged with $11K Progressive Insurance fraud scheme** Charyada Davis submitted six fictitious documents, including altered medical bills and a fake employer work excuse, to Progressive Insurance to fraudulently collect $11,763 in lost wages and medical expenses. Davis admitted to SLED agents in a recorded interview that the documents were fake, leading to… [Read more](https://www.wistv.com/2026/10/13/lexington-county-woman-charged-with-insurance-fraud/) \| \| \|---\| \| \|---\| \| \| \| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/bb0a9596-62da-984d-f30e-3857c977bdc3.png) \| \| \|:-:\| \| [](https://members.insurancefraud.org/general/custom.asp?page=2026AnnualMeeting)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/f82089f1-d9bc-38d8-bcca-4896d3565bda.jpeg) \| \| \|:-:\| \| \| \| Preparations are underway for another engaging and informative meeting. The Coalition’s Annual Meeting brings together insurers, regulators, consumer groups, legal experts, and other groups that serve the insurance fraud fighting community. If you are serious about staying ahead of evolving fraud tactics and strengthening your impact, make plans to attend. Take the extra step to invite others in your organization whom you feel will benefit from face-to-face time with our members. We look forward to seeing you in December! \| \| \|---\| \| \|---\| \| \| \| \| \|---\| \| [](https://members.insurancefraud.org/general/custom.asp?page=2026AnnualMeeting)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/3841391e-8654-2b6f-1cfd-9abe34230e51.png) \| \| \|:-:\| \| \| \| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/ae4500ef-da51-d597-bbb4-789dc3bf1f4f.jpeg) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/2ee9cd86-c5ec-1a1d-308f-52321446cea0.jpeg) \| \| \|:-:\| \| \| \| This study, sponsored by Shift Technology, will examine how insurers use antifraud technology, strategies for fraud detection and investigation, implementation challenges, emerging trends, and future technology priorities. Your participation is vital to ensuring the findings accurately reflect the current landscape and provide valuable industry insights. Access the survey [here](https://us.list-manage.com/cUmMhVNoX4S?e=5635068fb3&c2id=ef01f401596a97166f7a60a07fbae620). Participation is anonymous. Contact [Celeste Dodson](mailto:celeste@insurancefraud.org) with questions. **Extended Deadline: October 30, 2026** \| \| \|---\| \| \|---\| \| \| \| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/0bb17917-f3c2-28c2-9415-ee373ac90640.png) \| \| \|:-:\| \| \| \| *Click the image to enlarge.* \| \| \|---\| \| \|---\| \| \| \| \| \|---\| \| \| \| \| \| \| \| \| \| \| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/87b7a4fb-b1a3-fa76-bc5e-55b5fd58fa7b.png) \| \| \|:-:\| \| \| \| \| # Lauren Vitanye Joins the Coalition as Communications Lead \| \|---\|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \| \| Lauren will serve as the new Communications Lead, supporting the Coalition’s strategic priorities by developing and executing integrated communications. She brings more than 15 years of experience in corporate communications, public affairs and executive communications across insurance, healthcare and biotechnology. Previously, Lauren held senior communications roles at Exact Sciences, now part of Abbott, and American Family Insurance, partnering with business and executive leaders on strategic communications, organizational change and stakeholder engagement. She began her career in Washington, D.C., and holds a B.S. in Communication from Ohio University, with a minor in Business Administration. Join us in welcoming Lauren to the team! \| \| \|---\| \| \|---\| \| \| \| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/b9f2caad-329f-b053-61a3-b2b9c1ac04d7.jpeg) \| \| \|:-:\| \| \| \| **“From Identifier to Investigative Signal: How the NPI Supports Medical Fraud Detection”** \| \| \|---\| \| \|---\| \| \| \| \| \| \| \| \| \| \| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/c037d8dd-2926-b464-2d1d-b91332a5c62b.png) \| \| \|:-:\| \| \| \| \| Learn how this 10-digit number can strengthen medical fraud detection. Prepared by Beth Howard-Stalker and Shaddi Kamiabipour of the Coalition’s Workers’ Compensation Task Force, the report has practical applications for organizations paying medical bills or reviewing provider information across health, workers’ compensation, automobile, general liability, disability and long-term care insurance. Download the report [here](https://insurancefraud.org/wp-content/uploads/10-2026-From-Identifier-to-Investigative-Signal-How-the-NPI-Supports-Medical-Fraud-Detection.pdf). \| \|---\|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \| \| \| \|---\| \| \| \| \| \| \| \| \| \| \| \| [](https://insurancefraud.org/government-law/legislation/)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/302c3bca-ad87-d145-7470-41b8cf7a65cc.png) \| \| \|:-:\| \| \| \| \| Powered by LexisNexis’ State Net, the upgraded tool features intuitive search tools, streamlined navigation, and clear alignment with our top policy priorities. Members can also easily find Coalition-supported bills and track active advocacy efforts. Questions? Contact [Brent Walker](mailto:brent@insurancefraud.org). Click on the image to access the tracker. \| \|---\|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \| \| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/39c14db0-b611-ae6e-47f7-a81be32970ab.jpeg) \| \| \|:-:\| \| \| ![](https://dim.mcusercontent.com/cs/a440c5b647697de580a2fd586/images/dbd7e950-2265-6dd3-b3ef-c69d3d8212b3.png?dpr=2&rect=0%2C29%2C1015%2C912&w=612&h=549) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/90bfad17-b102-0fe6-80ff-eaf5e9504b6d.png) \| \| \|:-:\| \| \| \| \| \|---\| \| [](https://s.surveyplanet.com/bj1sw6en)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a911883f-21e6-3d6a-275f-885582442fe3.jpeg) \| \| \|:-:\| \| \| \| \| \|---\| \| [](https://members.insurancefraud.org/general/register_member_type.asp)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/b23f743e-bbd0-1730-077d-51ca64df91d1.jpeg) \| \| \|:-:\| \| \| \| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/d210adcc-cb79-3334-fc1e-f6caffd1c0f1.jpeg) \| \| \|:-:\| \| \| \| - **October 21** – [CE Webinar: Maximizing Returns – Strategies for Boosting Investigation Impact](https://insurancefraud.org/event/ce-webinar-maximizing-returns-strategies-for-boosting-investigation-impact/) – Frasco - **October 21** – [Members-Only Webinar: Insurance Fraud Litigation and Recent Developments](https://insurancefraud.org/event/iasiu-members-only-webinar-insurance-fraud-litigation-and-recent-developments/) – IASIU - **October 22** – [Disability Within Workers’ Compensation](https://insurancefraud.org/event/disability-within-workers-compensation/) — Allied Universal - **October 29** – [CE Webinar: Hitting Record – Empowering Claim Decisions with Surveillance Footage](https://insurancefraud.org/event/ce-webinar-hitting-record-empowering-claim-decisions-with-surveillance-footage/) – Frasco - **November 3** – [CE Webinar: Gathering the Facts – Ensuring Accuracy and Actionable Insights with Research Investigations](https://insurancefraud.org/event/ce-webinar-gathering-the-facts-ensuring-accuracy-and-actionable-insights-with-research-investigations/) – Frasco - **November 3** – [SCFIA Anti-Fraud Conference](https://insurancefraud.org/event/2026-scfia-anti-fraud-conference-2/) - **November 3** – [The Material Difference: Identifying Material Misrepresentation in Insurance Claims](https://insurancefraud.org/event/the-material-difference/) – Becker & Company - **November 4** – [Members-Only Webinar: Vehicle Fraud and Auto Theft Trends ](https://insurancefraud.org/event/iasiu-members-only-webinar-vehicle-fraud-and-auto-theft-trends/)– IASIU - **November 10** – [Litigation Attack Tactics and Trends Impacting Insurers ](https://insurancefraud.org/event/litigation-attack-tactics-and-trends-impacting-insurers/)(Demotech) - **November 18** – [Behind the Ride: How Insurance Fraud Impacts the Rideshare Industry](https://insurancefraud.org/event/iasiu-webinar-behind-the-ride-how-insurance-fraud-impacts-the-rideshare-industry/) – IASIU - **December 2** – [Counterfeit Parts, Fraudulent VINs, & Hidden Safety Threats: What You Need to Know](https://insurancefraud.org/event/iasiu-webinar-counterfeit-parts-fraudulent-vins-hidden-safety-threats-what-you-need-to-know/) – IASIU \| \| \|---\| \| \|---\| \| \| \| \| \|---\| \| \| \| **Follow Us on Our Social Media Platforms:** \| \| \|---\| \| \|---\| \| [](https://www.linkedin.com/company/coalition-against-insurance-fraud/)\| ![](https://dim.mcusercontent.com/cs/a440c5b647697de580a2fd586/images/d7ecc352-af0d-c6c0-84b7-fe66eca628c0.png?dpr=2&rect=0%2C39%2C551%2C112&w=551&h=112) \| \| \|:-:\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| \| \| \| \| \| [](https://www.facebook.com/profile.php?id=61579225779934)\| ![](https://dim.mcusercontent.com/cs/a440c5b647697de580a2fd586/images/a19e2277-53e5-5d03-770d-fa8a62202060.png?dpr=2&rect=1%2C26%2C505%2C122&w=505&h=122) \| \| \|:-:\| \| [](https://www.instagram.com/stopinsurancefraud/)\| ![](https://dim.mcusercontent.com/cs/a440c5b647697de580a2fd586/images/8da807b8-a79d-e1d1-8b42-e37bd860debd.png?dpr=2&rect=70%2C35%2C474%2C111&w=474&h=111) \| \| \|:-:\| \| \| \| \| [](https://www.insurancefraud.org)\| ![Logo](https://brand-assets.mailchimp.com/01KKVRP4PEH4PWEG0R0VSKKJ7H.png) \| \| \|:-:\| \| \| \| *Copyright (C) 2026 Coalition Against Insurance Fraud. All rights reserved.* You are receiving this email because either your organization is a member of the Coalition Against Insurance Fraud or you requested to be placed on our mailing list. Our mailing address is: Coalition Against Insurance Fraud 1012 14th St NW Ste 610 Washington, DC 20005-3424 USA Want to change how you receive these emails? You can [update your preferences](https://insurancefraud.mailchimpsites.com/manage/preferences?u=a440c5b647697de580a2fd586&id=b68dce7808&e=%5BUNIQID%5D&c=07b3a38c47) or [unsubscribe](https://insurancefraud.us1.list-manage.com/unsubscribe?u=a440c5b647697de580a2fd586&id=b68dce7808&t=b&e=%5BUNIQID%5D&c=07b3a38c47) \| \| \|:-:\| \| \|---\| \| \| \| \|---\| \| \|:-:\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| | |:-:| **Features:** Fraud News Weekly --- ### [Fraud News Weekly (FNW) Friday, October 9, 2026](https://insurancefraud.org/publications/fraud-news-weekly-fnw-friday-october-9-2026/) **Published:** October 9, 2026 **Author:** Coalition Against Insurance Fraud **Content:** Fraud News Weekly (FNW) Friday, October 9, 2026͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ | \| \| \| \| \| \| \| [View this email in your browser](https://mailchi.mp/ae683a4153c8/fraud-news-weekly-friday-may-1-10704956?e=%5BUNIQID%5D) \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| \| \| \| \| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/c5a99aeb-bc2b-aee1-9ca4-bd89e818010f.png) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/d2d67ba2-87f2-55d0-9155-f501649016f4.jpeg) \| \| \|:-:\| \| \| \| **Texas launches Insurance Fraud Task Force to combat fraud and protect consumers.** Governor Greg Abbott recently directed the Texas Department of Insurance (TDI) to create an Insurance Fraud Task Force to combat insurance fraud, which increases costs for consumers. The task force will bring together law enforcement, industry, consumer and antifraud organizations to address fraud schemes, develop disaster-related antifraud guidance, and provide public education and training. The Coalition has been invited to serve as a founding associate member and will work with TDI and its Fraud Unit on these efforts. [Read more](https://www.tdi.texas.gov/reports/documents/tdi-oog-directive-response.pdf)… **2026 insurance fraud legislation sets the stage for 2027.** As some state legislatures have adjourned and others wind down, the Coalition tracked and advocated on legislation focused on insurance fraud and related consumer protection issues. With 67 enacted measures, these new laws address towing and storage, public adjusters, contractors, counterfeit airbags, fraud reporting and enforcement, assignment of benefits, and emerging risks involving artificial intelligence, deepfakes and data. With November elections ahead, changes in legislative makeup could shape 2027 priorities. Members can follow these developments through the Coalition’s [advocacy efforts](https://insurancefraud.org/advocacy-efforts/), [legislative priorities](https://insurancefraud.org/legislative-priorities/)[,](https://insurancefraud.org/legislative-priorities/) or search 2026 bills via the Coalition’s antifraud [Legislative Tracker](https://insurancefraud.org/government-law/legislation/). As members begin to prepare for the 2027 legislative session, please share your thoughts with Coalition Director of Government Relations, Brent Walker. [Contact Brent](mailto:brent@insurancefraud.org)… **Coalition amicus program advances insurance fraud protections in 2026.** The Coalition’s Amicus Curiae Program gives the Coalition a voice in court cases that could shape how insurance fraud is investigated, prosecuted and challenged. In 2026, [member law firms](https://insurancefraud.org/law-firm-members/) serving on the Legal Affairs Committee helped bring important matters forward, with Coalition amicus work addressing fraudulent medical billing, arbitration, workers’ compensation referral arrangements, and criminal penalties. The resulting decisions help preserve tools available to insurers, prosecutors and fraud investigators. Members can help advance the program by identifying cases with broader antifraud implications and requesting the Amicus Review Committee to consider Coalition participation. [Read more](https://insurancefraud.org/amicus-program/)… \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/639dd51a-b5ce-1b6e-db24-25b13ce6cc3f.jpeg) \| \| \|:-:\| \| \| \| **American Land Title Association pushes for strong federal protections against growing real estate impersonation fraud.** The American Land Title Association reports seller impersonation fraud attempts doubled to 59 percent of surveyed title firms over the past year, highlighting an urgent need for proactive fraud prevention and legislative oversight. Speaking on industry advocacy, chief executive officer Chris Morton emphasized protecting homeowners from costly closing scams while ensuring emerging artificial intelligence technologies complement, rather than replace, investigative expertise. As real estate risk shifts toward consumers, Coalition members must track federal policy developments and push for equal regulatory standards on alternative title products to safeguard transactions. [Read more…](https://www.thetitlereport.com/articles/alta-ceo-discusses-fraud-ai-and-advocating-for-tit-98268.aspx) \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/df2df8da-5c89-a5b8-9eb9-788eeefd0017.jpeg) \| \| \|:-:\| \| \| \| *The arrest summaries in Fraud News Weekly are compiled from publicly available news sources. Individuals mentioned are presumed innocent until proven guilty in a court of law.* \| \| \|---\| \| \|---\| \| \| \| \| \|---\| \| \| \| **AGENT MISCONDUCT** **October 4 – Texas – Insurance broker receives 13-year sentence for $2M investment and identity theft scheme** Clayton Iley, operator of Clayton Texas Legacy Insurance Group, LLC, was sentenced to 13 years in prison for wire fraud and identity theft. Iley stole $2 million by opening fraudulent credit cards in victims’ names and collecting funds for a fake investment loan program. Federal authorities ordered the sale of 90 exotic collector vehicles purchased with stolen money to fund restitution… [Read more](https://www.fox4news.com/news/texas-businessman-gets-13-years-prison-must-sell-90-collector-cars-pay-back-fraud-victims) **HEALTHCARE FRAUD** **October 6 – Connecticut – Pennsylvania woman pleads guilty in $1.3M Medicaid fraud scheme** Jacqueline Pelphrey pleaded guilty to health care fraud after using her business, Women’s Health Resources, to steal from Medicaid and private insurers. Pelphrey submitted false insurance claims for custom breast prostheses that clients never ordered or received. Facing up to 10 years in prison, she now awaits sentencing while released on a… [Read more](https://www.fox61.com/article/news/crime/pennsylvania-womans-health-care-fraud-scheme-caused-ct-medicaid-to-lose-more-than-a-million-dollars/520-cb03badf-4cfc-4381-9dff-9d124a487251) **HEALTHCARE FRAUD** **Oct. 7 – New Jersey – Former New York podiatrist sentenced to 32 months in prison for role in $11M Amtrak healthcare fraud scheme** Michael DeNicola was sentenced to 32 months in prison for participating in a scheme that submitted over $11 million in fraudulent claims to Amtrak’s health care plan. The podiatrist billed the insurer for services that were never provided or medically unnecessary. Federal prosecutors revealed DeNicola also illegally issued… [Read more](https://www.justice.gov/usao-nj/pr/new-york-health-care-provider-sentenced-32-months-prison-role-11-million-health-care) **BUSINESS – PADDING/FAKING** **October 2 – Nevada – Cell phone repair store owner pleads guilty in $90,000 staged robbery scheme** Erwin Lanada pleaded guilty to mail fraud after staging an armed robbery at his Las Vegas cell phone repair store to submit false property and income loss claims to his insurer. Lanada paid an accomplice to hold him at gunpoint and tie him with zip ties before fleeing with cash and store inventory. His insurer issued over $88,000 in payouts before federal investigators uncovered… [Read more](https://www.justice.gov/usao-nv/pr/las-vegas-business-owner-pleads-guilty-90000-insurance-fraud-scheme) **AGENT MISCONDUCT** **October 1 – Florida – Pensacola insurance agent faces up to seven years in prison after pleading guilty to $318K premium finance scheme** Daniel Raney, owner of Raney Ventures LLC, pleaded guilty to organized fraud and misappropriation of insurance funds after using fake premium finance agreements with AFCO Credit Corp. to obtain money through two companies he owned… [Read more](https://www.miamiherald.com/news/article317458528.html) **AGENT MISCONDUCT** **Oct. 2 – Maryland – Owings Mills insurance agent pleads guilty to stealing $100K in life insurance commissions** Gregory Maslow pleaded guilty to stealing over $100,000 by submitting more than 75 fraudulent life insurance applications. Maslow used the stolen identities of clients and other licensed agents to collect upfront commissions before letting policies lapse for nonpayment. Under a binding plea agreement, he will serve 30 days in prison and five years… [Read more](https://oag.maryland.gov/News/pages/Owings-Mills-Insurance-Agent-Pleads-Guilty-to-Stealing-More-Than-$100,000-in-Life-Insurance-Commissions.aspx) **AGENT MISCONDUCT** **October 1 – South Carolina – SLED charges Summerville man with forgery and presenting false claims** Forrest Sanders Smith IV faces multiple forgery and insurance fraud charges for submitting falsified documents to an insurer. State agents booked Smith into the Florence County Detention Center following an investigation requested by the South Carolina Department of Insurance. Authorities revealed the fake filings created a substantial financial scheme that ultimately… [Read more](https://www.sled.sc.gov/about/updates/sled-charges-dorchester-county-man-insurance-fraud-0) \| \| \|---\| \| \|---\| \| \| \| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/bb0a9596-62da-984d-f30e-3857c977bdc3.png) \| \| \|:-:\| \| [](https://members.insurancefraud.org/general/custom.asp?page=2026AnnualMeeting)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/f82089f1-d9bc-38d8-bcca-4896d3565bda.jpeg) \| \| \|:-:\| \| \| \| Preparations are underway for another engaging and informative meeting. The Coalition’s Annual Meeting brings together insurers, regulators, consumer groups, legal experts, and other groups that serve the insurance fraud fighting community. If you are serious about staying ahead of evolving fraud tactics and strengthening your impact, make plans to attend. Take the extra step to invite others in your organization whom you feel will benefit from face-to-face time with our members. We look forward to seeing you in December! \| \| \|---\| \| \|---\| \| [](https://members.insurancefraud.org/page/advertising-annual)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/68dbd503-bea0-6ad6-cdb1-cc0f21feef66.png) \| \| \|:-:\| \| \| \| \| \|---\| \| [](https://members.insurancefraud.org/general/custom.asp?page=2026AnnualMeeting)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/11976ce2-3ad6-f243-26b0-d42594b3277a.jpeg) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/ae4500ef-da51-d597-bbb4-789dc3bf1f4f.jpeg) \| \| \|:-:\| \| \| \| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/8d5f853b-306e-def1-f3c7-9bf6d32e0efa.jpeg) \| \| \|:-:\| \| \| \| This study, sponsored by Shift Technology, will examine how insurers use antifraud technology, strategies for fraud detection and investigation, implementation challenges, emerging trends, and future technology priorities. Your participation is vital to ensuring the findings accurately reflect the current landscape and provide valuable industry insights. Access the survey [here](https://shift-technology.typeform.com/to/Dz7wSXKx). Participation is anonymous. Contact [Celeste Dodson](mailto:celeste@insurancefraud.org) with questions. **Survey Deadline: October 14, 2026** \| \| \|---\| \| \|---\| \| \| \| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/b9f2caad-329f-b053-61a3-b2b9c1ac04d7.jpeg) \| \| \|:-:\| \| \| \| Share these new resources across your organization. You can co-brand both with your company logo. **Workers’ Compensation Premium Fraud:** Learn what premium fraud is, how businesses cheat the system, what warning signs to look for, and how to report it in this [infographic](https://us.list-manage.com/ldGiuC_yVgg?e=5635068fb3&c2id=ef01f401596a97166f7a60a07fbae620). **Insurance Fraud Hurts Us All:** This [i](https://us.list-manage.com/QwQ5AavGthh?e=5635068fb3&c2id=ef01f401596a97166f7a60a07fbae620)[nfographic](https://insurancefraud.org/wp-content/uploads/Insurance-Fraud-Awareness_flyer.pdf) was created to inform the public of insurance fraud warning signs. Share this guide with your customers and employees so they can stay informed. The Coalition thanks the **Workers’ Compensation Task Force** and the **Public Information Committee** for developing these resources. For additional member resources, visit [www.insurancefraud.org](https://insurancefraud.org/). \| \| \|---\| \| \|---\| \| \| \| \| \| \| \| \| \| \| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/5a1e6a85-e051-7db2-5a75-00089cce9b7d.png) \| \| \|:-:\| \| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/38efbc0a-1934-c9a7-4886-871ecbd86d19.png) \| \|---\|---\| \| \|:-:\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \| \| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/39c14db0-b611-ae6e-47f7-a81be32970ab.jpeg) \| \| \|:-:\| \| \| ![](https://dim.mcusercontent.com/cs/a440c5b647697de580a2fd586/images/042f21bb-e750-3909-e8fd-5941016e6b17.png?dpr=2&rect=0%2C64%2C570%2C497&w=570&h=497) \| \| \|:-:\| \| \| \| \| \|---\| \| [](https://s.surveyplanet.com/bj1sw6en)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a911883f-21e6-3d6a-275f-885582442fe3.jpeg) \| \| \|:-:\| \| \| \| \| \|---\| \| [](https://members.insurancefraud.org/general/register_member_type.asp)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/b23f743e-bbd0-1730-077d-51ca64df91d1.jpeg) \| \| \|:-:\| \| \| \| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/d210adcc-cb79-3334-fc1e-f6caffd1c0f1.jpeg) \| \| \|:-:\| \| \| \| - **October 11 – 14** – [2026 Global Insurance Fraud Summit](https://insurancefraud.org/event/2026-global-insurance-fraud-summit/) (GIFS) - **October 14** – [Medical Case Management: The Value of Focused Care ](https://insurancefraud.org/event/medical-case-management-the-value-of-focused-care/)(Ethos) - **October 15** – [OSINT Live 2026](https://insurancefraud.org/event/osint-live-2026/) – Skopenow - **October 21** – [CE Webinar: Maximizing Returns – Strategies for Boosting Investigation Impact](https://insurancefraud.org/event/ce-webinar-maximizing-returns-strategies-for-boosting-investigation-impact/) – Frasco - **October 21** – [Members-Only Webinar: Insurance Fraud Litigation and Recent Developments](https://insurancefraud.org/event/iasiu-members-only-webinar-insurance-fraud-litigation-and-recent-developments/) – IASIU - **October 22** – [Disability Within Workers’ Compensation](https://insurancefraud.org/event/disability-within-workers-compensation/) — Allied Universal - **October 29** – [CE Webinar: Hitting Record – Empowering Claim Decisions with Surveillance Footage](https://insurancefraud.org/event/ce-webinar-hitting-record-empowering-claim-decisions-with-surveillance-footage/) – Frasco - **November 3** – [CE Webinar: Gathering the Facts – Ensuring Accuracy and Actionable Insights with Research Investigations](https://insurancefraud.org/event/ce-webinar-gathering-the-facts-ensuring-accuracy-and-actionable-insights-with-research-investigations/) – Frasco - **November 3** – [SCFIA Anti-Fraud Conference](https://insurancefraud.org/event/2026-scfia-anti-fraud-conference-2/) - **November 3** – [The Material Difference: Identifying Material Misrepresentation in Insurance Claims](https://insurancefraud.org/event/the-material-difference/) – Becker & Company - **November 4** – [Members-Only Webinar: Vehicle Fraud and Auto Theft Trends ](https://insurancefraud.org/event/iasiu-members-only-webinar-vehicle-fraud-and-auto-theft-trends/)– IASIU - **November 18** – [Behind the Ride: How Insurance Fraud Impacts the Rideshare Industry](https://insurancefraud.org/event/iasiu-webinar-behind-the-ride-how-insurance-fraud-impacts-the-rideshare-industry/) – IASIU - **December 2** – [Counterfeit Parts, Fraudulent VINs, & Hidden Safety Threats: What You Need to Know](https://insurancefraud.org/event/iasiu-webinar-counterfeit-parts-fraudulent-vins-hidden-safety-threats-what-you-need-to-know/) – IASIU \| \| \|---\| \| \|---\| \| \| \| \| \|---\| \| \| \| **Follow Us on Our Social Media Platforms:** \| \| \|---\| \| \|---\| \| [](https://www.linkedin.com/company/coalition-against-insurance-fraud/)\| ![](https://dim.mcusercontent.com/cs/a440c5b647697de580a2fd586/images/d7ecc352-af0d-c6c0-84b7-fe66eca628c0.png?dpr=2&rect=0%2C39%2C551%2C112&w=551&h=112) \| \| \|:-:\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| \| \| \| \| \| [](https://www.facebook.com/profile.php?id=61579225779934)\| ![](https://dim.mcusercontent.com/cs/a440c5b647697de580a2fd586/images/a19e2277-53e5-5d03-770d-fa8a62202060.png?dpr=2&rect=1%2C26%2C505%2C122&w=505&h=122) \| \| \|:-:\| \| [](https://www.instagram.com/stopinsurancefraud/)\| ![](https://dim.mcusercontent.com/cs/a440c5b647697de580a2fd586/images/8da807b8-a79d-e1d1-8b42-e37bd860debd.png?dpr=2&rect=70%2C35%2C474%2C111&w=474&h=111) \| \| \|:-:\| \| \| \| \| [](https://www.insurancefraud.org)\| ![Logo](https://brand-assets.mailchimp.com/01KKVRP4PEH4PWEG0R0VSKKJ7H.png) \| \| \|:-:\| \| \| \| *Copyright (C) 2026 Coalition Against Insurance Fraud. All rights reserved.* You are receiving this email because either your organization is a member of the Coalition Against Insurance Fraud or you requested to be placed on our mailing list. Our mailing address is: Coalition Against Insurance Fraud 1012 14th St NW Ste 610 Washington, DC 20005-3424 USA Want to change how you receive these emails? You can [update your preferences](https://insurancefraud.mailchimpsites.com/manage/preferences?u=a440c5b647697de580a2fd586&id=b68dce7808&e=%5BUNIQID%5D&c=ebe612e5e8) or [unsubscribe](https://insurancefraud.us1.list-manage.com/unsubscribe?u=a440c5b647697de580a2fd586&id=b68dce7808&t=b&e=%5BUNIQID%5D&c=ebe612e5e8) \| \| \|:-:\| \| \|---\| \| \| \| \|---\| \| \|:-:\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| | |:-:| **Features:** Fraud News Weekly --- ### [Coalition 2024 Hall of Shame](https://insurancefraud.org/publications/the-dirty-dozen-2024-hall-of-shame/) **Published:** December 11, 2023 **Author:** Coalition Against Insurance Fraud **Content:** --- ##### **View current *Hall of Shamers*:** [2025](https://insurancefraud.org/publications/coalition-2025-hall-of-shame/) **Features:** Hall of Shame --- ### [Coalition 2025 Hall of Shame](https://insurancefraud.org/publications/coalition-2025-hall-of-shame/) **Published:** January 1, 2026 **Author:** Coalition Against Insurance Fraud **Content:** --- ##### **View previous *Hall of Shamers*:** [2024](https://insurancefraud.org/publications/the-dirty-dozen-2024-hall-of-shame/) **Features:** Hall of Shame --- ### [Fraud News Weekly (FNW) Friday, October 2, 2026](https://insurancefraud.org/publications/fraud-news-weekly-fnw-friday-october-2-2026/) **Published:** October 2, 2026 **Author:** Coalition Against Insurance Fraud **Content:** Fraud News Weekly (FNW) Friday, October 2, 2026͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ | \| \| \| \| \| \| \| [View this email in your browser](https://mailchi.mp/927c6743f8bf/fraud-news-weekly-friday-may-1-10704934?e=%5BUNIQID%5D) \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| \| \| \| \| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/2207543d-72f0-3026-f692-f51ed3513e86.jpeg) \| \| \|:-:\| \| [](https://www.insurancefraud.org)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/e438a452-a9da-fc27-8c93-aad4b329206f.jpeg) \| \| \|:-:\| \| \| \| **Fraud was a recurring topic at the NAIC Insurance Summit.** This week, Coalition Director of Government Relations Brent Walker spoke twice at the Insurance Summit, a conference combining resources from the National Association of Insurance Commissioners (NAIC) and National Insurance Producer Registry (NIPR) to connect innovators and state regulators on technology, emerging ideas and the future of insurance regulation. Walker addressed technology trends in the antifraud fight, including artificial intelligence (AI) used to detect fraud and by fraudsters. He also joined Delaware Insurance Commissioner Trinidad Navarro to discuss emerging fraud patterns, focusing on sober home fraud. Other sessions covered the economic toll of insurance fraud, the fraud referral process and improper marketing of health care. [Read more](https://content.naic.org/events/insurance-summit)… **Oklahoma storage fee cap faces court challenge but draws insurer support.** Oklahoma’s Motor Vehicle Consumer Protection Act, enacted in 2025 as Senate Bill 641, limits certain administrative charges and establishes maximum daily storage rates for motor vehicles in Oklahoma. Collision repairers are challenging the storage provisions, while Oklahoma Farm Bureau Mutual Insurance Company has filed an amicus brief defending the law. The insurer told the court the Legislature acted to address what it described as unfair and unreasonable storage fees charged by repair shops, with costs potentially passed to consumers through higher premiums. The Coalition will monitor the case and its implications for claims, fraud and consumer protection. [Read more](https://www.autobodynews.com/news/insurer-files-brief-defending-oklahoma-storage-fee-cap-challenged-by-body-shops)… **California releases amended insurance fraud grant regulations for comment.** The California Department of Insurance on Sept. 28 released [amended text](https://insurancefraud.org/wp-content/uploads/Insurance-Fraud-Grant-Standardization-and-Modernization_15-day-Text-of-Regulation-1.pdf) for its proposed Insurance Fraud Grant Standardization and Modernization regulations and opened a comment period limited to the changes. The amendments would create longer grant periods, standardize application and performance reviews, strengthen corrective action requirements, establish tighter controls for grant funds and increase audit and reporting requirements. The Coalition monitored the Aug. 17 hearing, where stakeholders raised concerns about performance oversight, administrative burdens and funding flexibility. Comments are due Oct. 14. [Re](https://insurancefraud.org/wp-content/uploads/Insurance-Fraud-Grant-Standardization-and-Modernization_15-day-Notice.pdf)[ad more](https://insurancefraud.org/wp-content/uploads/Insurance-Fraud-Grant-Standardization-and-Modernization_15-day-Notice.pdf)… \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/639dd51a-b5ce-1b6e-db24-25b13ce6cc3f.jpeg) \| \| \|:-:\| \| \| \| **National Insurance Crime Bureau forms strategic partnership with Honk Technologies to combat predatory towing.** The NICB and roadside platform Honk Technologies established an alliance to exchange data and emerging intelligence targeting abusive towing, storage, and impound schemes. Unreasonable fees and unauthorized vehicle removals inflate auto claim costs and exploit vulnerable drivers nationwide. For Coalition members, this collaboration strengthens fraud investigations, enhances intelligence-sharing capabilities, and advances ongoing advocacy efforts to enforce fee transparency and regulatory oversight across the vehicle services market. [Read more](https://www.nicb.org/news/news-releases/nicb-announces-strategic-partnership-honk-combat-predatory-towing-and-vehicle)… **Florida Office of Insurance Regulation and Department of Financial Services shuts down unlicensed marine insurer.** The Florida Office of Insurance Regulation and the Florida Department of Financial Services issued an immediate cease-and-desist order against Hydrogen Deep LLC, doing business as The Wave Insurance. Regulators allege the unlicensed entity targeted marine businesses, collecting over $100,000 in premiums and issuing bogus coverage binders while diverting funds for personal use. The joint investigation highlights the critical need for proactive fraud detection to protect consumers and legitimate markets. Fraud prevention and enforcement remain top Coalition priorities. [Read more](https://insurancenewsnet.com/innarticle/florida-shuts-down-the-wave-insurance-after-alleged-100000-premium-scheme)… \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/df2df8da-5c89-a5b8-9eb9-788eeefd0017.jpeg) \| \| \|:-:\| \| \| \| *The arrest summaries in Fraud News Weekly are compiled from publicly available news sources. Individuals mentioned are presumed innocent until proven guilty in a court of law.* \| \| \|---\| \| \|---\| \| \| \| \| \|---\| \| \| \| **HOMEOWNERS – ARSON** **Sept. 29 – Louisiana – Seven individuals indicted for $3 million arson and homeowners insurance fraud scheme in West Monroe** Seven co-conspirators were arrested for operating a scheme involving 13 intentionally set residential fires. The group bought homeowners insurance policies on rented houses to collect fake personal property losses and hotel payouts. The case was investigated by the FBI, Louisiana State Fire Marshal, the Monroe Fire Department, and the Louisiana State Police.. [Read more](https://www.justice.gov/usao-wdla/pr/west-monroe-woman-her-family-members-and-their-associates-indicted-wire-fraud-money) **AGENT MISCONDUCT** **Sept. 28 – Arkansas – Former agency worker charged with pocketing customer cash payments** Kelsi Mercer is facing charges after allegedly taking cash payments from policyholders to pay her own bills. Mercer, who worked at an Arkansas Farm Bureau branch, entered customer cash payments into the system before reversing the transactions and pocketing the money. A routine audit uncovered four payments that were never reapplied to customer accounts… [Read more](https://www.kait8.com/2026/09/28/woman-accused-pocketing-customers-insurance-payments/) **HEALTHCARE FRAUD** **September 24 – Michigan – Executive pleads guilty in $500M COVID-19 test billing fraud scheme** Hasan Seyhun pleaded guilty to conspiracy to commit healthcare fraud after using customer information from Fast Lab Technologies to falsely bill healthcare programs for $500 million in unperformed medical services. The company submitted fraudulent claims for observed antigen tests and lab work before test kits were even delivered to customers. Federal investigators revealed that Seyhun routinely authorized… [Read more](https://www.justice.gov/usao-edmi/pr/chief-operating-officer-pleads-guilty-role-500m-covid-19-test-billing-fraud) **LIFE INSURANCE** **Sept. 24 – Tennessee – Funeral home owner charged with filing fraudulent life insurance claims** Chadrick Mundy, former funeral director at Mundy Funeral Home in Jamestown, faces criminal charges for filing at least 12 fraudulent burial insurance claims. State investigators discovered Mundy submitted false life insurance death claims for living individuals, including his spouse. State regulators suspended Mundy’s license after a financial audit uncovered missing documentation… [Read more](https://www.insurancejournal.com/news/southeast/2026/09/24/886721.htm) **AGENT MISCONDUCT** **Sept. 24 – Delaware – Former insurance agent gets three years in prison for siphoning client funds** Zenaida Nieves-Cordero, former owner of Apple Insurance Inc., was sentenced to three years in prison after pleading guilty to three counts of felony theft. Operating out of Georgetown, she made unauthorized bank withdrawals to steal over $625,000 intended for client premium payments. State investigators later discovered she emptied agency bank accounts and accessed hidden accounts to evade regulators during an official takeover… [Read more](https://news.delaware.gov/2026/09/24/delaware-department-of-insurance-announces-sentencing-of-former-insurance-agent-for-theft-of-client-funds/) **AUTO – STAGED ACCIDENT** **Sept. 28 – New Jersey – Luxury car rental owner gets four years in prison for $273K staged crash scheme** Bozena Kolc was sentenced to four years in prison for submitting a fraudulent $273,864 auto insurance claim. Kolc insured an already-damaged 2021 Bentley Bentayga through GEICO and staged an accident to collect benefits. She also submitted a forged foreign bank record and false sworn statements before her conviction… [Read more](https://www.njoag.gov/luxury-car-rental-company-owner-sentenced-to-four-years-in-prison-for-insurance-fraud-scheme-involving-staged-crash/) **HOMEOWNERS – FALSE CLAIM** **Sept. 24 – Montana – Billings man charged with felony insurance fraud over fake $100K stolen lawnmowers claim** Adam Walker was charged with felony criminal insurance fraud after claiming four lawnmowers were stolen from his property. Walker collected $100,000 from State Farm, but a national database check showed serial numbers did not match his mowers… [Read more](https://csimt.gov/2026/09/24/state-auditor-james-brown-charges-billings-man-with-felony-criminal-insurance-fraud-for-allegedly-filing-false-claim-over-stolen-lawnmowers/) **AUTO – FALSE CLAIM** **Sept. 28 – Kansas – Leavenworth County woman receives probation for auto insurance fraud** Jennifer Walker pleaded guilty to attempted insurance fraud after filing a false auto claim in Leavenworth County. Walker bought a new insurance policy and misrepresented the date of an auto collision to cover damage that occurred before her coverage began. She received a 12-month probation sentence, but officials warned that her actions drive up insurance costs for everyone… [Read more ](https://www.insurance.kansas.gov/Home/Components/News/News/324/16?widgetId=41) **MEDICARE/MEDICAID** **September 28 – Connecticut – Women charged in $601K Medicaid fraud investigation** Alyse Enderle and Carmen Wynter were charged with submitted false claims to Connecticut Medicaid for unprovided autism therapy services. Enderle, owner of Autism Sparkles, along with technician Wynter, allegedly billed the state program for $601,970 in fraudulent claims. Investigators found that additional claims were submitted for services that were only partially rendered… [Read more](https://www.fox61.com/article/news/local/hartford-county/2-women-charged-in-601000-connecticut-medicaid-investigation/520-581a1a9d-560e-4176-9a7b-a868b5511074) \| \| \|---\| \| \|---\| \| \| \| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/bb0a9596-62da-984d-f30e-3857c977bdc3.png) \| \| \|:-:\| \| [](https://members.insurancefraud.org/general/custom.asp?page=2026AnnualMeeting)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/f82089f1-d9bc-38d8-bcca-4896d3565bda.jpeg) \| \| \|:-:\| \| \| \| Preparations are underway for another engaging and informative meeting. The Coalition’s Annual Meeting brings together insurers, regulators, consumer groups, legal experts, and other groups that serve the insurance fraud fighting community. If you are serious about staying ahead of evolving fraud tactics and strengthening your impact, make plans to attend. Take the extra step to invite others in your organization whom you feel will benefit from face-to-face time with our members. We look forward to seeing you in December! \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/89c5a17d-9a73-d960-c81a-0190423246d3.png) \| \| \|:-:\| \| [](https://members.insurancefraud.org/page/advertising-annual)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/3994ef75-33c2-f036-53ee-6288594686cf.jpeg) \| \| \|:-:\| \| \| \| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/ae4500ef-da51-d597-bbb4-789dc3bf1f4f.jpeg) \| \| \|:-:\| \| \| \| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/8d5f853b-306e-def1-f3c7-9bf6d32e0efa.jpeg) \| \| \|:-:\| \| \| \| This study, sponsored by Shift Technology, will examine how insurers use antifraud technology, strategies for fraud detection and investigation, implementation challenges, emerging trends, and future technology priorities. Your participation is vital to ensuring the findings accurately reflect the current landscape and provide valuable industry insights. Access the survey [here](https://shift-technology.typeform.com/to/Dz7wSXKx). Participation is anonymous. Contact [Celeste Dodson](mailto:celeste@insurancefraud.org) with questions. **Survey Deadline: October 14, 2026** \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/39c14db0-b611-ae6e-47f7-a81be32970ab.jpeg) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/ac4a173c-64fd-8528-6dff-25d794512084.png) \| \| \|:-:\| \| \| \| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/9e09caab-f751-c6e9-d847-4fb595564c79.jpeg) \| \| \|:-:\| \| [](https://s.surveyplanet.com/bj1sw6en)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a911883f-21e6-3d6a-275f-885582442fe3.jpeg) \| \| \|:-:\| \| \| \| \| \|---\| \| [](https://members.insurancefraud.org/general/register_member_type.asp)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/b23f743e-bbd0-1730-077d-51ca64df91d1.jpeg) \| \| \|:-:\| \| \| \| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/d210adcc-cb79-3334-fc1e-f6caffd1c0f1.jpeg) \| \| \|:-:\| \| \| \| - **October 7 –** [Members-Only Webinar: Racing Against the Clock: The Growing Threat of Luxury Watch Insurance Fraud ](https://insurancefraud.org/event/iasiu-members-only-racing-against-the-clock-the-growing-threat-of-luxury-watch-insurance-fraud/)– IASIU - **October 8 –** [Property Insurance Fraud Awareness](https://insurancefraud.org/event/property-insurance-fraud-awareness/) – Allied Universal - **October 11 – 14** – [2026 Global Insurance Fraud Summit](https://insurancefraud.org/event/2026-global-insurance-fraud-summit/) (GIFS) - **October 14** – [Medical Case Management: The Value of Focused Care ](https://insurancefraud.org/event/medical-case-management-the-value-of-focused-care/)(Ethos) - **October 15** – [OSINT Live 2026](https://insurancefraud.org/event/osint-live-2026/) – Skopenow - **October 21** – [CE Webinar: Maximizing Returns – Strategies for Boosting Investigation Impact](https://insurancefraud.org/event/ce-webinar-maximizing-returns-strategies-for-boosting-investigation-impact/) – Frasco - **October 21** – [Members-Only Webinar: Insurance Fraud Litigation and Recent Developments](https://insurancefraud.org/event/iasiu-members-only-webinar-insurance-fraud-litigation-and-recent-developments/) – IASIU - **October 22** – [Disability Within Workers’ Compensation](https://insurancefraud.org/event/disability-within-workers-compensation/) — Allied Universal - **October 29** – [CE Webinar: Hitting Record – Empowering Claim Decisions with Surveillance Footage](https://insurancefraud.org/event/ce-webinar-hitting-record-empowering-claim-decisions-with-surveillance-footage/) – Frasco - **November 3** – [CE Webinar: Gathering the Facts – Ensuring Accuracy and Actionable Insights with Research Investigations](https://insurancefraud.org/event/ce-webinar-gathering-the-facts-ensuring-accuracy-and-actionable-insights-with-research-investigations/) – Frasco - **November 3** – [SCFIA Anti-Fraud Conference](https://insurancefraud.org/event/2026-scfia-anti-fraud-conference-2/) - **November 3** – [The Material Difference: Identifying Material Misrepresentation in Insurance Claims](https://insurancefraud.org/event/the-material-difference/) – Becker & Company - **November 4** – [Members-Only Webinar: Vehicle Fraud and Auto Theft Trends ](https://insurancefraud.org/event/iasiu-members-only-webinar-vehicle-fraud-and-auto-theft-trends/)– IASIU - **November 18** – [Behind the Ride: How Insurance Fraud Impacts the Rideshare Industry](https://insurancefraud.org/event/iasiu-webinar-behind-the-ride-how-insurance-fraud-impacts-the-rideshare-industry/) – IASIU - **December 2** – [Counterfeit Parts, Fraudulent VINs, & Hidden Safety Threats: What You Need to Know](https://insurancefraud.org/event/iasiu-webinar-counterfeit-parts-fraudulent-vins-hidden-safety-threats-what-you-need-to-know/) – IASIU \| \| \|---\| \| \|---\| \| \| \| \| \|---\| \| \| \| **Follow Us on Our Social Media Platforms:** \| \| \|---\| \| \|---\| \| [](https://www.linkedin.com/company/coalition-against-insurance-fraud/)\| ![](https://dim.mcusercontent.com/cs/a440c5b647697de580a2fd586/images/d7ecc352-af0d-c6c0-84b7-fe66eca628c0.png?dpr=2&rect=0%2C39%2C551%2C112&w=551&h=112) \| \| \|:-:\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| \| \| \| \| \| [](https://www.facebook.com/profile.php?id=61579225779934)\| ![](https://dim.mcusercontent.com/cs/a440c5b647697de580a2fd586/images/a19e2277-53e5-5d03-770d-fa8a62202060.png?dpr=2&rect=1%2C26%2C505%2C122&w=505&h=122) \| \| \|:-:\| \| [](https://www.instagram.com/stopinsurancefraud/)\| ![](https://dim.mcusercontent.com/cs/a440c5b647697de580a2fd586/images/8da807b8-a79d-e1d1-8b42-e37bd860debd.png?dpr=2&rect=70%2C35%2C474%2C111&w=474&h=111) \| \| \|:-:\| \| \| \| \| [](https://www.insurancefraud.org)\| ![Logo](https://brand-assets.mailchimp.com/01KKVRP4PEH4PWEG0R0VSKKJ7H.png) \| \| \|:-:\| \| \| \| *Copyright (C) 2026 Coalition Against Insurance Fraud. All rights reserved.* You are receiving this email because either your organization is a member of the Coalition Against Insurance Fraud or you requested to be placed on our mailing list. Our mailing address is: Coalition Against Insurance Fraud 1012 14th St NW Ste 610 Washington, DC 20005-3424 USA Want to change how you receive these emails? You can [update your preferences](https://insurancefraud.mailchimpsites.com/manage/preferences?u=a440c5b647697de580a2fd586&id=b68dce7808&e=%5BUNIQID%5D&c=5c0e083b5d) or [unsubscribe](https://insurancefraud.us1.list-manage.com/unsubscribe?u=a440c5b647697de580a2fd586&id=b68dce7808&t=b&e=%5BUNIQID%5D&c=5c0e083b5d) \| \| \|:-:\| \| \|---\| \| \| \| \|---\| \| \|:-:\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| | |:-:| **Features:** Fraud News Weekly --- ### [Fraud News Weekly (FNW) Thursday, September 25, 2026](https://insurancefraud.org/publications/fraud-news-weekly-fnw-thursday-september-25-2026/) **Published:** September 25, 2026 **Author:** Coalition Against Insurance Fraud **Content:** Fraud News Weekly (FNW) Friday, September 25, 2026͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ | \| \| \| \| \| \| \| [View this email in your browser](https://mailchi.mp/a28c2734a494/fraud-news-weekly-friday-may-1-10704893?e=%5BUNIQID%5D) \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| \| \| \| \| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/c9768117-4cce-014d-965c-7840e3c4d70c.jpeg) \| \| \|:-:\| \| [](https://www.insurancefraud.org)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/e438a452-a9da-fc27-8c93-aad4b329206f.jpeg) \| \| \|:-:\| \| \| \| **New York groups urge Scaffold Law reform to address fraud and insurance costs.** A coalition of New York business and insurance organizations is urging New York City Mayor Mamdani to recommend reforms to Labor Law Sections 240 and 241, known as the Scaffold Law, as part of the city’s housing affordability strategy. The group’s [letter](https://acrobat.adobe.com/id/urn:aaid:sc:US:ce134a15-640e-4085-a4aa-8e266af8fc1d?viewer%21megaVerb=group-discover) cites high insurance and construction costs and alleged staged construction accidents and fraudulent claims exploiting the law’s absolute liability standard. They propose comparative negligence, while worker advocates argue the existing law promotes job site safety. [Read more](https://www.thecentersquare.com/new_york/article_51d6983f-7cd4-480f-8fda-df48aad73539.html)… **Coalition brings next generation of fraud issues to the Insurance Consumer Affairs Exchange.** Brent Walker, Director of Government Relations, spoke this week at the 50th Anniversary of the Insurance Consumer Affairs Exchange (ICAE) Annual Exchange in San Antonio, Texas. The ICAE was established to shape the discourse between insurers, regulators and consumer groups. Walker’s presentation focused on the growing sophistication of insurance fraud and what consumers affairs professionals should know. The discussion was very interactive and complemented broader ICAE conversations about complaint trends, artificial intelligence, data, consumer education and the changing insurance environment. [Read more](https://icae.com/)… **Insurance government affairs professionals gather in Seattle where fraud took the stage.** Brent Walker co-presented with the National Insurance Crime Bureau (NICB) at the 2026 State Insurance Trade Association (SITA) Annual Conference in Seattle to provide an update on the state of insurance fraud. The session reviewed this year’s antifraud efforts, examined current and emerging fraud trends, and opened discussion on 2027 antifraud legislative priorities. Insurance fraud also surfaced throughout other conference presentations, underscoring its relevance across insurance issues and the work ahead. [Read more](https://sita.wildapricot.org/events)… **Rafeld partners with Coalition members at IASIU Conference.** Executive Director Michelle Rafeld presented at the 2026 International Association of Special Investigative Units (IASIU) Conference in Orlando this week. Michelle joined leaders from NICB, Mercury Insurance, Florida Department of Financial Services, ICW Group, and Erie for a panel discussion on: *“Stronger Together: Uniting Fraud Fighters: A United Approach to Combating Insurance Fraud”.* She also *moderated “From Suspicion to Submission: Best Practices for Reporting Suspected Insurance Fraud”.* As a guest panelist for SHIFT’s *Level Up: Women Driving Insurance Innovation* event, Michelle spoke about career growth, leadership, and innovation. \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/639dd51a-b5ce-1b6e-db24-25b13ce6cc3f.jpeg) \| \| \|:-:\| \| \| \| **South Korea targets AI insurance fraud as detection systems face strain.** Lawmakers and financial regulators in South Korea are pursuing new legislation and cross-agency data sharing to counter sophisticated AI-driven insurance fraud that is testing current carrier detection controls. Following record fraudulent payouts reaching 1.16 trillion won in 2025, officials formed a cross-party forum and multi-agency task force to upgrade cross-verification infrastructure and establish anti-fraud laws. This initiative demonstrates the urgent international necessity for advanced digital detection tools and legislative frameworks to protect insurers from deepfake documentation and automated claim schemes. [Read more](https://www.insurancebusinessmag.com/asia/news/cyber/south-korea-targets-ai-insurance-fraud-as-detection-systems-come-under-strain-590289.aspx)[… ](https://www.insurancebusinessmag.com/asia/news/cyber/south-korea-targets-ai-insurance-fraud-as-detection-systems-come-under-strain-590289.aspx) **Connecticut Insurance Department launches Preparedness & Resiliency Center.** The Connecticut Insurance Department has launched the *“Be Weather Ready: Preparedness & Resiliency Center”*, a new online hub offering hazard guidance, insurance basics (including flood), home resilience steps, and plain language preparedness resources. The Center provides Connecticut specific tools, videos, and checklists to help residents understand their risks and prepare before severe weather occurs. [Read Story](https://portal.ct.gov/cid/home/consumer-information-center/preparedness-and-resiliency-center?language=en_US) \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/df2df8da-5c89-a5b8-9eb9-788eeefd0017.jpeg) \| \| \|:-:\| \| \| \| *The arrest summaries in Fraud News Weekly are compiled from publicly available news sources. Individuals mentioned are presumed innocent until proven guilty in a court of law.* \| \| \|---\| \| \|---\| \| \| \| \| \|---\| \| \| \| **AUTO – FALSE CLAIM** **Sept. 21 – North Carolina – Charlotte man charged in multi-county auto insurance fraud scheme** Joshua Willis was charged with 14 felonies for fraudulently adding individuals to Progressive Premier Insurance policies without their knowledge to buy vehicles in their names. Union County, Gaston County, and Mecklenburg County authorities served the warrants following an investigation by the North Carolina Department of Insurance. The multi-county investigation into the vehicle purchases… [Read more](https://www.ncdoi.gov/news/press-releases/2026/09/21/charlotte-man-charged-multi-county-insurance-fraud-scheme) **AGENT MISCONDUCT** **Sept. 23 – North Carolina – Licensed insurance agent charged with using stolen identity to buy life insurance policy** Tony Gunter was charged with exploiting an elderly person after allegedly using her checking account information to buy a life insurance policy without her consent. Gunter earned $257 in commission from Foresters Insurance Co. on the unauthorized policy. State investigators revealed the license-holder was previously on probation for a prior conviction… [Read more](https://www.insurancejournal.com/news/southeast/2026/09/23/886448.htm) **PROPERTY – FALSE CLAIM** **Sept. 23 – Kansas – Probation for man who forged receipts to validate fake property damage claims** Dwayne Wright was sentenced to 24 months of probation for filing multiple fraudulent property claims. The Johnson County man submitted false claims for stolen and damaged worksite materials. Wright created forged receipts to validate the claims, which led a court to order $1,449… [Read more](https://www.insurancejournal.com/news/midwest/2026/09/23/886575.htm) \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/f6fbd4df-0324-bd7b-d734-f4c51eace4a1.png) \| \| \|:-:\| \| [](https://us02web.zoom.us/webinar/register/WN_A6PNu_xKSbugfoi-53vsQg)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/dcb5c12d-e86b-1a2f-d26e-9b193155b679.jpeg) \| \| \|:-:\| \| \| \| Restoring systems may close a cyber incident for an organization but for the people whose information was stolen, the threat may just be beginning. Exposed data can fuel identity theft, fraudulent claims, tax fraud and other crimes long after operations return to normal. In this webinar, crisis response strategist Dave Smolensky of Resolute Strategic Services, challenges the traditional definition of cyber recovery and makes the case for measuring success by the harm prevented, not simply the systems restored. Attendees will learn how: - Insurers can bring SIU and fraud expertise left of boom - To strengthen incident response planning - Assess the fraud potential of compromised data, and better protect consumers from the risks that can follow a cyber incident. The session offers a practical framework for connecting cybersecurity, fraud prevention and consumer protection before the next incident occurs. Click on the image to register, and share this opportunity with colleagues who will benefit from attending! \| \| \|---\| \| \|---\| \| \| \| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/bb0a9596-62da-984d-f30e-3857c977bdc3.png) \| \| \|:-:\| \| [](https://members.insurancefraud.org/general/custom.asp?page=2026AnnualMeeting)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/f82089f1-d9bc-38d8-bcca-4896d3565bda.jpeg) \| \| \|:-:\| \| \| \| Preparations are underway for another engaging and informative meeting. The Coalition’s Annual Meeting brings together insurers, regulators, consumer groups, legal experts, and other groups that serve the insurance fraud fighting community. If you are serious about staying ahead of evolving fraud tactics and strengthening your impact, make plans to attend. Take the extra step to invite others in your organization whom you feel will benefit from face-to-face time with our members. We look forward to seeing you in December! \| \| \|---\| \| \|---\| \| [](https://members.insurancefraud.org/general/custom.asp?page=2026AnnualMeeting)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/cad4d5fd-f586-1411-57f3-c02d32e3c632.jpeg) \| \| \|:-:\| \| [](https://members.insurancefraud.org/page/advertising-annual)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/3994ef75-33c2-f036-53ee-6288594686cf.jpeg) \| \| \|:-:\| \| \| \| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/ae4500ef-da51-d597-bbb4-789dc3bf1f4f.jpeg) \| \| \|:-:\| \| \| \| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/39c14db0-b611-ae6e-47f7-a81be32970ab.jpeg) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/78ef5bbf-da04-1923-3d4b-f7dabe43dfbe.jpeg) \| \| \|:-:\| \| \| \| \| \|---\| \| [](https://s.surveyplanet.com/bj1sw6en)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a911883f-21e6-3d6a-275f-885582442fe3.jpeg) \| \| \|:-:\| \| \| \| \| \|---\| \| [](https://members.insurancefraud.org/general/register_member_type.asp)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/b23f743e-bbd0-1730-077d-51ca64df91d1.jpeg) \| \| \|:-:\| \| \| \| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/d210adcc-cb79-3334-fc1e-f6caffd1c0f1.jpeg) \| \| \|:-:\| \| \| \| - **October 8 –** [Property Insurance Fraud Awareness](https://insurancefraud.org/event/property-insurance-fraud-awareness/) – Allied Universal - **October 11 – 14** – [2026 Global Insurance Fraud Summit](https://insurancefraud.org/event/2026-global-insurance-fraud-summit/) (GIFS) - **October 15** – [OSINT Live 2026](https://insurancefraud.org/event/osint-live-2026/) – Skopenow - **October 21** – [CE Webinar: Maximizing Returns – Strategies for Boosting Investigation Impact](https://insurancefraud.org/event/ce-webinar-maximizing-returns-strategies-for-boosting-investigation-impact/) – Frasco - **October 29** – [CE Webinar: Hitting Record – Empowering Claim Decisions with Surveillance Footage](https://insurancefraud.org/event/ce-webinar-hitting-record-empowering-claim-decisions-with-surveillance-footage/) – Frasco - **November 3** – [CE Webinar: Gathering the Facts – Ensuring Accuracy and Actionable Insights with Research Investigations](https://insurancefraud.org/event/ce-webinar-gathering-the-facts-ensuring-accuracy-and-actionable-insights-with-research-investigations/) – Frasco - **November 3** – [SCFIA Anti-Fraud Conference](https://insurancefraud.org/event/2026-scfia-anti-fraud-conference-2/) \| \| \|---\| \| \|---\| \| \| \| \| \|---\| \| \| \| **Follow Us on Our Social Media Platforms:** \| \| \|---\| \| \|---\| \| [](https://www.linkedin.com/company/coalition-against-insurance-fraud/)\| ![](https://dim.mcusercontent.com/cs/a440c5b647697de580a2fd586/images/d7ecc352-af0d-c6c0-84b7-fe66eca628c0.png?dpr=2&rect=0%2C39%2C551%2C112&w=551&h=112) \| \| \|:-:\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| \| \| \| \| \| [](https://www.facebook.com/profile.php?id=61579225779934)\| ![](https://dim.mcusercontent.com/cs/a440c5b647697de580a2fd586/images/a19e2277-53e5-5d03-770d-fa8a62202060.png?dpr=2&rect=1%2C26%2C505%2C122&w=505&h=122) \| \| \|:-:\| \| [](https://www.instagram.com/stopinsurancefraud/)\| ![](https://dim.mcusercontent.com/cs/a440c5b647697de580a2fd586/images/8da807b8-a79d-e1d1-8b42-e37bd860debd.png?dpr=2&rect=70%2C35%2C474%2C111&w=474&h=111) \| \| \|:-:\| \| \| \| \| [](https://www.insurancefraud.org)\| ![Logo](https://brand-assets.mailchimp.com/01KKVRP4PEH4PWEG0R0VSKKJ7H.png) \| \| \|:-:\| \| \| \| *Copyright (C) 2026 Coalition Against Insurance Fraud. All rights reserved.* You are receiving this email because either your organization is a member of the Coalition Against Insurance Fraud or you requested to be placed on our mailing list. Our mailing address is: Coalition Against Insurance Fraud 1012 14th St NW Ste 610 Washington, DC 20005-3424 USA Want to change how you receive these emails? You can [update your preferences](https://insurancefraud.mailchimpsites.com/manage/preferences?u=a440c5b647697de580a2fd586&id=b68dce7808&e=%5BUNIQID%5D&c=98670f7306) or [unsubscribe](https://insurancefraud.us1.list-manage.com/unsubscribe?u=a440c5b647697de580a2fd586&id=b68dce7808&t=b&e=%5BUNIQID%5D&c=98670f7306) \| \| \|:-:\| \| \|---\| \| \| \| \|---\| \| \|:-:\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| | |:-:| **Features:** Fraud News Weekly --- ### [Fraud News Weekly (FNW) Thursday, September 18, 2026](https://insurancefraud.org/publications/fraud-news-weekly-fnw-thursday-september-18-2026/) **Published:** September 18, 2026 **Author:** Coalition Against Insurance Fraud **Content:** Fraud News Weekly (FNW) Friday, September 18, 2026͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ | \| \| \| \| \| \| \| [View this email in your browser](https://mailchi.mp/90de40c066f3/fraud-news-weekly-friday-may-1-10704854?e=%5BUNIQID%5D) \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| \| \| \| \| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/bb7d92a3-3bbd-5959-3d4f-64c0449a2df6.jpeg) \| \| \|:-:\| \| [](https://www.insurancefraud.org)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/e438a452-a9da-fc27-8c93-aad4b329206f.jpeg) \| \| \|:-:\| \| \| \| **Coalition recommends stronger antifraud protections in latest comments on NAIC consumer privacy model revisions.** This week, the Coalition submitted [comments](https://insurancefraud.org/wp-content/uploads/Coalition-Comments-9.17.2026-on-NAIC-Revised-MO672-Full-Exposure-Draft-7.24.26.pdf) to the National Association of Insurance Commissioners (NAIC) Privacy Protections Working Group on the full draft of Model #672, the proposed *Privacy of Consumer Information Act*. Building on [earlier engagement](https://insurancefraud.org/advocacy-efforts/), the Coalition supports modernized consumer privacy protections alongside antifraud exemptions. The Coalition worked with multiple stakeholders to find consensus and cited California Senate Bill 354 as an example for addressing antifraud exceptions within individual consumer rights. The Coalition’s recent comments focused on additional antifraud exceptions to prevent those rights from inadvertently revealing or compromising an ongoing fraud investigation and ensure proposed model language does not interfere with existing state requirements for fraud reporting, immunity and confidentiality. NAIC hopes to vote on these proposed revisions during the Fall National Meeting in November. [Read more](https://content.naic.org/committees/h/privacy-protections-wg)… **Texas consumer feedback adds perspective to insurance affordability and fraud efforts.** Texas Department of Insurance (TDI) launched “*Speak Up, Texas!*” to gather consumer recommendations on homeowners and auto insurance. Recommendations relevant to Coalition members include licensing roofers, strengthening adjuster transparency and enforcement, protecting digital document integrity, and regulating storage and auto repair rates. The effort is timely as Gov. Greg Abbott has [directed TDI](https://gov.texas.gov/news/post/governor-abbott-directs-tdi-to-take-action-to-make-property-insurance-more-affordable) to address insurance affordability, including creating an Insurance Fraud Task Force. TDI will share the feedback from “*Speak Up, Texas!*” with policymakers and the insurance industry. The Coalition is monitoring the effort and staying connected with TDI Fraud Unit as the work moves forward. [Read more](https://www.tdi.texas.gov/speakuptexas/speak-up-texas-results.html)… **Oregon warns of AI powered scams as states address financial exploitation.** Oregon’s Division of Financial Regulation is warning that scammers are using artificial intelligence to create convincing investment pitches, websites, videos, deepfakes, voice clones and chatbots. The schemes reflect a broader financial exploitation threat, including life insurance and annuity products addressed by legislation enacted in Iowa and Nebraska. Similar schemes are also being examined through Coalition committees and task forces. [Read more](https://dfr.oregon.gov/news/news2026/Pages/20260914-AI-powered-investment-scams.aspx)… \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/639dd51a-b5ce-1b6e-db24-25b13ce6cc3f.jpeg) \| \| \|:-:\| \| \| \| **Rafeld presents evolving fraud trends at ICA Conference.** On Sept. 14, Executive Director Michelle Rafeld spoke at the International Claim Association (ICA) Conference, which brought together more than 400 representatives from the life, disability, and long-term care insurance sectors. Presenting alongside Jeff Ferrand of Coalition member illumifin, Rafeld provided an overview of the evolving insurance fraud landscape. She highlighted how the Coalition unites diverse organizations to combat fraud through education, advocacy, research, and collaboration. Ferrand also explained how the Coalition helps the industry raise awareness of long-term care fraud and strengthen collective prevention efforts. **The TDI celebrates 150 years of protecting Texans.** The Texas Department of Insurance (TDI) is celebrating our 150-year anniversary in 2026. In 1876, the 15th Legislature created the Department of Insurance, Statistics, and History. In the 1870s, most Texans bought insurance policies from companies based in other states and foreign countries. Only four of the 61 companies selling insurance in Texas were Texas-based in 1874. Today, TDI regulates 3,447 companies, including 843 Texas-based insurers. [Read More](https://links.naic.org/lnk/BAAACU0-s7oAAc5547IABDA06-MAAYKJiqUAoMjqAC9RAwBqqBsVG79-DWnLRXG7iNdXQPDmbAAp8h8/15/9f8scFJ4BHv7EN6uYBNIfA/aHR0cHM6Ly93d3cudGRpLnRleGFzLmdvdi9ibG9nL2NlbGVicmF0aW5nLTE1MC15ZWFycy1wcm90ZWN0aW5nLXRleGFucy5odG1s) **American Land Title Association study finds sharp rise in seller impersonation fraud.** Nearly 60% of title insurance firms experienced seller impersonation fraud attempts in 2025, up from 28% in 2024, according to a study by the American Land Title Association. Fraudsters increasingly target vacant land, rental properties, and unencumbered homes using fake identity documents and deepfake technology. These schemes lead to massive claim payouts and severe losses across the industry. Insurers, Special Investigation Units, and regulators must enhance verification protocols, adopt advanced authentication tools, and strengthen cross-industry fraud prevention partnerships. [Read more…](https://www.nar.realtor/news/real-estate-news/6-in-10-title-insurance-firms-experienced-seller-impersonation-fraud-attempts-last-year-study-finds) **Better Business Bureau warns of fraudsters targeting seniors with bogus life insurance schemes.** Scammers are cold-calling older adults, claiming they owe premiums or have existing life insurance policies to steal personal and financial details. Victims in Ohio reported unauthorized bank withdrawals and aggressive demands for policy information. The fraud schemes rely on public data to trick consumers into confirming sensitive bank account or Social Security information. Fraud investigators, regulators, and SIU teams must address these emerging imposter tactics to protect vulnerable policyholders and prevent financial exploitation. [Read more…](https://insurancenewsnet.com/oarticle/better-business-bureau-scam-alert-beware-of-life-insurance-impostors-targeting-older-adults) \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/df2df8da-5c89-a5b8-9eb9-788eeefd0017.jpeg) \| \| \|:-:\| \| \| \| *The arrest summaries in Fraud News Weekly are compiled from publicly available news sources. Individuals mentioned are presumed innocent until proven guilty in a court of law.* \| \| \|---\| \| \|---\| \| \| \| \| \|---\| \| \| \| **HOMEOWNERS – ARSON** **September 10 – Virginia – Man found guilty in fatal arson and home insurance fraud scheme** Jacob Bogatin was found guilty of first-degree murder and multiple arson charges after setting fire to his foreclosed Sterling townhouse to collect insurance money. The three-alarm blaze killed a neighbor and destroyed multiple units. Investigators discovered that Bogatin filed a fraudulent homeowners insurance claim the very next morning… [Read more](https://www.wusa9.com/article/news/crime/sterling-home-fire-insurance-fraud-man-found-guilty/65-46e4d7dc-6cb7-4ff1-bccf-d285092f74c5) **HOMEOWNERS – ARSON** **Sept. 11 – Louisiana – Second accomplice arrested in connection to Columbia house fire** The Louisiana State Fire Marshal announced investigators have arrested a second person linked to an insurance fraud scheme that followed a June residential fire in Columbia. Kandi Barnett was identified as an accomplice who conspired to participate in a scheme tied to the destruction of a home… [Read more](https://www.knoe.com/2026/09/11/investigators-make-second-arrest-columbia-house-fire-insurance-fraud-probe/) **AGENT MISCONDUCT** **Sept. 14 – Indiana – Former Schererville insurance agent sentenced to 70 months in prison for $5M life insurance fraud scheme** Thomas Lemmen was sentenced to 70 months in federal prison for writing over 2,000 fraudulent life insurance policies without clients’ knowledge. Lemmen forged signatures and stole identities of retirees and elderly residents to collect more than $5 million in unearned commissions. He used the stolen funds to buy home renovations, an outdoor pool, and… [Read more](https://chicagocrusader.com/former-schererville-insurance-agent-sentencedto-70-months-in-prison/) **WORKERS’ COMPENSATION** **Sept. 10 – New York – Asbestos removal company owner charged with $163K workers’ compensation insurance fraud scheme** Joseph Arthurs, owner of VGN Enterprise Corp., was charged after allegedly underpaying $163,561 in workers’ compensation insurance premiums. Authorities claim Arthurs hid hazardous asbestos work and reported a single employee to Wesco Insurance Company instead of a full crew. An investigation revealed actual payroll totaled $354,112, leaving workers without required coverage… [Read more](https://www.suffolkcountyda.org/patchogue-employer-charged-with-workers-comp-insurance-fraud/) **UNLICENSED AGENT** **September 15 – Connecticut – Fraudulent prize insurance scheme leads to guilty plea** Kevin Kolenda pleaded guilty to wire fraud after operating an unlicensed prize insurance business, Hole-in-Won LLC, to collect premiums while avoiding legitimate payouts. Kolenda collected payments from charitable groups for contest promotions, but used fake aliases and fictitious claims departments to deny legitimate prize payouts. After violating his pre-trial bond by continuing to sell policy coverage… [Read more](https://insurancenewsnet.com/oarticle/norwalk-prize-insurance-businessman-pleads-guilty-to-defrauding-dozens-of-organizations) \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/f6fbd4df-0324-bd7b-d734-f4c51eace4a1.png) \| \| \|:-:\| \| [](https://us02web.zoom.us/webinar/register/WN_A6PNu_xKSbugfoi-53vsQg)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/dcb5c12d-e86b-1a2f-d26e-9b193155b679.jpeg) \| \| \|:-:\| \| \| \| Restoring systems may close a cyber incident for an organization but for the people whose information was stolen, the threat may just be beginning. Exposed data can fuel identity theft, fraudulent claims, tax fraud and other crimes long after operations return to normal. In this webinar, crisis response strategist Dave Smolensky of Resolute Strategic Services, challenges the traditional definition of cyber recovery and makes the case for measuring success by the harm prevented, not simply the systems restored. Attendees will learn how: - Insurers can bring SIU and fraud expertise left of boom - To strengthen incident response planning - Assess the fraud potential of compromised data, and better protect consumers from the risks that can follow a cyber incident. The session offers a practical framework for connecting cybersecurity, fraud prevention and consumer protection before the next incident occurs. Click on the image to register, and share this opportunity with colleagues who will benefit from attending! \| \| \|---\| \| \|---\| \| \| \| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/bb0a9596-62da-984d-f30e-3857c977bdc3.png) \| \| \|:-:\| \| [](https://members.insurancefraud.org/general/custom.asp?page=2026AnnualMeeting)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/f82089f1-d9bc-38d8-bcca-4896d3565bda.jpeg) \| \| \|:-:\| \| \| \| Preparations are underway for another engaging and informative meeting. The Coalition’s Annual Meeting brings together insurers, regulators, consumer groups, legal experts, and other groups that serve the insurance fraud fighting community. If you are serious about staying ahead of evolving fraud tactics and strengthening your impact, make plans to attend. Take the extra step to invite others in your organization whom you feel will benefit from face-to-face time with our members. We look forward to seeing you in December! \| \| \|---\| \| \|---\| \| [](https://members.insurancefraud.org/general/custom.asp?page=2026AnnualMeeting)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/24de52a8-af1c-6398-c4db-febe83e72cd6.jpeg) \| \| \|:-:\| \| [](https://members.insurancefraud.org/page/advertising-annual)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/3994ef75-33c2-f036-53ee-6288594686cf.jpeg) \| \| \|:-:\| \| \| \| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/ae4500ef-da51-d597-bbb4-789dc3bf1f4f.jpeg) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/78e0822a-a830-a5a7-3f1d-f8e19660d52f.png) \| \| \|:-:\| \| \| \| The Coalition’s Technology Task Force kicked off this week with 61 inaugural members. The task force will focus on combating tech-enabled fraud, evaluating anti-fraud tools, sharing operational practices, and navigating compliance and privacy needs. They will also create technology guidance and educational resources for members and consumers. The next meeting is November 17. To join the task force, contact Kendra Smith at <Kendra@insurancefraud.org>. \| \| \|---\| \| \|---\| \| \| \| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/96263f9c-8991-c928-b83e-7a61c85bef5e.jpeg) \| \| \|:-:\| \| \| \| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/39c14db0-b611-ae6e-47f7-a81be32970ab.jpeg) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/53853acd-da36-233a-717e-8f8b7a044a04.jpeg) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/c56fe2e3-c052-ce16-fb96-f79ba9854ad4.png) \| \| \|:-:\| \| \| \| \| \|---\| \| [](https://s.surveyplanet.com/bj1sw6en)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a911883f-21e6-3d6a-275f-885582442fe3.jpeg) \| \| \|:-:\| \| \| \| \| \|---\| \| [](https://members.insurancefraud.org/general/register_member_type.asp)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/b23f743e-bbd0-1730-077d-51ca64df91d1.jpeg) \| \| \|:-:\| \| \| \| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/d210adcc-cb79-3334-fc1e-f6caffd1c0f1.jpeg) \| \| \|:-:\| \| \| \| - [**September**](https://www.iii.org/press-release/press-release-triple-i-launches-insurance-affordability-index-to-provide-state-by-state-view-of-insurance-costs-and-market-conditions) **20 – 23** – [IASIU Annual Conference](https://insurancefraud.org/event/2026-iasiu-annual-conference/) - **September 23** – [CE Webinar: The Ethical Edge – Navigating Insurance Claim Investigations](https://insurancefraud.org/event/ce-webinar-the-ethical-edge-navigating-insurance-claim-investigations/) – Frasco - **September 23** – [Transport Fraud: Maritime, Trucking and Trains](https://insurancefraud.org/event/free-ce-webinar-series-transport-fraud-maritime-trucking-and-trains/) – Ethos - **September 24** – [Social Media in Investigations](https://insurancefraud.org/event/the-reality-of-using-social-media-in-investigations-2/) – Allied Universal - **September 28** – [Broker and Agent Forum](https://insurancefraud.org/event/nysifs-broker-and-agent-forum/) – NYSIF - **September 27 – 30** – [NAMIC’s 131st Annual Convention](https://insurancefraud.org/event/namics-131st-annual-convention/) - **October 11 – 14** – [2026 Global Insurance Fraud Summit](https://insurancefraud.org/event/2026-global-insurance-fraud-summit/) (GIFS) - **October 15** – [OSINT Live 2026](https://insurancefraud.org/event/osint-live-2026/) – Skopenow - **October 21** – [CE Webinar: Maximizing Returns – Strategies for Boosting Investigation Impact](https://insurancefraud.org/event/ce-webinar-maximizing-returns-strategies-for-boosting-investigation-impact/) – Frasco - **October 29** – [CE Webinar: Hitting Record – Empowering Claim Decisions with Surveillance Footage](https://insurancefraud.org/event/ce-webinar-hitting-record-empowering-claim-decisions-with-surveillance-footage/) – Frasco - **November 3** – [CE Webinar: Gathering the Facts – Ensuring Accuracy and Actionable Insights with Research Investigations](https://insurancefraud.org/event/ce-webinar-gathering-the-facts-ensuring-accuracy-and-actionable-insights-with-research-investigations/) – Frasco - **November 3** – [SCFIA Anti-Fraud Conference](https://insurancefraud.org/event/2026-scfia-anti-fraud-conference-2/) \| \| \|---\| \| \|---\| \| \| \| \| \|---\| \| \| \| **Follow Us on Our Social Media Platforms:** \| \| \|---\| \| \|---\| \| [](https://www.linkedin.com/company/coalition-against-insurance-fraud/)\| ![](https://dim.mcusercontent.com/cs/a440c5b647697de580a2fd586/images/d7ecc352-af0d-c6c0-84b7-fe66eca628c0.png?dpr=2&rect=0%2C39%2C551%2C112&w=551&h=112) \| \| \|:-:\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| \| \| \| \| \| [](https://www.facebook.com/profile.php?id=61579225779934)\| ![](https://dim.mcusercontent.com/cs/a440c5b647697de580a2fd586/images/a19e2277-53e5-5d03-770d-fa8a62202060.png?dpr=2&rect=1%2C26%2C505%2C122&w=505&h=122) \| \| \|:-:\| \| [](https://www.instagram.com/stopinsurancefraud/)\| ![](https://dim.mcusercontent.com/cs/a440c5b647697de580a2fd586/images/8da807b8-a79d-e1d1-8b42-e37bd860debd.png?dpr=2&rect=70%2C35%2C474%2C111&w=474&h=111) \| \| \|:-:\| \| \| \| \| [](https://www.insurancefraud.org)\| ![Logo](https://brand-assets.mailchimp.com/01KKVRP4PEH4PWEG0R0VSKKJ7H.png) \| \| \|:-:\| \| \| \| *Copyright (C) 2026 Coalition Against Insurance Fraud. All rights reserved.* You are receiving this email because either your organization is a member of the Coalition Against Insurance Fraud or you requested to be placed on our mailing list. Our mailing address is: Coalition Against Insurance Fraud 1012 14th St NW Ste 610 Washington, DC 20005-3424 USA Want to change how you receive these emails? You can [update your preferences](https://insurancefraud.mailchimpsites.com/manage/preferences?u=a440c5b647697de580a2fd586&id=b68dce7808&e=%5BUNIQID%5D&c=b0adc5db9a) or [unsubscribe](https://insurancefraud.us1.list-manage.com/unsubscribe?u=a440c5b647697de580a2fd586&id=b68dce7808&t=b&e=%5BUNIQID%5D&c=b0adc5db9a) \| \| \|:-:\| \| \|---\| \| \| \| \|---\| \| \|:-:\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| | |:-:| **Features:** Fraud News Weekly --- ### [Fraud News Weekly (FNW) Thursday, September 11, 2026](https://insurancefraud.org/publications/fraud-news-weekly-fnw-thursday-september-11-2026/) **Published:** September 11, 2026 **Author:** Coalition Against Insurance Fraud **Content:** Fraud News Weekly (FNW) Friday, September 11, 2026͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ | \| \| \| \| \| \| \| [View this email in your browser](https://mailchi.mp/e68494b2ebfb/fraud-news-weekly-friday-may-1-10704826?e=%5BUNIQID%5D) \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| \| \| \| \| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/dd4bbd76-d0df-3084-e9b2-4e49aae95036.png) \| \| \|:-:\| \| [](https://www.insurancefraud.org)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/e438a452-a9da-fc27-8c93-aad4b329206f.jpeg) \| \| \|:-:\| \| \| \| **Triple I launches state insurance affordability index.** The Insurance Information Institute (Triple I) launched an interactive Insurance Affordability Index examining personal auto and homeowners insurance costs, availability and market conditions through 2025. The tool identifies claim frequency and severity, repair costs, expenses and claims litigation as factors influencing insurance costs, while also recognizing legal system abuse as a source of pressure on premiums. For Coalition members, the state level data provides useful context for examining the broader cost pressures that make insurance affordability a continuing policy concern. [Read more](https://www.iii.org/press-release/press-release-triple-i-launches-insurance-affordability-index-to-provide-state-by-state-view-of-insurance-costs-and-market-conditions)... **Bipartisan House bill expands federal focus on staged crash fraud.** Reps. Laura Gillen, Troy Nehls, Josh Gottheimer and Vince Fong introduced the Stop Auto Fraud Act of 2026, which would establish federal penalties for intentionally staging or fabricating motor vehicle crashes, both personal and commercial, and submitting fraudulent insurance claims. The measure follows growing congressional attention to staged accident fraud, including Senate Bill 5058 and House Bill 2662, which target staged crashes involving commercial vehicles. In 2025, the Coalition joined the National Insurance Crime Bureau and International Association of Special Investigation Units in supporting H.R. 2662 and a proposed federal staged accident task force. [Read more](https://gillen.house.gov/media/press-releases/reps-gillen-nehls-gottheimer-and-fong-introduce-bipartisan-legislation-make)… **Australia’s storm fraud shows how schemes cross borders.** Australia is seeing more fraud following severe weather events, including “disaster chasers” who approach property owners and offer repair or claims assistance. Australia’s financial services regulator, the Australian Securities and Investments Commission, is increasing scrutiny of brokers and other businesses that help policyholders manage claims after disasters. Australia is also developing a national system for insurers to share fraud intelligence. The similarities show why fraud fighters benefit from sharing experiences across borders. That will be one of the focuses at the upcoming [Global Insurance Fraud Summit](https://globalinsurancefraudsummit.org/summit/overview) in Panama City, Panama, where the Coalition’s Celeste Dodson serves as vice president. [Read more](https://www.insurancebusinessmag.com/au/news/catastrophe/storm-fraud-surge-puts-broker-conduct-records-in-asics-sights-589008.aspx)… \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/639dd51a-b5ce-1b6e-db24-25b13ce6cc3f.jpeg) \| \| \|:-:\| \| \| \| **Crime is falling, so why doesn’t it feel that way?** Despite crime statistics dropping across many states, public perception of safety remains low because anecdotes, social media, and news coverage move far faster than delayed official figures. While speaking at the National Conference of State Legislatures (NCSL), crime data expert Jeff Asher highlighted that traditional federal reporting can take up to 18 months, leaving a data vacuum where public anxiety thrives even years into a historic decline. Closing the gap between crime reality and public sentiment requires faster, more reliable data, careful application of AI tools with strict guardrails, and a critical eye from policymakers toward stats that omit limitations or context. [Read more](https://www.ncsl.org/state-legislatures-news/details/crime-is-falling-so-why-doesnt-it-feel-that-way?utm_source=act-on+software&utm_term=crime%20is%20falling.%20so%20why%20doesn%5cu2019t%20it%20feel%20that%20way&utm_campaign=spotlight%20on%20criminal%20justice%20data%21&cm_mmc=act-on%20software-_-email-_-spotlight%20on%20criminal%20justice%20data%21-_-crime%20is%20falling.%20so%20why%20doesn%5cu2019t%20it%20feel%20that%20way&utm_medium=email&utm_content=email) \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/df2df8da-5c89-a5b8-9eb9-788eeefd0017.jpeg) \| \| \|:-:\| \| \| \| *The arrest summaries in Fraud News Weekly are compiled from publicly available news sources. Individuals mentioned are presumed innocent until proven guilty in a court of law.* \| \| \|---\| \| \|---\| \| \| \| \| \|---\| \| \| \| **AUTO – STAGED ACCIDENT** **Sept. 6 – Louisiana – Federal jury convicts man for staged crash scheme targeting commercial trucks** Sean Alfortish was convicted by a federal jury for participating in a scheme to intentionally stage crashes involving commercial trucks to create fraudulent insurance claims and lawsuits. Prosecutors revealed Alfortish offered a cooperating witness $500,000 and relocation assistance to take full responsibility for the collisions. Facing a maximum statutory sentence of 90 years in prison… [Read more](https://www.trucknews.com/security/man-convicted-in-scheme-to-defraud-trucking-insurance-companies-through-staged-crashes/1003221211/) **HEALTHCARE FRAUD** **Sept. 4 – Kansas – Crawford County woman sentenced to 24 months probation for fake medical claims** Kelly Heiskell pleaded guilty and received a sentence of 24 months probation for committing felony insurance fraud. Heiskell submitted falsified documents to Aflac Insurance for fake medical visits and injuries. Prosecutors dismissed a forgery charge, but court records reveal the scheme dated back to… [Read more](https://morningsun.net/news/local-news/woman-sentenced-for-insurance-fraud/) **FALSE CLAIM** **Sept. 3 – South Carolina –** [**SLED charges Greenville County woman with insurance fraud and forgery**](https://links.naic.org/lnk/EAAACT87bxcAAc55YXoAA-s7HDgAAYKJiqUAoMjqAC9RAwBqoESke6DrIwSMS5ySJWFX5dv-AwAp8h8/26/kInS9DfO0i5kMIQXIunO5A/aHR0cHM6Ly93d3cuc2xlZC5zYy5nb3YvYWJvdXQvdXBkYXRlcy9zbGVkLWNoYXJnZXMtZ3JlZW52aWxsZS1jb3VudHktd29tYW4taW5zdXJhbmNlLWZyYXVkLWFuZC1mb3JnZXJ5) The South Carolina Law Enforcement Division (SLED) charged Kelsey Moore with presenting a false claim for insurance with a value more than $2,000, but less than $10,000 and three counts of forgery with a value less than $10,000. The South Carolina Department of Insurance requested the SLED investigation. The case will be prosecuted by the South Carolina Department of Insurance. [Read ](https://links.naic.org/lnk/EAAACT87bxcAAc55YXoAA-s7HDgAAYKJiqUAoMjqAC9RAwBqoESke6DrIwSMS5ySJWFX5dv-AwAp8h8/27/X71DC2r9S__7_ZHjmKvEoA/aHR0cHM6Ly93d3cuc2xlZC5zYy5nb3YvYWJvdXQvdXBkYXRlcy9zbGVkLWNoYXJnZXMtZ3JlZW52aWxsZS1jb3VudHktd29tYW4taW5zdXJhbmNlLWZyYXVkLWFuZC1mb3JnZXJ5)more **DISABILITY FRAUD** **Sept. 9 – North Carolina – Charlotte woman charged with disability insurance fraud** Remonica Earl was charged with insurance fraud after submitting altered medical records to UNUM Insurance Co. for five disability claims. Earl allegedly fabricated provider details and dates of treatment from Atrium Health and OrthoCarolina to collect $6,980 in benefits. She was held on a $20,000 bond pending an upcoming appearance in district court… [Read more](https://www.ncdoi.gov/news/press-releases/2026/09/09/mecklenburg-county-woman-charged-medical-insurance-fraud) \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/f6fbd4df-0324-bd7b-d734-f4c51eace4a1.png) \| \| \|:-:\| \| [](https://us02web.zoom.us/webinar/register/WN_MYn1lWotQb-PszV3ND1lbg)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/9f139a3c-f40a-0bd8-ef8a-9e1fd64c75f2.png) \| \| \|:-:\| \| \| \| Sober home fraud exploits individuals in recovery, devastates families, and drains insurance resources through deceptive recruitment, kickbacks, and unnecessary billing. Join the Coalition for an inside look at how these schemes operate, and what it takes to dismantle them. Speakers include prosecutors from the Orange County District Attorney’s Office and Wendy McEntyre, founder of JarrodsLaw.org, offering both legal and consumer perspectives on systemic reform. Attendees will learn: - How brokering, kickbacks, and insurance abuse operate as coordinated networks - The warning signs of patient exploitation and fraudulent billing. - Investigative challenges and how advocates and law enforcement can strengthen accountability. Click on the image to register, and share this opportunity with colleagues who will benefit from attending! \| \| \|---\| \| \|---\| \| \| \| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/bb0a9596-62da-984d-f30e-3857c977bdc3.png) \| \| \|:-:\| \| [](https://members.insurancefraud.org/general/custom.asp?page=2026AnnualMeeting)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/f82089f1-d9bc-38d8-bcca-4896d3565bda.jpeg) \| \| \|:-:\| \| \| \| Preparations are underway for another engaging and informative meeting. The Coalition’s Annual Meeting brings together insurers, regulators, consumer groups, legal experts, and other groups that serve the insurance fraud fighting community. If you are serious about staying ahead of evolving fraud tactics and strengthening your impact, make plans to attend. Take the extra step to invite others in your organization whom you feel will benefit from face-to-face time with our members. We look forward to seeing you in December. \| \| \|---\| \| \|---\| \| [](https://members.insurancefraud.org/general/custom.asp?page=2026AnnualMeeting)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/5cda36ae-b990-8fa4-d6d3-20c6c3f30732.jpeg) \| \| \|:-:\| \| [](https://members.insurancefraud.org/page/advertising-annual)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/3994ef75-33c2-f036-53ee-6288594686cf.jpeg) \| \| \|:-:\| \| \| \| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/ae4500ef-da51-d597-bbb4-789dc3bf1f4f.jpeg) \| \| \|:-:\| \| \| ![](https://dim.mcusercontent.com/cs/a440c5b647697de580a2fd586/images/905b5825-1f65-3539-1c29-49f5dfad8e0a.jpeg?dpr=2&rect=0%2C23%2C600%2C581&w=600&h=581) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/1ed76ae8-8ac1-9ca0-49cc-69c0dfe872e6.png) \| \| \|:-:\| \| \| \| \| \|---\| \| \| \| \| \| \| \| \| \| \| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/c6e92a36-e798-da77-26b7-40675ed9ff90.png) \| \| \|:-:\| \| \| \| \| # Global Insurance Fraud Summit (GIFS) Heads to Panama City \| \|---\|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \| \| In October, the Global Insurance Fraud Summit (GIFS) will bring together insurance executives, regulators, law enforcement leaders, and innovators in Panama City to advance the global fight against insurance fraud. This year’s Summit will focus on Transnational Organized Crime and its growing impact on insurance and vehicle crime worldwide. Through high-level discussions and international collaboration, GIFS 2026 will explore strategies to combat increasingly organized, cross-border, and technology-enabled fraud. Flagship panels will address regulatory perspectives, law enforcement collaboration, global vehicle crime, emerging technology, and country-specific fraud trends and best practices, providing actionable intelligence and forward-looking strategies. The Coalition’s Member Relations Director Celeste Dodson will present a Coalition Overview and moderate two panels: “From Account Takeover to Organized Financial Crime” and “After the Storm: Fighting Insurance Fraud in an Era of Global Disasters”. \| \| \|---\| \| \|---\| \| \| \| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/c964bba6-7536-44cd-df8f-7e6485f7b390.png) \| \| \|:-:\| \| \| \| **Visit the Coalition’s New Anti-Fraud Legislation Tracker** \| \| \|---\| \| \|---\| \| \| \| \| \| \| \| \| \| \| \| [](https://insurancefraud.org/government-law/legislation/)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/bef375b8-2fb3-d0ea-5907-83f7f087ad20.png) \| \| \|:-:\| \| \| \| \| Powered by LexisNexis’ State Net, the upgraded tool features intuitive search tools, streamlined navigation, and clear alignment with our top policy priorities. Members can also easily find Coalition-supported bills and track active advocacy efforts. Questions? Contact [Brent Walker](mailto:brent@insurancefraud.org). Click on the image to access the tracker. \| \|---\|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \| \| \| \|---\| \| [](https://s.surveyplanet.com/bj1sw6en)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a911883f-21e6-3d6a-275f-885582442fe3.jpeg) \| \| \|:-:\| \| \| \| \| \|---\| \| [](https://members.insurancefraud.org/general/register_member_type.asp)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/b23f743e-bbd0-1730-077d-51ca64df91d1.jpeg) \| \| \|:-:\| \| \| \| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/d210adcc-cb79-3334-fc1e-f6caffd1c0f1.jpeg) \| \| \|:-:\| \| \| \| - **September 16 –** [IASIU Legal Update Webinar: Emerging Issues in Insurance Fraud & SIU Investigations](https://insurancefraud.org/event/iasiu-legal-update-webinar-emerging-issues-in-insurance-fraud-siu-investigations/) - [**September**](https://www.iii.org/press-release/press-release-triple-i-launches-insurance-affordability-index-to-provide-state-by-state-view-of-insurance-costs-and-market-conditions) **20 – 23** – [IASIU Annual Conference](https://insurancefraud.org/event/2026-iasiu-annual-conference/) - **September 23** – [CE Webinar: The Ethical Edge – Navigating Insurance Claim Investigations](https://insurancefraud.org/event/ce-webinar-the-ethical-edge-navigating-insurance-claim-investigations/) – Frasco - **September 23** – [Transport Fraud: Maritime, Trucking and Trains](https://insurancefraud.org/event/free-ce-webinar-series-transport-fraud-maritime-trucking-and-trains/) – Ethos - **September 24** – [Social Media in Investigations](https://insurancefraud.org/event/the-reality-of-using-social-media-in-investigations-2/) – Allied Universal - **September 28** – [Broker and Agent Forum](https://insurancefraud.org/event/nysifs-broker-and-agent-forum/) – NYSIF - **September 27 – 30** – [NAMIC’s 131st Annual Convention](https://insurancefraud.org/event/namics-131st-annual-convention/) - **October 11 – 14** – [2026 Global Insurance Fraud Summit](https://insurancefraud.org/event/2026-global-insurance-fraud-summit/) (GIFS) - **October 15** – [OSINT Live 2026](https://insurancefraud.org/event/osint-live-2026/) – Skopenow - **October 21** – [CE Webinar: Maximizing Returns – Strategies for Boosting Investigation Impact](https://insurancefraud.org/event/ce-webinar-maximizing-returns-strategies-for-boosting-investigation-impact/) – Frasco - **October 29** – [CE Webinar: Hitting Record – Empowering Claim Decisions with Surveillance Footage](https://insurancefraud.org/event/ce-webinar-hitting-record-empowering-claim-decisions-with-surveillance-footage/) – Frasco - **November 3** – [CE Webinar: Gathering the Facts – Ensuring Accuracy and Actionable Insights with Research Investigations](https://insurancefraud.org/event/ce-webinar-gathering-the-facts-ensuring-accuracy-and-actionable-insights-with-research-investigations/) – Frasco - **November 3** – [SCFIA Anti-Fraud Conference](https://insurancefraud.org/event/2026-scfia-anti-fraud-conference-2/) \| \| \|---\| \| \|---\| \| \| \| \| \|---\| \| \| \| **Follow Us on Our Social Media Platforms:** \| \| \|---\| \| \|---\| \| [](https://www.linkedin.com/company/coalition-against-insurance-fraud/)\| ![](https://dim.mcusercontent.com/cs/a440c5b647697de580a2fd586/images/d7ecc352-af0d-c6c0-84b7-fe66eca628c0.png?dpr=2&rect=0%2C39%2C551%2C112&w=551&h=112) \| \| \|:-:\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| \| \| \| \| \| [](https://www.facebook.com/profile.php?id=61579225779934)\| ![](https://dim.mcusercontent.com/cs/a440c5b647697de580a2fd586/images/a19e2277-53e5-5d03-770d-fa8a62202060.png?dpr=2&rect=1%2C26%2C505%2C122&w=505&h=122) \| \| \|:-:\| \| [](https://www.instagram.com/stopinsurancefraud/)\| ![](https://dim.mcusercontent.com/cs/a440c5b647697de580a2fd586/images/8da807b8-a79d-e1d1-8b42-e37bd860debd.png?dpr=2&rect=70%2C35%2C474%2C111&w=474&h=111) \| \| \|:-:\| \| \| \| \| [](https://www.insurancefraud.org)\| ![Logo](https://brand-assets.mailchimp.com/01KKVRP4PEH4PWEG0R0VSKKJ7H.png) \| \| \|:-:\| \| \| \| *Copyright (C) 2026 Coalition Against Insurance Fraud. All rights reserved.* You are receiving this email because either your organization is a member of the Coalition Against Insurance Fraud or you requested to be placed on our mailing list. Our mailing address is: Coalition Against Insurance Fraud 1012 14th St NW Ste 610 Washington, DC 20005-3424 USA Want to change how you receive these emails? You can [update your preferences](https://insurancefraud.mailchimpsites.com/manage/preferences?u=a440c5b647697de580a2fd586&id=b68dce7808&e=%5BUNIQID%5D&c=ac206dc499) or [unsubscribe](https://insurancefraud.us1.list-manage.com/unsubscribe?u=a440c5b647697de580a2fd586&id=b68dce7808&t=b&e=%5BUNIQID%5D&c=ac206dc499) \| \| \|:-:\| \| \|---\| \| \| \| \|---\| \| \|:-:\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| | |:-:| **Features:** Fraud News Weekly --- ### [Fraud News Weekly (FNW) Thursday, September 3, 2026](https://insurancefraud.org/publications/fraud-news-weekly-fnw-thursday-september-3-2026/) **Published:** September 3, 2026 **Author:** Coalition Against Insurance Fraud **Content:** Fraud News Weekly (FNW) Thursday, September 3, 2026͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ | \| \| \| \| \| \| \| [View this email in your browser](https://mailchi.mp/d46110dba684/fraud-news-weekly-friday-may-1-10704808?e=%5BUNIQID%5D) \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| \| \| \| \| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/53b00010-f0d6-2ec9-f860-f93b5bb6c5c6.png) \| \| \|:-:\| \| \| \| ***Fraud News Weekly*** **is being published early due to the holiday weekend.** \| \| \|---\| \| \|---\| \| [](https://www.insurancefraud.org)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/e438a452-a9da-fc27-8c93-aad4b329206f.jpeg) \| \| \|:-:\| \| \| \| **NAIC releases next version of AI Risk Evaluation Supplement.** The National Association of Insurance Commissioners (NAIC) Big Data and Artificial Intelligence (H) Working Group released version 5.0 of its AI Risk Evaluation Supplement this week, following a pilot involving 12 states and participating insurers. The revision adds guidance on machine learning, clarifies risk assessment and consumer impact, and updates model types, definitions and regulator questions. Fraud detection is included among uses of AI systems in operations or program areas. The Coalition attended the meeting and will monitor the next comment period and October discussion. [Read more](https://content.naic.org/sites/default/files/call_materials/materials-bdaiwg083126.pdf)… **Mississippi adopts NAIC AI model bulletin framework with state specific requirements.** Mississippi has issued [Bulletin 2026-9](https://www.mid.ms.gov/wp-content/uploads/2026/07/202609Bul.pdf), closely following the National Association of Insurance Commissioners’ (NAIC) Model Bulletin on the Use of Artificial Intelligence Systems by Insurers. Mississippi becomes the next state to implement the framework, joining about [half of the states](https://content.naic.org/sites/default/files/legal-adoption-map-ai-model-bulletin.pdf) to adopt the model. The bulletin applies Mississippi’s existing laws governing unfair trade practices, corporate governance, property and casualty rates, and market conduct to insurer use of artificial intelligence. It establishes expectations for governance, risk management, testing, documentation, and third party oversight. Fraud detection is specifically identified as an insurance use case subject to the framework. [Read more](https://aaisviews.aaisonline.com/compliance-alerts/mississippi-issues-bulletin-2026-9)... **Coalition discusses collaboration with Auto Glass Safety Council on auto glass fraud prevention.** The Coalition was invited to attend Auto Glass Week 2026 by the Auto Glass Safety Council ([AGSC](https://agsc.org/)), an accredited standards development organization focused on safe auto glass repair and replacement. AGSC President Jacques Navant presented the Coalition to the board and invited Coalition input on a new, voluntary Integrity Assurance Program for its member shops. The program aims to reduce fraudulent or inflated auto glass claims, validate legitimate repairs, improve documentation, establish defensible audit standards, and enhance transparency among insurers and service providers. The Coalition looks forward to seeing this AGSC initiative advance and encourages insurers to stay tuned. [Read more](https://autoglassweek.com/)… \| \| \|---\| \| \|---\| \| \| \| \| \| \| \| \| \| \| \| \| ![](https://dim.mcusercontent.com/cs/a440c5b647697de580a2fd586/images/383bdf26-95fb-85b7-3dc8-e7899c1250c3.jpeg?dpr=2&rect=0%2C14%2C600%2C353&w=600&h=353) \| \| \|:-:\| \| \| \| *Coalition director of government relations Brent Walker with leaders from the Auto Glass Safety Council at the premier of a documentary celebrating its 25th year.* \| \| \|---\| \| \|---\| \| \| ![](https://dim.mcusercontent.com/cs/a440c5b647697de580a2fd586/images/6d831144-7120-81c7-7d44-3dfa04f22ec7.png?dpr=2&rect=0%2C87%2C1065%2C540&w=612&h=310) \| \| \|:-:\| \| \| \| *AGSC board members: Aric Harala, Troy Mason (treasurer), Jacques Navant (president), Brent Walker, Peter Brown (vice president), Linda Rollinson, and Patricia Smiley.* \| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/639dd51a-b5ce-1b6e-db24-25b13ce6cc3f.jpeg) \| \| \|:-:\| \| \| \| **Iowa Division of Insurance Warns of Licensing Credential Theft Tied to Insurance Fraud Scheme** The Iowa Insurance Division is warning of a multistate scheme in which scammers recruit individuals to obtain insurance producer licenses, then exploit their National Producer Numbers and credentials to issue unauthorized health and life policies. The scheme can generate fraudulent commissions and federal health insurance subsidies while exposing licensed producers to liability and consumers to identity theft. The warning underscores the need for stronger credential protection, verification and reporting across insurance licensing and fraud prevention systems. [Read more…](https://content.govdelivery.com/accounts/IACIO/bulletins/427298c) [**When Storms Strike, Don’t Let Scammers Rip You Off**](https://links.naic.org/lnk/AVcAAKRXPnsAAc54KQ4AA-s7HDgAAYKJiqUAoMjqAC9RAwBqlayWO_o7ICRTRCuZaZ4E8u1nNwAp8h8/8/ge5yYDCoBUT_gMcQuzYauQ/aHR0cHM6Ly93d3cuYXZlcnlqb3VybmFsLmNvbS9uZXdzL3doZW4tc3Rvcm1zLXN0cmlrZS1kb24tdC1sZXQtc2NhbW1lcnMtcmlwLXlvdS1vZmYvYXJ0aWNsZV9iZjcyZDk5NS1kMGMxLTQ0YjEtYWYyMy1hMGE3ZGY4NDgwNTIuaHRtbA) North Carolina Insurance Commissioner Mike Causey cautions that September is only the midpoint of the hurricane season. While El Niño conditions have been primarily responsible for a “comparatively mild” tropical season, Causey notes that “\[t\]hese El Niño weather patterns won’t keep other forms of hazardous weather from occurring.” He says, “We still have our share of severe thunderstorms, with the possibility of tornadoes occurring. Wind and rain from those storms can topple trees and damage our property.” Causey explains that scammers emerge following disasters and offers several tips to help avoid being ripped off. “For homeowners trying to figure out how to recover from a disaster, this can seem overwhelming. If you’re unsure what to do or feel uneasy about an unsolicited representative, trust your instincts. Call your insurance agent. You may also call the Department of Insurance and speak to a consumer specialist,” Causey adds. \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/df2df8da-5c89-a5b8-9eb9-788eeefd0017.jpeg) \| \| \|:-:\| \| \| \| *The arrest summaries in Fraud News Weekly are compiled from publicly available news sources. Individuals mentioned are presumed innocent until proven guilty in a court of law.* \| \| \|---\| \| \|---\| \| \| \| \| \|---\| \| \| \| **HOMEOWNERS – FALSE CLAIM** **August 30 – Louisiana – Disbarred attorney charged in $2M hurricane home insurance fraud scheme** Richard Huye III was charged with conspiracy to commit wire fraud after improperly representing homeowners following Hurricane Ida. Huye sent hundreds of false representation letters to insurers while secretly acting for a roofing company. Prosecutors say his firm unauthorizedly withheld fees and deposited storm settlement checks directly into its own account… [Read more](https://www.wdsu.com/article/texas-attorney-charged-in-alleged-hurricane-ida-louisiana-insurance-fraud-scheme/73559980) **AUTO – STAGED CRASH** **August 28 – New York – Prison sentences ordered for staged car crash ringleaders; Governor Hochul cracks down on insurance fraud** Jaime Huiracocha was sentenced to a one-to-three-year prison sentence for orchestrating three staged highway car crashes as part of an insurance fraud scheme. Huiracocha recruited co-conspirators to intentionally slam on brakes or reverse into vehicles, instructing passengers to feign injuries and file fraudulent claims. Co-defendant Victor Murillo drove in the staged crashes before fleeing… [Read more](https://www.dfs.ny.gov/reports_and_publications/press_releases/pr20260827) **LIFE INSURANCE** **August 28 – Utah – Convicted murderer ordered to pay $1.3M in life insurance restitution** Kouri Richins was ordered to repay more than $1.3 million to Auto Owner’s Insurance and TruStage after her conviction for murdering her husband for financial gain. Prosecutors proved she fatally poisoned him with fentanyl to collect on his life insurance policies. Though serving life in prison, her defense requested to delay repayment during appeal… [Read more](https://www.ksl.com/article/51617525/kouri-richins-ordered-to-pay-over-13m-in-life-insurance-after-murder-conviction) **AUTO – FALSE CLAIM** **August 31 – Kansas – Woman sentenced to probation for insuring already damaged car** Amber Conner pleaded guilty to one felony count of insurance fraud after opening a new policy on a vehicle that had already been damaged in a previous event. Conner then falsely reported the loss date to trick her insurer into covering the pre-existing vehicle damage. A judge sentenced Conner to 12 months of probation, but… [Read more](https://www.wibw.com/2026/08/31/kansas-woman-gets-probation-scheme-insure-already-damaged-car/) **CONTRACTOR FRAUD** **August 31 – North Carolina – Roofing scam sting leads to guilty pleas for Charlotte brothers** Brett Bentley and Robert Bentley pleaded guilty to property damage charges after intentionally damaging a “bait house” roof to create fake repair work and support fraudulent insurance claims. Robert Bentley received 24 months probation and a total prohibition from working in the roofing industry… [Read more](https://www.wakeweekly.com/news/charlotte-brothers-plead-guilty-in-wake-county-roofing-scam-9f140806) **BUSINESS CLAIM** **Aug. 27 – North Carolina – Man charged for fake $4K restaurant cockroach insurance claim** Melvin Junior Jones was charged after falsely claiming he found two cockroaches in his food at a KFC restaurant. Jones filed an insurance claim seeking $4,000 from PMA Insurance Group. State investigators later discovered similar claims filed against Denny’s Restaurant and two Waffle House locations… [Read more](https://www.ncdoi.gov/news/press-releases/2026/08/27/warren-county-man-charged-insurance-fraud-involving-restaurant-claims) \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/f6fbd4df-0324-bd7b-d734-f4c51eace4a1.png) \| \| \|:-:\| \| [](https://us02web.zoom.us/webinar/register/WN_MYn1lWotQb-PszV3ND1lbg)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/9f139a3c-f40a-0bd8-ef8a-9e1fd64c75f2.png) \| \| \|:-:\| \| \| \| Sober home fraud exploits individuals in recovery, devastates families, and drains insurance resources through deceptive recruitment, kickbacks, and unnecessary billing. Join the Coalition for an inside look at how these schemes operate, and what it takes to dismantle them. Speakers include prosecutors from the Orange County District Attorney’s Office and Wendy McEntyre, founder of JarrodsLaw.org, offering both legal and consumer perspectives on systemic reform. Attendees will learn: - How brokering, kickbacks, and insurance abuse operate as coordinated networks - The warning signs of patient exploitation and fraudulent billing. - Investigative challenges and how advocates and law enforcement can strengthen accountability. Register using the link below and share this opportunity with colleagues who will benefit from attending! \| \| \|---\| \| \|---\| \| \| \| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/ae4500ef-da51-d597-bbb4-789dc3bf1f4f.jpeg) \| \| \|:-:\| \| [](https://members.insurancefraud.org/general/custom.asp?page=2026AnnualMeeting)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/f82089f1-d9bc-38d8-bcca-4896d3565bda.jpeg) \| \| \|:-:\| \| \| \| Preparations are underway for another engaging and informative meeting. The Coalition’s Annual Meeting brings together insurers, regulators, consumer groups, legal experts, and other groups that serve the insurance fraud fighting community. If you are serious about staying ahead of evolving fraud tactics and strengthening your impact, make plans to attend. Take the extra step to invite others in your organization whom you feel will benefit from face-to-face time with our members. We look forward to seeing you in December. \| \| \|---\| \| \|---\| \| \| \| \| \|---\| \| \| ![](https://dim.mcusercontent.com/cs/a440c5b647697de580a2fd586/images/3dd7efe1-525c-25a7-7f57-c867556b8abe.png?dpr=2&rect=0%2C22%2C1404%2C475&w=626&h=212) \| \| \|:-:\| \| \| \| \| \| \| \| \| \| \| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/495b0645-8189-be7c-8508-0e7359c6970d.jpeg) \| \| \|:-:\| \| \| \| \| # Louisiana Office of the State Fire Marshal \| \|---\|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \| \| The Louisiana Office of the State Fire Marshal’s Fire Investigations Unit (FIU) protects citizens and property through statewide commissioned law enforcement investigators. These agents determine fire origins and causes, assess criminal responsibility, and respond to both active scenes and referrals from partner agencies like the Louisiana Department of Insurance. To combat insurance crime, the FIU is upgrading its technological capabilities and training. Investigators now utilize the ISO system’s Anti-Fraud One (AF1) platform to research suspicious claims, trace connections to past losses, and initiate proactive inquiries into potential fraud. Additionally, the unit is enhancing its capacity to analyze digital evidence, a crucial asset in unraveling complex financial crimes. By deepening partnerships with insurance professionals, local law enforcement, and prosecutors, the FIU pools resources to track fraudulent activity effectively. These ongoing investments empower the unit to uncover illicit operations, build stronger cases, and hold offenders accountable across the state. \| \| \|---\| \| \|---\| \| \| \| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/c964bba6-7536-44cd-df8f-7e6485f7b390.png) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7ab8f3b9-e95a-c777-4118-cd73c219eafc.jpeg) \| \| \|:-:\| \| \| \| A new white paper from the Coalition reveals how criminals use AI personas and deepfakes to pass remote job interviews and infiltrate insurance organizations from within. By securing internal roles, these bad actors gain unauthorized access to sensitive policyholder data, steal corporate assets, and deploy malware. To combat these financial, operational, and regulatory risks, the report details actionable strategies for improving remote identity verification, detecting deepfakes, strengthening post-hire monitoring, and sharing cross-industry intelligence. Member organizations can download the full report: “[***Employment Infiltration: How Synthetic Identities and Deepfakes Are Threatening the Insurance Industry From Within.***](https://insurancefraud.org/wp-content/uploads/08-2026-Employment-Infiltration_-How-synthetic-identities-and-deepfakes-are-threatening-the-insurance-industry-from-within.pdf)***”*** \| \| \|---\| \| \|---\| \| \| \| \| \|---\| \| [](https://s.surveyplanet.com/bj1sw6en)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a911883f-21e6-3d6a-275f-885582442fe3.jpeg) \| \| \|:-:\| \| \| \| \| \|---\| \| [](https://members.insurancefraud.org/general/register_member_type.asp)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/b23f743e-bbd0-1730-077d-51ca64df91d1.jpeg) \| \| \|:-:\| \| \| \| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/d210adcc-cb79-3334-fc1e-f6caffd1c0f1.jpeg) \| \| \|:-:\| \| \| \| - **September 8 –** [California Public Adjusters: What They Can and Cannot Do](https://insurancefraud.org/event/3rd-quarter-2026-virtual-training-california-public-adjusters-what-they-can-and-cannot-do/) – AFA - **September 9** – [Medical Canvassing: Unlocking Treatment History](https://insurancefraud.org/event/webinar-medical-canvassing/) – Ethos - **September 10** – [Social Media in Investigations](https://insurancefraud.org/event/the-reality-of-using-social-media-in-investigations/) – Allied Universal - **September 10** – [Avoid the Newest Online Scams with Tips from NACA Experts](https://insurancefraud.org/event/avoid-the-newest-online-scams-with-tips-from-naca-experts/) – Consumer Action - **September 20 – 23** – [IASIU Annual Conference](https://insurancefraud.org/event/2026-iasiu-annual-conference/) - **September 24** – [Social Media in Investigations](https://insurancefraud.org/event/the-reality-of-using-social-media-in-investigations-2/) – Allied Universal - **September 27 – 30** – [NAMIC’s 131st Annual Convention](https://insurancefraud.org/event/namics-131st-annual-convention/) \| \| \|---\| \| \|---\| \| \| \| \| \|---\| \| \| \| **Follow Us on Our Social Media Platforms:** \| \| \|---\| \| \|---\| \| [](https://www.linkedin.com/company/coalition-against-insurance-fraud/)\| ![](https://dim.mcusercontent.com/cs/a440c5b647697de580a2fd586/images/d7ecc352-af0d-c6c0-84b7-fe66eca628c0.png?dpr=2&rect=0%2C39%2C551%2C112&w=551&h=112) \| \| \|:-:\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| \| \| \| \| \| [](https://www.facebook.com/profile.php?id=61579225779934)\| ![](https://dim.mcusercontent.com/cs/a440c5b647697de580a2fd586/images/a19e2277-53e5-5d03-770d-fa8a62202060.png?dpr=2&rect=1%2C26%2C505%2C122&w=505&h=122) \| \| \|:-:\| \| [](https://www.instagram.com/stopinsurancefraud/)\| ![](https://dim.mcusercontent.com/cs/a440c5b647697de580a2fd586/images/8da807b8-a79d-e1d1-8b42-e37bd860debd.png?dpr=2&rect=70%2C35%2C474%2C111&w=474&h=111) \| \| \|:-:\| \| \| \| \| [](https://www.insurancefraud.org)\| ![Logo](https://brand-assets.mailchimp.com/01KKVRP4PEH4PWEG0R0VSKKJ7H.png) \| \| \|:-:\| \| \| \| *Copyright (C) 2026 Coalition Against Insurance Fraud. All rights reserved.* You are receiving this email because either your organization is a member of the Coalition Against Insurance Fraud or you requested to be placed on our mailing list. Our mailing address is: Coalition Against Insurance Fraud 1012 14th St NW Ste 610 Washington, DC 20005-3424 USA Want to change how you receive these emails? You can [update your preferences](https://insurancefraud.mailchimpsites.com/manage/preferences?u=a440c5b647697de580a2fd586&id=b68dce7808&e=%5BUNIQID%5D&c=1e7bc11f4f) or [unsubscribe](https://insurancefraud.us1.list-manage.com/unsubscribe?u=a440c5b647697de580a2fd586&id=b68dce7808&t=b&e=%5BUNIQID%5D&c=1e7bc11f4f) \| \| \|:-:\| \| \|---\| \| \| \| \|---\| \| \|:-:\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| | |:-:| **Features:** Fraud News Weekly --- ### [Fraud News Weekly (FNW) Friday, August 28, 2026](https://insurancefraud.org/publications/fraud-news-weekly-fnw-friday-august-28-2026/) **Published:** August 28, 2026 **Author:** Coalition Against Insurance Fraud **Content:** Fraud News Weekly (FNW) Friday, August 28, 2026͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ | \| \| \| \| \| \| \| [View this email in your browser](https://mailchi.mp/c727e9e517d0/fraud-news-weekly-friday-may-1-10704767?e=%5BUNIQID%5D) \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| \| \| \| \| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/3e8916ec-1db7-6019-9e1f-33c01b6e1bd8.jpeg) \| \| \|:-:\| \| [](https://www.insurancefraud.org)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/e438a452-a9da-fc27-8c93-aad4b329206f.jpeg) \| \| \|:-:\| \| \| \| **Texas directs insurance department to create Insurance Fraud Task Force.** Governor Greg Abbott has directed the Texas Department of Insurance (TDI) to take several actions aimed at making property and casualty insurance more affordable, including creating an Insurance Fraud Task Force to address fraud that increases costs for consumers. TDI has also been directed to study excessive, unnecessary and inflated claims costs in the commercial auto, personal auto and homeowners markets. The agency must recommend additional administrative and statutory changes by Sept. 14. The Coalition recently met with TDI Commissioner Amanda Crawford at the NAIC Summer National Meeting, remains engaged with the TDI Fraud Unit, and will be available to assist TDI as needed. [Read more](https://gov.texas.gov/news/post/governor-abbott-directs-tdi-to-take-action-to-make-property-insurance-more-affordable)… **Louisiana enacts two insurance fraud related regulatory changes.** In August, the Louisiana Department of Insurance enacted [Regulation 138](https://ldi.la.gov/docs/default-source/documents/legaldocs/regulations/lr/regulation-138-final-lr-august-2026), requiring liability premium discounts for commercial vehicles equipped with dashboard cameras paired with telematics. The regulation aims to enhance public safety, reduce insurance fraud and lower claim costs by encouraging technology that documents driving behavior and crash events. For fraud investigators, video and telematics data can provide useful evidence in staged crashes and questionable claims. LDI also enacted [Rule 13](https://ldi.la.gov/docs/default-source/documents/legaldocs/rules/lr/rule-13-final-lr-august-2026), requiring fees collected for insurance fraud investigations to remain in the dedicated fund account at the end of each fiscal year. [Read more](https://ldi.la.gov/docs/default-source/documents/legaldocs/regulations/lr/regulation-138-final-lr-august-2026)… **Washington insurance commissioner highlights organized treatment fraud through ‘Shuffle’ screening.** Last week, Washington Insurance Commissioner Patty Kuderer hosted a free screening of *Shuffle*, an award winning documentary examining organized addiction treatment fraud and its impact on people and insurers. The film follows individuals caught in schemes that cycle patients through treatment facilities for profit. The discussion also highlighted increasingly sophisticated insurance fraud and proposed legislation to strengthen the Washington Office of the Insurance Commissioner’s fraud fighting capabilities. The event underscores the growing connection between organized fraud, health care abuse and consumer harm. [Read more](https://www.insurance.wa.gov/about-us/current-initiatives/community-connect)… \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/639dd51a-b5ce-1b6e-db24-25b13ce6cc3f.jpeg) \| \| \|:-:\| \| \| \| **Chuck Myers Appointed as Chief Deputy Commissioner of the North Carolina Department of Insurance** North Carolina Insurance Commissioner Mike Causey has appointed Chuck Myers as the new chief deputy commissioner of the North Carolina Department of Insurance, effective October 1. Myers succeeds Jackie Obusek, who is retiring after 30 years with the department. Myers brings extensive experience in insurance regulation, accounting, and law enforcement, including over 20 years as a licensed insurance agent, a former role as a special agent accountant for the Virginia State Police, and a recent three-and-a-half-year tenure as deputy commissioner for the Louisiana Department of Insurance, where he oversaw the Office of Property and Casualty. Both Causey and Myers expressed enthusiasm for the appointment, highlighting Myers’s qualifications to help drive the department’s mission of protecting consumers and combating fraud. [Read more](https://www.captiveinternational.com/north-carolina-doi-names-new-chief-deputy-commissioner)… \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/df2df8da-5c89-a5b8-9eb9-788eeefd0017.jpeg) \| \| \|:-:\| \| \| \| *The arrest summaries in Fraud News Weekly are compiled from publicly available news sources. Individuals mentioned are presumed innocent until proven guilty in a court of law.* \| \| \|---\| \| \|---\| \| \| \| \| \|---\| \| \| \| **PROPERTY & CASUALTY – TITLE INSURANCE** **August 21 – California – Financier arrested for nearly $100M bank and title insurance fraud** Mahender Makhijani faces federal bank fraud charges after allegedly manipulating real estate loan positions. Controlled through Cantor Group V LLC, Makhijani and a subordinate used editing software to alter legitimate title insurance policies to falsify first-lien priority. The bank relied on these falsified policies to advance funds until detecting metadata tampering on… [Read more](https://newsantaana.com/orange-county-financier-arrested-in-nearly-100-million-bank-fraud-scheme/) **AUTO – UNDERWRITING** **August 24 – Florida – $206K premium refund scheme leads to arrest in luxury vehicle insurance fraud** Adam Otrok was arrested in Broward County for submitting 41 fraudulent insurance applications for luxury vehicles using fake identification details. He issued stop-payment orders on underfunded accounts while demanding full cash refunds on premiums before the insurer detected invalid payments. Authorities confirmed he stole $44,704 before… [Read more](https://www.news4jax.com/news/local/2026/08/24/florida-man-arrested-in-206k-luxury-vehicle-insurance-fraud-scheme/) **HOMEOWNERS – ARSON** **Aug. 25 – Louisiana – Columbia woman arrested for intentionally setting house fire in insurance fraud scheme** Cynthia Lisenby faces one count of insurance fraud after Louisiana State Fire Marshal deputies determined a early morning house fire was intentionally set to defraud an insurance provider. Firefighters responded to the June blaze on Templeton Bend Road, which completely destroyed the residence. State investigators arrested Lisenby following a multi-week probe that revealed the destruction was part of a planned scheme to… [Read more](https://www.knoe.com/2026/08/25/columbia-woman-arrested-insurance-fraud-caldwell-parish-arson-investigation/) **AGENT MISCONDUCT** **August 21 – Virginia – Former insurance agent pleads guilty after pocketing $164K in premium payments** Thomas Hoyt pleaded guilty to wire fraud after stealing client premium payments intended for insurance carriers and selling a fraudulent book of business. Hoyt diverted funds to his personal bank account, leaving multiple clients without valid coverage while falsely assuring them their policies were active. The scheme unravelled when an independent agency purchased his business and discovered a significant number of policies had lapsed or… [Read more ](https://www.justice.gov/usao-edva/pr/former-insurance-agent-pleads-guilty-wire-fraud) **HOMEOWNERS – FALSE CLAIM** **Aug. 20 – Georgia – Dunwoody man charged after fake bank statement triggers $18K insurance fraud probe** Darrion Lucius faces fraud and forgery charges after submitting a counterfeit bank statement to back an $18,000 burglary claim with Lemonade Insurance. State officials launched an investigation after the digital insurer’s automated screening system flagged the forged paperwork. The inquiry led authorities to issue arrest warrants that remained open until police… [Read more](https://hoodline.com/2026/08/atlanta-man-accused-of-faking-bank-statement-to-cash-in-18k-fraud-claim/) \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/f6fbd4df-0324-bd7b-d734-f4c51eace4a1.png) \| \| \|:-:\| \| [](https://us02web.zoom.us/webinar/register/WN_MYn1lWotQb-PszV3ND1lbg)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/9f139a3c-f40a-0bd8-ef8a-9e1fd64c75f2.png) \| \| \|:-:\| \| \| \| Sober home fraud exploits individuals in recovery, devastates families, and drains insurance resources through deceptive recruitment, kickbacks, and unnecessary billing. Join the Coalition for an inside look at how these schemes operate, and what it takes to dismantle them. Speakers include prosecutors from the Orange County District Attorney’s Office and Wendy McEntyre, founder of JarrodsLaw.org, offering both legal and consumer perspectives on systemic reform. Attendees will learn: - How brokering, kickbacks, and insurance abuse operate as coordinated networks - The warning signs of patient exploitation and fraudulent billing. - Investigative challenges and how advocates and law enforcement can strengthen accountability. Register using the link below and share this opportunity with colleagues who will benefit from attending! \| \| \|---\| \| \|---\| \| \| \| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/ae4500ef-da51-d597-bbb4-789dc3bf1f4f.jpeg) \| \| \|:-:\| \| \| ![](https://dim.mcusercontent.com/cs/a440c5b647697de580a2fd586/images/3dd7efe1-525c-25a7-7f57-c867556b8abe.png?dpr=2&rect=0%2C22%2C1404%2C475&w=626&h=212) \| \| \|:-:\| \| \| \| \| \| \| \| \| \| \| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a6979290-6563-157b-22ca-0bade3d31adc.png) \| \| \|:-:\| \| \| \| \| # Indiana Department of Insurance Consumer Protection Unit \| \|---\|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \| \| The Indiana Department of Insurance Consumer Protection Unit informs and protects consumers by ensuring licensed companies and producers comply with state insurance laws. Operating through its Consumer Services, Enforcement, and Title Divisions, the unit assists with policy inquiries and resolves complaints across all insurance types. The unit investigates statutory violations and addresses non-compliance through administrative actions, negotiations, or voluntary agreements. To operate in Indiana, agents and firms must maintain active licenses and adhere to state regulations. While the department lacks statutory authority to prosecute criminal fraud directly, it actively monitors for suspicious activity and collaborates with law enforcement and state agencies to boost fraud detection and prosecution. Administrative penalties for non-compliant entities include civil fines, compliance orders, and severe licensing sanctions such as suspension, revocation, or refusal to renew certificates of authority. \| \| \|---\| \| \|---\| \| \| ![](https://dim.mcusercontent.com/cs/a440c5b647697de580a2fd586/images/8795712d-2810-b11a-3eab-4ef792d002d2.png?dpr=2&rect=0%2C87%2C951%2C301&w=612&h=193) \| \| \|:-:\| \| \| \| \| \| \| We value your partnership in the fight against insurance fraud and appreciate your contributions to the Coalition. If your circumstances have changed and your organization is no longer able to maintain membership for the following calendar year, please advise us by the deadline. Our bylaws require formal written notice by Sept. 1, 2026, to cancel membership for 2027. To discuss your membership status or submit a notice, contact Kendra Smith at <memberservices@insurancefraud.org>. 2027 invoices will be sent early December. \| \| \|---\| \| \|---\| \| \| \| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \| ![](https://dim.mcusercontent.com/cs/a440c5b647697de580a2fd586/images/07a5c411-a1c7-d260-5c57-a6edf6fd418d.png?dpr=2&rect=0%2C72%2C2007%2C576&w=612&h=175) \| \| \|:-:\| \| \| \| **THREE DAYS LEFT!** The Coalition invites you to submit nominations for a long-standing tradition of the annual **Prosecutor of the Year**. Our past winners have convicted serial fraudsters and dismantled fraud rings involving more than $500 million. We are looking for the next impactful story! - [Submission Criteria](https://members.insurancefraud.org/general/custom.asp?page=prosecutor-of-the-year): Use this [form](https://members.insurancefraud.org/page/prosecutor-of-the-year-form) to nominate outstanding individual prosecutors or dedicated teams at the federal, state, or local level. - **Submission Deadline: September 1** \| \| \|---\| \| \|---\| \| \| \| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a5a4ce02-56c9-e1e8-9189-d63330ffdabd.jpeg) \| \| \|:-:\| \| \| \| \| \|---\| \| [](https://s.surveyplanet.com/bj1sw6en)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a911883f-21e6-3d6a-275f-885582442fe3.jpeg) \| \| \|:-:\| \| \| \| \| \|---\| \| [](https://members.insurancefraud.org/general/register_member_type.asp)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/b23f743e-bbd0-1730-077d-51ca64df91d1.jpeg) \| \| \|:-:\| \| \| \| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/d210adcc-cb79-3334-fc1e-f6caffd1c0f1.jpeg) \| \| \|:-:\| \| \| \| - **August 30 – September 4** – [74th Annual IAATI/ATPA Vehicle Crimes Conference](https://insurancefraud.org/event/74th-annual-iaati-atpa-vehicle-crimes-training-conference/) - **September 1** – [Your Phone Isn’t Listening. It’s Talking](https://insurancefraud.org/event/investigative-intelligence-in-action-session-1-your-phone-isnt-listening-its-talking/) – Lemieux & Associates - **September 8 –** [California Public Adjusters: What They Can and Cannot Do](https://insurancefraud.org/event/3rd-quarter-2026-virtual-training-california-public-adjusters-what-they-can-and-cannot-do/) – AFA - **September 9** – [Medical Canvassing: Unlocking Treatment History](https://insurancefraud.org/event/webinar-medical-canvassing/) – Ethos - **September 10** – [Social Media in Investigations](https://insurancefraud.org/event/the-reality-of-using-social-media-in-investigations/) – Allied Universal - **September 10** – [Avoid the Newest Online Scams with Tips from NACA Experts](https://insurancefraud.org/event/avoid-the-newest-online-scams-with-tips-from-naca-experts/) – Consumer Action - **September 20 – 23** – [IASIU Annual Conference](https://insurancefraud.org/event/2026-iasiu-annual-conference/) - **September 24** – [Social Media in Investigations](https://insurancefraud.org/event/the-reality-of-using-social-media-in-investigations-2/) – Allied Universal - **September 27 – 30** – [NAMIC’s 131st Annual Convention](https://insurancefraud.org/event/namics-131st-annual-convention/) \| \| \|---\| \| \|---\| \| \| \| \| \|---\| \| \| \| **Follow Us on Our Social Media Platforms:** \| \| \|---\| \| \|---\| \| [](https://www.linkedin.com/company/coalition-against-insurance-fraud/)\| ![](https://dim.mcusercontent.com/cs/a440c5b647697de580a2fd586/images/d7ecc352-af0d-c6c0-84b7-fe66eca628c0.png?dpr=2&rect=0%2C39%2C551%2C112&w=551&h=112) \| \| \|:-:\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| \| \| \| \| \| [](https://www.facebook.com/profile.php?id=61579225779934)\| ![](https://dim.mcusercontent.com/cs/a440c5b647697de580a2fd586/images/a19e2277-53e5-5d03-770d-fa8a62202060.png?dpr=2&rect=1%2C26%2C505%2C122&w=505&h=122) \| \| \|:-:\| \| [](https://www.instagram.com/stopinsurancefraud/)\| ![](https://dim.mcusercontent.com/cs/a440c5b647697de580a2fd586/images/8da807b8-a79d-e1d1-8b42-e37bd860debd.png?dpr=2&rect=70%2C35%2C474%2C111&w=474&h=111) \| \| \|:-:\| \| \| \| \| [](https://www.insurancefraud.org)\| ![Logo](https://brand-assets.mailchimp.com/01KKVRP4PEH4PWEG0R0VSKKJ7H.png) \| \| \|:-:\| \| \| \| *Copyright (C) 2026 Coalition Against Insurance Fraud. All rights reserved.* You are receiving this email because either your organization is a member of the Coalition Against Insurance Fraud or you requested to be placed on our mailing list. Our mailing address is: Coalition Against Insurance Fraud 1012 14th St NW Ste 610 Washington, DC 20005-3424 USA Want to change how you receive these emails? You can [update your preferences](https://insurancefraud.mailchimpsites.com/manage/preferences?u=a440c5b647697de580a2fd586&id=b68dce7808&e=%5BUNIQID%5D&c=1d939c5159) or [unsubscribe](https://insurancefraud.us1.list-manage.com/unsubscribe?u=a440c5b647697de580a2fd586&id=b68dce7808&t=b&e=%5BUNIQID%5D&c=1d939c5159) \| \| \|:-:\| \| \|---\| \| \| \| \|---\| \| \|:-:\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| | |:-:| **Features:** Fraud News Weekly --- ### [Fraud News Weekly (FNW) Friday, August 21, 2026](https://insurancefraud.org/publications/fraud-news-weekly-fnw-friday-august-21-2026/) **Published:** August 21, 2026 **Author:** Coalition Against Insurance Fraud **Content:** Fraud News Weekly (FNW) Friday, August 14, 2026͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ | \| \| \| \| \| \| \| [View this email in your browser](https://mailchi.mp/078357a21c86/fraud-news-weekly-friday-may-1-10704743?e=%5BUNIQID%5D) \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| \| \| \| \| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/55dfc9f2-3931-056b-f213-bc8bf7f6814e.jpeg) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/e438a452-a9da-fc27-8c93-aad4b329206f.jpeg) \| \| \|:-:\| \| \| \| **California SIU Annual Report training scheduled for Sept. 2.** The California Department of Insurance will host a virtual workshop Sept. 2 to review the new portal and reporting requirements for the 2025 Special Investigative Unit (SIU) Annual Report. The electronic filing deadline is 11:59 p.m. Pacific time Sept. 15. For the prior year reporting period, the Department will require only SIU organizational charts and, when applicable, the SIU Structure Matrix for contracted entities. The workshop will also provide an opportunity to submit questions to SIU Compliance Unit staff. [Register here](https://us06web.zoom.us/meeting/register/Ly_WD2Y-QK68L2KWLdO8pg#/registration)… **Indiana Department of Insurance joins Coalition, bringing all 50 state insurance departments into membership.** The Indiana Department of Insurance has joined the Coalition. As the final state to join, insurance departments from all 50 states are now Coalition members. Indiana Insurance Commissioner Holly Williams Lambert leads the department, including its Consumer Protection Unit and Enforcement Division. Key contacts from those divisions will begin participating in the Coalition’s State Fraud Directors Subcommittee, creating another avenue for states to share fraud fighting practices and challenges. Commissioner Lambert also recently met with the Coalition during a [NAIC Consumer Participation Program](https://content.naic.org/consumer/consumer-participation-program) virtual meeting. The timing of their joining is important as Indiana [House Bill 1260](https://iga.in.gov/legislative/2026/bills/house/1260/details), became effective July 1. The new law strengthens insurance fraud reporting requirements and protects good faith reporting in that state. [Read more](https://www.in.gov/idoi/enforcement/)… **California insurance fraud grant hearing highlights oversight and funding concerns.** The California Department of Insurance held an Aug. 17 public hearing on proposed regulations to standardize and modernize its insurance fraud grant programs. The Coalition attended virtually to monitor the proceeding. Prosecutors raised concerns that proposed Section 2698.59E, which would allow warning letters and corrective action plans based on downward statistical trends, could add administrative burdens and legal risks. Insurer feedback, provided to the Coalition, similarly supports effective oversight, with an emphasis on measurable outcomes, funding flexibility and directing assessment dollars toward programs producing strong fraud fighting results. [Read more](https://insurancefraud.org/wp-content/uploads/CDI-Ins-Fraud-Grant-Standardization-2026.pdf)… \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/639dd51a-b5ce-1b6e-db24-25b13ce6cc3f.jpeg) \| \| \|:-:\| \| \| \| **Growing Account Takeover Threat Draws Strong Industry Response** More than 600 registered and nearly 450 attended the Coalition’s ***“Account Takeover Risks & Best Practices”*** webinar Aug. 20. Pilotbird founder Evgeny Aleksandrov moderated a panel featuring Julia Senn of State Farm, Carlota Balet of Allianz Life, and Matt Mortvedt of the Iowa Insurance Fraud Bureau. They examined common schemes, changing criminal tactics, potential solutions and lessons from recent incidents. Coalition members can access the recording next week under Member Resources. A member login is required. Share this with colleagues to support training and awareness. **Iowa Insurance Department Stopping Suspicious Transactions;** **Law Protects Elders from Financial Fraud** Iowa seniors have an added layer of security for their hard-earned retirement savings under a new state law designed to combat financial exploitation. The legislation empowers financial advisors and insurance providers to temporarily pause suspicious transactions involving life insurance policies and annuities, giving them up to 15 business days to investigate red flags, notify trusted contacts, or alert state authorities before funds are lost. Through targeted regulatory efforts and rapid intervention protocols, the Iowa Insurance Division has been actively shutting down fraud before funds leave accounts, safeguarding millions of dollars in retirement savings and delivering tangible, high-impact security to older adults across the state. In 2025, the Iowa Insurance Division and financial professionals stopped $2.59 million from reaching scammers after flagging 42 suspicious securities transactions, every single one confirmed to be active financial exploitation. Through joint enforcement efforts with law enforcement, the Division also recovered over $1.13 million for Iowa fraud victims. [Read more](https://www.kimt.com/news/new-iowa-law-shields-seniors-from-financial-fraud-starting-july-1/article_9a76f969-26bf-4abf-ba13-e6a188747beb.html)… **Insurance Fraud: How to Avoid Becoming a Victim** Frank Sztuk, public information chair of the New York Alliance Against Insurance Fraud, shares practical tips with WABC. Documenting details and leveraging technology after an accident, such as calling the police, photographing damage, and noting the number of vehicle occupants, helps protect honest consumers and prevents fraud. [Read more](https://abc7ny.com/post/insurance-fraud-how-avoid-becoming-victim-local-spotlight/19692401/)… \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/df2df8da-5c89-a5b8-9eb9-788eeefd0017.jpeg) \| \| \|:-:\| \| \| \| *The arrest summaries in Fraud News Weekly are compiled from publicly available news sources. Individuals mentioned are presumed innocent until proven guilty in a court of law.* \| \| \|---\| \| \|---\| \| \| \| \| \|---\| \| \| \| **AUTO INSURANCE** **August 19 – Maryland – Former police officer sentenced for role in auto insurance fraud scheme** Michael Owen, Jr. was sentenced to six months in federal prison for falsifying records to assist fellow police officers in submitting fraudulent vehicle claims to USAA, Liberty Mutual Insurance, and GEICO. The conspirators wrote fictitious police reports to help offload unwanted vehicles, prompting insurers to pay out over $56,000 on fake thefts and staged vandalism… [Read more](https://www.justice.gov/usao-md/pr/former-prince-georges-county-police-officer-sentenced-connection-insurance-fraud-scheme) **HEALTHCARE** **August 17 – Ohio – Pepper Pike man pleads guilty in $1.4B healthcare fraud scheme** Eldar Zarbavel pleaded guilty to laundering $3.4 million in stolen Medicare and private health insurance funds through regional bank accounts. The international scheme submitted $1.42 billion in false medical equipment claims through a company Zarbavel managed. Investigators discovered Zarbavel bypassed bank internal controls using false corporate records to funnel the proceeds into overseas… [Read more](https://www.thecentersquare.com/ohio/article_75cd4d25-1cdc-4591-9520-6ca1c440251b.html) **LIFE INSURANCE** **August 18 – North Carolina – Former insurance executive faces $1.6B restitution order following federal fraud conviction** Greg Lindberg lost an appeal to stay a $1.6 billion restitution order tied to a $2 billion scheme that targeted several life insurers, including Southland National Insurance Corp. and Colorado Bankers Life Insurance Co. The former mogul siphoned millions of dollars through fraudulent loans to buy luxury assets, forgiving more than $125 million in personal debts before… [Read more](https://insurancenewsnet.com/innarticle/court-losses-bring-greg-lindberg-fraud-victims-closer-to-restitution) \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/ae4500ef-da51-d597-bbb4-789dc3bf1f4f.jpeg) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/3b2dfe80-574d-ba4c-36fd-c15f209a8d76.jpeg) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/18da62b9-4a6f-43e5-314b-69ef4ac7e804.jpeg) \| \| \|:-:\| \| \| \| \| \|---\| \| \| \| \| \| \| \| \| \| \| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/1227fda0-9ed9-4068-fe81-acfc2543ad5f.jpeg) \| \| \|:--\| \| \| \| \| **Michelle Rafeld Joins Consumer Action Board of Directors** \| \|---\|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \| \| Coalition Executive Director Michelle Rafeld was named to the Board of Directors of Consumer Action this week. Using multilingual consumer education materials, community outreach and issue-focused advocacy, Consumer Action empowers low- and moderate-income, limited-English-speaking and other underrepresented consumers nationwide to financially prosper through education and advocacy. Consumer Action also serves on the Coalition’s Executive Committee through its executive director, Anna Flores, reflecting the groups’ shared commitment to consumer education, advocacy and protection from financial harm. *“I’m honored to join Consumer Action’s Board,”* Rafeld said. *“I look forward to working with fellow board members to advance its mission and further strengthen its partnership with the Coalition.”* To learn more about Consumer Action and its work, visit [www.consumer-action.org](http://www.consumer-action.org/). \| \| \|---\| \| \|---\| \| \| \| \| \|---\| \| \| ![](https://dim.mcusercontent.com/cs/a440c5b647697de580a2fd586/images/1bd8ffce-a0a2-d8f0-c234-56af917ce3b2.jpeg?dpr=2&rect=0%2C6%2C600%2C180&w=600&h=180) \| \| \|:-:\| \| \| \| The Coalition will launch its ‘2026 State of Insurance Fraud Technology Study’ in September with the assistance of Shift Technology, the sponsor of the study. Now in its seventh edition, the 2026 study will provide a comprehensive view of how insurers are using antifraud technology, the strategies supporting fraud detection and the capabilities they plan to strengthen. It will also examine emerging trends, operational challenges and future priorities shaping the industry’s use of technology to combat fraud. Insurer participation is critical to the study’s success. Insurers will be able to participate anonymously, and findings will be reported in aggregate. Each response will provide a clearer picture of how antifraud technology is being used across the industry, identify shared challenges and emerging priorities, and strengthen the report as a credible benchmarking resource. The Coalition encourages insurers of all sizes and lines of business to participate. Instructions and additional details will be coming soon. \| \| \|---\| \| \|---\| \| \| ![](https://dim.mcusercontent.com/cs/a440c5b647697de580a2fd586/images/07a5c411-a1c7-d260-5c57-a6edf6fd418d.png?dpr=2&rect=0%2C72%2C2007%2C576&w=612&h=175) \| \| \|:-:\| \| \| \| **TWO WEEKS LEFT!** The Coalition invites you to submit nominations for a long-standing tradition of the annual **Prosecutor of the Year**. Our past winners have convicted serial fraudsters and dismantled fraud rings involving more than $500 million. We are looking for the next impactful story! - [Submission Criteria](https://members.insurancefraud.org/general/custom.asp?page=prosecutor-of-the-year): Use this [form](https://members.insurancefraud.org/page/prosecutor-of-the-year-form) to nominate outstanding individual prosecutors or dedicated teams at the federal, state, or local level. - **Submission Deadline: September 1** \| \| \|---\| \| \|---\| \| \| \| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a5a4ce02-56c9-e1e8-9189-d63330ffdabd.jpeg) \| \| \|:-:\| \| \| \| \| \|---\| \| [](https://s.surveyplanet.com/bj1sw6en)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a911883f-21e6-3d6a-275f-885582442fe3.jpeg) \| \| \|:-:\| \| \| \| \| \|---\| \| [](https://members.insurancefraud.org/general/register_member_type.asp)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/b23f743e-bbd0-1730-077d-51ca64df91d1.jpeg) \| \| \|:-:\| \| \| \| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/d210adcc-cb79-3334-fc1e-f6caffd1c0f1.jpeg) \| \| \|:-:\| \| \| \| - **August 30 – September 4** – [74th Annual IAATI/ATPA Vehicle Crimes Conference](https://insurancefraud.org/event/74th-annual-iaati-atpa-vehicle-crimes-training-conference/) - **September 10** – [Social Media in Investigations](https://insurancefraud.org/event/the-reality-of-using-social-media-in-investigations/) – Allied Universal - **September 20 – 23** – [IASIU Annual Conference](https://insurancefraud.org/event/2026-iasiu-annual-conference/) - **September 24** – [Social Media in Investigations](https://insurancefraud.org/event/the-reality-of-using-social-media-in-investigations-2/) – Allied Universal - **September 27 – 30** – [NAMIC’s 131st Annual Convention](https://insurancefraud.org/event/namics-131st-annual-convention/) \| \| \|---\| \| \|---\| \| \| \| \| \|---\| \| \| \| **Follow Us on Our Social Media Platforms:** \| \| \|---\| \| \|---\| \| [](https://www.linkedin.com/company/coalition-against-insurance-fraud/)\| ![](https://dim.mcusercontent.com/cs/a440c5b647697de580a2fd586/images/d7ecc352-af0d-c6c0-84b7-fe66eca628c0.png?dpr=2&rect=0%2C39%2C551%2C112&w=551&h=112) \| \| \|:-:\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| \| \| \| \| \| [](https://www.facebook.com/profile.php?id=61579225779934)\| ![](https://dim.mcusercontent.com/cs/a440c5b647697de580a2fd586/images/a19e2277-53e5-5d03-770d-fa8a62202060.png?dpr=2&rect=1%2C26%2C505%2C122&w=505&h=122) \| \| \|:-:\| \| [](https://www.instagram.com/stopinsurancefraud/)\| ![](https://dim.mcusercontent.com/cs/a440c5b647697de580a2fd586/images/8da807b8-a79d-e1d1-8b42-e37bd860debd.png?dpr=2&rect=70%2C35%2C474%2C111&w=474&h=111) \| \| \|:-:\| \| \| \| \| \| ![Logo](https://brand-assets.mailchimp.com/01KKVRP4PEH4PWEG0R0VSKKJ7H.png) \| \| \|:-:\| \| \| \| *Copyright (C) 2026 Coalition Against Insurance Fraud. All rights reserved.* You are receiving this email because either your organization is a member of the Coalition Against Insurance Fraud or you requested to be placed on our mailing list. Our mailing address is: Coalition Against Insurance Fraud 1012 14th St NW Ste 610 Washington, DC 20005-3424 USA Want to change how you receive these emails? You can [update your preferences](https://insurancefraud.mailchimpsites.com/manage/preferences?u=a440c5b647697de580a2fd586&id=b68dce7808&e=%5BUNIQID%5D&c=f6ba1b9b15) or [unsubscribe](https://insurancefraud.us1.list-manage.com/unsubscribe?u=a440c5b647697de580a2fd586&id=b68dce7808&t=b&e=%5BUNIQID%5D&c=f6ba1b9b15) \| \| \|:-:\| \| \|---\| \| \| \| \|---\| \| \|:-:\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| | |:-:| **Features:** Fraud News Weekly --- ### [Fraud News Weekly (FNW) Friday, August 14, 2026](https://insurancefraud.org/publications/fraud-news-weekly-fnw-friday-august-14-2026/) **Published:** August 14, 2026 **Author:** Coalition Against Insurance Fraud **Content:** Fraud News Weekly (FNW) Friday, August 14, 2026͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ | \| \| \| \| \| \| \| [View this email in your browser](https://mailchi.mp/ff0c9c9a4457/fraud-news-weekly-friday-may-1-10704719?e=%5BUNIQID%5D) \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| \| \| \| \| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/c1a1299a-f343-1a15-9423-558b58ae82ac.png) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/0c2401e8-ae3e-c72f-38a3-7a802c835a05.png) \| \| \|:-:\| \| \| \| **Eighth Circuit sends Iowa public adjuster case back for further review.** The Eighth Circuit upheld Iowa’s public adjuster licensing laws but said the case must continue to determine whether Iowa improperly restricted a contractor’s communications with consumers. The dispute involves Shamrock Hills, LLC, which challenged Iowa’s limits on what contractors can say and do when helping customers with insurance claims. The court noted that public adjusting involves more than speech, including evaluating coverage, assessing damage and preparing estimates. The court also cited *Texas Department of Insurance v. Stonewater Roofing*, where NAPIA and the Coalition previously advocated for public adjuster licensing and consumer protections. [Read more](https://www.courthousenews.com/wp-content/uploads/2026/08/shamrock-hills-v-iowa-eighth-circuit-decision.pdf)… **Massachusetts prohibits insurance policies from restricting use of public adjusters.** Governor Maura Healey signed Senate Bill 785 into law Aug. 7, adding new requirements governing property and casualty insurance policies. The law prohibits insurers, including non-admitted and surplus lines insurers, from including policy language, forms or endorsements that prohibit an insured from hiring, retaining, engaging, utilizing, consulting or contracting with a public insurance adjuster as a condition of recovering under the policy. It also classifies such provisions as an unfair insurance practice under Massachusetts law. [Read more](https://malegislature.gov/Bills/194/S785)… **Coalition leaders advance fraud prevention at NAIC meeting.** Michelle Rafeld and Brent Walker represented the Coalition at the National Association of Insurance Commissioners (NAIC) Summer National Meeting, Aug. 11-15 in Columbus, Ohio. Throughout the event, they pushed key education and advocacy priorities, met with state insurance regulators, spoke to NAIC working groups, and connected with prospective members and partners. Rafeld briefed the Pre-Disaster Mitigation and Risk Modeling (EX) Working Group on shifting fraud risks linked to severe weather. Speaking to the Producer Licensing Task Force, she highlighted new schemes targeting the licensing process and urged regulators to treat licensing as a critical line of defense against fraud. During a closed session of the Commissioners’ Roundtable, Rafeld called on leaders to make fraud prevention an industrywide strategic priority backed by modern tools, stronger collaboration, and dedicated resources. Walker represented the Coalition before the Consumer Liaison, as an appointed NAIC consumer representative, sharing the fraud risks associated with unclaimed property in the life and annuity space. Walker also commented during the Privacy Protections (H) Working Group, focusing on balancing consumer data privacy protections with the appropriate antifraud exemptions. His participation ensures anti-fraud considerations remain central to state regulatory and public policy discussions. Rafeld and Walker also gave a Coalition update to the Antifraud (D) Task Force, including the release of new sober home fraud brochures that state regulators may use for consumer protection. \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/1f3bb500-cfa3-84c3-d35e-75de1be2fec0.png) \| \| \|:-:\| \| \| \| **NICB Analysis Shows Significant Decline in Recreational Vehicle Thefts** According to a new report from the National Insurance Crime Bureau (NICB), recreational vehicle thefts dropped 20% in 2025 to nearly 59,000 reported stolen units, including motorcycles, ATVs, snowmobiles, and watercraft. However, recovery rates have become a growing concern, with roughly 63% of stolen vehicles remaining unrecovered. Motorcycles made up over three-quarters of all thefts, while ATVs suffered the worst recovery rate at just 23%. Because these vehicles are valuable and easily portable, NICB officials emphasize that owners should utilize layered anti-theft measures, secure storage, and detailed record-keeping, while stressing that reporting thefts immediately to law enforcement offers the best chance of recovery within the critical two-week window. [Read more](https://www.nicb.org/news/news-releases/recreational-vehicle-thefts-declined-2025-most-remain-unrecovered)… \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/f32efd68-e5b9-df90-ba9a-8905b2da867c.png) \| \| \|:-:\| \| \| \| *The arrest summaries in Fraud News Weekly are compiled from publicly available news sources. Individuals mentioned are presumed innocent until proven guilty in a court of law.* \| \| \|---\| \| \|---\| \| \| \| \| \|---\| \| \| \| **AGENT MISCONDUCT** **August 11 – Alabama – Insurance agent sentenced for $30K federal crop insurance fraud** Jonathan Eubanks, a Slocomb insurance agent, was sentenced to 18 months in federal prison for crop insurance fraud. Eubanks forged a farmer’s signature and created a fake email to secure policy coverage from the Federal Crop Insurance Corporation. The scheme collapsed after investigators discovered his email listed a Saturday date that Eubanks claimed was a Tuesday… [Read more](https://www.justice.gov/usao-mdal/pr/geneva-county-insurance-agent-sentenced-falsifying-federal-crop-insurance-application) **HOMEOWNERS – FALSE CLAIM** **Aug. 11 – Kansas – Johnson County woman sentenced to 24 months probation for insurance fraud** Jinky Alcantara was sentenced to 24 months of supervised probation and assessed $500 in fines after pleading guilty to felony insurance fraud. Investigators found that Alcantara submitted false invoices to her insurer for a burglary claim to secure financial gain. Court records reveal the fraudulent documents were uncovered during… [Read more](https://www.wibw.com/2026/08/11/woman-sentenced-24-months-probation-insurance-fraud-case/) **AUTO – FALSE CLAIM** **August 4 – Maryland – Leonardtown man charged in $6,600 auto insurance fraud scheme** Damont Barnes was charged with felony theft and identity fraud after using another driver’s GEICO policy to submit $6,600 in fake auto claims. Barnes filed false reports for two collisions, causing the victim’s monthly insurance premium to increase significantly. Investigators uncovered the scheme after analyzing voice recordings, fraudulent receipts, and undamaged vehicle photos… [Read more](https://thebaynet.com/leonardtown-man-charged-in-alleged-6600-auto-insurance-fraud-scheme/) [**AUTO – FALSE CLAIM**](https://doi.idaho.gov/pressrelease/man-pleads-guilty-after-fraudulent-80000-dental-claim-exposed/) [**August 11 – Idaho – Man sentenced after submitting $80K false auto insurance dental claim**](https://doi.idaho.gov/pressrelease/man-pleads-guilty-after-fraudulent-80000-dental-claim-exposed/) Jeremy Antone pleaded guilty in Kootenai County to insurance fraud after filing an $80,000 claim with Sentry Insurance Company. Antone claimed an auto collision knocked out all of his teeth. However, state investigators discovered his dental issues were preexisting, leading a judge to impose a five-year suspended prison sentence… [Read more](https://doi.idaho.gov/pressrelease/man-pleads-guilty-after-fraudulent-80000-dental-claim-exposed/) **CONTRACTOR FRAUD** **August 11 – North Carolina – Subcontractor charged with felony for submitting fraudulent insurance certificate** Charles Edwards IV faces a felony charge of obtaining property by false pretense after submitting a fake insurance certificate. State investigators accuse him of presenting the fraudulent document to general contractor Tru-Co Inc. to obtain subcontracting work in New Bern. Authorities later arrested Edwards, who was released under a $10,000 unsecured bond… [Read more](https://wcti12.com/news/local/new-bern-man-charged-with-felony-in-insurance-fraud-investigation) \| \| \|---\| \| \|---\| \| \| ![](https://dim.mcusercontent.com/cs/a440c5b647697de580a2fd586/images/2caf4788-5ba5-cab4-c031-ec437d009492.png?dpr=2&rect=0%2C0%2C988%2C114&w=612&h=71) \| \| \|:-:\| \| [](https://us02web.zoom.us/webinar/register/WN_KXQ05407Qg2qUIFJ0XE7Cg#/registration)\| ![](https://dim.mcusercontent.com/cs/a440c5b647697de580a2fd586/images/6e66f996-ff80-a089-f708-fa735167bed5.png?dpr=2&rect=0%2C20%2C843%2C829&w=612&h=602) \| \| \|:-:\| \| \| \| Join us as we examine the increase in account takeover attempts, the schemes fraudsters commonly use, the warning signs to watch for, and best practices for combating account takeover fraud. Information shared will benefit all Coalition members, including insurers, regulators, law enforcement agencies, consumer organizations, and antifraud service providers. \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/1ffe4a96-de6f-7aa1-0f83-cec8bfb9b249.png) \| \| \|:-:\| \| \| \| **Track insurance fraud bills as they happen** \| \| \|---\| \| \|---\| \| \| \| The Coalition’s Anti-Fraud Legislation Tracker has been revamped to give members visibility into state and federal legislative activity. Powered by LexisNexis’ State Net, the upgraded tool features intuitive search tools, streamlined navigation, and clear alignment with our top policy priorities. Members can also easily find Coalition-supported bills and track active advocacy efforts. Fresh off a preview with our Government Affairs Committee, the tracker is live to help you stay ahead of policy changes. Questions? Contact [Brent Walker](mailto:brent@insurancefraud.org). Click on the image to access the tracker. \| \| \|---\| \| \|---\| \| [](https://insurancefraud.org/government-law/legislation/)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/bef375b8-2fb3-d0ea-5907-83f7f087ad20.png) \| \| \|:-:\| \| \| \| \| \|---\| \| \| \| \| \| \| \| \| \| \| \| \| \| **New Consumer Brochures Available to Help Combat Sober Home Fraud and Body Brokering** \| \| \|---\| \| \|---\| \| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/3b034e08-4eda-424b-6cda-6d2e21b740fc.png) \| \|---\|---\| \| \|:-:\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \| \| \| \| \| \| \| \| \| \| \| \| To help combat sober home and addiction treatment fraud, the Coalition has created two new consumer brochures: one for individuals seeking care and one for their families. Available under the [**Consumer Resources**](https://insurancefraud.org/sober-home-fraud-body-brokering-resources/) tab on our website, these brochures detail common warning signs, critical questions to ask, and tips for finding safe, reliable treatment. - **Flexible Formats:** Available in digital versions for electronic sharing and print-ready versions that members can co-brand with their own logo. - **How to Help:** Download and share these resources with your communications teams and other colleagues who can help reach policyholders, employees, community partners and the public. \| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \| \| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7ae894ca-d4a9-ad6a-9b44-d621c43376af.png) \| \| \|:-:\| \| \| ![](https://dim.mcusercontent.com/cs/a440c5b647697de580a2fd586/images/8795712d-2810-b11a-3eab-4ef792d002d2.png?dpr=2&rect=0%2C87%2C951%2C301&w=612&h=193) \| \| \|:-:\| \| \| \| We value your partnership in the fight against insurance fraud and appreciate your contributions to the Coalition. If your circumstances have changed and your organization is no longer able to maintain membership for the following calendar year, please advise us by the deadline. Our bylaws require formal written notice by Sept. 1, 2026, to cancel membership for 2027. To discuss your membership status or submit a notice, contact Kendra Smith at <memberservices@insurancefraud.org>. 2027 invoices will be sent early December. \| \| \|---\| \| \|---\| \| \| \| \| \|---\| \| \| ![](https://dim.mcusercontent.com/cs/a440c5b647697de580a2fd586/images/07a5c411-a1c7-d260-5c57-a6edf6fd418d.png?dpr=2&rect=0%2C72%2C2007%2C635&w=612&h=193) \| \| \|:-:\| \| \| \| The Coalition invites you to submit nominations for a long-standing tradition of the annual **Prosecutor of the Year**. Our past winners have convicted serial fraudsters and dismantled fraud rings involving more than $500 million. We are looking for the next impactful story! - [Submission Criteria](https://members.insurancefraud.org/general/custom.asp?page=prosecutor-of-the-year): Use this [form](https://members.insurancefraud.org/page/prosecutor-of-the-year-form) to nominate outstanding individual prosecutors or dedicated teams at the federal, state, or local level. - **Submission Deadline: September 1** \| \| \|---\| \| \|---\| \| \| \| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/ba8442dc-6d3e-f5cb-a9db-cc5ce107d6c3.png) \| \| \|:-:\| \| \| \| \| \|---\| \| [](https://s.surveyplanet.com/bj1sw6en)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/d0b048d2-a961-e385-14cd-46ecbc552cea.png) \| \| \|:-:\| \| \| \| \| \|---\| \| [](https://members.insurancefraud.org/general/register_member_type.asp)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/35c0a4f3-d5a8-6156-bbcf-9e3b94bceb36.png) \| \| \|:-:\| \| \| \| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/78293987-c284-f808-311d-6b5145fef4e1.png) \| \| \|:-:\| \| \| \| - **August 30 – September 4** – [74th Annual IAATI/ATPA Vehicle Crimes Conference](https://insurancefraud.org/event/74th-annual-iaati-atpa-vehicle-crimes-training-conference/) - **September 20 – 23** – [IASIU Annual Conference](https://insurancefraud.org/event/2026-iasiu-annual-conference/) - **September 27 – 30** – [NAMIC’s 131st Annual Convention](https://insurancefraud.org/event/namics-131st-annual-convention/) \| \| \|---\| \| \|---\| \| \| \| \| \|---\| \| \| \| **Follow Us on Our Social Media Platforms:** \| \| \|---\| \| \|---\| \| [](https://www.linkedin.com/company/coalition-against-insurance-fraud/)\| ![](https://dim.mcusercontent.com/cs/a440c5b647697de580a2fd586/images/d7ecc352-af0d-c6c0-84b7-fe66eca628c0.png?dpr=2&rect=0%2C39%2C551%2C112&w=551&h=112) \| \| \|:-:\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| \| \| \| \| \| [](https://www.facebook.com/profile.php?id=61579225779934)\| ![](https://dim.mcusercontent.com/cs/a440c5b647697de580a2fd586/images/a19e2277-53e5-5d03-770d-fa8a62202060.png?dpr=2&rect=1%2C26%2C505%2C122&w=505&h=122) \| \| \|:-:\| \| [](https://www.instagram.com/stopinsurancefraud/)\| ![](https://dim.mcusercontent.com/cs/a440c5b647697de580a2fd586/images/8da807b8-a79d-e1d1-8b42-e37bd860debd.png?dpr=2&rect=70%2C35%2C474%2C111&w=474&h=111) \| \| \|:-:\| \| \| \| \| \| ![Logo](https://brand-assets.mailchimp.com/01KKVRP4PEH4PWEG0R0VSKKJ7H.png) \| \| \|:-:\| \| \| \| *Copyright (C) 2026 Coalition Against Insurance Fraud. All rights reserved.* You are receiving this email because either your organization is a member of the Coalition Against Insurance Fraud or you requested to be placed on our mailing list. Our mailing address is: Coalition Against Insurance Fraud 1012 14th St NW Ste 610 Washington, DC 20005-3424 USA Want to change how you receive these emails? You can [update your preferences](https://insurancefraud.mailchimpsites.com/manage/preferences?u=a440c5b647697de580a2fd586&id=b68dce7808&e=%5BUNIQID%5D&c=aec91af2bf) or [unsubscribe](https://insurancefraud.us1.list-manage.com/unsubscribe?u=a440c5b647697de580a2fd586&id=b68dce7808&t=b&e=%5BUNIQID%5D&c=aec91af2bf) \| \| \|:-:\| \| \|---\| \| \| \| \|---\| \| \|:-:\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| | |:-:| **Features:** Fraud News Weekly --- ### [Fraud News Weekly (FNW) Friday, August 7, 2026](https://insurancefraud.org/publications/fraud-news-weekly-fnw-friday-august-7-2026/) **Published:** August 7, 2026 **Author:** Coalition Against Insurance Fraud **Content:** Fraud News Weekly (FNW) Friday, August 7, 2026New Technology Task Force; Legislative Tracker Launched͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ | \| \| \| \| \| \| \| [View this email in your browser](https://mailchi.mp/1d9bcc77ab38/fraud-news-weekly-friday-may-1-10704704?e=%5BUNIQID%5D) \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| \| \| \| \| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/b44ca1ee-8c4f-f13c-a86f-197de5d2ba3f.png) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/0c2401e8-ae3e-c72f-38a3-7a802c835a05.png) \| \| \|:-:\| \| \| \| **Kansas Department of Insurance annual report highlights growing investment in antifraud efforts.** The Kansas Department of Insurance’s [2025 Annual Report](https://www.insurance.kansas.gov/home/showdocument?id=5401&t=639209262608651540) highlights the state’s continued investment in antifraud efforts. The Department has noted a steady increase in insurance fraud referrals each year since 2021. Automobile fraud accounts for 51% of insurance fraud cases investigated, followed by other insurance fraud at 18%, health and life at 14%, homeowners at 12% and property at 5%. Commissioner Vicki Schmidt has continued to propose legislation creating more tools for the Department to fight fraud. Most recently, this included the enacted House Bill 2323, which the Coalition helped support and which strengthens the Commissioner’s ability to fight insurance fraud. [Read more](https://www.insurance.kansas.gov/Home/Components/News/News/296/16?widgetId=41)… **Federal commercial vehicle staged crash bill gains Senate companion.** U.S. [Senate Bill 5058](http://congress.gov/bill/119th-congress/senate-bill/5058/all-info?__cf_chl_tk=RCcVTYQAnTPcMem9DCrz6GWiz1aHuHQvtinUgl04TMU-1785264811-1.0.1.1-1m9vZNzU5dUxR3M6hNKv5.JakVkhLOtjk5Me1RW0u.M) would make intentionally staging a crash involving a commercial truck a federal crime, expanding momentum behind legislation the Coalition supported in 2025. Last summer, the Coalition joined the National Insurance Crime Bureau (NICB) and the International Association of Special Investigation Units (IASIU) in urging Congress to advance the House companion bill, H.R. 2662, and support creation of a U.S. Department of Homeland Security staged accident task force. [Read more](https://www.insurancebusinessmag.com/us/news/auto-motor/senate-bill-would-make-staged-truck-crash-fraud-a-federal-crime-583774.aspx)… **New Jersey Supreme Court expands Consumer Fraud Act liability for insurance producers.** The New Jersey Supreme Court ruled that insurance brokers, producers, and agents are not exempt from liability under the state’s Consumer Fraud Act based on the judicially created “semi-professional” exception. The decision allows Consumer Fraud Act claims involving alleged deceptive or unconscionable conduct in the sale of insurance products to proceed and may affect producer sales practices, compliance, litigation, and regulatory oversight. The impact of the decision will depend on how lower courts apply the precedent in future cases. [Read more](https://www.insurancejournal.com/news/east/2026/07/16/877800.htm)… **Coalition launches new Anti-Fraud Legislation Tracker with real time legislative updates.** To improve member value, the Coalition has launched its redesigned Anti-Fraud Legislation Tracker, giving members real time access to the latest insurance fraud legislation across all states and Congress. Powered by State Net from LexisNexis, the enhanced platform offers improved functionality, intuitive search tools, and legislation organized around the Coalition’s [legislative priorities](https://insurancefraud.org/legislative-priorities/). Members also can identify Coalition supported legislation and monitor advocacy efforts when applicable. The tracker debuted this week during the Government Affairs Committee meeting, where committee members provided valuable feedback to help refine the member experience before the broader rollout. [Take a look](https://insurancefraud.org/government-law/legislation/)… \| \| \|---\| \| \|---\| \| \| ![](https://dim.mcusercontent.com/cs/a440c5b647697de580a2fd586/images/5efc6b71-8f60-4490-1969-37ef1f7739ad.png?dpr=2&rect=10%2C8%2C381%2C470&w=381&h=470) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/1f3bb500-cfa3-84c3-d35e-75de1be2fec0.png) \| \| \|:-:\| \| \| \| **Coalition International Partner Shares Crash for Cash Scheme in UK** Coalition international partner, City of London Police, has issued a warning to drivers about increasingly aggressive “crash for cash” scams, which put motorists at risk of both insurance fraud and identity theft. Over the last five years, the Insurance Fraud Enforcement Department (IFED) has investigated more than £25.3 million in suspected cases, with approximately 75 percent involving staged or induced collisions. Scammers are using tactics like targeting lone drivers with staged moped collisions, inflating repair bills through dishonest garages, and pressuring victims at the roadside to allow photos of their driving licenses. To stay safe, drivers are urged to install dash cams for objective video evidence, avoid making roadside payments, and remember that while insurance and contact details must be exchanged after a collision, there is no legal obligation to show or share a driving license. [Read more](https://www.cityoflondon.police.uk/news/city-of-london/news/2026/august/driver-warning-issued-as-crash-for-cash-evolves-and-puts-identity-data-at-risk/)… **Should Auto Insurers Bundle Fraud Protection?** In a recent Forbes Business Council article, Matt Cullina of TransUnion suggests that auto insurers should start bundling personal cyber and fraud protection into standard vehicle policies to counter the surge in digital identity theft and scams. Highlighting that 26 percent of U.S. consumers lost money to digital fraud in late 2025 alone, Cullina explains that connected vehicles and telematics have blurred the line between physical and digital driving risks, especially with personal data frequently left vulnerable in smart cars. By embedding personal cyber coverage into routine auto policies rather than selling standalone plans, insurers can bridge the consumer awareness gap, differentiate their offerings in a market where shopping rates are rising, and build stronger customer retention. [Read more](https://www.forbes.com/councils/forbesbusinesscouncil/2026/08/05/why-auto-insurers-should-start-offering-fraud-protection/)… \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/f32efd68-e5b9-df90-ba9a-8905b2da867c.png) \| \| \|:-:\| \| \| \| *The arrest summaries in Fraud News Weekly are compiled from publicly available news sources. Individuals mentioned are presumed innocent until proven guilty in a court of law.* \| \| \|---\| \| \|---\| \| \| \| \| \|---\| \| \| \| **HEALTHCARE FRAUD** **August 4 – District of Columbia – WMATA train operator sentenced to two years in prison for $362K AFLAC insurance fraud scheme** Michelle Shropshire, a Washington Metropolitan Area Transit Authority (WMATA) train operator, was sentenced to two years in prison for defrauding AFLAC of $362,035. Shropshire fabricated medical records and forged doctor signatures to submit false disability claims for herself and fellow transit employees. She collected 20% kickbacks from each fraudulent payout while her co-conspirators continued working… [Read more](https://www.justice.gov/usao-dc/pr/wmata-train-operator-sentenced-four-year-scheme-defraud-aflac-insurance-more-360000) **HEALTHCARE FRAUD** **August 6 – North Carolina – Jonesville woman charged in $123K health insurance fraud scheme** Melissa Mountzoures was charged with submitting 17 fraudulent medical claims totaling $123,056 to Blue Cross Blue Shield of North Carolina. Investigators found she forged claim records for treatment from four medical providers, though three of the doctor names were completely fabricated. The single real physician listed confirmed no medical care was ever provided… [Read more](https://ourdavie.com/2026/08/06/jonesville-woman-charged-in-100000-insurance-fraud-scheme/) **AGENT MISCONDUCT** **July 31 – Maryland – Former insurance agent sentenced to jail for fraud, again** A Baltimore County judge sentenced Michael C. Okolo of Pikesville to six months incarceration for 10 counts of insurance fraud for acting as an insurance agent without a license. With an already revoked license, Okolo used Wise Money Group to sell 11 annuities, pocketing $88,000 in commissions. Following release, he faces three years of probation where any violation could trigger 14 additional years behind bars… [Read more ](https://www.insurancejournal.com/news/east/2026/07/31/879797.htm) **AUTO – FALSE CLAIM** **July 31 – South Carolina – Myrtle Beach business owner charged in $38K glass replacement fraud scheme** Christopher Angulo faces charges for submitting 31 fake claims to Allstate and Progressive Insurance for auto glass work that never occurred. The South Carolina Law Enforcement Division (SLED) investigated Safe Pro Auto Glass after receiving a request from state regulators. The state agency will handle the prosecution… [Read more](https://www.wmbfnews.com/2026/07/31/sled-horry-county-business-owner-charged-with-insurance-fraud/) \| \| \|---\| \| \|---\| \| \| ![](https://dim.mcusercontent.com/cs/a440c5b647697de580a2fd586/images/2caf4788-5ba5-cab4-c031-ec437d009492.png?dpr=2&rect=0%2C0%2C988%2C114&w=612&h=71) \| \| \|:-:\| \| [](https://us02web.zoom.us/webinar/register/WN_KXQ05407Qg2qUIFJ0XE7Cg#/registration)\| ![](https://dim.mcusercontent.com/cs/a440c5b647697de580a2fd586/images/6e66f996-ff80-a089-f708-fa735167bed5.png?dpr=2&rect=0%2C20%2C843%2C829&w=612&h=602) \| \| \|:-:\| \| \| \| Join us as we examine the increase in account takeover attempts, the schemes fraudsters commonly use, the warning signs to watch for, and best practices for combating account takeover fraud. Information shared will benefit all Coalition members, including insurers, regulators, law enforcement agencies, consumer organizations, and antifraud service providers. \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7ae894ca-d4a9-ad6a-9b44-d621c43376af.png) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/02098796-31c3-fb57-64da-1f0c145dd487.png) \| \| \|:-:\| \| \| \| The Coalition is launching a new Technology Task Force on Sept. 15. Members will address emerging technology-enabled fraud risks, antifraud tools, operational practices, and legal and compliance requirements while developing practical resources for Coalition members and consumers. **Watch for more details in a member alert next week.** If you’d like to join, contact [memberservices@insurancefraud.org](mailto:memberservices@insurancefraud.org?subject=&body=). \| \| \|---\| \| \|---\| \| \| \| \| \|---\| \| \| ![](https://dim.mcusercontent.com/cs/a440c5b647697de580a2fd586/images/c03f5497-bcdf-0364-db8b-56d0b7a660ae.png?dpr=2&rect=6%2C7%2C769%2C759&w=607&h=598) \| \| \|:-:\| \| \| \| \| \|---\| \| \| ![](https://dim.mcusercontent.com/cs/a440c5b647697de580a2fd586/images/07a5c411-a1c7-d260-5c57-a6edf6fd418d.png?dpr=2&rect=0%2C72%2C2007%2C635&w=612&h=193) \| \| \|:-:\| \| \| \| The Coalition invites you to submit nominations for a long-standing tradition of the annual **Prosecutor of the Year**. Our past winners have convicted serial fraudsters and dismantled fraud rings involving more than $500 million. We are looking for the next impactful story! - [Submission Criteria](https://members.insurancefraud.org/general/custom.asp?page=prosecutor-of-the-year); Use this [form](https://members.insurancefraud.org/page/prosecutor-of-the-year-form) to nominate outstanding individual prosecutors or dedicated teams at the federal, state, or local level. - **Submission Deadline: September 1** \| \| \|---\| \| \|---\| \| \| \| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/ba8442dc-6d3e-f5cb-a9db-cc5ce107d6c3.png) \| \| \|:-:\| \| \| \| \| \|---\| \| [](https://s.surveyplanet.com/bj1sw6en)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/d0b048d2-a961-e385-14cd-46ecbc552cea.png) \| \| \|:-:\| \| \| \| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/3b819528-59bc-4b07-2a29-6aef082babc9.png) \| \| \|:-:\| \| \| \| \| \| \| \| \| \| \| \| \| \| - Check your spam or promotions folder and mark us as “safe.” - Add Coalition@insurancefraud.org to your contacts or address book. Most email filters treat known contacts as trusted. - Open, click, and occasionally reply to our emails. Engagement signals to filters that the mail is legitimate. \| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \| \| \| \|---\| \| [](https://members.insurancefraud.org/general/register_member_type.asp)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/35c0a4f3-d5a8-6156-bbcf-9e3b94bceb36.png) \| \| \|:-:\| \| \| \| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/78293987-c284-f808-311d-6b5145fef4e1.png) \| \| \|:-:\| \| \| \| - **August 12** – [Psychosocial Risk: The Next Wave of Workers’ Comp Complexity ](https://insurancefraud.org/event/free-ce-webinar-series-psychosocial-risk-the-next-wave-of-workers-comp-complexity/)– Ethos - **August 30 – September 4** – [74th Annual IAATI/ATPA Vehicle Crimes Conference](https://insurancefraud.org/event/74th-annual-iaati-atpa-vehicle-crimes-training-conference/) - **September 20 – 23** – [IASIU Annual Conference](https://insurancefraud.org/event/2026-iasiu-annual-conference/) - **September 27 – 30** – [NAMIC’s 131st Annual Convention](https://insurancefraud.org/event/namics-131st-annual-convention/) \| \| \|---\| \| \|---\| \| \| \| \| \|---\| \| \| \| **Follow Us on Our Social Media Platforms:** \| \| \|---\| \| \|---\| \| [](https://www.linkedin.com/company/coalition-against-insurance-fraud/)\| ![](https://dim.mcusercontent.com/cs/a440c5b647697de580a2fd586/images/d7ecc352-af0d-c6c0-84b7-fe66eca628c0.png?dpr=2&rect=0%2C39%2C551%2C112&w=551&h=112) \| \| \|:-:\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| \| \| \| \| \| [](https://www.facebook.com/profile.php?id=61579225779934)\| ![](https://dim.mcusercontent.com/cs/a440c5b647697de580a2fd586/images/a19e2277-53e5-5d03-770d-fa8a62202060.png?dpr=2&rect=1%2C26%2C505%2C122&w=505&h=122) \| \| \|:-:\| \| [](https://www.instagram.com/stopinsurancefraud/)\| ![](https://dim.mcusercontent.com/cs/a440c5b647697de580a2fd586/images/8da807b8-a79d-e1d1-8b42-e37bd860debd.png?dpr=2&rect=70%2C35%2C474%2C111&w=474&h=111) \| \| \|:-:\| \| \| \| \| \| ![Logo](https://brand-assets.mailchimp.com/01KKVRP4PEH4PWEG0R0VSKKJ7H.png) \| \| \|:-:\| \| \| \| *Copyright (C) 2026 Coalition Against Insurance Fraud. All rights reserved.* You are receiving this email because either your organization is a member of the Coalition Against Insurance Fraud or you requested to be placed on our mailing list. Our mailing address is: Coalition Against Insurance Fraud 1012 14th St NW Ste 610 Washington, DC 20005-3424 USA Want to change how you receive these emails? You can [update your preferences](https://insurancefraud.mailchimpsites.com/manage/preferences?u=a440c5b647697de580a2fd586&id=b68dce7808&e=%5BUNIQID%5D&c=a3ccf72ebc) or [unsubscribe](https://insurancefraud.us1.list-manage.com/unsubscribe?u=a440c5b647697de580a2fd586&id=b68dce7808&t=b&e=%5BUNIQID%5D&c=a3ccf72ebc) \| \| \|:-:\| \| \|---\| \| \| \| \|---\| \| \|:-:\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| | |:-:| **Features:** Fraud News Weekly --- ### [Fraud News Weekly (FNW) Friday, July 31, 2026](https://insurancefraud.org/publications/fraud-news-weekly-fnw-friday-july-31-2026/) **Published:** August 2, 2026 **Author:** Coalition Against Insurance Fraud **Content:** Fraud News Weekly (FNW) – Friday, July 31, 2026͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ | \| \| \| \| \| \| \| [View this email in your browser](https://mailchi.mp/b6239e25d057/fraud-news-weekly-friday-may-1-10704658?e=%5BUNIQID%5D) \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| \| \| \| \| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/643300c7-9871-8057-85f6-7a6abcd92289.png) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/0c2401e8-ae3e-c72f-38a3-7a802c835a05.png) \| \| \|:-:\| \| \| \| **NAIC advances AI risk evaluation supplement and governance discussions.** The National Association of Insurance Commissioners (NAIC) Big Data and Artificial Intelligence (H) [Working Group](https://content.naic.org/committees/h/big-data-artificial-intelligence-wg) continued discussions on insurer AI governance, with the Coalition attending the virtual meeting, last week. The group renamed its AI Systems Evaluation Tool pilot as the AI Risk Evaluation Supplement, with 12 states testing the framework and additional public input expected before possible adoption this fall. Discussions highlighted the importance of transparency, data quality, bias controls, explainability, and human oversight. These issues have direct implications for Special Investigation Units, fraud analysts, and antifraud technology providers as insurers expand AI use in claims, fraud detection, and consumer interactions while regulators focus on accountability and consumer protection. [Read more](https://content.naic.org/sites/default/files/call_materials/Materials-Big-Data-AI-WG072226_0.pdf)… **New York expands law enforcement training to combat auto insurance fraud.** New York Gov. Kathy Hochul recently announced that nearly 270 law enforcement officials from 55 agencies participated in specialized training on auto insurance fraud and related financial crimes at the New York State Police Academy. The training, led by the New York State Police and Department of Financial Services (DFS), is intended to improve the ability of investigators and local law enforcement to detect, investigate and prosecute insurance fraud schemes. DFS Acting Superintendent Kaitlin Asrow said, “*DFS is proud to partner with the New York State Police and law enforcement agencies statewide to advance Governor Hochul’s mission to crack down on insurance fraud that increases insurance costs for drivers. Today’s training strengthens our efforts to hold criminals accountable and reduce insurance premiums for New Yorkers*.” The initiative reflects New York’s broader focus on reducing fraud-driven insurance costs and builds on recent antifraud measures that the Coalition actively supported. [Read more](https://www.dfs.ny.gov/reports_and_publications/press_releases/pr20260722)… **Coalition participates in Restoration Industry Association ethics initiatives.** The Coalition participated in a recent Restoration Industry Association (RIA) carrier representatives meeting that focused on advancing ethics and professional standards within the restoration industry. Discussions highlighted a new interactive RIA ethics training program, broader educational partnerships, and opportunities for collaboration on fraud awareness and industry best practices. The meeting also identified opportunities for the Coalition to share insurance fraud expertise through training, podcasts, and executive roundtables. The Coalition applauds professional organizations like RIA that are strengthening ethics, education, and consumer trust across the insurance claims process. [Read more](https://www.restorationindustry.org/RIA-code-of-ethics)… **Minnesota Court of Appeals upholds insurance fraud conviction and recognizes consumer cost of fraud.** The Minnesota Court of Appeals upheld an insurance fraud conviction in *State v. Jenni*, reinforcing a key message long advanced by the Coalition and the insurance industry: insurance fraud harms consumers by increasing costs. The court found testimony about the prevalence and financial impact of fraud provided proper context and ruled prosecutors may explain that fraud costs are ultimately borne by policyholders without making an improper appeal to jurors. The decision strengthens fraud investigations and prosecutions by validating consumer harm as a legitimate framework for explaining why insurance fraud matters. [Read more…](https://www.jdsupra.com/legalnews/minnesota-court-of-appeals-upholds-6332669/) \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/1f3bb500-cfa3-84c3-d35e-75de1be2fec0.png) \| \| \|:-:\| \| \| \| **Florida Chief Financial Officer Blaise Ingoglia Praised for 600 Insurance Fraud Arrests** Sheriffs from across Florida gathered at Trump National Doral on Tuesday to discuss recent arrests. Miami-Dade County Sheriff Rosie Cordero-Stutz, Polk County Sheriff Grady Judd, and Putnam County Sheriff Homer “Gator” DeLoach were joined by Florida Chief Financial Officer Blaise Ingoglia. According to Ingoglia, since taking office, there have been more than 1,200 arrests, totaling more than $38 million in restitution. Ingoglia said there were 600 arrests by the Bureau of Insurance Fraud, 344 arrests by the Bureau of Arson and explosives, 199 arrests for public assistance fraud, 42 arrests from the Office of Fiscal Integrity and 126 illegal immigrants that were handed to Immigration and Customs Enforcement. *“My investigators have worked to put fraudsters behind bars and send a clear and concise message to criminals who are attempting to commit fraud here in the state of Florida; we will find you, and we will send you to prison,”* he said. During the press conference, the sheriffs praised Ingoglia’s collaboration to make these arrests happen. [Read more](https://www.nbcmiami.com/news/local/florida-sheriffs-to-gather-at-trump-national-doral/3839304/) **State Auditor Informs Montanans About Fraud Warning Signs and Resources** Justice Summit Auditor James Brown delivered a presentation on elder fraud and abuse as part of the Montana Department of Justice’s Elder Justice Summit, held in Kalispell on July 22. Older Montanans are frequently targeted by perpetrators of financial abuse and fraud schemes. That’s why Brown has made public outreach and education – specifically to seniors – a top priority of his administration. From 2020 to 2024, the number of seniors who reported losses of $100,000 or more in a fraud scheme increased nearly sevenfold, according to the Federal Trade Commission. Fraudsters and scammers often target older Montanans because of their larger savings and retirement account balances, as well as their increased vulnerability due to social isolation, health issues, or unfamiliarity with emerging technologies like AI and cryptocurrency. [Read more](https://news.mt.gov/State-Auditor-Office/State-Auditor-James-Brown-Informs-Montanans-About-Fraud-Warning-Signs-Resources-as-Part-of-State-Elder-Justice-Summit) **Insurance Commissioner Shares Tips for Wisconsinites Impacted by Storm Damage** Wisconsin Insurance Commissioner Nathan Houdek is sharing tips for filing an insurance claim with Wisconsinites who may have experienced property damage from this week’s severe storms. *“Monday’s devastating storms produced high winds, tornadoes, and hail, which caused significant property damage, particularly in the Eastern part of the state,”* said Commissioner Houdek. *“If you experienced any damage, it’s important to notify your insurance agent or company right away to begin the claim process.”* [Read more](https://oci.wi.gov/Pages/PressReleases/20260728AfterAStormResponse.aspx) **TDI Warns About Buying Fake Auto Insurance Policies** **The Texas Department of Insurance (TDI) offers tips to help Texans avoid auto insurance scams online, warning that scams and fake policies are on the rise. Scammers without a TDI license to sell insurance collect money but never use it to buy coverage with an insurance company.** ***“Then the consumer is in a car collision, attempts to file a claim, and finds out that the policy they have isn’t valid, and they’re not covered in any form or fashion,”*** **said Fraud Unit investigator Capt. Kevin Lemon. Fraudsters often target victims on social media with unusually low-cost insurance offers.** ***“They might get lured in by the fact that it’s way cheaper than going through an insurance agent. And, unfortunately, you get what you pay for,”*** **said investigator Capt. Tyler Hampton. Hampton said insurance fraud affects everyone, from the person in the car accident with a driver who didn’t have insurance to everyone who pays for insurance.** ***“When insurance companies are out hundreds of thousands of dollars, they pass that down, and it causes premiums to go up,”*** **said Hampton.** ***“And we all share the burden of that.”*** [**Read More**](https://www.tdi.texas.gov/news/2026/tdi07272026.html) \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/f32efd68-e5b9-df90-ba9a-8905b2da867c.png) \| \| \|:-:\| \| \| \| *The arrest summaries in Fraud News Weekly are compiled from publicly available news sources. Individuals mentioned are presumed innocent until proven guilty in a court of law.* \| \| \|---\| \| \|---\| \| \| \| \| \|---\| \| \| \| **AGENT MISCONDUCT** **July 27 — Massachusetts – $962K insurance brokerage fraud scheme results in prison sentence for couple** Brendan and Lisa Lawler were sentenced to eight months in prison for conspiring to commit wire fraud through BL Insurance Brokerage, LLC. The New Bedford couple collected over $962,000 from clients without forwarding payments to insurance providers. They maintained the scheme by using new client funds to pay old balances and issuing fake policy documents, leaving… [Read more](https://www.wwlp.com/news/crime/massachusetts-couple-sentenced-for-nearly-1-million-insurance-fraud/) **HOMEOWNERS – FALSE CLAIM** **July 28 – Louisiana – Woman charged with homeowners insurance fraud after claiming pre-policy fire damage** Tashira S. Glover was arrested in Monroe after fraudulently submitting a homeowners insurance claim for damage from a residential fire. State investigators found that the house fire occurred several months before her insurance policy actually took effect. Authorities booked her into jail on charges of insurance fraud and theft over $5,000 after an investigation revealed… [Read more](https://www.ldi.la.gov/news/press-releases/7-28-26-monroe-woman-arrested-on-fraud-charges-following-fire-investigation) **AUTO – TOWING FRAUD** **July 27 – North Carolina – Towing business manager charged in $4,250 towing insurance fraud scheme** Antonio Lorenzo Covington, general manager of Tow Godz LLC in Charlotte, was charged with felony insurance fraud and obtaining property by false pretense. Covington submitted a $4,250 fraudulent towing invoice to Peak Property and Casualty Insurance Corp., including $1,250 in fake cleanup and equipment fees. Surveillance video and witness statements revealed no special equipment was actually used… [Read more](https://www.ncdoi.gov/news/press-releases/2026/07/27/mecklenburg-county-towing-business-manager-faces-insurance-fraud-related-charges) \| \| \|---\| \| \|---\| \| \| ![](https://dim.mcusercontent.com/cs/a440c5b647697de580a2fd586/images/2caf4788-5ba5-cab4-c031-ec437d009492.png?dpr=2&rect=0%2C0%2C988%2C114&w=612&h=71) \| \| \|:-:\| \| [](https://us02web.zoom.us/webinar/register/WN_KXQ05407Qg2qUIFJ0XE7Cg#/registration)\| ![](https://dim.mcusercontent.com/cs/a440c5b647697de580a2fd586/images/6e66f996-ff80-a089-f708-fa735167bed5.png?dpr=2&rect=0%2C20%2C843%2C829&w=612&h=602) \| \| \|:-:\| \| \| \| Join us as we examine the increase in account takeover attempts, the schemes fraudsters commonly use, the warning signs to watch for, and best practices for combating account takeover fraud. The information shared will benefit all Coalition members, including insurers, regulators, law enforcement agencies, consumer organizations, and antifraud service providers. \| \| \|---\| \| \|---\| \| \| \| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7ae894ca-d4a9-ad6a-9b44-d621c43376af.png) \| \| \|:-:\| \| \| ![](https://dim.mcusercontent.com/cs/a440c5b647697de580a2fd586/images/86a79b22-5b20-0ce8-a9de-8b3f90fddd47.png?dpr=2&rect=38%2C0%2C1442%2C346&w=596&h=142) \| \| \|:-:\| \| \| \| The Coalition’s Executive Committee approved the establishment of a new Technology Task Force to address the rise of high-tech insurance crime. Tools like artificial intelligence (AI) and predictive analytics improve fraud detection, but they also allow fraudsters to create sophisticated schemes. These threats include deepfakes, fake documents, and automated claims that exploit both insurers and consumers. The Technology Task Force will provide a structured forum for members to collaborate, exchange perspectives, and share practical experiences to better understand how technology impacts insurance fraud. Our inaugural meeting is scheduled for September. Additional details will follow soon. \| \| \|---\| \| \|---\| \| \| ![](https://dim.mcusercontent.com/cs/a440c5b647697de580a2fd586/images/03ef7b7a-8fd7-29c1-e913-1ad792a5d0b2.png?dpr=2&rect=13%2C22%2C1352%2C322&w=599&h=142) \| \| \|:-:\| \| \| \| The Coalition’s Executive Committee announced new appointments across its specialized committees and task forces. The Coalition’s committees and task forces play a vital role in advancing industry best practices, strengthening partnerships, and addressing emerging insurance fraud challenges. Join us in welcoming these members to their new roles. - **Amicus Committee: Member Devin Chapman**, Attorney Supervisor for the Insurance Fraud & Law Enforcement Division of the New Mexico Office of Superintendent of Insurance (OSI) - **Government Affairs Committee: Vice-chair Breann Heininger,** Assistant Vice President of Operations, Delta Group - **Public Information Committee: Vice-chair Chris Sloan**, Executive Director, Pennsylvania Insurance Fraud Prevention Authority (IFPA) - **Property & Casualty Task Force: Co-chair Armand Glick**, Fraud Director, Utah Department of Insurance - **Workers’ Compensation Task Force:** **Co-chair Jennifer Cunningham**, Director of Special Investigations, State of Ohio, Bureau of Workers’ Compensation; **Co-chair Dan Kruege**r, SIU Manager, Zurich Insurance - **Technology Task Force: Co-chair Julia Senn**, Technology Director, State Farm Mutual Automobile Insurance Company; **Co-chair Alicia Holmes**, Head of Solutions & Consulting – North America P&C, Shift Technology \| \| \|---\| \| \|---\| \| \| ![](https://dim.mcusercontent.com/cs/a440c5b647697de580a2fd586/images/07a5c411-a1c7-d260-5c57-a6edf6fd418d.png?dpr=2&rect=0%2C72%2C2007%2C635&w=612&h=193) \| \| \|:-:\| \| \| \| The Coalition invites you to submit nominations for a long-standing tradition of the annual **Prosecutor of the Year**. Our past winners have convicted serial fraudsters and dismantled fraud rings involving more than $500 million. We are looking for the next impactful story! - [Submission Criteria](https://members.insurancefraud.org/general/custom.asp?page=prosecutor-of-the-year); Use this [form](https://members.insurancefraud.org/page/prosecutor-of-the-year-form) to nominate outstanding individual prosecutors or dedicated teams at the federal, state, or local level. - **Submission Deadline: September 1** \| \| \|---\| \| \|---\| \| \| \| \| \|---\| \| [](https://s.surveyplanet.com/bj1sw6en)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/d0b048d2-a961-e385-14cd-46ecbc552cea.png) \| \| \|:-:\| \| \| \| \| \|---\| \| \| \| # Don’t miss out on Coalition messages! \| \| \|---\| \| \|---\| \| \| \| \| \| \| \| \| \| \| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/9ed3fe29-a778-e309-d115-ca2439d8b08d.jpg) \| \| \|:-:\| \| \| \| \| **Never miss an update!** Want to make sure our weekly alerts and announcements reach you? If you haven’t seen our emails lately, take a quick peek at your spam or promotions folder and mark us as “safe.” [Subscribe](https://insurancefraud.org/news-publications/) to Coalition publications. Encourage others in your organization to do the same. \| \|---\|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \| \| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/f0173610-06d7-9728-0b67-70f75839269f.png) \| \| \|:-:\| \| \| \| # Registration opens September 1. \| \| \|---\| \| \|---\| \| \| \| \| \|---\| \| [](https://members.insurancefraud.org/general/register_member_type.asp)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/35c0a4f3-d5a8-6156-bbcf-9e3b94bceb36.png) \| \| \|:-:\| \| \| \| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/78293987-c284-f808-311d-6b5145fef4e1.png) \| \| \|:-:\| \| \| \| - **August 4** – [Recorded Statements That Win](https://insurancefraud.org/event/recorded-statements-that-win/) – Becker & Company - **August 12** – [Psychosocial Risk: The Next Wave of Workers’ Comp Complexity ](https://insurancefraud.org/event/free-ce-webinar-series-psychosocial-risk-the-next-wave-of-workers-comp-complexity/)– Ethos - **August 30 – September 4** – [74th Annual IAATI/ATPA Vehicle Crimes Conference](https://insurancefraud.org/event/74th-annual-iaati-atpa-vehicle-crimes-training-conference/) - **September 20 – 23** – [IASIU Annual Conference](https://insurancefraud.org/event/2026-iasiu-annual-conference/) - **September 27 – 30** – [NAMIC’s 131st Annual Convention](https://insurancefraud.org/event/namics-131st-annual-convention/) \| \| \|---\| \| \|---\| \| \| \| \| \|---\| \| \| \| **Follow Us on Our Social Media Platforms:** \| \| \|---\| \| \|---\| \| [](https://www.linkedin.com/company/coalition-against-insurance-fraud/)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/148b79cf-2c06-6469-b7c8-335c1c8b971a.jpg) \| \| \|:-:\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| \| \| \| \| \| [](https://www.facebook.com/profile.php?id=61579225779934)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/39ae0e7d-0388-20e5-5755-020aec6cf995.jpg) \| \| \|:-:\| \| [](https://www.instagram.com/stopinsurancefraud/)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/86c49df9-4380-51e5-da9c-f83034fc7555.jpg) \| \| \|:-:\| \| \| \| \| \| ![Logo](https://brand-assets.mailchimp.com/01KKVRP4PEH4PWEG0R0VSKKJ7H.png) \| \| \|:-:\| \| \| \| *Copyright (C) 2026 Coalition Against Insurance Fraud. All rights reserved.* You are receiving this email because either your organization is a member of the Coalition Against Insurance Fraud or you requested to be placed on our mailing list. Our mailing address is: Coalition Against Insurance Fraud 1012 14th St NW Ste 610 Washington, DC 20005-3424 USA Want to change how you receive these emails? You can [update your preferences](https://insurancefraud.mailchimpsites.com/manage/preferences?u=a440c5b647697de580a2fd586&id=b68dce7808&e=%5BUNIQID%5D&c=fa401c3541) or [unsubscribe](https://insurancefraud.us1.list-manage.com/unsubscribe?u=a440c5b647697de580a2fd586&id=b68dce7808&t=b&e=%5BUNIQID%5D&c=fa401c3541) \| \| \|:-:\| \| \|---\| \| \| \| \|---\| \| \|:-:\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| | |:-:| **Features:** Fraud News Weekly --- ### [Fraud News Weekly (FNW) Friday, July 24, 2026](https://insurancefraud.org/publications/fraud-news-weekly-fnw-friday-july-24-2026/) **Published:** July 24, 2026 **Author:** Coalition Against Insurance Fraud **Content:** Fraud News Weekly (FNW) – Friday, July 24, 2026͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ | \| \| \| \| \| \| \| [View this email in your browser](https://mailchi.mp/2f2dfdd10765/fraud-news-weekly-friday-may-1-10704633?e=%5BUNIQID%5D) \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| \| \| \| \| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/74b45efc-3095-abd7-b2e1-55d9056a868a.png) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/0c2401e8-ae3e-c72f-38a3-7a802c835a05.png) \| \| \|:-:\| \| \| \| **New Jersey Supreme Court affirms position supported by the Coalition that Fraud Act and RICO claims are not subject to PIP arbitration.** The New Jersey Supreme Court affirmed a significant victory in *Allstate v. Carteret*, holding that claims under the New Jersey Insurance Fraud Prevention Act and Racketeer Influenced and Corrupt Organizations (RICO) statute are properly venued in the courts and not subject to personal injury protection (PIP) arbitration. The Coalition supported Allstate’s position through its [Amicus Curiae Program](https://insurancefraud.org/amicus-program/), with Legal Affairs Committee member [Bruno, Gerbino, Soriano & Aitken](https://bgslaw-ny.com/), partner Daniel Hunczak, Esq. on the brief and arguing before the courts. The decision confirms that complex fraud claims involving extensive discovery, multiple defendants, attorney fees, and treble damages belong in court rather than in the arbitration forum. [Read more](https://insurancefraud.org/wp-content/uploads/7-21-2026-NJ-Supreme-Ct-Decision-Allstate-v-Carteret.pdf)… **NCOIL summer meeting highlights insurance fraud, AI regulation and unclaimed property concerns.** The Coalition attended the National Council of Insurance Legislators (NCOIL) Summer National Meeting in Boston, last week, where more than 70 legislators and 10 insurance commissioners discussed emerging insurance challenges. Discussions focused on insurance fraud trends, artificial intelligence oversight, unclaimed life insurance benefits, litigation financing, staged accidents and market conduct modernization. The meeting created new opportunities for the Coalition to support state fraud bureau staffing, work with policymakers on medical fraud concerns and continue research into an issue brought up by the Coalition’s [Life & Disability Task Force](https://insurancefraud.org/committees/), i.e., fraud involving unclaimed insurance proceeds. The NCOIL discussions reinforced strong legislative interest in preserving state insurance regulation and strengthening antifraud capabilities alongside consumer protections. [Read more](https://ncoil.org/wp-content/uploads/2026/07/Boston-30-Day-Materials.pdf)… **Coalition priorities align with state response to technology driven fraud.** States enacted new laws in 2026 addressing artificial intelligence, deepfakes, digital impersonation, and synthetic identity fraud, providing new tools for regulators, law enforcement, insurers, and fraud investigators. Measures adopted this year in Colorado, Connecticut, Hawaii, Maryland, Oklahoma, Rhode Island, Virginia, and Washington closely align with the Coalition’s legislative priorities, which emphasize protecting consumers from fraud, safeguarding the insurance system, and addressing emerging technology risks to prohibit criminal misuse. A recent enactment, Rhode Island’s Impersonation and Identity Fraud Law, expands its identity fraud law to criminalize digital forgery and the knowing impersonation of individuals or entities to facilitate fraud. Similar legislative language is emerging in multiple states, aligning with Coalition priorities focused on consumer protection, antifraud modernization, and emerging fraud threats. [Read more](https://www.rilegislature.gov/pressrelease/_layouts/15/ril.pressrelease.inputform/DisplayForm.aspx?List=c8baae31-3c10-431c-8dcd-9dbbe21ce3e9&ID=376670)… **NAIC advances framework for third party data and model oversight.** The National Association of Insurance Commissioners (NAIC) Third Party Data and Models (H) Working Group continued developing a regulatory framework for third party data and model vendors. The exposed framework includes a voluntary multi-state registry, rate filing requirements and ongoing insurer oversight through annual attestations. While fraud detection models were considered during development, the current phase focuses on underwriting and pricing models. The Coalition is tracking developments, including potential future impacts on fraud detection models, vendor governance and insurer accountability. The framework is open for public comment through August 5, 2026, and will be discussed at the NAIC Summer National Meeting, which the Coalition will attend. Members are encouraged to share feedback or questions with Coalition Director of Government Relations, Brent Walker at [brent@insurancefraud.org](mailto:brent@insurancefraud.org?subject=&body=)[.](mailto:brent@insurancefraud.org?subject=&body=) [Read more… ](https://content.naic.org/committees/h/third-party-data-models-wg) \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/1f3bb500-cfa3-84c3-d35e-75de1be2fec0.png) \| \| \|:-:\| \| \| \| **Consumer Notice: Protect Yourself from Post-Storm Scams** Recent storms are a reminder that severe weather can leave behind more than property damage. It can also create opportunities for scammers. The Connecticut Insurance Department (CID) urges homeowners and renters to use caution when hiring contractors, responding to unsolicited repair offers, or sharing personal and insurance information following a storm. Following severe weather, scammers often take advantage of the urgency homeowners feel to make repairs. They may pressure consumers to act quickly, request large upfront payments, or offer to handle the insurance claim on the homeowner’s behalf before the full extent of the damage has been evaluated. Only discuss your claim with your insurance company or authorized representatives. Be cautious of anyone who claims they can “guarantee” claim approval, inflate repair costs, or promises a larger insurance settlement. If someone claims to represent your insurance company, verify their identity by contacting your insurer directly using the phone number listed on your policy or the company’s official website. If you believe you have encountered an insurance-related scam or have questions about your insurance claim, contact the CID’s Consumer Affairs Division at <cid.ca@ct.gov>. [Read more](https://links.naic.org/lnk/AXMAAKChhh8AAc5yjYoAA-s7HDgAAYKJiqUAoMjqAC9RAwBqXla9m8Xy7MOWQ1WxyivcSkvjGAAp8h8/13/VmHrb-8P1ALwsA7ffIroCg/aHR0cHM6Ly9wb3J0YWwuY3QuZ292L2NpZC9jb25zdW1lci1pbmZvcm1hdGlvbi1jZW50ZXIvY29uc3VtZXItYWxlcnRzLzIwMjYtY29uc3VtZXItYWxlcnRzL3Byb3RlY3QteW91cnNlbGYtZnJvbS1wb3N0LXN0b3JtLXNjYW1zP2xhbmd1YWdlPWVuX1VT)… [**Shapiro Administration Reminds Pennsylvanians to be Mindful of Contractor Scams Following Major Summer Storms**](https://links.naic.org/lnk/AWcAAJ-F6PYAAc5uUZ4AA-s7HDgAAYKJiqUAoMjqAC9RAwBqPWYeQj89zP6JRaOgsjQu1T2LwgAp8h8/12/597WsdDHwhQ-F9CkxyVdkw/aHR0cHM6Ly93d3cucGEuZ292L2FnZW5jaWVzL2luc3VyYW5jZS9uZXdzcm9vbS9zaGFwaXJvLWFkbWluLXJlbWluZHMtY29udHJhY3Rvci1zY2Ftcy1mb2xsb3dpbmctbWFqb3Itc3VtbWVyLXN0b3Jtcw) The Pennsylvania Insurance Department (PID) encourages Pennsylvanians to be cautious this summer of deceptive business practices, such as contractor fraud. Contractor fraud can occur in many forms and typically takes place in communities that were recently impacted by severe weather. PID wants to ensure Pennsylvanians know what to look for and how to avoid being scammed. “Unfortunately, one of the most enjoyable times of the year is also one of the worst times for severe weather, and that’s when contractor fraud is most prevalent,” said Pennsylvania Insurance Commissioner Michael Humphreys. “Pennsylvanians have every right to do their homework when it comes to hiring a contractor and should know that if an offer or high-pressure tactic doesn’t feel quite right, it’s probably best to move on and choose another contractor.” [Read more](https://links.naic.org/lnk/AWcAAJ-F6PYAAc5uUZ4AA-s7HDgAAYKJiqUAoMjqAC9RAwBqPWYeQj89zP6JRaOgsjQu1T2LwgAp8h8/13/ofV-i86GW6D_n76Tb-9vkQ/aHR0cHM6Ly93d3cucGEuZ292L2FnZW5jaWVzL2luc3VyYW5jZS9uZXdzcm9vbS9zaGFwaXJvLWFkbWluLXJlbWluZHMtY29udHJhY3Rvci1zY2Ftcy1mb2xsb3dpbmctbWFqb3Itc3VtbWVyLXN0b3Jtcw)… **Hundreds of officers and officials complete training to detect car insurance fraud under new NY law** New York Governor Kathy Hochul announced that nearly 270 law enforcement officials from 55 agencies recently completed specialized training at the State Police Academy to aggressively combat rising auto insurance fraud. The state is prioritizing inter-agency collaboration between the New York State Police and the Department of Financial Services to equip local investigators with advanced detection tools and updated legal frameworks, hoping to dismantle fraudulent networks, hold criminals accountable, and deliver economic relief to New Yorkers. [Read more…](https://www.whec.com/top-news/hundreds-of-officers-and-other-officials-complete-training-to-detect-car-insurance-fraud-under-new-ny-law/) \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/f32efd68-e5b9-df90-ba9a-8905b2da867c.png) \| \| \|:-:\| \| \| \| *The arrest summaries in Fraud News Weekly are compiled from publicly available news sources. Individuals mentioned are presumed innocent until proven guilty in a court of law.* \| \| \|---\| \| \|---\| \| \| \| \| \|---\| \| \| \| **LIFE INSURANCE** **July 20 – Louisiana – Federal jury convicts two men in $4.325M life insurance fraud scheme** Calvin Kemp and Chevez Tywan Robillard were convicted in Baton Rouge of conspiracy and identity theft after fraudulently obtaining nine life insurance policies worth $4.325 million. They impersonated three victims during calls to eight insurance providers while operating fake shell companies. Robillard listed himself as beneficiary and filed claims on four policies after one victim was murdered… [Read more](https://www.justice.gov/usao-mdla/pr/federal-jury-convicts-two-local-men-conspiracy-commit-wire-fraud-and-aggravated) **PROPERTY & CASUALTY** **July 23 – Nevada – Las Vegas store owner indicted in $88K staged robbery insurance scheme** Erwin Lanada was indicted for orchestrating a fake armed robbery at his cellphone repair store to collect $88,611 from his insurer. Lanada hired an accomplice, gave him a revolver to stage the crime, and filed fraudulent loss claims. The insurance company paid out the funds before federal agents discovered he armed the robber… [Read more](https://www.fox5vegas.com/2026/07/23/nevada-business-owner-accused-robbing-his-own-store-defraud-insurance-company/) **HEALTHCARE FRAUD** **July 17 – Florida – Florida man arrested after submitting $159K in fake health insurance claims** Torey Jermaine Keith was arrested for submitting 15 fraudulent health insurance claims that totaled $159,557. The Florida Department of Financial Services launched an investigation after an unnamed insurance company reported it could not verify the claims. Investigators discovered that Keith altered documents to secure the payouts, and he now faces multiple felony charges including grand theft… [Read more](https://abc7amarillo.com/news/nation-world/financial-crime-florida-man-accused-of-filing-more-than-159k-in-fraudulent-health-insurance-claims-florida-department-of-financial-services-cheif-financial-officer-blaise-ingoglia-insurance-company-false-claims-illegal-behavior-fraudsters-justice) **AGENT MISCONDUCT** **July 22 – North Carolina – Charlotte brokers charged in $43K false life insurance commission scheme** Johnnisha Kierra Albert, a Charlotte insurance broker, was charged with submitting 17 false life insurance applications to steal commissions. Albert collected $43,454 from Corebridge Direct Insurance Services Inc. and Gerber Life Insurance Co. Regina Renee King targeted United of Omaha Life Insurance Co. Special agents arrested both suspects following a joint investigation… [Read more](https://www.charlotteobserver.com/news/local/crime/article316607413.html) **AGENT MISCONDUCT** **July 20 – Iowa – Insurance agent pleads guilty to $45K annuity fraud scheme targeting retirees** Starrla Ramae Norman pleaded guilty to felony insurance fraud after submitting falsified annuity applications to Allianz Life Insurance Company. Norman targeted retired postal workers, convincing them to liquidate retirement accounts and buy replacement contracts to collect high commissions. Ordered to pay $44,954 in restitution, Norman now faces felony sentencing for submitting false customer records… [Read more](https://iid.iowa.gov/press-release/2026-07-20/iowa-insurance-commissioner-revokes-license-and-orders-restitution-preying-retired-postal-workers) **HEALTHCARE FRAUD** **July 20 – Connecticut – $27K disability insurance fraud scheme leads to arrest of former state employee** Former state employee Jeffrey Bernadel was arrested after submitting fabricated medical documents to collect disability benefits from Colonial Life Insurance Company. Investigators found Bernadel forged doctor notes and altered medical records to misrepresent his health status while claiming payouts. He now faces multiple felony counts, including first-degree larceny and insurance fraud, as prosecutors reveal… [Read more ](https://portal.ct.gov/dcj/press-releases/division-of-criminal-justice/07202026bernadel?language=en_US) \| \| \|---\| \| \|---\| \| \| ![](https://dim.mcusercontent.com/cs/a440c5b647697de580a2fd586/images/2caf4788-5ba5-cab4-c031-ec437d009492.png?dpr=2&rect=0%2C0%2C988%2C114&w=612&h=71) \| \| \|:-:\| \| [](https://us02web.zoom.us/webinar/register/WN_KXQ05407Qg2qUIFJ0XE7Cg#/registration)\| ![](https://dim.mcusercontent.com/cs/a440c5b647697de580a2fd586/images/6e66f996-ff80-a089-f708-fa735167bed5.png?dpr=2&rect=0%2C20%2C843%2C829&w=612&h=602) \| \| \|:-:\| \| \| \| Join us as we examine the increase in account takeover attempts, the schemes fraudsters commonly use, the warning signs to watch for, and best practices for combating account takeover fraud. The information shared will benefit all Coalition members, including insurers, regulators, law enforcement agencies, consumer organizations, and antifraud service providers. \| \| \|---\| \| \|---\| \| \| \| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7ae894ca-d4a9-ad6a-9b44-d621c43376af.png) \| \| \|:-:\| \| \| ![](https://dim.mcusercontent.com/cs/a440c5b647697de580a2fd586/images/07a5c411-a1c7-d260-5c57-a6edf6fd418d.png?dpr=2&rect=0%2C72%2C2007%2C635&w=612&h=193) \| \| \|:-:\| \| \| \| The Coalition invites you to submit nominations for a long-standing tradition of the annual **Prosecutor of the Year**. Our past winners have convicted serial fraudsters and dismantled fraud rings involving more than $500 million. We are looking for the next impactful story! - [Submission Criteria](https://members.insurancefraud.org/general/custom.asp?page=prosecutor-of-the-year); Use this [form](https://members.insurancefraud.org/page/prosecutor-of-the-year-form) to nominate outstanding individual prosecutors or dedicated teams at the federal, state, or local level. - **Submission Deadline: September 1** \| \| \|---\| \| \|---\| \| \| \| \| \|---\| \| [](https://s.surveyplanet.com/bj1sw6en)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/d0b048d2-a961-e385-14cd-46ecbc552cea.png) \| \| \|:-:\| \| \| \| \| \|---\| \| \| \| # Don’t miss out on Coalition messages! \| \| \|---\| \| \|---\| \| \| \| \| \| \| \| \| \| \| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/9ed3fe29-a778-e309-d115-ca2439d8b08d.jpg) \| \| \|:-:\| \| \| \| \| **Never miss an update!** Want to make sure our weekly alerts and announcements reach you? If you haven’t seen our emails lately, take a quick peek at your spam or promotions folder and mark us as “safe.” [Subscribe](https://insurancefraud.org/news-publications/) to Coalition publications. Encourage others in your organization to do the same. \| \|---\|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \| \| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/f0173610-06d7-9728-0b67-70f75839269f.png) \| \| \|:-:\| \| \| \| # Registration opens September 1. \| \| \|---\| \| \|---\| \| \| \| \| \|---\| \| [](https://members.insurancefraud.org/general/register_member_type.asp)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a3679910-4f7f-5e6f-1e43-0b3dfad0c5b8.png) \| \| \|:-:\| \| \| \| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/78293987-c284-f808-311d-6b5145fef4e1.png) \| \| \|:-:\| \| \| \| - **July 29 –** [Beyond Disclosure: Forensic Intelligence Meets Real-Time Underwriting](https://insurancefraud.org/event/beyond-disclosure-forensic-intelligence-meets-real-time-underwriting/) – ForMotiv - **August 4** – [Recorded Statements That Win](https://insurancefraud.org/event/recorded-statements-that-win/) – Becker & Company - **August 30 – September 4** – [74th Annual IAATI/ATPA Vehicle Crimes Conference](https://insurancefraud.org/event/74th-annual-iaati-atpa-vehicle-crimes-training-conference/) - **September 20 – 23** – [IASIU Annual Conference](https://insurancefraud.org/event/2026-iasiu-annual-conference/) - **September 27 – 30** – [NAMIC’s 131st Annual Convention](https://insurancefraud.org/event/namics-131st-annual-convention/) \| \| \|---\| \| \|---\| \| \| \| \| \|---\| \| \| \| **Follow Us on Our Social Media Platforms:** \| \| \|---\| \| \|---\| \| [](https://www.linkedin.com/company/coalition-against-insurance-fraud/)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/148b79cf-2c06-6469-b7c8-335c1c8b971a.jpg) \| \| \|:-:\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| \| \| \| \| \| [](https://www.facebook.com/profile.php?id=61579225779934)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/39ae0e7d-0388-20e5-5755-020aec6cf995.jpg) \| \| \|:-:\| \| [](https://www.instagram.com/stopinsurancefraud/)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/86c49df9-4380-51e5-da9c-f83034fc7555.jpg) \| \| \|:-:\| \| \| \| \| \| ![Logo](https://brand-assets.mailchimp.com/01KKVRP4PEH4PWEG0R0VSKKJ7H.png) \| \| \|:-:\| \| \| \| *Copyright (C) 2026 Coalition Against Insurance Fraud. All rights reserved.* You are receiving this email because either your organization is a member of the Coalition Against Insurance Fraud or you requested to be placed on our mailing list. Our mailing address is: Coalition Against Insurance Fraud 1012 14th St NW Ste 610 Washington, DC 20005-3424 USA Want to change how you receive these emails? You can [update your preferences](https://insurancefraud.mailchimpsites.com/manage/preferences?u=a440c5b647697de580a2fd586&id=b68dce7808&e=%5BUNIQID%5D&c=d4ab46f18c) or [unsubscribe](https://insurancefraud.us1.list-manage.com/unsubscribe?u=a440c5b647697de580a2fd586&id=b68dce7808&t=b&e=%5BUNIQID%5D&c=d4ab46f18c) \| \| \|:-:\| \| \|---\| \| \| \| \|---\| \| \|:-:\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| | |:-:| **Features:** Fraud News Weekly --- ### [Fraud News Weekly (FNW) Friday, July 17, 2026](https://insurancefraud.org/publications/fraud-news-weekly-fnw-friday-july-17-2026/) **Published:** July 24, 2026 **Author:** Coalition Against Insurance Fraud **Content:** Fraud News Weekly (FNW) – Friday, July 17, 2026͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ | \| \| \| \| \| \| \| [View this email in your browser](https://mailchi.mp/faa6e5a1d219/fraud-news-weekly-friday-may-1-10704603?e=%5BUNIQID%5D) \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| \| \| \| \| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/064886f6-842e-f206-5d48-225e60fd5c50.png) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/0c2401e8-ae3e-c72f-38a3-7a802c835a05.png) \| \| \|:-:\| \| \| \| **Ohio law addresses foreign third party litigation funding concerns.** Ohio Governor Mike DeWine recently signed [House Bill 105](https://www.legislature.ohio.gov/legislation/136/hb105), prohibiting foreign-domiciled persons and entities from entering into consumer legal financing or commercial litigation financing agreements in Ohio. The General Assembly stated its intent is to protect due process rights for litigants by addressing risks posed by foreign actors seeking to interfere with Ohio courts. The measure aligns with similar concerns raised by Coalition committees and task forces regarding growing transnational and cross-border fraud activity. In 2024, the Coalition provided [written comments](https://insurancefraud.org/wp-content/uploads/Coalition-Comments-on-NCOIL-Transparency-in-TPLF-Model-Act-9-23-2024.pdf) on the National Council of Insurance Legislators (NCOIL) *Transparency in Third Party Litigation Financing Model Act*, supporting similar efforts to address this issue while ensuring insurance consumers maintain access to justice and the court system. The Coalition highlighted then the need to prohibit direct or indirect financing by foreign entities of concern or foreign countries or persons of concern. [Read more](https://ohiohouse.gov/members/dontavius-l-jarrells/news/ohio-senate-passes-rep-craigs-house-bill-105-145728)… **NAIC journal highlights artificial intelligence’s role in insurance fraud detection.** The National Association of Insurance Commissioners (NAIC) Center for Insurance Policy and Research recently examined insurers’ use of artificial intelligence, including its growing role in insurance fraud detection and prevention. While the research notes that artificial intelligence offers significant benefits for insurers, it also raises important concerns about proper oversight, transparency, and responsible implementation. The study found fraud detection is one of the leading AI applications, with the majority of insurers using or considering AI tools to identify claims for further investigation. For Coalition members, the discussion highlights AI’s potential while reinforcing the need for governance and safeguards against emerging threats such as deepfakes and synthetic fraud. [Read more](https://content.naic.org/sites/default/files/jir-45-3.pdf)... **National Conference of State Legislatures (NCSL) legislative databases serve as an additional tool for Coalition members to track state policy trends.** NCSL maintains more than 40 legislative tracking databases that Coalition members can use to monitor policy issues with fraud relevance. Key databases include artificial intelligence, autonomous vehicles, health care, prescription drugs, occupational licensing, traffic safety, and sentencing corrections. The NCSL, founded in 1975, provides bipartisan research and technical assistance to state legislators and staff. These tools support identification of legislative trends that may shape fraud risk and antifraud policy development. [Read more](https://www.ncsl.org/technology-and-communication/ncsl-50-state-searchable-bill-tracking-databases)… \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/1f3bb500-cfa3-84c3-d35e-75de1be2fec0.png) \| \| \|:-:\| \| \| \| **Licensed contractor calls for major reforms after Palm Beach County construction fraud bust** A licensed Florida contractor says a recent construction fraud case uncovered by the Palm Beach County Sheriff’s Office should be a wake-up call for the state, warning that similar schemes are “common” and are warping the market for homeowners and honest builders… [Read more](https://www.wptv.com/news/palm-beach-county/licensed-contractor-calls-for-major-reforms-after-palm-beach-county-construction-fraud-bust)… **Florida’s hurricane season brings out the worst in fraud \| Opinion** Hurricane season started June 1. For most Floridians, that means stocking up on water, checking insurance policies and making sure the generator works. For scammers, it means opportunity. Florida is the fraud capital of the United States…[Read more](https://f.datasrvr.com/fr1/626/75570/Florida.pdf)… \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/f32efd68-e5b9-df90-ba9a-8905b2da867c.png) \| \| \|:-:\| \| \| \| *The arrest summaries in Fraud News Weekly are compiled from publicly available news sources. Individuals mentioned are presumed innocent until proven guilty in a court of law.* \| \| \|---\| \| \|---\| \| \| \| \| \|---\| \| \| \| **HEALTHCARE FRAUD** **July 14 – New Jersey – $620,000 healthcare fraud scheme leads to prison sentences for pharmacy owner and technician** Kirtan S. Patel and Christopher Lugo were sentenced for executing a healthcare fraud scheme involving a Jersey City pharmacy. The operation caused over $620,000 in losses by submitting falsified audit documents and fake prescription records to insurers. Patel even texted a friend about collecting “free money” while plying doctors with cash and trips to strip clubs… [Read more](https://www.justice.gov/opa/pr/pharmacy-owner-and-technician-sentenced-falsifying-audit-documents-and-submitting-fraudulent)… **AUTO – STAGED THEFT** **July 10 – Maryland – Former Anne Arundel County police officer sentenced for $56K auto insurance fraud scheme** Jaron Earl Taylor of Ft. Washington was sentenced to probation for conspiring with fellow officers to stage vehicle thefts. The conspirators used their positions to write false police reports, tricking the United Services Automobile Association and Liberty Mutual Insurance into paying fraudulent claims. Investigators eventually uncovered the plot after a co-conspirator hid a car inside a… [Read more](https://www.justice.gov/usao-md/pr/former-anne-arundel-county-police-officer-sentenced-connection-insurance-fraud-scheme)… **AUTO – FALSE CLAIM** **July 13 – California – Former NFL wide receiver reaches deal to resolve auto insurance fraud charges** Alshon Jeffery reached an agreement with San Diego prosecutors to resolve felony auto insurance fraud charges. The former football star reinstated coverage after a crash but claimed it happened later to trick Kemper Insurance. He must complete 50 hours of volunteer work to dismiss the charges, which previously triggered an arrest warrant… [Read more](https://www.usatoday.com/story/sports/nfl/eagles/2026/07/13/alshon-jeffery-insurance-fraud-nfl-receiver-felony-charges-deal-philadelphia-eagles/90906596007/)… **PROPERTY & CASUALTY** **July 15 – Indiana – Eight sentenced to federal prison for $1.2M travel insurance fraud scheme** Eight individuals have been sentenced to federal prison for their roles in a scheme that defrauded multiple insurers of $1.2 million by filing false travel insurance claims. The defendants manipulated claims processes to secure illicit payouts, according to the Department of Justice… [Read more](https://www.justice.gov/usao-sdin/pr/eight-sentenced-federal-prison-12-million-travel-insurance-fraud-scheme)… \| \| \|---\| \| \|---\| \| \| \| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7ae894ca-d4a9-ad6a-9b44-d621c43376af.png) \| \| \|:-:\| \| \| \| # Coalition Q2 2026 Dashboard *(Click on image to enlarge.)* \| \| \|---\| \| \|---\| \| \| ![](https://dim.mcusercontent.com/cs/a440c5b647697de580a2fd586/images/55c620cf-4a65-611a-2cb6-b3de5ebde31f.png?dpr=2&rect=0%2C149%2C1984%2C958&w=612&h=295) \| \| \|:-:\| \| \| \| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/f1060324-a14f-0444-3dd0-edb059fae68e.png) \| \| \|:-:\| \| \| \| \| \| \| \| \| \| \| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/1bcbb32a-4b88-42ae-a80e-4096832abad8.png) \| \| \|:-:\| \| \| \| The Coalition hosted *From Suspicion to Submission: Best Practices for Reporting Suspected Insurance Fraud* on July 16 to provide investigative, compliance and legal professionals with a clearer understanding of fraud bureau processes, the information agencies rely on when deciding whether to open a criminal investigation, the factors considered when assessing referrals, and the need for stronger communication between insurers and government agencies. The Coalition thanks the panel members for contributing to this important discussion and the nearly 700 registrants for their interest in the program. Additional webinars will be held in the coming months, so visit the Coalition’s website regularly for information about upcoming events. \| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \| \| \| \|---\| \| \| ![](https://dim.mcusercontent.com/cs/a440c5b647697de580a2fd586/images/07a5c411-a1c7-d260-5c57-a6edf6fd418d.png?dpr=2&rect=0%2C72%2C2007%2C635&w=612&h=193) \| \| \|:-:\| \| \| \| The Coalition invites you to submit nominations for a long-standing tradition of the annual **Prosecutor of the Year**. Our past winners have convicted serial fraudsters and dismantled fraud rings involving more than $500 million. We are looking for the next impactful story! - [Submission Criteria](https://members.insurancefraud.org/general/custom.asp?page=prosecutor-of-the-year); Use this [form](https://members.insurancefraud.org/page/prosecutor-of-the-year-form) to nominate outstanding individual prosecutors or dedicated teams at the federal, state, or local level. - **Submission Deadline: September 1** \| \| \|---\| \| \|---\| \| \| \| \| \|---\| \| [](https://s.surveyplanet.com/bj1sw6en)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/d0b048d2-a961-e385-14cd-46ecbc552cea.png) \| \| \|:-:\| \| \| \| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/f0173610-06d7-9728-0b67-70f75839269f.png) \| \| \|:-:\| \| \| \| # Registration opens September 1. \| \| \|---\| \| \|---\| \| \| \| \| \|---\| \| [](https://members.insurancefraud.org/general/register_member_type.asp)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a3679910-4f7f-5e6f-1e43-0b3dfad0c5b8.png) \| \| \|:-:\| \| \| \| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/78293987-c284-f808-311d-6b5145fef4e1.png) \| \| \|:-:\| \| \| \| - **July 20 – 22** – [The 2026 Florida Insurance Fraud Education Committee and 34th Annual Conference](https://insurancefraud.org/event/the-2026-florida-insurance-fraud-education-committee-and-34th-annual-conference/) – FIFEC - **July 22** – [Resolving Ambiguity with OSINT](https://insurancefraud.org/event/resolving-ambiguity-with-osint/) – Skopenow - **July 22** – [Natural Disaster Fraud: ​​​The Winds of Fraud are Blowing](https://insurancefraud.org/event/natural-disaster-fraud/) – Ethos - **August 4** – [Recorded Statements That Win](https://insurancefraud.org/event/recorded-statements-that-win/) – Becker & Company - **August 30 – September 4** – [74th Annual IAATI/ATPA Vehicle Crimes Conference](https://insurancefraud.org/event/74th-annual-iaati-atpa-vehicle-crimes-training-conference/) \| \| \|---\| \| \|---\| \| \| \| \| \|---\| \| \| \| **Follow Us on Our Social Media Platforms:** \| \| \|---\| \| \|---\| \| [](https://www.linkedin.com/company/coalition-against-insurance-fraud/)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/148b79cf-2c06-6469-b7c8-335c1c8b971a.jpg) \| \| \|:-:\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| \| \| \| \| \| [](https://www.facebook.com/profile.php?id=61579225779934)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/39ae0e7d-0388-20e5-5755-020aec6cf995.jpg) \| \| \|:-:\| \| [](https://www.instagram.com/stopinsurancefraud/)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/86c49df9-4380-51e5-da9c-f83034fc7555.jpg) \| \| \|:-:\| \| \| \| \| \| ![Logo](https://brand-assets.mailchimp.com/01KKVRP4PEH4PWEG0R0VSKKJ7H.png) \| \| \|:-:\| \| \| \| *Copyright (C) 2026 Coalition Against Insurance Fraud. All rights reserved.* You are receiving this email because either your organization is a member of the Coalition Against Insurance Fraud or you requested to be placed on our mailing list. Our mailing address is: Coalition Against Insurance Fraud 1012 14th St NW Ste 610 Washington, DC 20005-3424 USA Want to change how you receive these emails? You can [update your preferences](https://insurancefraud.mailchimpsites.com/manage/preferences?u=a440c5b647697de580a2fd586&id=b68dce7808&e=%5BUNIQID%5D&c=b3e897f7fa) or [unsubscribe](https://insurancefraud.us1.list-manage.com/unsubscribe?u=a440c5b647697de580a2fd586&id=b68dce7808&t=b&e=%5BUNIQID%5D&c=b3e897f7fa) \| \| \|:-:\| \| \|---\| \| \| \| \|---\| \| \|:-:\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| | |:-:| **Features:** Fraud News Weekly --- ### [Fraud News Weekly (FNW) Friday, July 10, 2026](https://insurancefraud.org/publications/fraud-news-weekly-fnw-friday-july-10-2026/) **Published:** July 10, 2026 **Author:** Coalition Against Insurance Fraud **Content:** Fraud News Weekly (FNW) – Friday, July 10, 2026͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ | \| \| \| \| \| \| \| [View this email in your browser](https://mailchi.mp/5e2cc5b6fb39/fraud-news-weekly-friday-may-1-10704598?e=%5BUNIQID%5D) \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| \| \| \| \| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/839f0777-8516-7a6a-8c2f-995c5f2ce1e7.png) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a417349b-dfdc-a052-790d-07cfde53b716.jpg) \| \| \|:-:\| \| \| \| **NAIC Antifraud Technology Working Group advances fraud reporting improvements.** The Coalition attended the National Association of Insurance Commissioners (NAIC) Antifraud Technology (D) Working Group virtual meeting on July 1 to review policy and fraud referral categories for the NAIC Online Fraud Reporting System to improve the quality and consistency of fraud data. Previously, the Coalition gathered member feedback at the Working Group’s request to help refine reporting categories. The current plan is to implement these enhancements in early 2027. The effort complements the Coalition’s [Fraud Referral Guidance for Industry Investigators](https://insurancefraud.org/wp-content/uploads/Coalition-Fraud-Referral-Guide.pdf) and supports stronger fraud referrals, trend analysis, and nationwide enforcement. [Read more](https://content.naic.org/committees/d/antifraud-technology-wg)… **California Department of Insurance proposes major changes to insurance fraud grant programs.** The California Department of Insurance has proposed regulations to modernize its insurance fraud grant programs, citing the need for greater consistency, transparency, accountability, and more effective distribution of public funds supporting district attorney fraud investigations and prosecutions. The proposal would standardize program administration, update funding cycles, strengthen oversight, and revise grant evaluation criteria. A [virtual public hearing](https://us06web.zoom.us/webinar/register/WN_MZI1GhskT62Rgg-vMlRXbQ#/registration) is scheduled for Aug. 17, with written comments accepted through the same date. Members interested in providing feedback for potential Coalition comments should contact Coalition Director of Government Relations Brent Walker at <brent@insurancefraud.org>. [Read more](https://insurancefraud.org/wp-content/uploads/CDI-Ins-Fraud-Grant-Standardization-2026.pdf)… **NAIC market conduct modernization effort heard from consumer representatives with fraud concerns.** The Coalition attended the next iteration of the National Association of Insurance Commissioners (NAIC) Market Conduct Regulation Modernization (D) Working Group virtual session, where consumer representatives discussed expanding access to standardized market conduct data to help consumers compare insurers and strengthen regulatory oversight. Comments also addressed artificial intelligence systems, telematics, third party data, and terminology that may affect regulatory reviews. Participants noted that improving consumer experiences could also help reduce conditions that contribute to insurance fraud. The Coalition will also attend the next open discussion on this topic at the NAIC Summer National Meeting. [Read more](https://content.naic.org/committees/d/market-conduct-regulation-modernization-wg)… **States advance insurance fraud efforts through new laws, reporting, and enforcement initiatives.** Indiana [House Bill 1260](https://iga.in.gov/legislative/2026/bills/house/1260/details), effective July 1, strengthens insurance fraud reporting by requiring regulated entities that know or reasonably believe a fraudulent insurance act has occurred to report it to the Indiana Department of Insurance or the National Insurance Crime Bureau within 60 days and provides liability protections for good faith reporting. Michigan’s 2026 Fraud Investigation Unit [annual report](https://insurancefraud.org/wp-content/uploads/2026-DIFS-FIU-Annual-Report.pdf) highlights 5,610 fraud reports, 55 investigations, eight convictions, and more than $343,000 in restitution, fines, and costs. Meanwhile, New Jersey expanded fraud enforcement resources with a new regional Bureau of Fraud Deterrence office in Whippany. [Read more](https://www.nj.gov/dobi/pressreleases/pr260617.html)… **Iowa’s Stop the Scammers Tour highlights consumer reporting role in fraud investigations.** The Iowa Insurance Division’s recent 2026 Stop the Scammers Tour reached more than 1,400 Iowans through educational events focused on various forms of financial scams. The tour generated actionable leads as attendees shared suspicious calls, emails, texts, and investment pitches they encountered, helping the Fraud Bureau identify 19 active scams under investigation. “*Our approach is simple: Detect. Disrupt. Deploy,*” said Fraud Bureau Chief Matt Mortvedt, describing the Division’s focus on identifying emerging fraud, disrupting scams, and deploying investigative resources. Mortvedt also recently spoke at the Coalition’s Midyear Meeting, and the initiative aligns with a recent Coalition [member alert](https://insurancefraud.org/wp-content/uploads/5-27-26-Govt-Affairs-Alert_-Iowa-Nebraska-Senior-Exploitation-MLR-1.pdf) on senior exploitation risks in Iowa and Nebraska. [Read more](https://content.govdelivery.com/accounts/IACIO/bulletins/41ec1e0)… \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a59ee231-0718-f09f-54a7-8d3ca68ea73c.jpg) \| \| \|:-:\| \| \| \| # **Texas DOI Names New Chief Prosecutor and Fraud Counsel** Patrick Cryer has become the Texas Department of Insurance’s new Chief Prosecutor and Fraud Counsel, aiming to strengthen insurance fraud enforcement statewide, including expanding prosecution resources to underserved rural areas. He says insurance fraud raises costs for all Texans through higher premiums and hopes to increase public awareness while ensuring more fraud cases are investigated and prosecuted… [Read more](https://www.tdi.texas.gov/blog/chief-prosecutor-to-strengthen-fraud-enforcement.html)… # **Settlement Announced in Medical Billing Fraud Case** San Francisco District Attorney Brooke Jenkins announced a $3.325 million civil settlement with Circle Medical to resolve allegations of medical billing fraud. The settlement was reached in partnership with the California Department of Insurance and the U.S. Attorney’s Office for the Northern District of California, and involves Circle Medical’s California entities and its Chief Medical Officer, Dr. Nicole Tsang… [Read more](https://cslea.com/2026/07/settlement-announced-in-medical-billing-fraud-case-against-circle-medical/)… **July is National Vehicle Theft Prevention Month** A vehicle is stolen in the U.S. every 48 seconds, making auto theft a costly crime that drives up insurance premiums for everyone. During National Vehicle Theft Prevention Month each July, the National Insurance Crime Bureau (NICB) partners with the National Highway Traffic Safety… [Read more](https://www.nicb.org/national-vehicle-theft-prevention-month-tips)… \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/28c467dc-8276-830d-664e-03edc5954526.jpg) \| \| \|:-:\| \| \| \| *The arrest summaries in Fraud News Weekly are compiled from publicly available news sources. Individuals mentioned are presumed innocent until proven guilty in a court of law.* \| \| \|---\| \| \|---\| \| \| \| \| \|---\| \| \| \| **HEALTHCARE** **July 7 – Minnesota – Nationwide health insurance bait-and-switch scheme leads to guilty pleas** Arthur Walsh pleaded guilty in federal court to conspiracy and wire fraud charges for masterminding a nationwide bait-and-switch operation. His company, Seguro Medico, used unlicensed agents and deceptive scripts to trick up to 1,000 state consumers into purchasing bare-bones plans disguised as comprehensive health insurance. The state regulatory agency fined the entities $150,000… [Read more](https://kstp.com/kstp-news/local-news/minnesota-orders-150k-fine-for-health-insurance-company-charged-in-fraud-scheme/) **WORKERS’ COMPENSATION** **June 29 – Massachusetts – Roofing company owner indicted for $584K workers’ compensation insurance premium scam** Craig Galligan underreported payroll payments for his company, The Roof Kings, LLC, to evade higher insurance premiums. He hid more than $1.5 million in labor costs from A.I.M. Mutual Insurance Companies during multiple audits. Investigators later uncovered the undisclosed bank transactions… [Read more](https://www.mass.gov/news/ags-office-secures-indictments-against-quincy-roofing-company-and-owner-for-workers-compensation-insurance-fraud-and-larceny) \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/f64d0d16-cc76-6149-b007-5b99b4dcf4c0.jpg) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/54774644-97aa-f04e-7b79-a07f2d452cad.png) \| \| \|:-:\| \| \| \| A referral must do more than report suspicion. It must provide fraud bureaus with the specific data required to thoroughly evaluate an allegation. This webinar features state fraud bureau directors discussing the Coalition’s [Fraud Referral Guidance Resource](https://insurancefraud.org/wp-content/uploads/Coalition-Fraud-Referral-Guide.pdf). Speakers will provide practical guidance on what critical information to include in a referral, how state bureaus evaluate incoming allegations, common issues that create challenges for bureaus, and referral issues that raise compliance concerns for insurers. Industry investigators will gain the necessary insights to improve submission quality and help fraud bureaus assess suspected insurance fraud effectively. \| \| \|---\| \| \|---\| \| \| [Click here to register](https://us02web.zoom.us/webinar/register/WN_5KkwcHdBTUSO5s0QqbVfDw) \| \| \|\| \| \|:-:\| \| \| \| \| \|---\| \| \| \| # **Evadata Webinar Highlights Top Insurance Fraud Trends** More than 350 registered to attend the Coalition’s June 26th webinar with Evadata. Thank you to all who participated, and a special thanks to Jake Obstfeld and Wesley Abraham for sharing their expertise on current fraud trends affecting the life, annuity, and disability insurance industries. The webinar explored five critical fraud trends: check fraud, vulnerable adult fraud, account takeovers, disability claim fraud, and life insurance claim fraud, emphasizing the need for industry collaboration. Key prevention strategies shared included implementing Positive Pay services and transitioning away from paper checks to combat check fraud, alongside enhanced employee training and activity monitoring to protect vulnerable adults from financial exploitation. For those who were unable to attend or would like to review the presentation, the webinar recording and materials are available on the [Coalition’s website](https://insurancefraud.org/podcasts-videos/). \| \| \|---\| \| \|---\| \| \| \| \| \|---\| \| \| \| \| \| \| \| \| \| \| \| \| \| # **Staffing Change** Joe Matos, Head of Communications, concluded his time with the Coalition on July 8 after four years of service. We thank Joe for his contributions and wish him all the best in his future endeavors. Members with communications-related needs or questions are encouraged to contact the Coalition at **Communications@insurancefraud.org.** \| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| [](https://members.insurancefraud.org/general/register_member_type.asp)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/4e08fedc-6fea-9426-9143-d421962a8d68.jpg) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/9d9a163b-d608-c29e-1f8c-71c58f193f3a.jpg) \| \| \|:-:\| \| \| \| - **July 15 –** [Joint NYACT – NYSSIU Summer Conference](https://www.nyact.org/index.php?option=com_jevents&task=icalrepeat.detail&evid=69&Itemid=115&year=2026&month=07&day=15&title=joint-nyact-nyssiu-summer-conference-&uid=861099eeba073224bd2540ed64857c15) – NYACT - **July 20 – 22** – [The 2026 Florida Insurance Fraud Education Committee and 34th Annual Conference](https://www.fifec.org/registration) – FIFEC - **August 4** – [Recorded Statements That Win](https://events.teams.microsoft.com/event/bcf53ee1-b34e-455a-ba65-bcea2b520593@aa3f6158-a750-475d-a17c-8438fe053836/registration) – Becker & Company \| \| \|---\| \| \|---\| \| [](https://s.surveyplanet.com/bj1sw6en)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/82bc7396-3a2d-5c34-e4ff-a1d3855f62d0.jpg) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/b99b7c25-65ae-cd0c-1e44-8d51b81e8021.jpg) \| \| \|:-:\| \| \| \| \| \|---\| \| \| \| **Follow Us On Our Social Media Platforms:** \| \| \|---\| \| \|---\| \| [](https://www.linkedin.com/company/coalition-against-insurance-fraud/)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/148b79cf-2c06-6469-b7c8-335c1c8b971a.jpg) \| \| \|:-:\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| \| \| \| \| \| [](https://www.facebook.com/profile.php?id=61579225779934)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/39ae0e7d-0388-20e5-5755-020aec6cf995.jpg) \| \| \|:-:\| \| [](https://www.instagram.com/stopinsurancefraud/)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/86c49df9-4380-51e5-da9c-f83034fc7555.jpg) \| \| \|:-:\| \| \| \| \| \| ![Logo](https://brand-assets.mailchimp.com/01KKVRP4PEH4PWEG0R0VSKKJ7H.png) \| \| \|:-:\| \| \| \| *Copyright (C) 2026 Coalition Against Insurance Fraud. All rights reserved.* You are receiving this email because either your organization is a member of the Coalition Against Insurance Fraud or you requested to be placed on our mailing list. Our mailing address is: Coalition Against Insurance Fraud 1012 14th St NW Ste 610 Washington, DC 20005-3424 USA Want to change how you receive these emails? You can [update your preferences](https://insurancefraud.mailchimpsites.com/manage/preferences?u=a440c5b647697de580a2fd586&id=b68dce7808&e=%5BUNIQID%5D&c=5033d7b31a) or [unsubscribe](https://insurancefraud.us1.list-manage.com/unsubscribe?u=a440c5b647697de580a2fd586&id=b68dce7808&t=b&e=%5BUNIQID%5D&c=5033d7b31a) \| \| \|:-:\| \| \|---\| \| \| \| \|---\| \| \|:-:\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| | |:-:| <html><p class="wp-block-paragraph"></p> **Features:** Fraud News Weekly --- ### [Fraud News Weekly (FNW) Friday, June 26, 2026](https://insurancefraud.org/publications/fraud-news-weekly-fnw-friday-june-26-2026/) **Published:** June 26, 2026 **Author:** Joseph Matos **Content:** Fraud News Weekly (FNW) – Friday, June 26, 2026͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ | \| \| \| \| \| \| \| [View this email in your browser](https://mailchi.mp/ffa4f5d3d572/fraud-news-weekly-friday-may-1-10704550?e=%5BUNIQID%5D) \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| \| \| \| \| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/c2fb469c-5c82-bc00-0da9-bd1b44579f70.png) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/b12c86f4-ca16-743b-70dd-c690ceae327d.jpg) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a417349b-dfdc-a052-790d-07cfde53b716.jpg) \| \| \|:-:\| \| \| \| **ADVOCACY** **Texas Department of Insurance issues artificial intelligence guidance for insurers and regulated entities.** The Texas Department of Insurance issued [Bulletin B-0003-26](https://www.tdi.texas.gov/bulletins/2026/b-0003-26.html) outlining expectations for the use of artificial intelligence by insurers, agents, adjusters, and other regulated entities. The guidance emphasizes that AI supported decisions affecting consumers must comply with existing laws governing unfair trade practices, claims handling, discrimination, and market conduct. TDI expects companies to maintain governance and risk management controls, conduct human review of consequential AI driven decisions, and provide documentation during examinations or investigations. The bulletin also cites the National Association of Insurance Commissioners’ Principles on Artificial Intelligence as a framework for responsible AI use and consumer protection. [Read more](https://content.naic.org/sites/default/files/inline-files/AI%20principles%20as%20Adopted%20by%20the%20TF_0807.pdf)… **Alaska airbag fraud provisions become law through omnibus crime bill.** Alaska House Bill 239 became law June 18 after Governor Mike Dunleavy’s deadline to act expired without a signature. The legislation includes airbag fraud provisions originally introduced in House Bill 74 and supported [previously](https://insurancefraud.org/wp-content/uploads/3-13-2026-Coalition-Support-of-Alaska-HB-74.pdf) and [recently](https://insurancefraud.org/wp-content/uploads/5-21-2026-Coalition-Support-of-Airbag-Fraud-Provisions-in-Alaska-HB-239.pdf) by the Coalition. The new law criminalizes the manufacture, sale, installation, or concealment of counterfeit or nonfunctioning airbags, helping protect consumers from dangerous vehicle repairs and related fraud schemes. Alaska joins more than 30 states with similar protections. [Read more](https://www.akleg.gov/PDF/34/Bills/HB0239Z.PDF)… **Louisiana Senate confirms insurance department leaders, including fraud bureau chief.** The Louisiana State Senate confirmed four senior appointments at the Louisiana Department of Insurance, including Dominique Jones as deputy commissioner for the Office of Insurance Fraud. Jones recently attended the Coalition’s Midyear Meeting, where fraud fighters discussed emerging trends and antifraud initiatives. [Read more](https://www.ldi.la.gov/news/press-releases/6-11-26-louisiana-state-senate-confirms-four-key-leadership-appointments-at-the-department-of-insurance)… **Washington launches first insurance fraud prosecution under new county partnership.** The Pierce County Prosecuting Attorney’s Office filed its first insurance fraud charges under a new partnership with the Washington State Office of the Insurance Commissioner. Funded by the Legislature in 2025, the program supports prosecution of fraud referrals and is designed to strengthen consumer protection and reduce fraud related insurance costs. [Read more](https://www.insurance.wa.gov/about-us/news/2026/pierce-county-prosecutes-first-insurance-fraud-case-under-partnership-oic)… \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a59ee231-0718-f09f-54a7-8d3ca68ea73c.jpg) \| \| \|:-:\| \| \| \| **Insurance agents adopt AI faster than firms can govern it** Insurance agencies are rapidly adopting AI, with 64% already using it and 98% planning further investment, yet only 13% have formal AI governance policies in place. This gap presents a growing challenge for insurance fraud professionals, as AI is accelerating both… [Read more](https://eciks.org/10352-70607-insurance-agents-ai-adoption-governance)… **Synthetic Evidence, Real Losses: The Growing AI Fraud Challenge** Insurance fraud professionals have been tracking manipulated digital evidence for years, but generative AI is dramatically lowering the barrier to entry and increasing the sophistication of synthetic claim documentation. What once required specialized… [Read more](https://insurancenewsnet.com/innarticle/ai-created-images-in-insurance-fraud-and-the-impacts-on-clients-advisors)… \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/28c467dc-8276-830d-664e-03edc5954526.jpg) \| \| \|:-:\| \| \| \| *The arrest summaries in Fraud News Weekly are compiled from publicly available news sources. Please note that all individuals mentioned are presumed innocent until proven guilty in a court of law.* \| \| \|---\| \| \|---\| \| \| \| \| \|---\| \| \| \| **UNEMPLOYMENT FRAUD** **June 19 – Wyoming – Cheyenne woman sentenced for falsifying unemployment insurance claims** Lisa Valencia pleaded guilty to two felony counts of unemployment insurance fraud following an investigation by the Wyoming Department of Workforce Services (DWS). District Judge Robin Cooley handed down concurrent prison terms and ordered her to repay DWS more than… [Read more](https://www.wyomingnewsnow.tv/news/workforce-services-conducts-felony-fraud-investigation-leads-to-sentencing-of-cheyenne-woman/article_3f605475-c5d6-4b55-be84-939f3ec4da84.html)… **HEALTHCARE** **June 21 – Illinois – Federal jury convicts former owner of chiropractic business in $600K insurance fraud scheme** Seung Han Lim was convicted by a federal jury on 14 counts of health care fraud for submitting more than $600,000 in false billing claims. Lim operated Movement Health and Rehab, also known as Motu Chiropractic and Motu Chiromassage, in Libertyville. Investigators discovered that between 2016 and 2019, Lim routinely… [Read more](https://www.lakemchenryscanner.com/2026/06/21/federal-jury-convicts-former-owner-of-chiropractic-business-in-libertyville-of-defrauding-insurance-out-of-600k/)… **HEALTHCARE** **June 22 – Florida – Fugitive captured in Turkey and returned to U.S. to face $3.7B Medicare fraud charges** Ibrahim Khaldoon Hilmi was returned to the United States following an international manhunt and a foreign transfer-of-custody operation. The suspect had been on the run since May 2025 after being accused of helping mastermind a massive $3.7 billion health care scam, one of the largest Medicare fraud schemes in… [Read more](https://www.foxnews.com/us/fbi-brings-back-fugitive-accused-37b-medicare-fraud-scheme-capture-turkey)… **HEALTHCARE** **June 22 – Illinois – Two individuals charged in Madison County in multiyear managed health care fraud scheme** Collinsville man and a St. Louis woman were charged after allegedly defrauding Meridian Health Plan of Illinois, the State of Illinois, and the Illinois Medicaid Managed Care Program of between $10,000 and $100,000 between May 2024 and July 2025. The pair face felony charges including managed health care fraud, theft, conspiracy to… [Read more](https://insurancenewsnet.com/oarticle/collinsville-man-st-louis-woman-charged-in-illinois-health-fraud-case)… **AGENT MISCONDUCT** **June 23 – Utah – Coalition member Utah Insurance Department Fraud Division intercepts unlicensed “ghost broker” in $832K scheme** Carlos David Garcia Gonzalez was arrested at his home in Liberty Hills, Texas, following a 14-month, multi-agency investigation led by the Utah Insurance Department Fraud Division. Authorities said that between January 2023 and January 2026, Gonzalez led a large-scale “ghost broker” scheme targeting predominantly Hispanic victims residing in Utah and operating… [Read more](https://insurance.utah.gov/insurance-fraud-division-stops-ghost-broker/)… **HEALTHCARE** **June 23 – Washington, D.C. – Historic Department of Justice takedown charges 455 individuals in $6.5B health care fraud sweep** The Justice Department announced a massive national enforcement action resulting in criminal charges against 455 defendants, including 90 doctors, across 56 federal districts. The coordinated sweep targeted widespread insurance fraud networks that submitted more than $6.5 billion in false claims. The historic crackdown led to the seizure of more than $182 million in… [Read more](https://www.justice.gov/opa/pr/national-health-care-fraud-takedown-results-455-defendants-charged-connection-over-65)… **HEALTHCARE** **June 23 – Texas – North Texas health care sweep nets 13 defendants in more than $365M in fraudulent insurance claims** Federal prosecutors charged 13 individuals, including doctors and other medical professionals, as part of the 2026 National Health Care Fraud Takedown. The coordinated enforcement action exposed seven localized schemes that collectively billed more than $365 million in… [Read more](https://www.wfaa.com/article/news/crime/13-i-doctors-charged-north-texas-health-care-fraud-scheme/287-55709695-a621-4023-87d8-436428893349)… **LIFE INSURANCE** **June 25 – Florida – Broward County husband and wife arrested for executing multiyear group life insurance fraud ring** Phillip Salvatore Nunzio Jr., 59, and Christine Ann Nunzio, 56, were arrested by the Florida Department of Financial Services’ Criminal Investigations Division for a scheme to defraud Mutual of Omaha and Lincoln Financial Group. They enrolled nonconsenting individuals in group life insurance policies, pocketing… [Read more](https://www.local10.com/news/local/2026/06/25/broward-couple-accused-in-yearslong-insurance-fraud-scheme/)… \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/f64d0d16-cc76-6149-b007-5b99b4dcf4c0.jpg) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/54774644-97aa-f04e-7b79-a07f2d452cad.png) \| \| \|:-:\| \| \| \| A referral must do more than report suspicion. It must provide fraud bureaus with the specific data required to thoroughly evaluate an allegation. This webinar features state fraud bureau directors discussing the Coalition’s Fraud Referral Guidance Resource. Speakers will provide practical guidance on what critical information to include in a referral, how state bureaus evaluate incoming allegations, common issues that create challenges for bureaus, and referral issues that raise compliance concerns for insurers. Industry investigators will gain the necessary insights to improve submission quality and help fraud bureaus assess suspected insurance fraud effectively. \| \| \|---\| \| \|---\| \| \| [Click here to register](https://us02web.zoom.us/webinar/register/WN_5KkwcHdBTUSO5s0QqbVfDw) \| \| \|\| \| \|:-:\| \| \| \| \| \|---\| \| [](https://members.insurancefraud.org/general/register_member_type.asp)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/4e08fedc-6fea-9426-9143-d421962a8d68.jpg) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/9d9a163b-d608-c29e-1f8c-71c58f193f3a.jpg) \| \| \|:-:\| \| \| \| - **June 30** – [Not Buying It: Protecting consumers from deceptive ads and misinformation ](https://register.gotowebinar.com/register/1233946071635117910)– Consumer Action - **July 9 –** 2026 – [SCFIA Anti-Fraud Conference](https://scfia.org/) – Southern California Fraud Investigators Association - **July 9 –** [Before AI, Before Analytics: Get the Entity Right](https://www.quantexa.com/events/register/before-ai-before-analytics-get-the-entity-right/?utm_campaign=701Nz00000qlByF&utm_medium=email&_hsenc=p2ANqtz-_2Q6libWPdBdfo_XZ0tmnewKi4KQoPoAJtqt0KhopyQFE0gSJ9qBfQX0RR7KWzD5W7hXvK5DCLr36N5kOQzksfYemzhw&_hsmi=422179572&utm_source=hs_email) – Quantexa - **July 15 –** [Joint NYACT – NYSSIU Summer Conference](https://www.nyact.org/index.php?option=com_jevents&task=icalrepeat.detail&evid=69&Itemid=115&year=2026&month=07&day=15&title=joint-nyact-nyssiu-summer-conference-&uid=861099eeba073224bd2540ed64857c15) – NYACT - **July 20 – 22** – [The 2026 Florida Insurance Fraud Education Committee and 34th Annual Conference](https://www.fifec.org/registration) – FIFEC - **August 4** – [Recorded Statements That Win](https://events.teams.microsoft.com/event/bcf53ee1-b34e-455a-ba65-bcea2b520593@aa3f6158-a750-475d-a17c-8438fe053836/registration) – Becker & Company \| \| \|---\| \| \|---\| \| [](https://s.surveyplanet.com/bj1sw6en)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/82bc7396-3a2d-5c34-e4ff-a1d3855f62d0.jpg) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/b99b7c25-65ae-cd0c-1e44-8d51b81e8021.jpg) \| \| \|:-:\| \| \| \| \| \|---\| \| \| \| **Follow Us On Our Social Media Platforms:** \| \| \|---\| \| \|---\| \| [](https://www.linkedin.com/company/coalition-against-insurance-fraud/)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/148b79cf-2c06-6469-b7c8-335c1c8b971a.jpg) \| \| \|:-:\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| \| \| \| \| \| [](https://www.facebook.com/profile.php?id=61579225779934)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/39ae0e7d-0388-20e5-5755-020aec6cf995.jpg) \| \| \|:-:\| \| [](https://www.instagram.com/stopinsurancefraud/)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/86c49df9-4380-51e5-da9c-f83034fc7555.jpg) \| \| \|:-:\| \| \| \| \| \| ![Logo](https://brand-assets.mailchimp.com/01KKVRP4PEH4PWEG0R0VSKKJ7H.png) \| \| \|:-:\| \| \| \| *Copyright (C) 2026 Coalition Against Insurance Fraud. All rights reserved.* You are receiving this email because either your organization is a member of the Coalition Against Insurance Fraud or you requested to be placed on our mailing list. Our mailing address is: Coalition Against Insurance Fraud 1012 14th St NW Ste 610 Washington, DC 20005-3424 USA Want to change how you receive these emails? You can [update your preferences](https://insurancefraud.mailchimpsites.com/manage/preferences?u=a440c5b647697de580a2fd586&id=b68dce7808&e=%5BUNIQID%5D&c=f6ae94f147) or [unsubscribe](https://insurancefraud.us1.list-manage.com/unsubscribe?u=a440c5b647697de580a2fd586&id=b68dce7808&t=b&e=%5BUNIQID%5D&c=f6ae94f147) \| \| \|:-:\| \| \|---\| \| \| \| \|---\| \| \|:-:\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| | |:-:| **Features:** Fraud News Weekly --- ### [Fraud News Weekly (FNW) Friday, June 12, 2026](https://insurancefraud.org/publications/fraud-news-weekly-fnw-friday-june-12-2026/) **Published:** June 12, 2026 **Author:** Joseph Matos **Content:** Fraud News Weekly (FNW) – Friday, June 12, 2026͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ | \| \| \| \| \| \| \| [View this email in your browser](https://mailchi.mp/086409bcb20e/fraud-news-weekly-friday-may-1-10704444?e=%5BUNIQID%5D) \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| \| \| \| \| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/8d27ad65-ebbb-8ea6-0d58-6ae6451992f0.jpg) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a84038d5-6f92-80ca-540f-1b45cae29d65.jpg) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a417349b-dfdc-a052-790d-07cfde53b716.jpg) \| \| \|:-:\| \| \| \| **Coalition supports California Senate Bill 536 to strengthen workers’ compensation premium fraud investigations.** This week, the Coalition endorsed pending California Senate Bill 536, which would strengthen workers’ compensation premium fraud investigations by allowing insurers to verify payroll tax information through the California Employment Development Department when fraud is suspected, while maintaining strict privacy protections. The Coalition submitted a [letter of support](https://insurancefraud.org/wp-content/uploads/6-8-2026-Coalition-Support-of-California-SB-536.pdf), stating the measure provides a balanced approach that improves fraud detection, protects confidential employer information, and complies with federal privacy requirements. [Read more](https://leginfo.legislature.ca.gov/faces/billNavClient.xhtml?bill_id=202520260SB536)… **California reminds insurers of SIU annual report deadline and training dates.** California insurers should [register](https://click-1686174.icptrack.com/icp/relay.php?r=60677112&msgid=273912&act=9KRF&c=1686174&pid=3727670&destination=https%3A%2F%2Fstaticapp.icpsc.com%2Ficp%2Fresources%2Fmogile%2F1686174%2F1e4f321916fe990bea25b5175db70efc.pdf%3Ff_type%3Dfile%26f_name%3DeSIUAR%2520Registration%2520Process%2520-%25206-10.pdf&cf=10321&v=3acf267d05b7155b3b0cff03a5922c045b1476a7f3d317df8ad173fe79ad73f7) now for the updated Special Investigative Unit annual report portal before filing their required 2025 SIU Annual Report. Reports are due by September 15, 2026, with no changes to reporting requirements. The California Department of Insurance will offer training on the new portal July 15 and September 2. Attendance is encouraged because recordings will not be available. [Read more](https://www.insurance.ca.gov/0300-fraud/0100-fraud-division-overview/12-siu/2026-SIU-E-Blasts.cfm)… **Coalition monitors NAIC privacy revisions and market regulation modernization efforts.** The Coalition recently attended and continued to monitor two recent National Association of Insurance Commissioners meetings with potential implications for insurers and antifraud programs. Last week, the Privacy Protections (H) Working Group continued revising the Privacy of Consumer Information Act and adopted clarifying language stating the model neither creates nor limits existing private causes of action. This week, the Market Conduct Regulation Modernization (D) Working Group gave time for life insurers, specialty lines, and Insurtech to provide feedback, including comments on standardizing market conduct data calls, examination procedures, complaint reporting, interstate coordination, and oversight of third party administrators, issues that closely parallel insurer antifraud plans and annual fraud reporting. Read more about the NAIC [privacy efforts](https://content.naic.org/committees/h/privacy-protections-wg) or [market conduct modernization](https://content.naic.org/committees/d/market-conduct-regulation-modernization-wg)… \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a59ee231-0718-f09f-54a7-8d3ca68ea73c.jpg) \| \| \|:-:\| \| \| \| **Coalition partner, National Insurance Crime Bureau, warns consumers about surging post-disaster contractor fraud** David J. Glawe, president and chief executive officer of the National Insurance Crime Bureau (NICB), issued an urgent alert as weather-driven catastrophes grow more frequent. The organization is deployed in storm-prone zones to combat unethical operators who exploit property owners following major disasters. Reports of contractor scams surged by 38% over the past three years, prompting investigators to track fraudulent networks that… [Read more](https://markets.businessinsider.com/news/stocks/national-insurance-crime-bureau-shares-tips-for-avoiding-fraud-and-scams-after-a-natural-disaster-with-yourupdatetv-1036236557)… \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/28c467dc-8276-830d-664e-03edc5954526.jpg) \| \| \|:-:\| \| \| \| *The arrest summaries in Fraud News Weekly are compiled from publicly available news sources. Please note that all individuals mentioned are presumed innocent until proven guilty in a court of law.* \| \| \|---\| \| \|---\| \| \| \| \| \|---\| \| \| \| **AGENT MISCONDUCT** **June 4 – Georgia – Former insurance agency owner indicted for pocketing premiums and issuing fake certificates** Charles Curtis Poteet IV was indicted by a grand jury on four counts of insurance fraud for stealing commercial insurance premium payments from multiple small business owners. Poteet operated Poteet & Poteet and allegedly issued fraudulent certificates of insurance for workers’ compensation, automobile, general liability, and umbrella policies while converting the funds for… [Read more](https://www.atlantanewsfirst.com/2026/06/05/former-metro-atlanta-insurance-business-owner-indicted-fraud-charges-after-anf-investigation/)… **HEALTHCARE** **June 5 – Connecticut – Former behavioral analyst sentenced for $102K Medicaid fraud scheme** Glenroy Patterson was sentenced to a three-year prison term and five years of conditional discharge for billing the state for behavioral analysis services that never occurred. The provider owned Trading Spaces ABA, LLC and pocketed $102,084 by submitting false autism therapy claims to the Department of Social Services. His guilty plea automatically… [Read more](https://www.fox61.com/article/news/national/bcba-from-new-jersey-sentenced-in-hartford-for-102k-health-insurance-fraud-scheme/520-9a234c3f-5406-4355-b1f3-d6224227129e)… **LIFE INSURANCE** **June 5 – Georgia – Man convicted of insurance fraud in funeral home investigation faces dozens of charges** James A. Sirmans was convicted by a jury for committing insurance fraud. The Fitzgerald resident altered the cause of death on a 2022 death certificate to fraudulently secure additional life insurance proceeds. His scheme came to light during a broader investigation into a local mortuary where deputies discovered 18 decomposing… [Read more](https://www.walb.com/2026/06/05/man-found-guilty-case-tied-ongoing-coffee-co-funeral-home-investigation/)… **PROPERTY & CASUALTY** **June 6 – North Carolina – Raleigh couple face felonies for filing duplicate $30K property insurance claim** North Carolina Insurance Commissioner Mike Causey announced the arrests of Gurjant Singh Gill and Karmpreet Kaur Gill. Special agents with the North Carolina Department of Insurance Criminal Investigations Division allege the couple submitted duplicate insurance claims with Homesite Insurance and State Farm… [Read more](https://www.springhopeenterprise.com/news/special-agents-charge-raleigh-couple-with-insurance-fraud-scheme-db1fe7dd/)… **HEALTHCARE** **June 8 – Massachusetts – Former physician gets over four years in prison for healthcare fraud and tax evasion** Pankaj Merchia was sentenced to 58 months in prison and ordered to pay nearly $2 million dollars in restitution for conducting multiple healthcare fraud schemes. The doctor billed insurance providers for phantom medical equipment rentals and bypassed family billing restrictions by creating a sham… [Read more](https://www.justice.gov/usao-ma/pr/former-brookline-doctor-sentenced-more-four-years-prison-health-care-fraud-and-tax-fraud)… **AGENT MISCONDUCT** **June 8 – Florida – Insurance agent facing felony charges for pocketing $90K in premium payments** Checree Bryant was arrested after investigators discovered she pocketed commercial bond premiums instead of forwarding them to Old Republic Surety Company. The Palm Beach Gardens agent ran Innovative Bonding Services LLC and collected the funds from two construction firms. Bank records revealed she spent the money on… [Read more](https://cbs12.com/news/local/south-florida-news-insurance-agent-in-palm-beach-county-accused-of-keeping-90k-meant-for-coverage-department-of-financial-services-north-palm-beach-old-republic-surety-company-bonds-florida-department-of-financial-services-criminal-investigations)… **HEALTHCARE** **June 9 – Oklahoma – Attorney General’s Medicaid fraud control unit cracks down; secures conviction and guilty plea** Janice Cliver-Dudash and Maria Dianda were ordered to pay more than $85,000 in restitution after separate Oklahoma Medicaid fraud cases involving fraudulent billing, identity theft, and claims for services not provided. Investigators found Cliver-Dudash billed Medicaid for… [Read more](https://oklahoma.gov/oag/news/newsroom/2026/june/medicaid-fraud-investigations-lead-to-conviction-guilty-plea.html)… **UNEMPLOYMENT INSURANCE FRAUD** **June 9 – Virginia – Man sentenced to over four years in prison for $221K pandemic unemployment insurance fraud scheme** Dashawn Hunter was sentenced to four years and three months in federal prison for running an unemployment insurance benefit fraud conspiracy. He used stolen personal identity information from state prison inmates to submit fraudulent benefit applications to the… [Read more](https://www.wric.com/news/local-news/louisa-county/mineral-man-sentenced-unemployment-fraud/)… **HEALTHCARE** **June 10 – Illinois – Jacksonville chiropractor gets federal prison sentence for stealing more than $250K** Sean Rondeau was sentenced to a year and a day in federal prison after pleading guilty to healthcare fraud, mail fraud, and wire fraud. The provider submitted more than 2,000 separate fraudulent claims to Blue Cross Blue Shield of Illinois. When the insurer requested documentation to verify his bills, he leveraged relationships with patients to… [Read more](https://www.justice.gov/usao-cdil/pr/jacksonville-chiropractor-sentenced-year-prison-healthcare-fraud-and-related-offenses)… **AUTO – STAGED ACCIDENT** **June 10 – California – Road rage incident leads to insurance fraud conviction** Ken Pham Tran was convicted of felony insurance fraud after hiding his role in a staged road rage crash. He brake-checked a commercial semi-truck three times on Highway 101, causing a collision caught on dashcam. He then blamed the other driver to claim vehicle damages from Progressive Insurance, leaving him… [Read more](https://www.carriermanagement.com/news/2026/06/10/288928.htm)… \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/f64d0d16-cc76-6149-b007-5b99b4dcf4c0.jpg) \| \| \|:-:\| \| \| ![](https://dim.mcusercontent.com/cs/a440c5b647697de580a2fd586/images/01a06098-d374-4b85-c3f8-455957f6b6ff.jpg?dpr=2&rect=0%2C0%2C600%2C785&w=600&h=785) \| \| \|:-:\| \| \| \| Understanding life, disability and annuity fraud starts with knowing the patterns and warning signs to watch for. On June 25 at 2 p.m. EST, the Coalition will host a webinar examining five fraud trends emerging with life, disability and annuity products. Evadata representatives Jake Obstfeld, Rob Strange, and Wesley Abraham will walk attendees through each trend, explain the red flags that may indicate suspicious activity, and share considerations for identifying and reducing risk. This webinar is designed for insurers, regulators, investigators, consumers, and others who want to better understand how life and annuity fraud schemes may develop, why these risks matter, and what warning signs should not be overlooked. \| \| \|---\| \| \|---\| \| \| [Click here to register](https://us02web.zoom.us/webinar/register/WN_-M4eJqIcQmq_j5GDIff5aw) \| \| \|\| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a4e430c0-c419-3044-1add-d368ddda9e22.jpg) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/47a71a8c-1901-c2bf-d5b9-4b963e0021dc.png) \| \| \|:-:\| \| \| \| Equifax is proud to join the Coalition and become part of a distinct network dedicated to combating insurance fraud and protecting consumers. As fraud activities continue to grow in sophistication, we recognize the importance of bringing together industry leaders, insurers, government agencies and technology providers to share insights and develop effective solutions. At Equifax, we help organizations make more informed decisions through data, analytics, and technology. Our work in identity verification, fraud prevention, and risk management provides valuable tools to help businesses detect suspicious activity, mitigate risk, and improve operational efficiency. These capabilities can help support the Coalition’s mission to reduce the impact of insurance fraud on consumers, insurers, and the broader marketplace. Insurance fraud remains a significant challenge that affects individuals, businesses, and communities across the country. Addressing this issue requires innovation and a proactive approach to identifying emerging threats. Together, we can help protect consumers, strengthen confidence in the insurance system, and drive positive outcomes for the industry. \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/18f9920e-e738-5103-cd8e-7ba476e9eb86.jpg) \| \| \|:-:\| \| \| \| \| \| \| \| \| \| \| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/ffaf5da7-f7d4-5bc9-affa-9e9c0aeb3cfc.jpg) \| \| \|:-:\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \| \| **Executive Director – Michelle Rafeld** \| \| \|---\| \| \|---\| \| \| \| **We look forward to seeing you on Monday!** **2026 Midyear Meeting in New Orleans** **June 15 – 16** \| \| \|---\| \| \|---\| \| \| \| We are just three days away from the Midyear Meeting, and look forward to seeing you in the Big Easy. Visit the Coalition website’s [Know Before You Go](https://members.insurancefraud.org/general/custom.asp?page=2026MidyearMeeting) section for travel and meeting details. \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/b69c6595-0760-ad0d-a8ee-f022ae1d34fc.jpg) \| \| \|:-:\| \| \| \| \| \|---\| \| [](https://members.insurancefraud.org/general/register_member_type.asp)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/4e08fedc-6fea-9426-9143-d421962a8d68.jpg) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/9d9a163b-d608-c29e-1f8c-71c58f193f3a.jpg) \| \| \|:-:\| \| \| \| - **June 17 –** [In Case You Missed It: Organized Crime Webinar REPLAY](https://us02web.zoom.us/webinar/register/WN_5KcWM3zfSwy8SnsFtM0h0Q#/registration) – Diligence international Group - **June 24 –** [The Future of Insurance: ​​​How AI is Impacting the Claims Lifecycle](https://event.on24.com/wcc/r/5311439/4CBC1A82414E39B776872259182E9DFC) – ethos - **June 25 –** [Organized Crime Part II: The Mexican Cartels](https://us02web.zoom.us/webinar/register/WN_rIjg5FnUQxe7vV2SLAj5sg#/registration) – Diligence international Group - **June 23** **–** [More Than Just a Selfie: The Power of Social Media in Claims Evaluations](https://share.hsforms.com/1XfYV0y0rTMKqH1Z9XWD5Jgc0z6w?utm_medium=email&_hsenc=p2ANqtz-_5i3HYaW3tYiLr0-a0rzdQ86s_UOHqlJu4fGVd2QBqGb7L19N8Yjo5elO6XCiIpuArZwvT-5tiu_nof1FYhRpvTNcMlACFDCQQeXaVKCcHBbbvUAU&_hsmi=421840547&utm_content=421840547&utm_source=hs_email) – Social Discovery - **June 30** – [Not Buying It: Protecting consumers from deceptive ads and misinformation ](https://register.gotowebinar.com/register/1233946071635117910)– Consumer Action - **July 9 –** 2026 – [SCFIA Anti-Fraud Conference](https://scfia.org/) – Southern California Fraud Investigators Association - **July 9 –** [Before AI, Before Analytics: Get the Entity Right](https://www.quantexa.com/events/register/before-ai-before-analytics-get-the-entity-right/?utm_campaign=701Nz00000qlByF&utm_medium=email&_hsenc=p2ANqtz-_2Q6libWPdBdfo_XZ0tmnewKi4KQoPoAJtqt0KhopyQFE0gSJ9qBfQX0RR7KWzD5W7hXvK5DCLr36N5kOQzksfYemzhw&_hsmi=422179572&utm_source=hs_email) – Quantexa - **July 15 –** [Joint NYACT – NYSSIU Summer Conference](https://www.nyact.org/index.php?option=com_jevents&task=icalrepeat.detail&evid=69&Itemid=115&year=2026&month=07&day=15&title=joint-nyact-nyssiu-summer-conference-&uid=861099eeba073224bd2540ed64857c15) – NYACT - **July 20 – 22** – [The 2026 Florida Insurance Fraud Education Committee and 34th Annual Conference](https://www.fifec.org/registration) – FIFEC \| \| \|---\| \| \|---\| \| [](https://s.surveyplanet.com/bj1sw6en)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/82bc7396-3a2d-5c34-e4ff-a1d3855f62d0.jpg) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/b99b7c25-65ae-cd0c-1e44-8d51b81e8021.jpg) \| \| \|:-:\| \| \| \| \| \|---\| \| \| \| **Follow Us On Our Social Media Platforms:** \| \| \|---\| \| \|---\| \| [](https://www.linkedin.com/company/coalition-against-insurance-fraud/)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/148b79cf-2c06-6469-b7c8-335c1c8b971a.jpg) \| \| \|:-:\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| \| \| \| \| \| [](https://www.facebook.com/profile.php?id=61579225779934)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/39ae0e7d-0388-20e5-5755-020aec6cf995.jpg) \| \| \|:-:\| \| [](https://www.instagram.com/stopinsurancefraud/)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/86c49df9-4380-51e5-da9c-f83034fc7555.jpg) \| \| \|:-:\| \| \| \| \| \| ![Logo](https://brand-assets.mailchimp.com/01KKVRP4PEH4PWEG0R0VSKKJ7H.png) \| \| \|:-:\| \| \| \| *Copyright (C) 2026 Coalition Against Insurance Fraud. All rights reserved.* You are receiving this email because either your organization is a member of the Coalition Against Insurance Fraud or you requested to be placed on our mailing list. Our mailing address is: Coalition Against Insurance Fraud 1012 14th St NW Ste 610 Washington, DC 20005-3424 USA Want to change how you receive these emails? You can [update your preferences](https://insurancefraud.mailchimpsites.com/manage/preferences?u=a440c5b647697de580a2fd586&id=b68dce7808&e=%5BUNIQID%5D&c=427685826b) or [unsubscribe](https://insurancefraud.us1.list-manage.com/unsubscribe?u=a440c5b647697de580a2fd586&id=b68dce7808&t=b&e=%5BUNIQID%5D&c=427685826b) \| \| \|:-:\| \| \|---\| \| \| \| \|---\| \| \|:-:\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| | |:-:| <html><p class="wp-block-paragraph"></p> **Features:** Fraud News Weekly --- ### [Fraud News Weekly (FNW) Friday, June 5, 2026](https://insurancefraud.org/publications/fraud-news-weekly-fnw-friday-june-5-2026/) **Published:** June 5, 2026 **Author:** Joseph Matos **Content:** Fraud News Weekly (FNW) – Friday, June 5, 2026͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ | \| \| \| \| \| \| \| [View this email in your browser](https://mailchi.mp/ccfd39b5ac1f/fraud-news-weekly-friday-may-1-10704428?e=%5BUNIQID%5D) \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| \| \| \| \| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/d796ed76-e234-a9d3-e93a-8649141b461a.jpg) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a417349b-dfdc-a052-790d-07cfde53b716.jpg) \| \| \|:-:\| \| \| \| **Enacted Connecticut insurance bill removes annual fraud reporting requirements for auto insurers.** Connecticut Governor Ned Lamont signed House Bill 5373 this week, enacting a package of insurance department recommendations that includes repealing the annual insurer fraud reporting requirement tied specifically to motor vehicle insurance claims. The provision had required insurers to submit yearly reports by March 31st to the insurance commissioner summarizing fraud information and investigations involving auto insurance claims. The change does not affect requirements to report suspected fraudulent insurance transactions on individual cases. State officials told the Coalition they still expect referrals through the NICB and the NAIC Online Fraud Reporting System (OFRS). [Read more](https://www.cga.ct.gov/asp/CGABillStatus/cgabillstatus.asp?selBillType=Bill&bill_num=HB05373&which_year=2026)… **New York budget enacts major auto and workers’ compensation antifraud measures after months of Coalition advocacy.** Following weeks of delayed negotiations, New York’s Fiscal Year 2027 Budget includes several [automobile](https://www.governor.ny.gov/news/governor-hochul-signs-budget-makes-new-york-more-affordable-keeps-new-yorkers-safe-and-expands) and [workers’ compensation](https://www.governor.ny.gov/news/governor-hochul-secures-protections-workers-part-fy27-budget) fraud fighting priorities long supported by the Coalition. The enacted provisions strengthen efforts against staged automobile crashes by allowing prosecutors to pursue individuals who organize or orchestrate fraud schemes, not just participating drivers, and by limiting certain recoveries involving criminal conduct. The budget also establishes a $7 million grant program to help district attorneys create dedicated workers’ compensation fraud units and a $5 million grant program supporting criminal wage theft investigations. The Coalition actively supported these measures through advocacy letters, meetings with lawmakers, and participation in Albany legislative events throughout the budget process. [Read more](https://insurancefraud.org/advocacy-efforts/)… **Texas Division of Workers’ Compensation launches new fraud training.** The Texas Department of Insurance Division of Workers’ Compensation Fraud Unit has released a free online training video, “Spotting Fraud in the Texas Workers’ Compensation System,” to help adjusters, special investigative units, and employers identify fraud schemes and warning signs. The training covers employer, health care provider, claimant, and beneficiary fraud, and emphasizes the importance of early detection and reporting. The resource may be useful for Coalition members involved in workers’ compensation fraud prevention and investigations. [Read more](https://tdi.texas.gov/wc/ci/wcfraud.html)… **NAIC AI working group advances AI systems evaluation tool as insurers and regulators address emerging governance risks.** The NAIC Big Data and Artificial Intelligence (H) [Working Group](https://content.naic.org/committees/h/big-data-artificial-intelligence-wg) continued its focus on responsible AI oversight this week, reviewing progress on its AI Systems Evaluation Tool [pilot](https://content.naic.org/sites/default/files/inline-files/Pilot%20Project%20Summary_1.pdf) and discussing governance practices for insurers. Twelve states are now testing the evaluation tool through examinations, surveys, data calls, and other approaches, with updated versions planned through the fall. Discussion this week highlighted emerging risks from agentic AI, including unintended actions and accountability challenges that could create compliance, and consumer protection concerns. The Coalition continues to monitor AI developments as insurers, regulators, and antifraud professionals adapt governance frameworks to address evolving risks and opportunities. [Read more](https://content.naic.org/sites/default/files/call_materials/Slide-Deck-BDAIWG060126%20v1_0.pdf)**…** \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a59ee231-0718-f09f-54a7-8d3ca68ea73c.jpg) \| \| \|:-:\| \| \| \| **Investigative team uncovers 14-claim staged accident fraud ring** Pranay Mittal leads Travelers Investigative Services — a team of investigators, data analysts and forensic specialists. He says insurance fraud is becoming harder to detect as AI-generated documents and organized fraud networks make suspicious claims appear legitimate. Pranay noted that many schemes are only uncovered when investigators identify patterns across multiple claims rather than individual red flags, highlighting the growing role of… [Read more](https://riskandinsurance.com/the-new-face-of-insurance-fraud-looks-just-like-a-legitimate-claim/) **Survey reveals over half of Gen Z would use artificial intelligence to alter insurance claims** Coalition member Verisk shared data that shows 55% of Gen Z consumers would consider using artificial intelligence to alter documents or images for financially favorable claim outcomes. The Consumer Federation of America (CFA), member and Coalition co-founder, noted this trend stems from widespread consumer frustration regarding industry… [Read more](https://www.ibtimes.com/gen-z-using-ai-gamble-insurance-system-exposing-broken-system-3803453#goog_rewarded) \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/28c467dc-8276-830d-664e-03edc5954526.jpg) \| \| \|:-:\| \| \| \| **UNEMPLOYMENT INSURANCE** **May 29 – Indiana – Texas man sentenced to nearly six years in prison for $2.6M multi-fraud scheme** Khalid Ahamad was sentenced to 70 months in prison for leading a highly sophisticated conspiracy that stole millions of dollars from businesses and state taxpayers. Ahamad targeted a company in Fort Wayne using business email compromise scams alongside widespread unemployment insurance fraud. Investigators traced the stolen funds through his bank accounts before he laundered the illicit profits into… [Read more](https://www.wane.com/top-stories/texas-man-sentenced-in-2-6m-fraud-scheme-that-targeted-fort-wayne-business/) **WORKERS’ COMPENSATION** **May 29 – Massachusetts – Lowell business owner pleads guilty in $6.1M insurance fraud scheme** Coalition member, Insurance Fraud Bureau of Massachusetts, assisted in the investigation of Henry Lam, who pleaded guilty in federal court to workers’ compensation fraud, among other charges. The Lowell business owner cashed client checks to pay… [Read more](https://www.insurancejournal.com/news/east/2026/05/29/871771.htm) **AUTO – VEHICLE IDENTIFICATION** **May 29 – Pennsylvania – Fugitive ringleader of $1.6M title-washing organization captured in Philadelphia** Reginald Manson, Jr. was captured after spending two months as a fugitive. A collaborative investigation between the Office of Attorney General’s Organized Crime and Insurance Fraud Sections, Pennsylvania State Police, and Philadelphia Police Department resulted in charges to 10 individuals… [Read more](https://www.attorneygeneral.gov/taking-action/ringleader-of-se-pa-based-1-6m-title-washing-crew-captured-in-philadelphia-10-people-charged-in-thefts-resale-of-50-vehicles/) **AUTO – FALSE CLAIM** **May 29 – South Carolina – Richland County woman charged with forgery and insurance fraud** Jasmine Shada Grate was charged with forgery and presenting a false claim for insurance payment of $10,000 or more. Grate falsified an employment verification letter for a co-conspirator to claim lost wages following an incident. Geico Insurance denied the payout after identifying conflicting details, exposing a sham company that… [Read more](https://www.sled.sc.gov/about/updates/sled-charges-richland-county-woman-insurance-fraud-0) **HEALTHCARE** **June 3 – New York – Healthcare services company settles Medicare fraud lawsuit for $36.5M** Matrix Medical Network settled a civil healthcare fraud lawsuit for $36.5 million to resolve False Claims Act violations. The provider caused Medicare Advantage organizations to submit invalid chronic condition diagnoses, artificially inflating taxpayer-funded insurance payments. Internal quality staff even added high-paying medical codes without nurse practitioner approval, creating a five-year… [Read more](https://www.justice.gov/usao-sdny/pr/united-states-announces-365-million-settlement-medicare-fraud-lawsuit-against-matrix) **UNEMPLOYMENT INSURANCE FRAUD** **June 3 – Georgia – Florida woman convicted for role in $480K multi-state pandemic unemployment insurance scam** Cheryl Galloway coordinated a multi-state scheme to steal pandemic unemployment insurance benefits by submitting fraudulent applications to agencies across at least 40 states. She and her co-conspirators used the postal system to acquire the funds over a two-year period. Galloway faces up to… [Read more](https://www.wsav.com/crime-safety/florida-woman-found-guilty-in-federal-mail-fraud-case-federal-officials-announce/) **LIFE INSURANCE** **June 2 – Pennsylvania – Montgomery County man charged with stealing $100K in life insurance payouts** Christopher O. Johnson was charged with felony financial exploitation after allegedly stealing more than $100,000 intended for his disabled former stepson. The funds originated from life insurance payouts following the death of the teenager’s mother. Investigators arrested the suspect in Upper Pottsgrove Township after discovering… [Read more](https://www.attorneygeneral.gov/taking-action/montgomery-county-man-charged-with-stealing-more-than-100k-from-disabled-former-stepson/) \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a4e430c0-c419-3044-1add-d368ddda9e22.jpg) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/30e45a2f-6689-24d9-4227-b3ea918d94c3.png) \| \| \|:-:\| \| \| \| The Coalition is honored to be part of the Global Insurance Fraud Summit (GIFS), uniting leading international industry organizations, consortiums, insurance fraud and crime bureaus, regulators, and subject matter experts to strengthen and formalize the global fight against insurance fraud. Over the years, GIFS has grown into one of the world’s premier forums dedicated to combating transnational organized crime tied to insurance fraud and vehicle crime. Join GIFS President Dennis Toomey and Executive Director Matthew Smith for the upcoming “**Global Insurance Fraud Summit Midyear Update**,” a global update on the organization’s ongoing anti-fraud initiatives and achievements since the 2025 Summit in Toronto. To accommodate international audiences, the session will be offered twice: - June 9, 2026 \| 12:00–1:00 PM EST / 6:00–7:00 PM CEST - June 10, 2026 \| 2:00–3:00 PM HKT / 8:00–9:00 AM CEST This is a valuable opportunity to hear about GIFS’ recent progress, emerging priorities, and the next steps in the worldwide effort to combat insurance fraud. To learn more and register, visit [the Global Insurance Fraud Summit website](https://www.globalinsurancefraudsummit.org/?utm_source=chatgpt.com) or follow GIFS on [LinkedIn](https://www.linkedin.com/company/global-insurance-fraud-summit/posts/?feedView=all).​ \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/5c4205af-65c6-2e49-9422-0daff19aea21.jpg) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/4efaac97-cdb1-5435-bb2c-2af750d105e5.png) \| \| \|:-:\| \| \| \| **Coalition Welcomes Summer Intern Ryan Perman** The Coalition welcomes Ryan Perman as the new operations and organizational support intern for the summer of 2026. A native of Columbus, Ohio, Ryan is a rising senior at Miami University, majoring in organizational leadership with a minor in business. He will assist the Coalition with projects related to organization, data analytics, and strategic planning over the summer. Ryan will also assist with member outreach, so you may receive a call from him on behalf of the Coalition. When he is not supporting the mission to fight insurance fraud, Ryan spends time with family, works on cars, and plays guitar. Please join the Coalition in welcoming Ryan to the team! \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/18f9920e-e738-5103-cd8e-7ba476e9eb86.jpg) \| \| \|:-:\| \| \| \| **We look forward to seeing you soon!** **2026 Midyear Meeting in New Orleans** **June 15 – 16** \| \| \|---\| \| \|---\| \| \| \| **Know Before You Go** \| \| \|---\| \| \|---\| \| \| \| We are only 11 days away from the Midyear Meeting, and look forward to seeing you in the Big Easy. We want you to be prepared for your travels and experience while in New Orleans. Visit the Coalition website’s [Know Before You Go](https://members.insurancefraud.org/page/know-before-you-go) section for details. \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/b69c6595-0760-ad0d-a8ee-f022ae1d34fc.jpg) \| \| \|:-:\| \| \| \| \| \|---\| \| [](https://members.insurancefraud.org/general/register_member_type.asp)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/4e08fedc-6fea-9426-9143-d421962a8d68.jpg) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/9d9a163b-d608-c29e-1f8c-71c58f193f3a.jpg) \| \| \|:-:\| \| \| \| - **June 9** – [California Fair Claims Act Training 2026](https://go-command.zoom.us/webinar/register/WN_lnl2dpnCRk6VP5_fMPjl-A#/registration) – Command Investigations - **June 23** – [More Than Just a Selfie: The Power of Social Media in Claims Evaluations](https://share.hsforms.com/1XfYV0y0rTMKqH1Z9XWD5Jgc0z6w?utm_medium=email&_hsenc=p2ANqtz-_5i3HYaW3tYiLr0-a0rzdQ86s_UOHqlJu4fGVd2QBqGb7L19N8Yjo5elO6XCiIpuArZwvT-5tiu_nof1FYhRpvTNcMlACFDCQQeXaVKCcHBbbvUAU&_hsmi=421840547&utm_content=421840547&utm_source=hs_email) – Social Discovery - **July 9** – 2026 – [SCFIA Anti-Fraud Conference](https://scfia.org/) – Southern California Fraud Investigators Association - **July 20 – 22** – [The 2026 Florida Insurance Fraud Education Committee and 34th Annual Conference](https://www.fifec.org/registration) – FIFEC \| \| \|---\| \| \|---\| \| [](https://s.surveyplanet.com/bj1sw6en)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/82bc7396-3a2d-5c34-e4ff-a1d3855f62d0.jpg) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/b99b7c25-65ae-cd0c-1e44-8d51b81e8021.jpg) \| \| \|:-:\| \| \| \| \| \|---\| \| \| \| **Follow Us On Our Social Media Platforms:** \| \| \|---\| \| \|---\| \| [](https://www.linkedin.com/company/coalition-against-insurance-fraud/)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/148b79cf-2c06-6469-b7c8-335c1c8b971a.jpg) \| \| \|:-:\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| \| \| \| \| \| [](https://www.facebook.com/profile.php?id=61579225779934)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/39ae0e7d-0388-20e5-5755-020aec6cf995.jpg) \| \| \|:-:\| \| [](https://www.instagram.com/stopinsurancefraud/)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/86c49df9-4380-51e5-da9c-f83034fc7555.jpg) \| \| \|:-:\| \| \| \| \| \| ![Logo](https://brand-assets.mailchimp.com/01KKVRP4PEH4PWEG0R0VSKKJ7H.png) \| \| \|:-:\| \| \| \| *Copyright (C) 2026 Coalition Against Insurance Fraud. All rights reserved.* You are receiving this email because either your organization is a member of the Coalition Against Insurance Fraud or you requested to be placed on our mailing list. Our mailing address is: Coalition Against Insurance Fraud 1012 14th St NW Ste 610 Washington, DC 20005-3424 USA Want to change how you receive these emails? You can [update your preferences](https://insurancefraud.mailchimpsites.com/manage/preferences?u=a440c5b647697de580a2fd586&id=b68dce7808&e=%5BUNIQID%5D&c=2022c9584d) or [unsubscribe](https://insurancefraud.us1.list-manage.com/unsubscribe?u=a440c5b647697de580a2fd586&id=b68dce7808&t=b&e=%5BUNIQID%5D&c=2022c9584d) \| \| \|:-:\| \| \|---\| \| \| \| \|---\| \| \|:-:\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| | |:-:| <html><p class="wp-block-paragraph"></p> **Features:** Fraud News Weekly --- ### [Fraud News Weekly (FNW) Friday, May 29, 2026](https://insurancefraud.org/publications/fraud-news-weekly-fnw-friday-may-29-2026/) **Published:** May 29, 2026 **Author:** Joseph Matos **Content:** ͏ ‌ Fraud News Weekly (FNW) – Friday, May 29, 2026͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ | \| \| \| \| \| \| \| [View this email in your browser](https://mailchi.mp/ce292c3525d6/fraud-news-weekly-friday-may-1-10704412?e=%5BUNIQID%5D) \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| \| \| \| \| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/637dc7ce-078c-ecd2-6c7a-2d89ac8ee03b.jpg) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a417349b-dfdc-a052-790d-07cfde53b716.jpg) \| \| \|:-:\| \| \| \| **New York governor’s budget finally passes, enacting antifraud measures after months of Coalition advocacy.** This week and after nearly two months past deadline, New York’s Fiscal Year 2027 budget passed and includes several antifraud measures championed by Governor Kathy Hochul and supported by the Coalition. Enacted provisions include expanding the definition of insurance fraud in New York to anyone who “hires, requests, encourages, orchestrates, or invites another individual to stage a motor vehicle accident.” Throughout the process, the Coalition engaged lawmakers repeatedly this session through advocacy letters and legislative events supporting stronger antifraud measures, prosecution resources, and coordinated enforcement efforts targeting organized fraud schemes that drive insurance costs higher for New Yorkers. Stay tuned as more details on what passed become available. [Read more](https://cbs6albany.com/news/local/gov-hochul-budget-deal-targets-fraud-and-lawsuits-to-bring-down-ny-auto-insurance-rates-new-york-outdated-laws-fy27-enacted-budget-fraudulent-claims-battle-fraud-governors-office-yorkers-car-insurance-bill-senator-jamaal-bailey-assemblymember-cbs6-wrgb)… **NAIC continues industry listening sessions on market conduct modernization.** The National Association of Insurance Commissioners (NAIC) [Market Conduct Regulation Modernization (D) Working Group](https://content.naic.org/committees/d/market-conduct-regulation-modernization-wg) held its second industry listening session with health insurance representatives focused on improving consistency in data calls, complaint handling, examination scope, and response timelines. The discussion followed an earlier session with property and casualty industry representatives on inconsistent Market Conduct Examination practices and duplicate regulatory requests. The Coalition continues to attend and monitor these discussions as regulators seek written comments through mid July. Members should note the [NAIC Market Regulation Handbook](https://content.naic.org/sites/default/files/publication-mes-hb-market-handbook-examination.pdf) requires insurers to maintain antifraud initiatives reasonably designed to detect, prevent, and prosecute fraudulent insurance acts. [Read more](https://content.naic.org/sites/default/files/call_materials/MCRM%20WG%20Materials%205.26.26.pdf)… **New Jersey appoints new insurance fraud prosecutor.** New Jersey Governor Mikie Sherrill has nominated Bernard J. Cooney as New Jersey’s insurance fraud prosecutor, with Cooney already serving on an interim basis pending State Senate confirmation. Cooney previously served as an Assistant U.S. Attorney from 2013 to 2022 and again from 2023 until March, including leadership of the healthcare fraud unit and government fraud unit, and worked at the Financial Industry Regulatory Authority. The Office of Insurance Fraud Prosecutor post had been vacant since 2022 following Tracy Thompson’s retirement, with interim leadership provided by Al Garcia. Attorney General Jennifer Davenport said Cooney will build on existing enforcement efforts. [Read more](https://newjerseyglobe.com/campaigns/sherrill-picks-new-insurance-fraud-prosector/)… \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a59ee231-0718-f09f-54a7-8d3ca68ea73c.jpg) \| \| \|:-:\| \| \| \| **Justice Department launches fast-track crackdown on benefits fraud complaints** The U.S. Department of Justice (DOJ) will now prioritize whistleblower complaints to accelerate the review of fraud against government programs like Medicare. Officials confirmed the DOJ Civil Division will aim to investigate or dismiss these claims within a 60- to 120-day window to dismantle sophisticated insurance fraud schemes more rapidly. The new policy targets emerging scams and aims to recover taxpayer funds through strategically deployed… [Read more](https://www.cbsnews.com/news/justice-department-benefits-fraud-enforcement/)… **Colorado governor rewrites AI rules, replacing existing AI Act** Governor Jared Polis signed the Colorado Automated Decision-Making Technology in Consequential Decisions Act to replace the state’s previous artificial intelligence regulations. The law creates targeted requirements for developers and deployers using automated technology to influence material decisions in “covered domains” like insurance, healthcare, and lending. Starting January 1, 2027, companies must provide clear consumer notices and allow for human review of outcomes that… [Read more](https://www.gtlaw.com/en/insights/2026/5/colorado-repeals-and-replaces-the-colorado-ai-act)… \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/28c467dc-8276-830d-664e-03edc5954526.jpg) \| \| \|:-:\| \| \| \| **INSIDER – INSURER** **May 26 – North Carolina – Former Durham insurance executive sentenced to federal prison for role in $2 billion fraud scheme** Greg Lindberg was sentenced to 12 years in prison for orchestrating a multibillion-dollar conspiracy that bankrupted multiple insurance companies. Lindberg, owner of Global Bankers Insurance Group, laundered $2 billion through circular transactions to fund a lavish lifestyle including private jets and a luxury yacht. Thousands of policyholders are still owed more than $1 billion while Lindberg’s companies remain in… [Read more](https://www.justice.gov/opa/pr/owner-multinational-investment-company-sentenced-2b-fraud-money-laundering-and-bribery)… **PROPERTY & CASUALTY** **May 22 – Connecticut – Couple charged with insurance fraud for staging $70K armed robbery** Eunice and Reginald Blakey were arrested for staging an armed robbery in a West Haven parking lot. Eunice submitted fraudulent jewelry appraisals totaling more than $70,000 to support her insurance claim for the nonexistent theft. Detectives spent four months uncovering inconsistencies in the couple’s statements before the suspects surrendered to police to face… [Read more](https://www.wtnh.com/news/connecticut/new-haven/wife-husband-charged-after-allegedly-staging-armed-robbery-in-west-haven/)… **AGENT MISCONDUCT** **May 22 – Oklahoma – Agent fined $12,000 and license revoked after $90K premium theft investigation** Cheri Ellis, owner of Independent Insurance Agency in McAlester, had her insurance license revoked for misappropriating more than $90,000 in customer premium payments. An Oklahoma Insurance Department investigation found Ellis failed to forward funds to carriers, which caused multiple policies to be canceled without the insureds’ knowledge. The investigation also uncovered that Ellis issued a fraudulent certificate of insurance and… [Read more](https://okcfox.com/news/local/oklahoma-insurance-department-cheri-ellis-fraud-revokes-mcalester-insurance-agents-license-after-alleged-fraud-claims)… **HEALTHCARE FRAUD** **May 22 – Iowa – Family therapist faces license discipline after pleading guilty to insurance fraud** Michelle Raye Stewart-Sandusky pleaded guilty to insurance fraud for forging a financial document to reinstate her business health insurance after a cancellation for nonpayment. Stewart-Sandusky allegedly used the name of a Wellmark employee to falsify the document for her company, SS Therapy and Consulting. State regulators have now initiated disciplinary proceedings against her professional license for conduct that… [Read more](https://iowacapitaldispatch.com/2026/05/22/family-therapist-faces-licensing-issues-after-pleading-guilty-to-theft-and-fraud/)… **LIFE INSURANCE** **May 23 – Iowa – Man charged with $30K fraud for claiming life insurance on living children** Thompson Nagbe Jr. was charged with first-degree theft and insurance fraud after submitting death benefit claims for three children whose deaths could not be verified. Nagbe successfully obtained $30,000 for one daughter through his employer-sponsored policy before investigators discovered he used fraudulent death certificates from Liberia. Authorities found that all three children were still alive and Nagbe had… [Read more](https://insurancenewsnet.com/oarticle/investigators-say-c-r-mans-life-insurance-claims-for-3-children-were-fraudulent)… **HEALTHCARE FRAUD** **May 26 – Maryland – Pocomoke woman sentenced in Wicomico County insurance fraud and theft scheme** Taylor Clark was sentenced to five years in prison for orchestrating a theft and insurance fraud scheme while working as a business manager in Wicomico County. Clark stole more than $191,000 from her employer through unauthorized cash withdrawals and fraudulent pay increases. She also submitted a falsified letter to her health insurance provider to add an ineligible beneficiary… [Read more](https://www.wboc.com/news/pocomoke-woman-sentenced-for-theft-and-insurance-fraud-in-wicomico-county/article_ebef5790-7e47-499d-838d-a1e45f4f8ceb.html)… **AGENT MISCONDUCT** **May 26 – Maryland – Prince George’s County agent charged for using fictitious identities to steal $5,000** Corrie Dewayne Alston was charged with felony theft and 21 counts of insurance fraud for submitting fraudulent life insurance applications. Alston allegedly created fake identities using Hispanic surnames to exploit Senior Life Insurance Company for commission payments. The Bowie resident admitted he targeted these specific names believing the insurer would not verify Social Security numbers for… [Read more](https://oag.maryland.gov/News/pages/Attorney-General-Brown-Announces-Prince-George%E2%80%99s-County-Insurance-Agent-Charged-with-Felony-Theft-and-Insurance-Fraud-.aspx)… **AUTO – STAGED ACCIDENT** **May 27 – California – Four charged in $36K staged crash scheme targeting innocent drivers** Jhoiner Rodriguez Cellis, Nailer Mendez Diaz, Melissa Cervantes De La Torre, and Plata Sampayo were charged with felony insurance fraud for staging collisions in the Inland Empire. The group allegedly crashed into one another in Upland and targeted an unsuspecting motorist in a separate Montclair incident to trigger $36,000 in fraudulent payouts. Two of the suspects also face assault with a deadly weapon charges because… [Read more](https://abc7.com/post/4-suspects-arrested-accused-staging-inland-empire-crashes-alleged-insurance-fraud-scheme/19182914/)… \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/18f9920e-e738-5103-cd8e-7ba476e9eb86.jpg) \| \| \|:-:\| \| \| \| **We look forward to seeing you soon!** **2026 Midyear Meeting in New Orleans** **June 15 – 16** \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/b69c6595-0760-ad0d-a8ee-f022ae1d34fc.jpg) \| \| \|:-:\| \| \| \| **Midyear Meeting agenda:** \| \| \|---\| \| \|---\| \| \| \| **Verisk 2026 State of Insurance Fraud Study** Shane Riedman, Verisk **Regulating Artificial Intelligence Use in the Insurance Industry** John Wood, American Policyholders Association **Beyond Borders: How Transnational Organized Crime Is Reshaping Insurance Fraud** Dennis Toomey, PwC Gregory P. Hengber, Esq., Goldstein Law Group Vanessa Gillis, Sentry Insurance Steve Hall, NICB **From Test to Theft: How Illicit Licensing May Be Fueling Insurance Fraud** Joel Norris, Pearson Professional Assessments **Title Insurance Fraud: Emerging Fraud Schemes Impacting The Industry** Mary Thomas / John Crowley, Stewart Title Guaranty Company Steve Gottheim, American Land Title Association **Account Takeover Risks & Best Practices** Evgeny Aleksandrov, Pilotbird Ken Kerby, Cincinnati Insurance Carlota Balet, Allianz Life Insurance Company Matt Mortvedt, Iowa Department of Insurance & Financial Services **From Surge to Strategy: Facing Synthetic Identity Insurance Fraud** Celeste Dodson, Coalition Against Insurance Fraud Mike Horan, State Farm Matt Huls, The Hartford Jessica Gallagher, Faegre Drinker **When Cyber Incidents Become Fraud Opportunities** David Smolensky, Resolute **The Power of Partnership: Scaling Anti-Fraud Awareness Collaboratively** Brian Biggs, ICW Group / Anti-Fraud Alliance **Advocacy in Action: An Update on Coalition Amicus & Advocacy Efforts** Brent Walker, Coalition Against Insurance Fraud **Legal Frontlines: Court Decisions Shaping the Fight Against** **Insurance Fraud** Vince Gerbino, Bruno Gerbino Soriano & Aitken LLP **The Future of SIU and Fraud Bureau Leadership** Delpha DiGiacomo, Zurich Katie Sutter, American Family Insurance Dawnde Pence, Interinsurance Exchange of the Automobile Club Mariela Pennock, Assurant Armand Glick, Utah Department of Insurance **Mingle After The Midyear** Pat O’Brien’s, 718 St. Peter Street \| \| \|---\| \| \|---\| \| \| \| \| \|---\| \| [](https://members.insurancefraud.org/general/register_member_type.asp)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/4e08fedc-6fea-9426-9143-d421962a8d68.jpg) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/9d9a163b-d608-c29e-1f8c-71c58f193f3a.jpg) \| \| \|:-:\| \| \| \| - **June 2** – [The California Department of Insurance Present: SIU Compliance](https://register.gotowebinar.com/register/1456577384739922269) – AFA - **June 23** – [More Than Just a Selfie: The Power of Social Media in Claims Evaluations](https://share.hsforms.com/1XfYV0y0rTMKqH1Z9XWD5Jgc0z6w?utm_medium=email&_hsenc=p2ANqtz-_DIWbhKXwWAYTTVpmV9p7euhjxbCtMyrOG13iuWxI5OI1Yp2bJEfGrat-qOg0W7rhkWnmYLKxPLZgp9NPyMi2tU5tZNcy4FtM5UG0c-bWSrYgEml8&_hsmi=419288803&utm_content=419288803&utm_source=hs_email) – Social Discovery - **July 9 –** 2026 – [SCFIA Anti-Fraud Conference](https://scfia.org/) – California Department of Insurance - **July 20 – 22** – [The 2026 Florida Insurance Fraud Education Committee and 34th Annual Conference](https://www.fifec.org/registration) – FIFEC \| \| \|---\| \| \|---\| \| [](https://s.surveyplanet.com/bj1sw6en)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/82bc7396-3a2d-5c34-e4ff-a1d3855f62d0.jpg) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/b99b7c25-65ae-cd0c-1e44-8d51b81e8021.jpg) \| \| \|:-:\| \| \| \| \| \|---\| \| \| \| **Follow Us On Our Social Media Platforms:** \| \| \|---\| \| \|---\| \| [](https://www.linkedin.com/company/coalition-against-insurance-fraud/)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/148b79cf-2c06-6469-b7c8-335c1c8b971a.jpg) \| \| \|:-:\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| \| \| \| \| \| [](https://www.facebook.com/profile.php?id=61579225779934)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/39ae0e7d-0388-20e5-5755-020aec6cf995.jpg) \| \| \|:-:\| \| [](https://www.instagram.com/stopinsurancefraud/)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/86c49df9-4380-51e5-da9c-f83034fc7555.jpg) \| \| \|:-:\| \| \| \| \| \| ![Logo](https://brand-assets.mailchimp.com/01KKVRP4PEH4PWEG0R0VSKKJ7H.png) \| \| \|:-:\| \| \| \| *Copyright (C) 2026 Coalition Against Insurance Fraud. All rights reserved.* You are receiving this email because either your organization is a member of the Coalition Against Insurance Fraud or you requested to be placed on our mailing list. Our mailing address is: Coalition Against Insurance Fraud 1012 14th St NW Ste 610 Washington, DC 20005-3424 USA Want to change how you receive these emails? 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Friday, May 22, 2026](https://insurancefraud.org/publications/fraud-news-weekly-fnw-friday-may-22-2026/) **Published:** May 22, 2026 **Author:** Joseph Matos **Content:** Fraud News Weekly (FNW) – Friday, May 22, 2026͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ | \| \| \| \| \| \| \| [View this email in your browser](https://mailchi.mp/24433f1d0f5d/fraud-news-weekly-friday-may-1-10704400?e=%5BUNIQID%5D) \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| \| \| \| \| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/4d93ffcd-3ac0-9a63-c9d1-36ff53bc88ee.jpg) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a417349b-dfdc-a052-790d-07cfde53b716.jpg) \| \| \|:-:\| \| \| \| **Coalition urges Alaska governor to sign airbag fraud provisions in omnibus crime bill.** The Coalition [previously supported](https://insurancefraud.org/wp-content/uploads/3-13-2026-Coalition-Support-of-Alaska-HB-74.pdf) Alaska House Bill 74, which would establish the crime of airbag fraud, before those provisions were incorporated into House Bill 239, the omnibus crime bill now before the governor. By [letter](https://insurancefraud.org/wp-content/uploads/5-21-2026-Coalition-Support-of-Airbag-Fraud-Provisions-in-Alaska-HB-239.pdf), the Coalition is urging Governor Mike Dunleavy to sign the airbag fraud provisions into law. The measure would criminalize the manufacture, sale, installation, or concealment of counterfeit or nonfunctioning airbags, closing a gap in Alaska law and strengthening protections for drivers and passengers. More than 30 states have adopted similar laws. [Read more](https://alaskabeacon.com/2026/05/20/alaska-legislature-approves-wide-ranging-crime-bill-package/)… **Texas Department of Insurance expands insurance fraud training for law enforcement.** The Coalition participated in a recent advisory board meeting for the Texas Department of Insurance Fraud Unit’s statewide basic insurance fraud investigation training program for Texas peace officers who serve as force multipliers in the fight against insurance fraud. Brent Walker, Coalition director of government relations, serves on the advisory board and recently received an update on the program. Since March 2025, the program has delivered 23 eight-hour courses to 140 officers from 60 agencies. Training is now being tailored to the fraud trends most common in the regions where each class is held, expanded to include fire marshals, and future prosecutor training is under development. Student feedback also shows increased cooperation between local law enforcement officers and insurer Special Investigative Units during fraud investigations. [Read more](https://www.tdi.texas.gov/committee/gr/fraud-unit-training.html)… **Iowa and Nebraska pass new safeguards against the financial exploitation of elderly or vulnerable adults in life insurance and annuity disbursements.** Iowa has enacted [House File 2232](https://www.legis.iowa.gov/legislation/BillBook?ga=91&ba=HF2232) to strengthen safeguards against financial exploitation involving life insurance policies and annuities. Iowa previously enacted consumer protections related to securities transaction delays and cryptocurrency ATMs and has since recognized that scammers are increasingly targeting life insurance policies and annuities, prompting this bill to create another tool to address the growing trend. The new law establishes authority to delay suspicious transactions, enhance reporting, require employee training, and provides good faith immunity by insurers and financial professionals. Nebraska has also enacted the very similar [Legislative Bill 967](https://nebraskalegislature.gov/FloorDocs/109/PDF/Engrossed/LB967.pdf) with comparable provisions. In Iowa, the Fraud Bureau is supported by two senior financial exploitation investigators who provide statewide training, assist victims, and conduct investigations. The Coalition previously met with the Iowa Insurance Division on this legislation and has kept the Coalition’s Life and Disability Task Force regularly updated as both measures advanced. There is at least one additional nearby state that has already expressed interest in pursuing similar legislation in the 2027 session. [Read more](https://iid.iowa.gov/regulated-individuals/agents-advisers/senior-financial-exploitation)… \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a59ee231-0718-f09f-54a7-8d3ca68ea73c.jpg) \| \| \|:-:\| \| \| \| **Connecticut Insurance Department warns consumers about insurance fraud and online scam risks.** The Connecticut Insurance Department (CID) issued a consumer notice to stay alert to insurance related fraud and online scams that use email, text, and digital messages to steal personal and financial information. Scammers may impersonate legitimate insurers, create fake websites, and pressure quick action. Advice includes watching for suspicious payment requests, unverified contacts, and… [Read more](https://portal.ct.gov/cid/consumer-information-center/consumer-alerts/2026-consumer-alerts/notice-2026-05-15?language=en_US)… \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/28c467dc-8276-830d-664e-03edc5954526.jpg) \| \| \|:-:\| \| \| \| **WORKERS’ COMPENSATION FRAUD** **May 14 – Georgia – Former Dalton insurance agent charged with workers’ compensation fraud scheme** Lucy Margarita Suarez was charged with five counts of insurance fraud for allegedly stealing thousands of dollars from business owners. Suarez operated EliteOne Solutions in Whitfield County where she sold fake workers’ compensation policies and pocketed the premium payments for personal use. Victims received fraudulent certificates of insurance while leaving their businesses completely uninsured against workplace accidents… [Read more](https://www.local3news.com/local-news/dalton-woman-charged-with-issuing-fake-workers-compensation-insurance-stealing-thousands-of-dollars/article_e91e0e66-88fb-43dc-9a26-139cd41e5954.html)… **AUTO – STAGED ACCIDENT / HEALTHCARE** **May 18 – Florida – Five arrested in separate staged crash and medical fraud scheme incidents** Vidal Jose Rojas Balbas and Yumilka Melendez Pagan were arrested for staging a one-car accident by driving into a tree in Miami-Dade County. Yancenia Diaz, Milaimi Gonzalez Acosta, and Alfredo Ernesto Phinney Estrada allegedly used a physical therapy clinic to submit $30,936 in fraudulent claims for services never rendered. All five individuals face charges including insurance fraud and grand theft… [Read more](https://cbs12.com/news/local/florida-crime-news-five-nabbed-in-staged-crash-scam-as-authorities-cite-nearly-31k-insurance-haul-cfo-says-blaise-ingoglia-miami-dade-fraud-scheme-illegal-alien-immigrant-crisis-on-the-border-collecting-insurance-payments-grand-theft)… **HEALTHCARE** **May 18 – New York – Business owner sentenced to 37 months for laundering $1.5M in medical fraud proceeds** Elnar Zarbailov was sentenced to 37 months in prison for using shell companies to launder money from a massive healthcare fraud operation. Zarbailov moved nearly $1.5 million in fraudulent Medicare and private insurance reimbursements through multiple bank accounts in Staten Island and overseas. The scheme involved a transnational criminal organization and remains tied to one of the largest healthcare… [Read more](https://www.justice.gov/opa/pr/new-york-business-owner-sentenced-prison-using-shell-companies-launder-health-care-fraud)… **ARSON** **May 19 – New Jersey – Business owner sentenced to life for murders; arson linked to financial dispute** Paul Caneiro was sentenced to four life terms for killing his brother, Keith Caneiro, and his family before setting their Colts Neck home on fire. The attack stemmed from a financial dispute involving two co-owned Asbury Park businesses and was fueled by an insurance-related fraud motive. Investigators discovered that Caneiro also attempted to ignite a fire at his own residence to… [Read more](https://abc7ny.com/post/colts-neck-murders-paul-caneiro-man-convicted-killing-brothers-family-sentenced/19129793/)… **HEALTHCARE** **May 21 – Ohio – Four charged in Medicaid and nursing home theft cases** Four Columbus residents were charged for their involvement in separate schemes targeting Medicaid and vulnerable nursing home residents. The individuals allegedly enabled fraudulent billing for medical services never provided and stole funds from citizens in long-term care settings. These cases are part of a statewide crackdown on health program fraud that resulted in significant taxpayer losses… [Read more](https://www.msn.com/en-us/news/crime/four-columbus-residents-charged-by-state-with-health-care-fraud-theft/ar-AA23FCXj)… \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/56974cfd-2ff6-bb70-a83e-f5ee3107b274.jpg) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/9ab06b65-2efa-37a8-7182-83ded90f6485.jpg) \| \| \|:-:\| \| \| \| The Coalition, in partnership with National Insurance Crime Bureau, rolled out #[ContractorFraudAwarenessWeek](https://nicb.org/CFAW-Toolkit) this week, with a focused effort on helping consumers better understand and avoid contractor fraud. Drawing from the NICB toolkit, the Coalition shared a series of daily posts designed to provide clear, practical guidance on spotting red flags, verifying contractors, and avoiding common pressure tactics. Content was shared throughout the week on LinkedIn and Facebook, including videos, graphics, and prevention resources aimed at strengthening awareness and encouraging informed decision-making. \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/18f9920e-e738-5103-cd8e-7ba476e9eb86.jpg) \| \| \|:-:\| \| \| \| **Last day to register!** **2026 Midyear Meeting in New Orleans** **June 15 – 16** \| \| \|---\| \| \|---\| \| \| \| Join us next month in one of America’s most vibrant cities for expert sessions, meaningful conversations, and connections that move the industry forward. Plus, reconnect with familiar faces and meet the newest members of the fraud-fighting community. \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/b69c6595-0760-ad0d-a8ee-f022ae1d34fc.jpg) \| \| \|:-:\| \| \| \| - [**Register**](https://members.insurancefraud.org/page/2026MidyearMeeting) by May 22. - [**Book your guest room**](https://book.passkey.com/event/51119626/owner/111/home?utm_campaign=298519693) at the group rate May 26 ($159/night). - Join us after the meeting for a mingle at the famous Pat O’Brien’s (5:00 – 7:15). Reserve your spot when you register. \| \| \|---\| \| \|---\| \| [](https://members.insurancefraud.org/page/2026MidyearMeeting?_gl=1%2A8v1o4f%2A_ga%2AMzY4NDE0MjA4LjE3MTgxNDY1MDM.%2A_ga_SWDYZ10RHD%2AczE3NzI4MTE1NzYkbzgzMSRnMSR0MTc3MjgxMTU3NiRqNjAkbDAkaDA.)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/dc00bf75-24a7-66a7-20ba-e2c944930eb3.png) \| \| \|:-:\| \| \| \| **Midyear Meeting agenda:** \| \| \|---\| \| \|---\| \| \| \| **Verisk 2026 State of Insurance Fraud Study** Shane Riedman, Verisk **Regulating Artificial Intelligence Use in the Insurance Industry** John Wood, American Policyholders Association **Beyond Borders: How Transnational Organized Crime Is Reshaping Insurance Fraud** Dennis Toomey, PwC Gregory P. Hengber, Esq., Goldstein Law Group Vanessa Gillis, Sentry Insurance Steve Hall, NICB **From Test to Theft: How Illicit Licensing May Be Fueling Insurance Fraud** Joel Norris, Pearson Professional Assessments **Title Insurance Fraud: Emerging Fraud Schemes Impacting The Industry** Mary Thomas / John Crowley, Stewart Title Guaranty Company Steve Gottheim, American Land Title Association **Account Takeover Risks & Best Practices** Evgeny Aleksandrov, Pilotbird Ken Kerby, Cincinnati Insurance Carlota Balet, Allianz Life Insurance Company Matt Mortvedt, Iowa Department of Insurance & Financial Services **From Surge to Strategy: Facing Synthetic Identity Insurance Fraud** Celeste Dodson, Coalition Against Insurance Fraud Mike Horan, State Farm Matt Huls, The Hartford Jessica Gallagher, Faegre Drinker **When Cyber Incidents Become Fraud Opportunities** David Smolensky, Resolute **The Power of Partnership: Scaling Anti-Fraud Awareness Collaboratively** Brian Biggs, ICW Group / Anti-Fraud Alliance **Advocacy in Action: An Update on Coalition Amicus & Advocacy Efforts** Brent Walker, Coalition Against Insurance Fraud **Legal Frontlines: Court Decisions Shaping the Fight Against** **Insurance Fraud** Vince Gerbino, Bruno Gerbino Soriano & Aitken LLP **The Future of SIU and Fraud Bureau Leadership** Delpha DiGiacomo, Zurich Katie Sutter, American Family Insurance Dawnde Pence, Interinsurance Exchange of the Automobile Club Mariela Pennock, Assurant Armand Glick, Utah Department of Insurance **Mingle After The Midyear** Pat O’Brien’s, 718 St. Peter Street \| \| \|---\| \| \|---\| \| \| \| \| \|---\| \| [](https://members.insurancefraud.org/general/register_member_type.asp)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/4e08fedc-6fea-9426-9143-d421962a8d68.jpg) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/9d9a163b-d608-c29e-1f8c-71c58f193f3a.jpg) \| \| \|:-:\| \| \| \| - **June 2** – [The California Department of Insurance Present: SIU Compliance](https://register.gotowebinar.com/register/1456577384739922269) – AFA - **June 23** – [More Than Just a Selfie: The Power of Social Media in Claims Evaluations](https://share.hsforms.com/1XfYV0y0rTMKqH1Z9XWD5Jgc0z6w?utm_medium=email&_hsenc=p2ANqtz-_DIWbhKXwWAYTTVpmV9p7euhjxbCtMyrOG13iuWxI5OI1Yp2bJEfGrat-qOg0W7rhkWnmYLKxPLZgp9NPyMi2tU5tZNcy4FtM5UG0c-bWSrYgEml8&_hsmi=419288803&utm_content=419288803&utm_source=hs_email) – Social Discovery - **July 9 –** 2026 – [SCFIA Anti-Fraud Conference](https://scfia.org/) (California Department of Insurance) - **July 20 – 22** – [The 2026 Florida Insurance Fraud Education Committee and 34th Annual Conference](https://www.fifec.org/registration) (FIFEC) \| \| \|---\| \| \|---\| \| [](https://s.surveyplanet.com/bj1sw6en)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/82bc7396-3a2d-5c34-e4ff-a1d3855f62d0.jpg) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/b99b7c25-65ae-cd0c-1e44-8d51b81e8021.jpg) \| \| \|:-:\| \| \| \| \| \|---\| \| \| \| **Follow Us On Our Social Media Platforms:** \| \| \|---\| \| \|---\| \| [](https://www.linkedin.com/company/coalition-against-insurance-fraud/)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/148b79cf-2c06-6469-b7c8-335c1c8b971a.jpg) \| \| \|:-:\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| \| \| \| \| \| [](https://www.facebook.com/profile.php?id=61579225779934)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/39ae0e7d-0388-20e5-5755-020aec6cf995.jpg) \| \| \|:-:\| \| [](https://www.instagram.com/stopinsurancefraud/)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/86c49df9-4380-51e5-da9c-f83034fc7555.jpg) \| \| \|:-:\| \| \| \| \| \| ![Logo](https://brand-assets.mailchimp.com/01KKVRP4PEH4PWEG0R0VSKKJ7H.png) \| \| \|:-:\| \| \| \| *Copyright (C) 2026 Coalition Against Insurance Fraud. All rights reserved.* You are receiving this email because either your organization is a member of the Coalition Against Insurance Fraud or you requested to be placed on our mailing list. Our mailing address is: Coalition Against Insurance Fraud 1012 14th St NW Ste 610 Washington, DC 20005-3424 USA Want to change how you receive these emails? You can [update your preferences](https://insurancefraud.mailchimpsites.com/manage/preferences?u=a440c5b647697de580a2fd586&id=b68dce7808&e=%5BUNIQID%5D&c=b545880ead) or [unsubscribe](https://insurancefraud.us1.list-manage.com/unsubscribe?u=a440c5b647697de580a2fd586&id=b68dce7808&t=b&e=%5BUNIQID%5D&c=b545880ead) \| \| \|:-:\| \| \|---\| \| \| \| \|---\| \| \|:-:\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| | |:-:| **Features:** Fraud News Weekly --- ### [Fraud News Weekly - Friday, May 15, 2026](https://insurancefraud.org/publications/fraud-news-weekly-friday-may-15-2026/) **Published:** May 15, 2026 **Author:** Joseph Matos **Content:** Fraud News Weekly – Friday, May 15, 2026͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ | \| \| \| \| \| \| \| [View this email in your browser](https://mailchi.mp/f18e952bbab7/fraud-news-weekly-friday-may-1-10704376?e=%5BUNIQID%5D) \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| \| \| \| \| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/31ce2e17-c39a-a516-7ead-eeaec9ec54fa.jpg) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a417349b-dfdc-a052-790d-07cfde53b716.jpg) \| \| \|:-:\| \| \| \| **Coalition attends New York insurance industry Legislative Action Day in Albany.** The Coalition was invited to meet with insurers and industry leaders at the Property and Casualty Legislative Action Day in Albany, NY, hosted by American Property Casualty Insurance Association, National Association of Mutual Insurance Companies, New York Insurance Association, National Insurance Crime Bureau, and Reinsurance Association of America. Coalition General Counsel Kate Gordon and Director of Government Relations Brent Walker met with lawmakers to answer questions about fraud-driven affordability challenges and support for the pending antifraud efforts targeting staged accidents, assignment of benefits abuse, and fraudulent contractor activity. One-on-one discussions with lawmakers also highlighted Coalition research revealing that more than half of Americans personally know someone who has committed insurance fraud and the need for dedicated fraud prosecution funding and modernized fraud reporting systems in New York. The still pending Governor’s budget was also a hot topic. [Read more](https://members.nyia.org/events/details/2026-legislative-action-day-1626597)… \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/e1cf27b5-065c-8bc3-d2a3-458f139025fd.png) \| \| \|:--\| \| \| \| *Coalition General Counsel Kate Gordon and Director of Government Relations Brent Walker with New York Assemblyman and Insurance Committee chair David Weprin and Assemblyman and ranking member of the Insurance Committee, Kenneth Blankenbush.* **NAIC begins industry listening sessions on regulatory modernization.** The National Association of Insurance Commissioners (NAIC) Market Conduct Regulation Modernization (D) Working Group recently held its first industry listening session focused on property and casualty insurance market conduct regulation modernization. Industry representatives discussed concerns with inconsistent Market Conduct Examination (MCE) practices across states, short response timelines, duplicate regulatory requests, consumer complaint variability, and growing burdens tied to artificial intelligence generated complaints. Participants also discussed potential solutions such as standardized templates, interstate collaboration, shared data platforms, self reporting and self audit frameworks, and clearer remediation expectations. A consumer representative emphasized AI-assisted complaints should not be discounted if valid. As many state market conduct examinations ask about insurer antifraud initiatives, the Coalition attended the discussion as regulators continue gathering input through mid July, with a second listening session focused on healthcare scheduled for May 26, 2026. [Read more](https://content.naic.org/sites/default/files/inline-files/Industry%20Discussion%20Questions%205.8.26.pdf)… **The Oklahoma Insurance Department sets a deadline for annual antifraud assessment.** The Oklahoma Insurance Department has issued a special notice requiring insurers to remit the $750 Anti Fraud Assessment Annual Fee by July 1, 2026 under Title 36 O.S. § 362 and Order No. 16-0636-PRJ. Payments must be submitted electronically through OPTins, with paper filings and checks are no longer accepted. See the special notice for specific instructions. [Read more](https://www.oid.ok.gov/2026-special-notice-anti-fraud-assessment-annual-fee/)… \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a59ee231-0718-f09f-54a7-8d3ca68ea73c.jpg) \| \| \|:-:\| \| \| \| **Insurers Need a New Playbook Against Account Takeover Fraud** Insurers are facing rising exposure to account takeover fraud, where criminals gain control of customer accounts and redirect insurance benefits, payments, or policy changes through identity manipulation. As AI-enabled impersonation raises the stakes for insurers, five actions can help strengthen fraud defenses across servicing, claims, and payments… [Read more](https://deloitte.wsj.com/riskandcompliance/insurers-need-a-new-playbook-against-account-takeover-fraud-e4359ecb)… **Carpe Data warns AI is accelerating insurance fraud and calls for cross-industry defense strategy** Coalition member Carpe Data is calling for industry-wide collaboration to combat a rapid rise in AI-driven insurance fraud, warning that bad actors are using generative tools to scale and automate deceptive schemes across the insurance ecosystem. Company officials say fraudsters are increasingly using AI to… [Read more](https://insurancenewsnet.com/innarticle/carpe-data-urges-industry-wide-collaboration-to-stem-ai-driven-insurance-fraud)… \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/28c467dc-8276-830d-664e-03edc5954526.jpg) \| \| \|:-:\| \| \| \| **HEALTHCARE** **May 8 – South Carolina – Woman accused of using fake medical bills to defraud GEICO** Erin Shaquaile Robbs Kilgore, of Spartanburg County, was charged with insurance fraud after allegedly submitting altered medical bills and a forged bank statement to GEICO in an attempt to obtain more than $13,000 in insurance payments. According to investigators, Kilgore uploaded falsified medical bills from Atrium Health and Spartanburg Regional through… [Read more](https://www.foxcarolina.com/2026/05/08/spartanburg-county-woman-accused-attempting-defraud-geico-thousands/)… **CONTRACTOR FRAUD** **May 8 – South Carolina – “Independent Contractor” claim turns into insurance fraud case for Lexington man** Granison Dwight Peterson Jr., of Lexington County, was charged with forgery and insurance fraud involving more than $10,000. Authorities said Peterson submitted a false employment verification letter claiming he worked as an independent contractor for MellyGirl Logistics and provided the document to GEICO to support a… [Read more](https://wach.com/news/local/man-accused-of-fraud-and-forgery-in-insurance-scheme-sled-south-carolina-lexington-county-department-of-insurance-scam-payment)… **HEALTHCARE** **May 8 – California – Vocational nurse charged in $1.5M Medi-Cal insurance fraud scheme tied to hospice billing** Mariafe Concepcion Garcia, a Los Angeles County vocational nurse, was arrested by the California Attorney General’s Bureau of Medi-Cal Fraud on allegations she stole more than $1.5 million through fraudulent billing. Prosecutors allege Garcia submitted false claims for hospice services to Medi-Cal between December 2020 and March 2024, resulting in payments totaling… [Read more](https://www.nbclosangeles.com/news/local/nurse-charged-medi-cal-billing-fraud-scheme/3887966/)… **AUTO – TOWING FRAUD** **May 9 – California – Man found guilty in $50K insurance fraud ring** Colin Jackson, of San Francisco, was convicted in federal court of fraud and money laundering for his role in an insurance fraud scheme tied to a larger criminal operation led by towing company operator Jose Badillo, according to the U.S. Department of Justice. Federal prosecutors said Jackson and another defendant fraudulently obtained more than $50,000 from an insurance company… [Read more](https://www.msn.com/en-us/news/crime/sf-man-convicted-of-insurance-fraud-as-part-of-rogue-tow-truck-operator-s-scheme/ar-AA22NvmX?apiversion=v2&domshim=1&noservercache=1&noservertelemetry=1&batchservertelemetry=1&renderwebcomponents=1&wcseo=1)… **UNEMPLOYMENT INSURANCE FRAUD** **May 10 – Virginia – Woman sentenced in $588K unemployment insurance fraud scheme** Lakeia Shepperd, of Newport News, was sentenced to seven years and four months in prison for conspiracy to commit mail fraud and aggravated identity theft tied to a large-scale unemployment insurance fraud scheme. According to prosecutors, Shepperd used the personal information of prison inmates and others to file fraudulent unemployment claims between May 2020… [Read more](https://www.wavy.com/news/local-news/newport-news-woman-sentenced-to-seven-years-and-four-months-in-prison-for-mail-fraud-and-identity-theft/)… **HEALTHCARE** **May 10 – New Jersey – Former healthcare CEO sentenced to 5 years in prison for role in $212M fraud conspiracy** Parmjit “Paul” Parmar, of New Jersey, was sentenced to five years in federal prison after pleading guilty to conspiracy to commit securities fraud in connection with a $212 million investment fraud scheme, according to the U.S. Department of Justice. Federal prosecutors said Parmar and his co-conspirators fraudulently inflated the value of a publicly traded healthcare company… [Read more](https://healthexec.com/topics/healthcare-management/legal-news/former-healthcare-ceo-sentenced-5-years-prison-role-212m-fraud-conspiracy)… **AGENT MISCONDUCT** **May 11 – Maryland – Financial advisor found guilty in insurance fraud scheme** Michael C. Okolo, of Parkville, was found guilty by a Baltimore County jury on 10 felony counts of insurance fraud for acting as an insurance agent without a license, according to Maryland Attorney General Anthony G. Brown. Prosecutors said Okolo sold annuity policies on 10 occasions between 2021 and 2024 after the Maryland Insurance Administration revoked his insurance license… [Read more](https://oag.maryland.gov/News/pages/Attorney-General-Brown-Announces-Guilty-Verdict-for-Baltimore-County-Financial-Advisor%C2%A0who%C2%A0Committed%C2%A0FelonyInsurance-Fraud.aspx)… **AUTO – STAGED THEFT** **May 11 – Texas – Three men indicted in alleged insurance fraud scheme faking truck and camper theft** Cameron Flores, Niklas Burkland, and Kenneth Shavers have been indicted in Texarkana in connection with an alleged insurance fraud scheme involving a staged theft of a truck and camper. Authorities allege the three conspired to make it appear that Flores’ 2020 Ford F-250 and attached camper were stolen from a business property in October, enabling… [Read more](https://txktoday.com/news/three-indicted-in-alleged-insurance-fraud-truck-theft-scheme/)… **HEALTHCARE** **May 12 – Maryland – Family of nine indicted in Medicaid insurance fraud scheme tied to developmental disability benefits** Nine Eastern Shore family members were indicted on charges of Medicaid insurance fraud for allegedly defrauding the state health program used to support residents with developmental disabilities. Attorney General Anthony Brown said the group is accused of… [Read more](https://foxbaltimore.com/news/local/eastern-shore-family-members-indicted-medicaid-fraud-scheme-deputy-sheriff-maryland)… **AUTO – FALSE CLAIMS** **May 12 – New York – Man charged in $400K repeat staged crash insurance fraud scheme targeting truckers** Michael McMahon, of Poughkeepsie, was arrested on three counts of mail fraud for allegedly running a repeat insurance fraud scheme targeting trucking companies. Prosecutors say McMahon parked roadside and waited for tractor-trailers to pass before filing false accident claims under fake names and submitting fabricated repair invoices… [Read more](https://cbs6albany.com/news/local/prosecutors-say-man-waited-roadside-for-trucks-then-filed-bogus-claims-under-false-names-michael-mcmahon-new-york-division-inspector-united-states-attorney-john-sarcone-iii-postal-inspection-400k-federal-charges-prison-proven-guilty-imprisoned-cbs6-wrgb)… **PROPERTY & CASUALTY** **May 13 – Louisiana – Louisiana Department of Insurance (LDI) referral leads to six arrests in years-long insurance fraud scheme** Lashaundalyn Whitlock, Laquadra Whitlock Brown, and four other West Monroe residents were arrested in Ouachita Parish in connection with a long-running insurance fraud scheme involving fraudulent fire and water damage claims. Investigators said the suspects submitted false claims over nearly a decade, resulting in charges including insurance fraud, identity theft, forgery, money laundering and… [Read more](https://ldi.la.gov/news/press-releases/5-13-26-ldi-referral-leads-to-six-arrests-in-years-long-insurance-fraud-scheme)… **LIFE INSURANCE** **May 13 – Utah – Children’s author Kouri Richins gets life in life insurance poisoning case** Kouri Richins, a mother and author of a children’s grief book, was sentenced this week to life in prison without parole after being convicted of aggravated murder and insurance fraud tied to her husband’s death. Prosecutors said Richins poisoned her husband, Eric Richins, in March 2022 and later attempted to collect on multiple life insurance policies totaling about $2.2 million… [Read more](https://www.cnn.com/2026/05/13/us/kouri-richins-murder-sentencing)… \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/56974cfd-2ff6-bb70-a83e-f5ee3107b274.jpg) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/205dffe6-bcaa-b25e-9a41-03620ea488c3.png) \| \| \|:-:\| \| \| \| The Coalition, in partnership with the NICB, is leading a consumer awareness campaign during Contractor Fraud Awareness Week (May 18-22). Using the NICB toolkit, the Coalition will promote awareness across the social media platforms to help consumers hire contractors with confidence. Follow the Coalition on LinkedIn and Facebook throughout the week. Share Coalition posts on your own social media feeds to expand the reach. Access fraud prevention resources at NICB: [nicb.org/prevent-disaster-fraud](http://nicb.org/prevent-disaster-fraud) \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/78c5ce69-a52f-df22-e1cc-d2afe0bb6ca3.jpg) \| \| \|:-:\| \| [](https://us02web.zoom.us/webinar/register/WN_v0tVfA63SI-440EOWpPFwQ)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/1ba1294b-3a55-0293-2aab-6f8697681662.jpg) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/18f9920e-e738-5103-cd8e-7ba476e9eb86.jpg) \| \| \|:-:\| \| \| \| **One Week to Register!** **2026 Midyear Meeting in New Orleans** **June 15 – 16** \| \| \|---\| \| \|---\| \| \| \| Join us this June in one of America’s most vibrant cities for expert sessions, meaningful conversations, and connections that move the industry forward. Plus, reconnect with familiar faces and meet the newest members of the fraud-fighting community. \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/b69c6595-0760-ad0d-a8ee-f022ae1d34fc.jpg) \| \| \|:-:\| \| \| \| - [**Register**](https://members.insurancefraud.org/page/2026MidyearMeeting) by May 22. - [**Book your guest room**](https://book.passkey.com/event/51119626/owner/111/home?utm_campaign=298519693) at the group rate May 26 ($159/night). - Join us after the meeting for a mingle at the famous Pat O’Brien’s (5:00 – 7:15). Reserve your spot when you register. \| \| \|---\| \| \|---\| \| [](https://members.insurancefraud.org/page/2026MidyearMeeting?_gl=1%2A8v1o4f%2A_ga%2AMzY4NDE0MjA4LjE3MTgxNDY1MDM.%2A_ga_SWDYZ10RHD%2AczE3NzI4MTE1NzYkbzgzMSRnMSR0MTc3MjgxMTU3NiRqNjAkbDAkaDA.)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/dc00bf75-24a7-66a7-20ba-e2c944930eb3.png) \| \| \|:-:\| \| \| \| **Midyear Meeting agenda:** \| \| \|---\| \| \|---\| \| \| \| **Verisk 2026 State of Insurance Fraud Study** Shane Riedman, Verisk **Regulating Artificial Intelligence Use in the Insurance Industry** John Wood, American Policyholders Association **Beyond Borders: How Transnational Organized Crime Is Reshaping Insurance Fraud** Dennis Toomey, PwC Gregory P. Hengber, Esq., Goldstein Law Group Vanessa Gillis, Sentry Insurance Steve Hall, NICB **From Test to Theft: How Illicit Licensing May Be Fueling Insurance Fraud** Joel Norris, Pearson Professional Assessments **Title Insurance Fraud: Emerging Fraud Schemes Impacting The Industry** Mary Thomas / John Crowley, Stewart Title Guaranty Company Steve Gottheim, American Land Title Association **Account Takeover Risks & Best Practices** Evgeny Aleksandrov, Pilotbird Ken Kerby, Cincinnati Insurance Carlota Balet, Allianz Life Insurance Company Matt Mortvedt, Iowa Department of Insurance & Financial Services **From Surge to Strategy: Facing Synthetic Identity Insurance Fraud** Celeste Dodson, Coalition Against Insurance Fraud Mike Horan, State Farm Matt Huls, The Hartford Jessica Gallagher, Faegre Drinker **When Cyber Incidents Become Fraud Opportunities** David Smolensky, Resolute **The Power of Partnership: Scaling Anti-Fraud Awareness Collaboratively** Brian Biggs, ICW Group / Anti-Fraud Alliance **Advocacy in Action: An Update on Coalition Amicus & Advocacy Efforts** Brent Walker, Coalition Against Insurance Fraud **Legal Frontlines: Court Decisions Shaping the Fight Against** **Insurance Fraud** Vince Gerbino, Bruno Gerbino Soriano & Aitken LLP **The Future of SIU and Fraud Bureau Leadership** Delpha DiGiacomo, Zurich Katie Sutter, American Family Insurance Dawnde Pence, Interinsurance Exchange of the Automobile Club Mariela Pennock, Assurant Armand Glick, Utah Department of Insurance **Mingle After The Midyear** Pat O’Brien’s, 718 St. Peter Street \| \| \|---\| \| \|---\| \| \| \| \| \|---\| \| [](https://members.insurancefraud.org/general/register_member_type.asp)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/4e08fedc-6fea-9426-9143-d421962a8d68.jpg) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/9d9a163b-d608-c29e-1f8c-71c58f193f3a.jpg) \| \| \|:-:\| \| \| \| - **May 20 –** [Arson: The Three Prongs](https://event.on24.com/wcc/r/5126009/F5B6C758085B4449F56D3C023FE2B6A2) (Ethos) - **May 21 –** [Property Insurance Fraud Awareness](https://register.gotowebinar.com/register/6298405480060146266?source=Newsletter) – (Allied Universal) - **July 9 –** 2026 – [SCFIA Anti-Fraud Conference](https://scfia.org/) (California Department of Insurance) - **July 20 – July 22** – [The 2026 Florida Insurance Fraud Education Committee and 34th Annual Conference](https://www.fifec.org/registration) (FIFEC) - **August 24 – August 27** – [OWL Intel Summit 2026](https://insurancefraud.org/event/owl-intel-summit-2026/) (Whooster) \| \| \|---\| \| \|---\| \| [](https://s.surveyplanet.com/bj1sw6en)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/82bc7396-3a2d-5c34-e4ff-a1d3855f62d0.jpg) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/b99b7c25-65ae-cd0c-1e44-8d51b81e8021.jpg) \| \| \|:-:\| \| \| \| \| \|---\| \| \| \| **Follow Us On Our Social Media Platforms:** \| \| \|---\| \| \|---\| \| [](https://www.linkedin.com/company/coalition-against-insurance-fraud/)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/148b79cf-2c06-6469-b7c8-335c1c8b971a.jpg) \| \| \|:-:\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| \| \| \| \| \| [](https://www.facebook.com/profile.php?id=61579225779934)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/39ae0e7d-0388-20e5-5755-020aec6cf995.jpg) \| \| \|:-:\| \| [](https://www.instagram.com/stopinsurancefraud/)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/86c49df9-4380-51e5-da9c-f83034fc7555.jpg) \| \| \|:-:\| \| \| \| \| \| ![Logo](https://brand-assets.mailchimp.com/01KKVRP4PEH4PWEG0R0VSKKJ7H.png) \| \| \|:-:\| \| \| \| *Copyright (C) 2026 Coalition Against Insurance Fraud. All rights reserved.* You are receiving this email because either your organization is a member of the Coalition Against Insurance Fraud or you requested to be placed on our mailing list. Our mailing address is: Coalition Against Insurance Fraud 1012 14th St NW Ste 610 Washington, DC 20005-3424 USA Want to change how you receive these emails? You can [update your preferences](https://insurancefraud.mailchimpsites.com/manage/preferences?u=a440c5b647697de580a2fd586&id=b68dce7808&e=%5BUNIQID%5D&c=64f8ae12c6) or [unsubscribe](https://insurancefraud.us1.list-manage.com/unsubscribe?u=a440c5b647697de580a2fd586&id=b68dce7808&t=b&e=%5BUNIQID%5D&c=64f8ae12c6) \| \| \|:-:\| \| \|---\| \| \| \| \|---\| \| \|:-:\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| | |:-:| **Features:** Fraud News Weekly --- ### [Fraud News Weekly - Friday, May 8, 2026](https://insurancefraud.org/publications/fraud-news-weekly-fnw-may-8-2026/) **Published:** May 8, 2026 **Author:** Joseph Matos **Content:** Fraud News Weekly – Friday, May 8, 2026͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ | \| \| \| \| \| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| \| \| \| \| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/ccca4f5b-ec47-9831-0a46-e2d34469b79a.jpg) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a417349b-dfdc-a052-790d-07cfde53b716.jpg) \| \| \|:-:\| \| \| \| **Coalition appears on the Restoration Industry Association’s (RIA) podcast to examine fraud risk and ethics in the restoration contractor industry.** The Coalition Against Insurance Fraud appeared on the Restoration Industry Association *RIA Beyond* podcast, in advance of NICB’s [Contractor Fraud Awareness Week](https://www.nicb.org/CFAW). Coalition Director of Government Relations Brent Walker, who also served as an advisor on the RIA Carrier Representative Task Force to update the association’s Code of Ethics, discussed how fraud moves through the restoration ecosystem, including contractor schemes, unlicensed activity, and gray areas where routine decisions can cross legal lines. The episode emphasized the RIA Code of Ethics and industry guidance as practical tools to reduce fraud exposure with a heavy emphasis on prioritizing the customer over financial temptations. [Read more](https://www.restorationindustry.org/RIA-code-of-ethics)… **California Department of Insurance (CDI) transitions to a new SIU Annual Report portal.** The CDI SIU Compliance Unit has completed the transition to the new SIU Annual Report portal. Primary reporting insurers should have received registration instructions and must register no later than May 15, 2026. CDI points out that the SIU Annual Report portal is separate from the eFD-1 system. Only primary companies need to register since subsidiaries will be automatically included. Contracted entities must coordinate access through insurers. Training will be provided ahead of 2025 Annual Report submissions and CDI asks that insurers watch for additional E-Blasts for details about upcoming training sessions. Questions may be directed to SIU-AnnualReport@insurance.ca.gov. [Read more](https://www.icontact-archive.com/archive?c=1686174&f=10321&s=17555&m=272446&t=eeb86db8b67ba7399a9fb12e867eabfed38771adbe153ec9858c9a9ec9151c81)… **Utah enacts workers compensation attestation requirement targeting zero exposure policy fraud.** Utah’s [House Bill 396](https://le.utah.gov/~2026/bills/static/HB0396.html) became effective May 6, 2026 and requires employers seeking zero estimated exposure workers compensation policies to sign a sworn statement confirming they have no employees, agree to report any hiring within 60 days with payroll details, and acknowledge that misrepresentation is a criminal offense. The new law targets contractor schemes involving zero estimated exposure policies used to secure lower-cost coverage and bid on projects, which can be exploited through undisclosed payroll, misclassified workers, and inaccurate certificates of insurance that obscure true exposure. The Coalition has also tracked related efforts in Alaska, Arizona, Massachusetts, and Tennessee to strengthen verification tools through public databases that validate coverage in real time, reduce reliance on paper certificates, and help investigators detect fraudulent or expired policies. [Read more](https://le.utah.gov/~2026/bills/static/HB0396.html)… \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a59ee231-0718-f09f-54a7-8d3ca68ea73c.jpg) \| \| \|:-:\| \| \| \| **DOJ launches West Coast strike force to target surge in healthcare and insurance fraud schemes** The U.S. Department of Justice has formed a new West Coast Health Care Fraud Strike Force focused on Arizona, Nevada, and California to aggressively target rising healthcare and insurance-related fraud, including complex schemes tied to Medicare, Medicaid, and private insurers. The initiative brings together federal and state partners such as the DOJ, HHS-OIG, FBI, and DEA, with a particular focus on high-risk activity in Northern California’s tech sector, where investigators say sophisticated, data-driven fraud operations have expanded. This effort builds on past nationwide enforcement. These actions led to thousands of prosecutions and tens of billions in losses. This work helps find and stop new fraud networks…[Read more](https://healthexec.com/topics/healthcare-management/healthcare-policy/doj-unveils-west-coast-strike-force-new-tactic-used-tackle-healthcare-fraud)… **Auto insurance fraud driving rising costs in Utah** Coalition member Armand Glick, Director of the Utah Department of Insurance Fraud Division, was interviewed by KSLTV5 about rising auto insurance fraud in Utah. He said auto fraud now makes up about half of all fraud investigations in the state, with referrals up 80% since 2022. Glick said most cases involve paper-based schemes, including false accident reports, “crash and buy” claims where coverage is purchased after a loss, and misrepresentation of vehicle use or location to lower premiums. He also cited growing windshield fraud, where pre-existing damage is falsely submitted as a new claim. He warned these schemes are driving up costs for insurers and contributing to higher premiums for Utah drivers…[Read more](https://ksltv.com/ksl-investigates/get-gephardt/insurance-fraud/905254/)… **Staged 18-wheeler crashes cost Louisiana truckers millions and drove up insurance rates** Federal prosecutors say staged 18-wheeler crashes in New Orleans, Louisiana, generated millions of dollars in fraudulent insurance payouts and contributed to rising commercial auto insurance costs. Investigators allege drivers, passengers, attorneys, and medical providers coordinated intentional crashes between 2015 and 2020 to support bogus injury lawsuits and inflated medical claims. Authorities said the schemes targeted trucking companies with…[Read more](https://www.fox8live.com/2026/05/05/how-staged-18-wheeler-crashes-cost-louisiana-truckers-millions-drove-up-insurance-rates/)… \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/28c467dc-8276-830d-664e-03edc5954526.jpg) \| \| \|:-:\| \| \| \| **PROPERTY & CASUALTY** **May 1 – California – Huntington Beach couple pleads guilty in inflated property insurance claim scheme** Hung Ta and Tam Truong pleaded guilty in a scheme involving false insurance claims tied to a reported home burglary. According to investigators, the couple submitted inflated property loss claims and falsified receipts to support an insurance payout, resulting in tens of thousands of dollars in improper payments. The couple repaid $27,696 and were sentenced to…[Read more](https://www.latimes.com/socal/daily-pilot/news/story/2026-05-01/huntington-beach-couple-pleads-guilty-to-insurance-fraud)… **HEALTHCARE** **May 1 – Oklahoma – Woman sentenced in $1.1M private health insurance fraud scheme involving fake behavioral health counseling claims** Natasha Allmon of Oklahoma City was sentenced to 20 months in federal prison for submitting false health care claims to Blue Cross Blue Shield. According to court records, Allmon billed for thousands of behavioral health sessions that were not performed, including claims for treatment durations exceeding 24 hours in a single day, resulting in approximately $1.1 million in improper insurance reimbursements. She was ordered to pay full restitution…[Read more](https://www.justice.gov/usao-wdok/pr/oklahoma-city-woman-sentenced-federal-prison-11-million-health-care-fraud-scheme)… **PROPERTY & CASUALTY** **May 3 – Nevada – County Fire Safe Council executives indicted on insurance fraud and embezzlement charges** Jamie Jones and Christopher Wackerly of the Fire Safe Council of Nevada County were indicted on multiple felony charges, including insurance fraud, embezzlement, money laundering, mortgage fraud, and forgery following a two-year investigation into the alleged misuse of taxpayer and public program funds. The defendants are accused of concealing criminal proceeds and making fraudulent representations tied to public benefits and insurance-related claims, with…[Read more](https://www.cbsnews.com/sacramento/news/nevada-county-grand-jury-fire-safe-council-executive-director-indictment/)… **UNEMPLOYMENT FRAUD** **May 3 – Michigan – Three women charged in $450K unemployment insurance fraud scheme tied to pandemic benefits** Lela Lewis, Letora Liggins, and Mesa Allen of Metro Detroit were charged in a 19-month scheme involving more than $450,000 in fraudulent unemployment insurance benefits. According to federal investigators, the trio used coordinated digital activity, banking systems, and ATM withdrawals to file and cash out false pandemic unemployment claims through…[Read more](https://www.clickondetroit.com/news/local/2026/05/03/how-3-michigan-women-drained-more-than-450000-in-19-month-fraud-scheme-feds-say/)… **HEALTHCARE** **May 4 – Georgia – Half-billion dollar genetic testing healthcare fraud scheme ends in prison sentences for two Georgia men** Reyad Salahaldeen and Mohamad Mustafa were sentenced to federal prison for their roles in a healthcare and insurance fraud scheme that submitted more than $522 million in false genetic testing claims to Medicare, Medicaid, and private insurers. Prosecutors say the scheme used illegal kickbacks to generate unnecessary tests and falsified records to support fraudulent billing, resulting in more than $84 million in payments before being uncovered…[Read more](https://www.justice.gov/opa/pr/two-sentenced-prison-522m-genetic-testing-fraud-and-illegal-kickback-scheme-targeting)… **HEALTHCARE** **May 5 – Wisconsin – Milwaukee woman charged in $2.2M Medicaid false claims and money laundering scheme** Debbie Long is accused of defrauding Wisconsin Medicaid out of nearly $2.2 million by submitting false claims for in-home healthcare services that investigators say were never provided through her business, Pinnacle Home Health Care LLC. Authorities also allege Long obtained a fraudulent $219,000 pandemic relief loan and used proceeds from the scheme to purchase businesses and luxury assets. She faces insurance fraud and money laundering charges in Milwaukee County…[Read more](https://www.wisn.com/article/milwaukee-woman-accused-of-22-million-medicaid-fraud/71224682)… **HEALTHCARE** **May 5 – Connecticut – Woman sentenced for Medicaid fraud involving services not provided** Carmen Berroa, of Waterbury, was sentenced after admitting to submitting fraudulent Medicaid claims for personal care assistance services she did not provide. Prosecutors said Berroa collected more than $13,000 through false timesheets. Berroa was ordered to pay restitution and is barred from serving as a Medicaid provider...[Read more](https://portal.ct.gov/dcj/press-releases/division-of-criminal-justice/05052026berroa?language=en_US)… **WORKERS’ COMPENSATION FRAUD** **May 6 – Florida – Orlando residents sentenced in $148M construction payroll and workers’ compensation insurance fraud scheme** Rene Mauricio Escobar and Juana Nelida Escobar were sentenced to federal prison for a $148 million construction payroll scheme that defrauded workers’ compensation insurers and the IRS by paying workers off the books and misrepresenting payroll to reduce insurance costs. Prosecutors said the defendants used Escobar Plastering to issue fraudulent certificates of insurance that falsely placed subcontractors under the company’s workers’ compensation policy, resulting in…[Read more](https://www.justice.gov/usao-mdfl/pr/two-orlando-residents-sentenced-148-million-construction-payroll-scheme-defrauded-irs)… **AUTO – FALSE CLAIMS** **May 6 – Nebraska – Woman convicted in attempted auto insurance fraud scheme** Makayla Ekross, of Ord, was convicted of attempted insurance fraud after prosecutors said she applied for auto insurance following a motor vehicle crash on Interstate 80 and falsely reported the accident occurred after coverage was obtained. Ekross was found guilty of a reduced misdemeanor charge and agreed to pay a $500 fine and $1,191.86 in restitution…[Read more](https://ruralradio.com/krvn/news/ord-woman-convicted-of-attempted-insurance-fraud/)… **AGENT MISCONDUCT** **May 6 – West Virginia – Tax preparer sentenced in unauthorized insurance policy fraud scheme** Amanda Gorham, of Harpers Ferry, was sentenced to 18 months in federal prison for an insurance fraud scheme where prosecutors said she used clients’ personal information to open unauthorized insurance policies and collect more than $44,000 in commissions and bonuses without their knowledge. Authorities said the fraud involved policies issued under…[Read more](https://www.wvnews.com/news/wvnews/tax-preparer-sentenced-to-18-months-for-44-000-insurance-fraud-scheme/article_3b86ea8e-dc2d-4881-bd55-e3294f483d01.html)… \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/78c5ce69-a52f-df22-e1cc-d2afe0bb6ca3.jpg) \| \| \|:-:\| \| [](https://us02web.zoom.us/webinar/register/WN_v0tVfA63SI-440EOWpPFwQ)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/3dddeb0d-3592-873b-52d0-6ad190eab2b1.jpg) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/18f9920e-e738-5103-cd8e-7ba476e9eb86.jpg) \| \| \|:-:\| \| \| \| **We’re just a little over a month away from the** **2026 Midyear Meeting in New Orleans!** **June 15 – June 16** \| \| \|---\| \| \|---\| \| \| \| Join us this June in one of America’s most vibrant cities for expert sessions, meaningful conversations, and connections that move the industry forward. Plus, reconnect with familiar faces and meet the newest members of the fraud-fighting community. \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/b69c6595-0760-ad0d-a8ee-f022ae1d34fc.jpg) \| \| \|:-:\| \| \| \| **Midyear Meeting agenda:** \| \| \|---\| \| \|---\| \| \| \| **Verisk 2026 State of Insurance Fraud Study** Shane Riedman, Verisk **Regulating Artificial Intelligence Use in the Insurance Industry** John Wood, American Policyholders Association **Beyond Borders: How Transnational Organized Crime Is Reshaping Insurance Fraud** Dennis Toomey, PwC Gregory P. Hengber, Esq., Goldstein Law Group Vanessa Gillis, Sentry Insurance Steve Hall, NICB **From Test to Theft: How Illicit Licensing May Be Fueling Insurance Fraud** Joel Norris, Pearson Professional Assessments **Title Insurance Fraud: Emerging Fraud Schemes Impacting The Industry** Mary Thomas / John Crowley, Stewart Title Guaranty Company Steve Gottheim, American Land Title Association **Account Takeover Risks & Best Practices** Evgeny Aleksandrov, Pilotbird Ken Kerby, Cincinnati Insurance Carlota Balet, Allianz Life Insurance Company Matt Mortvedt, Iowa Department of Insurance & Financial Services **From Surge to Strategy: Facing Synthetic Identity Insurance Fraud** Celeste Dodson, Coalition Against Insurance Fraud Mike Horan, State Farm Matt Huls, The Hartford Jessica Gallagher, Faegre Drinker **When Cyber Incidents Become Fraud Opportunities** David Smolensky, Resolute **The Power of Partnership: Scaling Anti-Fraud Awareness Collaboratively** Brian Biggs, ICW Group / Anti-Fraud Alliance **Advocacy in Action: An Update on Coalition Amicus & Advocacy Efforts** Brent Walker, Coalition Against Insurance Fraud **Legal Frontlines: Court Decisions Shaping the Fight Against** **Insurance Fraud** Vince Gerbino, Bruno Gerbino Soriano & Aitken LLP **The Future of SIU and Fraud Bureau Leadership** Delpha DiGiacomo, Zurich Katie Sutter, American Family Insurance Dawnde Pence, Interinsurance Exchange of the Automobile Club Mariela Pennock, Assurant Armand Glick, Utah Department of Insurance **Mingle After The Midyear** Pat O’Brien’s, 718 St. Peter Street \| \| \|---\| \| \|---\| \| \| \| \| \|---\| \| \| \| - [**Register**](https://members.insurancefraud.org/page/2026MidyearMeeting) **by May 22** - [**Deadline to book guest room**](https://book.passkey.com/event/51119626/owner/111/home?utm_campaign=298519693) **at the group rate May 26** ($159/night). And, stay after the meeting Tuesday evening for a mingle at the famous **Pat O’Brien’s (5:00 – 7:15 p.m.)**. Reserve your spot when you register. \| \| \|---\| \| \|---\| \| [](https://members.insurancefraud.org/page/2026MidyearMeeting?_gl=1%2A8v1o4f%2A_ga%2AMzY4NDE0MjA4LjE3MTgxNDY1MDM.%2A_ga_SWDYZ10RHD%2AczE3NzI4MTE1NzYkbzgzMSRnMSR0MTc3MjgxMTU3NiRqNjAkbDAkaDA.)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/dc00bf75-24a7-66a7-20ba-e2c944930eb3.png) \| \| \|:-:\| \| [](https://members.insurancefraud.org/general/register_member_type.asp)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/4e08fedc-6fea-9426-9143-d421962a8d68.jpg) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/9d9a163b-d608-c29e-1f8c-71c58f193f3a.jpg) \| \| \|:-:\| \| \| \| - **May 14 –** [How OSINT Analysts Make Decisions Under Uncertainty](https://events.skopenow.com/how-osint-analysts-make-decisions-under-uncertainty?utm_medium=email&_hsenc=p2ANqtz-_URROuXE-InzaMWCP3xJaKZFWEcCqF8KIglIpcNVNsKdFNhAYon6XmqlpUoIF6Ybvr689Iblne37cnNyByRHa5V72K6Q&_hsmi=417714622&utm_content=417714622&utm_source=hs_email) – (Skopenow) - **May 20 –** [Arson: The Three Prongs](https://event.on24.com/wcc/r/5126009/F5B6C758085B4449F56D3C023FE2B6A2) (Ethos) - **May 21 –** [Property Insurance Fraud Awareness](https://register.gotowebinar.com/register/6298405480060146266?source=Newsletter) – (Allied Universal) - **July 9 –** 2026 – [SCFIA Anti-Fraud Conference](https://scfia.org/) (California Department of Insurance) - **July 20 – July 22** – [The 2026 Florida Insurance Fraud Education Committee and 34th Annual Conference](https://www.fifec.org/registration) (FIFEC) - **August 24 – August 27** – [OWL Intel Summit 2026](https://insurancefraud.org/event/owl-intel-summit-2026/) (Whooster) \| \| \|---\| \| \|---\| \| [](https://s.surveyplanet.com/bj1sw6en)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/82bc7396-3a2d-5c34-e4ff-a1d3855f62d0.jpg) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/b99b7c25-65ae-cd0c-1e44-8d51b81e8021.jpg) \| \| \|:-:\| \| \| \| \| \|---\| \| \| \| **Follow Us On Our Social Media Platforms:** \| \| \|---\| \| \|---\| \| [](https://www.linkedin.com/company/coalition-against-insurance-fraud/)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/148b79cf-2c06-6469-b7c8-335c1c8b971a.jpg) \| \| \|:-:\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| \| \| \| \| \| [](https://www.facebook.com/profile.php?id=61579225779934)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/39ae0e7d-0388-20e5-5755-020aec6cf995.jpg) \| \| \|:-:\| \| [](https://www.instagram.com/stopinsurancefraud/)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/86c49df9-4380-51e5-da9c-f83034fc7555.jpg) \| \| \|:-:\| \| \| \| \| \| ![Logo](https://brand-assets.mailchimp.com/01KKVRP4PEH4PWEG0R0VSKKJ7H.png) \| \| \|:-:\| \| \| \| *Copyright (C) 2026 Coalition Against Insurance Fraud. All rights reserved.* You are receiving this email because either your organization is a member of the Coalition Against Insurance Fraud or you requested to be placed on our mailing list. Our mailing address is: Coalition Against Insurance Fraud 1012 14th St NW Ste 610 Washington, DC 20005-3424 USA Want to change how you receive these emails? You can [update your preferences](https://insurancefraud.mailchimpsites.com/manage/preferences?u=a440c5b647697de580a2fd586&id=b68dce7808&e=%5BUNIQID%5D&c=02891a476f) or [unsubscribe](https://insurancefraud.us1.list-manage.com/unsubscribe?u=a440c5b647697de580a2fd586&id=b68dce7808&t=b&e=%5BUNIQID%5D&c=02891a476f) \| \| \|:-:\| \| \|---\| \| \| \| \|---\| \| \|:-:\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| | |:-:| <html><p class="wp-block-paragraph"></p> **Features:** Fraud News Weekly --- ### [Fraud News Weekly - Friday, May, 1, 2026](https://insurancefraud.org/publications/fraud-news-weekly-friday-may-1-2026/) **Published:** May 4, 2026 **Author:** Joseph Matos **Content:** Fraud News Weekly – Friday, May 1, 2026͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ | \| \| \| \| \| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| \| \| \| \| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/83dedb9d-ddd8-855f-1b03-b32477a15e3c.jpg) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a417349b-dfdc-a052-790d-07cfde53b716.jpg) \| \| \|:-:\| \| \| \| **The Coalition clarifies antifraud exemption during National Association of Insurance Commissioners (NAIC) meeting to revise Privacy of Consumer Information Act model.** The NAIC Privacy Protections (H) Working Group ([PPWG](https://content.naic.org/committees/h/privacy-protections-wg)) held a [meeting](https://content.naic.org/sites/default/files/call_materials/Agenda%204.30.26.pdf) to discuss [comments made](https://content.naic.org/sites/default/files/inline-files/Article%20VII%20-%20Compilation%20of%20Public%20Comments.pdf) as they continue drafting a revised model law, focusing on Article VII rules for health information in attempt to build consensus across regulators, industry, and consumer representatives. Brent Walker, representing the Coalition Against Insurance Fraud and serving as a NAIC consumer representative, clarified Section 25 language on antifraud nonprofit organizations and its intent to preserve exemptions supporting mandatory fraud reporting through NAIC systems and the National Insurance Crime Bureau (NICB) after initial coordination with NICB and the NAIC Antifraud Technology (D) Working Group. The PPWG will begin revision on Article VIII then release a full reassembled draft for review and comment with its next meeting to be held during the NAIC Summer National Meeting. [Read more](https://content.naic.org/sites/default/files/inline-files/PPWG%20Drafting%20Guidelines.pdf)… **Kentucky enacted bills face legal challenge as public adjusters dispute regulatory changes.** The Coalition Against Insurance Fraud unintentionally referenced several bills as antifraud laws but clarifies that Kentucky [House Bill 568](https://apps.legislature.ky.gov/record/26rs/hb568.html) and [House Bill 355](https://apps.legislature.ky.gov/record/26rs/hb355.html), are regulatory measures now under legal challenge by public adjusters in the state. In a [press release](https://www.napia.com/news/napia-strongly-opposes-enactment-of-kentucky-house-bill-568), the National Association of Public Insurance Adjusters (a Coalition member) states the laws restrict core functions, including claims negotiation, and may limit policyholder representation. Plaintiffs seek to block enforcement and recover damages such as lost income and attorney fees. For Coalition members, the case reflects how differing views on how consumer protection and regulatory policy intersect within the licensed public adjusting profession. [Read more](https://www.napia.com/news/napia-strongly-opposes-enactment-of-kentucky-house-bill-568)… **Coalition seeks to connect auto residual market fraud fighters with broader antifraud community.** This week, Coalition Against Insurance Fraud Director of Government Relations Brent Walker presented at the 2026 Residual Market Forum hosted by [AIPSO](https://www.aipso.com/), which administers assigned risk auto programs for high-risk drivers unable to obtain voluntary coverage. He learned that their key fraud risks are premium fraud and rate evasion through commercial trucking companies misrepresenting drivers, employment status, and vehicles; a fraud scheme that closely mirrors those same schemes seen in workers compensation. Soon after, Coalition Director of Member Services and Initiatives Celeste Dodson shared these insights with the Coalition Workers Compensation Task Force. Members who wish to learn more should contact [Walker](mailto:brent@insurancefraud.org) and resources are available that highlight these fraud trends in the auto residual market. [Read more](https://www.cbsnews.com/projects/2026/chameleon-carrier-trucks/)… **NAIC Improper Marketing of Health Insurance Working Group highlights Federal Trade Commission (FTC) action on deceptive health coverage scheme.** The NAIC Improper Marketing of Health Insurance (D) Working Group shared a recent enforcement [case](https://www.ftc.gov/system/files/ftc_gov/pdf/2423043innovativepartnerscomplaint.pdf) from the FTC involving alleged deceptive marketing of health coverage. The FTC claims the scheme generated millions by misleading consumers seeking comprehensive plans or targeting those already insured, raising concerns about fraud, misrepresentation, and data use. [Read more](https://www.ftc.gov/news-events/news/press-releases/2026/04/ftc-sues-stop-deceptive-health-care-scheme)… \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a59ee231-0718-f09f-54a7-8d3ca68ea73c.jpg) \| \| \|:-:\| \| \| \| **Coalition hosts virtual screening of “SHUFFLE”** Thank you to the more than 300 members who joined our virtual screening of “**SHUFFLE”** on April 28th. The documentary is a powerful film that provides a truly eye-opening look into the realities of sober home fraud, highlighting how vulnerable individuals are exploited and how the insurance system is manipulated for profit. As the Coalition continues to support the film’s nationwide rollout, please watch for upcoming announcements about screenings in your area. **Verisk highlights analytics shift strengthening insurance fraud detection** Coalition member Verisk highlights how insurers are using analytics to detect insurance fraud patterns that traditional claims review may miss, including synthetic identities, hijacked policies, and staged claims activity. The focus is on how link analysis, geolocation, and digital forensics are increasingly used by SIU teams to identify coordinated fraud schemes across multiple claims and policyholders… [Read more](https://www.verisk.com/blog/analytics-inside-the-new-fraud-fighting-mindset/)… **Federal court shuts down health insurance scam targeting consumers with fake coverage schemes** A federal court granted a temporary order from the Federal Trade Commission to shut down an operation accused of fraudulently selling fake health insurance plans by impersonating insurers and government entities. The scheme allegedly misled consumers into purchasing worthless coverage while falsely representing benefits, deductibles, and plan legitimacy, resulting in financial losses and unpaid medical bills tied to unusable insurance products… [Read more](https://www.kare11.com/article/news/nation-world/health-insurance-scam-protect-yourself/507-2928c0eb-cd00-442e-aad1-0bb2d83af401)… **Carriers face evolving threat as Generative AI rewrites the playbook on insurance fraud** Insurance fraud is undergoing a structural shift as generative AI tools transform how false claims are filed, forcing carriers to adapt or absorb growing losses, according to new analysis from Gen Re developed with the National Insurance Crime Bureau. The scale is significant. A 2022 study from the Coalition Against Insurance Fraud estimates fraud costs the U.S. economy $308.6 billion annually, while the North Carolina Department of Insurance reports fraud accounts for roughly 20 cents of every premium dollar. Gen Re notes insurers face both a responsibility and legal obligation to protect policyholders, with the risk most acute in liability claims involving medical components, where claims examiners often serve as the first line of defense… [Read more](https://www.insurancebusinessmag.com/reinsurance/news/breaking-news/generative-ai-rewrites-the-playbook-on-insurance-fraud--gen-re-573117.aspx)… **Spike in fake insurance cards leaves drivers at risk** A growing surge in fake auto insurance cards is leaving drivers unknowingly uninsured, often discovering the scam only after a crash or traffic stop. Lured by low-cost deals through unofficial websites and social media, consumers are paying for policies that do not exist, creating legal and financial consequences for victims and contributing to higher premiums for insured drivers nationwide… [Read more](https://www.nbcdfw.com/news/nbc-5-responds/spike-fake-insurance-cards/4017572/)… \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/28c467dc-8276-830d-664e-03edc5954526.jpg) \| \| \|:-:\| \| \| \| **HEALTHCARE** **April 24 – New York – Queens pharmacy owner sentenced in $24.4M Medicare and Medicaid prescription fraud laundering scheme** Taesung “Terry” Kim of Harrison was sentenced for laundering proceeds from a $24.4 million Medicare and Medicaid fraud scheme involving medically unnecessary prescriptions. Prosecutors said the scheme relied on kickbacks and bribes to generate fraudulent prescription claims submitted to federal health care insurance programs, resulting in improper reimbursements that were later concealed through financial transactions… [Read more](https://www.justice.gov/opa/pr/queens-pharmacy-owner-sentenced-over-five-years-prison-money-laundering-scheme)… **HEALTHCARE** **April 27 – Missouri – Columbia doctor indicted in Medicare and Medicaid billing and prescription drug fraud scheme** Dr. Jonathan Morris, owner of Columbia Urgent Care, was indicted on federal charges of Medicare and Medicaid billing fraud tied to services not personally provided, along with unlawful distribution of controlled substances. Prosecutors allege the scheme involved fraudulent insurance claims submitted to government health care programs and improper prescribing practices that triggered reimbursement fraud concerns… [Read more](https://abc17news.com/news/crime/2026/04/27/columbia-doctor-indicted-on-38-federal-fraud-counts-could-hear-bond-decision-by-wednesday/)…​ **UNEMPLOYMENT FRAUD** **April 27 – Georgia – $3M unemployment insurance fraud scheme leads to federal prison sentence for Atlanta podcaster** Jonathan Dupiton, host of “Rich and Unemployed”, was sentenced for participating in a scheme that used stolen identities to file fraudulent unemployment insurance claims during the COVID-19 pandemic. Dupiton, whose motto is “F.R.A.U.D. is Dope” (acronym for “Finally Rich After Unstoppable Determination”), targeted a state unemployment insurance program by submitting false claims and diverting benefits through prepaid debit cards, resulting in… [Read more](https://www.cbsnews.com/atlanta/news/atlanta-podcaster-sentenced-to-federal-prison-for-unemployment-benefit-fraud-scheme/)… ​ **HEALTHCARE** **April 28 – California – United States seizes more than $2M from Pasadena-Based advanced wound care clinic accused of Medicare fraud** Expert Wound Care PC, a Pasadena-based clinic, is accused of submitting fraudulent Medicare claims for wound care services and skin graft procedures that were allegedly not performed, resulting in a federal seizure of approximately $2 million in fraud proceeds. Authorities allege the clinic engaged in systematic overbilling and inflated claims submitted to Medicare, including high-dollar billing concentrated around a small number of beneficiaries… [Read more](https://www.justice.gov/usao-cdca/pr/united-states-seizes-more-2-million-pasadena-based-advanced-wound-care-clinic-0)… ​ **AUTO – FALSE CLAIMS** **April 28 – Missouri – Former St. Louis alderman sentenced in auto insurance repair fraud scheme and FBI deception case** Brandon Bosley, was sentenced for orchestrating an auto insurance fraud scheme involving inflated vehicle repair estimates submitted to an insurer following a collision. Prosecutors said the scheme involved exaggerated repair billing intended to increase insurance payouts, followed by false statements made to federal investigators during the inquiry… [Read more](https://www.justice.gov/usao-edmo/pr/former-st-louis-alderman-sentenced-16-months-prison-fraud-lying-fbi)… ​ **PUBLIC ADJUSTER MISCONDUCT** **April 29 – Pennsylvania – Bucks County public adjuster charged in $140K insurance claim misappropriation scheme** Greg A. Micucci, owner of Advanced Public Adjusters in Bucks County, was charged this week with multiple counts of insurance fraud and theft after allegedly misappropriating approximately $140,000 in insurance claim funds intended for homeowners and contractors. According to the District Attorney’s Office, Micucci directed insurance payments to his business and failed to distribute funds tied to property damage claims, leaving victims unable to pay for repairs and, in some cases, forcing homeowners to cover costs out of pocket… [Read more](https://crimewatch.net/us/pa/bucks/da/29567/post/bucks-county-public-adjuster-charged-stealing-over-140000-insurance-payouts-clients)**…** **AUTO – STAGED ACCIDENT** **April 30 – Missouri – Wyandotte County man sentenced in staged auto insurance claim fraud scheme** Christopher Dunn was sentenced this week to 16 months in prison for filing a fraudulent auto insurance claim. According to the Kansas Insurance Commissioner, Dunn pleaded guilty to insurance fraud after falsely reporting that his vehicle was damaged in a crash, when the damage occurred while he was fleeing police during a traffic stop. He will serve 12 months of probation following his release… [Read more](https://fox4kc.com/news/man-sentenced-in-wyandotte-county-court-for-insurance-fraud/)… **WORKERS’ COMPENSATION FRAUD** **April 30 – New York – Oswego County resident sentenced for Insurance fraud after concealing work while collecting workers’ compensation benefits** Christopher Cronk of Central Square, was sentenced this week to five years of probation for fraudulently collecting workers’ compensation insurance benefits while concealing his return to work. According to the New York State Workers’ Compensation Fraud Inspector General, Cronk continued working and earning income while certifying he was not employed, resulting in more than $10,000 in improper wage-replacement benefits paid by the New York State Insurance Fund. He was also ordered to pay full restitution… [Read more](https://oswegocountytoday.com/news/oswego-county-resident-sentenced-for-insurance-fraud-after-concealing-work-while-collecting-workers-compensation-benefits/)… \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a4e430c0-c419-3044-1add-d368ddda9e22.jpg) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/6221c1bc-6ff5-6977-9557-0e28ba822a48.png) \| \| \|:-:\| \| \| \| The Coalition welcomes the [Shasta County District Attorney’s Office](https://www.shastacounty.gov/district-attorney) as its newest member. The office plays a vital role in strengthening the fight against insurance fraud through proactive investigation, strategic prosecution, and strong collaboration with partners such as the California Department of Insurance and local law enforcement agencies. Insurance fraud in all its forms, from staged vehicle collisions and inflated claims to workers’ compensation schemes, continues to cost billions annually and erode public trust in the insurance system. In response, the Shasta County District Attorney’s Office brings a focused and disciplined approach to identifying, investigating, and prosecuting these complex crimes. A key strength of the office is its commitment to collaboration. Working closely with insurance carriers, regulatory agencies, and law enforcement partners, the team helps identify suspicious patterns and assemble the evidence needed to move cases forward. Through careful review of claims data, financial records, and recorded statements, analysts and investigators work to uncover inconsistencies that signal potential fraud. In more complex matters, investigative tools such as surveillance, interviews, and search warrants are used to build thorough and defensible cases. The office also leverages partnerships with organizations like the National Insurance Crime Bureau to share intelligence and strengthen coordination across jurisdictions. This collective approach enhances the ability to identify broader fraud schemes and respond effectively to organized criminal activity. Prosecution remains a powerful deterrent. Deputy district attorneys pursue cases ranging from misdemeanor offenses to serious felonies, depending on the scope and impact of the fraud. Outcomes often include restitution, fines, and incarceration, reinforcing the message that insurance fraud carries significant consequences. Importantly, the office also prioritizes disrupting organized fraud networks, not just individual offenders. Beyond enforcement, the Shasta County District Attorney’s Office supports prevention through education and outreach. By raising awareness of the consequences of insurance fraud and encouraging the reporting of suspicious activity, the office helps empower the public and industry partners to take an active role in detection. The Coalition welcomes the Shasta County District Attorney’s Office and looks forward to the impact of its investigative expertise, prosecutorial strength, and commitment to safeguarding the integrity of the insurance system. \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/78c5ce69-a52f-df22-e1cc-d2afe0bb6ca3.jpg) \| \| \|:-:\| \| [](https://us02web.zoom.us/webinar/register/WN_v0tVfA63SI-440EOWpPFwQ)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/3dddeb0d-3592-873b-52d0-6ad190eab2b1.jpg) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/18f9920e-e738-5103-cd8e-7ba476e9eb86.jpg) \| \| \|:-:\| \| \| \| **We’re just a little over a month away from the** **2026 Midyear Meeting in New Orleans!** **June 15 – June 16** \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/b69c6595-0760-ad0d-a8ee-f022ae1d34fc.jpg) \| \| \|:-:\| \| \| \| **Join us for panels and presentations on these topics:** - Verisk 2026 State of Insurance Fraud Study - Regulating Artificial Intelligence Use in the Insurance Industry - Beyond Borders: How Transnational Organized Crime Is Reshaping Insurance Fraud - From Test to Theft: How Illicit Licensing May Be Fueling Insurance Fraud - Title Insurance Fraud: Emerging Fraud Schemes Impacting The Industry - Account Takeover Risks & Best Practices - From Surge to Strategy: Facing Synthetic Identity Insurance Fraud - When Cyber Incidents Become Fraud Opportunities - The Power of Partnership: Scaling Anti-Fraud Awareness Collaboratively - Advocacy in Action: An Update On Coalition Amicus & Advocacy Efforts - Legal Frontlines: Court Decisions Shaping the Fight Against Insurance Fraud - The Future of SIU and Fraud Bureau Leadership **Program Highlights:** ***The full agenda will be announced soon.*** - [**Register**](https://members.insurancefraud.org/page/2026MidyearMeeting) **by May 22** - [**Deadline to book guest room**](https://book.passkey.com/event/51119626/owner/111/home?utm_campaign=298519693) **at the group rate May 26** ($159/night). And, stay after the meeting Tuesday evening for a mingle at the famous **Pat O’Brien’s (5:00 – 7:15 p.m.)**. Reserve your spot when you register. \| \| \|---\| \| \|---\| \| [](https://members.insurancefraud.org/page/2026MidyearMeeting?_gl=1%2A8v1o4f%2A_ga%2AMzY4NDE0MjA4LjE3MTgxNDY1MDM.%2A_ga_SWDYZ10RHD%2AczE3NzI4MTE1NzYkbzgzMSRnMSR0MTc3MjgxMTU3NiRqNjAkbDAkaDA.)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/dc00bf75-24a7-66a7-20ba-e2c944930eb3.png) \| \| \|:-:\| \| [](https://members.insurancefraud.org/general/register_member_type.asp)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/4e08fedc-6fea-9426-9143-d421962a8d68.jpg) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/9d9a163b-d608-c29e-1f8c-71c58f193f3a.jpg) \| \| \|:-:\| \| \| \| - **May 4 – May 6** – [Evadata ACT Anti-Fraud Conference](https://whova.com/web/q1wi0epkylJtzgvBjy4ES1K-nsi4hWOOugnM0M7js90%3D/) (Evadata) - **May 5 – May 6** – [Vehicle Fraud & Crime Conference](https://www.nicb.org/news/events/vehicle-fraud-crime-conference) (NICB) - **May 6 –** [Medical Provider Fraud: When Care Turns Criminal](https://event.on24.com/wcc/r/5256532/DA2D411534BB6F66E69E51E95E414E6B) (ETHOS) - **July 20 – July 22** – [The 2026 Florida Insurance Fraud Education Committee and 34th Annual Conference](https://www.fifec.org/registration) (FIFEC) - **August 24 – August 27** – [OWL Intel Summit 2026](https://insurancefraud.org/event/owl-intel-summit-2026/) (Whooster) \| \| \|---\| \| \|---\| \| [](https://s.surveyplanet.com/bj1sw6en)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/82bc7396-3a2d-5c34-e4ff-a1d3855f62d0.jpg) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/b99b7c25-65ae-cd0c-1e44-8d51b81e8021.jpg) \| \| \|:-:\| \| \| \| \| \|---\| \| \| \| **Follow Us On Our Social Media Platforms:** \| \| \|---\| \| \|---\| \| [](https://www.linkedin.com/company/coalition-against-insurance-fraud/)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/148b79cf-2c06-6469-b7c8-335c1c8b971a.jpg) \| \| \|:-:\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| \| \| \| \| \| [](https://www.facebook.com/profile.php?id=61579225779934)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/39ae0e7d-0388-20e5-5755-020aec6cf995.jpg) \| \| \|:-:\| \| [](https://www.instagram.com/stopinsurancefraud/)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/86c49df9-4380-51e5-da9c-f83034fc7555.jpg) \| \| \|:-:\| \| \| \| \| \| ![Logo](https://brand-assets.mailchimp.com/01KKVRP4PEH4PWEG0R0VSKKJ7H.png) \| \| \|:-:\| \| \| \| *Copyright (C) 2026 Coalition Against Insurance Fraud. All rights reserved.* You are receiving this email because either your organization is a member of the Coalition Against Insurance Fraud or you requested to be placed on our mailing list. Our mailing address is: Coalition Against Insurance Fraud 1012 14th St NW Ste 610 Washington, DC 20005-3424 USA Want to change how you receive these emails? You can [update your preferences](https://insurancefraud.mailchimpsites.com/manage/preferences?u=a440c5b647697de580a2fd586&id=b68dce7808&e=%5BUNIQID%5D&c=d9d59f2fb9) or [unsubscribe](https://insurancefraud.us1.list-manage.com/unsubscribe?u=a440c5b647697de580a2fd586&id=b68dce7808&t=b&e=%5BUNIQID%5D&c=d9d59f2fb9) \| \| \|:-:\| \| \|---\| \| \| \| \|---\| \| \|:-:\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| | |:-:| **Features:** Fraud News Weekly --- ### [Fraud News Weekly - Friday, April 24, 2026](https://insurancefraud.org/publications/fraud-news-weekly-friday-april-24-2026/) **Published:** April 29, 2026 **Author:** Joseph Matos **Content:** Fraud News Weekly (FNW) – Friday, April 24, 2026͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ | \| \| \| \| \| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| \| \| \| \| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/e0b4fed6-33e1-60b8-9673-44a6f9e3ff7d.jpg) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a417349b-dfdc-a052-790d-07cfde53b716.jpg) \| \| \|:-:\| \| \| \| **Coalition attends state legislator conference.** This past week, the Coalition attended the National Council of Insurance Legislators (NCOIL) Spring Meeting in Louisville, Kentucky. NCOIL is a national bipartisan legislative organization with members from all 50 states represented by legislators serving on insurance and financial institutions committees. Discussions focused on artificial intelligence governance, market conduct modernization, insurer data analytics, affordability and availability pressures, and ongoing questions around federal preemption and state regulatory authority. While there, the Coalition engaged with key antifraud stakeholders and legislators in states with pending antifraud legislation, reinforcing relationships and supporting ongoing policy discussions. [**Read more**](https://ncoil.org/wp-content/uploads/2026/04/Louisville-30-Day-Materials-2.pdf)… **Louisiana bill to strengthen insurance fraud laws passes both chambers unanimously.** Louisiana [House Bill 739](https://legis.la.gov/legis/BillInfo.aspx?i=250601) updates the state’s insurance fraud laws by allowing the Louisiana Department of Insurance (LDI) Office of Insurance Fraud to assist law enforcement in investigations when requested. It also clarifies what counts as the “business of insurance” under unfair trade practice rules, including activities tied to selling, advertising, and handling claims, while excluding attorneys providing legal services and healthcare providers helping patients with approvals. The bill also strengthens the LDI Commissioner’s authority to take action against both licensed and unlicensed individuals who engage in unfair or deceptive insurance practices, including issuing orders, fines, and other penalties. The House Bill was passed unanimously by the Senate this week and is headed back to the House before being delivered to the Governor. [**Read more**](https://legis.la.gov/legis/BillInfo.aspx?i=250601)… **Coalition shared an update at the Kentucky Insurance Fraud Council (KIFC)** meeting this week. Hosted by the Insurance Institute of Kentucky (IIKY), the KIFC meeting brought together local antifraud stakeholders. An IIKY legislative update highlighted key antifraud laws that have been enacted, including Kentucky [House Bill 627](https://apps.legislature.ky.gov/record/26rs/hb627.html) applying workers compensation fee schedules to personal injury protection (PIP) billing, [House Bill 568](https://apps.legislature.ky.gov/record/26rs/hb568.html) limiting public adjuster activity throughout the state, [House Bill 355](https://apps.legislature.ky.gov/record/26rs/hb355.html) addressing appraiser misrepresentation, and [Senate Bill 153](https://apps.legislature.ky.gov/record/26rs/sb153.html) strengthening contractor fraud enforcement and Attorney General authority. Kentucky Department of Insurance Fraud Division reported year-to-date fraud referral statistics that include 19 convictions and more than $109,000 dollars in restitution, while the National Insurance Crime Bureau shared that insurance fraud referrals are up year-over-year with exaggerated injuries, staged crashes, and predatory towing trending. [**Read more**](https://iiky.org/)… \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a59ee231-0718-f09f-54a7-8d3ca68ea73c.jpg) \| \| \|:-:\| \| \| \| **AI images are now being abused to fake evidence for vehicle insurance fraud** AI-generated car damage is turning into a real insurance fraud issue, with Admiral linking a sharp rise in cases during 2025 to manipulated images and fabricated supporting materials. The problem is no longer limited to suspicious paperwork. Photos of damaged vehicles can now be edited to make a loss look worse or to help support a duplicate filing. [**Read more**](https://finance.yahoo.com/economy/policy/articles/ai-images-now-being-abused-124551159.html)… **National Fraud Enforcement Division uncovers $340M in fraud schemes in its first week of operation** The DOJ’s newly created National Fraud Enforcement Division announced Friday a wave of arrests, convictions and sentences in fraud schemes that targeted more than $340 million in taxpayer funds over just the past week. The actions, spanning April 10 through April 17, involved cases from… [**Read more**](https://lynnwoodtimes.com/2026/04/19/fraud-enforcement/)… \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/28c467dc-8276-830d-664e-03edc5954526.jpg) \| \| \|:-:\| \| \| \| **AUTO – FALSE CLAIMS** **April 19 – Florida – Crash claim fraud alleged in Florida insurance case** Richard Roy, 76, is accused of insurance fraud in Charlotte County, Florida, after authorities say he falsified details of a vehicle crash claim. The Florida Department of Financial Services Criminal Investigations Division said the investigation began after a complaint alleging Roy misrepresented information tied to the crash and received a payout from GEICO. Officials allege the false statements were used to support an improper insurance claim payment… [**Read more**](https://www.gulfcoastnewsnow.com/article/man-accused-falsifying-details-insurance-claim-crash-charlotte-county/71061504)… **AUTO – FALSE CLAIMS** **April 20 – South Carolina – Insurance fraud charges filed against Ex-NFL receiver** Alshon Jeffery was arrested in California on insurance fraud charges, according to court records, after authorities alleged he filed a false insurance claim. Investigators said he is accused of concealing or failing to disclose information related to an insurance payment or benefit in order to support the claim and obtain improper compensation. Authorities say the claim was supported through false statements tied to an insurance payout... [**Read more**](https://www.wistv.com/2026/04/20/alshon-jeffrey-arrested-charged-with-insurance-fraud-california/)… **HEALTHCARE** **April 20 – Boston – Previously convicted individual charged with Healthcare insurance fraud and aggravated identity theft** Amaurys Arias Arias, 44, was charged in Boston, Massachusetts, with healthcare insurance fraud, making false statements, and aggravated identity theft. Authorities allege he used another individual’s identity and misrepresented information to submit fraudulent healthcare insurance claims and obtain benefits. He was arrested and ordered detained following his initial appearance in federal court… [**Read more**](https://www.justice.gov/usao-ma/pr/illegal-alien-previously-convicted-drug-offenses-charged-healthcare-benefit-fraud-and)… **AGENT MISCONDUCT** **April 20 – Alabama – Former Geneva Co. insurance agent pleads guilty to fraud charges** Jonathan Lawrence Eubanks, a former Hartford, Alabama insurance agent, pleaded guilty to making false statements in connection with a federal crop insurance program. Federal court records show Eubanks submitted falsified documentation to Great American Insurance Company to secure crop insurance coverage for a farmer. Prosecutors allege the forged paperwork was used to misrepresent eligibility under the federally backed insurance program… [**Read more**](https://www.wtvy.com/2026/04/20/former-geneva-co-insurance-agent-pleads-guilty-fraud-charges/)… **HEALTHCARE** **April 21 – Louisiana – Mayor of Louisiana town accused of illegally taking $75K in Medicaid benefits** Alice Wallace, mayor of Winnsboro, Louisiana, was arrested this week on six counts of Medicaid insurance fraud for allegedly receiving $75,000 in benefits for herself and a dependent. Authorities said Wallace failed to report income, did not disclose her marital status, and misrepresented access to employer-sponsored health insurance between 2021 and 2026 to maintain eligibility. Officials allege her employment would have made her ineligible for coverage under the Louisiana Department of Health Medicaid program… [**Read more**](https://www.knoe.com/2026/04/21/winnsboro-mayor-arrested-accused-government-benefits-fraud/)… **HEALTHCARE** **April 22 – Pennsylvania – Man sentenced to prison for medical impersonation and insurance fraud scheme** Adam Herman, a Lehigh County man with no medical training or licenses, was sentenced to state prison for posing as a medical professional in Carbon County and providing patient care. Attorney General Dave Sunday said Herman submitted claims tied to the services that resulted in payments from Medicare, Medicaid, and private insurers. He was sentenced this week to 9 to 24 months in prison, followed by four years of probation, and ordered to pay more than $104,000 in restitution… [**Read more**](https://www.attorneygeneral.gov/taking-action/lehigh-county-man-sentenced-to-prison-for-posing-as-a-medical-professional/)… \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/78c5ce69-a52f-df22-e1cc-d2afe0bb6ca3.jpg) \| \| \|:-:\| \| [](https://us02web.zoom.us/webinar/register/WN_v0tVfA63SI-440EOWpPFwQ)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/3dddeb0d-3592-873b-52d0-6ad190eab2b1.jpg) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/18f9920e-e738-5103-cd8e-7ba476e9eb86.jpg) \| \| \|:-:\| \| \| \| **We’re less than two months away from the** **2026 Midyear Meeting in New Orleans!** **June 15 – June 16** \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/b69c6595-0760-ad0d-a8ee-f022ae1d34fc.jpg) \| \| \|:-:\| \| \| \| **Join us for panels and presentations on these topics:** - Transnational Fraud Trends - Cyber Incidents & Insurance Fraud - Fighting Back Against Synthetic Identity Fraud - Account Takeover Risks & Best Practices - Insurance Fraud Schemes in the Title Insurance Industry - Fraud in Agent Licensing - Verisk State of Insurance Fraud Study - Regulatory Guidance Related to the Use of AI - Legal Update - Coalition Advocacy Efforts - Preparing Tomorrow’s Antifraud Leaders - Antifraud Awareness Initiatives **Program Highlights:** ***The full agenda will be announced soon.*** - [**Register**](https://members.insurancefraud.org/page/2026MidyearMeeting) **by May 22** - [**Deadline to book guest room**](https://book.passkey.com/event/51119626/owner/111/home?utm_campaign=298519693) **at the group rate May 26** ($159/night). And, stay after the meeting Tuesday evening for a mingle at the famous **Pat O’Brien’s (5:00 – 7:15 p.m.)**. Reserve your spot when you register. \| \| \|---\| \| \|---\| \| [](https://members.insurancefraud.org/page/2026MidyearMeeting?_gl=1%2A8v1o4f%2A_ga%2AMzY4NDE0MjA4LjE3MTgxNDY1MDM.%2A_ga_SWDYZ10RHD%2AczE3NzI4MTE1NzYkbzgzMSRnMSR0MTc3MjgxMTU3NiRqNjAkbDAkaDA.)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/dc00bf75-24a7-66a7-20ba-e2c944930eb3.png) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7dc17823-f626-e74f-fb63-6bcf042f1157.jpg) \| \| \|:-:\| \| \| \| **Secure your own spot today, and invite your colleagues to register to experience this powerful story.** \| \| \|---\| \| \|---\| \| [](https://us02web.zoom.us/webinar/register/WN_61L_tXUGT2GFIA23o1KIGQ)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/200552a3-37cd-a637-90ee-3e448f717c8b.jpg) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/80a5df2f-f76c-30f0-7dd1-313d88e1bf44.jpg) \| \| \|:-:\| \| \| ![](https://dim.mcusercontent.com/cs/a440c5b647697de580a2fd586/images/b098d5eb-b484-26c7-2bfb-4a1693dcd0f5.jpg?dpr=2&rect=0%2C23%2C640%2C87&w=612&h=83) \| \| \|:-:\| \| \| \| **Coalition & Aon Unveil 2026 P&C Antifraud Benchmarking Study Results** On April 16, 2026, the Coalition Against Insurance Fraud, with the assistance of Aon, hosted a webinar to present the results of the 2026 Property & Casualty SIU Benchmarking Study. Approximately 50 representatives from the 33 participating carriers attended, where key findings and emerging trends in SIU structures, funding, staffing, and operations were shared—providing practical, data-driven insights to help strengthen antifraud programs across the industry. This study builds on a nearly 15-year effort to provide credible benchmarking data, on a biennial basis, to insurers seeking greater visibility into SIU operations and performance. Developed in collaboration with Aon’s Strategy and Technology Group, the study enables carriers to evaluate their programs against peers and identify opportunities for improvement. The Coalition thanks Vince Albers and Aon for their continued partnership, the participating P&C carriers for their valuable contributions, and the members of the Research Committee for their assistance in making this study possible. As the first of three research initiatives planned for this year, the P&C Antifraud Benchmarking Study sets the stage for continued insights and collaboration in the fight against insurance fraud. The biennial study will be conducted again in 2028, and carriers interested in participating may contact the Coalition at <Coalition@insurancefraud.org> \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/599cd350-ea52-4495-1186-5f4cf595e458.jpg) \| \| \|:-:\| \| \| \| The Coalition is pleased to announce the release of a new [**Fraud Referral Guidance Resource for Industry Investigators**](https://insurancefraud.org/wp-content/uploads/Coalition-Fraud-Referral-Guide.pdf). Prepared with input from State Fraud Bureau Directors, this document is intended to serve as an informational resource for insurance industry investigative, compliance, and legal personnel. **It provides general guidance on considerations that may be helpful when preparing and submitting fraud referrals to State Fraud Bureaus, including:** - **What to include in a referral** - **Best practices for reporting suspected fraud** - **Key factors fraud bureaus consider when evaluating referrals** - **Guidance on the provision of records** The Fraud Referral Guidance document is available for download on the Coalition’s website, **www.insurancefraud.org**, under the **Member Resources** section, which requires a member login. Employees of member organizations who do not have login credentials need to create a member profile to access the resource. **A Valuable Tool for All Coalition Members:** **Insurer Members:** Utilize this as a training tool for investigative teams and SIUs, and to help assess alignment with what state fraud bureaus and regulators expect to see included in fraud referrals. **Government Members:** Leverage this as a training and educational tool when engaging with industry groups, helping to reinforce expectations and improve the quality of referrals received. **Association Members:** Share this with your members as a training and educational tool; consider incorporating it into your programming, webinars, or guidance materials. **Associate Members:** Evaluate how the insights and best practices outlined in this guide can enhance or complement the services and solutions your organization provides to clients and partners. **Consumer Groups:** Use this to better understand how fraud referrals are evaluated and to educate consumers on the importance of reporting suspected fraud. This resource reflects the Coalition’s continued commitment to strengthening fraud reporting practices and supporting collaboration across the antifraud community. \| \| \|---\| \| \|---\| \| [](https://members.insurancefraud.org/general/register_member_type.asp)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/4e08fedc-6fea-9426-9143-d421962a8d68.jpg) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/9d9a163b-d608-c29e-1f8c-71c58f193f3a.jpg) \| \| \|:-:\| \| \| \| - **April 28** – [Commercial Trucking Fire & Theft Claims Investigations](https://events.teams.microsoft.com/event/d9726f0b-d1ff-4965-a66e-4c3b5e00e142@aa3f6158-a750-475d-a17c-8438fe053836) (Becker & Company) - **May 4 – May 6** – [Evadata ACT Anti-Fraud Conference](https://whova.com/web/q1wi0epkylJtzgvBjy4ES1K-nsi4hWOOugnM0M7js90%3D/) (Evadata) - **May 5 – May 6** – [Vehicle Fraud & Crime Conference](https://www.nicb.org/news/events/vehicle-fraud-crime-conference) (NICB) - **May 6 –** [Medical Provider Fraud: When Care Turns Criminal](https://event.on24.com/wcc/r/5256532/DA2D411534BB6F66E69E51E95E414E6B) (ETHOS) - **July 20 – July 22** – [The 2026 Florida Insurance Fraud Education Committee and 34th Annual Conference](https://www.fifec.org/registration) (FIFEC) - **August 24 – August 27** – [OWL Intel Summit 2026](https://insurancefraud.org/event/owl-intel-summit-2026/) (Whooster) \| \| \|---\| \| \|---\| \| [](https://s.surveyplanet.com/bj1sw6en)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/82bc7396-3a2d-5c34-e4ff-a1d3855f62d0.jpg) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/b99b7c25-65ae-cd0c-1e44-8d51b81e8021.jpg) \| \| \|:-:\| \| \| \| \| \|---\| \| \| \| **Follow Us On Our Social Media Platforms:** \| \| \|---\| \| \|---\| \| [](https://www.linkedin.com/company/coalition-against-insurance-fraud/)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/148b79cf-2c06-6469-b7c8-335c1c8b971a.jpg) \| \| \|:-:\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| \| \| \| \| \| [](https://www.facebook.com/profile.php?id=61579225779934)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/39ae0e7d-0388-20e5-5755-020aec6cf995.jpg) \| \| \|:-:\| \| [](https://www.instagram.com/stopinsurancefraud/)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/86c49df9-4380-51e5-da9c-f83034fc7555.jpg) \| \| \|:-:\| \| \| \| \| \| ![Logo](https://brand-assets.mailchimp.com/01KKVRP4PEH4PWEG0R0VSKKJ7H.png) \| \| \|:-:\| \| \| \| *Copyright (C) 2026 Coalition Against Insurance Fraud. All rights reserved.* You are receiving this email because either your organization is a member of the Coalition Against Insurance Fraud or you requested to be placed on our mailing list. Our mailing address is: Coalition Against Insurance Fraud 1012 14th St NW Ste 610 Washington, DC 20005-3424 USA Want to change how you receive these emails? You can [update your preferences](https://insurancefraud.mailchimpsites.com/manage/preferences?u=a440c5b647697de580a2fd586&id=b68dce7808&e=%5BUNIQID%5D&c=53b5da24e6) or [unsubscribe](https://insurancefraud.us1.list-manage.com/unsubscribe?u=a440c5b647697de580a2fd586&id=b68dce7808&t=b&e=%5BUNIQID%5D&c=53b5da24e6) \| \| \|:-:\| \| \|---\| \| \| \| \|---\| \| \|:-:\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| | |:-:| <html><p class="wp-block-paragraph"></p> **Features:** Fraud News Weekly --- ### [Fraud News Weekly - Friday, April 17, 2026](https://insurancefraud.org/publications/fraud-news-weekly-friday-april-17-2026/) **Published:** April 28, 2026 **Author:** Joseph Matos **Content:** Fraud News Weekly (FNW) – Friday, April 17, 2026͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ | \| \| \| \| \| \| \| [View this email in your browser](https://mailchi.mp/137dab9c6759/fraud-news-weekly-fnw-friday-april-17-2026?e=%5BUNIQID%5D) \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| \| \| \| \| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/0e6bf40c-913c-8bcc-7f63-92f495d385b7.jpg) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a417349b-dfdc-a052-790d-07cfde53b716.jpg) \| \| \|:-:\| \| \| \| **Connecticut Senate confirms Hershman as insurance commissioner.** The Connecticut Insurance Department announced the State Senate unanimously confirmed Josh Hershman as the state’s 34th insurance commissioner after serving in an interim role since December 2025. Hershman brings experience spanning regulation, operations, and innovation, including prior roles as deputy commissioner and chief operating officer and as a life insurer chief executive. He said, “I remain focused on advancing solutions that improve the affordability and availability of insurance across all lines while supporting innovation that strengthens our markets and delivers better outcomes for consumers.” [Read more](https://portal.ct.gov/cid/press-releases/2026-press-releases/2026-04-10?language=en_US)… **States send late session Coalition tracked bills to governors advancing 2026 antifraud priorities.** Late in the legislative cycle, several Coalition Against Insurance Fraud tracked bills moved to governors’ desks across multiple states, advancing key 2026 Legislative Priorities. If signed by the governors in Alabama, Georgia, Kentucky, Maryland, Mississippi, and Virginia, these measures would address artificial intelligence limits in health coverage ([Alabama SB 63](https://legiscan.com/AL/bill/SB63/2026)), fund prosecuting attorneys to pursue insurance fraud ([Georgia HB 1344](https://www.legis.ga.gov/legislation/73286)), towing and storage oversight ([Maryland HB 30](https://legiscan.com/MD/text/HB30/id/3373504),[ Mississippi SB 2848](https://billstatus.ls.state.ms.us/documents/2026/html/SB/2800-2899/SB2848SG.htm),[ Virginia SB 124](https://lis.virginia.gov/bill-details/20261/SB124) and[ SB 455](https://lis.virginia.gov/bill-details/20261/SB455/text/SB455)) and contractor and roofing fraud ([Kentucky HB 568](https://apps.legislature.ky.gov/record/26rs/hb568.html) and[ Virginia HB 677](https://lis.virginia.gov/bill-details/20261/HB677)). These bills highlight continued state momentum to strengthen enforcement, close fraud gaps, and protect policyholders in line with Coalition legislative priorities. [Read more](https://insurancefraud.org/legislative-priorities/)… **Coalition members see cyber and insurance fraud converge as states begin addressing identity driven risk through new laws.** Committee and task force discussions among Coalition members continue to highlight how the line between cyber incidents and insurance fraud is increasingly blurred as identity compromise, impersonation, and system access drive losses across claims and payments. This legislative session, several enacted bills reflect that shift, including [Iowa HB 2232](https://www.legis.iowa.gov/legislation/BillBook?ga=91&ba=HF%202232),[ Oregon SB 1546](https://olis.oregonlegislature.gov/liz/2026R1/Measures/Overview/SB1546) and[ Washington SB 5886](https://app.leg.wa.gov/billsummary?BillNumber=5886&Year=2025), which target financial exploitation, digital forgeries, and artificial intelligence. These actions align with Coalition legislative priorities to strengthen consumer protection, improve fraud detection and reporting, and address emerging technology risks. Recent findings from the Insurance Information Institute (III) reinforce this growing convergence. [Read more](https://www.iii.org/press-release/triple-i-fenix24-report-identifies-emerging-cybersecurity-priorities-for-insurers-040126)… \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a59ee231-0718-f09f-54a7-8d3ca68ea73c.jpg) \| \| \|:-:\| \| \| \| **Statewide grand jury indicts insurance broker for fraud and theft** The statewide grand jury indicted George Gonzalez, 55, of Denver on 14 counts for allegedly diverting thousands of dollars in insurance premium payments instead of sending them to insurance companies as required by law, Attorney General Phil Weiser announced… [Read more](https://coag.gov/press-releases/statewide-grand-jury-indicts-insurance-broker-for-fraud-and-theft/)… **Attention: Scam targeting injured Spanish-speaking workers in Oregon** The State of Oregon is warning about fraud related to workers’ compensation. Scammers are contacting Spanish-speaking workers by phone, email, social media, or video calls and pretending to be authorities. They convince workers to attend fake online hearings and then demand payments to receive benefits or reach settlement agreements. They have compiled consumer resources… [Read more](https://insurancefraud.org/wp-content/uploads/WCD-English-scam-one-pager.pdf)… **Colorado Attorney General seeking potential victims in insurance fraud case** The Colorado Attorney General’s Office is seeking individuals or businesses who have made payments to Amerimex Insurance Agency for insurance from 2023-2026 and believe that their payment may have been more than what was paid to their insurance company. If you have been impacted, contact the Colorado Attorney General’s Office at [Amerimexinfo@coag.gov](mailto:Amerimexinfo@coag.gov?subject=&body=). [Read press release](https://coag.gov/press-releases/statewide-grand-jury-indicts-insurance-broker-for-fraud-and-theft/)… \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/28c467dc-8276-830d-664e-03edc5954526.jpg) \| \| \|:-:\| \| \| \| **WORKERS’ COMPENSATION** **April 9 – California – Hidden payroll scheme exposes workers’ compensation premium fraud risks** A fatal explosion investigation in Esparto led to eight arrests and uncovered suspected workers’ compensation premium fraud. Authorities allege the company Devastating Pyrotechnics concealed payroll and misrepresented workforce data to reduce insurance costs. Such schemes shift risk across the system and undermine fair premium distribution… *The case underscores the importance of audits and cross-agency collaboration in detecting employer fraud*… [Read more](https://fox40.com/news/local-news/yolo-county/charges-filed-in-deadly-esparto-fireworks-explosion-das-office-says/)… **HEALTHCARE** **April 11 – Minnesota – Suspect’s failure to appear stalls $11M Medicaid fraud prosecution** A defendant accused of orchestrating an $11 million Medicaid fraud scheme failed to appear in court this week, prompting an arrest warrant. Abdirashid Ismail Said is accused of a fraudulent billing scheme involving millions of dollars in illicit claims… *The case involves alleged fraudulent billing practices targeting public healthcare insurance funds. The missed hearing complicates efforts to recover losses and move the case forward. It highlights ongoing challenges in prosecuting large-scale healthcare fraud*… [Read more](https://www.foxnews.com/us/minnesota-fraud-suspect-skips-court-forfeits-bond-throwing-11m-medicaid-case-doubt)… **HEALTHCARE** **April 13 – California – Fraud conspiracy involving illegal procedures drives $3.2M healthcare insurance losses** U.S. District Judge Jennifer Thurston sentenced Felipe Ruiz of Fresno, and Jose Gabriel Aguirre of Clovis, to 63 months in prison for conspiracy to commit health care fraud. Prosecutors said the pair submitted $3.2 million in fraudulent claims to Medicare, Medicaid, and Medi-Cal… *The scheme exposed gaps in provider credentialing and claims verification processes. It reinforces the need for stronger oversight to prevent fraudulent medical billing*… Read more… **HEALTHCARE** **April 14 – Florida – $11.4M Medicare fraud scheme involving unnecessary braces leads to prison sentence** Christian “Chris” Cruz was sentenced to nine years in prison for an $11.4 million healthcare fraud scheme targeting Medicare. Investigators found that beneficiaries were sent unnecessary orthotic braces, which were billed to federal insurance programs… *The case reflects a common fraud model involving durable medical equipment. It underscores the value of data analytics and proactive detection in claims monitoring*… [Read more](https://www.justice.gov/opa/pr/florida-nursing-assistant-sentenced-nine-years-prison-114m-health-care-fraud-scheme)… **HEALTHCARE** **April 14 – Georgia – Behavioral therapist admits to inflating insurance reimbursement claims in fraud case** A Georgia behavioral therapy provider, Mira Stallings pleaded guilty to submitting inflated insurance reimbursement claims. Prosecutors allege services were overstated to increase payouts from insurers… *The scheme resulted in significant financial losses and exposed billing vulnerabilities. It highlights the need for stronger oversight in behavioral health services*… [Read more](https://www.justice.gov/usao-sdga/pr/behavioral-therapist-pleads-guilty-health-care-fraud-submitting-inflated-insurance)… **PROPERTY & CASUALTY** **April 14 – Texas – Body shop fraud and vehicle theft case highlights repair scam risks for insurers** An investigation by the El Paso Police Department’s Auto Theft Task Force has resulted in the arrest of two individuals connected to a reported vehicle theft and fraud case involving a local body shop. Emmanuel Cervantes, 42, and Gema Fernanda Garcia, 23, face multiple charges… *The case highlights risks tied to repair fraud and post-claim vehicle handling. It underscores the need for insurer vigilance and stronger shop oversight*… [Read more](https://kfoxtv.com/news/local/body-shop-repair-dispute-ends-with-2-arrests-after-car-vanishes-police-say)… **STAGED ACCIDENTS** # April 15 – New York – Judge Shuts Down Staged Crash Ring, Backs Insurer’s Fraud Defense Judge Maureen T. Liccione delivered a strong message against insurance fraud, siding with an insurer that uncovered a coordinated scheme involving eight deliberately staged commercial vehicle crashes… *This case highlights the importance of identifying patterns across claims and using evidence-based investigations to combat organized fraud rings*… [Read more](https://www.ttnews.com/articles/ny-staged-crash-scheme-2026)… \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/80a5df2f-f76c-30f0-7dd1-313d88e1bf44.jpg) \| \| \|:-:\| \| \| ![](https://dim.mcusercontent.com/cs/a440c5b647697de580a2fd586/images/b098d5eb-b484-26c7-2bfb-4a1693dcd0f5.jpg?dpr=2&rect=0%2C23%2C640%2C87&w=612&h=83) \| \| \|:-:\| \| \| \| **Coalition & Aon Unveil 2026 P&C Antifraud Benchmarking Study Results** On April 16, 2026, the Coalition Against Insurance Fraud, with the assistance of Aon, hosted a webinar to present the results of the 2026 Property & Casualty SIU Benchmarking Study. Approximately 50 representatives from the 33 participating carriers attended, where key findings and emerging trends in SIU structures, funding, staffing, and operations were shared—providing practical, data-driven insights to help strengthen antifraud programs across the industry. This study builds on a nearly 15-year effort to provide credible benchmarking data, on a biennial basis, to insurers seeking greater visibility into SIU operations and performance. Developed in collaboration with Aon’s Strategy and Technology Group, the study enables carriers to evaluate their programs against peers and identify opportunities for improvement. The Coalition thanks Vince Albers and Aon for their continued partnership, the participating P&C carriers for their valuable contributions, and the members of the Research Committee for their assistance in making this study possible. As the first of three research initiatives planned for this year, the P&C Antifraud Benchmarking Study sets the stage for continued insights and collaboration in the fight against insurance fraud. The biennial study will be conducted again in 2028, and carriers interested in participating may contact the Coalition at <Coalition@insurancefraud.org> \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/18f9920e-e738-5103-cd8e-7ba476e9eb86.jpg) \| \| \|:-:\| \| [](https://members.insurancefraud.org/page/2026MidyearMeeting?_gl=1%2A8v1o4f%2A_ga%2AMzY4NDE0MjA4LjE3MTgxNDY1MDM.%2A_ga_SWDYZ10RHD%2AczE3NzI4MTE1NzYkbzgzMSRnMSR0MTc3MjgxMTU3NiRqNjAkbDAkaDA.)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/263b7b17-94fa-9ef2-e8ab-fdf3c4dd3d39.png) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/b69c6595-0760-ad0d-a8ee-f022ae1d34fc.jpg) \| \| \|:-:\| \| \| \| **We’re less than two months away from the 2026 Midyear Meeting in New Orleans! Join us for panels and presentations on these topics:** - Transnational Fraud Trends - Cyber Incidents & Insurance Fraud - Fighting Back Against Synthetic Identity Fraud - Account Takeover Risks & Best Practices - Insurance Fraud Schemes in the Title Insurance Industry - Fraud in Agent Licensing - Verisk State of Insurance Fraud Study - Regulatory Guidance Related to the Use of AI - Legal Update - Coalition Advocacy Efforts - Preparing Tomorrow’s Antifraud Leaders - Antifraud Awareness Initiatives **Program Highlights:** ***The full agenda will be announced soon.*** - [**Deadline to register**](https://members.insurancefraud.org/page/2026MidyearMeeting) **for the Midyear Meeting** - **Friday, May 22** - [**Deadline to book guest rooms**](https://book.passkey.com/event/51119626/owner/111/home?utm_campaign=298519693) **at the group rate** - **Book by May 26** ($159/night). **And, stay after the meeting Tuesday evening for a mingle at the famous Pat O’Brien’s (5:00 – 7:15 p.m.). Reserve your spot when you register.** \| \| \|---\| \| \|---\| \| [](https://members.insurancefraud.org/page/2026MidyearMeeting?_gl=1%2A8v1o4f%2A_ga%2AMzY4NDE0MjA4LjE3MTgxNDY1MDM.%2A_ga_SWDYZ10RHD%2AczE3NzI4MTE1NzYkbzgzMSRnMSR0MTc3MjgxMTU3NiRqNjAkbDAkaDA.)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/dc00bf75-24a7-66a7-20ba-e2c944930eb3.png) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7dc17823-f626-e74f-fb63-6bcf042f1157.jpg) \| \| \|:-:\| \| \| \| **Virtual seating is filling up fast; secure your spot before April 20** We’re giving our members **exclusive early access** to register for this virtual event before it opens to the public. Secure your own spot, and invite your colleagues to register to experience this powerful story. \| \| \|---\| \| \|---\| \| [](https://us02web.zoom.us/webinar/register/WN_61L_tXUGT2GFIA23o1KIGQ)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/b9fa2283-8c52-d050-9a7b-a08d0186e73b.jpg) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/599cd350-ea52-4495-1186-5f4cf595e458.jpg) \| \| \|:-:\| \| \| \| The Coalition is pleased to announce the release of a new [**Fraud Referral Guidance Resource for Industry Investigators**](https://insurancefraud.org/wp-content/uploads/Coalition-Fraud-Referral-Guide.pdf). Prepared with input from State Fraud Bureau Directors, this document is intended to serve as an informational resource for insurance industry investigative, compliance, and legal personnel. **It provides general guidance on considerations that may be helpful when preparing and submitting fraud referrals to State Fraud Bureaus, including:** - **What to include in a referral** - **Best practices for reporting suspected fraud** - **Key factors fraud bureaus consider when evaluating referrals** - **Guidance on the provision of records** The Fraud Referral Guidance document is available for download on the Coalition’s website, **www.insurancefraud.org**, under the **Member Resources** section, which requires a member login. Employees of member organizations who do not have login credentials need to create a member profile to access the resource. **A Valuable Tool for All Coalition Members:** **Insurer Members:** Utilize this as a training tool for investigative teams and SIUs, and to help assess alignment with what state fraud bureaus and regulators expect to see included in fraud referrals. **Government Members:** Leverage this as a training and educational tool when engaging with industry groups, helping to reinforce expectations and improve the quality of referrals received. **Association Members:** Share this with your members as a training and educational tool; consider incorporating it into your programming, webinars, or guidance materials. **Associate Members:** Evaluate how the insights and best practices outlined in this guide can enhance or complement the services and solutions your organization provides to clients and partners. **Consumer Groups:** Use this to better understand how fraud referrals are evaluated and to educate consumers on the importance of reporting suspected fraud. This resource reflects the Coalition’s continued commitment to strengthening fraud reporting practices and supporting collaboration across the antifraud community. \| \| \|---\| \| \|---\| \| [](https://members.insurancefraud.org/general/register_member_type.asp)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/4e08fedc-6fea-9426-9143-d421962a8d68.jpg) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/9d9a163b-d608-c29e-1f8c-71c58f193f3a.jpg) \| \| \|:-:\| \| \| \| - April 22 – April 24 – [2026 Annual Anti-Fraud Conference](https://annualantifraudconference.com/#Registration) (AFA) - April 28 – [Commercial Trucking Fire & Theft Claims Investigations](https://events.teams.microsoft.com/event/d9726f0b-d1ff-4965-a66e-4c3b5e00e142@aa3f6158-a750-475d-a17c-8438fe053836) (Becker & Company) - May 4 – May 6 – [Evadata ACT Anti-Fraud Conference](https://whova.com/web/q1wi0epkylJtzgvBjy4ES1K-nsi4hWOOugnM0M7js90%3D/) (Evadata) - May 5 – May 6 – [Vehicle Fraud & Crime Conference](https://www.nicb.org/news/events/vehicle-fraud-crime-conference) (NICB) - July 20 – July 22 – [The 2026 Florida Insurance Fraud Education Committee and 34th Annual Conference](https://www.fifec.org/registration) (FIFEC) - August 24 – August 27 – [OWL Intel Summit 2026](https://insurancefraud.org/event/owl-intel-summit-2026/) (Whooster) \| \| \|---\| \| \|---\| \| [](https://s.surveyplanet.com/bj1sw6en)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/82bc7396-3a2d-5c34-e4ff-a1d3855f62d0.jpg) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/b99b7c25-65ae-cd0c-1e44-8d51b81e8021.jpg) \| \| \|:-:\| \| \| \| \| \|---\| \| \| \| **Follow Us On Our Social Media Platforms:** \| \| \|---\| \| \|---\| \| [](https://www.linkedin.com/company/coalition-against-insurance-fraud/)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/148b79cf-2c06-6469-b7c8-335c1c8b971a.jpg) \| \| \|:-:\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| \| \| \| \| \| [](https://www.facebook.com/profile.php?id=61579225779934)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/39ae0e7d-0388-20e5-5755-020aec6cf995.jpg) \| \| \|:-:\| \| [](https://www.instagram.com/stopinsurancefraud/)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/86c49df9-4380-51e5-da9c-f83034fc7555.jpg) \| \| \|:-:\| \| \| \| \| \| ![Logo](https://brand-assets.mailchimp.com/01KKVRP4PEH4PWEG0R0VSKKJ7H.png) \| \| \|:-:\| \| \| \| *Copyright (C) 2026 Coalition Against Insurance Fraud. All rights reserved.* You are receiving this email because either your organization is a member of the Coalition Against Insurance Fraud or you requested to be placed on our mailing list. Our mailing address is: Coalition Against Insurance Fraud 1012 14th St NW Ste 610 Washington, DC 20005-3424 USA Want to change how you receive these emails? You can [update your preferences](https://insurancefraud.mailchimpsites.com/manage/preferences?u=a440c5b647697de580a2fd586&id=b68dce7808&e=%5BUNIQID%5D&c=6c2bbc205c) or [unsubscribe](https://insurancefraud.us1.list-manage.com/unsubscribe?u=a440c5b647697de580a2fd586&id=b68dce7808&t=b&e=%5BUNIQID%5D&c=6c2bbc205c) \| \| \|:-:\| \| \|---\| \| \| \| \|---\| \| \|:-:\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| | |:-:| <html><p class="wp-block-paragraph"></p> **Features:** Fraud News Weekly --- ### [Fraud News Weekly - April 3, 2026](https://insurancefraud.org/publications/fraud-news-weekly-april-3-2026/) **Published:** April 3, 2026 **Author:** Coalition Against Insurance Fraud **Content:** Fraud News Weekly (FNW) Friday, April 3, 2026͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ | \| \| \| \| \| \| \| [View this email in your browser](https://mailchi.mp/89904727b605/fraud-news-weekly-fnw-friday-april-3-2026?e=%5BUNIQID%5D) \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| \| \| \| \| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/f509627b-3336-07b4-b977-ccce7ffa1f80.jpg) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a417349b-dfdc-a052-790d-07cfde53b716.jpg) \| \| \|:-:\| \| \| \| **Coalition amicus curiae filings aim to shape how courts apply insurance fraud criminal penalties and whether long term care policies can be rescinded upon findings of fraud.** Two amicus curiae briefs filed last week reinforce the Coalition’s role as a leading voice to courts on critical insurance fraud issues that shape national precedent. In *People v. Woods* before the California Supreme Court and filed by [GladstoneWeisberg ALC](https://gladstoneweisberg.com/) and [Lewis Brisbois Bisgaard & Smith LLP](https://lewisbrisbois.com/), the Coalition argues against narrowing felony fraud statutes in a way that could weaken enforcement despite legislative fixes to close the loophole. In parallel, a case before the United States Court of Appeals for the Eleventh Circuit examines whether long term care policies can be voided following proven fraud, a high stakes issue for carriers and consumers. This Coalition amicus was filed by [Faegre Drinker Biddle & Reath LLP](https://www.faegredrinker.com/en/) and pends motion for leave approval. These filings reflect Coalition priorities and the collective expertise of our members to strengthen the fraud fight nationwide, and we thank our Legal Affairs Committee for leading these important efforts. [Read more](https://insurancefraud.org/amicus-program/)… **Several states look to sober home legislative reforms to combat fraud risks.** Legislatures in Arizona, California, Connecticut, and Rhode Island have filed bills seeking to strengthen oversight of sober living homes, recovery residences, and treatment facilities by requiring licensing, service documentation, site visits, prohibiting patient brokering, and closing gaps that could enable insurance fraud or exploitation of vulnerable individuals. Heightened awareness of this fraud scheme follows the 2025 Coalition’s Annual Meeting that featured the filmmaker of *Shuffle*, a film exposing how fraudulent treatment cycles can generate massive illicit insurance reimbursements. Building on momentum from last year’s New Jersey and Ohio actions addressing “body brokering” and recovery-related consumer protections, these efforts reinforce Coalition priorities to strengthen oversight, disrupt fraudulent billing models, and safeguard vulnerable patients. [Learn more](https://www.imdb.com/video/vi139773977/?ref_=ttvg_vi_1)… **Coalition presents to risk management and insurance college students on insurance fraud awareness and industry roles.** This week, Coalition Director of Government Relations Brent Walker virtually joined an undergraduate [Risk Management and Insurance](https://www.subr.edu/page/risk-management-insurance-overview) class at Southern University and A&M College to deliver a discussion on the definition, cost, and consumer perceptions of insurance fraud. The session walked through the insurance lifecycle from marketing and underwriting to claims, outlining key roles and career opportunities at each stage while highlighting where insurance fraud can appear. The students were also encouraged to like, comment, and share the ongoing college-led Social Media Competition on the Coalition’s [Instagram](https://www.instagram.com/stopinsurancefraud/) page. Class participation was strong; students were very interested in learning more about how college graduates can enter the insurance industry and internship opportunities available to them. Interactions like these reinforce the value in building the next generation of insurance professionals and fraud fighters. [Learn more](https://www.subr.edu/page/southern-university-mission-statement)… \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a59ee231-0718-f09f-54a7-8d3ca68ea73c.jpg) \| \| \|:-:\| \| \| \| **Victims of ghost broking fraud are seeing their identities reused** Victims of motor insurance ‘ghost broking’ scams, where criminals posing as legitimate brokers sell fake or invalid motor insurance policies, have surged 93%, with two-thirds of victims’ identities reused in further fraud. Analysis from the National SIRA shared risk intelligence consortium found that 66% of… [Read more](https://insurance-edge.net/2026/03/27/victims-of-ghost-broking-fraud-are-seeing-their-ids-used-again/)… **Pennsylvania Insurance Fraud Prevention Authority releases their 2025 Annual Report** Since 1995, Coalition member, the Pennsylvania Insurance Fraud Prevention Authority (IFPA), has been responsible for assessing the scope of Pennsylvania’s insurance fraud problem and for directing resources to prevent and prosecute insurance fraud. Funding is received from annual insurance carriers’ fraud assessments and distributed in grants to state and local… [Read more](https://insurancefraud.org/wp-content/uploads/IFPA_ANNUALREPORT_2025_.pdf)… **Insurance fraud must be recognized as part of the Global Fraud and Organized Crime Agenda** Coalition member Dennis Toomey, president of the Global Insurance Fraud Summit (GIFS), shares that fraud no longer exists at the periphery of economic crime. It is increasingly organized, technology-enabled, borderless, and interconnected with broader criminal ecosystems. Across sectors, fraud now exploits jurisdictional gaps, fragmented intelligence, digital scale, and the limitations of… [Read more](https://insurancefraud.org/wp-content/uploads/Insurance-Fraud-Must-Be-Recognized-as-Part-of-the-Global-Fraud-and-Organized-Crime-Agenda.pdf)… \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/28c467dc-8276-830d-664e-03edc5954526.jpg) \| \| \|:-:\| \| \| \| **HEALTHCARE** **March 27 – Texas – $61 million Medicare fraud takedown: Fugitive behind sham foot bath and genetic test scheme sentenced to prison** Robert “Bobby” Leon Smith III, who fled after pleading guilty to a multimillion-dollar Medicare fraud scheme, has been sentenced to more than a decade in prison. Federal prosecutors said they presented phone call recordings at Smith’s trial in which he could be heard… [Read more](https://www.fox9.com/news/medicare-fraud-archer-city-texas-robert-leon-smith)… **AGENT MISCONDUCT** **March 27 – Ohio – Justice delivered: Contractor sentenced to 17 years for fraud** A pole barn contractor who defrauded consumers of more than $400,000 has been sentenced to at least 17 years in prison after being convicted of 47 felony counts, Ohio Attorney General Dave Yost announced this week. Ryan C. Needels, owner of Clear View Construction… [Read more](https://www.insurancejournal.com/news/midwest/2026/03/27/863795.htm)… **PROPERTY & CASUALTY** **March 27 – New York – Fraud alert: Woman files claims on property she doesn’t own and wasn’t damaged** Katherine Ann Davis, 37, allegedly filed three home insurance claims in one week last year. The problem, according to prosecutors, is that she does not own the house, and nothing actually happened to the residence. The Syracuse woman was charged with insurance fraud and… [Read more](https://www.ksl.com/article/51474015/woman-filed-insurance-claims-for-undamaged-home-she-doesnt-own-charges-say)… **AUTO – FALSE CLAIMS** **March 30 – South Carolina – Fraud crackdown: Spartanburg County woman arrested on insurance charges** 47-year-old Miranda Jeanette Fuller was arrested after being accused of using another person’s identity to obtain insurance and then filing a fraudulent claim for vehicle damage. She faces charges of financial identity fraud… [Read more](https://www.wspa.com/news/local-news/spartanburg-co-woman-arrested-for-insurance-fraud/)… **AGENT MISCONDUCT** **March 31 – Florida – Enforcement action: Broward adjuster accused in $611,000 Hurricane Ian fraud case** A South Florida insurance adjuster exploited Hurricane Ian victims by withholding more than $600,000 in insurance settlement money, according to arrest documents obtained this week. Jail records show Francisco Javier Chaparro Araus, 45, of Miramar, is facing… [Read more](https://www.local10.com/news/local/2026/03/31/broward-insurance-adjuster-accused-of-stealing-over-611k-from-hurricane-ian-victims/)… **AUTO – FALSE CLAIMS** **April 2 – Florida – Surveillance footage derails alleged Mercedes insurance fraud plot** There are bad ideas, there are terrible ideas, and then there is staging your own car theft only to have it unraveled by a web of surveillance cameras and a suspicious police department that refuses to take things at face value. This story out of Sunny Isles Beach sits… [Read more](https://www.yahoo.com/news/articles/fed-mercedes-owner-fakes-wreck-160033284.html)… \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/e04f063d-6836-b86d-4717-427e4a69a52d.jpg) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/bac8a138-7df4-8307-edf6-9b0b6509e3da.jpg) \| \| \|:-:\| \| \| \| The Coalition this week announced new appointments across its [committees and task forces](https://insurancefraud.org/committees/), reinforcing its commitment to advancing industry best practices and strengthening anti-fraud efforts. Armand Glick, Fraud Director at the Utah Department of Insurance, has been named co-chair of the Property & Casualty Task Force, where he will serve alongside co-chair Pranay Mittal of Travelers Insurance to help drive initiatives addressing emerging P&C fraud trends. Devin Chapman, Attorney Supervisor for the Prosecution Section of the Office of Superintendent of Insurance (OSI) Fraud Bureau at the New Mexico Department of Insurance, is joining the Amicus Committee, led by Chair John Doak of Insurance Care Direct. The Coalition’s 14 committees and task forces remain central to fostering collaboration, sharing expertise, and delivering impactful solutions across the insurance fraud community. \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/e39a43d5-1852-e819-a006-2665f664bc2f.jpg) \| \| \|:-:\| \| \| \| Click on the image below to enlarge \| \| \|---\| \| \|---\| \| [](https://insurancefraud.org/wp-content/uploads/Q1-2026-Highlights.png)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/d432b50e-9c9e-c9da-638a-71db0107f43c.png) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/18f9920e-e738-5103-cd8e-7ba476e9eb86.jpg) \| \| \|:-:\| \| [](https://members.insurancefraud.org/page/2026MidyearMeeting?_gl=1%2A8v1o4f%2A_ga%2AMzY4NDE0MjA4LjE3MTgxNDY1MDM.%2A_ga_SWDYZ10RHD%2AczE3NzI4MTE1NzYkbzgzMSRnMSR0MTc3MjgxMTU3NiRqNjAkbDAkaDA.)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7ffc6c66-114b-490b-79cf-9feed9317774.png) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7dc17823-f626-e74f-fb63-6bcf042f1157.jpg) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/da5774e1-d3bc-4a22-88d1-3d2334e79102.jpg) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/599cd350-ea52-4495-1186-5f4cf595e458.jpg) \| \| \|:-:\| \| [](https://members.insurancefraud.org/general/register_member_type.asp)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/4e08fedc-6fea-9426-9143-d421962a8d68.jpg) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/9d9a163b-d608-c29e-1f8c-71c58f193f3a.jpg) \| \| \|:-:\| \| \| \| - **April 9 –** [Surveillance and the Law](https://register.gotowebinar.com/register/7213150774088545115?source=April+CE+Newsletter) (Allied Universal) - **April 13 – April 15 –** [NAMIC Claims Conference](https://www.namic.org/event/claims-conference/) (NAMIC) - **April 13 – April 15 –** [ACCI 2026 Annual Conference](https://www.consumerinterests.org/conference-2026) (ACCI) - **April 16 – April 17 –** [PA Insurance Fraud Prevention Authority 2026 Conference](https://web.cvent.com/event/883703d6-97b3-455e-bd96-079b65e8b481/summary) (IFPA) - **April 22 – April 24 –** [2026 Annual Anti-Fraud Conference](https://annualantifraudconference.com/#Registration) (AFA) - **May 4 – May 6 –** [Evadata ACT Anti-Fraud Conference](https://whova.com/web/q1wi0epkylJtzgvBjy4ES1K-nsi4hWOOugnM0M7js90%3D/) (Evadata) - **May 5 – May 6 –** [Vehicle Fraud & Crime Conference](https://www.nicb.org/news/events/vehicle-fraud-crime-conference) (NICB) \| \| \|---\| \| \|---\| \| [](https://s.surveyplanet.com/bj1sw6en)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/82bc7396-3a2d-5c34-e4ff-a1d3855f62d0.jpg) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a1806adf-c687-1648-4098-c09ab2a2f5a5.png) \| \| \|:-:\| \| \| \| \| \|---\| \| \| \| **Follow Us On Our Social Media Platforms:** \| \| \|---\| \| \|---\| \| [](https://www.linkedin.com/company/coalition-against-insurance-fraud/)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/148b79cf-2c06-6469-b7c8-335c1c8b971a.jpg) \| \| \|:-:\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| \| \| \| \| \| [](https://www.facebook.com/profile.php?id=61579225779934)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/39ae0e7d-0388-20e5-5755-020aec6cf995.jpg) \| \| \|:-:\| \| [](https://www.instagram.com/stopinsurancefraud/)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/86c49df9-4380-51e5-da9c-f83034fc7555.jpg) \| \| \|:-:\| \| \| \| \| \| ![Logo](https://brand-assets.mailchimp.com/01KKVRP4PEH4PWEG0R0VSKKJ7H.png) \| \| \|:-:\| \| \| \| *Copyright (C) 2026 Coalition Against Insurance Fraud. All rights reserved.* You are receiving this email because either your organization is a member of the Coalition Against Insurance Fraud or you requested to be placed on our mailing list. Our mailing address is: Coalition Against Insurance Fraud 1012 14th St NW Ste 610 Washington, DC 20005-3424 USA Want to change how you receive these emails? You can [update your preferences](https://insurancefraud.mailchimpsites.com/manage/preferences?u=a440c5b647697de580a2fd586&id=b68dce7808&e=%5BUNIQID%5D&c=66cb367f03) or [unsubscribe](https://insurancefraud.us1.list-manage.com/unsubscribe?u=a440c5b647697de580a2fd586&id=b68dce7808&t=b&e=%5BUNIQID%5D&c=66cb367f03) \| \| \|:-:\| \| \|---\| \| \| \| \|---\| \| \|:-:\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| | |:-:| <html><p class="wp-block-paragraph"></p> **Features:** Fraud News Weekly --- ### [Fraud News Weekly - April 10, 2026](https://insurancefraud.org/publications/fraud-news-weekly-april-10-2026/) **Published:** April 10, 2026 **Author:** Coalition Against Insurance Fraud **Content:** Fraud News Weekly (FNW) Friday, April 10, 2026͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ | \| \| \| \| \| \| \| [View this email in your browser](https://mailchi.mp/a1e4b73d2e63/fraud-news-weekly-fnw-friday-april-10-2026?e=%5BUNIQID%5D) \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| \| \| \| \| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/e1562165-ad43-ceed-994f-f83cac9da7eb.jpg) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a417349b-dfdc-a052-790d-07cfde53b716.jpg) \| \| \|:-:\| \| \| \| **The Coalition supports New York Governor Hochul’s anti-fraud budget and state police training initiative.** The Coalition continues to support Governor Hochul’s antifraud provisions as budget [negotiations continue](https://www.whec.com/top-news/lawmakers-expected-to-extend-state-budget-deadline-again-heres-what-the-holdup-is/), submitting [letters of support](https://insurancefraud.org/advocacy-efforts/) this week urging full funding for workers compensation fraud units, expanded auto insurance investigations, and stronger prosecution tools targeting repeat and organized fraud. Letters were sent to key Senate and Assembly leaders and insurance committees. This aligns with the April 8th announcement of specialized training for 250 New York law enforcement personnel to better detect, investigate, and prosecute insurance fraud. Coalition Executive Director Michelle Rafeld was quoted, “*… enhanced training and stronger coordination between the New York State Police and the Department of Financial Services are essential to disrupting increasingly sophisticated insurance fraud schemes.*”[ Read more](https://www.dfs.ny.gov/reports_and_publications/press_releases/pr20260408#:~:text=Governor%20Kathy%20Hochul%20today%20announced,state%20so%20they%20can%20better)… **Hawaii warns its citizens of contractor fraud risks after disaster recovery begins.** Following severe statewide flooding, Hawaii Department of Commerce and Consumer Affairs and Governor Josh Green are urging residents to guard against contractor fraud as rebuilding accelerates. Officials report ongoing complaints involving unlicensed contractors, including cases where money is taken with little or no work completed. Hawaii homeowners are advised to verify licenses, avoid large upfront payments, and distinguish between adjusters and contractors to prevent fraud schemes that can also jeopardize insurance claims.[ Read more](https://governor.hawaii.gov/newsroom/release-public-urged-to-be-vigilant-against-contractor-fraud-following-statewide-disaster/)… **The Georgia Legislature sends Insurance Affordability and Claims Integrity Act to the governor with strengthened antifraud tools.** The Georgia legislature passed [House Bill 1344](https://www.legis.ga.gov/legislation/73286) which has been sent to the governor for signature. The Bill combines insurance affordability measures with robust fraud enforcement. If signed by the governor, these antifraud provisions would empower insurers to share suspected fraud information with the Commissioner before completing full investigations, fund prosecuting attorneys to pursue insurance fraud, and substantially increase monetary penalties for fraudulent insurance acts. The Bill would also criminalize solicitation or sale of accident information, while targeting organized and repeat fraud schemes. For Coalition members, these measures reinforce the link between affordability and effective fraud prevention.[ Read more](https://ocgnews.com/ga-speaker-jon-burns-applauds-passage-of-insurance-affordability-reform/)… \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a59ee231-0718-f09f-54a7-8d3ca68ea73c.jpg) \| \| \|:-:\| \| \| \| **New York reform battle intensifies as Uber and trial lawyers clash over insurance costs** A high-stakes fight is unfolding in New York as Uber and trial lawyers take opposing sides on proposed reforms aimed at lowering auto insurance premiums. The outcome could carry significant implications for fraud trends, claims costs, and the broader insurance landscape… [Read more](https://www.insurancebusinessmag.com/us/news/auto-motor/uber-and-lawyers-clash-over-new-york-insurance-reforms-570769.aspx)… **Ohio launches fraud prevention month initiative, urging consumers to report insurance scams** Ohio officials are sounding the alarm on insurance fraud as Governor Mike DeWine designates April as Fraud Prevention Month. Citing the Coalition’s $308.6 billion annual economic impact, the initiative underscores the real cost to consumers and… [Read more](https://littermedia.com/fraud-prevention-month-ohioans-urged-to-protect-themselves-from-insurance-fraud-and-report-scams/)… **DOJ targets $60 million hospice fraud scheme in California crackdown** Federal prosecutors have charged 15 individuals in a sweeping Medicare hospice fraud case involving alleged kickbacks and the enrollment of ineligible patients. The takedown underscores the evolving tactics driving large-scale healthcare fraud schemes… [Read more](https://www.foxla.com/news/la-hospice-fraud-multimillion-dollar-medicare-arrests)… \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/28c467dc-8276-830d-664e-03edc5954526.jpg) \| \| \|:-:\| \| \| \| **CONTRACTOR FRAUD** **April 4 – Iowa – Unlicensed contractor charged after alleged scheme to exploit insurance claims** Joseph Starr, 39, is facing felony charges after allegedly inserting himself into insurance claims without a license and billing for work left incomplete. The Iowa Insurance Division’s Fraud Bureau filed the charges following an investigation… [Read more](https://www.kimt.com/news/rockwell-man-arrested-for-insurance-fraud-unlicensed-work/article_5247908a-ffb6-434c-b704-bb3ece90baf3.html)… **PROPERTY & CASUALTY** **April 5 – Colorado – Dance studio owner indicted on 21 felony counts in sweeping fraud case** A grand jury has indicted Cindy Burdine, the former owner of Frequency Dance, on 21 felony charges including fraud, theft, and forgery. The charges are tied in part to a reported 2023 break in at the studio that led to an insurance claim… [Read more](https://boulderreportinglab.org/2026/04/05/boulder-dance-studio-owner-indicted-on-21-felony-charges-tied-to-alleged-fraud-warrant-issued/)… **PROPERTY & CASUALTY** **April 6 – Kansas – Farmer pleads guilty in federal crop insurance fraud case** David L. Mongeau, pleaded guilty to defrauding the federal crop insurance system after falsely reporting crop losses while records showed the grain had already been sold. Federal prosecutors say the 54-year-old from Holcomb claimed hail and high winds destroyed a… [Read more](https://www.ksn.com/news/kansas-farmer-pleads-guilty-to-crop-insurance-fraud-2/)… **HEALTHCARE April 7 – California – Hospice fraud scheme exploited vulnerable patient to improperly bill Medicare, DOJ says** Federal prosecutors allege healthcare workers falsely claimed a dementia patient was terminally ill to enroll him in hospice and collect Medicare payments… [Read more](https://www.msn.com/en-us/health/other/health-workers-pretended-constipated-man-with-dementia-was-dying-and-only-had-months-to-live-so-they-could-reap-medicare-benefits-doj-says/ar-AA20krwV?apiversion=v2&domshim=1&noservercache=1&noservertelemetry=1&batchservertelemetry=1&renderwebcomponents=1&wcseo=1&cvid=69d56b951bf04f90932dfd75ea8e70c8)… **AGENT MISCONDUCT April 7 – Kentucky – Agent charged after clients discover possible gaps in coverage despite paid premiums; fraud probe widens** David Ramey, owner of David Ramey Insurance has been arrested and charged in a fraud and theft case involving more than $10,000, with investigators warning the situation could expand as additional victims come forward. Authorities say the case centers on… [Read more](https://www.paducahsun.com/news/murray-insurance-agent-charged-in-fraud-case-detective-says-more-victims-may-come-forward/article_e5a1124a-39f1-56fb-b019-d85f00697588.html)… \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/e04f063d-6836-b86d-4717-427e4a69a52d.jpg) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/d3552c1b-17e2-051f-1c5f-4b6644ad0820.jpg) \| \| \|:-:\| \| \| \| **Coalition Recognizes Social Media Competition Winners from Wayne State University for Standout Insurance Fraud Content** The Coalition Against Insurance Fraud’s Executive Director, Michelle Rafeld, recently recognized and awarded Social Media Marketing students from Wayne State University for their outstanding work as part of the Coalition’s latest Social Media Competition. The initiative provided students with hands-on, real-world experience while supporting the Coalition’s efforts to raise awareness about insurance fraud. Over the course of just six weeks, student teams developed and shared 59 social media posts, generating more than 28,000 views and over 2,400 interactions, while helping the Coalition gain 63 new followers. Since launching the competition last September, student-driven content has generated more than 40,000 total views of the Coalition’s Instagram content to date. In addition to these strong results, students noted that the experience deepened their understanding of insurance fraud and its personal impact, and they contributed valuable ideas to enhance the Coalition’s Instagram strategy moving forward. The Coalition would like to thank and recognize CarpeData for sponsoring the competition, Wayne State University Professor Nick Mattar for his continued partnership, and the students for their exceptional work and contributions. To view this semester’s student-created content, visit the Coalition’s Instagram page, [@stopinsurancefraud](https://www.instagram.com/stopinsurancefraud/). \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/73f106c1-2497-ca1c-4dc6-f15bacb93473.jpg) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a178d7bd-0f36-59d4-29a9-a30ca462f46f.jpg) \| \| \|:-:\| \| \| \| The Coalition Against Insurance Fraud announces the upcoming retirements of Simon Blank, Director of the Division of Investigative & Forensic Services at the Florida Department of Financial Services, and Paul Hill, Assistant Director and Chief Law Enforcement Officer at the Arizona Department of Insurance and Financial Institutions. Luis Negrete will succeed Simon Blank, and Damas Salas will succeed Paul Hill. The Coalition extends its sincere thanks to Simon and Paul for their dedicated service and the valued expertise they brought to the fight against insurance fraud. We look forward to working with Luis Negrete and Damas Salas in continuing our important work. \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/18f9920e-e738-5103-cd8e-7ba476e9eb86.jpg) \| \| \|:-:\| \| [](https://members.insurancefraud.org/page/2026MidyearMeeting?_gl=1%2A8v1o4f%2A_ga%2AMzY4NDE0MjA4LjE3MTgxNDY1MDM.%2A_ga_SWDYZ10RHD%2AczE3NzI4MTE1NzYkbzgzMSRnMSR0MTc3MjgxMTU3NiRqNjAkbDAkaDA.)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7ffc6c66-114b-490b-79cf-9feed9317774.png) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7dc17823-f626-e74f-fb63-6bcf042f1157.jpg) \| \| \|:-:\| \| \| \| **1,000 Seats Available; Secure a Spot Before April 20** We’re giving our members exclusive early access to register for this virtual event before it opens to the public. Secure your own spot, and invite your colleagues to register to experience this powerful story. \| \| \|---\| \| \|---\| \| [](https://us02web.zoom.us/webinar/register/WN_61L_tXUGT2GFIA23o1KIGQ)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/b9fa2283-8c52-d050-9a7b-a08d0186e73b.jpg) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/599cd350-ea52-4495-1186-5f4cf595e458.jpg) \| \| \|:-:\| \| [](https://members.insurancefraud.org/general/register_member_type.asp)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/4e08fedc-6fea-9426-9143-d421962a8d68.jpg) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/9d9a163b-d608-c29e-1f8c-71c58f193f3a.jpg) \| \| \|:-:\| \| \| \| - **April 13 – April 15 –** [NAMIC Claims Conference](https://www.namic.org/event/claims-conference/) (NAMIC) - **April 13 – April 15 –** [ACCI 2026 Annual Conference](https://www.consumerinterests.org/conference-2026) (ACCI) - **April 15 –** [The Psychology Behind Fraud](https://event.on24.com/wcc/r/5193664/2DDBA2DEB4E03BABBA3A7E6537567131) (ETHOS) - **April 16 – April 17 –** [PA Insurance Fraud Prevention Authority 2026 Conference](https://web.cvent.com/event/883703d6-97b3-455e-bd96-079b65e8b481/summary) (IFPA) - **April 22 – April 24 –** [2026 Annual Anti-Fraud Conference](https://annualantifraudconference.com/#Registration) (AFA) - **May 4 – May 6 –** [Evadata ACT Anti-Fraud Conference](https://whova.com/web/q1wi0epkylJtzgvBjy4ES1K-nsi4hWOOugnM0M7js90%3D/) (Evadata) - **May 5 – May 6 –** [Vehicle Fraud & Crime Conference](https://www.nicb.org/news/events/vehicle-fraud-crime-conference) (NICB) \| \| \|---\| \| \|---\| \| [](https://s.surveyplanet.com/bj1sw6en)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/82bc7396-3a2d-5c34-e4ff-a1d3855f62d0.jpg) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/b99b7c25-65ae-cd0c-1e44-8d51b81e8021.jpg) \| \| \|:-:\| \| \| \| \| \|---\| \| \| \| **Follow us on our social media platforms:** \| \| \|---\| \| \|---\| \| [](https://www.linkedin.com/company/coalition-against-insurance-fraud/)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/148b79cf-2c06-6469-b7c8-335c1c8b971a.jpg) \| \| \|:-:\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| \| \| \| \| \| [](https://www.facebook.com/profile.php?id=61579225779934)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/39ae0e7d-0388-20e5-5755-020aec6cf995.jpg) \| \| \|:-:\| \| [](https://www.instagram.com/stopinsurancefraud/)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/86c49df9-4380-51e5-da9c-f83034fc7555.jpg) \| \| \|:-:\| \| \| \| \| \| ![Logo](https://brand-assets.mailchimp.com/01KKVRP4PEH4PWEG0R0VSKKJ7H.png) \| \| \|:-:\| \| \| \| *Copyright (C) 2026 Coalition Against Insurance Fraud. All rights reserved.* You are receiving this email because either your organization is a member of the Coalition Against Insurance Fraud or you requested to be placed on our mailing list. Our mailing address is: Coalition Against Insurance Fraud 1012 14th St NW Ste 610 Washington, DC 20005-3424 USA Want to change how you receive these emails? You can [update your preferences](https://insurancefraud.mailchimpsites.com/manage/preferences?u=a440c5b647697de580a2fd586&id=b68dce7808&e=%5BUNIQID%5D&c=1323889ac0) or [unsubscribe](https://insurancefraud.us1.list-manage.com/unsubscribe?u=a440c5b647697de580a2fd586&id=b68dce7808&t=b&e=%5BUNIQID%5D&c=1323889ac0) \| \| \|:-:\| \| \|---\| \| \| \| \|---\| \| \|:-:\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| | |:-:| <html><p class="wp-block-paragraph"></p> **Features:** Fraud News Weekly --- ### [Fraud News Weekly - March 27, 2026](https://insurancefraud.org/publications/fraud-news-weekly-march-27-2026/) **Published:** March 27, 2026 **Author:** Coalition Against Insurance Fraud **Content:** Fraud News Weekly (FNW) – Friday, March 27, 2026͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ | \| \| \| \| \| \| \| [View this email in your browser](https://mailchi.mp/bde0a5c5d41d/fraud-news-weekly-fnw-friday-march-27-2026?e=%5BUNIQID%5D) \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| \| \| \| \| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/d9ddb729-c7b2-2173-aa33-878caccc26c3.jpg) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a417349b-dfdc-a052-790d-07cfde53b716.jpg) \| \| \|:-:\| \| \| \| **The Federal policy for artificial intelligence regulation has been unveiled with a push for Congress to act this year**. Last week, the White House released its legislative recommendations for the [National Policy Framework for Artificial Intelligence](https://www.whitehouse.gov/wp-content/uploads/2026/03/03.20.26-National-Policy-Framework-for-Artificial-Intelligence-Legislative-Recommendations.pdf), reinforcing President Trump’s December 2025 Executive Order and signaling strong federal intent to preempt state AI regulation in favor of “one national standard.” Specific to fraud, the framework urges Congress to bolster law enforcement against AI-enabled impersonation scams and fraud targeting seniors while preserving state powers to protect children, prevent fraud, and safeguard consumers. With more than 150 AI bills filed in 19 states, including a failed measure that would have required human oversight of insurance claim decisions, tensions between federal preemption, NCOIL and NAIC, and state authorities are rising. Coalition members should watch how this evolving landscape, and potential Congressional action, will affect antifraud strategy, regulatory compliance, and enforcement priorities… [Read more](https://www.foxnews.com/politics/white-house-unveils-its-first-federal-ai-framework-pushes-congress-act-this-year)… **Coalition supported Kansas bill that strengthens insurance fraud enforcement passes both chambers and lands on Governor’s desk.** After a two-year effort and multiple [advocacy efforts](https://insurancefraud.org/advocacy-efforts/) with key stakeholders, Kansas House Bill 2323 is awaiting Governor approval. With overwhelming House support and unanimous Senate approval after amendment, the bill, if signed by the Governor, will expand the Insurance Commissioner’s authority to pursue civil penalties for insurance fraud, enhance licensing application transparency for agents and public adjusters with expunged insurance fraud convictions, and close fraud-reporting gaps and provide immunity within the state’s automobile assigned claims plan… [Read more](https://www.kslegislature.gov/li/b2025_26/measures/hb2323/)… **Hawaii insurance fraud bill focused on strengthening enforcement and post-disaster fraud moves forward.** This week, Hawaii [Senate Bill 2948](https://www.capitol.hawaii.gov/session/measure_indiv.aspx?billtype=SB&billnumber=2948&year=2026) was heard in the House Committee of Judiciary & Hawaiian Affairs. The Bill focuses on expanding insurance fraud enforcement by prohibiting certain solicitations and inducements tied to claims, broadening fraud offenses, establishing a disaster-related fraud crime to address post-event scams, and would require the state to deploy fraud analytics and provide an annual report to legislature. After hearing testimony from the Hawaii Department of Commerce and Consumer Affairs, National Insurance Crime Bureau, representatives from the consumer legal funding industry, and justice advocates, the Committee voted to move the Bill forward with amendments… [Read more](https://www.capitol.hawaii.gov/session/measure_indiv.aspx?billtype=SB&billnumber=2948&year=2026)… \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a59ee231-0718-f09f-54a7-8d3ca68ea73c.jpg) \| \| \|:-:\| \| \| \| **After CBS exposes Hospice fraud, the industry calls for five priority guardrails to protect patients** In the wake of a sweeping investigation by CBS News identifying Los Angeles as “ground zero” for hospice fraud, Robin Heffernan, co-founder and CEO of Empassion Health, is calling for urgent action to strengthen oversight, restore trust, and better protect patients and… [Read more](https://finance.yahoo.com/sectors/healthcare/articles/cbs-exposes-hospice-fraud-industry-141300314.html)… **New Orleans staged accident schemes drive up insurance costs nationwide** David A. Sampson, President and CEO of the American Property Casualty Insurance Association and Coalition member, warns that organized staged auto accidents and legal system abuse are driving up insurance costs nationwide, pointing to recent criminal cases in New Orleans as a stark example of how fraud schemes inflate premiums for everyday drivers… [Read more](https://blackchronicle.com/southeast/louisiana-southeast/opinion-staged-accidents-turn-nola-into-mad-max/)… \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/28c467dc-8276-830d-664e-03edc5954526.jpg) \| \| \|:-:\| \| \| \| **WORKERS’ COMPENSATION** **March 23 – Florida – Hidden payroll scheme lands Orlando man in federal court** Honduran national Mario Lisandro Flores Moradel pleaded guilty to conspiring with others as part of a years-long off-the-books payroll scheme that caused more than $38 million in losses to the U.S. government. According to court documents and statements made in… [Read more](https://www.justice.gov/opa/pr/orlando-man-pleads-guilty-his-role-years-long-books-payroll-scheme)… **HEALTHCARE** **March 23 – Massachusetts – Physician pleads guilty in multi-million-dollar durable medical equipment fraud scheme** Simon Grinshteyn, 52, has pleaded guilty in federal court in Boston to making false statements in connection with a multi-million-dollar health care fraud scheme involving medically unnecessary genetic testing and durable medical equipment… [Read more](https://www.justice.gov/usao-ma/pr/florida-doctor-pleads-guilty-making-false-statements-connection-multi-million-dollar)… **HEALTHCARE** **March 23 – Wisconsin – Prenatal care owner sentenced to 5 years for $2.6 million healthcare fraud scheme** Brad D. Schimel, First Assistant U.S. Attorney for the Eastern District of Wisconsin, announced that Lakia Jackson, 36, was sentenced to 60 months’ incarceration for committing a healthcare fraud scheme through which she stole more than $2.65 million from a… [Read more](https://www.justice.gov/usao-edwi/pr/owner-now-closed-milwaukee-prenatal-care-coordination-company-sentenced-60-months)… **AUTO – FALSE CLAIMS** **March 23 – Florida – Man faked brain injury for years in attempt to gain $6 million in auto insurance claim** When Thomas A. George and Tamika Hampton attempted to defraud an auto insurer out of $6.6 million by faking a catastrophic brain injury, the scheme ultimately unraveled after Allied Universal Compliance & Investigations alerted the Florida Department of Financial Services, both Coalition members, triggering a criminal investigation… [Read more](https://www.insurancejournal.com/news/southeast/2026/03/23/863064.htm)… **HEALTHCARE** **March 24 – Maryland – $4 million settlement reached over alleged unnecessary vein procedure billing scheme** Attorney General Anthony G. Brown announced that his office has reached a settlement with CVR Management, LLC, to resolve allegations that the company’s multistate network of vascular medicine clinics billed government health programs for… [Read more](https://oag.maryland.gov/News/pages/Attorney-General%E2%80%99s-Medicaid-Fraud-and-Vulnerable-Victims-Unit-Obtains-$4-Million-Settlement-with-Center-for-Vein-Restoratio.aspx)… **ARSON** **March 24 – New York – Man admits to arson-for-profit scheme in $1 million insurance fraud case** A Yonkers man, Majid Haddad, has pleaded guilty to conspiracy, arson, and insurance fraud charges after admitting to hiring someone to burn down his home in 2021 in order to collect over $1 million in insurance… [Read more](https://nationaltoday.com/us/ny/yonkers/news/2026/03/24/yonkers-man-admits-guilt-in-insurance-fraud-scheme/)… **HEALTHCARE** **March 24 – California – Woman sentenced in $14 million Medicare hospice and diagnostic fraud scheme** Sophia Shaklian, 38, from the Larchmont area of Los Angeles was sentenced to 35 months in federal prison for defrauding Medicare out of more than $14 million by submitting fraudulent claims for hospice care and diagnostic testing services that were either unnecessary… [Read more](https://www.justice.gov/usao-cdca/pr/larchmont-woman-sentenced-nearly-3-years-federal-prison-her-role-hospice-and)… \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/e04f063d-6836-b86d-4717-427e4a69a52d.jpg) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/13278143-702e-fac4-41ce-f8cd1f7dd370.jpg) \| \| \|:-:\| \| \| \| **The Coalition actively participates in the NAIC Spring National Meeting.** State insurance regulators and other interested parties met this week in San Diego, CA, during the National Association of Insurance Commissioners (NAIC) Spring National Meeting. Executive Director Michelle Rafeld and Director of Government Relations Brent Walker engaged directly with regulators throughout the meeting. Rafeld shared the results of a Coalition survey into long-term care fraud trends at both the Senior Issues (B) Task Force and the Antifraud (D) Task Force meetings. As an appointed NAIC consumer representative, Walker was able to meet one-on-one with several state insurance commissioners, several of whom expressed that insurance fraud was a top priority for their state. Walker also provided an antifraud legislative update to the Antifraud (D) Task Force, while Rafeld briefed the group on the Coalition’s forthcoming fraud referral job aid and ongoing social media competition. The Coalition further tracked ongoing efforts with the Third-Party Data and Models (H) Working Group and the Big Data and Artificial Intelligence (H) Working Group’s current pilot of the AI system evaluation tool. [Read more](https://content.naic.org/committees/d/antifraud-tf) or contact <brent@insurancefraud.org> for more information. \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/18f9920e-e738-5103-cd8e-7ba476e9eb86.jpg) \| \| \|:-:\| \| [](https://members.insurancefraud.org/page/2026MidyearMeeting?_gl=1%2A8v1o4f%2A_ga%2AMzY4NDE0MjA4LjE3MTgxNDY1MDM.%2A_ga_SWDYZ10RHD%2AczE3NzI4MTE1NzYkbzgzMSRnMSR0MTc3MjgxMTU3NiRqNjAkbDAkaDA.)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7ffc6c66-114b-490b-79cf-9feed9317774.png) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/599cd350-ea52-4495-1186-5f4cf595e458.jpg) \| \| \|:-:\| \| [](https://members.insurancefraud.org/general/register_member_type.asp)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/4e08fedc-6fea-9426-9143-d421962a8d68.jpg) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/9d9a163b-d608-c29e-1f8c-71c58f193f3a.jpg) \| \| \|:-:\| \| \| \| - **March 31** – [From FNOL to Resolution: How Social Media Provides Insights at Each Stage](https://share.hsforms.com/1aZWvPffpQwGm-tSqUoQ6fAc0z6w?utm_medium=email&_hsenc=p2ANqtz-_euiMs-z2Vk15ct4s-bMs4GZ786GAQ2hwKJT0QT5cm4Npo4E4yUiplmAkQdzOYWVcMd7s3Z73sybn9Ajb6mUEuj1Y3VzeF_JBeBt19Px8nBURCnLs&_hsmi=403228581&utm_content=403228581&utm_source=hs_email) (Social Discovery) - **April 13 – April 15 –** [NAMIC Claims Conference](https://www.namic.org/event/claims-conference/) (NAMIC) - **April 13 – April 15 –** [ACCI 2026 Annual Conference](https://www.consumerinterests.org/conference-2026) (ACCI) - **April 16 – April 17 –** [PA Insurance Fraud Prevention Authority 2026 Conference](https://web.cvent.com/event/883703d6-97b3-455e-bd96-079b65e8b481/summary) (IFPA) - **April 22 – April 24 –** [2026 Annual Anti-Fraud Conference](https://annualantifraudconference.com/#Registration) (AFA) - **May 4 – May 6 –** [Evadata ACT Anti-Fraud Conference](https://whova.com/web/q1wi0epkylJtzgvBjy4ES1K-nsi4hWOOugnM0M7js90%3D/) (Evadata) - **May 5 – May 6 –** [Vehicle Fraud & Crime Conference](https://www.nicb.org/news/events/vehicle-fraud-crime-conference) (NICB) \| \| \|---\| \| \|---\| \| [](https://s.surveyplanet.com/bj1sw6en)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/82bc7396-3a2d-5c34-e4ff-a1d3855f62d0.jpg) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a1806adf-c687-1648-4098-c09ab2a2f5a5.png) \| \| \|:-:\| \| \| \| \| \|---\| \| \| \| **Follow Us On Our Social Media Platforms:** \| \| \|---\| \| \|---\| \| [](https://www.linkedin.com/company/coalition-against-insurance-fraud/)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/148b79cf-2c06-6469-b7c8-335c1c8b971a.jpg) \| \| \|:-:\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| \| \| \| \| \| [](https://www.facebook.com/profile.php?id=61579225779934)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/39ae0e7d-0388-20e5-5755-020aec6cf995.jpg) \| \| \|:-:\| \| [](https://www.instagram.com/stopinsurancefraud/)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/86c49df9-4380-51e5-da9c-f83034fc7555.jpg) \| \| \|:-:\| \| \| \| \| \| ![Logo](https://brand-assets.mailchimp.com/01KKVRP4PEH4PWEG0R0VSKKJ7H.png) \| \| \|:-:\| \| \| \| *Copyright (C) 2026 Coalition Against Insurance Fraud. All rights reserved.* You are receiving this email because either your organization is a member of the Coalition Against Insurance Fraud or you requested to be placed on our mailing list. Our mailing address is: Coalition Against Insurance Fraud 1012 14th St NW Ste 610 Washington, DC 20005-3424 USA Want to change how you receive these emails? You can [update your preferences](https://insurancefraud.mailchimpsites.com/manage/preferences?u=a440c5b647697de580a2fd586&id=b68dce7808&e=%5BUNIQID%5D&c=52e2121fe4) or [unsubscribe](https://insurancefraud.us1.list-manage.com/unsubscribe?u=a440c5b647697de580a2fd586&id=b68dce7808&t=b&e=%5BUNIQID%5D&c=52e2121fe4) \| \| \|:-:\| \| \|---\| \| \| \| \|---\| \| \|:-:\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| | |:-:| <html><p class="wp-block-paragraph"></p> **Features:** Fraud News Weekly --- ### [Fraud News Weekly - March 20, 2026](https://insurancefraud.org/publications/fraud-news-weekly-march-20-2026/) **Published:** March 20, 2026 **Author:** Coalition Against Insurance Fraud **Content:** Fraud News Weekly (FNW) – Friday, March 20, 2026͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ͏ ‌ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ | \| \| \| \| \| \| \| [View this email in your browser](https://mailchi.mp/0f46bdcf1325/fraud-news-weekly-fnw-friday-march-20-2026?e=%5BUNIQID%5D) \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| \| \| \| \| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/45aaa06a-ba63-339f-4d4d-58287dc72ea9.jpg) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a417349b-dfdc-a052-790d-07cfde53b716.jpg) \| \| \|:-:\| \| \| \| **SPECIAL UPDATE:** The following bills have advanced through both chambers of state legislatures and await the governor’s action, with one enacted so far. They reflect key Coalition legislative priorities and highlight trends in towing and storage regulation, public adjuster and contractor oversight, and emerging technology and digital fraud. **Towing and storage regulation bills strengthen consumer protections and combat fraud.** Legislation in Alabama, Utah, and Virginia reflects the Coalition’s 2026 focus on protecting consumers from abusive towing practices. All bills are currently awaiting the governor’s signature, including Alabama[ HB 42](https://alison.legislature.state.al.us/files/pdf/SearchableInstruments/2026RS/HB42-enr.pdf), Utah[ HB 268](https://le.utah.gov/~2026/bills/static/HB0268.html),[ SB 120](https://le.utah.gov/~2026/bills/static/SB0120.html), and[ SB 191](https://le.utah.gov/~2026/bills/static/SB0191.html), as well as Virginia[ HB 788](https://lis.virginia.gov/bill-details/20261/HB788),[ HB 908](https://lis.virginia.gov/bill-details/20261/HB908),[ SB 124](https://lis.virginia.gov/bill-details/20261/Sb124), and[ SB 455](https://lis.virginia.gov/bill-details/20261/SB455). If passed, these bills, taken together, would require notice to owners and lienholders, regulate impound lot standards and rotations, mandate tow operator registration, and clarify crash report access and state payment responsibilities, reducing opportunities for fraud and supporting insurers in managing auto claims. **Public adjuster, contractor, roofing, and auto glass legislation would enhance claims integrity.** Virginia and New York are attempting to strengthen protections against fraud in insurance claims. This aligns with Coalition priorities for ethical practices and transparency. Enacted New York[ SB 8824](https://www.nysenate.gov/legislation/bills/2025/S8824) establishes standards for glass repair, requiring repair shops to obtain claim numbers and notify customers about ADAS recalibration. Likewise, an auto glass bill in Virginia ([HB 312](https://lis.virginia.gov/bill-details/20261/HB312) and[ SB 767](https://lis.virginia.gov/bill-details/20261/SB767)) awaits the governor’s action. Other Virginia bills awaiting the governor’s signature include[ HB 437](https://lis.virginia.gov/bill-details/20261/HB437),[ HB 677](https://lis.virginia.gov/bill-details/20261/HB677), and[ SB 402](https://lis.virginia.gov/bill-details/20261/SB402). These laws would enforce licensing and standards for public adjusters, safeguard homeowners from roofing-related coverage abuses, and improve transparency in claims handling, curbing contractor and adjuster-driven fraud while protecting policyholders and insurers. **Emerging technology and digital fraud bills address AI and deepfake risks.** Washington and Oregon are taking action against evolving fraud threats in digital media and AI, aligning with Coalition priorities to track emerging threats and leverage antifraud technology. Both bills await the governor’s signature, including Washington[ SB 5886](https://app.leg.wa.gov/billsummary?BillNumber=5886&Year=2025) and[ Oregon SB 1546](https://olis.oregonlegislature.gov/liz/2026R1/Measures/Overview/SB1546). Washington would establish property rights in names, voices, and protections against “forged digital likenesses”, creating liability for misuse, while the Oregon bill would require AI companion platforms to clearly disclose artificial interactions. These measures would protect consumers, equip regulators and insurers to identify fraud, and promote responsible use of AI and digital content. Governors could sign these bills at any time, and the Coalition will continue to track their status. \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a59ee231-0718-f09f-54a7-8d3ca68ea73c.jpg) \| \| \|:-:\| \| \| \| **AI editing tools are fueling a new era of insurance fraud, according to new research from Verisk** From adjusting the lighting in a photo to repairing a blurry image, AI-powered image editing tools have become part of everyday life – and increasingly, part of the insurance claims process. New data from the Verisk State of Insurance Fraud study reveals that more than one-third of… [Read more](https://www.verisk.com/company/newsroom/ai-editing-tools-are-fueling-a-new-era-of-insurance-fraud-according-to-new-research-from-verisk/)… **5 trends impacting the commercial insurance market** Understanding market trends is the first step to controlling insurance costs. According to Hylant’s risk advisors, organizations that take a proactive approach to risk management, loss control, and coverage strategy are better positioned to secure favorable terms in an evolving commercial… [Read more](https://www.dbusiness.com/sponsor-content/5-trends-impacting-the-commercial-insurance-market/)… **University of Buffalo researchers are developing a tool to spot AI-generated radiology reports** Impersonating a doctor to create a fake radiology report. Inserting nonexistent fractures into real X-ray images. Both are ways in which artificial intelligence can be misused for insurance fraud, falsifying disability or malpractice claims, and… [Read more](https://www.buffalo.edu/news/releases/2026/03/fake-radiology-reports-generated-by-artificial-intelligence-ai.html)… **When surveillance makes insurance fraud impossible to hide** The Alabama dentist who blew up his own practice was undone by something most business owners never consider: the surveillance cameras next door. Dr. Douglas P. O’Connor’s 15-year sentence for torching his Evergreen dental office tells a bigger story than just another insurance… [Read more](https://insnerds.com/insights/when-surveillance-makes-insurance-fraud-impossible-to-hide)… **NICB – U.S. Vehicle Thefts Experience Historic Decline** Vehicle thefts across the United States declined in 2025 to the lowest levels in several decades, marking a 23% decrease from 2024, according to a new analysis of reported thefts from the National Insurance Crime Bureau (NICB), the nation’s leading not-for-profit organization… [Read more](https://www.nicb.org/news/news-releases/us-vehicle-thefts-experience-historic-decline)… \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/28c467dc-8276-830d-664e-03edc5954526.jpg) \| \| \|:-:\| \| \| \| **AGENT MISCONDUCT** **March 16, 2026 – Oklahoma – Former Farmers’ agent under fire in lawsuit over confidential data sharing** Farmers Insurance said in a lawsuit that a former agent in Oklahoma allegedly conspired to move Farmers’ insureds to other insurance companies, including an agency where his wife works. Farmers said Bradley McKinney broke his agent appointment agreement with… [Read more](https://www.insurancejournal.com/news/southcentral/2026/03/16/862115.htm)… **LIFE INSURANCE** **March 16, 2026 – Utah – Update: Murder for money: Jury convicts Utah woman in life insurance scheme** Kouri Richins was found guilty of multiple counts this week which included committing insurance fraud by taking out a $100,000 insurance policy on her husband by forging his signature and submitting a claim… [Read more](https://abcnews.com/US/closing-arguments-murder-trial-kouri-richins-utah-mom/story?id=131117904)… **AUTO – FALSE CLAIMS** **March 16, 2026 – Pennsylvania – Reading repair shop owner accused of staging crashes with wife in insurance fraud scheme** Fatima V. Valenzuela of Reading filed an auto insurance claim alleging her husband’s flatbed tow truck had been rear-ended by an SUV three months earlier on Route 222 near Kutztown. But an investigation by Three Insurance Co. revealed an identical claim involving the… [Read more](https://www.yahoo.com/news/articles/pa-authorities-reading-repair-shop-103300113.html)… **AGENT MISCONDUCT** **March 16, 2026 – Maryland – Authorities charge insurance agent in alleged misconduct case** A Montgomery County insurance agent who reportedly stole more than $674,000 from clients and forged their names on documents is facing 55 charges. Ryan Owen Tarjanyi, 52, of Huber Heights was charged with 22 counts of forgery, 12 counts each of theft and… [Read more](https://www.pressreader.com/usa/dayton-daily-news/20260316/281556592340663)… **AUTO – STAGED ACCIDENT** **March 16, 2026 – Louisiana – New Orleans staged crash trial heats up as Motta-linked witness testifies** The federal government’s sprawling staged-crash trial continued this week as a new star witness took the stand. Ryan Harris, an admitted “slammer” who pleaded guilty in January 2025 for his role in the fraud ring and was previously linked to the murder of a fellow federal witness… [Read more](https://www.wdsu.com/article/new-orleans-staged-wrecks-trial-ryan-harris-testimony/70758168)… **HEALTHCARE** **March 17, 2026 – Pennsylvania – Racketeering case: Three convicted in dental practice scheme** Three individuals associated with a Pennsylvania dental practice were convicted in a racketeering conspiracy that defrauded Medicaid of more than $30 million, Savani Group owners and… [Read more](https://adanews.ada.org/ada-news/2026/march/3-convicted-in-racketeering-conspiracy-involving-dental-practice/)… **AUTO – FALSE CLAIMS** **March 18, 2026 – North Carolina – Officials say Winston-Salem women charged in insurance fraud scheme** According to North Carolina Commissioner of Insurance Mike Causey, Arshana Young, 27, and Vernell Wagner, 57, were arrested after being accused of forging a DMV collision report to get an insurance payment. Arrest warrants said Young falsely claimed she was driving Wagner’s vehicle and was injured in a crash in… [Read more](https://www.wxii12.com/article/winston-salem-women-charged-insurance-fraud-dmv/70786861)… \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/18f9920e-e738-5103-cd8e-7ba476e9eb86.jpg) \| \| \|:-:\| \| [](https://members.insurancefraud.org/page/2026MidyearMeeting?_gl=1%2A8v1o4f%2A_ga%2AMzY4NDE0MjA4LjE3MTgxNDY1MDM.%2A_ga_SWDYZ10RHD%2AczE3NzI4MTE1NzYkbzgzMSRnMSR0MTc3MjgxMTU3NiRqNjAkbDAkaDA.)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7ffc6c66-114b-490b-79cf-9feed9317774.png) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/599cd350-ea52-4495-1186-5f4cf595e458.jpg) \| \| \|:-:\| \| [](https://members.insurancefraud.org/general/register_member_type.asp)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/4e08fedc-6fea-9426-9143-d421962a8d68.jpg) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/9d9a163b-d608-c29e-1f8c-71c58f193f3a.jpg) \| \| \|:-:\| \| \| \| - **March 23 – March 26 –** [Verisk Academy](https://events.verisk.com/event/VeriskAcademy/home?RefId=EC-Consideration&elq_cid=33592776&elq_mid=19745&rt=WUDwXBM8PUKk3EoCBebOKg&utm_campaign=vmc-brand-verisk_academy-2025-12-22&utm_content=consider-reservecta&utm_medium=email&utm_source=Eloqua) (Verisk) - **March 25** – [The Most Common Types of Staged Automotive Accidents](https://event.on24.com/wcc/r/5193663/E4AAAECD8A1E7476CDDC0D6C29C24AB9) (Ethos) - **March 31** – [From FNOL to Resolution: How Social Media Provides Insights at Each Stage](https://share.hsforms.com/1aZWvPffpQwGm-tSqUoQ6fAc0z6w?utm_medium=email&_hsenc=p2ANqtz-_euiMs-z2Vk15ct4s-bMs4GZ786GAQ2hwKJT0QT5cm4Npo4E4yUiplmAkQdzOYWVcMd7s3Z73sybn9Ajb6mUEuj1Y3VzeF_JBeBt19Px8nBURCnLs&_hsmi=403228581&utm_content=403228581&utm_source=hs_email) (Social Discovery) - **April 13 – April 15 –** [NAMIC Claims Conference](https://www.namic.org/event/claims-conference/) (NAMIC) - **April 13 – April 15 –** [ACCI 2026 Annual Conference](https://www.consumerinterests.org/conference-2026) (ACCI) - **April 16 – April 17 –** [PA Insurance Fraud Prevention Authority 2026 Conference](https://web.cvent.com/event/883703d6-97b3-455e-bd96-079b65e8b481/summary) (IFPA) - **April 22 – April 24 –** [2026 Annual Anti-Fraud Conference](https://annualantifraudconference.com/#Registration) (AFA) - **May 4 – May 6 –** [Evadata ACT Anti-Fraud Conference](https://whova.com/web/q1wi0epkylJtzgvBjy4ES1K-nsi4hWOOugnM0M7js90%3D/) (Evadata) - **May 5 – May 6 –** [Vehicle Fraud & Crime Conference](https://www.nicb.org/news/events/vehicle-fraud-crime-conference) (NICB) \| \| \|---\| \| \|---\| \| [](https://s.surveyplanet.com/bj1sw6en)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/82bc7396-3a2d-5c34-e4ff-a1d3855f62d0.jpg) \| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a1806adf-c687-1648-4098-c09ab2a2f5a5.png) \| \| \|:-:\| \| \| \| \| \|---\| \| \| \| **Follow Us On Our Social Media Platforms:** \| \| \|---\| \| \|---\| \| [](https://www.linkedin.com/company/coalition-against-insurance-fraud/)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/148b79cf-2c06-6469-b7c8-335c1c8b971a.jpg) \| \| \|:-:\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| \| \| \| \| \| [](https://www.facebook.com/profile.php?id=61579225779934)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/39ae0e7d-0388-20e5-5755-020aec6cf995.jpg) \| \| \|:-:\| \| [](https://www.instagram.com/stopinsurancefraud/)\| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/86c49df9-4380-51e5-da9c-f83034fc7555.jpg) \| \| \|:-:\| \| \| \| \| \| ![Logo](https://brand-assets.mailchimp.com/01KKVRP4PEH4PWEG0R0VSKKJ7H.png) \| \| \|:-:\| \| \| \| *Copyright (C) 2026 Coalition Against Insurance Fraud. All rights reserved.* You are receiving this email because either your organization is a member of the Coalition Against Insurance Fraud or you requested to be placed on our mailing list. Our mailing address is: Coalition Against Insurance Fraud 1012 14th St NW Ste 610 Washington, DC 20005-3424 USA Want to change how you receive these emails? You can [update your preferences](https://insurancefraud.mailchimpsites.com/manage/preferences?u=a440c5b647697de580a2fd586&id=b68dce7808&e=%5BUNIQID%5D&c=d93a9b70ea) or [unsubscribe](https://insurancefraud.us1.list-manage.com/unsubscribe?u=a440c5b647697de580a2fd586&id=b68dce7808&t=b&e=%5BUNIQID%5D&c=d93a9b70ea) \| \| \|:-:\| \| \|---\| \| \| \| \|---\| \| \|:-:\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|---\| \| \|:-:\| | |:-:| <html><p class="wp-block-paragraph"></p> **Features:** Fraud News Weekly --- ### [Fraud News Weekly - March 13, 2026](https://insurancefraud.org/publications/fraud-news-weekly-march-13-2026/) **Published:** March 13, 2026 **Author:** Coalition Against Insurance Fraud **Content:** Fraud News Weekly – Friday, March 13, 2026 | \| \| \|---\| \| \| \| [View this email in your browser](https://mailchi.mp/fc88434093bf/fraud-news-weekly-friday-march-13-2026?e=%5BUNIQID%5D) \| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/1407bcfd-5c29-48b1-9b65-a84a16ade1fe.jpg) \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a417349b-dfdc-a052-790d-07cfde53b716.jpg) \| \|---\| \| \|---\| \| \| **New York budget negotiations leave antifraud provisions in flux.** As the April 1st state budget deadline approaches, insurance fraud measures remain unsettled. Governor Kathy Hochul proposed expanded definitions of fraudulent insurance acts, increased penalties, a $2 million auto insurance fraud fund, and a $17 million workers’ compensation fraud prosecution program through the New York State Workers’ Compensation Board to support district attorneys. Both the New York State Senate and New York State Assembly removed most of these provisions from their one-house budgets ([Assembly proposal](https://assembly.state.ny.us/Reports/WAM/AssemblyBudgetProposal/2026/2026AssemblySummary.pdf?t=1773177714%20) and [Senate proposal](https://www.nysenate.gov/legislation/bills/2025/R1722)), cutting funding and deferring policy changes. The next steps are conference committee negotiations, where advocates can push for restoration or amendments to secure these critical antifraud priorities. The coming weeks are critical for antifraud advocates to push for these provisions. [Read more](https://nysfocus.com/2026/03/12/new-york-state-budget-negotiations-2026)… **The Coalition continues its support for a Kansas bill that would strengthen the Commissioner’s ability to fight insurance fraud across the state.** On March 9, the Coalition submitted a [letter of support](https://insurancefraud.org/wp-content/uploads/Coalition-3-9-2026-Support-of-HB-2323.pdf) for Kansas House Bill 2323 and the next day provided [remote testimony](https://www.youtube.com/watch?v=JLITmF7__S4) to the Kansas Senate Committee on Judiciary. The bill overwhelmingly passed the House in 2025 but did not advance in the Senate. In early 2026, collaboration with key stakeholders and conversations with the committee chair helped place the bill on the Senate committee’s agenda. If passed, the bill will expand the Insurance Commissioner’s authority to pursue civil penalties for insurance fraud, enhance licensing application transparency for agents and public adjusters with expunged insurance fraud convictions, and close fraud-reporting gaps in the automobile assigned claims plan. Early indications suggest it will pass the Senate with a suitable amendment. [Read more](https://www.kslegislature.gov/li/b2025_26/measures/hb2323/)… **Florida lawmakers are split on AI regulation involving insurance claim decisions.** Florida’s legislature is weighing the role of artificial intelligence in insurance claims as the House unanimously approved House Bill 527 which now moves to the Senate. The bill would require a “qualified human professional” to review claim facts, analyze the policy, evaluate AI output, and make final determinations. If passed, insurers may still use AI to assist in claims processing but would not be able to rely on AI alone and would be required to document human review. This would also seem to strengthen the need for SIU investigation, when appropriate. The legislation comes as a presidential executive order pushes federal challenges to state AI laws, raising questions about state versus national control. [Read more](https://www.floridabar.org/the-florida-bar-news/florida-lawmakers-split-on-ai-regulation/)… **Indiana enacts mandatory insurance fraud reporting across all lines.** Last week, Governor Mike Braun signed House Bill 1260, sponsored by Representative Matt Lehman, into law. The new law adds a 60-day “reasonable belief” mandatory insurance fraud reporting requirement for all lines of insurance in the Hoosier State. It also allows for reporting either to the Indiana Department of Insurance or National Insurance Crime Bureau. The new law also strengthens good faith immunity provisions. [Read more](https://iga.in.gov/legislative/2026/bills/house/1260/details)… **The U.S. government invites technology and analytics input to detect healthcare fraud across federal programs.** The Centers for Medicare and Medicaid Services (CMS) has issued a [Request for Information](https://www.federalregister.gov/documents/2026/02/27/2026-03968/request-for-information-rfi-related-to-comprehensive-regulations-to-uncover-suspicious-healthcare) seeking feedback on potential Comprehensive Regulations to Uncover Suspicious Healthcare, or CRUSH, aimed at strengthening oversight of healthcare fraud, waste, and abuse in Medicare, Medicaid, and other government programs. CMS is requesting input on fraud relevant areas including provider enrollment screening, identity proofing, laboratory and genetic testing schemes, supplier fraud, improper medical billing, AI driven coding practices, beneficiary solicitation tactics, and stronger data sharing and analytics to detect suspicious claims. Comments are due March 30, 2026, giving antifraud stakeholders an opportunity to help shape the next generation of federal program integrity tools. [Read more](https://www.federalregister.gov/documents/2026/02/27/2026-03968/request-for-information-rfi-related-to-comprehensive-regulations-to-uncover-suspicious-healthcare)… \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/6bbcb403-e1c7-fb75-bb1a-d5bd83716791.jpg) \| \|---\| \| \|---\| \| \| **Catching fake insurance claims: Why image verification has become essential** We’ve been working with reverse image search technology for years now, and one thing that keeps surprising us is how many industries are quietly dealing with the same problem: people submitting fake or recycled images to… [Read more](https://markets.businessinsider.com/news/stocks/catching-fake-insurance-claims-why-image-verification-has-become-essential-1035908157)… **New York’s no-fault insurance fraud problem: A warning for Alberta’s Care-First system** Alberta’s Care-First regulated auto insurance system is still set to be introduced, and those towards the South, in New York (NY) state are already experiencing a similar system, ripe with fraud. The fraud in NY’s no-fault auto insurance system comes from… [Read more](https://www.westernstandard.news/news/new-yorks-no-fault-insurance-fraud-problem-a-warning-for-albertas-care-first-system/71559)… \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/5c344377-ec7c-90a1-73a3-c230d0a948a9.jpg) \| \|---\| \| \|---\| \| \| *Note: The arrest summaries included in the Coalition’s Fraud News Weekly are based on information from publicly available news sources. Individuals referenced in these reports are presumed innocent unless and until guilt is established in a court of law.* \| \|---\| \| \|---\| \| \| **HEALTHCARE** **March 9, 2026 – Massachusetts – Sleep doctor convicted of insurance fraud, tax evasion** According to court documents and evidence presented at trial, Dr. Merchia, of Boca Raton, Fla., and Brookline, Mass., was a Harvard-educated sleep doctor who was in charge of several sleep medicine companies. From 2017 to 2019, the defendant fraudulently billed insurance companies millions of dollars for sleep apnea machines that had not been…[Read more](https://www.mpo-mag.com/breaking-news/jury-convicts-sleep-doctor-of-insurance-fraud-and-tax-evasion/)… **ARSON – BUSINESS** **March 9, 2026 – Alabama – Dentist sentenced for arson scheme targeting insurance payout** A dentist from Conecuh County, Alabama, has been sentenced for carrying out an insurance fraud scheme. According to a news release from Attorney General Steve Marshall, Douglas Patrick O’Connor was sentenced to serve 15 years in prison for second-degree arson and… [Read more](https://fox2now.com/news/national/alabama-dentist-sentenced-after-setting-fire-to-his-office/amp/)… **HEALTHCARE** **March 9, 2026 – Florida – Medicaid fraud: Telehealth provider for Laconia company sentenced to prison** A former employee of a Laconia-based telehealth company will serve a year for Medicaid fraud, according to a media release from the U.S. Department of Justice. Dr. Erik X. Alonso, 55, of Miami, Florida, will serve one year and one day in prison, as well as… [Read more](https://www.laconiadailysun.com/news/local/telehealth-provider-for-laconia-company-sentenced-to-1-year-in-prison-for-medicaid-fraud/article_d097c579-1a44-4ea1-9554-a3ee5f257293.html)… **HEALTHCARE** **March 9, 2026 – New York – Fraud investigation leads to arrest of Herkimer business owner** A Herkimer business owner was arrested in March on numerous charges after he turned himself in to police, according to information from the Otsego County District Attorney’s Office. The charges stem from a fraud investigation that started with a complaint from… [Read more](https://www.wbng.com/2026/03/09/herkimer-business-owner-arrested-numerous-charges-following-fraud-investigation/)… **HEALTHCARE** **March 10, 2026 – Pennsylvania – Brothers charged in multimillion dollar Medicaid fraud scheme** Two Pennsylvania brothers were convicted of stealing millions from Medicaid through fraud as well as issuing numerous fake visas to immigrants, according to the Department of Justice. Bhaskar and Arun Savani built a complex criminal enterprise called… [Read more](https://www.wtaj.com/news/regional-news/pennsylvania-brothers-stole-millions-from-medicaid-issued-fake-visas-to-immigrants/)… **HEALTHCARE** **March 10, 2026 – Pennsylvania – CEO sentenced in $1.7 million Medicaid fraud scheme** Attorney General Dave Sunday announced that Naya Campbell has been sentenced to prison for her role in a multi-million dollar Medicaid fraud scheme involving a Montgomery County home care agency where she served as CEO. Campbell, of Audubon, previously pleaded guilty to… [Read more](https://www.attorneygeneral.gov/taking-action/ceo-of-montgomery-county-home-care-agency-sentenced-to-incarceration-ordered-to-pay-for-1-7-million-medicaid-fraud-scheme/)… **HEALTHCARE** **March 10, 2026 – South Carolina – Federal indictment targets former Greenville CEO in major healthcare fraud scheme** A federal grand jury in Greenville returned a 16-count indictment, presented by the U.S. Attorney’s Office, charging Kevin S. Murdock, 56, Thomas C. Lee, 56, both of Greenville, and Vidhya V. Narayanan, 45, of Atlanta, for health care fraud and conspiracy to commit… [Read more](https://www.justice.gov/usao-sc/pr/former-greenville-ceo-employees-indicted-multi-million-dollar-health-care-fraud-scheme)… **WORKERS’ COMPENSATION** **March 11, 2026 – California – $6 million fraud scheme leads to arrest of southern California towing business owners** Brothers and tow company owners, Mark Hassan, 46, of Corona Del Mar, and Ahmed Hassan, 35 of Walnut, were arrested today on multiple counts of felony insurance fraud after allegedly underreporting employee payroll and paying portions of employees’ wages in… [Read more](https://www.insurance.ca.gov/0400-news/0100-press-releases/2026/release013-2026.cfm)… **AGENT MISCONDUCT** **March 11, 2026 – North Carolina – Insurance agency owner accused of fraud** A Jamestown man who owns an Archdale insurance agency has been arrested on multiple felonies related to accepting insurance premium payments without forwarding the money to the insurers, the N.C. Department of Insurance announced… [Read more](https://www.yesweekly.com/news/jamestown_news/insurance-agency-owner-accused-of-cheating-customers/article_a456d38d-5bdc-4352-9ad7-cc18ba939916.html)… \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/18f9920e-e738-5103-cd8e-7ba476e9eb86.jpg) \| \|---\| \| \|---\| \| \| [ ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/760af717-1ad1-00f0-0f20-41662c39eae7.jpg) ](https://members.insurancefraud.org/page/2026MidyearMeeting?_gl=1%2A8v1o4f%2A_ga%2AMzY4NDE0MjA4LjE3MTgxNDY1MDM.%2A_ga_SWDYZ10RHD%2AczE3NzI4MTE1NzYkbzgzMSRnMSR0MTc3MjgxMTU3NiRqNjAkbDAkaDA.) \| \|---\| \| \|---\| \| \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a4e430c0-c419-3044-1add-d368ddda9e22.jpg) \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/433719d9-0ff5-830a-9deb-a23681e9216f.jpg) \| \|---\| \| \|---\| \| \|---\| \| \| \| The Coalition Against Insurance Fraud welcomes Demotech, Inc. as a new Associate Member. Founded in 1985 and based in Columbus, Ohio, Demotech is a financial analysis firm known for providing independent Financial Stability Ratings® (FSRs) for property and casualty insurers, life and health insurers, and title underwriters. Demotech has played an important role in evaluating the financial stability and operational safeguards of title insurance underwriters, helping strengthen industry practices aimed at reducing risks such as escrow theft and the online misdirection of funds in real estate transactions. Today, Demotech reviews and rates title underwriters protecting virtually 100 percent of real property transactions in the United States. The organization’s recent research into tech-enabled litigation instigation, along with its longstanding focus on financial transparency, aligns closely with the Coalition’s mission to combat insurance fraud and abuse. The Coalition looks forward to working with Demotech to advance industry awareness and strengthen fraud prevention efforts. \| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/599cd350-ea52-4495-1186-5f4cf595e458.jpg) \| \|---\| \| \|---\| \| \| [ ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/26e4e97f-1c44-78b9-6f67-60c0aaf88dbc.jpg) ](https://members.insurancefraud.org/general/pick_username.asp) \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/092a75b2-e5e6-9838-8a25-790566e52b92.jpg) \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/9d9a163b-d608-c29e-1f8c-71c58f193f3a.jpg) \| \|---\| \| \|---\| \| \| - **March 17 March 19** – [Virtual Fraud Investigation Academy](https://www.nicb.org/news/events/virtual-fraud-investigations-academy) (NICB) - **March 23 – March 26 –** [Verisk Academy](https://events.verisk.com/event/VeriskAcademy/home?RefId=EC-Consideration&elq_cid=33592776&elq_mid=19745&rt=WUDwXBM8PUKk3EoCBebOKg&utm_campaign=vmc-brand-verisk_academy-2025-12-22&utm_content=consider-reservecta&utm_medium=email&utm_source=Eloqua) (Verisk) - **March 31** – [From FNOL to Resolution: How Social Media Provides Insights at Each Stage](https://share.hsforms.com/1aZWvPffpQwGm-tSqUoQ6fAc0z6w?utm_medium=email&_hsenc=p2ANqtz-_euiMs-z2Vk15ct4s-bMs4GZ786GAQ2hwKJT0QT5cm4Npo4E4yUiplmAkQdzOYWVcMd7s3Z73sybn9Ajb6mUEuj1Y3VzeF_JBeBt19Px8nBURCnLs&_hsmi=403228581&utm_content=403228581&utm_source=hs_email) (Social Discovery) - **April 13 – April 15 –** [NAMIC Claims Conference](https://www.namic.org/event/claims-conference/) (NAMIC) - **April 13 – April 15 –** [ACCI 2026 Annual Conference](https://www.consumerinterests.org/conference-2026) (ACCI) - **April 16 – April 17 –** [PA Insurance Fraud Prevention Authority 2026 Conference](https://web.cvent.com/event/883703d6-97b3-455e-bd96-079b65e8b481/summary) (IFPA) - **April 22 – April 24 –** [2026 Annual Anti-Fraud Conference](https://annualantifraudconference.com/#Registration) (AFA) - **May 4 – May 6 –** [Evadata ACT Anti-Fraud Conference](https://whova.com/web/q1wi0epkylJtzgvBjy4ES1K-nsi4hWOOugnM0M7js90%3D/) (Evadata) - **May 5 – May 6 –** [Vehicle Fraud & Crime Conference](https://www.nicb.org/news/events/vehicle-fraud-crime-conference) (NICB) [Click here to view ](https://insurancefraud.org/anti-fraud-events/)[the full calendar of member events](https://insurancefraud.org/anti-fraud-events/)… \| \|---\| \| \|---\| \| \| [ ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/06c25334-a44b-83f1-621b-dbfc959b59ea.jpg) ](https://s.surveyplanet.com/bj1sw6en) \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/4b1136e8-4c9e-4d00-bc11-54758a3ea8a6.png) \| \|---\| \| \|---\| \| \|---\| \| \| \| **Follow Us On Our Social Media Platforms:** \| \| \|---\| \| \| [ ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/148b79cf-2c06-6469-b7c8-335c1c8b971a.jpg) ](https://insurancefraud.us1.list-manage.com/track/click?u=a440c5b647697de580a2fd586&id=5214c5e629&e=cf8d2cdb4f) \| \|---\| \| \|---\| \| \| [ ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/39ae0e7d-0388-20e5-5755-020aec6cf995.jpg) ](https://insurancefraud.us1.list-manage.com/track/click?u=a440c5b647697de580a2fd586&id=06da6de163&e=cf8d2cdb4f) \| \|---\| \| \|---\| \| \| [ ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/86c49df9-4380-51e5-da9c-f83034fc7555.jpg) ](https://insurancefraud.us1.list-manage.com/track/click?u=a440c5b647697de580a2fd586&id=b349097e98&e=cf8d2cdb4f) \| \|---\| \| \|---\| \| \| \| \|---\| \| \|---\| \| \| **Contact:** Phone: [202.393.7330](tel:2023937330) Email: [coalition](mailto:coalition@insurancefraud.org)[@insurancefraud.org](mailto:coalition@insurancefraud.org) Address: 1012 14th Street, NW Suite 610 Washington, DC 20005 [www.InsuranceFraud.org](http://www.insurancefraud.org/) Want to change how you receive these emails? You can [update your preferences](https://coalitionagainstinsurancefraud.mailchimpsites.com/manage/preferences?u=a440c5b647697de580a2fd586&id=b68dce7808&e=%5BUNIQID%5D&c=563bcf1980) or [unsubscribe from this list](https://insurancefraud.us1.list-manage.com/unsubscribe?u=a440c5b647697de580a2fd586&id=b68dce7808&t=b&e=%5BUNIQID%5D&c=563bcf1980). \| \|---\| \| \|---\| \| \|---\| | |:-:| <html><p class="wp-block-paragraph"></p> **Features:** Fraud News Weekly --- ### [Fraud News Weekly - February 27, 2026](https://insurancefraud.org/publications/fraud-news-weekly-february-27-2026/) **Published:** February 27, 2026 **Author:** Coalition Against Insurance Fraud **Content:** Fraud News Weekly (FNW) – Friday, February 27, 2026 | \| \| \|---\| \| \| \| [View this email in your browser](https://mailchi.mp/73d1b62fd7f9/fraud-news-weekly-fnw-friday-february-27-2026?e=%5BUNIQID%5D) \| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/0bcc4fb8-94e9-7b64-5158-167172294cc6.jpg) \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a417349b-dfdc-a052-790d-07cfde53b716.jpg) \| \|---\| \| \|---\| \| \| **Coalition supports New York Governor Hochul’s antifraud provisions in the Executive Budget.** This week, the Coalition submitted [written support](https://insurancefraud.org/wp-content/uploads/Coalition-2-24-2026-Written-Support-of-Antifraud-Provisions-in-New-York-Executive-Budget.pdf) for antifraud measures in Governor Hochul’s [Executive Budget](https://www.governor.ny.gov/sites/default/files/2026-01/FY2027ExecutiveBudgetBook.pdf), which target staged accidents, workers’ compensation fraud, and wage theft. These provisions provide additional resources for prosecutors and investigators, strengthening enforcement and helping stabilize insurance costs for New Yorkers. The Coalition emphasizes that these actions support consumer protection and fraud reduction, aligning with ongoing state and national priorities to combat organized and opportunistic insurance fraud. [Read more](https://www.governor.ny.gov/news/money-your-pockets-governor-hochul-proposes-measures-bring-down-crushingly-expensive-auto)… **Washington insurance fraud bill passes Senate to House with Coalition support.** For a third time, the Coalition submitted [written support](https://insurancefraud.org/wp-content/uploads/Coalition-2-23-2026-Support-of-SB-6031.pdf) for Senate Bill 6031 this week as it passed the Senate and moved to the House Committee on Consumer Protection & Business. The legislation elevates insurance fraud to a felony, expands prosecutorial powers, clarifies venue and statute of limitations, and strengthens the Commissioner’s authority to share information. Coalition director of government relations Brent Walker previously testified and submitted comments on both the Senate bill and its companion bill that failed to move out of the House. The Coalition highlighted the need to enhance the Criminal Investigations Unit with financial and digital specialists to address increasingly sophisticated fraud schemes. [Read more](https://www.insurance.wa.gov/about-us/news/2026/insurance-fraud-modernization-bill-passes-state-senate)… **Texas TDI marks 150 years and signals a consumer-first agenda with a new commissioner.** The Coalition attended last week’s *TDI Meet the Regulator* [event](https://www.tdi.texas.gov/alert/event/2026/02/meet-the-regulator.html) in Austin, where new Commissioner Amanda Crawford, former leader at the Texas Office of the Attorney General and Department of Information Resources, emphasized consumer protection, compliance transparency, and new online tools to help homeowners find coverage. Texas regulates more than 2,200 insurers in the nation’s second-largest insurance market. Chief Deputy Dan Paschal outlined 2026 rulemaking including stakeholder input on SB 458 appraisal reforms and a new format for quarterly virtual meetings. Consumer Protection leaders reported roughly 120 complaints daily, with property and casualty leading and auto representing about half, often related to claim delays. Breakouts addressed third-party complaints, public adjuster filings, steering allegations, aerial imagery nonrenewals, and the TDI Disaster Coalition. We will monitor rulemaking and opportunities to advance strong antifraud safeguards that protect policyholders and support fair claims handling. [Read more](https://www.tdi.texas.gov/news/2026/tdi02032026.html)… **NAIC Privacy Protections Working Group advances its review of its proposed consumer privacy model, now focused on health information.** The NAIC Privacy Protections Working Group ([PPWG](https://content.naic.org/committees/h/privacy-protections-wg)) is reviewing Article VII, Rules for Health Information, in the [Chair Draft revision of Model 672](https://content.naic.org/sites/default/files/call_materials/Chair%20Draft%20Amendments%20to%20%23672%208.5.24.pdf), with written comments due by March 11th. The Drafting Group is moving section by section to build consensus among regulators, industry stakeholders, and consumer representatives. Brent Walker, Coalition director of government relations and NAIC-appointed consumer representative, recently engaged to clarify proposed Section 25’s impact on NICB and NAIC antifraud activities, ensuring antifraud capabilities and compliance remain in place as debate continues on responsible data use. The final draft is planned to be ready for consideration at NAIC’s Fall National Meeting. [Read more](https://content.naic.org/sites/default/files/inline-files/PPWG%20Drafting%20Guidelines.pdf)… \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/6bbcb403-e1c7-fb75-bb1a-d5bd83716791.jpg) \| \|---\| \| \|---\| \| \| **Expedited final ruling holding up $4B settlement distribution** Two community organizations and two businesses that suffered Maui wildfire losses have petitioned the Hawaii Supreme Court to dismiss an insurance industry lawsuit on appeal that’s delaying distribution of a $4 billion settlement to victims. The four entities… [Read more](https://insurancenewsnet.com/oarticle/expedited-final-ruling-holding-up-4b-settlement-distribution)… **Lawmakers consider hiking fines for insurers who flout Georgia’s mental health parity law** Georgia officials on both sides of the aisle are proposing legislation aimed at holding insurance companies accountable when they fall short of the long-held promise of mental health parity, which is the idea that insurance coverage for mental health should be… [Read more](https://georgiarecorder.com/2026/02/24/lawmakers-consider-hiking-fines-for-insurers-who-flaunt-georgias-mental-health-parity-law/)… **DOJ signals continued aggressive False Claims Act Enforcement** At the Federal Bar Association’s (FBA’s) 2026 Qui Tam Conference, Brenna Jenny, deputy assistant attorney general for the Commercial Litigation Branch of the Department of Justice (DOJ) Civil Division, highlighted several themes likely to shape False Claims Act (FCA)… [Read more](https://www.skadden.com/insights/publications/2026/02/doj-signals-continued-aggressive-false-claims-act-enforcement)… **Understanding Medicaid home care amid CMS focus on potential fraud and abuse** Potential fraud in state Medicaid programs is getting renewed attention, with a recent emphasis on home care, also known as personal care or in-home supportive services. [Home care](https://www.kff.org/medicaid/medicaid-home-care-hcbs-in-2025/) helps with self-care activities such as bathing, dressing, and eating for older… [Read more](https://www.kff.org/medicaid/understanding-medicaid-home-care-amid-cms-focus-on-potential-fraud-and-abuse/)… **Insurance fraud detection market sees strong future growth by 2033** Coherent Market Insights’ most recent research study, “Global Insurance Fraud Detection Market Size, Share, Pricing, Trends, Growth, Opportunities and Forecast 2026-2033,” provides a thorough overview of the market for Insurance Fraud Detection Market on… [Read more](https://www.openpr.com/news/4404624/insurance-fraud-detection-market-see-strong-future-growth)… **Mississippi Insurance Commissioner says insurance fraud affects everyone** Insurance fraud is not a victimless crime. It’s been around for as long as insurance, and it costs businesses billions of dollars each year – an expense that is passed on to consumers in the form of higher premiums. Although the overwhelming majority of… [Read more](https://magnoliatribune.com/2026/02/25/insurance-fraud-effects-everyone/)… **New York DFS highlights fraud and litigation as key auto insurance cost drivers in Executive Budget hearing** The Coalition listened as lawmakers questioned New York State Department of Financial Services officials during the Joint Legislative Public Hearing on the 2026 Executive Budget Proposal. Acting Superintendent Kaitlin Asrow noted that every state is facing inflation and rising parts costs but emphasized that New York uniquely faces fraud and excessive litigation that are driving up auto insurance costs. Lawmakers pressed DFS on its reliance on insurer fraud referrals. DFS responded that it actively investigates and prosecutes fraud and conducts market conduct exams to ensure antifraud compliance. [Read more](http://www.governor.ny.gov/sites/default/files/2026-01/FY2027ExecutiveBudgetBook.pdf)… \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/5c344377-ec7c-90a1-73a3-c230d0a948a9.jpg) \| \|---\| \| \|---\| \| \| *Note: The arrest summaries included in the Coalition’s Fraud News Weekly are based on information from publicly available news sources. Individuals referenced in these reports are presumed innocent unless and until guilt is established in a court of law.* \| \|---\| \| \|---\| \| \| **AGENT MISCONDUCT** **February 20, Florida – Former broker, Co-defendant sentenced to 20 years in fraudulent ACA sign-ups** The leaders of a $180 million scheme to sell Affordable Care Act insurance plans to homeless people and others who did not qualify were sentenced to 20 years in federal prison and full restitution. Cory Loyd, 47, who was a licensed insurance broker in Florida and head of FloridaCare Insurance, and Steven Strong, 43, the marketing leader in the scheme, were convicted in … [Read more](https://www.insurancejournal.com/news/southeast/2026/02/20/858896.htm)… **HEALTH INSURANCE** **February 21, Texas – Lubbock mother sentenced in shocking fraud scheme targeting disabled son** A federal judge told a 61-year-old woman who stole Medicare money meant for her severely disabled son that her case showed a level of cruelty and brutality he’d never seen in typical bank fraud cases.Before handing down a 17-year federal… [Read more](https://www.amarillo.com/story/news/courts/2026/02/21/lubbock-mom-to-prison-federal-bank-fraud-charge-linked-to-disabled-son/88781550007/)… **LIFE INSURANCE February 22, Utah – Mom on trial for father’s death after writing book to help children cope** A year after her husband died, a mother of three in Utah self-published a children’s book that she said helped her sons cope with the sudden loss. Kouri Richins promoted her book “Are You With Me?” on a local TV station and drew praise for helping… [Read more](https://www.wgal.com/article/kouri-richins-children-book-husband-killing/70441149)… **HEALTHCARE** **February 22, Massachusetts – New York man sentenced in massive $70.6 million Medicare fraud scheme** A former New York based sales director for the Northeast region of a mobile medical diagnostics company was sentenced in federal court in Boston for conspiring to offer and pay kickbacks to doctors in exchange for ordering medically unnecessary… [Read more](https://fallriverreporter.com/new-york-man-sentenced-in-massachusetts-court-for-scheme-that-led-to-approximately-70-6-million-in-fraudulent-bills-submitted-to-medicare/)… **ARSON February 23, Ohio – $2 million insurance fraud scheme ends in arson conviction for couple** An Ohio couple have been sentenced for devising a scheme to collect more than $2 million dollars in insurance money by conspiring to set insured houses on fire, the U.S. Attorney’s Office, Northern District of Ohio announced. Lonnie White, 48, from Willoughby Hills, Ohio, was sentenced to… [Read more](https://www.insurancejournal.com/magazines/mag-features/2026/02/23/858351.htm)… **HEALTHCARE** **February 24, Colorado – Zynex hit with $873 million class-action over alleged insurance overbilling scheme** A federal securities class action filed on February 20, has laid out what prosecutors describe as an $873 million insurance billing fraud machine run by the former top executives of medical device maker Zynex, Inc. The case, Beidel v. Sandgaard… [Read more](https://www.insurancebusinessmag.com/us/news/claims/zynex-class-action-alleges-873-million-insurance-overbilling-scheme-566369.aspx)… **HEALTHCARE** **February 24, Texas – $145 million healthcare fraud lands doctor behind bars for 8.5 years** An orthopedic surgeon was sentenced to 102 months in prison and ordered to pay over $13 million in restitution for his role in a $145 million scheme to defraud the Department of Labor through the submission of fraudulent claims for prescription… [Read more](https://www.justice.gov/opa/pr/texas-doctor-sentenced-85-years-prison-145-million-health-care-fraud-scheme)… **HEALTHCARE** **February 24, Michigan – $3 million healthcare fraud: Pharmacist and business owner admits guilt in scheme targeting Medicare, Medicaid, and insurers** A pharmacist and business owner who engaged in a five-year pharmacy shortage fraud scheme at two separate pharmacies pled guilty, announced United States Attorney Jerome F. Gorgon, Jr. Gorgon was joined in the announcement… [Read more](https://www.justice.gov/usao-edmi/pr/pharmacist-and-business-owner-convicted-3m-medicare-medicaid-and-private-insurer-fraud)… **AGENT MISCONDUCT** **February 24, Florida – Fraud crackdown: Florida insurance agent arrested over fake tow truck policies** Florida Chief Financial Officer Blaise Ingoglia announced the arrest of a licensed insurance agent and an unlicensed individual for selling fraudulent commercial insurance policies for tow trucks in Miami-Dade County. Javier Gonzalez Jr., a licensed insurance agent, and… [Read more](https://collisionweek.com/2026/02/24/florida-announces-arrest-insurance-agent-fraudulent-tow-truck-policy-scheme/)… **WORKERS’ COMP** **February 26, California – Officer accused of insurance fraud after allegedly skydiving while on disability leave** A Los Angeles police officer has been charged with felony insurance fraud after he was spotted skydiving while on disability leave. Christopher Carnahan, of Norwalk, hurt his elbow while on duty in 2023, according to the Los Angeles County District… [Read more](https://abc7.com/post/lapd-officer-charged-insurance-fraud-allegedly-skydiving-disability-leave/18653298/)… \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/e04f063d-6836-b86d-4717-427e4a69a52d.jpg) \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/be0e3c08-6f77-38b4-9757-dc882d3aed55.jpg) \| \|---\| \| \|---\| \| \|---\| \| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/599cd350-ea52-4495-1186-5f4cf595e458.jpg) \| \| \|---\| \| \| [ ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/26e4e97f-1c44-78b9-6f67-60c0aaf88dbc.jpg) ](https://members.insurancefraud.org/general/pick_username.asp) \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/092a75b2-e5e6-9838-8a25-790566e52b92.jpg) \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/9d9a163b-d608-c29e-1f8c-71c58f193f3a.jpg) \| \|---\| \| \|---\| \| \| - **March 1 – March 4 –** [Insurance Fraud Management Conference](https://events.verisk.com/event/8d7e5635-89e2-4500-a65b-6044cf54ab9b/home?RefId=VeriskConferences&rt=WUDwXBM8PUKk3EoCBebOKg) (Verisk / NICB) - **March 4 – March 5 –** [NYSSIU Winter Conference](https://nyssiu.org/meetings/) (NYSSIU) - **March 4 – March 6 –** [Enhancing Your Skills: Managing and Navigating Complex Investigations](https://www.nhcaa.org/events/enhancing-your-skills-managing-and-navigating-complex-investigations-2/) (NHCAA) - **March 10 –** [AFA Q1 2026 Training Webinar – Explosive Verdicts, Smarter Choices](https://register.gotowebinar.com/register/4537577188979207258) (AFA) - **March 11 –** [IME: Accelerating Claim Resolution](https://event.on24.com/wcc/r/5193660/641F34879FADE617C142AEB7DC56A45F) (Ethos) - **March 12 –** [Disability Within Workers’ Compensation Claims](https://register.gotowebinar.com/register/6643433326597261920?utm_campaign=345943266-CE%20Course%20Announcements&utm_source=email) (Allied Universal) - **March 17 March 19** – [Virtual Fraud Investigation Academy](https://www.nicb.org/news/events/virtual-fraud-investigations-academy) (NICB) - **March 23 – March 26 –** [Verisk Academy](https://events.verisk.com/event/VeriskAcademy/home?RefId=EC-Consideration&elq_cid=33592776&elq_mid=19745&rt=WUDwXBM8PUKk3EoCBebOKg&utm_campaign=vmc-brand-verisk_academy-2025-12-22&utm_content=consider-reservecta&utm_medium=email&utm_source=Eloqua) (Verisk) - **March 23 – March 26 –** [The Verisk Insurance Conference](https://events.verisk.com/event/VIC2025/home?RefId=VeriskConferences&rt=WUDwXBM8PUKk3EoCBebOKg) (Verisk) - **March 31** – [From FNOL to Resolution: How Social Media Provides Insights at Each Stage](https://share.hsforms.com/1aZWvPffpQwGm-tSqUoQ6fAc0z6w?utm_medium=email&_hsenc=p2ANqtz-_euiMs-z2Vk15ct4s-bMs4GZ786GAQ2hwKJT0QT5cm4Npo4E4yUiplmAkQdzOYWVcMd7s3Z73sybn9Ajb6mUEuj1Y3VzeF_JBeBt19Px8nBURCnLs&_hsmi=403228581&utm_content=403228581&utm_source=hs_email) (Social Discovery) - **April 13 – April 15 –** [NAMIC Claims Conference](https://www.namic.org/event/claims-conference/) (NAMIC) [Click here to view ](https://insurancefraud.org/anti-fraud-events/)[the full calendar of member events](https://insurancefraud.org/anti-fraud-events/)… \| \|---\| \| \|---\| \| \| [ ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/06c25334-a44b-83f1-621b-dbfc959b59ea.jpg) ](https://s.surveyplanet.com/bj1sw6en) \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/4b1136e8-4c9e-4d00-bc11-54758a3ea8a6.png) \| \|---\| \| \|---\| \| \|---\| \| \| \| **Follow Us On Our Social Media Platforms:** \| \| \|---\| \| \| [ ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/148b79cf-2c06-6469-b7c8-335c1c8b971a.jpg) ](https://insurancefraud.us1.list-manage.com/track/click?u=a440c5b647697de580a2fd586&id=5214c5e629&e=cf8d2cdb4f) \| \|---\| \| \|---\| \| \| [ ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/39ae0e7d-0388-20e5-5755-020aec6cf995.jpg) ](https://insurancefraud.us1.list-manage.com/track/click?u=a440c5b647697de580a2fd586&id=06da6de163&e=cf8d2cdb4f) \| \|---\| \| \|---\| \| \| [ ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/86c49df9-4380-51e5-da9c-f83034fc7555.jpg) ](https://insurancefraud.us1.list-manage.com/track/click?u=a440c5b647697de580a2fd586&id=b349097e98&e=cf8d2cdb4f) \| \|---\| \| \|---\| \| \| \| \|---\| \| \|---\| \| \| **Contact:** Phone: [202.393.7330](tel:2023937330) Email: [coalition](mailto:coalition@insurancefraud.org)[@insurancefraud.org](mailto:coalition@insurancefraud.org) Address: 1012 14th Street, NW Suite 610 Washington, DC 20005 [www.InsuranceFraud.org](http://www.insurancefraud.org/) Want to change how you receive these emails? You can [update your preferences](https://coalitionfraud.mailchimpsites.com/manage/preferences?u=a440c5b647697de580a2fd586&id=b68dce7808&e=%5BUNIQID%5D&c=204e99125b) or [unsubscribe from this list](https://insurancefraud.us1.list-manage.com/unsubscribe?u=a440c5b647697de580a2fd586&id=b68dce7808&t=b&e=%5BUNIQID%5D&c=204e99125b). \| \|---\| \| \|---\| \| \|---\| | |:-:| <html><p class="wp-block-paragraph"></p> **Features:** Fraud News Weekly --- ### [Fraud News Weekly - March 6, 2026](https://insurancefraud.org/publications/fraud-news-weekly-march-6-2026/) **Published:** March 6, 2026 **Author:** Coalition Against Insurance Fraud **Content:** Fraud News Weekly (FNW) – March 6, 2026 | \| \| \|---\| \| \| \| [View this email in your browser](https://mailchi.mp/ab0167f87359/fraud-news-weekly-fnw-march-6-2026?e=%5BUNIQID%5D) \| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/360d7616-1660-5037-0843-d32a22224dfa.jpg) \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a417349b-dfdc-a052-790d-07cfde53b716.jpg) \| \|---\| \| \|---\| \| \| **A Georgia House bill that would strengthen fraud enforcement and industry accountability advances to the Senate.** Georgia House Bill 1344, also known as the Insurance Affordability and Claims Integrity Act, overwhelmingly passed by the House and is now headed to the Senate. The Bill would specifically outlaw “cappers” and “runners” who steer auto accident victims to providers, a practice that has fueled auto insurance fraud and make it a felony punishable by up to ten years in prison and fines up to $200 000, while staged accident claim participants could face fines up to $100 000. The measure would also authorize the Georgia Commissioner of Insurance to hire prosecutors and fund enforcement through fees on captive insurers, increasing the state’s ability to pursue fraudsters. These fraud provisions are central to the bill’s approach to improving market integrity and reducing loss drivers in Georgia’s insurance system. [Read more](https://www.insurancejournal.com/news/southeast/2026/03/04/860355.htm)… **Louisiana Department of Insurance joins forces to combat third‑party litigation funding fraud tactics.** The Louisiana Department of Insurance announced a first‑of‑its‑kind partnership with the National Insurance Crime Bureau and digital intelligence firm 4WARN to alert consumers and protect the market from misleading online marketing tied to third‑party litigation funding that can fuel unnecessary litigation and insurance fraud by steering policyholders away from direct insurer contact and into costly claims disputes. “The LDI is dedicated to protecting Louisianans from opportunists who manipulate the claims process to fuel excessive litigation, which is a primary driver of our high insurance costs,” said Insurance Commissioner Tim Temple. “I’m excited to partner with NICB and 4WARN to expose these misleading practices that prey on policyholders when they are most vulnerable.” [Read more](https://www.ldi.la.gov/news/press-releases/3-2-26-ldi-partners-with-nicb-and-4warn-to-combat-third-party-litigation-funding-marketing-tactics)… **NAIC releases 2026 strategic priorities emphasizing modernization, data, AI, and resilience.** The National Association of Insurance Commissioners 2026 agenda emphasizes leadership in AI governance, innovation oversight, and cybersecurity resilience, initiatives that have growing implications for fraud detection and mitigation. As fraud schemes increasingly exploit emerging technologies, these priorities help state regulators and insurers implement robust safeguards, improve predictive analytics, and strengthen data protection. NAIC President and Virginia Insurance Commissioner Scott A. White emphasized that these priorities underscore the state-based system’s commitment to consumer protection and proactive oversight. For Coalition members, the NAIC’s focus reinforces proactive antifraud strategies and encourages collaboration across public and private sectors to address technology‑enabled fraud risks effectively. [Read more](https://content.naic.org/article/leadership-modernization-resilience-naic-2026-strategic-priorities)… \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/6bbcb403-e1c7-fb75-bb1a-d5bd83716791.jpg) \| \|---\| \| \|---\| \| \| **On the front lines of fraud** As fraud soars across New York state and the country, AARP and other organizations are working to broaden their education and prevention efforts. Brewer-Montero, a fraud/scam prevention coordinator at Lifespan of Greater Rochester, is part of … [Read more](https://www.aarp.org/states/new-york/fighting-fraud-new-york/)… **Employment trends are reshaping the insurance industry** Insurers occupy a dual role in today’s employment environment. They are both large employers themselves, and they operate in an industry that is highly sensitive to broader labor market trends. As the latest jobs data rolls in, carriers are… [Read more.](https://insurancenewsnet.com/innarticle/employment-trends-are-reshaping-the-insurance-industry).. **United States cyber insurance market size, share, industry trends, growth and forecast 2026-2034** Explore the trends, challenges, and market forecast shaping the United States cyber insurance market as organizations strengthen financial protection against cyberattacks, data breaches, and… [Read more](https://vocal.media/trader/united-states-cyber-insurance-market-size-share-industry-trends-growth-and-forecast-2026-2034)… **Billing fraud tops list of employee crimes at large US companies** Eight in 10 risk managers at large American companies said their organizations experienced employee theft, fraud, or embezzlement in the past 12 months, a new QBE Insurance survey has found, as artificial intelligence reshapes how workplace crimes are… [Read more](https://www.insurancebusinessmag.com/us/news/breaking-news/billing-fraud-tops-list-of-employee-crimes-at-large-us-companies-567343.aspx)… **Clearwater takes a look at FX protection** Clearwater Analytics, the most comprehensive technology platform for investment management, recently released industry research revealing that US insurers are quietly stepping up their FX protection strategies as fresh volatility ripples through…[ Read more](https://insurance-edge.net/2026/03/03/clearwater-takes-a-look-at-fx-protection/)… \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/5c344377-ec7c-90a1-73a3-c230d0a948a9.jpg) \| \|---\| \| \|---\| \| \| *Note: The arrest summaries included in the Coalition’s Fraud News Weekly are based on information from publicly available news sources. Individuals referenced in these reports are presumed innocent unless and until guilt is established in a court of law.* \| \|---\| \| \|---\| \| \| **HEALTHCARE March 1, California – Hospice fraud scandal in Los Angeles drains tens of millions from taxpayers** A network of hundreds of hospices are under investigation for allegedly ripping tens of millions of dollars from taxpayers in Los Angeles Country and across California. The Centers for Medicare and Medicaid Services is now actively cutting off payments to… [Read more](https://nypost.com/2026/03/01/us-news/multimillion-dollar-fraud-probe-targets-california-hospice-agencies/)… **AGENT MISCONDUCT** **March 2, Wisconsin – Repeat arrest: Former Beaver Dam insurance agent back in custody** A former Beaver Dam insurance agent is in trouble with the law again. The Dane County Sheriff’s Office said Mason Gunderson was arrested in Bristol. The criminal complaint states that Gunderson crashed his vehicle into another vehicle with… [Read more](https://dailydodge.com/former-beaver-dam-insurance-agent-arrested-again/)… **AGENT MISCONDUCT** **March 2, California – Tragic death leads to alleged insurance fraud case against Oxnard agent** Licensed insurance agent Gonzalo Lorona, 58, of Oxnard, has been charged with 37 felony counts, including insurance fraud and grand theft, after a California Department of Insurance investigation found he allegedly stole client premium payments and… [Read more](https://www.insurance.ca.gov/0400-news/0100-press-releases/2026/release011-2026.cfm)… **AUTO** **March 2, Louisiana – $30k insurance scam leads to arrest of Baton Rouge couple** A Baton Rouge couple accused of attempting to defraud an insurance company out of approximately $30,000. The investigation began after authorities received a criminal referral from the Louisiana Department of Insurance regarding allegations of… [Read more](https://www.klfy.com/local/baton-rouge-couple-arrested-for-30k-insurance-scam/)… **CONTRACTOR** **March 2, Louisiana – Contractor taken into custody in fraud investigation** A contractor was arrested last week on charges of fraud, filing false public records and forgery. The contractor, Jon Andersen, also received a cease-and-desist letter from Louisiana Insurance Commissioner Tim Temple. Andersen was arrested… [Read more](https://www.insurancejournal.com/news/southcentral/2026/03/02/860112.htm)… **STAGED** **March 2, South Carolina – Authorities charge man in alleged staged hit-and-run insurance scam** A Sumter County man has been charged with insurance fraud, according to the South Carolina Law Enforcement Division. SLED charged 21-year-old Jakeem J. Samuel with presenting a false claim for insurance payment valued at $10,000 or more… [Read more](https://wach.com/news/local/2026-03-02-sled-man-charged-with-insurance-fraud-in-staged-hit-and-run-jakeem-samuel-false-claim-crime-investigation)… **STAGED** **March 4, Louisiana – Federal prosecutors take on New Orleans attorneys in staged truck crash fraud trial** The jury heard from victims and conspirators of staged wrecks in the New Orleans area, an FBI special agent and an attorney familiar with the scheme. Opening statements were made in a high-stakes federal fraud trial that targets two local attorneys accused of… [Read more](https://www.wwltv.com/article/news/investigations/federal-fraud-trial-begins-for-new-orleans-attorneys-accused-in-staged-crash-scheme/289-8ae8db90-b55c-400f-a4de-2a42809568e7)… **AGENT MISCONDUCT** **March 5, California – Fraud charges filed against California insurance broker** Insurance broker, Andre De Gazon, 56, of Bellflower, was arraigned recently at the Orange County Superior Court on multiple felony counts of grand theft and embezzlement after allegedly using his status as a licensed insurance agent to pocket more than $100,000 of … [Read more](https://insurance-edge.net/2026/03/05/charges-brought-against-insurance-broker-in-california/)… **PROPERTY & CASUALTY March 5, Idaho – Insurance fraud charges filed against Mayor for misreporting boat price** The mayor of Spencer has been charged with a felony after allegedly lying about the price of his boat to insurance agents after he crashed it onto a sandbar in 2024. David Dwayne Price, 62, is charged with felony insurance fraud in Bonneville County. Price was… [Read more](https://www.eastidahonews.com/2026/03/local-mayor-charged-with-insurance-fraud-after-allegedly-lying-about-the-price-of-his-boat/)… **HEALTHCARE** **March 5, North Carolina – $12M Medicaid fraud scheme results in 14-year prison sentences for facility and staff** A federal judge has handed down more than 14 years in federal prison to participants in a $12.7 Million Medicaid fraud scheme that paid more than $1 Million in kickbacks to drug addict patients. The case also resulted in the permanent closure of the… [Read more](https://www.justice.gov/usao-ednc/pr/over-12-million-medicaid-fraud-scheme-leads-14-years-prison-substance-abuse-facility)… **WORKERS’ COMPENSATION** **March 6, New York – Painter in Oswego County pleads guilty to fraud scheme** An Oswego County painter who was injured at his job returned to work and illegally collected more than $10,000 in workers’ compensation benefits, according to state investigators. Christopher Cronk, 58, of Central Square, pleaded… [Read more](https://www.oswegocountynewsnow.com/news/oswego-county-painter-pleads-guilty-to-workers-compensation-fraud/article_9a3d7db1-9ef6-4a23-9c0f-68ccbda76854.html)… \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/18f9920e-e738-5103-cd8e-7ba476e9eb86.jpg) \| \|---\| \| \|---\| \| \| [ ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/760af717-1ad1-00f0-0f20-41662c39eae7.jpg) ](https://members.insurancefraud.org/page/2026MidyearMeeting?_gl=1%2A8v1o4f%2A_ga%2AMzY4NDE0MjA4LjE3MTgxNDY1MDM.%2A_ga_SWDYZ10RHD%2AczE3NzI4MTE1NzYkbzgzMSRnMSR0MTc3MjgxMTU3NiRqNjAkbDAkaDA.) \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/e04f063d-6836-b86d-4717-427e4a69a52d.jpg) \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/ef701823-c009-b155-023d-8aea9a20ebde.jpg) \| \|---\| \| \|---\| \| \| **Coalition Staff Attend Verisk IFM Conference** Staff from the Coalition Against Insurance Fraud attended **Verisk’s Insurance Fraud Management (IFM) Conference** in Phoenix, Arizona, where more than 500 insurance fraud professionals gathered to share insights, receive training, and discuss emerging fraud threats. The conference provided an opportunity to reconnect with member organizations, strengthen partnerships, and introduce new attendees to the Coalition’s work. During the conference, **Michelle Rafeld, Executive Director of the Coalition Against Insurance Fraud**, participated in a panel discussion with **IASIU President Aimee Stidham** and **John Selleck, Vice President of Operations for the National Insurance Crime Bureau (NICB)**. The session, moderated by **Shane Riedman, President of Anti-Fraud Solutions for Verisk**, focused on the importance of modernization and collaboration across the industry. In addition, **Brent Walker, Director of Government Relations for the Coalition Against Insurance Fraud**, served as a panelist in the session **“Legislating Against Fraud,”** discussing legislative strategies and policy initiatives aimed at strengthening efforts to combat insurance fraud. The Coalition extends its appreciation to **Verisk** for hosting another successful conference and to the many sponsors whose support helped make the event possible. \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a4e430c0-c419-3044-1add-d368ddda9e22.jpg) \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/27c8a7f3-b48a-848c-44b3-21116f581062.png) \| \|---\| \| \|---\| \| \|---\| \| \| \| We are proud to celebrate **Brenda Cude, PhD**, a distinguished member of the Coalition’s Executive Committee, on receiving the highest honor from the UGA College of Family and Consumer Sciences, induction into its prestigious Honor Hall of Recognition. A Professor Emerita at the University of Georgia, Dr. Cude has shaped generations of students, advanced consumer economics research, and strengthened the college through decades of leadership, teaching, service, and outreach. Her work has had a lasting impact on the field of consumer and financial education nationwide. In her acceptance remarks, Dr. Cude reflected on the many individuals who helped shape her career and underscored the responsibility we all share to support and encourage others. As she noted, even the smallest act can influence the trajectory of someone’s life. The Coalition congratulates Dr. Cude on this well-earned and inspiring recognition and is proud to have her leadership and expertise represented on our Board. We invite you to watch the tribute video celebrating Dr. Cude’s extraordinary contributions to the UGA College of Family and Consumer Sciences and to the field of consumer economics. [Click here to watch](https://www.youtube.com/watch?v=jUQu9rK5Nlw). \| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/8aa8989f-0ac3-4d3c-80cf-8d0dbf8cadf3.jpg) \| \|---\| \| \|---\| \| \| **Social Discovery:** There are just two weeks left to register for our CE-accredited webinar for adjusters and claims professionals – From FNOL to Resolution: How Social Media Provides Insights at Each Stage. Click on the image below to register. \| \|---\| \| \|---\| \| \| [ ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/d7b9aade-8d45-e07c-d9bd-913741f335c4.png) ](https://share.hsforms.com/1aZWvPffpQwGm-tSqUoQ6fAc0z6w?utm_medium=email&_hsenc=p2ANqtz-98dzqbFkWjNfestin28pjhl5pTNtPENn-hvSd8E1Dsyo8JtkDvXBQPGiGStWcKK8cmKrb4T1X5rJbJrusKv4EFPJGm_W64FtlYOh-9heQLTPP6mEI&_hsmi=407197707&utm_content=407197707&utm_source=hs_email) \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/599cd350-ea52-4495-1186-5f4cf595e458.jpg) \| \|---\| \| \|---\| \| \| [ ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/26e4e97f-1c44-78b9-6f67-60c0aaf88dbc.jpg) ](https://members.insurancefraud.org/general/pick_username.asp) \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/092a75b2-e5e6-9838-8a25-790566e52b92.jpg) \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/9d9a163b-d608-c29e-1f8c-71c58f193f3a.jpg) \| \|---\| \| \|---\| \| \| - **March 10 –** [AFA Q1 2026 Training Webinar – Explosive Verdicts, Smarter Choices](https://register.gotowebinar.com/register/4537577188979207258) (AFA) - **March 11 –** [IME: Accelerating Claim Resolution](https://event.on24.com/wcc/r/5193660/641F34879FADE617C142AEB7DC56A45F) (Ethos) - **March 12 –** [Disability Within Workers’ Compensation Claims](https://register.gotowebinar.com/register/6643433326597261920?utm_campaign=345943266-CE%20Course%20Announcements&utm_source=email) (Allied Universal) - **March 17 March 19** – [Virtual Fraud Investigation Academy](https://www.nicb.org/news/events/virtual-fraud-investigations-academy) (NICB) - **March 23 – March 26 –** [Verisk Academy](https://events.verisk.com/event/VeriskAcademy/home?RefId=EC-Consideration&elq_cid=33592776&elq_mid=19745&rt=WUDwXBM8PUKk3EoCBebOKg&utm_campaign=vmc-brand-verisk_academy-2025-12-22&utm_content=consider-reservecta&utm_medium=email&utm_source=Eloqua) (Verisk) - **March 31** – [From FNOL to Resolution: How Social Media Provides Insights at Each Stage](https://share.hsforms.com/1aZWvPffpQwGm-tSqUoQ6fAc0z6w?utm_medium=email&_hsenc=p2ANqtz-_euiMs-z2Vk15ct4s-bMs4GZ786GAQ2hwKJT0QT5cm4Npo4E4yUiplmAkQdzOYWVcMd7s3Z73sybn9Ajb6mUEuj1Y3VzeF_JBeBt19Px8nBURCnLs&_hsmi=403228581&utm_content=403228581&utm_source=hs_email) (Social Discovery) - **April 13 – April 15 –** [NAMIC Claims Conference](https://www.namic.org/event/claims-conference/) (NAMIC) [Click here to view ](https://insurancefraud.org/anti-fraud-events/)[the full calendar of member events](https://insurancefraud.org/anti-fraud-events/)… \| \|---\| \| \|---\| \| \| [ ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/06c25334-a44b-83f1-621b-dbfc959b59ea.jpg) ](https://s.surveyplanet.com/bj1sw6en) \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/4b1136e8-4c9e-4d00-bc11-54758a3ea8a6.png) \| \|---\| \| \|---\| \| \|---\| \| \| \| **Follow Us On Our Social Media Platforms:** \| \| \|---\| \| \| [ ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/148b79cf-2c06-6469-b7c8-335c1c8b971a.jpg) ](https://insurancefraud.us1.list-manage.com/track/click?u=a440c5b647697de580a2fd586&id=5214c5e629&e=cf8d2cdb4f) \| \|---\| \| \|---\| \| \| [ ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/39ae0e7d-0388-20e5-5755-020aec6cf995.jpg) ](https://insurancefraud.us1.list-manage.com/track/click?u=a440c5b647697de580a2fd586&id=06da6de163&e=cf8d2cdb4f) \| \|---\| \| \|---\| \| \| [ ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/86c49df9-4380-51e5-da9c-f83034fc7555.jpg) ](https://insurancefraud.us1.list-manage.com/track/click?u=a440c5b647697de580a2fd586&id=b349097e98&e=cf8d2cdb4f) \| \|---\| \| \|---\| \| \| \| \|---\| \| \|---\| \| \| **Contact:** Phone: [202.393.7330](tel:2023937330) Email: [coalition](mailto:coalition@insurancefraud.org)[@insurancefraud.org](mailto:coalition@insurancefraud.org) Address: 1012 14th Street, NW Suite 610 Washington, DC 20005 [www.InsuranceFraud.org](http://www.insurancefraud.org/) Want to change how you receive these emails? You can [update your preferences](https://coalitionagainstinsurancefraud.mailchimpsites.com/manage/preferences?u=a440c5b647697de580a2fd586&id=b68dce7808&e=%5BUNIQID%5D&c=a3008fa3df) or [unsubscribe from this list](https://insurancefraud.us1.list-manage.com/unsubscribe?u=a440c5b647697de580a2fd586&id=b68dce7808&t=b&e=%5BUNIQID%5D&c=a3008fa3df). \| \|---\| \| \|---\| \| \|---\| | |:-:| <html><p class="wp-block-paragraph"></p> **Features:** Fraud News Weekly --- ### [Fraud News Weekly - February 20, 2026](https://insurancefraud.org/publications/fraud-news-weekly-february-20-2026/) **Published:** February 20, 2026 **Author:** Coalition Against Insurance Fraud **Content:** Fraud News Weekly (FNW) – February 20, 2026 | \| \| \|---\| \| \| \| [View this email in your browser](https://mailchi.mp/da779e1eadf8/fraud-news-weekly-fnw-february-20-2026?e=%5BUNIQID%5D) \| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/c7cc296d-8624-b0d5-67b5-3541f5c85a21.jpg) \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a417349b-dfdc-a052-790d-07cfde53b716.jpg) \| \|---\| \| \|---\| \| \| **Hawaii Senate Bill 2948 advances with insurance industry support and DCCA concerns on fraud enforcement tools.** Hawaii lawmakers are weighing sweeping updates to the state’s insurance fraud laws as the bill moves through the Senate Commerce and Consumer Protection Committee. Overall industry comments were supportive, suggesting consideration for amendment. The Department of Commerce and Consumer Affairs (DCCA) backs the intent but flagged overlap with existing statutes, sentencing thresholds, and implementation challenges. For fraud fighters, the debate underscores the need for strong but workable enforcement tools. During the committee meeting, the bill moved forward with recommendation to pass with amendments, including deleting the definitions of claims harvesting and post-loss assignment abuse. [Read more](https://www.capitol.hawaii.gov/session/measure_indiv.aspx?billtype=SB&billnumber=2948&year=2026)… **Washington insurance fraud modernization bill unanimously passes Senate and advances to House with Coalition support.** The Washington State Office of the Insurance Commissioner secured unanimous Senate approval of Senate Bill 6031 this week, a major step in modernizing the state’s insurance fraud framework. Championed by Commissioner Patty Kuderer, the bill creates a standalone felony offense for insurance fraud, updates authorities for the Criminal Investigations Unit first established in 2006, expands required fraud reporting, and broadens restitution to include consumers and beneficiaries. The Coalition gave testimony and submitted [comments](https://insurancefraud.org/wp-content/uploads/Coalition-Written-Testimony-in-Support-of-SB-6031.pdf) in support, underscoring the need for clear statutory tools to pursue complex fraud schemes that drive up costs for honest policyholders. The measure now moves to the Washington House of Representatives for consideration. [Read more](https://www.insurance.wa.gov/about-us/news/2026/insurance-fraud-modernization-bill-passes-state-senate)… **NAIC expands AI pilot to eleven states as regulators refine governance tool with fraud implications.** The Coalition attended a follow up meeting with the National Association of Insurance Commissioners (NAIC) [Big Data and Artificial Intelligence (H) Working Group](https://content.naic.org/committees/h/big-data-artificial-intelligence-wg), which finalized the version of the AI Systems Evaluation Tool to be used in a March through September pilot now expanded to eleven states, including Maryland and Louisiana. During the second call, regulators welcomed industry feedback and pledged coordination to limit duplicative requests. Pilot findings will inform revisions ahead of possible adoption at the Fall National Meeting. [Read more](https://content.naic.org/sites/default/files/call_materials/Pilot%20Project%20Summary.pdf)… \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/6bbcb403-e1c7-fb75-bb1a-d5bd83716791.jpg) \| \|---\| \| \|---\| \| \| **Florida Senator targets healthcare fraudsters, pushing tougher penalties** Florida Senator Ashley Moody is targeting health care fraudsters and pushing for tougher penalties to bring criminals to justice. The Republican Senator introduced her Punishing Health Care Fraudsters Act, legislation that will enhance harsher financial and criminal penalties for health care fraud. “For too long, the American taxpayer has been abused at the… [Read more](https://westorlandonews.com/florida-senator-targeting-health-care-fraudsters-pushing-tougher-penalties/)… **New Mexico House approves fund to pay for expired federal healthcare tax credits** The New Mexico House of Representatives quickly passed a bill that ensures the state will continue to have funding available to offset cuts to federal health care programs. House Bill 4 increases distributions into the state’s Healthcare Affordability Fund, which is generated through surcharges the state imposes on health insurance companies. House Democrats said the … [Read more](https://insurancenewsnet.com/oarticle/nm-house-approves-fund-to-pay-for-expired-federal-health-care-tax-credits)… **Emerging growth trends drive expansion in the insurance data lakehouse platforms market** The insurance industry is undergoing a significant transformation driven by advances in data management technologies. One of the most promising developments is the rise of insurance data lakehouse platforms, which combine the benefits of data lakes and data warehouses to enhance analytics and operational efficiency. This report explores the… [Read more](https://www.openpr.com/news/4392356/emerging-growth-trends-driving-expansion-in-the-insurance-data)… \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/5c344377-ec7c-90a1-73a3-c230d0a948a9.jpg) \| \|---\| \| \|---\| \| \| *Note: The arrest summaries included in the Coalition’s Fraud News Weekly are based on information from publicly available news sources. Individuals referenced in these reports are presumed innocent unless and until guilt is established in a court of law.* \| \|---\| \| \|---\| \| \| **HEALTHCARE** **February 14, Chicago – Fraud fighters score: Two indicted in $10M Chicago Medicare scam** Federal prosecutors have indicted 31-year-old Burhan Mirza and 48-year-old Kashif Iqbal for orchestrating a $10 million Medicare and private insurance fraud scheme through 2023 and 2024. The pair allegedly used nominee-owned laboratories and durable medical equipment providers to submit bogus claims for items and services that were never… [Read more](https://nationaltoday.com/us/tx/plano/news/2026/02/14/two-men-indicted-in-10m-chicago-medicare-fraud-scheme/)… **HEALTHCARE** **February 17, Pennsylvania – Accountability in motion: Masury fraud trial now in the hands of a jury** A federal jury is expected to begin deliberations today in the trial of a Masury man accused of taking part in a $2 million fraud scheme against a Sharon-based healthcare network. Closing arguments are scheduled for this morning in the case of John O’Brien. Prosecutors say O’Brien and four others defrauded the… [Read more](https://www.wfmj.com/story/53442107/masury-mans-fraud-trial-headed-to-the-jury)… **HEALTHCARE** **February 17, Missouri** **– Another scheme uncovered: Home healthcare owner admits over $200,000 fraud** The owner of a home healthcare company on Tuesday admitted defrauding the Missouri Medicaid Program and the U.S. Department of Veterans Affairs out of more than $209,000. Natavia Boyd-Wells, 41, pleaded guilty in U.S. District Court in St. Louis to… [Read more](https://www.justice.gov/usao-edmo/pr/local-home-healthcare-company-owner-admits-over-200000-fraud)… **HEALTHCARE** **February 17, Massachusetts** **–** **Accountability secured: AG Campbell wins guilty verdicts in Medicaid fraud and illegal practice case** After an eight-day jury trial, the Attorney General’s Office (AGO) has secured guilty verdicts against Fritz Gabriel, age 71, of Milton, in connection with a scheme to defraud MassHealth, the state’s Medicaid program, illegal prescribing and the… [Read more](https://www.mass.gov/news/ag-campbell-secures-guilty-verdicts-against-milton-man-for-the-unlicensed-practice-of-dentistry-illegal-prescribing-and-medicaid-fraud)… **AUTO** **February 17, New York** **– Fraud ring crippled: New York judge deals major blow to alleged staged crash scheme** An alleged insurance fraud ring in New York State has been shut down in its attempts to receive money from insurers after a New York Supreme Court judge issued a summary judgement last month against a group of defendants who… [Read more](https://www.roadandtrack.com/news/a70334000/alleged-staged-car-accident-insurance-fraud-ring-broken-up-new-york/)… **AUTO** **February 19, Idaho – Protecting policyholders: Two Idaho men sentenced in $200K insurance fraud scheme** The Idaho Department of Insurance (DOI) announced that two Idaho residents have pled guilty to insurance fraud in connection with a scheme to obtain coverage for three classic vehicles that were destroyed by… [Read more](https://doi.idaho.gov/pressrelease/idaho-cracks-down-on-insurance-fraud-two-idaho-men-sentenced-in-200k-scheme/)… \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/e04f063d-6836-b86d-4717-427e4a69a52d.jpg) \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/78213f90-606c-4c22-7f04-13a1d15f6ea9.jpg) \| \|---\| \| \|---\| \| \| Yesterday, over **700** professionals joined the Coalition webinar **“Exploited Lives, Exploited Systems: The Human Trafficking – Insurance Fraud Connection,”** exploring how transnational criminal networks exploit the insurance industry to fund human trafficking. **Michelle Rafeld, Executive Director of the Coalition,** opened the session, welcoming attendees and introducing Michael Skiba, widely known in the industry as **Dr. Fraud.** Michael then led participants through exclusive UN-level case studies and demonstrated how investigators successfully disrupted these dangerous fraud cycles. The webinar and its accompanying presentation will be available next week on the Coalition website under **Member Resources > Resources > Webinar and Podcasts.** Stay tuned for the announcement so you don’t miss access to these critical insights. The strong turnout underscores the Coalition’s commitment to equipping fraud fighters with actionable knowledge to protect both the industry and vulnerable populations. \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a4e430c0-c419-3044-1add-d368ddda9e22.jpg) \| \|---\| \| \|---\| \| \|---\| \| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7d31a033-3224-ca87-3b85-85c8baf6feac.png) \| \| \|---\| \| \| The Coalition is proud to welcome Plymouth Rock Assurance as our newest member. As a respected provider of personal and commercial insurance solutions, Plymouth Rock brings valuable industry expertise and a strong commitment to protecting policyholders. We are excited to collaborate with their team to strengthen fraud prevention efforts, share intelligence, and advance innovative strategies that safeguard consumers and the insurance marketplace. \| \|---\| \| \|---\| \| \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/599cd350-ea52-4495-1186-5f4cf595e458.jpg) \| \|---\| \| \|---\| \| \| [ ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/26e4e97f-1c44-78b9-6f67-60c0aaf88dbc.jpg) ](https://members.insurancefraud.org/general/pick_username.asp) \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/092a75b2-e5e6-9838-8a25-790566e52b92.jpg) \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/9d9a163b-d608-c29e-1f8c-71c58f193f3a.jpg) \| \|---\| \| \|---\| \| \| - **February 24 –** [Hitting Record: Empowering Claim Decisions with Surveillance Footage](https://frasco.zoom.us/webinar/register/8017660912424/WN_j8yYMMeOSkmoDblLdslfrQ#/registration) (Frasco) - **February 25 –** [OSINT Advantage: Uncovering Fraud with Open-Source Intelligence](https://event.on24.com/wcc/r/5126008/D98F452787F88A3EEF672B24D271F929) (Ethos) - **March 1 – March 4 –** [Insurance Fraud Management Conference](https://events.verisk.com/event/8d7e5635-89e2-4500-a65b-6044cf54ab9b/home?RefId=VeriskConferences&rt=WUDwXBM8PUKk3EoCBebOKg) (Verisk / NICB) - **March 4 – March 5 –** [NYSSIU Winter Conference](https://insurancefraud.org/event/nyssiu-winter-conference/) (NYSSIU) - **March 4 – March 6 –** [Enhancing Your Skills: Managing and Navigating Complex Investigations](https://www.nhcaa.org/events/enhancing-your-skills-managing-and-navigating-complex-investigations-2/) (NHCAA) - **March 10 –** [AFA Q1 2026 Training Webinar – Explosive Verdicts, Smarter Choices](https://register.gotowebinar.com/register/4537577188979207258) (AFA) - **March 17 March 19** – [Virtual Fraud Investigation Academy](https://www.nicb.org/news/events/virtual-fraud-investigations-academy) (NICB) - **March 23 – March 26 –** [Verisk Academy](https://events.verisk.com/event/VeriskAcademy/home?RefId=EC-Consideration&elq_cid=33592776&elq_mid=19745&rt=WUDwXBM8PUKk3EoCBebOKg&utm_campaign=vmc-brand-verisk_academy-2025-12-22&utm_content=consider-reservecta&utm_medium=email&utm_source=Eloqua) (Verisk) - **March 23 – March 26 –** [The Verisk Insurance Conference](https://events.verisk.com/event/VIC2025/home?RefId=VeriskConferences&rt=WUDwXBM8PUKk3EoCBebOKg) (Verisk) - **March 26 –** [Using AI to Fight Medicare Fraud – Updates from CMS and Center for Program Integrity](https://cahealthadvocates.org/event/using-ai-to-fight-medicare-fraud-updates-from-cms-and-center-for-program-integrity/) (California Health Advocates) - **March 31** – [From FNOL to Resolution: How Social Media Provides Insights at Each Stage](https://share.hsforms.com/1aZWvPffpQwGm-tSqUoQ6fAc0z6w?utm_medium=email&_hsenc=p2ANqtz-_euiMs-z2Vk15ct4s-bMs4GZ786GAQ2hwKJT0QT5cm4Npo4E4yUiplmAkQdzOYWVcMd7s3Z73sybn9Ajb6mUEuj1Y3VzeF_JBeBt19Px8nBURCnLs&_hsmi=403228581&utm_content=403228581&utm_source=hs_email) (Social Discovery) - **April 13 – April 15 –** [NAMIC Claims Conference](https://www.namic.org/event/claims-conference/) (NAMIC) [Click here to view ](https://insurancefraud.org/anti-fraud-events/)[the full calendar of member events](https://insurancefraud.org/anti-fraud-events/)… \| \|---\| \| \|---\| \| \| [ ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/06c25334-a44b-83f1-621b-dbfc959b59ea.jpg) ](https://s.surveyplanet.com/bj1sw6en) \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/4b1136e8-4c9e-4d00-bc11-54758a3ea8a6.png) \| \|---\| \| \|---\| \| \|---\| \| \| \| **Follow Us On Our Social Media Platforms:** \| \| \|---\| \| \| [ ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/148b79cf-2c06-6469-b7c8-335c1c8b971a.jpg) ](https://insurancefraud.us1.list-manage.com/track/click?u=a440c5b647697de580a2fd586&id=5214c5e629&e=cf8d2cdb4f) \| \|---\| \| \|---\| \| \| [ ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/39ae0e7d-0388-20e5-5755-020aec6cf995.jpg) ](https://insurancefraud.us1.list-manage.com/track/click?u=a440c5b647697de580a2fd586&id=06da6de163&e=cf8d2cdb4f) \| \|---\| \| \|---\| \| \| [ ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/86c49df9-4380-51e5-da9c-f83034fc7555.jpg) ](https://insurancefraud.us1.list-manage.com/track/click?u=a440c5b647697de580a2fd586&id=b349097e98&e=cf8d2cdb4f) \| \|---\| \| \|---\| \| \| \| \|---\| \| \|---\| \| \| **Contact:** Phone: [202.393.7330](tel:2023937330) Email: [coalition](mailto:coalition@insurancefraud.org)[@insurancefraud.org](mailto:coalition@insurancefraud.org) Address: 1012 14th Street, NW Suite 610 Washington, DC 20005 [www.InsuranceFraud.org](http://www.insurancefraud.org/) Want to change how you receive these emails? You can [update your preferences](https://coalitionfraud.mailchimpsites.com/manage/preferences?u=a440c5b647697de580a2fd586&id=b68dce7808&e=%5BUNIQID%5D&c=8b446f416e) or [unsubscribe from this list](https://insurancefraud.us1.list-manage.com/unsubscribe?u=a440c5b647697de580a2fd586&id=b68dce7808&t=b&e=%5BUNIQID%5D&c=8b446f416e). \| \|---\| \| \|---\| \| \|---\| | |:-:| <html><p class="wp-block-paragraph"></p> **Features:** Fraud News Weekly --- ### [Fraud News Weekly - February 13, 2026](https://insurancefraud.org/publications/fraud-news-weekly-february-13-2026/) **Published:** February 13, 2026 **Author:** Coalition Against Insurance Fraud **Content:** Fraud News Weekly (FNW) Friday, February 13, 2026 | \| \| \|---\| \| \| \| [View this email in your browser](https://mailchi.mp/430c7da27a2c/fraud-news-weekly-fnw-friday-february-13-2026?e=%5BUNIQID%5D) \| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/5fb2e70a-9290-99dc-a72c-130407bdc4c7.jpg) \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a417349b-dfdc-a052-790d-07cfde53b716.jpg) \| \|---\| \| \|---\| \| \| **State regulators advance efforts to pilot the examination of insurer use of artificial intelligence (AI) systems.** The Coalition attended the National Association of Insurance Commissioners (NAIC) Big Data and Artificial Intelligence Working Group meeting this week, where discussions continued on the AI Systems Evaluation Tool [draft](https://content.naic.org/sites/default/files/call_materials/Attachment-C.pdf) and a multi-state [pilot](https://content.naic.org/sites/default/files/call_materials/Pilot%20Project%20Summary.pdf) launching in March through September 2026. All pilot findings will remain confidential. Fraud detection is included in the tool and listed as part of insurers’ core operations. The goal is to collect information on current AI systems used by insurers and give regulators greater visibility into how AI affects claims handling, underwriting, and antifraud efforts. The tool may be refined with public comment before possible adoption at the Fall National Meeting. Regulators welcomed insurer feedback, and members participating in the pilot are encouraged to share fraud-specific insights with [brent@insurancefraud.org](http://brent@insurancefraud.org/), as promptly as possible. [Read more](https://content.naic.org/committees/h/big-data-artificial-intelligence-wg)… **The Texas Department of Insurance (TDI) will host an in-person Meet the Regulator event to introduce the newly appointed commissioner.** On Friday, February 20th, interested stakeholders, along with Coalition members, have an opportunity to engage directly with newly appointed Commissioner Amanda Crawford in Austin, TX, at the annual TDI Meet the Regulator event. Commissioner Crawford will kick off the event, and breakout sessions will include deputy commissioners and staff from Property and Casualty, Life and Health, Consumer Protection, and Financial Regulation. [Read more](https://content.govdelivery.com/accounts/TXINSUR/bulletins/40954c5)… **Colorado DOI seeks comment on the draft of an aerial imagery bulletin that may affect underwriting and claims investigations.** The Colorado Division of Insurance is seeking comments on a draft proposed new bulletin, which would outline the Division’s position on insurers’ use of aerial imagery in underwriting, pricing, and claims service. The guidance will shape how property and casualty insurers document decisions, support investigative findings, and communicate with policyholders when imagery is used. Comments are due by February 20, 2026, through the Division’s online submission portal. The draft and other proposals open for informal public comment are available on the Division’s website. [Read more](https://doi.colorado.gov/sites/doi/files/documents/DRAFT%20Proposed%20New%20Bulletin%20No.%20B-5.XX%20Concerning%20Use%20of%20Aerial%20Imagery%20by%20Insurers%20in%20Decision%20Making%20.pdf?utm_medium=email&utm_source=govdelivery)… \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/6bbcb403-e1c7-fb75-bb1a-d5bd83716791.jpg) \| \|---\| \| \|---\| \| \| **Facing Medicaid fraud allegations, California changes the subject** Dr. Mehmet Oz has been raising a stir over what he claims is rampant Medicaid fraud. The administrator of the Centers for Medicare and Medicaid Services alleges that California has spent an estimated $1.3 billion in federal funds providing coverage to… [Read more](https://www.forbes.com/sites/sallypipes/2026/02/09/facing-medicaid-fraud-allegations-california-changes-the-subject/)… **Louisiana Department of Health targets fraud with new internal watchdog role** The Louisiana Department of Health is expanding its internal watchdog role, with officials aiming to create closer oversight of how public money is spent and whether the agency’s programs are working as intended. As part of that effort, the department is establishing a chief accountability officer, a position officials said is modeled after the… [Read more](https://www.theadvocate.com/baton_rouge/news/louisiana-health-fraud-accountability-officer/article_fb56edac-e06a-567f-9f1e-05e445e1b625.amp.html)… **Sick of fighting insurers, hospitals offer their own Medicare Advantage plans** Ever since Larry Wilkewitz retired more than 20 years ago from a wood products company, he’s had a commercial Medicare Advantage plan from the insurer Humana. But two years ago, he heard about Peak Health, a new Advantage plan started by the West Virginia University Health System, where his doctors practice. It was cheaper and… [Read more](https://insurancenewsnet.com/oarticle/sick-of-fighting-insurers-hospitals-offer-their-own-medicare-advantage-plans)… \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/5c344377-ec7c-90a1-73a3-c230d0a948a9.jpg) \| \|---\| \| \|---\| \| \| *Note: The arrest summaries included in the Coalition’s Fraud News Weekly are based on information from publicly available news sources. Individuals referenced in these reports are presumed innocent unless and until guilt is established in a court of law.* \| \|---\| \| \|---\| \| \| **PROPERTY & CASUALTY February 8, Colorado** **– Broomfield murder case expands to include insurance fraud charges** Gregory Miles, accused of murdering his girlfriend and endangering officers and civilians in a shooting incident in Broomfield in 2024, also has been charged with insurance fraud and false reporting to authorities, according to a… [Read more](https://www.broomfieldenterprise.com/2026/02/08/man-accused-murdering-girlfriend-broomfield-shooting-fraud/)… **HEALTHCARE** **February 9, New York – Two Queens men charged with $120M adult day care and pharmacy fraud on Medicare and Medicaid** A complaint was unsealed in Brooklyn charging two Queens men with defrauding Medicare and Medicaid by paying illegal kickbacks and bribes and submitting claims for services that were never provided. “The defendants allegedly turned a pharmacy and social adult day care centers meant to help senior citizens into a $120 million dollar Medicare and… [Read more](https://www.justice.gov/opa/pr/two-queens-men-charged-120m-adult-day-care-and-pharmacy-fraud-medicare-and-medicaid)… **HEALTHCARE** **February 9, Florida – $197 Million healthcare fraud scheme targeting seniors and veterans ends in DOJ conviction** A federal jury in the Middle District of Florida recently convicted the owner of a marketing company for his role in a multiyear scheme to defraud Medicare and the Civilian Health and Medical Program of the Department of Veterans Affairs of nearly… [Read more](https://www.afslaw.com/perspectives/investigations-blog/doj-secures-conviction-197-million-health-care-fraud-scheme)… **PROPERTY & CASUALTY** **February 9, California – Serafini testimony highlights insurance fraud allegations and prior threat concerns** On day 3 of testimony at the Placer County Superior Courthouse in Auburn, the hearing for convicted killer Daniel Serafini saw the prosecution zeroing in on his credibility, character, and past conduct. Serafini was found guilty last July of ambushing and shooting his… [Read more](https://fox40.com/daniel-serafini-trial/daniel-serafini-questioned-about-past-threats-insurance-fraud-on-day-3-of-testimony/)… **AGENT MISCONDUCT** **February 9, Florida – Chief Financial Officer Blaise Ingoglia announces arrest of multiple state government employees for fraud** Chief Financial Officer Blaise Ingoglia announced the arrest of six individuals who defrauded the Florida taxpayers. These individuals orchestrated a scheme to process property damage claims through the Florida Division of Risk Management, allegedly defrauding the state of $1.7 million. The Florida Department of Financial Services Criminal… [Read more](https://myfloridacfo.com/news/pressreleases/press-release-details/2026/02/09/chief-financial-officer-blaise-ingoglia-announces-arrest-of-multiple-state-government-employees-for-fraud)… **HEALTHCARE** **February 10, Colorado – Federal indictments target separate nonemergent medical transportation fraud operations** The United States Attorney’s Office for the District of Colorado and the Colorado Attorney General’s Office announce that Ashley Marie Stevens, 40, of Mesa County, and Wesam Yassin, 42, of Douglas County, have been separately charged with defrauding Medicaid’s non-emergent medical transportation program. Stevens faces… [Read more](https://oig.hhs.gov/fraud/enforcement/federal-charges-filed-in-two-separate-cases-involving-non-emergent-medical-transportation-fraud/)… **HEALTHCARE** **February 11, New York –** **$120 million fraud scheme allegedly paid seniors to enroll in sham adult day care programs** Two Flushing men orchestrated a decade-long scheme that defrauded Medicare and Medicaid of roughly $120 million through adult day care centers and a pharmacy, federal prosecutors said. Inwoo Kim, 42, and Daniel Lee, 56, were each charged with conspiracy to commit health care fraud, a charge that carries a maximum sentence of… [Read more.](https://gothamist.com/news/feds-say-flushing-men-paid-seniors-cash-to-join-day-cares-then-billed-120m).. **IDENTITY THEFT February 11, Georgia – Court imposes federal prison term for bank fraud and aggravated identity theft** A Columbia County, Georgia woman was sentenced to federal prison for using stolen and counterfeit business checks to commit Bank Fraud and Aggravated Identity Theft. Dechanta Benning, 35, was sentenced to 70 months in prison, along with substantial financial penalties and five years of supervised release upon completion of any… [Read more](https://insurancenewsnet.com/oarticle/defendant-sentenced-to-federal-prison-for-bank-fraud-and-aggravated-identity-theft)… \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/e04f063d-6836-b86d-4717-427e4a69a52d.jpg) \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/ee3c53d3-9065-508f-fb92-648b44954c48.jpg) \| \|---\| \| \|---\| \| \| **New Co-chairs Announced** The Coalition is pleased to announce new leadership appointments across several committees and task forces. The newly appointed co-chairs will help guide strategic discussions and advance industry best practices across the Coalition’s membership.New leaders include: - Medical Fraud Task Force: [**Rob McGinley**](https://www.linkedin.com/in/robert-mcginley-918a01119/), Senior Manager, Financial Crimes Unit, PwC (joining co-chair Craig Koerner, Farmers Insurance) - Public Information Committee: [**Chris Sloan**](https://www.linkedin.com/in/christopher-sloan-081b193/), Executive Director, Pennsylvania Insurance Fraud Prevention Authority (joining co-chair Tom Donahue, Verisk) - Workers’ Compensation Task Force: [**Jenn Cunningham**](https://www.linkedin.com/in/jennifer-cunningham-7949a337/), Director of Special Investigations, Ohio Bureau of Workers’ Compensation (joining co-chair Gene Donnely, Zenith Insurance) A special thank you to these new leaders and to all who serve on the [Coalition’s committees and task forces](https://insurancefraud.org/committees/). \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a4e430c0-c419-3044-1add-d368ddda9e22.jpg) \| \|---\| \| \|---\| \| \|---\| \| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/d58a831b-4119-d4c2-075c-5c461f214258.jpg) \| \| \|---\| \| \| We are pleased to announce that Larmtjänst has joined the Coalition as our newest member, further strengthening our international network dedicated to combating insurance fraud. As a nonprofit subsidiary of Insurance Sweden, which represents more than 90 percent of Sweden’s insurance market, Larmtjänst plays a central role in addressing insurance-related crime. The organization gathers and analyzes industry intelligence, provides investigative support and forensic expertise, and serves as a key liaison between insurers and law enforcement at both the national and international levels. Through its work, Larmtjänst helps deter fraud, protect honest policyholders, and support a stable insurance marketplace. We look forward to partnering with their team to enhance cross-border collaboration and continue advancing the global fight against insurance fraud. \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/78c5ce69-a52f-df22-e1cc-d2afe0bb6ca3.jpg) \| \|---\| \| \|---\| \| \| [ ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/0d2921cd-b093-cfaa-d1cd-652912036674.jpg) ](https://us02web.zoom.us/webinar/register/WN_6iCq8cKxRySHQ09bIDwrBA#/registration) \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/599cd350-ea52-4495-1186-5f4cf595e458.jpg) \| \|---\| \| \|---\| \| \| [ ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/26e4e97f-1c44-78b9-6f67-60c0aaf88dbc.jpg) ](https://members.insurancefraud.org/general/pick_username.asp) \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/092a75b2-e5e6-9838-8a25-790566e52b92.jpg) \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/9d9a163b-d608-c29e-1f8c-71c58f193f3a.jpg) \| \|---\| \| \|---\| \| \| - **February 17 –** [Medical Canvassing ](https://go-command.zoom.us/webinar/register/WN_RlIc6Q6pScOzbMPH7oq7eA#/registration)(Command Investigations) - **February 24 –** [Hitting Record: Empowering Claim Decisions with Surveillance Footage](https://frasco.zoom.us/webinar/register/8017660912424/WN_j8yYMMeOSkmoDblLdslfrQ#/registration) (Frasco) - **February 25 –** [OSINT Advantage: Uncovering Fraud with Open-Source Intelligence](https://event.on24.com/wcc/r/5126008/D98F452787F88A3EEF672B24D271F929) (Ethos) - **March 1 – March 4 –** [Insurance Fraud Management Conference](https://events.verisk.com/event/8d7e5635-89e2-4500-a65b-6044cf54ab9b/home?RefId=VeriskConferences&rt=WUDwXBM8PUKk3EoCBebOKg) (Verisk / NICB) - **March 4 – March 5 –** [NYSSIU Winter Conference](https://insurancefraud.org/event/nyssiu-winter-conference/) - **March 4 – March 6 –** [Enhancing Your Skills: Managing and Navigating Complex Investigations](https://www.nhcaa.org/events/enhancing-your-skills-managing-and-navigating-complex-investigations-2/) (NHCAA) [Click here to view ](https://insurancefraud.org/anti-fraud-events/)[the full calendar of member events](https://insurancefraud.org/anti-fraud-events/)… \| \|---\| \| \|---\| \| \| [ ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/06c25334-a44b-83f1-621b-dbfc959b59ea.jpg) ](https://s.surveyplanet.com/bj1sw6en) \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/4b1136e8-4c9e-4d00-bc11-54758a3ea8a6.png) \| \|---\| \| \|---\| \| \|---\| \| \| \| **Follow Us On Our Social Media Platforms:** \| \| \|---\| \| \| [ ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/148b79cf-2c06-6469-b7c8-335c1c8b971a.jpg) ](https://insurancefraud.us1.list-manage.com/track/click?u=a440c5b647697de580a2fd586&id=5214c5e629&e=cf8d2cdb4f) \| \|---\| \| \|---\| \| \| [ ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/39ae0e7d-0388-20e5-5755-020aec6cf995.jpg) ](https://insurancefraud.us1.list-manage.com/track/click?u=a440c5b647697de580a2fd586&id=06da6de163&e=cf8d2cdb4f) \| \|---\| \| \|---\| \| \| [ ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/86c49df9-4380-51e5-da9c-f83034fc7555.jpg) ](https://insurancefraud.us1.list-manage.com/track/click?u=a440c5b647697de580a2fd586&id=b349097e98&e=cf8d2cdb4f) \| \|---\| \| \|---\| \| \| \| \|---\| \| \|---\| \| \| **Contact:** Phone: [202.393.7330](tel:2023937330) Email: [coalition](mailto:coalition@insurancefraud.org)[@insurancefraud.org](mailto:coalition@insurancefraud.org) Address: 1012 14th Street, NW Suite 610 Washington, DC 20005 [www.InsuranceFraud.org](http://www.insurancefraud.org/) Want to change how you receive these emails? You can [update your preferences](https://coalitionfraud.mailchimpsites.com/manage/preferences?u=a440c5b647697de580a2fd586&id=b68dce7808&e=%5BUNIQID%5D&c=48a96bd768) or [unsubscribe from this list](https://insurancefraud.us1.list-manage.com/unsubscribe?u=a440c5b647697de580a2fd586&id=b68dce7808&t=b&e=%5BUNIQID%5D&c=48a96bd768). \| \|---\| \| \|---\| \| \|---\| | |:-:| <html><p class="wp-block-paragraph"></p> **Features:** Fraud News Weekly --- ### [Fraud News Weekly - February 6, 2026](https://insurancefraud.org/publications/fraud-news-weekly-february-6-2026/) **Published:** February 6, 2026 **Author:** Coalition Against Insurance Fraud **Content:** Fraud News Weekly (FNW) – February 6, 2026 | \| \| \|---\| \| \| \| [View this email in your browser](https://mailchi.mp/47fc7d8f7bda/fraud-news-weekly-fnw-february-6-2026?e=%5BUNIQID%5D) \| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/88807270-2366-c1f8-f0c8-87128b17fe4e.jpg) \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a417349b-dfdc-a052-790d-07cfde53b716.jpg) \| \|---\| \| \|---\| \| \| **Colorado bill creates concern from Coalition members over limits on criminal restitution for insurers.** Coalition members and stakeholders are closely watching Colorado House Bill 1017, which would restrict criminal restitution for insurers, even when insurance fraud has occurred, and leave insurers reliant on civil actions to recover losses from it. Recent amendment efforts stalled after some lawmakers argued the language was too broad, raising fears that bad actors could avoid meaningful accountability. This approach risks weakening prosecutions, increasing litigation, and could encourage more fraudulent schemes. The Coalition is actively engaging partners and lawmakers ahead of this week’s second reading. [Read more](https://leg.colorado.gov/bills/HB26-1017)… **National Association of Insurance Commissioners (NAIC) announces 2026 consumer liaison representatives.** The NAIC recently announced its 2026 consumer liaison representatives through its Consumer Participation Program, a long-standing effort to ensure diverse consumer voices help shape state-based insurance regulation. This year’s roster includes 43 representatives, with 23 funded and 20 serving in an unfunded capacity, including the reappointment of Coalition Secretary Brenda Cude and Director of Government Relations Brent Walker. This role helps ensure insurance fraud risks, emerging schemes, and consumer protection priorities remain front and center in national regulatory discussions, aligning closely with the Coalition’s advocacy and legislative goals. [Read more](https://content.naic.org/article/naic-announces-2026-consumer-liaison-representatives)… **Washington bill to prohibit assignment of benefits (AOB) advances.** The Washington state Senate unanimously approved Senate Bill 6178 at the request of Insurance Commissioner Patty Kuderer, strengthening consumer protections and limiting post loss assignment of benefits agreements that have fueled fraud related overbilling, claim manipulation, and abusive contractor practices in disaster prone states. Kuderer said, “Disreputable contractors have shown up in storm-ravaged towns and pressure consumers to sign AOBs, and then take control of their claims with a focus on maximizing costs with no priority on making repairs and making the original policyholder whole.” The Coalition views this as a meaningful step to protect consumers and reinforce antifraud enforcement as the bill moves to the House. [Read more](https://www.insurance.wa.gov/about-us/news/2026/assignment-benefits-bill-unanimously-passes-washington-state-senate)… \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/6bbcb403-e1c7-fb75-bb1a-d5bd83716791.jpg) \| \|---\| \| \|---\| \| \| **Record-breaking U.S. DOJ year of settlements and judgments under the False Claims Act** At the same time that many members of Congress suggested that the Department of Justice (DOJ) has retreated from white collar enforcement, the DOJ announced that False Claims Act settlements and judgments reached a single-year record of… [Read more](https://www.jdsupra.com/legalnews/record-breaking-u-s-doj-year-of-8070785/)… **State-level long-term care trends to watch in 2026** State interest in long-term care continues. Washington state’s program moves forward, while Massachusetts is exploring statewide solutions. Overall, with the reduction of Medicaid funding to states slated to begin at the end of 2026, conversations around LTC are likely to… [Read more](https://insurancenewsnet.com/innarticle/state-level-trends-to-watch-in-2026)… **Insurance fraud detection market: Predictive modeling driving market momentum** Rising fraudulent claims, expanding digital insurance platforms, stricter regulatory requirements, and growing adoption of AI-driven analytics are accelerating demand for advanced, real-time insurance fraud detection solutions. According to IMARC Group’s latest research publication, global insurance fraud detection market size reached $5.58 Billion in… [Read more](https://vocal.media/futurism/insurance-fraud-detection-market-predictive-modeling-driving-market-momentum)… **Global dashboard camera market set to surge – A new tool against fraud** The global dashboard camera market is gaining momentum driven by rising concerns over road safety, increasing vehicle ownership, and growing adoption of dashcams for insurance claims and legal evidence. Technological advancements such as AI-enabled cameras, GPS integration, and cloud storage further fuel demand. However, data privacy… [Read more](https://www.prnewswire.co.uk/news-releases/global-dashboard-camera-market-poised-for-strong-growth-as-road-safety-awareness-and-insurance-adoption-accelerate-verified-market-research-302677527.html)… **LexisNexis risk solutions launches IDVerse for insurance as carriers confront AI-driven fraud** LexisNexis Risk Solutions has launched LexisNexis IDVerse for Insurance, positioning the offering as a packaged identity verification capability for U.S. insurers facing rising identity fraud and AI-enabled attack techniques. The company is pitching the product as a way to reduce fraud while supporting digital customer experiences that do not… [Read more](https://idtechwire.com/lexisnexis-risk-solutions-launches-idverse-for-insurance-as-carriers-confront-ai-driven-fraud/)… \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/5c344377-ec7c-90a1-73a3-c230d0a948a9.jpg) \| \|---\| \| \|---\| \| \| *Note: The arrest summaries included in the Coalition’s Fraud News Weekly are based on information from publicly available news sources. Individuals referenced in these reports are presumed innocent unless and until guilt is established in a court of law.* \| \|---\| \| \|---\| \| \| **STAGED AUTO** **January 31, Florida – Miami police foil staged auto accident scheme, four men charged with insurance fraud** Four men have found themselves on the wrong side of the law after staging a traffic accident in Miami, which turned out to be an elaborate fraud scheme, said the police. A keen-eyed detective from the Miami Police Real Time Crime Center, monitoring the city’s ever-watchful surveillance system, noticed the suspicious crash at the… [Read more](https://hoodline.com/2026/01/miami-police-foil-staged-auto-accident-scheme-four-men-charged-with-insurance-fraud/)… **HEALTHCARE** **February 2, Massachusetts** – **When treatment turns criminal: Counselor indicted in $850K MassHealth fraud** The Massachusetts Attorney General’s Office (AGO) announced that Rachel Pezzuto,49, of Peabody, and her two companies, Recovery Journey Service, Inc. (RJS) and RJ Recovery LLC (RJ Recovery), were indicted by a Statewide Grand Jury on multiple charges related to fraudulently billing MassHealth and MassHealth managed care entities (MCEs) for… [Read more](https://www.mass.gov/news/ags-office-secures-indictments-against-peabody-alcohol-and-drug-counselor-and-her-businesses-for-more-than-850000-in-masshealth-fraud)… **HEALTHCARE** **February 2, Connecticut – Unmasking a Medicaid fraud ring using doctor impersonation** Two Connecticut men have been arrested and charged in connection with a scheme to defraud the Medicaid program by impersonating a physician. Sultan Quraishi, 83, of Glastonbury, and owner of Silver Lane Medical Group and Stafford Medical Group, was arrested on January 22, and charged with Health Insurance Fraud in the… [Read more](https://portal.ct.gov/dcj/press-releases/division-of-criminal-justice/02022026silverlane?language=en_US)… **AGENT MISCONDUCT February 3, Louisiana** – **Commissioner Temple announces $1M in premium repayments and maximum fine for Metairie producer** Insurance Commissioner Tim Temple announced that Metairie surety bond producer Alexander Ellsworth and his agency, Ellsworth Corporation, will refund over $1.2 million in premium payments and pay a fine of $250,000 for fraudulently charging his customers fees in excess of the lawful premium quoted by their insurance companies. The $250,000 fine is the… [Read more](https://www.ldi.la.gov/news/press-releases/2-3-26-commissioner-temple-announces-$1m-in-premium-repayments-and-maximum-fine-for-metairie-producer)… **HEALTHCARE** **February 3, Texas** – **Feds allege $3.4 billion Medicare fraud scheme tied to Russian citizen living in Austin** Federal authorities say a Texas man helped orchestrate a health care fraud scheme that billed Medicare billions of dollars for medical equipment such as orthotic braces, glucose monitors, urinary catheters and wound dressings that patients often did not need and, in many cases, never received, according to a U.S. District Court criminal complaint uncovered… [Read more](https://www.kxan.com/investigations/feds-allege-3-4-billion-medicare-fraud-scheme-tied-to-russian-citizen-living-in-austin/)… **HEALTHCARE** **February 5, Washington – From the gridiron to a guilty verdict: Former NFL player convicted of healthcare fraud** A federal jury in the Middle District of Florida has convicted Joel Rufus French, Armory, Miss., the owner of a marketing company and a former NFL player, for his role in a yearslong scheme to bilk Medicare and the Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) out of nearly $200 million by selling patient information and… [Read more](https://www.hmenews.com/article/former-nfl-player-convicted-of-health-care-fraud)… **HEALTHCARE** **February 5, Washington – MultiCare agrees to $3.7 million settlement in neurosurgeon fraud case** MultiCare has agreed to pay $3.7 million to settle federal allegations that the healthcare system allowed a neurosurgeon to perform unnecessary spinal surgeries, the U.S. Attorney’s Office announced. The settlement involves Dr. Jason Dreyer, a formerly licensed neurosurgeon who worked at MultiCare from 2019 until his license was… [Read more](https://www.kxly.com/news/multicare-agrees-to-3-7-million-settlement-in-neurosurgeon-fraud-case/article_ff6fdc0e-282b-4f76-87b2-17631586223d.html)… \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/e04f063d-6836-b86d-4717-427e4a69a52d.jpg) \| \|---\| \| \|---\| \| \| The Coalition is pleased to announce the completion of a large project this week in the launch of a program specifically designed to bolster the fight against insurance fraud. **The Victim Impact Statement Program** delivers vital guidance and tools to assist victims of insurance fraud in preparing thorough and impactful victim impact letters for court proceedings. These letters can play a crucial role in giving victims of insurance fraud a voice and opportunity to educate the court about the financial harm and societal impact of insurance fraud. By considering the long-term consequences of the crime, courts are better equipped to administer justice that truly reflects the impact on the victim and the community. These [resources](https://insurancefraud.org/victim-impact-statement-program/) are available on the [Coalition’s website](https://insurancefraud.org/). **Insurers and government members:** Consider sharing these resources with your management, legal team, and investigators. \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/46832526-a5b5-7ae9-7c7b-1c5baf014081.png) \| \|---\| \| \|---\| \| \| ### **Student-Led Social Media Campaign Expands Insurance Fraud Education in Phase Two** Phase Two of the Coalition’s Social Media Competition is officially underway, with the first student-created posts live on the Coalition’s Instagram page, **@stopinsurancefraud**. Wayne State University marketing students are translating weekly educational themes into creative, peer-focused messaging designed to resonate with the next generation. This week’s theme invites audiences to consider what they could do with an extra $932 per year**,** the estimated annual cost of insurance fraud for every American. \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/9144f088-3f2c-7ef9-e722-25372b3204ab.png) \| \|---\| \| \|---\| \| \| The Coalition would like to thank Associate member **Carpe Data** for sponsoring Phase Two of the Social Media Competition and supporting this education and outreach initiative! \| \|---\| \| \|---\| \| \| [ ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/2b6bc1f1-4916-3ce9-13d8-9d8694dd9ef6.jpg) ](https://carpe.io/) \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a4e430c0-c419-3044-1add-d368ddda9e22.jpg) \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/092a6390-42db-9318-763a-b3fc6a0051a3.png) \| \|---\| \| \|---\| \| \| **Coalition Congratulates TDI Fraud Unit on Major Enforcement Milestone** The Coalition congratulates its member, the Texas Department of Insurance Fraud Unit, on its outstanding work, which contributed to $50.9 million in court-ordered restitution in fiscal year 2025. Through the efforts of more than 20 investigators statewide, TDI examined 314 insurance fraud cases, uncovering complex schemes, building strong cases, and supporting successful prosecutions that resulted in prison sentences, fines, and restitution for victims. One notable investigation led to prison time, a $10,000 fine, and restitution for a former Houston insurance agent who stole more than $318,000 from clients. This achievement reflects TDI’s continued commitment to protecting consumers and holding fraudsters accountable. The Coalition applauds TDI’s leadership and dedication in the fight against insurance fraud. [Read the Insurance Journal article](https://www.insurancejournal.com/news/southcentral/2026/01/30/856357.htm)… \| \|---\| \| \|---\| \| \|---\| \| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/78c5ce69-a52f-df22-e1cc-d2afe0bb6ca3.jpg) \| \| \|---\| \| \| [ ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/5c61f510-0b1d-f7f2-cce1-e6d7160e18ce.jpg) ](https://us02web.zoom.us/webinar/register/WN_6iCq8cKxRySHQ09bIDwrBA#/registration) \| \|---\| \| \|---\| \| \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/599cd350-ea52-4495-1186-5f4cf595e458.jpg) \| \|---\| \| \|---\| \| \| [ ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/26e4e97f-1c44-78b9-6f67-60c0aaf88dbc.jpg) ](https://members.insurancefraud.org/general/pick_username.asp) \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/092a75b2-e5e6-9838-8a25-790566e52b92.jpg) \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/9d9a163b-d608-c29e-1f8c-71c58f193f3a.jpg) \| \|---\| \| \|---\| \| \| - **February 11 –** [Earn CE Credit – Utilization Review 101](https://event.on24.com/wcc/r/5126000/3BB6C292E6E7FB09E532B66DFFE579BA) (Ethos) - **February 17 –** [Medical Canvassing ](https://go-command.zoom.us/webinar/register/WN_RlIc6Q6pScOzbMPH7oq7eA#/registration) (Command Investigations) - **February 24 –** [Hitting Record: Empowering Claim Decisions with Surveillance Footage](https://frasco.zoom.us/webinar/register/8017660912424/WN_j8yYMMeOSkmoDblLdslfrQ#/registration) (Frasco) - **February 25 –** [OSINT Advantage: Uncovering Fraud with Open-Source Intelligence](https://event.on24.com/wcc/r/5126008/D98F452787F88A3EEF672B24D271F929) (Ethos) - **March 1 – March 4 –** [Insurance Fraud Management Conference](https://events.verisk.com/event/8d7e5635-89e2-4500-a65b-6044cf54ab9b/home?RefId=VeriskConferences&rt=WUDwXBM8PUKk3EoCBebOKg) (Verisk / NICB) - **March 4 – March 5 –** [NYSSIU Winter Conference](https://insurancefraud.org/event/nyssiu-winter-conference/) [Click here to view ](https://insurancefraud.org/anti-fraud-events/)[the full calendar of member events](https://insurancefraud.org/anti-fraud-events/)… \| \|---\| \| \|---\| \| \| [ ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/06c25334-a44b-83f1-621b-dbfc959b59ea.jpg) ](https://s.surveyplanet.com/bj1sw6en) \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/4b1136e8-4c9e-4d00-bc11-54758a3ea8a6.png) \| \|---\| \| \|---\| \| \|---\| \| \| \| **Follow Us On Our Social Media Platforms:** \| \| \|---\| \| \| [ ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/148b79cf-2c06-6469-b7c8-335c1c8b971a.jpg) ](https://insurancefraud.us1.list-manage.com/track/click?u=a440c5b647697de580a2fd586&id=5214c5e629&e=cf8d2cdb4f) \| \|---\| \| \|---\| \| \| [ ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/39ae0e7d-0388-20e5-5755-020aec6cf995.jpg) ](https://insurancefraud.us1.list-manage.com/track/click?u=a440c5b647697de580a2fd586&id=06da6de163&e=cf8d2cdb4f) \| \|---\| \| \|---\| \| \| [ ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/86c49df9-4380-51e5-da9c-f83034fc7555.jpg) ](https://insurancefraud.us1.list-manage.com/track/click?u=a440c5b647697de580a2fd586&id=b349097e98&e=cf8d2cdb4f) \| \|---\| \| \|---\| \| \| \| \|---\| \| \|---\| \| \| **Contact:** Phone: [202.393.7330](tel:2023937330) Email: [coalition](mailto:coalition@insurancefraud.org)[@insurancefraud.org](mailto:coalition@insurancefraud.org) Address: 1012 14th Street, NW Suite 610 Washington, DC 20005 [www.InsuranceFraud.org](http://www.insurancefraud.org/) Want to change how you receive these emails? You can [update your preferences](https://coalitionfraud.mailchimpsites.com/manage/preferences?u=a440c5b647697de580a2fd586&id=b68dce7808&e=%5BUNIQID%5D&c=911e464174) or [unsubscribe from this list](https://insurancefraud.us1.list-manage.com/unsubscribe?u=a440c5b647697de580a2fd586&id=b68dce7808&t=b&e=%5BUNIQID%5D&c=911e464174). \| \|---\| \| \|---\| \| \|---\| | |:-:| <html><p class="wp-block-paragraph"></p> **Features:** Fraud News Weekly --- ### [Fraud News Weekly - January 30, 2026](https://insurancefraud.org/publications/fraud-news-weekly-january-30-2026/) **Published:** January 30, 2026 **Author:** Coalition Against Insurance Fraud **Content:** Fraud News Weekly (FNW) Friday, January 30, 2026 | \| \| \|---\| \| \| \| [View this email in your browser](https://mailchi.mp/7927c7bbdb26/fraud-news-weekly-fnw-friday-january-30-2026?e=%5BUNIQID%5D) \| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/c06429c2-fc37-1754-4f48-85e5b3d1c0cd.jpg) \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a417349b-dfdc-a052-790d-07cfde53b716.jpg) \| \|---\| \| \|---\| \| \| **The Coalition is tracking a Hawaii bill that introduces new legal definitions to problematic fraud schemes.** Hawaii [Senate Bill 2948](https://www.capitol.hawaii.gov/sessions/session2026/bills/SB2948_.HTM) seems to be a legislative response to recent post-disaster abuses and fraud schemes. The Bill appears to be the first attempt to define both “claim harvesting” and “litigation-related insurance fraud” in statute. Specifically, the Bill targets deceptive solicitation of claims through the use of runners, call centers, social media campaigns, or other disaster-response canvassing. It also prohibits the initiation, financing, support of, or maintaining litigation tied to false information or inflated losses. Additionally, if passed, it will also provide good-faith immunity for fraud reporting and equip the Hawaii Insurance Division’s [Insurance Fraud Investigation Branch](https://cca.hawaii.gov/ins/about/insurance_branches/#insurance_fraud) with fraud analytics to help them identify patterns, anomalies, and indicators of insurance fraud. The Coalition is tracking this bill closely and will engage local stakeholders. [Read the bill](https://www.capitol.hawaii.gov/session/measure_indiv.aspx?billtype=SB&billnumber=2948&year=2026)… **States continue to regulate artificial intelligence (AI) regulation despite a federal executive order.** State lawmakers continue advancing artificial intelligence legislation despite President Trump’s December 2025 [Executive Order](https://www.whitehouse.gov/presidential-actions/2025/12/eliminating-state-law-obstruction-of-national-artificial-intelligence-policy/) seeking to limit state authority and promote federal preemption. Recent reporting shows that more than 150 bills related to AI have been prefiled or introduced in 19 states. A couple of the 2026 bills are aimed at ensuring humans, and not AI, are responsible for denying insurance claims. Florida’s House Bill 527 would require human review of claim denials and limit AI-driven claim decisions, while New Hampshire House Bill 1406 would prohibit health carriers from using AI to override the clinical judgment of medical providers. Other noteworthy AI bills include: Missouri House Bill 1747, creating civil liability for undisclosed AI-generated or modified content; Missouri Senate Bill 1395, addressing unauthorized legal practice using AI, and New Mexico House Bill 28, requiring appeals for significant AI-driven decisions. [Read more](https://www.lexisnexis.com/community/insights/legal/capitol-journal/b/state-net/posts/states-continue-to-focus-on-ai-early-in-2026)… **Coalition member feedback is helping to strengthen and modernize online insurance fraud reporting data.** The Antifraud Technology Working Group of the National Association of Insurance Commissioners (NAIC) is advancing updates to the Online Fraud Reporting System (OFRS) with input from the Coalition and key antifraud partners. This effort will improve the ability to collect, standardize, analyze, and share high-quality fraud data nationwide and aligns with the NAIC Antifraud Task Force’s 2026 charges to coordinate activities among fraud bureaus, the insurance industry, and national partners such as NICB. At the Working Group’s request, the Coalition gathered frontline input from its members in an effort to remove seldom-used OFRS data categories, consolidate duplicative ones, and propose new categories to reflect emerging areas of fraud. The Coalition applauds this collaborative approach, which will enhance referrals, trend analysis, and enforcement outcomes for fraud fighters nationwide. [Read more](https://content.naic.org/sites/default/files/national_meeting/17_Minutes-AFTF_0.pdf)… \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/6bbcb403-e1c7-fb75-bb1a-d5bd83716791.jpg) \| \|---\| \| \|---\| \| \| **Around the nation: Healthcare fraud settlements hit $5.7B in 2025** According to the Department of Justice (DOJ), healthcare fraud settlements under the False Claims Act (FCA) reached $5.7 billion in fiscal year 2025, the… [Read more](https://www.advisory.com/daily-briefing/2026/01/28/around-the-nation)… **Attorney General Jeff Jackson announces $8.8 million healthcare fraud settlement** Attorney General Jeff Jackson announced Bethany Medical Center, P.A., a medical group with several locations in North Carolina, and its founder, Lenin Peters, M.D. have paid $8,828,890 to resolve allegations that they violated the… [Read more](https://ncdoj.gov/attorney-general-jeff-jackson-announces-8-8-million-health-care-fraud-settlement/)… **DOJ will create a National Fraud Enforcement Division** This month the White House announced that the United States Department of Justice (DOJ) will establish a new National Fraud Enforcement Division. The White House’s [Fact Sheet](https://www.whitehouse.gov/fact-sheets/2026/01/fact-sheet-president-donald-j-trump-establishes-new-department-of-justice-division-for-national-fraud-enforcement/) regarding the initiative reveals a… [Read more](https://www.reedsmith.com/our-insights/blogs/health-industry-washington-watch/102mdjy/doj-will-create-a-national-fraud-enforcement-division/)… \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/5c344377-ec7c-90a1-73a3-c230d0a948a9.jpg) \| \|---\| \| \|---\| \| \| *Note: The arrest summaries included in the Coalition’s Fraud News Weekly are based on information from publicly available news sources. Individuals referenced in these reports are presumed innocent unless and until guilt is established in a court of law.* \| \|---\| \| \|---\| \| \| **MEDICAID / MEDICARE** **January 26, New Jersey – Healthcare fraud charges filed against two women for allegedly providing illegal medical services** Acting Attorney General Jennifer Davenport, the Division of Criminal Justice (DCJ), and the Office of the Insurance Fraud Prosecutor (OIFP) announced today that the owner of a health center and one of her employees have been… [Read more](https://www.njoag.gov/two-women-charged-with-health-care-fraud-for-allegedly-illegally-providing-medical-services/)… **MEDICAID / MEDICARE** **January 26, Oregon – Forced labor and healthcare fraud at center of charges against Oregon mother and daughter** A grand jury in Oregon yesterday returned a superseding indictment charging a mother and daughter from Tigard, Oregon, with 12-counts of conspiracy to commit health care fraud and forced labor. The indictment alleges that… [Read more](https://www.justice.gov/opa/pr/oregon-mother-and-daughter-facing-new-charges-related-forced-labor-and-health-care-fraud)… **FRAUD GENERAL** **January 26, New York – RICO action filed as Merchants Insurance Group targets large-scale fraud in New York** Merchants Insurance Group (Merchants Mutual Insurance Company), headquartered in Buffalo, New York, has filed a federal civil action under the Racketeer Influenced and Corrupt Organizations Act (RICO) to expose and stop an… [Read more](https://finance.yahoo.com/news/merchants-insurance-group-files-rico-155600844.html)… **IDENTITY THEFT** **January 27, Michigan –** **Justice served: Fake nurse sentenced to 75 months for healthcare fraud** Grand Rapids, MI., – U.S. Attorney for the Western District of Michigan Timothy VerHey today announced that Leticia Gallarzo, age 51, formerly of Wayland, Michigan, was sentenced yesterday to 75 months in prison for… [Read more](https://www.justice.gov/usao-wdmi/pr/2026_0127_Gallarzo_Sentencing_PR)… **PROPERTY & CASUALTY** **January 28, Alabama – From trusted dentist to criminal charges: Insurance fraud case tied to 2025 office explosion** In March of 2025 a well-known dentist’s office exploded in the town of Evergreen, Alabama, near the Florida line. Today, the owner of that office, a dentist described as “very successful” and a “very nice guy,” is in jail, charged with arson and… [Read more](https://www.insurancejournal.com/news/southeast/2026/01/28/855897.htm)… **PROPERTY & CASUALTY** **January 28, Ohio – Willoughby Hills man sentenced after burning five homes in insurance fraud scheme** A Willoughby Hills man was sentenced to more than four years in prison for burning down five homes in a $2.3 million insurance fraud scheme. Lonnie White, 48, and his wife conspired to buy rental properties, transfer them to someone else and… [Read more](https://www.cleveland.com/court-justice/2026/01/willoughby-hills-man-sentenced-for-burning-5-homes-in-insurance-fraud.html)… **MEDICAID / MEDICARE** **January 28, Florida – Justice delivered as repeat offender is sentenced for New Hampshire Medicaid fraud** A Florida man was sentenced today to one year and one day in prison for causing psychotherapy sessions to be fraudulently billed to New Hampshire Medicaid. According to court documents, Erik X. Alonso, 55, of Miami, Florida, was convicted in… [Read more](https://www.justice.gov/usao-nh/pr/repeat-health-care-fraud-offender-sentenced-defrauding-new-hampshire-medicaid)… **MEDICAID / MEDICARE January 28, Louisiana – Slidell chiropractor sentenced for healthcare fraud** John Dennis Michael Peyroux, age 58, of Slidell, Louisiana, was sentenced on January 26, 2026 by U.S. District Judge Lance M. Africk for conspiracy to commit healthcare fraud, in violation of 18 U.S.C. §§ 1347 and 1349, in connection with a scheme to bill Medicare… [Read more](https://www.justice.gov/usao-edla/pr/slidell-chiropractor-sentenced-health-care-fraud)… **HEALTHCARE** **January 29, Massachusetts – Guilty verdict: Doctor convicted in IRS and healthcare fraud scheme** A federal jury in Boston, Massachusetts, convicted a medical doctor Tuesday for health care fraud, money laundering, conspiracy to defraud the IRS, and tax evasion. “Over ten years, the defendant hid millions in income from the IRS and… [Read more](https://www.justice.gov/opa/pr/doctor-convicted-trial-defrauding-irs-and-health-care-insurers)… \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a4e430c0-c419-3044-1add-d368ddda9e22.jpg) \| \|---\| \| \|---\| \| \|---\| \| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/97a2a777-b50a-f38e-2360-84fe70c91481.png) \| \| \|---\| \| \| ### The Coalition applauds the California Department of Insurance on 90 years of fighting insurance fraud. The Coalition Against Insurance Fraud is proud to congratulate one of its valued members, the California Department of Insurance, on marking 90 years of protecting consumers and combating insurance fraud. For nearly a century, the Department’s Investigation Division has served as a front-line defender in the nation’s largest insurance market by investigating insurance fraud, unlicensed insurance activity, and misconduct by insurance agents, claims adjusters, and other licensed professionals. Its work protects consumers during everyday insurance transactions and during disasters, when policyholders are often most vulnerable to fraud and abuse. Under the leadership of Insurance Commissioner Ricardo Lara, investigators continue to deliver strong results that safeguard consumers and uphold the integrity of California’s insurance marketplace. Following major disasters, investigators have swiftly taken action against bad actors targeting victims, while also working directly in affected communities to educate consumers and deter fraud. During recent wildfire recovery efforts in Pacific Palisades, Topanga, and Malibu, investigators assisted claims adjusters in safely accessing restricted areas and expedited insurance payments to survivors. These efforts supported more than 22.4 billion dollars in insurance payments and advanced more than 160 claims across hundreds of impacted properties. As the Department enters its tenth decade of service, this milestone reflects a legacy of enforcement, consumer protection, and public trust. The Coalition congratulates Commissioner Ricardo Lara and the entire California Department of Insurance team on this remarkable achievement. Read more in the California Department of Insurance’s full [press release](https://www.insurance.ca.gov/0400-news/0100-press-releases/2026/release003-2026.cfm) highlighting the 90-year milestone. \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/78c5ce69-a52f-df22-e1cc-d2afe0bb6ca3.jpg) \| \|---\| \| \|---\| \| \| [ ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/5c61f510-0b1d-f7f2-cce1-e6d7160e18ce.jpg) ](https://us02web.zoom.us/webinar/register/WN_6iCq8cKxRySHQ09bIDwrBA#/registration) \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/599cd350-ea52-4495-1186-5f4cf595e458.jpg) \| \|---\| \| \|---\| \| \| [ ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/26e4e97f-1c44-78b9-6f67-60c0aaf88dbc.jpg) ](https://members.insurancefraud.org/general/pick_username.asp) \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/092a75b2-e5e6-9838-8a25-790566e52b92.jpg) \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/9d9a163b-d608-c29e-1f8c-71c58f193f3a.jpg) \| \|---\| \| \|---\| \| \| - **February 11 –** [Earn CE Credit – Utilization Review 101](https://event.on24.com/wcc/r/5126000/3BB6C292E6E7FB09E532B66DFFE579BA) (Ethos) - **February 17 –** [Medical Canvassing ](https://go-command.zoom.us/webinar/register/WN_RlIc6Q6pScOzbMPH7oq7eA#/registration)(Command Investigations) - **February 24 –** [Hitting Record: Empowering Claim Decisions with Surveillance Footage](https://frasco.zoom.us/webinar/register/8017660912424/WN_j8yYMMeOSkmoDblLdslfrQ#/registration) (Frasco) - **February 25 –** [OSINT Advantage: Uncovering Fraud with Open-Source Intelligence](https://event.on24.com/wcc/r/5126008/D98F452787F88A3EEF672B24D271F929) (Ethos) - **March 1 – March 4 –** [Insurance Fraud Management Conference](https://events.verisk.com/event/8d7e5635-89e2-4500-a65b-6044cf54ab9b/home?RefId=VeriskConferences&rt=WUDwXBM8PUKk3EoCBebOKg) (Verisk / NICB) - **March 4 – March 5 –** [NYSSIU Winter Conference](https://nyssiu.org/meetings/) \| \|---\| \| \|---\| \| \| [ ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/06c25334-a44b-83f1-621b-dbfc959b59ea.jpg) ](https://s.surveyplanet.com/bj1sw6en) \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/4b1136e8-4c9e-4d00-bc11-54758a3ea8a6.png) \| \|---\| \| \|---\| \| \|---\| \| \| \| **Follow Us On Our Social Media Platforms:** \| \| \|---\| \| \| [ ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/148b79cf-2c06-6469-b7c8-335c1c8b971a.jpg) ](https://insurancefraud.us1.list-manage.com/track/click?u=a440c5b647697de580a2fd586&id=5214c5e629&e=cf8d2cdb4f) \| \|---\| \| \|---\| \| \| [ ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/39ae0e7d-0388-20e5-5755-020aec6cf995.jpg) ](https://insurancefraud.us1.list-manage.com/track/click?u=a440c5b647697de580a2fd586&id=06da6de163&e=cf8d2cdb4f) \| \|---\| \| \|---\| \| \| [ ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/86c49df9-4380-51e5-da9c-f83034fc7555.jpg) ](https://insurancefraud.us1.list-manage.com/track/click?u=a440c5b647697de580a2fd586&id=b349097e98&e=cf8d2cdb4f) \| \|---\| \| \|---\| \| \| \| \|---\| \| \|---\| \| \| **Contact:** Phone: [202.393.7330](tel:2023937330) Email: [coalition](mailto:coalition@insurancefraud.org)[@insurancefraud.org](mailto:coalition@insurancefraud.org) Address: 1012 14th Street, NW Suite 610 Washington, DC 20005 [www.InsuranceFraud.org](http://www.insurancefraud.org/) Want to change how you receive these emails? You can [update your preferences](https://coalitionfraud.mailchimpsites.com/manage/preferences?u=a440c5b647697de580a2fd586&id=b68dce7808&e=%5BUNIQID%5D&c=b496a50d92) or [unsubscribe from this list](https://insurancefraud.us1.list-manage.com/unsubscribe?u=a440c5b647697de580a2fd586&id=b68dce7808&t=b&e=%5BUNIQID%5D&c=b496a50d92). \| \|---\| \| \|---\| \| \|---\| | |:-:| <html><p class="wp-block-paragraph"></p> **Features:** Fraud News Weekly --- ### [Fraud News Weekly - January 23, 2026](https://insurancefraud.org/publications/fraud-news-weekly-january-23-2026/) **Published:** January 24, 2026 **Author:** Coalition Against Insurance Fraud **Content:** Fraud News Weekly (FNW) Friday, January, 23, 2026 | \| \| \|---\| \| \| \| [View this email in your browser](https://mailchi.mp/ae9115e625ee/fraud-news-weekly-fnw-friday-january-23-2026?e=%5BUNIQID%5D) \| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/82529a22-8054-f128-3a0e-0ed2a5a8728e.jpg) \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a417349b-dfdc-a052-790d-07cfde53b716.jpg) \| \|---\| \| \|---\| \| \| **The Coalition attends an event with New York Governor Hochul outlining her 2026 anti-fraud measures ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a2aee690-0711-8658-e73c-cd4af76ec2a0.jpg)** Coalition Against Insurance Fraud General Counsel Kate Gordon was invited to attend a New York event with Governor Kathy Hochul to highlight the [Executive Budget for Fiscal Year 2027](https://www.governor.ny.gov/sites/default/files/2026-01/FY2027ExecutiveBudgetBook.pdf). The invitation signals meaningful recognition of the Coalition’s role as a trusted, credible voice on insurance fraud policy. The budget’s antifraud provisions include $2 million for State Police to investigate auto insurance fraud, $17 million to fund dedicated workers’ compensation fraud units through district attorneys, and new criminal penalties for staged accidents. In the Governor’s press release, Coalition Against Insurance Fraud Executive Director Michelle Rafeld was quoted, *“When fraud goes unchecked, consumers pay the price through higher insurance premiums. Governor Hochul’s plan recognizes that staged crashes and organized fraud schemes hurt families and businesses across New York. The Coalition Against Insurance Fraud has long supported strengthening the prosecution of staged accidents in New York. The Coalition applauds Governor Hochul’s proposal to pursue legislation targeting individuals who organize staged accidents. It is not only a cost-saving antifraud measure but also a life-saving effort that will protect honest drivers.”* This engagement strengthens the Coalition’s advocacy posture, aligning with its [2026 Legislative Priorities](https://insurancefraud.org/legislative-priorities/), and helps ensure antifraud investments remain focused on protecting consumers, honest businesses, and the insurance system from escalating fraud-driven costs. [Read more](https://www.governor.ny.gov/news/money-your-pockets-governor-hochul-highlights-proposals-bring-down-costs-vehicle-insurance)… **Coalition provides testimony in support of Washington’s anti-fraud bill ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/64e2cdcd-fbcf-375b-67ce-4685688d33ce.jpg)** The Coalition Against Insurance Fraud has endorsed Senate Bill 6031, praising it as a significant step to strengthen Washington’s ability to combat insurance fraud. The legislation seeks to elevate insurance fraud to a felony, expand prosecutorial powers, clarify venue and statute of limitations, and increase the Insurance Commissioner’s authority to share information. The bill also aims to enhance the Criminal Investigations Unit by adding financial and digital specialists to address increasingly sophisticated fraud schemes such as identity theft, premium fraud, medical billing fraud, and appraisal manipulation. Coalition Director of Government Relations Brent Walker [testified this week](https://app.leg.wa.gov/committeeschedules#/Senate/29195/01-21-2026/01-21-2026/Schedule///Bill/) before the Washington State Senate Committee on Business, Trade & Economic Development in support of the bill. The Committee has now scheduled the bill for its executive session next week. The Coalition views this effort as a forward-looking model that will protect consumers and insurers while enhancing enforcement tools. [Read the bill](https://lawfilesext.leg.wa.gov/biennium/2025-26/Pdf/Bills/Senate%20Bills/6031.pdf?q=20260121145034)… **Kentucky and Texas state fraud bureaus share updates during insurance fraud meetings** This week, the Coalition attended and gave presentations at the Kentucky Insurance Fraud Council (KIFC), hosted virtually by the [Insurance Institute of Kentucky](https://iiky.org/), along with the Texas Committee on Insurance Fraud (TCIF), hosted in Austin, TX by the [Insurance Council of Texas](https://www.insurancecouncil.org/). The Kentucky Department of Insurance’s Division of Insurance Fraud Investigation shared 2025 statistics, highlighting that fraud referrals in the Bluegrass State continue to rise year over year. The Texas Department of Insurance’s Fraud Unit also gave updates and, similar to Kentucky, reported a continued rise in suspected fraud referrals. Coalition Director of Government Relations Brent Walker briefed KIFC members on 2026 antifraud regulatory and legislative advocacy priorities and updates to the Coalition’s [Amicus Curiae Program](https://insurancefraud.org/amicus-program/). At TCIF, Walker expanded on the Coalition and PwC [research](https://insurancefraud.org/wp-content/uploads/2025-Generative-AI-Study.pdf) examining the use of generative AI in the insurance fraud ecosystem, an emerging risk area for fraud fighters nationwide. **Arizona Department of Insurance and Financial Institutions welcomes new director** Charles Bassett has been appointed by Arizona Governor Hobbs as the new director of the Arizona Department of Insurance and Financial Institutions ([DIFI](https://difi.az.gov/)). Bringing over 30 years of expertise in insurance law and healthcare policy, Bassett previously served as Vice President of Government Relations and Public Policy at Blue Cross Blue Shield of Arizona. His experience managing legislative affairs and advising on regulatory issues positions him to strengthen Arizona’s insurance oversight, including anti-fraud efforts. The Coalition Against Insurance Fraud looks forward to partnering with Director Bassett to advance consumer protections and enhance fraud enforcement in the Grand Canyon State. [Read more](https://difi.az.gov/announcementnews/arizona-department-insurance-and-financial-institutions-welcomes-new-director)… \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/6bbcb403-e1c7-fb75-bb1a-d5bd83716791.jpg) \| \|---\| \| \|---\| \| \| **The Coalition unveils its 2025 Hall of Shame** This week the Coalition shared its [2025 Hall of Shame](https://insurancefraud.org/wp-content/uploads/Press-Release-Hall-of-Shame-2025-.pdf) with selected media organizations, highlighting 12 of the most egregious insurance fraud cases from across the United States. The annual Hall of Shame shines a spotlight on schemes that exploited insurance systems, endangered lives, and defrauded insurers and policyholders, while underscoring the serious consequences of fraud. By distributing the release to the media, the Coalition aims to educate the public, inform policymakers and industry leaders, and encourage the reporting of suspicious activity to help protect consumers and strengthen the integrity of the insurance system. **Virginia State Police warn of surge in staged crashes and auto insurance fraud** Virginia State Police says auto insurance fraud tied to staged crashes and fabricated claims is rising fast, as more individuals attempt to extract quick payouts from insurers. The trend shows up clearly in… [Read more](https://beinsure.com/news/virginia-state-police-warn-of-surge-insurance-fraud/)… **$55M fraud scheme exposed: Out-of-state providers target native communities, auditor warns** Out-of-state substance use treatment facilities have been carrying out a deceptive scheme targeting Native people in Montana, resulting in up to $55 million worth of fraudulent health insurance claims, according to an announcement from… [Read more](https://www.bozemandailychronicle.com/news/montana-auditor-out-of-state-providers-targeted-native-people-in-55m-insurance-scheme/article_4a9c5e42-fd38-565c-b01c-02fd7f92c0bb.html)… **WIA lawsuit advances over sellers who allegedly hid damaging AIG audit** World Insurance Associates bought a wholesale agency in 2021. Eighteen months later, [AIG](https://www.insurancebusinessmag.com/us/companies/aig/66988/) surfaced with news that upended the deal. A Delaware court ruled on January 20 that WIA can move forward with claims that the sellers of Scottish American Insurance General Agency concealed a… [Read more](https://www.insurancebusinessmag.com/us/news/legal-insights/wia-lawsuit-advances-over-sellers-who-allegedly-hid-damaging-aig-audit-562770.aspx)… **The future of insurance: Trust and efficiency through intelligent automation** The insurance industry is undergoing a profound transformation. As digital expectations rise and fraudsters become more sophisticated, insurers must deliver faster, more transparent, and more secure services. The answer lies in harnessing advanced automation and… [Read more](https://insurance-edge.net/2026/01/19/the-future-of-insurance-trust-and-efficiency-through-intelligent-automation/)… \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/5c344377-ec7c-90a1-73a3-c230d0a948a9.jpg) \| \|---\| \| \|---\| \| \| *Note: The arrest summaries included in the Coalition’s Fraud News Weekly are based on information from publicly available news sources. Individuals referenced in these reports are presumed innocent unless and until guilt is established in a court of law.* \| \|---\| \| \|---\| \| \| **Health Care Fraud** **January 19, North Carolina – $15.6 million health care fraud scheme uncovered and prosecuted** A federal judge sentenced a Kinston woman to six years in federal prison and ordered her to pay nearly $15.3 million in restitution to North Carolina Medicaid and $373,810 to the Internal Revenue Service. On Aug. 14, Francine Sims Super, 64,… [Read more](https://www.newsargus.com/news/local/woman-convicted-of-health-care-fraud-ordered-to-pay-15-6m/article_0a8ababc-04cc-5813-a1bb-d180767ec8f4.html)… **Crop Insurance Fraud** **January 20, Kentucky – Crop insurance fraud exposed, seven farmers and a warehouse manager sentenced** Cave City, Ky., farmer, Larry Walden, 69, was sentenced to 52 months’ incarceration by U.S. District Judge Karen Caldwell, after pleading guilty to conspiring to commit money laundering, by committing crop insurance fraud. According to his… [Read more](https://insurancenewsnet.com/oarticle/seven-farmers-and-a-tobacco-warehouse-manager-sentenced-for-crop-insurance-fraud-scheme)… **Health Care Fraud** **January 20, Michigan – Fatal hyperbaric chamber incident triggers health care fraud prosecution** The former CEO of the Oxford Center, who is charged in the fatal hyperbaric chamber explosion case, has now been charged with health care fraud, according to the Michigan Attorney General’s office. Tamela Peterson was arraigned on… [Read more](https://www.cbsnews.com/detroit/news/former-ceo-charged-health-care-fraud-hyperbaric-chamber-explosion/)… **Life Insurance Fraud** **January 21, Texas** – **Woman linked to former Harris County deputy’s murder charged in life insurance scheme** Investigators say Bre-Andrea Walker adjusted her husband’s life insurance policy alongside LaMarcus Smith just months before Smith’s wife was murdered… [Read more](https://www.click2houston.com/news/local/2026/01/20/mistress-of-former-harris-county-pct-4-deputy-accused-of-wifes-murder-charged-with-adjusting-husbands-life-insurance/)… **Health Care Fraud** **January 22, New Jersey – Inside an $11 million health care fraud scheme involving Amtrak employees** Four Amtrak employees admitted participating in a health care fraud scheme to defraud Amtrak, Senior Counsel Philip Lamparello announced. Yesterday, Timothy Bogen, 60, of Hamden, Connecticut, pleaded guilty before U.S. District Judge Madeline Cox Arleo in… [Read more](https://www.justice.gov/usao-nj/pr/amtrak-employees-admit-participating-11-million-health-care-fraud-scheme-0)… **Health And Disability Insurance Fraud** **January 22, Maryland – Fraud prevention win: Former D.C. teacher jailed for insurance theft scheme** Attorney General Anthony G. Brown announced today the sentencing of Kanika Oni Boston, 51, of Washington, D.C., on one count of felony theft scheme and one count of felony insurance fraud. The charges stem from fraudulent insurance payments… [Read more](https://oag.maryland.gov/News/pages/Former-DC-Teacher-to-Serve-One-Year-in-Jail-for-Felony-Insurance-Theft-Scheme.aspx)… \| \|---\| \| \|---\| \| \|---\| \| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/e04f063d-6836-b86d-4717-427e4a69a52d.jpg) \| \| \|---\| \| \| **Identity Fraud Awareness Week** **January 26 – 30, 2026** \| \|---\| \| \|---\| \| \| Next week is [Identity Fraud Awareness Week,](https://consumer.ftc.gov/features/identity-theft-awareness-week) providing an important opportunity to remind ourselves and our colleagues that identity-related crime continues to evolve, and that our vigilance must evolve with it. According to the Identity Theft Resource Center (ITRC), 2026 will be a pivotal year for data privacy, cybersecurity, and the ongoing fight against identity theft, fraud, and scams. In its newly released 2026 predictions, ITRC outlines emerging threats and trends expected to significantly impact consumers and organizations alike in the year ahead. Here are just a few of the risks and developments to watch closely this year: - **The Regulatory Landscape for AI and Data Privacy Will Become a Complex Global Patchwork:** Expect a flurry of new and updated data privacy regulations specifically targeting the use of AI. The European Union’s AI Act and GDPR will continue to set a high bar, and the U.S. will implement their own distinct AI and data privacy laws. This will create a complex and fragmented global regulatory landscape, posing significant compliance challenges for multinational corporations. - **Synthetic Identities, the Collapse of Digital Trust, and the Rise of Fake Ads & Counterfeit Shops:** Criminals use AI to create fake IDs, voice samples and “live” videos that fool verification systems. These synthetic identities are being used to open accounts, apply for jobs, and commit large-scale fraud. AI-generated fake websites and paid search ads impersonate insurers, banks, and retailers to harvest personal data later used in insurance fraud. The result is greater identity compromise, elevated fraud risk, and increased friction for consumers trying to secure or maintain insurance coverage. - **AI-Powered Social Engineering Will Drive a Surge in Hyper-Personalized Identity Theft:** AI will increasingly power highly sophisticated, scalable social-engineering attacks, enabling criminals to tailor scams using personal data from multiple breaches. These targeted narratives can manipulate individuals into disclosing sensitive information or authorizing payments, driving higher rates of identity theft and financial fraud. For insurers, this elevates exposure to application and claims fraud, increases loss severity, and can create added barriers for legitimate customers seeking coverage or claim resolution. Read ITRC’s full list of 2026 Predictions here. Share this messaging with your colleagues. [Link to .pdf](https://www.idtheftcenter.org/wp-content/uploads/2025/12/ITRC-2026-Predictions.pdf) or link to [website](https://www.idtheftcenter.org/identity-theft-resource-center-2026-predictions/) \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a4e430c0-c419-3044-1add-d368ddda9e22.jpg) \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/069ef289-dcca-dcfd-91bf-384bc24e3f98.jpg) \| \|---\| \| \|---\| \| \| [The Coalition Against Insurance Fraud ](https://insurancefraud.org)welcomes [Faegre Drinker ](https://www.faegredrinker.com/en/)as its newest member. Faegre Drinker is an international law firm with an insurance group of 80 attorneys and professionals dedicated to advising and representing the insurance industry. The firm handles numerous fraud-related cases each year across life and annuity, property and casualty, long-term care, health, structured settlements, and insurance intermediary disputes. Known for pioneering legal strategies and expanding precedent in life insurance and long-term care fraud, Faegre Drinker helps insurers combat fraud nationwide. Their attorneys regularly litigate complex cases involving false claims, account takeovers, policy rescissions, interpleader actions, coverage disputes, arson, business interruption misrepresentations, contractor fraud, long-term care fraud, and producer schemes. The firm also manages extensive overpayment recovery programs. Its appellate and amicus practice includes representation before every federal appellate court and the U.S. Supreme Court, preparing influential briefs for trade associations and industry groups, including the Coalition. Faegre Drinker maintains strong relationships across the insurance regulatory landscape, attending NAIC meetings and collaborating with stakeholders to advance anti-fraud initiatives. Their legal expertise, advocacy, and commitment to industry education make them a valuable new member of the Coalition in the fight against insurance fraud. \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/5c4205af-65c6-2e49-9422-0daff19aea21.jpg) \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/c6341975-f6ef-1d6f-5041-fcfad54ffdd0.jpg) \| \|---\| \| \|---\| \| \| **Coalition partners again with Wayne State for Insurance Fraud Awareness campaign** \| \|---\| \| \|---\| \| \| This week Michelle Rafeld visited Wayne State University to kick off the Coalition’s renewed partnership with the school on an insurance fraud awareness campaign targeting the 18–25 demographic. During her visit, Rafeld provided participating students with an overview of the insurance fraud landscape and discussed the industry’s ongoing challenges in shifting attitudes among younger audiences. This second collaboration will involve approximately 25 marketing students working in teams as part of the Coalition’s Social Media Competition. Participants will be tasked with creating engaging digital content to educate their peers and leveraging their own social media platforms to serve as micro-influencers. To follow the campaign, monitor the Coalition’s Instagram page, where student-created posts will begin appearing at the end of January. \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/599cd350-ea52-4495-1186-5f4cf595e458.jpg) \| \|---\| \| \|---\| \| \| [ ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/26e4e97f-1c44-78b9-6f67-60c0aaf88dbc.jpg) ](https://members.insurancefraud.org/general/pick_username.asp) \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/092a75b2-e5e6-9838-8a25-790566e52b92.jpg) \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/9d9a163b-d608-c29e-1f8c-71c58f193f3a.jpg) \| \|---\| \| \|---\| \| \| - **January 27 –** [CrashCon: Spotting Staged Auto Accidents](https://events.teams.microsoft.com/event/b4faa160-8d52-4a31-9986-070f2f3451e7@aa3f6158-a750-475d-a17c-8438fe053836) (Becker & Company) - **January 27 – January 29 –** [Motor Vehicle Fire Investigation](https://insurancefraud.org/event/motor-vehicle-fire-investigation/ "Motor Vehicle Fire Investigation") (IAAI) - **February 24 –** [Hitting Record: Empowering Claim Decisions with Surveillance Footage](https://frasco.zoom.us/webinar/register/8017660912424/WN_j8yYMMeOSkmoDblLdslfrQ#/registration) (Frasco Investigative Services) - **February 25 –** [OSINT Advantage: Uncovering Fraud with Open-Source Intelligence](https://event.on24.com/wcc/r/5126008/D98F452787F88A3EEF672B24D271F929) (Ethos) - **March 1 – March 4 –** [Insurance Fraud Management Conference](https://events.verisk.com/event/8d7e5635-89e2-4500-a65b-6044cf54ab9b/home?RefId=VeriskConferences&rt=WUDwXBM8PUKk3EoCBebOKg) (Verisk / NICB) \| \|---\| \| \|---\| \| \| [ ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/06c25334-a44b-83f1-621b-dbfc959b59ea.jpg) ](https://s.surveyplanet.com/bj1sw6en) \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/4b1136e8-4c9e-4d00-bc11-54758a3ea8a6.png) \| \|---\| \| \|---\| \| \|---\| \| \| \| **Follow Us On Our Social Media Platforms:** \| \| \|---\| \| \| [ ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/148b79cf-2c06-6469-b7c8-335c1c8b971a.jpg) ](https://insurancefraud.us1.list-manage.com/track/click?u=a440c5b647697de580a2fd586&id=5214c5e629&e=cf8d2cdb4f) \| \|---\| \| \|---\| \| \| [ ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/39ae0e7d-0388-20e5-5755-020aec6cf995.jpg) ](https://insurancefraud.us1.list-manage.com/track/click?u=a440c5b647697de580a2fd586&id=06da6de163&e=cf8d2cdb4f) \| \|---\| \| \|---\| \| \| [ ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/86c49df9-4380-51e5-da9c-f83034fc7555.jpg) ](https://insurancefraud.us1.list-manage.com/track/click?u=a440c5b647697de580a2fd586&id=b349097e98&e=cf8d2cdb4f) \| \|---\| \| \|---\| \| \| \| \|---\| \| \|---\| \| \| **Contact:** Phone: [202.393.7330](tel:2023937330) Email: [coalition](mailto:coalition@insurancefraud.org)[@insurancefraud.org](mailto:coalition@insurancefraud.org) Address: 1012 14th Street, NW Suite 610 Washington, DC 20005 [www.InsuranceFraud.org](http://www.insurancefraud.org/) Want to change how you receive these emails? You can [update your preferences](https://insurancefraud.us1.list-manage.com/profile?u=a440c5b647697de580a2fd586&id=b68dce7808&e=%5BUNIQID%5D&c=b527e0fe4b) or [unsubscribe from this list](https://insurancefraud.us1.list-manage.com/unsubscribe?u=a440c5b647697de580a2fd586&id=b68dce7808&t=b&e=%5BUNIQID%5D&c=b527e0fe4b). \| \|---\| \| \|---\| \| \|---\| | |:-:| <html><p class="wp-block-paragraph"></p> **Features:** Fraud News Weekly --- ### [Fraud News Weekly - January 16, 2026](https://insurancefraud.org/publications/fraud-news-weekly-january-16-2026/) **Published:** January 16, 2026 **Author:** Coalition Against Insurance Fraud **Content:** Fraud News Weekly – Friday, January 16, 2026 | \| \| \|---\| \| \| \| [View this email in your browser](https://mailchi.mp/781504fe89b2/fraud-news-weekly-friday-january-16-2026?e=%5BUNIQID%5D) \| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a28b73a3-5fad-52df-235e-b5d54e3bfc42.jpg) \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a417349b-dfdc-a052-790d-07cfde53b716.jpg) \| \|---\| \| \|---\| \| \| **Fifth Circuit decision aligns with Coalition amicus brief on strengthening RICO tools against insurance fraud.** For almost three decades, the Coalition’s [Amicus Curiae Program](https://insurancefraud.org/amicus-program/) has filed amicus briefs to ensure federal and state courts hear the collective voice of insurance fraud fighters on cases that shape national antifraud precedent. Those efforts paid off again as the Fifth Circuit reversed and remanded a trial court’s dismissal of Allstate’s complaint in *Allstate v. Bhagat*, rejecting nearly every lower court holding and reaffirming established RICO standards for mail fraud, causation, and damages. The decision bolsters the ability of insurers and prosecutors to pursue complex, systemic insurance fraud that harms consumers and markets alike. [Read Opinion](https://insurancefraud.org/wp-content/uploads/Bhagat-Fifth-Circuit-Opinion.pdf)… **New York Governor’s 2026 State of the State address targets insurance fraud to lower auto premiums.** This week, Governor Kathy Hochul revealed her 2026 State of the State affordability plan that includes a comprehensive strategy to combat auto insurance fraud, staged crashes, and other fraudulent schemes. The proposals would reinvigorate the Motor Vehicle Theft and Insurance Fraud Prevention Board, empower DFS, DMV, DCJS, and NYSP to coordinate investigations, expand fraud reporting timeframes for insurers, and strengthen tools for prosecutors to target organized fraud rings. The Coalition is tracking this closely and has engaged with state leaders. [Read More](https://www.governor.ny.gov/news/money-your-pockets-governor-hochul-proposes-measures-bring-down-crushingly-expensive-auto)… **Washington OIC, Commissioner Kuderer prioritizes insurance fraud enforcement in 2026 session.** Washington Insurance Commissioner Patty Kuderer launched the 2026 legislative session with a clear focus on consumer protection and an enhanced fight against insurance fraud. Key bills under consideration expand the definition of insurance fraud, elevate it to a class B felony, and recognize consumers as eligible victims for criminal restitution under [House Bill 2394](https://app.leg.wa.gov/billsummary/?BillNumber=2394&Chamber=House&Year=2025) and [Senate Bill 6031](https://app.leg.wa.gov/billsummary/?BillNumber=6031&Chamber=Senate&Year=2025). This legislative agenda aligns closely with the Coalition Against Insurance Fraud’s [support](https://insurancefraud.org/wp-content/uploads/Coalition-10_29_2025-Comments-WA-OIC-Draft-RCW-48.135.pdf) for modernizing Washington’s Insurance Fraud Program, strengthening the Criminal Investigations Unit by adding financial and digital specialists, and addressing increasingly sophisticated, technology-driven fraud schemes targeting insurers and policyholders alike. [Read More](https://www.insurance.wa.gov/about-us/news/2026/kuderer-announces-priorities-2026-legislative-session)… \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/6bbcb403-e1c7-fb75-bb1a-d5bd83716791.jpg) \| \|---\| \| \|---\| \| \| **From ‘Frankenstein’ plans to annuities: Regulators warn of rising insurance abuse** Insurance fraud remains a significant issue, stealing over $308 billion annually from consumers, according to the [Coalition Against Insurance Fraud.](http://www.insurancefraud.org) The New Hampshire Insurance Department (NHID) Fraud Unit recently held a webinar to help insurance professionals and… [Read more](https://insurancenewsnet.com/innarticle/identifying-financial-abuse-in-insurance-what-you-should-know)… **Insurance Commissioner announces savings or recovery of more than $140 million in 2025** Insurance Commissioner Mike Causey announced that the North Carolina Department of Insurance saved or recovered $142 million for North Carolinians in 2025. The recovered funds include those from insurance fraud restitution,consumer assistance, market monitoring and… [Read more](https://whky.com/insurance-commissioner-announces-savings-or-recovery-of-more-than-140-million-in-2025/)… **Department of Justice launches division for national fraud enforcement to boost federal anti-fraud efforts** Last week, President Trump announced the upcoming creation of the Department of Justice’s new division for national fraud enforcement to streamline federal investigations and prosecutions of complex fraud schemes affecting government programs, businesses, and consumers nationwide. This division will improve… [Read More](https://www.whitehouse.gov/fact-sheets/2026/01/fact-sheet-president-donald-j-trump-establishes-new-department-of-justice-division-for-national-fraud-enforcement/)… **Drivers are willing to share their data: Telematics opens new frontiers for auto fraud prevention** Consumer acceptance of telematics technology in auto insurance is growing, creating opportunity for insurers who can cater to tech-driven drivers who crave personalized pricing and service. Today, 82% of policyholders view telematics apps positively, according to… [Read more](https://www.insurancejournal.com/news/national/2026/01/14/854253.htm)… \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/5c344377-ec7c-90a1-73a3-c230d0a948a9.jpg) \| \|---\| \| \|---\| \| \| *Note: The arrest summaries included in the Coalition’s Fraud News Weekly are based on information from publicly available news sources. Individuals referenced in these reports are presumed innocent unless and until guilt is established in a court of law.* \| \|---\| \| \|---\| \| \| **Agent Misconduct** **January 9, Maryland** – **Former Parkville insurance agent and financial advisor was sentenced for insurance fraud and obstruction of justice** A judge sentenced a former insurance agent and financial advisor to six months in jail on Friday following his conviction for defrauding a client and subsequently attempting to… [Read more](https://nottinghammd.com/2026/01/09/former-parkville-insurance-adviser-financial-advisor-sentenced-for-insurance-fraud-obstruction-of-justice/)… **Health Care Fraud** **January 9, Virginia – Revenue over patients: Pain clinic owner sentenced in widespread insurance fraud case** The owner of multiple pain clinics throughout Virginia – including Lynchburg, Madison Heights and Christiansburg – was sentenced on Friday to 45 months in federal prison for healthcare fraud and… [Read more](https://wset.com/news/local/owner-of-virginia-pain-clinics-sentenced-to-45-months-for-fraud-and-drug-conspiracies-john-gregory-barnes-operation-mountain-highlands-prescription-pain-doj-january-2026)… **Medicaid/Medicare Fraud** **January 12, Oklahoma – From back pain to big fraud: Chiropractor indicted in $30M DME kickback scheme** A federal grand jury has indicted Oklahoma chiropractor and medical supply company owner Mark Loftis, 38, for allegedly orchestrating a $30 million durable medical equipment (DME) fraud involving orthotic braces billed to… [Read more](https://www.medicaleconomics.com/view/oklahoma-dme-owner-charged-in-30m-brace-fraud-scheme-intoxicated-without-drinking-pharmacists-face-a-higher-suicide-risk-morning-medical-update)… **Fraud General** **January 13, Iowa** – **Alleged misuse of agency funds and fabricated claims leads to felony charges in Iowa insurance fraud case Cristal Gale Kastantin, of Wheatland, Iowa, was arrested on Saturday, January 3, 2026, on outstanding arrest warrants. Kastantin was charged with… [Read more](https://iid.iowa.gov/press-release/2026-01-13/clinton-county-woman-charged-insurance-fraud)… **Identity Fraud** **January 14, Kansas – Fraudulent policy, real consequences: Sedgwick county man sentenced** Kansas Insurance Commissioner Vicki Schmidt announced a Sedgwick county man has been sentenced to 24 months of probation for insurance and identity fraud. Marquez Gails, age 43, pleaded guilty … [Read more](https://www.insurancejournal.com/news/midwest/2026/01/14/854294.htm)… \| \|---\| \| \|---\| \| \|---\| \| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/e04f063d-6836-b86d-4717-427e4a69a52d.jpg) \| \| \|---\| \| \| **2025 Q4 and Year-end Dashboards** \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/2c274a2b-4946-9af6-3720-144a2241fc0f.png) \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a0536fcc-5197-5780-1a13-91f16f09eb8e.png) \| \|---\| \| \|---\| \| \| \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a4e430c0-c419-3044-1add-d368ddda9e22.jpg) \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/8dd1cf2b-cefa-226f-4af4-9e2f943282c6.jpg) \| \|---\| \| \|---\| \| \| [The Coalition Against Insurance Fraud](https://insurancefraud.org/) welcomes [Group 1001](https://www.group1001.com/home) as its newest member. Group 1001 is a diversified insurance carrier specializing primarily in annuity and life products through its companies Gainbridge Financial, Delaware Life, and Clear Spring Life, with Clear Spring also offering property, casualty, and health insurance products. Group 1001 brings a strong, demonstrated commitment to protecting consumers and safeguarding its companies from insurance fraud. Its comprehensive Fraud Risk Management program includes dedicated teams focused on detecting, preventing, and investigating potential fraud across its business lines. Central to this effort is Group 1001’s Fraud Operations Center of Excellence (FOCE), which partners closely with business units to strengthen fraud detection and prevention through targeted training, process analysis, and continuous improvement following fraud incidents. The FOCE also maintains active collaboration with industry organizations, including ACFE, IASIU, IAFCI, LOMA, and LIMRA’s Financial Crimes Governance Council, Evadata, and now the Coalition Against Insurance Fraud, to advance anti-fraud best practices across the insurance and financial services sectors. Group 1001’s Special Investigation Unit (SIU) plays a critical role in investigating and reporting suspicious activity, working closely with the FOCE, business partners, regulatory agencies, and law enforcement. The SIU also collaborates with Group 1001’s cybersecurity team when fraud activity involves cyber-related risks. The Coalition looks forward to working with Group 1001 and leveraging its expertise and leadership to further strengthen collective efforts to combat insurance fraud and protect consumers nationwide. \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/599cd350-ea52-4495-1186-5f4cf595e458.jpg) \| \|---\| \| \|---\| \| \| [ ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/26e4e97f-1c44-78b9-6f67-60c0aaf88dbc.jpg) ](https://members.insurancefraud.org/general/pick_username.asp) \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/6f32c8d9-0deb-a125-81c4-c021c924e5d8.jpg) \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/9d9a163b-d608-c29e-1f8c-71c58f193f3a.jpg) \| \|---\| \| \|---\| \| \| - **January 21** – [Earn CE Credit – Understanding Consumer Distrust ](https://event.on24.com/wcc/r/5125934/E50A1FE0E2E51E1D198423F882EF4410) (Ethos) - **January 21 –** [OSINT Workflows for Art and Antiquities Crime](https://events.skopenow.com/osint-workflows-for-art-and-antiquities-crime?utm_medium=email&_hsenc=p2ANqtz-8_vIwGBkjYUuQIn4DE10F18aIpsUkEx3V5nEvLphla4wf2-8LwD0GEtcKRbEQ_O9u6gOegJJ5Jdhm9VlzjdqNBAFFVUoUpuQbh0RV-j6nlQXLom78&_hsmi=398565773&utm_content=398565773&utm_source=hs_email) (SKOPENOW) - **January 22 –** [Hospice Scams in California: What the State Audit Found and How New Regulations Protect Seniors](https://us02web.zoom.us/webinar/register/WN_OOvuzFNuRTazEx2YrCnfpQ#/registration) (California Health Advocates) - **January 22 –** [Diligence Insights: Organized Crime and Its Impact on the Insurance Industry](https://us02web.zoom.us/webinar/register/WN_GQYK08EwQuOINdW-IvKzhA#/registration) (Diligence International Group) - **January 27 –** [CrashCon: Spotting Staged Auto Accidents](https://events.teams.microsoft.com/event/b4faa160-8d52-4a31-9986-070f2f3451e7@aa3f6158-a750-475d-a17c-8438fe053836) (Becker & Company) - **January 27 – January 29 –** [Motor Vehicle Fire Investigation](https://insurancefraud.org/event/motor-vehicle-fire-investigation/ "Motor Vehicle Fire Investigation") (IAAI) - **March 1 – March 4 –** [Insurance Fraud Management Conference](https://events.verisk.com/event/8d7e5635-89e2-4500-a65b-6044cf54ab9b/home?RefId=VeriskConferences&rt=WUDwXBM8PUKk3EoCBebOKg) (Verisk / NICB) - **August 24 – 27 –** Save the date for the OWL Intel Summit (Whooster) \| \|---\| \| \|---\| \| \| [ ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/06c25334-a44b-83f1-621b-dbfc959b59ea.jpg) ](https://s.surveyplanet.com/bj1sw6en) \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/4b1136e8-4c9e-4d00-bc11-54758a3ea8a6.png) \| \|---\| \| \|---\| \| \|---\| \| \| \| **Follow Us On Our Social Media Platforms:** \| \| \|---\| \| \| [ ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/148b79cf-2c06-6469-b7c8-335c1c8b971a.jpg) ](https://insurancefraud.us1.list-manage.com/track/click?u=a440c5b647697de580a2fd586&id=5214c5e629&e=cf8d2cdb4f) \| \|---\| \| \|---\| \| \| [ ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/39ae0e7d-0388-20e5-5755-020aec6cf995.jpg) ](https://insurancefraud.us1.list-manage.com/track/click?u=a440c5b647697de580a2fd586&id=06da6de163&e=cf8d2cdb4f) \| \|---\| \| \|---\| \| \| [ ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/86c49df9-4380-51e5-da9c-f83034fc7555.jpg) ](https://insurancefraud.us1.list-manage.com/track/click?u=a440c5b647697de580a2fd586&id=b349097e98&e=cf8d2cdb4f) \| \|---\| \| \|---\| \| \| \| \|---\| \| \|---\| \| \| **Contact:** Phone: [202.393.7330](tel:2023937330) Email: [coalition](mailto:coalition@insurancefraud.org)[@insurancefraud.org](mailto:coalition@insurancefraud.org) Address: 1012 14th Street, NW Suite 610 Washington, DC 20005 [www.InsuranceFraud.org](http://www.insurancefraud.org/) Want to change how you receive these emails? You can [update your preferences](https://insurancefraud.us1.list-manage.com/profile?u=a440c5b647697de580a2fd586&id=b68dce7808&e=%5BUNIQID%5D&c=cc040fd0bb) or [unsubscribe from this list](https://insurancefraud.us1.list-manage.com/unsubscribe?u=a440c5b647697de580a2fd586&id=b68dce7808&t=b&e=%5BUNIQID%5D&c=cc040fd0bb). \| \|---\| \| \|---\| \| \|---\| | |:-:| <html><p class="wp-block-paragraph"></p> **Features:** Fraud News Weekly --- ### [Fraud News Weekly - January 9, 2026](https://insurancefraud.org/publications/fraud-news-weekly-january-9-2026/) **Published:** January 9, 2026 **Author:** Coalition Against Insurance Fraud **Content:** 2026 Legislative Priorities, Commercial Vehicle Dashboard Camera Initiative, Coalition Executive Committee Re-Elections | \| \| \|---\| \| \| \| [View this email in your browser](https://mailchi.mp/d8564939649f/2026-legislative-priorities-commercial-vehicle-dashboard-camera-initiative-coalition-executive-committee-re-elections?e=%5BUNIQID%5D) \| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/c97f01f7-1c1e-d862-5223-e552088eba3a.jpg) \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a417349b-dfdc-a052-790d-07cfde53b716.jpg) \| \|---\| \| \|---\| \| \| **The Coalition continues to track anti-fraud bills that have carried over into 2026.** As we move into a new year, the Coalition sets its sights on new legislative opportunities that align with our [2026 legislative priorities](https://insurancefraud.org/legislative-priorities/), as well as forty-nine (49) 2025 anti-fraud bills that have carried over into 2026. Carryover legislation allows bills introduced in the first year of a biennium to remain active into the second year without needing reintroduction, a process that applies to about half of the states. This is also true at the federal level, with the 119th Congress active until 2027. Among the 2025-2026 bills carrying over, key themes include bills that support stronger anti-fraud laws, legislation that strengthens information or requires insurer fraud reporting, along with bills focused on consumer privacy and insurer use of technology. A federal bill that would criminalize staged accidents with commercial vehicles also moves into 2026. The Coalition has also identified legislative potential in various states. Those issues involve several states focused on establishing an insurance fraud statute, clarifying prosecutorial venue, strengthening anti-fraud immunity, and others. Coalition members can search these anti-fraud bills via the [Online Interactive Map](https://insurancefraud.org/government-law/). **Louisiana Department of Insurance advances a regulation that incentivizes the use of commercial vehicle dashboard cameras and telematics to deter fraud.** The Louisiana Department of Insurance (LDI) has issued a [Notice of Intent](https://ldi.la.gov/docs/default-source/documents/legaldocs/regulations/noi/noi-promulgate-reg-138-final) to promulgate Regulation 138 under Title 37, Part XIII, Chapter 213, implementing La. R.S. 22:1482.2 and the 2025 enactment of [HB 549](https://www.legis.la.gov/legis/BillInfo.aspx?i=248595). The regulation requires insurers to provide a premium discount on the liability portion of policies covering commercial motor vehicles equipped with dashboard cameras paired with telematics systems. LDI clearly frames the purpose: enhance public safety, reduce insurance fraud, and lower claim costs by encouraging technology that documents driving behavior and crash events. For insurance fraud fighters, this matters. Video and telematics data can expose staged crashes, inflated injury claims, and false liability narratives that drive losses and litigation pressure. As insurers prepare to operationalize the discount, SIU should also consider the investigative and evidentiary value that this move creates. **Texas names Amanda Crawford as insurance commissioner as Cassie Brown prepares to retire.** Texas Insurance Commissioner Cassie Brown will [retire](https://www.tdi.texas.gov/news/2026/tdi01062026.html) Feb. 2, 2026, closing more than four years leading the Texas Department of Insurance and overseeing the nation’s second largest insurance market, valued at $293 billion, while Governor Greg Abbott has [appointed](https://gov.texas.gov/news/post/governor-abbott-appoints-crawford-as-commissioner-of-insurance) Amanda Crawford to succeed her for a term expiring Feb. 1, 2027. Appointed by Abbott, outgoing Brown regulated more than 3,400 insurers and the licensing of over 875,000 agents and adjusters, with a consistent emphasis on consumer protection and education to help Texans avoid insurance scams. Her tenure strengthened complaint resolution and restitution for fraud victims, featured proactive market oversight, and an on the ground Fraud Unit disaster response that helped counter post catastrophe fraud schemes targeting policyholders. Brown will cap her service by hosting TDI’s annual [Meet the Regulator event](https://www.tdi.texas.gov/alert/event/2026/01/meet-the-regulator.html) next week. Incoming Commissioner Crawford brings a technology and legal background that could shape Texas’ fraud fighting posture, having served as executive director of the Department of Information Resources and the state’s Chief Information Officer, as well as deputy attorney general for administration and general counsel at the Texas Office of the Attorney General. As fraud schemes grow more sophisticated, Coalition members will be watching closely how Texas aligns regulatory oversight, data security, and antifraud enforcement under new leadership. **Pennsylvania advances public adjuster bill to House hearing.** Pennsylvania [House Bill 1972](https://legiscan.com/PA/bill/HB1972/2025) moved forward after unanimous approval by the House Insurance Committee and is scheduled for [second consideration in the House on Jan. 26, 2026](https://www.palegis.us/house/session/watch). Sponsored by Rep. Bob Merski of Erie, the bill would revise key definitions in the state’s Public Adjuster Licensing Law, tighten licensure requirements, and expand mandatory written disclosures of financial interests. “We need stronger rules to protect Pennsylvanians when they’re recovering from property loss,” Merski [said](https://www.pahouse.com/Merski/InTheNews/NewsRelease/?id=140832). “My legislation would close loopholes that have allowed conflicts of interest and unreasonable fees, ensure clear disclosures before any contract is signed, and give regulators the tools they need to hold bad actors accountable.” After debate and votes in the House, the bill could pass or fail, be amended further, and then potentially move to the Senate, according to the [Pennsylvania General Assembly](https://www.google.com/search?q=Pennsylvania+General+Assembly&oq=Pennsylvania+House+Bill+1972+second+consideration&gs_lcrp=EgZjaHJvbWUyBggAEEUYOTIHCAEQIRigAdIBCTcyMjBqMGoxNagCCLACAfEFPpl7Pmg648HxBT6Zez5oOuPB&sourceid=chrome&ie=UTF-8&mstk=AUtExfD6yeVv5vRy5WcUFFlFHX_WHOFTT_Fqo00Ljty1dItG9Wvfb3Rq-j6TLnTrauiDnvRLYmAe3heMFjFqbR5IZJQ5jS5luGr3V48-Sn_fZIej29a1VTA5deO-tbqJvIp6xbqhJrFN5dQ7VzFZr6Ian0qMJgGCuBMPZWKFh5Gj8llstXM&csui=3&ved=2ahUKEwj4qsiMyvyRAxVbSDABHZaOL3gQgK4QegQICRAB) process. \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/6bbcb403-e1c7-fb75-bb1a-d5bd83716791.jpg) \| \|---\| \| \|---\| \| \| **As 2026 begins, the insurance industry has reached an AI inflection point.** Insurers are moving decisively from AI pilots to full scale deployment, while new state regulations took effect January 1, creating immediate compliance requirements. At the same time, cyber insurers have excluded deepfake fraud from standard policies, exposing major coverage gaps. Together, these developments signal that AI is no longer experimental and now requires immediate execution, governance, and risk management by insurance leaders. [**Read more**](https://insuranceindustry.ai/ai-insights-jan-2-2026/#:~:text=Cyber%20Insurers%20Exclude%20Deepfake%20Fraud%3A,cyber%20insurance%20policies%20throughout%20late)… **As insurance fraud grows more coordinated, automated, and difficult to detect, 2026 is forcing claims and SIU leaders to rethink investigation models.** This article outlines the fastest growing fraud schemes, from synthetic identities and deepfake evidence to organized claim rings, and explains why alert driven detection is no longer enough. It emphasizes the need for investigator centered workflows, integrated data, and structured investigation tools to restore control, efficiency, and confidence in modern fraud response. [**Read more**](https://fraudops.ai/articles/the-10-fastest-growing-insurance-fraud-schemes-2026-and-how-carriers-can-stay-ahead/)… **False Claims Act enforcement in 2026 to focus on DEI and AI fraud.** The enforcement landscape entering 2026 points to sustained False Claims Act activity across traditional health care fraud, AI-enabled misconduct, civil rights–based claims, customs and tariff fraud, and expanding theories of investor liability. The US Department of Justice’s institutional investments also point to faster case development and more targeted priorities. **[Read more](https://news.bloomberglaw.com/legal-exchange-insights-and-commentary/false-claims-act-enforcement-in-2026-to-focus-on-dei-ai-fraud)**… \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/5c344377-ec7c-90a1-73a3-c230d0a948a9.jpg) \| \|---\| \| \|---\| \| \| **Healthcare Fraud** **December 29, 2025, Las Vegas, Nevada – Attorney General Ford announces the sentencing of Brothers Behavioral Health and its owner.** Las Vegas-based Brothers Behavioral Health LLC and owner Isai Anaya-Estrada were convicted of billing Medicaid for services never provided, resulting in nearly $48,000 in restitution. Anaya-Estrada received probation and a suspended jail sentence. Nevada authorities emphasize that healthcare fraud will not be tolerated. **[Read more](https://ag.nv.gov/News/PR/2025/Attorney_General_Ford_Announces_Sentencing_of_Brothers_Behavioral_Health_and_Its_Owner/)**… **Property & Casualty** **December 31, 2025, Ogden, Utah – Man renewed lapsed insurance 10 minutes after crash, charges say.** A man faces felony insurance fraud charges after allegedly trying to renew his lapsed car insurance minutes after a crash to get coverage. Authorities say the timing of his online renewal raises serious questions about intent. **[Read more](https://www.ksl.com/article/51425620/ogden-man-renewed-lapsed-insurance-10-minutes-after-crash-charges-say)**… **Property & Casualty** **December 31, 2025, Wichita, Kansas – Sedgwick County man was sentenced for dirt bike insurance fraud.** Man pleaded guilty to falsely reporting his dirt bike as stolen to collect insurance and loan payouts. He was sentenced to 18 months of probation and ordered to pay restitution to both his insurer and lender. **[Read more](https://www.ksn.com/news/local/sedgwick-county-man-sentenced-for-dirt-bike-insurance-fraud/)**… **Property & Casualty** **December 31, 2025, Danville, Kentucky – Final sentencing in large-scale crop fraud case costs insurers nearly $35 million.** A major crop insurance fraud investigation has ended with prison sentences and multi-million-dollar restitution for seven farmers and a warehouse manager. The scheme, which involved fake receipts, falsified sales, and millions in fraudulent insurance claims, underscores the high stakes of agricultural fraud. **[Read more](https://www.carriermanagement.com/news/2025/12/31/283030.htm)**… **Travel Insurance Fraud** **January 2, 2026, Trenton, New Jersey – Authorities have charged four individuals in connection with an alleged scheme involving fraudulent travel insurance claims for trips never taken and medical emergencies that never occurred.** Investigators say the defendants used multiple policies, false identities, and fabricated records to try to collect thousands of dollars from insurers. **[Read more](https://www.njoag.gov/four-people-charged-in-travel-insurance-conspiracy/)**… **Healthcare Fraud** **January 7, 2026, West Palm Beach, Florida – Woman accused of collecting over $11 million in dental insurance fraud pleads no contest in Palm Beach County.** A woman accused of running an illegal dental operation that generated more than $11 million in insurance payments has entered a plea in a high-profile Florida fraud case. Prosecutors say the scheme involved unlicensed ownership, misuse of dentists’ credentials, and years of improper insurance billing across multiple clinics. **[Read more](https://www.wpbf.com/article/florida-woman-accused-evelyn-cruz-over-11-million-in-dental-insurance-fraud-no-contest-palm-beach-county/69927281)**… **Agent Fraud / Misconduct** **January 8, 2026, Pembroke Pines, Florida – Insurance Agency VP was sentenced to three years in massive ACA fraud scheme.** A broker was sentenced to nearly three years in prison and millions in restitution for enrolling thousands, including many homeless individuals, into ineligible ACA plans to collect commissions. Authorities say the scheme defrauded the federal program of $134 million. **[Read more](https://www.insurancejournal.com/news/southeast/2026/01/08/853600.htm)**… \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a87896d8-5c0c-5f11-a057-a26dd5714ac8.jpg) \| \|---\| \| \|---\| \| \|---\| \| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/f244ee6b-2485-0e14-93ee-8743bccd08fd.jpg) \| \| Florida Man Arrested for Multi-Felony Insurance Fraud [**Read more**](https://www.bocaratontribune.com/bocaratonnews/2026/01/florida-man-arrested-on-multiple-felony-fraud-charges-in-alleged-insurance-scheme-records-show/)… \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/b2eac1ff-4cbd-be61-2ae1-cf2d8906d7d8.jpg) \| \|:-:\| \| Ex-Deputy Faces New Charge in Murder-for-Hire Plot [**Read more**](https://www.click2houston.com/news/local/2026/01/05/former-pct-4-deputy-charged-with-wifes-murder-facing-new-charge-related-to-murder-for-hire-plot-of-mistress-husband/)… \| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/e04f063d-6836-b86d-4717-427e4a69a52d.jpg) \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/ae21bf90-7039-34ab-a15f-730919c006ad.jpg) \| \|---\| \| \|---\| \| \| The Coalition Against Insurance Fraud continues to strengthen its leadership as it enters 2026. Steve Piper, AVP – Global Head of Special Investigations at CNA Insurance, is serving as Insurer Co-Chair for a two-year term, bringing extensive industry experience and a collaborative leadership approach to the role. John Sokit, AVP, P&C Recovery Operations & Special Investigations at Nationwide Insurance, has been re-elected Treasurer for a two-year term, continuing his effective oversight of the Coalition’s financial responsibilities. Anna Flores, Executive Director of Consumer Action, along with Piper, Sokit, and David Rioux, have also been re-elected to the Executive Committee for another four-year term. These elections reflect the Coalition’s continued focus on stability, collaboration, and strong governance as it advances its mission to combat insurance fraud. \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/599cd350-ea52-4495-1186-5f4cf595e458.jpg) \| \|---\| \| \|---\| \| \| [ ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/26e4e97f-1c44-78b9-6f67-60c0aaf88dbc.jpg) ](https://members.insurancefraud.org/general/pick_username.asp) \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/6f32c8d9-0deb-a125-81c4-c021c924e5d8.jpg) \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/9d9a163b-d608-c29e-1f8c-71c58f193f3a.jpg) \| \|---\| \| \|---\| \| \| - **January 22 –** [Hospice Scams in California: What the State Audit Found and How New Regulations Protect Seniors](https://us02web.zoom.us/webinar/register/WN_OOvuzFNuRTazEx2YrCnfpQ#/registration) (California Health Advocates) - **January 27 –** [CrashCon: Spotting Staged Auto Accidents](https://events.teams.microsoft.com/event/b4faa160-8d52-4a31-9986-070f2f3451e7@aa3f6158-a750-475d-a17c-8438fe053836) (Becker & Company) - **January 27 – January 29 –** [Motor Vehicle Fire Investigation](https://insurancefraud.org/event/motor-vehicle-fire-investigation/ "Motor Vehicle Fire Investigation") (IAAI) - **March 1 – March 4 –** [Insurance Fraud Management Conference](https://www.nicb.org/news/events/insurance-fraud-management-conference) (Verisk / NICB) - **August 24 – 27 –** Save the date for the OWL Intel Summit (Whooster) \| \|---\| \| \|---\| \| \| [ ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/06c25334-a44b-83f1-621b-dbfc959b59ea.jpg) ](https://s.surveyplanet.com/bj1sw6en) \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/4b1136e8-4c9e-4d00-bc11-54758a3ea8a6.png) \| \|---\| \| \|---\| \| \|---\| \| \| \| **Follow Us On Our Social Media Platforms:** \| \| \|---\| \| \| [ ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/148b79cf-2c06-6469-b7c8-335c1c8b971a.jpg) ](https://insurancefraud.us1.list-manage.com/track/click?u=a440c5b647697de580a2fd586&id=5214c5e629&e=cf8d2cdb4f) \| \|---\| \| \|---\| \| \| [ ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/39ae0e7d-0388-20e5-5755-020aec6cf995.jpg) ](https://insurancefraud.us1.list-manage.com/track/click?u=a440c5b647697de580a2fd586&id=06da6de163&e=cf8d2cdb4f) \| \|---\| \| \|---\| \| \| [ ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/86c49df9-4380-51e5-da9c-f83034fc7555.jpg) ](https://insurancefraud.us1.list-manage.com/track/click?u=a440c5b647697de580a2fd586&id=b349097e98&e=cf8d2cdb4f) \| \|---\| \| \|---\| \| \| \| \|---\| \| \|---\| \| \| **Contact:** Phone: [202.393.7330](tel:2023937330) Email: <info@insurancefraud.org> Address: 1012 14th Street, NW Suite 610 Washington, DC 20005 [www.InsuranceFraud.org](http://www.insurancefraud.org/) Want to change how you receive these emails? You can [update your preferences](https://insurancefraud.us1.list-manage.com/profile?u=a440c5b647697de580a2fd586&id=b68dce7808&e=%5BUNIQID%5D&c=c2670bdd4e) or [unsubscribe from this list](https://insurancefraud.us1.list-manage.com/unsubscribe?u=a440c5b647697de580a2fd586&id=b68dce7808&t=b&e=%5BUNIQID%5D&c=c2670bdd4e). \| \|---\| \| \|---\| \| \|---\| | |:-:| <html><p class="wp-block-paragraph"></p> **Features:** Fraud News Weekly --- ### [Fraud News Weekly - December 19, 2025](https://insurancefraud.org/publications/fraud-news-weekly-december-19-2025/) **Published:** December 19, 2025 **Author:** Coalition Against Insurance Fraud **Content:** California’s SIU Compliance Unit Rolls Out Upgraded Report Portal, AI Tools Drive New Fraud Patterns, Historic Lutsen Lodge Owner Charged With Arson | \| \| \| [View this email in your browser](https://mailchi.mp/726cb33c737f/californias-siu-compliance-unit-rolls-out-upgraded-report-portal-ai-tools-drive-new-fraud-patterns-historic-lutsen-lodge-owner-charged-with-arson?e=%5BUNIQID%5D) \| \|---\| \| \|---\| \| \|---\| \| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/88a1033e-bd7b-c36d-c5c3-e5b09de50106.jpg) \| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a417349b-dfdc-a052-790d-07cfde53b716.jpg) \| \|---\| \| \|---\| \| \| **![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/b7b0dba5-abe6-c6f8-b169-3f4530b153e7.jpg)** **California SIU Compliance Unit to rollout upgraded Annual Report Portal for 2026** **This will require all insurers doing business in California to re-register by January 30, 2026 to remain in compliance and ensure uninterrupted communication with regulators.** The current system went offline last week, giving companies a short runway to secure access to the new platform. State officials will email step-by-step registration guidance in the coming weeks. Questions or concerns can be directed to the SIU Compliance Unit at <SIU-AnnualReport@insurance.ca.gov>. **Federal executive order on artificial intelligence raises stakes for states and their insurance regulators.** President Trump’s December 11, 2025 [executive order](https://www.whitehouse.gov/presidential-actions/2025/12/eliminating-state-law-obstruction-of-national-artificial-intelligence-policy/) signals a major federal shift toward a national AI framework and limits on state-level regulation, even as NCOIL advances a [draft model law](https://ncoil.org/wp-content/uploads/2025/06/NCOIL-Insurance-Artifical-Intelligence-Model-Draft-6-17-25.pdf) to guide state oversight of AI in insurance. NCOIL has strongly [criticized](https://ncoil.org/2025/12/15/statement-from-ncoil-officers-on-the-trump-administrations-executive-order-regarding-the-regulation-of-ai/) the executive order, stating it “*aims to limit the ability of states to regulate artificial intelligenc*e” and warning that states must retain the ability to protect consumers through state-based policies. [Recent reporting](https://www.lexisnexis.com/community/insights/legal/capitol-journal/b/state-net/posts/will-trump-s-executive-order-stifle-state-efforts-to-regulate-ai) notes that in 2025 alone, legislatures in 40 states enacted AI laws, while the executive order directs federal agencies to challenge state AI laws deemed burdensome by creating an AI Litigation Task Force at the Department of Justice to set the stage for broad federal preemption. States, however, seem undeterred and continue to pursue AI oversight tailored to their markets and consumers. The NAIC’s Model Bulletin on the Use of Artificial Intelligence by Insurance Companies has gained significant traction, with about half the states [adopting](https://content.naic.org/sites/default/files/cmte-h-big-data-artificial-intelligence-wg-map-ai-model-bulletin.pdf) it, including Hawaii’s Insurance Division, which recently became the 25th state to adopt its own [version](https://cca.hawaii.gov/ins/commissioners-memorandum-2025-13a-the-use-of-artificial-intelligence-systems-in-insurance/). The executive order aims to assert U.S. leadership by removing regulatory barriers, curbing state AI laws through federal preemption, and promoting a national framework focused on innovation, economic security, and competitiveness. This follows the NAIC’s 2025 Annual Meeting, where regulators advanced the [Artificial Intelligence Systems Evaluation Tool](https://content.naic.org/sites/default/files/inline-files/AI%20Systems%20Evaluation%20Tool%20DRAFT%20for%20exposure%2007.07.2025.docx), designed to assess AI-driven consumer, financial, and fraud risks in insurer operations and as part of future market conduct exams, with pilot programs planned for 2026. For Coalition members, this executive order signals a rapidly evolving legal environment where antifraud innovation, regulatory clarity, and constitutional challenges will intersect. The Coalition will monitor these developments as federal agencies, courts, and states navigate this new AI governance landscape and its impact on fighting insurance fraud nationwide. **New York vetoes workers’ compensation fraud assessment commission bill despite Coalition support.** The Coalition Against Insurance Fraud has long supported dedicated, accountable funding for insurance fraud investigations and prosecutions. The Coalition recently [urged](https://insurancefraud.org/wp-content/uploads/Coalition-Support-of-NY-S-7950.pdf) New York Governor Kathy Hochul to sign legislation creating a workers’ compensation fraud assessment commission. The Coalition emphasized that any employer funded assessment must be used solely for investigating and prosecuting workers compensation fraud, with strong oversight and accountability. On December 9th, Governor Hochul [vetoed](https://www.businessinsurance.com/ny-governor-vetoes-fraud-assessment-commission/) the [bill](https://legiscan.com/NY/bill/S07950/2025), which would have created a commission to work with the Workers’ Compensation Board and the Workers’ Compensation Inspector General to help fund district attorney prosecutions. The bill had unanimous bipartisan support in both legislative chambers. The veto leaves New York without a dedicated funding mechanism for workers’ compensation fraud enforcement, a continued concern for fraud fighters and Coalition members. The governor did not explain her reason for vetoing the bill. \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/6bbcb403-e1c7-fb75-bb1a-d5bd83716791.jpg) \| \|---\| \| \|---\| \| \| **![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/1ffa8982-c76f-008d-6c8d-4cee3909e0c5.png) Washington State Whatcom County officials warn of contractor fraud targeting thousands of dollars in the wake of the Nooksack River flooding.** Following the recent Nooksack River flooding that submerged homes in Ferndale and Everson, local leaders are [urging residents to remain vigilant against fraudulent contractors](https://seattlered.com/weather/whatcom-flood-contractor-scams/4115657). Officials are concerned that “*bad actors*” will try to exploit families as they begin the difficult process of home recovery. Everson Mayor John Perry noted that this was a significant issue after the 2021 floods when many out-of-town contractors arrived to take advantage of the disaster. Perry highlighted extreme cases where residents were charged thousands of dollars for work that was either never completed or significantly overpriced, such as a $5,000 bill for temporary heat that should have cost only a few hundred dollars. **AI tools drive new fraud patterns: voice clones, deepfakes, and fake sites surge.** AI tools are driving new fraud patterns, changing how scams are carried out across voice, video, web, and messaging channels, and affecting fraud and cyber risk exposure. Cybersecurity firm Norton reports that artificial intelligence and deepfake technology are increasingly being used to [modify long-standing scam methods](https://www.insurancebusinessmag.com/nz/news/cyber/ai-tools-drive-new-nz-fraud-patterns-voice-clones-deepfakes-and-fake-sites-surge-560314.aspx) rather than create entirely new ones, with criminals applying the tools to impersonation, phishing, romance fraud, and investment schemes that target both individuals and organisations. The company has identified five main AI-enabled scam types in 2025: voice cloning, AI-built phishing websites, AI-assisted romance scams, business email compromise using synthetic media, and fake celebrity endorsement schemes. “*AI tools are advancing at lightning speed, making everyday life more efficient and creative. But scammers are always close behind, weaponizing the same technology to trick, manipulate, and steal,*” said Michal Salát, a threat research expert at Norton. \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/5c344377-ec7c-90a1-73a3-c230d0a948a9.jpg) \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/1bb7e663-0a3b-3ed4-5c1d-9081a8caa44e.png) **Historic Lutsen Lodge owner charged with arson released on bail.** **BUSINESS ARSON** **December 17, Sacramento County, Calif. —** Bryce James Campbell has been accused of burning down an iconic North Shore lodge to escape financial woes and is now out of jail after posting bail Tuesday. *The allegations:* Court documents say that on the night of the fire at historic Lutsen Lodge, an employee called Campbell more than 30 times after discovering the fire on Feb. 6, 2024, but he didn’t answer. Prosecutors say Campbell texted his partner that he was driving a Ford Explorer from the resort, and squad car video from a deputy responding to the fire showed an SUV matching that description driving away from the fire. Campbell was arrested in Michigan on Dec. 3 and waived extradition back to Cook County. On Tuesday, the defendant posted $100,000 bail and agreed to a number of conditions for his release. Those conditions include refraining from mood-altering chemicals, not possessing firearms or ammunition, complying with warrantless searches of his person or property, and reporting to his probation officer once each month. **WORKERS’ COMPENSATION** **Former California Highway Patrol Officer ordered to pay over $300,000 in restitution for insurance fraud.** **December 17, Sacramento County, Calif. —** Jordan Roy Lester [pleaded guilty to felony insurance fraud on Wednesday](https://fox40.com/news/local-news/sacramento/ex-chp-officer-ordered-to-pay-over-300k-in-restitution-for-insurance-fraud/). Lester was a CHP officer assigned to the Central Division. On July 11, 2021, he told his superior that he had been injured on the job. The injury was deemed insignificant, and Lester was not placed on duty. Officials reported that during that time, Lester purchased a property in the Quincy area. He traveled there on his days off and worked on his property. When Lester did not receive the transfer to Quincy he requested, he began communicating with a former CHP officer about obtaining a medical retirement and offered to pay the retired officer for his assistance. Authorities stated that a medical retirement would result in 85 percent of his salary for life, tax-free. In 2022, Lester saw a doctor for the injury he claimed to have sustained almost six months earlier. After being seen, he was placed on medical leave based on his statements to his physician. While on medical leave, Lester told his treating physician that standing, sitting, and simple household chores caused significant pain. SCDAO said that Lester was placed off duty due to his complaints of pain and his stated limited physical abilities. As Lester was collecting workers’ compensation benefits, he was working on his new property, cutting trees, stacking firewood, operating heavy machinery, and engaging in heavy physical activity. A few months later, an independent medical examiner saw Lester in Feb. 2024 and determined that he was able to perform all work duties and that Lester exaggerated his complaints. **CONTRACTOR FRAUD** **North Carolina roof scam sting leads to arrests.** **December 12, Raleigh, N.C. —** North Carolina Insurance Commissioner Mike Causey announced that a roof scam sting operation resulted in the arrest of one man, with a second pending. The operation was coordinated by the Department of Insurance’s fraud investigators and the North Carolina Farm Bureau’s Special Investigations Unit. The allegations: Robert Allen Bentley is a senior project manager with A&M Premier Roofing & Construction. He faces charges of insurance fraud, attempted obtaining property by false pretenses, and conspiracy — all felonies. Bentley allegedly conspired with a co-worker to defraud North Carolina Farm Bureau Insurance Group. Investigators say the men [damaged and bent shingles on a Wake County home and then filed a false claim](https://www.johnstoniannews.com/news/north-carolina-roof-scam-sting-leads-to-arrest-772f6dba), stating the roof damage was caused by wind and hail. The scheme was an attempt to collect a $30,000 insurance payout. The investigation used a “*bait house*” to catch roofing company employees who intentionally damaged roofs to create repair work for themselves and support fraudulent insurance claims. **HOMEOWNERS CLAIMS** **Charleston man accused of forgery in $8,500 insurance claim on his home.** **December 16, Charleston, S.C. —** Stephen Andrew Adams faces charges of forgery valued at less than $10,000 and [presenting a false claim for insurance payment](https://abcnews4.com/news/local/charleston-man-accused-of-forgery-in-8500-insurance-claim-sled-investigation-reveals). *The allegations:* Adams filed an invoice for reimbursement totaling over $8,500 with USAA, claiming his home was uninhabitable during renovations for a covered property insurance claim. The reimbursement was reportedly intended to cover the man’s expenses for renting a temporary property until work was complete, but USAA reviewed the claim and found “*multiple concerns.*” USAA discovered that the rental property’s address did not exist, SLED said. After providing an alternate address, an investigation uncovered that Adams had not entered into any lease agreement to rent the property. **BUSINESS ARSON** **Convicted father-son duo that set fire to his family restaurant learn their sentence.** **December 16, White Cloud, Mich. —** David Robinson and his son Ryan co-owned Charlie’s Family Grill. A jury [convicted the pair of arson and insurance fraud](https://www.wzzm13.com/article/news/local/father-convicted-arsonist-who-set-fire-family-restaurant-with-his-son-for-insurance-money-learns-sentence/69-5e002509-98be-47da-862d-94653e4052b3) this summer. Now, weeks after his son was sentenced for the crime, David learned his sentence. David and Ryan co-owned Charlie’s Family Grill in White Cloud. The restaurant was destroyed by a fire on March 18, 2023. Prosecutors said the fire was a ploy to get insurance payouts. In court on Monday, he was sentenced to 2.9 years to 20 years with credit for 128 days already served. His son, Ryan, was sentenced in November to 5.5 years to 20 years. Ryan was also convicted on false pretense charges in relation to a garage fire. While there were no victims in the fire, the prosecutor spoke at David’s sentencing and said the fire still had a significant impact on the community and put many lives at risk, and asked that this be taken into consideration. “*It is clear that Mr. Robinson didn’t care about anyone else. He wanted this, he wanted the money, and he didn’t care how he got it, he didn’t care who he hurt in the process,*” Thee prosecutor said. “*It’s not a victimless crime; this is the thing that makes everyone else’s insurance rates skyrocket.*“ **MEDICAL CLAIMS** **Delaware man indicted on healthcare fraud and identity theft.** **December 18, Lewes, Del. —** Ty Mauldin, who worked at several healthcare clinics in Delaware, faces charges of identity theft, healthcare fraud, and obtaining drugs by fraud. *The allegations:* Mauldin provided medical billing and credentialing services at a clinic that provided transcranial magnetic stimulation in 2024 and 2025, and for a healthcare clinic focused on mental health treatment that shared the same building; and he worked at an urgent care walk-in clinic in 2023-25. The indictment states [Mauldin lied about his professional qualifications](https://www.capegazette.com/article/former-lewes-man-indicted-healthcare-fraud-stealing-identity/299448) and falsified information to obtain medical credentials that he would not otherwise have been granted. In February 2024, court records state, he applied to be a registered nurse in Delaware, listing false degrees and credentials before withdrawing his application after officials questioned it. In May 2024, records state, Mauldin applied for medical assistant certification and forged the signature of a nurse practitioner to attest to competency in venipuncture and other techniques. By August 2024, records state he obtained TMS therapy training certification that falsely showed he had a Bachelor of Science degree in nursing and was a registered nurse. \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a87896d8-5c0c-5f11-a057-a26dd5714ac8.jpg) \| \|---\| \| \|---\| \| \|---\| \| \| \| [ ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/6caa8d84-b38a-7084-bcf0-9b5d7306f4be.png) ](https://www.wral.com/consumer/5onyourside/roof-insurance-fraud-sting-arrest-december-2025/) \| \| **Robert Allen Bentley** Charlotte, N.C. Contractor Fraud *ARRESTED* \| \| [ ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/55c8e59b-63ca-32a0-3ebf-d5c7e2954c0e.png) ](https://www.walb.com/2025/12/17/minister-son-arrested-insurance-fraud-charges-coffee-county/) \| \|:-:\| \| **Horace Kelly** Coffee County, Ga. Fraud General *ARRESTED* \| \| \|---\| \| \| [ ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/699b6149-b650-b4da-023b-d68383376237.png) ](https://www.walb.com/2025/12/17/minister-son-arrested-insurance-fraud-charges-coffee-county/) \| \|:-:\| \| **Greta Patterson** Coffee County, Ga. Fraud General *ARRESTED* \| \| [ ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/ade62f31-85b3-75a1-e964-56bae32400cd.jpg) ](https://insurancefraud.org/report-fraud/) \| \|:-:\| \| \| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a4e430c0-c419-3044-1add-d368ddda9e22.jpg) \| \|---\| \| \|---\| \| \| **![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/781d09ff-0b1e-f8f2-939b-fea070289d01.png) Welcome Global Insurance Fraud Summit** The Coalition would like to welcome the Global Insurance Fraud Summit as our newest member. (GIFS) was created to confront a growing global reality. Insurance fraud is no longer isolated or opportunistic. It is increasingly organized, transnational, and interconnected across carriers, jurisdictions, and criminal networks. No single insurer, agency, or organization can address these threats alone. Meaningful progress depends on trusted collaboration, shared intelligence, strong industry partnerships, and values aligned with the mission of the Coalition Against Insurance Fraud. GIFS is a global, cross sector nonprofit charitable organization that convenes senior leaders from insurance carriers, special investigation units, law enforcement, regulators, prosecutors, and select industry partners, many of whom are active Coalition members. The Summit is designed to foster high value networking, strategic collaboration, and real world intelligence sharing among professionals on the front lines of fraud detection, investigation, and enforcement. Rather than emphasizing formal education or vendor driven presentations, GIFS prioritizes candid dialogue, peer exchange, and relationship building that continues well beyond any single event. Insurance fraud has become a global, organized threat requiring an equally coordinated response built on collaboration, shared intelligence, and strong public private partnerships. GIFS advances this effort by connecting organizations, jurisdictions, and disciplines to disrupt transnational criminal networks and protect the integrity of the global insurance ecosystem. As insurance fraud continues to evolve, GIFS remains committed to expanding its global footprint in partnership with the Coalition Against Insurance Fraud, turning collaboration into collective action and putting fraudsters on notice that the global insurance community is united. Once again we welcome GIFS and look forward to working together in the coming years. \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/599cd350-ea52-4495-1186-5f4cf595e458.jpg) \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/57adb490-3a05-788f-da57-73f58fa10ff3.png) \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/6c567831-8198-51ef-1328-53ac3dc0446a.jpg) \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/9d9a163b-d608-c29e-1f8c-71c58f193f3a.jpg) \| \|---\| \| \|---\| \| \| **January 27 — [CrashCon: Spotting Staged Auto Accidents](https://events.teams.microsoft.com/event/b4faa160-8d52-4a31-9986-070f2f3451e7@aa3f6158-a750-475d-a17c-8438fe053836)** Online (Becker & Company) **January 27-29 — [Motor Vehicle Fire Investigation](https://www.firearson.com/training/classes/motor-vehicle-fire-investigation-3-day/)** (IAAI) **April 22, 2026 — [2026 Annual Anti-Fraud Conference](https://insurancefraud.us1.list-manage.com/track/click?u=a440c5b647697de580a2fd586&id=ae9d6a7a4d&e=cf8d2cdb4f)** Monterey, Calif. (AFA) \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/31844b25-f788-1b6b-2be5-b149c03a44dd.jpg) \| \|---\| \| \|---\| \| \| \* [**Doctor Acquitted of Conspiracy in Workers’ Comp Fraud Case**](https://mynewsla.com/crime/2025/12/18/doctor-acquitted-of-conspiracy-in-workers-comp-fraud-case/#google_vignette) \* [**Australian Regulators Anticipate Holiday Spike in Scam Activity**](https://www.insurancebusinessmag.com/au/news/cyber/australian-regulators-anticipate-holiday-spike-in-scam-activity-560749.aspx) \* [**Man Indicted for Stealing $1 Million in Social Security and Insurance**](https://www.abc4.com/news/crime/man-indicted-allegedly-stealing-benefits/amp/) \* [**Man Sentenced in Newark Court for Role in Health Care Fraud**](https://www.rlsmedia.com/article/man-sentenced-newark-court-role-health-care-fraud-kickback-scheme) \* [**Major Irregularities in Crop Insurance Scheme**](https://the420.in/bundelkhand-crop-insurance-scam-land-area-four-times-mahoba-jhansi/) \| \|---\| \| \|---\| \| \| [ ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/97dd66bf-afb1-c7d4-8c40-be93fffb3d95.jpg) ](https://s.surveyplanet.com/bj1sw6en) \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/4b1136e8-4c9e-4d00-bc11-54758a3ea8a6.png) \| \|---\| \| \|---\| \| \|---\| \| \| \| **Follow Us On Our Social Media Platforms:** \| \| \|---\| \| \| [ ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/148b79cf-2c06-6469-b7c8-335c1c8b971a.jpg) ](https://insurancefraud.us1.list-manage.com/track/click?u=a440c5b647697de580a2fd586&id=5214c5e629&e=cf8d2cdb4f) \| \|---\| \| \|---\| \| \| [ ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/39ae0e7d-0388-20e5-5755-020aec6cf995.jpg) ](https://insurancefraud.us1.list-manage.com/track/click?u=a440c5b647697de580a2fd586&id=06da6de163&e=cf8d2cdb4f) \| \|---\| \| \|---\| \| \| [ ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/86c49df9-4380-51e5-da9c-f83034fc7555.jpg) ](https://insurancefraud.us1.list-manage.com/track/click?u=a440c5b647697de580a2fd586&id=b349097e98&e=cf8d2cdb4f) \| \|---\| \| \|---\| \| \| \| \|---\| \| \|---\| \| \| **Contact:** Phone: [202.393.7330](tel:2023937330) Email: <info@insurancefraud.org> Address: 1012 14th Street, NW Suite 610 Washington, DC 20005 [www.InsuranceFraud.org](http://www.insurancefraud.org/) Want to change how you receive these emails? You can [update your preferences](https://insurancefraud.us1.list-manage.com/profile?u=a440c5b647697de580a2fd586&id=b68dce7808&e=%5BUNIQID%5D&c=a0d117cf04) or [unsubscribe from this list](https://insurancefraud.us1.list-manage.com/unsubscribe?u=a440c5b647697de580a2fd586&id=b68dce7808&t=b&e=%5BUNIQID%5D&c=a0d117cf04). \| \|---\| \| \|---\| \| \|---\| | |:-:| <html><p class="wp-block-paragraph"></p> **Features:** Fraud News Weekly --- ### [Fraud News Weekly - December 12, 2025](https://insurancefraud.org/publications/fraud-news-weekly-december-12-2025/) **Published:** December 12, 2025 **Author:** Coalition Against Insurance Fraud **Content:** UPDATE: 2025 Annual Meeting Content Now Available, Coalition Engages Key Regulators At The NAIC Annual Meeting, And New Warning On Insurance Scams | \| \| \| [View this email in your browser](https://mailchi.mp/c8c5792dde12/2025-annual-meeting-content-now-available-coalition-engages-key-regulators-at-the-naic-annual-meeting-and-new-warning-issued-on-insurance-scams-107036?e=%5BUNIQID%5D) \| \|---\| \| \|---\| \| \|---\| \| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/6a6e3e69-c10d-ae49-9e8e-f949ae4ca259.jpg) \| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/00ed7ac4-bb10-4f87-9d66-746db8688e48.png) \| \|---\| \| \|---\| \| \| **![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/1e84faf0-e87f-b8cf-b437-ddfd940751b6.jpg) NAIC Annual Meeting in Florida addresses AI Oversight,Third-Party Data, and Insurance Fraud Updates.** **The [2025 NAIC Annual Meeting](https://content.naic.org/events), held this week in Hollywood, Florida, brought together more than 2,500 state insurance regulators, industry stakeholders, consumer representatives, and numerous Coalition members to address pressing insurance regulatory priorities.** Florida CFO Blaise Ingolia welcomed attendees at the opening session, and outgoing NAIC president, North Dakota Commissioner Jon Godfread, officially passed leadership to incoming president Virginia Commissioner Scott White. The Coalition attended several key sessions relevant to its members. A significant focus was the [Big Data and Artificial Intelligence (H) Working Group](https://content.naic.org/committees/h/big-data-artificial-intelligence-wg), which reviewed detailed feedback on the second draft of the Artificial Intelligence Systems Evaluation Tool. This NAIC-developed framework is designed to help regulators identify and assess AI-related financial and consumer risks within insurers’ operations. The NAIC AI Systems Evaluation Tool is directly applicable to antifraud efforts, as it specifically addresses the use of AI systems for fraud detection in insurance operations or program areas. Discussion during the session included defining “*AI systems,*” protecting the confidentiality of market conduct findings, and ensuring the tool’s practicality. A third draft is in development, with plans for several states to pilot the evaluation tool in 2026. Regulators encouraged insurer participation in the pilot but are watchful of potential federal preemption concerns. [NAIC Consumer Representatives](https://content.naic.org/cmte_conliaison.htm), including Coalition director of government relations Brent Walker, engaged with key regulators, including Commissioner White and directors and commissioners from Missouri, Alaska, and Arkansas, to align on emerging priorities for 2026. Concurrently, the [Third Party Data and Models (H) Working Group](https://content.naic.org/committees/h/third-party-data-models-wg) explored regulatory frameworks for third-party model developers, considering possible state registration requirements and centralized filings while addressing trade secret protections and confidentiality concerns. This draft framework is relevant as it sets out to strengthens oversight of models from third-party vendors with consumer-impacting functions, including fraud detection. At the [Antifraud (D) Task Force](https://content.naic.org/committees/d/antifraud-tf), the Coalition presented findings from the recent PwC-supported Coalition research study examining generative AI’s impact on the insurance fraud landscape. The presentation highlighted insights gathered from state insurance fraud bureaus and prosecutors, emphasizing evolving risks and opportunities for fraud prevention. The Coalition also provided an organizational update and encouraged state fraud directors to share their legislative antifraud priorities for 2026. In addition to formal sessions, the meeting fostered important networking opportunities. The Coalition strengthened existing relationships and established new connections with regulators, legislators, and consumer advocates. As AI and data-driven technologies continue to transform the insurance ecosystem, the Coalition remains committed to supporting effective regulatory frameworks that protect consumers and advance the fight against insurance fraud. **Louisiana touts 2024 anti-fraud law as it was recently adopted as a national model.** The Louisiana Department of Insurance’s 2024 passage of an anti-fraud law that expanded definitions of fraudulent acts, is now recognized as a national model for states seeking to enhance their insurance fraud statutes with Coalition support at the recent National Council of Insurance Legislators (NCOIL) meeting. Sponsored by Rep. Gabe Firment, the new NCOIL amendment closes loopholes and gives states stronger tools to hold scammers accountable. “*Insurance fraud is a widespread problem that harms both policyholders and insurers,*” [said Insurance Commissioner Tim Temple](https://www.ldi.la.gov/news/press-releases/12-4-25-louisiana-anti-fraud-law-adopted-as-national-model). “*The adoption of Louisiana’s fraud law as the NCOIL national benchmark is a testament to our state’s commitment to protecting consumers and strengthening our insurance market. The Louisiana Department of Insurance applauds the efforts of Rep. Firment and NCOIL in passing this important model law.*” This success builds on the Coalition’s recent work at the NCOIL Annual Meeting in Atlanta, where legislators also approved critical amendments to update decades-old model laws targeting contractor fraud and storm chaser abuses. These efforts are helping states close enforcement gaps and respond to evolving fraud schemes, particularly in property and casualty insurance. \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/6b5470a4-ef85-47e4-bc7d-6740f8ed0cdb.png) \| \|---\| \| \|---\| \| \| **![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/89b143d2-b523-843b-7e5d-00cf4d23e562.jpg) New York Governor vetoes fraud assessment commission.** **New York Gov. Kathy Hochul vetoed a proposal to create an employer-funded account to pay for workers compensation fraud investigations and prosecutions, according to the Legislature’s website.** The governor on Friday vetoed S. 7950 and A 8429, which [would have created a nine-member fraud assessment commission](https://www.businessinsurance.com/ny-governor-vetoes-fraud-assessment-commission/) to work with the State Workers’ Compensation Board and the Workers’ Compensation Inspector General to raise money for prosecutors. The bill would have tasked the commission with helping determine the assessment to levy on employers and how to distribute the money to district attorneys. The proposal is similar to a fraud assessment commission California lawmakers created in 1991 and had unanimous support in both chambers. The governor did not explain her reason for vetoing the bill, and a veto message was not available Monday. **Insurance scam warning: fake delivery driver jobs this Christmas.** Job seekers are being warned of fake delivery driver work being listed over the festive period, [enabling insurance details to be stolen](https://nen.press/insurance-scam-warning-fake-delivery-driver-jobs-this-christmas/) by fraudsters. Stolen identities are highly valuable to fraudsters, who use them to carry out harmful scams such as Crash for Cash and Ghost Broking. Cases of identity theft reported to the Insurance Fraud Bureau (IFB) have risen annually, with a sharp [42% increase](https://email.cisionone.cision.com/c/eJwsj8uSpCAQRb9Gd1khmai4YNEbf6ODR9IypeAAdkf9_YQ1vT0nH_d6jcrJoWct5mmUhIrmftODmIUXZIxlZM9hccRzsMZiMCRn6qOeFjKjD9NCdrafQvgBlRBEo-zkUKPnZ_wLh4k7lwrTZKUNKkgJf55n2h-36He9tXbWjj46XDtcY6pXMclxKOby9ipsrkcuXx2uB_towHFqhe_JYCHxT-1wxQHHDte2MVxPqNDyCWfeo3vB-wxsudUztwqFv9ns7MFUOC-7Rwc_piT2kAOUWBligug5tdhe0DYOrf__t_DO5vZev8HnL-joQyyKBuqLTrm0jX1M71xy-LorPlw--toK83EvhwXNSKhgQjGAtORABYUQ5nkk4RnVOPXfGv8FAAD__9mmhAY) in the past year alone. Amid this trend, several insurers have told the IFB they’re finding more people are having their personal information stolen through fake delivery driver roles for insurance scams. Nicola Smith, Intelligence and Investigations Manager at the IFB, said: “*We’re concerned that more people are being caught out by fake delivery driver jobs and having their insurance details stolen for organised fraud. With more of these roles appearing in the run-up to Christmas and January sales, it’s crucial for those looking for delivery work to be aware and stay vigilant.*” **Ghost portals ‘*fool every police officer*’ as new fraud trend undermines frontline policing.** new breed of insurance fraud involving fake online portals designed to fool police officers by mimicking real digital insurer platforms has been confirmed. IFED head and detective chief inspector Nik Jethwa warned that the so-called “*ghost portals*” being seen by his policing unit [represented a significant evolution beyond traditional ghost broking](https://www.insurancetimes.co.uk/analysis/in-focus-ghost-portals-fool-every-police-officer-as-new-fraud-trend-undermines-frontline-policing/1457249.article), with the critical difference being that criminal groups are selling these fake insurance platforms to other fraudsters. “*\[Previously, I have spoken\] about how we’re seeing ghost brokers train other ghost brokers. That still continues, but what we’ve seen more recently is a number of fake portals coming up, which is relatively new, but it’s causing us a real issue.*” Unlike ghost broking – where victims are usually unaware they have been sold fraudulent insurance – ghost portal purchasers understand precisely what they are buying. The fraudulent platforms charge users for access to an insurer style app that displays fake policy documentation. \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/1d6f4f15-f20b-53f1-9319-4e9f7a9178e3.png) \| \|---\| \| \|---\| \| \| **![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/c855dc4d-ba63-e845-e240-95106a42db21.png) Brothers spent insurance fraud money on gold bars and watches.** **Two brothers from Naperville, Ill., are accused of submitting nearly $300 million in fraudulent insurance claims for services not provided and spending the proceeds on real estate, watches, vehicles and gold bars.** The brothers were indicted last week in a superseding indictment on charges related to the fraud scheme and for participating in a money laundering conspiracy with the proceeds. *The allegations:* Minhaj Feroz Muhammad, 37, and Sufyan Feroze, 35, owned and controlled, sometimes through straw owners, four clinical laboratories in Illinois and California. Their scheme sought to [defraud Medicare, Medicaid and private insurers](https://patch.com/illinois/naperville/naperville-brothers-spent-insurance-fraud-money-gold-bars-watches-doj) by submitting fraudulent claims of over $293 million for COVID-19 laboratory testing services that were never provided, for which insurers paid at least $65 million in reimbursements, according to the department. They participated in a money laundering conspiracy by transferring fraud proceeds between laboratories and other businesses. If convicted, they face up to 10 years in prison on each health care fraud charge and 20 years on the conspiracy to commit money laundering charge. **South Carolina woman charged with life insurance fraud.** Kimberly Denise Holloway has been charged with forging a deceased person’s signature to cash a life insurance policy surrender check. *The allegations:* According to the arrest warrants, around June 9, 2023, Holloway [forged the signature of a person who had died](https://www.wyff4.com/article/woman-charged-life-insurance-fraud-greenwood-sc/69664680) more than two months prior on a life insurance policy surrender check for $2,028. The check was issued by American General Life Insurance Company. SLED said that Holloway admitted that she forged the signature and cashed the check. **South Dakota man sentenced for wire fraud.** Gary Aaron King was an insurance broker company that sold college student health insurance. King has been the sole owner and president of Cypress Risk Management. In July of 2022 through the beginning of January 2023, [he planned a scheme to defraud various clients](https://www.kotatv.com/2025/12/05/gary-aaron-king-was-sentenced-3-years-1-month-wire-fraud/) utilizing his company, Cypress, with the purpose of enriching himself. Instead of remitting the premiums to the managing general agents, King switched the funds for his own personal spending and other business ventures. When Student Assurance Services didn’t get the insurance premium payments, the clients contacted King and the other employees of the company to question why they had not received any payment. King made many fake and fraudulent statements as to why the money had not been sent to the clients. In total, he fraudulently diverted $1,418,220.87 in insurance premiums for his own benefit. **South Carolina woman charged for staging a car theft.** Dearra Lashay Griffin, 39, was formally charged with Presenting a False Claim for Insurance Payment – Value $10,000 or More on Monday. *The allegations:* Griffin submitted a false claim for an insurance payment to GEICO [reporting that her 2017 Kia Sportage was stolen](https://www.wjbf.com/news/crime-news/aiken-co-woman-charged-by-sled-with-insurance-fraud/) from I-20 near Mile Marker 33 on July 9th, but GEICO was contacted by a local repair facility that the insured vehicle had been on the repair facility’s lot since July 6th. The arrest warrant states that Griffin admitted to falsely reporting the claim to GEICO due to mechanical issues during an audio/video recorded voluntary statement. Authorities state that Griffin unlawfully received $15,010 from the claim. **Calgary dentist who submitted $680k in phoney billings could get 3 years in prison.** Alena Smadych used to own All About Family Dental, once the highest billing clinic in Canada for root canals. In an agreed statement of facts filed as part of her guilty plea, Smadych [admitted to filing more than $684,000 in falsified billings](https://www.cbc.ca/news/canada/calgary/calgary-dentist-smadych-fraud-phoney-billing-sentencing-hearing-9.7005238) between 2013 to 2023. At a sentencing hearing on Friday, Justice Gord Wong heard that Smadych has since made full restitution. Smadych pleaded guilty to fraud in June for submitting more than $125,000 in phoney billing claims to Sun Life and Blue Cross insurance companies. Since then, three more insurance companies came forward, and Smadych has now admitted to another $558,000 in fraudulent billings. At Friday’s sentencing hearing, prosecutor Greg Whiteside told the judge that Smadych has a 2007 conviction for fraud that she received a pardon for in 2018, but that her new crime “*effectively brings that conviction back to life for the purpose of her criminal record.*” Whiteside proposed a two- to three-year sentence, while defence lawyer Alain Hepner asked Wong to consider a two-year conditional sentence order, meaning Smadych would be allowed to serve her sentence at home, under conditions. **Florida woman charged with insurance fraud.** 84-year-old Louise Leslie Waxman Feinstein is facing a felony charge after state investigators allege she submitted doctored receipts to support a $45,000 insurance claim for jewelry she said disappeared during a flight. *The allegations:* Feinstein filed a claim with USAA Insurance on December 20, 2024, reporting that various items—including a Cartier watch, a diamond ring, and a bracelet—were stolen while she was traveling from Florida to Ohio. Investigators say Feinstein submitted altered invoices to boost the value of the missing items, such as changing a $3,700 receipt for a Cartier Ballon Bleu watch to read $8,700, and manually changing the description on a bracelet receipt from sapphire to diamond. When confronted by detectives, Feinstein allegedly [admitted to modifying the documents](https://bocanewsnow.com/2025/12/09/elderly-boynton-beach-woman-charged-with-insurance-fraud/#google_vignette), reportedly telling investigators that she “*has a bad habit of writing on receipts*”. She further explained that she believed the alterations should not matter because her actual loss exceeded her policy limits, claiming the photos she submitted were taken from a jewelry catalog rather than depicting the actual items she owned. \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a87896d8-5c0c-5f11-a057-a26dd5714ac8.jpg) \| \|---\| \| \|---\| \| \|---\| \| \| \| [ ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/c766f9f5-9b00-1d8c-a31c-62b8cd476663.png) ](https://alachuachronicle.com/it-always-catches-up-with-you-gainesville-woman-arrested-for-over-10k-in-insurance-fraud/) \| \| **Chloe English Dunnell** Gainesville, Fla. Medical claims *ARRESTED* \| \| [ ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/c5ebbd1c-7602-e1c3-198b-6fd8bdf769f2.png) ](https://www.northernnewsnow.com/2025/12/04/lutsen-lodge-owner-bryce-campbell-charged-with-arson-insurance-fraud/) \| \|:-:\| \| **Bryce Campbell** St. Paul, Minn. Business arson *ARRESTED* \| \| \|---\| \| \| [ ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/913c43b1-7b44-99b8-2f15-111e48e6a473.png) ](https://www.northescambia.com/2025/12/jesse-lacoste-of-cantonment-gets-10-years-for-grand-theft-contractor-fraud) \| \|:-:\| \| **Jesse Wayne LaCoste** Escambia County, Fla. Contractor fraud *ARRESTED* \| \| [ ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/ade62f31-85b3-75a1-e964-56bae32400cd.jpg) ](https://insurancefraud.org/report-fraud/) \| \|:-:\| \| \| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/599cd350-ea52-4495-1186-5f4cf595e458.jpg) \| \|---\| \| \|---\| \| \| [ ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/fbbe3de1-57ef-b1af-7741-126f9df20b79.jpg) ](https://insurancefraud.org/2025-annual-membership-meeting-2/) \| \|---\| \| \|---\| \| \| [ ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/c493e399-5287-d9ab-a863-6def55ac173a.jpg) ](https://insurancefraud.us1.list-manage.com/track/click?u=a440c5b647697de580a2fd586&id=df84941755&e=cf8d2cdb4f) \| \|---\| \| \|---\| \| \| [ ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/8ae404df-58cf-d901-2972-452104d3ff1c.jpg) ](Mailto:communications@insurancefraud.org) \| \|---\| \| \|---\| \| \| [ ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/82bc7396-3a2d-5c34-e4ff-a1d3855f62d0.jpg) ](https://insurancefraud.us1.list-manage.com/track/click?u=a440c5b647697de580a2fd586&id=ffff4156fe&e=cf8d2cdb4f) \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/fea484ec-3c40-0761-f1da-d518a8cb9723.jpg) \| \|---\| \| \|---\| \| \| [ ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/10c48859-1279-e806-3a55-7ceca7e085a6.jpg) ](https://insurancefraud.us1.list-manage.com/track/click?u=a440c5b647697de580a2fd586&id=dbc5b5c389&e=cf8d2cdb4f) \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/9d9a163b-d608-c29e-1f8c-71c58f193f3a.jpg) \| \|---\| \| \|---\| \| \| **December 17 — [A Claimant’s Right To Privacy](https://event.on24.com/wcc/r/5028400/7129A49D74E96B49772B809511A5CA65)** Webinar (Ethos) **December 18 — [Emerging Fraud Trends in P&C Insurance](https://insurancefraud.us1.list-manage.com/track/click?u=a440c5b647697de580a2fd586&id=58bf78ed7d&e=cf8d2cdb4f)** Webinar (Coalition Against Insurance Fraud) **April 22, 2026 — [2026 Annual Anti-Fraud Conference](https://insurancefraud.us1.list-manage.com/track/click?u=a440c5b647697de580a2fd586&id=e75ea74833&e=cf8d2cdb4f)** Monterey, Calif. (AFA) \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/31844b25-f788-1b6b-2be5-b149c03a44dd.jpg) \| \|---\| \| \|---\| \| \| **\* [State Agencies Remind Pennsylvania Farmers of Affordable Options](https://fcfreepresspa.com/state-agencies-remind-pennsylvania-farmers-of-affordable-health-insurance-options/) \* [Failure in insurance process enables $38M work injury insurance fraud](https://www.asiainsurancereview.com/News/View-NewsLetter-Article/id/93864/type/eCin/Failure-in-insurance-process-enables-US-38m-work-injury-insurance-fraud) \* [Will Ontario’s auto insurance fraud reporting service go national?](https://canadianunderwriter.ca/news/industry/will-ontarios-auto-insurance-fraud-reporting-service-go-national/) \* [Life agent has license cancelled](https://www.bangkokpost.com/business/general/3154894/thai-life-agent-has-licence-cancelled) \* [Connecticut business owner didn’t offer employees workers’ comp insurance](https://www.fox61.com/article/news/crime/connecticut-business-owner-didnt-offer-employees-workers-comp-insurance/520-5477a6c5-34a8-4992-a453-58303b975f3c)** \| \|---\| \| \|---\| \| \| **Follow Us On Our Social Media Platforms:** \| \|---\| \| \|---\| \| \| [ ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/be4e5708-bdc4-c0df-6c03-a6ebd5b34c13.png) ](https://insurancefraud.us1.list-manage.com/track/click?u=a440c5b647697de580a2fd586&id=5214c5e629&e=cf8d2cdb4f) \| \|---\| \| \|---\| \| \| [ ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a1492a86-29b0-90b6-d879-527e5492037e.png) ](https://insurancefraud.us1.list-manage.com/track/click?u=a440c5b647697de580a2fd586&id=06da6de163&e=cf8d2cdb4f) \| \|---\| \| \|---\| \| \| [ ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/d2bd23eb-8810-4f7a-49d3-d2fe7aa1891e.png) ](https://insurancefraud.us1.list-manage.com/track/click?u=a440c5b647697de580a2fd586&id=b349097e98&e=cf8d2cdb4f) \| \|---\| \| \|---\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/4b1136e8-4c9e-4d00-bc11-54758a3ea8a6.png) \| \|---\| \| \|---\| \| \|---\| \| \| \| \| \| \|---\| \| \| **Contact:** Phone: [202.393.7330](tel:2023937330) Email: <info@insurancefraud.org> Address: 1012 14th Street, NW Suite 610 Washington, DC 20005 [www.InsuranceFraud.org](http://www.insurancefraud.org/) Want to change how you receive these emails? You can [update your preferences](https://insurancefraud.us1.list-manage.com/profile?u=a440c5b647697de580a2fd586&id=b68dce7808&e=%5BUNIQID%5D&c=31223f443b) or [unsubscribe from this list](https://insurancefraud.us1.list-manage.com/unsubscribe?u=a440c5b647697de580a2fd586&id=b68dce7808&t=b&e=%5BUNIQID%5D&c=31223f443b). \| \|---\| \| \|---\| \| \|---\| | |:-:| <html><p class="wp-block-paragraph"></p> **Features:** Fraud News Weekly --- ### [Fraud News Weekly - December 5, 2025](https://insurancefraud.org/publications/fraud-news-weekly-december-5-2025/) **Published:** December 5, 2025 **Author:** Coalition Against Insurance Fraud **Content:** 2025 Annual Meeting Success, AI Rewriting Insurance Playbook, Upcoming December 18th Webinar | \| \| \|:-:\| \| Friday, December 5, 2025 \| \| \| | |:-:| | \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/df906857-d727-9ee9-0397-2a09caac30a4.png) \| \|:-:\| \| \| \| \| \| \|:-:\| | |:-:| | \| [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a1492a86-29b0-90b6-d879-527e5492037e.png)](https://www.facebook.com/profile.php?id=61579225779934#) \| \|:-:\| \| \| \| \| \| \| [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/d2bd23eb-8810-4f7a-49d3-d2fe7aa1891e.png)](https://www.instagram.com/stopinsurancefraud/)[![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/be4e5708-bdc4-c0df-6c03-a6ebd5b34c13.png)](https://www.linkedin.com/company/coalition-against-insurance-fraud) \| \| \| \| \| \|:-:\|---\| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7e6cccc1-3a5e-4803-a7f8-7325e7e155cb.gif) \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7e6cccc1-3a5e-4803-a7f8-7325e7e155cb.gif) \| ![](images/spacer.gif) \| \| \|:-:\| \| \| | |:-:| | \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a57e030f-61fa-473f-b132-259b1a34e42e.png) \| \|:-:\| \| \| \| \| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a1d370da-d7d1-8ca9-e60b-90d2a856a84d.jpeg) New Hampshire Insurance Department shared insights into agent and broker misconduct via webinar and issued a bulletin reminding insurers to report health care fraud. Last week, the Coalition attended the New Hampshire Insurance Department’s (NHID) [webinar](https://www.youtube.com/@NHInsuranceDept), “*Identifying Financial Abuse in Insurance,*” focused on agent and broker misconduct as a key source of financial abuse and fraud risk in the Granite State’s insurance market. [NHID Commissioner Bettencourt](https://www.insurance.nh.gov/about-us) began by emphasizing that most agents and brokers in the state operate honestly and serve consumers well. The session provided a comprehensive overview of how financial abuse emerges through deceptive sales of bundled “Frankenstein” products, questionable annuity practices like commission churning, and issues with Medicare Advantage and Medicare Supplement sales. NHID handles about 1,200 consumer complaints and several hundred fraud referrals annually related to such misconduct. Its Enforcement, Market Conduct, and Fraud divisions collaborate to investigate civil, systemic, and criminal violations, resulting in fines, cease sale orders, and ongoing probes. Separately, NHID [recently](https://www.insurance.nh.gov/news-and-media/new-hampshire-insurance-department-reinforces-fraud-reporting-obligations-health) issued a [bulletin](https://mm.nh.gov/files/uploads/nhid/documents/20251121-bulletin-ins-25-084-ab-1.pdf) reminding health carriers and producers to report suspected fraudulent medical billing by health care providers to NHID. Together, these efforts reflect NHID’s proactive leadership and highlight the vital role of timely fraud reporting and strong public-private cooperation in protecting consumers and the insurance marketplace from misconduct that often leads to fraud. Connecticut announces leadership change as Commissioner Mais retires and Hershman is nominated. Connecticut Governor Ned Lamont has [announced](https://portal.ct.gov/governor/news/press-releases/2025/11-2025/governor-lamont-announces-insurance-commissioner-andrew-mais-retiring-from-state-service?language=en_US) that Connecticut Insurance Department Commissioner Andrew N. Mais will retire, after a tenure marked by strong consumer protection and national regulatory leadership. As 2024 NAIC president, Mais championed the theme “*Mind the (Insurance) Gap,*” urging regulators to remove unnecessary barriers to insurance coverage and expand access to underserved populations. Governor Lamont has nominated former CID Deputy Commissioner Josh Hershman to succeed him in an interim role. Hershman brings experience as a life-insurer CEO, regulatory innovator, and leader during CID’s modernization and data-driven oversight initiatives. Mais and Hershman have both emphasized safeguarding consumers, promoting market stability, and supporting a vibrant, forward-looking insurance industry. NAIC Antifraud Task Force proposes new mission language and technology priorities for 2026. The National Association of Insurance Commissioners (NAIC) Antifraud (D) Task Force’s [proposed 2026 charges](https://content.naic.org/sites/default/files/inline-files/17-AFTF.pdf) reflect an intent to expand its mission and strengthen state-level fraud oversight, while modernizing the infrastructure that regulators use to detect insurance crime. New language defines the Task Force’s purpose as serving the public interest by assisting state insurance supervisors through the detection, monitoring, and referral of insurance crime, both by and against consumers. It also outlines new responsibilities that include maintaining and improving electronic fraud databases, disseminating fraud trend analysis and case-specific insights to regulators, and providing a liaison function with state, federal, local, and international law enforcement as well as antifraud organizations. These updates are in line with several Coalition advocacy efforts with NAIC, including [urging](https://insurancefraud.org/wp-content/uploads/6-2-25-NAIC-LTC-Letter.pdf) the Task Force to create a new Long Term Care fraud category in the Online Fraud Reporting System (OFRS) and [calling for](https://insurancefraud.org/wp-content/uploads/CAIF-Letter-To-NAIC-CEO-8-13-24.pdf) stronger NAIC IT investment after delays in the Antifraud Plan Repository. The 2026 proposed charges begin to address these concerns by directing ongoing repository maintenance and enhancing OFRS functionality. The Coalition will also provide an organizational update during the upcoming [2025 NAIC Fall National Meeting](https://content.naic.org/events) in Hollywood, Florida. \| \| \| \| \| \|:-:\|---\| \| \|:-:\| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7e6cccc1-3a5e-4803-a7f8-7325e7e155cb.gif) \| \| \| | |:-:| | \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/8cabe36d-e42d-387f-2792-ee8bb3005e58.png) \| \|:-:\| \| \| \| \| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/71263c51-bfff-f338-a87a-8b2a6e77b3dc.png) AI isn't just cutting costs – it's rewriting the insurance playbook. For years, customers struggled to understand how premiums were calculated. Now, AI offers more transparency. According to José Luis Bernal, chief digital, data and innovation officer at MAPFRE USA, the biggest impact may be trust. “*AI is bringing much more predictive predictability into the premiums,*” Bernal said. “*It can be done much more accurately and, with a new technology, much more firm and being explainable to the end customer.*” Bernal said this shift could finally give customers clarity on what they’re paying for – something they’ve long demanded. Alongside greater accuracy, automation [continues to drive down operating costs](https://www.insurancebusinessmag.com/us/news/technology/ai-isnt-just-cutting-costs--its-rewriting-the-insurance-playbook-558813.aspx). But Bernal pointed to another win: better fraud detection. “*Right now, those third customers are paying the premium of the fraudulent customers,*” he said. “*Thanks to AI, now we can detect much more accurately.*” Insurance companies face privacy risks while fighting AI fraud. Artificial intelligence (AI) is transforming the way the insurance industry detects insurance fraud, shifting from a reactive system to predictive and real-time prevention. However, as insurance companies automate the random analysis of claims and insurance policies, the need to balance innovation with confidentiality and [ethical accountability is becoming increasingly important](https://insurancekhabar.com/en/insurance-companies-face-privacy-risks-while-fighting-ai-fraud-2/). According to Rupa Malhotra, Head of Customer and Digital at APAC, Zurich Insurance, this transformation represents a major change in the way insurance companies fight fraud. “*AI is moving from static rule-based systems to dynamic learning models. Who can identify suspicious behavior as soon as it occurs.*” For Ho Sheng Chia, Senior Customer Success Manager at Shift Technologies, adopting AI is about fulfilling a larger societal purpose. “*Our aim here is really for the good of society. This is really about protecting the honest insured and ensuring genuine claims are paid quickly and accurately,*” he said, adding that keeping premiums affordable and maintaining a sustainable claim loss ratio is critical to the long-term survival of insurance companies. However, both experts agree that the promise of AI depends on trust. Malhotra said, “*AI and data privacy have to evolve along with privacy. One cannot move forward responsibly without the other.*” Callers requesting Social Security numbers from Iowa Medicare beneficiaries. The Iowa Insurance Division’s Senior Health Information and Senior Medicare Patrol Program has issued a [fraud alert for calls requesting social security numbers](https://www.kwqc.com/2025/12/04/scam-alert-callers-requesting-social-security-numbers-iowa-medicare-beneficiaries/) from Iowa Medicare beneficiaries. Callers are identifying themselves as representatives of Medicare plans and tell Iowans their Social Security information is necessary to ensure plan premiums are withheld from Social Security payments. “*Anyone calling and asking for your Social Security number or banking information is likely trying to commit fraud,*” said Iowa Senior Health Information and Senior Medicare Patrol Director Kristin Griffith. “*Be especially vigilant of callers using high-pressure tactics such as threatening to remove services because you are not taking immediate action.*” According to the media release, Medicare Advantage Plan providers and Medicare Prescription Drug Plan providers can set up premium withholdings without a Social Security number. \| \| \| \| \| \|:-:\|---\| \| \|:-:\| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7e6cccc1-3a5e-4803-a7f8-7325e7e155cb.gif) \| \| \| | |:-:| | \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/1d6f4f15-f20b-53f1-9319-4e9f7a9178e3.png) \| \|:-:\| \| \| \| \| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/2dc456c4-d2c9-bb9d-d2ec-428bf97e0ed4.jpg) New York construction firm and it’s owner sentenced for insurance fraud. Mahendranauth Khargie, 36, and his company, GC Stud Inc., [substantially underreported the total amount of their payroll](https://lilifepolitics.com/news/businesses/rockville-centre-man-construction-firm-sentenced-for-insurance-fraud/) during three policy periods between April 2019 and March 2022, resulting in premium fraud. As a NYSIF Workers’ Compensation policyholder, Khargie and his company are required to provide financial records concerning income and employee payroll to NYSIF every year the policyholder renews its coverage. Records revealed that large payments to the defendants were made by three different steel and iron fabrication companies during the time of the investigation. The defendants hid the money, deposited the funds in a JPMorganChase account, and did not provide that account to the NYSIF premium auditors. Over the course of the scheme, Khargie underreported his payroll to NYSIF by more than $3.5 million, resulting in underpayments of the company’s Worker’s Compensation policy premiums. Construction company must pay $725,000 for wage theft settlement. Christian Siding, a construction company that has worked on projects across DC, must pay $725,000 to resolve allegations that the company failed to pay “*prevailing wages*" to workers on three publicly-funded affordable housing projects and misclassified workers as independent contractors on 13 additional projects. They were not paid overtime wages when they worked more than 40 hours in a week, did not receive paid sick leave, and [were not protected by unemployment insurance or workers’ compensation](https://oag.dc.gov/release/attorney-general-schwalb-secures-725000). The Office of the Attorney General (OAG) also alleged that Christian Siding deprived these workers of overtime wages and benefits, like paid sick leave and overtime pay, that they were legally entitled to. Under the terms of a settlement agreement, Christian Siding will pay more than $364,000 to 229 harmed workers, as well as $360,000 in penalties to the District, and will be required to make significant changes to its business practices and submit to compliance monitoring for two years. California suspects linked to insurance scam involving staged rideshare crashes. A staged crash on the I-215 freeway that targeted a rideshare driver and aimed to [defraud their insurance](https://www.vvng.com/hesperia-and-adelanto-suspects-linked-to-insurance-scam-involving-staged-rideshare-crash/) has led to felony convictions for four men, including one from Hesperia, while a fifth suspect from Adelanto remains charged and faces additional counts of pimping, pandering, and false imprisonment. Kalil Davis pleaded no contest to insurance fraud and assault with a deadly weapon. He was sentenced to 180 days in county jail and two years of felony probation. Meanwhile, Deshawn Perater-Nickson was the registered owner of the vehicle used in the staged crash. He was arrested earlier this year and initially charged with insurance fraud and assault with a deadly weapon. However, while in custody, investigators uncovered evidence linking him to additional crimes including false imprisonment, pimping, and pandering. He is expected to appear in court on January 26, 2026. GEICO alleges a $4 million no-fault pharmacy fraud scheme in Queens. In a filing dated November 26 in the United States District Court for the Eastern District of New York, GEICO set out detailed allegations against United Pharmacy NYC Inc., its owner, Irina Alishayeva, two nurse practitioners, and a series of unnamed “John Doe” defendants. *The lawsuit alleges:* GEICO alleges the defendants exploited individuals involved in motor vehicle accidents who were eligible for Personal Injury Protection benefits by [systematically dispensing certain prescription drugs](https://www.insurancebusinessmag.com/us/news/claims/geico-alleges-4-million-nofault-pharmacy-fraud-scheme-in-queens-558456.aspx) without regard to genuine patient care. According to the filing, the defendants submitted more than $4 million in pharmaceutical claims through United Pharmacy under GEICO policies. State Farm sued over PHL policies as buyers insurance claim fraud, gutted payouts. The lawsuit, Jason v. State Farm, 25-cv-14507, filed Nov. 26 in Chicago, accuses State Farm of fraud and unjust enrichment, arguing the insurer [concealed what it knew about PHL’s condition](https://beinsure.com/news/state-farm-sued-over-phl-policies/) and the repercussions for policyholders. *The allegations:* Plaintiffs say they trusted State Farm’s agents and brand, only to discover years later that their promised benefits had quietly shrunk. Three customers bought PHL-issued life insurance from State Farm agents: Jenny Nappo, Patrick McLaughlin and Gordon Jason. Nappo says she expected a $2mn payout when her husband died of cancer but received only $300,000. McLaughlin and Jason each bought policies worth $1.5mn and $500,000, respectively, and now report their benefits capped at $300,000 apiece. PHL’s troubles aren’t new. The Connecticut-based company has dealt with outdated actuarial assumptions, poor investment performance and a decade of balance sheet erosion. Its owner, Golden Gate Capital, tried to stabilise the business using complex risk-shifting transactions, but the fixes didn’t hold. Thousands of policyholders ended up in limbo as PHL’s capital hole widened. Golden Gate didn’t respond to requests for comment. State Farm says it’s aware of the lawsuit but hasn’t been served and can’t comment on the specifics. Iowa man receives deferred judgment for forging pet insurance claim. Greg Buelow pleaded last Thursday to tampering with records, an aggravated misdemeanor. In his written plea, Buelow admitted “*I did falsify, destroy, remove or conceal a writing or record with the intent to injure, deceive or to conceal a wrongdoing.*” In addition, he pleaded guilty last week for [submitting a forged receipt for pet medications](https://www.thegazette.com/crime-courts/cedar-rapids-man-convicted-of-filing-fake-pet-insurance-claim-will-ask-for-probation/) to an insurance company and received a deferred judgment Tuesday. Buelow provided false information to an insurance company for a pet insurance claim. The submitted falsified invoice for reimbursement, purportedly issued by a veterinary clinic, was for prescription medications for his dog. The incident happened June 2, the complaint stated. The complaints don’t include the amount of false reimbursements. Texas man arrested on organized criminal activity and insurance fraud charges. Jorge Celiz, has been arrested and is currently in custody in Tarrant County, Texas, where he is [facing two serious felony charges](https://www.breakingbelizenews.com/2025/11/26/orange-walk-resident-jorge-celiz-arrested-in-texas-on-organized-criminal-activity-and-insurance-fraud-charges/). *The allegations:* No additional details regarding the alleged criminal scheme have been released, and it is unclear whether more charges may follow. U.S. authorities have not yet issued a formal statement regarding the circumstances leading to his arrest. Celiz is expected to face court in the coming days as the investigation continues. Records indicate that Celiz has been placed on no-bond hold conditions, meaning he cannot be released until further court proceedings. His current housing location is the Tarrant County Corrections Center, where he remains detained pending legal action. \| \| \| \| \| \|:-:\|---\| \| \|:-:\| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7e6cccc1-3a5e-4803-a7f8-7325e7e155cb.gif) \| \| \| | |:-:| | \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/05ebd826-d3ed-4100-a4b0-7c83841fc259.png) \| \|:-:\| \| \| \| \| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/_compresseds/a0d786f0-e8c5-8430-8a08-e0e884ddc836.jpg) What an incredible Annual Meeting we had this year. Nearly **180 members** joined us in Arlington, VA., on Dec 2 and 3, along with **37 first-time attendees** and **7 new members** since June, making this one of our strongest turnouts yet. Member engagement and collaboration set the tone for an incredible meeting, featuring a dynamic lineup of speakers and panelists who delivered insights on the current landscape of insurance fraud, policy shifts, investigative trends, and innovative solutions. Their expertise helped spark meaningful conversations and actionable ideas, and we extend our sincere thanks to each presenter who contributed to the strength of this year’s program. This year also marked an important transition in **Coalition leadership**. The Executive Committee confirmed several key appointments that will guide the organization forward. Most notably, **Steve Piper of CNA Insurance** was unanimously named the Coalition’s new **Insurer Co-Chair**. Steve steps into the role previously held by **Dave Rioux of Erie Insurance**, whose dedication and service have left a lasting impact. Steve’s steady involvement and deep commitment to the Coalition make him exceptionally well-positioned to carry this responsibility. Additional leadership actions included the selection of **John Sokit** of **Nationwide Insurance** as Treasurer, the reappointment of **Michelle Rafeld** as Executive Director for another one-year term, and the appointment of **Anna Flores** of **Consumer Action** to a new four-year term. One of the many highlights of the meeting was the recognition of **Sean Clifford**, First Assistant Attorney General with the Office of the Colorado Attorney General, who received the **Prosecutor of the Year** award. His exceptional work and dedication to combating insurance fraud made this honor especially well-deserved. The Coalition thanks every member who attended and contributed to the success of the 2025 Annual Meeting. Your participation continues to push the Coalition forward. We look forward to building on this momentum with you in 2026 and to seeing everyone next June at the Midyear Meeting in New Orleans. Please watch out for an announcement next week with information on how to access the presentations shared during the meeting. ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/f8628f05-c69a-b49b-5c6b-325c1455059a.png) ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/34d1f340-93a8-03e8-65ff-99fd6a723e6d.png) [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/1ce4a222-3707-daaf-86bf-d0078f1d7693.png)](https://s.surveyplanet.com/bj1sw6en) [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/6c8550d3-4d99-bc65-c8f8-cd1902423e17.png)](https://members.insurancefraud.org/general/pick_username.asp) ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/3ef40901-b851-f621-08b2-322f09ca8a57.png) [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/6f681cdb-233b-3a23-d74d-8d2ea782b4a3.png)](https://us02web.zoom.us/webinar/register/WN_UJnqT5-bQ6-zLdlTPU2PHQ) \| \| \| \| \| \|:-:\|---\| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7e6cccc1-3a5e-4803-a7f8-7325e7e155cb.gif) \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7e6cccc1-3a5e-4803-a7f8-7325e7e155cb.gif) \| ![](images/spacer.gif) \| \| \|:-:\| \| \| | |:-:| | \| \| \| FACES OF FRAUD \| \|---\|:--\| \| \| \| \| \| \| \| [![](https://via.placeholder.com/125x166)](https://www.tn.gov/finance/news/2020/9/28/davidson-co--woman-charged-with-tenncare-fraud.html) \| \| \| \| [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/08af8687-5ff9-8030-ce3b-351c890fe6ea.png)](https://www.kltv.com/2025/12/02/longview-funeral-home-chair-accused-defrauding-woman-sisters-life-insurance/) **Joshua Anderson Sr.** Longview, Texas Life insurance *ARRESTED* \| \| \| \| [![](https://via.placeholder.com/125x166)](https://www.southwesttimes.com/2020/09/false-scripts-bills-send-doctor-to-prison/) \| \|:-:\|---\|:-:\| \| \| \| [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/180e5e4e-9d3a-5953-525c-538d9e453268.png)](https://wreg.com/news/mid-south/tn-man-accused-of-setting-his-suv-on-fire-in-fraud-scheme/) **William Holland** Covington, Tenn. Auto arson *ARRESTED* \| \| \|:-:\| \| \|:-:\| \| \| \| [![](https://via.placeholder.com/125x166)](https://www.timesrepublican.com/news/todays-news/2020/09/mpd-handles-multiple-burglaries-1-arrested/) \| \|:-:\| \| \| \| [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/51b72e0a-8053-ffc6-fbdd-8555c1d2bfb3.png)](https://www.wzzm13.com/article/news/local/charlies-family-grill-arson-ryan-robinson-sentenced/69-0c27944c-bbae-4ec6-8832-8e2bfc3e4cef) **Ryan Robinson** Newaygo County, Mich. Business arson *SENTENCED* \| \| \| \| [![](https://via.placeholder.com/125x166)](https://www.wmbfnews.com/2020/09/22/longs-woman-arrested-accused-forging-prescriptions/) \| \|:-:\|---\|:-:\| \| \| \| [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/ade62f31-85b3-75a1-e964-56bae32400cd.jpg)](https://insurancefraud.org/report-fraud/) \| \| \|:-:\| \| \|:-:\| \| \|---\| \| \|:-:\| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7e6cccc1-3a5e-4803-a7f8-7325e7e155cb.gif) \| \| \| \| \| \|:-:\|---\| | |:-:| | \| \| \| EVENTS \| \|---\|:--\| \| \| \| \| **December 9 — [AFA Q4 2025 Training Webinar – Premium Fraud Blueprint](https://register.gotowebinar.com/#register/8654957961927397468) Webinar (AFA)** \| \| \| \| \|:--\| \| \| **December 18 — [Emerging Fraud Trends in P&C Insurance](https://us02web.zoom.us/webinar/register/WN_UJnqT5-bQ6-zLdlTPU2PHQ) Webinar (Coalition Against Insurance Fraud)** \| \| \| \| \|:--\| \| \| **April 22, 2026 — [2026 Annual Anti-Fraud Conference](https://annualantifraudconference.com/#Registration) Monterey, Calif. (AFA)** \| \| \| \| \|:--\| \| \| \|:-:\|---\| | |:-:| | \| \| \| FRAUD NEWS FRIDAY \| \|---\|:--\| \| \| \| \| **\* [Lutsen Resort owner charged with arson, insurance fraud in fire case](https://www.kaaltv.com/news/lutsen-resort-owner-charged-with-arson-insurance-fraud-in-fire-case/) \* [Bipartisan Group Announce New Health Care Framework](https://gottheimer.house.gov/posts/release-bipartisan-group-of-35-house-members-announce-new-health-care-framework-commonground-2025) \* [Washington Insurance Commissioner Patty Kudere pushes 2026 bills on restitution](https://beinsure.com/news/washington-pushes-2026-bills-on-restitution-aob-bans/) \* [Insurance schemes are evolving, not disappearing](https://floridapolitics.com/archives/768352-fraudemic-2-0-insurance-schemes-are-evolving-not-disappearing/) \* [How scammers use fake insurance texts to steal your identity](https://www.malwarebytes.com/blog/news/2025/12/how-scammers-use-fake-insurance-texts-to-steal-your-identity)** \| \| \| \| \|:--\| \| \| \|:-:\|---\| | |:-:| | \| \| \| \| \|---\|---\| \| \| \| \| Connect with Us: \| \| \| [![FB](https://mcusercontent.com/a440c5b647697de580a2fd586/images/ef66a2aa-ea17-4447-95b6-ad328c555988.png)](https://www.facebook.com/insurancefraud) \| \| [![TW](https://mcusercontent.com/a440c5b647697de580a2fd586/images/43f8397b-2f36-4358-87e9-549e6d9b749b.png)](https://twitter.com/insurance_fraud) \| \| [![YT](https://mcusercontent.com/a440c5b647697de580a2fd586/images/c202c8ca-32dc-49b1-a471-9669d36f946e.png)](https://www.youtube.com/user/stopinsurancefraud) \| \| [![IN](https://mcusercontent.com/a440c5b647697de580a2fd586/images/0cb8e5d8-9435-49a5-91b2-1a214a5f2fa0.png)](https://www.linkedin.com/groups/3856550) \| \| \|:-:\| \| [![Coalition Against Insurance Fraud](https://mcusercontent.com/a440c5b647697de580a2fd586/images/539d436e-d608-44a9-ba5e-b64d3a1ddd06.png)](https://www.insurancefraud.org) \| \| \|:-:\| \| Contact: \| \|:--\| \| Phone: [202.393.7330](tel:2023937330) Email: <info@insurancefraud.org> Address: 1012 14th Street NW Suite 610 Washington DC 20005 [www.InsuranceFraud.org](http://www.insurancefraud.org/) \| \| \|---\| \| \|:-:\| \| \| \| \| \|:-:\|---\| | |:-:| | | |---| | \| \| \| \| \|:-:\| | |:-:| **Features:** Fraud News Weekly --- ### [Fraud News Weekly - November 21, 2025](https://insurancefraud.org/publications/fraud-news-weekly-november-21-2025/) **Published:** November 21, 2025 **Author:** Coalition Against Insurance Fraud **Content:** International Fraud Awareness Week Comes To An End, State Regulators Discuss Big Data, And Action Is Being Urged On Workers’ Compensation Fraud | \| \| \|:-:\| \| Friday, November 21, 2025 \| \| \| | |:-:| | \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/df906857-d727-9ee9-0397-2a09caac30a4.png) \| \|:-:\| \| \| \| \| \| \|:-:\| | |:-:| | \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/f879a635-c7e6-41f2-eb8d-bea89f7bf8d4.jpg) \| \|:-:\| \| \| \| \| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/281a3ca2-edb3-1fb7-9837-02c292520f13.png) This past week was a huge success in promoting insurance fraud awareness across our social media platforms; however, you know that five days of awareness is not nearly enough. Continue to join us in sharing Coalition resources across your organization. Forward our Member Alerts. Encourage your colleagues to sign up for our member-only resources. Spread the word! Thanks to each of you for your passion and drive to bring insurance fraud to its knees. [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a1492a86-29b0-90b6-d879-527e5492037e.png)](https://m.facebook.com/61579225779934) [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/d2bd23eb-8810-4f7a-49d3-d2fe7aa1891e.png)](https://www.instagram.com/stopinsurancefraud/)[![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/be4e5708-bdc4-c0df-6c03-a6ebd5b34c13.png)](https://www.linkedin.com/company/coalition-against-insurance-fraud) \| \| \| \| \| \|:-:\|---\| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7e6cccc1-3a5e-4803-a7f8-7325e7e155cb.gif) \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7e6cccc1-3a5e-4803-a7f8-7325e7e155cb.gif) \| ![](images/spacer.gif) \| \| \|:-:\| \| \| | |:-:| | \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/00ed7ac4-bb10-4f87-9d66-746db8688e48.png) \| \|:-:\| \| \| \| \| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/aac11d1f-4f3e-2cb8-ebe0-7d7e7baab9f3.jpeg) NCOIL Annual Meeting in Atlanta advances Coalition supported amendments to two anti-fraud model laws. Last week at the National Council of Insurance Legislators ([NCOIL](https://ncoil.org/)) Annual Meeting in Atlanta, legislators from across the country voted to approve important [amendments](https://ncoil.org/wp-content/uploads/2025/10/Atlanta-30-Day-Materials.pdf) to two model laws backed by the Coalition. NCOIL, a legislative organization of state insurance and financial committee members, develops model laws and works to preserve state jurisdiction over insurance. During the Financial Services and Multi Lines Issues Committee, amendments sponsored by Rep. Gabe Firment of Louisiana were presented to update the 30-year-old NCOIL Insurance Fraud Model Act originally proposed by the Coalition in 1995. These revisions expand the definition of fraudulent insurance acts, directly address contractor fraud, close a criminal enforcement gap, and enhance consumer protections. The following day, the Property and Casualty Committee considered amendments to the Storm Chaser Consumer Protection Model Act, which originally focused only on roofing contractors. Sponsored by Sen. Larry Walker of Georgia, the updated model expands regulations to all contractors operating after disasters and addresses abandoned work, fraudulent liens, solicitation abuses, conflicts of interest, and prohibits assignments of benefits. The Coalition, working alongside NICB, testified in support of both models and worked to build consensus between the insurance and restoration industries. With broad legislative backing, these amendments will help states strengthen consumer protections, advance fraud awareness, and enhance insurance market integrity nationwide. Coalition’s Life & Disability Task Force connects with state treasury representatives to discuss unclaimed property fraud. Earlier this year, the Coalition’s [Life & Disability Task Force](https://insurancefraud.org/committees/) escalated a growing fraud threat involving state unclaimed property websites being exploited by criminals submitting false claims on unclaimed life insurance and annuity proceeds. The schemes involve unclaimed life insurance and annuity proceeds where fraudsters use forged estate documents and fake IDs, often sourced from dark web marketplaces, to impersonate rightful heirs and unlawfully claim funds. The Coalition found a partner in this specific fight against fraud via the National Association of Unclaimed Property Administrators ([NAUPA](https://unclaimed.org/)), an affiliate of the National Association of State Treasurers. As the leading authority on unclaimed property, NAUPA's mission is to support collaboration among state administrators to return unclaimed assets, including insurance payments and annuities, to their rightful owners. The Coalition learned that NAUPA had a [Fraud Community](https://member.nast.org/members/group_content_view.asp?group=213448&id=1059750), a collaborative network among state treasury departments that shares resources and strategies to detect, prevent, and combat fraudulent practices related to unclaimed property. This week, the Coalition briefed the NAUPA Fraud Community on the fraud schemes being identified by the carrier members of its Life & Disability Task Force. That same day, the NAUPA Fraud Community was a guest speaker during the Coalition's Life & Disability Task Force meeting. This new relationship will continue to be explored as both groups work to identify the most effective ways to collaborate, strengthen protections, and better safeguard consumers and insurers from unclaimed property fraud. State regulators discuss big data, AI, and privacy protections. This month, the National Association of Insurance Commissioners ([NAIC](https://content.naic.org/)) Big Data and Artificial Intelligence (H) Working Group [updated](https://content.naic.org/sites/default/files/call_materials/20251119%20Meeting%20Materials.pdf) regulators on revisions to the [AI Systems Evaluation Tool](https://content.naic.org/sites/default/files/inline-files/AI%20Systems%20Evaluation%20Tool%202.0.docx) ahead of the fall national meeting, which will include AI tool updates, exhibit discussions, and instruction reviews. Discussion of a new AI model law was removed from the current agenda with plans to survey members before revisiting the topic. Meanwhile, the NAIC Privacy Protections (H) Drafting Group extended its timeline finalize a model draft to the Fall of 2026. Consumer groups, insurance industry representatives, and regulators continue to seek consensus on [key issues](https://content.naic.org/committees/h/privacy-protections-wg), particularly consumer consent, opt-out provisions, and balancing privacy with operational needs, but progress remains challenging. These ongoing deliberations highlight the complex intersection of emerging technologies, consumer rights, and fraud prevention that remain central to the Coalition’s legislative priorities. \| \| \| \| \| \|:-:\|---\| \| \|:-:\| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7e6cccc1-3a5e-4803-a7f8-7325e7e155cb.gif) \| \| \| | |:-:| | \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/6ab2c291-f95a-060c-22cd-2622f315f1e5.png) \| \|:-:\| \| \| \| \| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a78370eb-0576-e15d-0132-01e0d4a745be.jpeg) Insurance fraud adds $900 to the average policy – here’s how to avoid it. Coalition Executive Committee member Pranay Mittal of Travelers is marking International Fraud Awareness Week by sharing key strategies to help businesses and consumers protect themselves from insurance fraud. A recent Travelers survey found that businesses are most concerned about medical provider schemes involving coordinated networks of health care professionals, [digital scams targeting business systems and data](https://www.insurancebusinessmag.com/us/news/breaking-news/insurance-fraud-adds-900-to-average-policy--heres-how-to-avoid-it-557298.aspx), and employee fraud within organizations. Consumers, on the other hand, reported concerns about contractor fraud and staged car accidents that target individuals. Pranay Mittal, Vice President of Travelers Investigative Services, said, “*Insurance fraud drives up the overall cost for everyone and undermines consumer trust and the integrity of the insurance process.*” Raising awareness about the various forms of fraud and providing tools to recognize and prevent it can help create a more secure marketplace, Mittal said. Pennsylvanians urged to be vigilant against fraud, scams during International Fraud Awareness Week. The Pennsylvania Insurance Department (PID) and the Department of Banking and Securities (DoBS) urge Pennsylvanians to [remain on the lookout for attempted fraud](https://www.thecorryjournal.com/hometown/article_ab11171c-3239-4db9-b17f-c3ea2c4f6d99.html) and other deceptive business practices that could cause financial strain and hardship. Pennsylvania joined this week’s global observance of fraud awareness, as Nov. 16-22 marks the 25th International Fraud Awareness Week. “*International Fraud Awareness Week is an important reminder to pause and reinforce vigilance about fraud,*” said Pennsylvania Insurance Commissioner Michael Humphreys. “*Fraudsters use urgency, confusion and emotional tactics to steal from and harm people. We want to ensure consumers know to be on the lookout for fraud and deceptive business practices. Insurance fraud can cause real financial harm, but it’s preventable when you’re aware of what to look for and what to avoid, such as buying insurance over the phone from cold callers. Consumers should never feel pressured to make quick decisions or share personal information over the phone, through email or via text message.*” Urging industry action on workers’ compensation fraud. Combatting fraud requires a shared approach to fraud prevention, recognising that fraudulent activity in workers' compensation can involve not only injured workers but also employers and service providers. Older workers, particularly those aged 55 to 64 and 65 years and over, had the highest rates of serious claims at 9.5 and 10.0 per million hours worked, respectively. Mental health conditions made up 12% of serious claims, a figure that has increased by 14.7% since the previous year and by 161% over the past decade. The median time lost from work for mental health claims was nearly five times longer than for other types of injuries or illnesses. Aidan Brophy, executive general manager – Victoria at Gallagher Bassett, said the conversation around fraud must be balanced and considerate of the wider system. “*It’s important to acknowledge a fundamental truth: almost everyone in the system acts with good intentions. Fraud prevention isn’t about treating all participants as suspects; it’s about [using information responsibly to identify anomalies](https://www.insurancebusinessmag.com/au/news/workers-compensation/gallagher-bassett-urges-industry-action-on-workers-compensation-fraud-557265.aspx) that may require closer review. Even then, fraud indicators are not proof – they simply highlight patterns that demand judgement, quality data, and an ethical approach to investigation.*” NICB warns of fraud facilitated by Third-Party Litigation Funding, calls for transparency and insurance industry vigilance. TPLF involves outside investors and entities – including both domestic and foreign sources – providing financial resources for claimants and/or law firms in exchange for a portion of any settlement. In some cases, the outside investor may influence case selection, litigation strategy, and settlement posture to maximize return on investment. At its worst, TPLF-facilitated fraud involves outside investors secretly funding litigation that is based entirely on exaggerated, fraudulent, and even fictitious insurance claims. The activity undermines the insurance industry, causes premiums to rise, and puts unfair strain on policyholders. In one case, a single funder supported 13 law firms that [unethically targeted 66 different insurers](https://finance.yahoo.com/news/ica-partners-exl-shift-insurance-112927129.html) to drive claims litigation and maximize the investor's return. Since NICB's direct assistance in investigating the [United States v. Constantine](https://www.justice.gov/usao-sdny/pr/new-york-attorney-and-doctor-convicted-defrauding-new-york-city-area-businesses-and) case—a $31 million trip-and-fall insurance fraud scheme facilitated by TPLF that preyed upon the poor and homeless—NICB has documented the influence of outside funding on driving claims and insurance litigation. Coordinated networks of unethical lawyers and medical providers facilitate these fraud schemes, which are often exacerbated through digital marketing tactics to drive mass litigation. \| \| \| \| \| \|:-:\|---\| \| \|:-:\| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7e6cccc1-3a5e-4803-a7f8-7325e7e155cb.gif) \| \| \| | |:-:| | \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/c16e2322-ff90-895b-a2c8-2802034b1ffc.png) \| \|:-:\| \| \| \| \| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/ed93f33f-37a4-2849-2ae3-01028316bd5e.jpg) Four Californians sentenced to prison for $16 Million hospice fraud and money laundering scheme. Juan Carlos Esparza was sentenced to 57 months in prison, Susanna Harutyunyan to 15 months, Mihran Panosyan, to 57 months in prison, and Petros Fichidzhyan to 12 years in prison. Esparza schemed with others, including co-defendants Fichidzhyan and Srapyan, to bill Medicare for hospice services that were medically unnecessary and never provided. From July 2019 until January 2023, Esparza, Fichidzhyan, and Srapyan operated four sham hospices, one of which, House of Angels Hospice, was owned by Esparza. Fichidzhyan, Esparza and Srapyan concealed the scheme by [using foreign nationals’ names and personally identifiable information](https://oig.hhs.gov/fraud/enforcement/four-california-residents-sentenced-to-prison-in-connection-with-16m-hospice-fraud-and-money-laundering-scheme/) to act as straw owners for the hospices and to open bank accounts, submit information to Medicare and sign property leases. They also controlled and used cell phones in the names of the foreign nationals in furtherance of the scheme. In total, Medicare paid the sham hospices nearly $16 million. Alaskan doctor and her husband plead guilty to more than $12 million in health care fraud. Dr. Claribel Kohchet Chua Tan, a rheumatologist, and her husband, Daniel Tan were indicted by a federal grand jury in July 2024. Both Tans entered guilty pleas to charges of health-care fraud and tax evasion during a hearing Tuesday in U.S. District Court in Anchorage. *The crimes they are pleading guilty to:* Tan’s practice specialized in the diagnosis and treatment of autoimmune and musculoskeletal diseases including rheumatoid arthritis. Daniel Tan handled administrative and management duties at the clinic. The couple [deceived patients about injections administered in the office](https://www.adn.com/alaska-news/crime-courts/2025/11/19/anchorage-doctor-and-husband-plead-guilty-to-more-than-12-million-in-health-care-fraud/), underdosing them or lying about the type of medication in the shot, according to a plea agreement Claribel Tan signed in late October. They also billed health insurance plans for reimbursement of medications they didn’t purchase. The couple executed the fraud scheme over a 13-year period from 2010 until 2023, according to last year’s indictment. It also accused Tan of injecting an estimated 400 patients who were deceived “*regarding the identity, quantity, and other material facts regarding substances that she injected into their bodies, and administered medications to which patients did not consent.*” Middle Georgia ‘*Insurance Agent of the Year*’ sentenced for federal bank fraud. Jeremy Lasseter was sentenced to 27 months in federal prison after pleading guilty to one count of bank fraud on Aug. 27. He was also ordered to pay $221,515.16 in restitution to the victim, which he paid in full at sentencing. Lasseter owned an Alfa Insurance agency group in Warner Robins and had been selected as Alfa’s Georgia “*Insurance Agent of the Year*” for four consecutive years. Beginning in March 2020, he instructed one of his customers to [make premium payments directly to him](https://www.macon.com/news/local/crime/article312984151.html) and did not apply the payments towards her policies, sometimes telling her to write checks in his name or pay in cash for “*tax purposes,*” according to the news release. Lasseter used the victim’s premium payments toward the premiums for other insurance customers without the victim’s knowledge or consent. The victim relied on Lasseter’s instructions to her and, at his direction, made a total of $221,515.16 in payments that were not used towards her policies, but were used to pay other customers of Lasseter’s policies. Lawsuit claims Farm Bureau hid fraudulent activity from insurance regulators. Two alleged whistleblowers are suing Farm Bureau Property & Casualty Insurance Co. and its affiliates for alleged racketeering, wrongful termination and concealment of information from state regulators. *The lawsuit alleges:* Farm Bureau officials repeatedly concealed from regulators in Iowa and other states instances of fraudulent activity committed by company agents or employees. The defendants’ [conduct in the matter amounts to racketeering, obstruction of justice, and mail fraud](https://iowacapitaldispatch.com/2025/11/19/lawsuit-claims-farm-bureau-hid-fraudulent-activity-from-insurance-regulators/) or wire fraud, the lawsuit claims. The lawsuit claims Farm Bureau officials “*engaged in a scheme to defraud insurance policyholders, insurance and other governmental regulatory authorities, and other participants in the insurance industry who are complying with their mandatory duty of reporting fraud and other fraudulent or other illegal acts.*” It also claims the defendants violated Iowa’s law on the wrongful discharge of employees in violation of public policy. That law prohibits the termination of employees for refusing to participate in illegal conduct or for acting as whistleblowers by reporting or objecting to illegal conduct. The defendants in the case have yet to file a response to the lawsuit. Arkansas psychologist indicted for alleged $500,000 Medicare and insurance fraud scheme. A Little Rock psychologist, Krameelah Banks, has been indicted on multiple charges, including wire fraud and making false statements, for allegedly defrauding Medicare and Arkansas Blue Cross and Blue Shield. *The allegations:* The indictment claims Banks billed for thousands of hours of nonexistent psychology services, causing insurers to lose over $500,000. Banks is accused of [billing for therapy sessions with patients who had passed away](https://katv.com/news/local/little-rock-psychologist-indicted-for-alleged-500000-medicare-and-insurance-fraud-scheme-katv-news-share-inform-public) and for services supposedly rendered while she was vacationing in Florida and Mexico. She also created fictitious records to cover her tracks and misled the FBI by blaming overbilling on her online calendaring software. Owner of a towing company sentenced after charging a driver $10K to tow a vehicle less than a half mile. Vincent G. Fannick, the owner of a towing company in Pittsburgh, pleaded guilty to felony charges after inflating prices to extraordinary levels for customers. Investigators learned of the crimes in 2023 when a driver reported that their insurance company was charged $11,390 by Vince’s Towing for a [short trip that the vehicle owner did not even request](https://www.wwnytv.com/2025/11/18/owner-towing-company-receives-sentence-after-charging-driver-10k-tow-vehicle-less-than-half-mile/). Law enforcement learned that other drivers were subjected to the same scam. Investigators uncovered a pattern of Fannick charging insurance companies exorbitant tow costs by initially not revealing prices on invoices and later charging hidden fees. Some vehicle owners’ insurance companies were charged between $9,460 and $13,105 for single short-trip tows. In one case, Fannick charged $9,805 for towing a vehicle one-third of a mile. Fannick pleaded guilty to felony theft by deception, felony insurance fraud and misdemeanor execution of documents by deception. Attorney General Ford announces sentencing of former Nevada police officer in insurance fraud scheme. Christopher Michael Mitchell of Henderson was sentenced in the Eighth Judicial District Court for one count of Misconduct of a Public Officer. Mitchell asked a fellow Las Vegas Metropolitan Police Department officer to [create and file a false stolen vehicle report](https://www.8newsnow.com/news/local-news/former-las-vegas-police-officer-sentenced-for-insurance-fraud-scheme/amp/) so he could pursue an illegitimate insurance claim. Mitchell to a minimum of 12 months and a maximum of 48 months in the Nevada Department of Corrections, suspended, and placed him on probation for an indeterminate period not to exceed18 months. Mitchell was also ordered to complete Veteran’s Specialty Court, pay $1,000 in investigative costs to the Office of the Attorney General, and successfully complete a 13-week LRS Anger Management Course. \| \| \| \| \| \|:-:\|---\| \| \|:-:\| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7e6cccc1-3a5e-4803-a7f8-7325e7e155cb.gif) \| \| \| | |:-:| | \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/f8628f05-c69a-b49b-5c6b-325c1455059a.png) \| \|:-:\| \| \| \| \| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/34d1f340-93a8-03e8-65ff-99fd6a723e6d.png) [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/1ce4a222-3707-daaf-86bf-d0078f1d7693.png)](https://s.surveyplanet.com/bj1sw6en) [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/6c8550d3-4d99-bc65-c8f8-cd1902423e17.png)](https://members.insurancefraud.org/general/pick_username.asp) ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/3ef40901-b851-f621-08b2-322f09ca8a57.png) [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/6f681cdb-233b-3a23-d74d-8d2ea782b4a3.png)](https://us02web.zoom.us/webinar/register/WN_UJnqT5-bQ6-zLdlTPU2PHQ) [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/10603368-408a-d879-f877-12cb1c3ee19d.jpg)](mailto:alisonf.oneill1@lexisnexis.com) \| \| \| \| \| \|:-:\|---\| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7e6cccc1-3a5e-4803-a7f8-7325e7e155cb.gif) \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7e6cccc1-3a5e-4803-a7f8-7325e7e155cb.gif) \| ![](images/spacer.gif) \| \| \|:-:\| \| \| | |:-:| | \| \| \| FACES OF FRAUD \| \|---\|:--\| \| \| \| \| \| \| \| [![](https://via.placeholder.com/125x166)](https://www.tn.gov/finance/news/2020/9/28/davidson-co--woman-charged-with-tenncare-fraud.html) \| \| \| \| [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/24658a78-7519-c236-fc11-ca9ed7186f1d.png)](https://txktoday.com/crime/texarkana-police-make-third-arrest-in-staged-truck-and-camper-theft-case/) **Cameron Flores** Texarkana, Texas Auto claims *ARRESTED* \| \| \| \| [![](https://via.placeholder.com/125x166)](https://www.southwesttimes.com/2020/09/false-scripts-bills-send-doctor-to-prison/) \| \|:-:\|---\|:-:\| \| \| \| [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/5ff5cac3-24be-3b06-7470-b2f99f1b1c3d.png)](https://www.walb.com/2025/11/19/south-ga-insurance-agents-arrested-insurance-fraud-exploitation-elderly/) **Michelle “Allie” Joiner** Ben Hill County, Ga. Insider agent *ARRESTED* \| \| \|:-:\| \| \|:-:\| \| \| \| [![](https://via.placeholder.com/125x166)](https://www.timesrepublican.com/news/todays-news/2020/09/mpd-handles-multiple-burglaries-1-arrested/) \| \|:-:\| \| \| \| [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/4e90f55c-520c-cc71-832d-bb4bf5cfd8cd.png)](https://www.walb.com/2025/11/19/south-ga-insurance-agents-arrested-insurance-fraud-exploitation-elderly/) **Angela Krause** Ben Hill County, Ga. Insider agent *ARRESTED* \| \| \| \| [![](https://via.placeholder.com/125x166)](https://www.wmbfnews.com/2020/09/22/longs-woman-arrested-accused-forging-prescriptions/) \| \|:-:\|---\|:-:\| \| \| \| [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/f27da177-00d4-18b1-9457-cdad95195f00.png)](https://www.ctpost.com/news/article/ct-therapist-ivette-betancourt-medicaid-fraud-21172166.php) **Ivette Betancourt** Wethersfield, Conn. Medicare/Medicaid *ARRESTED* \| \| \|:-:\| \| \|:-:\| \| \|---\| \| \|:-:\| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7e6cccc1-3a5e-4803-a7f8-7325e7e155cb.gif) \| \| \| \| \| \|:-:\|---\| | |:-:| | \| \| \| EVENTS \| \|---\|:--\| \| \| \| \| **November 24-25 — [Digging for treasure: Company Research Strategies for Attorneys](mailto:alisonf.oneill1@lexisnexis.com)** Virtual (LexisNexis) \| \| \| \| \|:--\| \| \| **December 2-3 — [Coalition Annual Meeting](https://insurancefraud.org/coalition-annual-membership-meeting/) Arlington, VA. (Coalition Against Insurance Fraud)** \| \| \| \| \|:--\| \| \| **December 18 — [Emerging Fraud Trends in P&C Insurance](https://us02web.zoom.us/webinar/register/WN_UJnqT5-bQ6-zLdlTPU2PHQ) Webinar (Coalition Against Insurance Fraud)** \| \| \| \| \|:--\| \| \| **April 22, 2026 — [2026 Annual Anti-Fraud Conference](https://annualantifraudconference.com/#Registration) Monterey, Calif. (AFA)** \| \| \| \| \|:--\| \| \| \|:-:\|---\| | |:-:| | \| \| \| FRAUD NEWS FRIDAY \| \|---\|:--\| \| \| \| \| **\* [Allstate alleges 17 companies ran $2 million no-fault fraud scheme](https://www.insurancebusinessmag.com/us/news/claims/allstate-alleges-17-companies-ran-2-million-nofault-fraud-scheme-557416.aspx)** \* [Application Fraud is On The Rise](https://insurance-edge.net/2025/11/21/application-fraud-is-on-the-rise/) \* [Man claims insurance payment for Cadillac Escalade, charged with fraud](https://wpde.com/news/local/marlboro-county-auto-insurance-fraud-illegal-nowland-jr-thomas-scorr-south-carolina-progressive) \* [Insurance broker imprisoned after diverting payments into personal account](https://www.cityoflondon.police.uk/news/city-of-london/news/2025/november/insurance-broker-imprisoned-after-diverting-customer-payments-into-personal-account-leaving-public-and-businesses-uninsured/) \* [China Targets Drug Over-Prescribing to Curb Insurance Fraud](https://www.caixinglobal.com/2025-11-21/china-targets-drug-over-prescribing-to-curb-insurance-fraud-102385480.html) \| \| \| \| \|:--\| \| \| \|:-:\|---\| | |:-:| | \| \| \| \| \|---\|---\| \| \| \| \| Connect with Us: \| \| \| [![FB](https://mcusercontent.com/a440c5b647697de580a2fd586/images/ef66a2aa-ea17-4447-95b6-ad328c555988.png)](https://www.facebook.com/insurancefraud) \| \| [![TW](https://mcusercontent.com/a440c5b647697de580a2fd586/images/43f8397b-2f36-4358-87e9-549e6d9b749b.png)](https://twitter.com/insurance_fraud) \| \| [![YT](https://mcusercontent.com/a440c5b647697de580a2fd586/images/c202c8ca-32dc-49b1-a471-9669d36f946e.png)](https://www.youtube.com/user/stopinsurancefraud) \| \| [![IN](https://mcusercontent.com/a440c5b647697de580a2fd586/images/0cb8e5d8-9435-49a5-91b2-1a214a5f2fa0.png)](https://www.linkedin.com/groups/3856550) \| \| \|:-:\| \| [![Coalition Against Insurance Fraud](https://mcusercontent.com/a440c5b647697de580a2fd586/images/539d436e-d608-44a9-ba5e-b64d3a1ddd06.png)](https://www.insurancefraud.org) \| \| \|:-:\| \| Contact: \| \|:--\| \| Phone: [202.393.7330](tel:2023937330) Email: <info@insurancefraud.org> Address: 1012 14th Street NW Suite 610 Washington DC 20005 [www.InsuranceFraud.org](http://www.insurancefraud.org/) \| \| \|---\| \| \|:-:\| \| \| \| \| \|:-:\|---\| | |:-:| | | |---| | \| \| You are receiving this email because either your organization is a member of the Coalition Against Insurance Fraud or you requested to be placed on our mailing list. [Unsubscribe](https://insurancefraud.us1.list-manage.com/unsubscribe?u=a440c5b647697de580a2fd586&id=b68dce7808&t=b&e=%5BUNIQID%5D&c=575c4ed861) [<< Test Email Address >>](%3C%3C%20Test%20Email%20Address%20%3E%3E) from this list. Our mailing address is: Coalition Against Insurance Fraud1012 14th St NW Ste 610 Washington, DC 20005-3424 [Add us to your address book](https://insurancefraud.us1.list-manage.com/vcard?u=a440c5b647697de580a2fd586&id=b68dce7808) Copyright (C) 2025 Coalition Against Insurance Fraud All rights reserved. [Forward this email to a friend](https://us1.forward-to-friend.com/forward?u=a440c5b647697de580a2fd586&id=575c4ed861&e=%5BUNIQID%5D) [Update your profile](https://insurancefraud.us1.list-manage.com/profile?u=a440c5b647697de580a2fd586&id=b68dce7808&e=%5BUNIQID%5D&c=575c4ed861) \| \| \|:-:\| | |:-:| <html><p class="wp-block-paragraph"></p> **Features:** Fraud News Weekly --- ### [Fraud News Weekly - November 14, 2025](https://insurancefraud.org/publications/fraud-news-weekly-november-14-2025/) **Published:** November 14, 2025 **Author:** Coalition Against Insurance Fraud **Content:** IFAW Begins Sunday, The Coalition Welcomes Celeste Dodson, And The Coalition’s Social Media Competition Update | \| \| \|:-:\| \| Friday, November 14, 2025 \| \| \| | |:-:| | \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/df906857-d727-9ee9-0397-2a09caac30a4.png) \| \|:-:\| \| \| \| \| \| \|:-:\| | |:-:| | \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/6882e709-bba3-7d0d-9860-532f3bd86c0b.jpg) \| \|:-:\| \| \| \| \| \| \| As professionals in the fight against insurance fraud, you know the serious impact it has on businesses, communities, and individuals. You’ve no doubt educated those around you, but we want to equip you with even more tools for those hard conversations. International Fraud Awareness Week 2025 kicks off this Sunday! As members, you can visit our IFAW Resource Page ahead of social media posts the Coalition’s website at [insurancefraud.org](https://insurancefraud.org/) to access quick, ready-to-share resources you can use to raise awareness across your organization and with your colleagues, family, and friends. Together, we can make insurance fraud prevention everyone’s business. Follow us on [LinkedIn](https://www.linkedin.com/company/coalition-against-insurance-fraud), [Facebook](https://m.facebook.com/61579225779934), and [Instagram](https://www.instagram.com/stopinsurancefraud/) as we promote International Fraud Awareness Week starting next Monday. \#FraudAwarenessWeek #FightFraud #ProtectYourself ![](https://mcusercontent.com/a440c5b647697de580a2fd586/_compresseds/05ad0ad3-f37b-541b-c3e5-2d6c83eb5275.jpg) This September, the Coalition launched a social media competition in partnership with Wayne State University to help raise awareness among 18–25-year-olds about the staggering $308.6 billion impact of insurance fraud. Over the eight-week campaign, marketing students leveraged their creativity and social media platforms to drive public engagement, resulting in more than 14,000 views of the Coalition’s new [Instagram](https://www.instagram.com/stopinsurancefraud/) page. This week, Executive Director Michelle Rafeld had the pleasure of meeting the students and recognizing those who produced the most compelling content. Over the next several weeks, the Coalition will showcase the students’ remaining posts on the Coalition’s Instagram page as well as present the full results of this important pilot project to those attending the Coalition’s Annual Meeting. [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a1492a86-29b0-90b6-d879-527e5492037e.png)](https://m.facebook.com/61579225779934) [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/d2bd23eb-8810-4f7a-49d3-d2fe7aa1891e.png)](https://www.instagram.com/stopinsurancefraud/)[![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/be4e5708-bdc4-c0df-6c03-a6ebd5b34c13.png)](https://www.linkedin.com/company/coalition-against-insurance-fraud) \| \| \| \| \| \|:-:\|---\| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7e6cccc1-3a5e-4803-a7f8-7325e7e155cb.gif) \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7e6cccc1-3a5e-4803-a7f8-7325e7e155cb.gif) \| ![](images/spacer.gif) \| \| \|:-:\| \| \| | |:-:| | \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a57e030f-61fa-473f-b132-259b1a34e42e.png) \| \|:-:\| \| \| \| \| \| \| **![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/575d5a5b-3a4e-d539-3cba-c77e8529b28e.jpg) Insurance Council of Texas releases 2025 workers’ compensation market report highlighting fraud trends and market resilience. **The Insurance Council of Texas (ICT) recently published its [Texas Workers’ Compensation Market Report 2025](https://www.insurancecouncil.org/assets/pdf/Workers-Comp_Market-Report_2025/), offering a comprehensive overview of the fifth largest workers’ compensation market in the U.S.** The report detailed a highly competitive market with 98 groups representing 335 companies in 2024, covering 87% of the state's employees. Workplace safety metrics continue to improve, including a decline in fatalities and a decade-low nonfatal incident rate below the national average. Legislative engagement was robust in 2025, with ICT tracking 59 workers’ compensation bills and supporting the enactment of 15 new laws. On the antifraud front, the Texas Division of Workers’ Compensation received 1,856 insurance carrier consumer complaints in 2024, down 13.5% from 2023, with no consumer complaints specifically citing fraud. However, fraud reporting remains steady with 1,536 reports filed, leading to 53 investigations, 4 prosecutions, and 3 convictions, a slight increase in fraud activity in recent years.** **Governor Sanders appoints Jimmy Harris as Arkansas Insurance Commissioner. Governor Sarah Huckabee Sanders has [appointed](https://commerce.arkansas.gov/governor-sanders-appoints-jimmy-harris-as-arkansas-insurance-commissioner/) Jimmy Harris as Arkansas Insurance Commissioner. Harris has served with the Arkansas Insurance Department (AID) since 2012, most recently as Interim Commissioner and previously as Deputy Commissioner for Market Regulation. AID regulates insurers, oversees workers’ compensation, provides Medicare counseling, and investigates consumer complaints and [insurance fraud](https://insurance.arkansas.gov/consumer-services/criminal-investigation/). Harris succeeds former Commissioner Alan McClain, who retired in August 2025. The Coalition looks forward to working with Commissioner Harris and AID to strengthen antifraud efforts and uphold consumer confidence statewide.** **The rapid expansion of US state-level data privacy laws creates new challenges and opportunities for insurance fraud fighters. In 2025, nine additional states enacted data protection laws, with three more set to join in January 2026, resulting in a complex patchwork that insurers, investigators, and prosecutors must navigate. These laws vary widely in thresholds, sensitive data categories, consumer rights, and importantly, exemptions affecting fraud investigations. [Maryland’s law](https://mgaleg.maryland.gov/2024RS/bills/hb/hb0567e.pdf), for instance, specifically exempts nonprofit entities processing or sharing data to assist law enforcement investigating fraud or insurance-related crime, and includes additional exclusions that do not restrict the ability to prevent, detect, or investigate fraud. These are essential provisions that safeguards investigative capabilities and highlights the critical balance the Coalition Against Insurance Fraud pursues as a legislative priority: ensuring consumer data privacy laws do not unduly restrict insurers’ and law enforcement’s ability to detect and combat fraud.** \| \| \| \| \| \|:-:\|---\| \| \|:-:\| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7e6cccc1-3a5e-4803-a7f8-7325e7e155cb.gif) \| \| \| | |:-:| | \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/6b5470a4-ef85-47e4-bc7d-6740f8ed0cdb.png) \| \|:-:\| \| \| \| \| \| \| **![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/1583d5e3-dd2d-ac47-d490-5449a5d18561.jpg) 19% of people think it's justifiable not to disclose the full truth on insurance applications. **Nearly one in five people believe it’s justifiable not to disclose the full truth on an insurance application – a figure that rises to 21% among those with motor insurance.** That was according to research from Ageas UK and YouGov, which worked together to uncover the public’s attitudes towards insurance fraud. The data also showed that [12% of respondents admitted to either having committed insurance fraud](https://www.insurancetimes.co.uk/news/19-of-people-think-its-justifiable-not-to-disclose-full-truth-on-insurance-application/1456839.article) themselves or know someone who has. Meanwhile, 8% of people think it is acceptable to fail to disclose accurate information when applying for insurance and that amongst those with home insurance, one in 10 think inflating the cost of damage and the price of the insured goods are acceptable.** **The average cost of a fake insurance claim is around 84K. Adyen has found that fraudulent claims are [eroding insurer revenues as the average cost of a fake claim hits £84,000](https://insurance-edge.net/2025/11/10/average-cost-of-a-fake-insurance-claim-is-around-84k/). Following these findings, Adyen’s 2025 Insurance Report points to ways insurers could strengthen their response to fraud. The report exposes the financial impact of fraud on insurers, with one in seven claims proven to be fraudulent (15%). The findings reveal that 90% of businesses estimate that fraud, including staged accidents and inflated claims, accounts for an average reported loss of 2.6% of annual revenue, peaking at 5%. “*Legacy systems are eroding insurers’ margins. Many still rely on cheques and bank transfers, slowing payouts and frustrating customers who expect instant service,*” said Adrian Davis, Commercial Leader for Financial Services and Insurance at Adyen. “*Meanwhile, AI-driven fraud is exploiting these outdated systems. By adopting real-time, embedded payment solutions, insurers can automate verification, speed up legitimate claims, and deliver the seamless experience customers expect.*”** **Here’s how much young drivers are losing buying fake policies. Aviva has detected an increasing number of motorists being conned into handing over their coin to fraudsters who pose as middle-men for well-known insurance companies. Young motorists are [losing £2,000 each on average when they buy fake policies](https://metro.co.uk/2025/11/07/much-young-drivers-losing-buying-fake-policies-24644367/), according to research by the insurance giant. This includes the average premium paid and extra fees charged by ghost brokers selling fraudulent policies. Many scams start on social media and Aviva said it has identified a sharp rise in fraudsters using fake, professional-looking websites that impersonate legitimate insurers. Detective Chief Inspector Nik Jethwa, from the City of London Police’s Insurance Fraud Enforcement Department (IFED), told Metro: ‘Ghost brokers prey on trust and vulnerability, leaving victims financially exposed and legally unprotected – often facing the same penalties as uninsured drivers.** \| \| \| \| \| \|:-:\|---\| \| \|:-:\| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7e6cccc1-3a5e-4803-a7f8-7325e7e155cb.gif) \| \| \| | |:-:| | \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/c16e2322-ff90-895b-a2c8-2802034b1ffc.png) \| \|:-:\| \| \| \| \| \| \| **![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/684aff70-9174-3ea8-f084-b3736b6eebf6.jpg) Connecticut man sentenced for scheme that defrauded Connecticut’s Medicaid program. **Ramon Appellaniz, of Middletown, has been sentenced to serve 78 months in prison, followed by two years of supervised release; and ordered to pay over $1.8 million in restitution to CT Medicaid.** Apellaniz previously operated The Gemini Project, LLC (“Gemini”), a Newington-based business that offered counseling to patients with mental, behavioral, and emotional disorders. In 2020, Apellaniz was charged by the state with larceny, health care fraud, and identity theft offenses related to his providing of services to numerous Medicaid beneficiaries as a non-licensed provider, and Gemini billing Medicaid for those services, [or for services that were not rendered at all](https://www.fbi.gov/contact-us/field-offices/newhaven/news/middletown-man-sentenced-for-scheme-that-defrauded-connecticuts-medicaid-program-of-more-than-18-million). Apellaniz pleaded nolo contendere and, on April 17, 2024, was sentenced in Hartford Superior Court to eight years in prison, execution suspended after 15 months, and five years of parole. He was released from Department of Correction custody on November 19, 2024.** **Two Arkansas men face arrests over insurance fraud charges. Bobbie Jean Troup and Shaquilla Maria Henry were each arrested and charged with Medicaid fraud. *Prosecutors say:* Troup, who was employed as an aide for a personal care agency, [fraudulently billed for services by clocking in and out](https://arkansasag.gov/news-release/attorney-general-griffin-announces-2-arrests-for-medicaid-fraud/) of shifts at Henry’s residence while Troup was working at the Arkansas Department of Corrections. Troup and Henry then shared the proceeds from the fraudulent billing.** **Chicago construction company and owner face charges for unpaid wages and insurance fraud. PMJ Enterprises Inc. (PMJ) and its owner and president, Jose T. Espiritu, have been charged over allegations the Chicago construction company misclassified workers as independent contractors and failed to pay employees hundreds of thousands of dollars in owed overtime wages. *The allegations:* PMJ [misclassified workers as independent contractors](https://illinoisattorneygeneral.gov/news/story/attorney-general-raoul-files-lawsuit-against-chicago-construction-company-and-owner-for-unpaid-wages-and-worker-misclassification) and paid some of their wages through money orders and checks issued by pass-through companies. Raoul’s lawsuit also alleges PMJ underreported its wages to the Illinois Department of Employment Security (IDES) in order to avoid paying required unemployment insurance contributions. The lawsuit seeks to recover all owed wages, statutory damages, interest and penalties available under the statutes. It also seeks injunctive relief requiring PMJ and Espiritu to cease any future violations.** **Monroe man accused of staging, planning car crashes in insurance fraud scheme. Adrian Sampson has been arrested following an investigation into a suspected staged-crash and insurance fraud scheme. *The allegations:* Sampson allegedly [planned, staged and orchestrated multiple crashes](https://www.myarklamiss.com/news/ouachita-parish/monroe-man-accused-of-staging-planning-car-crashes-in-insurance-fraud-scheme/amp/) in May 2024 through September 2025 to file fraudulent insurance claims potentially worth over $150,000 from his victims. On September 30, 2025, the Louisiana State Police secured warrants for Sampson’s arrest for 16 counts of insurance fraud, 16 counts of aggravated criminal damage to property, 16 counts of staging a motor vehicle collision, and racketeering. Sampson was arrested on October 24, 2025, in Bossier City, La.** **Johnston contractor charged with faking roof repair invoice for insurance payout. Shawn Heuss was arrested Oct. 30 and charged with [three Class D felonies](https://www.desmoinesregister.com/story/news/crime-and-courts/2025/11/07/johnston-contractor-arrested-insurance-fraud/87130047007/): one count of fraudulent submission, one count of second-degree theft, and one count of second-degree fraudulent practice. He also had an outstanding warrant for failure to appear on an animal at large charge. *The allegations:* Heuss, owner of Allure Roofing & Construction, filed an insurance claim in September 2024 for weather-related damage to the roof of his home. The insurer approved the claim and issued an initial payment for the actual cash value of the repairs. Heuss painted part of his roof to make it appear repaired, then created a false invoice from his company stating the job was finished. Heuss is being held in the Polk County Jail.** **Allstate blasts Texas clinics, claims $5.2 million auto fraud scheme. Allstate is taking aim at what it calls a sweeping medical billing fraud, [accusing a network of Texas clinics and providers of inflating auto injury claims](https://www.insurancebusinessmag.com/us/news/claims/allstate-blasts-texas-clinics-claims-5-2-million-auto-fraud-scheme-555820.aspx) with unnecessary procedures and questionable billing. *The lawsuit alleges:* The operation relied heavily on referrals from personal injury attorneys, who, according to deposition testimony cited in the lawsuit, had to approve injection procedures before they were performed. Nurse practitioners, rather than physicians, conducted most of the examinations and made recommendations for injections – often without the required physician supervision under Texas law. The lawsuit claims that Texas delegation requirements for nurse practitioners were not followed, and that the decision to proceed with injections was based on attorney authorization rather than medical necessity. The insurer further alleges that the defendants increased costs by utilizing improper facility fees, unbundled medical charges, and at times billed for services that were not rendered. Both Foundation and Prime are said to have charged for epidurography and anesthesia, even when documentation did not support those services. After Memorial MRI & Diagnostic and Complete Pain Solutions acquired Foundation and Prime in September 2021, the lawsuit claims the same practices continued.** **Oakland County insurance agent charged with forging client documents, embezzling municipal funds. Robert Joseph Bucko was arraigned on October 31 in the Oakland County District Court in Novi for allegedly forging letters from his insurance clients to embezzle funds. *The allegations:* Bucko allegedly collected full insurance premiums from eight municipalities but only remitted a quarter or one-half of the premiums to the insurer, embezzling the remaining funds for his own personal use. The alleged scheme relied on using premium payments from new clients to replace and fund previous accounts. Bucko reportedly owed more than $400,000 to the insurer in unpaid premiums when the alleged scheme was discovered. It is further alleged that Bucko overcharged municipalities and failed to file Michigan income tax returns from 2021 to 2023.** \| \| \| \| \| \|:-:\|---\| \| \|:-:\| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7e6cccc1-3a5e-4803-a7f8-7325e7e155cb.gif) \| \| \| | |:-:| | \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/05ebd826-d3ed-4100-a4b0-7c83841fc259.png) \| \|:-:\| \| \| \| \| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/78c612a3-7ad1-121e-6c84-8644673b1231.jpg) **Coalition Welcomes Celeste Dodson as Director of Member Relations & Initiatives** The Coalition Against Insurance Fraud is pleased to announce that **Celeste Dodson** will join the organization as its new **Director of Member Relations and Initiatives**. She will begin part-time on December 1, 2025, and transition to full-time on January 1, 2026. Celeste brings more than 30 years of experience in the insurance industry, including leadership of regional and national SIU operations, as well as extensive work in claims, underwriting, and project management. She has held key leadership roles in the anti-fraud community, including President of IASIU, Vice President of GIFS, Secretary of the Pennsylvania ATPA, and advisor to the NICB Board of Governors. She also previously served on the Coalition’s Executive Board. In her new role, Celeste will lead efforts to strengthen member engagement, support membership growth, and enhance the Coalition’s visibility across the industry. She will also provide strategic direction for the Coalition’s committees and task forces. Please join us in welcoming Celeste to the Coalition. Her leadership and expertise will be invaluable as we continue advancing collaboration across the anti-fraud community. [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/99d2319a-c3f2-ffcb-dba6-d40d951e79c7.png)](https://insurancefraud.org/coalition-annual-membership-meeting/) [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/1ce4a222-3707-daaf-86bf-d0078f1d7693.png)](https://s.surveyplanet.com/bj1sw6en) [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/6c8550d3-4d99-bc65-c8f8-cd1902423e17.png)](https://members.insurancefraud.org/general/pick_username.asp) ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/3ef40901-b851-f621-08b2-322f09ca8a57.png) [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/6f681cdb-233b-3a23-d74d-8d2ea782b4a3.png)](https://us02web.zoom.us/webinar/register/WN_UJnqT5-bQ6-zLdlTPU2PHQ) ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/10603368-408a-d879-f877-12cb1c3ee19d.jpg) \| \| \| \| \| \|:-:\|---\| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7e6cccc1-3a5e-4803-a7f8-7325e7e155cb.gif) \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7e6cccc1-3a5e-4803-a7f8-7325e7e155cb.gif) \| ![](images/spacer.gif) \| \| \|:-:\| \| \| | |:-:| | \| \| \| FACES OF FRAUD \| \|---\|:--\| \| \| \| \| \| \| \| [![](https://via.placeholder.com/125x166)](https://www.tn.gov/finance/news/2020/9/28/davidson-co--woman-charged-with-tenncare-fraud.html) \| \| \| \| [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/ac027363-7786-2633-43d6-0b982cf15403.png)](https://www.lowellsun.com/2025/11/12/hudson-nh-man-arrested-in-hit-and-run-and-insurance-fraud-case/) **Andrew Collins** Hudson, N.H. Auto claims *ARRESTED* \| \| \| \| [![](https://via.placeholder.com/125x166)](https://www.southwesttimes.com/2020/09/false-scripts-bills-send-doctor-to-prison/) \| \|:-:\|---\|:-:\| \| \| \| [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/c9ba2e5c-9323-4261-10da-dae2a867d466.png)](https://jocoreport.com/johnston-county-woman-accused-of-filing-false-insurance-claims/) **Charnay Hayden Padilla** Clayton, N.C. Fraud general *ARRESTED* \| \| \|:-:\| \| \|:-:\| \| \| \| [![](https://via.placeholder.com/125x166)](https://www.timesrepublican.com/news/todays-news/2020/09/mpd-handles-multiple-burglaries-1-arrested/) \| \|:-:\| \| \| \| [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/3444a8c7-1fb0-d12e-1240-2c32e333fe52.png)](https://thencbeat.com/raleigh-woman-identity-theft-insurance-fraud/) **Sha-Niaya Fae Davis Raleigh, N.C. Medical claims *ARRESTED*** \| \| \| \| [![](https://via.placeholder.com/125x166)](https://www.wmbfnews.com/2020/09/22/longs-woman-arrested-accused-forging-prescriptions/) \| \|:-:\|---\|:-:\| \| \| \| [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/ade62f31-85b3-75a1-e964-56bae32400cd.jpg)](https://insurancefraud.org/report-fraud/) \| \| \|:-:\| \| \|:-:\| \| \|---\| \| \|:-:\| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7e6cccc1-3a5e-4803-a7f8-7325e7e155cb.gif) \| \| \| \| \| \|:-:\|---\| | |:-:| | \| \| \| EVENTS \| \|---\|:--\| \| \| \| \| **November 17-21 — [Digging for treasure: Company Research Strategies for Attorneys](mailto:alisonf.oneill1@lexisnexis.com)** Virtual (LexisNexis) \| \| \| \| \|:--\| \| \| **November 19 — [The Hidden Threat: Synthetic Identities & Account Takeovers in Modern Fraud](https://www.iasiu.org/events/EventDetails.aspx?id=1976262)** Webinar (IASIU) \| \| \| \| \|:--\| \| \| **December 2-3 — [Coalition Annual Meeting](https://insurancefraud.org/coalition-annual-membership-meeting/) Arlington, VA. (Coalition Against Insurance Fraud)** \| \| \| \| \|:--\| \| \| **December 18 — [Emerging Fraud Trends in P&C Insurance](https://us02web.zoom.us/webinar/register/WN_UJnqT5-bQ6-zLdlTPU2PHQ) Webinar (Coalition Against Insurance Fraud)** \| \| \| \| \|:--\| \| \| **April 22, 2026 — [**2026 Annual Anti-Fraud Conference**](https://annualantifraudconference.com/#Registration) Monterey, Calif. (AFA)** \| \| \| \| \|:--\| \| \| \|:-:\|---\| | |:-:| | \| \| \| FRAUD NEWS FRIDAY \| \|---\|:--\| \| \| \| \| **\* [Charlotte Man Charged with Felony Insurance Fraud](https://hoodline.com/2025/11/charlotte-man-charged-with-felony-insurance-fraud-over-81k-dodge-charger-claim/)** \* **[Rogue Pittsburgh tow truck operator ordered to pay back nearly $400,000](https://www.cbsnews.com/pittsburgh/news/pittsburgh-tow-truck-operator-predatory/)** \* **[How AI and network analytics transformed fraud detection](https://www.sas.com/en_us/customers/db-insurance-en.html)** \* **[N.Y. State warns of health insurance scams](https://www.thedailynewsonline.com/news/n-y-state-warns-of-health-insurance-scams/article_77b40431-35f9-4292-9839-46ade4d7b712.html)** \* [**Understanding what insurers really need from technology**](https://www.dig-in.com/opinion/understanding-what-insurers-really-need-from-technology) \| \| \| \| \|:--\| \| \| \|:-:\|---\| | |:-:| | \| \| \| \| \|---\|---\| \| \| \| \| Connect with Us: \| \| \| [![FB](https://mcusercontent.com/a440c5b647697de580a2fd586/images/ef66a2aa-ea17-4447-95b6-ad328c555988.png)](https://www.facebook.com/insurancefraud) \| \| [![TW](https://mcusercontent.com/a440c5b647697de580a2fd586/images/43f8397b-2f36-4358-87e9-549e6d9b749b.png)](https://twitter.com/insurance_fraud) \| \| [![YT](https://mcusercontent.com/a440c5b647697de580a2fd586/images/c202c8ca-32dc-49b1-a471-9669d36f946e.png)](https://www.youtube.com/user/stopinsurancefraud) \| \| [![IN](https://mcusercontent.com/a440c5b647697de580a2fd586/images/0cb8e5d8-9435-49a5-91b2-1a214a5f2fa0.png)](https://www.linkedin.com/groups/3856550) \| \| \|:-:\| \| [![Coalition Against Insurance Fraud](https://mcusercontent.com/a440c5b647697de580a2fd586/images/539d436e-d608-44a9-ba5e-b64d3a1ddd06.png)](https://www.insurancefraud.org) \| \| \|:-:\| \| Contact: \| \|:--\| \| Phone: [202.393.7330](tel:2023937330) Email: <info@insurancefraud.org> Address: 1012 14th Street NW Suite 610 Washington DC 20005 [www.InsuranceFraud.org](http://www.insurancefraud.org/) \| \| \|---\| \| \|:-:\| \| \| \| \| \|:-:\|---\| | |:-:| | | |---| | \| \| You are receiving this email because either your organization is a member of the Coalition Against Insurance Fraud or you requested to be placed on our mailing list. [Unsubscribe](https://insurancefraud.us1.list-manage.com/unsubscribe?u=a440c5b647697de580a2fd586&id=b68dce7808&t=b&e=%5BUNIQID%5D&c=ad472df6c6) [<< Test Email Address >>](%3C%3C%20Test%20Email%20Address%20%3E%3E) from this list. Our mailing address is: Coalition Against Insurance Fraud1012 14th St NW Ste 610 Washington, DC 20005-3424 [Add us to your address book](https://insurancefraud.us1.list-manage.com/vcard?u=a440c5b647697de580a2fd586&id=b68dce7808) Copyright (C) 2025 Coalition Against Insurance Fraud All rights reserved. [Forward this email to a friend](https://us1.forward-to-friend.com/forward?u=a440c5b647697de580a2fd586&id=ad472df6c6&e=%5BUNIQID%5D) [Update your profile](https://insurancefraud.us1.list-manage.com/profile?u=a440c5b647697de580a2fd586&id=b68dce7808&e=%5BUNIQID%5D&c=ad472df6c6) \| \| \|:-:\| | |:-:| <html><p class="wp-block-paragraph"></p> **Features:** Fraud News Weekly --- ### [Fraud News Weekly - November 7, 2025](https://insurancefraud.org/publications/fraud-news-weekly-november-7-2025/) **Published:** November 7, 2025 **Author:** Coalition Against Insurance Fraud **Content:** Two days left for Annual Meeting room rate discount, Minnesota Enacts Anti-Kickback Statute, And NICB Launches National Campaign | \| \| \|:-:\| \| Friday, November 7, 2025 \| \| \| | |:-:| | \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/df906857-d727-9ee9-0397-2a09caac30a4.png) \| \|:-:\| \| \| \| \| \| \|:-:\| | |:-:| | \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/2f971e24-7875-ac59-92b3-95d69a0bb60a.jpg) \| \|:-:\| \| \| \| \| \| \| [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a1492a86-29b0-90b6-d879-527e5492037e.png)](https://www.facebook.com/) [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/d2bd23eb-8810-4f7a-49d3-d2fe7aa1891e.png)](https://www.instagram.com/stopinsurancefraud/)[![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/be4e5708-bdc4-c0df-6c03-a6ebd5b34c13.png)](https://www.linkedin.com/company/coalition-against-insurance-fraud) \| \| \| \| \| \|:-:\|---\| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7e6cccc1-3a5e-4803-a7f8-7325e7e155cb.gif) \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7e6cccc1-3a5e-4803-a7f8-7325e7e155cb.gif) \| ![](images/spacer.gif) \| \| \|:-:\| \| \| | |:-:| | \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a57e030f-61fa-473f-b132-259b1a34e42e.png) \| \|:-:\| \| \| \| \| \| \| **![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/52a7588b-3756-7e8c-cba9-5a194c3994ed.jpeg)** **The Coalition supports the Washington Office of the Insurance Commissioner’s (OIC) 2026 proposal to modernize the state’s Insurance Fraud Program. In a recent comment [letter](https://insurancefraud.org/wp-content/uploads/Coalition-10_29_2025-Comments-WA-OIC-Draft-RCW-48.135.pdf), the Coalition commended Commissioner Patty Kuderer for seeking legislative updates that respond to the growing sophistication of technology-driven fraud schemes targeting both insurers and consumers.** The OIC is actively preparing for the 2026 legislative session and plans to find a sponsor to introduce this important measure. The proposal would amend to [Chapter 48.135 RCW](https://app.leg.wa.gov/rcw/default.aspx?cite=48.135) and elevate insurance fraud to a class B felony, expand prosecutorial powers, clarify venue and statute of limitations issues, and allow for greater information sharing. It also strengthens the Criminal Investigations Unit ([CIU](https://www.insurance.wa.gov/complaints-appeals-fraud/fraud/criminal-investigations-unit-ciu/about-criminal-investigations-unit-ciu)) by adding financial and digital specialists to better address complex fraud, including identity theft, premium and billing fraud, property repair scams, and appraisal manipulation. The Coalition sees this as a smart, forward-looking approach that not only protects Washington consumers but also enhances enforcement tools, and could serve as a model for other states grappling with increasingly sophisticated fraud threats. **Minnesota [enacts](https://www.jdsupra.com/legalnews/minnesota-implements-an-anti-kickback-8729953/) state Anti-Kickback Statute.** With the passing of *[HB 2115](https://www.revisor.mn.gov/laws/2025/0/38/laws.5.32.0#laws.5.32.0)*, Minnesota’s new Anti-Kickback Statute criminalizes illegal remuneration or the intentional soliciting or receiving anything of value in exchange for patient referrals or recommending services reimbursed by federal or state health care programs. Unlike the federal law’s “*knowing and willful*” standard, Minnesota applies a lower “*intentional*” threshold, potentially broadening enforcement of medical provider activity. Penalties include fines up to $100,000 and prison terms up to 20 years for larger kickbacks. The law incorporates federal safe harbors and allows prosecutors to aggregate remuneration over six months. This update was shared on the Coalition’s Medical Fraud Task Force call to keep members informed. **Maryland Insurance Administration’s upcoming virtual Property & Casualty Industry Meeting will focus on consumer protection and fraud-related topics.** The Maryland Insurance Administration (MIA) will host its [Property & Casualty Industry Meeting](https://insurance.maryland.gov/Documents/newscenter/legislativeinformation/Agenda-PC-Industry-Meeting-Fall-2025.pdf) virtually on November 12, 2025, spotlighting key issues impacting insurers, regulators, and consumers in the P&C sector. Commissioner Marie Grant and Deputy Commissioner Joy Hatchette will lead discussions on consumer complaints, highlighting MIA’s new complaint system designed to improve carrier response times. The agenda also includes review of the 2026 legislative package, including industry requests focused on third-party litigation funding and reforms targeting unfair trade practices by roofing contractors. Regulatory changes finalized in 2025 will also be discussed. The Coalition encourages members to participate and engage with the MIA to help shape effective antifraud strategies and regulatory policies for Maryland’s P&C industry. \| \| \| \| \| \|:-:\|---\| \| \|:-:\| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7e6cccc1-3a5e-4803-a7f8-7325e7e155cb.gif) \| \| \| | |:-:| | \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/8cabe36d-e42d-387f-2792-ee8bb3005e58.png) \| \|:-:\| \| \| \| \| \| \| **![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/c9fd1806-c196-ae1a-82b9-e023e445f6e4.png)** **Virginia State Police sees spike in insurance fraud cases. Virginia State Police is seeing a spike in insurance fraud cases across the Commonwealth, which First Sergeant Eric Futrell is investigating alongside his team.** “*We’re trying to educate everyone out there to make sure that they don’t become a victim of insurance fraud,*” said Futrell. “*We do see cases where we have folks who will come in and lower their deductibles in their insurance and then report something that is taking place outside the parameters of their covered time period, and that is insurance fraud as well.*” Last year, [Virginia State Police said more than 2,000 referrals were sent](https://www.12onyourside.com/2025/11/03/it-affects-everyone-virginia-state-police-sees-spike-insurance-fraud-cases/?outputType=amp). Out of those referrals, 335 investigations were initiated, leading to 54 arrests. Among the cases the agency tracks are staged car crashes. “*You’ll have a vehicle crash and the parties may or may not call law enforcement to the scene,*” said Futrell. “*Where you have cases of fraud you’ll have often times people who are not present inside the vehicle claiming injury, so if you’re not inside the vehicle, you shouldn’t be injured. That’s completely fraud.*” Troopers said the scheme could also involved unsuspecting drivers, making them victims of insurance fraud. **NICB Launches National Campaign Urging Consumers to Fight Back Against Insurance Fraud.** On November 5, 2025, the National Insurance Crime Bureau (NICB) kicked off a [nationwide campaign warning consumers](https://www.nicb.org/news/news-releases/nicb-warns-consumers-nationwide-insurance-fraud-coming-your-pocketbook) that insurance fraud is hitting their wallets. Partnering with the Anti-Fraud Alliance, NICB is rallying Americans to recognize, report, and prevent the deceptive schemes that cost the U.S. an estimated **$308.6 billion each year** and add about **$900** to the average policyholder’s annual premiums. From staged car crashes and bogus home repair offers after storms to inflated medical bills and contractor scams, fraudsters prey on confusion and vulnerability. NICB’s new initiative calls on consumers to learn the warning signs, and report suspicious activity to contact law enforcement, state insurance fraud units, insurance companies, or NICB’s 24-hour hotline at **800-TEL-NICB (800-835-6422)**. ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/8035aab9-f5ca-dce7-9394-bc043df5878a.png) \| \| \| \| \| \|:-:\|---\| \| \|:-:\| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7e6cccc1-3a5e-4803-a7f8-7325e7e155cb.gif) \| \| \| | |:-:| | \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/bd099ba2-96e8-cf07-257c-1d3faf0782c7.png) \| \|:-:\| \| \| \| \| \| \| **![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/e286f500-773f-af4b-d153-3019f9f6e6ac.png)** **Alaska prosecutors charge Knights of Ni with significant Medicaid fraud. No, it isn’t Monty Python's Flying Circus, it’s a real case of insurance fraud.** Prosecutors with the Alaska Department of Law’s Office of Special Prosecutions [have filed seven criminal felony charges](https://alaskabeacon.com/briefs/alaska-prosecutors-charge-knights-of-ni-with-significant-medicaid-fraud/) against The Knights of Ni LLC and its owner, Ryan Carroll, accusing Caroll of defrauding the state’s Medicaid system of more than $500,000. *The allegations:* Carroll operated as a care coordinator. Under state law and regulation, a care coordinator can be paid by the Alaska Department of Health for their work if they document their patient visits and submit a report to the state. According to the criminal complaint, the Department of Health received a message warning that Carroll “*was having an inappropriate relationship with one of his … clients.*” That prompted an investigation which found Carroll had missed several reports that could have caused as many as 19 Alaskans to lose health care. Further review discovered Carroll “*documenting that he was providing monthly care coordination contacts to more than one client on the same date, time, but at different locations.*” In many cases, state investigators found Carroll had not submitted the proper forms to bill Medicaid, and in some cases, “*It was not clear whether Carroll was making any contact with his assigned recipients due to the lack of documentation to support his services.*” Records published by Alaska’s division of corporate, business and professional licensing show that The Knights of Ni LLC was involuntarily dissolved in 2024 after failing to meet the requirements to keep operating. **Allstate alleges nine DME firms ran a $679,000 fraud scheme.** [Allstate](https://www.insurancebusinessmag.com/us/companies/allstate/66989/) has accused nine medical equipment companies of running a $679,000 fraud ring that exploited New York's no-fault auto insurance system. *The lawsuit alleges:* The companies operated what [appeared to be separate businesses but shared a single phone number](https://www.insurancebusinessmag.com/us/news/claims/allstate-alleges-nine-dme-firms-ran-679k-fraud-scheme-555132.aspx) and coordinated to bill for unnecessary medical devices following car accidents. The case invokes federal racketeering statutes and targets a network of durable medical equipment suppliers that allegedly dispensed pneumatic compression devices, electrical stimulation units, and bone growth stimulators to patients who didn't need them. At the heart of the alleged scheme was a simple deception: nine companies – BSD OS, Luminex BK, TM OS, Vital Craft OS, Harmony OS, Pinnacle OS, Wellspring Solutions, Nexgen Line, and Platinum Line – presented themselves as independent operators while using the same telephone number on delivery receipts submitted to Allstate. The insurer claims the companies falsified their business addresses on licensing applications, listing virtual office spaces, shipping stores, and coworking facilities as their headquarters. **Connecticut woman charged with filing fraudulent Medicaid claims.** Ivette Betancourt, of Wethersfield, was arrested on October 22 in violation of Connecticut General Statutes § 53a-122(a)(3), and one count of Health Insurance Fraud. *The allegations:* Betancourt is a Licensed Marital and Family Therapist enrolled as a provider in the Connecticut Medicaid Program. Between October 2020 and June 2025, [Betancourt billed Medicaid for therapy sessions that did not take place](https://portal.ct.gov/dcj/press-releases/division-of-criminal-justice/11042025betancourt?language=en_US). Inspectors interviewed and/or reviewed patient records for 38 out of Betancourt’s 138 Medicaid patients and found numerous claims for counseling sessions that were not performed. Betancourt submitted claims to Medicaid for these unrendered sessions and as a result of her fraudulent billings, she received $141,087.35 in Medicaid payments she was not entitled to. **Pennsylvania man charged with felony insurance fraud.** Corey Jeffrey Bloom, from DuBois, has been charged with one count of insurance fraud, a felony in the third degree, and one count of criminal attempt/theft by deception, a misdemeanor in the third degree. *Prosecutors say:* On June 9 at 7:50 p.m., Bloom reportedly [canceled his policy with Geico insurance](https://www.thecourierexpress.com/news/crime/dubois-man-charged-with-felony-insurance-fraud/article_f93cad51-e007-4812-ad9e-793e7b967132.html). On June 18, Bloom utilized the Geico online app to file a claim reporting damages to his 2014 Subaru Crosstrek, which occurred on June 12, due to a tree falling on the vehicle. Geico investigated the claim, and determined the damages did not occur on the date in which Bloom listed. It was revealed the damages reportedly occurred on or before June 9, and prior to Bloom reinstating his canceled policy. When police spoke to Bloom on Sept. 23, he said he had his policy payments set up for automatic withdraw from Geico. He was not aware that his premium payment did not go through when he learned that the policy lapsed. Bloom was told that according to Geico, he had his insurance policy reinstated on June 9. Bloom reportedly acknowledged this. Bloom stated damage to his Subaru occurred on June 12, as the result of a tree falling on it. Geico obtained the metadata of the photos, depicting the damages to said vehicle, which revealed the loss occurred prior to June 9. He later withdrew his claim with Geico. **Idaho woman receives up to 5 years for insurance fraud.** Michelle Stone, of Post Falls, was sentenced in [Kootenai County](https://idahobusinessreview.com/tag/kootenai-county/) District Court and given supervised probation in favor of up to five years in prison. Stone also must complete 150 hours of community service and pay restitution, court costs and related fines. The [Idaho Department of Insurance](https://idahobusinessreview.com/tag/idaho-department-of-insurance/) Fraud Unit investigated Stone after [she reported an alleged burglary](https://idahobusinessreview.com/2025/11/04/post-falls-woman-insurance-fraud-sentencing/) to the Post Falls Police Department and filed a claim with Allstate Insurance. Stone supplied the insurance company with photographs purporting to show evidence of the burglary, however, investigators determined the photos were taken after the date of burglary. Stone was tried on July 9, 2025, and sentenced on Oct. 14, 2025. **Plea deal over explosive insurance fraud in Iowa.** Zachary Marshall Robbins, of Rockwell, and an unnamed individual staged a car accident on March 13, 2019. *Investigators say:* Two vehicles were [deliberately crashed together,](https://www.kimt.com/news/plea-deal-over-explosive-insurance-fraud-in-mitchell-county/article_07d150b3-822c-411c-828d-80ef47ac94cf.html) and then Robbins allegedly set fire to his vehicle, causing an explosion that destroyed the vehicle and everything in it. Robbins then lied about the fake accident and filed an insurance claim of more than $70,000. Robbins had pleaded not guilty to first-degree arson, insurance fraud, and false report of an indictable offense to a public entity. He’s now entered a guilty plea to one count of fraudulent submissions, a class D felony. **Public insurance adjuster in N.C. charged with embezzlement.** Tyler Englin, was arrested in Johnston County and charged with felony embezzlement. *The allegations say:* Englin took an insurance claim payment [meant for his client](https://abc11.com/post/tyler-englin-public-adjuster-center-abc11-troubleshooter-investigation-criminally-charged-embezzlement/18091927/). A Cary couple hired Englin and said he kept close to $100,000 of their insurance money for work that was done to their home. Also, a roofing company that recommended Englin to several homeowners says that he didn't pay them for the work they did on those jobs, despite Englin getting the insurance money. Englin has not been charged in these cases. **Couple accused of stealing $2.9 million in enormous Medicaid fraud.** A couple running two transportation companies allegedly billed Medicaid nearly [$3 million for bogus medical transport trips](https://www.yahoo.com/news/articles/hudson-valley-couple-accused-stealing-140555898.html) in what Orange County officials are calling the biggest Medicaid fraud scheme ever prosecuted in the county. Husband and wife Rohail Raja and Sharma Alam pleaded not guilty to felony grand larceny this week after a state audit discovered patterns of fraudulent billing at their companies from 2020 to 2024. *Prosecutors accusations:* The couple billed the government health insurance program to transport patients to medical appointments that did not exist, netting $2,008,000 in excess payments. They also stole an additional $895,000 by falsely claiming to have driven patients separately, when in fact they had taken multiple Medicaid recipients in a single trip. Prosecutors did not name the New Windsor couple's two companies, which were authorized by the state Department of Health to bring Medicaid recipients to and from approved medical providers. \| \| \| \| \| \|:-:\|---\| \| \|:-:\| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7e6cccc1-3a5e-4803-a7f8-7325e7e155cb.gif) \| \| \| | |:-:| | \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/05ebd826-d3ed-4100-a4b0-7c83841fc259.png) \| \|:-:\| \| \| \| \| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/6895b24f-859d-2077-d852-9a8883c6d91e.png) **The Coalition Against Insurance Fraud is pleased to announce that Sphere Investigations has joined as our newest Associate Member.** Sphere Investigations brings extensive expertise in fraud prevention and corporate investigations, offering a comprehensive suite of services that includes field investigations, internet based investigative solutions, surveillance, and medical canvassing. Formed through the partnership of Mangrove Equity Partners and Sunlake Capital Partners, Sphere Investigations unites the established capabilities and resources of Fraud Sniffr, Phenix Investigations, and Marshall Investigative Group. Together, this integrated platform is positioned to deliver enhanced investigative insight and data driven strategies to support insurers and organizations working to reduce fraud. We are excited to welcome Sphere Investigations to the Coalition and look forward to collaborating closely as we continue to strengthen the fight against insurance fraud, protect consumers, and support the integrity of insurance systems nationwide. ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/f8628f05-c69a-b49b-5c6b-325c1455059a.png) ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/34d1f340-93a8-03e8-65ff-99fd6a723e6d.png) [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/c5a7e273-4356-b023-cb33-bb8b15cc583d.jpg)](https://insurancefraud.org/coalition-annual-membership-meeting/) [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/1ce4a222-3707-daaf-86bf-d0078f1d7693.png)](https://s.surveyplanet.com/bj1sw6en) [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/6c8550d3-4d99-bc65-c8f8-cd1902423e17.png)](https://members.insurancefraud.org/general/pick_username.asp) ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/3ef40901-b851-f621-08b2-322f09ca8a57.png) ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/10603368-408a-d879-f877-12cb1c3ee19d.jpg) [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/4548f138-b492-dc93-2261-b81c5687ca63.jpg)](https://events.skopenow.com/osint-workflows-for-sanctions-restricted-party-exposure?utm_campaign=22205851-Q3_2025_DisasterResponse&utm_medium=email&_hsenc=p2ANqtz-_5PnFj32mxMBL5PzlVqHDXh7XY5o9bvGl0PFp2D2-w2jO8bXQQfdrrn7flpvwBGBvB0fOsqU8OkCyIz95EbkCmrxLL1xOj1ABoVCIGdj_RYCPReT4&_hsmi=388574047&utm_content=388574047&utm_source=hs_email) \| \| \| \| \| \|:-:\|---\| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7e6cccc1-3a5e-4803-a7f8-7325e7e155cb.gif) \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7e6cccc1-3a5e-4803-a7f8-7325e7e155cb.gif) \| ![](images/spacer.gif) \| \| \|:-:\| \| \| | |:-:| | \| \| \| FACES OF FRAUD \| \|---\|:--\| \| \| \| \| \| \| \| [![](https://via.placeholder.com/125x166)](https://www.tn.gov/finance/news/2020/9/28/davidson-co--woman-charged-with-tenncare-fraud.html) \| \| \| \| [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/146e34c8-9666-1762-abc5-5e973c7bf375.png)](https://youarecurrent.com/2025/11/04/troubled-carmel-nurse-practitioner-accused-of-insurance-fraud/) **Katherine Curtis** Carmel, Ind. Drug diversion *ARRESTED* \| \| \| \| [![](https://via.placeholder.com/125x166)](https://www.southwesttimes.com/2020/09/false-scripts-bills-send-doctor-to-prison/) \| \|:-:\|---\|:-:\| \| \| \| [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/3e6ed4b1-68a0-a322-1db1-68126a528337.png)](https://www.live5news.com/video/2025/11/04/video-charleston-county-woman-accused-insurance-fraud/) **Porscha McWhite** Charleston County, S.C. Homeowners claims *ARRESTED* \| \| \|:-:\| \| \|:-:\| \| \| \| [![](https://via.placeholder.com/125x166)](https://www.timesrepublican.com/news/todays-news/2020/09/mpd-handles-multiple-burglaries-1-arrested/) \| \|:-:\| \| \| \| [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/239c5d7c-5664-2c7a-3b58-033db4cecc54.png)](https://iid.iowa.gov/press-release/2025-11-05/johnston-contractor-arrested-insurance-fraud) **Shawn Heuss** Johnston, Iowa Homeowners claims *ARRESTED* \| \| \| \| [![](https://via.placeholder.com/125x166)](https://www.wmbfnews.com/2020/09/22/longs-woman-arrested-accused-forging-prescriptions/) \| \|:-:\|---\|:-:\| \| \| \| [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/eeb7c79f-2df7-997a-44ff-a99aadd6e5a0.png)](https://www.valleynewslive.com/2025/11/05/park-rapids-man-charged-with-arson-insurance-fraud-2022-house-fire/) **Mark John Jenni** Park Rapids, Minn. Homeowners arson *ARRESTED* \| \| \|:-:\| \| \|:-:\| \| \|---\| \| \|:-:\| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7e6cccc1-3a5e-4803-a7f8-7325e7e155cb.gif) \| \| \| \| \| \|:-:\|---\| | |:-:| | \| \| \| EVENTS \| \|---\|:--\| \| \| \| \| **November 10-14 — [Digging for treasure: Company Research Strategies for Attorneys](mailto:alisonf.oneill1@lexisnexis.com)** Virtual (LexisNexis) \| \| \| \| \|:--\| \| \| **November 12 — [OSINT Workflows for Sanctions & Restricted Party Exposure](https://events.skopenow.com/osint-workflows-for-sanctions-restricted-party-exposure?utm_campaign=22205851-Q3_2025_DisasterResponse&utm_medium=email&_hsenc=p2ANqtz-_5PnFj32mxMBL5PzlVqHDXh7XY5o9bvGl0PFp2D2-w2jO8bXQQfdrrn7flpvwBGBvB0fOsqU8OkCyIz95EbkCmrxLL1xOj1ABoVCIGdj_RYCPReT4&_hsmi=388574047&utm_content=388574047&utm_source=hs_email)** Virtual (Skopenow) \| \| \| \| \|:--\| \| \| **November 19 — [The Hidden Threat: Synthetic Identities & Account Takeovers in Modern Fraud](https://www.iasiu.org/events/EventDetails.aspx?id=1976262)** Webinar (IASIU) \| \| \| \| \|:--\| \| \| **December 2-3 — [Coalition Annual Meeting](https://insurancefraud.org/coalition-annual-membership-meeting/) Arlington, VA. (Coalition Against Insurance Fraud)** \| \| \| \| \|:--\| \| \| **April 22, 2026 — [**2026 Annual Anti-Fraud Conference**](https://annualantifraudconference.com/#Registration) Monterey, Calif. (AFA)** \| \| \| \| \|:--\| \| \| \|:-:\|---\| | |:-:| | \| \| \| FRAUD NEWS FRIDAY \| \|---\|:--\| \| \| \| \| **\* [Austin Woman Avoids T-Bone Crash. Then She Realizes It's a Setup](https://www.motor1.com/news/778217/texas-t-bone-insurance-scam/) \* [Kentucky farmer sentenced for $1.9M crop fraud, others await sentencing](https://www.kentucky.com/news/local/crime/article312805079.html) \* [Allstate blasts Texas clinics, claims $5.2 million auto fraud scheme](https://www.insurancebusinessmag.com/us/news/claims/allstate-blasts-texas-clinics-claims-5-2-million-auto-fraud-scheme-555820.aspx) \* [Wendy Osefo in court today demanding 16 fraud charges dismissed](https://www.red94.net/news/11417-wendy-osefo-in-court-today-demanding-16-fraud-charges-dismissed-faces-critical-j/) \* [Consumers Are the Front Line in Fighting Insurance Fraud](https://www.insurancejournal.com/news/national/2025/11/07/846780.htm)** \| \| \| \| \|:--\| \| \| \|:-:\|---\| | |:-:| | \| \| \| \| \|---\|---\| \| \| \| \| Connect with Us: \| \| \| [![FB](https://mcusercontent.com/a440c5b647697de580a2fd586/images/ef66a2aa-ea17-4447-95b6-ad328c555988.png)](https://www.facebook.com/insurancefraud) \| \| [![TW](https://mcusercontent.com/a440c5b647697de580a2fd586/images/43f8397b-2f36-4358-87e9-549e6d9b749b.png)](https://twitter.com/insurance_fraud) \| \| [![YT](https://mcusercontent.com/a440c5b647697de580a2fd586/images/c202c8ca-32dc-49b1-a471-9669d36f946e.png)](https://www.youtube.com/user/stopinsurancefraud) \| \| [![IN](https://mcusercontent.com/a440c5b647697de580a2fd586/images/0cb8e5d8-9435-49a5-91b2-1a214a5f2fa0.png)](https://www.linkedin.com/groups/3856550) \| \| \|:-:\| \| [![Coalition Against Insurance Fraud](https://mcusercontent.com/a440c5b647697de580a2fd586/images/539d436e-d608-44a9-ba5e-b64d3a1ddd06.png)](https://www.insurancefraud.org) \| \| \|:-:\| \| Contact: \| \|:--\| \| Phone: [202.393.7330](tel:2023937330) Email: <info@insurancefraud.org> Address: 1012 14th Street NW Suite 610 Washington DC 20005 [www.InsuranceFraud.org](http://www.insurancefraud.org/) \| \| \|---\| \| \|:-:\| \| \| \| \| \|:-:\|---\| | |:-:| | | |---| | \| \| You are receiving this email because either your organization is a member of the Coalition Against Insurance Fraud or you requested to be placed on our mailing list. [Unsubscribe](https://insurancefraud.us1.list-manage.com/unsubscribe?u=a440c5b647697de580a2fd586&id=b68dce7808&t=b&e=%5BUNIQID%5D&c=7a7f7c9698) [<< Test Email Address >>](%3C%3C%20Test%20Email%20Address%20%3E%3E) from this list. Our mailing address is: Coalition Against Insurance Fraud1012 14th St NW Ste 610 Washington, DC 20005-3424 [Add us to your address book](https://insurancefraud.us1.list-manage.com/vcard?u=a440c5b647697de580a2fd586&id=b68dce7808) Copyright (C) 2025 Coalition Against Insurance Fraud All rights reserved. [Forward this email to a friend](https://us1.forward-to-friend.com/forward?u=a440c5b647697de580a2fd586&id=7a7f7c9698&e=%5BUNIQID%5D) [Update your profile](https://insurancefraud.us1.list-manage.com/profile?u=a440c5b647697de580a2fd586&id=b68dce7808&e=%5BUNIQID%5D&c=7a7f7c9698) \| \| \|:-:\| | |:-:| <html><p class="wp-block-paragraph"></p> **Features:** Fraud News Weekly --- ### [Fraud News Weekly - October 31, 2025](https://insurancefraud.org/publications/fraud-news-weekly-october-31-2025/) **Published:** October 31, 2025 **Author:** Coalition Against Insurance Fraud **Content:** Social Media Competition Member Message, Louisiana Updates Anti-Fraud Rules, and New LexisNexis CLE dates | \| \| \|:-:\| \| Friday, October 31, 2025 \| \| \| | |:-:| | \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/df906857-d727-9ee9-0397-2a09caac30a4.png) \| \|:-:\| \| \| \| \| \| \|:-:\| | |:-:| | \| [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/c4bd2cef-0e24-df7f-80b1-6aa6db82d2d9.jpg)](https://www.facebook.com/profile.php?id=61579225779934) \| \|:-:\| \| \| \| \| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/2f971e24-7875-ac59-92b3-95d69a0bb60a.jpg) [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a1492a86-29b0-90b6-d879-527e5492037e.png)](https://www.facebook.com/) [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/d2bd23eb-8810-4f7a-49d3-d2fe7aa1891e.png)](https://www.instagram.com/stopinsurancefraud/)[![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/be4e5708-bdc4-c0df-6c03-a6ebd5b34c13.png)](https://www.linkedin.com/company/coalition-against-insurance-fraud) [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/aad432e9-0fa4-74a6-0369-a690608d63a1.jpg)](https://vimeo.com/1132161532?share=copy) \| \| \| \| \| \|:-:\|---\| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7e6cccc1-3a5e-4803-a7f8-7325e7e155cb.gif) \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7e6cccc1-3a5e-4803-a7f8-7325e7e155cb.gif) \| ![](images/spacer.gif) \| \| \|:-:\| \| \| | |:-:| | \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a57e030f-61fa-473f-b132-259b1a34e42e.png) \| \|:-:\| \| \| \| \| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/01b16b3a-58fd-f851-0e5c-e2eaabad818e.png) **Colorado reminds insurers of their responsibilities in preventing repair shop deductible waivers. **The Colorado Division of Insurance issued [Bulletin B-5.54](https://links-2.govdelivery.com/CL0/https:%2F%2Fdoi.colorado.gov%2Fsites%2Fdoi%2Ffiles%2Fdocuments%2FBulletin%2520No.%2520B-5.54%2520Auto%2520Deductibles.pdf%3Futm_medium=email%26utm_source=govdelivery/1/0101019a08dad197-42a49663-3f44-485b-8b62-995d3bc30ed1-000000/4bZ-Uf6lP4Nc1i9iK15SWXj98KLmYwEo7YSgw15p1zs=428) to remind insurers of their role in preventing the waiver of policyholders’ deductibles by auto repair shops.** The Division noted that some repair shops are advertising for and have waived deductibles to attract business, and that insurers could have referred customers to these shops. The Division stated in the bulletin that deductibles are the policyholder’s contractual responsibility, and waivers, or failure to clearly inform policyholders of that responsibility, may constitute misrepresentation or fraud, potentially inflating repair costs and premiums for all consumers. The Division expects that insurers must clearly communicate policyholder deductible obligations, and must investigate and report any known instances as potential fraud or violations of Colorado law. **Louisiana updates anti-fraud plan filing requirements for insurers.** The Louisiana Department of Insurance issued [Directive 228](https://ldi.la.gov/docs/default-source/documents/legaldocs/directives/dir228-cur-amendedanti-fraudpla), updating anti-fraud plan filing requirements for all authorized insurers and HMOs to align with Act 614 of the 2024 Regular Legislative Session and the amended provisions of La. R.S. 22:572.1. Insurers must now electronically submit anti-fraud plans, annual summaries, and any material updates via LDI’s Industry Access Portal by April 1st of each year. Reporting must include detailed fraud metrics such as investigated claims, referrals, estimated losses and recoveries, and resources devoted to fraud investigations by line of business. **Michigan reminds insurers of prompt investigation and fair settlement duties under new claims administration bulletin.** The Michigan Department of Insurance and Financial Services issued [Bulletin 2025-25-INS](https://www.michigan.gov/difs/-/media/Project/Websites/difs/Bulletins/2025/Bulletin_2025-25-INS.pdf?rev=1cba21679fe3421ca2a47ddf00b5a5d2) to clarify expectations for automobile claims administration. Director Anita G. Fox emphasized that insurers must adopt reasonable standards for the prompt investigation of claims and make fair, equitable settlements when liability is clear, as required by MCL 500.2026. The bulletin cites improper practices such as misrepresenting claim information, delaying investigations, failing to pay undisputed claims, and withholding total loss payments. The Department said that insurers engaging in such conduct could face fines or suspension of their certificate of authority. While no violations are alleged, DIFS will investigate complaints as allowed by law. **Oklahoma enacts 2025 rules to limit post-loss assignments, adjuster commissions, and storage fees.** The Oklahoma Insurance Department’s [Bulletin 2025-07](https://www.oid.ok.gov/bulletin-no-2025-07/) details legislative changes effective November 1, 2025, aimed at reducing common fraud risks. [HB 1084](https://www.oklegislature.gov/cf_pdf/2025-26%20ENR/hB/HB1084%20ENR.PDF) bans post-loss assignments for property and auto claims, closing a loophole used for inflated claims. [HB 1501](https://www.oklegislature.gov/cf_pdf/2025-26%20ENR/hB/HB1501%20ENR.PDF) caps public insurance adjuster commissions at 10% for political subdivisions, promoting transparency. [SB 641](https://www.oklegislature.gov/cf_pdf/2025-26%20ENR/SB/SB641%20ENR.PDF) limits labor rates and daily storage fees for total loss vehicles to prevent excessive billing. **The NAIC Third-Party Data and Models Working Group is moving closer to a regulatory framework for insurer use of third-party data and predictive models.** State regulators and interested parties met virtually this week to discuss advancing a third party data and models regulatory framework, focused on insurer accountability and regulator access to ensure proper governance and quality controls. The [Working Group](https://content.naic.org/committees/h/third-party-data-models-wg) is considering some form of future registration requirement with current efforts starting with property and casualty rate-making and rate filing, deferring focus on underwriting, claims, marketing, and fraud detection to a future date. Healthcare priorities may later include prior authorization and health coverage application fraud. Industry feedback was generally supportive, and comments are encouraged as the framework will be drafted for review and discussion at the [NAIC Fall National Meeting](https://content.naic.org/sites/default/files/naic-event-2025-fall-nm-tentative-agenda.pdf) in December 2025. \| \| \| \| \| \|:-:\|---\| \| \|:-:\| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7e6cccc1-3a5e-4803-a7f8-7325e7e155cb.gif) \| \| \| | |:-:| | \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/6ab2c291-f95a-060c-22cd-2622f315f1e5.png) \| \|:-:\| \| \| \| \| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/d559c4fb-3581-5e82-e68d-e666a871bbe2.jpg) **Urgent action is needed in the ground transportation industry due to insurance crisis.** **The National Limousine Association (NLA) has issued a stark warning about a [growing insurance crisis](https://www.travelandtourworld.com/news/article/urgent-action-needed-to-prevent-ground-transportation-industry-collapse-due-to-insurance-crisis/) that is threatening the very survival of small and mid-sized chauffeured ground transportation companies across the United States.** The crisis, primarily marked by soaring insurance premiums, has left operators struggling to maintain financial stability despite having impeccable safety records and minimal claims. A newly released report by the University Transportation Research Center (UTRC) has confirmed what many operators have been feeling: the insurance system is broken, and without urgent reform, the future of the industry is in jeopardy. The NLA’s call for immediate action comes after a disturbing trend revealed by the UTRC’s study. According to the findings, 87% of limousine operators have faced premium hikes over the past three years, with a quarter reporting increases greater than 25%. Despite these price hikes, nearly half of operators had no claims, and 93% had no claims exceeding policy limits. The UTRC report identifies several key factors driving the insurance crisis in the ground transportation sector. These include widespread insurance fraud, inflated legal settlements, and delays in regulatory processes. Insurance fraud, often tied to staged accidents or exaggerated claims, has driven up the cost of coverage for all companies in the industry. Additionally, the legal system, with its often excessive settlements, places enormous pressure on insurers, who in turn pass these costs down to the operators. **Can the insurance sector take a leap of faith to deliver a fraud strategy?** Rarely does a week go by without another warning over the rising levels of insurance fraud. From the current issues with crash for cash moped schemes, where scammers look to obtain driver details to take out bogus insurance policies, to opportunistic claims fraud, the industry is [embroiled in a constant fight against fraudsters](https://www.insurancetimes.co.uk/analysis/briefing-can-the-insurance-sector-take-a-leap-of-faith-to-deliver-fraud-strategy/1456756.article). This month saw industry body the Insurance Fraud Bureau (IFB) unveil its five year strategy for 2026-2030, entitled Connected to Protect. The strategy is aimed at increasing the quantity and quality of data held by the IFB, unlocking opportunities for the industry in the UK, as well as globally, and further raising public understanding of insurance fraud. Its release comes at a time of heightened government and regulatory expectations on the insurance sector, following the signing of the Insurance Fraud Charter, which was developed in response to the UK Economic Crime Strategy. At the launch of the strategy, IFB Board Chair Karl Helgesen said: “*Through our five year strategy we’ll be propelling the industry forward so we’re all in the best position to reduce our fraud-related exposure, protect the honest customer and create a positive societal impact.*” \| \| \| \| \| \|:-:\|---\| \| \|:-:\| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7e6cccc1-3a5e-4803-a7f8-7325e7e155cb.gif) \| \| \| | |:-:| | \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/1d6f4f15-f20b-53f1-9319-4e9f7a9178e3.png) \| \|:-:\| \| \| \| \| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/ed6993b7-3caa-c92d-3f2a-dc90d441c971.png) **South Carolina woman accused of staging a hit-and-run with a child inside for insurance claim.** **Shakita Shawntale Head is accused of presenting a false claim for insurance payment after she and an unknown co-defendant staged a hit-and-run with a child inside the vehicle.** *The allegations:* Documents show Head conspired to submit the false claim that [included 14 fraudulent medical bills](https://www.qcnews.com/news/u-s/chester-county/chester-county-woman-accused-of-staging-a-hit-and-run-with-a-child-inside-for-insurance-claim/) from MUSC Chester Hospital that totaled $24,786. The co-defendant was the driver and reported the staged collision. Head utilized the two occupants in the collision and they allegedly provided false information to the state trooper during the accident investigation. SLED says four people were falsely reported as injured from the incident, and that the name of the person who was not in the vehicle was used throughout the claim. Head was booked into the Chester County Detention Center Oct. 16. The case will be prosecuted by the South Carolina Department of Insurance. **New York business owner stole $1.8M in Medicaid scam.** Mohammad Chaudhry, the owner and operator of Angel Medical Transportation on State Street in Schenectady, faces health care fraud charges and other felonies for fleecing the state Medicaid program out of $1.8 million over four years in a scam that [took advantage of recovering drug addicts](https://www.yahoo.com/news/articles/officials-schenectady-business-owner-stole-193712712.html). *The allegations:* Chaudhry billed the state for patient trips that never happened, submitting claims for what were supposed to be individual rides that were actually group rides, which are not allowed, and lying about the destinations to boost payments. Chaudhry had signed up as a Medicaid provider. Under Medicaid rules, patients may use transportation services for legitimate appointments, which are then billed to the Medicaid program by the provider. Schenectady County District Attorney Robert Carney said to ensure that the addicts, who had to go to methadone clinics for treatment every day, continued to use his company and not competitors, Chaudhry would arrange to have them paid between $200 and $500 in cash. His office manager, Noah Shook, 45, is accused of paying the cash kickbacks. Shook was charged with one count of money laundering. **New Jersey doctor’s license suspended after $5M insurance scam.** Dr. Sokalsky, once a practicing physician at the shore, just got out early in July after he was supposed to serve a 15-month prison sentence for his role in a scheme that involved prescribing unnecessary medications. According to state officials, he signed off on [pre-filled prescriptions for patients he never examined](https://catcountry1073.com/ocean-city-nj-doctor-license-suspended/), or even spoke to. Among the medications? Scar creams, anti-fungal gels, high-priced compounded vitamins, and even libido boosters. Why? These prescriptions came with sky-high insurance reimbursement rates. Investigators say Sokalsky worked closely with a co-conspirator who arranged appointments solely to generate these bogus prescriptions. The doctor was handed pre-printed forms and simply signed off, knowing full well the treatments weren’t needed. As a result, New Jersey's state and local health benefits programs, along with private insurers, were fleeced out of more than $5 million. **GEICO sues medical firms in Florida and New York over alleged no-fault auto fraud.** GEICO is taking aggressive action against medical firms in Florida and New York, accusing them of leading multimillion-dollar, no-fault auto insurance fraud schemes. *The lawsuit alleges:* GEICO charged that AJ Therapy Center and its principals had submitted and received more than [$4.6 million in fraudulent personal injury protection](https://www.insurancejournal.com/news/southeast/2025/10/23/844916.htm) insurance claims for unnecessary medical treatments. In multiple examples over the last few years, the clinic misrepresented the extent of injuries from auto accidents, despite police reports showing little damage to vehicles and no serious injuries. In federal court in Brooklyn, GEICO filed a similar lawsuit against Droz Medical Supply, GB Medical Supply and the firms’ leadership. The defendants “*intentionally made the above described false and fraudulent statements and concealed material facts in a calculated effort to induce GEICO to pay charges submitted through Droz Supply that were not compensable under New York No-Fault insurance laws,*” the suit notes. **Two plead guilty to Medicaid fraud in Minnesota.** Shantel Magadanz and Heather Heim pled guilty to conspiracy to commit wire fraud following their participation in a years-long Medicaid fraud scheme. *The crimes they are admitting to:* For years, Grygo, Heim, and Magadanz overbilled DHS and UCare for [substance abuse treatment services they did not deliver](https://www.ag.state.mn.us/Office/Communications/2025/10/22_EvergreenRecovery.asp). The overbilling scheme included adding client names to counselor logs after the fact, and other falsification of back-dated records. In addition to overbilling, Evergreen also steered hundreds of clients to a sober housing provider, Second Chances Sober Living, which is controlled by one of Evergreen’s owners. Evergreen clients were offered free housing at Second Chances, but only if they agreed to attend a certain amount of programming at Evergreen Recovery, which Evergreen could bill Medicaid for, but which, in many cases, Evergreen did not actually provide. Through these illegal kickbacks and other false billing practices, Evergreen’s leaders are accused of stealing millions from Minnesota taxpayers. As laid out in Heim and Magadanz’ written plea Evergreen employees who raised concerns were either silenced, shut down, or lied to regarding the lawfulness of Evergreen’s practices. **Two Pennsylvanians facing charges of insurance fraud.** Wayne Fazzino and Angela Nini have been charged after they allegedly committed insurance fraud. *The allegations:* In January of this year, Fazzino filed an insurance claim saying [he hit a deer with no police report, witnesses, or video from the crash](https://butlerradio.com/two-facing-charges-of-insurance-fraud/). Following an investigation, police say the damage to Fazzino’s car happened before the filed insurance claim. Nini allegedly told police damage to the car existed when the vehicle was purchased, but after speaking with the seller of the vehicle, pictures before the sale suggested otherwise. Both have been charged with several accounts of insurance fraud and Fazzino was released from the Butler County Prison after putting up his $50,000 bail. They are both awaiting preliminary hearings. \| \| \| \| \| \|:-:\|---\| \| \|:-:\| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7e6cccc1-3a5e-4803-a7f8-7325e7e155cb.gif) \| \| \| | |:-:| | \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/05ebd826-d3ed-4100-a4b0-7c83841fc259.png) \| \|:-:\| \| \| \| \| \| \| [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/26834148-ab5d-169c-278c-905a092ace4e.png)](https://insurancefraud.org/coalition-annual-membership-meeting/) [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/1ce4a222-3707-daaf-86bf-d0078f1d7693.png)](https://s.surveyplanet.com/bj1sw6en) [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/6c8550d3-4d99-bc65-c8f8-cd1902423e17.png)](https://members.insurancefraud.org/general/pick_username.asp) ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/3ef40901-b851-f621-08b2-322f09ca8a57.png) [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/10603368-408a-d879-f877-12cb1c3ee19d.jpg)](mailto:alisonf.oneill1@lexisnexis.com) \| \| \| \| \| \|:-:\|---\| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7e6cccc1-3a5e-4803-a7f8-7325e7e155cb.gif) \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7e6cccc1-3a5e-4803-a7f8-7325e7e155cb.gif) \| ![](images/spacer.gif) \| \| \|:-:\| \| \| | |:-:| | \| \| \| FACES OF FRAUD \| \|---\|:--\| \| \| \| \| \| \| \| [![](https://via.placeholder.com/125x166)](https://www.tn.gov/finance/news/2020/9/28/davidson-co--woman-charged-with-tenncare-fraud.html) \| \| \| \| [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a3a07f33-24b1-eb63-0b06-74ebdfbea5b7.png)](https://www.fresnobee.com/news/local/crime/article312702269.html) **Bobby Salazar** Fresno, Calif. Business arson *ARRESTED* \| \| \| \| [![](https://via.placeholder.com/125x166)](https://www.southwesttimes.com/2020/09/false-scripts-bills-send-doctor-to-prison/) \| \|:-:\|---\|:-:\| \| \| \| [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/91e76bf4-cc6d-5bf0-8a22-a10b3eb0ad2c.png)](https://louisianaradionetwork.com/2025/10/28/44198/) **Adrian Sampson** Monroe, La. Staged auto claims *ARRESTED* \| \| \|:-:\| \| \|:-:\| \| \| \| [![](https://via.placeholder.com/125x166)](https://www.timesrepublican.com/news/todays-news/2020/09/mpd-handles-multiple-burglaries-1-arrested/) \| \|:-:\| \| \| \| [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/8bc9af12-b15a-e063-abbe-7ad54535074b.png)](https://www.qcnews.com/news/u-s/chester-county/chester-county-woman-accused-of-staging-a-hit-and-run-with-a-child-inside-for-insurance-claim/) **Shakita Shawntale Head** Chester, S.C. Staged auto claims *ARRESTED* \| \| \| \| [![](https://via.placeholder.com/125x166)](https://www.wmbfnews.com/2020/09/22/longs-woman-arrested-accused-forging-prescriptions/) \| \|:-:\|---\|:-:\| \| \| \| [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/ade62f31-85b3-75a1-e964-56bae32400cd.jpg)](https://insurancefraud.org/report-fraud/) \| \| \|:-:\| \| \|:-:\| \| \|---\| \| \|:-:\| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7e6cccc1-3a5e-4803-a7f8-7325e7e155cb.gif) \| \| \| \| \| \|:-:\|---\| | |:-:| | \| \| \| EVENTS \| \|---\|:--\| \| \| \| \| **November 3 — [Digging for treasure: Company Research Strategies for Attorneys](mailto:alisonf.oneill1@lexisnexis.com)** Virtual (LexisNexis) \| \| \| \| \|:--\| \| \| **November 4 — [Digging for treasure: Company Research Strategies for Attorneys](mailto:alisonf.oneill1@lexisnexis.com)** Virtual (LexisNexis) \| \| \| \| \|:--\| \| \| **November 4 — [SCFIA 47th Annual Anti-Fraud Conference](https://scfia.starchapter.com/meetinginfo.php?id=77&ts=1755230802)** Downey, Calif. (SCFIA) \| \| \| \| \|:--\| \| \| **November 5 — [Digging for treasure: Company Research Strategies for Attorneys](mailto:alisonf.oneill1@lexisnexis.com)** Virtual (LexisNexis) \| \| \| \| \|:--\| \| \| **November 6 — [Digging for treasure: Company Research Strategies for Attorneys](mailto:alisonf.oneill1@lexisnexis.com)** Virtual (LexisNexis) \| \| \| \| \|:--\| \| \| **November 7 — [Digging for treasure: Company Research Strategies for Attorneys](mailto:alisonf.oneill1@lexisnexis.com)** Virtual (LexisNexis) \| \| \| \| \|:--\| \| \| **November 19 — [The Hidden Threat: Synthetic Identities & Account Takeovers in Modern Fraud](https://www.iasiu.org/events/EventDetails.aspx?id=1976262)** Webinar (IASIU) \| \| \| \| \|:--\| \| \| **December 2-3 — [Coalition Annual Meeting](https://insurancefraud.org/coalition-annual-membership-meeting/) Arlington, VA. (Coalition Against Insurance Fraud)** \| \| \| \| \|:--\| \| \| **April 22, 2026 — [**2026 Annual Anti-Fraud Conference**](https://annualantifraudconference.com/#Registration) Monterey, Calif. (AFA)** \| \| \| \| \|:--\| \| \| \|:-:\|---\| | |:-:| | \| \| \| FRAUD NEWS FRIDAY \| \|---\|:--\| \| \| \| \| \* [**Two Face Insurance Fraud Charges In Titus County**](https://easttexasradio.com/two-face-insurance-fraud-charges-in-titus-county/) \* [**Five N.Y. correction officers accused of workers compensation fraud**](https://www.recordonline.com/story/news/local/2025/10/30/state-charges-five-correction-officers-in-ulster-county-with-fraud/86989679007/?gnt-cfr=1&gca-cat=p&gca-uir=false&gca-epti=z116454p116450c116450e002400v116454&gca-ft=66&gca-ds=sophi) \* **[Calgary dentist admits defrauding three more insurers](https://calgaryherald.com/news/crime/calgary-dentist-alena-smadych-more-fraud-insurance-companies)** \* [**IBC applauds federal crackdown on trucking fraud**](https://www.insurancebusinessmag.com/ca/news/breaking-news/ibc-applauds-federal-crackdown-on-trucking-fraud-555016.aspx) \* [**Odisha businessman plans fake theft to claim insurance**](https://www.newindianexpress.com/cities/bhubaneswar/2025/Oct/31/odisha-businessman-plans-fake-theft-to-claim-insurance-held-with-his-12-accomplices) \| \| \| \| \|:--\| \| \| \|:-:\|---\| | |:-:| | \| \| \| \| \|---\|---\| \| \| \| \| Connect with Us: \| \| \| [![FB](https://mcusercontent.com/a440c5b647697de580a2fd586/images/ef66a2aa-ea17-4447-95b6-ad328c555988.png)](https://www.facebook.com/insurancefraud) \| \| [![TW](https://mcusercontent.com/a440c5b647697de580a2fd586/images/43f8397b-2f36-4358-87e9-549e6d9b749b.png)](https://twitter.com/insurance_fraud) \| \| [![YT](https://mcusercontent.com/a440c5b647697de580a2fd586/images/c202c8ca-32dc-49b1-a471-9669d36f946e.png)](https://www.youtube.com/user/stopinsurancefraud) \| \| [![IN](https://mcusercontent.com/a440c5b647697de580a2fd586/images/0cb8e5d8-9435-49a5-91b2-1a214a5f2fa0.png)](https://www.linkedin.com/groups/3856550) \| \| \|:-:\| \| [![Coalition Against Insurance Fraud](https://mcusercontent.com/a440c5b647697de580a2fd586/images/539d436e-d608-44a9-ba5e-b64d3a1ddd06.png)](https://www.insurancefraud.org) \| \| \|:-:\| \| Contact: \| \|:--\| \| Phone: [202.393.7330](tel:2023937330) Email: <info@insurancefraud.org> Address: 1012 14th Street NW Suite 610 Washington DC 20005 [www.InsuranceFraud.org](http://www.insurancefraud.org/) \| \| \|---\| \| \|:-:\| \| \| \| \| \|:-:\|---\| | |:-:| | | |---| | \| \| You are receiving this email because either your organization is a member of the Coalition Against Insurance Fraud or you requested to be placed on our mailing list. [Unsubscribe](https://insurancefraud.us1.list-manage.com/unsubscribe?u=a440c5b647697de580a2fd586&id=b68dce7808&t=b&e=%5BUNIQID%5D&c=0f86d038a1) [<< Test Email Address >>](%3C%3C%20Test%20Email%20Address%20%3E%3E) from this list. Our mailing address is: Coalition Against Insurance Fraud1012 14th St NW Ste 610 Washington, DC 20005-3424 [Add us to your address book](https://insurancefraud.us1.list-manage.com/vcard?u=a440c5b647697de580a2fd586&id=b68dce7808) Copyright (C) 2025 Coalition Against Insurance Fraud All rights reserved. [Forward this email to a friend](https://us1.forward-to-friend.com/forward?u=a440c5b647697de580a2fd586&id=0f86d038a1&e=%5BUNIQID%5D) [Update your profile](https://insurancefraud.us1.list-manage.com/profile?u=a440c5b647697de580a2fd586&id=b68dce7808&e=%5BUNIQID%5D&c=0f86d038a1) \| \| \|:-:\| | |:-:| <html><p class="wp-block-paragraph"></p> **Features:** Fraud News Weekly --- ### [Fraud News Weekly - October 24, 2025](https://insurancefraud.org/publications/fraud-news-weekly-october-24-2025/) **Published:** October 24, 2025 **Author:** Coalition Against Insurance Fraud **Content:** | \| \| \|:-:\| \| Friday, October 24, 2025 \| \| \| | |:-:| | \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/df906857-d727-9ee9-0397-2a09caac30a4.png) \| \|:-:\| \| \| \| \| \| \|:-:\| | |:-:| | \| [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/2f971e24-7875-ac59-92b3-95d69a0bb60a.jpg)](https://www.facebook.com/profile.php?id=61579225779934) \| \|:-:\| \| \| \| \| \| \| [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a1492a86-29b0-90b6-d879-527e5492037e.png)](https://www.facebook.com/people/Coalition-Against-Insurance-Fraud/61579225779934/) [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/d2bd23eb-8810-4f7a-49d3-d2fe7aa1891e.png)](https://www.instagram.com/stopinsurancefraud/)[![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/be4e5708-bdc4-c0df-6c03-a6ebd5b34c13.png)](https://www.linkedin.com/company/coalition-against-insurance-fraud) \| \| \| \| \| \|:-:\|---\| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7e6cccc1-3a5e-4803-a7f8-7325e7e155cb.gif) \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7e6cccc1-3a5e-4803-a7f8-7325e7e155cb.gif) \| ![](images/spacer.gif) \| \| \|:-:\| \| \| | |:-:| | \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/00ed7ac4-bb10-4f87-9d66-746db8688e48.png) \| \|:-:\| \| \| \| \| \| \| **![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a1b734d3-6332-af32-d546-dec62125bca5.png)** **Coalition joins New Jersey fraud fighters at NJSIA Insurance Fraud Summit and Annual Seminar.** ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/97a475fd-8d6f-1ded-9b99-3b3e0a844dff.jpg) **The Coalition joined over 400 fraud fighters in Atlantic City this week for the New Jersey Special Investigators Association’s (NJSIA) Insurance Fraud [Summit](https://njsia.wildapricot.org/page-408040) and Annual [Seminar](https://njsia.wildapricot.org/page-323971).** The Summit, presented by NJSIA and the Insurance Council of New Jersey (ICNJ), kicked off Monday and brought together industry leaders, insurance professionals, law enforcement, legal experts, and policymakers for a full day of collaboration, insight, and strategy focused on combating insurance fraud. Acting head of the New Jersey Office of Insurance Fraud Prosecutor, Al Garcia, opened the Summit with a call for cooperation, communication, and collaboration among private and public fraud fighters. Coalition Director of Government Relations Brent Walker contributed by sharing insights from the recent Coalition webinar, What Generations of Investigators Can Teach Each Other, during the Summit’s opening, participated in a panel where he shared regulatory and legislative responses to AI-driven fraud and insurers use of that technology, and led a seminar session highlighting the results of the Coalition and PwC study on Generative AI’s use by both fraudsters and fraud fighters, covering trends, impacts, and strategies to stay ahead. The Coalition commends NJSIA for once again delivering an outstanding and educational antifraud event. **The Kentucky Insurance Fraud Council (KIFC) met this week to exchange legislative updates and hear from the Kentucky Department of Insurance Fraud Investigation Division.** The Coalition Against Insurance Fraud participated in the meeting, where the featured program included a detailed presentation from the Department outlining the state’s referral process, [year-to-date statistics](https://insurance.ky.gov/ppc/new_docs.aspx?cat=194), and enforcement priorities. Commissioner Sharon Clark joined the discussion, emphasizing her commitment to expanding fraud prosecutions across the Bluegrass State. Additional discussions covered legislative updates and early planning for 2026 antifraud legislation, along with an update from Coalition Director of Government Relations Brent Walker, who shared information on the Coalition’s latest initiatives, including recent webinars, the ongoing medical fraud trends survey, and upcoming support for proposed amendments to two NCOIL model laws influenced by Kentucky’s own legislative work. Walker encouraged members to share emerging antifraud priorities for 2026. Attendees also heard from the National Insurance Crime Bureau, a strong Coalition partner, which is collaborating on the NCOIL model amendments. The Coalition commends the KIFC for its continued leadership, collaboration, and steadfast commitment to advancing effective antifraud measures statewide. **NCOIL Property and Casualty Committee narrowly rejects insurer use of aerial imagery model bill.** The NCOIL Property and Casualty Committee met in the last week of September to consider a [draft model Aerial Imagery bill](https://url.us.m.mimecastprotect.com/s/d0fhCM8gLptxorBlhkhOt8HM6Y?domain=url3596.namic.org). Supporters included legislators, agent groups, and consumer advocates, who said the model was a modest, consistent framework to ensure transparency, timely notice, and opportunities for homeowners to address issues found by aerial imagery, while opponents, primarily industry groups, worried about regulatory clarity, insurer obligations, and potential costs. After hearing from industry representatives and consumer advocates, the committee initially approved [proposed amendments](https://namicstorage.blob.core.windows.net/namicorgassets/pdf/25memberadvisory/250930_amendments-9-29-25.pdf) 15-14, but in the final vote, the motion to adopt the model, as amended, did not pass 13-16. Some legislators cited industry concerns regarding potential cost increases and limits on the technology’s utility in expanding affordable property insurance. The last time the committee voted down a proposed model was in 2014, underscoring just how rare this outcome is. Guided by its [2025 legislative priorities](https://insurancefraud.org/legislative-priorities/), the Coalition monitors model acts like this, along with pending legislation, to ensure that the use of such technology balances consumer protection while supporting the detection and prevention of insurance fraud. **North Carolina Commissioner Mike Causey recently highlighted the impact of fraud on health insurance premiums.** Commissioner Causey [opined](https://www.averyjournal.com/news/causey-health-insurance-fraud-makes-premiums-more-expensive/article_f931edb8-50bd-4ec1-a61f-247fa78799af.html) that health-insurance fraud continues to raise premiums and threaten affordability for consumers. In his recent commentary, Causey cited Coalition Against Insurance Fraud [data](https://insurancefraud.org/wp-content/uploads/The-Impact-of-Insurance-Fraud-on-the-U.S.-Economy-Report-2022-8.26.2022-1.pdf) showing that insurance fraud costs Americans more than $300 billion annually, with a large share stemming from healthcare-related scams. He noted that false claims, inflated billing, and the misuse of consumer health-insurance information ultimately drive up costs for all policyholders. For Coalition members, including insurers, regulators, and prosecutors, his message reinforces the growing urgency to strengthen detection, reporting, and cross-sector collaboration, across all lines of business but especially health insurance fraud schemes. The Coalition’s ongoing work through its Medical Fraud Task Force complements this call by coordinating efforts to identify and combat fraudulent medical practices and deceptive insurance products. Causey’s remarks affirm the shared mission of antifraud professionals nationwide: to protect consumers, stabilize premiums, and preserve trust in the health-insurance system. \| \| \| \| \| \|:-:\|---\| \| \|:-:\| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7e6cccc1-3a5e-4803-a7f8-7325e7e155cb.gif) \| \| \| | |:-:| | \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/68807164-2e16-1495-1d0d-98e30b545813.png) \| \|:-:\| \| \| \| \| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a8e5b553-45f6-6119-7a11-8676f711eb40.jpg) **Michigan promotes Cybersecurity Awareness Month to help avoid online scams.** **The Michigan Department of Insurance and Financial Services (DIFS) is reminding you to take proactive steps to [protect themselves from scammers](https://www.michigan.gov/difs/news-and-outreach/press-releases/2025/10/20/difs-promotes-cybersecurity-awareness-month-to-help-michiganders-avoid-online-scams) and cyberattacks. “***Cybercriminals are constantly evolving their tactics to steal personal and financial information. Taking proactive measures to protect your information is always a smart decision,*” said DIFS Director Anita Fox. “*By staying informed, Michiganders can protect their families and their finances. DIFS is here to help Michiganders understand the threats and take practical steps to safeguard their money and personal information.*” DIFS regularly reminds banks, credit unions, and other financial services entities to review, update, and test their data protection processes. Additionally, the Department has set forth data security requirements for licensed insurers and producers under the Michigan Insurance Data Security Law, which requires insurance licensees to establish information security programs. ***Think Before You Sign:*** Homeowners should stay alert for insurance scams. Home insurance is intended to give homeowners peace of mind by protecting their most valuable asset, but not everyone who purports to be selling insurance operates with integrity. Consumers can work to protect themselves by [highlighting some common home insurance fraud schemes](https://www.prnewswire.com/news-releases/think-before-you-sign-mercury-insurance-urges-homeowners-to-stay-alert-for-insurance-scams-302590075.html). Consumers should do their homework on prospective insurance providers to verify that they're even real. Scam companies will lure consumers in with artificially low rates. A shady insurance agent may sell a policy that offers little to no coverage, or a rogue broker may apply for a policy, cancel it and pocket the money. Scammers might also manipulate policy details, forge documents or create fictitious policies. It's important to note that sometimes consumers themselves are the ones engaging in illegal home insurance fraud. This can include falsifying or exaggerating home insurance claims or intentionally causing damage like a fire for an insurance payout. No matter the scheme, fraudulent insurance claims raise prices for everyone across the board and benefit no one. ***Redefining Insurance Fraud Detection With AI:* purposeful rigor.** When talking about artificial intelligence in the insurance industry, it is no longer about the future, it is about the present. Yet, what will truly make the difference is not who adopts it first, but who applies it with purpose and rigor. AI is not a magic wand that solves every challenge. It is a powerful tool that d[emands ethical management](https://mexicobusiness.news/professional-services/news/redefining-insurance-fraud-detection-ai-purposeful-rigor), constant oversight, and a clear vision of intent. When it comes to fraud detection, its proper use can completely redefine how we understand risk, prevention, and trust between insurers and customers. Insurance fraud remains one of the most complex challenges for our industry. It represents millions in losses each year and carries a hidden cost that ultimately affects honest policyholders. Traditionally, fraud detection relied heavily on intuition, experience, and manual review. But with the volume of data now generated daily, that model is no longer sustainable. This is where AI proves invaluable — capable of processing thousands of variables in seconds and detecting patterns that human analysis alone could never uncover. **'*Senior Scam Stoppers*': Event aims to help seniors identify and report scams.** Scammers are getting smarter and seniors are [often their main targets](https://www.ksby.com/news/local-news/senior-scam-stoppers-event-aims-to-help-seniors-identify-and-report-scams). That's why Assemblymember Dawn Addis and local leaders hosted a Senior Scam Stoppers event on Wednesday to help residents spot fraud before it's too late. Addis' office says they've seen a rise in cases where people click fake links or lose money to bogus contractors. Seniors are especially vulnerable because they may be less familiar with new technology or just want to help. "*These scams are evolving and they are much harder to recognize than they used to be,*" said Andrea Chmelik, Assembly District 30 District Director. "*You know, beforehand, it could be an email or it would be typos and people kind of get an idea that it is not a real email. However, this is evolving so fast, but this is really important for people to be continuously reminded, to be vigilant and to understand the new types of scams that are out there, to not follow them and think before you click, tap, send somebody money that you've never met in person so you don't become a victim.*" \| \| \| \| \| \|:-:\|---\| \| \|:-:\| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7e6cccc1-3a5e-4803-a7f8-7325e7e155cb.gif) \| \| \| | |:-:| | \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/c16e2322-ff90-895b-a2c8-2802034b1ffc.png) \| \|:-:\| \| \| \| \| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/2ca37418-49ca-d9a5-e2cb-0671a9bf26b9.jpeg) **New York man and owner of Long Island construction firm pleads guilty to insurance fraud.** **Mahendranauth Khargie and his business, GC Stud Inc. substantially underreported the total amount of their payroll during three policy periods between April 2019 and March 2022, resulting in premium fraud.** As a NYSIF Workers’ Compensation policy holder, Khargie and his company are required to provide financial records concerning income and employee payroll to NYSIF every year the policy holder renews its coverage. Records revealed that large payments to the defendants were made by three different steel and iron fabrication companies during the time of the investigation. The [defendants hid the money](https://lilifepolitics.com/news/businesses/rockville-centre-man-construction-firm-plead-guilty-to-insurance-fraud/), deposited the funds in a JPMorganChase account, and did not provide that account to the NYSIF premium auditors. Over the course of the scheme, Khargie underreported his payroll to NYSIF by more than $3.5 million, resulting in under payments of the company’s Worker’s Compensation policy premiums. **Man allegedly attempts insurance fraud after claiming stolen property, sentenced to 12 months of probation.** William Owens pleaded guilty to one felony count of insurance fraud in Cherokee County District Court. Owens attempted to collect benefits from his insurance company, seeking coverage for items that he [claimed were stolen and damaged](https://www.wibw.com/2025/10/21/man-allegedly-attempts-insurance-fraud-sentenced-12-months-probation/), but actually were not. He was sentenced on Sept. 5, 2025, and ordered to pay a $500 fine in addition to court costs and fees, with 18 months of underlying prison time if his probation is violated. **Doctor and insurance broker arrested for fake surgeries and fraudulent insurance claims.** A group of suspects, including a doctor and a broker, who pretended to perform breast augmentation surgery and tumor removal procedures to fraudulently obtain over 1 billion Korean won in actual expense insurance payments, were arrested by Korean police. *The allegations:* Busan Metropolitan Police Agency’s Criminal Investigation Unit announced on the 20th that they had referred to prosecutors for indictment three individuals, including a male doctor in his 40s, A, and a male broker in his 50s, B, on charges of violating the Insurance Fraud Prevention Special Act and the Medical Service Act. Additionally, [117 doctors and patients involved in the crime](https://www.chosun.com/english/national-en/2025/10/20/QZKUQSYOLZCHBMXGDJXQ2GOJRM/) were referred to prosecutors without detention. The group is suspected of creating fake tumors for patients from February 2023 to April of this year, fabricating medical records to make it appear as though the patients had undergone tumor removal procedures, and then claiming actual expense insurance payments. By April of this year, 115 patients had obtained 1 billion Korean won in insurance payments from 14 insurance companies. They also fabricated records to make it appear as though non-covered items such as hospitalization and extracorporeal shockwave therapy had been performed, allowing patients to receive additional insurance payouts. The patients reportedly used the fraudulently obtained insurance money to receive cosmetic or aesthetic procedures such as breast augmentation. **California woman sentenced for insurance fraud.** The Marin County District Attorney's Office on February 13 filed multiple insurance fraud charges against 46-year-old Marilyn Gibson. Gibson pleaded guilty to filing a false insurance claim, a felony, and admitted several enhancements related to her prior criminal history, which includes multiple prior fraud-related convictions. *The allegations:* Gibson rear-ended another car on Sept. 15, 2021, which caused significant damage to the hood of her vehicle. The day following the accident, she called an insurance company and obtained a policy without disclosing the accident she had caused. Six weeks later Gibson obtained a second insurance policy with a different insurance carrier, which went into effect on Dec. 8, 2021. In January of 2022 Gibson submitted a false claim under the second policy, asserting once again that her parked car was struck by another vehicle that fled the scene. She submitted as proof the same photos of the damaged hood that she had submitted in support of her Sept. false claim. **Father-Son Duo Operated School Buses With Fraudulent Insurance.** Malik Turnage Sr. and his son Malik Turnage Jr. provided forged certificates of insurance to the Valley Stream Central High School District. *The allegations:* The school district requested [updated certificates of liability insurance](https://patch.com/new-york/malverne-lynbrook/father-son-duo-operated-school-buses-fraudulent-insurance-da) from its bus providers in October of 2023. Turnage Jr. reportedly emailed two COIs to the district on Nov. 1, 2023, listing Integon National Insurance Company as Cheese Bus’s insurance carrier, then emailed the district two additional documents eight hours later. Those documents were dated Nov. 1, 2023, and again listed Integon as the provider with the same policy number as the first documents. Upon review, the school district found that the COIs were forged, Donnelly said. Cheese Bus did have insurance, investigators said, but the insurance didn’t cover its contract with Valley Stream Central High School. The District Attorney’s office said records from the insurance company showed no record of Cheese Bus ever having insurance for its Valley Stream contract. **Bergen County doctor permanently stripped of medical license amid federal and state convictions.** The State Board of Medical Examiners has permanently revoked the medical license of Dr. Robert Delagente, a Bergen County physician currently serving a six-year federal prison sentence for illegally prescribing opioids and other controlled substances without legitimate medical justification. The investigation, conducted jointly by the FBI and the New Jersey Office of the Insurance Fraud Prosecutor (OIFP), found that from May 2014 onward, Delagente issued prescriptions for highly addictive opioids—such as oxycodone and Percocet—and benzodiazepines, including alprazolam and clonazepam, outside the bounds of legitimate medical practice. In addition to the federal conviction, Delagente also pleaded guilty in a separate state case involving more than [$32,000 in fraudulent insurance billing](https://morristownminute.town.news/g/morristown-nj/post/347102/bergen-county-doctor-permanently-stripped-medical-license-amid-federal) for unperformed services, including allergy testing and immunotherapy. He was sentenced to five years in state prison for second-degree health care claims fraud, to be served concurrently with his federal sentence. \| \| \| \| \| \|:-:\|---\| \| \|:-:\| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7e6cccc1-3a5e-4803-a7f8-7325e7e155cb.gif) \| \| \| | |:-:| | \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/05ebd826-d3ed-4100-a4b0-7c83841fc259.png) \| \|:-:\| \| \| \| \| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/6744a7ca-f31c-58e9-c6b2-cda92ef96a2e.jpg)**The Coalition Against Insurance Fraud was proud to serve as a sponsor of the Global Insurance Fraud Summit, held October 20–23 in Toronto, Canada.** The summit brought together more than 100 antifraud leaders from across the globe. Representatives from insurance carriers, third-party administrators, industry associations, regulatory agencies, law enforcement, and technology companies came together with a shared mission to strengthen global collaboration and accelerate the fight to detect, prevent, and combat insurance fraud. Coalition Executive Director Michelle Rafeld represented the organization and presented an overview of the Coalition’s mission, current initiatives, and the fraud trends most frequently discussed among its committees and task forces. Discussions throughout the Summit explored the growing use of artificial intelligence and synthetic identities in fraud schemes, the link between cybersecurity incidents and insurance fraud, and the rising threat of transnational organized crime. Common themes centered on the urgent need for enhanced information sharing and cross-sector partnerships. The Global Insurance Fraud Summit’s vision is to foster international cooperation by bringing together insurance carriers, consortiums, fraud bureaus, law enforcement agencies, regulators, and thought leaders to build a united global front against insurance fraud. The Coalition extends its appreciation to the GIFS Executive Committee for hosting such an impactful event and to Dennis Toomey for his leadership and vision in uniting the global fraud-fighting community. ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/f8628f05-c69a-b49b-5c6b-325c1455059a.png) ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/34d1f340-93a8-03e8-65ff-99fd6a723e6d.png) [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/bb9acb2d-c75c-b97a-3b4a-947514fb56f0.png)](https://insurancefraud.org/coalition-annual-membership-meeting/) [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/be4befee-e858-6a55-8559-22b8aaaf9228.jpg)](https://insurancefraud.org/workers-comp-resources/) [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/1ce4a222-3707-daaf-86bf-d0078f1d7693.png)](https://s.surveyplanet.com/bj1sw6en) [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/6c8550d3-4d99-bc65-c8f8-cd1902423e17.png)](https://members.insurancefraud.org/general/pick_username.asp) ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/3ef40901-b851-f621-08b2-322f09ca8a57.png) [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/c736527b-4d31-30bd-84f2-938724ff2fc4.png)](https://www.surveymonkey.com/r/PNNRW2P?j=6791105&e=EML-CSV-ContactCenter@nysif.com&l=35226_HTML&u=368063469&mid=7205125&jb=0) [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/5b92c840-a0b2-1c66-7582-0e98eec55ba3.png)](https://www.iasiu.org/events/EventDetails.aspx?id=1951822) [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/8456e5fe-4c2e-a285-2dbb-280a6777ac0b.png)](https://register.gotowebinar.com/register/1173269515288725598) \| \| \| \| \| \|:-:\|---\| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7e6cccc1-3a5e-4803-a7f8-7325e7e155cb.gif) \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7e6cccc1-3a5e-4803-a7f8-7325e7e155cb.gif) \| ![](images/spacer.gif) \| \| \|:-:\| \| \| | |:-:| | \| \| \| FACES OF FRAUD \| \|---\|:--\| \| \| \| \| \| \| \| [![](https://via.placeholder.com/125x166)](https://www.tn.gov/finance/news/2020/9/28/davidson-co--woman-charged-with-tenncare-fraud.html) \| \| \| \| [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/ae87e198-1192-a834-9221-e77e23ba86cb.png)](https://iid.iowa.gov/press-release/2025-10-22/urbandale-man-charged-public-adjusting-without-license) **Jared Harrison** Urbandale, Iowa Insider Agent *ARRESTED* \| \| \| \| [![](https://via.placeholder.com/125x166)](https://www.southwesttimes.com/2020/09/false-scripts-bills-send-doctor-to-prison/) \| \|:-:\|---\|:-:\| \| \| \| [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/2103d0ff-ef98-0aad-1b14-b2ebab4246e5.png)](https://www.aol.com/news/oakland-doc-fed-pen-fueling-165638646.html) **Robert Delagente** Oakland, N.J. Drug Diversion *SENTENCED* \| \| \|:-:\| \| \|:-:\| \| \| \| [![](https://via.placeholder.com/125x166)](https://www.timesrepublican.com/news/todays-news/2020/09/mpd-handles-multiple-burglaries-1-arrested/) \| \|:-:\| \| \| \| [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/f0bf5d79-99b9-9723-0196-bb813ddbb3e2.png)](https://www.orangeobserver.com/news/2025/oct/20/ocoee-pastor-accused-of-forging-former-church-members-life-insurance-policy/) **Gary Wheeler** Ocoee, Fla. Insider Agent *ARRESTED* \| \| \| \| [![](https://via.placeholder.com/125x166)](https://www.wmbfnews.com/2020/09/22/longs-woman-arrested-accused-forging-prescriptions/) \| \|:-:\|---\|:-:\| \| \| \| [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/ade62f31-85b3-75a1-e964-56bae32400cd.jpg)](https://insurancefraud.org/report-fraud/) \| \| \|:-:\| \| \|:-:\| \| \|---\| \| \|:-:\| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7e6cccc1-3a5e-4803-a7f8-7325e7e155cb.gif) \| \| \| \| \| \|:-:\|---\| | |:-:| | \| \| \| EVENTS \| \|---\|:--\| \| \| \| \| **October 28 — [The Fraud Factor](https://www.surveymonkey.com/r/PNNRW2P?j=6791105&e=EML-CSV-ContactCenter@nysif.com&l=35226_HTML&u=368063469&mid=7205125&jb=0)** Buffalo, N.Y. (NYSIF) \| \| \| \| \|:--\| \| \| **October 28 — [OH/PA/WV Joint Fall Training Seminar](https://www.iasiu.org/events/EventDetails.aspx?id=1951822)** Virtual (IASIU) \| \| \| \| \|:--\| \| \| **November 4 — [SCFIA 47th Annual Anti-Fraud Conference](https://scfia.starchapter.com/meetinginfo.php?id=77&ts=1755230802)** Downey, Calif. (SCFIA) \| \| \| \| \|:--\| \| \| **November 19 — [The Hidden Threat: Synthetic Identities & Account Takeovers in Modern Fraud](https://www.iasiu.org/events/EventDetails.aspx?id=1976262)** Webinar (IASIU) \| \| \| \| \|:--\| \| \| **December 2-3 — [Coalition Annual Meeting](https://insurancefraud.org/coalition-annual-membership-meeting/) Arlington, VA. (Coalition Against Insurance Fraud)** \| \| \| \| \|:--\| \| \| \|:-:\|---\| | |:-:| | \| \| \| FRAUD NEWS FRIDAY \| \|---\|:--\| \| \| \| \| \* **[Former Maryland corrections employee pleads guilty in fraud scheme](https://www.cbsnews.com/baltimore/news/maryland-fraud-scheme-guilty-plea-business-state-employee/)** \* [**Pipefy Announces Integration of AI Agents for Its Insurance Solution**](https://www.globenewswire.com/news-release/2025/10/23/3172216/0/en/Pipefy-Announces-Integration-of-AI-Agents-for-Its-Insurance-Solution.html) \* **[Woman Sentenced After Guilty Plea To Felony Insurance Fraud](https://beritasriwijaya.co.id/marin-co-woman-sentenced-after-guilty-plea-to-felony-insurance-fraud/#google_vignette)** \* **[Insurance identity fraud soars by 211% in the UK](https://www.digitaljournal.com/business/insurance-identity-fraud-soars-by-211-in-the-uk/article)** \* [**GEICO Sues Medical Firms in Florida, NY Over Alleged No-Fault Auto Fraud**](https://www.insurancejournal.com/news/southeast/2025/10/23/844916.htm) \| \| \| \| \|:--\| \| \| \|:-:\|---\| | |:-:| | \| \| \| \| \|---\|---\| \| \| \| \| Connect with Us: \| \| \| [![FB](https://mcusercontent.com/a440c5b647697de580a2fd586/images/ef66a2aa-ea17-4447-95b6-ad328c555988.png)](https://www.facebook.com/insurancefraud) \| \| [![TW](https://mcusercontent.com/a440c5b647697de580a2fd586/images/43f8397b-2f36-4358-87e9-549e6d9b749b.png)](https://twitter.com/insurance_fraud) \| \| [![YT](https://mcusercontent.com/a440c5b647697de580a2fd586/images/c202c8ca-32dc-49b1-a471-9669d36f946e.png)](https://www.youtube.com/user/stopinsurancefraud) \| \| [![IN](https://mcusercontent.com/a440c5b647697de580a2fd586/images/0cb8e5d8-9435-49a5-91b2-1a214a5f2fa0.png)](https://www.linkedin.com/groups/3856550) \| \| \|:-:\| \| [![Coalition Against Insurance Fraud](https://mcusercontent.com/a440c5b647697de580a2fd586/images/539d436e-d608-44a9-ba5e-b64d3a1ddd06.png)](https://www.insurancefraud.org) \| \| \|:-:\| \| Contact: \| \|:--\| \| Phone: [202.393.7330](tel:2023937330) Email: <info@insurancefraud.org> Address: 1012 14th Street NW Suite 610 Washington DC 20005 [www.InsuranceFraud.org](http://www.insurancefraud.org/) \| \| \|---\| \| \|:-:\| \| \| \| \| \|:-:\|---\| | |:-:| | | |---| | \| \| You are receiving this email because either your organization is a member of the Coalition Against Insurance Fraud or you requested to be placed on our mailing list. [Unsubscribe](https://insurancefraud.us1.list-manage.com/unsubscribe?u=a440c5b647697de580a2fd586&id=b68dce7808&t=b&e=%5BUNIQID%5D&c=5d2598c2a3) [<< Test Email Address >>](%3C%3C%20Test%20Email%20Address%20%3E%3E) from this list. Our mailing address is: Coalition Against Insurance Fraud1012 14th St NW Ste 610 Washington, DC 20005-3424 [Add us to your address book](https://insurancefraud.us1.list-manage.com/vcard?u=a440c5b647697de580a2fd586&id=b68dce7808) Copyright (C) 2025 Coalition Against Insurance Fraud All rights reserved. [Forward this email to a friend](https://us1.forward-to-friend.com/forward?u=a440c5b647697de580a2fd586&id=5d2598c2a3&e=%5BUNIQID%5D) [Update your profile](https://insurancefraud.us1.list-manage.com/profile?u=a440c5b647697de580a2fd586&id=b68dce7808&e=%5BUNIQID%5D&c=5d2598c2a3) \| \| \|:-:\| | |:-:| <html><p class="wp-block-paragraph"></p> **Features:** Fraud News Weekly --- ### [Fraud News Weekly - October 17, 2025](https://insurancefraud.org/publications/fraud-news-weekly-october-17-2025/) **Published:** October 17, 2025 **Author:** Coalition Against Insurance Fraud **Content:** Social Media Competition Underway, Calif. Gov. Signs Coalition Backed Bill, Coalition Q3 2025 Highlights | \| \| \|:-:\| \| Friday, October 17, 2025 \| \| \| | |:-:| | \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/df906857-d727-9ee9-0397-2a09caac30a4.png) \| \|:-:\| \| \| \| \| \| \|:-:\| | |:-:| | \| [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/2f971e24-7875-ac59-92b3-95d69a0bb60a.jpg)](https://www.facebook.com/profile.php?id=61579225779934) \| \|:-:\| \| \| \| \| \| \| [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a1492a86-29b0-90b6-d879-527e5492037e.png)](https://www.facebook.com/people/Coalition-Against-Insurance-Fraud/61579225779934/) [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/d2bd23eb-8810-4f7a-49d3-d2fe7aa1891e.png)](https://www.instagram.com/stopinsurancefraud/)[![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/be4e5708-bdc4-c0df-6c03-a6ebd5b34c13.png)](https://www.linkedin.com/company/coalition-against-insurance-fraud) \| \| \| \| \| \|:-:\|---\| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7e6cccc1-3a5e-4803-a7f8-7325e7e155cb.gif) \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7e6cccc1-3a5e-4803-a7f8-7325e7e155cb.gif) \| ![](images/spacer.gif) \| \| \|:-:\| \| \| | |:-:| | \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a57e030f-61fa-473f-b132-259b1a34e42e.png) \| \|:-:\| \| \| \| \| \| \| **![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/51bd0674-a6df-119f-86e6-72d3f4c6cd79.jpg)** **California Governor signs a Coalition-backed bill into law, closing a workers’ comp kickback loophole.** **California has enacted [Assembly Bill 1398](https://legiscan.com/CA/text/AB1398/id/3137082) to close a loophole that limited prosecution of workers’ compensation kickback schemes to misdemeanors instead of felonies.** The issue surfaced after courts applied the Williamson rule, concluding that kickback conduct charged under the broader insurance fraud statute in the Penal Code could only be prosecuted under the narrower workers’ compensation Labor Code kickback provision. That interpretation was central to *[People v. Woods](https://law.justia.com/cases/california/court-of-appeal/2025/g061948.html)*, where the Court of Appeal reversed dozens of felony convictions, a decision now under review by the California Supreme Court. During legislative hearings, lawmakers called the bill *“common sense legislation that provides prosecutors the tools to properly choose how to handle those cases involving those who prey on injured workers.”* [The Coalition supported the bill](https://insurancefraud.org/wp-content/uploads/Coalition-Support-of-CA-AB-1398.pdf), emphasizing its importance to insurance fraud prosecutors and SIUs, urging Governor Newsom to enact the bill with his signature. With the legislation now law, prosecutors have clear authority to pursue felony charges in serious kickback cases, restoring accountability and strengthening California’s fight against workers’ comp fraud. The pending Woods appeal will determine how far these reforms reach and could shape similar antifraud efforts nationwide. **NCOIL releases advance materials as Coalition prepares to speak twice at NCOIL Annual Meeting, next month.** The National Council of Insurance Legislators (NCOIL) has released its [30-day materials](https://ncoil.org/wp-content/uploads/2025/10/Atlanta-30-Day-Materials.pdf) for the 2025 Annual Meeting, November 12–15 in Atlanta, Georgia. The Coalition Against Insurance Fraud will take an active role, with Brent Walker, Director of Government Relations, scheduled to speak twice in support of proposed amendments to two NCOIL model laws. This continues the Coalition’s long-standing work in shaping consumer-focused antifraud policy nationwide. Last July, at NCOIL’s Summer Meeting in Chicago, Walker addressed the Financial Services & Multi-Lines Issues Committee on Trends and Developments in Combatting Insurance Fraud, alongside Louisiana Insurance Commissioner Tim Temple, Colonel Simon Blank of Florida’s Department of Financial Services, and NICB. Walker highlighted the need to protect consumers from predatory post-disaster contractor schemes and other fraud that targets vulnerable residents. Walker also spoke before the Property & Casualty Insurance Committee during consideration of the Storm Chaser Consumer Protection Model Act, supporting re-adoption while supporting [updates (beginning on page 275)](https://ncoil.org/wp-content/uploads/2025/10/Atlanta-30-Day-Materials.pdf) to expand the definition of contractor beyond roofers. To prepare, the Coalition has discussed this with a broad range of stakeholders, including associations representing the roofing contractor and property restoration industries. In Atlanta, the Coalition will also back [proposed amendments (beginning on page 143)](https://ncoil.org/wp-content/uploads/2025/10/Atlanta-30-Day-Materials.pdf) to the Insurance Fraud Model, originally introduced by the Coalition in 1995, to broaden the definition of a fraudulent insurance act, continuing its decades-long leadership in educating legislators and advancing effective antifraud laws through NCOIL. If Coalition members would like to discuss these proposed amendments further, please contact <brent@insurancefraud.org>. \| \| \| \| \| \|:-:\|---\| \| \|:-:\| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7e6cccc1-3a5e-4803-a7f8-7325e7e155cb.gif) \| \| \| | |:-:| | \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/6b5470a4-ef85-47e4-bc7d-6740f8ed0cdb.png) \| \|:-:\| \| \| \| \| \| \| **![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/9c6b5d16-c0fd-2ded-81be-dafadfe64d8f.jpg)** **Workers’ Comp Task Force Webinar – Premium Fraud and the Intersection to Auto Insurance Fraud** **Yesterday, over 250 attendees joined a Coalition webinar focused on workers’ compensation premium fraud, a $25 billion-a-year crime in the United States.** National experts with decades of experience in investigation, auditing, and prosecution shared insights on how premium fraud intersects with auto insurance fraud, tax evasion, wage theft, and other schemes by dishonest businesses.The session was **moderated by Lina Valencia Ignatius**, Investigations Project Lead at Pinnacol Assurance, and featured panelists **Kathy Lowe**, Retired Audit Manager and Premium Fraud Investigator at Delta Group; **Eric Kriczky, CPCU, CFE**, Supervising Forensic Consultant in the Premium Fraud SIU at Liberty Mutual; and **Dominic Dugo**, Chief Deputy District Attorney and Workers’ Comp Task Force Co-Chair for the Coalition Workers’ Compensation Fraud Task Force. The discussion highlighted real-world recovery efforts, including a 2025 Coalition **Premium Fraud Case Study** demonstrating how nearly **$1.5 million** was recovered in a single investigation. A copy of the webinar will be available next week on the Coalition website, with an announcement and link to access it. As a reminder, Workers’ Compensation resources are available on the Coalition website, ([insurancefraud.org](http://insurancefraud.org/)) located under the **Member Resources** tab and clicking on **Topics**. **Consumer groups blast plan to limit review of future California rate requests.** California Insurance Commissioner Ricardo Lara has [proposed reforms to streamline the state’s rate review process](https://insurancenewsnet.com/innarticle/consumer-groups-blast-plan-on-limit-review-of-future-california-rate-requests) under Proposition 103, a voter-approved measure that allows public participation in insurer rate hike requests. Lara’s plan aims to reduce delays, increase transparency, and *“protect consumers from hidden fees”* by clarifying how public intervenors—consumer advocates who challenge rate hikes—are compensated and monitored. Lara argues that the current system, unchanged since 2006, is dominated by a few recurring groups, mainly **Consumer Watchdog**, which received nearly all compensation from recent reviews. His proposal would set clearer standards for participation, require public reporting, and introduce firm timelines for rate case progress.Consumer advocates, however, claim the move is an attempt to **weaken public oversight** and **fast-track insurer rate hikes**. They point to prior interventions that saved Californians millions, including reducing State Farm’s requested rate hike after recent wildfires. The proposal is part of Lara’s broader **Sustainable Insurance Strategy**, launched in 2023 to stabilize California’s insurance market and encourage insurers to resume writing policies in wildfire-prone areas. A **public hearing** on the proposed changes is scheduled for **November 20**. \| \| \| \| \| \|:-:\|---\| \| \|:-:\| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7e6cccc1-3a5e-4803-a7f8-7325e7e155cb.gif) \| \| \| | |:-:| | \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/bd099ba2-96e8-cf07-257c-1d3faf0782c7.png) \| \|:-:\| \| \| \| \| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/32eb51b6-b192-1df1-0f50-aea47edf8255.jpg) **"Real Housewives of Potomac" star [Wendy Osefo, husband arrested](https://www.cbsnews.com/baltimore/news/real-housewives-star-husband-arrested-maryland-accused-falsely-reporting-home-break-in/) for alleged insurance fraud in Maryland.** *“Real Housewives of Potomac”* star **Wendy Osefo** and her husband **Edward Osefo** have been charged with **insurance fraud** after allegedly staging a fake burglary at their Maryland home. The couple claimed more than **$200,000** in stolen designer handbags and jewelry while vacationing in Jamaica in April 2024. Investigators found **no evidence of forced entry or theft**, and surveillance footage showed no break-in activity. Authorities also discovered that some “stolen” items had been returned to retailers years earlier. A search of the Osefos’ home later uncovered several pieces they had reported as missing, including luxury jewelry and handbags. Emails obtained by investigators allegedly showed Edward asking Wendy to inflate their insurance claim to reach their **$423,000 policy limit**. Both were **arrested and released on bail** after being indicted on multiple charges. Officials emphasized that insurance fraud drives up costs for all policyholders and will be prosecuted aggressively. **Over $430K stolen by LA County workers in employment fraud, prosecutor says.** Thirteen Los Angeles County government employees have been charged with stealing more than $430,000 in fraudulent unemployment benefits during the COVID-19 pandemic. Despite being fully employed, the defendants allegedly filed false claims with the California Employment Development Department between 2020 and 2023, claiming to have earned less than $600 per week. Each has been[ **charged with one felony count of grand theft**](https://www.nbclosangeles.com/news/local/la-county-employees-unemployment-benefits-fraud/3792073/) and faces up to three years in state prison if convicted. Those charged include employees from multiple agencies, notably the Department of Children and Family Services, the Department of Public Social Services, and the Sheriff’s Department. District Attorney **Nathan Hochman** called the scheme *“egregious,”* noting that it exploited funds meant for Californians truly in need. While 172 instances of suspected fraud were identified in a broader county audit, only 13 cases remain prosecutable due to statute of limitation constraints. Officials emphasized the importance of whistleblower reports in uncovering public-sector fraud and encouraged residents to use the county’s anonymous fraud hotline to report suspected misconduct. **Kulpmont woman [charged with insurance fraud following vehicle crash](https://insurancenewsnet.com/oarticle/kulpmont-woman-charged-with-insurance-fraud-following-vehicle-crash).** A 27-year-old Kulpmont woman, Jessica Wright, has been charged with insurance fraud and theft by deception after allegedly lying to her insurer about the timing of a vehicle crash. Investigators say Wright’s Progressive policy had been canceled earlier in November 2024 due to nonpayment. She reinstated the policy at 4:40 p.m. on Nov. 26, then filed a claim just over two hours later, reporting a crash that occurred before the policy was active. Records show the accident happened around 4:39 p.m., just minutes before coverage was reinstated. Progressive concluded that Wright misrepresented the facts to secure coverage for a crash that had already occurred. She now faces felony charges filed by the Pennsylvania Attorney General’s Office. . **Sumter County woman [accused of staging hit-and-run crash](https://www.wistv.com/2025/10/16/sumter-county-woman-accused-staging-hit-and-run-crash-insurance-money/) for insurance money.** A South Carolina woman, Ulanda Shamicka Yarborough, has been arrested for allegedly staging a hit-and-run crash to file a false $10,000 insurance claim. Investigators say Yarborough and a 19-year-old accomplice, Jamari Demetrius Pringle, fabricated a March collision where their vehicle was supposedly rear-ended and forced off the road. Both initially claimed injuries requiring medical care, but an investigation by Progressive and the South Carolina Law Enforcement Division revealed the crash never happened. Pringle and another participant later admitted it was staged. Pringle was arrested earlier this month and released on bond, while Yarborough was booked into the Sumter-Lee Regional Detention Center. A third suspect remains at large. **Pharmacy owners plead guilty in Medicaid fraud involving unregulated HIV medications.** Haussermann’s Pharmacy in Philadelphia has [agreed to pay $2.3 million in restitution](https://www.hmpgloballearningnetwork.com/site/pln/commentary/pharmacy-owners-plead-guilty-medicaid-fraud-involving-unregulated-hiv) after pleading guilty to felony Medicaid fraud involving unregulated HIV medications. Owned by Subhash Patel under Surnil Pharmacy Inc., the pharmacy was found to have purchased and dispensed HIV drugs from illegitimate sources, then billed Medicare and Medicaid for reimbursement. A six-month investigation by the Pennsylvania Office of Attorney General’s Medicaid Fraud Section revealed that Patel stocked unregulated medications, often with removed or altered labels, and bypassed legitimate wholesalers. Approximately 100,000 tablets were dispensed before the scheme was uncovered. While no patients were reported harmed, the court ordered restitution and imposed a five-year suspension of Patel’s pharmacist license and his eligibility to serve as a Medicare or Medicaid provider. Haussermann’s Pharmacy and Patel’s four other pharmacies have since closed. Officials condemned the scheme as a dangerous abuse of public trust that prioritized profit over patient safety. **Wisconsin contractor [fined for acting as a public adjuster](https://www.insurancejournal.com/news/midwest/2025/10/14/843652.htm).** Wisconsin Insurance Commissioner Nathan Houdek has ordered a $6,000 civil forfeiture against a contractor found to be unlawfully acting as a public adjuster and violating state insurance laws. The contractor’s business model combined home repair services with *“claim assistance”* through assignments of benefits, a practice prohibited under Wisconsin law.Houdek emphasized that anyone negotiating insurance claims must adhere to public adjuster regulations, which bar financial conflicts of interest. The decision reinforces consumer protections by ensuring that claim negotiations remain transparent and unbiased. The Office of the Insurance Commissioner also cautioned consumers to review contracts carefully and avoid assigning insurance benefits to contractors or third parties, as such arrangements are not allowed under Wisconsin law. **Virginia businesswoman to serve prison term and owe over $3M for health care fraud case.** Jennifer Adams pleaded guilty to two counts of misprision of a felony and was sentenced back in July to serve three years in prison. However, the judge delayed a decision about how much, if any, restitution she would be required to pay. On Oct. 2, Chief U.S. District Judge Elizabeth K. Dillion in Virginia issued her debt ruling, deciding that she will be [held liable for paying nearly $3.39 million in restitution](https://www.postandcourier.com/news/crime/mount-pleasant-businesswoman-health-care-fraud/article_d15afcef-be6e-42a3-805f-793d3caf2c6d.html). Adams was indicted along with others involved in the Virginia clinics in 2023. She was accused of knowing about and concealing multiple criminal conspiracies, including the illegal distribution of controlled substances and widespread health care fraud. The conspiracy ran between December 2014 and February 2020. “*While Adams was not a medical provider, she had full knowledge of and enabled the criminal conduct through her management position at the company,*” the judge wrote in her order setting the restitution. \| \| \| \| \| \|:-:\|---\| \| \|:-:\| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7e6cccc1-3a5e-4803-a7f8-7325e7e155cb.gif) \| \| \| | |:-:| | \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/05ebd826-d3ed-4100-a4b0-7c83841fc259.png) \| \|:-:\| \| \| \| \| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/5d3e16c4-2821-e586-3bfa-7f84e5c68c2a.png) [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/1ce4a222-3707-daaf-86bf-d0078f1d7693.png)](https://s.surveyplanet.com/bj1sw6en) [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/6c8550d3-4d99-bc65-c8f8-cd1902423e17.png)](https://members.insurancefraud.org/general/pick_username.asp) ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/3ef40901-b851-f621-08b2-322f09ca8a57.png) [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/73314a3e-da5b-23f8-8ce9-56b2e1ef25da.png)](https://event.on24.com/wcc/r/5028396/115A7558FC4035359FDF996AAFD7BEA4) [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/0d00f4b9-bb32-1804-3077-402e2f978e01.png)](https://us02web.zoom.us/webinar/register/7817597702831/WN_FaDiDJpmTrmoFwSKBmVNeA#/registration) [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/c736527b-4d31-30bd-84f2-938724ff2fc4.png)](https://www.surveymonkey.com/r/PNNRW2P?j=6791105&e=EML-CSV-ContactCenter@nysif.com&l=35226_HTML&u=368063469&mid=7205125&jb=0) [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/5b92c840-a0b2-1c66-7582-0e98eec55ba3.png)](https://www.iasiu.org/events/EventDetails.aspx?id=1951822) [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/8456e5fe-4c2e-a285-2dbb-280a6777ac0b.png)](https://register.gotowebinar.com/register/1173269515288725598) \| \| \| \| \| \|:-:\|---\| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7e6cccc1-3a5e-4803-a7f8-7325e7e155cb.gif) \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7e6cccc1-3a5e-4803-a7f8-7325e7e155cb.gif) \| ![](images/spacer.gif) \| \| \|:-:\| \| \| | |:-:| | \| \| \| FACES OF FRAUD \| \|---\|:--\| \| \| \| \| \| \| \| [![](https://via.placeholder.com/125x166)](https://www.tn.gov/finance/news/2020/9/28/davidson-co--woman-charged-with-tenncare-fraud.html) \| \| \| \| [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/0d9b5571-0eca-9a02-cfcb-a92bd290cc61.png)](https://people.com/steven-mcbee-sr-sentenced-24-months-insurance-fraud-case-exclusive-11830756) **Steve McBee** Kansas City, Mo. Crop fraud *SENTENCED* \| \| \| \| [![](https://via.placeholder.com/125x166)](https://www.southwesttimes.com/2020/09/false-scripts-bills-send-doctor-to-prison/) \| \|:-:\|---\|:-:\| \| \| \| [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/5a5705a5-9f51-c1fe-9fd8-4f1fbd778f5e.png)](https://www.blackcatholicmessenger.org/osefo-arrests/) **Wendy Osefo** Potomac, MD Homeowners claims *ARRESTED* \| \| \|:-:\| \| \|:-:\| \| \| \| [![](https://via.placeholder.com/125x166)](https://www.timesrepublican.com/news/todays-news/2020/09/mpd-handles-multiple-burglaries-1-arrested/) \| \|:-:\| \| \| \| [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/ea13ff0d-29d4-f033-5ea6-a435d066eccf.png)](https://www.blackcatholicmessenger.org/osefo-arrests/) **Eddie Osefo** Potomac, MD Homeowners claims *ARRESTED* \| \| \| \| [![](https://via.placeholder.com/125x166)](https://www.wmbfnews.com/2020/09/22/longs-woman-arrested-accused-forging-prescriptions/) \| \|:-:\|---\|:-:\| \| \| \| [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/43899ed9-e696-19b9-cf35-e58272cb4f6f.png)](https://www.northescambia.com/2025/10/jesse-lacoste-of-cantonment-convicted-of-grand-theft-contractor-fraud) **Jesse LaCoste** Escambia County, FL Contractor fraud *CONVICTED* \| \| \|:-:\| \| \|:-:\| \| \|---\| \| \|:-:\| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7e6cccc1-3a5e-4803-a7f8-7325e7e155cb.gif) \| \| \| \| \| \|:-:\|---\| | |:-:| | \| \| \| EVENTS \| \|---\|:--\| \| \| \| \| **October 19-22 —** [**2025 Global Insurance Fraud Summit**](https://globalinsurancefraudsummit.org/2025-global-insurance-summit/) Toronto, Canada (GIFS) \| \| \| \| \|:--\| \| \| **October 22 — [Staged Auto Accidents](https://event.on24.com/wcc/r/5028396/115A7558FC4035359FDF996AAFD7BEA4)** Webinar (Ethos) \| \| \| \| \|:--\| \| \| **October 23 — [AI: Friend or Foe?](https://us02web.zoom.us/webinar/register/7817597702831/WN_FaDiDJpmTrmoFwSKBmVNeA#/registration)** Webinar (Diligence) \| \| \| \| \|:--\| \| \| **October 28 — [The Fraud Factor](https://www.surveymonkey.com/r/PNNRW2P?j=6791105&e=EML-CSV-ContactCenter@nysif.com&l=35226_HTML&u=368063469&mid=7205125&jb=0)** Buffalo, N.Y. (NYSIF) \| \| \| \| \|:--\| \| \| **October 28 — [OH/PA/WV Joint Fall Training Seminar](https://www.iasiu.org/events/EventDetails.aspx?id=1951822)** Virtual (IASIU) \| \| \| \| \|:--\| \| \| **November 4 — [SCFIA 47th Annual Anti-Fraud Conference](https://scfia.starchapter.com/meetinginfo.php?id=77&ts=1755230802)** Downey, Calif. (SCFIA) \| \| \| \| \|:--\| \| \| **November 19 — [The Hidden Threat: Synthetic Identities & Account Takeovers in Modern Fraud](https://www.iasiu.org/events/EventDetails.aspx?id=1976262)** Webinar (IASIU) \| \| \| \| \|:--\| \| \| **December 2-3 — [Coalition Annual Meeting](https://insurancefraud.org/coalition-annual-membership-meeting/) Arlington, VA. (Coalition Against Insurance Fraud)** \| \| \| \| \|:--\| \| \| \|:-:\|---\| | |:-:| | \| \| \| FRAUD NEWS FRIDAY \| \|---\|:--\| \| \| \| \| \* [Zurich boosts fraud detection with Quantexa partnership](https://www.sourcesecurity.com/amp/news/zurich-boosts-fraud-detection-quantexa-partnership-co-1758101005-ga.1760621741.html) \* [SLED: Teen charged with insurance fraud in fake car accident](https://wach.com/news/local/sled-teen-charged-with-insurance-fraud-in-fake-car-accident-sumter-county-jamari-d-pringle-crime-investigation) \* [Dallas man sentenced to more than 13 years in multi-million dollar insurance fraud](https://www.msn.com/en-us/news/us/dallas-man-sentenced-to-more-than-13-years-in-multi-million-dollar-insurance-fraud/ar-AA1zDsgV?apiversion=v2&domshim=1&noservercache=1&noservertelemetry=1&batchservertelemetry=1&renderwebcomponents=1&wcseo=1) \* [PSV operators seek MPs’ help to curb rising insurance fraud](https://nation.africa/kenya/business/psv-operators-seek-mps-help-to-curb-insurance-fraud-5234374#google_vignette) \| \| \| \| \|:--\| \| \| \|:-:\|---\| | |:-:| | \| \| \| \| \|---\|---\| \| \| \| \| Connect with Us: \| \| \| [![FB](https://mcusercontent.com/a440c5b647697de580a2fd586/images/ef66a2aa-ea17-4447-95b6-ad328c555988.png)](https://www.facebook.com/insurancefraud) \| \| [![TW](https://mcusercontent.com/a440c5b647697de580a2fd586/images/43f8397b-2f36-4358-87e9-549e6d9b749b.png)](https://twitter.com/insurance_fraud) \| \| [![YT](https://mcusercontent.com/a440c5b647697de580a2fd586/images/c202c8ca-32dc-49b1-a471-9669d36f946e.png)](https://www.youtube.com/user/stopinsurancefraud) \| \| [![IN](https://mcusercontent.com/a440c5b647697de580a2fd586/images/0cb8e5d8-9435-49a5-91b2-1a214a5f2fa0.png)](https://www.linkedin.com/groups/3856550) \| \| \|:-:\| \| [![Coalition Against Insurance Fraud](https://mcusercontent.com/a440c5b647697de580a2fd586/images/539d436e-d608-44a9-ba5e-b64d3a1ddd06.png)](https://www.insurancefraud.org) \| \| \|:-:\| \| Contact: \| \|:--\| \| Phone: [202.393.7330](tel:2023937330) Email: <info@insurancefraud.org> Address: 1012 14th Street NW Suite 610 Washington DC 20005 [www.InsuranceFraud.org](http://www.insurancefraud.org/) \| \| \|---\| \| \|:-:\| \| \| \| \| \|:-:\|---\| | |:-:| | | |---| | \| \| You are receiving this email because either your organization is a member of the Coalition Against Insurance Fraud or you requested to be placed on our mailing list. [Unsubscribe](https://insurancefraud.us1.list-manage.com/unsubscribe?u=a440c5b647697de580a2fd586&id=b68dce7808&t=b&e=%5BUNIQID%5D&c=0b4c8d88d4) [<< Test Email Address >>](%3C%3C%20Test%20Email%20Address%20%3E%3E) from this list. Our mailing address is: Coalition Against Insurance Fraud1012 14th St NW Ste 610 Washington, DC 20005-3424 [Add us to your address book](https://insurancefraud.us1.list-manage.com/vcard?u=a440c5b647697de580a2fd586&id=b68dce7808) Copyright (C) 2025 Coalition Against Insurance Fraud All rights reserved. [Forward this email to a friend](https://us1.forward-to-friend.com/forward?u=a440c5b647697de580a2fd586&id=0b4c8d88d4&e=%5BUNIQID%5D) [Update your profile](https://insurancefraud.us1.list-manage.com/profile?u=a440c5b647697de580a2fd586&id=b68dce7808&e=%5BUNIQID%5D&c=0b4c8d88d4) \| \| \|:-:\| | |:-:| <html><p class="wp-block-paragraph"></p> **Features:** Fraud News Weekly --- ### [Fraud News Weekly - October 10, 2025](https://insurancefraud.org/publications/fraud-news-weekly-october-10-2025/) **Published:** October 10, 2025 **Author:** Coalition Against Insurance Fraud **Content:** Register Today For The WC Webinar On Oct. 16 At 2 PM, Coalition Continues Planning For Legislative Priorities, Register For The 2025 Annual Meeting | \| \| \|:-:\| \| Friday, October 10, 2025 \| \| \| | |:-:| | \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/df906857-d727-9ee9-0397-2a09caac30a4.png) \| \|:-:\| \| \| \| \| \| \|:-:\| | |:-:| | \| [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a1492a86-29b0-90b6-d879-527e5492037e.png)](https://www.facebook.com/profile.php?id=61579225779934) \| \|:-:\| \| \| \| \| \| \| [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/d2bd23eb-8810-4f7a-49d3-d2fe7aa1891e.png)](https://www.instagram.com/stopinsurancefraud/)[![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/be4e5708-bdc4-c0df-6c03-a6ebd5b34c13.png)](https://www.linkedin.com/company/coalition-against-insurance-fraud) \| \| \| \| \| \|:-:\|---\| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7e6cccc1-3a5e-4803-a7f8-7325e7e155cb.gif) \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7e6cccc1-3a5e-4803-a7f8-7325e7e155cb.gif) \| ![](images/spacer.gif) \| \| \|:-:\| \| \| | |:-:| | \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/00ed7ac4-bb10-4f87-9d66-746db8688e48.png) \| \|:-:\| \| \| \| \| \| \| **![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/d87f3b63-547c-b732-1811-75b154716a1e.png)** **Florida House panel discussion highlighted** **lawmaker concerns regarding the use of Artificial Intelligence (AI) in insurance decision-making.** **This week, Florida’s House Insurance and Banking Subcommittee held a fact-finding hearing on AI use in insurance, recognizing the potential efficiencies it offers but alongside the need for oversight.** Lawmakers were urged to distinguish between generative AI, which summarizes, drafts, and provides probabilistic analyses, and agentic AI, which would make fully autonomous decisions. It was pointed out that agentic AI is not currently used for complex coverage calls, exclusions, underwriting, or claim resolutions because it simply cannot interpret nuanced policy language. By contrast, fraud detection was described as a "*big use*", with AI models flagging potential suspicious activity for human review before escalation. Committee members focused on disclosure, transparency, and regulatory gaps, noting that consumers are often unaware when AI influences claim outcomes or pricing. “*This is going to be an ongoing learning process for all of us,*” House Insurance & Banking Chairman Brad Yeager [said](https://www.wusf.org/politics-issues/2025-10-07/florida-lawmakers-ponder-ai-in-insurance) at the end of the meeting. The discussion framed AI as a strategic tool for insurers while underscoring the need for measured, consumer-focused regulation to prevent insurance fraud and protect policyholders. Recognizing these challenges, both the NAIC and NCOIL are proactively shaping state-level frameworks to govern AI in insurance. NAIC’s model [bulletin](https://content.naic.org/sites/default/files/cmte-h-big-data-artificial-intelligence-wg-ai-model-bulletin.pdf.pdf) and [adoption map](https://content.naic.org/sites/default/files/cmte-h-big-data-artificial-intelligence-wg-map-ai-model-bulletin.pdf) reflect growing state oversight of AI transparency and accountability, while NCOIL’s [draft model law](https://ncoil.org/wp-content/uploads/2025/06/NCOIL-Insurance-Artifical-Intelligence-Model-Draft-6-17-25.pdf) seeks to guide responsible innovation. These efforts align with the Coalition’s legislative priorities to balance consumer protections with the ability to responsibly leverage technology to fight insurance fraud. **Ned Gaines appointed Nevada Insurance Commissioner, bringing decades of regulatory and industry experience to the Silver State.** The Nevada Department of Business and Industry has [announced](https://doi.nv.gov/News_Notices/Press_Releases/October_07,_2025_-_Ned_Gaines_Named_Nevada_Insurance_Commissioner/?csrt=14309837916491796220) the appointment of Ned Gaines as Commissioner of the Nevada Division of Insurance effective October 6, 2025. Gaines, who has been serving as Acting Commissioner since July, brings more than 25 years of experience spanning both insurance regulation and private sector leadership. His tenure with the Washington State Office of the Insurance Commissioner and his extensive work in claims management and compliance position him well to guide Nevada through complex insurance challenges. "*Serving Nevadans as Commissioner is an extraordinary honor,*" said Ned Gaines. "*I am committed to ensuring Nevadans have access to a fair insurance market and to strengthening the Division's work on consumer education, market oversight, and industry engagement. I look forward to continuing our work with the Department of Business and Industry, insurance providers, and community partners to protect consumers and promote a stable insurance market for Nevada.*" As a reminder to fraud fighters, it is the Nevada Office of Attorney General [Fraud Unit](https://ag.nv.gov/About/Criminal_Justice/Fraud/) who maintains both an Insurance Fraud Unit and Workers' Compensation Fraud Unit in that state. **Coalition continues 2026 planning for legislative priorities.** Each fall, the Coalition Against Insurance Fraud’s Government Affairs Committee begins its annual process of shaping next year’s [legislative priorities](https://insurancefraud.org/legislative-priorities/), and that work is now well underway in advance of the upcoming [Annual Meeting](https://insurancefraud.org/coalition-annual-membership-meeting/). This is a key time of year when Coalition members identify trends, and help set the direction for the Coalition’s 2026 advocacy agenda. As preparations continue for the Annual Meeting, the Coalition encourages all members to share ideas and perspectives to help refine the 2026 legislative priorities. Input may be sent to Brent Walker, Director of Government Relations, at <brent@insurancefraud.org>. \| \| \| \| \| \|:-:\|---\| \| \|:-:\| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7e6cccc1-3a5e-4803-a7f8-7325e7e155cb.gif) \| \| \| | |:-:| | \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/6ab2c291-f95a-060c-22cd-2622f315f1e5.png) \| \|:-:\| \| \| \| \| \| \| **![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/32979a6f-27a2-5c53-3f9f-bb4d4a9e3089.png)** **Consumer Alert: Crime of “*staged car crashes”* is costly and on the rise in NYS** **Citizens for Affordable Rates (CAR) today issued a consumer warning urging New York drivers to be vigilant against staged car crashes.** Criminal networks that are a major driver of the state’s skyrocketing auto insurance costs. The warning accompanies a new [fact sheet](https://drive.google.com/file/d/1RnuUGT854RYTuS6aq4rja16wA8JrWfbk/view?usp=sharing) detailing how these schemes operate and their impact on every driver’s wallet. “*Staged car crashes are not a victimless crime,*” said CAR spokesperson James Freedland. “*They’re organized networks that prey on unsuspecting drivers and force law-abiding New Yorkers to pay higher auto premiums. We’re issuing this warning so consumers can protect themselves in this affordability crisis — and to urge Albany lawmakers to take action before insurance costs skyrocket even further.*” Staged crashes and inflated medical claims [account for 75% of all insurance fraud cases in New York](https://wellsvillesun.com/blog/2025/10/08/consumer-alert-nys-crime-of-staged-car-crashes-is-costly-and-on-the-rise/) (NYS Department of Financial Services), adding an estimated $300 per driver per year. **Van fleets warned about insurance fraud.** Operators of light commercial vehicles have been warned of the heightened risk of becoming a victim of insurance fraud. The [Association of Fleet Professionals](https://www.theafp.co.uk/) (AFP) said fraudulent insurance claims are rising, with criminals deliberately targeting commercial vehicles. “*Lone drivers present only one witness to counter the fraudsters’ claim and commercial vehicles are pretty much guaranteed to have valid insurance, making them a better target,*” said Martin Evans, chair of the AFP’s Risk and Compliance Committee. Examples include ‘*crash-for-cash*’ scammers who [deliberately cause an accident](https://www.fleeteurope.com/en/safety/europe/features/van-fleets-warned-about-insurance-fraud?a=JMA06&t%5B0%5D=Insurance&t%5B1%5D=Allianz&t%5B2%5D=LCVs&curl=1) so that they can blame the innocent driver. These cases often involve a moped or motorbike that rides head-on into a fleet vehicle, or riding past just as a driver opens the vehicle door, so that it hits the motorbike. The criminals then seek compensation from insurance companies. Detective Chief Inspector Tom Hill, from the City of London Police’s Insurance Fraud Enforcement Department (IFED), said: “*The value of the claims that can be lodged for repairs, personal injury and replacement vehicles makes this an incredibly lucrative opportunity for fraudsters.*” \| \| \| \| \| \|:-:\|---\| \| \|:-:\| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7e6cccc1-3a5e-4803-a7f8-7325e7e155cb.gif) \| \| \| | |:-:| | \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/c16e2322-ff90-895b-a2c8-2802034b1ffc.png) \| \|:-:\| \| \| \| \| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/015a96c3-1c1a-7101-52f9-4d9c4984defb.png) **Wilson County woman claimed $87,000 in fraudulent insurance claims and stealing weight loss drugs.** **Heather Ann Robinson was arrested on 86 counts of insurance fraud, 46 counts of identity theft, and 38 counts of obtaining or attempting to obtain property by false pretense.** She was also charged with 20 counts of practicing medicine without a license, which are misdemeanors. The other 170 charges are felonies. *The allegations against her:* Robinson’s arrest was the result of a six-month-long investigation from the North Carolina Department of Insurance's Criminal Investigations Division and came after her home was searched on May 12. Robinson filed fraudulent insurance claims with [two different insurance companies](https://www.wral.com/news/local/wilson-county-woman-insurance-drugs-steal-october-2025/) and attempting to support these claims with fabricated medical records and receipts. According to arrest warrants, Robinson collected $87,415 from the claims and attempted to collect an additional $157,303.93. Robinson also stole several individuals' identities and using them to open credit card accounts, make multiple purchases and withdraw retirements savings. Warrants also accuse Robinson of stealing GLP-1 weight loss medication from a local business and using some of the identities she had stolen to open accounts with drug companies out of state to acquire additional GLP-1 weight loss medication. Robinson then sold this medication to members of the community. **Cedar Rapids man pleads not guilty to submitting forged pet insurance claim.** Greg Buelow, the city of Cedar Rapids’ housing and nuisance manager, pleaded not guilty this week for submitting a forged receipt for pet medication prescriptions. *The allegations:* Buelow [provided false information to an insurance company](https://www.thegazette.com/crime-courts/cedar-rapids-man-pleads-not-guilty-to-submitting-forged-pet-insurance-claim/) for a pet insurance claim. The submitted falsified invoice for reimbursement, purportedly issued by a veterinary clinic, was for prescription medications for his dog. The incident happened June 2, the complaint stated. The complaints don’t include the amount of false reimbursement and his trial is set for Feb. 10 in Linn County District Court. **GEICO accuses Brooklyn suppliers of orchestrating $835k insurance fraud scheme.** A sweeping federal lawsuit accuses two Brooklyn medical supply companies of orchestrating a multimillion-dollar insurance fraud scheme that targeted [GEICO](https://www.insurancebusinessmag.com/us/companies/geico/116487/) with bogus claims for unnecessary medical equipment. *The lawsuit alleges:* The complaint by Government Employees Insurance Company and its affiliates alleges that Droz Medical Supply Inc., GB Medical Supply Inc., their listed owners Daniel M. Drozdov and Gennadiy Bortnikov, and a cast of unnamed conspirators, masterminded a [complex operation to siphon more than $835,000 from GEICO](https://www.insurancebusinessmag.com/us/news/life-insurance/geico-accuses-brooklyn-suppliers-of-orchestrating-835k-insurance-fraud-scheme-552155.aspx) through fraudulent no-fault insurance claims. The companies are accused of submitting hundreds of claims for durable medical equipment – such as powered pressure-reducing air mattresses, osteogenesis bone stimulators, and pneumatic compression devices – purportedly prescribed to individuals who claimed to have been involved in automobile accidents in New York and were eligible for coverage under no-fault insurance policies issued by GEICO. The lawsuit claims these devices were medically unnecessary, illusory, or otherwise non-reimbursable, and in some instances, may not have been provided at all. **Pittsburgh-area man charged with providing fraudulent insurance services without a license.** Charles Harris has been charged with five counts of forgery, identity theft, insurance fraud, fraudulent business practices and unlicensed activity. These charges stem from allegations that he continued to engage in insurance dealings after his license was revoked in March 2023 for misusing business and client funds. *Prosecutors say:* These charges stem from allegations that he continued to engage in insurance dealings [after his license was revoked](https://www.wpxi.com/news/local/pittsburgh-area-man-charged-with-providing-fraudulent-insurance-services-without-license/DBFFQGTGQZGNHHD6GJQCDJHEUU/) in March 2023 for misusing business and client funds. Harris is accused of continuing to conduct insurance meetings, write and sell policies and forge documents and signatures of employees, despite the revocation of his license. The lack of a valid license prohibited him from selling or soliciting insurance, accounting and discussing policies with prospective clients. **Georgia Bureau of Investigation arrests a funeral homeowner on multiple counts of abuse of a dead body and fraud.** *Chris Johnson, a funeral home owner, was charged with the following:* One count of Violation of Vital Records Registration, One count of Felony Theft by Taking, Seven counts of Misdemeanor Theft by Taking, Three counts of Felony Theft by Deception, Thirteen counts of Misdemeanor Theft by Deception, Thirteen counts of First-Degree Forgery. *The allegations:* These additional charges are a continuation of the investigation into the remains found at Johnson’s Funeral Home and his related business practices. These charges stem from a 2023 investigation into an attempt by Sirmans to [fraudulently obtain additional life insurance proceeds](https://valdostatoday.com/news-2/region/2025/10/gbi-arrests-funeral-homeowner-on-multiple-charges/) by altering the cause of death on a death certificate in 2022. **Attorney General Mayes announces medical employee will serve prison time for insurance fraud and money laundering after impersonating doctor.** Jose Andres Lopez has been sentenced to 3.5 years in prison, following by a 7 year term of supervised probation, and ordered to pay $45,000 back in restitution after defrauding the medical practice where he was employed. Lopez was sentenced after he pled guilty to Fraudulent Schemes & Artifices, a Class 2 felony, and Money Laundering in the Second Degree, a Class 3 felony. Lopez was sentenced by the Mohave County Superior Court on September 22, 2025. Between June 2017 through March 2021, Jose Lopez was employed as the office manager by a medical clinic located in Mohave County. On numerous occasions in 2020 and 2021, Lopez used this access to send unauthorized prescriptions for himself and another employee. Lopez created multiple false patient visit records for himself in the clinic’s electronic medical records system, which portrayed that he was receiving physical therapy treatment from the doctor. Lopez [was not a patient of the doctor](https://www.azag.gov/press-release/attorney-general-mayes-announces-medical-employee-will-serve-prison-time-insurance) nor did the doctor treat Lopez as portrayed in these records. These patient records produced billing records that were submitted to two insurance carriers for a personal injury claim made by Lopez due to an automobile accident. Based upon these submissions, the insurance companies paid a sum of at least $45,000.00 to settle Lopez’s personal injury claim. **Virginia businesswoman to serve prison term and owe over $3M for health care fraud case.** Jennifer Adams pleaded guilty to two counts of misprision of a felony and was sentenced back in July to serve three years in prison. However, the judge delayed a decision about how much, if any, restitution she would be required to pay. On Oct. 2, Chief U.S. District Judge Elizabeth K. Dillion in Virginia issued her debt ruling, deciding that she will be [held liable for paying nearly $3.39 million in restitution](https://www.postandcourier.com/news/crime/mount-pleasant-businesswoman-health-care-fraud/article_d15afcef-be6e-42a3-805f-793d3caf2c6d.html). Adams was indicted along with others involved in the Virginia clinics in 2023. She was accused of knowing about and concealing multiple criminal conspiracies, including the illegal distribution of controlled substances and widespread health care fraud. The conspiracy ran between December 2014 and February 2020. “*While Adams was not a medical provider, she had full knowledge of and enabled the criminal conduct through her management position at the company,*” the judge wrote in her order setting the restitution. \| \| \| \| \| \|:-:\|---\| \| \|:-:\| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7e6cccc1-3a5e-4803-a7f8-7325e7e155cb.gif) \| \| \| | |:-:| | \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/05ebd826-d3ed-4100-a4b0-7c83841fc259.png) \| \|:-:\| \| \| \| \| \| \| [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/30dea1b7-abdd-d53a-187c-e09bbd6859d1.png)](https://us02web.zoom.us/webinar/register/WN_P4vHP_CFTASvEqIfUZ5O-Q) \| \| \| \| \| \|:-:\|---\| \| \|:-:\| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7e6cccc1-3a5e-4803-a7f8-7325e7e155cb.gif) \| \| \| | |:-:| | \| [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/6ca05e8b-8eae-81c3-c07e-7c73d299ebdb.png)](https://s.surveyplanet.com/3y6ssmr7) \| \|:-:\| \| \| \| \| \| \| [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/273bd3e9-4a94-70ee-787f-0e7552ff2536.png)](https://insurancefraud.org/coalition-annual-membership-meeting/) [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/1ce4a222-3707-daaf-86bf-d0078f1d7693.png)](https://s.surveyplanet.com/bj1sw6en) [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/6c8550d3-4d99-bc65-c8f8-cd1902423e17.png)](https://members.insurancefraud.org/general/pick_username.asp) ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/3ef40901-b851-f621-08b2-322f09ca8a57.png) [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/c736527b-4d31-30bd-84f2-938724ff2fc4.png)](https://www.surveymonkey.com/r/PNNRW2P?j=6791105&e=EML-CSV-ContactCenter@nysif.com&l=35226_HTML&u=368063469&mid=7205125&jb=0) [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/5b92c840-a0b2-1c66-7582-0e98eec55ba3.png)](https://www.iasiu.org/events/EventDetails.aspx?id=1951822) [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/73314a3e-da5b-23f8-8ce9-56b2e1ef25da.png)](https://event.on24.com/wcc/r/5028396/115A7558FC4035359FDF996AAFD7BEA4) [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/0d00f4b9-bb32-1804-3077-402e2f978e01.png)](https://us02web.zoom.us/webinar/register/7817597702831/WN_FaDiDJpmTrmoFwSKBmVNeA#/registration) [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/8456e5fe-4c2e-a285-2dbb-280a6777ac0b.png)](https://register.gotowebinar.com/register/1173269515288725598) ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/cfd97936-cc54-e9f4-d8ad-5f0914c6c872.jpg) The [Global Insurance Fraud Summit](https://globalinsurancefraudsummit.org/) is continuing its work to fight insurance fraud globally. There are a several ways for our members to participate and become a part of the work the GIFS is doing: - Register to receive information about the GIFS and attend their Report to the Nations conducted in June of each year by using this [link](https://globalinsurancefraudsummit.org/membership/become-a-member/) to establish your membership log-in credentials. - Once you are approved, you are then invited to create your own professional profile on the [Global Insurnace Fraud Directory](https://globalinsurancefraudsummit.org/membership/gifs-directory-consent/). This is the first-ever world-wide listing of insurance fraud professionals. Only viewable by registered members of the GIFS, the Directory is open to all anti-fraud professionals including insurers, regulators, law enforcement and professional service providers. - This year's [Global Summit](https://globalinsurancefraudsummit.org/2025-global-insurance-summit/) will be in Toronto Canada from October 19-22. Attendance at the Summit is by invitation only. If you are interested in being a part of this, or future, Global Summits you are welcome to submit an [application](https://globalinsurancefraudsummit.org/get-involved/summit-registration/). Summit sponsorships are still available which include 2 complimentary registrations. To find out more about becoming a sponsor just send an email to <director@globalfraud.org>. \| \| \| \| \| \|:-:\|---\| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7e6cccc1-3a5e-4803-a7f8-7325e7e155cb.gif) \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7e6cccc1-3a5e-4803-a7f8-7325e7e155cb.gif) \| ![](images/spacer.gif) \| \| \|:-:\| \| \| | |:-:| | \| \| \| FACES OF FRAUD \| \|---\|:--\| \| \| \| \| \| \| \| [![](https://via.placeholder.com/125x166)](https://www.tn.gov/finance/news/2020/9/28/davidson-co--woman-charged-with-tenncare-fraud.html) \| \| \| \| [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/0cdc6cb1-0b96-e4e5-e793-cf9b992c1495.png)](https://www.kplctv.com/2025/10/06/kinder-man-charged-with-arson-insurance-fraud/) **Noah Lawrence Moncla** Lake Charles, La, Auto arson *ARRESTED* \| \| \| \| [![](https://via.placeholder.com/125x166)](https://www.southwesttimes.com/2020/09/false-scripts-bills-send-doctor-to-prison/) \| \|:-:\|---\|:-:\| \| \| \| [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/15ce38ef-6271-11d6-2656-27c5b891df81.png)](https://www.scottsdale.org/city_news/billion-dollar-insurance-fraudster-gets-15-years/article_e036c599-75a1-4ea3-bead-f259c6c4a40f.html) **Alexandra Gehrke** Scottsdale, Ariz. Medicare/Medicaid *SENTENCED* \| \| \|:-:\| \| \|:-:\| \| \| \| [![](https://via.placeholder.com/125x166)](https://www.timesrepublican.com/news/todays-news/2020/09/mpd-handles-multiple-burglaries-1-arrested/) \| \|:-:\| \| \| \| [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7a3faa9b-27fe-f44f-7481-3d85c3fc1c9b.png)](https://people.com/steven-mcbee-sr-facing-3-years-prison-crop-fraud-case-11827415) **Steven McBee Sr.** Gallatin, Miss. Crop fraud *SENTENCE PENDING* \| \| \| \| [![](https://via.placeholder.com/125x166)](https://www.wmbfnews.com/2020/09/22/longs-woman-arrested-accused-forging-prescriptions/) \| \|:-:\|---\|:-:\| \| \| \| [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/060e71e9-1bc5-13ea-a8ec-b9317a97d6a6.png)](https://iol.co.za/news/crime-and-courts/home-affairs-employee-guilty-of-faking-deaths-for-insurance/) **Dawn Celeste Pieterson** Calvinia, South Africa Life insurance *CONVICTED* \| \| \|:-:\| \| \|:-:\| \| \|---\| \| \|:-:\| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7e6cccc1-3a5e-4803-a7f8-7325e7e155cb.gif) \| \| \| \| \| \|:-:\|---\| | |:-:| | \| \| \| EVENTS \| \|---\|:--\| \| \| \| \| **October 14-16 —** [**Medical Investigations Symposium**](https://www.nicb.org/news/events/medical-investigations-symposium) Virtual (NICB) \| \| \| \| \|:--\| \| \| **October 15 — [OSINT Live](https://www.skopenow.com/osint-live)** Virtual (Skopenow) \| \| \| \| \|:--\| \| \| **October 16 — [Workers' Compensation Premium Fraud and the Intersection to Auto Insurance Fraud and Other Crimes](https://us02web.zoom.us/webinar/register/WN_P4vHP_CFTASvEqIfUZ5O-Q)** Webinar (Coalition Against Insurance Fraud) \| \| \| \| \|:--\| \| \| **October 19-22 —** [**2025 Global Insurance Fraud Summit**](https://globalinsurancefraudsummit.org/2025-global-insurance-summit/) Toronto, Canada (GIFS) \| \| \| \| \|:--\| \| \| **October 22 — [Staged Auto Accidents](https://event.on24.com/wcc/r/5028396/115A7558FC4035359FDF996AAFD7BEA4)** Webinar (Ethos) \| \| \| \| \|:--\| \| \| **October 23 — [AI: Friend or Foe?](https://us02web.zoom.us/webinar/register/7817597702831/WN_FaDiDJpmTrmoFwSKBmVNeA#/registration)** Webinar (Diligence) \| \| \| \| \|:--\| \| \| **October 28 — [The Fraud Factor](https://www.surveymonkey.com/r/PNNRW2P?j=6791105&e=EML-CSV-ContactCenter@nysif.com&l=35226_HTML&u=368063469&mid=7205125&jb=0)** Buffalo, N.Y. (NYSIF) \| \| \| \| \|:--\| \| \| **October 28 — [OH/PA/WV Joint Fall Training Seminar](https://www.iasiu.org/events/EventDetails.aspx?id=1951822)** Virtual (IASIU) \| \| \| \| \|:--\| \| \| **November 4 — [SCFIA 47th Annual Anti-Fraud Conference](https://scfia.starchapter.com/meetinginfo.php?id=77&ts=1755230802)** Downey, Calif. (SCFIA) \| \| \| \| \|:--\| \| \| **November 19 — [The Hidden Threat: Synthetic Identities & Account Takeovers in Modern Fraud](https://www.iasiu.org/events/EventDetails.aspx?id=1976262)** Webinar (IASIU) \| \| \| \| \|:--\| \| \| **December 2-3 — [Coalition Annual Meeting](https://insurancefraud.org/coalition-annual-membership-meeting/) Arlington, VA. (Coalition Against Insurance Fraud)** \| \| \| \| \|:--\| \| \| \|:-:\|---\| | |:-:| | \| \| \| FRAUD NEWS FRIDAY \| \|---\|:--\| \| \| \| \| \* [**Insurance application lands Chester Township man before district judge**](https://www.delcotimes.com/2025/10/09/insurance-application-lands-chester-township-man-before-district-judge/) \* **[Hartley couple jailed for insurance fraud](https://www.nwestiowa.com/news/hartley-couple-jailed-for-insurance-fraud/article_0b1e9b5d-000a-48b0-8ff1-64096b2dd2ba.html)** \* **[IRDAI directs insurers to adopt a board-approved anti-fraud policy](https://www.thehindubusinessline.com/money-and-banking/irdai-directs-insurers-to-adopt-a-board-approved-anti-fraud-policy/article70147943.ece)** \* **[Blockchain in Insurance Market Set to Reach USD 82.56 Billion by 2033](https://www.globenewswire.com/news-release/2025/10/10/3164904/0/en/Blockchain-in-Insurance-Market-Set-to-Reach-USD-82-56-Billion-by-2033-Driven-by-Demand-for-Secure-and-Transparent-Processes-Research-by-SNS-Insider.html)** \* [**Mumbai Trader Gets Four Years In Jail For Faking Fire To Claim Insurance**](https://www.outlookmoney.com/insurance/mumbai-trader-gets-four-years-in-jail-for-faking-fire-to-claim-insurance) \| \| \| \| \|:--\| \| \| \| \| \| \| \|:--\| \| \| \|:-:\|---\| | |:-:| | \| \| \| \| \|---\|---\| \| \| \| \| Connect with Us: \| \| \| [![FB](https://mcusercontent.com/a440c5b647697de580a2fd586/images/ef66a2aa-ea17-4447-95b6-ad328c555988.png)](https://www.facebook.com/insurancefraud) \| \| [![TW](https://mcusercontent.com/a440c5b647697de580a2fd586/images/43f8397b-2f36-4358-87e9-549e6d9b749b.png)](https://twitter.com/insurance_fraud) \| \| [![YT](https://mcusercontent.com/a440c5b647697de580a2fd586/images/c202c8ca-32dc-49b1-a471-9669d36f946e.png)](https://www.youtube.com/user/stopinsurancefraud) \| \| [![IN](https://mcusercontent.com/a440c5b647697de580a2fd586/images/0cb8e5d8-9435-49a5-91b2-1a214a5f2fa0.png)](https://www.linkedin.com/groups/3856550) \| \| \|:-:\| \| [![Coalition Against Insurance Fraud](https://mcusercontent.com/a440c5b647697de580a2fd586/images/539d436e-d608-44a9-ba5e-b64d3a1ddd06.png)](https://www.insurancefraud.org) \| \| \|:-:\| \| Contact: \| \|:--\| \| Phone: [202.393.7330](tel:2023937330) Email: <info@insurancefraud.org> Address: 1012 14th Street NW Suite 610 Washington DC 20005 [www.InsuranceFraud.org](http://www.insurancefraud.org/) \| \| \|---\| \| \|:-:\| \| \| \| \| \|:-:\|---\| | |:-:| | | |---| | \| \| You are receiving this email because either your organization is a member of the Coalition Against Insurance Fraud or you requested to be placed on our mailing list. [Unsubscribe](https://insurancefraud.us1.list-manage.com/unsubscribe?u=a440c5b647697de580a2fd586&id=b68dce7808&t=b&e=%5BUNIQID%5D&c=78c6c0d76d) [<< Test Email Address >>](%3C%3C%20Test%20Email%20Address%20%3E%3E) from this list. Our mailing address is: Coalition Against Insurance Fraud1012 14th St NW Ste 610 Washington, DC 20005-3424 [Add us to your address book](https://insurancefraud.us1.list-manage.com/vcard?u=a440c5b647697de580a2fd586&id=b68dce7808) Copyright (C) 2025 Coalition Against Insurance Fraud All rights reserved. [Forward this email to a friend](https://us1.forward-to-friend.com/forward?u=a440c5b647697de580a2fd586&id=78c6c0d76d&e=%5BUNIQID%5D) [Update your profile](https://insurancefraud.us1.list-manage.com/profile?u=a440c5b647697de580a2fd586&id=b68dce7808&e=%5BUNIQID%5D&c=78c6c0d76d) \| \| \|:-:\| | |:-:| <html><p class="wp-block-paragraph"></p> **Features:** Fraud News Weekly --- ### [Fraud News Weekly - October 3, 2025](https://insurancefraud.org/publications/fraud-news-weekly-october-3-2025/) **Published:** October 3, 2025 **Author:** Coalition Against Insurance Fraud **Content:** New GenAI Study Available Now, Upcoming Coalition Webinar-Register Today, States Lead On AI Oversight As Federal Guidance Evolves | \| \| \|:-:\| \| Friday, October 3, 2025 \| \| \| | |:-:| | \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/df906857-d727-9ee9-0397-2a09caac30a4.png) \| \|:-:\| \| \| \| \| \| \|:-:\| | |:-:| | \| [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/a1492a86-29b0-90b6-d879-527e5492037e.png)](https://www.facebook.com/profile.php?id=61579225779934) \| \|:-:\| \| \| \| \| \| \| [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/d2bd23eb-8810-4f7a-49d3-d2fe7aa1891e.png)](https://www.instagram.com/stopinsurancefraud/)[![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/be4e5708-bdc4-c0df-6c03-a6ebd5b34c13.png)](https://www.linkedin.com/company/coalition-against-insurance-fraud) \| \| \| \| \| \|:-:\|---\| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7e6cccc1-3a5e-4803-a7f8-7325e7e155cb.gif) \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7e6cccc1-3a5e-4803-a7f8-7325e7e155cb.gif) \| ![](images/spacer.gif) \| \| \|:-:\| \| \| | |:-:| | \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/00ed7ac4-bb10-4f87-9d66-746db8688e48.png) \| \|:-:\| \| \| \| \| \| \| **![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/ef764c72-0d72-65f4-400b-11fbd02b83c1.png)** **Federal court upholds Iowa law stopping roofers in the Hawkeye State from acting as public adjusters.** **A federal judge has [upheld](https://www.desmoinesregister.com/story/news/crime-and-courts/2025/09/25/iowa-roofers-insurance-adjusters-lawsuit-dismissed-shamrock-roofing/86311054007/) Iowa’s law barring roofing contractors from directly negotiating with insurance companies, reinforcing the state’s crackdown on unlicensed public adjusting.** U.S. District Judge Rebecca Goodgame Ebinger dismissed a roofing company's challenge, ruling the law regulates professional conduct, not protected speech. The Iowa Insurance Division has actively enforced the statute, issuing more than 70 warning letters and multiple cease-and-desist orders against contractors accused of acting as unlicensed adjusters. The roofing company, which operates in several states with looser standards, argued the law unfairly restricted its marketing and communications but the judge disagreed, stating, "*This law has a clear legitimate regulatory goal, and it is one reflected by the vast majority of states which have instituted similar laws.*" This outcome mirrors a 2024 Texas Supreme Court [decision](https://www.insurancejournal.com/news/southeast/2024/06/11/778845.htm), where justices upheld a similar law to ensure contractors remain distinct from licensed public adjusters. Together, the rulings highlight a broader trend: states are drawing firm lines between contractors and adjusters to prevent conflicts of interest, protect homeowners after disasters, and reduce opportunities for contractor-driven fraud. For Coalition members, these decisions underscore the importance of defending strong public adjuster licensing laws nationwide. **New York DFS superintendent transitions leadership.** The New York Department of Financial Services [announced](https://www.dfs.ny.gov/reports_and_publications/press_releases/pr202509291) that Superintendent Adrienne Harris will depart after a four‑year tenure, with Kaitlin Asrow, currently Executive Deputy Superintendent for Research and Innovation, serving as Acting Superintendent beginning October 18, 2025. Harris’s tenure included rebuilding DFS’s Insurance Fraud Unit, implementing AI guardrails in underwriting and pricing, and recovering over $725 million for consumers. As Asrow assumes leadership, she will continue advancing innovation and regulatory modernization, including oversight of emerging technologies, claims processing, and anti-fraud initiatives. Asrow said, “*I am humbled by the opportunity to continue working in service of New Yorkers under Governor Hochul’s leadership. I am committed to ensuring that New York remains the global financial capital, a leader in consumer protection, and a hub for responsible financial innovation*.” **States lead on AI oversight as federal guidance evolves, keeping fraud protections in focus.** A recent [article](https://www.route-fifty.com/artificial-intelligence/2025/09/stopping-federal-moratorium-empowers-states-continue-robust-tailored-ai-oversight/408381/?oref=rf-homepage-river) highlights how states are now moving forward with tailored AI oversight after the federal moratorium failed a few months ago. For insurance fraud fighters, this remains a critical development because AI continues to transform claims handling, underwriting, and fraud detection while new risks, including deepfakes, synthetic identities, and manipulated claim documentation become emerging threats. State insurance regulators’ work on AI through the NAIC includes developing regulatory principles, such as the “*Model Bulletin on the Use of Artificial Intelligence by Insurance Companies*” that 24 states have now implemented, with four other jurisdictions taking similar or related actions to protect consumers. The Coalition’s Government Affairs Committee is actively monitoring these developments and the Coalition and PwC's [recent study](https://insurancefraud.org/wp-content/uploads/2025-Generative-AI-Study.pdf) on *The Impact of Generative AI on the Insurance Fraud Ecosystem* revealed how fraud fighters are leveraging this tool to combat these threats and how fraudsters are also using it to commit fraud. \| \| \| \| \| \|:-:\|---\| \| \|:-:\| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7e6cccc1-3a5e-4803-a7f8-7325e7e155cb.gif) \| \| \| | |:-:| | \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/68807164-2e16-1495-1d0d-98e30b545813.png) \| \|:-:\| \| \| \| \| \| \| **![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/5a627343-d15a-9c21-8368-98a83a5414bb.png) The Coalition Against Insurance Fraud is excited to release this [groundbreaking ](https://insurancefraud.org/wp-content/uploads/2025-Generative-AI-Study.pdf) [study](https://insurancefraud.org/wp-content/uploads/2025-Generative-AI-Study.pdf) with PwC on the role of generative artificial intelligence (GenAI) in the insurance fraud ecosystem. This research is unique in that it takes a two-fold approach.** It examines how the industry is leveraging GenAI to prevent, detect, investigate, and prosecute fraud, while also exploring how fraudsters are beginning to exploit the technology to carry out increasingly sophisticated insurance fraud schemes. We are deeply grateful to PwC for their collaboration and expertise in bringing this important research to fruition as their analysis and contributions were instrumental to the development of the findings presented in this report. Looking ahead, the Coalition is committed to making certain these insights are communicated beyond the insurance community. As part of our advocacy efforts, we will be sharing the findings with leading AI companies and policymakers to underscore the urgent and critical need for AI providers to implement guardrails that safeguard their platforms from being misused to commit insurance fraud and other crimes. [You can read the study here](https://insurancefraud.org/wp-content/uploads/2025-Generative-AI-Study.pdf). **US university professor warns global healthcare fraud costs reach $850B.** Dr. Mohammed Ranavaya, a professor of medicine at Marshall University in the US, said on Saturday that “[*billions of dollars of insurance*” fraud occur every year](https://www.aa.com.tr/en/health/us-university-professor-warns-global-healthcare-fraud-costs-reach-850b/3701354), making it a significant global problem. “*Healthcare fraud is increasingly prevalent, and it is an issue that is worldwide,*" Dr. Ranavaya said during the 20th International Forensic Medicine Days, held in the Turkish resort city of Antalya, at the Foundation for Strengthening the Organization of Justice. The event, in its sixth day, brought together heads of forensic institutions, academics, members of the judiciary, criminal law experts, lawyers, and forensic specialists from 26 countries. During the panel, Ranavaya delivered a presentation on Fraud, Malingering, and Exaggerated Claims in Injury and Disability Cases in the US. He stressed on Saturday that fraud is a criminal offense and carries legal consequences. He explained that individuals may fabricate physical or psychological symptoms to gain financial benefits, avoid work or legal responsibility, or obtain medication. He noted: “*Producing fake symptoms is a form of fraud. … Exaggeration is common, and overstating your claim occurs quite often. Judges are really used to looking at the overstating of the claim. So, overstating a claim about full fabrication, whether intentionally or unintentionally, can be exaggeration if it is unintentional.*" **Better Business Bureau: Beware of health insurance scams.** Have you noticed an increase in unsolicited calls a week telling you there’s been a change in Medicare and wanting to be sure you're getting your correct benefits? You are not alone. Some callers actually purport to be from Medicare while others are from official-sounding but non-existent government agencies or other organizations. Many, maybe all, originate overseas. And the calls are likely to pick up when the Medicare open enrollment season starts on Oct. 15. The crooks may try to sell you an insurance plan that isn’t very good or they might use your Medicare number and other information to [bill Medicare for unnecessary products or services](https://www.jacksonsun.com/story/opinion/columnists/2025/10/01/better-business-bureau-beware-of-health-insurance-scams/86328779007/). Another involves peddling a medical discount plan as full coverage health insurance. You pay for discounts on specific medical services or products that may or may not be as good as advertised, but such a plan isn’t a substitute for health insurance. Other health insurance scams the FTC warns about include scammers saying you need to pay a fee for a new Medicare card to retain your coverage or you need to pay a fee for help with the Health Insurance Marketplace. **Insurance Fraud Bureau unveils ambitious five-year anti-fraud roadmap.** The Insurance Fraud Bureau (IFB) has introduced Connected to Protect, a five-year strategy designed to address member needs and [advance the industry’s approach to combating insurance fraud](https://www.insurancebusinessmag.com/uk/news/breaking-news/insurance-fraud-bureau-unveils-ambitious-fiveyear-antifraud-roadmap-551868.aspx). The initiative aims to expand both the quantity and quality of data managed by the IFB, open new opportunities for the sector in the UK and internationally, and increase public awareness of insurance fraud. Connected to Protect comes at a time of heightened expectations from government and regulators, following the signing of the Insurance Fraud Charter, which was developed in line with the UK Economic Crime Strategy. The strategy builds on the IFB’s previous Forward Together 2023-25 plan and outlines objectives for the next five years. \| \| \| \| \| \|:-:\|---\| \| \|:-:\| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7e6cccc1-3a5e-4803-a7f8-7325e7e155cb.gif) \| \| \| | |:-:| | \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/bd099ba2-96e8-cf07-257c-1d3faf0782c7.png) \| \|:-:\| \| \| \| \| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/f73a0cca-3bd6-bab4-2fa6-53201b9a4798.jpg) **2 North Carolina women face fraud charges for staging U-Haul crash.** **April Montero and Deborah Brown, both from Gaston County, face felony counts of insurance fraud and conspiracy to commit fraud.** *The allegations:* Investigators say the pair staged a U-Haul accident on April 10. Brown was arrested Aug. 13 and held without bond. She was arrested earlier this year for [possession of a stolen vehicle](https://www.wcnc.com/article/news/crime/gastonia-woman-face-fraud-charges-u-haul-crash/275-57a1e133-e3d9-4805-84b1-b444af7a6708), breaking and entering, and failing to appear in court. Brown has convictions for drug charges and larceny in Lincoln County, according to court records. Montero was arrested Tuesday, Sept. 30 and received a $2,500 secured bond. She is due in Gaston County District Court on Oct. 21. **Former adjuster charged with creating then approving $190K in fake property claims.** John Philbin, a former New Jersey insurance adjuster has been charged with creating and submitting phony claims, approving them himself, and directing nearly $200,000 in payments to bank accounts he controlled. *The allegations:* Philbin was a property claims adjuster for Assurant Insurance Co. and had authority to approve insurance claims. From October 3, 2022, to May 22, 2023, Philbin allegedly knowingly created or caused to be created [11 fictitious claim files under false identities](https://www.insurancejournal.com/news/east/2025/10/03/842306.htm). According to prosecutors, he also fabricated vendor estimates and invoices purporting to reflect emergency mitigation or restoration work by non-existent companies. Philbin allegedly assigned the claims to himself and approved the claims under his individual authority. To facilitate the scheme, prosecutors maintain Philbin sed Post Office boxes in Clementon and Blackwood. Internal audit logs and document metadata bearing Philbin’s unique identifier allegedly linked him to the creation and approval of the fabricated documents. The insurer paid out approximately $191,163 on these fictitious claims … **Missouri AG charges St. Peters insurance agent with fraud.** This lawsuit follows an investigation into deceptive practices of Pamela Walsh, of J. Walsh Insurance, a now-closed agency owned by her husband. *The allegations:* From Aug. 2022 through Nov. 2024, Walsh sold commercial property insurance policies to [nine condominium associations but failed to actually obtain coverage](https://www.yahoo.com/news/articles/missouri-ag-charges-st-peters-200349889.html) or forward their premiums to insurance carriers, leaving them all uninsured. She also forged documents claiming to be real insurance policies, creating the false impression that the victims had coverage. In total, Walsh made more than $160,000 off the scheme, affecting more than 100 families in the state. Walsh faces nine counts of deceptive business practices, and nine counts of fraud in the sale of insurance. These crimes are punishable by up to 10 years in prison. **Bethel psychologist charged with Medicaid fraud.** Robert Vaillancourt of Bethel, Vermont, was arraigned yesterday on four counts of felony Medicaid Fraud. *The allegations:* The investigation, conducted by MFRAU and the Secretary of State’s Office of Professional Regulation, began after a referral was received from the Department of Vermont Health Access due to concerns with Mr. Vaillancourt’s overall therapeutic and billing practices. Mr. Vaillancourt had submitted claims for payment to Vermont Medicaid for psychotherapy sessions he had not provided, [defrauding Vermont Medicaid of over $600,000 in public health care funds](https://vermontbiz.com/news/2025/october/01/bethel-psychologist-charged-medicaid-fraud). Mr. Vaillancourt also failed to maintain patient records as agreed in his Medicaid Provider agreement and as required by state law and federal law. Mr. Vaillancourt pleaded not guilty at his arraignment yesterday in Vermont Superior Court, Windsor Criminal Division. The Court, Judge Elizabeth Mann presiding, ordered Mr. Vaillancourt released on his own recognizance on the condition that he present himself to Vermont State Police for fingerprinting within seven days. **Long island radiology company pleads guilty to federal healthcare fraud charges.** New York, Zwanger-Pesiri Inc., a Long Island radiology company, pleaded guilty to two counts of health care fraud for [illegally performing and billing for procedures that had not been ordered](https://www.justice.gov/usao-edny/pr/long-island-radiology-company-zwanger-pesiri-inc-pleads-guilty-federal-health-care) by treating physicians. After accepting the guilty plea, United States District Court Judge Joanna Seybert approved a settlement with the United States and the State of New York in which Zwanger-Pesiri agreed to forfeit $2.4 million in the criminal case and pay $8,153,727 million to resolve civil liability arising from its fraudulent practices. **Jury finds 2 police officers guilty of staging truck arson for insurance scam in Maryland.** Philip James Dupree is a former Fairmount Heights Police Department officer, while Mark Ross Johnson is a former Prince George’s County Police Department officer. Dupree and Johnson worked together on two separate fraud schemes. The schemes involved filing false police reports and falsifying loss claims to obtain funds from an insurance company and three financial institutions, per court documents. The first scheme took place in November 2018, when Dupree and Johnson orchestrated the burning of Johnson’s Ford F450 truck. While on duty, they arranged for [Dupree to "*discover*" the burning vehicle and filed a false impound report](https://foxbaltimore.com/news/local/ex-police-officers-convictedwire-fraud-wire-fraud-arson-and-bank-fraud-philip-james-dupree-pikesville-md-fairmount-heights-police-department-mark-ross-johnson-jr-38-camp-springs-md-prince-georges-county-police-department). Johnson used this report to claim a total loss from his insurer, who paid over $68,000 based on the fraudulent documentation. From May to June 2019, the pair, along with others, defrauded financial institutions by falsely claiming their debit cards were stolen and used for unauthorized ATM withdrawals. Dupree submitted a fake police report to support his claim, which included a non-existent officer's name and was never entered into the official records. \| \| \| \| \| \|:-:\|---\| \| \|:-:\| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7e6cccc1-3a5e-4803-a7f8-7325e7e155cb.gif) \| \| \| | |:-:| | \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/05ebd826-d3ed-4100-a4b0-7c83841fc259.png) \| \|:-:\| \| \| \| \| \| \| [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/03da373d-4ca2-80fc-b2c6-2ba03bd84dfc.png)](https://us02web.zoom.us/webinar/register/WN_P4vHP_CFTASvEqIfUZ5O-Q) \| \| \| \| \| \|:-:\|---\| \| \|:-:\| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7e6cccc1-3a5e-4803-a7f8-7325e7e155cb.gif) \| \| \| | |:-:| | \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/f8628f05-c69a-b49b-5c6b-325c1455059a.png) \| \|:-:\| \| \| \| \| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/34d1f340-93a8-03e8-65ff-99fd6a723e6d.png) \| \| \| \| \| \|:-:\|---\| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7e6cccc1-3a5e-4803-a7f8-7325e7e155cb.gif) \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7e6cccc1-3a5e-4803-a7f8-7325e7e155cb.gif) \| ![](images/spacer.gif) \| \| \|:-:\| \| \| | |:-:| | \| [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/35dcea9a-afd2-7a33-9f64-aeddb83147f4.png)](https://s.surveyplanet.com/3y6ssmr7) \| \|:-:\| \| \| \| \| \| \| [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/2ede82e9-7e14-3951-991f-3616bb74c3fd.png)](https://insurancefraud.org/coalition-annual-membership-meeting/) [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/1ce4a222-3707-daaf-86bf-d0078f1d7693.png)](https://s.surveyplanet.com/bj1sw6en) [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/6c8550d3-4d99-bc65-c8f8-cd1902423e17.png)](https://members.insurancefraud.org/general/pick_username.asp) ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/3ef40901-b851-f621-08b2-322f09ca8a57.png) [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/e867e12b-34fe-a503-bbd9-6cd676fe1f1b.png)](https://event.on24.com/wcc/r/5076408/233AEF442E13CC7C633235CB7C77EDEB) ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/5b92c840-a0b2-1c66-7582-0e98eec55ba3.png) [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/73314a3e-da5b-23f8-8ce9-56b2e1ef25da.png)](https://event.on24.com/wcc/r/5028396/115A7558FC4035359FDF996AAFD7BEA4) [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/8456e5fe-4c2e-a285-2dbb-280a6777ac0b.png)](https://register.gotowebinar.com/register/1173269515288725598) ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/cfd97936-cc54-e9f4-d8ad-5f0914c6c872.jpg) The [Global Insurance Fraud Summit](https://globalinsurancefraudsummit.org/) is continuing its work to fight insurance fraud globally. There are a several ways for our members to participate and become a part of the work the GIFS is doing: - Register to receive information about the GIFS and attend their Report to the Nations conducted in June of each year by using this [link](https://globalinsurancefraudsummit.org/membership/become-a-member/) to establish your membership log-in credentials. - Once you are approved, you are then invited to create your own professional profile on the [Global Insurnace Fraud Directory](https://globalinsurancefraudsummit.org/membership/gifs-directory-consent/). This is the first-ever world-wide listing of insurance fraud professionals. Only viewable by registered members of the GIFS, the Directory is open to all anti-fraud professionals including insurers, regulators, law enforcement and professional service providers. - This year's [Global Summit](https://globalinsurancefraudsummit.org/2025-global-insurance-summit/) will be in Toronto Canada from October 19-22. Attendance at the Summit is by invitation only. If you are interested in being a part of this, or future, Global Summits you are welcome to submit an [application](https://globalinsurancefraudsummit.org/get-involved/summit-registration/). Summit sponsorships are still available which include 2 complimentary registrations. To find out more about becoming a sponsor just send an email to <director@globalfraud.org>. \| \| \| \| \| \|:-:\|---\| \| \|:-:\| \| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7e6cccc1-3a5e-4803-a7f8-7325e7e155cb.gif) \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7e6cccc1-3a5e-4803-a7f8-7325e7e155cb.gif) \| ![](images/spacer.gif) \| \| \|:-:\| \| \| | |:-:| | \| \| \| FACES OF FRAUD \| \|---\|:--\| \| \| \| \| \| \| \| [![](https://via.placeholder.com/125x166)](https://www.tn.gov/finance/news/2020/9/28/davidson-co--woman-charged-with-tenncare-fraud.html) \| \| \| \| [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/9e336d3e-4061-6ad0-791f-5ac595baf81a.png)](https://www.johnstoniannews.com/news/clayton-man-charged-with-insurance-fraud-0b6c6cac) **Craig Bourgeois** Raleigh, N.C. Insider agent *ARRESTED* \| \| \| \| [![](https://via.placeholder.com/125x166)](https://www.southwesttimes.com/2020/09/false-scripts-bills-send-doctor-to-prison/) \| \|:-:\|---\|:-:\| \| \| \| [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/5ede8cfe-dee0-c1c5-4952-ea27eefecb1d.png)](https://www.wmbfnews.com/2025/09/29/dog-abuse-suspect-accused-pet-insurance-fraud-horry-county/) **Steven Tolsinao** Horry County, S.C. Pet insurance *ARRESTED* \| \| \|:-:\| \| \|:-:\| \| \| \| [![](https://via.placeholder.com/125x166)](https://www.timesrepublican.com/news/todays-news/2020/09/mpd-handles-multiple-burglaries-1-arrested/) \| \|:-:\| \| \| \| [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/1b5b4a51-c06c-76ec-869b-59790da0d81d.png)](https://community.triblive.com/c/monroeville-times-express/news/3889888) **Chad G. Skena** Monroeville, Penn. Insider agent *ARRESTED* \| \| \| \| [![](https://via.placeholder.com/125x166)](https://www.wmbfnews.com/2020/09/22/longs-woman-arrested-accused-forging-prescriptions/) \| \|:-:\|---\|:-:\| \| \| \| [![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/76f391ce-bf10-d477-ab73-e91205acd2d1.png)](https://insurancefraud.org/report-fraud/) \| \| \|:-:\| \| \|:-:\| \| \|---\| \| \|:-:\| \| ![](https://mcusercontent.com/a440c5b647697de580a2fd586/images/7e6cccc1-3a5e-4803-a7f8-7325e7e155cb.gif) \| \| \| \| \| \|:-:\|---\| | |:-:| | \| \| \| EVENTS \| \|---\|:--\| \| \| \| \| **October 14-16 —** [**Medical Investigations Symposium**](https://www.nicb.org/news/events/medical-investigations-symposium) Virtual (NICB) \| \| \| \| \|:--\| \| \| **October 14-16 — [Vehicle Fraud & Crime Conference](https://www.nicb.org/news/events/medical-investigations-symposium)** Virtual (NICB) \| \| \| \| \|:--\| \| \| **October 19-22 —** [**2025 Global Insurance Fraud Summit**](https://globalinsurancefraudsummit.org/2025-global-insurance-summit/) Toronto, Canada (GIFS) \| \| \| \| \|:--\| \| \| **October 22 — [Staged Auto Accidents](https://event.on24.com/wcc/r/5028396/115A7558FC4035359FDF996AAFD7BEA4)** Webinar (Ethos) \| \| \| \| \|:--\| \| \| **October 28 — [OH/PA/WV Joint Fall Training Seminar](https://www.iasiu.org/events/EventDetails.aspx?id=1951822)** Virtual (IASIU) \| \| \| \| \|:--\| \| \| **November 4 — [SCFIA 47th Annual Anti-Fraud Conference](https://scfia.starchapter.com/meetinginfo.php?id=77&ts=1755230802)** Downey, Calif. (SCFIA) \| \| \| \| \|:--\| \| \| **November 19 — [The Hidden Threat: Synthetic Identities & Account Takeovers in Modern Fraud](https://www.iasiu.org/events/EventDetails.aspx?id=1976262)** Webinar (IASIU) \| \| \| \| \|:--\| \| \| **December 2-3 — [Coalition Annual Meeting](https://insurancefraud.org/coalition-annual-membership-meeting/) Arlington, VA. (Coalition Against Insurance Fraud)** \| \| \| \| \|:--\| \| \| \|:-:\|---\| | |:-:| | \| \| \| FRAUD NEWS FRIDAY \| \|---\|:--\| \| \| \| \| \* **[Kouri Richins files to reconsider release after witness recants statement](https://www.abc4.com/richins/kouri-richins-witness-recants-statements/amp/)** \* **[Insurance and Auto Software Breaches Put Over 2 Million at Risk](https://the420.in/allianz-motility-data-breach-insurance-car-dealerships/)** \* **[Parents tempted by illegal ‘fronting’ to cut car insurance costs](https://www.which.co.uk/news/article/parents-tempted-by-illegal-fronting-to-cut-car-insurance-costs-aWygR9J1Z72c)** \* **[Official convicted of faking deaths to claim insurance payouts](https://www.kaya959.co.za/news/insurance-fraud-at-home-affairs-official-convicted-of-faking-deaths-to-claim-insurance-payouts/)** \* [**Gang kills physically challenged man, sets up accident to claim insurance**](https://www.thehawk.in/news/india/gang-kills-physically-challenged-ktaka-man-sets-up-accident-scene-to-claim-rs-520-crore-insurance) \| \| \| \| \|:--\| \| \| \| \| \| \| \|:--\| \| \| \|:-:\|---\| | |:-:| | \| \| \| \| \|---\|---\| \| \| \| \| Connect with Us: \| \| \| [![FB](https://mcusercontent.com/a440c5b647697de580a2fd586/images/ef66a2aa-ea17-4447-95b6-ad328c555988.png)](https://www.facebook.com/insurancefraud) \| \| [![TW](https://mcusercontent.com/a440c5b647697de580a2fd586/images/43f8397b-2f36-4358-87e9-549e6d9b749b.png)](https://twitter.com/insurance_fraud) \| \| [![YT](https://mcusercontent.com/a440c5b647697de580a2fd586/images/c202c8ca-32dc-49b1-a471-9669d36f946e.png)](https://www.youtube.com/user/stopinsurancefraud) \| \| [![IN](https://mcusercontent.com/a440c5b647697de580a2fd586/images/0cb8e5d8-9435-49a5-91b2-1a214a5f2fa0.png)](https://www.linkedin.com/groups/3856550) \| \| \|:-:\| \| [![Coalition Against Insurance Fraud](https://mcusercontent.com/a440c5b647697de580a2fd586/images/539d436e-d608-44a9-ba5e-b64d3a1ddd06.png)](https://www.insurancefraud.org) \| \| \|:-:\| \| Contact: \| \|:--\| \| Phone: [202.393.7330](tel:2023937330) Email: <info@insurancefraud.org> Address: 1012 14th Street NW Suite 610 Washington DC 20005 [www.InsuranceFraud.org](http://www.insurancefraud.org/) \| \| \|---\| \| \|:-:\| \| \| \| \| \|:-:\|---\| | |:-:| | | |---| | \| \| You are receiving this email because either your organization is a member of the Coalition Against Insurance Fraud or you requested to be placed on our mailing list. [Unsubscribe](https://insurancefraud.us1.list-manage.com/unsubscribe?u=a440c5b647697de580a2fd586&id=b68dce7808&t=b&e=%5BUNIQID%5D&c=41bde77c99) [<< Test Email Address >>](%3C%3C%20Test%20Email%20Address%20%3E%3E) from this list. Our mailing address is: Coalition Against Insurance Fraud1012 14th St NW Ste 610 Washington, DC 20005-3424 [Add us to your address book](https://insurancefraud.us1.list-manage.com/vcard?u=a440c5b647697de580a2fd586&id=b68dce7808) Copyright (C) 2025 Coalition Against Insurance Fraud All rights reserved. [Forward this email to a friend](https://us1.forward-to-friend.com/forward?u=a440c5b647697de580a2fd586&id=41bde77c99&e=%5BUNIQID%5D) [Update your profile](https://insurancefraud.us1.list-manage.com/profile?u=a440c5b647697de580a2fd586&id=b68dce7808&e=%5BUNIQID%5D&c=41bde77c99) \| \| \|:-:\| | |:-:| <html><p class="wp-block-paragraph"></p> **Features:** Fraud News Weekly --- ### [FraudBlog: Inevitable Convergence between Cybersecurity and Fraud fighting in the Future of Insurance](https://insurancefraud.org/publications/fraudblog-inevitable-convergence/) **Published:** January 30, 2024 **Author:** Coalition Against Insurance Fraud **Content:** ![](https://insurancefraud.org/wp-content/uploads/MAXIE-BLOG-HEADER-YELLOW-1024x297.png)By Maxence Bizien \| January 30, 2024 The digital revolution has become a priority in insurers’ strategies, marked by the proliferation of mobile applications and the creation of client spaces to facilitate remote interactions. Despite initial, occasionally unsuccessful forays into big data and artificial intelligence, insurance companies are shifting towards more pragmatic solutions while maintaining a constant drive towards digital transformation. Simultaneously, securing information systems has become an unavoidable focus, though maturity levels vary significantly among businesses, with smaller entities struggling to adopt best practices. Enhancing risk management mechanisms, including control processes, heightened threat detection, and vulnerability correction, is crucial. The absence of regular testing of business continuity plans and significant reliance on outsourcing amplify risks. Fraudsters have belatedly targeted the insurance sector but are at the forefront of exploiting the growing digitization to carry out various scams. Identity theft is becoming more frequent, and anti-fraud services recognize that a successful fraud begins as early as the subscription process. The retrieval of login credentials through collusion, deception, or the exploitation of security vulnerabilities is also on the rise. Illegitimate penetration into client spaces is now a primary objective for fraudsters, enabling them to alter bank account numbers, emails, and phone numbers, creating fake claims and seeking reimbursement through false invoices or the total or partial reimbursement of saved capital. The current impact of these frauds is limited, as companies benefit from interruptions in insurance processes based on distribution channels, product types, and each company’s specificities. While omnichannel integration is not fully achieved due to a gradual sector concentration, insurance digitization is rapidly advancing, accentuating the cyber risk. Given these observations, it seems time for IT security and anti-fraud teams to enhance their collaboration or even develop joint programs. Beyond cooperation, the inevitable convergence of efforts appears on the horizon, driven by increasing digitization and the sophistication of fraud schemes. Illegitimate access to client spaces becomes a challenge for IT security and insurers’ core business. Automated monitoring of behaviors, devices, and situational changes is more crucial than ever, especially when facing not just ordinary fraudsters but also bots. Early detection facilitates damage avoidance, with artificial intelligence and machine learning contributing significantly to the security of anti-fraud and cyber risk domains while safeguarding clients’ personal data. The traces left by fraudsters will require preservation in case of disputes. Beyond detection, investigation often becomes imperative, demanding multidisciplinary skills in cyber and anti-fraud domains. A holistic approach is preferable to anticipate the fight against future insurance fraud. Risks are interconnected, and who knows, the contribution of information systems security to combating insurance fraud could become a major lever for insurance company IT directors to fund the enterprise’s information security. ***The author*** Maxence Bizien has started his career in 2002 as assistant in the security and information protection division for a french defence and security company. In 2003, he is urban security consultant for the prefecture of Southern Corsica. He joined a facility management group in 2004 to initiate the concept of « outsourced Security Manager » for sensitive customers. During 11 years within the Insurer Generali France, he successively having held the position of Head of Security and Risk and Compliance manager leading the insurance counter fraud strategy and the special investigation unit. Since march 2018, he runs ALFA, the french professional non-for-profit organization fighting against insurance fraud. ALFA is directly linked with the French Insurance Federation (France Assureurs). **Topics:** Coalition Against Insurance Fraud **Features:** FraudBlog --- ### [FraudBlog: Unmasking Auto Fraud: Cloning, Salvage, and Title Washing](https://insurancefraud.org/publications/fraudblog-unmasking-auto-fraud-cloning-salvage-and-title-washing/) **Published:** February 14, 2024 **Author:** Coalition Against Insurance Fraud **Content:** ![](https://insurancefraud.org/wp-content/uploads/George-Ripley-FRAUD-BLOG-Yellow-Bar-1024x297.png)By George Ripley, Donegal Insurance Group \| February 16, 2024 The automotive world, a realm of innovation and mobility, also harbors a darker side—auto fraud. This illegal practice takes on various forms, with vehicle cloning, salvage fraud, and title washing emerging as key players in this deceptive game. The impact extends beyond individual consumers, reaching deep into the pockets of insurance carriers. **1. Vehicle Cloning: A Twin Emerges** Vehicle cloning is basically creating an illegal twin for a car. It involves replicating a legitimate vehicle’s VIN. Criminals use this cloned identity to mask stolen or illicitly obtained cars, selling them to unsuspecting buyers. The consequences are twofold: innocent consumers unwittingly purchase stolen vehicles, and insurance carriers may find themselves dealing with false claims. The ripple effect on insurance carriers is substantial. Cloned vehicles often result in insurance claims for accidents or thefts, compounding financial losses for insurers. As carriers grapple with fraudulent claims, consumers, too, face the risk of legal entanglements and financial burdens stemming from their unknowing involvement with a cloned vehicle. **2. Salvage Fraud: The Phantom Resurrection** Salvage fraud involves breathing new life into vehicles deemed total losses due to accidents, floods, or other catastrophic events. Fraudsters go to great lengths to conceal a vehicle’s troubled history through extensive repairs. The impact is substantial for both consumers and insurance carriers alike. For consumers, buying a salvaged vehicle without knowledge of its past can lead to safety concerns and significant financial losses. Insurance carriers, on the other hand, face challenges in accurately assessing risks associated with salvaged vehicles. The potential for undetected damage may result in increased claims, driving up overall costs for insurers and, subsequently, consumer premiums. **3. Title Washing: The Art of Erasing History** Title washing involves manipulating a vehicle’s title to conceal its salvage or damage history. Fraudsters exploit loopholes in state regulations to erase negative information from a vehicle’s record, presenting it as clean and unsuspecting to potential buyers. The consequences of title washing penetrate through the insurance industry. Insurance carriers heavily rely on accurate vehicle titles to assess risk and determine premiums. When a title is washed, carriers may unknowingly insure vehicles with concealed issues, leading to higher claim payouts and increased financial strain. Consumers, unaware of the manipulated title, may find themselves caught in a web of insurance complications and unforeseen repair costs. The impact of auto fraud, specifically through vehicle cloning, salvage fraud, and title washing, extends far beyond individual consumers. Insurance carriers bear a significant burden, grappling with fraudulent claims, increased financial losses, and the challenge of accurately assessing risks. Heightened awareness, stringent regulations, and collaboration between consumers and insurers are essential in combating the menace of auto fraud and ensuring a safer, more transparent automotive landscape for all. Vin Verification is paramount to mitigating the effects of all three of these fraud schemes mentioned. For more information or specific questions about auto fraud, please contact your company’s SIU. ***About the author***: *George Ripley, CIFI, FCLS, ACLS, IAAI-FIT, PCLS, CVCS is the Manager, Claims – SIU for Donegal Insurance Group. A former homicide detective for the York (PA) City Police Department for 21 years, George Ripley joined the Donegal team three years ago. He manages Donegal’s SIU and all activities related to suspected fraud investigations across multiple lines of business, as well as oversees all investigative support services provided to our claims department. Additionally, George provides SIU fraud awareness training for claims staff, manages antifraud programs, and complies with yearly SIU reporting to Departments of Insurance.* **Topics:** Coalition Against Insurance Fraud **Features:** FraudBlog --- ### [Insurance Fraud Hall of Shame — 2021](https://insurancefraud.org/publications/insurance-fraud-hall-of-shame-2021/) **Published:** December 8, 2021 **Author:** Coalition Against Insurance Fraud **Content:** ![](https://insurancefraud.org/wp-content/uploads/Website-Postings-Fraud-Blog-JIFA-etc-1-1.svg)Mask up fast and hide while you can; a new set of viral spreaders have arrived. Let’s un-welcome the newest members of the ***Insurance Fraud Hall of Shame.*** Mask up fast and hide while you can; a new set of viral spreaders have arrived. Let’s un-welcome the newest members of the ***Insurance Fraud Hall of Shame.*** The No-Class of 2021 was chosen by the Coalition Against Insurance Fraud. The ***Shamers*** are this year’s most notorious convicted insurance fraud criminals. The barons of bleak crashed into trucks, drowned children, burned neighborhoods and mutilated women with scalpels– all to try and collectively steal nearly $700 million of insurance money. Yet these ***Shamers*** perform a backhanded public service. Their downfalls encourage honesty and break open the myth that insurance fraud is a victimless crime. People relate to true-life crime stories. Promoting the ***Shamers*** helps consumers better grasp insurance fraud as a public safety threat — and a financial drain that depletes all Americans by raising our premiums. Insurance fraud is the crime ***we*** all pay for. The ***Shamers*** also teach consumer deterrence: You’ll get convicted, lose your job, alienate your family, and enjoy years of cold jail cells. Is ruining your own life and others worth the risk? Let’s induct this shameful lot: --- #### **Freeway reign of error: Truckers framed for setup crashes** ##### *Wreck ring stalks truckers with dangerous freeway collisions; passengers lie they have whiplash* Busy freeways stretching around New Orleans were frightening ordeals for truckers passing through town. [Damian Labeaud ](#Damian-Labeaud)led a sprawling crime ring that maneuvered innocent big rig drivers into at least 40 sideswipes and collisions. Labeaud packed cars with passengers like motorized sardine cans. Then he and his cohorts staged the freeway crashes, claiming the innocent truckers were at fault. The passengers were unharmed, yet lied they had painful neck and back whiplash injuries. Many passengers were ghosts. They weren’t even in the cars, yet claimed they were hurt. Labeaud feasted on the truckers’ insurers with millions of dollars in dummied-up injury claims. Whiplash is a hard-to-prove soft-tissue injury. Unlike broken bones that can easily show up in X-rays, whiplash is easy to fake and hard for insurers to medically dispute. [Read More ↗](#Damian-Labeaud) ![](https://insurancefraud.org/wp-content/uploads/Hall-of-Shame-Webpage-images-3.svg) ![](https://insurancefraud.org/wp-content/uploads/Hall-of-Shame-Webpage-images-2.svg)--- #### **Hookah arson hoax ruins historic old neighborhood** ##### **Businesses closed, people lose homes as hookah bar owners ignite gasoline fire that shoots out of control** [Imad and Bahaa Dawara](#Imad-and-Bahaa-Dawara)’s flailing efforts to run a hookah bar had fizzled. They were $64,000 behind on rent, and feuding with their landlord. Their final bet to make money on the failed venture: torch the place for $750,000 of insurance money. The brothers botched insurance fraud even worse than they ran their hookah bar. The explosive gasoline fire ruined a scenic old neighborhood on Chestnut Street in the heart of Philadelphia’s historic district. Flames and smoke drove hundreds of people from their businesses and homes, killed pets and caused millions in damage. The Dawaras’ landlord had reached the end of his patience. Unpaid rent piled up, and the landlord also wouldn’t let them hire a DJ or use hookahs. So the brothers shuttered the bar, and the landlord permanently ejected them. [Read More ↗](#Imad-and-Bahaa-Dawara) --- #### **Father drives autistic kids off pier for life-insurance payday** ##### ***Straps helpless kids into back seat, sets up murders to look like accident*** Onlookers heard the tires screech as [Ali F. Elmezayen](#Ali-F.-Elmezayen)’s car sped down a commercial fishing wharf and shot into the harbor at Los Angeles. The Honda Civic quickly sank in 20-30 feet of murky salt water. Elmezayen swam out through the open driver-side window. His two autistic kids were tightly strapped in child seats. They never had a chance and drowned, still in their seats. Elmezayen also tried to drown his ex-wife. Rabab Diab couldn’t swim yet luckily she was rescued by fisherman after barely escaping through the car window. Elmezayen portrayed the wreck as a horrible accident. In fact it was stone-cold murder. Elhassan (age 13) and Abdelkrim (age 8) needed high levels of medical care, including state support. So the Egyptian native bought more than $7 million of life and accidental-death policies on himself, the kids’ lives and Diab. The accelerator pedal was his chance to cash in. His kids and wife were mere profit centers, not a family. [Read More ↗](#Ali-F.-Elmezayen) ![](https://insurancefraud.org/wp-content/uploads/Ali-F.-Elmezayen.svg) ![](https://insurancefraud.org/wp-content/uploads/Dr.-Javaid-Perwaiz.svg)--- #### **OB-GYN maims women with useless surgeries to steal $21 million** ##### ****Hysterectomies, botched surgeries, leave patients in chronic pain and permanently scarred**** Women trusted [Dr. Javaid Perwaiz](#Dr.%20Javaid%20Perwaiz), their tragically reassuring OB-GYN. Today, many former patients wrestle with consuming anger, betrayal and chronic pain. Perwaiz convinced them to have painful hysterectomies and other irreversible surgeries they didn’t need, maiming many for life. Perwaiz’s supercharged scalpel made him Ferrari-rich from nearly $21 million of dollars he received from false and inflated insurance billings. Fully 173 women reported unneeded surgeries under the Chesapeake, Va. OG-GYN’s supposed care. Perwaiz also botched many of the procedures; some women still suffer from chronic pain and other complications. Patients often were left with large scars as permanent reminders of his money-churning insurance scheme. [Read More ↗](#Javaid-Perwaiz) --- #### **Military insurer rifled for $510 million of worthless compound medicines** ##### *****Crime ring bills for overpriced tubes of creamy medicines that service members didn’t need or use***** Bland-looking tubes of creamy compound medicines were worth more than gold and diamonds to Wade Walters. His low-key pharmacy in Hattiesburg, Miss. began as the nerve center of a sprawling $510-million siphoning of health insurers — especially Tricare, the federal military insurer. Walters rapidly grew rich by hawking expensive and medically worthless compound medicines — mostly to young U.S. military service members around the U.S. who didn’t need the stuff. And hard-working taxpayers footed his insurance bills. Compound meds are flypaper for insurance fraud. They cost insurers much more than standard medicines. Ideally, compounds are hand-mixed and customized for each patient. That makes the stuff expensive — billed to insurers for thousands of dollars per tube. Targeting military members made sense to Walters. Military life can be hard and physical. So Walters’ fraud ring pureed compound pain and scar creams, and vitamin pills. For Tricare, the service members plausibly needed the medicines. More to the point, the glop was lucrative for Walters. Some pain creams, which contained ketamine or tramadol — both controlled substances — were falsely billed to Tricare and other insurers for up to $14,000 per tube. [Read More ](#Wade-Walters)[↗](#) ![](https://insurancefraud.org/wp-content/uploads/Wade-Walters.svg) ![](https://insurancefraud.org/wp-content/uploads/Melissa-Alvarez-Torres-Jose-Luis-Olmos-Hernandez.svg)--- #### **Pregnant Mexican women duped into buying fake maternity coverage** ##### ******Insurance scam imperils innocent women’s visa status, robs taxpayers****** More than 250 pregnant women from Mexico believed they bought affordable health insurance that let them legally give birth in the U.S., while covering the large maternity expenses. Instead the trusting women were foils for a scheme that stole premium dollars the lower-income women could scarcely afford to lose. The ruse also imperiled their U.S. non-resident visas — their lifelines to an income and better living. [Melissa Alvarez Torres and Jose Luis Olmos Hernandez](#Melissa-Alvarez-Torres-and-Jose-Luis-Olmos) set up the women, who’d hoped for their private slice of the American Dream. The San Diego-area duo lured the women into buying coverage for which they weren’t eligible. The goal: steal their hard-earned premium money. [Read More ↗](#Melissa-Alvarez-Torres-and-Jose-Luis-Olmos) --- #### **Crime ring peddles $78 million of unsafe, black-market drugs** ##### *******Prescription drugs stolen, resold to pharmacies despite unsafe storage, expiration******* Police raided a Miami-area house. They found a batch of prescription pills, seemingly being moved by a small-time drug ring. In fact, the basic search discovered a fast-growing criminal network that would balloon into a $78-million scheme that exploited a thriving black market for expensive prescription drugs around the U.S. [Joshua Ryan Joles](#Joshua-Ryan-Joles) was a key drug mover in the operation, which hauled in $78 million by reselling large volumes of stolen medicines for high-profit markups throughout the U.S. Life-giving drugs for HIV, cancer and psychiatric illnesses were the ring’s stock in trade. Thousands of bottles of potentially defective drugs ended in the hands of unknowing consumers. They had no idea their health was imperiled by drugs that often were expired, deliberately mislabeled, or decayed from unsafe storage. [Read More ↗](#Joshua-Ryan-Joles) ![](https://insurancefraud.org/wp-content/uploads/Hall-of-Shame-Webpage-images-814x1024.png) --- ## The *Shamers* **Damian Labeaud** Busy freeways stretching around New Orleans were frightening ordeals for truckers passing through town. Damian Labeaud led a sprawling crime ring that maneuvered innocent big rig drivers into at least 40 sideswipes and collisions. Labeaud packed cars with passengers like motorized sardine cans. Then he and his cohorts staged the freeway crashes, claiming the innocent truckers were at fault. The passengers were unharmed, yet lied they had painful neck and back whiplash injuries. Many passengers were ghosts. They weren’t even in the cars, yet claimed they were hurt. Labeaud feasted on the truckers’ insurers with millions of dollars in dummied-up injury claims. Whiplash is a hard-to-prove soft-tissue injury. Unlike broken bones that can easily show up in X-rays, whiplash is easy to fake and hard for insurers to medically dispute. ###### Piles up false, expensive lawsuits A personal-injury lawyer in cahoots with the ring knew the trucking firms were required to carry at least $1 million of insurance. The lawyers piled on large lawsuits, draining insurers for up to $200,000 apiece in false injury claims. In one setup wreck, Lois Russell, Tanya Givens and John Diggs teamed with passenger James “Curtis” Williams to stage a separate wreck with a tractor-trailer. Roderick Hickman drove Russell’s car. He rammed the 18-wheeler and fled with Labeaud in a getaway car. Russell lied to police that she drove the attack car. She made false injury claims, along with Givens and Diggs. Insurers paid out $272,500. In another case, four ring motorists sued after claiming a truck rammed them while turning into a truck stop. The driver and three passengers claimed no injuries in the police accident report. The report also cited only minor damage to the car — and not even a scratch on the truck. The officer even cited the car driver with two tickets and arrested her. Yet the driver and her passengers sued the trucker’s insurer nine months later. They claimed “severe and disabling injuries.” The case was settled out of court. ###### Unhurt, yet endure neck surgery Labeaud was just as active. He drove a Chevy Avalanche into a truck — yet claimed the trucker caused the wreck. Labeaud’s colluding attorney arranged bogus injury treatment for his “passengers” — some who weren’t even in the vehicle. Lucinda Thomas was unhurt, yet endured worthless neck surgery to increase her insurance take. The truck’s[ dashcam](https://www.facebook.com/insurancefraud/videos/551822425583502/) tipped off investigators, showing the entire bogus collision as it unfolded. That helped blow the lid off the ring, leading to the arrest of Labeaud and his crash cohorts. Many of the same ring members kept showing up in the same crashes and lawsuits, further fueling the months of investigations. Federal prosecutors methodically dismantled Labeaud’s ring in court. Most members now have criminal records. The Louisiana State Police played an invaluable role in the successful investigations. Labeaud will spend up to five years in federal prison when he’s sentenced. As he discovered to his dismay, insurance fraud was a freeway straight to jail. \*\*\*\*\* Ali F. Elmezayen Onlookers heard the tires screech as Ali F. Elmezayen’s car sped down a commercial fishing wharf and shot into the harbor at Los Angeles. The Honda Civic quickly sank in 20-30 feet of murky salt water. Elmezayen swam out through the open driver-side window. His two autistic kids were tightly strapped in child seats. They never had a chance and drowned, still in their seats. Elmezayen also tried to drown his ex-wife. Rabab Diab couldn’t swim yet luckily she was rescued by fisherman after barely escaping through the car window. Elmezayen portrayed the wreck as a horrible accident. In fact it was stone-cold murder. Elhassan (age 13) and Abdelkrim (age 8) needed high levels of medical care, including state support. So the Egyptian native bought more than $7 million of life and accidental-death policies on himself, the kids’ lives and Diab. The accelerator pedal was his chance to cash in. His kids and wife were mere profit centers, not a family. ###### Insurance money buys real estate, boat Elmezayen earned less than $30,000 a year in wages. Yet he somehow found the money to pay more than $6,000 of insurance premiums annually to keep the policies afloat. He frequently contacted the insurers, asking to confirm they wouldn’t investigate for fraud if he made the claims two years after buying the policies. That’s the time window that life insurers typically require for investigating deaths of insureds. So sure enough, Elmezayen raced his car off the pier just two years and 12 days after the policy purchases. He soon collected more than $260,000 on his dead sons’ lives. He used part of the money to buy real estate in Egypt, and a boat. Elmezayen garbled his stories when investigators questioned him after the kids died. He may have accidentally pressed the accelerator, he said. Or maybe he passed out from medicines he took for a blood disorder. Or maybe he fell prey to an “evil inside of me that pushed me to go.” ###### Killer wants a second wife At trial, prosecutors said Elmezayen beat Diab and phoned her parents in Egypt, “threatening to send her home in a coffin.” He’d “bury her alive” and take a second wife. His intentions were clear during a recorded call to an insurer. Elmezayen is heard in the background, speaking in Arabic with Diab. “May God compensate us for the kids. …” he said. “May God give us better than them.” The federal judge compensated Elmezayen with 212 years in prison. “These two boys deserved a loving father,” said U.S. Attorney Nick Hanna. “Instead they got a man who put his greed and self-interest above their lives.” \*\*\*\*\* Wade Walters Bland-looking tubes of creamy compound medicines were worth more than gold and diamonds to Wade Walters. His low-key pharmacy in Hattiesburg, Miss. began as the nerve center of a sprawling $510-million siphoning of health insurers — especially Tricare, the federal military insurer. Walters rapidly grew rich by hawking expensive and medically worthless compound medicines — mostly to young U.S. military service members around the U.S. who didn’t need the stuff. And hard-working taxpayers footed his insurance bills. Compound meds are flypaper for insurance fraud. They cost insurers much more than standard medicines. Ideally, compounds are hand-mixed and customized for each patient. That makes the stuff expensive — billed to insurers for thousands of dollars per tube. Targeting military members made sense to Walters. Military life can be hard and physical. So Walters’ fraud ring pureed compound pain and scar creams, and vitamin pills. For Tricare, the service members plausibly needed the medicines. More to the point, the glop was lucrative for Walters. Some pain creams, which contained ketamine or tramadol — both controlled substances — were falsely billed to Tricare and other insurers for up to $14,000 per tube. ###### Military service members bribed Walters’s fast-growing network included doctors, pharmacies, patient marketers and others. Marketers bribed hundreds of military service members to hand over their insurance information. They were covered by Tricare. In some cases, marketers convinced Marines they were joining a drug trial for pain and scar creams. Marines were paid about $300 in illegal cash kickbacks each month after handing over their insurance information for billing. Corrupt doctors prescribed the compound ointments without meeting the patients — or even determining if they needed the ointments. Ring members rigged prescriptions to ensure the highest possible insurance payouts. Pharmacies then mixed tubes of the medicines, and bottles of pills. The service members’ medical exams were forged to ensure the fraudulent bills fooled insurers. Tubes of compound medicine were repeatedly mailed to service members on a recurring basis. This maximized each prescription’s illicit insurance profits. Yet service members didn’t use the ointment, because they didn’t need it. Insurance money poured in. Walters’ scam rapidly expanded into a loosely built criminal network around the U.S. as word spread that compound medicines meant easy insurance money. ###### Patient paralyzed, in pain Leslie Cook had a severe reaction to a compounded vitamin pill she took. “It felt like I was vomiting blood,” said Cook. She was paralyzed and couldn’t speak when searing pain overtook her. Cook was alone at home for hours until her husband arrived and rushed her to the hospital. She later asked the pharmacist what was in the pills. They contained capsaicin, the ingredient that makes chili peppers hot. Needy military vets were victimized as well. Walters’ ring stole so much insurance money that Tricare was forced to reduce healthcare programs that vets depended on. Tricare even had to ask the feds for more money to operate at full strength. Justice finally caught up with Walters. He pled guilty, and streams of convictions have shelved other ring members. Walters was given 18 hard years in federal prison, and must repay more than $287 million. “My life has turned upside down,” Walters said. “I’ve embarrassed my family, my friends and my church family. I’m tired. I’m ready to move on and serve my time.” \*\*\*\*\* **Imad and Bahaa Dawara** Imad and Bahaa Dawara’s flailing efforts to run a hookah bar had fizzled. They were $64,000 behind on rent, and feuding with their landlord. Their final bet to make money on the failed venture: torch the place for $750,000 of insurance money. The brothers botched insurance fraud even worse than they ran their hookah bar. The explosive gasoline fire ruined a scenic old neighborhood on Chestnut Street in the heart of Philadelphia’s historic district. Flames and smoke drove hundreds of people from their businesses and homes, killed pets and caused millions in damage. The Dawaras’ landlord had reached the end of his patience. Unpaid rent piled up, and the landlord also wouldn’t let them hire a DJ or use hookahs. So the brothers shuttered the bar, and the landlord permanently ejected them. ###### Blaze flares out of control Their last hope of recouping their losses after screwing up: Insurance fraud. The Dawaras had been uninsured for years. Then they suddenly bought a $750,000 policy that covered accidental fires — just 16 days before their arson fire. And even though their club had closed its doors. They ignited a gasoline fire in the basement at 3 a.m. The combustible brew quickly flared out of control. Searing flames and menacing smoke rapidly flared through the neighborhood. Panicky business owners, hotel guests and apartment dwellers bolted for safety amid the fiery chaos. The blaze destroyed the Dawaras’ historic brick building, wrecking a treasured landmark. More than 400 firefighters had to combat the flames. Around 160 people were evacuated; some sought shelter in a city bus that was set up as a refuge. At least 10 pets died. The neighborhood remained shut down for months. The damage drove several restaurants out of business permanently. Many neighbors lost their homes. Guests in one neighborhood hotel were forced to evacuate in the middle of the night. They waited for days before they could return to retrieve their belongings. They found that most of their possessions were destroyed. Most of the hotel’s 25 employees lost their jobs. ###### Calls crippling fire merely a “mistake” The Dawaras’ rushed to pull down their false $750,000 claim — contacting their insurer the day after the blaze. The federal judge shared the community’s outrage after the Dawara were convicted. They each were handed nine years in prison, and must somehow repay $22 million. Bahaa showed little remorse in court. He merely called their ruinous insurance scheme a “mistake.” “You took gas and poured it into a basement. What did you think was going to happen? Mistake?” U.S. Chief District Judge Juan R. Sánchez shot back. “You were playing with fire and you never thought there was a threat to people, property and the life of the city? You think this was a mistake?” \*\*\*\*\* Dr. Javaid Perwaiz Women trusted Dr. Javaid Perwaiz, their tragically reassuring OB-GYN. Today, many former patients wrestle with consuming anger, betrayal and chronic pain. Perwaiz convinced them to have painful hysterectomies and other irreversible surgeries they didn’t need, maiming many for life. Perwaiz’s supercharged scalpel made him Ferrari-rich from nearly $21 million of dollars he received from false and inflated insurance billings. Fully 173 women reported unneeded surgeries under the Chesapeake, Va. OG-GYN’s supposed care. Perwaiz also botched many of the procedures; some women still suffer from chronic pain and other complications. Patients often were left with large scars as permanent reminders of his money-churning insurance scheme. ###### Phony cancer threats fool patients Perwaiz ran a hard-charging medical insurance fraud factory. He performed up to 30 surgeries a day. Staff could barely keep up with Perwaiz as he rushed from procedure to procedure. Cancer was imminent and Donna Ingram-Allen needed a hysterectomy right away, Perwaiz warned her. She chose to have her ovaries removed instead. When Ingram-Allen awoke in recovery, she discovered Perwaiz had inflicted a total abdominal hysterectomy. He also perforated her bladder. Ingram-Allen was rushed back to the hospital with blue skin, three days later. She’d developed a bad infection and was hospitalized for six days. She later obtained her medical files; they didn’t even mention precancerous cells. Angela Lee suffered from complications after a hysterectomy led to heavy bleeding. She was placed in an induced coma for days. Another patient says she can no longer use the bathroom normally after an unneeded hysterectomy. A patient Perwaiz treated for pregnancy problems discovered her fallopian tubes were “burnt down to nubs” without her knowledge or consent. She no longer can conceive naturally. Perwaiz also pressured patients to have permanent sterilizations, lying that the procedures were easily reversed. At least 33 pregnant women had early induced labor without a valid medical reason. Rushing their childbirths let Perwaiz deliver the babies on days he worked at the hospital — and thus would be paid by insurers. ###### Cons patients into repeated surgeries Many patients were lower-income Medicaid women who trusted Perwaiz’s medical diagnoses. Perwaiz persuaded them to keep having unneeded surgeries. Some came back every year, yet didn’t even know what surgeries he performed, or why. Perwaiz also billed insurers hundreds of thousands for diagnostic procedures he didn’t perform. Perwaiz even charged for hysteroscopies — used to view a woman’s uterus — yet his office scope was broken. Insurance money rolled in from Medicaid and private insurers. Perwaiz spent more than $2.3 million on credit card purchases. And he bought a fleet of luxury cars, including a Bentley, Jaguar, Mercedes and red Ferrari. Perwaiz’s samurai scalpel also bought him 59 years federal prison. The Virginia AG provided invaluable assistance in the case. “He doesn’t care about any of us. It was all about greed, money and a lavish lifestyle. That’s all he ever wanted,” former patient Anita Fuller said in court. \*\*\*\*\* Melissa Alvarez Torres and Jose Luis Olmos More than 250 pregnant women from Mexico believed they bought affordable health insurance that let them legally give birth in the U.S., while covering the large maternity expenses. Instead the trusting women were foils for a scheme that stole premium dollars the lower-income women could scarcely afford to lose. The ruse also imperiled their U.S. non-resident visas — their lifelines to an income and better living. Melissa Alvarez Torres and Jose Luis Olmos Hernandez set up the women, who’d hoped for their private slice of the American Dream. The San Diego-area duo lured the women into buying coverage for which they weren’t eligible. The goal: steal their hard-earned premium money. ###### Ads tout fake health insurance *Facebook* ads hawked phony maternity coverage. Torres and Hernandez promoted a bogus health insurance provider called Seguros Americanos Embarazo (American Pregnancy Insurance) to lure the women in. The women crossed into the U.S. mostly work or tourist visas. Alvarez and Hernandez lied that their so-called health plan was a safe and legal way to give birth, thus offering their babies U.S. citizenship by birthright. U.S. hospitals also were safer, some women with high-risk pregnancies also figured. So the victims believed they’d bought private pregnancy coverage. In fact, Torres and Hernandez secretly signed them up for Medi-Cal, the state-run health insurance plan. They lied that the women were California residents, and thus were eligible for a special Medi-Cal maternity healthcare program for working class women without health coverage. In truth, the Mexican women weren’t eligible for Medi-Cal because they were only in the U.S. on their visas. Torres and Hernandez harvested the sensitive personal information the women submitted from the false *Facebook* ads. ###### Pregnant woman reports scheme The pair also convincingly faked the documents needed to create the illusion the women were California residents. They invented fake addresses, elaborate tax and employment documents in the women’s names, and supporting letters from U.S. employers who hadn’t hired the women. One pregnant woman realized her purported health insurance was Medi-Cal, not the private insurance she was told she bought. The woman called authorities to report she was a fraud victim, then had her baby in Mexico. A state investigator looking into suspicious insurance applications knocked on doors in Imperial County to verify the women’s residences. That sleuthing prompted a call from a woman targeted by the scheme. She provided evidence that further helped break open the health ruse. Each faces up to 20 years in federal prison when sentenced, and must repay the stolen $1.5 million. So Torres and Hernandez now have their own piece of the American Dream — one that’s reserved for criminals. \*\*\*\*\* **Joshua Ryan Joles** Police raided a Miami-area house. They found a batch of prescription pills, seemingly being moved by a small-time drug ring. In fact, the basic search discovered a fast-growing criminal network that would balloon into a $78-million scheme that exploited a thriving black market for expensive prescription drugs around the U.S. Joshua Ryan Joles was a key drug mover in the operation, which hauled in $78 million by reselling large volumes of stolen medicines for high-profit markups throughout the U.S. Life-giving drugs for HIV, cancer and psychiatric illnesses were the ring’s stock in trade. Thousands of bottles of potentially defective drugs ended in the hands of unknowing consumers. They had no idea their health was imperiled by drugs that often were expired, deliberately mislabeled, or decayed from unsafe storage. ###### Steals from Medicare, Medicaid beneficiaries Joles convinced Medicare and Medicaid patients who filled their prescriptions at discounted prices to sell their medications to his network for extra spending money. He also acquired the expensive drugs by cargo theft and burglarizing pharmacies. Joles’ network soon spanned the U.S., disbursing drugs in Florida, Arizona, Delaware, Washington and Puerto Rico. It was the largest prescription drug ring South Florida had seen in recent years. Ring members picked up boxes of stolen black-market drugs by the hundreds in random parking lots or streets across South Florida. Ring members then repackaged the expensive medicines for resale to unwitting retail pharmacies and consumers. They removed the labels on drug bottles with lighter fluid and other chemicals. Then they forged new labels and glued them on to make the drugs seem fresh and legitimately obtained. In addition, they created phony paperwork saying the drugs came from mainstream wholesale suppliers. ###### Drugs stored in unsafe conditions Some drugs were past their expiration dates and stored in unsafe conditions. The operation also could be sloppy; one bottle contained pebbles instead of drugs. Joles sold his adulterated drugs to unwitting retail pharmacies that thought his medicine came from legitimate channels. His enticing wholesale prices — as much as 17% below normal wholesale rates — encouraged pharmacies to buy the drugs. The prices were low enough that pharmacies rushed to buy the drugs — though not low enough to appear suspicious. Sham wholesale companies run by Joles and a crony resold the drugs as fast the criminal network’s suppliers could re-package and supply them. They even used return addresses of unrelated lawful firms to further create the appearance of legitimacy. Fast-flowing money from the drug purchased was laundered through bank accounts. Joles pled guilty, and was re-packaged into federal prison with a 76-month sentence. He joins most of the other ring members in jail. “This scheme strikes at the peace of mind we should all feel when we buy prescription drugs from a pharmacy,” says U.S. Attorney Ariana Fajardo Orshan. “We all expect and should rest assured, knowing that the drugs we are buying are safe, effective, and properly stored and handled.” \*\*\*\*\* --- ##### **View current and previous *Hall of Shamers*: [2023](https://insurancefraud.org/publications/the-dirty-dozen-2023-hall-of-shame/), [2022](https://insurancefraud.org/publications/insurance-fraud-hall-of-shame-2022/),** [2020](https://insurancefraud.org/publications/insurance-fraud-hall-of-shame-2020/) --- ## Regulations ### [California-Mandatory Reporting-Cal Ins Code §1872.4 and §1877.3 Workers Compensation](https://insurancefraud.org/regulations/california-mandatory-reporting-cal-ins-code-§1872-4-and-§1877-3-workers-compensation/) **Published:** July 21, 2020 **Author:** Brent Walker **Content:** #### California Insurance Code DIVISION 1 – GENERAL RULES GOVERNING INSURANCE PART 2 – THE BUSINESS OF INSURANCE CHAPTER 12 – The Insurance Frauds Prevention Act ARTICLE 2 – Bureau of Fraudulent Claims [Section 1872.4.](https://law.justia.com/codes/california/code-ins/division-1/part-2/chapter-12/article-2/section-1872-4/) 1872.4. (a) Any company licensed to write insurance in this state that has determined, after the completion of the insurer’s special investigative unit investigation, that it reasonably suspects or knows an act of insurance fraud may have occurred or might be occurring shall, within 60 days after that determination by the insurer, send to the Fraud Division, on a form prescribed by the department, the information requested by the form and any additional information relative to the factual circumstances regarding the alleged insurance fraud and person or entity that may have committed or is committing insurance fraud, as specified in Section 2698.38 of Title 10 of the California Code of Regulations. The Fraud Division shall review each report and undertake further investigation it deems necessary and proper to determine the validity of the allegations. Whenever the commissioner is satisfied that fraud, deceit, or intentional misrepresentation of any kind has been committed in the submission of the claim, claims, application, or other insurance transaction, the commissioner shall report the violations of law to the insurer, to the appropriate licensing agency, and to the district attorney of the county in which the offenses were committed, as provided by Sections 12928 and 12930. If the commissioner is satisfied that fraud, deceit, or intentional misrepresentation has not been committed, the commissioner shall report that determination to the insurer. If prosecution by the district attorney concerned is not begun within 60 days of the receipt of the commissioner’s report, the district attorney shall inform the commissioner and the insurer as to the reasons for the lack of prosecution regarding the reported violations. (b) This section shall not require an insurer to submit to the Fraud Division the information specified in subdivision (a) in either of the following instances: (1) The insurer’s initial investigation indicated a potentially fraudulent claim but further investigation revealed that it was not fraudulent. (2) The insurer and the claimant have reached agreement as to the amount of the claim and the insurer does not have reasonable grounds to believe that claim to be fraudulent. (c) Nothing contained in this article shall relieve an insurer of its existing obligations to also report suspected violations of law to appropriate local law enforcement agencies. (d) Any police, sheriff, disciplinary body governed by the provisions of the Business and Professions Code, or other law enforcement agency shall furnish all papers, documents, reports, complaints, or other facts or evidence to the Fraud Division, when so requested, and shall otherwise assist and cooperate with the division. (e) If an insurer, at the time the insurer, pursuant to subdivision (a) forwards to the Fraud Division information on a claim that appears to be fraudulent, has no evidence to believe the insured on that claim is involved with the fraud or the fraudulent collision, the insurer shall take all necessary steps to assure that no surcharge is added to the insured’s premium because of the claim. *(Amended by Stats. 2022, Ch. 424, Sec. 21. (SB 1242) Effective January 1, 2023.)* #### California Insurance Code DIVISION 1 – GENERAL RULES GOVERNING INSURANCE PART 2 – THE BUSINESS OF INSURANCE CHAPTER 12 – The Insurance Frauds Prevention Act ARTICLE 7 – Workers’ Compensation Insurance Fraud Reporting [Section 1877.3](https://law.justia.com/codes/california/code-ins/division-1/part-2/chapter-12/article-7/section-1877-3/). 1877.3. (a) Upon written request to an insurer or a licensed rating organization by an authorized governmental agency, an insurer, an agent authorized by that insurer, or a licensed rating organization to act on behalf of the insurer, shall release to the requesting authorized governmental agency any or all relevant information deemed important to the authorized governmental agency that the insurer or licensed rating organization may possess relating to any specific workers’ compensation insurance fraud investigation. (b) (1) When an insurer or licensed rating organization knows or reasonably believes it knows the identity of a person or entity whom it has reason to believe committed a fraudulent act relating to a workers’ compensation insurance claim or a workers’ compensation insurance policy, including any policy application, or has knowledge of such a fraudulent act, then, for the purpose of notification and investigation, the insurer, or agent authorized by an insurer to act on its behalf, or licensed rating organization shall notify the local district attorney’s office and the Fraud Division of the Department of Insurance, and may notify any other authorized governmental agency of that suspected fraud and provide any additional information in accordance with subdivision (a). The insurer or licensed rating organization shall state in its notice the basis of the suspected fraud. (2) Insurers shall use a form prescribed by the department for the purposes of reporting suspected fraudulent workers’ compensation acts pursuant to this subdivision. (3) This section does not abrogate or impair the rights or powers created under subdivision (a). (c) The authorized governmental agency provided with information pursuant to subdivision (a), (b), or (e) shall, upon request, unless it would violate federal law or otherwise compromise an investigation, release or provide that information in a confidential manner to any other authorized governmental agency for purposes of investigation, prosecution, or prevention of insurance fraud or workers’ compensation fraud. (d) An insurer or licensed rating organization providing information to an authorized governmental agency pursuant to this section shall provide the information within a reasonable time, but not exceeding 60 days from the day on which the duty arose. (e) Upon written request by an authorized governmental agency, as specified in subdivision (o) of Section 1095 of the Unemployment Insurance Code, the Employment Development Department shall release to the requesting agency any or all relevant information that the Employment Development Department may possess relating to any specific workers’ compensation insurance fraud investigation. If an authorized governmental agency seeks to disclose this information to any other governmental agency that is not authorized to receive that information pursuant to subdivision (o) of Section 1095 of the Unemployment Insurance Code or subdivision (c) of Section 603.9 of Title 20 of the Code of Federal Regulations, that agency shall submit a request to the Employment Development Department for approval prior to disclosure. Relevant information may include, but is not limited to, all of the following: (1) Copies of unemployment and disability insurance application and claim forms and copies of any supporting medical records, documentation, and records pertaining thereto. (2) Copies of returns filed by an employer pursuant to Section 1088 of the Unemployment Insurance Code and copies of supporting documentation. (3) Copies of benefit payment checks issued to claimants. (4) Copies of any documentation that specifically identifies the claimant by social security number, residence address, or telephone number. *(Amended by Stats. 2023, Ch. 204, Sec. 13. (AB 1140) Effective January 1, 2024.)* **State:** California **Requirement Types:** Mandatory Reporting --- ### [Connecticut-Annual Reporting-Sec. 38a-356. (Formerly Sec. 38-175v).](https://insurancefraud.org/regulations/connecticut-annual-reporting-sec-38a-356-formerly-sec-38-175v/) **Published:** July 21, 2020 **Author:** Brent Walker **Content:** **Connecticut repealed annual insurance fraud reporting requirement for auto insurers.** The repeal takes effect Oct. 1, 2026. Connecticut Gov. Ned Lamont signed [House Bill 5373](https://insurancefraud.org/wp-content/uploads/Enacted-CT-HB-5373-Public-Act-26-69.pdf), repealing the state’s annual insurance fraud reporting requirement for motor vehicle insurers. Individual fraud referral obligations remain in place. Insurers are still required to report cases of suspected insurance fraud through usual channels such as the National Insurance Crime Bureau (NICB) and the National Association of Insurance Commissioners (NAIC) Online Fraud Reporting System. The following language has been repealed: *(c) On or before March thirty-first of each year, each insurance company shall provide the Insurance Commissioner annual reports detailing all information received or investigations conducted by such company during the past year concerning insurance fraud in any claim under a motor vehicle insurance policy. Such reports shall be filed in a manner prescribed by the commissioner.* **State:** Connecticut **Requirement Types:** Annual Reporting --- ### [California-SIU Education-Section 2698.39 Anti-Fraud Training](https://insurancefraud.org/regulations/california-siu-education-section-2698-39-anti-fraud-training/) **Published:** July 21, 2020 **Author:** Brent Walker **Content:** **Section 2698.39 Anti-Fraud Training** Requirements for training provided by and for the SIU shall include: (a) The insurer shall establish and maintain an ongoing anti-fraud training program, planned and conducted to develop and improve the anti-fraud awareness skills of the integral anti-fraud personnel. (b) The insurer shall designate an SIU staff person to be responsible for coordinating the ongoing anti-fraud training program. (c) The anti-fraud training program shall consist of three (3) levels: (1) All newly-hired employees shall receive an anti-fraud orientation within ninety (90) days of commencing assigned duties. The orientation shall provide information regarding: (A) the function and purpose of the SIU; (B) an overview of fraud detection and referral of suspected insurance fraud to the SIU for investigation; (C) a review of the Fraud Division’s insurance fraud reporting requirements; (D) an organization chart depicting the insurer’s SIU; and (E) SIU contact telephone numbers and email addresses. (2) Integral anti-fraud personnel shall receive annual anti-fraud in-service training, which shall include: (A) review of the function and purpose of the SIU; (B) introduction/review of the written procedures established by the SIU regarding the identification, documentation, and referral of incidents of suspected fraud to the SIU; (C) identification and recognition of red flags or red flag events; (D) any changes to current procedures for identifying, documenting, and referring incidents of suspected insurance fraud to the SIU; (E) the Fraud Division’s insurance fraud reporting requirements; and (F) introduction/review of existing and new, emerging insurance fraud trends. (3) The SIU personnel shall receive at least five (5) hours of continuing anti-fraud training per calendar year. The training shall include instruction in one or more of the following topics: (A) investigative techniques; (B) communication with the Fraud Division and authorized governmental agencies; (C) fraud indicators; (D) emerging fraud trends; or (E) legal and related issues. (d) The training requirements stated in subdivision (c) of this Section 2698.39 shall not apply to persons retained to provide an expert opinion on a medical, technical, or scientific topic on behalf of the insurer and who do not participate in the claims handling or decision making function of the insurer. (e) Training, instruction, or courses that may be used in order to satisfy the requirement stated in subdivision (c)(3) of this section shall include, without limitation: anti-fraud conferences; SIU roundtables hosted by the Fraud Division; anti-fraud association meetings and trainings; and insurer in-house trainings. (f) Records of the anti-fraud training shall be prepared at the time training is provided and be maintained and available for inspection by the Department on request. The training records shall include: (1) the title and date of the anti-fraud training, instruction, or course; (2) the name, title, and contact information of the instructor(s), to the extent applicable; (3) copies of the training, instruction, or course materials or, if the materials are unavailable, a description of the training, instruction, or course content; (4) the length of the training, instruction, or course; and (5) the name and job title(s) of participating personnel. ***Note: Information last updated 10/6/2023. Please refer to the [most current version online](https://govt.westlaw.com/calregs/Browse/Home/California/CaliforniaCodeofRegulations?guid=IE8C3D8105C2F11EC9C68000D3A7C4BC3&originationContext=documenttoc&transitionType=Default&contextData=(sc.Default)) for compliance purposes.*** **State:** California **Requirement Types:** SIU Education --- ### [Maine-Title 24-Mandatory Reporting](https://insurancefraud.org/regulations/maine-title-24-mandatory-reporting/) **Published:** December 2, 2021 **Author:** Coalition Against Insurance Fraud **Content:** **Title 24-A: MAINE INSURANCE CODE** **Chapter 23: TRADE PRACTICES AND FRAUDS** §2186. Insurance fraud prevention Reporting of fraudulent insurance acts. Fraudulent insurance acts must be reported in accordance with this subsection. A. An insurer shall, annually on or before March 1st or within any reasonable extension of time granted by the superintendent, file with the superintendent a report relating to fraudulent insurance acts that the insurer knew or reasonably believed had been committed during the previous calendar year. The report must contain information required by the superintendent in the manner prescribed by the superintendent. The information must be reported on an aggregate basis and may not contain any information identifying any individuals or entities. The superintendent shall adopt by January 1, 1999 rules necessary to define the information that must be reported. Rules adopted pursuant to this subsection are routine technical rules as defined in Title 5, chapter 375, subchapter II‑A. **State:** Maine **Requirement Types:** Mandatory Reporting --- ### [New Hampshire-Fraud Plan-Section 417:30 & 4601.05](https://insurancefraud.org/regulations/new-hampshire-fraud-plan-section-41730-4601-05/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** 417:30. Insurer Antifraud Initiatives. I. Except for insurance companies writing only credit, home warranty, travel, or title insurance, every insurance company licensed to write direct business in this state shall have antifraud initiatives reasonably calculated to detect, prosecute, and prevent fraudulent insurance acts, including a written antifraud plan. This plan shall be furnished to the commissioner, upon request. II. Antifraud plans submitted to the commissioner shall be privileged and confidential and shall not be a public record and shall not be subject to discovery or subpoena in a civil or criminal action. III. The provisions of RSA 400-A:36, III shall apply to the furnishing of information by an insurer to the unit or to any other insurer involved in the prevention or detection of fraudulent insurance acts. IV. If the commissioner finds that an insurer licensed to do business in New Hampshire has failed to execute an antifraud plan, the commissioner may issue a fine or suspend the right of the insurer to do business in this state until such time as that insurer comes into compliance with the provisions of this chapter. 4601\. Antifraud Plans 4601.01 Purpose. The purpose of this chapter is to establish standards for the **insurance fraud** investigation unit, **insurance** company special investigative unit (SIU), and any other interested parties regarding the preparation of an antifraud plan that meets the mandated requirements for developing an antifraud plan pursuant to [RSA 417:30](https://advance.lexis.com/document?crid=457d60dc-39e5-468e-bccd-a4a5cc5d0eb2&pddocfullpath=%2Fshared%2Fdocument%2Fadministrative-codes%2Furn%3AcontentItem%3A61S9-V8S1-JW5H-X4TH-00000-00&pdsourcegroupingtype=I&pdcontentcomponentid=292484&pdalertresultid=3393194290&pdalertprofileid=2f6a580a-542d-4afb-9415-01c84ce7d4e2&pdmfid=1000516&pdisurlapi=true). Ins 4601.02 Applicability and Scope. This chapter shall be applicable to every **insurance** company licensed to write direct business in this state, except for **insurance** companies writing only credit, home warranty, travel, or title **insurance**. Ins 4601.03 Definitions. - (a) “Commissioner” means the **insurance** commissioner. - (b) “Department” means the New Hampshire **Insurance** Department. - (c) “National Association of **Insurance** Commissioners (NAIC)” means the organization comprised of elected or appointed state government officials of the 50 states, the District of Columbia and the U.S. territories whose departments regulate the business of **insurance**. - (d) “National Health Care Antifraud Association (NHCAA)” means the organization founded in 1985 by private health insurers and federal and state governments whose activities focus exclusively on fighting health care **fraud**. - (e) “National **Insurance** Crime Bureau (NCIB)” means the not-for-profit organization created by the **insurance** industry to address **insurance**-related crime. - (f) “Online **Fraud** Reporting System (OFRS)” means the online **fraud** reporting system developed by the NAIC for regulators, consumers and **insurance** industry to report **insurance fraud**. - (g) “Special Investigations Unit (SIU)” means the non-law enforcement units of an insurer or insurer affiliated entity whose sole mission is to detect, deter, defeat, and report **insurance fraud**. An SIU includes any of the following: o (1) An internal unit of the **insurance** company; o (2) An external unit of more than one **insurance** company that is part of the same **insurance** holding company system; or o (3) An independent third-party unit under contract with an insurer or insurers. Ins 4601.04 Antifraud Plans Submitted Upon Request. - (a) An insurer, if requested by the department, subject to [RSA 408-D:14](https://advance.lexis.com/document?crid=457d60dc-39e5-468e-bccd-a4a5cc5d0eb2&pddocfullpath=%2Fshared%2Fdocument%2Fadministrative-codes%2Furn%3AcontentItem%3A61S9-V8S1-JW5H-X4TH-00000-00&pdsourcegroupingtype=I&pdcontentcomponentid=292484&pdalertresultid=3393194290&pdalertprofileid=2f6a580a-542d-4afb-9415-01c84ce7d4e2&pdmfid=1000516&pdisurlapi=true) and [RSA 417:30](https://advance.lexis.com/document?crid=457d60dc-39e5-468e-bccd-a4a5cc5d0eb2&pddocfullpath=%2Fshared%2Fdocument%2Fadministrative-codes%2Furn%3AcontentItem%3A61S9-V8S1-JW5H-X4TH-00000-00&pdsourcegroupingtype=I&pdcontentcomponentid=292484&pdalertresultid=3393194290&pdalertprofileid=2f6a580a-542d-4afb-9415-01c84ce7d4e2&pdmfid=1000516&pdisurlapi=true), shall submit to the commissioner a detailed description of the company’s antifraud plan. - (b) Any antifraud plans so submitted shall be subject to review by the commissioner. Ins 4601.05 Antifraud Plan Requirements. - (a) The antifraud plan shall be an acknowledgement by the insurer and its SIU that they have established criteria that shall be used to detect suspicious or fraudulent **insurance** activity relating to the different types of **insurance** offered by that insurer. - (b) One SIU antifraud plan may cover several insurer affiliated entities if one SIU has the **fraud** investigation mission for all entities. - (c) The following information shall be included in the antifraud plan to satisfy the requirements of this chapter, [RSA 408-D:14](https://advance.lexis.com/document?crid=457d60dc-39e5-468e-bccd-a4a5cc5d0eb2&pddocfullpath=%2Fshared%2Fdocument%2Fadministrative-codes%2Furn%3AcontentItem%3A61S9-V8S1-JW5H-X4TH-00000-00&pdsourcegroupingtype=I&pdcontentcomponentid=292484&pdalertresultid=3393194290&pdalertprofileid=2f6a580a-542d-4afb-9415-01c84ce7d4e2&pdmfid=1000516&pdisurlapi=true), and [RSA 417:30](https://advance.lexis.com/document?crid=457d60dc-39e5-468e-bccd-a4a5cc5d0eb2&pddocfullpath=%2Fshared%2Fdocument%2Fadministrative-codes%2Furn%3AcontentItem%3A61S9-V8S1-JW5H-X4TH-00000-00&pdsourcegroupingtype=I&pdcontentcomponentid=292484&pdalertresultid=3393194290&pdalertprofileid=2f6a580a-542d-4afb-9415-01c84ce7d4e2&pdmfid=1000516&pdisurlapi=true): - (1) General information requirements including: - a. An acknowledgment that the SIU has established criteria that shall be used for the investigation of acts of suspected **insurance fraud** relating to the different types of **insurance** offered by that insurer; - b. An acknowledgment that the insurer or SIU shall record the date that suspected fraudulent activity is detected and shall record the date that reports of such suspected **insurance fraud** were sent directly to the department, with a specific time frame which is consistent with [RSA 417:28](https://advance.lexis.com/document?crid=457d60dc-39e5-468e-bccd-a4a5cc5d0eb2&pddocfullpath=%2Fshared%2Fdocument%2Fadministrative-codes%2Furn%3AcontentItem%3A61S9-V8S1-JW5H-X4TH-00000-00&pdsourcegroupingtype=I&pdcontentcomponentid=292484&pdalertresultid=3393194290&pdalertprofileid=2f6a580a-542d-4afb-9415-01c84ce7d4e2&pdmfid=1000516&pdisurlapi=true); - c. A provision stating whether the SIU is an internal unit or an external or third-party unit; - d. If the SIU is an internal unit, provide a description of whether the unit is part of the insurer’s claims or underwriting departments, or whether it is separate from such departments; - e. A written description or chart outlining the organizational arrangement of the insurer’s antifraud positions responsible for the investigation and reporting of possible fraudulent **insurance** acts, including: - 1. If the SIU is an internal unit, the insurer shall provide general contact information for the company’s SIU; - 2. If the SIU is an external unit, the insurer shall provide: - (i) The name of the company or companies used; - (ii) Contact information for the company; - (iii) A company organizational chart; and - (iv) The person or position at the insurer responsible for maintaining contact with the external SIU company; and - 3. If an external SIU is employed for purposes of surveillance, the insurer shall include a description of the policies and procedures implemented; - f. A provision where the insurer provides the NAIC individual and group code numbers; - g. A statement as to whether the insurer has implemented a **fraud** awareness or outreach program. If the insurer has an awareness or outreach program, a brief description of the program shall be included; and - h. If the SIU is a third-party, a description of the insurer’s policies and procedures for ensuring that the third-party unit fulfills its contractual obligations to the insurer and a copy of the contract with the third party vendor; - (2) Prevention, detection, and investigation of **fraud** information, including: - a. A description of the insurer’s corporate policies for preventing fraudulent **insurance** acts by its policy holders; - b. A description of the insurer’s established **fraud** detection procedures, such as technology and other detection procedures; - c. A description of the internal referral criteria used in reporting suspicious claims of **insurance fraud** for investigation by the SIU; - d. A description of the SIU investigation program, such as by business line, external form claims adjustment, vendor management standard, operating procedures; and - e. A description of the insurer’s policies and procedures for referring suspicious or fraudulent activity from the claims or underwriting departments to the SIU; - (3) Reporting of **fraud** information, including: - a. A description of the insurer’s reporting procedures for the mandatory reporting of possible fraudulent **insurance** acts to the commissioner pursuant to [RSA 408-D:14](https://advance.lexis.com/document?crid=457d60dc-39e5-468e-bccd-a4a5cc5d0eb2&pddocfullpath=%2Fshared%2Fdocument%2Fadministrative-codes%2Furn%3AcontentItem%3A61S9-V8S1-JW5H-X4TH-00000-00&pdsourcegroupingtype=I&pdcontentcomponentid=292484&pdalertresultid=3393194290&pdalertprofileid=2f6a580a-542d-4afb-9415-01c84ce7d4e2&pdmfid=1000516&pdisurlapi=true), [RSA 417:28](https://advance.lexis.com/document?crid=457d60dc-39e5-468e-bccd-a4a5cc5d0eb2&pddocfullpath=%2Fshared%2Fdocument%2Fadministrative-codes%2Furn%3AcontentItem%3A61S9-V8S1-JW5H-X4TH-00000-00&pdsourcegroupingtype=I&pdcontentcomponentid=292484&pdalertresultid=3393194290&pdalertprofileid=2f6a580a-542d-4afb-9415-01c84ce7d4e2&pdmfid=1000516&pdisurlapi=true), and [RSA 417:30](https://advance.lexis.com/document?crid=457d60dc-39e5-468e-bccd-a4a5cc5d0eb2&pddocfullpath=%2Fshared%2Fdocument%2Fadministrative-codes%2Furn%3AcontentItem%3A61S9-V8S1-JW5H-X4TH-00000-00&pdsourcegroupingtype=I&pdcontentcomponentid=292484&pdalertresultid=3393194290&pdalertprofileid=2f6a580a-542d-4afb-9415-01c84ce7d4e2&pdmfid=1000516&pdisurlapi=true); - b. A description of the insurer’s criteria or threshold for reporting **fraud** to the commissioner; and - c. A description of the insurer’s means of submission of reports of suspected **fraud** to the commissioner, such as through the NAIC, OFRS, NICB, NHCAA, electronic state system, or other means; - (4) Education and training information, including, if applicable, a description of the insurer’s plan for antifraud education and training initiatives of any personnel involved in antifraud related efforts. Such description shall include: - a. The internal positions the insurer offers regular education and training, such as underwriters, adjusters, claims representatives, appointment agents, and attorneys, etc.; - b. If the training will be internal or external; - c. Number of hours expected per year; and - d. If training includes ethics, false claims, or other legal-related issues; - (5) Internal **fraud** detection and prevention information, including: - a. A description of the insurer’s internal **fraud** detection policy for employees, consultants, or others, such as underwriters, claims representatives, appointed agents, etc.; and - b. A description of the insurer’s internal **fraud** reporting system. Ins 4601.06 Regulatory Compliance. Pursuant to [RSA 417:30](https://advance.lexis.com/document?crid=457d60dc-39e5-468e-bccd-a4a5cc5d0eb2&pddocfullpath=%2Fshared%2Fdocument%2Fadministrative-codes%2Furn%3AcontentItem%3A61S9-V8S1-JW5H-X4TH-00000-00&pdsourcegroupingtype=I&pdcontentcomponentid=292484&pdalertresultid=3393194290&pdalertprofileid=2f6a580a-542d-4afb-9415-01c84ce7d4e2&pdmfid=1000516&pdisurlapi=true), the department shall review insurer antifraud plans, as needed, in order to determine compliance with appropriate state laws. Further, the department shall, in accordance with [RSA 417:30, IV](https://advance.lexis.com/document?crid=457d60dc-39e5-468e-bccd-a4a5cc5d0eb2&pddocfullpath=%2Fshared%2Fdocument%2Fadministrative-codes%2Furn%3AcontentItem%3A61S9-V8S1-JW5H-X4TH-00000-00&pdsourcegroupingtype=I&pdcontentcomponentid=292484&pdalertresultid=3393194290&pdalertprofileid=2f6a580a-542d-4afb-9415-01c84ce7d4e2&pdmfid=1000516&pdisurlapi=true), take appropriate administrative action against an insurer that fails to comply with the mandated requirements or state laws. Ins 4601.07 Confidentiality of Antifraud Plans. Any requested submission of required information shall not constitute a waiver of an insurer’s privilege, trade secret, confidentiality, or any proprietary interest in its antifraud plan or its antifraud related policies and procedures. The commissioner shall maintain the antifraud plan as confidential. Submitted plans shall not be subject to RSA 91-A, if submitted properly under the state statutes or rules which would afford protection of these materials under [RSA 408-D:14](https://advance.lexis.com/document?crid=457d60dc-39e5-468e-bccd-a4a5cc5d0eb2&pddocfullpath=%2Fshared%2Fdocument%2Fadministrative-codes%2Furn%3AcontentItem%3A61S9-V8S1-JW5H-X4TH-00000-00&pdsourcegroupingtype=I&pdcontentcomponentid=292484&pdalertresultid=3393194290&pdalertprofileid=2f6a580a-542d-4afb-9415-01c84ce7d4e2&pdmfid=1000516&pdisurlapi=true) and [RSA 417:30, II](https://advance.lexis.com/document?crid=457d60dc-39e5-468e-bccd-a4a5cc5d0eb2&pddocfullpath=%2Fshared%2Fdocument%2Fadministrative-codes%2Furn%3AcontentItem%3A61S9-V8S1-JW5H-X4TH-00000-00&pdsourcegroupingtype=I&pdcontentcomponentid=292484&pdalertresultid=3393194290&pdalertprofileid=2f6a580a-542d-4afb-9415-01c84ce7d4e2&pdmfid=1000516&pdisurlapi=true). Ins 4601.08 Waiver of Rules. - (a) The commissioner, upon the commissioner’s own initiative or upon request by an insurer, shall waive any requirement of this chapter if such waiver does not contradict the objective or intent of the rule and: - (1) Applying the rule provision would cause confusion or would be misleading to consumers; - (2) The rule provision is in whole or in part inapplicable to the given circumstances; - (3) There are specific circumstances unique to the situation such that strict compliance with the rule would be onerous without promoting the objective or intent of the rule provision; or - (4) Any other similar extenuating circumstances exist such that application of an alternative standard or procedure better promotes the objective or intent of the rule provision. - (b) No requirement prescribed by statute shall be waived unless expressly authorized by law. - (c) Any person or entity seeking a waiver shall make a request in writing. - (d) A request for a waiver shall specify the basis for the waiver and proposed alternative, if any. **State:** New Hampshire **Requirement Types:** Fraud Plan --- ### [California-Title 10-SIU requirement](https://insurancefraud.org/regulations/title-10-investment/) **Published:** September 28, 2020 **Author:** admcaif **Content:** Chapter 5. Insurance Commissioner Subchapter 9. Insurance Fraud Article 2. Special Investigative Units Amend 2698.30. Definitions. As used in this article, the following definitions shall apply: (a) “Act” means any violation of California Code of Regulations, Title 10, Chapter 5, Section 2698.30-42, inclusive. (b) “Authorized governmental agency (agencies)” shall have the same meaning as used in the Insurance Frauds Prevention Act (IFPA). (c) “Claims handler” means every employee and agent of an insurer whose principal responsibilities include the investigation, adjustment, settlement, and resolution of claims. (d) “Commissioner” means the Insurance Commissioner of the State of California. (e) “Communication” includes the referral of suspected insurance fraud to the Department of Insurance and providing information and documents requested by the Fraud Division. (f) “Contracted entity” means any entity with which an insurer contracts to perform SIU or integral anti-fraud personnel duties or functions on behalf of the insurer. “Contracted entity” includes subcontractors and sub-subcontractors contracted to perform SIU or integral anti-fraud personnel duties or functions on behalf of the insurer. The term “contracted entity” does not include the insurer’s affiliates, or subsidiaries, with which the insurer contracts to perform SIU or integral anti-fraud personnel duties or functions on behalf of the insurer. “Contracted entity” does not include entities with whom an insurer, or another of the insurer’s contracted entities, contracts to provide an expert opinion on a medical, technical, or scientific topic, or perform a discreet, specific investigative task such as surveillance, accident reconstruction, background checks, scene inspections, social media checks, interviews, witness canvassing, Arising Out of Employment/Course of Employment (AOE/COE) investigations, activity checks, or database vendor services including, but not limited to, ISO ClaimSearch, LexisNexis, and Accurint, on behalf of the insurer in connection with the insurer’s performance of its SIU or integral antifraud personnel duties or functions. However, the immediately preceding sentence notwithstanding, entities that (1) participate in the claims handling function of the insurer, (2) make decisions on behalf of the insurer with respect to the insurer’s SIU or integral anti-fraud functions, or (3) contract with other entities to perform SIU or integral anti-fraud duties or functions on behalf of the insurer, are included within the meaning of the term “contracted entity.” (gf) “Department” means the California Department of Insurance. (hg) “Fraud Division” means the California Department of Insurance Fraud Division formerly known as the Bureau of Fraudulent Claims. (ih) “Hearing” means an adjudicative proceeding initiated by the Insurance Commissioner pursuant to the provisions of California Insurance Code Ssection 1875.24(d). (ji) “Inadvertent” means unintentional. (kj) “Insurer” means every insurer admitted to do business in this state except the following: (1) Reinsurers. (2) Title insurers. (3) Fraternal fire insurers. (4) Fraternal benefit societies. (5) Firemen, policemen, or peace officer benefit and relief associations. (6) Grant and annuity societies. (7) Home protection. (lk) “Integral anti-fraud personnel” includes insurer personnel who the insurer has not identified as being directly assigned to its SIU but whose duties may include the processing, investigating, or litigation pertaining to payment or denial of a claim or application for adjudication ofor claim or application for insurance. These personnel may include claims handlers, underwriters, policy handlers, call center staff within the claims or policy function, legal staff, and other insurer employee classifications that perform similar duties. (ml) “Reasonable belief” is a level of belief that an act of insurance fraud may have or might be occurring for which there is an objective justification based on articulable fact(s) and rational inferences therefrom. (nm) “Red flag” or “red flag event” means facts, circumstances, or events which, singly or in combination, support(s) an inference that insurance fraud may have been committed., and includes patterns or trends that may indicate fraud, facts or circumstances present on a claim, and behavior or history of person(s) submitting a claim or application. (on) “Regulations” means these regulations, California Code of Regulations, Title 10, Chapter 5, Subchapter 9, Article 2. (po) “Special Investigative Unit” (SIU) means an insurer’s unit or division that is established to investigate suspected insurance fraud. The SIU may be comprised of insurer employees or by contracting with other entities for the purpose of complying with applicable sections of the Insurance Frauds Prevention Act (IFPA) for the direct responsibility of performing the functions and activities as set forth in these regulations. (qp) “Suspected insurance fraud” includes any misrepresentation of fact or omission of fact pertaining to a transaction of insurance including claims, premium, and application fraud. These facts may include evidence of doctoring, altering or destroying forms;, prior history of the claimant, policy holder, applicant, or provider;, receipts;, estimates;, explanations of benefits (EOBs), medical evaluations or billings;, medical provider notes (commonly known as SOAPE notes:); Subjective complaint, Objective findings, Assessment, Plan and Evaluation);, Health Care Financing Administration (HCFA) forms;, police and/or investigative reports;, relevant discrepancies in written or oral statements and examinations under oath (EUO);, unusual policy activity; and falsified or untruthful application for insurance. An identifiable pattern in a claim history may also suggest the possibility of suspected fraudulent claims activity. A claim may contain evidence of suspected insurance fraud regardless of the payment status. (rq) “The Insurance Frauds Prevention Act” or “(IFPA)” shall refer to California Insurance Code sections 1871-through 1879.8. (sr) “Willful” means a purpose or willingness to commit the act or make the omission referred to in the California Insurance Code or in these regulations. The Commissioner shall use the factors set forth at California Code of Regulations, Title 10, Section 2591.3(d)(1)(A-E) to determine whether or not an act is willful. NOTE: Authority cited: Sections 1872.4, 1875.24, 1877.3, 1879.5 and 1879.6, Insurance Code; Calfarm Ins. Co. v. Deukmejian (1989) 48 Cal.3d. 805, 824, 258 Cal. Rptr. 161, 771 P.2d 1247; Credit Ins. Gen. Agents Assn. v. Payne (1976) 16 Cal.3d 651, 656, 128 Cal. Rptr. 881, 547 P.2d 993; and Garris v. Carpenter (1939) 33 Cal. App. 2d. 649, 653, 92 P.2d 688. Reference: Sections 1875.20, 1875.21, 1875.24, 1879.5, 9080, 10970, 11400, 11520, 11760, 11880, 12400.1, 12743, 12921(a) and 12926, Insurance Code. Amend Section 2698.33. SIU and Integral Anti-Fraud Personnel Contracted Responsibilities. (a) Any contract entered into by an insurer, or an entity under contract with an insurer for the performance of SIU or integral anti-fraud personnel duties or functions as provided under these regulations, shall not relieve the insurer of any obligation under these regulations or the IFPA. (b) Notwithstanding any other provisions of these regulations, a complete and executed copy of any such agreement, including all attachments, exhibits and amendments thereto, shall be provided to the Fraud Division upon request by the Fraud Divisionon execution. (c) Any contract entered into by an insurer with a contracted entity under this section shall: (1) Specify all SIU or integral anti-fraud personnel duties and functions to be performed by the parties to the contract and how the insurer monitors performance of the contract responsibilities; (2) Not include provisions that could provide disincentives to the referral and/or investigation of suspected insurance fraud; (3) Not include provisions that purport to relieve an insurer of any obligation to comply with the requirements of these regulations and the IFPA.; and (4) Expressly include a provision to require the contracted entity to comply with all applicable provisions of the IFPA and this articlethese regulations.; and (5) Expressly require the contracted entity to include the following provisions in any agreement the contracted entity may enter into with any subcontractor to perform SIU or integral anti-fraud personnel duties or functions for the contracted entity on behalf of the insurer: (A) Subcontractor to provide entire agreement to the Fraud Division upon request: An express provision requiring that the contractor provide to the Fraud Division a complete and executed copy of any such agreement between the contractor and its subcontractor, including all attachments, exhibits and amendments thereto, upon request by the Fraud Division, (B) Subcontractor to be bound by same requirements as contractor: An express provision that any such agreement between the contractor and its subcontractor shall conform to the requirements set forth in subdivisions (c)(1), (c)(2), (c)(3), and (c)(4) of this Section 2698.33, and (C) Limitations on subcontractor contracting with other entities: An express provision that, in the event any subcontractor to the contracted entity contracts with any other entity or entities to perform SIU or integral anti-fraud personnel duties or functions on behalf of the insurer, the agreement between the subcontractor and the entity so contracted (hereinafter a “sub-subcontractor”) shall contain the following provisions: 1\. Sub-subcontractor to be bound by same requirements as contractor and subcontractor: The express provision described in subdivision (c)(5)(B) of this section, 2\. Sub-subcontractor to provide entire agreement to the Fraud Division upon request: An express provision identical in substance to the provision described in subdivision (c)(5)(A) of this section, binding the subcontractor to provide, upon request by the Fraud Division, the documents specified in that subdivision (c)(5)(A) but with respect to the agreement between the subcontractor and its sub-subcontractor, and 3\. No further subcontracting: An express provision prohibiting the sub-subcontractor from permitting, or contracting with, any other entity to perform the SIU or integral anti-fraud personnel duties or functions which the sub-subcontractor has contracted with the subcontractor to perform on behalf of the insurer. (d) An insurer shall no later than April 1, 2021 ensure that the provisions described in subdivisions (c)(5)(A) through (c)(5)(C) of this section are included in any and all of its contracts with contracted entities for the performance of SIU or integral anti-fraud personnel duties or functions. NOTE: Authority cited: Sections 1875.23, 1875.24, 1879.5 and 1879.6, Insurance Code; Calfarm Ins. Co. v. Deukmejian (1989) 48 Cal.3d. 805, 824, 258 Cal. Rptr. 161, 771 P.2d 1247; Credit Ins. Gen. Agents Assn. v. Payne (1976) 16 Cal.3d 651, 656, 128 Cal. Rptr. 881, 547 P.2d 993; and Garris v. Carpenter (1939) 33 Cal. App. 2d. 649, 653, 92 P.2d 688. Reference: Sections 1875.20, 1875.21, 1875.24, 1879.5, 12921(a) and 12926, Insurance Code. Amend Section 2698.34. Communication with the Fraud Division and Authorized Governmental Agencies. (a) The insurer and any entity performing the SIU function(s) shall comply with specific sections of the IFPA regarding communication with the Fraud Division and authorized governmental agencies. (b) On written request by the Fraud Division or an authorized governmental agency, an insurer or its agents, shall release in a timely and complete manner any or all relevant information deemed important that the insurer may possess relating to any specific incident of insurance fraud. SuchThe information released pursuant to this subdivision (b) shall include: (1) Insurance policy information; (2) Applications; (3) Policy premium payment records; (4) History of claims; (5) Information relating to the carrier’s investigation, including statements, proof and notice of loss; (6) Claim file documents; (7) Claim notes; (8) Investigation files; (9) Investigator notes; and (10) Other information which the Fraud Division or an Aauthorized Ggovernmental Aagency may deem relevant and important. (c) For the purpose of this section, timely release of information means immediate, but no more than thirty (30) calendar days after the request or, in the event of a request relating to workers’ compensation insurance fraud, sixty (60) calendar days after the request, unless otherwise agreed to by the Fraud Division or by the other authorized governmental agency making the request. (d) Information released pursuant to this Section 2698.34 shall be transmitted only as follows, unless otherwise agreed to by the Fraud Division: (1) Via the Fraud Division’s electronic portal provided for this purpose; (2) As hardcopy; or (3) In an electronic file. For purposes of this subdivision (d)(3): (A) If the file is password-protected, the password must be provided to the Fraud Division and must not expire. (B) If the file is encrypted, the insurer shall provide Fraud Division with any materials necessary in order for the encrypted information to be accessed by the Fraud Division. (ec) A single written request shall be considered sufficient to compel production of all information deemed relevant by the requesting governmental agency relating to any specific insurance fraud investigation. The single request is applicable throughout the duration of the investigation and is applicable to the requested records of the insurer named in the request and the records of all persons, agents, and brokers employed by and conducting business on behalf of the insurer. NOTE: Authority cited: Sections 1872.4, 1875.24, 1877.3, 1879.5 and 1879.6, Insurance Code; Calfarm Ins. Co. v. Deukmejian (1989) 48 Cal.3d. 805, 824, 258 Cal. Rptr. 161, 771 P.2d 1247; Credit Ins. Gen. Agents Assn. v. Payne (1976) 16 Cal.3d 651, 656, 128 Cal. Rptr. 881, 547 P.2d 993; and Garris v. Carpenter (1939) 33 Cal. App. 2d. 649, 653, 92 P.2d 688. Reference: Sections 1872.3, 1873, 1874.2, 1874.4, 1875.4, 1875.20, 1875.21, 1875.24, 1877.1, 1877.2, 1877.3, 1877.4, 1877.5, 1879.5, 12921(a) and 12926, Insurance Code. Amend Section 2698.35. Detecting Suspected Insurance Fraud. (a) An insurer’s integral anti-fraud personnel are responsible for identifying suspected insurance fraud during the handling of insurance transactions and referring it to the SIU as part of their regular duties. (b) The SIU shall establish, maintain, distribute, and monitor written procedures to be used by the integral anti-fraud personnel to detect, identify, document, and refer suspected insurance fraud to the SIU. The written procedures shall include a listing of the red flags to be used to detect suspected insurance fraud for the insurer. The red flags listed pursuant to the immediately preceding sentence shall be specific to each line of insurance, or each insurance product, transacted in or issued by the insurer. (c) The procedures for detecting suspected insurance fraud shall provide for comparison of any insurance transaction against red flags and other criteria that may indicate possible fraud.: (1) Patterns or trends of possible fraud; (2) Red flags; (3) Events or circumstances present on a claim; (4) Behavior or history of person(s) submitting a claim or application; and (5) Other criteria that may indicate possible fraud. NOTE: Authority cited: Sections 1875.24, 1879.5 and 1879.6, Insurance Code; Calfarm Ins. Co. v. Deukmejian (1989) 48 Cal.3d. 805, 824, 258 Cal. Rptr. 161, 771 P.2d 1247; Credit Ins. Gen. Agents Assn. v. Payne (1976) 16 Cal.3d 651, 656, 128 Cal. Rptr. 881, 547 P.2d 993; and Garris v. Carpenter (1939) 33 Cal. App. 2d. 649, 653, 92 P.2d 688. Reference: Sections 1875.20, 1875.21, 1875.24, 1879.5, 12921(a) and 12926, Insurance Code. Amend Section 2698.36. Investigating Suspected Insurance Fraud. (a) The SIU shall establish, maintain, distribute, and adhere to written procedures for the investigation of possible suspected insurance fraud. An investigation of possible suspected insurance fraud shall include: (1) A thorough analysis of a claim file, application, or insurance transaction, that includes consideration of factors indicating insurance fraud. (2) Identification and interviews of potential witnesses who may provide information on the accuracy of the claim or application. (3) Utilizing one or more industry-recognized databases identified by the SIU as appropriate for use in fraud investigations involving the particular line of insurance in question. (4) Preservation of documents and other evidence obtained during an investigation. (5) Writing a concise and complete summary of the entire investigation, which is specific to the investigation at hand, is separate from any other document prepared in connection with the investigation, and includesing the investigators’s findings regarding the suspected insurance- fraud and the basis for their findings. The summary shall answer the following questions: (A) What facts caused the reporting party to believe insurance fraud occurred or may have occurred? (B) What are the suspected misrepresentations and who allegedly made them? (C) How are the alleged misrepresentations material and how do they affect the claim or insurance transaction? (D) Who are the pertinent witnesses to the alleged misrepresentation, if there are pertinent witnesses? (E) What documentation is there of the alleged misrepresentation, if documented? (F) In addition, the summary prepared pursuant to this subdivision (a)(5) shall include a statement as to whether or not the investigation is complete. (b) Each investigation of suspected insurance fraud shall include performing at least the procedures specified pursuant to subdivision (a) of this Section 2698.36, to the extent they are applicable. (c) The SIU shall investigate each credible referral of suspected insurance fraud that it receives from integral anti-fraud personnel, including automated or system-generated referrals. A credible referral of suspected insurance fraud is one that includes a red flag or red flags. However, the first sentence of this subdivision (c) notwithstanding, in the event that upon a preliminary review the SIU determines that it is reasonably clear that the red flag or red flags contained in the referral is not or are not the result of suspected insurance fraud, the SIU need not open an investigation. In the event that the SIU refrains from opening an investigation pursuant to the immediately preceding sentence, the SIU shall document in the claim file or SIU investigation file the reasons supporting its conclusion that the red flag or red flags contained in the referral is not or are not the result of suspected insurance fraud. NOTE: Authority cited: Sections 1875.24, 1879.5 and 1879.6, Insurance Code; Calfarm Ins. Co. v. Deukmejian (1989) 48 Cal.3d. 805, 824, 258 Cal. Rptr. 161, 771 P.2d 1247; Credit Ins. Gen. Agents Assn. v. Payne (1976) 16 Cal.3d 651, 656, 128 Cal. Rptr. 881, 547 P.2d 993; and Garris v. Carpenter (1939) 33 Cal. App. 2d. 649, 653, 92 P.2d 688. Reference: Sections 1875.20, 1875.21, 1875.24, 1879.5, 12921(a) and 12926, Insurance Code. Amend Section 2698.37. Referral of Suspected Insurance Fraud. (a) The SIU shall provide for the referral of acts of suspected insurance fraud to the Fraud Division and, as required, district attorneys. (b) Referrals shall be submitted in any insurance transaction where the facts and circumstances create a reasonable belief that a person or entity may have committed or is committing insurance fraud. (c) Referrals shall be made within the period specified by statute. (d) The SIU shall complete as much of its investigation as is reasonable prior to the time the referral is made to the Fraud Division. Each referral of suspected insurance fraud shall indicate whether the investigation is complete or further investigation is needed. (ed) The requirements of this section do not affect the immunity granted under California Insurance Code section 1872.5 or other such similar codes contained in the Insurance Frauds Prevention Act. (fe) The requirements of this section do not diminish statutory requirements contained in the Insurance Frauds Prevention Act regarding the confidentiality of any information provided in connection with an investigation. NOTE: Authority cited: Section 1708, Civil Code; Sections 1872.4, 1874.6, 1875.24, 1875.4, 1877.3, 1877.5, 1879.5 and 1879.6, Insurance Code; Calfarm Ins. Co. v. Deukmejian (1989) 48 Cal.3d. 805, 824, 258 Cal. Rptr. 161, 771 P.2d 1247; **State:** California **Requirement Types:** SIU Requirement --- ### [New York-Fraud Plan-Section 409](https://insurancefraud.org/regulations/new-york-fraud-plan-section-409/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Fraud prevention plans and special investigations units. (a) Every insurer writing private or commercial automobile insurance, workers’ compensation insurance, or individual, group or blanket accident and health insurance policies issued or issued for delivery in this state, except for insurers that write less than three thousand of such policies, issued or issued for delivery in this state annually, and every entity licensed pursuant to article forty-four of the public health law except those entities with an enrolled population of less than sixty thousand persons in the aggregate and, except those entities licensed pursuant to sections forty-four hundred three-a, forty-four hundred three-c, forty-four hundred-d, forty-four hundred three-f and forty-four hundred eight-a of the public health law shall, within one hundred twenty days of the effective date of this amended section to be promulgated by the superintendent to implement this section, file with the superintendent a plan for the detection, investigation and prevention of fraudulent insurance activities in this state and those fraudulent insurance activities affecting policies issued or issued for delivery in this state. The superintendent may accept programs and processes implemented pursuant to section forty-four hundred fourteen of the public health law as satisfying the obligations of this section and regulations promulgated thereunder. (b) (1) The plan shall provide the time and manner in which such plan shall be implemented, including provisions for a full-time special investigations unit and staffing levels within such unit. Such unit shall be separate from the underwriting or claims functions of an insurer, and shall be responsible for investigating information on or cases of suspected fraudulent activity and for effectively implementing fraud prevention and reduction activities pursuant to the plan filed with the superintendent. An insurer shall include in such plan staffing levels and allocations of resources in such full-time special investigations unit as may be necessary and appropriate for the proper implementation of the plan and approval of such plan pursuant to subsection (d) of this section. (2) In lieu of a special investigations unit, an insurer may contract with a provider of services related to the investigation of information on or cases of suspected fraudulent activities; provided, however, that an insurer which opts for contracting with a separate provider of services, shall provide to the superintendent a detailed plan therefor, pursuant to requirements set forth in regulation by the superintendent. (3) Persons employed by special investigations units as investigators or by an independent provider of investigative services under contract with an insurer shall be qualified by education or experience which shall include an associate’s or bachelor’s degree in criminal justice or related field, or five years of insurance claims investigation experience or professional investigation experience with law enforcement agencies, or seven years of professional investigation experience involving economic or insurance related matters. For the purposes of evaluation of medical related claims insurers may employ or retain duly licensed or authorized medical professionals. Notwithstanding these minimum requirements anyone employed as an investigator in a special investigation unit or by a provider of investigative services under contract to an insurer as of the effective date of this paragraph and who was also so employed on or before September tenth, nineteen hundred ninety-six may continue in such employment provided the insurer identifies such person in writing to the superintendent giving the date such employment began and a description of the person’s qualifications, employment history and current job duties. ( c) The plan shall provide for the following: interface of special investigation unit personnel with law enforcement and prosecutorial agencies and with the financial frauds and consumer protection unit of the department of financial services; ( 2\) reporting of fraud data to a central organization approved by the superintendent; (3) in-service education and training for underwriting and claims personnel in identifying and evaluating instances of suspected fraudulent activity in underwriting or claims activities; (4) coordination with other units of an insurer for the investigation and initiation of civil actions based upon information received by or through the special investigation unit; (5) public awareness of the cost and frequency of fraudulent activities, and the methods of preventing fraud; (6) development and use of a fraud detection and procedures manual to assist in the detection and elimination of fraudulent activity; and (7) the time and manner in which such plan shall be implemented and a demonstration that the fraud prevention and reduction measures outlined in the plan will be fully implemented. (d) (1) A fraud detection and prevention plan filed by an insurer with the superintendent pursuant to this section shall be deemed approved by the superintendent if not returned by the superintendent for revision within one hundred twenty days of the date of filing. If the superintendent returns a plan for revision, the superintendent shall state the points of objection with such plan, and any amendments as the superintendent may require consistent with the provisions of this section, including, but not limited to, staffing levels, resource allocation, or other policy or operational considerations. An amended plan reflecting the changes shall be filed with the superintendent within forty-five days from the date of return. (2) If the superintendent has returned a plan for revision more than one time, the insurer shall be entitled to a hearing pursuant to the provisions of article three of this chapter and regulations promulgated thereunder. (3) If an insurer fails to submit a final plan within thirty days after a determination of the superintendent after the hearing held pursuant to paragraph two of this subsection, or otherwise fails to submit a plan, or fails to implement the provisions of a plan in a time and manner provided for in such plan, or otherwise refuses to comply with the provisions of this section, the superintendent may: (i) impose a fine of not more than two thousand dollars per day for such failure by an insurer until the superintendent deems the insurer to be in compliance; or (ii) impose upon the insurer a fraud detection and prevention plan deemed to be appropriate by the superintendent which shall be implemented by the insurer; or (iii) impose the provisions of both subparagraphs (i) and (ii) of this paragraph. (e) Any plan, the information contained therein, or correspondence related thereto, or any other information furnished pursuant to this section shall be deemed to be a confidential communication and shall not be open for review or be subject to a subpoena except by a court order or by request from any law enforcement agency or authority. For purposes of this section, the term “policies” shall refer to individuals covered if coverage is issued on a group basis. (g) Every insurer required to file a fraud prevention plan shall report to the superintendent on an annual basis, no later than March fifteenth, describing the insurer’s experience, performance and cost effectiveness in implementing the plan, utilizing such forms as the superintendent may prescribe. Upon consideration of such reports, the superintendent may require amendments to the insurer’s fraud prevention plan as deemed necessary. **State:** New York **Requirement Types:** Fraud Plan --- ### [Alabama-Mandatory Reporting-§ 27-12A-21. Mandatory reporting requirements.](https://insurancefraud.org/regulations/alabama-mandatory-reporting-§-27-12a-21-mandatory-reporting-requirements/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** § 27-12A-21. Mandatory reporting requirements. (a) Persons engaged in the business of insurance, having knowledge or a reasonable belief that insurance fraud is being, will be, or has been committed, shall provide to the department such information that is required by, and in a manner prescribed by, the department. As used in this section, “persons engaged in the business of insurance” refers only to those entities defined in Section 27-12A-1(5) which hold a certificate of authority from the commissioner. (b) A person other than an insurer having knowledge or having a reasonable belief that insurance fraud is being, will be, or has been committed may provide the information to the Attorney General, the department, or both. **State:** Alabama **Requirement Types:** Mandatory Reporting --- ### [West Virginia-Mandatory Reporting-Section 33-41-5](https://insurancefraud.org/regulations/west-virginia-mandatory-reporting-section-33-41-5/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** §33-41-5. Reporting of insurance fraud or criminal offenses otherwise related to the business of insurance. (a) A person engaged in the business of insurance having knowledge or a reasonable belief that fraud or another crime related to the business of insurance is being, will be or has been committed shall provide to the commissioner the information required by, and in a manner prescribed by, the commissioner. (b) The commissioner may prescribe a reporting form to facilitate reporting of possible fraud or other offenses related to the business of insurance for use by persons other than those persons referred to in subsection (a) of this section. **State:** West Virginia **Requirement Types:** Mandatory Reporting --- ### [Wisconsin-Mandatory Reporting-Sec. 102-125 - Fraudulent Claims Reporting](https://insurancefraud.org/regulations/wisconsin-mandatory-reporting-sec-102-125-fraudulent-claims-reporting/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Workers compensation only. Sec. 102-125 – Fraudulent Claims Reporting “(1) If an insurer or self-insured employer has evidence that a claim is false or fraudulent in violation of Sec. 943.395 and if the insurer or self-insured employer is satisfied that reporting the claim to the department will not impede its ability to defend the claim, the insurer or self-insured employer shall report the claim to the department. The department may require an insurer or self-insured employer to investigate an alleged false or fraudulent claim and may provide the insurer or self-insured employer with any records of the department relating to that claim. An insurer or self-insured employer that investigates a claim under this subsection shall report on the results of that investigation to the department.” **State:** Wisconsin **Requirement Types:** Mandatory Reporting --- ### [Tennessee-Fraud Warning-56-53-111](https://insurancefraud.org/regulations/tennessee-fraud-warning-56-53-111/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Chapter No. 356 – Enacted 2001 Legislative Session Section 12 (b) (1)(A) No later than six (6) months after the effective date of this act, all applications for insurance, and all claim forms regardless of the form of transmission provided and required by an insurer or required by law as a condition of payment of a claim, shall contain a statement, permanently affixed to the application or claim form, that clearly states in substance the following, or words to that effect: “It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.” (1)(B) The lack of a statement required in this subsection does not constitute a defense in any criminal prosecution under Section 3 nor in any civil action under Section 3 or 4. (2) The warning required by this subsection shall not be required on forms relating to reinsurance. Fraud Plan/SIU Requirement Chapter No. 356 – Enacted 2001 Legislative Session Section 12 (a) Anti-Fraud Plans Within six months of the effective date of this legislation, every insurer with direct written premiums exceeding ten million dollars ($10,000,000) shall prepare, implement, and maintain an insurance anti-fraud plan. Each insurer’s anti-fraud plan shall outline specific procedures, appropriate to the type of insurance the insurer writes in the state, to: (1) Prevent, detect and investigate all forms of insurance fraud, including fraud involving the insurer’s employees or agents; fraud resulting from misrepresentations in the application, renewal or rating of insurance policies; claims fraud; and security of the insurer’s data processing system; (2) Educate appropriate employees on fraud detection and the insurer’s anti-fraud plan; (3) Provide for the hiring of or contracting for fraud investigators; (4) Report insurance fraud to appropriate law enforcement and regulatory authorities in the investigation and prosecution of insurance fraud; and (5) Pursue restitution for financial loss caused by insurance fraud, where appropriate. **State:** Tennessee **Requirement Types:** Fraud Warning --- ### [Tennessee-Fraud Warning-All workers compensation forms - Sec. 56-_-112(b); Section 56-47-112(b) - Language is mandatory](https://insurancefraud.org/regulations/tennessee-fraud-warning-all-workers-compensation-forms-sec-56-_-112b-section-56-47-112b-language-is-mandatory/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** All workers compensation forms – Sec. 56-\_-112(b) Section 56-47-112(b) – Language is mandatory (b)(1) All printed applications for insurance, and all printed claim forms provided and required by an insurer or required by law as a condition of payment of a claim, shall contain a statement, permanently affixed to the application or claim form, that clearly states in substance the following: “It is a crime to knowingly provide false, incomplete or misleading information to any party to a workers’ compensation transaction for the purpose of committing fraud. Penalties include imprisonment, fines and denial of insurance benefits.” (2) The lack of a statement required in this section does not constitute a defense in any criminal prosecution under § 56-47-103 nor in any civil action under § 56-47-103 or § 56-47-104. **State:** Tennessee **Requirement Types:** Fraud Warning --- ### [Tennessee-Mandatory Reporting-Section 56-47-110 as passed in the Tennessee Workers Compensation Act of 1996](https://insurancefraud.org/regulations/tennessee-mandatory-reporting-section-56-47-110-as-passed-in-the-tennessee-workers-compensation-act-of-1996/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Workers compensation only. (b) Any insurer, insurance professional or other person that has reasonable belief that an act violating Section 56-47-103 or 56-47-104 will be, is being, or has been committed, shall furnish and disclose any information in its possession concerning such act to the appropriate law enforcement official or authority, Department of Commerce and Insurance or Department of Labor, subject to any legal privilege protecting such information.” **State:** Tennessee **Requirement Types:** Mandatory Reporting --- ### [Tennessee-Mandatory Reporting-Section 56-53-109(b)](https://insurancefraud.org/regulations/tennessee-mandatory-reporting-section-56-53-109b/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Section 56-53-109(b) Any insurer or insurance professional that has reasonable belief that an violating Section 56-53-102 or Section 56-53-103 will be, is being, or has been committed shall furnish and disclose any information in its possession concerning such act to the appropriate law enforcement official or authority, insurance department, state division of insurance fraud, or state or federal regulatory or licensing authority, subject to any legal privilege protecting such information. In no case shall the information be required by subpoena or otherwise to be given to the person alleged to have committed a violation, unless in possession of an insurer and that insurer used the information to deny a claim of the person, in whole or in part. **State:** Tennessee **Requirement Types:** Mandatory Reporting --- ### [Tennessee-SIU Requirement-Section 56-47-112](https://insurancefraud.org/regulations/tennessee-siu-requirement-section-56-47-112/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** For workers compensation only. Section 56-47-112 requires insurers to prepare, implement, maintain and submit anti-fraud plans to the Department of Commerce and Insurance. “Each insurer’s antifraud plan shall outline specific procedures to: (A) prevent, detect and investigate all forms of insurance fraud, including fraud involving the insurer’s employees or agents; fraud resulting from misrepresentations in the application, renewal or rating of insurance policies, claims fraud; and security of the insurer’s data processing system; (B) educate appropriate employees on fraud detection and the insurer’s anti-fraud plan; (C) provide for the hiring of or contracting for fraud investigators; (D) report insurance fraud to appropriate law enforcement and regulatory authorities in the investigation and prosecution of insurance fraud; and (E) pursue restitution for financial loss caused by insurance fraud where appropriate.” **State:** Tennessee **Requirement Types:** SIU Requirement --- ### [Texas-Fraud Plan-Texas Insurance Code 704.051; 704.001](https://insurancefraud.org/regulations/texas-fraud-plan-texas-insurance-code-704-051-704-001/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** § 704.051. Antifraud Plan Required for Certain Plan Issuers A plan issuer who collects direct written premium shall adopt an antifraud plan under this subchapter. § 704.001. Definition In this chapter, “plan issuer” means: (1) a health insurer, including a life, health, and accident insurer, a health and accident insurer, a health maintenance organization, and any other person operating under Chapter 841, 842, 843, 884, 885, 982, or 1501 who is authorized to issue, issue for delivery, or deliver insurance policies, certificates, contracts, or evidences of coverage in this state; (2) an approved nonprofit health corporation that holds a certificate of authority issued under Chapter 844; or (3) an insurer authorized by the department to write workers’ compensation insurance in this state. NOTE: Provision affects Life insurer’s, health insurer’s including HMO’s, disability insurer’s and worker’s comp insurer’s. **State:** Texas **Requirement Types:** Fraud Plan --- ### [Texas-Fraud Warning-Texas Insurance Code §704.002.](https://insurancefraud.org/regulations/texas-fraud-warning-texas-insurance-code-§704-002/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** State law requires us to include the following statement: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. **State:** Texas **Requirement Types:** Fraud Warning --- ### [Texas-Mandatory Reporting-Texas Insurance Code Section 701.051](https://insurancefraud.org/regulations/texas-mandatory-reporting-texas-insurance-code-section-701-051/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** § 701.051. DUTY TO REPORT. (a) Not later than the 30th day after the date the person makes the determination or reasonably suspects that a fraudulent insurance act has been or is about to be committed in this state, the person: (1) shall report the information in writing to the insurance fraud unit of the department, in the format prescribed by the fraud unit or by the National Association of Insurance Commissioners; and (2) may also report the information to another authorized governmental agency. (b) A report made to the insurance fraud unit constitutes notice to each other authorized governmental agency. (c) A person who is a member of an organization primarily dedicated to the detection, investigation, and prosecution of insurance fraud fully complies with the person’s obligations under Subsection (a) by authorizing the organization to report on the person’s behalf information required to be reported under Subsection (a). The person retains any liability resulting from the failure of the organization to report in a manner that complies with Subsection (a). **State:** Texas **Requirement Types:** Mandatory Reporting --- ### [Utah-Fraud Plan-31A-31-112. Insurance Antifraud Plan.](https://insurancefraud.org/regulations/utah-fraud-plan-31a-31-112-insurance-antifraud-plan/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** NOTE: The state does not require insurers to file their plans with the department. Only Utah-domiciled insurers will be asked to provide these plans, which will only occur during a normal audit. Plans need not be submitted outside of the normal audit process. 31A-31-112. Insurance Antifraud Plan. (1) An insurer, as defined in Section 31A-31-102, shall prepare, implement, and maintain an insurance antifraud plan for its operations in this state. (2) The insurance antifraud plan required by Subsection (1) shall outline specific procedures, actions, and safeguards that include how the authorized insurer or health maintenance organization will do each of the following: (a) detect, investigate, and prevent all forms of insurance fraud, including: (i) fraud involving its employees or agents; (ii) fraud resulting from misrepresentations in the application, renewal, or rating of insurance policies; (iii) fraudulent claims; and (iv) breach of security of its data processing systems; (b) educate employees of fraud detection and the insurance antifraud plan; (c) provide for fraud investigations, whether through the use of internal fraud investigators or third-party contractors; (d) report a suspected fraudulent insurance act, as described in Section 31A-31-103, to the department as required by Section 31A-31-110; and (e) pursue restitution for financial loss caused by insurance fraud. (3) The commissioner may investigate and examine the records and operations of authorized insurers and health maintenance organizations to determine if they have implemented and complied with the insurance antifraud plan. (4) The commissioner may: (a) direct any modification to the insurance antifraud plan necessary to comply with the requirements of this section; and (b) require action to remedy substantial noncompliance with the insurance antifraud plan. **State:** Utah **Requirement Types:** Fraud Plan --- ### [Utah-Fraud Warning-Section 35-1-109 - Language is permissive for first paragraph and mandatory for second paragraph](https://insurancefraud.org/regulations/utah-fraud-warning-section-35-1-109-language-is-permissive-for-first-paragraph-and-mandatory-for-second-paragraph/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** All workers compensation forms – Sec. 35-1-109 Section 35-1-109 – Language is permissive for first paragraph and mandatory for second paragraph “For your protection, Utah law requires the following to appear on this form: Any person who knowingly presents false or fraudulent underwriting information, files or causes to be filed a false or fraudulent claim for disability compensation or medical benefits, or submits a false or fraudulent report or billing for health care fees or other professional services is guilty of a crime and may be subject to fines and confinement in state prison.” **State:** Utah **Requirement Types:** Fraud Warning --- ### [Utah-Fraud Warning-Statutes Section 28-35-39](https://insurancefraud.org/regulations/utah-fraud-warning-statutes-section-28-35-39/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** For benefit checks. Workers compensation insurance fraud is a crime punishable by Utah law. **State:** Utah **Requirement Types:** Fraud Warning --- ### [Utah-Mandatory Reporting-Utah Code Section 31A-31-110](https://insurancefraud.org/regulations/utah-mandatory-reporting-utah-code-section-31a-31-110/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Utah Code Section 31A-31-110 (1)(a) A person shall report a fraudulent insurance act to the department if: (i) the person has a good faith belief on the basis of a preponderance of the evidence that a fraudulent insurance act is being, will be, or has been committed by a person other than the person making the report; and (ii) the person is: (A) an insurer; or (B) in relation to the business of title insurance, an auditor that is employed by a title insurer. (b) The report required by this Subsection (1) shall: (ii) provide information in detail relating to: (A) the fraudulent insurance act; and (B) the perpetrator of the fraud insurance act; and (iii)(A) state whether the person required to report under Subsection (1)(a) also reported the fraudulent insurance act to: (I) the attorney general; (II) a state law enforcement agency; (III) a criminal investigative department or agency of the United States; (IV) a district attorney; or (V) the prosecuting attorney of a municipality or county; and (B) if the person reported the fraudulent insurance act as provided in Subsection (1)(b)(iii)(A), state the agency to which the person reported the fraudulent insurance act. (c) A person required to submit a written report under Subsection (1) shall submit a written report to the department by no later than 90 days from the day on which the person required to report the fraudulent insurance act has a good faith belief on the basis of a preponderance of the evidence that the fraudulent insurance act is being, will be, or has been committed. (2) An action brought under Section 31A-2-201, 31A-2-308, or 31A-31-109, for failure to comply with Subsection (1) shall be commenced within four years from the date on which a person described in Subsection (1) (a) has a good faith belief on the basis of a preponderance of the evidence that a fraudulent insurance act is being, will be, or has been committed; and (b) willfully fails to report the fradulent insurance act. (3) The department may be rule made in accordance with Title 63, chapter 46a, Utah Administrative Rulemaking Act, provide a process by which a person described in Subsection (1)(a)(ii)(B) may comply with the requirements of Subsection (1) by reporting a fraudulent insurance act to the insurer with whom the person is employed, except that the rule shall provide that if the person reports the fraudulent insurance act to the insurer, the insurer is required to report the fraudulent insurance act to the department. (4) A person described in Subsection (1)(a)(ii) who in good faith makes a report under this section, in accordance with Section 21A-31-105, is immun from civil action, civl penalty, or damages for making the report. **State:** Utah **Requirement Types:** Mandatory Reporting --- ### [Vermont-Fraud Plan-Chapter 130 Section 4750](https://insurancefraud.org/regulations/vermont-fraud-plan-chapter-130-section-4750/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** CHAPTER 130. INSURANCE FRAUD § 4750. INSURER ANTI-FRAUD PLANS (a) Every insurer with direct written premiums shall prepare, implement, and maintain an insurance anti-fraud plan. Each insurer’s anti-fraud plan shall outline specific procedures, appropriate to the type of insurance the insurer writes in this state, to: (1) Prevent, detect, and investigate all forms of insurance fraud, including fraud involving the insurer’s employees or agents; fraud resulting from misrepresentations in the application, renewal, or rating of insurance policies; claims fraud; and security of the insurer’s data processing systems. (2) Educate appropriate employees on fraud detection and the insurer’s anti-fraud plan. (3) Provide for the hiring of or contracting for fraud investigators. (4) Report insurance fraud to appropriate law enforcement and regulatory authorities in the investigation and prosecution of insurance fraud. (5) Where appropriate, pursue restitution for financial loss caused by insurance fraud. (6) Ensure that applicable state and federal privacy laws are complied with and that the confidential personal and financial information of consumers and insureds is protected. (7) Comply with such other procedures as the commissioner may require by rule. b) The commissioner may require an insurer to file annually its anti-fraud plan with the department and an annual summary of the insurer’s anti-fraud activities and results, including misclassification and miscoding. A workers’ compensation insurer shall file an anti-fraud plan with the department of labor, including information about fraud investigations, referrals, or prosecutions involving Vermont workers’ compensation claims, misclassifications, and miscoding, if requested by the commissioner of labor. Information regarding fraud investigations and referrals shall not be public unless the commissioner of labor or the attorney general commences administrative or criminal proceedings. (c) This section confers no private rights of action. This section does not affect private rights of action conferred under other laws or court decisions. (d) Enforcement. Notwithstanding any other provision of this title, the following are the exclusive monetary penalties for violation of this section. Insurers that fail to prepare, implement, maintain, or submit to the department of banking, insurance, securities, and health care administration an insurance anti-fraud plan are subject to a penalty of $500.00 per day, not to exceed $10,000.00. Sec. 3. 1 V.S.A. § 317(c)(36) is added to read: (36) anti-fraud plans and summaries submitted by insurers to the department of banking, insurance, securities, and health care administration for the purposes of complying with 8 V.S.A. § 4750. **State:** Vermont **Requirement Types:** Fraud Plan --- ### [Virginia-Fraud Warning-Section 52-40(B) - of S. 421, Chapter 590, Laws 1998](https://insurancefraud.org/regulations/virginia-fraud-warning-section-52-40b-of-s-421-chapter-590-laws-1998/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Section 52-40(B) – of S. 421, Chapter 590, Laws 1998 B. All applications for insurance and all claim forms provided and required by an insurer or required by law as a condition of payment of a claim shall contain a statement, permanently affixed to, or included as a part of the application or claim form, that clearly states in substance the following: “It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.” The lack of a statement required in this subsection does not constitute a defense in any criminal prosecution. The statement required by this subsection shall not be required on applications and forms relating to reinsurance. **State:** Virginia **Requirement Types:** Fraud Warning --- ### [Virginia-Mandatory Reporting-Section 52-40(A) - of S. 421, Chapter 590, Laws 1998](https://insurancefraud.org/regulations/virginia-mandatory-reporting-section-52-40a-of-s-421-chapter-590-laws-1998/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Section 52-40(A) – of S. 421, Chapter 590, Laws 1998 A. If any insurer, any employee thereof, or any insurance professional has knowledge of, or has reason to believe that a violation of Section 18.2-178 will be, is being, or has been committed, that person shall furnish and disclose any information in his possession concerning the fraudulent act to the Department, (Department of State Police) subject to any legal privilege protecting such information. **State:** Virginia **Requirement Types:** Mandatory Reporting --- ### [Washington-Annual Reporting-48.30A.060](https://insurancefraud.org/regulations/washington-annual-reporting-48-30a-060/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** By March 31st of each year, each insurer shall provide to the insurance commissioner a summary report on actions taken under its antifraud plan to prevent and combat insurance fraud. The report must also include, but not be limited to, measures taken to protect and ensure the integrity of electronic data processing-generated data and manually compiled data, statistical data on the amount of resources committed to combatting fraud, and the amount of fraud identified and recovered during the reporting period. The antifraud plans and summary of the insurer’s antifraud activities are not public records and are exempt from chapter 42.56 RCW, are proprietary, are not subject to public examination, and are not discoverable or admissible in civil litigation. **State:** Washington **Requirement Types:** Annual Reporting --- ### [Washington-Fraud Plan-Chapter 285, Laws of 1995 - Sections 8 - 11](https://insurancefraud.org/regulations/washington-fraud-plan-chapter-285-laws-of-1995-sections-8-11/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Section 9 — Each insurer licensed to write direct insurance in this state shall institute and maintain an insurance antifraud plan. An insurer licensed on the effective date of this act shall file its antifraud plan with the insurance commissioner no later than December 31, 1995. An insurer licensed after the effective date of this act shall file its antifraud plan within six months of licensure. An insurer shall file any change to the antifraud plan with the insurance commissioner within thirty days after the plan has been modified. Section 10 — An insurer’s antifraud plan must establish specific procedures to: (1) Prevent insurance fraud, including internal fraud involving employees or company representatives, fraud resulting from misrepresentation on applications for insurance coverage, and claims fraud; (2) Review claims in order to detect evidence of possible insurance fraud and to investigate claims where fraud is suspected; (3) Report fraud to appropriate law enforcement agencies and cooperate with those agencies in their prosecution of fraud cases; (4) Undertake civil actions against persons who have engaged in fraudulent activities; (5) Train company employees and agents in the detection and prevention of fraud.” Section 11 — If after review of an insurer’s antifraud plan, the commissioner finds that the plan does not comply with section 10 of this act, the commissioner may disapprove the antifraud plan . . . Note: In 1997, HB 1002 exempted life and health insurers from anti-fraud plan requirements. Department Advisory: http://www.insurance.wa.gov/companies/anti-fraud-guidelines.shtml **State:** Washington **Requirement Types:** Fraud Plan --- ### [Washington-Fraud Warning-48.135.080](https://insurancefraud.org/regulations/washington-fraud-warning-48-135-080/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** No later than six months after July 1, 2006, or when the insurer has used all its existing paper application and claim forms which were in its possession on July 1, 2006, whichever is later, all applications for insurance, and all claim forms regardless of the form of transmission provided and required by an insurer or required by law as condition of payment of a claim, must contain a statement, permanently affixed to the application or claim form, that clearly states in substance the following: “It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.” The lack of a statement required in this section does not constitute a defense in any criminal prosecution nor any civil action. **State:** Washington **Requirement Types:** Fraud Warning --- ### [Washington-Mandatory Reporting-Section 48.135.050 Section 48.50.030 Section 48.50.040 (fire) Section 48.50.070 (immunity)](https://insurancefraud.org/regulations/washington-mandatory-reporting-section-48-135-050-section-48-50-030-section-48-50-040-fire-section-48-50-070-immunity/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** RCW 48.135.050 Furnishing and disclosing insurance fraud knowledge and information. (1) Any insurer or licensee of the commissioner that has reasonable belief that an act of insurance fraud which is or may be a crime under Washington law has been, is being, or is about to be committed shall furnish and disclose the knowledge and information to the commissioner or the national insurance crime bureau, the national association of insurance commissioners, or similar organization, who shall disclose the information to the commissioner, and cooperate fully with any investigation conducted by the commissioner. (2) Any person that has a reasonable belief that an act of insurance fraud which is or may be a crime under Washington law has been, is being, or is about to be committed; or any person who collects, reviews, or analyzes information concerning insurance fraud which is or may be a crime under Washington law may furnish and disclose any information in its possession concerning such an act to the commissioner or to an authorized representative of an insurer that requests the information for the purpose of detecting, prosecuting, or preventing insurance fraud. 48.50.030 Release of information or evidence by insurer. (1) Any authorized agency may request, in writing, that an insurer release to the agency any or all relevant information or evidence which the insurer may have in its possession relating to criminal activity, if such information or evidence is deemed important by the agency in its discretion. (2) An insurer who has reason to believe that a person participated or is participating in criminal activity relating to a contract of insurance may report relevant information to an authorized agency. (3) The information provided to an authorized agency under this section may include, without limitation: (a) Pertinent insurance policy information relating to a claim under investigation and any application for such a policy; (b) Policy premium payment records which are available; (c) History of previous claims in which the person was involved; and (d) Material relating to the investigation of the loss, including statements of any person, proof of loss, and any other evidence found in the investigation. (4) The insurer receiving a request under subsection (1) of this section shall furnish all relevant information requested to the agency within a reasonable time, orally or in writing. 48.50.040. Notification by insurer. (1) When an insurer has reason to believe that a fire loss reported to the insurer may be of other than accidental cause, the insurer shall notify the chief of the Washington state patrol, through the director of fire protection, in the manner prescribed under RCW 48.05.320 concerning the circumstances of the fire loss, including any and all relevant material developed from the insurer’s inquiry into the fire loss. (2) Notification of the chief of the Washington state patrol, through the director of fire protection, under subsection (1) of this section does not relieve the insurer of the duty to respond to a request for information from any other authorized agency and does not bar an insurer from other reporting under RCW 48.50.030(2). 48.50.070. Immunity from liability for releasing information. Any licensed insurance producer, title insurance agent, or insurer or person acting in the insurer’s behalf, health maintenance organization or person acting in behalf of the health maintenance organization, health care service contractor or person acting in behalf of the health care service contractor, or any authorized agency which releases information, whether oral or written, to the commissioner, the national insurance crime bureau, the national association of insurance commissioners, other law enforcement agent or agency, or another insurer under RCW 48.50.030, 48.50.040, 48.50.050, 48.50.055, or 48.135.050 is immune from liability in any civil or criminal action, suit, or prosecution arising from the release of the information, unless actual malice on the part of the insurance producer, title insurance agent, insurer, health care maintenance organization, health care service contractor, or authorized agency against the insured is shown. **State:** Washington **Requirement Types:** Mandatory Reporting --- ### [West Virginia-Fraud Warning-Section 33-41-3](https://insurancefraud.org/regulations/west-virginia-fraud-warning-section-33-41-3/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** §33-41-3. Fraud warning authorized; statement required of nonadmitted insurers. (a) Claims forms and applications for insurance, regardless of the form of transmission, may contain the following warning or a substantially similar caveat: “Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.” (b) The lack of a warning as authorized by the provisions of subsection (a) of this section does not constitute a defense in any prosecution for a fraudulent or illegal act nor shall it constitute the basis for any type of civil cause of action. (c) Policies issued by nonadmitted insurers pursuant to article twelve-c of this chapter shall contain a statement disclosing the status of the insurer to do business in the state where the policy is delivered or issued for delivery or the state where coverage is in force. The requirement of this subsection may be satisfied by a disclosure specifically required by section five, article twelve-c of this chapter; section nine, article thirty-two of this chapter; and section eighteen, article thirty-two of this chapter. **State:** West Virginia **Requirement Types:** Fraud Warning --- ### [Oklahoma-Fraud Warning-Section 3613.1](https://insurancefraud.org/regulations/oklahoma-fraud-warning-section-3613-1/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Section 3613.1 – Language is permissive “WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.” The section also states that the absence of a warning is not a defense against prosecution for insurance fraud. **State:** Oklahoma **Requirement Types:** Fraud Warning --- ### [Oklahoma-Mandatory Reporting-Section 3(a) of House Bill 1502 - Title 36 Section 363](https://insurancefraud.org/regulations/oklahoma-mandatory-reporting-section-3a-of-house-bill-1502-title-36-section-363/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (A) Any insurer who has reason to believe that a person or entity has engaged in or is engaging in an act or practice that violates any statute or administrative rule of this state related to insurance fraud shall immediately notify the Anti-Fraud Unit of the Insurance Department. **State:** Oklahoma **Requirement Types:** Mandatory Reporting --- ### [Oregon-Fraud Warning-Bulletin INS 2010-03 TO: All Insurers RE: Use of a Fraud or Misstatement Warning This Bulletin replaces INS 98-5](https://insurancefraud.org/regulations/oregon-fraud-warning-bulletin-ins-2010-03-to-all-insurers-re-use-of-a-fraud-or-misstatement-warning-this-bulletin-replaces-ins-98-5/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Warning statements may be included on insurance applications, claim forms and claim payments. They may appear in policies and declaration pages only if the statement is part of the application for insurance. The Insurance Division reviews statements according to the following guidelines: For remedies other than denial of a claim (e.g. rescission or cancellation, depending upon statute), fraud or misstatement warnings must assert that misstatements, misrepresentations, omissions or concealments on the part of the insured must either be fraudulent or material to the interests of the insurer in order for the insurer to assert a right to remedy. Fraud or misstatement warnings must clarify that in order for an insurer to deny a claim on the basis of misstatements, misrepresentations, omissions or concealments on the part of the insured, the insurer must show that the misinformation is material to the content of the contract, that the insurer relied upon the misinformation and that the information was either material to the risk assumed by the insurer or that the misinformation was provided fraudulently (ORS 742.013). Depending on the type of contract, fraud or misstatement warnings may need to include an acknowledgment that material misrepresentations must be willful or intentional in order to trigger the right to remedy (e.g. fire insurance, ORS 742.208). Fraud or misstatement warnings must acknowledge that misstatements, misrepresentations, omissions or concealments on the part of the insured are not fraudulent unless they are made with intent to knowingly defraud. Fraud or misstatement warnings using the term “deceptive” must clearly relate the term to activities that are material to the risk at issue or to the claim. Fraud or misstatement warnings that connect fraud statements with criminal penalties must be phrased to avoid definite statements of guilt. Phrases such as, “may be guilty of insurance fraud,” or “may be subject to prosecution for insurance fraud” are acceptable. Fraud or misstatement warnings on life insurance policies must not conflict with the applicable two-year limit on contestability under Oregon law. Fraud or misstatement warnings on health insurance policies must not conflict with the applicable two-year limit on contestability under Oregon law, except that they must disclose that there is no time limit on contestability in the event of fraud on the part of the insured. **State:** Oregon **Requirement Types:** Fraud Warning --- ### [Oregon-Mandatory Reporting-Section 731.592](https://insurancefraud.org/regulations/oregon-mandatory-reporting-section-731-592/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Section 731.592 (1) Notwithstanding ORS 746.665 (Limitations and conditions on disclosure of certain information), an insurer shall cooperate with any law enforcement agency or other state or federal agency that is investigating or prosecuting suspected criminal conduct involving insurance. The insurer shall provide any information requested by the agency unless the information is subject to a legal privilege that would prohibit disclosure. (2) If an insurer has reason to believe that criminal conduct involving insurance has been, is being or is about to be committed, the insurer shall notify the appropriate agency of that fact. The insurer is not required to notify the agency if the information or any part of the information upon which the belief is based is protected from disclosure by legal privilege. (3) An insurer providing information under this section may request information relating to the investigation that is in the possession or control of the agency. The agency may not provide an insurer with information that is privileged or confidential. Otherwise, the agency shall disclose requested information unless disclosure would jeopardize an ongoing investigation or prosecution. The agency may require that the insurer not disclose the information to any other person. (4) A person who has reason to believe criminal conduct involving insurance has been, is being or is about to be committed, or who collects, reviews or analyzes information concerning suspected criminal conduct involving insurance, may furnish any unprivileged information in the person’s possession concerning the suspected criminal conduct to an insurer who requests the information for the purpose of detecting, prosecuting or preventing criminal conduct involving insurance. (5) If an insurer or agency does not provide information as required by this section and the suspected criminal conduct results in a conviction, the insurer or agency is not eligible for any compensation to which the insurer or agency might otherwise be entitled from any award under ORS 137.106 (Restitution to victims). **State:** Oregon **Requirement Types:** Mandatory Reporting --- ### [Pennsylvania-Annual Reporting-Section 1814 — “Report on antifraud activities](https://insurancefraud.org/regulations/pennsylvania-annual-reporting-section-1814-report-on-antifraud-activities/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** All insurer shall annually provide to the department a summary report on actions taken under the plan to prevent and combat insurance fraud, including, but not limited to, measures taken to protect and ensure the integrity of electronic data-processing-generated data and manually compiled data, statistical data on the amount of resources committed to combating fraud, and the amount of fraud identified and recovered during the reporting period. \[Deadlines for submission is April 1.\] **State:** Pennsylvania **Requirement Types:** Annual Reporting --- ### [Pennsylvania-Fraud Plan-Title 75 Sections 1811-1816](https://insurancefraud.org/regulations/pennsylvania-fraud-plan-title-75-sections-1811-1816/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Title 75 Sections 1811-1816 (Motor Vehicle Insurance Fraud) Section 1811 — Each insurer licensed to write motor vehicle insurance in this Commonwealth shall institute and maintain a motor vehicle insurance antifraud plan…. All insurers licensed … shall file within six months of licensure. All changes to the antifraud plan shall be filed with the department within 30 days after it has been modified. § 1812. Content of plans. The antifraud plans of each insurer shall establish specific procedures: (1) To prevent insurance fraud, including internal fraud involving employees or company representatives, fraud resulting from misrepresentation on applications for insurance coverage, and claims fraud. (2) To review claims in order to detect evidence of possible insurance fraud and to investigate claims where fraud is suspected. (3) To report fraud to appropriate law enforcement agencies and to cooperate with such agencies in their prosecution of fraud cases. (4) To undertake civil actions against persons who have engaged in fraudulent activities. (5) To report fraud-related data to a comprehensive database system. (6) To ensure that costs incurred as a result of insurance fraud are not included in any rate base affecting the premiums of motor vehicle insurance consumers. WORKERS COMPENSATION FRAUD PLANS Pennsylvania Administrative Code TITLE 31. INSURANCE PART VII. PROPERTY, FIRE AND CASUALTY INSURANCE CHAPTER 119. ANTI-FRAUD — STATEMENT OF POLICY ANTIFRAUD PLANS § 119.22. Institution and maintenance of anti-fraud plans (a) Section 1203 of the act (77 P. S. § 1040.3) requires insurers, as defined in section 1101of the act (77 P. S. § 1039.1), to institute and maintain an insurance anti-fraud plan. This requirement applies to a workers’ compensation insurer with workers’ compensation premium volume as of August 31, 1993. Workers’ compensation insurers which become licensed or commence a writing premium volume, or both, after August 31, 1993, should institute and maintain an anti-fraud plan within 4 months of commencing to write business. Maintenance of the anti-fraud plan includes its ongoing implementation and operation by insurers. Since a substantial number of workers’ compensation insurers also actively write motor vehicle insurance, the Department encourages insurers to merge their workers’ compensation anti- fraud initiatives into their established motor vehicle insurance anti-fraud plans established under 75 Pa.C.S. Chapter 18 (relating to motor vehicle insurance fraud). The content of each insurers’ workers’ compensation anti-fraud plan should reflect the following minimum requirements: (1) Policies and procedures established by the insurer to prevent workers’ compensation insurance fraud. The policies and procedures should cover all aspects of the insurer’s operation and recognize the wide variety of potential fraudulent activity. Procedures should address internal fraud, fraud involving the integrity and security of company data including electronic data processed information, fraud involving employees or company representatives, and fraud resulting from misrepresentation on applications and renewals for insurance coverage and claims fraud. Detailed information should be provided describing existing procedure manuals, internal policies, guidelines and employe training programs implemented by the insurer to prevent fraud. It is recommended that specific policies and procedures be either included in the anti-fraud plan or, if the policies and procedures are voluminous, appropriately summarized. (2) Policies and procedures established by the workers’ compensation insurer to detect and investigate possible insurance fraud in the claims process. Reference should be made to specific procedure manuals, internal policies, guidelines and training initiatives designed to detect fraud in the claims process. (3) Policies and procedures established by the insurer to report workers’ compensation insurance fraud to appropriate criminal law enforcement agencies, including procedures to cooperate with and monitor progress of the agencies in their fraud cases. (b) To facilitate the Department’s understanding of insurers’ administration of their anti-fraud procedures, insurers are encouraged to cover the following areas in their plans: (1) Organizational components involved in or affected by the policies and procedures, including key positions involved. (2) Roles and interrelationships of components as they relate to the policies and the procedures described. (3) Personnel resources involved and budget allocations to implement the anti-fraud policies and procedures. (4) Extra-company relationships with central claims data bases and criminal law enforcement authorities as they relate to the policies and procedures implemented for anti-fraud plans. **State:** Pennsylvania **Requirement Types:** Fraud Plan --- ### [Pennsylvania-Fraud Warning-Section 117.4; 18 Pa. CSA 4117(k)(1)](https://insurancefraud.org/regulations/pennsylvania-fraud-warning-section-117-4-18-pa-csa-4117k1/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Anti-arson applications – Section 117.4 All application and claim forms Section 68.402 Section 117.4 – anti-arson applications – Language is mandatory “I (We) certify that all information contained herein is true and correct to the best of my (our) knowledge and belief. I (We) acknowledge that this statement is signed under the pains and penalties of perjury and any material false statement contained herein is punishable pursuant to 18 PA.C.S. Sec. 4904(b). I (We) acknowledge that this application shall constitute a part of any policy issued whether attached or not and that any willful concealment or misrepresentation of a material fact or circumstance shall be deemed grounds to void any policy issued. I (We) acknowledge that I (we) must notify the insurer in writing of any change in the information contained in this application within 60 days.” 18 Pa. CSA 4117(k)(1) (k) Insurance forms and verification of services.– All applications for insurance and all claim forms shall contain or have attached thereto the following notice: “Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.” **State:** Pennsylvania **Requirement Types:** Fraud Warning --- ### [Pennsylvania-Mandatory Reporting-Title 75 Section 1817;Title 31 Sections 119.22-26; 31 Sec. 119.22; 31 Sec. 119.23; 31 Section 119.24; 31 Section 119.25; Title 31, Section 119.25](https://insurancefraud.org/regulations/pennsylvania-mandatory-reporting-title-75-section-1817title-31-sections-119-22-26-31-sec-119-22-31-sec-119-23-31-section-119-24-31-section-119-25-title-31-section-119-25/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Title 75 Section 1817 — Reporting Requirements (Motor Vehicle Insurance Fraud) “Every insurer licensed to do business in this Commonwealth, and its employees, agents, brokers, motor vehicle physical damage appraisers and public adjusters, or public adjuster solicitors, who has a reasonable basis to believe insurance fraud has occurred shall be required to report the incidence of suspected insurance fraud to Federal, state or local criminal law enforcement authorities. Licensed insurance agents and physical damage appraisers may elect to report suspected fraud through the affected insurer with which they have a contractual relationship. All reports of insurance fraud shall be made in writing. Where insurance fraud involves agents, brokers, motor vehicle physical damage appraisers, public adjusters or public adjuster solicitors, a copy of the report shall also be sent to the department.” Title 31 Sections 119.22-26 — Reporting Requirements (Workers Compensation Fraud Plans) 31 Sec. 119.22 – Institution and maintenance of anti-fraud plans (a) Section 1203 of the act (\_\_\_ P.S. \_\_\_) requires insurers, as defined in section 1101 of the act (\_\_\_P.S.\_\_\_), to institute and maintain an insurance anti-fraud plan. This requirement applies to a workers’ compensation insurer with workers’ compensation premium volume as of August 31, 1993. Workers’ compensation insurers which become licensed or commence a writing premium volume, or both, after August 31, 1993, should institute and maintain an anti-fraud plan within 4 months of commencing to write business. Maintenance of the anti-fraud plan include its ongoing implementation and operation by insurers. Since a substantial number of workers’ compensation insurers also actively write motor vehicle insurance, the Department encourages insurers to merge their workers’ compensation anti-fraud initiatives into their established motor vehicle insurance anti-fraud plans established under 75 Pa.C.S. Chapter 18 (relating to motor vehicle insurance fraud). The content of each insurers’ workers’ compensation anti-fraud plan should reflect the following minimum requirements: (1) Policies and procedures established by the insurer to prevent workers’ compensation insurance fraud. The policies and procedures should cover all aspects of the insurer’s operation and recognize the wide variety of potential fraudulent activity. Procedures should address internal fraud, fraud involving the integrity and security of company data including electronic data processed information, fraud involving employers or company representatives, and fraud resulting from misrepresentation on applications and renewals for insurance coverage and claims fraud. Detailed information should be provided describing existing procedure manuals, internal policies, guidelines and employee training programs implemented by the insurer to prevent fraud. It is recommended that specific policies and procedures be either included in the anti-fraud plan or, if the policies and procedures are voluminous, appropriately summarized. (2) Policies and procedures established by the workers’ compensation insurer to detect and investigate possible insurance fraud in the claims process. Reference should be made to specific procedure manuals, internal policies, guidelines and training initiatives designed to detect fraud in the claims process. (3) Policies and procedures established by the insurer to report workers’ compensation insurance fraud to appropriate criminal law enforcement agencies, including procedures to cooperate with and monitor progress of the agencies in their fraud cases. (b) To facilitate the Department’s understanding of insurers’ administration of their anti-fraud procedures, insurers are encouraged to cover the following areas in their plans: (1) Organizational components involved in or affected by the policies and procedures, including key positions involved. (2) Roles and interrelationships of components as they relate to the policies and the procedures described. (3) Personnel resources involved and budget allocations to implement the anti-fraud policies and procedures. (4) Extra-company relationships with central claims data bases and criminal law enforcement authorities as they relate to the policies and procedures implemented for anti-fraud plans. 31 Sec. 119.23 – Anti-fraud plan certification Each insurer writing workers’ compensation insurance … shall certify … that it has instituted and maintains an anti-fraud plan. 31 Section 119.24 – Anti-fraud plan annual reports § 119.24. Anti-fraud plan annual reports. (a) Section 1204 of the act (77 P. S. § 1040.4) requires insurers to report annually to the Department a summary of actions taken under their anti-fraud plans to prevent and combat fraud. Annual reports under this section should cover anti-fraud activities for each calendar year. The first annual report should cover the period August 31, 1993, through December 31, 1994, and shall be filed with the Department by March 31, 1995. Thereafter, reports are to be filed by March 31 of each year and cover the previous calendar year’s anti-fraud activities. The annual report should provide detailed information on the following: (1) Specific actions taken by the insurer during the year to prevent and combat insurance fraud. The actions should be thoroughly described in the annual report and should contain statistical information relating to the number of cases of detected fraud, including the status of disposition of those cases, the number of personnel and other resources committed to detecting and combating fraud, the total dollar cost of fraud and the savings attributed to detected fraud or otherwise recovered by the insurer. (2) Measures implemented throughout the year to provide for the integrity and security of fraud related data and information collected and maintained. The measures apply to data collected and maintained in a manual or automated environment. (3) Originating sources of the information on the fraudulent activity—for example, an agent, adjuster, employe, policyholder or citizen. (b) The annual reports should be submitted to the Department in a standard report format, including a table of contents, summary, subdivisions of information in the report, including tables and graphs necessary to clearly illustrate the statistical information. Additionally, insurers should identify the person responsible for preparing and filing the annual report. The Department may require that the insurer clarify items addressed in the report or provide additional information relative to the annual report. (c) Workers’ compensation insurers which also write motor vehicle insurance may file a single annual report for both motor vehicle and workers’ compensation insurance anti-fraud activities. The combined report shall segregate the information reported for both motor vehicle and workers’ compensation lines of business. The reports should be sent to the attention of the Insurance Department, Dennis C. Shoop, Director, Bureau of Enforcement, 1321 Strawberry Square, Harrisburg, Pennsylvania, 17120. (Deadline for Submission is March 31) 31 Section 119.25 – Reporting of fraud to criminal law enforcement authorities Consistent with section 1109 of the act (77 P. S. § 1039.9), section 1205 of the act (77 P. S. § 1040.5) authorizes insurers to refer an incidence of fraud to criminal law enforcement agencies. Workers’ compensation insurers should refer cases directly to criminal law enforcement authorities and cooperate with and assist those authorities when requested. **State:** Pennsylvania **Requirement Types:** Mandatory Reporting --- ### [Rhode Island-Fraud Plan-27-54.1-5. Insurer antifraud initiatives.](https://insurancefraud.org/regulations/rhode-island-fraud-plan-27-54-1-5-insurer-antifraud-initiatives/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** 27-54.1-5. Insurer antifraud initiatives. — (a) Insurers shall have antifraud initiatives reasonably calculated to detect, report, prosecute and prevent fraudulent insurance acts, antifraud initiatives may include: (1) Fraud investigators, who may be insurer employees or independent contractors; or (2) An antifraud plan. (b) A person engaged in the business of insurance having knowledge or a reasonable belief that a fraudulent insurance act is being, will be or has been committed shall provide such information to the governmental unit responsible for investigation of such act, or if no such unit exists to the commissioner. **State:** Rhode Island **Requirement Types:** Fraud Plan --- ### [Rhode Island-Fraud Warning-27-54.1-3. Fraud warning required](https://insurancefraud.org/regulations/rhode-island-fraud-warning-27-54-1-3-fraud-warning-required/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** 27-54.1-3. Fraud warning required. — (a) Notwithstanding any similar requirements in title 28, every claim form and application for insurance, regardless of the form of transmission, shall contain the following statement or a substantially similar statement: “Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.” (b) The lack of a statement as required in subsection (a) of this section does not constitute a defense in any prosecution for a fraudulent insurance act. (c) The requirements of this section shall not apply to reinsurance claims forms or reinsurance applications. (d) The requirements of this section shall not apply to any claim form for health insurance which is on a form promulgated by the centers for Medicare and Medicaid services or in electronic format pursuant to 45 CFR Part 162. **State:** Rhode Island **Requirement Types:** Fraud Warning --- ### [Rhode Island-Fraud Warning-Section 27-5-2.1 - Language is mandatory](https://insurancefraud.org/regulations/rhode-island-fraud-warning-section-27-5-2-1-language-is-mandatory/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Anti-arson applications – Sec. 27-5-2.1 Section 27-5-2.1 – Language is mandatory Property insurers are required to use the ACORD Supplementary Property Application Form 190 as the mandatory anti-arson application. **State:** Rhode Island **Requirement Types:** Fraud Warning --- ### [Rhode Island-Fraud Warning-Statutes Section 28-35-39](https://insurancefraud.org/regulations/rhode-island-fraud-warning-statutes-section-28-35-39/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** For benefit checks. Statutes Section 28-35-39 I understand that endorsement whereon or deposit to my accounts constitutes my affirmation that I am receiving these benefits under the R.I. workers’ compensation act, that I have made no false claims or statements or concealed any material fact, and that doing so would make me liable for civil and criminal penalties including jail. **State:** Rhode Island **Requirement Types:** Fraud Warning --- ### [Rhode Island-Mandatory Reporting-Chapter 42-16.1-14 of the General Laws entitled “Department of Labor and Training” Section 27-49-5.1](https://insurancefraud.org/regulations/rhode-island-mandatory-reporting-chapter-42-16-1-14-of-the-general-laws-entitled-department-of-labor-and-training-section-27-49-5-1/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Workers compensation only. Disclosure of information to the fraud prevention unit — Any insurer, or agent authorized by the insurer to act on its behalf, having reason to believe that an insurance transaction may be fraudulent, shall send to the fraud prevention unit a report of the transaction and any additional information requested by the unit. The unit shall review the reports submitted and undertake further investigation in appropriate cases, as determined by the unit. § 27-49-5.1 — Insurer disclosure – Qualified immunity. (a) An insurer and an agent authorized to act on its behalf, upon written request, may provide to another insurer or insurance industry related organization whose purpose it is to investigate or assist in the prosecution of motor vehicle insurance fraud any and all relevant factually accurate information which the insurer may possess as to any motor vehicle claim or other information which may relate to whether a motor vehicle theft or motor vehicle insurance fraud has occurred. (b) No insurer, organization or agent authorized to act under subsection (a) of this section shall be subjected to any civil or criminal liability in any cause of action of any kind for releasing or receiving any relevant factually accurate information pursuant to subsection (a) of this section if it acts in good faith and with due care solely for the purpose of facilitating the discovery and prosecution of the theft or fraud. **State:** Rhode Island **Requirement Types:** Mandatory Reporting --- ### [Rhode Island-Pre-insurance Inspection-Pre-Inspection Regulation LXXVII (77)](https://insurancefraud.org/regulations/rhode-island-pre-insurance-inspection-pre-inspection-regulation-lxxvii-77/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Pre-Inspection Regulation LXXVII (77) Photograph required — Yes Grace Period (days) — 7 Exemptions/Waivers Existing Policyholder (years) — 4 Renewal Policy — Yes New Cars — Yes Vehicle Age — 6 **State:** Rhode Island --- ### [South Carolina-Mandatory Reporting-Section 38-55-570 (A)](https://insurancefraud.org/regulations/south-carolina-mandatory-reporting-section-38-55-570-a/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Section 38-55-570 (A) “Any person, insurer, or authorized agency having reason to believe that another has made a false statement or misrepresentation or has knowledge of a suspected false statement or misrepresentation shall, for purposes of reporting and investigation, notify the Insurance Fraud Division of the Office of the Attorney General of the knowledge or belief and provide any additional information within his possession relative thereto.” **State:** South Carolina **Requirement Types:** Mandatory Reporting --- ### [South Dakota-Mandatory Reporting-Section 58-33-76 Section 58-33-77 Section 58-33-79](https://insurancefraud.org/regulations/south-dakota-mandatory-reporting-section-58-33-76-section-58-33-77-section-58-33-79/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** 58-33-76. Notification of suspected fraud. An insurer, or any person authorized to act on its behalf, which reasonably believes that a false or fraudulent claim, statement, or representation has occurred, may notify an authorized agency and provide it with all relevant information in its possession. 58-33-77. Accessibility of information relevant to suspected fraud–Types of information. Upon request by an insurer to an authorized agency or by an authorized agency to an insurer, each may provide to the other, directly or through any person authorized to act on its behalf, all information relevant to any suspected false or fraudulent claim, statement, or representation, including the following information: (1) Insurance policy information relevant to an investigation, including any application for such a policy; (2) Available policy premium payment records; (3) History of previous claims made by an insured; and (4) Information relating to the investigation of any suspected insurance fraud, including statements of any person, proofs of loss and notice of loss. 58-33-79. Liability of supplier of information. Any insurer, authorized agency, or person authorized to act on their behalf, acting without bad faith or malice, who provides or receives information pursuant to §§ 58-33-76 and 58-33-77 is not subject to criminal prosecution, civil penalty, or civil liability therefor, except in cases of perjury or insurance fraud. Source: SL 1993, ch 368, § 5. **State:** South Dakota **Requirement Types:** Mandatory Reporting --- ### [Tennessee-Annual Reporting-Chapter No. 356 – Enacted 2001 Legislative Session, Section 12 (a)](https://insurancefraud.org/regulations/tennessee-annual-reporting-chapter-no-356-enacted-2001-legislative-session-section-12-a/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Chapter No. 356 – Enacted 2001 Legislative Session Section 12 (a) The commissioner may require each insurer to file a summary of the insurer’s anti-fraud activities and results. The anti-fraud plans and the summary of the insurer’s anti-fraud activities and results are not public records and are exempt from the public records act, and shall be proprietary and not subject to public examination, and shall not be discoverable or admissible in civil litigation. (Note: The commissioner currently is not requiring any summary filed with the department.) **State:** Tennessee **Requirement Types:** Annual Reporting --- ### [Tennessee-Annual Reporting-Section 56-47-112(a)(5)](https://insurancefraud.org/regulations/tennessee-annual-reporting-section-56-47-112a5/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** For Workers Compensation Only. Section 56-47-112(a)(5) The commissioner may require each insurer to file a summary of the insurer’s anti-fraud activities and results. The anti-fraud plans and the summary of the insurer’s anti-fraud activities and results are not public records and are exempt from title 10, chapter 7, part 5, and shall be proprietary and not subject to public examination, and shall not be discoverable or admissible in civil litigation. **State:** Tennessee **Requirement Types:** Annual Reporting --- ### [Tennessee-Fraud Plan-56-53-111](https://insurancefraud.org/regulations/tennessee-fraud-plan-56-53-111/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Chapter No. 356 – Enacted 2001 Legislative Session Section 12 (b) (1)(A) No later than six (6) months after the effective date of this act, all applications for insurance, and all claim forms regardless of the form of transmission provided and required by an insurer or required by law as a condition of payment of a claim, shall contain a statement, permanently affixed to the application or claim form, that clearly states in substance the following, or words to that effect: “It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.” (1)(B) The lack of a statement required in this subsection does not constitute a defense in any criminal prosecution under Section 3 nor in any civil action under Section 3 or 4. (2) The warning required by this subsection shall not be required on forms relating to reinsurance. Fraud Plan/SIU Requirement Chapter No. 356 – Enacted 2001 Legislative Session Section 12 (a) Anti-Fraud Plans Within six months of the effective date of this legislation, every insurer with direct written premiums exceeding ten million dollars ($10,000,000) shall prepare, implement, and maintain an insurance anti-fraud plan. Each insurer’s anti-fraud plan shall outline specific procedures, appropriate to the type of insurance the insurer writes in the state, to: (1) Prevent, detect and investigate all forms of insurance fraud, including fraud involving the insurer’s employees or agents; fraud resulting from misrepresentations in the application, renewal or rating of insurance policies; claims fraud; and security of the insurer’s data processing system; (2) Educate appropriate employees on fraud detection and the insurer’s anti-fraud plan; (3) Provide for the hiring of or contracting for fraud investigators; (4) Report insurance fraud to appropriate law enforcement and regulatory authorities in the investigation and prosecution of insurance fraud; and (5) Pursue restitution for financial loss caused by insurance fraud, where appropriate. **State:** Tennessee **Requirement Types:** Fraud Plan --- ### [Tennessee-Fraud Plan-Section 56-47-112](https://insurancefraud.org/regulations/tennessee-fraud-plan-section-56-47-112/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** For workers compensation only. Section 56-47-112 requires insurers to prepare, implement, maintain and submit anti-fraud plans to the Department of Commerce and Insurance. “Each insurer’s antifraud plan shall outline specific procedures to: (A) prevent, detect and investigate all forms of insurance fraud, including fraud involving the insurer’s employees or agents; fraud resulting from misrepresentations in the application, renewal or rating of insurance policies, claims fraud; and security of the insurer’s data processing system; (B) educate appropriate employees on fraud detection and the insurer’s anti-fraud plan; (C) provide for the hiring of or contracting for fraud investigators; (D) report insurance fraud to appropriate law enforcement and regulatory authorities in the investigation and prosecution of insurance fraud; and (E) pursue restitution for financial loss caused by insurance fraud where appropriate.” **State:** Tennessee **Requirement Types:** Fraud Plan --- ### [New Mexico-Mandatory Reporting-Section 59A-16C-6. Notice and cooperation required; tolling period.](https://insurancefraud.org/regulations/new-mexico-mandatory-reporting-section-59a-16c-6-notice-and-cooperation-required-tolling-period/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** 59A-16C-6. Notice and cooperation required; tolling period. A. Every insurer or licensed insurance professional that has a reasonable belief that an act of insurance fraud will be, is being or has been committed shall furnish and disclose knowledge and information about it to the superintendent and shall cooperate fully with any investigation conducted by the superintendent. Failure to comply with this subsection shall constitute grounds for the superintendent to impose an administrative penalty pursuant to Section 59A-1-18 NMSA 1978 in addition to any applicable suspension, revocation or denial of a license or certificate of authority. B. A person who has a reasonable belief that an act of insurance fraud will be, is being or has been committed, or any person who collects, reviews or analyzes information concerning insurance fraud, may furnish and disclose any information in his possession concerning the insurance fraud to the superintendent or to an authorized representative of an insurer that requests the information for the purpose of detecting, prosecuting or preventing insurance fraud. C. If an insurer has a reasonable belief or probable cause to believe that an insurance fraud has been committed and has properly notified the superintendent of its suspicion, that notification shall toll any applicable time period in any unfair claims proceeding based on the alleged fraud until thirty days after determination by the superintendent and notice to the insurer that the superintendent will not recommend action on the claim. The determination by the superintendent shall not be admissible in any subsequent civil proceeding. D. The superintendent, in cooperation with insurers or others, may establish a voluntary fund to reward persons not connected with the insurance industry who provide information or furnish evidence leading to the arrest and conviction of persons responsible for insurance fraud. **State:** New Mexico **Requirement Types:** Mandatory Reporting --- ### [New York-Annual Reporting-Section 409 (g)](https://insurancefraud.org/regulations/new-york-annual-reporting-section-409-g/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** “Every insurer required to file a fraud prevention plan shall report to the superintendent on an annual basis, no later than March fifteenth, describing the insurer’s experience, performance and cost effectiveness in implementing the plan, utilizing such forms as the superintendent may prescribe. Upon consideration of such reports, the superintendent may require amendments to the insurer’s fraud prevention plan as deemed necessary.” \[Deadline for submission is March 15.\] Note: Law changed in 2008 — changing submission from January 15 to March 15. **State:** New York **Requirement Types:** Annual Reporting --- ### [New York-Fraud Plan-Section 86.4;](https://insurancefraud.org/regulations/new-york-fraud-plan-section-86-4/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Regulation. Section 86.4 (a) All applications provided to applicants for commercial insurance and all claim forms for insurance, except personal automobile insurance, delivered to any person residing or located in this State on and after February 2, 1994 in connection with commercial insurance policies to be issued or issued for delivery in this State shall contain the following statement: “Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.” (b) All claim forms for personal automobile insurance delivered to any person residing or located in this state on and after February 2, 1994 in connection with policies of personal automobile insurance and claims arising under policies of such insurance shall contain the following statement: “Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, and any person who knowingly makes or knowingly assists, abets, solicits or conspires with another to make a false report of the theft, destruction, damage or conversion of any motor vehicle to a law enforcement agency, the department of motor vehicles or an insurance company commits a fraudulent insurance act, which is a crime shall also be subject to a civil penalty not to exceed five thousand dollars and the value of the subject motor vehicle or state claim for each such violation.” (c) Self insurers may adopt one or both of the required warning statements set forth in (a) or (b) (d) Location of warning statements and type size. (1) The warning statements required by subdivisions (a), (b) and (d) of this section shall be placed immediately above the space provided for the signature of the person executing the application or claim form and shall be printed in type which will produce a warning statement of conspicuous size. On claim forms which require execution by a person other than a claimant, or in addition to the claimant, the warning statements required by subdivisions (a), (b) and (d) of this section shall be placed at the top of the first page of the claim form or on the page containing instructions, either in print, by stamp or by attachment and shall be in type size which will produce a warning statement of conspicuous size. (2) Notwithstanding the provisions of paragraph (1) of this subdivision, insurers may affix the warning statements required by this Part to all applications and claim forms by means of labels and/or stamps or by attachment during the period February 2, 1994 to July 31, 1994. (e) Notwithstanding the provisions of subdivisions (a) or (b) of this section, insurers may use substantially similar warning statements provided such warning statements are submitted to the Insurance Frauds Bureau for prior approval. **State:** New York **Requirement Types:** Fraud Plan --- ### [New York-Fraud Plan-Section 86.6 - Fraud prevention plans and special investigation units & Title 11, Part 6 Electronic Filing](https://insurancefraud.org/regulations/new-york-fraud-plan-section-86-6-fraud-prevention-plans-and-special-investigation-units-title-11-part-6-electronic-filing/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Regulation. Section 86.6 – Fraud prevention plans and special investigation units. (a) Every insurer writing private or commercial automobile insurance, worker’s compensation insurance, or individual, group or blanket accident and health insurance policies issued or issued for delivery in this state, which writes three thousand or more such policies in any given year, shall develop and file with the superintendent a plan for the detection, investigation and prevention of fraudulent insurance activities in this state and those fraudulent insurance activities affecting policies issued or issued for delivery in this state. (b) The plan shall include the following provisions: (1) Establishment of a full time Special Investigation Unit separate from the underwriting or claims functions of the insurer, which shall be responsible for investigation of cases of suspected fraudulent activity and for implementation of the insurer’s fraud prevention and reduction activities under the Fraud Prevention Plan. In the alternative the insurer may contract with a provider of services to perform all or part of this function, but shall remain primarily responsible for the development and implementation of its Fraud Prevention Plan. The agreement under which such services are provided shall be filed with the Insurance Frauds Bureau as part of the Fraud Prevention Plan, and must provide for specific levels of staffing devoted to the investigation of suspected fraudulent claims. In the event that investigators employed by a provider of services will be working for more than one insurer or on cases in states other than New York, the plan must apportion the percentage of the investigator’s efforts which will be devoted to working for the insurer on its New York cases. The agreement shall also require that the provider of services cooperate fully with the Department of Insurance in any examination of the implementation of the Fraud Prevention Plan, and provide any and all assistance requested by the Insurance Frauds Bureau, any other law enforcement agency or any prosecutorial agency in the investigation and prosecution of insurance fraud and related crimes. (2) A description of the organization of the Special Investigation Unit, including the titles and job descriptions of the various investigators and investigative supervisors, the minimum qualifications for employment in these positions in addition to those required by this regulation, the geographical location and assigned territory of each investigator and investigative supervisor, the support staff and other physical resources, including database access available to the Unit and the supervisory and reporting structure within the Unit and between the Unit and the general management of the insurer. If investigators employed by the Unit will be responsible for investigating cases in more than one State, the plan must apportion that percentage of the investigators’ efforts which will be devoted to New York cases. (3) The rationale for the level of staffing and resources being provided for the Special Investigations Unit including objective criteria such as number of policies written and individuals insured in New York, number of claims received with respect to New York insureds on an annual basis, volume of suspected fraudulent New York claims currently being detected, other factors relating to the vulnerability of the insurer to fraud, and an assessment of optimal caseload which can be handled by an investigator on an annual basis. (4) A description of the relationship between the Special Investigation Unit and the claims and underwriting functions of the insurer, including procedures for detecting possible fraud, criteria for referral of a case to the Unit for evaluation, and the designation of the individuals authorized to make such a referral; and a description of the relationship between the Unit and the Insurance Frauds Bureau, other law enforcement agencies and prosecutors, including procedures for case investigation, detection of patterns of repetitive fraud involving one or more insurers, criteria for referral of a case to the Insurance Frauds Bureau, designation of the individuals authorized to make such referrals, and a policy to avoid duplication of effort due to concurrent referrals by the Unit to more than one law enforcement agency. (5) Provision for the reporting of fraud data to a data collection firm to be designated by the superintendent. (6) Provision for in-service training programs for investigative, underwriting and claims personnel in identifying and evaluating instances of suspected insurance fraud, including an introductory training session and periodic refresher sessions. This description shall include course descriptions, the approximate number of hours to be devoted to these sessions and their frequency. (7) Provision for the coordination with other units of the insurer to further fraud investigations, including a periodic review of claims and underwriting procedures and forms for the purpose of enhancing the ability of the insurer to detect fraud to increase the likelihood of its successful prosecution, and for initiation of civil actions where appropriate. (8) Development of a public awareness program focused on the cost and frequency of insurance fraud, and methods by which the public can prevent it. (9) Development of a fraud detection and procedures manual for use by underwriting, claims and investigative personnel. (10) Timetable for the implementation of the Fraud Prevention Plan. (c) Persons employed by the Special Investigations Units as investigators or by an independent provider of investigative services under contract with an insurer shall be qualified by education and/or experience which shall include a bachelor’s degree or either four years of claims investigation experience or five years of professional investigation experiences involving economic or insurance related matters. Notwithstanding these minimum requirements anyone employed as an investigator in a special investigation unit as of the effective date of this provision may continue in such employment provided the insurer identifies such person in writing to the superintendent giving the date such employment began and a description of the person’s qualifications, employment history and current job duties. (d) Every insurer required to file a fraud prevention plan shall file an annual report with the Insurance Frauds Bureau no later than January 15 of each year on a form approved by the superintendent, describing the insurer’s experience, performance and cost effectiveness in implementing the plan and its proposals for modifications to the plan to amend its operations, to improve performance or to remedy observed deficiencies. The report shall be reviewed and signed by the chief executive officer of the insurer. Title 11, Part 6 Electronic Filing Section 6.2. Required electronic filings and submissions: (a) Except where the Insurance Law requires a filer to submit a hard copy, a filer shall submit to the superintendent the following electronically, in a form and manner acceptable to the superintendent: (1) Insurance Fraud Prevention Plans and Reports. A report required by Insurance Law section 405(a) and a fraud prevention plan, subsequent plan amendments, and annual reports required by Insurance Law section 409(a), (d), and (g). **State:** New York **Requirement Types:** Fraud Plan --- ### [New York-Fraud Warning-Section 403 - All applications and claims forms - Language is permissive; Section 404 - Automobile applications and claims forms - Language is permissive](https://insurancefraud.org/regulations/new-york-fraud-warning-section-403-all-applications-and-claims-forms-language-is-permissive-section-404-automobile-applications-and-claims-forms-language-is-permissive/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Application forms – Section 403 All claim forms – Section 403 Section 403(d) – All applications and claims forms – Language is permissive “Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each violation.” Section 403(e) – Automobile applications and claims forms – Language is permissive “Any person who knowingly makes or knowingly assists, abets, solicits, or conspires with another to make a false report of the theft, destruction, damage or conversion of any motor vehicle to a law enforcement agency, the department of motor vehicles or an insurance company, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the value of the subject motor vehicle or stated claim for each violation.” **State:** New York **Requirement Types:** Fraud Warning --- ### [New York-Fraud Warning-Section 86.4 -](https://insurancefraud.org/regulations/new-york-fraud-warning-section-86-4/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Regulation. Section 86.4 (a) All applications provided to applicants for commercial insurance and all claim forms for insurance, except personal automobile insurance, delivered to any person residing or located in this State on and after February 2, 1994 in connection with commercial insurance policies to be issued or issued for delivery in this State shall contain the following statement: “Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.” (b) All claim forms for personal automobile insurance delivered to any person residing or located in this state on and after February 2, 1994 in connection with policies of personal automobile insurance and claims arising under policies of such insurance shall contain the following statement: “Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, and any person who knowingly makes or knowingly assists, abets, solicits or conspires with another to make a false report of the theft, destruction, damage or conversion of any motor vehicle to a law enforcement agency, the department of motor vehicles or an insurance company commits a fraudulent insurance act, which is a crime shall also be subject to a civil penalty not to exceed five thousand dollars and the value of the subject motor vehicle or state claim for each such violation.” (c) Self insurers may adopt one or both of the required warning statements set forth in (a) or (b) (d) Location of warning statements and type size. (1) The warning statements required by subdivisions (a), (b) and (d) of this section shall be placed immediately above the space provided for the signature of the person executing the application or claim form and shall be printed in type which will produce a warning statement of conspicuous size. On claim forms which require execution by a person other than a claimant, or in addition to the claimant, the warning statements required by subdivisions (a), (b) and (d) of this section shall be placed at the top of the first page of the claim form or on the page containing instructions, either in print, by stamp or by attachment and shall be in type size which will produce a warning statement of conspicuous size. (2) Notwithstanding the provisions of paragraph (1) of this subdivision, insurers may affix the warning statements required by this Part to all applications and claim forms by means of labels and/or stamps or by attachment during the period February 2, 1994 to July 31, 1994. (e) Notwithstanding the provisions of subdivisions (a) or (b) of this section, insurers may use substantially similar warning statements provided such warning statements are submitted to the Insurance Frauds Bureau for prior approval. **State:** New York **Requirement Types:** Fraud Warning --- ### [New York-Fraud Warning-Workers Compensation Law Section 132 (as amended in A. 11331, 1996)](https://insurancefraud.org/regulations/new-york-fraud-warning-workers-compensation-law-section-132-as-amended-in-a-11331-1996/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** For benefit checks. By endorsement of this check, the payee, under penalty of fine and/or imprisonment, certifies entitlement to this payment for benefits or services, circumstances affecting such entitlement have not changed and no false statements or representations have been made in support of the claim for payment. False representations could result in civil and criminal penalties. **State:** New York **Requirement Types:** Fraud Warning --- ### [New York-Mandatory Reporting-Section 86.5 - Reports of fraudulent acts](https://insurancefraud.org/regulations/new-york-mandatory-reporting-section-86-5-reports-of-fraudulent-acts/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Regulation. Section 86.5 – Reports of fraudulent acts. Any person licensed pursuant to the provisions of the Insurance Law who determines that an insurance transaction or purported insurance transaction appears to be fraudulent or suspect shall submit a report thereon to the Insurance Frauds Bureau. Reports shall be submitted on the prescribed reporting form issued by the Insurance Frauds Bureau or upon any other form approved by order of the superintendent. Reporting may also be done by means of any electronic medium or system approved by order of the superintendent. **State:** New York **Requirement Types:** Mandatory Reporting --- ### [New York-Mandatory Reporting-Section 86.5 - Reports of fraudulent acts](https://insurancefraud.org/regulations/new-york-mandatory-reporting-section-86-5-reports-of-fraudulent-acts-2/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Regulation. Any person licensed pursuant to the provisions of the Insurance Law who determines that an insurance transaction or purported insurance transaction appears to be fraudulent or suspect shall submit a report thereon to the Insurance Frauds Bureau. Reports shall be submitted on the prescribed reporting form issued by the Insurance Frauds Bureau or upon any other form approved by order of the superintendent. Reporting may also be done by means of any electronic medium or system approved by order of the superintendent. **State:** New York **Requirement Types:** Mandatory Reporting --- ### [New York-Mandatory Reporting-State Insurance Code Section 405; State Insurance Code Section 409 (Fraud prevention plans and special investigations units)*](https://insurancefraud.org/regulations/new-york-mandatory-reporting-state-insurance-code-section-405-state-insurance-code-section-409-fraud-prevention-plans-and-special-investigations-units/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** State Insurance Code Section 405 (a) Any person licensed or registered pursuant to the provisions of this chapter, and any person engaged in the business of insurance or life settlement in this state who is exempted from compliance with the licensing requirements of this chapter, including the state insurance fund of this state, who has reason to believe that an insurance transaction or life settlement act may be fraudulent, or has knowledge that a fraudulent insurance transaction or fraudulent life settlement act is about to take place, or has taken place shall, within thirty days after determination by such person that the transaction appears to be fraudulent, send to the superintendent on a form prescribed by the superintendent, the information requested by the form and such additional information relative to the factual circumstances of the transaction and the parties involved as the superintendent may require. The superintendent shall accept reports of suspected fraudulent insurance transactions or fraudulent life settlement acts from any self insurer, including but not limited to self insurers providing health insurance coverage or those defined in section fifty of the workers’ compensation law, and shall treat such reports as any other received pursuant to this section. (b) The superintendent shall review each report and undertake such further investigation as the superintendent deems necessary and proper to determine the validity of the allegations. State Insurance Code Section 409 (Fraud prevention plans and special investigations units)\* Every insurer writing insurance in the state except for insurers that write less than 3,000 policies shall file with the superintendent “a plan for the detection, investigation and prevention of fraudulent insurance activities ….” Section 409(b)(1) provides for provisions for full-time special investigation units that are separate from the underwriting or claims functions. Section 409 (b)(2) allows for the contracting of fraud investigators in lieu of an insurer providing its own special investigation unit. **State:** New York **Requirement Types:** Mandatory Reporting --- ### [New York-Mandatory Reporting-State Insurance Code Section 405; State Insurance Code Section 409 (Fraud prevention plans and special investigations units)*](https://insurancefraud.org/regulations/new-york-mandatory-reporting-state-insurance-code-section-405-state-insurance-code-section-409-fraud-prevention-plans-and-special-investigations-units-2/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** State Insurance Code Section 405 “Any person licensed … who has reason to believe that an insurance transaction may be fraudulent, or has knowledge that a fraudulent insurance transaction is about to take place, or has taken place shall, within thirty days after determination by such person that the transaction appears to be fraudulent, send to the insurance frauds bureau on a form prescribed by the superintendent, the information requested by the form and such additional information relative to the factual circumstances of the transaction and the parties involved as the superintendent may require.” State Insurance Code Section 409 (Fraud prevention plans and special investigations units)\* Every insurer writing insurance in the state except for insurers that write less than 3,000 policies shall file with the superintendent “a plan for the detection, investigation and prevention of fraudulent insurance activities ….” Section 409(b)(1) provides for provisions for full-time special investigation units that are separate from the underwriting or claims functions. Section 409 (b)(2) allows for the contracting of fraud investigators in lieu of an insurer providing its own special investigation unit. **State:** New York **Requirement Types:** Mandatory Reporting --- ### [New York-Pre-insurance Inspection-New York Insurance Code Section 3411; New York Rules & Regulations Section 67](https://insurancefraud.org/regulations/new-york-pre-insurance-inspection-new-york-insurance-code-section-3411-new-york-rules-regulations-section-67/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Photograph required — Yes Grace Period (days) — 5 Exemptions/Waivers Existing Policyholder (years) — 4 Renewal Policy — No New Cars — No Vehicle Age — 7 **State:** New York --- ### [New York-SIU Education-(c) Persons employed by the Special Investigations Units as investigators or by an independent provider of investigative services under contract with an insurer shall be qualified by education and/or experience which shall include a bachelor’s degree or either four years of claims investigation experience or five years of professional investigation experiences involving economic or insurance related matters. Notwithstanding these minimum requirements anyone employed as an investigator in a special investigation unit as of the effective date of this provision may continue in such employment provided the insurer identifies such person in writing to the superintendent giving the date such employment began and a description of the person’s qualifications, employment history and current job duties.](https://insurancefraud.org/regulations/new-york-siu-education-c-persons-employed-by-the-special-investigations-units-as-investigators-or-by-an-independent-provider-of-investigative-services-under-contract-with-an-insurer-shall-be-qualifi/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (c) Persons employed by the Special Investigations Units as investigators or by an independent provider of investigative services under contract with an insurer shall be qualified by education and/or experience which shall include a bachelor’s degree or either four years of claims investigation experience or five years of professional investigation experiences involving economic or insurance related matters. Notwithstanding these minimum requirements anyone employed as an investigator in a special investigation unit as of the effective date of this provision may continue in such employment provided the insurer identifies such person in writing to the superintendent giving the date such employment began and a description of the person’s qualifications, employment history and current job duties. **State:** New York **Requirement Types:** SIU Education --- ### [New York-SIU Requirement-Section 86.6 - Fraud prevention plans and special investigation units](https://insurancefraud.org/regulations/new-york-siu-requirement-section-86-6-fraud-prevention-plans-and-special-investigation-units/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (b) The plan shall include the following provisions: (1) Establishment of a full time Special Investigation Unit separate from the underwriting or claims functions of the insurer, which shall be responsible for investigation of cases of suspected fraudulent activity and for implementation of the insurer’s fraud prevention and reduction activities under the Fraud Prevention Plan. In the alternative the insurer may contract with a provider of services to perform all or part of this function, but shall remain primarily responsible for the development and implementation of its Fraud Prevention Plan. The agreement under which such services are provided shall be filed with the Insurance Frauds Bureau as part of the Fraud Prevention Plan, and must provide for specific levels of staffing devoted to the investigation of suspected fraudulent claims. In the event that investigators employed by a provider of services will be working for more than one insurer or on cases in states other than New York, the plan must apportion the percentage of the investigator’s efforts which will be devoted to working for the insurer on its New York cases. The agreement shall also require that the provider of services cooperate fully with the Department of Insurance in any examination of the implementation of the Fraud Prevention Plan, and provide any and all assistance requested by the Insurance Frauds Bureau, any other law enforcement agency or any prosecutorial agency in the investigation and prosecution of insurance fraud and related crimes. (2) A description of the organization of the Special Investigation Unit, including the titles and job descriptions of the various investigators and investigative supervisors, the minimum qualifications for employment in these positions in addition to those required by this regulation, the geographical location and assigned territory of each investigator and investigative supervisor, the support staff and other physical resources, including database access available to the Unit and the supervisory and reporting structure within the Unit and between the Unit and the general management of the insurer. If investigators employed by the Unit will be responsible for investigating cases in more than one State, the plan must apportion that percentage of the investigators’ efforts which will be devoted to New York cases. (3) The rationale for the level of staffing and resources **State:** New York **Requirement Types:** SIU Requirement --- ### [North Carolina-Mandatory Reporting-General Statutes Section 58-2-163](https://insurancefraud.org/regulations/north-carolina-mandatory-reporting-general-statutes-section-58-2-163/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** General Statutes Section 58-2-163 Whenever any insurance company, or employee or representative of such company, or any other person licensed or registered under … this Chapter knows or has reasonable cause to believe that any other person has violated G.S. 58-2-161, 58-2-162, 58-2-180, 58-8-1, or 58-24-180(e), … it is the duty of such person, upon acquiring such knowledge, to notify the Commissioner and provide the Commissioner with a complete statement of all of the relevant facts and circumstances. **State:** North Carolina **Requirement Types:** Mandatory Reporting --- ### [North Dakota-Mandatory Reporting-26.1-02.1-06. Mandatory reporting of fraudulent insurance acts.](https://insurancefraud.org/regulations/north-dakota-mandatory-reporting-26-1-02-1-06-mandatory-reporting-of-fraudulent-insurance-acts/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** 26.1-02.1-06. Mandatory reporting of fraudulent insurance acts. 1. A person engaged in the business of insurance having knowledge or a reasonable belief that a fraudulent insurance act is being, will be, or has been committed shall provide to the commissioner the information required by, and in a manner prescribed by, the commissioner. 2. Any other person having knowledge or a reasonable belief that a fraudulent insurance act is being, will be, or has been committed may provide to the commissioner the information required by, and in a manner prescribed by, the commissioner. 3. A person who provides nonpublic personal information to the commissioner pursuant to this section does not violate the insurance privacy law under section 26.1-02-27. **State:** North Dakota **Requirement Types:** Mandatory Reporting --- ### [Ohio-Fraud Plan-Section 3999.41](https://insurancefraud.org/regulations/ohio-fraud-plan-section-3999-41/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (A) Except as provided in Division (D) of this section, every insurer, as defined in Division (A) of Section 3999.36 of the revised code, shall adopt an antifraud program and shall specify in a written plan the procedures it will follow when instances of insurance fraud or suspected insurance fraud are brought to its attention. The insurer shall identify in the written plan the person or persons responsible for the insurer’s antifraud program. (B)(1) An insurer shall develop a written plan required by Division (A) of this section within ninety days after obtaining its license to transact business within this state or within ninety days after beginning to engage in the business of insurance within this state and shall thereafter maintain such a written plan. (2) An insurer engaged in the business of insurance within this state on the effective date of this section shall develop a written plan required by Division (A) required by Division (A) of this section within ninety days after the effective date of this section and shall thereafter maintain such a written plan. (C) If an insurer modifies the procedures it follows for instances of insurance fraud or suspected insurance fraud, or if there is a change in the person or persons responsible for the insurer’s antifraud program, the insurer shall modify the written plan it maintains pursuant to this section. (D) The requirements of this section are not applicable to any insurer identified in Division (A) of this section that is not engaged in writing direct insurance in this state. **State:** Ohio **Requirement Types:** Fraud Plan --- ### [Ohio-Fraud Warning-Section 3999.21](https://insurancefraud.org/regulations/ohio-fraud-warning-section-3999-21/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Section 3999.21 – Language is permissive, statement must be approved by Insurance Department “Any person who, with the intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.” The section also states that the absence of a warning is not a defense against prosecution for insurance fraud. **State:** Ohio **Requirement Types:** Fraud Warning --- ### [Ohio-Mandatory Reporting-Ohio Administrative Code Rule 3901-1-54 (Bulletin 93-3); 3999.42 Fraud; notification to department](https://insurancefraud.org/regulations/ohio-mandatory-reporting-ohio-administrative-code-rule-3901-1-54-bulletin-93-3-3999-42-fraud-notification-to-department/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Ohio Administrative Code Rule 3901-1-54 (Bulletin 93-3) “If an insurer reasonably believes, based upon information obtained and documented within the claim file, that a claimant has fraudulently caused or contributed to the loss represented by a properly executed and documented proof of loss, such information shall be presented to the Fraud Division of the Department within sixty days of receipt of the proof of loss. Any person making such report shall be afforded such immunity and the information submitted will be confidential as provided in Sections 3901.44 and 3999.01 of the Revised Code.” 3999.42 Fraud; notification to department (A) If an insurer, as defined in division (A) of section 3999.36 of the Revised Code, has a reasonable belief that a person is perpetrating or facilitating an insurance fraud, as established by section 2913.47 of the Revised Code, or has done so, the insurer shall notify the department of insurance. (B) The notification required by division (A) of this section shall be made in accordance with rules adopted by the department of insurance. (C) Division (A) of this section does not require notification of the department of insurance if the insurance fraud involves a claim of an amount less than one thousand dollars. (D) This section applies to insurance fraud perpetrated or facilitated by any person, including, but not limited to, any applicant, policyholder, subscriber, or enrollee, or any officer, director, manager, employee, representative, or agent of the insurer. **State:** Ohio **Requirement Types:** Mandatory Reporting --- ### [Minnesota-Fraud Plan-General Insurance Powers Statutes Section 60A.954](https://insurancefraud.org/regulations/minnesota-fraud-plan-general-insurance-powers-statutes-section-60a-954/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Section 60A.954 – Antifraud plan — Subdivision 1. Establishment. An insurer shall institute, implement, and maintain an antifraud plan. For the purpose of this section, the term insurer does not include reinsurers, self-insurers, and excess insurers. Within 30 days after instituting or modifying an antifraud plan, the insurer shall notify the commissioner in writing. The notice must include the name of the person responsible for administering the plan. An anti-fraud plan shall establish procedures to: (1) prevent insurance fraud, include: internal fraud involving the insurer’s officers, employees or agents; fraud resulting from misrepresentations on applications for insurance; and claims fraud; (2) report insurance fraud to appropriate law enforcement authorities; and (3) cooperate with the prosecution of insurance fraud cases. Subdivision 2. Review. The commissioner may review each insurer’s antifraud plan to determine whether it complies with the requirements of this section…. **State:** Minnesota **Requirement Types:** Fraud Plan --- ### [Minnesota-Fraud Warning-Section 60A.955 - Language is permissive](https://insurancefraud.org/regulations/minnesota-fraud-warning-section-60a-955-language-is-permissive/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** All claim forms – Sec. 60A.955 Section 60A.955 – Language is permissive All insurance claim forms issued by an insurer for use in submitting a claim for payment or a claim for any other benefit pursuant to a policy shall clearly contain a warning substantially as follows: “A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.” An insurer may comply with this section by including the warning on an addendum attached to the claim form. The absence of the required warning does not constitute a defense in a prosecution for a violation of chapter 609 or any other chapter of Minnesota Statutes. **State:** Minnesota **Requirement Types:** Fraud Warning --- ### [Minnesota-Mandatory Reporting-Minnesota Statutes Sec. 60A.951](https://insurancefraud.org/regulations/minnesota-mandatory-reporting-minnesota-statutes-sec-60a-951/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Insurers shall notify an authorized person of a suspected fraudulent insurance act. An authorized person includes the county attorney, sheriff or chief of police, Bureau of Criminal Apprehension, the Commerce Commissioner, the Attorney General or a federal criminal investigative agency. Notice to one authorized person is deemed notice to all. **State:** Minnesota **Requirement Types:** Mandatory Reporting --- ### [Missouri-Mandatory Reporting-Revised Statutes Section 375.992](https://insurancefraud.org/regulations/missouri-mandatory-reporting-revised-statutes-section-375-992/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Any company which believes that a fraudulent claim is being made shall, within sixty days of the receipt of such notice, send to the department of insurance, on a form prescribed by the department, the information requested and such additional information relative to the claim and the parties claiming loss or damages because of the accident as the department may require. The department of insurance shall review such reports and select such claims as, in its judgment, may require further investigation. It shall then cause an independent examination of the facts surrounding such claim to be made to determine the extent, if any, to which fraud, deceit, or intentional misrepresentation of any kind exists in the submission of the claim. The department of insurance shall report any alleged violations of law which its investigations disclose to the appropriate licensing agency and prosecutive authority having jurisdiction with respect to any such violation. **State:** Missouri **Requirement Types:** Mandatory Reporting --- ### [Montana-Mandatory Reporting-33-2-2303 (1); 33-1-1205](https://insurancefraud.org/regulations/montana-mandatory-reporting-33-2-2303-1-33-1-1205/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** 33-2-2303 (1) intended for reporting of fraud committed by insurance producers or adjusters (1) An insurer, insurance producer, or other person who has reason to believe insurance fraud has occurred shall report the suspected fraud to the commissioner or to the insurance producer’s or other person’s insurer within 60 days of discovery of the occurrence. An insurer shall review a report given to the insurer, and if the insurer determines that there is a reasonable likelihood that fraud has occurred the insurer shall forward the report to the commissioner within 30 days of receipt. 33-1-1205 Duties of authorized insurers, adjusters, administrators, consultants, and producers. (1) Each insurer, independent adjuster, independent administrator, independent consultant, and independent producer shall cooperate fully with the commissioner with respect to the provisions of this part. (2) An insurer, an officer, or an employee of the insurer, an independent adjuster, an independent administrator, an independent consultant, or an independent producer who has reason to believe that an insurance fraud has been or is being committed shall provide notice of the alleged insurance fraud to the commissioner within 60 days. A producer of an insurer who has reason to believe that an insurance fraud has been or is being committed shall report the alleged fraud to the insurer within 60 days of discovery of the alleged insurance fraud. The insurer shall review the report. If the insurer determines that there is reasonable likelihood that fraud has occurred, the insurer shall forward the report to the commissioner within 30 days of the receipt of the report. (3) Notice to the commissioner by an insurer who has reason to believe that an insurance fraud has been committed in connection with an insurance claim, application, or policy tolls any applicable time period, for the commissioner, in any applicable insurance statute, related insurance regulation, or applicable sections of the criminal code and tolls any time period arising under 33-18-232 or 33-18-242 regarding unfair claims settlement practices. **State:** Montana **Requirement Types:** Mandatory Reporting --- ### [Nebraska-Mandatory Reporting-Neb. Rev. Stat. Section 44-393 Section 44-3,136](https://insurancefraud.org/regulations/nebraska-mandatory-reporting-neb-rev-stat-section-44-393-section-44-3136/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Every insurance company, agent, solicitor, or broker, and every person or party having knowledge of violation of any of the provisions of this chapter, is required to promptly report the facts and circumstances pertaining thereto to the Department of Insurance, which report and the name of the informant may be held confidential by the department, its officers, assistants and employees, and not be made public. Motor vehicle theft or fraud; notification by insurer Section 44-3,136 When an insurer knows the identity of a person whom the insurer has probable cause to believe committed a criminal or fraudulent act relating to a motor vehicle theft or a motor vehicle insurance claim or has knowledge of such a criminal or fraudulent act which the insurer reasonably believes has not been reported to an authorized agency and the suspected person is insured by the insurer, then for the purpose of notification and investigation the insurer or person acting on behalf of the insurer may notify, in writing, an authorized agency of such knowledge or reasonable belief and provide any additional relevant information in accordance with section 44-3,135. **State:** Nebraska **Requirement Types:** Mandatory Reporting --- ### [Nevada-Mandatory Reporting-Nevada Revised Statutes Sec. 679B.159 (1)](https://insurancefraud.org/regulations/nevada-mandatory-reporting-nevada-revised-statutes-sec-679b-159-1/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** “Every insurer, agent, solicitor, broker, administrator or other person who has knowledge of a violation of any provision of this code shall promptly report the facts and circumstances pertaining to the violation to the commissioner.” **State:** Nevada **Requirement Types:** Mandatory Reporting --- ### [New Hampshire-Fraud Warning-Section 402:82 - Language is permissive](https://insurancefraud.org/regulations/new-hampshire-fraud-warning-section-40282-language-is-permissive/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** All claim forms – Sec. 402:82 All insurance claim forms shall contain a statement that clearly states in substance the following: “Any person who, with a purpose to injure, defraud or deceive any insurance company, files a statement of claim containing any false, incomplete or misleading information is subject to prosecution and punishment for insurance fraud as provided in R.S.A. 638.20.” However, the lack of such a statement shall not constitute a defense against prosecution under RSA 638.20 (Insurance fraud law). **State:** New Hampshire **Requirement Types:** Fraud Warning --- ### [New Hampshire-Mandatory Reporting-Section 417:28](https://insurancefraud.org/regulations/new-hampshire-mandatory-reporting-section-41728/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Any company which believes that an insurance fraud has been committed shall, within 60 days of the forming such belief, send to the unit, on a form prescribed by the unit, the information requested and such additional information relative to the claim and other parties claiming loss or damage because of the claim as the unit may require. The unit shall review such report and select such claims as, in its judgment, warrant further investigation. In the absence of fraud or malice, no public official or insurance company or person who furnishes information on behalf of the insurance company shall be liable for damages in a civil action or subject to criminal prosecution for any oral or written statement made or any other action taken that is necessary to supply information required pursuant to this section. **State:** New Hampshire **Requirement Types:** Mandatory Reporting --- ### [New Hampshire-SIU Requirement-Section 417:30](https://insurancefraud.org/regulations/new-hampshire-siu-requirement-section-41730/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** I. Except for insurance companies writing only credit, home warranty, travel, or title insurance, every insurance company licensed to write direct business in this state shall have antifraud initiatives reasonably calculated to detect, prosecute, and prevent fraudulent insurance acts, including: (a) Fraud investigations, who may be insurer employees or independent contractors; or (b) An antifraud plan submitted to the commissioner. II. Antifraud plans submitted to the commissioner shall be privileged and confidential and shall not be a public record and shall not be subject to discovery or subpoena in a civil or criminal action. PART Ins 4601 ANTIFRAUD PLANS Ins 4601.01 Purpose. The purpose of this chapter is to establish standards for the insurance fraud investigation unit, insurance company special investigative unit (SIU) and any other interested parties regarding the preparation of an antifraud plan that meets the mandated requirements for submitting a plan with the department pursuant to RSA 417:30. Ins 4601.02 Applicability and Scope. This chapter shall be applicable to every insurance company licensed to write direct business in this state except for insurance companies writing only credit, home warranty, travel, or title insurance. Ins 4601.03 Definitions. (a) “Commissioner” means.he insurance commissioner. (b) “Department” means the New Hampshire Insurance Department. (c) “National Association of Insurance Commissioners (NAIC)” means the organization comprised of elected or appointed state government officials of the 50 states, the district of columbia and the U.S. territories whose departments regulate the business of insurance. (d) “National Health Care Antifraud Association (NHCAA)” means the organization founded in 1985 by private health insurers and federal and state governments whose activities focus exclusively on fighting health care fraud. (e) “National Insurance Crime Bureau (NCIB)” means the not-for-profit organization created by the insurance industry to address insurance-related crime. (f) “Online Fraud Reporting System (OFRS)” means the online fraud reporting system developed by the NAIC for regulators, consumers and insurance industry to report insurance fraud. (g) “Special Investigations Unit (SIU)” means the non-law enforcement units of an insurer or insurer affiliated entity whose sole mission is to detect, deter, defeat and report insurance fraud. An SIU includes any of the following: (1) An internal unit of the insurance company; (2) An external unit of more than one insurance company that is part of the same insurance holding company system; or (3) An independent third-party unit under contract with an insurer or insurers. Ins 4601.04 Antifraud Plan Submission Requirement. (a) An insurer, if required by the department, subject to RSA 408-D:14 and RSA 417:30, shall submit to the commissioner a detailed description of the company’s antifraud plan. (b) All antifraud plans submitted shall be subject to review by the commissioner. Ins 4601.05 Antifraud Plan Requirements. (a) The antifraud plan shall be an acknowledgement by the insurer and its SIU that they have established criteria that shall be used to detect suspicious or fraudulent insurance activity relating to the different types of insurance offered by that insurer. (b) One SIU antifraud plan may cover several insurer affiliated entities if one STU has the fraud investigation mission for all entities. (c) The following information shall be included in the submitted antifraud plan to satisfy the requirements of this chapter, RSA 408-D:14 and RSA 417:30: (1) General information requirements including: a. An acknowledgment that the SIU has established criteria that shall be used for the investigation of acts of suspected insurance fraud relating to the different types of insurance offered by that insurer; b. An acknowledgment that the insurer or SIU shall record the date that suspected fraudulent activity is detected, and shall record the date that reports of such suspected insurance fraud were sent directly to the department with a specific time frame which is.consistent with RSA 417:28; c. A provision stating whether the SIU is an internal unit or an external or third party unit; d. If the SIU is an internal unit, provide a description of whether the unit is part of the insurer’s claims or underwriting departments, or whether it is separate from such departments; e. A written description or chart outlining the organizational arrangement of the insurer’s antifraud positions responsible for the investigation and reporting of possible fraudulent insurance acts, including: 1. If the SIU is an internal unit, the insurer shall provide general contact information for the company’s SIU; 2. If the SIU is an external unit, the insurer shall provide: (i) The name of the company or companies used; (ii) Contact information for the company; (iii) A company organizational chart; and (iv) The person or position at the insurer responsible for maintaining contact with the external SIU company; 3. If an external SIU is employed for purposes of surveillance, the insurer shall include a description of the policies and procedures implemented; f. A provision where the insurer provides the NAld. individual and group code numbers; g. A statement as to whether the insurer has implemented a fraud awareness or outreach program. If the insurer has an awareness or outreach program; a brief description of the program shall be included; h. If the SIU is a third party, a description of the insurer’s policies and procedures for ensuring that the third party unit fulfills its contractual obligations to the insurer and a copy of the contract with the third party vendor. (2) Prevention, detection and investigation of fraud information, including: a. A description of the insurer’s corporate policies for preventing fraudulent insurance acts by its policy holders; b. A description of the insurer’s established fraud detection procedures, such as technology and other detection procedures; c. A description of the internal referral criteria used in reporting suspicious claims of insurance fraud for investigation by the SIU; d. A description of the SIU investigation program, such as by business line, external form claims adjustment, vendor management standard operating procedures; and e. A description of the insurer’s policies and procedures for referring suspicious or fraudulent activity from the Claims or underwriting departments to the SIU. (3) Reporting of fraud information, including: a. A description of the insurer’s reporting procedures for the mandatory reporting of possible fraudulent insurance acts to the commissioner pursuant to RSA 408-D:14, RSA 417:28, and RSA 417:30; b. A description of the insurer’s criteria or threshold for reporting fraud to the commissioner; RSA 408-D:14, RSA 417:28, and RSA 417:30 and c. A description of the insurer’s means of submission of reports of suspected fraud to the commissioner such as through the NAIC, OFRS, NICB, NHCAA, electronic state system, or other. (4) Education and training information, including, if applicable, a description of the insurer’s plan for antifraud education and training initiatives of any personnel involved in antifraud related efforts. Which description shall include: a. The internal positions the insurer offers regular education and training, such as underwriters, adjusters, claims representatives, appointment agents, and attorneys, etc. b. If the training will be internal and/or external; c. Number of hours expected per year; and d. If training includes ethics, false claims or other legal-related issues. (5) Internal fraud detection and prevention information, including: a. A description of the insurer’s internal fraud detection policy for employees, consultants or others, such as underwriters, claims representatives, appointed agents, etc.; and b. A description of the insurer’s internal fraud reporting system. Ins 4601.06 Compliance with 18 USC 1033 & 1034. The insurer shall include a description of its policies and procedures for candidates for employment and existing employees for compliance with 18 USC 1033 & 1034. Ins 4601.07 Regulatory Compliance. Pursuant to RSA 417:30, the department shall review insurer antifraud plans in order to determine compliance with appropriate state laws. Further, the department shall in accordance with RSA 417:30 IV take appropriate administrative action against an insurer that fails to comply with’the mandated requirements and/or state laws. Ins 4601.08 Confidentiality of Antifraud Plans. The submission of required information shall not constitute a waiver of an insurer’s privilege, trade secret, confidentiality or any proprietary interest in its antifraud plan or its antifraud related policies and procedures. The commissioner shall maintain the antifraud plan as confidential. Submitted plans shall not be subject to RSA 91-A if submitted properly under the state statutes or rules which would afford protection of these materials under RSA 408-D:14 and RSA 417:30 II. Ins 4601.09 Required Antifraud Plan Submission. An insurer shall submit its antifraud plan within 90 days of receiving a certificate of authority. Plans shall be submitted every 5 years thereafter. An Surer shall submit revisions to its plan within 30 days of a material change being made. **State:** New Hampshire **Requirement Types:** SIU Requirement --- ### [New Jersey-Annual Reporting-NJAC 11:16-6.8 Record retention](https://insurancefraud.org/regulations/new-jersey-annual-reporting-njac-1116-6-8-record-retention/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) Insurers shall maintain up-to-date and accurate records on their fraud prevention and detection plan, which shall at minimum include those necessary to prepare the report required in (b) below. (b) Insurers shall submit to the Commissioner on or before March 31 of each year an annual re-port for the prior calendar year on MCEAFC Form #1A and/or #2A, pursuant to instructions and definitions provided in MCEAFC Form #1B (for the completion of #1A) and Form #2B (for the completion of #2A), incorporated herein by reference in the subchapter Appendix. Individual insurers that comprise a group shall submit separate reports. Reports shall be submitted in hard copy or by email to: New Jersey Department of Banking and Insurance Market Conduct Examinations and Anti-Fraud Compliance Unit 20 West State Street PO Box 329 Trenton, NJ 08625-0329 Email: mceafc@dobi.state.nj.us 1. The information shall be submitted in a spreadsheet format established by the Department. Insurers may acquire the required spreadsheet format from the Department: i. By directing an email request for the “Annual Filing Template” to mceafc@dobi.state.nj.us; or ii. By directing a written request, along with a blank 3.5 inch, 1.44 MB MS-DOS format-ted disk, to the above address. The Department shall return the disk and a blank spread-sheet for completion by the insurer. **State:** New Jersey **Requirement Types:** Annual Reporting --- ### [New Jersey-Fraud Plan-11:16-6.1 Purpose and scope; 11:16-6.2 Definitions; N.J.A.C. 11:4-16.7, 11:20-4.1 and 11:21-6.1; 17:30A-1 et seq.; 17:48D-1 et seq.;11:16-6.3 General requirements and filing format](https://insurancefraud.org/regulations/new-jersey-fraud-plan-1116-6-1-purpose-and-scope-1116-6-2-definitions-n-j-a-c-114-16-7-1120-4-1-and-1121-6-1-1730a-1-et-seq-1748d-1-et-seq-1116-6-3-general-requirements-and-filing-form/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** 17:33A-15. Filing of plan for prevention, detection of fraudulent health, auto insurance claims 1. a. Every insurer writing health insurance or private passenger automobile insurance in this State shall file with the commissioner a plan for the prevention and detection of fraudulent insurance applications and claims. The plan shall be deemed approved by the commissioner if not affirmatively approved or disapproved by the commissioner within 90 days of the date of filing. The commissioner may call upon the expertise of the director in his review of plans filed pursuant to this subsection. The commissioner may request such amendments to the plan as he deems necessary. Any subsequent amendments to a plan filed with and approved by the commissioner shall be submitted for filing and deemed approved if not affirmatively approved or disapproved within 90 days from the filing date. b. The implementation of plans filed and approved pursuant to subsection a. of this section shall be monitored by the division. The division shall promptly notify the Attorney General of any evidence of criminal activity encountered in the course of monitoring the implementation and execution of the plans. Each insurer writing health insurance or private passenger automobile insurance in this State shall report to the director on an annual basis, on January 1st of each year, on the experience in implementing its fraud prevention plan. 11:16-6.1 Purpose and scope (a) This subchapter sets forth the standards for plan for the prevention and detection of fraudulent insurance applications and claims filed for approval pursuant to N.J.S.A. 17:33A-15 by insurers which transact the business of private passenger automobile insurance or health insurance this State. These provisions apply to all insurers that transact the business of private passenger automobile insurance in New Jersey, including both personal and commercial coverage; and to all insurers transacting the business of health insurance as sets forth in N.J.S.A. 17:33A-3 and N.J.A.C. 11:16-6.2. (b) The subchapter also sets forth the reporting standards and forms necessary to refer insurance fraud matters to the Office of Insurance Fraud Prosecutor (“OIFP”). These provisions apply to all insurers as defined by N.J.S.A. 17:33A-3 and N.J.A.C. 11:16-6.2 including those with PAIP and CAIP assignments. 11:16-6.2 Definitions The following words and terms, as used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise: “Application” means any document that contains the minimum information necessary as set forth at N.J.A.C. 11:3-44.3(a) to determine whether an applicant is an eligible person or is used in any way by the insurer to rate or underwrite a policy, including the coverage of selection form and renewal questionnaire as provided at N.J.A.C. 11:3-15.7 and 11:3-8 and, if requested, a copy of the applicant’s driver’s license, a copy of the motor vehicle registration of the principal vehicle to be insured and any additional proof of New Jersey residency. The term “application” shall also mean those signed forms, data, reports, analysis and other documents supplied in support of an application when requested by an insurer or by any other person, and/or supplied by the insured/applicant, or other person(s), seeking coverage under a policy or plan of health insurance that is provided to or used by an insurer in assessing the risk, or premium, or which is relied upon by the insurer in agreeing to provide coverage under the policy or plan, including but not limited to that information submitted in accordance with N.J.A.C. 11:4-16.7, 11:20-4.1 and 11:21-6.1. “Commissioner” means the Commissioner of the New Jersey Department of Banking and Insurance. “DAFC” means the Division of Anti-Fraud Compliance in the Department of Banking and Insurance. “Department” means the New Jersey Department of Banking and Insurance. “Eligible person” means an individual who meets the qualifications set forth in N.J.A.C. 11:3-34. “Fraud and misrepresentation” means the knowing misrepresentation of any material fact in a claim or application or the knowing failure to disclose any material fact in a claim or application which, if properly revealed or disclosed, would change the premium; either would affect the placement or underwriting of the risk, the assignment in the insurer’s rating plan, or affect the payment of a claim. “Fraud and prevention detection plan” or “plan” means an insurer’s plan for the prevention and detection of fraudulent insurance applications and claims. “Health insurance” means a contract or agreement whereby an insurer is obligated to pay or allow a benefit of pecuniary value with respect to the bodily injury, disablement, sickness, death by accident or accidental means of a human being, or because of any expense relating thereto, or because of any expense incurred in prevention of sickness, and includes every risk pertaining to any of the enumerated risks. Health insurance does not include any administrative services only (ASO) contracts, workers’ compensation coverage, or stop-loss coverage. “Insured lives” means the actual number of New Jersey residents entitled to receive benefits under a contract delivered or issued for delivery in this State. “Insurer” means any person or entity authorized to transact the business of private passenger automobile insurance in New Jersey, whether in accordance with a personal lines or commercial lines rating system, and includes a group of affiliated companies, and the Property-Liability Insurance Guaranty Association established pursuant to N.J.S.A. 17:30A-1 et seq. when performing its statutory function. “Insurer” pursuant to N.J.S.A. 17:33A-3 (health insurance) also means: 1. Any corporation, association, partnership, reciprocal exchange, interinsurer, Lloyd’s insurer, fraternal benefit society or other person engaged in the business of insurance pursuant to N.J.S.A. 17:17-1 et seq. or 17B:17-1 et seq.); 2. Any medical service corporation operating pursuant to N.J.S.A. 17:48A-1 et seq.; 3. Any hospital service corporation operating pursuant to N.J.S.A. 17:48-1 et seq.; 4. Any health service corporation operating pursuant to N.J.S.A. 17:48E-1 et seq.; 5. Any dental service corporation operating pursuant to N.J.S.A. 17:48C-1 et seq.; 6. Any dental plan organization operating pursuant to N.J.S.A. 17:48D-1 et seq.; “OIFP” means the Office of the Insurance Fraud Prosecutor in the Division of Criminal Justice in the Department of Law and Public Safety. “Special Investigations Unit” or “SIU” means the functional group established by an insurer to carry out the duties set forth in N.J.A.C. 11:16-6.4(a). “Stop-loss or excess risk insurance” means insurance designed to reimburse a self-funded arrangement for catastrophic and unexpected expenses exceeding specified per person retention limits and/or aggregate retention limit, wherein neither employees nor other individuals are third party beneficiaries under the policy, contract or plan. 11:16-6.3 General requirements and filing format (a) All insurers shall file for approval a fraud prevention and detection plan (“plan”) in accordance with N.J.S.A. 17:33A-15 and this subchapter. No insurer shall use or implement any plan that is not filed and approved. (b) Insurers shall submit their plan on 8 1/2 by 11-inch paper. The first page shall show the filer’s company name, the filer’s identifying number for this filing, National Association of Insurance Commissioners (“NAIC”) company number(s), and NAIC group number. (c) Insurers shall file their plan with the Department at the following address: Fraud Prevention and Detection Plan New Jersey Department of Banking and Insurance Division of Anti-Fraud Compliance P.O. Box 324 Trenton, N.J. 08625-0324 **State:** New Jersey **Requirement Types:** Fraud Plan --- ### [New Jersey-Fraud Warning-17:33A-6; NJAC 11:16-1.2 17:33A-6](https://insurancefraud.org/regulations/new-jersey-fraud-warning-1733a-6-njac-1116-1-2-1733a-6/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** a. Insurance claims forms shall contain a statement in a form approved by the commissioner that clearly states in substance the following: “Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties.” b. (Deleted by P.L. 1987, c. 342) c. Insurance application forms shall contain a statement in a form approved by the commissioner that clearly states in substance the following: “Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.” NJAC 11:16-1.2 (a) Insurers shall either place on or attach to all claim forms the following warning: “Any person who knowingly files a a statement of claim containing any false or misleading information is subject to criminal and civil penalties.” (b) Pursuant to NJSA 17:33A-6, all applications for insurance shall prominently and clearly contain the following statement: “Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.” (c) In lieu of the statement in (a) or (b) above, insurers may use a substantially similar statement with the prior approval of the Commissioner. 1. The Commissioner may approve the use of a statement substantially similar to that set forth above upon finding that the statement properly describes the prohibited conduct and references both criminal and civil penalties. 2. Request for approval of substantially similar statements shall be directed to the Department at the following address: Division of Anti Fraud Compliance New Jersey Department of Banking and Insurance PO Box 324 Trenton, NJ 08625-0324 **State:** New Jersey **Requirement Types:** Fraud Warning --- ### [New Jersey-Mandatory Reporting-Section 17:33A-9](https://insurancefraud.org/regulations/new-jersey-mandatory-reporting-section-1733a-9/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** “Any person who believes that a violation of this act has been or is being made shall notify the division immediately after discovery of the alleged violation of this act and shall send to the division, on a form and in a manner prescribed by the commissioner, the information requested and such additional information relative to the alleged violation as the division may require.” **State:** New Jersey **Requirement Types:** Mandatory Reporting --- ### [New Jersey-Pre-insurance Inspection-New Jersey Statutes 17:33B-33; NJAC 11:3-36.1 New Jersey Statutes 17:33B-33; NJAC 11:3-36.1](https://insurancefraud.org/regulations/new-jersey-pre-insurance-inspection-new-jersey-statutes-1733b-33-njac-113-36-1-new-jersey-statutes-1733b-33-njac-113-36-1/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** New Jersey Pre-insurance Inspection Photograph required — Yes Grace Period (days) — 7 Exemptions/Waivers Existing Policyholder (years) — 3 Renewal Policy — Yes New Cars — Yes Vehicle Age — 7 **State:** New Jersey --- ### [New Jersey-SIU Education-§ 11:16-6.5 Training program and manual for the prevention and detection of fraud](https://insurancefraud.org/regulations/new-jersey-siu-education-§-1116-6-5-training-program-and-manual-for-the-prevention-and-detection-of-fraud/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** § 11:16-6.5 Training program and manual for the prevention and detection of fraud (a) The requirements with respect to fraud prevention and detection training programs are set forth in this subsection. Except for automobile insurers that insure fewer than 2,500 New Jersey automobile policies and health insurers that insure fewer than 10,000 lives, the plan shall provide anti-fraud education for SIU investigators, SIU specialists, claims adjusters, and underwriters that shall include a detailed and comprehensive program of insurance fraud awareness and education to prepare claims adjusting and underwriting personnel for insurance fraud prevention and detection. 1. The training program shall include Basic Entry Level Training and Continuing Education Training for all adjusters, claims processors, underwriters, SIU investigators, and SIU specialists, and shall be submitted to and approved by the Department. The Continuing Education Training instructions format may be classroom instruction, self-guided instruction, videotape, seminar, computer based, or by any other means. 2. The training programs referred to in (a)1 above shall be provided as follows: i. In the case of automobile insurers, training shall include, but not be limited to, the following areas as appropriate: automobile theft investigations, automobile property damage and fire investigations, personal injury protection investigations, bodily injury liability claim investigation, statutory requirements for fraud referrals, techniques for the identification of fraudulent applications for coverage, insurance rate making practices, tier rating plans used by the insurer, PIP medical expense benefits and medical treatment protocols and precertification plans, and current indicators of fraud. ii. In the case of health insurers, training shall include, but not be limited to, the following areas as appropriate: overcharging and overpayment detection, claims processing guidelines, medical coding, duplicate bills, excessive charges, unnecessary services or supplies, over-utilization, services never rendered, miscoded or misleading claim information, hospital inpatient or outpatient billing abuse or inappropriate commitment or confinement, abusive or fraudulent referrals, statutory requirements dealing with fraud referrals, techniques for the identification of fraudulent applications for coverage, the type, methods of service and operating procedures of various health insurers, and current indicators of fraud. iii. Each company shall submit for approval the Basic Entry Level Training, which shall be no less than nine hours of classroom instruction for SIU personnel and no less than four and one-half hours of classroom instruction for non-SIU personnel. Continuing Education Training shall be no less than nine hours of training per year for SIU personnel and no less than two hours per year for claims and underwriting personnel. Basic Entry Level Training shall be given to all employees within 180 days from the commencement of their employment at each of these positions: underwriters, adjusters, claims processors, SIU investigators, or SIU specialists. The no less than two hours of continuing education training provided to non-SIU personnel shall emphasize the responsibility of all employees to identify and report indications of internal and external fraud to the proper authority. (b) The requirements with respect to fraud prevention and detection procedures manuals are set forth in this subsection. Except for insurers which insure fewer than 2,500 New Jersey automobile policies, or health insurers fewer than 10,000 lives, the plan shall provide a fraud prevention and detection procedure manual and disseminate it to, or make it available to, as appropriate, all SIU, claims adjusters, and underwriting personnel. The fraud prevention and detection procedure manual shall include, at a minimum, the following: 1. Information for claim adjusters, underwriting personnel, SIU investigators and SIU specialists regarding general investigation guidelines; unfair claims practices; conducting interviews; report writing; information disclosure; law enforcement relations; and the New Jersey Insurance Fraud Prevention Act; 2. The process to be employed for reporting to OIFP when specific facts and circumstances are identified, in connection with a claim or application, which upon further SIU investigation leads to a reasonable conclusion that a violation of N.J.S.A. 17:33A-4 has occurred; 3. For automobile insurers, the “fraud indicators” used for automobile theft, automobile physical damage fraud, personal injury claims fraud, bodily injury claims fraud, and application fraud; 4. For health insurers, “fraud factors” or “indicators” for health fraud, application fraud, and claims fraud; 5. The duties and functions of the SIU; 6. The procedure for referral of a claim or application to the SIU; 7. The post-referral procedure for communication between the claims unit and/or the underwriting unit and the SIU regarding claim resolution and file closure; 8. All update pages for the protocol, training program, and procedure manual shall include a description of the content being updated, the page number, and its effective date; 9. Hard copy procedure manuals shall include version/filing numbers in footers along with page numbering and a table of contents; 10. Internet-based procedure manuals shall provide home pages displaying hyperlinks or other navigation to the required content; and 11. Updates shall be referenced in hard copy and Internet manuals. (c) As used in (b) above: 1. “Unfair claims practices” is understood to include copies of or valid hyperlinks to both: i. N.J.S.A. 17B:30-13 and N.J.A.C. 11:2-17, Unfair Claim Settlement Practices, (health insurers); and ii. N.J.S.A. 17:29B-4(9) and N.J.A.C. 11:2-17, Unfair Claim Settlement Practices, (property/casualty); 2. “New Jersey Insurance Fraud Prevention Act” is understood to include copies of or valid hyperlinks to both: i. N.J.S.A. 17:33A-1 et seq., New Jersey Insurance Fraud Prevention Act; and ii. N.J.A.C. 11:16-6, Fraud Prevention and Detection; and 3. “Information disclosure” is understood to include copies of or valid hyperlinks to: i. P.L. 106-102, Gramm-Leach-Bliley; ii. P.L. 104-191, Health Insurance Portability and Accountability Act of 1996; iii. N.J.S.A. 56:11-44 et seq., Identity Theft Prevention Act; iv. N.J.S.A. 17:23A-13, Disclosure limitations and conditions; and v. N.J.A.C. 13:45F, Identity Theft. (d) Specimen formats of the anti-fraud prevention and detection protocol, anti-fraud prevention and detection training program, and anti-fraud prevention and detection procedure manual are available for viewing on-line at http://www.state.nj.us/dobi/division\_consumers/insurance/mceu.html. **State:** New Jersey **Requirement Types:** SIU Education --- ### [New Jersey-SIU Requirement-11:16-6.4 Special Investigations Unit (SIU)-duties, qualifications, and composition;11:16-6.5 Training program and manual for the prevention and detection of fraud;11:16-6.6 Fraud prevention and detection plan;11:16-6.7 Referrals to OIFP;11:16-6.8 Record retention;11:16-6.9 Approval and filing of fraud prevention and detection plans;11:16-6.10 Penalties;11:16-6.11 Transition;11:16-6.12 Confidential records and information](https://insurancefraud.org/regulations/new-jersey-siu-requirement-1116-6-4-special-investigations-unit-siu-duties-qualifications-and-composition1116-6-5-training-program-and-manual-for-the-prevention-and-detection-of-fraud1116-6-6/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** 11:16-6.4 Special Investigations Unit (SIU)-duties, qualifications, and composition ( a) Except for automobile insurers that insure fewer than 2,500 New Jersey automobile policies, and health insurers that insure fewer than 10,000 lives, the plan in accordance with N.J.A.C. 11:16-6.3 shall establish a full-time Special Investigations Unit (“SIU”). (b) The SIU shall be responsible for the following: 1. Conducting investigations of claims referred by the claim personnel or applications referred by underwriting personnel whenever the adjuster, processor, or underwriter identifies specific facts and circumstances which, upon further SIU investigation, may lead to a reasonable conclusion that a violation of N.J.A.C. 17:33A-4 has occurred; 2. Providing liaison with OIFP, other law enforcement personnel and the DAFC; 3. Providing in-service training to claims personnel, underwriting personnel, and adjusters in accordance with the provisions of N.J.A.C. 1:16-6.5; 4. Maintaining a database of fraudulent claims and application fraud which shall contain, at a minimum, the names, addresses and other identifying information regarding all parties to the investigation referred to in (b) 1 above; 5. Informing insurance underwriters of ineligible risks by reason of prior fraudulent activities from the database in (b)4 above; 6. Identifying persons and organizations that are involved in suspicious claim activity and application fraud, as described in (b)1 above; 7. Referring matters to OIFP in accordance with N.J.A.C. 11:16-6.6(b) and N.J.A.C. 11:16-6.7 and providing notice of suspicious claims in accordance with N.J.A.C. 11:16-6.6(c); and 8. Ensuring that all evidence on matters referred to the SIU including, but not limited to, checks issued in payment of claims, taped statements, original receipts, and original documents submitted by a person or entity in support of or in opposition of a claim applicant, are identified, collected and preserved in order to be turned over to OIFP in connection with the referral of cases to OIFP. (c) The SIU shall have the following composition: 1. SIU investigators and SIU specialists shall be a separate unit from the claims adjusting or underwriting function. For purposes of this paragraph, it shall not violate this provision if the SIU issues a check paying a claim or denies payment of a claim so long as: i. The SIU personnel are a separate and distinct unit and ii. When closing the file at the completion of the investigation, the SIU records its findings in writing together with its recommendations to pay or deny the claim with the reasons. 2. Automobile insurers shall employ at least one SIU investigator or SIU specialist (when permitted by N.J.A.C. 11:16-6.4(d)2) for each 30,000 New Jersey automobile policies serviced. 3. Health insurers offering comprehensive benefits contracts shall employ at least one SIU investigator or SIU specialist (when permitted by N.J.A.C. 11:16-6.4(d)2) for every 60,000 insured lives. 4. Health insurers offering limited benefit contracts shall employ at least one SIU or SIU specialist (when permitted by NJAC 11:16-6.4(d)2) for every 250,000 insured lives. Limited benefits contracts shall include, but not be limited to, the following: accident only; credit; disability; long-term care; Medicare supplement; dental only; vision only; insurance issued as a supplement to liability insurance; and any other supplemental hospital indemnity benefits. (d) Qualifications of SIU investigators and specialists shall be as follows: 1. SIU investigators shall have at least one of the following: i. A Bachelor’s degree; ii. An Associate’s degree plus a minimum of two years experience with insurance related employment; iii. A minimum of four years of experience with insurance related employment; or iv. A minimum of five years of law enforcement experience. 2. When approved by the Department in the plan, an insurer shall be permitted to employ a limited number of SIU specialists who shall possess unique qualifications by way of training, technical skill, and/or experience to investigate and identify cases of fraud, but lack the specific educational requirements set forth in (d)1 above, to be SIU investigators. (e) The plan may provide that the functions of the SIU may be assigned to an outside vendor or third party administrator. In such case, the plan shall provide that the outside vendor or third party administrator shall be also be responsible together with the insurer, for compliance with NJAC 11:16-6. § 11:16-6.5 Training program and manual for the prevention and detection of fraud (a) The requirements with respect to fraud prevention and detection training programs are set forth in this subsection. Except for automobile insurers that insure fewer than 2,500 New Jersey automobile policies and health insurers that insure fewer than 10,000 lives, the plan shall provide anti-fraud education for SIU investigators, SIU specialists, claims adjusters, and underwriters that shall include a detailed and comprehensive program of insurance fraud awareness and education to prepare claims adjusting and underwriting personnel for insurance fraud prevention and detection. 1. The training program shall include Basic Entry Level Training and Continuing Education Training for all adjusters, claims processors, underwriters, SIU investigators, and SIU specialists, and shall be submitted to and approved by the Department. The Continuing Education Training instructions format may be classroom instruction, self-guided instruction, videotape, seminar, computer based, or by any other means. 2. The training programs referred to in (a)1 above shall be provided as follows: i. In the case of automobile insurers, training shall include, but not be limited to, the following areas as appropriate: automobile theft investigations, automobile property damage and fire investigations, personal injury protection investigations, bodily injury liability claim investigation, statutory requirements for fraud referrals, techniques for the identification of fraudulent applications for coverage, insurance rate making practices, tier rating plans used by the insurer, PIP medical expense benefits and medical treatment protocols and precertification plans, and current indicators of fraud. ii. In the case of health insurers, training shall include, but not be limited to, the following areas as appropriate: overcharging and overpayment detection, claims processing guidelines, medical coding, duplicate bills, excessive charges, unnecessary services or supplies, over-utilization, services never rendered, miscoded or misleading claim information, hospital inpatient or outpatient billing abuse or inappropriate commitment or confinement, abusive or fraudulent referrals, statutory requirements dealing with fraud referrals, techniques for the identification of fraudulent applications for coverage, the type, methods of service and operating procedures of various health insurers, and current indicators of fraud. iii. Each company shall submit for approval the Basic Entry Level Training, which shall be no less than nine hours of classroom instruction for SIU personnel and no less than four and one-half hours of classroom instruction for non-SIU personnel. Continuing Education Training shall be no less than nine hours of training per year for SIU personnel and no less than two hours per year for claims and underwriting personnel. Basic Entry Level Training shall be given to all employees within 180 days from the commencement of their employment at each of these positions: underwriters, adjusters, claims processors, SIU investigators, or SIU specialists. The no less than two hours of continuing education training provided to non-SIU personnel shall emphasize the responsibility of all employees to identify and report indications of internal and external fraud to the proper authority. (b) The requirements with respect to fraud prevention and detection procedures manuals are set forth in this subsection. Except for insurers which insure fewer than 2,500 New Jersey automobile policies, or health insurers fewer than 10,000 lives, the plan shall provide a fraud prevention and detection procedure manual and disseminate it to, or make it available to, as appropriate, all SIU, claims adjusters, and underwriting personnel. The fraud prevention and detection procedure manual shall include, at a minimum, the following: 1. Information for claim adjusters, underwriting personnel, SIU investigators and SIU specialists regarding general investigation guidelines; unfair claims practices; conducting interviews; report writing; information disclosure; law enforcement relations; and the New Jersey Insurance Fraud Prevention Act; 2. The process to be employed for reporting to OIFP when specific facts and circumstances are identified, in connection with a claim or application, which upon further SIU investigation leads to a reasonable conclusion that a violation of N.J.S.A. 17:33A-4 has occurred; 3. For automobile insurers, the “fraud indicators” used for automobile theft, automobile physical damage fraud, personal injury claims fraud, bodily injury claims fraud, and application fraud; 4. For health insurers, “fraud factors” or “indicators” for health fraud, application fraud, and claims fraud; 5. The duties and functions of the SIU; 6. The procedure for referral of a claim or application to the SIU; 7. The post-referral procedure for communication between the claims unit and/or the underwriting unit and the SIU regarding claim resolution and file closure; 8. All update pages for the protocol, training program, and procedure manual shall include a description of the content being updated, the page number, and its effective date; 9. Hard copy procedure manuals shall include version/filing numbers in footers along with page numbering and a table of contents; 10. Internet-based procedure manuals shall provide home pages displaying hyperlinks or other navigation to the required content; and 11. Updates shall be referenced in hard copy and Internet manuals. (c) As used in (b) above: 1. “Unfair claims practices” is understood to include copies of or valid hyperlinks to both: i. N.J.S.A. 17B:30-13 and N.J.A.C. 11:2-17, Unfair Claim Settlement Practices, (health insurers); and ii. N.J.S.A. 17:29B-4(9) and N.J.A.C. 11:2-17, Unfair Claim Settlement Practices, (property/casualty); 2. “New Jersey Insurance Fraud Prevention Act” is understood to include copies of or valid hyperlinks to both: i. N.J.S.A. 17:33A-1 et seq., New Jersey Insurance Fraud Prevention Act; and ii. N.J.A.C. 11:16-6, Fraud Prevention and Detection; and 3. “Information disclosure” is understood to include copies of or valid hyperlinks to: i. P.L. 106-102, Gramm-Leach-Bliley; ii. P.L. 104-191, Health Insurance Portability and Accountability Act of 1996; iii. N.J.S.A. 56:11-44 et seq., Identity Theft Prevention Act; iv. N.J.S.A. 17:23A-13, Disclosure limitations and conditions; and v. N.J.A.C. 13:45F, Identity Theft. (d) Specimen formats of the anti-fraud prevention and detection protocol, anti-fraud prevention and detection training program, and anti-fraud prevention and detection procedure manual are available for viewing on-line at http://www.state.nj.us/dobi/division\_consumers/insurance/mceu.html. 11:16-6.6 Fraud prevention and detection plan (a) The plan shall provide for underwriting inquiry to verify that the insured is an eligible person and the policy is properly rated within 60 days of receipt of the application. These underwriting inquiries shall verify the insured’s residency provided by the insured on his or her application for insurance. The plan may provide that these inquires are generally done “in-house” by telephone and by using information from the New Jersey Division of Motor Vehicle Services (or similar agencies in other states) and prior insurers. (b) The following concern referral of application and claims: 1.The plan shall provide that an application or claim shall be referred as a case to OIFP, for further OIFP investigation or other appropriate action, on the prescribed Referral Form (OIFP-1A for Claim Fraud Referral, OIFP-1B for Application Fraud Referral, OIFP-2 for Suspicious Claim/Application Notification, OIFP-3A for Health Claim Fraud Referral, OIFP-3B for Health Application Fraud Referral, and OIFP-4 for Suspicious Health Claim/Application notification incorporated herein by reference in the subchapter Appendix), with all other information required by the form, when the investigation complies with the requirements set forth in N.J.A.C. 11:16-6.7. 2. The plan shall provide that all applications and claims, which meet the standard for referral set forth in N.J.A.C. 11:16-6.7, shall be referred to OIFP by the SIU as soon as practicable, but in no case later than 30 days from when the investigation is complete. 3. The plan shall provide criteria and levels of economic impact for the referral of insurance claims and application fraud in accordance with the requirements of NJAC 11:16-6.7. (c) The plan shall provide that after completion of an SIU investigation, or after identification by an SIU of a pattern of applications or claims, the insurer shall provide notice to OIFP on Notification Form OIFP-2 and for Health insurance Notification on OIFP-4 (incorporated herein by reference in the subchapter Appendix), unless this form is superseded by an electronic reporting form, of instances in which a violation of N.J.S.A. 17:33A-4 is suspected on the basis of fraud factors or indicators, but where sufficient evidence to support a case referral pursuant to N.J.A.C. 11:16-6.7 has not been developed. (d) The plan shall provide that all referrals of application and claims fraud and notifications of suspected application or claims fraud by the insurer to OIFP shall be made by personnel in the insurer’s SIU or other personnel designated in the plan so long as records are kept of all referrals and notifications and the appropriate form is used. (e) Where an insurer contracts any of its SIU functions to an outside vendor or third party administrator in accordance with NJAC 11:16-6.4(e), the plan shall provide the name and address of the outside vendor or third party administrator used by the insurer to conduct investigations or perform SIU functions together with a copy of the contract between the insurer and the outside vendor or third party administrator. (f) The plan may include such other items as the insurer may wish to provide. 11:16-6.7 Referrals to OIFP (a) The plan shall provide that upon completion of its investigation, as described in (d) below, an SIU shall refer cases, on form OIFP-1A, OIFP-1B, OIFP-3A or OIFP-3B which meet the following standard to OIFP: 1. Any application or claim where the facts and circumstances crate a reasonable suspicion that a person or entity has violated N.J.S.A. 17:33A-4: and; 2. There is sufficient independent evidence corroborating the reasonable suspicion described in (a)1 above, from which a person could reasonably conclude that the person or entity has violated N.J.S.A. 17:33A-4. (b) The facts and circumstances referred to in (a)1 above can include, but are not limited to, “fraud indicators” contained in an insurer’s approved plan, and such other facts and circumstances as would lead a reasonable person to suspect that a violation of N.J.S.A. 17:33A-4 has occurred. (c) As referred to in (a)2 above, independent evidence corroborating the reasonable suspicion that a person has violated N.J.S.A. 17:33A-4 includes, but is not limited to: 1. A statement from a witness; 2. Documentary evidence that directly negates a material element of the claim or directly establishes the falsity of a material element of an insurance application; 3. A report of an expert; or 4. Additional apparent misrepresentations tending to negate a possibility that the misrepresentation was merely an error. (d) An investigation shall be complete for purposes of referral to OIFP when all reasonable and appropriate investigative leads and opportunities have been exhausted. When an investigation has identified a pattern of possible violations of N.J.S.A. 17:33A-4, the investigation will be deemed complete for purposes of referral as a case to OIFP when one or more violations included in the identified pattern have been sufficiently investigated and corroborated, in accordance with (a) above for referral to OIFP. 11:16-6.8 Record retention (a) Insurers shall maintain up-to-date and accurate records on their fraud prevention and detection plan, which shall at minimum include those necessary to prepare the report required in (b) below. (b) As of January 1 of each year, insurers shall submit an annual report for the prior calendar year to the Commissioner on DAFC From #1 found in this Appendix. 1. The report referred to in (b) above shall be filed with the Department on or before February 1 of each year and sent to the following address: New Jersey Department of Banking and Insurance Division of Anti-Fraud Compliance PO Box 324 Trenton, N.J. 08625-0324 2. Insurers shall submit the report referred to in (b) above in written copy and on an MS-DOS formatted disk. The disk shall be a 3.5 inch 1.44 MB disk. The information shall be provided in an Access Database provided by DAFC. Insurers may submit a disk, together with a self-addressed stamped diskette mailer to the DAFC. The DAFC will properly format the disk and return to the insurer to facilitate compliance. 3. As an alternative to the filings described in (1) and (2) above, insurers may submit this annual informational filing to the Department at the following e-mail address: DAFC@DOBI.STATE.NJ.US. Insurers can acquire the required Access Database format from the Department by directing a request for the “annual filing template” to the DAFC e-mail address referenced here. 11:16-6.9 Approval and filing of fraud prevention and detection plans (a) An insurer’s fraud prevention and detection plan shall be deemed approved by the Commissioner if not affirmatively approved or disapproved by the Commissioner within 90 days of the date of filing. (b) The Commissioner may request such amendments to the plan as he or she deems necessary. (c) An insurer must submit amendments to its plan when necessary to achieve compliance with these rules. Any amendments to a plan filed with the Commissioner shall be deemed approved by the Commissioner if not affirmatively approved or disapproved within 90 days of the date of filing. (d) The insurer shall permit the DAFC access to its offices upon reasonable notice and at reasonable hours to conduct an audit of the insurer’s compliance with its fraud prevention plan. Nothing in this section shall be construed as to preclude the DAFC from conducting reviews of an insurer’s compliance with its fraud prevention and detection plan at the office of the DAFC when determined to be necessary by the DAFC. (e) In those instances in which an insurer uses an outside agent, third party administrator or contractor to perform SIU functions or claims investigations, the Plan and contract with the outside vendor or third party administrator shall provide the Department shall be permitted to audit the records, books and documents maintained by the outside contractor or third party administrator in the same manner and fashion as it would be able to examine the books and records in accordance with N.J.S.A. 17:33A-15 and N.J.S.A. 17:23-22. (f) All information included in an insurer’s plan submitted to the DAFC pursuant to this subchapter or any other information including training programs submitted to DAFC pursuant to this subchapter shall be confidential and not subject to public disclosure or inspection. 11:16-6.10 Penalties Failure to comply with the provisions of this subchapter shall subject the insurer to penalties as prescribed by law. 11:16-6.11 Transition No later than 120 days following the adoption of this subchapter, all insurers shall file with the Department a new fraud prevention and detection plan and manual in conformance with these rules. 11:16-6.12 Confidential records and information (a) All information and materials in the possession of the Office of Insurance Fraud Prosecutor concerning the existence or occurrence of insurance fraud or related criminal activities are confidential and privileged against disclosure, and shall not be deemed public records, so as to protect the public interest in the prosecution of insurance fraud, including protecting witness security, the State’s relationship with informants and witnesses, the privacy interests of persons investigated by OIFP where no fraud has been proven and other confidential relationships. (b) The confidentiality which extends to information and materials possessed by the Office of Insurance Fraud Prosecutor with respect to the existence or occurrence of insurance fraud or related criminal activities extends to all papers, documents, reports, evidence and databases, such as investigative reports, referrals, reports or notifications of suspicious claims or applications or suspected insurance fraud, computer maintained databases of such investigative information, and such other materials and information as the Insurance Fraud Prosecutor, on the basis of his experience and exercise of judgment, believes must be kept confidential in order to ensure the orderly investigation and prosecution of insurance fraud. c. Confidentiality of the information and materials in the possession of OIFP shall not preclude OIFP from fulfilling its statutory obligations of working with other law enforcement agencies, the Department of Health and Senior Services, the Department of Human Services, any professional board in the Division of Consumer Affairs in the Department of Law and Public Safety, the Department of Banking and Insurance, the Division of State Police and such local government units as may be necessary or practicable and of coordinating and providing information to and among referring entities on pending cases of suspected insurance fraud, where such action would serve the public interest n facilitating the investigation or prosecution of insurance fraud. **State:** New Jersey **Requirement Types:** SIU Requirement --- ### [New Mexico-Fraud Plan-Section 10 - H 141, enacted 1998 session, effective July 1, 1998](https://insurancefraud.org/regulations/new-mexico-fraud-plan-section-10-h-141-enacted-1998-session-effective-july-1-1998/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** A. Within six months of the effective date of the Insurance Fraud Act and by July 1 of each succeeding year every insurer who in the previous calendar year reported ten million dollars ($10,000,000) or more in direct written premiums in New Mexico shall establish, prepare, implement and submit to the superintendent an anti-fraud plan that is reasonably calculated to detect, prosecute and prevent insurance fraud. Any subsequent amendments to the plan shall be submitted to the superintendent at the time they are adopted. B. Each insurer’s anti-fraud plan shall outline, at a minimum, specific procedures, appropriate to the type of insurance the insurer writes, to: (1) prevent, detect and investigate all forms of insurance fraud; (2) educate appropriate employees on fraud detection and the insurer’s anti-fraud plan; (3) provide for the hiring or contracting of fraud investigators; (4) report insurance fraud to appropriate law enforcement and regulatory authorities; and (5) pursue restitution, where appropriate, for financial loss caused by insurance fraud. C. The superintendent may review each insurer’s anti-fraud plan to determine if it adequately complies with the requirements of this section. The superintendent may examine the insurer to assure its compliance with anti-fraud plans submitted to the superintendent. The superintendent may require reasonable modifications to the insurer’s anti-fraud plan or may require other reasonable remedial action if the review or examination reveals substantial noncompliance with the plan. **State:** New Mexico **Requirement Types:** Fraud Plan --- ### [New Mexico-Fraud Warning-59A-16C-8](https://insurancefraud.org/regulations/new-mexico-fraud-warning-59a-16c-8/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Within six months of the effective date of the Insurance Fraud Act all claim forms and applications for insurance shall contain a statement permanently affixed to the application or claim form which states substantially as follows: “Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.” The failure to include that statement shall not constitute a defense against prosecution for commission of insurance fraud. **State:** New Mexico **Requirement Types:** Fraud Warning --- ### [Kentucky-SIU Education-806 KAR 47:030](https://insurancefraud.org/regulations/kentucky-siu-education-806-kar-47030/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** 806 KAR 47:030 — … Section 2. All insurers shall implement the following in conjunction with their SIUs: (1) Systematic and effective methods to detect and investigate suspected fraudulent insurance claims; (2) Development and implementation of a corporate antifraud strategy to provide for the appropriate disposition of fraudulent insurance claims; (3) Provisions to educate and train all claims handlers to identify possible insurance fraud; (4) Policies for the SIU to cooperate with the insurer’s claims handlers, the insurer’s legal personnel, technical support personnel, and database support personnel; (5) Procedures to facilitate insurer communications with the Insurance Fraud Unit and compliance with mandatory reporting of suspected fraudulent insurance acts, pursuant to KRS 304.47-050; and (6) Procedures to encourage, coordinate, and effectuate communications and cooperation between the SIU, the Insurance Fraud Unit and other relevant law enforcement agencies. **State:** Kentucky **Requirement Types:** SIU Education --- ### [Kentucky-SIU Requirement-KRS 304.47-080; 806 KAR 47:030](https://insurancefraud.org/regulations/kentucky-siu-requirement-krs-304-47-080-806-kar-47030/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** KRS 304.47-080 — (1) Every insurer admitted to do business in the Commonwealth shall maintain a unit to investigate possible fraudulent claims by insureds or by persons making claims for services or repairs against policies held by insureds. (2) Insurers may maintain the unit required by subsection (1) of this section, using its employees or by contracting with others for that purpose. (3) Insurers shall establish the unit required by this section no later than July 15, 1995. (4) The unit may include the assignment of fraud investigation to employees whose principal responsibilities are the investigation and disposition of claims. If an insurer creates a distinct unit, hires additional employees, or contracts with another entity to fulfill the requirements of this article, the additional cost incurred shall be included as an administrative expense. 806 KAR 47:030 — … Section 2. All insurers shall implement the following in conjunction with their SIUs: (1) Systematic and effective methods to detect and investigate suspected fraudulent insurance claims; (2) Development and implementation of a corporate antifraud strategy to provide for the appropriate disposition of fraudulent insurance claims; (3) Provisions to educate and train all claims handlers to identify possible insurance fraud; (4) Policies for the SIU to cooperate with the insurer’s claims handlers, the insurer’s legal personnel, technical support personnel, and database support personnel; (5) Procedures to facilitate insurer communications with the Insurance Fraud Unit and compliance with mandatory reporting of suspected fraudulent insurance acts, pursuant to KRS 304.47-050; and (6) Procedures to encourage, coordinate, and effectuate communications and cooperation between the SIU, the Insurance Fraud Unit and other relevant law enforcement agencies. **State:** Kentucky **Requirement Types:** SIU Requirement --- ### [Louisiana-Annual Reporting-Sec. 22:572.1(F)](https://insurancefraud.org/regulations/louisiana-annual-reporting-sec-22572-1f/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** F. The anti-fraud plan and any summary report shall be filed with the commissioner on or before April first of each calendar year. Either on a calendar year basis or on whatever other interval he deems appropriate, the commissioner is authorized to require that each authorized insurer and each health maintenance organization file a summary report of any material change to the insurance anti- fraud plan, including the total number of claims and the number of claims referred to the commissioner as suspicious, and the commissioner is authorized to direct each insurer and each health maintenance organization as to the format of the summary report. G. The insurance anti-fraud plan submitted to the department, as well as the summary report of the insurer’s or health maintenance organization’s insurance anti-fraud activities and results, are not public records and are exempt pursuant to R.S. 44:1 et seq., and specifically R.S. 44:4.1(B)(10), shall be and are hereby declared to be company proprietary and business confidential records and not subject to public examination or subpoena. **State:** Louisiana **Requirement Types:** Annual Reporting --- ### [Louisiana-Fraud Plan-§572.1. Insurance anti-fraud plan](https://insurancefraud.org/regulations/louisiana-fraud-plan-§572-1-insurance-anti-fraud-plan/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** §572.1. Insurance anti-fraud plan Each authorized insurer and each health maintenance organization licensed to operate in this state shall prepare, implement, and maintain an insurance anti-fraud plan for the insurer’s or health maintenance organization’s operations in this state. The insurance anti-fraud plan utilized by each authorized insurer and each health maintenance organization in this state shall be filed with the commissioner of insurance and shall outline specific procedures, actions, and safeguards that are applicable, relevant, and appropriate to the type of insurance the authorized insurer writes or the type of coverage offered by the health maintenance organization in this state and shall include how the authorized insurer or health maintenance organization will: Detect, investigate, and prevent all forms of insurance fraud, including fraud involving the insurer’s or health maintenance organization’s employees or agents; fraud resulting from misrepresentations in the application, renewal, or rating of insurance policies; fraudulent claims; and security of the insurer’s or health maintenance organization’s data processing systems. Educate appropriate employees on fraud detection and the insurer’s or health maintenance organization’s anti-fraud plan. Provide for fraud investigations, whether through the use of internal fraud investigators or third-party contractors. Report a suspected fraudulent insurance act, as defined by R.S. 9 22:1923(1), to the Department of Insurance as well as appropriate law enforcement and other regulatory authorities engaged in the investigation and prosecution of insurance fraud. (5) Pursue restitution for financial loss caused by insurance fraud, when applicable, relevant, and appropriate. The commissioner shall review the insurance anti-fraud plan submitted by each authorized insurer and each health maintenance organization to determine compliance with the requirements of this Section. D. The commissioner shall have the authority to investigate and examine the records and operations of each authorized insurer and each health maintenance organization to determine if the insurer or health maintenance organization has implemented and maintained compliance with the insurance anti-fraud plan. E. The commissioner is authorized to direct any authorized insurer or health maintenance organization to make any modification to the insurer’s or health maintenance organization’s insurance anti-fraud plan necessary to obtain and maintain compliance with the requirements of this Section, and the commissioner may require any other reasonable remedial action to the insurer’s or health maintenance organization’s insurance anti-fraud plan if the investigation and examination reveals substantial noncompliance by the insurer or health maintenance organization with the terms of the insurer’s or health maintenance organization’s insurance anti-fraud plan. F. The anti-fraud plan and any summary report shall be filed with the commissioner on or before April first of each calendar year. Either on a calendar year basis or on whatever other interval he deems appropriate, the commissioner is authorized to require that each authorized insurer and each health maintenance organization file a summary report of any material change to the insurance anti- fraud plan, including the total number of claims and the number of claims referred to the commissioner as suspicious, and the commissioner is authorized to direct each insurer and each health maintenance organization as to the format of the summary report. G. The insurance anti-fraud plan submitted to the department, as well as the summary report of the insurer’s or health maintenance organization’s insurance anti-fraud activities and results, are not public records and are exempt pursuant to R.S. 44:1 et seq., and specifically R.S. 44:4.1(B)(10), shall be and are hereby declared to be company proprietary and business confidential records and not subject to public examination or subpoena. **State:** Louisiana **Requirement Types:** Fraud Plan --- ### [Louisiana-Fraud Warning-LARS 40:1424](https://insurancefraud.org/regulations/louisiana-fraud-warning-lars-401424/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** B. All applications for insurance and all claim forms provided and required by an insurer or required by law as a condition of payment of a claim shall contain a statement, permanently affixed to or included as a part of the application or claim form, that clearly states in substance the following: “Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.” C. The lack of the statement required in Subsection B of this Section shall not constitute a defense in any criminal prosecution. **State:** Louisiana **Requirement Types:** Fraud Warning --- ### [Louisiana-Mandatory Reporting-LA R.S. 1208.2 Immunity for Reporting](https://insurancefraud.org/regulations/louisiana-mandatory-reporting-la-r-s-1208-2-immunity-for-reporting/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** § 23:1208.2. Duty to report fraud; immunity from civil liability. A. Any person having knowledge of or who believes that an act is being or has been committed in violation of this Chapter shall report orally or in writing to the director the information that forms the basis of such knowledge or belief, as well as any such additional information relevant thereto as the director or his employees or his agents may require. B. Any person who provides information pursuant to this Section without malice, fraudulent intent, or bad faith, shall be immune from all civil liability for such action. **State:** Louisiana **Requirement Types:** Mandatory Reporting --- ### [Louisiana-Mandatory Reporting-LA R.S. 22:1926](https://insurancefraud.org/regulations/louisiana-mandatory-reporting-la-r-s-221926/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** § 22:1926. Duties of companies and others. A. Any person, company, or other legal entity including but not limited to those engaged in the business of insurance, including producers and adjusters, that suspects that a fraudulent insurance act will be, is being, or has been committed shall, within sixty days of the receipt of such notice, send to the division of insurance fraud, on a form prescribed by the commissioner, the information requested and such additional information relative to the insurance act and the parties claiming loss or damages because of an occurrence or accident as the commissioner may require. The division of insurance fraud shall review such reports and select such insurance acts as, in its judgment, may require further investigation. It shall then cause an independent examination of the facts surrounding such insurance act to be made to determine the extent, if any, to which fraud, deceit, or intentional misrepresentation of any kind exists in the submission of the insurance act. B. The division of insurance fraud shall report any alleged violations of law which its investigations disclose to the appropriate licensing agency, the insurance fraud investigation unit of the office of state police, the insurance fraud support unit of the Department of Justice, and the prosecutive authority having jurisdiction with respect to any such violation. These units shall work jointly on criminal referrals. **State:** Louisiana **Requirement Types:** Mandatory Reporting --- ### [Louisiana-Mandatory Reporting-Section 22:1926 Workers Compensation - 23:1208.2](https://insurancefraud.org/regulations/louisiana-mandatory-reporting-section-221926-workers-compensation-231208-2/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** §1926. Duties of companies and others A. Any person, company, or other legal entity including but not limited to those engaged in the business of insurance, including agents, brokers, and adjusters, which believes that a fraudulent claim is being made, shall within sixty days of the receipt of such notice, send to the section of insurance fraud, on a form prescribed by the section, the information requested and such additional information relative to the claim and the parties claiming loss or damages because of an occurrence or accident as the section may require. The section of insurance fraud shall review such reports and select such claims as, in its judgment, may require further investigation. It shall then cause an independent examination of the facts surrounding such claim to be made to determine the extent, if any, to which fraud, deceit, or intentional misrepresentation of any kind exists in the submission of the claim. B. The section of insurance fraud shall report any alleged violations of law which its investigations disclose to the appropriate licensing agency, the insurance fraud investigation unit of the office of state police, the insurance fraud support unit of the Department of Justice, and the prosecutive authority having jurisdiction with respect to any such violation. These units shall work jointly on criminal referrals. Workers Compensation: §1208.2. Duty to report fraud; immunity from civil liability A. Any person having knowledge of or who believes that an act is being or has been committed in violation of this Chapter shall report orally or in writing to the director the information that forms the basis of such knowledge or belief, as well as any such additional information relevant thereto as the director or his employees or his agents may require. B. Any person who provides information pursuant to this Section without malice, fraudulent intent, or bad faith, shall be immune from all civil liability for such action. **State:** Louisiana **Requirement Types:** Mandatory Reporting --- ### [Maine-Annual Reporting-Sec. 2186 (4); Regulation: Chapter 920:](https://insurancefraud.org/regulations/maine-annual-reporting-sec-2186-4-regulation-chapter-920/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** 4\. Reporting of fraudulent insurance acts. Fraudulent insurance acts must be reported in accordance with this subsection. A. An insurer shall, annually on or before March 1st or within any reasonable extension of time granted by the superintendent, file with the superintendent a report relating to fraudulent insurance acts that the insurer knew or reasonably believed had been committed during the previous calendar year. The report must contain information required by the superintendent in the manner prescribed by the superintendent. The information must be reported on an aggregate basis and may not contain any information identifying any individuals or entities. The superintendent shall adopt by January 1, 1999 rules necessary to define the information that must be reported. Rules adopted pursuant to this subsection are routine technical rules as defined in Title 5, chapter 375, subchapter II-A. B. On the July 1st following the filing of the initial reports required by paragraph A, and annually thereafter, the superintendent shall report to the joint standing committee of the Legislature having jurisdiction over insurance matters. The report must include aggregate information detailing the fraudulent insurance activity experienced by insurers in this State. Chapter 920: REPORTING OF FRAUDULENT INSURANCE ACTS 1. Authority This Rule is adopted pursuant to the authority of 24-A M.R.S.A. §§ 212 and 2186, sub-§4, paragraph A. 2. Purpose Title 24-A M.R.S.A. §2186, sub-§4, paragraph A requires all insurers to annually, on or before March 1, file with the Superintendent a report relating to fraudulent insurance acts that the insurer knew or reasonably believed had been committed during the previous calendar year. This rule prescribes the form of the report which is required to be filed. 3. Definitions For purposes of this Rule, the following words and terms have the following meanings: A. “Fraudulent Insurance Act” has the same meaning as in 24-A M.R.S.A. §2186, sub-§1, paragraph A; and B. “Insurer” has the meaning set forth in 24-A M.R.S.A. §2186 sub-§1, paragraph B. 4. Format of Report of Fraudulent Insurance Acts The annual report by all insurers licensed to do business in Maine shall be in the format of attachment A. The report shall be filed by all insurers reporting premiums written in Maine in the preceding calendar year. All insurers are encouraged to report electronically through the web site of the Bureau of Insurance. In the alternative the report may be forwarded by disk or by hard copy. 5. Effective Date This rule is effective February 23, 1999. State of Maine Bureau of Insurance Transmittal Form Maine Fraud and Abuse Annual Report For Year Ending December 31, \_\_\_\_\_\_\_ Due March 1 ALTERNATIVE/CONSOLIDATED REPORTING BY INSURER GROUP In the alternative to individual insurer reporting, insurers may elect to report on a consolidated group basis. Group Name: NAIC #s of reporting insurers: Names of Insurers Reporting on a consolidated basis: Company Contact Person:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Telephone #\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Company Name: NAIC #: Company Contact Person:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Telephone #\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Number of cases by category: Claimant May Have: 1. Faked property damage 2. Inflated financial loss 3. Faked/exaggerated injury 4. Staged accident/injury 5. Been known to file suspect claims, including faking, exaggerating, or extending total or partial disability 6. Other Legal Provider May Have: 7. Hired or paid cappers/chasers to recruit clients 8. Charged inconsistent with services provided 9. Other Medical Provider May Have: 10. Provided an inaccurate/incomplete history 11. Billed for services not provided 12. Upcoding or billing for excessive treatments 13. Unbundling 14. Received compensation for referral to medical or legal providers 15. Hired or paid cappers/chasers to recruit clients 16. Fabricated services 17. Provided an inaccurate/incomplete history 18. Operated without a license 19. Other Other Person or Entity May Have: 20. Received/paid compensation for referral 21. Fabricated services 22. Charged inconsistent with services provided 23. Provided an inaccurate/incomplete history, or submitted false or inaccurate information to obtain an insurance policy or to reduce an insurance premium 24. Other 25. Total number of suspected fraud claims by line of business: Auto Worker Comp General Liability Life Health (including Medicare/Medicaid) Marine Property Other 26. Total number of suspected fraud claims by type of insurance: Personal Commercial 27. Number of cases reported/referred to law enforcement agency? County Attorney’s Office U.S. Attorney’s Office Other Law Enforcement Workers’ Compensation Board Abuse and Fraud Unit NICB Other, including U.S. Postal Authorities 28. Amount of money not paid on suspected fraudulent cases: Please complete report on an annual basis and return to: State of Maine Bureau of Insurance 34 State House Station Augusta ME 04333 Electronic reporting is also acceptable and information regarding the electronic submission of this form will be made available on the agency web site at http://www.state.me.us/ pfr/ins/inshome2.htm. **State:** Maine **Requirement Types:** Annual Reporting --- ### [Maine-Fraud Plan-24-A MRSA Section 2186 (as enacted by Maine H 1545, Public Law 675, Laws 1998)](https://insurancefraud.org/regulations/maine-fraud-plan-24-a-mrsa-section-2186-as-enacted-by-maine-h-1545-public-law-675-laws-1998/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** 5\. Insurer antifraud plans. Within 6 months of the effective date of this Act, every insurer writing direct insurance shall prepare and implement an antifraud plan. This subsection does not apply to any agency, producer or other person acting on behalf of an insurer. The superintendent may review an insurer’s antifraud plan to determine if the plan complies with the requirements of this subsection. The antifraud plan must outline specific procedures, appropriate to the lines of insurance the insurer writes in the State, to: A. Prevent, detect and investigate all forms of insurance fraud; B. Educate appropriate employees on the antifraud plan and fraud detection; C. Provide for the hiring of or contracting for fraud investigators; and D. Report insurance fraud to appropriate law enforcement and regulatory authorities in the investigation and prosecution of insurance fraud. **State:** Maine **Requirement Types:** Fraud Plan --- ### [Maine-Fraud Warning-24-A MRSA Section 2186 (as enacted by Maine H 1545, Public Law 675, Laws 1998)](https://insurancefraud.org/regulations/maine-fraud-warning-24-a-mrsa-section-2186-as-enacted-by-maine-h-1545-public-law-675-laws-1998/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** 3\. Fraud warning required. Fraud warnings are required in accordance with the following. A. All applications and claim forms for insurance used by insurers in this State, regardless of form of transmission, must contain the following statement or a substantially similar statement permanently affixed to the application or claim forms: “It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purposes of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.” B. The lack or omission of the statement required in paragraph A does not constitute a defense in any criminal prosecution or civil action for a fraudulent insurance act. C. This subsection applies to all insurers except reinsurers. The statement required in paragraph A must be included in all applications and claim forms filed and approved for use by the superintendent on or after January 1, 1999. **State:** Maine **Requirement Types:** Fraud Warning --- ### [Maine-SIU Requirement-24-A MRSA Section 2186 (as enacted by Maine H 1545, Public Law 675, Laws 1998)](https://insurancefraud.org/regulations/maine-siu-requirement-24-a-mrsa-section-2186-as-enacted-by-maine-h-1545-public-law-675-laws-1998/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** 5\. Insurer antifraud plans. Within 6 months of the effective date of this Act, every insurer writing direct insurance shall prepare and implement an antifraud plan. This subsection does not apply to any agency, producer or other person acting on behalf of an insurer. The superintendent may review an insurer’s antifraud plan to determine if the plan complies with the requirements of this subsection. The antifraud plan must outline specific procedures, appropriate to the lines of insurance the insurer writes in the State, to: A. Prevent, detect and investigate all forms of insurance fraud; B. Educate appropriate employees on the antifraud plan and fraud detection; C. Provide for the hiring of or contracting for fraud investigators; and D. Report insurance fraud to appropriate law enforcement and regulatory authorities in the investigation and prosecution of insurance fraud. **State:** Maine **Requirement Types:** SIU Requirement --- ### [Maryland-Annual Reporting-.06 - Reporting of Fraud Related Data](https://insurancefraud.org/regulations/maryland-annual-reporting-06-reporting-of-fraud-related-data/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (A) Records and Report (1) An insurer shall maintain appropriate records for the Commissioner to determine the effectiveness of its antifraud plan. (2) A report shall be developed and provided to the Administration on an annual basis regarding the plan’s effectiveness and the effectiveness of the investigative and prosecutorial efforts. (3) The report shall be filed with the Administration by March 31 of each year, reporting the previous year’s statistics. The following information shall be reported: (a) number of policies in force; (b) number of claims; (c) number of suspected fraud cases; (d) number of suspected fraud cases in which a claim was denied; (e) number of suspected fraud cases reported to the authorities; (f) number of suspected fraud cases by product line; (g) number of suspected fraud cases in which a claim was denied, by product line; (h) number of cases prosecuted by criminal authorities; (i) breakdown by perpetrator, as follows: (i) insured; (ii) claimant (iii) agent/employee (iv) noninsurance professional, by category, and (v) other. \[Deadline for submission is March 31.\] **State:** Maryland **Requirement Types:** Annual Reporting --- ### [Maryland-Fraud Plan-09.31.17.04 - Procedures and Requirements; 09.31.17.0.5 - Plan Components](https://insurancefraud.org/regulations/maryland-fraud-plan-09-31-17-04-procedures-and-requirements-09-31-17-0-5-plan-components/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Regulation — 09.31.17 .04 – Procedures and Requirements A. Antifraud Plan (1) An insurer authorized to write insurance business in this State shall institute, implement, and maintain an insurance antifraud plan. B. Contents of Antifraud Plan An antifraud plan shall: (1) Contain provisions for educating and training an insurer’s employees in the detection of insurance fraud; (2) Provide for methods and procedures concerning the investigation of suspicious claims; and (3) Apply to but not limited to: (a) Claims fraud, (b) Application fraud, (c) Agent fraud, (d) Broker fraud; (e) Third party administrator fraud, and (f) Internal fraud. 0.5 – Plan Components A. Education/Training. (1) An antifraud plan shall contain procedures for the provision of education or training, or both, to the insurer’s employees regarding the detection of insurance fraud. (2) Training in the recognition and referral of suspicious claims shall be: (a) required of new and existing claim personnel, underwriters, auditors, agents, and consumer service personnel; and (b) offered to independent agents or brokers who have appointments with the company. (3) At a minimum, the educational components an antifraud plans shall address the following: (a) courses of instruction shall be: (i) designed to address specific aspects of fraud associated with a company’s product line, and (ii) at least 2 hours in duration. (b) Personnel shall be presented with updated material at the entrance level and at least once every 2 years in conjunction with continuing education standards or as a company policy; (c) A new employee shall receive the regulated education and training regarding the detection of fraud within 6 months of the effective date of employment; and (d) Training programs may be developed and conducted either by internal personnel or by outside contractors. B. Detection (1) An antifraud plan shall have provisions regarding the early detection of all areas of fraud including, but not limited to: (a) Embezzlement and internal theft; (b) Underwriting and application fraud; (c) Theft and misappropriation of premiums by agents; (d) Claims fraud; and (e) Application fraud. (2) The antifraud plan shall delineate the methods or approaches, or both, that will be utilized in detecting fraud. (3) An authorized insurer shall: (a) designate an individual or individuals, or a specific unit, either in-house or outside, to be responsible for coordinating the detection, referral, and investigation of suspected fraudulent activity; (b) include the designation in the antifraud plan; and (c) submit amendments to the designation to the Administration. (4) Fraud detection guides shall be prepared, published, and maintained to assist claim personnel, underwriters, and agents in the identification, detection, and handling of suspicious claims. C. Investigation (1) An antifraud plan shall contain: (a) procedures for handling fraud complaints; (b) procedures that are to be followed when instances of suspected fraud have been detect, evaluated, and found to warrant a full investigation; (c) the requirement that the company representative responsible for the conduct and oversight of fraud investigations assign the matter for investigation; (d) the designation of the individuals responsible for conducting investigations on behalf of the insurer including the individuals responsible for providing the notifications required by Sec. C(1)(g) of this regulation; (e) guidelines and procedures for conducting investigations and cooperating with the Insurance Fraud Division or other law enforcement agency which is conducting a criminal investigation if in-house staff is utilized; (f) written considerations as to work product and court room testimony; and (g) guidelines and procedures for notifying the appropriate law enforcement agency, including the Insurance Fraud Division of the Administration. (2) Investigators (a) a company may maintain an in-house staff of investigators or contract with an outside firm. (b) if an outside firm is used, the firm shall comply with all Maryland licensing laws and regulations to the extent that they are applicable. (D) Auditing (1) An antifraud plan shall contain procedures regarding the auditing of agents by the company. (2) The auditing procedures shall provide for both routine auditing and random audits. (3) If an irregularity is discovered during an audit, the antifraud plan shall require that the duly authorized company representative who conducts or oversees investigations be notified immediately. **State:** Maryland **Requirement Types:** Fraud Plan --- ### [Maryland-Fraud Warning-Section 27-805](https://insurancefraud.org/regulations/maryland-fraud-warning-section-27-805/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (A) In this section, “claim form” means any document supplied by an insurer to a claimant that a claimant is required to complete and submit in support of a claim for benefits. (B)(1) Except as provided in Subsection (C) of this section, all applications for insurance and all claim forms, regardless of the form of transmission, shall contain the following statement or a substantially similar statement: “Any person who knowingly or willfully presents a false or fraudulent claim for payment for a loss or benefit or who knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.” (2) The lack of the statement required by paragraph (1) of this subsection does not constitute a defense in any legal proceedings. (C) Subsection (B)(1) of this subsection does not apply to: (1) reinsurance applications or claim forms; or (2) the uniform claims form for reimbursement of hospital services or the uniform claims form for reimbursement of health care practitioners services adopted by the commissioner under Section 15-1003 of this article. NOTE: The act takes effect on October 1, 2008 and compliance is on or before April 1, 2009. **State:** Maryland **Requirement Types:** Fraud Warning --- ### [Maryland-Mandatory Reporting-Section 27-802](https://insurancefraud.org/regulations/maryland-mandatory-reporting-section-27-802/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** §27–802. (a) (1) An authorized insurer, its employees, fund producers, insurance producers, a viatical settlement provider, or a viatical settlement broker who in good faith has cause to believe that insurance fraud has been or is being committed shall report the suspected insurance fraud in writing to the Commissioner, the Fraud Division, or the appropriate federal, State, or local law enforcement authorities. (2) An independent insurance producer shall meet the reporting requirement of this subsection by reporting the suspected insurance fraud in writing to the Fraud Division. (3) A registered premium finance company shall meet the requirement of this subsection by reporting suspected insurance fraud in writing to the Fraud Division. (b) In addition to any protection provided under Title 4, Subtitle 4, Part IV of the General Provisions Article, any information, documentation, or other evidence provided under this section by an insurer, its employees, fund producers, or insurance producers, a viatical settlement provider, a viatical settlement broker, an independent insurance producer, or a registered premium finance company to the Commissioner, the Fraud Division, or a federal, State, or local law enforcement authority in connection with an investigation of suspected insurance fraud is not subject to public inspection for as long as the Commissioner, Fraud Division, or law enforcement authority considers the withholding to be necessary to complete an investigation of the suspected fraud or to protect the person investigated from unwarranted injury. (c) A person is not subject to civil liability for a cause of action by virtue of reporting suspected insurance fraud, or furnishing or receiving information relating to suspected, anticipated, or completed fraudulent insurance acts, if: (1) the report was made, or the information was furnished to or received from: (i) the Commissioner, Fraud Division, or an appropriate federal, State, or local law enforcement authority; (ii) the National Association of Insurance Commissioners or its agent, employee, or designee; (iii) a not–for–profit organization established to detect and prevent fraudulent insurance acts or its agent, employee, or designee; (iv) a person that contracts to provide special investigative unit services to an insurer; or (v) a provider of a recognized comprehensive database system that the Commissioner approves to monitor activities involving insurance fraud or an employee of the provider; and (2) the person that reported the suspected insurance fraud, or furnished or received the information, acted in good faith when making the report or furnishing or receiving the information. **State:** Maryland **Requirement Types:** Mandatory Reporting --- ### [Maryland-SIU Education-09.31.17.04 - Procedures and Requirements; 09.31.17.0.5 - Plan Components](https://insurancefraud.org/regulations/maryland-siu-education-09-31-17-04-procedures-and-requirements-09-31-17-0-5-plan-components/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** 0.5 – Plan Components A. Education/Training. (1) An antifraud plan shall contain procedures for the provision of education or training, or both, to the insurer’s employees regarding the detection of insurance fraud. (2) Training in the recognition and referral of suspicious claims shall be: (a) required of new and existing claim personnel, underwriters, auditors, agents, and consumer service personnel; and (b) offered to independent agents or brokers who have appointments with the company. (3) At a minimum, the educational components an antifraud plans shall address the following: (a) courses of instruction shall be: (i) designed to address specific aspects of fraud associated with a company’s product line, and (ii) at least 2 hours in duration. (b) Personnel shall be presented with updated material at the entrance level and at least once every 2 years in conjunction with continuing education standards or as a company policy; (c) A new employee shall receive the regulated education and training regarding the detection of fraud within 6 months of the effective date of employment; and (d) Training programs may be developed and conducted either by internal personnel or by outside contractors. **State:** Maryland **Requirement Types:** SIU Education --- ### [Massachusetts-Mandatory Reporting-Chapter 76 Section 88 Chapter 26 Section 8B](https://insurancefraud.org/regulations/massachusetts-mandatory-reporting-chapter-76-section-88-chapter-26-section-8b/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** “Any insurer … having reason to believe that an insurance transaction may be fraudulent, or having knowledge that a fraudulent insurance transaction is about to take place, or has taken place, shall within thirty days after determination that the transaction may be fraudulent, send to said insurance fraud bureau, on a form prescribed by the executive director, the information requested by the form and such additional information relative to the transaction and the parties involved as the executive director may require.” Section 8B. There shall be in the division of insurance a fraudulent claims board, hereinafter called the board, consisting of the commissioner of insurance or his designee, the registrar of motor vehicles or his designee, and the director of the state rating bureau or his designee. The commissioner of insurance or his designee shall be the chairman of the board. The board shall have authority to investigate all claims alleging loss or damages arising out of the ownership, operation, maintenance or use of a motor vehicle anywhere within the commonwealth, filed by a claimant against any person insured by an insurance company which has issued a policy of insurance providing protection or indemnity to the insured owner and to any other person operating, maintaining or using the motor vehicle with the consent, express or implied, of the insured; and any other claim covered by insurance resulting from the operation of a motor vehicle. Any company notified that such a claim is being made shall, within sixty days of the receipt of such notice, send to the board on a form prescribed by the board the information requested and such additional information relative to the accident and the parties claiming loss or damages because of the accident as the board may require. The board shall review such reports and select such claims as, in its judgment, may require further investigation. It shall then cause an independent examination of the facts surrounding such claim to be made to determine the extent, if any, to which fraud, deceit, misrepresentation or exaggeration of any kind exists in the submission of the claim and the extent to which improper practices on the part of insurance companies contribute to or encourage the making of fraudulent or exaggerated claims, or result in fraud, misrepresentation or deceit on the part of such companies, leading to higher costs of insurance or public dissatisfaction with the insurance laws of the commonwealth. The board shall report its findings annually on or before December the first, to the governor and the attorney general, and may recommend legislation as in its judgment will best eliminate such fraud, deceit, misrepresentation or exaggeration, or improper practices as it finds exists. The board may submit interim reports at such other times as it deems necessary and shall report any violations of law which its investigations disclose to the attorney general, or to the proper district attorney who shall cause the offender to be prosecuted therefor. The board, with the approval of the governor, may appoint and remove a chief of accident claims investigations. The board may expend for expenses and for such legal, investigative, clerical and other assistance such sums as may be appropriated therefor; provided, however, that all costs of administration and operation of said board shall be borne by liability insurance companies doing business within the commonwealth. The commissioner shall apportion such costs among all such companies and shall assess them for the same on a fair and reasonable basis. Investigators employed by the board shall have access to all records kept by the registry of motor vehicles and to such records kept by insurance companies as may be pertinent to the processing of such claims as are within the investigatory powers of the board. Whoever is convicted of a fraudulent claim as a result of a court judgment shall automatically lose his privilege to operate a motor vehicle for a period of one year. **State:** Massachusetts **Requirement Types:** Mandatory Reporting --- ### [Massachusetts-Pre-insurance Inspection-Massachusetts General Laws Chapter 175 Section 113S; Code of Regulations 94:01](https://insurancefraud.org/regulations/massachusetts-pre-insurance-inspection-massachusetts-general-laws-chapter-175-section-113s-code-of-regulations-9401/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Photograph required — Yes Grace Period (days) — 7 Exemptions/Waivers Existing Policyholder (years) — 3 Renewal Policy — Yes New Cars — Yes Vehicle Age — 10 **State:** Massachusetts --- ### [Michigan-Mandatory Reporting-500.4507 Release of information; purpose.](https://insurancefraud.org/regulations/michigan-mandatory-reporting-500-4507-release-of-information-purpose/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Sec. 4507. (1) Upon written request by an authorized agency to an insurer, the insurer or an agent authorized by the insurer to act on its behalf may release to the authorized agency, at the authorized agency’s expense, any or all information that is considered important relating to any suspected insurance fraud. An authorized agency may release information on suspected insurance fraud to an insurer or an agent authorized by an insurer to act on its behalf upon a showing of good cause by the insurer or the insurer’s authorized agent. This information may include, but is not limited to, the following: (a) Insurance policy information relevant to an investigation, including any application for a policy. (b) Policy premium payment records that are available. (c) History of previous claims made by the insured. (d) Information relating to the investigation of the suspected insurance fraud, including statements of any person, proofs of loss, and notice of loss. (2) If an insurer knows or reasonably believes it knows the identity of a person who it has reason to believe committed a fraudulent insurance act or has knowledge of a suspected fraudulent insurance act that is reasonably believed not to have been reported to an authorized agency, then for the purpose of notification and investigation, the insurer or an agent authorized by an insurer to act on its behalf may notify an authorized agency of the knowledge or belief and provide any additional information in accordance with subsection (1). (3) An insurer providing information to an authorized agency pursuant to subsection (2) has the right to request in writing information in the possession or control of the authorized agency relating to the same suspected fraudulent insurance act of which the insurer notifies the authorized agency under subsection (2). Upon a showing of good cause by the insurer, the authorized agency may provide the requested information at the insurer’s expense within 30 days of the request. (4) In addition to providing information to an insurer under subsection (3), the authorized agency provided with information pursuant to subsection (1) or (2) may release or provide the information to any other authorized agency. (5) Nothing in this chapter impairs a person’s right, as of the effective date of this chapter, to submit to the insurer or the insurer’s representative a statement fully explaining the basis of the claim and to have that statement placed in the claim file. (6) An authorized agency, insurer, or an agent authorized by an insurer to act on its behalf shall not request or release information under subsection (1) for any purpose other than for the investigation of suspected insurance fraud. **State:** Michigan **Requirement Types:** Mandatory Reporting --- ### [Florida-Fraud Plan-Section 626.9891 and reg. 69D-2](https://insurancefraud.org/regulations/florida-fraud-plan-section-626-9891-and-reg-69d-2/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** § 626.9891. Insurer anti-fraud investigative units; reporting requirements; penalties for noncompliance. (1) As used in this section, the term: (a) “Anti-fraud investigative unit” means the designated anti-fraud unit or division, or contractor authorized under subparagraph (2)(a)2. (b) “Designated anti-fraud unit or division” includes a distinct unit or division or a unit or division made up of employees whose principal responsibilities are the investigation and disposition of claims who are also assigned investigation of fraud. (2) By December 31, 2017, every insurer admitted to do business in this state shall: (a) 1. Establish and maintain a designated anti-fraud unit or division within the company to investigate and report possible fraudulent insurance acts by insureds or by persons making claims for services or repairs against policies held by insureds; or 2. Contract with others to investigate and report possible fraudulent insurance acts by insureds or by persons making claims for services or repairs against policies held by insureds. (b) Adopt an anti-fraud plan. (c) Designate at least one employee with primary responsibility for implementing the requirements of this section. (d) Electronically file with the Division of Investigative and Forensic Services of the department, and annually thereafter, a detailed description of the designated anti-fraud unit or division or a copy of the contract executed under subparagraph (a)2., as applicable, a copy of the anti-fraud plan, and the name of the employee designated under paragraph (c). An insurer must include the additional cost incurred in creating a distinct unit or division, hiring additional employees, or contracting with another entity to fulfill the requirements of this section, as an administrative expense for ratemaking purposes. (3) Each anti-fraud plan must include: (a) An acknowledgement that the insurer has established procedures for detecting and investigating possible fraudulent insurance acts relating to the different types of insurance by that insurer; (b) An acknowledgment that the insurer has established procedures for the mandatory reporting of possible fraudulent insurance acts to the Division of Investigative and Forensic Services of the department; (c) An acknowledgement that the insurer provides the anti-fraud education and training required by this section to the anti-fraud investigative unit; (d) A description of the required anti-fraud education and training; (e) A description or chart of the insurer’s anti-fraud investigative unit, including the position titles and descriptions of staffing; and (f) The rationale for the level of staffing and resources being provided for the anti-fraud investigative unit which may include objective criteria, such as the number of policies written, the number of claims received on an annual basis, the volume of suspected fraudulent claims detected on an annual basis, an assessment of the optimal caseload that one investigator can handle on an annual basis, and other factors. (4) By December 31, 2018, each insurer shall provide staff of the anti-fraud investigative unit at least 2 hours of initial anti-fraud training that is designed to assist in identifying and evaluating instances of suspected fraudulent insurance acts in underwriting or claims activities. Annually thereafter, an insurer shall provide such employees a 1-hour course that addresses detection, referral, investigation, and reporting of possible fraudulent insurance acts for the types of insurance lines written by the insurer. (5) Each insurer is required to report data related to fraud for each identified line of business written by the insurer during the prior calendar year. The data shall be reported to the department by March 1, 2019, and annually thereafter, and must include, at a minimum: (a) The number of policies in effect; (b) The amount of premiums written for policies; (c) The number of claims received; (d) The number of claims referred to the anti-fraud investigative unit; (e) The number of other insurance fraud matters referred to the anti-fraud investigative unit that were not claim related; (f) The number of claims investigated or accepted by the anti-fraud investigative unit; (g) The number of other insurance fraud matters investigated or accepted by the anti-fraud investigative unit that were not claim related; (h) The number of cases referred to the Division of Investigative and Forensic Services; (i) The number of cases referred to other law enforcement agencies; (j) The number of cases referred to other entities; and (k) The estimated dollar amount or range of damages on cases referred to the Division of Investigative and Forensic Services or other agencies. (6) In addition to providing information required under subsections (2), (4), and (5), each insurer writing workers’ compensation insurance shall also report the following information to the department, on or before March 1, 2019, and annually thereafter: (a) The estimated dollar amount of losses attributable to workers’ compensation fraud delineated by the type of fraud, including claimant, employer, provider, agent, or other type. (b) The estimated dollar amount of recoveries attributable to workers’ compensation fraud delineated by the type of fraud, including claimant, employer, provider, agent, or other type. (c) The number of cases referred to the Division of Investigative and Forensic Services, delineated by the type of fraud, including claimant, employer, provider, agent, or other type. (7) An insurer who obtains a certificate of authority has 6 months in which to comply with subsection (2), and one calendar year thereafter, to comply with subsections (4), (5), and (6). (8) If an insurer fails or otherwise refuses to comply with the provisions of this section, the department, office, or commission may: (a) Impose an administrative fine of not more than $2,000 per day for such failure until the department, office, or commission deems the insurer to be in compliance; (b) Impose an administrative fine for failure by an insurer to implement or follow the provisions of an anti-fraud plan or anti-fraud investigative unit description; or (c) Impose the provisions of both paragraphs (a) and (b). (9) On or before December 31, 2018, the Division of Investigative and Forensic Services shall create a report detailing best practices for the detection, investigation, prevention, and reporting of insurance fraud and other fraudulent insurance acts. The report must be updated as necessary but at least every 2 years. The report must provide: (a) Information on the best practices for the establishment of anti-fraud investigative units within insurers; (b) Information on the best practices and methods for detecting and investigating insurance fraud and other fraudulent insurance acts; (c) Information on appropriate anti-fraud education and training of insurer personnel; (d) Information on the best practices for reporting insurance fraud and other fraudulent insurance acts to the Division of Investigative and Forensic Services and to other law enforcement agencies; (e) Information regarding the appropriate level of staffing and resources for anti-fraud investigative units within insurers; (f) Information detailing statistics and data relating to insurance fraud which insurers should maintain; and (g) Other information as determined by the Division of Investigative and Forensic Services. (10) The department may adopt rules to administer this section, except that it shall adopt rules to administer subsection (5). (11) (a) The information submitted to the department pursuant to paragraphs (3)(d), (e), and (f) and paragraphs (5)(d), (e), (f), (g), and (k) is exempt from s. 119.07(1) and s. 24(a), Art. I of the State Constitution. (b) This subsection is subject to the Open Government Sunset Review Act in accordance with s. 119.15 and shall stand repealed on October 2, 2022, unless reviewed and saved from repeal through reenactment by the Legislature. (c) This exemption applies to records held before, on, or after the effective date of this act. 69D-2.001 Purpose and Scope. The purpose of this rule chapter is to implement the provisions of Section 626.9891, FS., establishing guidelines and reporting requirements for insurer anti-fraud investigative units and anti-fraud plans. Specific Authority: 624.308, FS., 626.9891, FS., 626.9891(8), FS.; Law Implemented: 624.307, FS., 626.9891(8), FS.; History-New. 69D-2.002 Definitions. For the purposes of this rule: (1) “Division” refers to the Department of Financial Services, Division of Insurance Fraud. (2) “NAIC” refers to the National Association of Insurance Commissioners. (3) “Office” refers to the Office of Insurance Regulation. (4) “SIU” refers to an insurer’s internal or contracted anti-fraud investigative unit. Specific Authority: 624.308, FS., 626.9891, FS., 626.9891(8), FS.; Law Implemented: 624.307, FS., 626.9891(8), FS.; History-New. 69D-2.003 Insurer SIUs. (1) An insurer subject to Section 626.9891(1), FS., shall file with the Division a detailed description of their SIU, and shall submit the following information in the SIU description to satisfy this filing requirement: (a) The names of all personnel assigned to the SIU, and a description of each person’s work responsibilities relating to the SIU’s anti-fraud efforts; (b) An acknowledgment that the SIU has established criteria that will be used to detect suspicious or fraudulent activity during investigations relating to the different types of insurance offered by that insurer; (c) An acknowledgment that the SIU has established criteria that will be used for the investigation of acts of suspected insurance fraud relating to the different types of insurance offered by that insurer. (d) An acknowledgment that the insurer or SIU shall report all suspected fraudulent insurance acts directly to the Division electronically via Form DFS-L1-1691 (Eff.\_\_\_\_\_) “Suspected Fraud Referral Form,” or an electronic reporting interface that is linked to such form, as provided on the Division’s website at www.fldfs.com/fraud/. Form DFS-L1-1691 (Eff.\_\_\_\_\_\_) Suspected Fraud Referral Form is hereby adopted and incorporated by reference. (e) An acknowledgment that all such reports of suspected insurance fraud shall contain information that clearly defines and supports the allegation of suspicious activity. (f) An acknowledgement that the insurer or SIU shall record the date that suspected fraudulent activity is detected, and shall record the date that reports of such suspected insurance fraud are sent directly to the Division; (g) An acknowledgement that the insurer or SIU shall provide training relating to the detection and investigation of fraudulent insurance acts for all personnel involved in anti-fraud related efforts. (h) An acknowledgement that the insurer or SIU shall provide on-going training during the reporting period; (i) The contact information including names, email addresses, and telephone numbers, for personnel designated by the insurer or SIU to be responsible for achieving and maintaining compliance with Section 626.9891(1), FS., and this rule chapter; (j) The insurer’s NAIC individual and group code numbers; (2) An insurer or SIU subject to Section 626.9891(1), F.S., and this rule chapter, shall submit this SIU description electronically via the Division’s website at www.fldfs.com/fraud/. The SIU description shall be submitted electronically on Form DFS-L1-1689 (Eff.\_\_\_\_) “SIU Description Form” as provided on the Division’s website at www.fldfs.com/fraud/. Form DFS-L1-1689 (Eff.\_\_\_\_) SIU Description Form is hereby adopted and incorporated by reference. The insurer’s filing of the information required in subsection (1) above shall constitute an adequately detailed description of its SIU as required by Section 626.9891(1), FS. (3) Nothing in this rule shall require that an SIU utilize all established criteria in every circumstance. (4) The filing of the information required herein is not intended to constitute a waiver of an insurer’s privilege, trade secret, confidentiality or any proprietary interest in its SIU, its SIU description, or its SIU policies and procedures. Specific Authority: 624.308, FS., 626.9891, FS., 626.9891(8), FS.; Law Implemented: 624.307,FS., 626.989, FS., 626.9891(1), FS.; History-New. 69D-2.004 Insurer Anti-Fraud Plans. (1) An insurer subject to Section 626.9891(2), F.S., shall file with the Division of Insurance Fraud such anti-fraud plan, and such anti-fraud plan shall include: (a) A written description or chart outlining the organizational arrangement of the insurer’s anti-fraud personnel who are responsible for the investigation and reporting of possible fraudulent insurance acts. (b) A description of the insurer’s procedures for detecting and investigating possible fraudulent insurance acts. Nothing in this rule shall require that an insurer utilize all established criteria in every circumstance. This description shall include: 1. An acknowledgment that the insurer has established criteria that will be used to detect suspicious or fraudulent activity during investigations relating to the different types of insurance offered by that insurer; 2. An acknowledgment that the insurer has established criteria that will be used for the investigation of acts of suspected insurance fraud relating to the different types of insurance offered by that insurer. (c) A description of the insurer’s procedures for the mandatory reporting of possible fraudulent insurance acts to the Division pursuant to Section 626.989(6), F.S. This description shall include: 1. An explanation of the insurer’s method for reporting all suspected fraudulent insurance acts directly to the Division electronically on Form DFS-L1-1691, as incorporated and provided for in paragraph 69D-2.003(1)(d), F.A.C. 2. An acknowledgment that all such reports of suspected insurance fraud shall contain information that clearly defines and supports the allegation of suspicious activity. 3. An acknowledgment that the insurer shall record the date that suspected fraudulent activity is detected, and shall record the date that reports of such suspected insurance fraud are sent directly to the Division. (d) A description of the insurer’s plan for anti-fraud education and training of its claims adjusters and any other personnel involved in anti-fraud related efforts. This description shall include: 1. A plan that involves training relating to the detection and investigation of fraudulent insurance acts for all employees involved in anti-fraud related efforts. 2. A plan that involves on-going training during the reporting period; (e) The contact information, including names, e-mail addresses, and telephone numbers, for personnel designated by the insurer to be responsible for achieving and maintaining compliance with Section 626.9891(2), F.S., and this rule chapter; (f) The insurer’s NAIC individual and group code numbers; (2) An insurer subject to Section 626.9891(2), F.S., and this rule chapter, shall submit this anti-fraud plan electronically via the Division’s website at www.myfloridacfo.com. The anti-fraud plan shall be submitted electronically on Form DFS-L1-1690 (Eff. 10-5-06) “Anti-Fraud Plan Form as provided on the Division’s website at www.fldfs.com/fraud/. Form DFS-L1-1690 (Eff. 10-5-06) Anti-Fraud Plan Form is hereby adopted and incorporated by reference. The insurer’s filing of the information required in subsection (1) above shall constitute an acceptable anti-fraud plan as required by Section 626.9891(2), F.S. (3) The filing of the information required herein is not intended to constitute a waiver of an insurer’s privilege, trade secret, confidentiality or any proprietary interest in its anti-fraud plan or its anti-fraud related policies and procedures. 69D-2.005 Compliance and Enforcement. (1) The Division shall review the filings of SIU descriptions and insurer anti-fraud plans and the Office shall conduct audits pursuant to Section 624.3161, F.S., to determine compliance with Section 626.9891, F.S., and this rule chapter. (2) If an insurer fails to timely file an anti-fraud plan or SIU description, fails to implement or follow the provisions of their anti-fraud plan or SIU description, or in any other way fails to comply with the requirements of Section 626.9891, F.S., and this rule chapter, the Office shall take appropriate administrative action as provided in Sections 626.9891(7) and 624.4211, F.S. **State:** Florida **Requirement Types:** Fraud Plan --- ### [Florida-Fraud Warning-Sec. 817.234(1b);Sec. 440.37(2)(a);Sec. 440.185(4)ction 817.234(1)(b);Section 440.37(2)(a);Section 440.185(4)](https://insurancefraud.org/regulations/florida-fraud-warning-sec-817-2341bsec-440-372asec-440-1854ction-817-2341bsection-440-372asection-440-1854/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** All Claim Forms – Sec. 817.234(1b) All Workers Compensation Claim Forms Sec. 440.37(2)(a) Underwriting – Workers Compensation Informational Brochures – Sec. 440.185(4) Section 817.234(1)(b) – Language is permissive, but must be approved by the Department of Insurance “Any person who knowingly and with intent to injure, defraud or deceive any insurance company files a statement of claim containing any false, incomplete, or misleading information is guilty of a felony of the third degree.” Section 440.37(2)(a) – Language is permissive “Any person who, knowingly and with intent to injure, defraud, or deceive any employer or employee, insurance company, or self-insured program, files a statement of claim containing any false or misleading information is guilty of a felony of the third degree.” Section 440.185(4) – Language is permissive Same as above (Sec. 440.37(2)(a)) except for phrase at end “guilty of a felony … “ reads as “commits a felony …” **State:** Florida **Requirement Types:** Fraud Warning --- ### [Florida-Mandatory Reporting-Florida Insurance Code Section 626.989 (6) Workers Comp - Section440.105(1)](https://insurancefraud.org/regulations/florida-mandatory-reporting-florida-insurance-code-section-626-989-6-workers-comp-section440-1051/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** “… any insurer, agent, or other person licensed under the code, or an employee thereof, having knowledge or who believes that a fraudulent insurance act or any other act or practice which, upon conviction, constitutes a felony or a misdemeanor under the code … is being or has been committed shall send to the Division of Insurance Fraud a report or information pertinent to such knowledge or belief and such additional information relative thereto as the department may require….” Workers Compensation 440.105 Prohibited activities; reports; penalties; limitations.— (1)(a) Any insurance carrier, any individual self-insured, any commercial or group self-insurance fund, any professional practitioner licensed or regulated by the Department of Health, except as otherwise provided by law, any medical review committee as defined in s. 766.101, any private medical review committee, and any insurer, agent, or other person licensed under the insurance code, or any employee thereof, having knowledge or who believes that a fraudulent act or any other act or practice which, upon conviction, constitutes a felony or misdemeanor under this chapter is being or has been committed shall send to the Division of Investigative and Forensic Services, Bureau of Workers’ Compensation Fraud, a report or information pertinent to such knowledge or belief and such additional information relative thereto as the bureau may require. The bureau shall review such information or reports and select such information or reports as, in its judgment, may require further investigation. It shall then cause an independent examination of the facts surrounding such information or report to be made to determine the extent, if any, to which a fraudulent act or any other act or practice which, upon conviction, constitutes a felony or a misdemeanor under this chapter is being committed. The bureau shall report any alleged violations of law which its investigations disclose to the appropriate licensing agency and state attorney or other prosecuting agency having jurisdiction with respect to any such violations of this chapter. If prosecution by the state attorney or other prosecuting agency having jurisdiction with respect to such violation is not begun within 60 days of the bureau’s report, the state attorney or other prosecuting agency having jurisdiction with respect to such violation shall inform the bureau of the reasons for the lack of prosecution. **State:** Florida **Requirement Types:** Mandatory Reporting --- ### [Florida-Pre-insurance Inspection-Florida Insurance Code Section 627.744; Administrative Code Section 4-167.004](https://insurancefraud.org/regulations/florida-pre-insurance-inspection-florida-insurance-code-section-627-744-administrative-code-section-4-167-004/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Photograph required — No Grace Period (days) — 7 Exemptions/Waivers Existing Policyholder (years) — 3 Renewal Policy — Yes New Cars — Yes Vehicle Age — 10 **State:** Florida --- ### [Florida-SIU Education-Sec. 626.9891](https://insurancefraud.org/regulations/florida-siu-education-sec-626-9891/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (3) Each insurers anti-fraud plans shall include: (a) A description of the insurer’s procedures for detecting and investigating possible fraudulent insurance acts; (b) A description of the insurer’s procedures for the mandatory reporting of possible fraudulent insurance acts to the Division of Insurance Fraud of the department; (c) A description of the insurer’s plan for anti-fraud education and training of its claims adjusters or other personnel; and (d) A written description or chart outlining the organizational arrangement of the insurer’s anti-fraud personnel who are responsible for the investigation and reporting of possible fraudulent insurance acts. **State:** Florida **Requirement Types:** SIU Education --- ### [Florida-SIU Requirement-Section 626.9891; Rule Sections 69D - 2.001-2.005](https://insurancefraud.org/regulations/florida-siu-requirement-section-626-9891-rule-sections-69d-2-001-2-005/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** § 626.9891. Insurer anti-fraud investigative units; reporting requirements; penalties for noncompliance. (1) As used in this section, the term: (a) “Anti-fraud investigative unit” means the designated anti-fraud unit or division, or contractor authorized under subparagraph (2)(a)2. (b) “Designated anti-fraud unit or division” includes a distinct unit or division or a unit or division made up of employees whose principal responsibilities are the investigation and disposition of claims who are also assigned investigation of fraud. (2) By December 31, 2017, every insurer admitted to do business in this state shall: (a) 1. Establish and maintain a designated anti-fraud unit or division within the company to investigate and report possible fraudulent insurance acts by insureds or by persons making claims for services or repairs against policies held by insureds; or 2. Contract with others to investigate and report possible fraudulent insurance acts by insureds or by persons making claims for services or repairs against policies held by insureds. (b) Adopt an anti-fraud plan. (c) Designate at least one employee with primary responsibility for implementing the requirements of this section. (d) Electronically file with the Division of Investigative and Forensic Services of the department, and annually thereafter, a detailed description of the designated anti-fraud unit or division or a copy of the contract executed under subparagraph (a)2., as applicable, a copy of the anti-fraud plan, and the name of the employee designated under paragraph (c). An insurer must include the additional cost incurred in creating a distinct unit or division, hiring additional employees, or contracting with another entity to fulfill the requirements of this section, as an administrative expense for ratemaking purposes. (3) Each anti-fraud plan must include: (a) An acknowledgement that the insurer has established procedures for detecting and investigating possible fraudulent insurance acts relating to the different types of insurance by that insurer; (b) An acknowledgment that the insurer has established procedures for the mandatory reporting of possible fraudulent insurance acts to the Division of Investigative and Forensic Services of the department; (c) An acknowledgement that the insurer provides the anti-fraud education and training required by this section to the anti-fraud investigative unit; (d) A description of the required anti-fraud education and training; (e) A description or chart of the insurer’s anti-fraud investigative unit, including the position titles and descriptions of staffing; and (f) The rationale for the level of staffing and resources being provided for the anti-fraud investigative unit which may include objective criteria, such as the number of policies written, the number of claims received on an annual basis, the volume of suspected fraudulent claims detected on an annual basis, an assessment of the optimal caseload that one investigator can handle on an annual basis, and other factors. (4) By December 31, 2018, each insurer shall provide staff of the anti-fraud investigative unit at least 2 hours of initial anti-fraud training that is designed to assist in identifying and evaluating instances of suspected fraudulent insurance acts in underwriting or claims activities. Annually thereafter, an insurer shall provide such employees a 1-hour course that addresses detection, referral, investigation, and reporting of possible fraudulent insurance acts for the types of insurance lines written by the insurer. (5) Each insurer is required to report data related to fraud for each identified line of business written by the insurer during the prior calendar year. The data shall be reported to the department by March 1, 2019, and annually thereafter, and must include, at a minimum: (a) The number of policies in effect; (b) The amount of premiums written for policies; (c) The number of claims received; (d) The number of claims referred to the anti-fraud investigative unit; (e) The number of other insurance fraud matters referred to the anti-fraud investigative unit that were not claim related; (f) The number of claims investigated or accepted by the anti-fraud investigative unit; (g) The number of other insurance fraud matters investigated or accepted by the anti-fraud investigative unit that were not claim related; (h) The number of cases referred to the Division of Investigative and Forensic Services; (i) The number of cases referred to other law enforcement agencies; (j) The number of cases referred to other entities; and (k) The estimated dollar amount or range of damages on cases referred to the Division of Investigative and Forensic Services or other agencies. (6) In addition to providing information required under subsections (2), (4), and (5), each insurer writing workers’ compensation insurance shall also report the following information to the department, on or before March 1, 2019, and annually thereafter: (a) The estimated dollar amount of losses attributable to workers’ compensation fraud delineated by the type of fraud, including claimant, employer, provider, agent, or other type. (b) The estimated dollar amount of recoveries attributable to workers’ compensation fraud delineated by the type of fraud, including claimant, employer, provider, agent, or other type. (c) The number of cases referred to the Division of Investigative and Forensic Services, delineated by the type of fraud, including claimant, employer, provider, agent, or other type. (7) An insurer who obtains a certificate of authority has 6 months in which to comply with subsection (2), and one calendar year thereafter, to comply with subsections (4), (5), and (6). (8) If an insurer fails or otherwise refuses to comply with the provisions of this section, the department, office, or commission may: (a) Impose an administrative fine of not more than $2,000 per day for such failure until the department, office, or commission deems the insurer to be in compliance; (b) Impose an administrative fine for failure by an insurer to implement or follow the provisions of an anti-fraud plan or anti-fraud investigative unit description; or (c) Impose the provisions of both paragraphs (a) and (b). (9) On or before December 31, 2018, the Division of Investigative and Forensic Services shall create a report detailing best practices for the detection, investigation, prevention, and reporting of insurance fraud and other fraudulent insurance acts. The report must be updated as necessary but at least every 2 years. The report must provide: (a) Information on the best practices for the establishment of anti-fraud investigative units within insurers; (b) Information on the best practices and methods for detecting and investigating insurance fraud and other fraudulent insurance acts; (c) Information on appropriate anti-fraud education and training of insurer personnel; (d) Information on the best practices for reporting insurance fraud and other fraudulent insurance acts to the Division of Investigative and Forensic Services and to other law enforcement agencies; (e) Information regarding the appropriate level of staffing and resources for anti-fraud investigative units within insurers; (f) Information detailing statistics and data relating to insurance fraud which insurers should maintain; and (g) Other information as determined by the Division of Investigative and Forensic Services. (10) The department may adopt rules to administer this section, except that it shall adopt rules to administer subsection (5). (11) (a) The information submitted to the department pursuant to paragraphs (3)(d), (e), and (f) and paragraphs (5)(d), (e), (f), (g), and (k) is exempt from s. 119.07(1) and s. 24(a), Art. I of the State Constitution. (b) This subsection is subject to the Open Government Sunset Review Act in accordance with s. 119.15 and shall stand repealed on October 2, 2022, unless reviewed and saved from repeal through reenactment by the Legislature. (c) This exemption applies to records held before, on, or after the effective date of this act. 69D-2.001 Purpose and Scope. The purpose of this rule chapter is to implement the provisions of Section 626.9891, FS., establishing guidelines and reporting requirements for insurer anti-fraud investigative units and anti-fraud plans. Specific Authority: 624.308, FS., 626.9891, FS., 626.9891(8), FS.; Law Implemented: 624.307, FS., 626.9891(8), FS.; History-New. 69D-2.002 Definitions. For the purposes of this rule: (1) “Division” refers to the Department of Financial Services, Division of Insurance Fraud. (2) “NAIC” refers to the National Association of Insurance Commissioners. (3) “Office” refers to the Office of Insurance Regulation. (4) “SIU” refers to an insurer’s internal or contracted anti-fraud investigative unit. Specific Authority: 624.308, FS., 626.9891, FS., 626.9891(8), FS.; Law Implemented: 624.307, FS., 626.9891(8), FS.; History-New. 69D-2.003 Insurer SIUs. (1) An insurer subject to Section 626.9891(1), FS., shall file with the Division a detailed description of their SIU, and shall submit the following information in the SIU description to satisfy this filing requirement: (a) The names of all personnel assigned to the SIU, and a description of each person’s work responsibilities relating to the SIU’s anti-fraud efforts; (b) An acknowledgment that the SIU has established criteria that will be used to detect suspicious or fraudulent activity during investigations relating to the different types of insurance offered by that insurer; (c) An acknowledgment that the SIU has established criteria that will be used for the investigation of acts of suspected insurance fraud relating to the different types of insurance offered by that insurer. (d) An acknowledgment that the insurer or SIU shall report all suspected fraudulent insurance acts directly to the Division electronically via Form DFS-L1-1691 (Eff.\_\_\_\_\_) “Suspected Fraud Referral Form,” or an electronic reporting interface that is linked to such form, as provided on the Division’s website at www.fldfs.com/fraud/. Form DFS-L1-1691 (Eff.\_\_\_\_\_\_) Suspected Fraud Referral Form is hereby adopted and incorporated by reference. (e) An acknowledgment that all such reports of suspected insurance fraud shall contain information that clearly defines and supports the allegation of suspicious activity. (f) An acknowledgement that the insurer or SIU shall record the date that suspected fraudulent activity is detected, and shall record the date that reports of such suspected insurance fraud are sent directly to the Division; (g) An acknowledgement that the insurer or SIU shall provide training relating to the detection and investigation of fraudulent insurance acts for all personnel involved in anti-fraud related efforts. (h) An acknowledgement that the insurer or SIU shall provide on-going training during the reporting period; (i) The contact information including names, email addresses, and telephone numbers, for personnel designated by the insurer or SIU to be responsible for achieving and maintaining compliance with Section 626.9891(1), FS., and this rule chapter; (j) The insurer’s NAIC individual and group code numbers; (2) An insurer or SIU subject to Section 626.9891(1), F.S., and this rule chapter, shall submit this SIU description electronically via the Division’s website at www.fldfs.com/fraud/. The SIU description shall be submitted electronically on Form DFS-L1-1689 (Eff.\_\_\_\_) “SIU Description Form” as provided on the Division’s website at www.fldfs.com/fraud/. Form DFS-L1-1689 (Eff.\_\_\_\_) SIU Description Form is hereby adopted and incorporated by reference. The insurer’s filing of the information required in subsection (1) above shall constitute an adequately detailed description of its SIU as required by Section 626.9891(1), FS. (3) Nothing in this rule shall require that an SIU utilize all established criteria in every circumstance. (4) The filing of the information required herein is not intended to constitute a waiver of an insurer’s privilege, trade secret, confidentiality or any proprietary interest in its SIU, its SIU description, or its SIU policies and procedures. Specific Authority: 624.308, FS., 626.9891, FS., 626.9891(8), FS.; Law Implemented: 624.307,FS., 626.989, FS., 626.9891(1), FS.; History-New. 69D-2.004 Insurer Anti-Fraud Plans. (1) An insurer subject to Section 626.9891(2), F.S., shall file with the Division of Insurance Fraud such anti-fraud plan, and such anti-fraud plan shall include: (a) A written description or chart outlining the organizational arrangement of the insurer’s anti-fraud personnel who are responsible for the investigation and reporting of possible fraudulent insurance acts. (b) A description of the insurer’s procedures for detecting and investigating possible fraudulent insurance acts. Nothing in this rule shall require that an insurer utilize all established criteria in every circumstance. This description shall include: 1. An acknowledgment that the insurer has established criteria that will be used to detect suspicious or fraudulent activity during investigations relating to the different types of insurance offered by that insurer; 2. An acknowledgment that the insurer has established criteria that will be used for the investigation of acts of suspected insurance fraud relating to the different types of insurance offered by that insurer. (c) A description of the insurer’s procedures for the mandatory reporting of possible fraudulent insurance acts to the Division pursuant to Section 626.989(6), F.S. This description shall include: 1. An explanation of the insurer’s method for reporting all suspected fraudulent insurance acts directly to the Division electronically on Form DFS-L1-1691, as incorporated and provided for in paragraph 69D-2.003(1)(d), F.A.C. 2. An acknowledgment that all such reports of suspected insurance fraud shall contain information that clearly defines and supports the allegation of suspicious activity. 3. An acknowledgment that the insurer shall record the date that suspected fraudulent activity is detected, and shall record the date that reports of such suspected insurance fraud are sent directly to the Division. (d) A description of the insurer’s plan for anti-fraud education and training of its claims adjusters and any other personnel involved in anti-fraud related efforts. This description shall include: 1. A plan that involves training relating to the detection and investigation of fraudulent insurance acts for all employees involved in anti-fraud related efforts. 2. A plan that involves on-going training during the reporting period; (e) The contact information, including names, e-mail addresses, and telephone numbers, for personnel designated by the insurer to be responsible for achieving and maintaining compliance with Section 626.9891(2), F.S., and this rule chapter; (f) The insurer’s NAIC individual and group code numbers; (2) An insurer subject to Section 626.9891(2), F.S., and this rule chapter, shall submit this anti-fraud plan electronically via the Division’s website at www.myfloridacfo.com. The anti-fraud plan shall be submitted electronically on Form DFS-L1-1690 (Eff. 10-5-06) “Anti-Fraud Plan Form as provided on the Division’s website at www.fldfs.com/fraud/. Form DFS-L1-1690 (Eff. 10-5-06) Anti-Fraud Plan Form is hereby adopted and incorporated by reference. The insurer’s filing of the information required in subsection (1) above shall constitute an acceptable anti-fraud plan as required by Section 626.9891(2), F.S. (3) The filing of the information required herein is not intended to constitute a waiver of an insurer’s privilege, trade secret, confidentiality or any proprietary interest in its anti-fraud plan or its anti-fraud related policies and procedures. 69D-2.005 Compliance and Enforcement. (1) The Division shall review the filings of SIU descriptions and insurer anti-fraud plans and the Office shall conduct audits pursuant to Section 624.3161, F.S., to determine compliance with Section 626.9891, F.S., and this rule chapter. (2) If an insurer fails to timely file an anti-fraud plan or SIU description, fails to implement or follow the provisions of their anti-fraud plan or SIU description, or in any other way fails to comply with the requirements of Section 626.9891, F.S., and this rule chapter, the Office shall take appropriate administrative action as provided in Sections 626.9891(7) and 624.4211, F.S. **State:** Florida **Requirement Types:** SIU Requirement --- ### [Georgia-Mandatory Reporting-Section 33-1-16 (f)](https://insurancefraud.org/regulations/georgia-mandatory-reporting-section-33-1-16-f/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** “… any insurer, agent, or other person licensed under this title, or an employee thereof, having knowledge or who believes that a fraudulent insurance act is being or has been committed shall send to the Commissioner a report or information pertinent to such knowledge or belief and such additional information relative thereto as the Commissioner or agents may require….” **State:** Georgia **Requirement Types:** Mandatory Reporting --- ### [Hawaii-Fraud Warning-?](https://insurancefraud.org/regulations/hawaii-fraud-warning/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime punishable by fines or imprisonment, or both. **State:** Hawaii **Requirement Types:** Fraud Warning --- ### [Hawaii-Mandatory Reporting-Section 431:2-409](https://insurancefraud.org/regulations/hawaii-mandatory-reporting-section-4312-409/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) Within sixty days of an insurer or other licensee’s employee or agent discovering credible information indicating a violation of section 431:2-403, or as soon thereafter as practicable, the insurer or licensee shall provide to the branch information, including documents and other evidence, regarding the alleged violation of section 431:2-403. The insurance fraud investigations branch shall work with the insurer or licensee to determine what information shall be provided. (b) Information provided pursuant to this section shall be protected from public disclosure to the extent authorized by chapter 92F and section 431:2-209; provided that the branch may release the information in an administrative or judicial proceeding to enforce this part to federal, state, or local law enforcement or regulatory authorities, the National Association of Insurance Commissioners, the National Insurance Crime Bureau, or an insurer or other licensee aggrieved by the alleged violation of section 431:2-403. **State:** Hawaii **Requirement Types:** Mandatory Reporting --- ### [Idaho-Fraud Warning-Section 41-1331 - Language is permissive](https://insurancefraud.org/regulations/idaho-fraud-warning-section-41-1331-language-is-permissive/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** “Any person who knowingly, and with intent to defraud or deceive any insurance company, files a statement containing any false, incomplete, or misleading information is guilty of a felony.” The section also states that lack of a warning does not constitute a defense against prosecution. **State:** Idaho **Requirement Types:** Fraud Warning --- ### [Idaho-Mandatory Reporting-Section 41-290 Idaho Code: Section 41-292 Idaho Code](https://insurancefraud.org/regulations/idaho-mandatory-reporting-section-41-290-idaho-code-section-41-292-idaho-code/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Section 41-290 Idaho Code “Any insurer which has facts to support a belief that a fraudulent claim is being or has been made shall, within sixty (60) days of the receipt of such notice, send to the director of insurance, on a form prescribed by the director, the information requested and such additional information relative to the claim and the parties claiming loss or damages as the director may require.” Section 41-292 Idaho Code 2(a) “When an insurance company has facts to support a belief that a loss in which it has an interest may be of other than accidental cause, then, for the purpose of notification and for having such loss investigated, the company shall, in writing, notify the director of the department of insurance, the state fire marshal and any other authorized agency and provide any or all material developed from the company’s inquiry into the loss.” **State:** Idaho **Requirement Types:** Mandatory Reporting --- ### [Illinois-Mandatory Reporting-S 215 ILCS § 5/155.24](https://insurancefraud.org/regulations/illinois-mandatory-reporting-s-215-ilcs-§-5-155-24/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** NOTE: Auto only Insurance Code; Provisions Applicable to All Companies; Motor Vehicle Theft and Motor Insurance Fraud Reporting and Immunity Law (c) When an insurer knows or reasonably believes to know the identity of a person whom it has reason to believe committed a criminal or fraudulent act relating to a motor vehicle theft or a motor vehicle insurance claim or has knowledge of such a criminal or fraudulent act which is reasonably believed not to have been reported to an authorized governmental agency, then for the purpose of notification and investigation, the insurer or an agent authorized by an insurer to act on its behalf shall notify an authorized governmental agency of such knowledge or reasonable belief and provide any additional relevant information in accordance with subsection (b) of the Section. When the motor vehicle theft or motor vehicle claim that gives rise to the suspected criminal or fraudulent act has already generated an incident report to an Illinois authorized governmental agency, the insurer shall report the suspected criminal or fraudulent act to that agency. When no prior incident report has been made, the insurer shall report the suspected criminal or fraudulent act to the Attorney General or State’s Attorney in the county or counties where the incident is claimed to have occurred. When the incident that gives rise to the suspected criminal or fraudulent act is claimed to have occurred outside the State of Illinois, but the suspected criminal or fraudulent act occurs within the State of Illinois, the insurer shall make the report to the Attorney General or State’s Attorney in the county or counties where the suspected criminal or fraudulent act occurred. When the fraud occurs in multiple counties the report shall also be sent to the Attorney General. (d) When an insurer provides any of the authorized governmental agencies with notice pursuant to this Section it shall be deemed sufficient notice to all authorized governmental agencies for the purpose of this Act. **State:** Illinois **Requirement Types:** Mandatory Reporting --- ### [Indiana-Fraud Warning-Section 27-2-16-3(a); Section 27-2-16-3(b)](https://insurancefraud.org/regulations/indiana-fraud-warning-section-27-2-16-3a-section-27-2-16-3b/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** All preprinted claims forms – Sec. 27-2-16-3(a) Section 27-2-16-3(a) – Language is permissive “Any person who knowingly, and with intent to defraud an insurer, files a statement of claim containing false, incomplete or misleading information commits a felony.” Section 27-2-16-3(b) – the absence of a warning statement is not a defense against prosecution for insurance fraud. **State:** Indiana **Requirement Types:** Fraud Warning --- ### [Indiana-Mandatory Reporting-27-2-14-2 Fraudulent claims; notification by insurer](https://insurancefraud.org/regulations/indiana-mandatory-reporting-27-2-14-2-fraudulent-claims-notification-by-insurer/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Sec. 2. If an insurer has reason to believe that a vehicle theft claim made by an insured is fraudulent, the insurer shall: (1) notify, in writing, an authorized agency of the suspected fraudulent claim; and (2) provide the agency with all material developed from the insurer’s inquiry into the claim. **State:** Indiana **Requirement Types:** Mandatory Reporting --- ### [Iowa-Mandatory Reporting-Sec. 507E.6](https://insurancefraud.org/regulations/iowa-mandatory-reporting-sec-507e-6/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** “An insurer which believes that a claim or application for insurance coverage is being made which is a violation of section 507E.3 shall provide, within sixty days of the receipt of such claim or application, written notification to the bureau of the claim or application on a form prescribed by the bureau, including any additional information requested by the bureau related to the claim or application or the party making the claim or application. The fraud bureau shall review each notification and determine whether further investigation is warranted. If the bureau determines that further investigation is warranted, the bureau shall conduct an independent investigation of the facts surrounding the claim or application for insurance coverage to determine the extent, if any, to which fraud occurred in the submission of the claim or application. The bureau shall report any alleged violation of law disclosed by the investigation to the appropriate licensing agency or prosecuting authority having jurisdiction with respect to such violation.” **State:** Iowa **Requirement Types:** Mandatory Reporting --- ### [Kansas-Fraud Plan-KSA 40-2,118(d)](https://insurancefraud.org/regulations/kansas-fraud-plan-ksa-40-2118d/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (d)(1) Each insurer shall have antifraud initiatives reasonably calculated to detect fraudulent insurance acts. Antifraud initiatives may include: fraud investigators, who may be insurer employees or independent contractors; or an antifraud plan submitted to the commissioner no later than July 1, 2007. Each insurer that submits an antifraud plan shall notify the commissioner of any material change in the information contained in the antifraud plan within 30 days after such change occurs. Such insurer shall submit to the commissioner in writing the amended antifraud plan. The requirement for submitting any antifraud plan, or any amendment thereof, to the commissioner shall expire on the date specified in paragraph (2) of this subsection unless the legislatue reviews and reenacts the provisions of paragraph (2) pursuant to K.S.A. 45-229 and amendments thereto. (2) Any antifraud plan, or any amendment thereof, submitted to the commissioner for informational purposes only shall be confidential and not be a public record and shall not be subject to discovery or subpoena ina civil action unless following an in camera review, the court determines that the antifraud plan is relevant and otherwise admissable under the rules of evidence set forth in article 4, chapter 60 of the Kansas Statutes Annotated, and amendments thereto. The provisions of this paragraph shall expire on July 1, 2016, unless the legislatiure reviews and reenacts this provision pursuant to K.S.A. 45-229, and amendments thereto, prior to July 1, 2016. **State:** Kansas **Requirement Types:** Fraud Plan --- ### [Kansas-Mandatory Reporting-KSA 40-2,118 (b) and (c)](https://insurancefraud.org/regulations/kansas-mandatory-reporting-ksa-40-2118-b-and-c/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (b) An insurer that has knowledge or a good faith belief that a fraudulent insurance act is being or has been committed shall provide to the commissioner, on a form prescribed by the commissioner, any and all information and such additional information relating to such fraudulent insurance act as the commissioner may require. (c) Any other person that has knowledge or a good faith belief that a fraudulent insurance act is being or has been committed may provide to the commissioner, on a form prescribed by the commissioner, any and all information and such additional information relating to such fraudulent insurance act as the commissioner may request. **State:** Kansas **Requirement Types:** Mandatory Reporting --- ### [Kentucky-Fraud Plan-806 KAR 47:010. Fraud prevention.](https://insurancefraud.org/regulations/kentucky-fraud-plan-806-kar-47010-fraud-prevention/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** This administrative regulation establishes insurer requirements and a comprehensive process for reporting and investigating fraudulent insurance acts. Section 1. Definitions. “Division” is defined by KRS 304.47-010(6). “Special investigative unit” or “SIU” means a unit to investigate fraudulent insurance acts as required by KRS 304.47-080. Section 2. Scope. This administrative regulation shall apply to all insurers admitted to do business in the Commonwealth that are not otherwise exempted by KRS 304.47-080(1). Section 3. Primary Anti-fraud Contacts. To facilitate communication with the division, an insurer shall designate two (2) primary contact persons, one (1) of whom shall be the head of the SIU, who shall communicate with the division on matters relating to the reporting, investigation, and prosecution of suspected fraudulent insurance acts, as defined in KRS 304.47-020. Section 4. Special Investigative Units and Anti-fraud Plans. An insurer shall maintain an SIU to fulfill the requirements of KRS 304.47-080. In conjunction with its SIU, an insurer shall: (a) Implement systematic and effective methods to detect and investigate suspected fraudulent insurance claims; (b) Educate and train all claims handlers to identify possible insurance fraud; (c) Develop policies for the SIU to cooperate, coordinate, and communicate with: The insurer’s claims handlers, legal personnel, technical support personnel, and database support personnel; and The division and other relevant law enforcement agencies; and (d) Develop and submit to the division a written anti-fraud plan, which shall include: Acknowledgment of duty to report to the division, including mandatory reporting of the determination that a suspected fraudulent act has been committed within fourteen (14) days; SIU contact information; SIU investigative ethics; Procedures to detect and deter fraud; and Continuing education plans for SIU staff. Section 5. Compliance Report. (1) Within ninety (90) days of admission, and at least once every two (2) years, an insurer shall submit to the division a written report setting forth the manner in which the insurer is complying with Section 4 of this administrative regulation. The report shall also include: (a) The total number of SIU investigative staff responsible for cases in Kentucky, and whether any staff member also investigate cases in other jurisdictions; and (b)1. If the insurer formed the SIU in house and solely governs it, the year that the SIU was formed; or 2. If the insurer has contracted SIU services through another company, the identity of the company providing SIU services and the initial year of the contract between the insurer and the company. (2) Within thirty (30) days of a material change of the information provided in the compliance report, the insurer shall amend the compliance report and resubmit it to the division. Section 6. Reporting Fraudulent Insurance Acts. (1) All persons identified in KRS 304.47-050(2) shall report suspected fraudulent insurance acts to the division within fourteen (14) days of determination that a suspected fraudulent act has been committed. Reports submitted to a person or entity other than the division shall not satisfy the reporting duty of KRS 304.47-050(2). Reports shall be submitted by: Completing a report on the department’s electronic services portal at https://insurance.ky.gov/eservices/default.aspx; or Submitting a completed Uniform Suspected Insurance Fraud Reporting Form. (2) All persons identified in KRS 304.47-050(1) may report suspected fraudulent insurance acts to the division by: Completing a report on the department’s electronic services portal at https://insurance.ky.gov/eservices/default.aspx; or Submitting a completed Uniform Suspected Insurance Fraud Reporting Form. Section 7. Incorporation by Reference. The “Uniform Suspected Insurance Fraud Reporting Form,” 7/2019, is incorporated by reference. **State:** Kentucky **Requirement Types:** Fraud Plan --- ### [Kentucky-Fraud Warning-KRS 304.47-030(1); KRS 304.47-030(2) - Language is permissive](https://insurancefraud.org/regulations/kentucky-fraud-warning-krs-304-47-0301-krs-304-47-0302-language-is-permissive/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** KRS 304.47-030(1) – Language is permissive “Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.” KRS 304.47-030(2) – Language is permissive “Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim containing any materially false information or conceals, for the purpose of misleading, information any fact material thereto commits a fraudulent insurance act, which is a crime.” **State:** Kentucky **Requirement Types:** Fraud Warning --- ### [Kentucky-Mandatory Reporting-Section 304.47-050 (2); 806 KAR47:020](https://insurancefraud.org/regulations/kentucky-mandatory-reporting-section-304-47-050-2-806-kar47020/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Section 304.47-050 (2) “The following individuals having knowledge or believing that a fraudulent insurance act or any other act or practice which may constitute a felony or misdemeanor under this subtitle is being or has been committed shall send to the division a report or information pertinent to the knowledge or belief and additional relevant information that the commissioner or his employees or agents may require: (a) Any professional practitioner licensed or regulated by the Commonwealth, except as provided by law; (b) Any private medical review committee; (c) Any insurer, agent, or other person licensed under this chapter; and (d) Any employee of the persons named in paragraphs (a) to (c) of this subsection. 806 KAR47:020 Section 1 (1) All persons identified in KRS 304.47-050(2) shall report in writing all suspected fraudulent insurance acts to the Insurance Fraud Unit. (2) The report shall be filed within fourteen (14) days of determination by the reporter that a suspected fraudulent insurance act has been committed. **State:** Kentucky **Requirement Types:** Mandatory Reporting --- ### [California-SIU Requirement-Section 2698.40 Definitions, Section 2698.42, Section 2698.43 SIU Contracted Responsibilities, Section 2698.43, Section 2698.44 Section 2698.45 Section 2698.46 Section 2698.47 Section 2698.48 Section 2698.49 SIU Training Section 2698.50 SIU Annual Report Section 2698.51 Examinations Section 2698.52 Penalties](https://insurancefraud.org/regulations/california-siu-requirement-section-2698-40-definitions-section-2698-42-section-2698-43-siu-contracted-responsibilities-section-2698-43-section-2698-44-section-2698-45-section-2698-46-section-2698/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Section 2698.40 Definitions As used in this article, the following definitions shall apply: (a) “Authorized governmental agency (agencies)” shall have the same meaning as used in the Insurance Frauds Prevention Act (IFPA). (b) “Claims handler” means every employee and agent of an insurer whose principal responsibilities include the investigation, adjustment, settlement and resolution of claims. (c) “Commissioner” means the Insurance Commissioner of the State of California. (d) “Communication” includes the referral of suspected insurance fraud to the Department of Insurance and providing information and documents requested by the Fraud Division. (e) “Department” means the California Department of Insurance. (f) “Fraud Division” means the California Department of Insurance Fraud Division formerly known as the Bureau of Fraudulent Claims. (g) “Insurer” means every insurer admitted to do business in this state except the following: (1) Reinsurers. (2) Title insurers. (3) Fraternal fire insurers. (4) Fraternal benefit societies. (5) Firemen, policemen, or peace officer benefit and relief associations. (6) Grant and annuity societies. (7) Home protection (h) “Integral anti-fraud personnel” includes insurer personnel who the insurer has not identified as being directly assigned to its SIU but whose duties may include the receipt, processing, investigating, or litigation pertaining to payment or denial of a claim or application. These personnel may include claims handlers, underwriters, agents, policy handlers, call center staff, legal staff, and other insurer employee classifications that perform similar duties. (i) “Reasonable suspicion” is a level of belief that an act of insurance fraud may have or might be occurring for which there is an objective justification based on articulable fact(s) and rational inferences therefrom. (j) “Red flag” or “red flag event” means facts, circumstances or events which, singly or in combination, support(s) an inference that insurance fraud may have been committed. (k) “Regulations” means these regulations, California Code of Regulations, Title 10, Chapter 5, Subchapter 9, Article 2. (l) “Special Investigative Unit” (SIU) means an insurer’s unit or division that is established to investigate suspected insurance fraud. The SIU may be comprised of insurer employees or by contracting with other entities for the purpose of complying with applicable sections of the Insurance Frauds Prevention Act (IFPA) for the direct responsibility of performing the functions and activities as set forth in these regulations. (m) “Suspected insurance fraud” includes any misrepresentation of fact pertaining to a transaction of insurance including claims, premium and application fraud. These facts may include evidence of doctoring, altering or destroying forms, prior history of the claimant, policy holder, applicant or provider, receipts, estimates, explanation of benefits (EOB), medical evaluations or billings, medical provider notes (commonly known as SOAPE notes; Subjective complaint, Objective findings, Assessment, Plan and Evaluation), Health Care Financing Administration (HCFA) forms, police and/or investigative reports, relevant discrepancies in written or oral statements and examinations under oath (EUO), unusual policy activity and falsified or untruthful application for insurance. An identifiable pattern in a claim history may also suggest the possibility of suspected fraudulent claims activity. A claim may contain evidence of suspected insurance fraud regardless of the payment status. (n) “The Insurance Frauds Prevention Act” or “(IFPA)” shall refer to California Insurance Code section 1871 et seq. (a) Adequacy. The adequacy of an insurer’s SIU staffing shall be determined by its demonstrated ability to establish, operate and maintain an SIU that is in compliance with these regulations. (b) Knowledge. An SIU shall be composed of employees who have knowledge and experience in general claims practices, the analysis of claims for patterns of fraud, and current trends in insurance fraud, education and training in specific red flags, red flag events, and other criteria indicating possible fraud. They shall have the ability to conduct effective investigations of suspected insurance fraud and be familiar with insurance and related law and the use of available insurer related database resources. Section 2698.43 SIU Contracted Responsibilities (a) Any contract entered into by an insurer, or an entity under contract with an insurer as provided under these regulations, shall not relieve the insurer of any obligation under these regulations or the IFPA. (b) Notwithstanding any other provisions of these regulations, a complete and executed copy of any such agreement, including all attachments, exhibits and amendments thereto, shall be provided to the Fraud Division on execution. (c) Any contract entered into by an insurer under this section shall: (1) Specify all SIU duties and functions to be performed by the parties to the contract and how the insurer monitors performance of the contract responsibilities. (2) Not include provisions that could provide disincentives to the referral and/or investigation of suspected insurance fraud. (3) Not include provisions that purport to relieve an insurer of any obligation to comply with the requirements of these regulations and the IFPA. (4) Expressly include a provision to require the contracted entity to comply with all applicable provisions of the IFPA and these regulations. Section 2698.43 SIU Contracted Responsibilities (a) Any contract entered into by an insurer, or an entity under contract with an insurer as provided under these regulations, shall not relieve the insurer of any obligation under these regulations or the IFPA. (b) Notwithstanding any other provisions of these regulations, a complete and executed copy of any such agreement, including all attachments, exhibits and amendments thereto, shall be provided to the Fraud Division on execution. (c) Any contract entered into by an insurer under this section shall: (1) Specify all SIU duties and functions to be performed by the parties to the contract and how the insurer monitors performance of the contract responsibilities. (2) Not include provisions that could provide disincentives to the referral and/or investigation of suspected insurance fraud. (3) Not include provisions that purport to relieve an insurer of any obligation to comply with the requirements of these regulations and the IFPA. (4) Expressly include a provision to require the contracted entity to comply with all applicable provisions of the IFPA and these regulations. Section 2698.44 Communication with the Fraud Division and Authorized Governmental Agencies. (a) The insurer and any entity performing the SIU function(s) shall comply with specific sections of the IFPA regarding communication with the Fraud Division and authorized governmental agencies. (b) On written request by the Fraud Division or an authorized governmental agency, an insurer or its agents, shall release in an timely and complete manner any or all relevant information deemed important that the insurer may possess relating to any specific incident of insurance fraud. Such information shall include: (1) Insurance policy information. (2) Applications. (3) Policy premium payment records. (4) History of claims. (5) Information relating to the carrier’s investigation, including statements, proof and notice of loss. (6) Claim file documents. (7) Claim notes. (8) Investigation files. (9) Investigator notes. (10) Other information which the Fraud Division or an Authorized Governmental Agency may deem relevant and important. (c) For the purpose of this section, timely release of information means immediate unless otherwise agreed to by the Fraud Division. (d) A single written request shall be considered sufficient to compel production of all information deemed relevant by the requesting governmental agency relating to any specific insurance fraud investigation at the time the request is made and subsequent to require production of the requested records by the insurer named in the request and all persons, agents and brokers employed by and conducting business on behalf of the insurer. Section 2698.45 Detecting Suspected Insurance Fraud. (a) An insurer’s integral anti-fraud personnel are responsible for identifying suspected insurance fraud during the handling of insurance transactions and referring it to the SIU as part of their regular duties. (b) The SIU shall establish, maintain, distribute and monitor written procedures to be used by the integral anti-fraud personnel to detect, identify, document and refer suspected insurance fraud to the SIU. The written procedures will include a listing of the red flags to be used to detect suspected insurance fraud for the insurer. (c) The procedures for detecting suspected insurance fraud shall provide for comparison of any insurance transaction against: (1) Patterns or trends of possible fraud (2) Red flags (3) Events or circumstances present on a claim (4) Behavior or history of person(s) submitting a claim or application (5) Other criteria that may indicate possible fraud Section 2698.46 Investigating Suspected Insurance Fraud. (a) The SIU shall establish, maintain, distribute and adhere to written procedures for the investigation of possible suspected insurance fraud. An investigation of possible suspected insurance fraud will include: (1) A thorough analysis of a claim file, application, or insurance transaction. (2) Identification and interviews of potential witnesses who may provide information on the accuracy of the claim or application. (3) Utilizing industry-recognized databases. (4) Preservation of documents and other evidence. (5) Writing a concise and complete summary of the investigation, including the investigator’s conclusions regarding the suspected insurance fraud and the basis for their conclusions. Section 2698.47 Referral of Suspected Insurance Fraud. (a) The SIU shall provide for the referral of acts of suspected insurance fraud to the Fraud Division and, as required, district attorneys. (b) Referrals shall be submitted when in any insurance transaction the facts and circumstances create a reasonable belief that a person or entity may have committed or is committing insurance fraud. Section 2698.48 Referral Content A referral of an act of suspected insurance fraud to the Fraud Division shall be legible and in a format as directed by the Department and contain the information and data to the extent applicable, as provided in the following. (a) Fraud and referral type (1) Fraud type (2) New referral/amended referral indicator (b) Reporting party information (1) Reporting party type (2) Reporting party name (3) Reporting party California Company number (4) Reporting self-insured/contracted third party license number, as appropriate (5) Reporting party address, city, state and zip code (6) Reporting party email address (generally, contact address) (c) Alleged victim information, as appropriate (1) Alleged victim company name (2) Alleged victim California Company number (3) Alleged victim self-insured number (4) Alleged victim address, city, state and zip code (d) Insurance policy or claim information, as appropriate (1) Claim number associated with referral (2) Insurance policy number associated with referral (3) Date of loss or injury (4) Geographic location where loss or injury occurred (5) Insurance premium dollar loss (6) Total potential loss on claim prior to the identification of fraud (7) Total claim loss paid to date (8) Actual suspected fraudulent loss amount paid to date (9) A complete synopsis of all the facts on which the reasonable suspicion of the insurance fraud is based (10) Disaster claim indicator (e) Other agency referral information, as appropriate (1) Names of other authorized governmental agencies receiving this referral (2) Names of any District Attorney’s Office receiving this referral (3) National Insurance Crime Bureau (NICB) referral indicator (4) The names of any other agencies receiving this referral (f) Referral contact information, as appropriate (1) Referral contact name and phone number (2) Claim or case file handler and phone number (3) Name and phone number of person who completed referral (4) Date referral was completed (g) Information for each party associated with the referral (1) Identification of the role of the party to the loss (2) Phone number (3) Address, city, state and zip code (4) Date of birth or age (5) Social security number (6) Tax identification number (7) Drivers license number (8) State of party’s drivers license (9) Vehicle license plate number (10) Vehicle license plate state (11) Vehicle identification number (12) Other names or identifiers used by the party (13) Claim of injury indicator Section 2698.49 SIU Training Requirements for training provided by and for the SIU shall include: (a) The SIU shall establish and maintain an ongoing anti-fraud training program, planned and conducted to develop and improve the anti-fraud awareness skills of the integral anti-fraud personnel. (b) The insurer shall designate an SIU staff person to be responsible for the ongoing antifraud training program. (c) The anti-fraud training program shall include instruction on: (1) The function and purpose of the SIU. (2) Introduction/review of the written procedures established by the SIU regarding the identification, documentation and referral of incidents of suspected fraud to the SIU. (3) Identification and recognition of red flags or red flag events. (4) Any changes to current procedures for identifying, documenting and referring incidents of suspected insurance fraud to the SIU. (5) Fraud Division insurance fraud reporting requirements. (6) Introduction and review of existing and new, emerging insurance fraud trends. (d) In addition to training provided to integral antifraud personnel provided herein, the SIU personnel shall receive anti-fraud training that include investigative techniques, communication with the Fraud Division and authorized governmental agencies, fraud indicators, emerging fraud trends, legal and related issues. This training shall be provided to SIU personnel by qualified and experienced entities in the subject matter being presented. (e) All insurers shall provide an anti-fraud orientation program to all SIU and integral antifraud personnel within thirty (30) days after hire. Thereafter, insurers shall provide anti-fraud training to SIU and integral antifraud personnel on an annual basis. (f) Records of the anti-fraud training provided to all staff shall be prepared at the time training is provided and be maintained and available for inspection by the Department on request. The training records shall include the title and date of the anti-fraud training course, name and title and contact information of the instructor(s), description of the course content, length of the training course, and the name and job title(s) of participating personnel. Section 2698.50 SIU Annual Report (a) Every insurer shall, at the time its initial Certificate of Authority is issued and annually on a date prescribed by the Fraud Division on at least sixty (60) days prior to the due date, submit an annual report: (b) A complete, accurate and truthful annual report shall be submitted in a format as prescribed by the Department and shall include the following information. (1) The name(s), title(s) and contact information of the insurer’s SIU personnel, or (2) The name of the organization and organizational contacts with whom the insurer has contracted for the maintenance of the SIU or any function thereof, and (3) The names of personnel whose duties include communication with the Fraud Division on matters related to the reporting, investigation and prosecution of suspected fraudulent claims or other suspected insurance fraud. (4) A description of the insurer’s methods and written procedures used for detecting, investigating and reporting suspected insurance fraud. (5) A description of the insurer’s plan for initial and ongoing fraud education and training for integral anti-fraud personnel pursuant to these regulations. (6) A written description or chart outlining the organizational arrangement of the insurer’s anti-fraud personnel who are responsible for the investigation and reporting of suspected insurance fraud. (7) A description of how the SIU is adequately staffed to meet the requirements herein and the expertise of the staff; (8) The number of claims processed by the insurer and the number of claims referred to the SIU, for each reported company, for the past calendar year; (9) The number of suspected insurance fraud reported to the Department and to district attorney offices, for each reported company, for the past calendar year. (10) A description of any significant, anticipated changes to the insurer’s operations. (11) Insurers who enter into contracts for the purpose of compliance with CIC Section 1875.20 et seq. shall provide a complete copy of the fully executed, existing contract, including all attachments and addendum, to the Department and shall specify the manner in which the contract is monitored. (12) The number and type of civil actions for each reported company alleging acts of insurance fraud during the preceding calendar year. (c) A statement signed under penalty of perjury must accompany all reports mentioned herein. This statement must be signed by an officer of the holder of or applicant for the Certificate of Authority who attests to the accuracy of the reported information and the signor’s personal knowledge of the existence and proper maintenance of an SIU as required by CIC Section1875.20 et seq. and these regulations. (d) The insurer is to maintain a copy of the annual report that will be available for review. (e) For the purpose of these regulations, the name(s) of the insurer’s personnel who will communicate with the Fraud Division shall not be made part of the public record and shall be released only pursuant to the provisions of CIC Section 1873.1 applicable to information acquired pursuant to Article 3 of the Insurance Frauds Prevention Act. Section 2698.51 Examinations (a) The commissioner may conduct examinations of an insurer’s SIU and related operations, including operations undertaken by entities under contract with the insurer, as deemed necessary to determine compliance with the requirements of this article. (b) A written report of examination, including identification of violations of these applicable provisions of statute and regulation and required corrective action, if any, will be provided to the insurer on completion of the examination. (c) Notwithstanding any penalty imposed pursuant to the regulations, within thirty (30) days of receipt of a written report identifying any violation(s) of these regulations, an insurer shall submit to the Department a plan demonstrating how the insurer will correct such violation(s) and achieve compliance. Such plan shall be subject to examination by the Department. If accepted by the Department, the plan shall be submitted as a supplement to any existing annual report and shall be accompanied by an statement of an officer of the insurer as otherwise required for annual reports. Failure to submit a corrective action and compliance plan or to comply with such plan when accepted by the Department shall be considered a violation of these regulations. Section 2698.52 Penalties (a) On notice and hearing in accordance with Government Code sections 11550 et seq,. the Commissioner may impose sanctions for violation of these regulations and/or Article 5.6 (commencing with section 1875.20) of the California Insurance Code. (b) Not withstanding any other provisions of law, for each act in violation of these regulations an insurer will be subject to a penalty of not more than $55,000 and/or suspension or revocation of the insurer’s Certificate of Authority. **State:** California **Requirement Types:** SIU Requirement --- ### [California-SIU Requirement-State Insurance Code Section 1875.20; California Code of Regulations Subchapter 9 Insurance Fraud Section 2698.30 et. seq.](https://insurancefraud.org/regulations/california-siu-requirement-state-insurance-code-section-1875-20-california-code-of-regulations-subchapter-9-insurance-fraud-section-2698-30-et-seq/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** State Insurance Code Section 1875.20 (Fraud unit required); Administrative Code – Title 10 Section 2698.42 (Purpose and objectives of insurer special investigative unit) Section 1875.20 — Every insurer admitted to do business in this state shall maintain a unit or division to investigate possible fraudulent claims by insureds or by persons making claims for services or repairs against policies held by insureds. SPECIAL INVESTIGATIVE UNIT REGULATIONS Effective October 7, 2005 California Code of Regulations Subchapter 9 Insurance Fraud Article 2 Special Investigative Unit Regulations Section 2698.30 Definitions As used in this article, the following definitions shall apply: (a) “Act” means any violation of California Code of Regulations, Title 10, Chapter 5, Section 2698.30-42, inclusive. (b) “Authorized governmental agency (agencies)” shall have the same meaning as used in the Insurance Frauds Prevention Act (IFPA). (c) “Claims handler” means every employee and agent of an insurer whose principal responsibilities include the investigation, adjustment, settlement and resolution of claims. (d) “Commissioner” means the Insurance Commissioner of the State of California. (e) “Communication” includes the referral of suspected insurance fraud to the Department of Insurance and providing information and documents requested by the Fraud Division. (f) “Department” means the California Department of Insurance. (g) “Fraud Division” means the California Department of Insurance Fraud Division formerly known as the Bureau of Fraudulent Claims. (h) “Hearing” means an adjudicative proceeding initiated by the Insurance Commissioner pursuant to the provisions of California Insurance Code Section 1875.24(d). (i) Inadvertent” means unintentional. (j) “Insurer” means every insurer admitted to do business in this state except the following: (1) Reinsurers. (2) Title insurers. (3) Fraternal fire insurers. (4) Fraternal benefit societies. (5) Firemen, policemen, or peace officer benefit and relief associations. (6) Grant and annuity societies. (7) Home protection. (k) “Integral anti-fraud personnel” includes insurer personnel who the insurer has not identified as being directly assigned to its SIU but whose duties may include the processing, investigating, or litigation pertaining to payment or denial of a claim or application for adjudication or claim or application for insurance.. These personnel may include claims handlers, underwriters, policy handlers, call center staff within the claims or policy function, legal staff, and other insurer employee classifications that perform similar duties. (l) “Reasonable belief” is a level of belief that an act of insurance fraud may have or might be occurring for which there is an objective justification based on articulable fact(s) and rational inferences therefrom. (m) “Red flag” or “red flag event” means facts, circumstances or events which, singly or in combination, support(s) an inference that insurance fraud may have been committed. (n) “Regulations” means these regulations, California Code of Regulations, Title 10, Chapter 5, Subchapter 9, Article 2. (o) “Special Investigative Unit” (SIU) means an insurer’s unit or division that is established to investigate suspected insurance fraud. The SIU may be comprised of insurer employees or by contracting with other entities for the purpose of complying with applicable sections of the Insurance Frauds Prevention Act (IFPA) for the direct responsibility of performing the functions and activities as set forth in these regulations. (p) “Suspected insurance fraud” includes any misrepresentation of fact or omission of fact pertaining to a transaction of insurance including claims, premium and application fraud. These facts may include evidence of doctoring, altering or destroying forms, prior history of the claimant, policy holder, applicant or provider, receipts, estimates, explanations of benefits (EOB), medical evaluations or billings, medical provider notes (commonly known as SOAPE notes); Subjective complaint, Objective findings, Assessment, Plan and Evaluation, Health Care Financing Administration (HCFA) forms, police and/or investigative reports, relevant discrepancies in written or oral statements and examinations under oath (EUO), unusual policy activity and falsified or untruthful application for insurance. An identifiable pattern in a claim history may also suggest the possibility of suspected fraudulent claims activity. A claim may contain evidence of suspected insurance fraud regardless of the payment status. (q) “The Insurance Frauds Prevention Act” or “(IFPA)” shall refer to California Insurance Code section 1871-1879.8. (r) “Willful” means a purpose or willingness to commit the act or make the omission referred to in the California Insurance Code or in these regulations. The Commissioner shall use the factors set forth at California Code of Regulations Section 2591.3(d)(1)(A-E) to determine whether or not an act is willful. NOTE: Authority: Insurance Code Sections, 1872.4, 1875.24, 1877.3, 1879.5, 1879.6,; Calfarm Ins. Co. v. Deukmejian (1989) 48 Cal.3d. 805, 824, 258 Cal. Rptr. 161, 771 P.2d 1247; Credit Ins. Gen. Agents Assn. v. Payne (1976) 16 Cal.3d 651, 656, 128 Cal. Rptr. 881, 547 P.2d 993; Garris v. Carpenter (1939) 33 Cal. App. 2d. 649, 653, 92 P.2d 688. Reference: Insurance Code Sections 1875.20, 1875.21, 1875.24, 1879.5, 9080, 10970, 11400, 11520, 11760, 11880, 12400.1, 12743, 12921(a) and 12926 Section 2698.31 Insurer Responsibility The insurer shall comply with applicable sections of the IFPA and these regulations regarding the establishment, operation and continuous existence of an SIU. NOTE: Authority: Insurance Code Sections 1875.24, 1879.5, 1879.6; Calfarm Ins. Co. v. Deukmejian (1989) 48 Cal.3d. 805, 824, 258 Cal. Rptr. 161, 771 P.2d 1247; Credit Ins. Gen. Agents Assn. v. Payne (1976) 16 Cal.3d 651, 656, 128 Cal. Rptr. 881, 547 P.2d 993; Garris v. Carpenter (1939) 33 Cal. App. 2d. 649, 653, 92 P.2d 688. Reference: Insurance Code Sections 1875.20, 1875.21, 1875.24, 1879.5, 12921(a) and 12926. Section 2698.32 SIU Staffing (a) Adequacy. The adequacy of an insurer’s SIU staffing shall be determined by its demonstrated ability to establish, operate and maintain an SIU that is in compliance with these regulations. Factors that may be considered in staffing the SIU include, but not limited to, the number of policies written and individuals insured in California, number of claims received with respect to California insureds on an annual basis, volume of suspected fraudulent California claims currently being detected and other factors relating to the vulnerability of the insurer to insurance fraud. (b) Knowledge. An SIU shall be composed of employees who have knowledge and/or experience in general claims practices, the analysis of claims for patterns of fraud, and current trends in insurance fraud, education and training in specific red flags, red flag events, and other criteria indicating possible fraud. They shall have the ability to conduct effective investigations of suspected insurance fraud and be familiar with insurance and related law and the use of available insurer related database resources. NOTE: Authority: Insurance Code Sections 1875.24, 1879.5, 1879.6; Calfarm Ins. Co. v. Deukmejian (1989) 48 Cal.3d. 805, 824, 258 Cal. Rptr. 161, 771 P.2d 1247; Credit Ins. Gen. Agents Assn. v. Payne (1976) 16 Cal.3d 651, 656, 128 Cal. Rptr. 881, 547 P.2d 993; Garris v. Carpenter (1939) 33 Cal. App. 2d. 649, 653, 92 P.2d 688. Reference: Insurance Code Sections 1875.20, 1875.21, 1875.24, 1879.5, 12921(a) and 12926. Section 2698.33 SIU Contracted Responsibilities (a) Any contract entered into by an insurer, or an entity under contract with an insurer as provided under these regulations, shall not relieve the insurer of any obligation under these regulations or the IFPA. (b) Notwithstanding any other provisions of these regulations, a complete and executed copy of any such agreement, including all attachments, exhibits and amendments thereto, shall be provided to the Fraud Division on execution. (c) Any contract entered into by an insurer under this section shall: (1) Specify all SIU duties and functions to be performed by the parties to the contract and how the insurer monitors performance of the contract responsibilities; (2) Not include provisions that could provide disincentives to the referral and/or investigation of suspected insurance fraud; (3) Not include provisions that purport to relieve an insurer of any obligation to comply with the requirements of these regulations and the IFPA.; and (4) Expressly include a provision to require the contracted entity to comply with all applicable provisions of the IFPA and these regulations. NOTE: Authority: Insurance Code Sections 1875.24, 1879.5, 1879.6; Calfarm Ins. Co. v. Deukmejian (1989) 48 Cal.3d. 805, 824, 258 Cal. Rptr. 161, 771 P.2d 1247; Credit Ins. Gen. Agents Assn. v. Payne (1976) 16 Cal.3d 651, 656, 128 Cal. Rptr. 881, 547 P.2d 993; Garris v. Carpenter (1939) 33 Cal. App. 2d. 649, 653, 92 P.2d 688. Reference: Insurance Code Sections 1875.20, 1875.21, 1875.24,1879.5, 12921(a) and 12926. Section 2698.34 Communication with the Fraud Division and Authorized Governmental Agencies. (a) The insurer and any entity performing the SIU function(s) shall comply with specific sections of the IFPA regarding communication with the Fraud Division and authorized governmental agencies. (b) On written request by the Fraud Division or an authorized governmental agency, an insurer or its agents, shall release in a timely and complete manner any or all relevant information deemed important that the insurer may possess relating to any specific incident of insurance fraud. Such information shall include: (1) Insurance policy information; (2) Applications; (3) Policy premium payment records; (4) History of claims; (5) Information relating to the carrier’s investigation, including statements, proof and notice of loss; (6) Claim file documents; (7) Claim notes; (8) Investigation files; (9) Investigator notes; and (10) Other information which the Fraud Division or an Authorized Governmental Agency may deem relevant and important. (c) For the purpose of this section, timely release of information means immediate, but no more than thirty (30) calendar days after the request unless otherwise agreed to by the Fraud Division. (d) A single written request shall be considered sufficient to compel production of all information deemed relevant by the requesting governmental agency relating to any specific insurance fraud investigation. The single request is applicable throughout the duration of the investigation and is applicable to the requested records of the insurer named in the request and the records of all persons, agents and brokers employed by and conducting business on behalf of the insurer. NOTE: Authority: Insurance Code Sections 1872.4, 1875.24, 1877.3, 1879.5, 1879.6; Calfarm Ins. Co. v. Deukmejian (1989) 48 Cal.3d. 805, 824, 258 Cal. Rptr. 161, 771 P.2d 1247; Credit Ins. Gen. Agents Assn. v. Payne (1976) 16 Cal.3d 651, 656, 128 Cal. Rptr. 881, 547 P.2d 993; Garris v. Carpenter (1939) 33 Cal. App. 2d. 649, 653, 92 P.2d 688. Reference: Insurance Code Sections 1872.3, 1873, 1874.2, 1874.4, 1875.4, 1875.20, 1875.21, 1875.24, 1877.1, 1877.2, 1877.3, 1877.4, 1877.5, 1879.5, 12921(a) and 12926. Section 2698.35 Detecting Suspected Insurance Fraud. (a) An insurer’s integral anti-fraud personnel are responsible for identifying suspected insurance fraud during the handling of insurance transactions and referring it to the SIU as part of their regular duties. (b) The SIU shall establish, maintain, distribute and monitor written procedures to be used by the integral anti-fraud personnel to detect, identify, document and refer suspected insurance fraud to the SIU. The written procedures shall include a listing of the red flags to be used to detect suspected insurance fraud for the insurer. (c) The procedures for detecting suspected insurance fraud shall provide for comparison of any insurance transaction against: (1) Patterns or trends of possible fraud; (2) Red flags; (3) Events or circumstances present on a claim; (4) Behavior or history of person(s) submitting a claim or application; and (5) Other criteria that may indicate possible fraud. NOTE: Authority: Insurance Code Sections 1875.24, 1879.5, 1879.6; Calfarm Ins. Co. v. Deukmejian (1989) 48 Cal.3d. 805, 824, 258 Cal. Rptr. 161, 771 P.2d 1247; Credit Ins. Gen. Agents Assn. v. Payne (1976) 16 Cal.3d 651, 656, 128 Cal. Rptr. 881, 547 P.2d 993; Garris v. Carpenter (1939) 33 Cal. App. 2d. 649, 653, 92 P.2d 688. Reference: Insurance Code Sections 1875.20, 1875.21, 1875.24, 1879.5, 12921(a) and 12926. Section 2698.36 Investigating Suspected Insurance Fraud. (a) The SIU shall establish, maintain, distribute and adhere to written procedures for the investigation of possible suspected insurance fraud. An investigation of possible suspected insurance fraud shall include: (1) A thorough analysis of a claim file, application, or insurance transaction. (2) Identification and interviews of potential witnesses who may provide information on the accuracy of the claim or application. (3) Utilizing industry-recognized databases. (4) Preservation of documents and other evidence. (5) Writing a concise and complete summary of the investigation, including the investigator’s findings regarding the suspected insurance fraud and the basis for their findings. NOTE: Authority: Insurance Code Sections 1875.24, 1879.5, 1879.6; Calfarm Ins. Co. v. Deukmejian (1989) 48 Cal.3d. 805, 824, 258 Cal. Rptr. 161, 771 P.2d 1247; Credit Ins. Gen. Agents Assn. v. Payne (1976) 16 Cal.3d 651, 656, 128 Cal. Rptr. 881, 547 P.2d 993; Garris v. Carpenter (1939) 33 Cal. App. 2d. 649, 653, 92 P.2d 688. Reference: Insurance Code Sections 1875.20, 1875.21, 1875.24, 1879.5, 12921(a) and 12926. Section 2698.37 Referral of Suspected Insurance Fraud. (a) The SIU shall provide for the referral of acts of suspected insurance fraud to the Fraud Division and, as required, district attorneys. (b) Referrals shall be submitted in any insurance transaction where the facts and circumstances create a reasonable belief that a person or entity may have committed or is committing insurance fraud. (c) Referrals shall be made within the period specified by statute. (d) The requirements of this section do not affect the immunity granted under California Insurance Code section 1872.5 or other such similar codes contained in the Insurance Frauds Prevention Act. (e) The requirements of this section do not diminish statutory requirements contained in the Insurance Frauds Prevention Act regarding the confidentiality of any information provided in connection with an investigation. NOTE: Authority: California Civil Code Section 1708, Insurance Code Sections 1872.4, 1874.6, 1875.24, 1875.4; 1877.3 1877.5, 1879.5, 1879.6; Calfarm Ins. Co. v. Deukmejian (1989) 48 Cal.3d. 805, 824, 258 Cal. Rptr. 161, 771 P.2d 1247; Credit Ins. Gen. Agents Assn. v. Payne (1976) 16 Cal.3d 651, 656, 128 Cal. Rptr. 881, 547 P.2d 993; Garris v. Carpenter (1939) 33 Cal. App. 2d. 649, 653, 92 P.2d 688. Reference: Insurance Code Sections 1872.5, 1873.2, 1874.2, 1874.4, 1875.20, 1875.21, 1875.24, 1877.3, 1879.5, 12921(a) and 12926. Section 2698.38 Referral Content A referral of an act of suspected insurance fraud to the Fraud Division shall be legible and on a form as directed by the Department and contain the information and data to the extent applicable, as provided in the following: (a) Fraud and referral type (1) Fraud type (2) New referral/amended referral indicator (b) Reporting party information (1) Reporting party type (2) Reporting party name (3) Reporting party California Company number (4) Reporting self-insured/contracted third party license number, as appropriate (5) Reporting party address, city, state and zip code (6) Reporting party email address (generally, contact address) (c) Alleged victim information, as appropriate (1) Alleged victim company name (2) Alleged victim California Company number (3) Alleged victim self-insured number (4) Alleged victim address, city, state and zip code (d) Insurance policy or claim information, as appropriate (1) Claim number associated with referral (2) Insurance policy number associated with referral (3) Date of loss or injury (4) Geographic location where loss or injury occurred (5) Insurance premium dollar loss (6) Total potential loss on claim prior to the identification of fraud (7) Total claim loss paid to date (8) Actual suspected fraudulent loss amount paid to date (9) A complete synopsis of all the facts on which the reasonable belief of the insurance fraud is based. (10) Disaster claim indicator (e) Other agency referral information, as appropriate (1) Names of other authorized governmental agencies receiving this referral (2) Names of any District Attorney’s Office receiving this referral (3) National Insurance Crime Bureau (NICB) referral indicator (4) The names of any other agencies receiving this referral (f) Referral contact information, as appropriate (1) Referral contact name and phone number (2) Claim or case file handler and phone number (3) Name and phone number of person who completed referral (4) Date referral was completed (g) Information for each party associated with the referral (1) Identification of the role of the party to the loss (2) Phone number (3) Address, city, state and zip code (4) Date of birth or age (5) Social security number (6) Tax identification number (7) Drivers license number (8) State of party’s drivers license (9) Vehicle license plate number (10) Vehicle license plate state (11) Vehicle identification number (12) Other names or identifiers used by the party (13) Claim of injury indicator NOTE: Authority: Insurance Code Sections 1872.4, 1874.2, 1875.24, 1877.3, 1879.5, 1879.6; Calfarm Ins. Co. v. Deukmejian (1989) 48 Cal.3d. 805, 824, 258 Cal. Rptr. 161, 771 P.2d 1247; Credit Ins. Gen. Agents Assn. v. Payne (1976) 16 Cal.3d 651, 656, 128 Cal. Rptr. 881, 547 P.2d 993; Garris v. Carpenter (1939) 33 Cal. App. 2d. 649, 653, 92 P.2d 688. Reference: Insurance Code Sections 1875.20, 1875.21, 1875.24, 1877.3, 1879.5, 12921(a) and 12926. Section 2698.39 Anti-Fraud Training Requirements for training provided by and for the SIU shall include: (a) The insurer shall establish and maintain an ongoing anti-fraud training program, planned and conducted to develop and improve the anti-fraud awareness skills of the integral anti-fraud personnel (b) The insurer shall designate an SIU staff person to be responsible for coordinating the ongoing anti-fraud training program. (c) The anti-fraud training program shall consist of three (3) levels: (1) All newly- hired employees shall receive an anti-fraud orientation within ninety (90) days of commencing assigned duties. The orientation shall provide information regarding: (A) the function and purpose of the SIU; (B) an overview of fraud detection and referral of suspected insurance fraud to the SIU for investigation; (C) a review of Fraud Division insurance fraud reporting requirements: (D) an organization chart depicting the insurer’s SIU; and (E) SIU contact telephone numbers. (2) Integral anti-fraud personnel shall receive annual anti-fraud in-service training, which shall include: (A) review of the function and purpose of the SIU; (B) introduction/review of the written procedures established by the SIU regarding the identification, documentation and referral of incidents of suspected fraud to the SIU; (C) identification and recognition of red flags or red flag events; (D) any changes to current procedures for identifying, documenting and referring incidents of suspected insurance fraud to the SIU; (E) Fraud Division insurance fraud reporting requirements; and (F) introduction/review of existing and new, emerging insurance fraud trends. (3) The SIU personnel shall receive continuing anti-fraud training that includes; (A) investigative techniques; (B) communication with the Fraud Division and authorized governmental agencies; (C) fraud indicators; (D) emerging fraud trends; and (E) legal and related issues. (d) Records of the anti-fraud training provided to all staff shall be prepared at the time training is provided and be maintained and available for inspection by the Department on request. The training records shall include the title and date of the anti-fraud training course, name and title and contact information of the instructor(s), description of the course content, length of the training course, and the name and job title(s) of participating personnel. NOTE: Authority: Insurance Code Sections 1875.24, 1879.5, 1879.6; Calfarm Ins. Co. v. Deukmejian (1989) 48 Cal.3d. 805, 824, 258 Cal. Rptr. 161, 771 P.2d 1247; Credit Ins. Gen. Agents Assn. v. Payne (1976) 16 Cal.3d 651, 656, 128 Cal. Rptr. 881, 547 P.2d 993; Garris v. Carpenter (1939) 33 Cal. App. 2d. 649, 653, 92 P.2d 688. Reference: Insurance Code Sections 1875.20, 1875.21, 1875.24, 1879.5, 12921(a) and 12926. Section 2698.40 SIU Annual Report (a) Each insurer shall file a report as prescribed herein, at the time its initial Certificate of Authority is issued, and annually thereafter. The annual report shall be due no later than 90 days after the date of mailing of the notification by the Department. The Department shall issue the notification in June of each year. (b) A complete, accurate and truthful annual report shall be submitted on a form as prescribed by the Department and shall include the following information. (1) The name(s), title(s) and contact information of the insurer’s SIU personnel; or (2) The name of the organization and organizational contacts with whom the insurer has contracted for the maintenance of the SIU or any function thereof; and (3) The names of personnel whose duties include communication with the Fraud Division on matters related to the reporting, investigation and prosecution of suspected fraudulent claims or other suspected insurance fraud. (4) A description of the insurer’s methods and written procedures used for detecting, investigating and reporting suspected insurance fraud. (5) A description of the insurer’s plan for initial and on-going fraud education and training for integral anti-fraud personnel pursuant to these regulations. (6) A written description or chart outlining the organizational arrangement of the insurer’s anti-fraud personnel who are responsible for the investigation and reporting of suspected insurance fraud. (7) A description of how the SIU is adequately staffed to meet the requirements herein and the expertise of the staff. (8) The number of claims processed by the insurer and the number of claims referred to the SIU, for each reported company, for the past calendar year. (9) The number of incidents of suspected insurance fraud reported to the Department and to district attorney offices, for each reported company, for the past calendar year. (10) A description of any significant, anticipated changes to the insurer’s structure and operations. (11) Insurers who enter into contracts for the purpose of compliance with these regulations shall provide a complete copy of the fully executed, existing contract, including all attachments and addendum, to the Department and shall specify the manner in which the contract is monitored. (12) The number and type of civil actions initiated by each reported company alleging acts of insurance fraud during the preceding calendar year. (c) A statement signed under penalty of perjury pursuant to the laws of the state of California, must accompany all reports mentioned herein. This statement must be signed by an officer of the holder of or applicant for the Certificate of Authority who attests to the accuracy of the reported information and the signor’s personal knowledge of the existence and proper maintenance of an SIU described in this report and these regulations. (d) The insurer is to maintain a copy of the annual report that will be available for review during examinations as conducted pursuant to section 2698.41 of these regulations or as otherwise requested by the Department. (e) For the purpose of these regulations, the name(s) of the insurer’s personnel who will communicate with the Fraud Division shall not be made part of the public record and shall be released only pursuant to the provisions of CIC Section 1873.1 applicable to information acquired pursuant to Article 3 of the Insurance Frauds Prevention Act. NOTE: Authority: Insurance Code Sections 1875.24, 1879.5, 1879.6; Calfarm Ins. Co. v. Deukmejian (1989) 48 Cal.3d. 805, 824, 258 Cal. Rptr. 161, 771 P.2d 1247; Credit Ins. Gen. Agents Assn. v. Payne (1976) 16 Cal.3d 651, 656, 128 Cal. Rptr. 881, 547 P.2d 993; Garris v. Carpenter (1939) 33 Cal. App. 2d. 649, 653, 92 P.2d 688. Reference: Insurance Code Sections 1875.20, 1875.21, 1875.24, 1879.5, 12921(a) and 12926. Section 2698.41 Examinations (a) The commissioner may conduct examinations of an insurer’s SIU and related operations, including operations undertaken by entities under contract with the insurer, as deemed necessary to determine compliance with the requirements of this article. (b) A written report of examination, including identification of violations of these applicable provisions of statute and regulation and required corrective action, if any, will be provided to the insurer on completion of the examination. (c)(1) Notwithstanding any penalty imposed pursuant to the regulations, within thirty (30) days of receipt of a written report identifying any violation(s) of these regulations, an insurer shall submit to the Department a plan demonstrating how the insurer will correct such violation(s) and achieve compliance. Such plan shall be subject to examination by the Department. If accepted by the Department, the plan shall be submitted as a supplement to any existing annual report and shall be accompanied by a statement of an officer of the insurer as otherwise required for annual reports. Failure to submit a corrective action and compliance plan or to comply with such plan when accepted by the Department shall be considered a violation of these regulations. (2) Any insurer submitting a written report pursuant to Subsection 2698.41 (c)(1) setting forth a corrective action plan may also submit any of the following information to the Commissioner in conjunction with the report required by Subsection 2698.41 (c)(1): (A) any written material that may rebut any matters contained in the examination report. NOTE: Authority: Insurance Code Sections 730 et. seq, 1875.24, 1879.5, 1879.6; Calfarm Ins. Co. v. Deukmejian (1989) 48 Cal.3d. 805, 824, 258 Cal. Rptr. 161, 771 P.2d 1247; Credit Ins. Gen. Agents Assn. v. Payne (1976) 16 Cal.3d 651, 656, 128 Cal. Rptr. 881, 547 P.2d 993; Garris v. Carpenter (1939) 33 Cal. App. 2d. 649, 653, 92 P.2d 688. Reference: Insurance Code Sections 1875.20, 1875.21, 1875.24, 1879.5, 12921(a) and 12926 . Section 2698.42 Penalties (a) If the Commissioner acts pursuant to the provisions of California Insurance Code Section 1875.24( c) or (d) and finds that the insurer has failed to comply with the provisions of this article, the Commissioner shall impose a monetary penalty in an amount not to exceed $5,000 for each act of non-compliance. Where the Commissioner determines that an insurer has willfully failed to comply with this article, the Commissioner may impose a monetary penalty in an amount not to exceed $ 10,000 for each willful act of non -compliance. The Commissioner shall consider the factors enumerated at California Code of Regulations Title 10 Chapter 5, Subchapter 3,Section 2591.3 (a)-(f) and determine if any of the enumerated factors are applicable to the insurer’s conduct in the establishment and operation of its special investigative unit. If the Commissioner finds such factors are applicable to the insurer’s conduct, the Commissioner may reduce the amount of the monetary penalty prescribed in subsection 2698.42(a). (b) If the Commissioner acts pursuant to the provisions of California Insurance Code Section 1875.24(c) or (d) and determines that the acts of non-compliance are inadvertent and are solely relative to the maintenance and operation of the special investigative unit of the insurer, then the Commissioner shall consider such violations to be a single act for the purposes of imposition of a monetary penalty that is no greater than $5,000 for that single act. For all other inadvertent acts, the Commissioner shall impose a penalty in the amount of up to $5,000 per inadvertent act that is not in compliance with this article. NOTE: Authority: Insurance Code Sections 1875.24, 1879.5, 1879.6; Calfarm Ins. Co. v. Deukmejian (1989) 48 Cal.3d. 805, 824, 258 Cal. Rptr. 161, 771 P.2d 1247; Credit Ins. Gen. Agents Assn. v. Payne (1976) 16 Cal.3d 651, 656, 128 Cal. Rptr. 881, 547 P.2d 993; Garris v. Carpenter (1939) 33 Cal. App. 2d. 649, 653, 92 P.2d 688. Reference: Insurance Code Sections 1875.20, 1875.21, 1875.24, 1879.5, 12921(a) and 12926. Section 2698.43 Hearings (a) Any hearing conducted pursuant to these regulations shall be governed by the provisions of California Government code Section 11425.10(a). (b) The Commissioner shall give 30 days written notice of any hearing held pursuant to these regulations. NOTE: Authority: California Government Code Section 11425.10(a), Insurance Code Sections 1875.24, 1879.5, 1879.6; Calfarm Ins. Co. v. Deukmejian (1989) 48 Cal.3d. 805, 824, 258 Cal. Rptr. 161, 771 P.2d 1247; Credit Ins. Gen. Agents Assn. v. Payne (1976) 16 Cal.3d 651, 656, 128 Cal. Rptr. 881, 547 P.2d 993; Garris v. Carpenter (1939) 33 Cal. App. 2d. 649, 653, 92 P.2d 688. Reference: California Government Code Section 11425.10(a), Insurance Code Sections 1875.20, 1875.21, 1875.24, 1879.5, 12921(a) and 12926 . **State:** California **Requirement Types:** SIU Requirement --- ### [Colorado-Annual Reporting-Section 10-1-127 of the Colorado Revised Statutes as amended by HB 96-1149 Subsection 6 (c)](https://insurancefraud.org/regulations/colorado-annual-reporting-section-10-1-127-of-the-colorado-revised-statutes-as-amended-by-hb-96-1149-subsection-6-c/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Every licensed insurance company doing business in this state shall include as part of its annual report as required in Section 10-3-109 a summary of its anti-fraud efforts as described in paragraph (a) of Subsection (6). \[Deadline for submission is March 1.\] **State:** Colorado **Requirement Types:** Annual Reporting --- ### [Colorado-Fraud Plan-Section 10-1-128](https://insurancefraud.org/regulations/colorado-fraud-plan-section-10-1-128/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (5)(a) Every licensed insurance company doing business in Colorado shall prepare, implement, and maintain an insurance anti-fraud plan; except that this subsection (5) shall not apply to entities whose principal business is the assumption of reinsurance, reinsurance agreements, or reinsurance claims transactions. Insurance companies approved by the commissioner under article 5 of this title may be required, as a condition of such approval, to maintain an insurance anti-fraud plan. Each anti-fraud plan shall outline specific procedures, appropriate to the type of insurance provided by the insurance company in Colorado, to: (I) Prevent, detect, and investigate all forms of insurance fraud, including fraud by the insurance company’s employees and agents, fraud resulting from false representations or omissions of material fact in the application for insurance, renewal documents, or rating of insurance policies, claims fraud, and security of the insurance company’s data processing systems; (II) Educate appropriate employees about fraud detection and the company’s anti-fraud plan; (III) Provide for the hiring of or contracting for one or more fraud investigators; (IV) Report suspected or actual insurance fraud to the appropriate law enforcement and regulatory entities in the investigation and prosecution of insurance fraud. (b) The commissioner of insurance may review a licensed insurance company’s anti-fraud plan in connection with a market conduct examination to determine whether such plan complies with the requirements of paragraph (a) of this subsection (5). (c) Every licensed insurance company doing business in this state shall include, as part of its annual report as required in section 10-3-109, a summary of its anti-fraud efforts as described in paragraph (a) of this subsection (5). (d) The anti-fraud plan of an insurance company and the summary of anti-fraud efforts prepared as required in paragraph (c) of this subsection (5) are not public records and are exempted from article 72 of title 24, C.R.S.; are proprietary and not subject to public examination; and are not discoverable or admissible under the Colorado rules of civil procedure in any civil litigation. **State:** Colorado **Requirement Types:** Fraud Plan --- ### [Colorado-Fraud Warning-Section 10-1-128 (6A)](https://insurancefraud.org/regulations/colorado-fraud-warning-section-10-1-128-6a/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** “It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies.” **State:** Colorado **Requirement Types:** Fraud Warning --- ### [Colorado-Mandatory Reporting-Colorado Revised Statutes 10-4-1003 (as amended by Section 4 of HB 96-1149, enacted April 11, 1996)](https://insurancefraud.org/regulations/colorado-mandatory-reporting-colorado-revised-statutes-10-4-1003-as-amended-by-section-4-of-hb-96-1149-enacted-april-11-1996/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** “Any insurer or person that has reason to believe that … any insurance claim may be fraudulent may furnish and disclose any relevant information in its possession concerning such loss or claim to any authorized agency, as defined in Section 10-4-1002 (1), for the purpose of detecting, prosecuting, or preventing fraudulent insurance claims.” **State:** Colorado **Requirement Types:** Mandatory Reporting --- ### [Colorado-SIU Education-Section 10-1-128](https://insurancefraud.org/regulations/colorado-siu-education-section-10-1-128/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** 5)(a) Every licensed insurance company doing business in Colorado shall prepare, implement, and maintain an insurance anti-fraud plan; except that this subsection (5) shall not apply to entities whose principal business is the assumption of reinsurance, reinsurance agreements, or reinsurance claims transactions. Insurance companies approved by the commissioner under article 5 of this title may be required, as a condition of such approval, to maintain an insurance anti-fraud plan. Each anti-fraud plan shall outline specific procedures, appropriate to the type of insurance provided by the insurance company in Colorado, to: (I) Prevent, detect, and investigate all forms of insurance fraud, including fraud by the insurance company’s employees and agents, fraud resulting from false representations or omissions of material fact in the application for insurance, renewal documents, or rating of insurance policies, claims fraud, and security of the insurance company’s data processing systems; (II) Educate appropriate employees about fraud detection and the company’s anti-fraud plan; **State:** Colorado **Requirement Types:** SIU Education --- ### [Connecticut-Mandatory Reporting-Sec 53-445](https://insurancefraud.org/regulations/connecticut-mandatory-reporting-sec-53-445/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Sec. 53-445. Knowledge of health insurance fraud, report to Insurance Commissioner. Independent investigation conducted. Subject to civil liability, when. (a) Any person, including an insurer, as defined in subsection (c) of section 53-441, who has knowledge of or has reason to believe that health insurance fraud, as defined in section 53-442, has occurred, shall provide notice and any information, evidence and documentation in the person’s or its possession relative to the suspected fraud to the Insurance Commissioner. (b) The commissioner shall review and investigate any reports of or information received by any person regarding insurance fraud; he shall conduct an independent investigation of the suspected insurance fraud; and when he reasonably believes that a violation has occurred, he shall refer such investigation to the appropriate state agency for criminal prosecution, civil enforcement or disciplinary action. During the commissioner’s investigation and prior to the referral of such investigation, the investigation and record thereof shall be confidential. (c) Any person, including an insurer, as defined in subsection (c) of section 53-441, or a not-for-profit organization established to detect and prevent insurance fraud or his or its agents or employees may disclose otherwise personal or privileged information as defined in section 38a-976, orally or in writing to another person concerning any alleged, suspected or anticipated insurance fraud as defined in section 53-442, when such disclosure is limited to that which is reasonably necessary to detect, investigate or prevent criminal activity, fraud, material misrepresentation or material nondisclosure. (d) No person shall be subject to liability for libel, slander or any other civil liability in connection with the filing of reports or documents, or furnishing orally or in writing information concerning any suspected, anticipated or alleged insurance fraud, when the reports, documents or information are provided or received in accordance with the provisions of subsection (a) or (c) of this section or in accordance with an order issued by a court of competent jurisdiction to provide testimony or evidence, unless such person disclosed false information with malice or wilful intent to injure any person. Sec. 53-441. Definitions. As used in sections 53-440 to 53-443, inclusive: (a) “Statement” includes but is not limited to any notice, statement, invoice, account, bill for services, explanation of services, medical opinion, test result, computer generated document, electronic transmission or other evidence of loss, injury or expense; (b) “Person” means any individual, corporation, limited liability company, partnership, association or any other legal entity; (c) “Insurer” means any insurance company, health care center, corporation, Lloyd’s insurer, fraternal benefit society or any other legal entity authorized to provide health care benefits in this state, including benefits provided under health insurance, disability insurance, workers’ compensation and automobile insurance or any person, partnership, association or legal entity which is self-insured and provides health care benefits to its employees or governmental entity which provides medical benefits to Medicare or Medicaid recipients. **State:** Connecticut **Requirement Types:** Mandatory Reporting --- ### [Delaware-Fraud Warning-11 Delaware Code Section 913(b) - Language is permissive](https://insurancefraud.org/regulations/delaware-fraud-warning-11-delaware-code-section-913b-language-is-permissive/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** “Any person who knowingly, and with intent to injure, defraud or deceive any insurer, files a statement of claim containing any false, incomplete or misleading information is guilty of a felony.” The section further states that absences of a warning is not a defense against prosecution. **State:** Delaware **Requirement Types:** Fraud Warning --- ### [Delaware-Fraud Warning-Title 19 Section 2344](https://insurancefraud.org/regulations/delaware-fraud-warning-title-19-section-2344/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** For benefit checks. Your acceptance of this check for total or partial disability is a representation by you that you are legally entitled to such payment and a false representation is punishable under federal and state laws. **State:** Delaware **Requirement Types:** Fraud Warning --- ### [Delaware-Mandatory Reporting-Delaware Insurance Code Section 2408](https://insurancefraud.org/regulations/delaware-mandatory-reporting-delaware-insurance-code-section-2408/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** “Any insurer which has a reasonable belief that an act of insurance fraud is being, or has been, committed shall send to the Bureau, on a form prescribed by the Bureau, any and all information and such additional information relating to such act as the Bureau may require.” **State:** Delaware **Requirement Types:** Mandatory Reporting --- ### [District of Columbia-Annual Reporting-DC Code Sec. 22-3225.01 et seq.](https://insurancefraud.org/regulations/district-of-columbia-annual-reporting-dc-code-sec-22-3225-01-et-seq/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** The DC Insurance Anti-fraud Law and New Amendments may be found on Department’s website at www.disr.dc.gov, as a link under “Information/DC Insurance Anti-fraud Law.” A. Re: Submission of a CY Annual Anti-fraud Statistical Activity Reporting Form – NEW – Amendment, DC Code § 22-3225.12: (1) Current Filing Requirements: The new amendment requires insurers to report annually to the Fraud Bureau of DISR a summary of action taken under their anti-fraud plans to prevent and combat fraud for DC only. (2) DC Revised Form: The annual report should provide detailed information, as prescribed on the reporting form. DC has revised its “DC CY Annual Anti-fraud Statistical Reporting Form,” with Instructions. (Included) (3) Captured Data – Changed from DC’s fiscal year, i.e., October 1st to September 30th: Annual reports under this section should cover anti-fraud activities for each calendar year. Captured data should be cover the period from January 1st through December 31st. (4) Filing Deadline – Changed from December 31st: The reports are to be filed by March 31st of each year and cover previous calendar year’s anti-fraud activities. (5) Submit One (1) Composite Report, Per NAIC Group, as the principal company, send one (1) report, i.e., a compilation of all your companies within your same NAIC group, via line of businesses as shown on the reporting form, if applicable. The reporting form should reflect only the total compilation of statistical numbers under the applicable header column for all Life, Health, P/C, WC, etc. for all of your underwriting companies, i.e., if underwriting company #1 has 2 and underwriting company #2 has 4 cases, please enter the collective or total number of 6 under the respective header column. B. RE: Submission of an Anti-fraud Plan – DC Code § 22-3225.09(a): This provision requires insurers to report to the Fraud Bureau of DISR an anti-fraud plan. If there are any changes to your anti-fraud plan, please submit an updated anti-fraud plan to our office. C. RE: Other Compliance Reporting Forms: If there are changes to your compliance or SIU point of contact persons, please complete and submit an updated “DC POINT OF CONTACT PERSONS FORM” form to our office. Preferably, the form should be your company’s representative responsible for the District of Columbia geographical area. All of the above-mentioned compliance reporting forms, along with DC CYAnnual Anti-fraud Statistical Instructions, may be found on our website, as a link under “Services/Anti-fraud Compliance Reporting Forms.” D. RE: NEW – Reporting Forms of Suspected Insurance Fraud: The DC Code § 22-3225.08(a) provision requires insurers to report action that constitute the commission of insurance fraud to the Fraud Bureau of DISR. Please commence using the newly revised “NAIC Uniform Suspected Insurance Fraud Reporting Form,” when reporting suspicious claims or as part of your submission package for individual investigation cases. Please submit your referral form directly to gregory.marsillo@dc.gov, (202) 442-7826. The above-mentioned reporting form may be found on our website, as a link under “Services/Reporting Insurance and Securities Fraud/Insurer NAIC Uniform Suspected Insurance Fraud Reporting Form.” Please address compliance inquiries or correspondence to the attention: Betty M. Bates, MSIR, CPM DC Fraud Compliance Manager Insurance and Securities Fraud Bureau Department of Insurance and Securities Regulation 810 First Street, NE, Suite 701 Washington, DC 20002 (202) 442-7849 – Office – OR – (202) 535-1194 – Fax – OR – betty.bates@dc.gov – E-mail **State:** District of Columbia **Requirement Types:** Annual Reporting --- ### [District of Columbia-Fraud Plan-Section 22-3225.9 (Section 125I of Enrolled D.C. Act 12-595); Section 125I. Insurance fraud prevention and detection.](https://insurancefraud.org/regulations/district-of-columbia-fraud-plan-section-22-3225-9-section-125i-of-enrolled-d-c-act-12-595-section-125i-insurance-fraud-prevention-and-detection/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Section 22-3225.9 (Section 125I of Enrolled D.C. Act 12-595) Section 125I. Insurance fraud prevention and detection. (a) Within 6 months of the effective date of this act \[October 27, 1999\], every insurer licensed in the District shall submit to the Department of Insurance and Securities Regulation, an insurance fraud prevention and detection plan (“plan”). The plan shall indicate specific procedures for the accomplishment of the following: (1) Prevention, detection, and investigation of insurance fraud; (2) Orientation of employees on insurance fraud prevention and detection; (3) Employment of fraud investigators; (4) Reporting of insurance fraud to the appropriate authorities; and (5) Collection of restitution for financial loss caused by insurance fraud. (b) The Commissioner may review the plan for compliance with this section and may order reasonable modification or request a summary of the plan. The Commissioner may establish by regulation a fine for an insurer failing to comply with the plan. The plan shall not be deemed a public record for the purposes of any public records or Title II of the District of Columbia Administrative Procedure Act, effective March 25, 1977 (D.C. Law 1-96); D.C. Code Sec. 1-1521 et seq.). (c) Notwithstanding any other provisions of law, an insurer who fails to submit an insurance fraud prevention and detection plan, or the warning provision required by subsection (d) of this section shall be subject to a fine of $500 per day, not to exceed $25,000. New Insurers: Within six months of the effective date of the issuance date of your Certificate of Authority, you shall submit to the Department of Insurance and Securities Regulation, an insurance fraud prevention and detection plan. Bulletin 99-FR-001-5/1 Attachment 3 Recommendations for the Development and Application of the D.C. Insurance Fraud Prevention and Detection Plan I. Anti-fraud Plan Components: A. Prevention, Detection, and Investigation: D.C. Code 22-3825.9(a)(1) The anti-fraud plan should contain specific procedures for the prevention, detection and investigation of all areas of insurance fraud. Such procedures should be prepared, published, and maintained to assist your Special Investigation Unit (hereinafter referred to as “SIU”) or your point of contact. B. Orientation and education of employees on insurance fraud prevention and detection: D.C. Code 22-3825.9 (a)(2) The anti-fraud plan should contain specific procedures for an orientation, education, and training program for your employees. It is imperative that your employees have the skills to recognize and investigate all insurance fraud. To increase understanding of insurance fraud, your new and existing employees should undergo an ongoing training program on the multi-dimensional nature of insurance fraud. The program should include a minimum of 2-hour sessions on a continuing education basis. **State:** District of Columbia **Requirement Types:** Fraud Plan --- ### [District of Columbia-Fraud Warning-Section 22-3225.09 (Section 125I (d) of Enrolled D.C. Act 12-595)](https://insurancefraud.org/regulations/district-of-columbia-fraud-warning-section-22-3225-09-section-125i-d-of-enrolled-d-c-act-12-595/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** No later than 6 months after the effective date of this act \[October 27, 1999\], all insurance applications forms and claim forms shall contain a conspicuous warning in language the same or substantially similar to the following: “WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.” **State:** District of Columbia **Requirement Types:** Fraud Warning --- ### [District of Columbia-Mandatory Reporting-Section 22-3825.8 (Section 125h (a) of Enrolled D.C. Act 12-595); Bulletin 99-FR-001-5/1 Attachment 3](https://insurancefraud.org/regulations/district-of-columbia-mandatory-reporting-section-22-3825-8-section-125h-a-of-enrolled-d-c-act-12-595-bulletin-99-fr-001-5-1-attachment-3/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Section 22-3225.8 (Section 125h (a) of Enrolled D.C. Act 12-595) (a) Based upon a reasonable belief, an insurer, insurance professional, and any other pertinent person shall report to the Metropolitan Police Department or the Department of Insurance and Securities Regulation, actions that may constitute the commission of insurance fraud, and assist in the investigation of insurance fraud by reasonably providing information when required by an investigating authority. Bulletin 99-FR-001-5/1 Attachment 3 Recommendations for the Development and Application of the D.C. Insurance Fraud Prevention and Detection Plan D. Reporting of insurance fraud to the appropriate authorities: D.C. Code 22-3825.9(a)(4) The anti-fraud plan shall contain specific procedures for reporting all insurance fraud that you, in good faith, have cause to believe has been or is being committed in the District. Such reporting of insurance fraud must be reported to the Department, Fraud Bureau. In addition, you may report to the appropriate Federal, State or local law enforcement authorities. The anti-fraud plan shall include a provision for ensuring cooperation with the prosecution of all insurance fraud cases in the District. **State:** District of Columbia **Requirement Types:** Mandatory Reporting --- ### [District of Columbia-SIU Education-Bulletin 99-FR-001-5/1 Attachment 3](https://insurancefraud.org/regulations/district-of-columbia-siu-education-bulletin-99-fr-001-5-1-attachment-3/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Bulletin 99-FR-001-5/1 Attachment 3 Recommendations for the Development and Application of the D.C. Insurance Fraud Prevention and Detection Plan I. Anti-fraud Plan Components: A. Prevention, Detection, and Investigation: D.C. Code 22-3825.9(a)(1) The anti-fraud plan should contain specific procedures for the prevention, detection and investigation of all areas of insurance fraud. Such procedures should be prepared, published, and maintained to assist your Special Investigation Unit (hereinafter referred to as “SIU”) or your point of contact. B. Orientation and education of employees on insurance fraud prevention and detection: D.C. Code 22-3825.9 (a)(2) The anti-fraud plan should contain specific procedures for an orientation, education, and training program for your employees. It is imperative that your employees have the skills to recognize and investigate all insurance fraud. To increase understanding of insurance fraud, your new and existing employees should undergo an ongoing training program on the multi-dimensional nature of insurance fraud. The program should include a minimum of 2-hour sessions on a continuing education basis. **State:** District of Columbia **Requirement Types:** SIU Education --- ### [District of Columbia-SIU Requirement-Bulletin 99-FR-001-5/1 Attachment 3](https://insurancefraud.org/regulations/district-of-columbia-siu-requirement-bulletin-99-fr-001-5-1-attachment-3/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Recommendations for the Development and Application of the D.C. Insurance Fraud Prevention and Detection Plan C. Employment of fraud investigators: D.C. Code 22-3825.9 (a)(3) The anti-fraud plan should contain specific procedures for determining who should conduct or oversee such investigations. You should analyze your options to maintain an in-house staff of investigators or contract with an outside firm. **State:** District of Columbia **Requirement Types:** SIU Requirement --- ### [Florida-Annual Reporting-workers comp - Sec 626.9891(6)](https://insurancefraud.org/regulations/florida-annual-reporting-workers-comp-sec-626-98916/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (6) In addition to providing information required under subsections (2), (4), and (5), each insurer writing workers’ compensation insurance shall also report the following information to the department, on or before March 1, 2019, and annually thereafter: (a) The estimated dollar amount of losses attributable to workers’ compensation fraud delineated by the type of fraud, including claimant, employer, provider, agent, or other type. (b) The estimated dollar amount of recoveries attributable to workers’ compensation fraud delineated by the type of fraud, including claimant, employer, provider, agent, or other type. (c) The number of cases referred to the Division of Investigative and Forensic Services, delineated by the type of fraud, including claimant, employer, provider, agent, or other type. **State:** Florida **Requirement Types:** Annual Reporting --- ### [Alabama-Fraud Warning-§ 27-12A-20. Fraud warning.](https://insurancefraud.org/regulations/alabama-fraud-warning-§-27-12a-20-fraud-warning/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** § 27-12A-20. Fraud warning. (a) A fraud warning shall be included on at least one of the following: Claim release forms, applications, reinstatements for insurance, participation agreements, declaration pages, and claim documents, regardless of the method or form of transmission and shall contain the following statement or a substantially similar statement: “Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution, fines, or confinement in prison, or any combination thereof.” (b) The lack of a statement required by subsection (a) shall not constitute a defense in any prosecution for insurance fraud. (c) Policies issued by unauthorized insurers shall contain a statement disclosing the status of the insurer to do business in the state where the policy is delivered or issued for delivery or the state where coverage is in force. (d) Insurers shall comply with subsection (a) not later than February 1, 2013. (e) This section does not require notice to persons insured under existing policies, except to the extent the persons receive, after August 1, 2012, a document listed in subsection (a) which has been selected by the insurer to contain the “Fraud Warning.” (f) None of the requirements of this section shall be deemed to apply to reinsurers, reinsurance contracts, reinsurance agreements, or reinsurance claims transacted. (g) As used in this section, “insurer” refers only to those entities defined in Section 27-12A-1(5) which hold a certificate of authority from the commissioner, and “unauthorized insurers” refers only to those entities operating pursuant to Article 2, beginning with Section 27-10-20, of Chapter 10. **State:** Alabama **Requirement Types:** Fraud Warning --- ### [Alaska-Fraud Warning-Section 21.36.380](https://insurancefraud.org/regulations/alaska-fraud-warning-section-21-36-380/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** A claim form must contain a statement that states in substance the following: “A person who knowingly and with intent to injure, defraud, or deceive an insurance company files a claim containing false, incomplete, or misleading information may be prosecuted under state law.” A lack of the statement on a claim form does not constitute a defense to prosecution under this title. **State:** Alaska **Requirement Types:** Fraud Warning --- ### [Alaska-Mandatory Reporting-Sec. 21.36.390](https://insurancefraud.org/regulations/alaska-mandatory-reporting-sec-21-36-390/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) An insurer that has reason to believe that a fraudulent claim has been made against it shall send the director a report disclosing information that the director may require. (b) An insurer, employee, or agent of an insurer or another person acting without malice is not subject to civil liability for the filing of the report or furnishing other information required by this section or by the director. (c) The director shall investigate facts reported under this section and shall refer facts indicating a violation of law to the appropriate prosecutor. **State:** Alaska **Requirement Types:** Mandatory Reporting --- ### [Arizona-Fraud Warning-Revised Statutes Section 20-466.03](https://insurancefraud.org/regulations/arizona-fraud-warning-revised-statutes-section-20-466-03/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** The claims forms provided by an insurer to an insured or any other person for filing a notice or making a claim in connection with a policy or contract issued by the insurer shall include in substance the following statement in at least twelve point type: “For your protection Arizona law requires the following statement to appear on this form, any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties.” For the purposes of this section, “claims form” means any document supplied by an insurer to an insured, claimant or other person that the insured, claimant or other person is required to complete and submit in support of a claim for benefits. **State:** Arizona **Requirement Types:** Fraud Warning --- ### [Arizona-Mandatory Reporting-Arizona Revised Statutes Section 20-466 (A-K)](https://insurancefraud.org/regulations/arizona-mandatory-reporting-arizona-revised-statutes-section-20-466-a-k/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Fraud unit; peace officer status; powers; information sharing duty of insurers A. A fraud unit is established in the department of insurance. B. The fraud unit shall work in conjunction with the department of public safety. C. The director may investigate any act or practice of fraud prohibited by section 20-466.01 and any other act or practice of fraud against an insurer or entity licensed under this title. The director shall administer the fraud unit. D. The director may employ investigators for the fraud unit. A fraud unit investigator has and shall exercise the law enforcement powers of a peace officer of this state but only while acting in the course and scope of employment for the department. The director shall adopt guidelines for the conduct of investigations that are substantially similar to the investigative policy and procedural guidelines of the department of public safety for peace officers. Fraud unit investigators shall not preempt the authority and jurisdiction of other law enforcement agencies of this state or its political subdivisions. Fraud unit investigators: 1. Shall have at least the qualifications prescribed by the Arizona peace officer standards and training board pursuant to section 41-1822. 2. Are not eligible to participate in the public safety personnel retirement system established by title 38, chapter 5, article 4 due solely to employment as fraud unit investigators. E. The director may request the submission of papers, documents, reports or other evidence relating to an investigation under this section. The director may issue subpoenas and take other actions pursuant to section 20-160. The materials are privileged and confidential until the director completes the investigation. Any documents, materials or other information that is provided to the director pursuant to this section is not subject to discovery or subpoena until opened for public inspection by the director or, after notice and a hearing, a court determines that the director would not be unduly burdened by compliance with the subpoena. The director shall keep the identity of an informant confidential, including any information that might identify the informant, unless the request for information is made by a law enforcement agency, the attorney general or a county attorney for purposes of a criminal investigation or prosecution. The director may use the documents, materials or other information in the furtherance of any regulatory or legal action brought as a part of the director’s official duties. F. If the documents, materials or other information the director seeks to obtain by request is located outside this state, the person requested to provide the documents, materials or other information shall arrange for the fraud unit or a representative, including an official of the state in which the documents, materials or other information is located, to examine the documents, materials or other information where it is located. The director may respond to similar requests from other states. G. An insurer that believes a fraudulent claim has been or is being made shall send to the director, on a form prescribed by the director, information relative to the claim including the identity of parties claiming loss or damage as a result of an accident and any other information the fraud unit may require. The director shall review the report and determine if further investigation is necessary. If the director determines that further investigation is necessary, the director may conduct an independent investigation to determine if fraud, deceit or intentional misrepresentation in the submission of the claim exists. If the director is satisfied that fraud, deceit or intentional misrepresentation of any kind has been committed in the submission of a claim, the director may report the violations of the law to the reporting insurer, to the appropriate licensing agency as defined in section 20-466.04 and to the appropriate county attorney or the attorney general for prosecution. H. The director may: 1. Share nonpublic documents, materials or other information with other state, federal and international regulatory agencies, with the national association of insurance commissioners and its affiliates and subsidiaries and with state, federal and international law enforcement authorities if the recipient agrees and warrants that it has the authority to maintain the confidentiality and privileged status of the documents, materials or other information. 2. Receive documents, materials and other information from the national association of insurance commissioners and its affiliates and subsidiaries and from regulatory and law enforcement officials of other jurisdictions and shall maintain as confidential or privileged any document, material or other information received with notice or the understanding that it is confidential or privileged under the laws of the jurisdiction that is the source of the document, material or other information. 3. Enter into agreements that govern the sharing and use of documents, materials and other information and that are consistent with this section. I. A disclosure to or by the director pursuant to this section or as a result of sharing information pursuant to subsection G of this section is not a waiver of any applicable privilege or claim of confidentiality in the documents, materials or other information disclosed or shared. J. The director shall annually assess each insurer as defined in section 20-441, subsection B authorized to transact business in this state up to one thousand fifty dollars, as annually adjusted pursuant to this subsection for the administration and operation of the fraud unit and the prosecution of fraud pursuant to this section. Monies collected shall be deposited, pursuant to sections 35-146 and 35-147, in the state general fund. The director shall annually revise the assessment amount in such a manner that the revenue derived from the assessment equals at least ninety-five per cent but not more than one hundred ten per cent of the appropriated budget of the fraud unit for the prior fiscal year. K. A person, or an officer, employee or agent of the person acting within the scope of employment or agency of that officer, employee or agent, who in good faith files a report or provides other information to the fraud unit pursuant to this section is not subject to civil or criminal liability for reporting that information to the fraud unit. **State:** Arizona **Requirement Types:** Mandatory Reporting --- ### [Arkansas-Fraud Plan-Sec. 6 Antifraud initiative requirements; Sec. 7. Fraud Investigators and independent contractors](https://insurancefraud.org/regulations/arkansas-fraud-plan-sec-6-antifraud-initiative-requirements-sec-7-fraud-investigators-and-independent-contractors/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Sec. 6 Antifraud initiative requirements The antifraud initiative requirements of Arkansas Code Annotated Sec. 23-66-510(a) may be satisfied by an insurer by means of: (1) Fraud investigators, who may be insurer employees or independent contractors and who are in full compliance with Section (7) of this rule; or (2) An antifraud plan submitted to, and approved by, the commissioner, and which is in full compliance with Section (8) of this rule; or (3) An alternative antifraud initiative submitted to, and approved by, the commissioner, under the provisions of Arkansas Code Annotated Sec. 23-66-510(a); or (4) An exemption from the antifraud initiative requirements granted by the commissioner pursuant to Arkansas Code Annotated Sec. 23-66-510(b). Sec. 7. Fraud Investigators and independent contractors A. Fraud investigators who are employees of an insurer: (1) shall be qualified by education, experience or training in the detection, investigation and proper reporting of suspected fraudulent insurance acts, and may be employees whose principal responsibilities are the processing and disposition of claims, if they meet the qualification requirements herein stated; and (2) shall complete a minimum of three (3) hours of continuing education annually in the detection, investigation and proper reporting of suspected fraudulent insurance acts. The specific curriculum, location and certification of said continuing education courses are not mandated but shall be consistent with industry standards for continuing education for insurance fraud investigators. **State:** Arkansas **Requirement Types:** Fraud Plan --- ### [Arkansas-Fraud Plan-Section 23-66-510](https://insurancefraud.org/regulations/arkansas-fraud-plan-section-23-66-510/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) Insurers shall have antifraud initiatives reasonably calculated to detect, prosecute and prevent fraudulent insurance acts. Antifraud initiatives may include, but not limited to: (1) Fraud investigators, who may insurer employees or independent contractors; or (2) An antifraud plan submitted to the commissioner. Antifraud plans submitted to the commissioner shall be privileged and confidential and shall not be a public record and shall not be subject to discovery or subpoena in a civil or criminal action. (b) Upon the written request of an insurer, the commissioner may grant an exemption from the requirements of this section if he determines that such an exemption would not be detrimental to the interests of the public. **State:** Arkansas **Requirement Types:** Fraud Plan --- ### [Arkansas-Fraud Warning-Insurance Department Directive 1-95](https://insurancefraud.org/regulations/arkansas-fraud-warning-insurance-department-directive-1-95/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** For benefit checks. This check is for workers’ compensation related benefits. You must advise both the employer and (name of insurance company) of any other income received or earned, including from self-employment, while receiving these benefits. Failure to do so may result in civil and/or criminal liability. **State:** Arkansas **Requirement Types:** Fraud Warning --- ### [Arkansas-Fraud Warning-Section 11-9-106(a)(1), (b) - Language is mandatory](https://insurancefraud.org/regulations/arkansas-fraud-warning-section-11-9-106a1-b-language-is-mandatory/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** “Any person or entity who willfully and knowingly makes any material false statement or representation for the purpose of obtaining any benefit or payment, or for the purpose of defeating or wrongfully decreasing any claim for benefit or payment or obtaining or avoiding workers compensation coverage or avoiding payment of the proper insurance premium, or who aids and abets for either of said purposes, under this chapter shall be guilty of a Class D felony.” **State:** Arkansas **Requirement Types:** Fraud Warning --- ### [Arkansas-Fraud Warning-Section 23-66-503](https://insurancefraud.org/regulations/arkansas-fraud-warning-section-23-66-503/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) Claim forms, proofs of loss, or any similar documents, however designated, seeking payment or benefit pursuant to an insurance policy, and applications for insurance, regardless of the form of transmission, shall contain the following statement or a substantially similar statement: Any person who knowingly presents a false or fraudulent claim for payment for a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. (b) The lack of a statement as required in subsection (a) of this section does not constitute a defense in any prosecution for a fraudulent insurance act. (c) Policies issued by unauthorized insurers shall contain a statement disclosing the status of the insurer to do business in the state where the policy is delivered or issued for delivery or the state where coverage is in force. (d) All persons to whom this section applies shall have six (6) months from the effective date of this section to comply with the requirements thereof. (e) The requirements of this section shall not apply to reinsurance proofs of loss or applications. **State:** Arkansas **Requirement Types:** Fraud Warning --- ### [Arkansas-Mandatory Reporting-Arkansas Code Sec. 11-9-106(d)(6)](https://insurancefraud.org/regulations/arkansas-mandatory-reporting-arkansas-code-sec-11-9-106d6/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** For workers compensation only. (a) Every carrier or employer who has “reason to suspect that a violation of … has occurred shall be required to report all pertinent matters relating thereto to the Workers Compensation Fraud Investigation Unit.” (b) “No such carrier shall be liable to any employer or employee for any such report, and no employer shall be liable to any employee for such report unless they knowingly and intentionally include false information.” (c) “Any such carrier or employer who knowingly and intentionally fails to report any such violation shall be guilty of a misdemeanor and upon conviction … punished by a fine not to exceed … $1,000 or … imprisonment … not to exceed one (1) year….” **State:** Arkansas **Requirement Types:** Mandatory Reporting --- ### [Arkansas-Mandatory Reporting-Section 23-66-505; Reporting of Fraudulent Insurance Acts — Regulation 67;Sec. 6 Method of reporting suspected fraudulent insurance acts](https://insurancefraud.org/regulations/arkansas-mandatory-reporting-section-23-66-505-reporting-of-fraudulent-insurance-acts-regulation-67sec-6-method-of-reporting-suspected-fraudulent-insurance-acts/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Section 23-66-505 (a) A person engaged in the business of insurance having knowledge or a reasonable belief that a fraudulent insurance act is being, will be, or has been committed shall provide to the commissioner the information required by, and in a manner prescribed by, the commissioner. (b) Any person engaged in the business of insurance who knowingly fails to report as required by subsection (a) of this section shall be guilty of a misdemeanor and upon conviction shall be punished by a fine not to exceed one thousand dollars ($1,000) or by imprisonment for a period not to exceed one (1) year, or by both fine and imprisonment. (c) Any other person having knowledge or reasonable belief that a fraudulent insurance act is being, will be, or has been committed may provide the commissioner the information required by, and in a manner prescribed by, the commissioner. Reporting of Fraudulent Insurance Acts — Regulation 67 Sec. 6 Method of reporting suspected fraudulent insurance acts (a) The reporting requirement of Arkansas Code Annotated Sec. 23-66-505(a) may be satisfied by filing a completed fraud referral form with the Insurance Fraud Investigation Division of the Arkansas Insurance Department. The form shall be as prescribed by the commissioner and may be obtained from the Insurance Fraud Investigation Division. (b) A reporting form containing substantially similar language and providing all the information requested in the fraud referral form prescribed by the commissioner may be used, if previously approved by the commissioner. **State:** Arkansas **Requirement Types:** Mandatory Reporting --- ### [Arkansas-SIU Education-Sec. 6 Antifraud initiative requirements; Sec. 7. Fraud Investigators and independent contractors](https://insurancefraud.org/regulations/arkansas-siu-education-sec-6-antifraud-initiative-requirements-sec-7-fraud-investigators-and-independent-contractors/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Sec. 7. Fraud Investigators and independent contractors A. Fraud investigators who are employees of an insurer: (1) shall be qualified by education, experience or training in the detection, investigation and proper reporting of suspected fraudulent insurance acts, and may be employees whose principal responsibilities are the processing and disposition of claims, if they meet the qualification requirements herein stated; and (2) shall complete a minimum of three (3) hours of continuing education annually in the detection, investigation and proper reporting of suspected fraudulent insurance acts. The specific curriculum, location and certification of said continuing education courses are not mandated but shall be consistent with industry standards for continuing education for insurance fraud investigators. **State:** Arkansas **Requirement Types:** SIU Education --- ### [Arkansas-SIU Requirement-Sec. 6 Antifraud initiative requirements; Sec. 7. Fraud Investigators and independent contractors](https://insurancefraud.org/regulations/arkansas-siu-requirement-sec-6-antifraud-initiative-requirements-sec-7-fraud-investigators-and-independent-contractors/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Sec. 6 Antifraud initiative requirements The antifraud initiative requirements of Arkansas Code Annotated Sec. 23-66-510(a) may be satisfied by an insurer by means of: (1) Fraud investigators, who may be insurer employees or independent contractors and who are in full compliance with Section (7) of this rule; or (2) An antifraud plan submitted to, and approved by, the commissioner, and which is in full compliance with Section (8) of this rule; or (3) An alternative antifraud initiative submitted to, and approved by, the commissioner, under the provisions of Arkansas Code Annotated Sec. 23-66-510(a); or (4) An exemption from the antifraud initiative requirements granted by the commissioner pursuant to Arkansas Code Annotated Sec. 23-66-510(b). Sec. 7. Fraud Investigators and independent contractors A. Fraud investigators who are employees of an insurer: (1) shall be qualified by education, experience or training in the detection, investigation and proper reporting of suspected fraudulent insurance acts, and may be employees whose principal responsibilities are the processing and disposition of claims, if they meet the qualification requirements herein stated; and (2) shall complete a minimum of three (3) hours of continuing education annually in the detection, investigation and proper reporting of suspected fraudulent insurance acts. The specific curriculum, location and certification of said continuing education courses are not mandated but shall be consistent with industry standards for continuing education for insurance fraud investigators. **State:** Arkansas **Requirement Types:** SIU Requirement --- ### [California-Fraud Plan-California Code of Regulations: Section 2698.40 SIU Annual Report](https://insurancefraud.org/regulations/california-fraud-plan-california-code-of-regulations-section-2698-40-siu-annual-report/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** California Code of Regulations: Section 2698.40 SIU Annual Report 10 CCR § 2698.40 SIU Annual Report. (a) Each insurer shall file a report as prescribed herein, at the time its initial Certificate of Authority is issued, and annually thereafter. The annual report shall be due no later than 90 days after the date of mailing of the notification by the Department. The Department shall issue the notification in June of each year. (b) A complete, accurate and truthful annual report shall be submitted on a form as prescribed by the Department and shall include the following information. (1) The name(s), title(s) and contact information of the insurer’s SIU personnel; or (2) The name of the organization and organizational contacts with whom the insurer has contracted for the maintenance of the SIU or any function thereof; and (3) The names of personnel whose duties include communication with the Fraud Division on matters related to the reporting, investigation and prosecution of suspected fraudulent claims or other suspected insurance fraud. (4) A description of the insurer’s methods and written procedures used for detecting, investigating and reporting suspected insurance fraud. (5) A description of the insurer’s plan for initial and on-going fraud education and training for integral anti-fraud personnel pursuant to these regulations. (6) A written description or chart outlining the organizational arrangement of the insurer’s anti-fraud personnel who are responsible for the investigation and reporting of suspected insurance fraud. (7) A description of how the SIU is adequately staffed to meet the requirements herein and the expertise of the staff. (8) The number of claims processed by the insurer and the number of claims referred to the SIU, for each reported company, for the past calendar year. (9) The number of incidents of suspected insurance fraud reported to the Department and to district attorney offices, for each reported company, for the past calendar year. (10) A description of any significant, anticipated changes to the insurer’s structure and operations. (11) Insurers who enter into contracts for the purpose of compliance with these regulations shall provide a complete copy of the fully executed, existing contract, including all attachments and addendum, to the Department and shall specify the manner in which the contract is monitored. (12) The number and type of civil actions initiated by each reported company alleging acts of insurance fraud during the preceding calendar year. (c) A statement signed under penalty of perjury pursuant to the laws of the state of California, must accompany all reports mentioned herein. This statement must be signed by an officer of the holder of or applicant for the Certificate of Authority who attests to the accuracy of the reported information and the signor’s personal knowledge of the existence and proper maintenance of an SIU described in this report and these regulations. (d) The insurer is to maintain a copy of the annual report that will be available for review during examinations as conducted pursuant to section 2698.41 of these regulations or as otherwise requested by the Department. (e) For the purpose of these regulations, the name(s) of the insurer’s personnel who will communicate with the Fraud Division shall not be made part of the public record and shall be released only pursuant to the provisions of CIC Section 1873.1 applicable to information acquired pursuant to Article 3 of the Insurance Frauds Prevention Act. Note: Authority cited: Sections 1875.24, 1879.5 and 1879.6, Insurance Code; Calfarm Ins. Co. v. Deukmejian(1989) 48 Cal.3d. 805, 824, 258 Cal. Rptr. 161, 771 P.2d 1247; Credit Ins. Gen. Agents Assn. v. Payne(1976) 16 Cal.3d 651, 656, 128 Cal. Rptr. 881, 547 P.2d 993; and Garris v. Carpenter(1939) 33 Cal. App. 2d. 649, 653, 92 P.2d 688. Reference: Sections 1875.20, 1875.21, 1875.24, 1879.5, 12921(a) and 12926, Insurance Code. **State:** California **Requirement Types:** Fraud Plan --- ### [California-Fraud Warning-All Claim Forms - Sec. 1871.2-.3;All Claim Forms regarding theft of insured vehicles - Sec. 1871.2-3;All Workers Compensation claim forms - Sec. 5401.7](https://insurancefraud.org/regulations/california-fraud-warning-all-claim-forms-sec-1871-2-3all-claim-forms-regarding-theft-of-insured-vehicles-sec-1871-2-3all-workers-compensation-claim-forms-sec-5401-7/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Insurance Code – Sec. 1871.2 – Language is mandatory “For your protection California law requires the following to appear on this form: Any person who knowingly presents false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.” Insurance Code – Section 1871.3 – Language is permissive Claim form warnings for automobile thefts must contain that false representations will subject the insured to a penalty or perjury. Labor Code – Section 5401.7 – Language is mandatory “Any person who makes or causes to be made any knowingly false or fraudulent material statement or material misrepresentation for the purpose of obtaining or denying workers compensation benefits or payments is guilty of a felony.” Voluntary on or with check for temporary disability benefits “Acceptance of employment with a different employer that requires the performance of activities that you have stated that you cannot perform because of the injury for which you are receiving temporary disability benefits could constitute fraud and could result in criminal prosecution. If convicted, you could lose your rights to workers’ compensation benefits and face imprisonment for up to five years and a fine of up to fifty thousand dollars ($50,000) or double the amount of the fraud, whichever is greater.” **State:** California **Requirement Types:** Fraud Warning --- ### [California-Pre-insurance Inspection-California Insurance Code Section 400](https://insurancefraud.org/regulations/california-pre-insurance-inspection-california-insurance-code-section-400/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** \[repealed effective 1/1/99\] Photograph required — Yes Grace Period (days) — 7 Exemptions/Waivers: Existing Policyholder (years) — 3 Renewal Policy — Yes New Cars — Yes Vehicle Age — 7 **State:** California --- ## Statutes ### [State Antifraud Law Profile: Arizona](https://insurancefraud.org/statutes/state-antifraud-law-profile-arizona/) **Published:** October 13, 2026 **Author:** Brent Walker **Content:** **INSURANCE FRAUD STATUTES** --- **Insurance Fraud Bureau (IFB):**[Arizona Department of Insurance and Financial Institutions, Insurance Fraud Unit](https://difi.az.gov/consumers/insurance-fraud) **Primary Prosecutor:** Attorney General, District Attorney, Federal Prosecutor, County Prosecutor **Insurance Fraud Statute:** Arizona Revised Statutes, [Title 20 Insurance, Transaction Of Insurance Business Article 6, Unfair Practices And Frauds](https://www.azleg.gov/Ars/20/00463.Htm) **ANTIFRAUD COMPLIANCE** --- **SIU Required:** None **Fraud Plan Required:** None **Annual Fraud Report:** None **Mandatory Reporting:** [ARS 20-466.G](https://www.azleg.gov/ars/20/00466.htm) **Immunity:** [ARS 20-463.B](https://www.azleg.gov/ars/20/00463.htm) **State:** Arizona **Statute Areas:** State Insurance Antifraud Laws & Regulations --- ### [State Antifraud Law Profile: Alaska](https://insurancefraud.org/statutes/state-antifraud-law-profile-alaska/) **Published:** October 13, 2026 **Author:** Brent Walker **Content:** **INSURANCE FRAUD STATUTES** --- **Insurance Fraud Bureau (IFB):**[Alaska Division of Insurance, Fraud Unit](https://www.commerce.alaska.gov/web/ins/Resources/Fraud) **Primary Prosecutor:** Attorney General, District Attorney, Federal Prosecutor, County Prosecutor **Insurance Fraud Statute:** Alaska Statutes, [Title 21. Insurance, Chapter 36.](https://www.akleg.gov/Basis/Statutes.Asp#21.36.360) Trade Practices And Frauds, Article 4. Fraud, Crimes, And Investigations. **ANTIFRAUD COMPLIANCE** --- **SIU Required:** None **Fraud Plan Required:** None **Annual Fraud Report:** None **Mandatory Reporting:** Alaska Statute [21.36.390](https://www.akleg.gov/basis/statutes.asp#21.36.390) **Immunity:** Alaska Statute 21.36.365 and Alaska Statute [21.36.390](https://www.akleg.gov/basis/statutes.asp#21.36.390) (c) **State:** Alaska **Statute Areas:** State Insurance Antifraud Laws & Regulations --- ### [Georgia-Fraud Bureau-Ga. Code Ann., ¤ 33-1-17](https://insurancefraud.org/statutes/georgia-fraud-bureau-ga-code-ann-¤-33-1-17/) **Published:** July 21, 2020 **Author:** Brent Walker **Content:** (a) The General Assembly finds that the proper and expeditious investigation and prosecution of fraudulent insurance acts are beneficial to the public interest. The General Assembly further finds that proper investigation of fraudulent insurance acts, followed by vigorous prosecution of insurance fraud, will bring about lower insurance rates for the citizens of this state. (b) There is created a Special Insurance Fraud Fund for the purpose of funding the investigation and prosecution of insurance fraud. (c)(1) The Commissioner shall prepare, on an annual basis, a separate budget request to the General Assembly which sets forth the anticipated cost and expense of funding the investigation and prosecution of insurance fraud in this state for the ensuing 12 months. Beginning with the year 1997, such budget request shall set forth the annual cost and expense of the investigation and prosecution of insurance fraud in Georgia for the preceding 12 months. (2) There is imposed upon each foreign, alien, and domestic insurance company doing business in the state an annual assessment under a formula to be established by regulation promulgated by the Commissioner. The formula shall be calculated such that the total proceeds paid or collected from such assessments for any year shall not exceed the amounts appropriated by the General Assembly pursuant to paragraph (3) of this subsection, which appropriation shall be based upon the budget request setting forth the applicable annual cost and expense of the investigation and prosecution of insurance fraud in Georgia submitted by the Commissioner. Such assessments may be measured by kind of company, kind of insurance, income, volume of transactions, or such other factors as the Commissioner determines appropriate. Assessments shall be due and payable for each calendar quarter at the times specified in subsection (b) of Code Section 33-8-6. Any insurance company which fails to report and pay any installment of such assessment shall be subject to penalties and interest as provided by subsection (d) of Code Section 33-8-6. The Commissioner shall provide by regulation for such other terms and conditions for the payment or collection of such assessments as may be necessary to ensure the proper payment and collection thereof. (3) The General Assembly may appropriate to the Insurance Department funds for the investigation of insurance fraud and for the funding of the prosecution of insurance fraud. The Commissioner is authorized to use such funds for investigation of insurance fraud and to reimburse prosecuting attorneys for some or all of the costs of retaining assistant prosecuting attorneys to prosecute insurance fraud cases. The Commissioner shall provide by regulation for such other terms and conditions for the use of the funds for the investigation, reimbursement, and prosecution contemplated by the terms of this paragraph. (d) Insurers shall make personnel involved in investigating insurance fraud and any files relating to insurance fraud investigation available to the Commissioner, the Attorney General, local prosecuting officials, special prosecuting attorneys, or other law enforcement agencies as needed in order to further the investigation and prosecution of insurance fraud. Information supplied by an insurer and contained in such files shall upon receipt become part of the investigative file and subject to the provisions of Code Section 50-18-72. The insurer and its employees and agents shall be entitled to immunity as provided in Code Section 33-1-16. (e) Any expenses incurred by insurers as a result of this Code section shall be defrayed by such insurers from their own funds and shall not be borne by the state or by the Special Insurance Fraud Fund. See also https://rules.sos.ga.gov/gac/120-2-72. **State:** Georgia **Statute Areas:** Fraud Bureau --- ### [Arkansas - Anti-Runner Provisions - AR Code § 5-37-506](https://insurancefraud.org/statutes/arkansas-anti-runner-provisions-ar-code-§-5-37-506/) **Published:** June 21, 2023 **Author:** Coalition Against Insurance Fraud **Content:** 2018 Arkansas Code Title 5 – Criminal Offenses Subtitle 4 – Offenses Against Property Chapter 37 – Forgery and Fraudulent Practices Subchapter 5 – Business and Commercial Offenses Generally § 5-37-506. Prohibited activity by a procurer or provider **Universal Citation:** [AR Code § 5-37-506 (2018)](https://law.justia.com/citations.html) - (a) A person commits the offense of prohibited activity by a procurer or provider if: - (1) The person is a procurer and he or she knowingly: - (A) Offers or gives anything of value to a person in order to cause the person to seek medical care from a specific healthcare provider; or - (B) Solicits a person currently under the care of a chiropractic physician to seek care from another chiropractic physician; or - (2) The person is a provider and he or she knowingly permits a procurer that he or she uses, directs, or employs to engage in conduct prohibited by subdivision (a)(1) of this section. - (b) Prohibited activity by a procurer or provider is a Class D felony. **State:** Arkansas **Statute Areas:** Anti-Runner Provisions --- ### [California – Staged Accidents - CA PENAL s 550](https://insurancefraud.org/statutes/california-ca-penal-s-550/) **Published:** March 14, 2022 **Author:** Coalition Against Insurance Fraud **Content:** **§ 550. False or fraudulent claims or statements; prohibited acts** (a) It is unlawful to do any of the following, or to aid, abet, solicit, or conspire with any person to do any of the following: (3) Knowingly cause or participate in a vehicular collision, or any other vehicular accident, for the purpose of presenting any false or fraudulent claim. (c)(1) Every person who violates paragraph (1), (2), (3), (4), or (5) of subdivision (a) is guilty of a felony punishable by imprisonment [pursuant to subdivision (h) of Section 1170](https://signon.thomsonreuters.com/?productid=CBT&lr=0&culture=en-US&returnto=https%3a%2f%2f1.next.westlaw.com%2fCosi%2fSignOn%3fredirectTo%3d%252fLink%252fDocument%252fFullText%253ffindType%253dL%2526pubNum%253d1000217%2526cite%253dCAPES1170%2526originatingDoc%253dN956C880065EC11E0A3B6F8F5D7ACF878%2526refType%253dSP%2526originationContext%253ddocument%2526transitionType%253dDocumentItem%2526ppcid%253d8ff8b47d3948449e87a9bf7b9b2ebfa3%2526contextData%253d(sc.Search)%2526firstPage%253dtrue&tracetoken=03222213304002qpsGL7jPxqt_vsHTBjVgaDIHSLcUia39fpY9obsaDLi6IkxUaLriX5V9e0sbZgMZN-0qJ-aj21uoZKrsb5Xv34J3eKeS3yFlLK8663abNigwKDivKbah2g9QxRgxz1j-PH-C5lB-J2Cav7TNtKEgAY1vEQ38IIBJmbenUIm0eMGDS8cVVQUWfTu9MS4ptOZcvEdp9L5QONefoa9nsq947a982tK_P1xuvLGKQWAyxnpjhtOFZaLWemlL7TqcjSWEkH78hFFtOiLr15zF2R6um0EAwHf_1-WkKV_lggZUmcgeNtuSzdE1k79od9p27wsdAe7ryaEoMe8xCheXCd3xhsYrolgyxjtJPlGLi9SPbF_pt1niP9_pOtBeRieS1O4&bhcp=1&bhhash=1#co_pp_f383000077b35) for two, three, or five years, and by a fine not exceeding fifty thousand dollars ($50,000), or double the amount of the fraud, whichever is greater. **State:** California **Statute Areas:** Staged Accidents --- ### [New York - Staged Accidents - CLS Penal § 176.75](https://insurancefraud.org/statutes/new-york-staged-accidents-cls-penal-§-176-75/) **Published:** March 14, 2022 **Author:** Coalition Against Insurance Fraud **Content:** § 176.75. **Staging** a motor vehicle **accident** in the second degree. A person is guilty of **staging** a motor vehicle **accident** in the second degree when, with intent to commit and in furtherance of a fraudulent insurance act, he or she operates a motor vehicle and intentionally causes a collision involving a motor vehicle. **Staging** a motor vehicle **accident** in the second degree is a class E felony. **State:** New York **Statute Areas:** Staged Accidents --- ### [New York - Staged Accidents - CLS Penal § 176.80](https://insurancefraud.org/statutes/new-york-staged-accidents-cls-penal-§-176-80/) **Published:** March 14, 2022 **Author:** Coalition Against Insurance Fraud **Content:** § 176.80. **Staging** a motor vehicle **accident** in the first degree. A person is guilty of **staging** a motor vehicle **accident** in the first degree when he or she commits the offense of **staging** a motor vehicle **accident** in the second degree and thereby causes serious physical injury or death to another person, other than a participant in such offense. **Staging** a motor vehicle **accident** in the first degree is a class D felony. **State:** New York **Statute Areas:** Staged Accidents --- ### [Louisiana – Staged Accidents - LA R.S. 14:68.4.2 ](https://insurancefraud.org/statutes/louisiana-staged-accidents-la-r-s-1468-4-2/) **Published:** March 14, 2022 **Author:** Coalition Against Insurance Fraud **Content:** **§ 68.4.2. Aggravated staging of a motor vehicle collision** A. Aggravated staging of a motor vehicle collision is the staging of a motor vehicle collision, as defined in R.S. 14:68.4.1, which causes death or serious bodily injury to another person. B. Whoever commits the crime of aggravated staging of a motor vehicle collision shall be imprisoned, with or without hard labor, for not less than five years nor more than thirty years, fined not more than fifteen thousand dollars, or both. **State:** Louisiana **Statute Areas:** Staged Accidents --- ### [Louisiana – Staged Accidents - LA R.S. 14:68.4.1 ](https://insurancefraud.org/statutes/louisiana-staged-accidents-la-r-s-1468-4-1-and-la-r-s-1468-4-2/) **Published:** March 14, 2022 **Author:** Coalition Against Insurance Fraud **Content:** **§ 68.4.1. Staging of a motor vehicle collision** A. Staging of a motor vehicle collision is any of the following with an intent to defraud: (1) Causing a motor vehicle collision for the purpose of obtaining anything of value. (2) Providing information in connection with a motor vehicle collision, knowing that the collision was intentionally caused, for the purpose of obtaining anything of value. (3) Providing false information in connection with a motor vehicle collision that did not occur for the purpose of obtaining anything of value. B. Whoever commits the crime of staging of a motor vehicle collision shall be imprisoned, with or without hard labor, for not more than five years, fined not more than five thousand dollars, or both. **State:** Louisiana **Statute Areas:** Staged Accidents --- ### [Georgia – Staged Accidents - GA ST s 33-1.91](https://insurancefraud.org/statutes/georgia-staged-accidents-ga-st-s-33-1-91/) **Published:** March 14, 2022 **Author:** Coalition Against Insurance Fraud **Content:** **§ 33-1-9.1. Staging a collision; fraudulent claims** (a) A person shall be guilty of the crime of staging a collision when, with intent to commit insurance fraud as defined in [Code Section 33-1-9](https://1.next.westlaw.com/Link/Document/FullText?findType=L&pubNum=1000468&cite=GAST33-1-9&originatingDoc=N5362C020C43A11EBB976D40C53E8D6D0&refType=LQ&originationContext=document&transitionType=DocumentItem&ppcid=a13aa233d222468f9008ccbabb13eb4e&contextData=(sc.DocLink)), such person does any of the following: (1) Intentionally causes or attempts to cause a motor vehicle collision; or (2) Engages in a scheme to fabricate evidence of a motor vehicle collision that did not occur. Staging a collision shall constitute a felony punishable by no less than one year nor more than five years’ imprisonment. (b) A person shall be guilty of the crime of aggravated staging of a collision when, with intent to commit insurance fraud as defined in [Code Section 33-1-9](https://1.next.westlaw.com/Link/Document/FullText?findType=L&pubNum=1000468&cite=GAST33-1-9&originatingDoc=N5362C020C43A11EBB976D40C53E8D6D0&refType=LQ&originationContext=document&transitionType=DocumentItem&ppcid=a13aa233d222468f9008ccbabb13eb4e&contextData=(sc.DocLink)), such person commits acts in violation of subsection (a) of this Code section which result in serious personal injury to another. Aggravated staging of a collision shall constitute a felony punishable by no less than two years nor more than ten years’ imprisonment. (c) A person shall be guilty of the crime of making a fraudulent claim related to a staged collision when such person makes, or assists in making, a claim for insurance benefits of any type or brings, or assists in bringing, a civil lawsuit against another seeking monetary damages with knowledge that the injuries for which insurance benefits or monetary damages are sought resulted from a staged collision, or seeks to obtain any benefit to which such claimant is not legally entitled. Making a fraudulent claim related to a staged collision shall constitute a felony and shall be punishable by no less than one year nor more than five years’ imprisonment. **State:** Georgia **Statute Areas:** Staged Accidents --- ### [Colorado – Staged Accidents - CO ST s 18-5-221   ](https://insurancefraud.org/statutes/colorado-staged-accidents-co-st-s-18-5-221/) **Published:** March 14, 2022 **Author:** Coalition Against Insurance Fraud **Content:** **§ 18-5-211. Insurance Fraud -definitions** (1)A person commits insurance fraud if the person does any of the following: (c) With an intent to defraud causes or participates, or purports to be involved, in a vehicular collision, or any other vehicular accident, for the purpose of presenting any false or fraudulent insurance claim; (4) Insurance fraud committed in violation of paragraphs (b) to (e) of subsection (1) of this section or subsection (2) or (3) of this section is a class 5 felony. **State:** Colorado **Statute Areas:** Staged Accidents --- ### [Mississippi - Immunity - MS Code § 11–69–1 (2018)](https://insurancefraud.org/statutes/mississippi-immunity/) **Published:** January 7, 2021 **Author:** Coalition Against Insurance Fraud **Content:** (1) Except as otherwise provided in subsection (2) of this section, there shall be no civil liability imposed on and no cause of action shall arise against a person or entity for furnishing information concerning suspected or completed insurance fraud to any law enforcement, investigatory, prosecutorial or regulatory agent or agency, insurer, or statutory residual market plan. This shall not abrogate or modify common law or statutory privileges or immunities enjoyed by a person or entity. The prohibition of civil liability applies only to the act of reporting and does not limit civil liability against a person or entity for committing fraud or other tortious conduct. (2) Subsection (1) of this section shall not apply to claims against persons where false statements were made in bad faith by persons furnishing information concerning suspected or completed insurance fraud. Any civil action brought against a person for filing a report or furnishing other information concerning insurance fraud shall be dismissed unless the party bringing the action has pleaded specifically that subsection (1) of this section does not apply because the person filing the report or furnishing the information did so in bad faith, and has pleaded specifically facts that support a claim of bad faith. **State:** Mississippi **Statute Areas:** Immunity --- ### [Hawaii (state claims only)](https://insurancefraud.org/statutes/hawaii-false-claims-act-yes/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** [Click here](https://law.justia.com/codes/hawaii/2015/title-36/chapter-661/section-661-21/) for full statutory text. **State:** Hawaii **Statute Areas:** False Claims Act --- ### [Georgia (Medicaid only)](https://insurancefraud.org/statutes/georgia-false-claims-act-yes/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** [Click here](https://law.justia.com/codes/georgia/2010/title-49/chapter-4/article-7b/49-4-168/) for full statutory text. **State:** Georgia **Statute Areas:** False Claims Act --- ### [Colorado (medical only)](https://insurancefraud.org/statutes/colorado-false-claims-act-yes/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** [Click here](https://casetext.com/statute/colorado-revised-statutes/title-255-health-care-policy-and-financing/colorado-medical-assistance-act/article-4-colorado-medical-assistance-act-general-medical-assistance/part-3-recovery/section-255-4-3035-short-title) for full statutory text. **State:** Colorado **Statute Areas:** False Claims Act --- ### [Washington (Medicaid only)](https://insurancefraud.org/statutes/washington-false-claims-act-yes/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** [Click here](https://app.leg.wa.gov/rcw/default.aspx?cite=74.66) for full statutory text. **State:** Washington **Statute Areas:** False Claims Act --- ### [Virginia - False Claims Act](https://insurancefraud.org/statutes/virginia-false-claims-act-yes/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** [Click here](https://law.lis.virginia.gov/vacode/title8.01/chapter3/section8.01-216.3/) for full statutory text. **State:** Virginia **Statute Areas:** False Claims Act --- ### [Vermont (state claims solely)](https://insurancefraud.org/statutes/vermont-false-claims-act-yes/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** [Click here](https://legislature.vermont.gov/statutes/section/32/007/00631) for full statutory text. **State:** Vermont **Statute Areas:** False Claims Act --- ### [Texas (Medicaid only)](https://insurancefraud.org/statutes/texas-false-claims-act-yes/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** [Click here](http://whistleblowerlaws.com/false-claims-act/texas-false-claims-act/) for full statutory text. **State:** Texas **Statute Areas:** False Claims Act --- ### [Rhode Island (state claims solely)](https://insurancefraud.org/statutes/rhode-island-false-claims-act-yes/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** [Click here](http://webserver.rilin.state.ri.us/Statutes/TITLE9/9-1.1/INDEX.HTM) for full statutory text. **State:** Rhode Island **Statute Areas:** False Claims Act --- ### [North Carolina (state claims solely)](https://insurancefraud.org/statutes/north-carolina-false-claims-act-yes/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** [Click here](https://www.ncleg.net/EnactedLegislation/Statutes/HTML/ByArticle/Chapter_1/Article_51.html) for full statutory text. **State:** North Carolina **Statute Areas:** False Claims Act --- ### [New Mexico (Medicaid only)](https://insurancefraud.org/statutes/new-mexico-false-claims-act-yes/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** [Click here](https://law.justia.com/codes/new-mexico/2011/chapter27/article14/section27-14-1/) for full statutory text. **State:** New Mexico **Statute Areas:** False Claims Act --- ### [New Jersey (state claims solely)](https://insurancefraud.org/statutes/new-jersey-false-claims-act-yes/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** [Click here](http://www.sarrafgentile.com/wp-content/uploads/pdf/New_Jersey.pdf) for full statutory text. **State:** New Jersey **Statute Areas:** False Claims Act --- ### [New Hampshire (state claims solely)](https://insurancefraud.org/statutes/new-hampshire-false-claims-act-yes/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** [Click here](https://casetext.com/statute/new-hampshire-revised-statutes/title-12-public-safety-and-welfare/chapter-167-public-assistance-to-blind-aged-or-disabled-persons-and-to-dependent-children/medicaid-fraud-and-false-claims/section-16761-b-false-claims-against-the-department-definitions) for full statutory text. **State:** New Hampshire **Statute Areas:** False Claims Act --- ### [Nevada (state claims solely)](https://insurancefraud.org/statutes/nevada-false-claims-act-yes/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** [Click here](https://www.leg.state.nv.us/nrs/NRS-357.html) for full statutory text. **State:** Nevada **Statute Areas:** False Claims Act --- ### [Montana - False Claims Act](https://insurancefraud.org/statutes/montana-false-claims-act-yes/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** [Click here](https://leg.mt.gov/bills/mca_toc/17_8_4.htm) for full statutory text. **State:** Montana **Statute Areas:** False Claims Act --- ### [Minnesota (state claims solely)](https://insurancefraud.org/statutes/minnesota-false-claims-act-yes/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** [Click here](https://www.revisor.mn.gov/statutes/cite/15C) for full statutory text. **State:** Minnesota **Statute Areas:** False Claims Act --- ### [Michigan (Medicaid solely)](https://insurancefraud.org/statutes/michigan-false-claims-act-yes/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** [Click here](http://whistleblowerlaws.com/false-claims-act/michigan-false-claims-act/#:~:text=The%20Michigan%20Medicaid%20False%20Claims,designed%20to%20address%20Medicaid%20fraud) for full statutory text. **State:** Michigan **Statute Areas:** False Claims Act --- ### [Massachusetts - False Claims Act](https://insurancefraud.org/statutes/massachusetts-false-claims-act-yes/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** [Click here](https://malegislature.gov/laws/generallaws/parti/titleii/chapter12/section5a) for full statutory text. **State:** Massachusetts **Statute Areas:** False Claims Act --- ### [Maryland (state healthcare only)](https://insurancefraud.org/statutes/maryland-false-claims-act-yes/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** [Click here](https://law.justia.com/codes/maryland/2015/article-ghg/title-2/subtitle-6/section-2-602) for full statutory text. **State:** Maryland **Statute Areas:** False Claims Act --- ### [Louisiana - False Claims Act](https://insurancefraud.org/statutes/louisiana-false-claims-act-yes/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** [Click here](http://legis.la.gov/Legis/Law.aspx?p=y&d=100866) for full statutory text. **State:** Louisiana **Statute Areas:** False Claims Act --- ### [Iowa - False Claims Act](https://insurancefraud.org/statutes/iowa-false-claims-act-yes/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** [Click here](https://www.legis.iowa.gov/docs/ico/chapter/685.pdf) for full statutory text. **State:** Iowa **Statute Areas:** False Claims Act --- ### [Indiana - False Claims Act](https://insurancefraud.org/statutes/indiana-false-claims-act-yes/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** [Click here](https://casetext.com/statute/indiana-code/title-5-state-and-local-administration/article-11-accounting-for-public-funds/chapter-55-false-claims-and-whistleblower-protection) for full statutory text. **State:** Indiana **Statute Areas:** False Claims Act --- ### [Illinois - False Claims Act](https://insurancefraud.org/statutes/illinois-false-claims-act-yes/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** [Click here](https://www.ilga.gov/legislation/ilcs/ilcs3.asp?ActID=2039&ChapterID=57) for full statutory text. **State:** Illinois **Statute Areas:** False Claims Act --- ### [Florida - False Claims Act](https://insurancefraud.org/statutes/florida-false-claims-act-yes/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** [Click here](https://codes.findlaw.com/fl/title-xlvi-crimes/fl-st-sect-817-234.html) for full statutory text. **State:** Florida **Statute Areas:** False Claims Act --- ### [District of Columbia - False Claims Act](https://insurancefraud.org/statutes/district-of-columbia-false-claims-act-yes/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** [Click here](https://code.dccouncil.us/dc/council/code/sections/2-381.02.html) for full statutory text. **State:** District of Columbia **Statute Areas:** False Claims Act --- ### [California - False Claims Act](https://insurancefraud.org/statutes/california-false-claims-act-yes/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** [Click here](https://leginfo.legislature.ca.gov/faces/codes_displayText.xhtml?lawCode=GOV&division=3.&title=2.&part=2.&chapter=6.&article=9.) for full statutory text. **State:** California **Statute Areas:** False Claims Act --- ### [Delaware - False Claims Act](https://insurancefraud.org/statutes/delaware-false-claims-act-yes/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** [Click here](https://delcode.delaware.gov/title6/c012/) for full statutory text. --- --- **State:** Delaware **Statute Areas:** False Claims Act --- ### [New York - False Claims Act-Art. 13, §§187-194](https://insurancefraud.org/statutes/new-york-false-claims-act/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** § 187. SHORT TITLE This article shall be known and may be cited as the “New York false claims act”. § 188. DEFINITIONS As used in this article, the following terms shall mean: 1\. “Claim” (a) means any request or demand, whether under a contract or otherwise, for money or property that: (i) is presented to an officer, employee or agent of the state or a local government; or (ii) is made to a contractor, grantee, or other recipient, if the money or property is to be spent or used on the state or a local government’s behalf or to advance a state or local government program or interest, and if the state or local government (A) provides or has provided any portion of the money or property requested or demanded; or (B) will reimburse such contractor, grantee, or other recipient for any portion of the money or property which is requested or demanded; (b) does not include requests or demands for money or property that the state or a local government has already paid to an individual as compensation for government employment or as an income subsidy with no restrictions on that individual’s use of the money or property. 2\. “False claim” means any claim which is, either in whole or part, false or fraudulent. 3\. “Knowing and knowingly” (a) means that a person, with respect to information: (i) has actual knowledge of the information; (ii) acts in deliberate ignorance of the truth or falsity of the information; or (iii) acts in reckless disregard of the truth or falsity of the information; and (b) require no proof of specific intent to defraud, provided, however that acts occurring by mistake or as a result of mere negligence are not covered by this article. 4\. “Obligation” means an established duty, whether or not fixed, arising from an express or implied contractual, grantor-grantee, or licensor-licensee relationship, from a fee-based or similar relationship, from statute or regulation, or from the retention of any overpayment. 5\. “Material” means having a natural tendency to influence, or be capable of influencing the payment or receipt of money or property. 6\. “Local government” means any New York county, city, town, village, school district, board of cooperative educational services, local public benefit corporation or other municipal corporation or political subdivision of the state, or of such local government. 7\. “Original source” means a person who: (a) prior to a public disclosure under paragraph (b) of subdivision nine of section one hundred ninety of this article has voluntarily disclosed to the state or a local government the information on which allegations or transactions in a cause of action are based; or (b) who has knowledge that is independent of and materially adds to the publicly disclosed allegations or transactions, and who has voluntarily provided the information to the state or a local government before or simultaneous with filing an action under this article. 8\. “Person” means any natural person, partnership, corporation, association or any other legal entity or individual, other than the state or a local government. 9\. “State” means the state of New York and any state department, board, bureau, division, commission, committee, public benefit corporation, public authority, council, office or other governmental entity performing a governmental or proprietary function for the state. § 189. LIABILITY FOR CERTAIN ACTS 1\. Subject to the provisions of subdivision two of this section, any person who: (a) knowingly presents, or causes to be presented a false or fraudulent claim for payment or approval; (b) knowingly makes, uses, or causes to be made or used, a false record or statement material to a false or fraudulent claim; (c) conspires to commit a violation of paragraph (a), (b), (d), (e), (f) or (g) of this subdivision; (d) has possession, custody, or control of property or money used, or to be used, by the state or a local government and knowingly delivers, or causes to be delivered, less than all of that money or property; (e) is authorized to make or deliver a document certifying receipt of property used, or to be used, by the state or a local government and, intending to defraud the state or a local government, makes or delivers the receipt without completely knowing that the information on the receipt is true; (f) knowingly buys, or receives as a pledge of an obligation or debt, public property from an officer or employee of the state or a local government knowing that the officer or employee violates a provision of law when selling or pledging such property; (g) knowingly makes, uses, or causes to be made or used, a false record or statement material to an obligation to pay or transmit money or property to the state or a local government; or (h) knowingly conceals or knowingly and improperly avoids or decreases an obligation to pay or transmit money or property to the state or a local government, or conspires to do the same; shall be liable to the state or a local government, as applicable, for a civil penalty of not less than six thousand dollars and not more than twelve thousand dollars, as adjusted to be equal to the civil penalty allowed under the federal False Claims Act, 31 U.S.C. sec. 3729, et seq., as amended, as adjusted for inflation by the Federal Civil Penalties Inflation Adjustment Act of 1990, as amended (28 U.S.C. 2461 note; Pub. L. No. 101-410), plus three times the amount of all damages, including consequential damages, which the state or local government sustains because of the act of that person. 2\. The court may assess not more than two times the amount of damages sustained because of the act of the person described in subdivision one of this section, if the court finds that: (a) the person committing the violation of this section had furnished all information known to such person about the violation, to those officials responsible for investigating false claims violations on behalf of the state and any local government that sustained damages, within thirty days after the date on which such person first obtained the information; (b) such person fully cooperated with any government investigation of such violation; and (c) at the time such person furnished information about the violation, no criminal prosecution, civil action, or administrative action had commenced with respect to such violation, and the person did not have actual knowledge of the existence of an investigation into such violation. 3\. A person who violates this section shall also be liable for the costs, including attorneys’ fees, of a civil action brought to recover any such penalty or damages. 4.(a) This section shall apply to claims, records, or statements made under the tax law only if (i) the net income or sales of the person against whom the action is brought equals or exceeds one million dollars for any taxable year subject to any action brought pursuant to this article; (ii) the damages pleaded in such action exceed three hundred and fifty thousand dollars; and (iii) The person is alleged to have violated paragraph (a), (b), (c), (d), (e), (f) or (g) of subdivision one of this section; provided, however, that nothing in this subparagraph shall be deemed to modify or restrict the application of such paragraphs to any act alleged that relates to a violation of the tax law. (b) The attorney general shall consult with the commissioner of the department of taxation and finance prior to filing or intervening in any action under this article that is based on the filing of false claims, records or statements made under the tax law. If the state declines to participate or to authorize participation by a local government in such an action pursuant to subdivision two of section one hundred ninety of this article, the qui tam plaintiff must obtain approval from the attorney general before making any motion to compel the department of taxation and finance to disclose tax records. § 190. CIVIL ACTIONS FOR FALSE CLAIMS 1. Civil enforcement actions. The attorney general shall have the authority to investigate violations under section one hundred eighty- nine of this article. If the attorney general believes that a person has violated or is violating such section, then the attorney general may bring a civil action on behalf of the people of the state of New York or on behalf of a local government against such person. A local government also shall have the authority to investigate violations that may have resulted in damages to such local government under section one hundred eighty-nine of this article, and may bring a civil action on its own behalf, or on behalf of any subdivision of such local government, to recover damages sustained by such local government as a result of such violations. No action may be filed pursuant to this subdivision against the federal government, the state or a local government, or any officer or employee thereof acting in his or her official capacity. The attorney general shall consult with the office of medicaid inspector general prior to filing any action related to the medicaid program. 2\. Qui tam civil actions. (a) Any person may bring a qui tam civil action for a violation of section one hundred eighty-nine of this article on behalf of the person and the people of the state of New York or a local government. No action may be filed pursuant to this subdivision against the federal government, the state or a local government, or any officer or employee thereof acting in his or her official capacity. For purposes of subparagraphs (i) and (iv) of paragraph (a) of subdivision eight of section seventy-three of the public officers law, any activity by a former government employee in connection with the securing of rights, protections or benefits related to preparing or filing an action under this article shall not be deemed to be an appearance or practice before any agency. (b) A copy of the complaint and written disclosure of substantially all material evidence and information the person possesses shall be served on the state pursuant to subdivision one of section three hundred seven of the civil practice law and rules. Any complaint filed in a court of the state of New York shall be filed in supreme court in camera, shall remain under seal for at least sixty days, and shall not be served on the defendant until the court so orders. The seal shall not preclude the attorney general, a local government, or the qui tam plaintiff from serving the complaint, any other pleadings, or the written disclosure of substantially all material evidence and information possessed by the person bringing the action, on relevant state or local government agencies, or on law enforcement authorities of the state, a local government, or other jurisdictions, so that the actions may be investigated or prosecuted, except that such seal applies to the agencies or authorities so served to the same extent as the seal applies to other parties in the action. If the allegations in the complaint allege a violation of section one hundred eighty-nine of this article involving damages to a local government, then the attorney general may at any time provide a copy of such complaint and written disclosure to the attorney for such local government; provided, however, that if the allegations in the complaint involve damages only to a city with a population of one million or more, or only to the state and such a city, then the attorney general shall provide such complaint and written disclosure to the corporation counsel of such city within thirty days. The state may elect to supersede or intervene and proceed with the action, or to authorize a local government that may have sustained damages to supersede or intervene, within sixty days after it receives both the complaint and the material evidence and information; provided, however, that if the allegations in the complaint involve damages only to a city with a population of one million or more, then the attorney general may not supersede or intervene in such action without the consent of the corporation counsel of such city. The attorney general shall consult with the office of the medicaid inspector general prior to superseding or intervening in any action related to the medicaid program. The attorney general may, for good cause shown, move the court for extensions of the time during which the complaint remains under seal under this subdivision. Any such motions may be supported by affidavits or other submissions in camera. (c) Prior to the expiration of the sixty day period or any extensions obtained under paragraph (b) of this subdivision, the attorney general shall notify the court that he or she: (i) intends to file a complaint against the defendant on behalf of the people of the state of New York or a local government, and thereby be substituted as the plaintiff in the action and convert the action in all respects from a qui tam civil action brought by a private person into a civil enforcement action by the attorney general under subdivision one of this section; (ii) intends to intervene in such action, as of right, so as to aid and assist the plaintiff in the action; or (iii) if the action involves damages sustained by a local government, intends to grant the local government permission to: (A) file and serve a complaint against the defendant, and thereby be substituted as the plaintiff in the action and convert the action in all respects from a qui tam civil action brought by a private person into a civil enforcement action by the local government under subdivision one of this section; or (B) intervene in such action, as of right, so as to aid and assist the plaintiff in the action. The attorney general shall provide the local government with a copy of any such notification at the same time the court is notified. (d)If the state notifies the court that it intends to file a complaint against the defendant and thereby be substituted as the plaintiff in the action, or to permit a local government to do so, such complaint, whether filed separately or as an amendment to the qui tam plaintiff’s complaint, must be filed within thirty days after the notification to the court. For statute of limitations purposes, any such complaint filed by the state or a local government shall relate back to the filing date of the complaint of the qui tam plaintiff, to the extent that the cause of action of the state or local government arises out of the conduct, transactions, or occurrences set forth, or attempted to be set forth, in the complaint of the qui tam plaintiff. (e)If the state notifies the court that it intends to intervene in the action, or to permit a local government to do so, then such motion to intervene, whether filed separately or as an amendment to the qui tam plaintiff’s complaint, shall be filed within thirty days after the notification to the court. for statute of limitations purposes, any complaint filed by the state or a local government, whether filed separately or as an amendment to the qui tam plaintiff’s complaint, shall relate back to the filing date of the complaint of the qui tam plaintiff, to the extent that the cause of action of the state or local government arises out of the conduct, transactions, or occurrences set forth, or attempted to be set forth, in the complaint of the qui tam plaintiff. (f) If the state declines to participate in the action or to authorize participation by a local government, the qui tam action may proceed subject to judicial review under this section, the civil practice law and rules, and other applicable law. The qui tam plaintiff shall provide the state or any applicable local government with a copy of any document filed with the court on or about the date it is filed, or any order issued by the court on or about the date it is issued. A qui tam plaintiff shall notify the state or any applicable local government within five business days of any decision, order or verdict resulting in judgment in favor of the state or local government. 3\. Time to answer. If the state decides to participate in a qui tam action or to authorize the participation of a local government, the court shall order that the qui tam complaint be unsealed and served at the time of the filing of the complaint or intervention motion by the state or local government. After the complaint is unsealed, or if a complaint is filed by the state or a local government pursuant to subdivision one of this section, the defendant shall be served with the complaint and summons pursuant to article three of the civil practice law and rules. A copy of any complaint which alleges that damages were sustained by a local government shall also be served on such local government. The defendant shall be required to respond to the summons and complaint within the time allotted under rule three hundred twenty of the civil practice law and rules. 4\. Related actions. When a person brings a qui tam action under this section, no person other than the attorney general, or a local government attorney acting pursuant to subdivision one of this section or paragraph (b) of subdivision two of this section, may intervene or bring a related civil action based upon the facts underlying the pending action; provided, however, that nothing in this subdivision shall be deemed to deny persons the right, upon leave of court, to file briefs amicus curiae. 5\. Rights of the parties of qui tam actions. (a) If the attorney general elects to convert the qui tam civil action into an attorney general enforcement action, then the state shall have the primary responsibility for prosecuting the action. If the attorney general elects to intervene in the qui tam civil action then the state and the person who commenced the action, and any local government which sustained damages and intervenes in the action, shall share primary responsibility for prosecuting the action. If the attorney general elects to permit a local government to convert the action into a civil enforcement action, then the local government shall have primary responsibility for investigating and prosecuting the action. If the action involves damages to a local government but not the state, and the local government intervenes in the qui tam civil action, then the local government and the person who commenced the action shall share primary responsibility for prosecuting the action. Under no circumstances shall the state or a local government be bound by an act of the person bringing the original action. Such person shall have the right to continue as a party to the action, subject to the limitations set forth in paragraph (b) of this subdivision. Under no circumstances shall the state be bound by the act of a local government that intervenes in an action involving damages to the state. If neither the attorney general nor a local government intervenes in the qui tam action then the qui tam plaintiff shall have the responsibility for prosecuting the action, subject to the attorney general’s right to intervene at a later date upon a showing of good cause. (b) (i) The state may move to dismiss the action notwithstanding the objections of the person initiating the action if the person has been served with the motion to dismiss and the court has provided the person with an opportunity to be heard on the motion. If the action involves damages to both the state and a local government, then the state shall consult with such local government before moving to dismiss the action. If the action involves damages sustained by a local government but not the state, then the local government may move to dismiss the action notwithstanding the objections of the person initiating the action if the person has been served with the motion to dismiss and the court has provided the person with an opportunity to be heard on the motion. (ii) The state or a local government may settle the action with the defendant notwithstanding the objections of the person initiating the action if the court determines, after an opportunity to be heard, that the proposed settlement is fair, adequate, and reasonable with respect to all parties under all the circumstances. Upon a showing of good cause, such opportunity to be heard may be held in camera. (iii) Upon a showing by the attorney general or a local government that the original plaintiff’s unrestricted participation during the course of the litigation would interfere with or unduly delay the prosecution of the case, or would be repetitious or irrelevant, or upon a showing by the defendant that the original qui tam plaintiff’s unrestricted participation during the course of the litigation would be for purposes of harassment or would cause the defendant undue burden, the court may, in its discretion, impose limitations on the original plaintiff’s participation in the case, such as (A) limiting the number of witnesses the person may call; (B) limiting the length of the testimony of such witnesses; (C) limiting the person’s cross-examination of witnesses; or (D) otherwise limiting the participation by the person in the litigation. (c) Notwithstanding any other provision of law, whether or not the attorney general or a local government elects to supersede or intervene in a qui tam civil action, the attorney general and such local government may elect to pursue any remedy available with respect to the criminal or civil prosecution of the presentation of false claims, including any administrative proceeding to determine a civil money penalty or to refer the matter to the office of the medicaid inspector general for medicaid related matters. If any such alternate civil remedy is pursued in another proceeding, the person initiating the action shall have the same rights in such proceeding as such person would have had if the action had continued under this section. (d) Notwithstanding any other provision of law, whether or not the attorney general elects to supersede or intervene in a qui tam civil action, or to permit a local government to supersede or intervene in the qui tam civil action, upon a showing by the state or local government that certain actions of discovery by the person initiating the action would interfere with the state’s or a local government’s investigation or prosecution of a criminal or civil matter arising out of the same facts, the court may stay such discovery for a period of not more than sixty days. Such a showing shall be conducted in camera. The court may extend the period of such stay upon a further showing in camera that the state or a local government has pursued the criminal or civil investigation or proceedings with reasonable diligence and any proposed discovery in the civil action will interfere with the ongoing criminal or civil investigation or proceedings. 6\. Awards to qui tam plaintiff. (a) If the attorney general elects to convert the qui tam civil action into an attorney general enforcement action, or to permit a local government to convert the action into a civil enforcement action by such local government, or if the attorney general or a local government elects to intervene in the qui tam civil action, then the person or persons who initiated the qui tam civil action collectively shall be entitled to receive between fifteen and twenty-five percent of the proceeds recovered in the action or in settlement of the action. The court shall determine the percentage of the proceeds to which a person commencing a qui tam civil action is entitled, by considering the extent to which the plaintiff substantially contributed to the prosecution of the action. Where the court finds that the action was based primarily on disclosures of specific information (other than information provided by the person bringing the action) relating to allegations or transactions in a criminal, civil or administrative hearing, in a legislative or administrative report, hearing, audit or investigation, or from the news media, the court may award such sums as it considers appropriate, but in no case more than ten percent of the proceeds, taking into account the significance of the information and the role of the person or persons bringing the action in advancing the case to litigation. Any such person shall also receive an amount for reasonable expenses that the court finds to have been necessarily incurred, reasonable attorneys’ fees, and costs pursuant to article eighty-one of the civil practice law and rules. all such expenses, fees, and costs shall be awarded against the defendant. (b) If the attorney general or a local government does not elect to intervene or convert the action, and the action is successful, then the person or persons who initiated the qui tam action which obtains proceeds shall be entitled to receive between twenty-five and thirty percent of the proceeds recovered in the action or settlement of the action. The court shall determine the percentage of the proceeds to which a person commencing a qui tam civil action is entitled, by considering the extent to which the plaintiff substantially contributed to the prosecution of the action. Such person shall also receive an amount for reasonable expenses that the court finds to have been necessarily incurred, reasonable attorneys’ fees, and costs pursuant to article eighty-one of the civil practice law and rules. all such expenses, fees, and costs shall be awarded against the defendant. (c) With the exception of a court award of costs, expenses or attorneys’ fees, any payment to a person pursuant to this paragraph shall be made from the proceeds. (d) If the attorney general or a local government does not proceed with the action and the person bringing the action conducts the action, the court may award to the defendant its reasonable attorneys’ fees and expenses if the defendant prevails in the action and the court finds that the claim of the person bringing the action was clearly frivolous, clearly vexatious, or brought primarily for purposes of harassment. 7\. Costs, expenses, disbursements and attorneys’ fees. In any action brought pursuant to this article, the court may award any local government that participates as a party in the action an amount for reasonable expenses which the court finds to have been necessarily incurred, plus reasonable attorneys’ fees, plus costs pursuant to article eighty-one of the civil practice law and rules. All such expenses, fees and costs shall be awarded directly against the defendant and shall not be charged from the proceeds, but shall only be awarded if a local government prevails in the action. 8\. Exclusion from recovery. If the court finds that the qui tam civil action was brought by a person who planned or initiated the violation of section one hundred eighty-nine of this article upon which the action was brought, then the court may, to the extent the court considers appropriate, reduce the share of the proceeds of the action which the person would otherwise be entitled to receive under subdivision six of this section, taking into account the role of such person in advancing the case to litigation and any relevant circumstances pertaining to the violation. If the person bringing the qui tam civil action is convicted of criminal conduct arising from his or her role in the violation of section one hundred eighty-nine of this article, that person shall be dismissed from the qui tam civil action and shall not receive any share of the proceeds of the action. Such dismissal shall not prejudice the right of the attorney general to supersede or intervene in such action and to civilly prosecute the same on behalf of the state or a local government. 9\. Certain actions barred. (a) The court shall dismiss a qui tam action under this article if: (i) it is based on allegations or transactions which are the subject of a pending civil action or an administrative action in which the state or a local government is already a party; (ii) the state or local government has reached a binding settlement or other agreement with the person who violated section one hundred eighty-nine of this article resolving the matter and such agreement has been approved in writing by the attorney general, or by the applicable local government attorney; or (iii) against a member of the legislature, a member of the judiciary, or a senior executive branch official if the action is based on evidence or information known to the state when the action was brought. (b) The court shall dismiss a qui tam action under this article, unless opposed by the state or an applicable local government, or unless the qui tam plaintiff is an original source of the information, if substantially the same allegations or transactions as alleged in the action were publicly disclosed: (i) in a state or local government criminal, civil, or administrative hearing in which the state or a local government or its agent is a party; (ii) in a federal, New York state or New York local government report, hearing, audit, or investigation that is made on the public record or disseminated broadly to the general public; provided that such information shall not be deemed “publicly disclosed” in a report or investigation because it was disclosed or provided pursuant to article six of the public officers law, or under any other federal, state or local law, rule or program enabling the public to request, receive or view documents or information in the possession of public officials or public agencies; (iii) in the news media, provided that such allegations or transactions are not “publicly disclosed” in the “news media” merely because information of allegations or transactions have been posted on the internet or on a computer network. 10\. Liability. Neither the state nor any local government shall be liable for any expenses which any person incurs in bringing a qui tam civil action under this article. § 190-a. MONIES RECOVERED Notwithstanding any law to the contrary, all monies recovered or obtained under this article by a state agency or state official or employee acting in their official capacity shall be subject to subdivision eleven of section four of this chapter. § 190-b. Medicaid fraud recovery reporting. The attorney general shall make an annual report to the temporary president of the senate, speaker of the assembly, chair of the senate finance committee, chair of the assembly ways and means committee, chair of the senate health committee, and chair of the assembly health committee by April fifteenth of each year. Such report shall include the amount of monies recovered by the medicaid fraud control unit pursuant to the false claims act for the preceding calendar year. § 191. REMEDIES 1\. Any current or former employee, contractor, or agent of any private or public employer who is discharged, demoted, suspended, threatened, harassed or in any other manner discriminated against in the terms and conditions of employment, or otherwise harmed or penalized by an employer, or a prospective employer, because of lawful acts done by the employee, contractor, agent, or associated others in furtherance of an action brought under this article or other efforts to stop one or more violations of this article, shall be entitled to all relief necessary to make the employee, contractor or agent whole. Such relief shall include but not be limited to: (a) an injunction to restrain continued discrimination; (b) hiring, contracting or reinstatement to the position such person would have had but for the discrimination or to an equivalent position; (c) reinstatement of full fringe benefits and seniority rights; (d) payment of two times back pay, plus interest; and (e) compensation for any special damages sustained as a result of the discrimination, including litigation costs and reasonable attorneys’ fees. 2\. For purposes of this section, a “lawful act” shall include, but not be limited to, obtaining or transmitting to the state, a local government, a qui tam plaintiff, or private counsel solely employed to investigate, potentially file, or file a cause of action under this article, documents, data, correspondence, electronic mail, or any other information, even though such act may violate a contract, employment term, or duty owed to the employer or contractor, so long as the possession and transmission of such documents are for the sole purpose of furthering efforts to stop one or more violations of this article. Nothing in this subdivision shall be interpreted to prevent any law enforcement authority from bringing a civil or criminal action against any person for violating any provision of law. 3\. An employee, contractor or agent described in subdivision one of this section may bring an action in the appropriate supreme court for the relief provided in this section. § 192. LIMITATION OF ACTIONS, BURDEN OF PROOF (1) A civil action under this article shall be commenced no later than ten years after the date on which the violation of this article is committed. Notwithstanding any other provision of law, for the purposes of this article, an action under this article is commenced by the filing of the complaint. (1-a) For purposes of applying rule three thousand sixteen of the civil practice law and rules, in pleading an action brought under this article the qui tam plaintiff shall not be required to identify specific claims that result from an alleged course of misconduct, or any specific records or statements used, if the facts alleged in the complaint, if ultimately proven true, would provide a reasonable indication that one or more violations of section one hundred eighty-nine of this article are likely to have occurred, and if the allegations in the pleading provide adequate notice of the specific nature of the alleged misconduct to permit the state or a local government effectively to investigate and defendants fairly to defend the allegations made. (2) In any action brought under this article, the state, a local government that participates as a party in the action, or the person bringing the qui tam civil action, shall be required to prove all essential elements of the cause of action, including damages, by a preponderance of the evidence. § 193. OTHER LAW ENFORCEMENT AUTHORITY AND DUTIES This article shall not: 1\. preempt the authority, or relieve the duty, of other law enforcement agencies to investigate and prosecute suspected violations of law; 2\. prevent or prohibit a person from voluntarily disclosing any information concerning a violation of this article to any law enforcement agency; or 3\. limit any of the powers granted elsewhere in this chapter and other laws to the attorney general or state agencies or local governments to investigate possible violations of this article and take appropriate action against wrongdoers. § 194. REGULATIONS The attorney general is authorized to adopt such rules and regulations as is necessary to effectuate the purposes of this article. **State:** New York **Statute Areas:** False Claims Act --- ### [New York - Claims Fraud](https://insurancefraud.org/statutes/new-york-claims-fraud/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** A fraudulent insurance act is committed by any person who, knowingly and with intent to defraud presents, causes to be presented, or prepares with knowledge or belief that it will be presented to or by an insurer, self insurer, or purported insurer, or purported self insurer, or any agent thereof: 1\. Any written statement as part of, or in support of, an application for the issuance of, or the rating of a commercial insurance policy, or certificate or evidence of self insurance for commercial insurance or commercial self insurance, or a claim for payment or other benefit pursuant to an insurance policy or self insurance program for commercial or personal insurance that he or she knows to: (a) contain materially false information concerning any fact material thereto; or (b) conceal, for the purpose of misleading, information concerning any fact material thereto; or 2\. Any written statement or other physical evidence as part of, or in support of, an application for the issuance of a health insurance policy, or a policy or contract or other authorization that provides or allows coverage for, membership or enrollment in, or other services of a public or private health plan, or a claim for payment, services or other benefit pursuant to such policy, contract or plan that he or she knows to: (a) contain materially false information concerning any material fact thereto; or (b) conceal, for the purpose of misleading, information concerning any fact material thereto. Such policy or contract or plan or authorization shall include, but not be limited to, those issued or operating pursuant to any public or governmentally-sponsored or supported plan for health care coverage or services or those otherwise issued or operated by entities authorized pursuant to the public health law. For purposes of this subdivision an “application for the issuance of a health insurance policy” shall not include (i) any application for a health insurance policy or contract approved by the superintendent of financial services pursuant to the provisions of sections three thousand two hundred sixteen, four thousand three hundred four, four thousand three hundred twenty-one or four thousand three hundred twenty-two of the insurance law or any other application for a health insurance policy or contract approved by the superintendent of financial services in the individual or direct payment market; or (ii) any application for a certificate evidencing coverage under a self-insured plan or under a group contract approved by the superintendent of financial services. **State:** New York **Statute Areas:** Claims Fraud --- ### [Alabama-False Claims Act-n/a](https://insurancefraud.org/statutes/alabama-false-claims-act-n-a/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Alabama has no State False Claims Act. Though legislation has been proposed. See: https://www.maynardcooper.com/blog/alabama-false-claims-act-legislation-%E2%80%93-cause-concern-businesses-alabama **State:** Alabama **Statute Areas:** False Claims Act --- ### [Wyoming-Claims Fraud-W.S.1977 ¤ 26-13-201](https://insurancefraud.org/statutes/wyoming-claims-fraud-w-s-1977-¤-26-13-201/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) No person shall knowingly or willfully: (i) Make any false or fraudulent statement or representation in or with reference to any application for insurance or for the purpose of obtaining any money or benefit; (ii) Present or cause to be presented a false or fraudulent claim or any proof in support of a claim for the payment of the loss upon a contract of insurance; (iii) Prepare, make or subscribe a false or fraudulent certificate, or other document with intent that the certificate or other document may be presented or used in support of the claim. **State:** Wyoming **Statute Areas:** Claims Fraud --- ### [Wyoming-Failing to Remit Premium-W.S.1977 ¤ 26-13-121](https://insurancefraud.org/statutes/wyoming-failing-to-remit-premium-w-s-1977-¤-26-13-121/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) No person shall willfully collect any sum as premium or charge for insurance: (i) If the insurance is not then provided or is not in due course to be provided, subject to the insurer’s acceptance of the risk, by an insurance policy issued by the insurer as authorized by this code \[title 26\]; (ii) In excess of the premium or charge applicable to the insurance, and as specified in the policy, in accordance with the applicable classifications and rates as filed with and approved by the commissioner; or (iii) In cases where classifications, premiums or rates are not required by this code to be filed and approved, in excess of those specified in the policy and as fixed by the insurer. (b) Subsection (a) of this section does not prohibit the charging and collection by surplus lines brokers licensed under chapter 11 of this code of the amount of applicable state and federal taxes, examination fee and nominal service charge to cover communication expenses, in addition to the premium required by the insurer. Nor does it prohibit the charging and collection by a life insurer of amounts actually to be expended for medical examination of an applicant for life insurance or for reinstatement of a life insurance policy. (c) Each violation of this section is punishable under W.S. 26-1-107. **State:** Wyoming --- ### [Wyoming-Immunity-W.S.1977 ¤ 26-15-109](https://insurancefraud.org/statutes/wyoming-immunity-w-s-1977-¤-26-15-109/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) No cause of action shall arise nor shall any liability be imposed against the commissioner, the commissioner’s authorized representatives or any examiner appointed by the commissioner for any statements made or conduct performed in good faith while carrying out an examination or related activity under the provisions of this chapter. (b) No cause of action shall arise nor shall any liability be imposed against any person for the act of communicating or delivering information or data to the commissioner, the commissioner’s authorized representative or examiner or law enforcement agencies pursuant to an examination made under this chapter or any other criminal investigation under title 6 of the Wyoming statutes, if the act of communication or delivery was performed in good faith and without fraudulent intent. (c) Any person identified in subsection (a) or (b) of this section shall be entitled to an award of attorney’s fees and costs if he is a prevailing party in a civil cause of action for libel, slander or any other relevant tort arising out of activities in carrying out an examination or related activity under the provisions of this chapter and the party bringing the action was not substantially justified in doing so. For purposes of this section, a proceeding is “substantially justified” if it had a reasonable basis in law or fact at the time it was initiated. **State:** Wyoming **Statute Areas:** Immunity --- ### [Wyoming-Insurance Fraud - Definition-W.S.1977 ¤ 26-13-201](https://insurancefraud.org/statutes/wyoming-insurance-fraud-definition-w-s-1977-¤-26-13-201/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) No person shall knowingly or willfully: (i) Make any false or fraudulent statement or representation in or with reference to any application for insurance or for the purpose of obtaining any money or benefit; (ii) Present or cause to be presented a false or fraudulent claim or any proof in support of a claim for the payment of the loss upon a contract of insurance; (iii) Prepare, make or subscribe a false or fraudulent certificate, or other document with intent that the certificate or other document may be presented or used in support of the claim. **State:** Wyoming **Statute Areas:** Insurance Fraud - Definition --- ### [Wyoming-Placing Bogus Coverage-W.S.1977 ¤ 26-13-124](https://insurancefraud.org/statutes/wyoming-placing-bogus-coverage-w-s-1977-¤-26-13-124/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) A person is considered to be engaging in an unfair method of competition and unfair and deceptive act or practice in the business of insurance if that person commits or performs with such frequency as to indicate a general business practice any of the following unfair claims settlement practices: (i) Misrepresenting pertinent facts or insurance policy provisions relating to coverages at issue; **State:** Wyoming --- ### [Wyoming-Practitioner Penalites-n/a](https://insurancefraud.org/statutes/wyoming-practitioner-penalites-n-a/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** No statute found **State:** Wyoming **Statute Areas:** Practitioner Penalites --- ### [Wyoming-Premium Fraud-W.S.1977 ¤ 26-13-121](https://insurancefraud.org/statutes/wyoming-premium-fraud-w-s-1977-¤-26-13-121/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) No person shall willfully collect any sum as premium or charge for insurance: (i) If the insurance is not then provided or is not in due course to be provided, subject to the insurer’s acceptance of the risk, by an insurance policy issued by the insurer as authorized by this code \[title 26\]; (ii) In excess of the premium or charge applicable to the insurance, and as specified in the policy, in accordance with the applicable classifications and rates as filed with and approved by the commissioner; or (iii) In cases where classifications, premiums or rates are not required by this code to be filed and approved, in excess of those specified in the policy and as fixed by the insurer. (b) Subsection (a) of this section does not prohibit the charging and collection by surplus lines brokers licensed under chapter 11 of this code of the amount of applicable state and federal taxes, examination fee and nominal service charge to cover communication expenses, in addition to the premium required by the insurer. Nor does it prohibit the charging and collection by a life insurer of amounts actually to be expended for medical examination of an applicant for life insurance or for reinstatement of a life insurance policy. (c) Each violation of this section is punishable under W.S. 26-1-107. **State:** Wyoming **Statute Areas:** Premium Fraud --- ### [Wyoming-Range of Criminal Penalties-W.S.1977 ¤ 26-1-107](https://insurancefraud.org/statutes/wyoming-range-of-criminal-penalties-w-s-1977-¤-26-1-107/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) Each violation of this code \[title 26\] for which a greater penalty is not provided by another provision of this code or by other applicable laws of this state, in addition to any applicable prescribed denial, suspension or revocation of certificate of authority or license, is a misdemeanor punishable upon conviction by a fine of not more than one thousand dollars ($1,000.00), or by imprisonment in the county jail for not more than six (6) months, or both. Each violation is a separate offense. (b) Any person who violates, or who instructs his agent or adjuster to violate, any provision of this code, any lawful rule or final order of the commissioner or any final judgment or decree made by any court, upon the commissioner’s application, shall pay a civil penalty in an amount the commissioner determines of not more than five thousand dollars ($5,000.00) for each offense, or fifty thousand dollars ($50,000.00) in the aggregate for all offenses within any one (1) year period. In the case of individual agents or adjusters, the civil penalty shall be not more than one thousand dollars ($1,000.00) for each offense or ten thousand dollars ($10,000.00) in the aggregate for all offenses within any one (1) year period. The penalty shall be collected from the violator and paid by the commissioner, or the appropriate court, to the state treasurer and credited as provided in W.S. 8-1-109. (c) Before the commissioner imposes a civil penalty, he shall notify the person, agent or adjuster accused of a violation, in writing, stating specifically the nature of the alleged violation and fixing a time and place, at least ten (10) days from the date of the notice, when a hearing of the matter shall be held. After hearing or upon failure of the accused to appear at the hearing, the commissioner shall determine the amount of the civil penalty to be imposed in accordance with the limitations expressed in subsection (b) of this section. Each violation is a separate offense. (d) A civil penalty may be recovered in an action brought thereon in the name of the state of Wyoming in any court of appropriate jurisdiction, and the court may review the penalty as to both liability and reasonableness of amount. (e) The provisions of this section are in addition to and not instead of any other enforcement provisions contained in this code. **State:** Wyoming **Statute Areas:** Range of Criminal Penalties --- ### [Wyoming-Range of Civil Penalties-W.S.1977 ¤ 26-1-107](https://insurancefraud.org/statutes/wyoming-range-of-civil-penalties-w-s-1977-¤-26-1-107/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) Each violation of this code \[title 26\] for which a greater penalty is not provided by another provision of this code or by other applicable laws of this state, in addition to any applicable prescribed denial, suspension or revocation of certificate of authority or license, is a misdemeanor punishable upon conviction by a fine of not more than one thousand dollars ($1,000.00), or by imprisonment in the county jail for not more than six (6) months, or both. Each violation is a separate offense. (b) Any person who violates, or who instructs his agent or adjuster to violate, any provision of this code, any lawful rule or final order of the commissioner or any final judgment or decree made by any court, upon the commissioner’s application, shall pay a civil penalty in an amount the commissioner determines of not more than five thousand dollars ($5,000.00) for each offense, or fifty thousand dollars ($50,000.00) in the aggregate for all offenses within any one (1) year period. In the case of individual agents or adjusters, the civil penalty shall be not more than one thousand dollars ($1,000.00) for each offense or ten thousand dollars ($10,000.00) in the aggregate for all offenses within any one (1) year period. The penalty shall be collected from the violator and paid by the commissioner, or the appropriate court, to the state treasurer and credited as provided in W.S. 8-1-109. (c) Before the commissioner imposes a civil penalty, he shall notify the person, agent or adjuster accused of a violation, in writing, stating specifically the nature of the alleged violation and fixing a time and place, at least ten (10) days from the date of the notice, when a hearing of the matter shall be held. After hearing or upon failure of the accused to appear at the hearing, the commissioner shall determine the amount of the civil penalty to be imposed in accordance with the limitations expressed in subsection (b) of this section. Each violation is a separate offense. (d) A civil penalty may be recovered in an action brought thereon in the name of the state of Wyoming in any court of appropriate jurisdiction, and the court may review the penalty as to both liability and reasonableness of amount. (e) The provisions of this section are in addition to and not instead of any other enforcement provisions contained in this code. **State:** Wyoming **Statute Areas:** Range of Civil Penalties --- ### [Wyoming-Rating of an Insurance Policy-W.S.1977 ¤ 26-14-105](https://insurancefraud.org/statutes/wyoming-rating-of-an-insurance-policy-w-s-1977-¤-26-14-105/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) Rates shall not be excessive, inadequate or unfairly discriminatory. (b) Risks may be classified in any way except that no risk may be classified in whole or in part on the basis of race, color, creed or national origin. In determining whether rates in a noncompetitive market are excessive, inadequate or unfairly discriminatory, consideration may be given to the following elements: (i) Basic Rate Factors.–Consideration may be given to past and prospective loss and expense experience within and outside of this state, to catastrophe hazards and contingencies, to events or trends within and outside of this state, to dividends or savings to policyholders, members or subscribers and to all other factors and judgments deemed relevant by the insurer; (ii) Classification.–Rates may be modified for individual risks in accordance with rating plans or schedules which establish standards for measuring probable variations in hazards or expenses, or both; (iii) Expenses.–The expense provisions shall reflect the operating methods of the insurer and, so far as credible, its own actual and anticipated expense experience; and (iv) Contingencies and Profits.–The rates may contain a provision for contingencies and a provision for a reasonable underwriting profit, and shall reflect investment income directly attributable to unearned premium and loss reserves. (c) Any insurer delivering or issuing for delivery in this state any new or renewal policy or contract of private passenger automobile liability or collision insurance or both, shall allow a reduction in premium charges of not less than ten percent (10%) to any insured who: (i) Is at least fifty-five (55) years of age; (ii) Successfully completes, at least every two (2) years, a motor vehicle accident prevention course meeting criteria the motor vehicle division approves, provided no person shall receive any premium reduction for a self-instructed course or a course which does not provide for actual classroom or field driving instruction for a minimum number of hours as the motor vehicle division approves; and (iii) Presents to the insurer a certificate or other evidence of successful completion of the course specified in this subsection. **State:** Wyoming --- ### [Wyoming-Underwriting Fraud-W.S.1977 ¤ 26-13-124](https://insurancefraud.org/statutes/wyoming-underwriting-fraud-w-s-1977-¤-26-13-124/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) A person is considered to be engaging in an unfair method of competition and unfair and deceptive act or practice in the business of insurance if that person commits or performs with such frequency as to indicate a general business practice any of the following unfair claims settlement practices: (i) Misrepresenting pertinent facts or insurance policy provisions relating to coverages at issue; (ii) Failing to acknowledge and act reasonably promptly upon communications with respect to claims arising under insurance policies; (iii) Failing to adopt and implement reasonable standards for the prompt investigation of claims arising under insurance policies; (iv) Refusing to pay claims without conducting a reasonable investigation based upon all available information; (v) Failing to affirm or deny coverage of claims within a reasonable time after proof of loss statements have been completed; (vi) Not attempting in good faith to effectuate prompt, fair and equitable settlements of claims in which liability has become reasonably clear; (vii) Compelling insureds to institute litigation to recover amounts due under an insurance policy by offering substantially less than the amounts ultimately recovered in actions brought by such insureds; (viii) Attempting to settle a claim for less than the amount to which a reasonable person would have believed he was entitled by reference to written or printed advertising material accompanying or made part of an application; (ix) Attempting to settle claims on the basis of an application which was altered without notice to, or knowledge or consent of, the insured; (x) Making claims payments to insureds or beneficiaries not accompanied by a statement setting forth the coverage under which the payments are being made; (xi) Making known to insureds or claimants a policy of appealing from arbitration awards in favor of insureds or claimants for the purpose of compelling them to accept settlements or compromises less than the amount awarded in arbitration; (xii) Delaying the investigation or payment of claims by requiring an insured, claimant or the physician of either to submit a preliminary claim report and then requiring the subsequent submission of formal proof of loss forms, both of which submissions contain substantially the same information; (xiii) Failing to promptly settle claims, where liability has become reasonably clear, under one (1) portion of the insurance policy coverage in order to influence settlements under other portions of the insurance policy coverage; (xiv) Failing to promptly provide a reasonable explanation of the basis in the insurance policy in relation to the facts or applicable law for denial of a claim or for the offer of a compromise settlement; (xv) Denying or failing to timely pay disability insurance claims for medically necessary services, procedures or supplies as required by W.S. 26-40-201; (xvi) Failing to comply with the external review procedures required by W.S. 26-40-201; or (xvii) Failing to pay a claim after an external review organization has declared such claim to be a benefit covered under the terms of the insurance policy.. **State:** Wyoming **Statute Areas:** Underwriting Fraud --- ### [Wyoming-Unauthorized Entities-W.S.1977 ¤ 26-12-102](https://insurancefraud.org/statutes/wyoming-unauthorized-entities-w-s-1977-¤-26-12-102/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) No person in this state shall: (i) Act as agent for, or otherwise represent or aid on behalf of another, any insurer not then authorized to transact insurance in this state, in the: (A) Solicitation, negotiation, procurement or carrying out of insurance or annuity contracts or the renewal thereof; (B) Forwarding of applications for insurance; (C) Dissemination of information as to coverage or rates; (D) Inspection of risks; (E) Fixing of rates; (F) Investigation or adjustment of claims or losses; or (G) Collection or forwarding of premiums. (ii) In any other manner represent or assist that insurer in transacting insurance with respect to subjects of insurance resident, located or to be performed in this state. (b) This section does not apply to: (i) Matters the commissioner authorizes under W.S. 26-12-201 through 26-12-206; (ii) Surplus lines insurance and other transactions for which the insurer is not required to have a certificate of authority pursuant to W.S. 26-3-102; (iii) A licensed adjuster or attorney-at-law representing an unauthorized insurer in his professional capacity; (iv) Persons in this state compensated solely by salary, who secure and furnish information for the purpose of enrolling individuals in, or issuing certificates under, or otherwise assisting in administering group life, group or blanket disability or annuity contracts lawfully solicited, issued and delivered in and pursuant to the laws of a state in which the insurer is authorized to transact business; (v) Transactions in this state involving contracts of insurance issued to one (1) or more industrial insureds. **State:** Wyoming --- ### [Wisconsin-Claims Fraud-W.S.A. 895.486](https://insurancefraud.org/statutes/wisconsin-claims-fraud-w-s-a-895-486/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (1) In this section, “insurance fraud” means the presentation of any statement, document or claim, or the preparation of a statement, document or claim with the knowledge that the statement, document or claim will be presented, that the person knew or should have known contained materially false, incomplete or misleading information concerning any of the following: (b) A claim for payment, reimbursement or benefits payable under an insurance policy. **State:** Wisconsin **Statute Areas:** Claims Fraud --- ### [Wisconsin-Immunity-W.S.A. 895.486](https://insurancefraud.org/statutes/wisconsin-immunity-w-s-a-895-486/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (2) Any person who, absent malice, files a report with or furnishes information concerning suspected, anticipated, or completed insurance fraud is immune from civil liability for his or her acts or omissions in filing the report or furnishing the information to any of the following or to their agents, employees or designees: (a) The office of the commissioner of insurance. (b) A law enforcement officer. (c) The National Association of Insurance Commissioners. (d) Any governmental agency established to detect and prevent insurance fraud. (e) Any nonprofit organization established to detect and prevent insurance fraud. (f) Any insurer or authorized representative of an insurer. (3) Any information furnished by an insurer in response to a report or information furnished under sub. (2) is confidential and may be made public only if required in a civil or criminal action. (4) If a civil action is commenced against a person for damages related to the filing of a report or the furnishing of information under sub. (2) and the court determines that the person is immune from civil liability for his or her acts or omissions in filing the report or furnishing the information, the person filing the report or furnishing the information shall recover costs under ch. 814 and, notwithstanding s. 814.04(1), reasonable attorney fees. **State:** Wisconsin **Statute Areas:** Immunity --- ### [Wisconsin-Insurance Fraud - Definition-W.S.A. 895.486](https://insurancefraud.org/statutes/wisconsin-insurance-fraud-definition-w-s-a-895-486/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (1) In this section, “insurance fraud” means the presentation of any statement, document or claim, or the preparation of a statement, document or claim with the knowledge that the statement, document or claim will be presented, that the person knew or should have known contained materially false, incomplete or misleading information concerning any of the following: (a) An application for the issuance of an insurance policy. (b) A claim for payment, reimbursement or benefits payable under an insurance policy. (c) A payment made in accordance with the terms of an insurance policy. (d) A premium on an insurance policy. (e) The rating of an insurance policy. **State:** Wisconsin **Statute Areas:** Insurance Fraud - Definition --- ### [Wisconsin-Premium Fraud-W.S.A. 895.486](https://insurancefraud.org/statutes/wisconsin-premium-fraud-w-s-a-895-486/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (1) In this section, “insurance fraud” means the presentation of any statement, document or claim, or the preparation of a statement, document or claim with the knowledge that the statement, document or claim will be presented, that the person knew or should have known contained materially false, incomplete or misleading information concerning any of the following: (d) A premium on an insurance policy. **State:** Wisconsin **Statute Areas:** Premium Fraud --- ### [Wisconsin-Rating of an Insurance Policy-W.S.A. 625.11](https://insurancefraud.org/statutes/wisconsin-rating-of-an-insurance-policy-w-s-a-625-11/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (1) General. Rates shall not be excessive, inadequate or unfairly discriminatory, nor shall an insurer charge any rate which if continued will have or tend to have the effect of destroying competition or creating a monopoly. (2) Excessiveness. (a) Competitive market. Rates are presumed not to be excessive if a reasonable degree of price competition exists at the consumer level with respect to the class of business to which they apply. In determining whether a reasonable degree of price competition exists, the commissioner shall consider all relevant tests including: 1. The number of insurers actively engaged in the class of business; 2. The existence of rate differentials in that class of business; 3. Whether long-run profitability for insurers generally of the class of business is unreasonably high in relation to its riskiness. (b) Noncompetitive market. If such competition does not exist, rates are excessive if they are likely to produce a long run profit that is unreasonably high in relation to the riskiness of the class of business, or if expenses are unreasonably high in relation to the services rendered. (3) Inadequacy. Rates are inadequate if they are clearly insufficient, together with the investment income attributable to them, to sustain projected losses and expenses in the class of business to which they apply. (4) Unfair discrimination. One rate is unfairly discriminatory in relation to another in the same class if it clearly fails to reflect equitably the differences in expected losses and expenses. Rates are not unfairly discriminatory because different premiums result for policyholders with like loss exposures but different expense factors, or like expense factors but different loss exposures, so long as the rates reflect the differences with reasonable accuracy. Rates are not unfairly discriminatory if they are averaged broadly among persons insured under a group, franchise or blanket policy. **State:** Wisconsin --- ### [West Virginia-Claims Fraud-](https://insurancefraud.org/statutes/west-virginia-claims-fraud/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) Any person who knowingly and willfully and with intent to defraud submits a materially false statement in support of a claim for insurance benefits or payment pursuant to a policy of insurance or who conspires to do so is guilty of a crime and is subject to the penalties set forth in the provisions of this section. (b) Any person who commits a violation of the provisions of subsection (a) of this section where the benefit sought is one thousand dollars or more in value is guilty of a felony and, upon conviction thereof, shall be imprisoned in a correctional facility for not less than one nor more than ten years, fined not more than ten thousand dollars, or both, or in the discretion of the circuit court confined in jail for not more than one year and fined not more than ten thousand dollars, or both. (c) Any person who commits a violation of the provisions of subsection (a) of this section where the benefit sought is less than one thousand dollars in value is guilty of a misdemeanor and, upon conviction thereof, shall be confined in jail for not more than one year, fined not more than two thousand five hundred dollars, or both. (d) Any person convicted of a violation of this section is subject to the restitution provisions of article eleven-a, chapter sixty-one of this code. (e) In addition to the foregoing provisions, the offenses enumerated in sections twenty-four-e through twenty-four-h, inclusive, article three, chapter sixty-one of this code are applicable to matters concerning workers’ compensation insurance. (f) The circuit court may award to the unit or other law-enforcement agency investigating a violation of this section or other criminal offense related to the business of insurance its cost of investigation. **State:** West Virginia **Statute Areas:** Claims Fraud --- ### [West Virginia-Fraud Bureau-W. Va. Code, ¤ 33-41-8](https://insurancefraud.org/statutes/west-virginia-fraud-bureau-w-va-code-¤-33-41-8/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) There is established the West Virginia Insurance Fraud Unit within the office of the Insurance Commissioner of West Virginia. The commissioner may employ full-time supervisory, legal and investigative personnel for the unit who shall be qualified by training and experience in the areas of detection, investigation or prosecution of fraud within and against the insurance industry to perform the duties of their positions. The director of the fraud unit is a full-time position and shall be appointed by the commissioner and serve at his or her will and pleasure. The commissioner shall provide office space, equipment, supplies, clerical and other staff that is necessary for the unit to carry out its duties and responsibilities under this article. (b) The fraud unit may in its discretion: (1) Initiate inquiries and conduct investigations when the unit has cause to believe violations of any of the following provisions of this code relating to the business of insurance have been or are being committed: This chapter; chapter twenty-three of this code; article three, chapter sixty-one of this code; and section five, article four of said chapter. Notwithstanding any provision of this code to the contrary, the fraud unit may, with the agreement of the Director of the Public Employees Insurance Agency, conduct investigations related to possible fraud under article sixteen, chapter five of this code; (2) Review reports or complaints of alleged fraud related to the business of insurance activities from federal, state and local law-enforcement and regulatory agencies, persons engaged in the business of insurance and the general public to determine whether the reports require further investigation; and (3) Conduct independent examinations of alleged fraudulent activity related to the business of insurance and undertake independent studies to determine the extent of fraudulent insurance acts. (c) The insurance fraud unit may: (1) Employ and train personnel to achieve the purposes of this article and to employ legal counsel, investigators, auditors and clerical support personnel and other personnel as the commissioner determines necessary from time to time to accomplish the purposes of this article; (2) Inspect, copy or collect records and evidence; (3) Serve subpoenas issued by grand juries and trial courts in criminal matters; (4) Share records and evidence with federal, state or local law-enforcement or regulatory agencies, and enter into interagency agreements. For purposes of carrying out investigations under this article, the unit shall be deemed a criminal justice agency under all federal and state laws and regulations and as such shall have access to any information that is available to other criminal justice agencies concerning violations of the insurance laws of West Virginia or related criminal laws; (5) Make criminal referrals to the county prosecutors; (6) Conduct investigations outside this state. If the information the insurance fraud unit seeks to obtain is located outside this state, the person from whom the information is sought may make the information available to the insurance fraud unit to examine at the place where the information is located. The insurance fraud unit may designate representatives, including officials of the state in which the matter is located, to inspect the information on behalf of the insurance fraud unit, and the insurance fraud unit may respond to similar requests from officials of other states; (7) The insurance fraud unit may initiate investigations and participate in the development of and, if necessary, the prosecution of any health care provider, including a provider of rehabilitation services, suspected of fraudulent activity related to the business of insurance; (8) Specific personnel, designated by the commissioner, shall be permitted to operate vehicles owned or leased for the state displaying Class A registration plates; (9) Notwithstanding any provision of this code to the contrary, specific personnel designated by the commissioner may carry firearms in the course of their official duties after meeting specialized qualifications established by the Governor’s Committee on Crime, Delinquency and Correction, which shall include the successful completion of handgun training provided to law-enforcement officers by the West Virginia State Police: Provided, That nothing in this subsection shall be construed to include any person designated by the commissioner as a law-enforcement officer as that term is defined by the provisions of section one, article twenty-nine, chapter thirty of this code; and (10) The insurance fraud unit shall not be subject to the provisions of article nine-a, chapter six of this code and the investigations conducted by the insurance fraud unit and the materials placed in the files of the unit as a result of any such investigation are exempt from public disclosure under the provisions of chapter twenty-nine-b of this code. (d) The insurance fraud unit shall perform other duties as may be assigned to it by the commissioner. **State:** West Virginia **Statute Areas:** Fraud Bureau --- ### [West Virginia-Immunity-W. Va. Code, ¤ 33-41-6](https://insurancefraud.org/statutes/west-virginia-immunity-w-va-code-¤-33-41-6/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) There shall be no civil liability imposed on and no cause of action shall arise from a person’s furnishing information concerning suspected or anticipated fraud relating to the business of insurance, if the information is provided to or received from: (1) The commissioner or the commissioner’s employees, agents or representatives; (2) Federal, state, or local law-enforcement or regulatory officials or their employees, agents or representatives; (3) A person involved in the prevention and detection of insurance fraud or that person’s agents, employees or representatives; or (4) The national association of insurance commissioners or its employees, agents or representatives. (b) The provisions of subsection (a) of this section are not applicable to materially incorrect statements made maliciously or fraudulently by a person designated a mandated reporter pursuant to the provisions of subsection (a), section five of this article or made in reckless disregard to the truth or falsity of the statement by those not mandated to report. In an action brought against a person for filing a report or furnishing other information concerning an alleged insurance fraud, the party bringing the action shall plead with specificity any facts supporting the allegation that subsection (a) of this section does not apply because the person filing the report or furnishing the incorrect information did so maliciously in the case of a mandated reporter or in the case of a person not designated a mandated reporter, in reckless disregard for the truth or falsity of the statement. (c) Nothing in this article shall be construed to limit, abrogate or modify existing statutes or case law applicable to the duties or liabilities of insurers regarding bad faith or unfair trade practices. (d) This section does not abrogate or modify common law or statutory privileges or immunities. **State:** West Virginia **Statute Areas:** Immunity --- ### [West Virginia-Insurance Fraud - Definition-n/a](https://insurancefraud.org/statutes/west-virginia-insurance-fraud-definition-n-a/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** No comprehensive statute found. **State:** West Virginia **Statute Areas:** Insurance Fraud - Definition --- ### [West Virginia-Mandatory Restitution-W. Va. Code, ¤ 33-41-12](https://insurancefraud.org/statutes/west-virginia-mandatory-restitution-w-va-code-¤-33-41-12/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** A person or entity engaged in the business of insurance or a person or entity making a claim against an insurer who violates any provision of this article may be subject to the following: (1) Where applicable, suspension or revocation of license or certificate of authority or a civil penalty of up to ten thousand dollars per violation, or where applicable, both. Suspension or revocation of license or certificate of authority or imposition of civil penalties may be pursuant to an order of the commissioner issued pursuant to the provisions of section thirteen, article two of this chapter. The commissioner’s order may require a person found to be in violation of this article to make reasonable restitution to persons aggrieved by violations of this article. The commissioner may assess a person sanctioned pursuant to the provisions of this section the cost of investigation; **State:** West Virginia **Statute Areas:** Mandatory Restitution --- ### [West Virginia-Practitioner Penalites-W. Va. Code, ¤ 33-41-12](https://insurancefraud.org/statutes/west-virginia-practitioner-penalites-w-va-code-¤-33-41-12/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** A person or entity engaged in the business of insurance or a person or entity making a claim against an insurer who violates any provision of this article may be subject to the following: (1) Where applicable, suspension or revocation of license or certificate of authority or a civil penalty of up to ten thousand dollars per violation, or where applicable, both. Suspension or revocation of license or certificate of authority or imposition of civil penalties may be pursuant to an order of the commissioner issued pursuant to the provisions of section thirteen, article two of this chapter. The commissioner’s order may require a person found to be in violation of this article to make reasonable restitution to persons aggrieved by violations of this article. The commissioner may assess a person sanctioned pursuant to the provisions of this section the cost of investigation; (2) Notwithstanding any other provision of law, a civil penalty imposed pursuant to the provisions of this section is mandatory and not subject to suspension; (3) A person convicted of a felony violation law reasonably related to the business of insurance shall be disqualified from engaging in the business of insurance; and (4) The commissioner may apply for a temporary or permanent injunction in any appropriate circuit court of this state seeking to enjoin and restrain a person from violating or continuing to violate the provisions of this article or rule promulgated under this article, notwithstanding the existence of other remedies at law. The circuit court shall have jurisdiction of the proceeding and have the power to make and enter an order or judgment awarding temporary or permanent injunctive relief restraining any person from violating or continuing to violate any provision of this article or rule promulgated under the article as in its judgment is proper. **State:** West Virginia **Statute Areas:** Practitioner Penalites --- ### [West Virginia-Range of Criminal Penalties-W. Va. Code, ¤ 33-41-11](https://insurancefraud.org/statutes/west-virginia-range-of-criminal-penalties-w-va-code-¤-33-41-11/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) Any person who knowingly and willfully and with intent to defraud submits a materially false statement in support of a claim for insurance benefits or payment pursuant to a policy of insurance or who conspires to do so is guilty of a crime and is subject to the penalties set forth in the provisions of this section. (b) Any person who commits a violation of the provisions of subsection (a) of this section where the benefit sought is one thousand dollars or more in value is guilty of a felony and, upon conviction thereof, shall be imprisoned in a correctional facility for not less than one nor more than ten years, fined not more than ten thousand dollars, or both, or in the discretion of the circuit court confined in jail for not more than one year and fined not more than ten thousand dollars, or both. (c) Any person who commits a violation of the provisions of subsection (a) of this section where the benefit sought is less than one thousand dollars in value is guilty of a misdemeanor and, upon conviction thereof, shall be confined in jail for not more than one year, fined not more than two thousand five hundred dollars, or both. (d) Any person convicted of a violation of this section is subject to the restitution provisions of article eleven-a, chapter sixty-one of this code. (e) In addition to the foregoing provisions, the offenses enumerated in sections twenty-four-e through twenty-four-h, inclusive, article three, chapter sixty-one of this code are applicable to matters concerning workers’ compensation insurance. (f) The circuit court may award to the unit or other law-enforcement agency investigating a violation of this section or other criminal offense related to the business of insurance its cost of investigation. **State:** West Virginia **Statute Areas:** Range of Criminal Penalties --- ### [West Virginia-Range of Civil Penalties-W. Va. Code, ¤ 33-41-12](https://insurancefraud.org/statutes/west-virginia-range-of-civil-penalties-w-va-code-¤-33-41-12/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** A person or entity engaged in the business of insurance or a person or entity making a claim against an insurer who violates any provision of this article may be subject to the following: (1) Where applicable, suspension or revocation of license or certificate of authority or a civil penalty of up to ten thousand dollars per violation, or where applicable, both. Suspension or revocation of license or certificate of authority or imposition of civil penalties may be pursuant to an order of the commissioner issued pursuant to the provisions of section thirteen, article two of this chapter. The commissioner’s order may require a person found to be in violation of this article to make reasonable restitution to persons aggrieved by violations of this article. The commissioner may assess a person sanctioned pursuant to the provisions of this section the cost of investigation; (2) Notwithstanding any other provision of law, a civil penalty imposed pursuant to the provisions of this section is mandatory and not subject to suspension; (3) A person convicted of a felony violation law reasonably related to the business of insurance shall be disqualified from engaging in the business of insurance; and (4) The commissioner may apply for a temporary or permanent injunction in any appropriate circuit court of this state seeking to enjoin and restrain a person from violating or continuing to violate the provisions of this article or rule promulgated under this article, notwithstanding the existence of other remedies at law. The circuit court shall have jurisdiction of the proceeding and have the power to make and enter an order or judgment awarding temporary or permanent injunctive relief restraining any person from violating or continuing to violate any provision of this article or rule promulgated under the article as in its judgment is proper. **State:** West Virginia **Statute Areas:** Range of Civil Penalties --- ### [West Virginia-Rating of an Insurance Policy-W. Va. Code, ¤ 33-20-3 (Proposed Legislation)](https://insurancefraud.org/statutes/west-virginia-rating-of-an-insurance-policy-w-va-code-¤-33-20-3-proposed-legislation/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** All rates shall be made in accordance with the following provisions: (a) Due consideration shall be given to past and prospective loss experience within and outside this state, to catastrophe hazards, if any, to a reasonable margin for underwriting profit and contingencies, to dividends, savings or unabsorbed premium deposits allowed or returned by insurers to their policyholders, members or subscribers, to past and prospective expenses both countrywide and those specially applicable to this state and to all other relevant factors within and outside this state. (b) Rates may not be excessive, inadequate or unfairly discriminatory. (c) Rates for casualty and surety insurance to which this article applies shall also be subject to the following provisions: (1) The systems of expense provisions included in the rates for use by any insurer or group of insurers may differ from those of other insurers or groups of insurers to reflect the requirements of the operating methods of any such insurer or group with respect to any kind of insurance or with respect to any subdivision or combination thereof for which subdivision or combination separate expense provisions are applicable. (2) Risks shall be grouped by classifications and by territorial areas for the establishment of rates and minimum premiums. Classification of rates shall be modified to produce rates for individual risks in a territorial area in accordance with rating plans which establish standards for measuring variations in hazards or expense provisions, or both. Such standards may measure any differences among risks that can be demonstrated to have a probable effect upon losses or expenses: Provided, That such standards shall include the establishment of at least seven territorial rate areas within the state: Provided, however, That such territorial rate established by any insurer or group of insurers may differ from those of other insurers or group of insurers. (3) Due consideration shall be given to such factors as expense, management, individual experience, underwriting judgment, degree or nature of hazard or any other reasonable considerations, provided such factors apply to all risks under the same or substantially the same circumstances or conditions. (d) Rates for fire and marine insurance to which this article applies shall also be subject to the following provisions: (1) Manual, minimum, class rates, rating schedules or rating plans shall be made and adopted, except in the case of specific inland marine rates on risks specially rated. (2) Due consideration shall be given to the conflagration hazard and in the case of fire insurance rates, consideration shall be given to the experience of the fire insurance business during a period of not less than the most recent five-year period for which such experience is available. (e) Rates for title insurance to which this article applies shall also be subject to the following provisions: (1) Title insurance rates shall be reasonable and adequate for the class of risks to which they apply. Rates may not be unfairly discriminatory between risks involving essentially the same hazards and expense elements. The rates may be fixed in an amount sufficient to furnish a reasonable margin for profit after provisions to account for: (i) Probable losses as indicated by experience within and without this state; (ii) exposure to loss under policies; (iii) allocations to reserves; (iv) costs participating insurance; (v) operating costs; and (vi) other items of expense fairly attributable to the operation of a title insurance business. (2)(A) Policies may be grouped into classes for the establishment of rates. A title insurance policy that is unusually hazardous to the title insurance company because of an alleged defect or irregularity in the title insured or because of uncertainty regarding the proper interpretation or application of the law involved may be classified separately according to the facts of each case. (B) Title insurance companies shall file separate rate schedules for commercial and noncommercial risks. The Insurance Commissioner shall promulgate rules regarding the requirements of this subsection which shall give due consideration to the nature of commercial transactions and the need for greater protections for consumers in non-commercial transactions. (3) Title insurance rates may not include charges for abstracting, record searching, certificates regarding the record title, escrow services, closing services and other related services that may be offered or furnished or the cost and expenses of examinations of titles. (f) Except to the extent necessary to meet the provisions of subdivisions (b) and (c) of this section, uniformity among insurers in any matters within the scope of this section is neither required nor prohibited. (g) Rates made in accordance with this section may be used subject to the provisions of this article. **State:** West Virginia --- ### [West Virginia-Underwriting Fraud-n/a](https://insurancefraud.org/statutes/west-virginia-underwriting-fraud-n-a/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** No statue found. **State:** West Virginia **Statute Areas:** Underwriting Fraud --- ### [West Virginia-Unauthorized Entities-W. Va. Code, ¤ 33-44-4](https://insurancefraud.org/statutes/west-virginia-unauthorized-entities-w-va-code-¤-33-44-4/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) It is unlawful for any person to engage in any act which constitutes the transaction of insurance under the provisions of this article unless authorized by a license in force pursuant to the laws of this state, or unless exempted by the insurance laws of this state. Any person or insurer engaged in any act which constitutes the unauthorized transaction of insurance shall be subject to the provisions contained in chapter thirty-three of the code and the provisions and penalties set forth in this article. (b) It is unlawful for any person to, directly or indirectly, represent, aid, counsel, opine, administer, assist in any manner or capacity or otherwise act as an agent for or on behalf of an unauthorized insurer in the unauthorized transaction of insurance. Any person who represents, aids or assists, in any manner or capacity, an unauthorized insurer in violation of this article shall be subject to the provisions and penalties set forth in this article. (c) An unauthorized insurer shall be bound by the terms of the insurance contract, certificate or agreement as if the contract, certificate or agreement were legally procured under the insurance laws of this state. (d) This article does not apply to: (i) Any transaction for which a license is not required pursuant to section one, article three of this chapter, including the lawful transaction of surplus lines insurance and reinsurance by insurers; (ii) transactions in this state relative to a policy issued or to be issued outside this state involving insurance on cargo vessels, their craft or hulls, their cargoes, marine builder’s risk, commercial marine protection and indemnity or other risk, including strikes and war risks commonly insured under ocean marine forms of policy; (iii) transactions in this state involving group life insurance, group accident and sickness insurance or group annuities providing coverage under policies that are recognized under articles fourteen and sixteen, respectively, of this chapter where: (1) The master policy of such groups was lawfully issued and delivered in and pursuant to the laws of a state in which the insurer was authorized to do an insurance business, to a group organized for purposes other than the procurement of insurance, and where the policyholder is domiciled or otherwise has a bona fide situs; and (2) except for group annuities, the insurer complies with section thirty-five, article six of this chapter. The commissioner may require the insurer which has issued such master policy to submit such information as the commissioner requires in order to determine if probable cause exists to convene a hearing to determine whether the total charges for the insurance to the persons insured are reasonable in relation to the benefits provided under such policy. **State:** West Virginia --- ### [Washington-Claims Fraud-West's RCWA 48.30.230](https://insurancefraud.org/statutes/washington-claims-fraud-wests-rcwa-48-30-230/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (1) It is unlawful for any person, knowing it to be such, to: (a) Present, or cause to be presented, a false or fraudulent claim, or any proof in support of such a claim, for the payment of a loss under a contract of insurance; or (b) Prepare, make, or subscribe any false or fraudulent account, certificate, affidavit, or proof of loss, or other document or writing, with intent that it be presented or used in support of such a claim. (2)(a) Except as provided in (b) of this subsection, a violation of this section is a gross misdemeanor. (b) If the claim is in excess of one thousand five hundred dollars, the violation is a class C felony punishable according to chapter 9A.20 RCW. **State:** Washington **Statute Areas:** Claims Fraud --- ### [Washington-Fraud Bureau-West's RCWA 48.135.020](https://insurancefraud.org/statutes/washington-fraud-bureau-wests-rcwa-48-135-020/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (1) There is established an insurance fraud program within the office of the insurance commissioner. The commissioner may employ supervisory, legal, and investigative personnel for the program, who must be qualified by training and experience in the areas of detection, investigation, or prosecution of fraud in which the insurance industry is a victim. The chief of the fraud program is a full-time position that is appointed by the commissioner. The chief serves at the pleasure of the commissioner. The commissioner shall provide office space, equipment, supplies, investigators, clerical staff, and other staff that are necessary for the program to carry out its duties and responsibilities under this chapter. (2) The commissioner may fund one or more state patrol officers to work with the insurance fraud program and the funding for the officers must be paid out of the budget of the insurance fraud program. (3) The commissioner may fund one or more assistant attorneys general and support staff to work with the insurance fraud program and the funding for the assistant attorneys general and support staff must be paid out of the budget of the insurance fraud program. (4) The commissioner may make grants to or reimburse local prosecuting attorneys to assist in the prosecution of insurance fraud. The grants must be paid out of the budget of the insurance fraud program. The commissioner may investigate and seek prosecution of crimes involving insurance fraud upon the request of or with the concurrence of the county prosecuting attorney of the jurisdiction in which the offense has occurred. Before such a prosecution, the commissioner and the county in which the offense occurred shall reach an agreement regarding the payment of all costs, including expert witness fees, and defense attorneys’ fees associated with any such prosecution. (5) Staff levels for this program, until June 30, 2010, shall not exceed 8.0 full-time equivalents. **State:** Washington **Statute Areas:** Fraud Bureau --- ### [Washington-Immunity-West's RCWA 48.01.190; ¤ 48.50.070](https://insurancefraud.org/statutes/washington-immunity-wests-rcwa-48-01-190-¤-48-50-070/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (1) Any person who files reports, or furnishes other information, required under Title 48 RCW, required by the commissioner under authority granted by Title 48 RCW, useful to the commissioner in the administration of Title 48 RCW, or furnished to the National Association of Insurance Commissioners at the request of the commissioner or pursuant to Title 48 RCW, shall be immune from liability in any civil action or suit arising from the filing of any such report or furnishing such information to the commissioner or the National Association of Insurance Commissioners, unless actual malice, fraud, or bad faith is shown. (2) The commissioner and the National Association of Insurance Commissioners, and the agents and employees of each, are immune from liability in any civil action or suit arising from the publication of any report or bulletin or dissemination of information related to the official activities of the commissioner or the National Association of Insurance Commissioners, unless actual malice, fraud, or bad faith is shown. (3) Any licensee under chapter 48.17 RCW and any trade association of the licensees under chapter 48.15 RCW, and any officer, director, employee, agent, or committee of the licensee or association who furnishes information to or for the commissioner or to or for the association regarding unauthorized insurers or regarding attempts by any person to place or actual placement by any person of business with the insurers, whether in compliance with chapter 48.15 RCW or not, shall be immune from each and every kind of liability in any civil action or suit arising in whole or in part from the information or from the furnishing of the information. (4) The immunity granted by this section is in addition to any common law or statutory privilege or immunity enjoyed by such person, and nothing in this section is intended to abrogate or modify in any way such common law or statutory privilege or immunity.\*\*\*\*\*\* Any licensed insurance producer, title insurance agent, or insurer or person acting in the insurer’s behalf, health maintenance organization or person acting in behalf of the health maintenance organization, health care service contractor or person acting in behalf of the health care service contractor, or any authorized agency which releases information, whether oral or written, to the commissioner, the national insurance crime bureau, the national association of insurance commissioners, other law enforcement agent or agency, or another insurer under RCW 48.50.030, 48.50.040, 48.50.050, 48.50.055, or 48.135.050 is immune from liability in any civil or criminal action, suit, or prosecution arising from the release of the information, unless actual malice on the part of the insurance producer, title insurance agent, insurer, health care maintenance organization, health care service contractor, or authorized agency against the insured is shown. **State:** Washington **Statute Areas:** Immunity --- ### [Washington-Licensing Board Notification-n/a](https://insurancefraud.org/statutes/washington-licensing-board-notification-n-a/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** No statute found **State:** Washington --- ### [Washington-Mandatory Restitution-West's RCWA 48.135.070](https://insurancefraud.org/statutes/washington-mandatory-restitution-wests-rcwa-48-135-070/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** In a criminal prosecution for any crime under Washington law in which the insurance company is a victim, the insurance company is entitled to be considered as a victim in any restitution ordered by the court under RCW 9.94A.753, as part of the criminal penalty imposed against the defendant convicted for such a violation. **State:** Washington **Statute Areas:** Mandatory Restitution --- ### [Washington-Placing Bogus Coverage-West's RCWA 48.30.090](https://insurancefraud.org/statutes/washington-placing-bogus-coverage-wests-rcwa-48-30-090/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** No person shall make, issue or circulate, or cause to be made, issued or circulated any misrepresentation of the terms of any policy or the benefits or advantages promised thereby, or the dividends or share of surplus to be received thereon, or use any name or title of any policy or class of policies misrepresenting the nature thereof. **State:** Washington --- ### [Washington-Practitioner Penalites-West's RCWA 48.30A.040](https://insurancefraud.org/statutes/washington-practitioner-penalites-wests-rcwa-48-30a-040/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** A violation of this chapter is cause for discipline and constitutes unprofessional conduct that could result in any regulatory penalty provided by law, including refusal, revocation, or suspension of a business or professional license, or right or admission to practice. Conduct that constitutes a violation of this chapter is unprofessional conduct in violation of RCW 18.130.180. **State:** Washington **Statute Areas:** Practitioner Penalites --- ### [Washington-Range of Criminal Penalties-West's RCWA 48.01.080](https://insurancefraud.org/statutes/washington-range-of-criminal-penalties-wests-rcwa-48-01-080/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Except as otherwise provided in this code, any person violating any provision of this code is guilty of a gross misdemeanor and will, upon conviction, be fined not less than ten dollars nor more than one thousand dollars, or imprisoned for not more than three hundred sixty-four days, or both, in addition to any other penalty or forfeiture provided herein or otherwise by law. **State:** Washington **Statute Areas:** Range of Criminal Penalties --- ### [Washington-Range of Civil Penalties-West's RCWA 48.01.080](https://insurancefraud.org/statutes/washington-range-of-civil-penalties-wests-rcwa-48-01-080/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Except as otherwise provided in this code, any person violating any provision of this code is guilty of a gross misdemeanor and will, upon conviction, be fined not less than ten dollars nor more than one thousand dollars, or imprisoned for not more than three hundred sixty-four days, or both, in addition to any other penalty or forfeiture provided herein or otherwise by law. **State:** Washington **Statute Areas:** Range of Civil Penalties --- ### [Washington-Rating of an Insurance Policy-West's RCWA 48.19.020](https://insurancefraud.org/statutes/washington-rating-of-an-insurance-policy-wests-rcwa-48-19-020/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Premium rates for insurance shall not be excessive, inadequate, or unfairly discriminatory **State:** Washington --- ### [Washington-Underwriting Fraud-West's RCWA 48.30.180](https://insurancefraud.org/statutes/washington-underwriting-fraud-wests-rcwa-48-30-180/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** No person shall by misrepresentations or by misleading comparisons, induce or tend to induce any insured to lapse, terminate, forfeit, surrender, retain, or convert any insurance policy. **State:** Washington **Statute Areas:** Underwriting Fraud --- ### [Washington-Unauthorized Entities-West's RCWA 48.15.020](https://insurancefraud.org/statutes/washington-unauthorized-entities-wests-rcwa-48-15-020/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (1) An insurer that is not authorized by the commissioner may not solicit insurance business in this state or transact insurance business in this state, except as provided in this chapter. (2)(a) A person may not, in this state, represent an unauthorized insurer except as provided in this chapter. This subsection does not apply to any adjuster or attorney-at-law representing an unauthorized insurer from time to time in this state in his or her professional capacity. (b) A person, other than a duly licensed surplus line broker acting in good faith under his or her license, who makes a contract of insurance in this state, directly or indirectly, on behalf of an unauthorized insurer, without complying with the provisions of this chapter, is personally liable for the performance of such contract. (3) Each violation of subsection (2) of this section constitutes a separate offense punishable by a fine of not more than twenty-five thousand dollars, and the commissioner, at the commissioner’s discretion, may order replacement of policies improperly placed with an unauthorized insurer with policies issued by an authorized insurer. Violations may result in suspension or revocation of a license. **State:** Washington --- ### [Virginia-Aiding & Abetting-n/a](https://insurancefraud.org/statutes/virginia-aiding-abetting-n-a/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** No statute found **State:** Virginia --- ### [Virginia-Anti-Runner Provisions-n/a](https://insurancefraud.org/statutes/virginia-anti-runner-provisions-n-a/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** No statute found **State:** Virginia **Statute Areas:** Anti-Runner Provisions --- ### [Virginia-Attempted Fraud-n/a](https://insurancefraud.org/statutes/virginia-attempted-fraud-n-a/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** No statute found **State:** Virginia **Statute Areas:** Attempted Fraud --- ### [Virginia-Claims Fraud-n/a](https://insurancefraud.org/statutes/virginia-claims-fraud-n-a/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** No statute found **State:** Virginia **Statute Areas:** Claims Fraud --- ### [Virginia-Failing to Remit Premium-VA Code Ann. ¤ 38.2-1363](https://insurancefraud.org/statutes/virginia-failing-to-remit-premium-va-code-ann-¤-38-2-1363/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** B. The Commission may, in addition to or in lieu of a penalty imposed under ¤ 38.2-218, place on probation, suspend, revoke or refuse to issue or renew any person’s license as a managing general agent for any one or more of the following causes: 4. Improperly withholding, misappropriating, or converting any moneys or properties received in the course of doing business; **State:** Virginia --- ### [Virginia-Fraud Bureau-VA Code Ann. ¤ 52-37 (Proposed Legislation).](https://insurancefraud.org/statutes/virginia-fraud-bureau-va-code-ann-¤-52-37-proposed-legislation/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** A. There shall be established within the Department of State Police, Bureau of Criminal Investigation, the Insurance Fraud Investigation Unit. The purposes of this unit shall be to: 1. Initiate independent inquiries and conduct independent investigations when the Department has reason to believe that insurance fraud may have been or is currently being committed, and to undertake studies to determine the extent of such insurance fraud. 2. Respond to notification or complaints alleging insurance fraud generated by federal, state and local police, other law-enforcement authorities, governmental agencies or units, and any other person. 3. Review notices and reports of insurance fraud; select the incidents of suspected fraud that, in its judgment, require further detailed investigation; and conduct the investigations. B. The Superintendent may appoint such agents as he may deem necessary to assist the Department in carrying out its powers and duties under this chapter. **State:** Virginia **Statute Areas:** Fraud Bureau --- ### [Virginia-Immunity-VA Code Ann. ¤ 52-41](https://insurancefraud.org/statutes/virginia-immunity-va-code-ann-¤-52-41/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** A. Any insurer providing information to an authorized representative of the Department pursuant to ¤ 52-38 or pursuant to subdivision B 5 of ¤ 38.2-613 shall have the right to request relevant information and receive, within thirty days, the information requested. B. No cause of action in the nature of defamation, invasion of privacy, or negligence shall arise against any person furnishing information concerning any suspected, anticipated or completed criminal violation when the information is provided to or received from the Department, the National Association of Insurance Commissioners, another insurer, any federal or state governmental entity established for the purposes of detecting and preventing insurance fraud, or the National Insurance Crime Bureau. C. No insurer, its officers or employees, insurance professional or any other person shall be subject to such cause of action for cooperating with, or furnishing evidence or information regarding any suspected criminal violation to the Department. D. This section shall not provide immunity for those disclosing or furnishing false information with malice or willful intent to injure any person. E. This section does not abrogate or modify in any way common law or statutory privilege or immunity heretofore enjoyed by any person or entity, nor does it authorize the Department to make public insurance company records that are proprietary in nature. **State:** Virginia **Statute Areas:** Immunity --- ### [Virginia-Insurance Fraud - Definition-VA Code Ann. ¤ 18.2-178](https://insurancefraud.org/statutes/virginia-insurance-fraud-definition-va-code-ann-¤-18-2-178/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** A. If any person obtain, by any false pretense or token, from any person, with intent to defraud, money, a gift certificate or other property that may be the subject of larceny, he shall be deemed guilty of larceny thereof; or if he obtain, by any false pretense or token, with such intent, the signature of any person to a writing, the false making whereof would be forgery, he shall be guilty of a Class 4 felony. B. Venue for the trial of any person charged with an offense under this section may be in the county or city in which (i) any act was performed in furtherance of the offense, or (ii) the person charged with the offense resided at the time of the offense. **State:** Virginia **Statute Areas:** Insurance Fraud - Definition --- ### [Virginia-Licensing Board Notification-n/a](https://insurancefraud.org/statutes/virginia-licensing-board-notification-n-a/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** No statute found **State:** Virginia --- ### [Virginia-Mandatory Restitution-VA Code Ann. ¤ 38.2-218](https://insurancefraud.org/statutes/virginia-mandatory-restitution-va-code-ann-¤-38-2-218/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** D. 1. The Commission may require a person to make restitution in the amount of the direct actual financial loss: a. For charging a rate in excess of that provided by statute or by the rates filed with the Commission by the insurer; b. For charging a premium that is determined by the Commission to be unfairly discriminatory, such restitution being limited to a period of one year from the date of determination; c. For failing to pay amounts explicitly required by the terms of the insurance contract where no aspect of the claim is disputed by the insurer; and d. For improperly withholding, misappropriating, or converting any money or property received in the course of doing business. **State:** Virginia **Statute Areas:** Mandatory Restitution --- ### [Virginia-Practitioner Penalites-VA Code Ann. ¤ 38.2-219](https://insurancefraud.org/statutes/virginia-practitioner-penalites-va-code-ann-¤-38-2-219/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** A. Whenever the Commission has reason to believe that any person has committed a violation of this title or of any rule, regulation, or order issued by the Commission under this title, it shall issue and serve an order upon that person by certified or registered mail or in any other manner permitted by law. The order shall include a statement of the charges and a notice of a hearing on the charges to be held at a fixed time and place which shall be at least ten days after the date of service of the notice. The order shall require that person to show cause why an order should not be made by the Commission directing the alleged offender to cease and desist from the violation or to show cause why the Commission should not issue any other appropriate order as the nature of the case and the interests of the policyholders, creditors, shareholders, or the public may require. At the hearing, that person shall have an opportunity to be heard in accordance with the Commission’s order. In all matters in connection with the charges or hearing, the Commission shall have the jurisdiction, power and authority granted or conferred upon it by Title 12.1 and, except as otherwise provided in this title, the procedure shall conform to and the right of appeal shall be the same as that provided in Title 12.1. B. If the Commission finds in the hearing that there is about to be or has been a violation of this title, it may issue and serve upon any person committing the violation by certified or registered mail or in any other manner permitted by law (i) an order reciting its findings and directing the person to cease and desist from the violation or (ii) such other appropriate order as the nature of the case and the interests of the policyholders, creditors, shareholders, or the public requires. C. Any person who violates any order issued under subsection B of this section may upon conviction be subject to one or both of the following: 1. Punishment as provided in ¤ 38.2-218; or 2. The suspension or revocation of any license issued by the Commission. **State:** Virginia **Statute Areas:** Practitioner Penalites --- ### [Virginia-Range of Civil Penalties-VA Code Ann. ¤ 38.2-218](https://insurancefraud.org/statutes/virginia-range-of-civil-penalties-va-code-ann-¤-38-2-218/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** A. Any person who knowingly or willfully violates any provision of this title or any regulation issued pursuant to this title shall be punished for each violation by a penalty of not more than $5,000. B. Any person who violates without knowledge or intent any provision of this title or any rule, regulation, or order issued pursuant to this title may be punished for each violation by a penalty of not more than $1,000. For the purpose of this subsection, a series of similar violations resulting from the same act shall be limited to a penalty in the aggregate of not more than $10,000. C. Any violation resulting solely from a malfunction of mechanical or electronic equipment shall not be subject to a penalty. D. 1. The Commission may require a person to make restitution in the amount of the direct actual financial loss: a. For charging a rate in excess of that provided by statute or by the rates filed with the Commission by the insurer; b. For charging a premium that is determined by the Commission to be unfairly discriminatory, such restitution being limited to a period of one year from the date of determination; c. For failing to pay amounts explicitly required by the terms of the insurance contract where no aspect of the claim is disputed by the insurer; and d. For improperly withholding, misappropriating, or converting any money or property received in the course of doing business. 2. The Commission shall have no jurisdiction to adjudicate controversies growing out of this subsection regarding restitution among insurers, insureds, agents, claimants and beneficiaries. E. The provisions provided under this section may be imposed in addition to or without imposing any other penalties or actions provided by law. **State:** Virginia **Statute Areas:** Range of Civil Penalties --- ### [Virginia-Rating of an Insurance Policy-VA Code Ann. ¤ 38.2-1904](https://insurancefraud.org/statutes/virginia-rating-of-an-insurance-policy-va-code-ann-¤-38-2-1904/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** A. Rates for the classes of insurance to which this chapter applies shall not be excessive, inadequate, or unfairly discriminatory. All rates and all changes and amendments to rates to which this chapter applies for use in this Commonwealth shall consider loss experience and other factors within Virginia if relevant and actuarially sound, provided that other data, including countrywide, regional, or other state data, may be considered where such data is relevant and where a sound actuarial basis exists for considering data other than Virginia-specific data. 1. No rate shall be held to be excessive unless it is unreasonably high for the insurance provided and a reasonable degree of competition does not exist in the area with respect to the classification to which the rate applies. 2. No rate shall be held inadequate unless it is unreasonably low for the insurance provided and (i) continued use of it would endanger solvency of the insurer or (ii) use of the rate by the insurer has or, if continued, will have the effect of destroying competition or creating a monopoly. 3. No rate shall be unfairly discriminatory if a different rate is charged for the same coverage and the rate differential (i) is based on sound actuarial principles or (ii) is related to actual or reasonably anticipated experience. B. 1. In determining whether rates comply with the standards of subsection A, separate consideration shall be given to (i) past and prospective loss experience within and outside this Commonwealth, (ii) conflagration or catastrophe hazards, (iii) a reasonable margin for underwriting profit and contingencies, (iv) dividends, savings or unabsorbed premium deposits allowed or returned by insurers to their policyholders, members or subscribers, (v) past and prospective expenses both countrywide and those specifically applicable to this Commonwealth, (vi) the loss reserving practices, standards and procedures utilized by the insurer, (vii) investment income earned or realized by insurers from their unearned premium and loss reserve and the Commission may give separate consideration to investment income earned on surplus funds, and (viii) all other relevant factors within and outside this Commonwealth. When actual experience or data does not exist, the Commission may consider estimates. 2. In the case of fire insurance rates, consideration shall be given to the experience of the fire insurance business during a period of not less than the most recent five-year period for which such experience is available. 3. In the case of workers’ compensation insurance rates for volunteer firefighters or volunteer emergency medical services personnel, the rates shall be calculated based upon the combined experience of both volunteer firefighters or volunteer emergency medical services personnel and paid firefighters or paid emergency medical services personnel, so that the resulting rate is the same for both volunteer and paid members, but in no event shall resulting premiums be less than $40 per year for any volunteer firefighter or volunteer emergency medical services personnel. 4. In the case of uninsured motorist coverage required by subsection A of ¤ 38.2-2206, consideration shall be given to all sums distributed by the Commission from the Uninsured Motorists Fund in accordance with the provisions of Chapter 30 (¤ 38.2-3000 et seq.). C. For the classes of insurance to which this chapter applies, including insurance against contingent, consequential and indirect losses as defined in ¤ 38.2-133 (i) the systems of expense provisions included in the rates for use by any insurer or group of insurers may differ from those of other insurers or groups of insurers to reflect the requirements of the operating methods of any such insurer or group for any class of insurance, or with respect to any subdivision or combination of insurance for which separate expense provisions are applicable, and (ii) risks may be grouped by classifications for the establishment of rates and minimum premiums. Classification rates may be modified to produce rates for individual risks in accordance with rating plans that establish standards for measuring variations in hazards, expense provisions, or both. The standards may measure any difference between risks that can be demonstrated to have a probable effect upon losses or expenses. Notwithstanding any other provision of this subsection, except as permitted by ¤ 38.2-1908, each member of a rate service organization shall use the uniform classification system, uniform experience rating plan, and uniform statistical plan of its designated rate service organization in the provision of insurance defined in ¤ 38.2-119. D. No insurer shall use any information pertaining to any motor vehicle conviction or accident to produce increased or surcharged rates above their filed manual rates for individual risks for a period longer than 36 months. This period shall begin no later than 12 months after the date of the conviction or accident. E. Each authorized insurer subject to the provisions of this chapter may file with the Commission an expense reduction plan that permits variations in expense provisions. Such filing may contain provisions permitting agents to reduce their commission resulting in an appropriate reduction in premium. Nothing in this section shall be construed to require an agent to reduce a commission, nor may an insurer unreasonably refuse to reduce a premium due to a commission reduction as permitted by its filed expense reduction plan **State:** Virginia --- ### [Vermont-Claims Fraud-13 V.S.A. ¤ 2031 (Proposed Legislation)](https://insurancefraud.org/statutes/vermont-claims-fraud-13-v-s-a-¤-2031-proposed-legislation/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (b) Fraudulent insurance act. No person shall, with intent to defraud: (1) present or cause to be presented a claim for payment or benefit, pursuant to any insurance policy, that contains false representations as to any material fact or which conceals a material fact; **State:** Vermont **Statute Areas:** Claims Fraud --- ### [Vermont-Immunity-13 V.S.A. ¤ 2031 (Proposed Legislation)](https://insurancefraud.org/statutes/vermont-immunity-13-v-s-a-¤-2031-proposed-legislation/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (f) Immunity. No insurer or insurance professional acting in good faith and furnishing or disclosing information to the appropriate law enforcement official shall be subject to civil liability for libel, slander, or any other cause of action arising from the furnishing or disclosing of such information, except if the information is furnished solely to obtain an advantage in connection with a claim that will be, is being, or has been filed. **State:** Vermont **Statute Areas:** Immunity --- ### [Vermont-Insurance Fraud - Definition-13 V.S.A. ¤ 2031 (Proposed Legislation)](https://insurancefraud.org/statutes/vermont-insurance-fraud-definition-13-v-s-a-¤-2031-proposed-legislation/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) Definitions. As used in this section: (1) “Conceal” means to take affirmative action intended to prevent others from discovering information. Mere failure to disclose information does not constitute concealment. (2) “Insurance policy” has the same meaning as in 8 V.S.A. ¤ 4722(3) and includes a workers’ compensation policy issued pursuant to chapter 9 of Title 21. (3) “Insurer” has the same meaning as in 8 V.S.A. ¤ 4901(2) and includes a workers’ compensation insurer pursuant to chapter 9 of Title 21. (b) Fraudulent insurance act. No person shall, with intent to defraud: (1) present or cause to be presented a claim for payment or benefit, pursuant to any insurance policy, that contains false representations as to any material fact or which conceals a material fact; or (2) present or cause to be presented any information which contains false representations as to any material fact or which conceals a material fact concerning the solicitation for sale of any insurance policy or purported insurance policy, an application for certificate of authority, or the financial condition of any insurer. (c) Penalties. A person who violates subsection (b) of this section shall: (1) if the benefit wrongfully obtained or the loss suffered by any person as a result of the violation has a value of less than $900.00, be imprisoned for not more than six months or fined not more than $5,000.00, or both; or (2) if the benefit wrongfully obtained or the loss suffered by any person as a result of the violation has a value of more than $900.00, be imprisoned for not more than five years or fined not more than $10,000.00, or both; or (3) for a second or subsequent offense, regardless of the value of the benefit wrongfully obtained, be imprisoned not more than five years or fined not more than $20,000.00, or both. (d) Administrative action. Upon the conviction of a practitioner for a violation of subsection (b) of this section, the prosecutor shall inform the appropriate licensing authority. Any victim may notify the appropriate licensing authorities in this state and any other jurisdiction in which the practitioner is licensed of the conviction. (e) This section shall not be construed to limit or restrict prosecution under any other applicable law. (f) Immunity. No insurer or insurance professional acting in good faith and furnishing or disclosing information to the appropriate law enforcement official shall be subject to civil liability for libel, slander, or any other cause of action arising from the furnishing or disclosing of such information, except if the information is furnished solely to obtain an advantage in connection with a claim that will be, is being, or has been filed. (g) The public policy of this state is that the standards of this section shall not apply or be introduced into evidence in any civil or administrative proceeding, whether to argue public policy, materiality, or for any other purpose. **State:** Vermont **Statute Areas:** Insurance Fraud - Definition --- ### [Vermont-Licensing Board Notification-13 V.S.A. ¤ 2031 (Proposed Legislation)](https://insurancefraud.org/statutes/vermont-licensing-board-notification-13-v-s-a-¤-2031-proposed-legislation/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (b) Fraudulent insurance act. No person shall, with intent to defraud: (1) present or cause to be presented a claim for payment or benefit, pursuant to any insurance policy, that contains false representations as to any material fact or which conceals a material fact; or (2) present or cause to be presented any information which contains false representations as to any material fact or which conceals a material fact concerning the solicitation for sale of any insurance policy or purported insurance policy, an application for certificate of authority, or the financial condition of any insurer. (d) Administrative action. Upon the conviction of a practitioner for a violation of subsection (b) of this section, the prosecutor shall inform the appropriate licensing authority. Any victim may notify the appropriate licensing authorities in this state and any other jurisdiction in which the practitioner is licensed of the conviction. (e) This section shall not be construed to limit or restrict prosecution under any other applicable law. **State:** Vermont --- ### [Vermont-Practitioner Penalites-13 V.S.A. ¤ 2031 (Proposed Legislation)](https://insurancefraud.org/statutes/vermont-practitioner-penalites-13-v-s-a-¤-2031-proposed-legislation/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (b) Fraudulent insurance act. No person shall, with intent to defraud: (1) present or cause to be presented a claim for payment or benefit, pursuant to any insurance policy, that contains false representations as to any material fact or which conceals a material fact; or (2) present or cause to be presented any information which contains false representations as to any material fact or which conceals a material fact concerning the solicitation for sale of any insurance policy or purported insurance policy, an application for certificate of authority, or the financial condition of any insurer. (d) Administrative action. Upon the conviction of a practitioner for a violation of subsection (b) of this section, the prosecutor shall inform the appropriate licensing authority. Any victim may notify the appropriate licensing authorities in this state and any other jurisdiction in which the practitioner is licensed of the conviction. (e) This section shall not be construed to limit or restrict prosecution under any other applicable law. **State:** Vermont **Statute Areas:** Practitioner Penalites --- ### [Vermont-Range of Criminal Penalties-13 V.S.A. ¤ 2031 (Proposed Legislation)](https://insurancefraud.org/statutes/vermont-range-of-criminal-penalties-13-v-s-a-¤-2031-proposed-legislation/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (c) Penalties. A person who violates subsection (b) of this section shall: (1) if the benefit wrongfully obtained or the loss suffered by any person as a result of the violation has a value of less than $900.00, be imprisoned for not more than six months or fined not more than $5,000.00, or both; or (2) if the benefit wrongfully obtained or the loss suffered by any person as a result of the violation has a value of more than $900.00, be imprisoned for not more than five years or fined not more than $10,000.00, or both; or (3) for a second or subsequent offense, regardless of the value of the benefit wrongfully obtained, be imprisoned not more than five years or fined not more than $20,000.00, or both. (d) Administrative action. Upon the conviction of a practitioner for a violation of subsection (b) of this section, the prosecutor shall inform the appropriate licensing authority. Any victim may notify the appropriate licensing authorities in this state and any other jurisdiction in which the practitioner is licensed of the conviction. (e) This section shall not be construed to limit or restrict prosecution under any other applicable law. **State:** Vermont **Statute Areas:** Range of Criminal Penalties --- ### [Vermont-Range of Civil Penalties-13 V.S.A. ¤ 2031 (Proposed Legislation)](https://insurancefraud.org/statutes/vermont-range-of-civil-penalties-13-v-s-a-¤-2031-proposed-legislation/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (c) Penalties. A person who violates subsection (b) of this section shall: (1) if the benefit wrongfully obtained or the loss suffered by any person as a result of the violation has a value of less than $900.00, be imprisoned for not more than six months or fined not more than $5,000.00, or both; or (2) if the benefit wrongfully obtained or the loss suffered by any person as a result of the violation has a value of more than $900.00, be imprisoned for not more than five years or fined not more than $10,000.00, or both; or (3) for a second or subsequent offense, regardless of the value of the benefit wrongfully obtained, be imprisoned not more than five years or fined not more than $20,000.00, or both. (d) Administrative action. Upon the conviction of a practitioner for a violation of subsection (b) of this section, the prosecutor shall inform the appropriate licensing authority. Any victim may notify the appropriate licensing authorities in this state and any other jurisdiction in which the practitioner is licensed of the conviction. (e) This section shall not be construed to limit or restrict prosecution under any other applicable law. **State:** Vermont **Statute Areas:** Range of Civil Penalties --- ### [Vermont-Rating of an Insurance Policy-8 V.S.A. ¤ 4685](https://insurancefraud.org/statutes/vermont-rating-of-an-insurance-policy-8-v-s-a-¤-4685/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) General. Rates shall not be excessive, inadequate, or unfairly discriminatory. (b) Excessiveness. (1) Competitive market. A rate in a competitive market is not excessive. (2) Noncompetitive market. Rates in a noncompetitive market are excessive if they are producing or are likely to produce unreasonably high profits for the insurance provided or if expenses are unreasonably high in relation to services rendered. (c) Inadequacy. Rates are not inadequate unless insufficient to sustain projected losses and expenses in the class or classes of business to which they apply or the use of such rates has or, if continued, will have the effect of substantially lessening competition or the tendency to create a monopoly in any market. (d) Unfair discrimination. Unfair discrimination exists if, after allowing for practical limitations, price differentials fail to reflect equitably the differences in expected losses and expenses. A rate is not unfairly discriminatory because different premiums result for a class of policyholders with like loss exposures but different expenses, or like expenses but different loss exposures, provided that the rate equitably reflects the differences with reasonable accuracy. A rate is not unfairly discriminatory if it is averaged broadly among persons insured under a group, franchise, or blanket policy or a mass marketed plan. **State:** Vermont --- ### [Vermont-Underwriting Fraud-13 V.S.A. ¤ 2031 (Proposed Legislation)](https://insurancefraud.org/statutes/vermont-underwriting-fraud-13-v-s-a-¤-2031-proposed-legislation/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (b) Fraudulent insurance act. No person shall, with intent to defraud: (1) present or cause to be presented a claim for payment or benefit, pursuant to any insurance policy, that contains false representations as to any material fact or which conceals a material fact; or (2) present or cause to be presented any information which contains false representations as to any material fact or which conceals a material fact concerning the solicitation for sale of any insurance policy or purported insurance policy, an application for certificate of authority, or the financial condition of any insurer. **State:** Vermont **Statute Areas:** Underwriting Fraud --- ### [Vermont-Unauthorized Entities-8 V.S.A. ¤ 3368a](https://insurancefraud.org/statutes/vermont-unauthorized-entities-8-v-s-a-¤-3368a/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) No person shall transact insurance business in this State unless the Commissioner has issued a license or certificate of authority to such person as required by section 3361 or 3368 of this title, or by chapters 123, 125, and 139 of this title. The provisions of this section shall not apply to an insurer licensed in this State or in any foreign or alien jurisdiction who is subject to section 3368 of this title. (b) No person shall act as an officer, director, or controlling person for a person who is engaged in a violation of subsection (a) of this section. As used in this subsection, “controlling” is defined by subdivision 3681(3) of this title. (c) No person shall directly or indirectly represent or aid a person in violating subsection (a) of this section. (d)(1) No person shall use in its advertisements or other marketing materials or communications the term “insurance” or any other term in a manner which could reasonably lead a person into believing that the product marketed, offered, or issued is insurance, unless such person is authorized under this title to transact the business of insurance. (2) No person shall use in its advertisements or other marketing materials or communications the terms “health plan,” “coverage,” “co-pay,” “co-payments,” “deductible,” “preexisting conditions,” “guaranteed issue,” “premium,” “enrollment,” “preferred provider organization,” or any other term in a manner that could reasonably mislead an individual into believing that the product marketed, offered, or issued is health insurance, unless such person is authorized under this title to transact the business of health insurance. (e) In addition to any other remedies or penalties provided by law: (1) For each violation of the provisions of subsection (a), (b), or (c) of this section a person shall be imprisoned not more than five years or fined not more than $10,000.00, or both. (2) For each violation of the provisions of subsection (d) of this section a person shall be imprisoned not more than two years or fined not more than $5,000.00, or both. **State:** Vermont --- ### [Utah-Aiding & Abetting-U.C.A. 1953 ¤ 31A-31-103](https://insurancefraud.org/statutes/utah-aiding-abetting-u-c-a-1953-¤-31a-31-103/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (1) A person commits a fraudulent insurance act if that person with intent to deceive or defraud: (a) knowingly presents or causes to be presented to an insurer any oral or written statement or representation knowing that the statement or representation contains false, incomplete, or misleading information concerning any fact material to an application for the issuance or renewal of an insurance policy, certificate, or contract; (b) knowingly presents or causes to be presented to an insurer any oral or written statement or representation: (i)(A) as part of, or in support of, a claim for payment or other benefit pursuant to an insurance policy, certificate, or contract; or (B) in connection with any civil claim asserted for recovery of damages for personal or bodily injuries or property damage; and (ii) knowing that the statement or representation contains false, incomplete, or misleading information concerning any fact or thing material to the claim; (c) knowingly accepts a benefit from the proceeds derived from a fraudulent insurance act; (d) assists, abets, solicits, or conspires with another to commit a fraudulent insurance act; (e) knowingly supplies false or fraudulent material information in any document or statement required by the department; (f) knowingly fails to forward a premium to an insurer in violation of Section 31A-23a-411.1; or (g) knowingly employs, uses, or acts as a runner for the purpose of committing a fraudulent insurance act. (2) A service provider commits a fraudulent insurance act if that service provider with intent to deceive or defraud: (a) knowingly submits or causes to be submitted a bill or request for payment: (i) containing charges or costs for an item or service that are substantially in excess of customary charges or costs for the item or service; or (ii) containing itemized or delineated fees for what would customarily be considered a single procedure or service; (b) knowingly furnishes or causes to be furnished an item or service to a person: (i) substantially in excess of the needs of the person; or (ii) of a quality that fails to meet professionally recognized standards; (c) knowingly accepts a benefit from the proceeds derived from a fraudulent insurance act; or (d) assists, abets, solicits, or conspires with another to commit a fraudulent insurance act. (3) An insurer commits a fraudulent insurance act if that insurer with intent to deceive or defraud: (a) knowingly withholds information or provides false or misleading information with respect to an application, coverage, benefits, or claims under a policy or certificate; (b) assists, abets, solicits, or conspires with another to commit a fraudulent insurance act; (c) knowingly accepts a benefit from the proceeds derived from a fraudulent insurance act; or (d) knowingly supplies false or fraudulent material information in any document or statement required by the department. (4) An insurer or service provider is not liable for any fraudulent insurance act committed by an employee without the authority of the insurer or service provider unless the insurer or service provider knew or should have known of the fraudulent insurance act. **State:** Utah --- ### [Utah-Anti-Runner Provisions-U.C.A. 1953 ¤ 31A-31-102; U.C.A. 1953 ¤ 31A-31-103](https://insurancefraud.org/statutes/utah-anti-runner-provisions-u-c-a-1953-¤-31a-31-102-u-c-a-1953-¤-31a-31-103/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (1) A person commits a fraudulent insurance act if that person with intent to deceive or defraud: (g) knowingly employs, uses, or acts as a runner for the purpose of committing a fraudulent insurance act. (6)(a) “Runner” means a person who procures clients at the direction of, or in cooperation with a person who intends to: (i) perform or obtain a service or benefit under a contract of insurance; or (ii) assert a claim against an insured. (b) “Runner” includes: (i) a capper; or (ii) a steerer. **State:** Utah **Statute Areas:** Anti-Runner Provisions --- ### [Utah-Claims Fraud-U.C.A. 1953 ¤ 31A-31-103](https://insurancefraud.org/statutes/utah-claims-fraud-u-c-a-1953-¤-31a-31-103/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (1) A person commits a fraudulent insurance act if that person with intent to deceive or defraud: (a) knowingly presents or causes to be presented to an insurer any oral or written statement or representation knowing that the statement or representation contains false, incomplete, or misleading information concerning any fact material to an application for the issuance or renewal of an insurance policy, certificate, or contract; (b) knowingly presents or causes to be presented to an insurer any oral or written statement or representation: (i)(A) as part of, or in support of, a claim for payment or other benefit pursuant to an insurance policy, certificate, or contract; or (B) in connection with any civil claim asserted for recovery of damages for personal or bodily injuries or property damage; and (ii) knowing that the statement or representation contains false, incomplete, or misleading information concerning any fact or thing material to the claim; (c) knowingly accepts a benefit from the proceeds derived from a fraudulent insurance act; (d) assists, abets, solicits, or conspires with another to commit a fraudulent insurance act; **State:** Utah **Statute Areas:** Claims Fraud --- ### [Utah-Failing to Remit Premium-U.C.A. 1953 ¤ 31A-23a-411.1](https://insurancefraud.org/statutes/utah-failing-to-remit-premium-u-c-a-1953-¤-31a-23a-411-1/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** A person commits insurance fraud as described in Subsection 31A-31-103(1)(f) if that person knowingly fails to forward to the insurer a premium: (1) received from one of the following in partial or total payment of the premium due from: (a) an applicant; (b) a policyholder; or (c) a certificate holder; or (2) collected from or on behalf of an insured employee under an insured employee benefit plan. **State:** Utah --- ### [Utah-Fraud Bureau-U.C.A. 1953 ¤ 31A-2-104](https://insurancefraud.org/statutes/utah-fraud-bureau-u-c-a-1953-¤-31a-2-104/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (1) The department shall employ a chief examiner and such other professional, technical, and clerical employees as necessary to carry out the duties of the department. (2) An insurance fraud investigator employed pursuant to Subsection (1) may as approved by the commissioner: (a) be designated a law enforcement officer, as defined in Section 53-13-103; and (b) be eligible for retirement benefits under the Public Safety Employee’s Retirement System. **State:** Utah **Statute Areas:** Fraud Bureau --- ### [Utah-Immunity-U.C.A. 1953 ¤ 31A-31-105](https://insurancefraud.org/statutes/utah-immunity-u-c-a-1953-¤-31a-31-105/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (1)(a) A person, insurer, or authorized agency is immune from civil action, civil penalty, or damages when in good faith that person, insurer, or authorized agency: (i) cooperates with an agency described in Subsection (1)(b); (ii) furnishes evidence to an agency described in Subsection (1)(b); (iii) provides information regarding a suspected fraudulent insurance act to an agency described in Subsection (1)(b); (iv) receives information regarding a suspected fraudulent insurance act from an agency described in Subsection (1)(b); or (v) submits a required report to the department under Section 31A-31-110. (b) An agency referred to in Subsection (1)(a) is one or more of the following: (i) the department or a division of the department; (ii) a federal, state, or government agency established to detect and prevent insurance fraud; (iii) a nonprofit organization established to detect and prevent insurance fraud; or (iv) an agent, employee, or designee of an agency listed in this Subsection (1)(b). (2) An insurer, or person employed by an insurer, is immune from civil action, civil penalty, or damages when in good faith the insurer or person employed by an insurer provides or shares information with another insurer or insurer’s employee in a good faith effort to discover or prevent a fraudulent insurance act or other criminal conduct. (3) A person, insurer, or authorized agency is immune from civil action, civil penalty, or damages if that person, insurer, or authorized agency complies in good faith with a court order to provide evidence or testimony requested by an agency described in Subsection (1)(b). (4) This section does not abrogate or modify a common law or statutory right, privilege, or immunity enjoyed by a person. (5) Notwithstanding any other provision in this section, a person, insurer, or service provider is not immune from civil action, civil penalty or damages under this section if that person commits the fraudulent insurance act that is the subject of the information. **State:** Utah **Statute Areas:** Immunity --- ### [Utah-Insurance Fraud - Definition-U.C.A. 1953 ¤ 31A-31-103; U.C.A. 1953 ¤ 76-6-521](https://insurancefraud.org/statutes/utah-insurance-fraud-definition-u-c-a-1953-¤-31a-31-103-u-c-a-1953-¤-76-6-521/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (1) A person commits a fraudulent insurance act if that person with intent to deceive or defraud: (a) knowingly presents or causes to be presented to an insurer any oral or written statement or representation knowing that the statement or representation contains false, incomplete, or misleading information concerning any fact material to an application for the issuance or renewal of an insurance policy, certificate, or contract; (b) knowingly presents or causes to be presented to an insurer any oral or written statement or representation: (i)(A) as part of, or in support of, a claim for payment or other benefit pursuant to an insurance policy, certificate, or contract; or (B) in connection with any civil claim asserted for recovery of damages for personal or bodily injuries or property damage; and (ii) knowing that the statement or representation contains false, incomplete, or misleading information concerning any fact or thing material to the claim; (c) knowingly accepts a benefit from the proceeds derived from a fraudulent insurance act; (d) assists, abets, solicits, or conspires with another to commit a fraudulent insurance act; (e) knowingly supplies false or fraudulent material information in any document or statement required by the department; (f) knowingly fails to forward a premium to an insurer in violation of Section 31A-23a-411.1; or (g) knowingly employs, uses, or acts as a runner for the purpose of committing a fraudulent insurance act. (2) A service provider commits a fraudulent insurance act if that service provider with intent to deceive or defraud: (a) knowingly submits or causes to be submitted a bill or request for payment: (i) containing charges or costs for an item or service that are substantially in excess of customary charges or costs for the item or service; or (ii) containing itemized or delineated fees for what would customarily be considered a single procedure or service; (b) knowingly furnishes or causes to be furnished an item or service to a person: (i) substantially in excess of the needs of the person; or (ii) of a quality that fails to meet professionally recognized standards; (c) knowingly accepts a benefit from the proceeds derived from a fraudulent insurance act; or (d) assists, abets, solicits, or conspires with another to commit a fraudulent insurance act. (3) An insurer commits a fraudulent insurance act if that insurer with intent to deceive or defraud: (a) knowingly withholds information or provides false or misleading information with respect to an application, coverage, benefits, or claims under a policy or certificate; (b) assists, abets, solicits, or conspires with another to commit a fraudulent insurance act; (c) knowingly accepts a benefit from the proceeds derived from a fraudulent insurance act; or (d) knowingly supplies false or fraudulent material information in any document or statement required by the department. (4) An insurer or service provider is not liable for any fraudulent insurance act committed by an employee without the authority of the insurer or service provider unless the insurer or service provider knew or should have known of the fraudulent insurance act. **State:** Utah **Statute Areas:** Insurance Fraud - Definition --- ### [Utah-Licensing Board Notification-U.C.A. 1953 ¤ 31A-31-110](https://insurancefraud.org/statutes/utah-licensing-board-notification-u-c-a-1953-¤-31a-31-110/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (1)(a) A person shall report a fraudulent insurance act to the department if: (i) the person has a good faith belief on the basis of a preponderance of the evidence that a fraudulent insurance act is being, will be, or has been committed by a person other than the person making the report; and (ii) the person is: (A) an insurer; or (B) in relation to the business of title insurance, an auditor that is employed by a title insurer. (b) The report required by this Subsection (1) shall: (i) be in writing; (ii) provide information in detail relating to: (A) the fraudulent insurance act; and (B) the perpetrator of the fraudulent insurance act; and (iii)(A) state whether the person required to report under Subsection (1)(a) also reported the fraudulent insurance act in writing to: (I) the attorney general; (II) a state law enforcement agency; (III) a criminal investigative department or agency of the United States; (IV) a district attorney; or (V) the prosecuting attorney of a municipality or county; and (B) if the person reported the fraudulent insurance act as provided in Subsection (1)(b)(iii)(A), state the agency to which the person reported the fraudulent insurance act. (c) A person required to submit a written report under this Subsection (1) shall submit the written report to the department by no later than 90 days from the day on which the person required to report the fraudulent insurance act has a good faith belief on the basis of a preponderance of the evidence that the fraudulent insurance act is being, will be, or has been committed. (2) An action brought under Section 31A-2-201, 31A-2-308, or 31A-31-109, for failure to comply with Subsection (1) shall be commenced within four years from the date on which a person described in Subsection (1): (a) has a good faith belief on the basis of a preponderance of the evidence that a fraudulent insurance act is being, will be, or has been committed; and (b) willfully fails to report the fraudulent insurance act. (3) The department may by rule made in accordance with Title 63G, Chapter 3, Utah Administrative Rulemaking Act, provide a process by which a person described in Subsection (1)(a)(ii)(B) may comply with the requirements of Subsection (1) by reporting a fraudulent insurance act to the insurer with whom the person is employed, except that the rule shall provide that if the person reports the fraudulent insurance act to the insurer, the insurer is required to report the fraudulent insurance act to the department. (4) A person described in Subsection (1)(a)(ii) who in good faith makes a report under this section, in accordance with Section 31A-31-105, is immune from civil action, civil penalty, or damages for making that report. **State:** Utah --- ### [Utah-Looting & diverting-U.C.A. 1953 ¤ 31A-31-103](https://insurancefraud.org/statutes/utah-looting-diverting-u-c-a-1953-¤-31a-31-103/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (1) A person commits a fraudulent insurance act if that person with intent to deceive or defraud: (c) knowingly accepts a benefit from the proceeds derived from a fraudulent insurance act; or (d) assists, abets, solicits, or conspires with another to commit a fraudulent insurance act. **State:** Utah --- ### [Utah-Mandatory Restitution-U.C.A. 1953 ¤ 31A-31-109](https://insurancefraud.org/statutes/utah-mandatory-restitution-u-c-a-1953-¤-31a-31-109/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (1) In addition to other penalties provided by law, a person who violates this chapter: (a) is subject to the following civil penalties: (i) the person shall make full restitution; and (ii) the person shall pay the costs of enforcement of this chapter for the case in which the person is found to have violated this chapter: (A) as determined by the one or more authorized agencies involved; and (B) including costs of: (I) investigators; (II) attorneys; and (III) other public employees **State:** Utah **Statute Areas:** Mandatory Restitution --- ### [Utah-Placing Bogus Coverage-U.C.A. 1953 ¤ 31A-31-103](https://insurancefraud.org/statutes/utah-placing-bogus-coverage-u-c-a-1953-¤-31a-31-103/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (3) An insurer commits a fraudulent insurance act if that insurer with intent to deceive or defraud: (a) knowingly withholds information or provides false or misleading information with respect to an application, coverage, benefits, or claims under a policy or certificate; (b) assists, abets, solicits, or conspires with another to commit a fraudulent insurance act; (c) knowingly accepts a benefit from the proceeds derived from a fraudulent insurance act; or (d) knowingly supplies false or fraudulent material information in any document or statement required by the department. **State:** Utah --- ### [Utah-Practitioner Penalites-U.C.A. 1953 ¤ 31A-31-106](https://insurancefraud.org/statutes/utah-practitioner-penalites-u-c-a-1953-¤-31a-31-106/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (1) If, after giving notice and a hearing conducted pursuant to Title 63G, Chapter 4, Administrative Procedures Act, the commissioner finds by a preponderance of the evidence that a person licensed under Title 31A, Insurance Code, has committed a fraudulent insurance act, the commissioner may suspend or revoke the license issued under Title 31A, Insurance Code. (2) If the appropriate licensing authority finds by a preponderance of the evidence that a service provider violated Section 31A-31-103, the service provider is subject to revocation or suspension of the service provider’s license. (3) The commissioner may notify the appropriate licensing authority of conduct by a service provider that the commissioner believes may constitute a fraudulent insurance act. **State:** Utah **Statute Areas:** Practitioner Penalites --- ### [Utah-Premium Fraud-U.C.A. 1953 ¤ 31A-23a-411.1](https://insurancefraud.org/statutes/utah-premium-fraud-u-c-a-1953-¤-31a-23a-411-1/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** A person commits insurance fraud as described in Subsection 31A-31-103(1)(f) if that person knowingly fails to forward to the insurer a premium: (1) received from one of the following in partial or total payment of the premium due from: (a) an applicant; (b) a policyholder; or (c) a certificate holder; or (2) collected from or on behalf of an insured employee under an insured employee benefit plan. **State:** Utah **Statute Areas:** Premium Fraud --- ### [Utah-Range of Criminal Penalties-U.C.A. 1953 ¤ 76-6-521](https://insurancefraud.org/statutes/utah-range-of-criminal-penalties-u-c-a-1953-¤-76-6-521/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (2)(a) A violation of Subsection (1)(a) is a class B misdemeanor. (b) A violation of Subsections (1)(b) through (1)(g) is punishable as in the manner prescribed by Section 76-10-1801 for communication fraud for property of like value. (3) A corporation or association is guilty of the offense of insurance fraud under the same conditions as those set forth in Section 76-2-204. (4) The determination of the degree of any offense under Subsections (1)(b) through (1)(g) shall be measured by the total value of all property, money, or other things obtained or sought to be obtained by the fraudulent insurance act or acts described in Subsections (1)(b) through (1)(g). **State:** Utah **Statute Areas:** Range of Criminal Penalties --- ### [Utah-Range of Civil Penalties-U.C.A. 1953 ¤ 31A-31-109](https://insurancefraud.org/statutes/utah-range-of-civil-penalties-u-c-a-1953-¤-31a-31-109/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (1) In addition to other penalties provided by law, a person who violates this chapter: (a) is subject to the following civil penalties: (i) the person shall make full restitution; and (ii) the person shall pay the costs of enforcement of this chapter for the case in which the person is found to have violated this chapter: (A) as determined by the one or more authorized agencies involved; and (B) including costs of: (I) investigators; (II) attorneys; and (III) other public employees; and (b) in the discretion of the court, may be required to pay to the state a civil penalty not to exceed three times that amount of value improperly sought or received from the fraudulent insurance act. (2)(a) Money paid under Subsection (1)(a)(i) shall be paid to the person damaged by the fraudulent insurance act. (b) Money paid under Subsection (1)(a)(ii) shall be paid to each applicable authorized agency in the following order: (i) to the Insurance Fraud Investigation Restricted Account created in Section 31A-31-108 for the costs of enforcement incurred by the commissioner; (ii) to the General Fund for the costs of enforcement incurred by a state agency other than the commissioner; (iii) to the applicable political subdivision for the costs of enforcement incurred by the political subdivision; and (iv) to the applicable criminal investigative department or agency of the United States for the costs of enforcement incurred by the department or agency. (c) Money paid under Subsection (1)(b) shall be paid into the General Fund. (3)(a) A civil penalty assessed under Subsection (1) shall be awarded by the court as part of its judgment in both criminal and civil actions. (b) A criminal action need not be brought against a person in order for that person to be civilly liable under this section. **State:** Utah **Statute Areas:** Range of Civil Penalties --- ### [Utah-Rating of an Insurance Policy-U.C.A. 1953 ¤ 31A-19a-201](https://insurancefraud.org/statutes/utah-rating-of-an-insurance-policy-u-c-a-1953-¤-31a-19a-201/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (1) Rates may not be excessive, inadequate, or unfairly discriminatory. (2)(a) Rates are not excessive if a reasonable degree of price competition exists at the consumer level with respect to the class of business to which they apply. In determining whether a reasonable degree of price competition exists, the commissioner shall consider: (i) relevant tests of workable competition pertaining to: (A) market structure; (B) market performance; and (C) market conduct; and (ii) the practical opportunities available to consumers in the market to: (A) acquire pricing and other consumer information; and (B) compare and obtain insurance from competing insurers. (b) The tests described in Subsection (2)(a) include: (i) the size and number of insurers actively engaged in the market and class of business; (ii) the market shares of insurers actively engaged in the market and changes in market shares; (iii) the existence of rate differentials in that class of business; (iv) ease of entry and latent competition of insurers capable of easy entry; (v) availability of consumer information concerning the product and sales outlets or other sales mechanisms; and (vi) efforts of insurers to provide consumer information. (c) If reasonable price competition does not exist, rates are excessive if: (i) rates are likely to produce a long-term profit that is unreasonably high in relation to the riskiness of the class of business; or (ii) expenses are unreasonably high in relation to the services rendered. (3) Rates are inadequate if: (a) they are clearly insufficient, when combined with the investment income attributable to them, to sustain the projected losses and expenses in the class of business to which they apply; and (b) the use of such rates has or, if continued, will have: (i) the effect of substantially lessening competition; or (ii) the tendency to create a monopoly in any market. (4)(a) A rate is unfairly discriminatory if price differentials fail to equitably reflect the differences in expected losses and expenses after allowing for practical limitations. (b) A rate is not unfairly discriminatory if it is averaged broadly among persons insured under a: (i) group, franchise, or blanket policy; or (ii) mass marketed plan. **State:** Utah --- ### [Utah-Underwriting Fraud-U.C.A. 1953 ¤ 31A-31-103](https://insurancefraud.org/statutes/utah-underwriting-fraud-u-c-a-1953-¤-31a-31-103/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (2) A service provider commits a fraudulent insurance act if that service provider with intent to deceive or defraud: (a) knowingly submits or causes to be submitted a bill or request for payment: (i) containing charges or costs for an item or service that are substantially in excess of customary charges or costs for the item or service; or (ii) containing itemized or delineated fees for what would customarily be considered a single procedure or service; (b) knowingly furnishes or causes to be furnished an item or service to a person: (i) substantially in excess of the needs of the person; or (ii) of a quality that fails to meet professionally recognized standards;(3) An insurer commits a fraudulent insurance act if that insurer with intent to deceive or defraud: (a) knowingly withholds information or provides false or misleading information with respect to an application, coverage, benefits, or claims under a policy or certificate; (b) assists, abets, solicits, or conspires with another to commit a fraudulent insurance act; (c) knowingly accepts a benefit from the proceeds derived from a fraudulent insurance act; or (d) knowingly supplies false or fraudulent material information in any document or statement required by the department. (4) An insurer or service provider is not liable for any fraudulent insurance act committed by an employee without the authority of the insurer or service provider unless the insurer or service provider knew or should have known of the fraudulent insurance act. **State:** Utah **Statute Areas:** Underwriting Fraud --- ### [Utah-Unauthorized Entities-U.C.A. 1953 ¤ 31A-15-102](https://insurancefraud.org/statutes/utah-unauthorized-entities-u-c-a-1953-¤-31a-15-102/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (1) No person may do any act enumerated under Subsection (2) who knows or should know that the act may assist in the illegal placement of insurance with an unauthorized insurer or the subsequent servicing of an insurance policy illegally placed with an unauthorized insurer. (2) An act performed by mail is performed both at the place of mailing and at the place of delivery. Any of the following acts, whether performed by mail or otherwise, fall within the prohibition of Subsection (1): (a) soliciting, making, or proposing to make an insurance contract; (b) taking, receiving, or forwarding an application for insurance; (c) collecting or receiving, in full or in part, an insurance premium; (d) issuing or delivering an insurance policy or other evidence of an insurance contract except as a messenger not employed by the insurer, or an insurance producer; (e) doing any of the following in connection with the solicitation, negotiation, procuring, or effectuation of insurance coverage for another: inspecting risks, setting rates, advertising, disseminating information, or advising on risk management; (f) publishing or disseminating any advertisement encouraging the placement or servicing of insurance that would violate Subsection (1); however this provision does not apply to publication or dissemination to an audience primarily outside Utah that also reaches persons in Utah unless the extension to persons inside Utah can be conveniently avoided without substantial expense other than loss of revenue; nor does it apply to regional or national network programs on radio or television unless they originate in Utah; (g) investigating, settling, adjusting, or litigating claims; or (h) representing or assisting any person to do an unauthorized insurance business or to procure insurance from an unauthorized insurer. (3) Subsection (1) does not prohibit: (a) an attorney acting for a client; (b) a full-time salaried employee of an insured acting in the capacity of an insurance buyer or manager; or (c) insurance activities described under Section 31A-15-103. (4) Any act performed in Utah which is prohibited under this section constitutes appointment of the commissioner or the lieutenant governor as agent for service of process under Sections 31A-2-309 and 31A-2-310. (5) Any person or entity who knows or should know that the person’s or entity’s actions assist in the illegal placement of insurance in violation of this section is guilty of a third degree felony. **State:** Utah --- ### [Texas-Attempted Fraud-V.T.C.A., Insurance Code ¤ 701.001](https://insurancefraud.org/statutes/texas-attempted-fraud-v-t-c-a-insurance-code-¤-701-001/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (2) “Fraudulent insurance act” means an act that is a violation of a penal law and is: (A) committed or attempted while engaging in the business of insurance; (B) committed or attempted as part of or in support of an insurance transaction; or (C) part of an attempt to defraud an insurer. **State:** Texas **Statute Areas:** Attempted Fraud --- ### [Texas-Claims Fraud-V.T.C.A., Penal Code ¤ 35.02](https://insurancefraud.org/statutes/texas-claims-fraud-v-t-c-a-penal-code-¤-35-02/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) A person commits an offense if, with intent to defraud or deceive an insurer, the person, in support of a claim for payment under an insurance policy: (1) prepares or causes to be prepared a statement that: (A) the person knows contains false or misleading material information; and (B) is presented to an insurer; or (2) presents or causes to be presented to an insurer a statement that the person knows contains false or misleading material information. (a-1) A person commits an offense if the person, with intent to defraud or deceive an insurer and in support of an application for an insurance policy: (1) prepares or causes to be prepared a statement that: (A) the person knows contains false or misleading material information; and (B) is presented to an insurer; or (2) presents or causes to be presented to an insurer a statement that the person knows contains false or misleading material information. (b) A person commits an offense if, with intent to defraud or deceive an insurer, the person solicits, offers, pays, or receives a benefit in connection with the furnishing of goods or services for which a claim for payment is submitted under an insurance policy. **State:** Texas **Statute Areas:** Claims Fraud --- ### [Texas-Fraud Bureau-V.T.C.A., Insurance Code ¤ 701.101](https://insurancefraud.org/statutes/texas-fraud-bureau-v-t-c-a-insurance-code-¤-701-101/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) The purpose of the department’s insurance fraud unit is to enforce laws relating to fraudulent insurance acts. (b) The insurance fraud unit may receive, review, and investigate in a timely manner insurer antifraud reports submitted under Chapter 704. (c) The insurance fraud unit shall report annually to the commissioner in writing regarding: (1) the number of cases completed by the insurance fraud unit; and (2) recommendations for regulatory and statutory responses to the types of fraudulent activities encountered by the insurance fraud unit. **State:** Texas **Statute Areas:** Fraud Bureau --- ### [Texas-Immunity-V.T.C.A., Insurance Code ¤ 701.052](https://insurancefraud.org/statutes/texas-immunity-v-t-c-a-insurance-code-¤-701-052/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) A person is not liable in a civil action, including an action for libel or slander, and a civil action may not be brought against the person, for furnishing information relating to a suspected, anticipated, or completed fraudulent insurance act if the information is provided to: (1) an authorized governmental agency or the department; (2) a law enforcement officer or an agent or employee of the officer; (3) the National Association of Insurance Commissioners or an employee of the association; (4) a state or federal governmental agency established to detect and prevent fraudulent insurance acts or to regulate the business of insurance or an employee of the agency; (5) a special investigative unit of an insurer, including a person who contracts to provide special investigative unit services to the insurer or an employee of the insurer who is responsible for the investigation of suspected fraudulent insurance acts; or (6) an organization described by Section 701.051(c), if the person is a member of the organization and: (A) the person has reported the information as required by Section 701. 051(a); or (B) the organization has reported the information to the insurance fraud unit as required by Section 701.051(c) on behalf of the person and in a manner that fully complies with the person’s obligations under Section 701. 051(a). (b) A person may furnish information as described in Subsection (a) orally or in writing, including through publishing, disseminating, or filing a bulletin or report. (c) Subsection (a) does not apply to a person who acts with malice, fraudulent intent, or bad faith. (d) A person to whom Subsection (a) applies who prevails in a civil action arising from furnishing information as described in Subsection (a) is entitled to attorney’s fees and costs. (e) This section does not affect any common law or statutory privilege or immunity. **State:** Texas **Statute Areas:** Immunity --- ### [Texas-Insurance Fraud - Definition-V.T.C.A., Penal Code ¤ 35.02](https://insurancefraud.org/statutes/texas-insurance-fraud-definition-v-t-c-a-penal-code-¤-35-02/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) A person commits an offense if, with intent to defraud or deceive an insurer, the person, in support of a claim for payment under an insurance policy: (1) prepares or causes to be prepared a statement that: (A) the person knows contains false or misleading material information; and (B) is presented to an insurer; or (2) presents or causes to be presented to an insurer a statement that the person knows contains false or misleading material information. (a-1) A person commits an offense if the person, with intent to defraud or deceive an insurer and in support of an application for an insurance policy: (1) prepares or causes to be prepared a statement that: (A) the person knows contains false or misleading material information; and (B) is presented to an insurer; or (2) presents or causes to be presented to an insurer a statement that the person knows contains false or misleading material information. (b) A person commits an offense if, with intent to defraud or deceive an insurer, the person solicits, offers, pays, or receives a benefit in connection with the furnishing of goods or services for which a claim for payment is submitted under an insurance policy. (c) An offense under Subsection (a) or (b) is: (1) a Class C misdemeanor if the value of the claim is less than $100; (2) a Class B misdemeanor if the value of the claim is $100 or more but less than $750; (3) a Class A misdemeanor if the value of the claim is $750 or more but less than $2,500; (4) a state jail felony if the value of the claim is $2,500 or more but less than $30,000; (5) a felony of the third degree if the value of the claim is $30,000 or more but less than $150,000; (6) a felony of the second degree if the value of the claim is $150,000 or more but less than $300,000; or (7) a felony of the first degree if: (A) the value of the claim is $300,000 or more; or (B) an act committed in connection with the commission of the offense places a person at risk of death or serious bodily injury. (d) An offense under Subsection (a-1) is a state jail felony. (e) The court shall order a defendant convicted of an offense under this section to pay restitution, including court costs and attorney’s fees, to an affected insurer. (f) If conduct that constitutes an offense under this section also constitutes an offense under any other law, the actor may be prosecuted under this section, the other law, or both. (g) For purposes of this section, if the actor proves by a preponderance of the evidence that a portion of the claim for payment under an insurance policy resulted from a valid loss, injury, expense, or service covered by the policy, the value of the claim is equal to the difference between the total claim amount and the amount of the valid portion of the claim. (h) If it is shown on the trial of an offense under this section that the actor submitted a bill for goods or services in support of a claim for payment under an insurance policy to the insurer issuing the policy, a rebuttable presumption exists that the actor caused the claim for payment to be prepared or presented. **State:** Texas **Statute Areas:** Insurance Fraud - Definition --- ### [Texas-Licensing Board Notification-V.T.C.A., Insurance Code ¤ 701.051](https://insurancefraud.org/statutes/texas-licensing-board-notification-v-t-c-a-insurance-code-¤-701-051/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) Not later than the 30th day after the date the person makes the determination or reasonably suspects that a fraudulent insurance act has been or is about to be committed in this state, the person: (1) shall report the information in writing to the insurance fraud unit of the department, in the format prescribed by the fraud unit or by the National Association of Insurance Commissioners; and (2) may also report the information to another authorized governmental agency. (b) A report made to the insurance fraud unit constitutes notice to each other authorized governmental agency. (c) A person who is a member of an organization primarily dedicated to the detection, investigation, and prosecution of insurance fraud fully complies with the person’s obligations under Subsection (a) by authorizing the organization to report on the person’s behalf information required to be reported under Subsection (a). The person retains any liability resulting from the failure of the organization to report in a manner that complies with Subsection (a). **State:** Texas --- ### [Texas-Mandatory Restitution-V.A.T.S. Insurance Code, ¤ 101.102](https://insurancefraud.org/statutes/texas-mandatory-restitution-v-a-t-s-insurance-code-¤-101-102/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (e) The court shall order a defendant convicted of an offense under this section to pay restitution, including court costs and attorney’s fees, to an affected insurer. **State:** Texas **Statute Areas:** Mandatory Restitution --- ### [Texas-Placing Bogus Coverage-V.A.T.S. Insurance Code, ¤ 101.102](https://insurancefraud.org/statutes/texas-placing-bogus-coverage-v-a-t-s-insurance-code-¤-101-102/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) A person, including an insurer, may not directly or indirectly do an act that constitutes the business of insurance under this chapter except as authorized by statute. (b) With respect to insurance of a subject that is resident, located, or to be performed in this state, this section does not prohibit an act performed outside this state, including the collection of premiums, by a person, including an insurer, authorized to do business in this state if the transaction and insurance contract otherwise comply with statute. **State:** Texas --- ### [Texas-Practitioner Penalites-V.A.T.S. Insurance Code, ¤ 84.022](https://insurancefraud.org/statutes/texas-practitioner-penalites-v-a-t-s-insurance-code-¤-84-022/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) The penalty for a violation may not exceed $25,000, unless a greater or lesser penalty is specified by this code or another insurance law of this state. (b) The amount of the penalty shall be based on: (1) the seriousness of the violation, including: (A) the nature, circumstances, extent, and gravity of the violation; and (B) the hazard or potential hazard created to the health, safety, or economic welfare of the public; (2) the economic harm to the public interest or public confidence caused by the violation; (3) the history of previous violations; (4) the amount necessary to deter a future violation; (5) efforts to correct the violation; (6) whether the violation was intentional; and (7) any other matter that justice may require. **State:** Texas **Statute Areas:** Practitioner Penalites --- ### [Texas-Range of Criminal Penalties-V.T.C.A., Penal Code ¤ 35.02](https://insurancefraud.org/statutes/texas-range-of-criminal-penalties-v-t-c-a-penal-code-¤-35-02/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (c) An offense under Subsection (a) or (b) is: (1) a Class C misdemeanor if the value of the claim is less than $100; (2) a Class B misdemeanor if the value of the claim is $100 or more but less than $750; (3) a Class A misdemeanor if the value of the claim is $750 or more but less than $2,500; (4) a state jail felony if the value of the claim is $2,500 or more but less than $30,000; (5) a felony of the third degree if the value of the claim is $30,000 or more but less than $150,000; (6) a felony of the second degree if the value of the claim is $150,000 or more but less than $300,000; or (7) a felony of the first degree if: (A) the value of the claim is $300,000 or more; or (B) an act committed in connection with the commission of the offense places a person at risk of death or serious bodily injury. (d) An offense under Subsection (a-1) is a state jail felony. (e) The court shall order a defendant convicted of an offense under this section to pay restitution, including court costs and attorney’s fees, to an affected insurer. (f) If conduct that constitutes an offense under this section also constitutes an offense under any other law, the actor may be prosecuted under this section, the other law, or both. **State:** Texas **Statute Areas:** Range of Criminal Penalties --- ### [Texas-Underwriting Fraud-V.T.C.A., Penal Code ¤ 35.02](https://insurancefraud.org/statutes/texas-underwriting-fraud-v-t-c-a-penal-code-¤-35-02/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) A person commits an offense if, with intent to defraud or deceive an insurer, the person, in support of a claim for payment under an insurance policy: (1) prepares or causes to be prepared a statement that: (A) the person knows contains false or misleading material information; and (B) is presented to an insurer; or (2) presents or causes to be presented to an insurer a statement that the person knows contains false or misleading material information. (a-1) A person commits an offense if the person, with intent to defraud or deceive an insurer and in support of an application for an insurance policy: (1) prepares or causes to be prepared a statement that: (A) the person knows contains false or misleading material information; and (B) is presented to an insurer; or (2) presents or causes to be presented to an insurer a statement that the person knows contains false or misleading material information. (b) A person commits an offense if, with intent to defraud or deceive an insurer, the person solicits, offers, pays, or receives a benefit in connection with the furnishing of goods or services for which a claim for payment is submitted under an insurance policy. **State:** Texas **Statute Areas:** Underwriting Fraud --- ### [Texas-Unauthorized Entities-V.A.T.S. Insurance Code, ¤ 101.102](https://insurancefraud.org/statutes/texas-unauthorized-entities-v-a-t-s-insurance-code-¤-101-102/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) A person, including an insurer, may not directly or indirectly do an act that constitutes the business of insurance under this chapter except as authorized by statute. (b) With respect to insurance of a subject that is resident, located, or to be performed in this state, this section does not prohibit an act performed outside this state, including the collection of premiums, by a person, including an insurer, authorized to do business in this state if the transaction and insurance contract otherwise comply with statute. **State:** Texas --- ### [Tennessee-Aiding & Abetting-T. C. A. ¤ 56-53-102](https://insurancefraud.org/statutes/tennessee-aiding-abetting-t-c-a-¤-56-53-102/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (b) It shall be unlawful for any person to commit, or to attempt to commit, or aid, assist, abet or solicit another to commit, or to conspire to commit a fraudulent insurance act. **State:** Tennessee --- ### [Tennessee-Claims Fraud-T. C. A. ¤ 56-53-102](https://insurancefraud.org/statutes/tennessee-claims-fraud-t-c-a-¤-56-53-102/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) Any person who, knowingly and with intent to defraud, and for the purpose of depriving another of property or for pecuniary gain, commits, participates in or aids, abets, or conspires to commit or solicits another person to commit, or intentionally permits its employees or its agents to commit any of the following acts, has committed a fraudulent insurance act: (1) Presents, causes to be presented, or prepares with knowledge or belief that it will be presented, by or on behalf of an insured, claimant or applicant to an insurer, insurance professional or premium finance company in connection with an insurance transaction or premium finance transaction, any information that contains false representations as to any material fact, or that withholds or conceals a material fact concerning any of the following: (B) A claim for payment or benefit pursuant to any insurance policy; **State:** Tennessee **Statute Areas:** Claims Fraud --- ### [Tennessee-Failing to Remit Premium-T. C. A. ¤ 56-6-910](https://insurancefraud.org/statutes/tennessee-failing-to-remit-premium-t-c-a-¤-56-6-910/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) The commissioner may place on probation, cancel, terminate, suspend, revoke or refuse to issue or renew a public adjuster’s license, or may levy a civil penalty, in accordance with this section, or any combination of actions, for any one (1) or more of the following causes: (4) Improperly withholding, misappropriating, or converting to the licensee’s own use any moneys or properties received in the course of conducting business under this license; **State:** Tennessee --- ### [Tennessee-Fraud Bureau-n/a](https://insurancefraud.org/statutes/tennessee-fraud-bureau-n-a/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** No statute found **State:** Tennessee **Statute Areas:** Fraud Bureau --- ### [Tennessee-Immunity-T. C. A. ¤ 56-53-110](https://insurancefraud.org/statutes/tennessee-immunity-t-c-a-¤-56-53-110/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** In the absence of actual malice, no person furnishing, disclosing or requesting information pursuant to ¤ 56-53-109 shall be subject to civil liability for libel, slander, or any other cause of action arising from the furnishing, disclosing or requesting of the information. No person providing information pursuant to ¤ 56-53-109(a) shall be subject to civil liability for any cause of action arising from the person’s provision of requested information. Any person against whom any action is brought who is found to be immune from liability under this section, shall be entitled to recover reasonable attorneys’ fees and costs from the person or party who brought the action. This section does not abrogate or modify in any way any common law or statutory privilege or immunity heretofore enjoyed by any person. **State:** Tennessee **Statute Areas:** Immunity --- ### [Tennessee-Insurance Fraud - Definition-T. C. A. ¤ 56-53-103; T. C. A. ¤ 56-53-102](https://insurancefraud.org/statutes/tennessee-insurance-fraud-definition-t-c-a-¤-56-53-103-t-c-a-¤-56-53-102/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) Any person who commits, participates in, or aids, abets, or conspires to commit, or solicits another person to commit, or permits its employees or its agents to commit any of the following acts with an intent to induce reliance, has committed an unlawful insurance act: (1) Presents, causes to be presented, or prepares with knowledge or belief that it will be presented, by or on behalf of an insured, claimant or applicant to an insurer, insurance professional or a premium finance company in connection with an insurance transaction or premium finance transaction, any information that the person knows to contain false representations, or representations the falsity of which the person has recklessly disregarded, as to any material fact, or that withholds or conceals a material fact, concerning any of the following: (A) The application for, rating of, or renewal of, any insurance policy; (B) A claim for payment or benefit pursuant to any insurance policy; (C) Payments made in accordance with the terms of any insurance policy; or (D) The application for the financing of any insurance premium; (2) Presents, causes to be presented, or prepares with knowledge or belief that it will be presented, to or by an insurer, insurance professional or a premium finance company in connection with an insurance transaction or premium finance transaction, any information that the person knows to contain false representations, or representations the falsity of which the person has recklessly disregarded, as to any material fact, or that withholds or conceals a material fact, concerning any of the following: (A) The solicitation for sale of any insurance policy or purported insurance policy; (B) An application for certificate of authority; (C) The financial condition of any insurer; or (D) The acquisition, formation, merger, affiliation or dissolution of any insurer; or (3) Solicits or accepts new or renewal insurance risks by or for an insurer that the person knows was insolvent or the insolvency of which the person recklessly disregards. (b) It shall be unlawful for any person to commit, or to attempt to commit, or aid, assist, abet or solicit another to commit, or to conspire to commit an unlawful insurance act.(a) Any person who, knowingly and with intent to defraud, and for the purpose of depriving another of property or for pecuniary gain, commits, participates in or aids, abets, or conspires to commit or solicits another person to commit, or intentionally permits its employees or its agents to commit any of the following acts, has committed a fraudulent insurance act: (1) Presents, causes to be presented, or prepares with knowledge or belief that it will be presented, by or on behalf of an insured, claimant or applicant to an insurer, insurance professional or premium finance company in connection with an insurance transaction or premium finance transaction, any information that contains false representations as to any material fact, or that withholds or conceals a material fact concerning any of the following: (A) The application for, rating of, or renewal of, any insurance policy; (B) A claim for payment or benefit pursuant to any insurance policy; (C) Payments made in accordance with the terms of any insurance policy; or (D) The application used in any premium finance transaction; (2) Presents, causes to be presented, or prepares with knowledge or belief that it will be presented, to or by an insurer, insurance professional or a premium finance company in connection with an insurance transaction or premium finance transaction, any information that contains false representations as to any material fact, or that withholds or conceals a material fact, concerning any of the following: (A) The solicitation for sale of any insurance policy or purported insurance policy; (B) An application for certificate of authority; (C) The financial condition of any insurer; or (D) The acquisition, formation, merger, affiliation or dissolution of any insurer; (3) Solicits or accepts new or renewal insurance risks by or for an insolvent insurer; (4) Removes the assets or records of assets, transactions and affairs or a material part of the assets or records, from the home office or other place of business of the insurer, or from the place of safekeeping of the insurer, or destroys or sequesters the same from the department; or (5) Diverts, misappropriates, converts or embezzles funds of an insurer, an insured, claimant or applicant for insurance in connection with: (A) An insurance transaction; (B) The conduct of business activities by an insurer or insurance professional; or (C) The acquisition, formation, merger, affiliation or dissolution of any insurer. (b) It shall be unlawful for any person to commit, or to attempt to commit, or aid, assist, abet or solicit another to commit, or to conspire to commit a fraudulent insurance act. **State:** Tennessee **Statute Areas:** Insurance Fraud - Definition --- ### [Tennessee-Licensing Board Notification-T. C. A. ¤ 56-53-109](https://insurancefraud.org/statutes/tennessee-licensing-board-notification-t-c-a-¤-56-53-109/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) When any law enforcement official or authority, any insurance department, state division of insurance fraud, or state or federal regulatory or licensing authority requests information from an insurer or insurance professional for the purpose of detecting, prosecuting or preventing insurance fraud, the insurer or insurance professional shall take all reasonable actions to provide the information requested, subject to any legal privilege protecting the information. (b) Any insurer or insurance professional who has reasonable belief that an act violating ¤ 56-53-102 or ¤ 56-53-103 will be, is being, or has been committed shall furnish and disclose any information in the insurance professional’s possession concerning the act to the appropriate law enforcement official or authority, insurance department, state division of insurance fraud, or state or federal regulatory or licensing authority, subject to any legal privilege protecting the information. In no case shall the information be required by subpoena or otherwise to be given to the person alleged to have committed a violation, unless in possession of an insurer and that insurer used the information to deny a claim of the person, in whole or in part. (c) All documents or other information submitted to or generated by a law enforcement, regulatory, licensing or other governmental agency pursuant to subsection (a) or (b) shall not be subject to disclosure pursuant to the public records laws, codified in title 10, chapter 7, and shall be confidential unless disclosed by the law enforcement, regulatory, licensing or other governmental agency at the agency’s sole discretion. (d) Any person who has a reasonable belief that an act violating this chapter will be, is being, or has been committed, or any person who collects, reviews or analyzes information concerning insurance fraud may furnish and disclose any information in the person’s possession concerning the act to an authorized representative of an insurer who requests the information for the purpose of detecting, prosecuting or preventing insurance fraud. (e) Failure to cooperate with a request for information from an appropriate local, state or federal governmental authority shall bar a person’s eligibility for restitution from any proceeds resulting from the governmental investigation and prosecution. This subsection (e) shall not be construed as limiting the ability of any governmental authority from imposing lawful civil discipline upon a person or entity that fails to cooperate with a request for information as delineated in this subsection (e). **State:** Tennessee --- ### [Tennessee-Looting & diverting-T. C. A. ¤ 56-53-102](https://insurancefraud.org/statutes/tennessee-looting-diverting-t-c-a-¤-56-53-102/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) Any person who, knowingly and with intent to defraud, and for the purpose of depriving another of property or for pecuniary gain, commits, participates in or aids, abets, or conspires to commit or solicits another person to commit, or intentionally permits its employees or its agents to commit any of the following acts, has committed a fraudulent insurance act: (5) Diverts, misappropriates, converts or embezzles funds of an insurer, an insured, claimant or applicant for insurance in connection with: (A) An insurance transaction; (B) The conduct of business activities by an insurer or insurance professional; or (C) The acquisition, formation, merger, affiliation or dissolution of any insurer. (b) It shall be unlawful for any person to commit, or to attempt to commit, or aid, assist, abet or solicit another to commit, or to conspire to commit a fraudulent insurance act. **State:** Tennessee --- ### [Tennessee-Mandatory Restitution-T. C. A. ¤ 56-53-105](https://insurancefraud.org/statutes/tennessee-mandatory-restitution-t-c-a-¤-56-53-105/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) A person convicted of a violation of ¤ 56-53-102 shall be ordered to make monetary restitution for any financial loss or damages sustained by any other person as a result of the violation. Financial loss or damage shall include, but is not necessarily limited to, loss of earnings, out-of-pocket and other expenses, paid deductible amounts under an insurance policy, insurer claim payments, cost reasonably attributed to investigations and recovery efforts by owners, insurers, insurance professionals, law enforcement and other public authorities, and cost of prosecution. (b) When restitution is ordered, the court shall determine its extent and methods. Restitution may be imposed in addition to a fine and, if ordered, any other penalty, but not in lieu thereof. The court shall determine whether restitution, if ordered, shall be paid in a single payment or installments and shall fix a period of time, not in excess of three (3) years, within which payment of restitution is to be made in full. **State:** Tennessee **Statute Areas:** Mandatory Restitution --- ### [Tennessee-Placing Bogus Coverage-T. C. A. ¤ 56-53-103](https://insurancefraud.org/statutes/tennessee-placing-bogus-coverage-t-c-a-¤-56-53-103/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) Any person who commits, participates in, or aids, abets, or conspires to commit, or solicits another person to commit, or permits its employees or its agents to commit any of the following acts with an intent to induce reliance, has committed an unlawful insurance act: (3) Solicits or accepts new or renewal insurance risks by or for an insurer that the person knows was insolvent or the insolvency of which the person recklessly disregards. **State:** Tennessee --- ### [Tennessee-Practitioner Penalites-T. C. A. ¤ 56-53-106](https://insurancefraud.org/statutes/tennessee-practitioner-penalites-t-c-a-¤-56-53-106/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a)(1) Any practitioner determined by the court to have violated ¤ 56-53-102 shall be deemed to have committed an act involving moral turpitude that is inimical to the public well being. The court or prosecutor shall notify the appropriate licensing authority in this state of the judgment for appropriate disciplinary action, including revocation of the professional license, and may notify appropriate licensing authorities in any other jurisdictions where the practitioner is licensed. Any victim may notify the appropriate licensing authorities in this state and any other jurisdiction where the practitioner is licensed, of the conviction. (2) Upon notification of a conviction of the crimes enumerated in ¤ 56-53-102 or a substantially similar crime under the laws of another state or the United States, this state’s appropriate licensing authority may hold an administrative hearing, or take other appropriate administrative action authorized by state law, to consider the imposition of the administrative sanctions as provided by law against the practitioner. Where the practitioner has been convicted of a felony violation of ¤ 56-53-102 or a substantially similar crime under the laws of another state or of the United States, this state’s appropriate licensing authority may hold an administrative hearing, or take other appropriate administrative action authorized by state law, and may summarily and permanently revoke the license or take other action against the licensee as deemed appropriate. It is recommended by the legislature that the supreme court shall summarily and permanently disbar any attorney found guilty of such felony. (3) The referrals to the appropriate licensing or other agencies, and all dispositive actions of the referral, shall be a matter of public record. (b)(1) A person convicted of a felony involving dishonesty or breach of trust shall not participate in the business of insurance unless a waiver is granted by the commissioner. (2) A person in the business of insurance shall not knowingly or intentionally permit a person convicted of a felony involving dishonesty or breach of trust to participate in the business of insurance unless a waiver has been granted by the commissioner pursuant to subdivision (b)(1). **State:** Tennessee **Statute Areas:** Practitioner Penalites --- ### [Tennessee-Premium Fraud-T. C. A. ¤ 56-53-103; T. C. A. ¤ 56-53-102](https://insurancefraud.org/statutes/tennessee-premium-fraud-t-c-a-¤-56-53-103-t-c-a-¤-56-53-102/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) Any person who, knowingly and with intent to defraud, and for the purpose of depriving another of property or for pecuniary gain, commits, participates in or aids, abets, or conspires to commit or solicits another person to commit, or intentionally permits its employees or its agents to commit any of the following acts, has committed a fraudulent insurance act: (1) Presents, causes to be presented, or prepares with knowledge or belief that it will be presented, by or on behalf of an insured, claimant or applicant to an insurer, insurance professional or premium finance company in connection with an insurance transaction or premium finance transaction, any information that contains false representations as to any material fact, or that withholds or conceals a material fact concerning any of the following: (D) The application used in any premium finance transaction; **State:** Tennessee **Statute Areas:** Premium Fraud --- ### [Tennessee-Range of Criminal Penalties-T. C. A. ¤ 39-14-133](https://insurancefraud.org/statutes/tennessee-range-of-criminal-penalties-t-c-a-¤-39-14-133/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Any person who intentionally presents or causes to be presented a false or fraudulent claim, or any proof in support of such claim, for the payment of a loss, or other benefits, upon any contract of insurance coverage, or automobile comprehensive or collision insurance, or certificate of such insurance or prepares, makes or subscribes to a false or fraudulent account, certificate, affidavit or proof of loss, or other documents or writing, with intent that the same may be presented or used in support of such claim, is punished as in the case of theft. **State:** Tennessee **Statute Areas:** Range of Criminal Penalties --- ### [Tennessee-Range of Civil Penalties-T. C. A. ¤ 56-53-107](https://insurancefraud.org/statutes/tennessee-range-of-civil-penalties-t-c-a-¤-56-53-107/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a)(1) Any person injured in the person’s business or property by reason of a violation of ¤ 56-53-103 may recover for the injury from the person or persons violating ¤ 56-53-103, in any appropriate court having jurisdiction, the following: (A) Return of any profit, benefit, compensation or payment received by the person violating ¤ 56-53-103 directly resulting from the violation; and (B) Reasonable attorneys’ fees, related legal expenses, including internal legal expenses and court costs. (2) An action maintained under subdivision (a)(1) may neither be certified as a class action nor be made part of a class action. (b)(1) Any person injured in the person’s business or property by reason of a violation of ¤ 56-53-102 may recover for the injury from the person or persons violating ¤ 56-53-102, in any appropriate court having jurisdiction, the following: (A) Return of any profit, benefit, compensation or payment received by the person violating ¤ 56-53-102 directly resulting from the violation; (B) Reasonable attorneys’ fees, related legal expenses, including internal legal expenses and court costs; (C) All other economic damages directly resulting from the violation of ¤ 56-53-102; (D) Reasonable investigative fees based on a reasonable estimate of the time and expense incurred in the investigation of the violation or violations of ¤ 56-53-102 proved at trial; and (E) A penalty of no less than one hundred dollars ($100) and no greater than ten thousand dollars ($10,000). (2) An action maintained under subdivision (b)(1) may neither be certified as a class action nor be made part of a class action. (c) Any person injured in the person’s business or property by a person violating ¤ 56-53-102, upon a showing of clear and convincing evidence that the violation was part of a pattern or practice of such violations, shall be entitled to recover threefold the injured person’s economic damages. An action for treble damages must be brought within three (3) years of the violation. One third ( ÉÒ ) of the treble damages awarded shall be payable to the state to be used solely for the purpose of investigation and prosecution of violations of this chapter or other fraudulent behavior relating to insurance transactions, or for public education relating to insurance fraud. An action maintained under this subsection (c) may neither be certified as class action nor be made part of a class action, unless the violations of ¤ 56-53-102 giving rise to the action resulted in criminal conviction of the violator or violators under ¤ 56-53-104. (d)(1) The attorney general and reporter, district attorney general or other prosecutorial agency shall have authority to maintain civil proceedings on behalf of the department of commerce and insurance and any victims of violations of ¤ 56-53-102. In the action, the court shall proceed as soon as practicable to the hearing and determination of the hearing. Pending final determination, the court may at any time enter restraining orders or prohibitions, or take other actions, including the acceptance of satisfactory performance bonds, as it deems proper. (A) The circuit and chancery courts of the state shall have jurisdiction to prevent and restrain violations of ¤ 56-53-102 by issuing appropriate orders. (B) In any action commenced under this subsection (d), the court, upon finding that any person has violated ¤ 56-53-102, shall levy a fine of up to five thousand dollars ($5,000) for each violation. (2) Any court in which a prosecution for violation of ¤ 56-53-102 is pending shall have authority to stay or limit proceedings in any civil action regarding the same or related conduct. Any court in which is pending a civil action brought pursuant to this subsection (d) may stay or limit proceedings in actions brought pursuant to subsections (a)-(c) regarding the same or related conduct or may transfer the actions or consolidate them before itself or allow the plaintiffs in the actions to participate in the action brought pursuant to this subsection (d), as it shall prescribe. (e) Any cause of action under this section for violation of ¤ 56-53-102 or ¤ 56-53-103 must be brought within five (5) years of the commission of the acts constituting the violation, or within five (5) years of the time the plaintiff discovered, or with reasonable diligence could have discovered, the acts, whichever is later. (f) An insurer shall not pay damages awarded under this section, or provide a defense or money for a defense, on behalf of an insured under a contract of insurance or indemnification. A third party who has asserted a claim against an insured shall have no cause of action under this section against the insurer of the insured arising out of the insurer’s processing or settlement of the third party’s claim. An obligee under a surety bond shall not have a cause of action under this section against the surety arising out of the surety’s processing or settlement of the obligee’s claim against the bond. (g) Any person injured in the person’s business or property by reason of a violation of ¤ 56-53-102 or ¤ 56-53-103 may recover under only one (1) of the subsections of this section. **State:** Tennessee **Statute Areas:** Range of Civil Penalties --- ### [Tennessee-Rating of an Insurance Policy-T. C. A. ¤ 56-5-103](https://insurancefraud.org/statutes/tennessee-rating-of-an-insurance-policy-t-c-a-¤-56-5-103/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) GENERAL. Rates: (1) Shall not be excessive, inadequate or unfairly discriminatory; or (2) In the case of an advisory prospective loss costs filing, shall reasonably reflect projected losses and loss adjustment expenses. (b) EXCESSIVENESS. A rate is excessive if it is likely to produce a profit that is unreasonably high for the insurance provided or if the expense provision included in the rate is unreasonably high in relation to the services rendered. (c) INADEQUACY. A rate is not inadequate unless the rate is clearly insufficient to sustain projected losses and expenses in the class of business to which it applies and the use of the rate has or, if continued, will have the effect of substantially lessening competition or the tendency to create a monopoly. (d) UNFAIR DISCRIMINATION. Unfair discrimination exists if, after allowing for practical limitations, price differentials fail to reflect equitably the differences in expected losses and expenses. A rate is not unfairly discriminatory because different premiums result for policyholders with like loss exposures with different expenses, or like expenses but different loss exposures, so long as the rate reflects the differences with reasonable accuracy. **State:** Tennessee --- ### [Tennessee-Underwriting Fraud-T. C. A. ¤ 56-6-910](https://insurancefraud.org/statutes/tennessee-underwriting-fraud-t-c-a-¤-56-6-910/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) The commissioner may place on probation, cancel, terminate, suspend, revoke or refuse to issue or renew a public adjuster’s license, or may levy a civil penalty, in accordance with this section, or any combination of actions, for any one (1) or more of the following causes: (1) Providing materially incorrect, misleading, incomplete, or untrue information in the license application; (2) Violating any laws administered by the commissioner, or violating lawful regulations, or final orders of the commissioner or of another state’s insurance commissioner; (3) Obtaining or attempting to obtain a license through misrepresentation or fraud; (4) Improperly withholding, misappropriating, or converting to the licensee’s own use any moneys or properties received in the course of conducting business under this license; (5) Intentionally misrepresenting the terms of an actual or proposed insurance contract or application for insurance; (6) Having been convicted of a felony or other offense involving dishonesty, fraud, deceit or misrepresentation, in a final decision of a court of competent jurisdiction; (7) Having committed any insurance unfair trade practice or insurance fraud prohibited under chapters 8 and 53 of this title; (8) Using fraudulent, coercive or dishonest practices, or demonstrating incompetence, untrustworthiness or financial irresponsibility in the conduct of business in this state or elsewhere; (9) Having an insurance producer license, or its equivalent, suspended or revoked in any other state, province, district or territory; (10) Forging another’s name to an application for insurance or to any document related to an insurance transaction; (11) Cheating on an examination for an insurance license; (12) Knowingly accepting insurance business from an individual who is not licensed by the commissioner but who is required to be so licensed; (13) Allowing a person not licensed under this part to perform actions requiring licensure under this part; (14) Failing to comply with a final administrative or court order imposing a child support obligation; or (15) Failing to notify the insured, verbally and in writing, of the statutory requirements of this part, as they pertain to solicitation, contracting, and recission and the timeframes contained in this part. (b) Any action by the commissioner to put on probation, suspend, revoke or deny the renewal of a license pursuant to this part shall be governed by the Uniform Administrative Procedures Act, compiled in title 4, chapter 5. (c) In the event that the action of the commissioner is to deny an application for a license, the commissioner shall notify the applicant and advise, in writing, the applicant of the denial of the applicant’s application within thirty (30) days. (d) The license of a business entity may be suspended, revoked or refused, if the commissioner finds that an individual’s violation was known or should have been known by one (1) or more of the partners, officers or managers acting on behalf of the business entity, and the violation was not timely reported to the commissioner and corrective action was not taken. (e) In addition to, or in lieu of, any applicable denial, suspension, cancellation, termination, or revocation of a license, a person may, after a hearing, be subject to a civil penalty in an amount not less than one hundred dollars ($100), nor more than one thousand dollars ($1,000), for each separate violation of the grounds in subsection (a). Each day of continued violation shall constitute a separate violation. (f) The commissioner shall retain the authority to enforce this part and impose any penalty or remedy authorized by this part, or any other provision of this title against any person who is under investigation for or charged with a violation of this part, even if the person’s license or registration has been surrendered or has lapsed by operation of law. (g) The commissioner may serve a notice or order in any action arising under this part by registered or certified mail to the public adjuster or applicant at the address of record on file with the commissioner. Notwithstanding any law to the contrary, service in the manner set forth in this subsection (g) shall be deemed to constitute actual service on the public adjuster or applicant. **State:** Tennessee **Statute Areas:** Underwriting Fraud --- ### [Tennessee-Unauthorized Entities-T. C. A. ¤ 56-2-107](https://insurancefraud.org/statutes/tennessee-unauthorized-entities-t-c-a-¤-56-2-107/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Any of the following acts in this state, effected by mail or otherwise by an unauthorized insurer, are included among those deemed to constitute transacting insurance business in this state: (1) The issuance or delivery of contracts of insurance to residents of this state; (2) The solicitation of applications for contracts of insurance; (3) The collection of premiums, membership fees, assessments or other considerations for contracts of insurance; or (4) The transaction of matters subsequent to the execution of contracts of insurance and arising out of them. **State:** Tennessee --- ### [South Dakota-Aiding & Abetting-SDCL ¤ 58-4A-2](https://insurancefraud.org/statutes/south-dakota-aiding-abetting-sdcl-¤-58-4a-2/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (7) Assists, abets, solicits, or conspires with another to prepare or make any statement that is intended to be presented to or by an insurer or person in connection with or in support of any claim for payment or other benefit, or denial, pursuant to an insurance policy knowing that the statement contains any false, incomplete, or misleading information concerning any fact or thing material to the claim; **State:** South Dakota --- ### [South Dakota-Claims Fraud-SDCL ¤ 58-4A-2](https://insurancefraud.org/statutes/south-dakota-claims-fraud-sdcl-¤-58-4a-2/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** For purposes of this chapter, a person commits a fraudulent insurance act if the person: (2) Is engaged in the business of insurance, whether authorized or unauthorized, receives money for the purpose of purchasing insurance and converts the money to the person’s own benefit or for a purpose not intended or authorized by an insured or prospective insured; (6) Knowingly and with intent to defraud or deceive presents, causes to be presented, or prepares with knowledge or belief that it will be presented to or by an insurer, or any insurance producer of an insurer, any statement as part of a claim, in support of a claim, or in denial of a claim for payment or other benefit pursuant to an insurance policy knowing that the statement contains any false, incomplete, or misleading information concerning any fact or thing material to a claim; (7) Assists, abets, solicits, or conspires with another to prepare or make any statement that is intended to be presented to or by an insurer or person in connection with or in support of any claim for payment or other benefit, or denial, pursuant to an insurance policy knowing that the statement contains any false, incomplete, or misleading information concerning any fact or thing material to the claim; or (8) Makes any false or fraudulent representations as to the death or disability of a policy or certificate holder in any statement or certificate for the purpose of fraudulently obtaining money or benefit from an insurer. **State:** South Dakota **Statute Areas:** Claims Fraud --- ### [South Dakota-Fraud Bureau-SDCL ¤ 58-4A-3](https://insurancefraud.org/statutes/south-dakota-fraud-bureau-sdcl-¤-58-4a-3/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** The insurance fraud prevention unit through its investigator or attorney may do the following: (1) The investigator or attorney may initiate and conduct independent investigations if the unit has cause to believe that a fraudulent insurance act has been or may be committed; (2) The investigator or attorney may review reports or complaints of alleged fraudulent insurance acts to determine whether such reports require further investigation and to conduct such investigation; (3) The investigator or attorney may undertake independent studies to determine the extent of fraudulent insurance acts; (4) The investigator or attorney may promote awareness of insurance fraud through educational seminars and other education programs for the insurance industry and the general public; (5) The attorney, subject to applicable criminal or civil law and procedure, may prosecute fraudulent insurance acts on behalf of the state through criminal and civil proceedings; and (6) The investigator or attorney may cooperate with federal, state, and local law enforcement, prosecuting attorneys, and the attorney general in the investigation and prosecution of fraudulent insurance acts. **State:** South Dakota **Statute Areas:** Fraud Bureau --- ### [South Dakota-Immunity-SDCL ¤ 58-4A-13](https://insurancefraud.org/statutes/south-dakota-immunity-sdcl-¤-58-4a-13/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Any person acting in good faith is immune from civil liability for filing a report with or for furnishing any information relating to suspected, anticipated, or completed fraudulent insurance acts to: (1) The Department of Labor and Regulation and the director of insurance; (2) Any governmental agency established to detect and prevent fraud; (3) Law enforcement officials; (4) Deleted by SL 2011, ch 1 (Ex. Ord. 11-1), ¤ 162; (5) Any insurer or insurance producer; (6) The National Association of Insurance Commissioners; and (7) Any nonprofit organization established to detect and prevent insurance fraud, if the organization is approved by the director pursuant to rules promulgated by the director under chapter 1-26 setting forth the standards, criteria, and procedures necessary to obtain approval. If a civil action is commenced against a person for damages related to the filing of a report or the furnishing of information under this section and the court determines that the person acted in good faith in filing the report or furnishing the information, the person filing the report or furnishing the information may recover costs or disbursements under chapter 15-17, including reasonable attorney’s fees. If the trier of fact concludes that the person filing the report or furnishing the information was not acting in good faith, the person filing a civil action may recover costs or disbursements under chapter 15-17, including reasonable attorney’s fees. This section does not abrogate or modify in any way any common law or statutory privilege or immunity. **State:** South Dakota **Statute Areas:** Immunity --- ### [South Dakota-Insurance Fraud - Definition-SDCL ¤ 58-4A-2](https://insurancefraud.org/statutes/south-dakota-insurance-fraud-definition-sdcl-¤-58-4a-2/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** For purposes of this chapter, a person commits a fraudulent insurance act if the person: (1) Knowingly and with intent to defraud or deceive issues or possesses fake or counterfeit insurance policies, certificates of insurance, insurance identification cards, or insurance binders; (2) Is engaged in the business of insurance, whether authorized or unauthorized, receives money for the purpose of purchasing insurance and converts the money to the person’s own benefit or for a purpose not intended or authorized by an insured or prospective insured; (3) Willfully embezzles, abstracts, steals, misappropriates, or converts money, funds, premiums, credits, or other property of an insurer or person engaged in the business of insurance or of an insured or prospective insured; (4) Knowingly and with intent to defraud or deceive makes any false entry of a material fact in or pertaining to any document or statement filed with or required by the Division of Insurance; (5) Knowingly and with intent to defraud or deceive removes, conceals, alters, diverts, or destroys assets or records of an insurer or other person engaged in the business of insurance or attempts to remove, conceal, alter, divert, or destroy assets or records of an insurer or other person engaged in the business of insurance; (6) Knowingly and with intent to defraud or deceive presents, causes to be presented, or prepares with knowledge or belief that it will be presented to or by an insurer, or any insurance producer of an insurer, any statement as part of a claim, in support of a claim, or in denial of a claim for payment or other benefit pursuant to an insurance policy knowing that the statement contains any false, incomplete, or misleading information concerning any fact or thing material to a claim; (7) Assists, abets, solicits, or conspires with another to prepare or make any statement that is intended to be presented to or by an insurer or person in connection with or in support of any claim for payment or other benefit, or denial, pursuant to an insurance policy knowing that the statement contains any false, incomplete, or misleading information concerning any fact or thing material to the claim; or (8) Makes any false or fraudulent representations as to the death or disability of a policy or certificate holder in any statement or certificate for the purpose of fraudulently obtaining money or benefit from an insurer. Any violation of this section for an amount of four hundred dollars or less is a Class 2 misdemeanor. Any violation of this section for an amount in excess of four hundred dollars and less than one thousand dollars is a Class 1 misdemeanor. Any violation of this section for an amount of one thousand dollars and greater is a Class 4 felony. Any other violation of this section is a Class 1 misdemeanor. **State:** South Dakota **Statute Areas:** Insurance Fraud - Definition --- ### [South Dakota-Looting & diverting-SDCL ¤ 58-4A-2](https://insurancefraud.org/statutes/south-dakota-looting-diverting-sdcl-¤-58-4a-2/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** For purposes of this chapter, a person commits a fraudulent insurance act if the person: (2) Is engaged in the business of insurance, whether authorized or unauthorized, receives money for the purpose of purchasing insurance and converts the money to the person’s own benefit or for a purpose not intended or authorized by an insured or prospective insured; (3) Willfully embezzles, abstracts, steals, misappropriates, or converts money, funds, premiums, credits, or other property of an insurer or person engaged in the business of insurance or of an insured or prospective insured; (5) Knowingly and with intent to defraud or deceive removes, conceals, alters, diverts, or destroys assets or records of an insurer or other person engaged in the business of insurance or attempts to remove, conceal, alter, divert, or destroy assets or records of an insurer or other person engaged in the business of insurance; **State:** South Dakota --- ### [South Dakota-Placing Bogus Coverage-SDCL ¤ 58-4A-2](https://insurancefraud.org/statutes/south-dakota-placing-bogus-coverage-sdcl-¤-58-4a-2/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** For purposes of this chapter, a person commits a fraudulent insurance act if the person: (1) Knowingly and with intent to defraud or deceive issues or possesses fake or counterfeit insurance policies, certificates of insurance, insurance identification cards, or insurance binders; **State:** South Dakota --- ### [South Dakota-Practitioner Penalites-SDCL ¤ 58-30-167](https://insurancefraud.org/statutes/south-dakota-practitioner-penalites-sdcl-¤-58-30-167/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** The director may suspend for not more than twelve months, or may revoke or refuse to continue, any license issued under this chapter, or any license of a surplus lines broker after a hearing. Notice of such hearing and of the charges against the licensee shall be given to the licensee and to the insurers represented by such licensee or to the appointing agent of a producer at least twenty days before the hearing. The director may suspend, revoke, or refuse to issue or renew an insurance producer’s license or may accept a monetary penalty in accordance with ¤ 58-4-28.1 or any combination thereof, for any one or more of the following causes: (1) Providing incorrect, misleading, incomplete, or materially untrue information in the license application; (2) Violating any insurance laws or rules, subpoena, or order of the director or of another state’s insurance director, commissioner, or superintendent; (3) Obtaining or attempting to obtain a license through misrepresentation or fraud; (4) Withholding, misappropriating, or converting any monies or properties received in the course of doing insurance business; (5) Intentionally misrepresenting the terms of an actual or proposed insurance contract or application for insurance; (6) Having been convicted of a felony; (7) Having admitted or been found to have committed any insurance unfair trade practice or fraud; (8) Using fraudulent, coercive, or dishonest practices, or demonstrating incompetence, untrustworthiness, or financial irresponsibility in the conduct of business in this state or elsewhere; (9) Having an insurance producer license, or its equivalent, denied, suspended, or revoked in any other state, province, district, or territory; (10) Forging another’s name to an application for insurance or to any document related to an insurance transaction; (11) Using notes or any other reference material to complete an examination for an insurance license; (12) Knowingly accepting insurance business from an individual who sells, solicits, or negotiates insurance and is not licensed; or (13) Failing to comply with an administrative or court order imposing a child support obligation. At the conclusion of the matter, the director shall send a letter to the licensee, the insurers represented by such licensee, and the appointing agent of a producer, stating the final determination of the matter. **State:** South Dakota **Statute Areas:** Practitioner Penalites --- ### [South Dakota-Range of Criminal Penalties-SDCL ¤ 58-4A-5](https://insurancefraud.org/statutes/south-dakota-range-of-criminal-penalties-sdcl-¤-58-4a-5/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Any violation of this section for an amount of four hundred dollars or less is a Class 2 misdemeanor. Any violation of this section for an amount in excess of four hundred dollars and less than one thousand dollars is a Class 1 misdemeanor. Any violation of this section for an amount of one thousand dollars and greater is a Class 4 felony. Any other violation of this section is a Class 1 misdemeanor. The insurance fraud prevention unit may prosecute fraudulent insurance acts through criminal or civil proceedings. The attorney general may appoint the insurance fraud prevention unit attorney as an assistant attorney general for purposes of prosecuting cases of fraudulent insurance acts. The unit attorney may have all the powers attributed to the insurance fraud prevention unit in ¤ 58-4A-3. The unit attorney may refer or request assistance from other persons delineated in subdivision 58-4A-1(3) for the prosecution of fraudulent acts, including access to records. All costs associated with the prosecution of fraudulent insurance acts, including those incurred by designees assisting or acting on behalf of the insurance fraud prevention unit, may be paid by the insurance fraud prevention unit fund. **State:** South Dakota **Statute Areas:** Range of Criminal Penalties --- ### [South Dakota-Range of Civil Penalties-SDCL ¤ 58-4A-7](https://insurancefraud.org/statutes/south-dakota-range-of-civil-penalties-sdcl-¤-58-4a-7/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** If the insurance fraud prevention unit or its designees initiate civil action against any person and that person is found by a court of competent jurisdiction to have committed a fraudulent insurance act as set forth in ¤ 58-4A-2, that person is subject to a civil penalty not to exceed five thousand dollars for the first violation, ten thousand dollars for the second violation, and fifteen thousand dollars for each subsequent violation. Civil penalties paid under this section shall be deposited in the insurance fraud prevention unit fund. An action under this section may be in lieu of criminal prosecution under the laws of this state. **State:** South Dakota **Statute Areas:** Range of Civil Penalties --- ### [South Dakota-Rating of an Insurance Policy-SDCL ¤ 58-24-5](https://insurancefraud.org/statutes/south-dakota-rating-of-an-insurance-policy-sdcl-¤-58-24-5/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Rates shall not be excessive, inadequate, or unfairly discriminatory. **State:** South Dakota --- ### [South Dakota-Underwriting Fraud-SDCL ¤ 58-4A-2](https://insurancefraud.org/statutes/south-dakota-underwriting-fraud-sdcl-¤-58-4a-2/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** For purposes of this chapter, a person commits a fraudulent insurance act if the person: (3) Willfully embezzles, abstracts, steals, misappropriates, or converts money, funds, premiums, credits, or other property of an insurer or person engaged in the business of insurance or of an insured or prospective insured; (4) Knowingly and with intent to defraud or deceive makes any false entry of a material fact in or pertaining to any document or statement filed with or required by the Division of Insurance; (5) Knowingly and with intent to defraud or deceive removes, conceals, alters, diverts, or destroys assets or records of an insurer or other person engaged in the business of insurance or attempts to remove, conceal, alter, divert, or destroy assets or records of an insurer or other person engaged in the business of insurance; **State:** South Dakota **Statute Areas:** Underwriting Fraud --- ### [South Dakota-Unauthorized Entities-SDCL ¤ 58-8-1](https://insurancefraud.org/statutes/south-dakota-unauthorized-entities-sdcl-¤-58-8-1/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** No person may in this state, directly or indirectly, act as insurance producer for, or otherwise represent any insurer not then authorized to transact insurance business in this state, in the solicitation, negotiation, or effectuation of insurance or of annuity contracts, inspection of risks, fixing of rates, investigation or adjustment of losses, collection of premiums, or in any other manner in the transaction of insurance business with respect to subjects of insurance resident, located or to be performed in this state. Any violation of this section is a Class 2 misdemeanor. **State:** South Dakota --- ### [South Carolina-Aiding & Abetting-Code 1976 ¤ 38-55-540 (Proposed Legislation)](https://insurancefraud.org/statutes/south-carolina-aiding-abetting-code-1976-¤-38-55-540-proposed-legislation/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (A) A person who knowingly makes a false statement or misrepresentation, and any other person knowingly, with an intent to injure, defraud, or deceive, or who assists, abets, solicits, or conspires with a person to make a false statement or misrepresentation, is guilty of a: (1) misdemeanor, for a first offense violation, if the amount of the economic advantage or benefit received is less than one thousand dollars. Upon conviction, the person must be fined not less than one hundred nor more than five hundred dollars or imprisoned not more than thirty days; (2) misdemeanor, for a first offense violation, if the amount of the economic advantage or benefit received is one thousand dollars or more but less than ten thousand dollars. Upon conviction, the person must be fined not less than two thousand nor more than ten thousand dollars or imprisoned not more than three years, or both; (3) felony, for a first offense violation, if the amount of the economic advantage or benefit received is ten thousand dollars or more but less than fifty thousand dollars. Upon conviction, the person must be fined not less than ten thousand nor more than fifty thousand dollars or imprisoned not more than five years, or both; (4) felony, for a first offense violation, if the amount of the economic advantage or benefit received is fifty thousand dollars or more. Upon conviction, the person must be fined not less than twenty thousand nor more than one hundred thousand dollars or imprisoned not more than ten years, or both; (5) felony, for a second or subsequent violation, regardless of the amount of the economic advantage or benefit received. Upon conviction, the person must be fined not less than twenty thousand nor more than one hundred thousand dollars or imprisoned not more than ten years, or both. (B) In addition to the criminal penalties set forth in subsection (A), a person convicted pursuant to the provisions of this section must be ordered by the court to make full restitution to a victim for any economic advantage or benefit which has been obtained by the person as a result of that violation, and to pay the difference between any taxes owed and any taxes the person paid, if applicable. **State:** South Carolina --- ### [South Carolina-Anti-Runner Provisions-Code 1976 ¤ 38-55-170](https://insurancefraud.org/statutes/south-carolina-anti-runner-provisions-code-1976-¤-38-55-170/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** A person who knowingly causes to be presented a false claim for payment to an insurer transacting business in this State, to a health maintenance organization transacting business in this State, or to any person, including the State of South Carolina, providing benefits for health care in this State, whether these benefits are administered directly or through a third person, or who knowingly assists, solicits, or conspires with another to present a false claim for payment as described above, is guilty of a: (1) felony if the amount of the claim is ten thousand dollars or more. Upon conviction, the person must be imprisoned not more than ten years or fined not more than five thousand dollars, or both; (2) felony if the amount of the claim is more than two thousand dollars but less than ten thousand dollars. Upon conviction, the person must be fined in the discretion of the court or imprisoned not more than five years, or both; (3) misdemeanor triable in magistrates court or municipal court, notwithstanding the provisions of Sections 22-3-540, 22-3-545, 22-3-550, and 14-25-65, if the amount of the claim is two thousand dollars or less. Upon conviction, the person must be fined not more than one thousand dollars, or imprisoned not more than thirty days, or both. **State:** South Carolina **Statute Areas:** Anti-Runner Provisions --- ### [South Carolina-Claims Fraud-Code 1976 ¤ 38-55-170](https://insurancefraud.org/statutes/south-carolina-claims-fraud-code-1976-¤-38-55-170/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** A person who knowingly causes to be presented a false claim for payment to an insurer transacting business in this State, to a health maintenance organization transacting business in this State, or to any person, including the State of South Carolina, providing benefits for health care in this State, whether these benefits are administered directly or through a third person, or who knowingly assists, solicits, or conspires with another to present a false claim for payment as described above, is guilty of a: (1) felony if the amount of the claim is ten thousand dollars or more. Upon conviction, the person must be imprisoned not more than ten years or fined not more than five thousand dollars, or both; (2) felony if the amount of the claim is more than two thousand dollars but less than ten thousand dollars. Upon conviction, the person must be fined in the discretion of the court or imprisoned not more than five years, or both; (3) misdemeanor triable in magistrates court or municipal court, notwithstanding the provisions of Sections 22-3-540, 22-3-545, 22-3-550, and 14-25-65, if the amount of the claim is two thousand dollars or less. Upon conviction, the person must be fined not more than one thousand dollars, or imprisoned not more than thirty days, or both. **State:** South Carolina **Statute Areas:** Claims Fraud --- ### [South Carolina-Failing to Remit Premium-Code 1976 ¤ 38-43-130](https://insurancefraud.org/statutes/south-carolina-failing-to-remit-premium-code-1976-¤-38-43-130/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (A) The director or his designee may place on probation, revoke, or suspend a producer’s license after ten days’ notice or refuse to issue or reissue a license when it appears that a producer has been convicted of a crime involving moral turpitude, has violated this title or any regulation promulgated by the department, or has wilfully deceived or dealt unjustly with the citizens of this State. (C) The words “deceived or dealt unjustly with the citizens of this State” include, but are not limited to, action or inaction by the producer as follows: (4) improperly withholding, misappropriating, or converting any monies or properties received in the course of doing insurance business; **State:** South Carolina --- ### [South Carolina-Fraud Bureau-Code 1976 ¤ 38-55-560 (Proposed Legislation)](https://insurancefraud.org/statutes/south-carolina-fraud-bureau-code-1976-¤-38-55-560-proposed-legislation/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (A) There is established in the Office of the Attorney General a division to be known as the Insurance Fraud Division, which must prosecute violations of Sections 38-55-170 and 38-55-540 and related criminal insurance activity. Upon receipt of any claims or allegations of violations of Section 38-55-170 and 38-55-540 and related criminal insurance activity, the Attorney General shall forward the information to the State Law Enforcement Division for investigation. (B) The Attorney General, upon receipt of any claims or allegations of violations of Sections 38-55-170 and 38-55-540 and related criminal insurance activity, is empowered to: (1) refer the matter for investigation to the State Law Enforcement Division; (2) prosecute persons determined to be in violation of Sections 38-55-170 and 38-55-540 and related criminal insurance activity in a court of competent jurisdiction; and (3) collect fines and restitution ordered by the court. Where considered appropriate, the Attorney General may use the Setoff Debt Collection Act to collect fines and restitution ordered as a result of actions brought pursuant to Sections 38-55-170 and 38-55-540. (C) The State Law Enforcement Division shall investigate thoroughly all claims or allegations of violations of Sections 38-55-170 and 38-55-540 and related criminal insurance activity received from the Attorney General pursuant to this section. (D) The Insurance Fraud Division of the Office of Attorney General and the investigative services of the State law Enforcement Division as provided by this section must be funded by an appropriation of not less than two hundred thousand dollars annually from the general revenues of the State derived from the insurance premium taxes collected by the Department of Insurance and/or from fines assessed under Sections 38-55-170 and 38-55-540 which must be deposited in the general revenue fund to the credit of the Office of the Attorney General and the State Law Enforcement Division to offset the costs of this program; provided, that the funds generated from these fines, to be utilized by either the Office of the Attorney General or the State Law Enforcement Division shall not total more than five hundred thousand dollars. These monies must be shared equally on a fifty-fifty basis by the Office of the Attorney General and the State Law Enforcement Division, and the balance must go to the general fund of the State. (E) The Office of the Attorney General is authorized to hire, employ, and reasonably equip one forensic accountant, and this forensic accountant must be assigned to the Insurance Fraud Division of the Office of the Attorney General. A person is not qualified to be hired and the Insurance Fraud Division may not hire a forensic accountant unless he possesses and maintains a current license to engage in the practice of accounting pursuant to the provisions of Chapter 2, Title 40. **State:** South Carolina **Statute Areas:** Fraud Bureau --- ### [South Carolina-Immunity-Code 1976 ¤ 38-55-580](https://insurancefraud.org/statutes/south-carolina-immunity-code-1976-¤-38-55-580/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (A) A person, insurer, or authorized agency, when acting without malice or in good faith, is immune from any liability arising out of filing reports, cooperating with investigations by any authorized agency, or furnishing other information, whether written or oral, and whether in response to a request by an authorized agency or upon their own initiative, concerning any suspected, anticipated, or completed false statement or misrepresentation when such reports or information are provided to or received by any authorized agency. (B) Nothing herein abrogates or modifies in any way common law or statutory privilege or immunity heretofore enjoyed by any person, insurer, or authorized agency. (C) Nothing herein limits the liability of any person or insurer who, with malice or in bad faith, makes a report of suspected fraud under the provisions of this article. (D) In addition to the immunity granted in this section, persons identified as designated employees whose responsibilities include the investigation and disposition of claims relating to suspected fraudulent insurance acts may share information relating to persons suspected of committing fraudulent insurance acts with other designated employees employed by the same or other insurers whose responsibilities include the investigation and disposition of claims relating to fraudulent insurance acts, provided the department has been given written notice of the names and job titles of these designated employees prior to any designated employee sharing information. Unless the designated employees of the insurer act in bad faith or in reckless disregard for the rights of any insured, neither the insurer nor its designated employees are civilly liable for libel, slander, or any other relevant tort, and a civil action does not arise against the insurer or its designated employees: (1) for any information related to suspected fraudulent insurance acts provided to an insurer; or (2) for information related to suspected fraudulent insurance acts provided to the National Insurance Crime Bureau or the National Association of Insurance Commissioners. Provided, however, that the qualified immunity against civil liability conferred on any insurer or its designated employees shall be forfeited with respect to the exchange or publication of any defamatory information with third persons not expressly authorized by subsection (D) to share in such information. **State:** South Carolina **Statute Areas:** Immunity --- ### [South Carolina-Mandatory Restitution-Code 1976 ¤ 38-55-540 (Proposed Legislation)](https://insurancefraud.org/statutes/south-carolina-mandatory-restitution-code-1976-¤-38-55-540-proposed-legislation/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (B) In addition to the criminal penalties set forth in subsection (A), a person convicted pursuant to the provisions of this section must be ordered by the court to make full restitution to a victim for any economic advantage or benefit which has been obtained by the person as a result of that violation, and to pay the difference between any taxes owed and any taxes the person paid, if applicable. **State:** South Carolina **Statute Areas:** Mandatory Restitution --- ### [South Carolina-Placing Bogus Coverage-SECTION 38-55-130. SECTION 38-55-150.](https://insurancefraud.org/statutes/south-carolina-placing-bogus-coverage-section-38-55-130-section-38-55-150/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Doing business after charter has been canceled or surrendered is unlawful. It is unlawful for an insurer or for any person acting for or on its behalf knowingly to solicit, deliver any policy, or collect any premiums of insurance for the insurer from any person within this State when the insurer has surrendered its charter or when its charter has been revoked or canceled for any reason. It is unlawful for a director or officer of an insurer to wilfully receive a premium or assessment on behalf of the insurer, knowing at the time of receipt of the premium or assessment that the insurer is insolvent according to the laws of its home state, and to fail to notify the person paying the premium or assessment of this fact. A person who violates the provisions of this section is guilty of a misdemeanor and, upon conviction, must be fined in the discretion of the court or imprisoned not more than three years. Accepting premiums or assessments in insolvent insurer. It is unlawful for a director or officer of an insurer to wilfully receive a premium or assessment on behalf of the insurer, knowing at the time of receipt of the premium or assessment that the insurer is insolvent according to the laws of its home state, and to fail to notify the person paying the premium or assessment of this fact. A person who violates the provisions of this section is guilty of a misdemeanor and, upon conviction, must be fined in the discretion of the court or imprisoned not more than three years. **State:** South Carolina --- ### [South Carolina-Premium Fraud-Code 1976 ¤ 38-55-150](https://insurancefraud.org/statutes/south-carolina-premium-fraud-code-1976-¤-38-55-150/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** It is unlawful for a director or officer of an insurer to wilfully receive a premium or assessment on behalf of the insurer, knowing at the time of receipt of the premium or assessment that the insurer is insolvent according to the laws of its home state, and to fail to notify the person paying the premium or assessment of this fact. A person who violates the provisions of this section is guilty of a misdemeanor and, upon conviction, must be fined in the discretion of the court or imprisoned not more than three years. **State:** South Carolina **Statute Areas:** Premium Fraud --- ### [South Carolina-Range of Criminal Penalties-Code 1976 ¤ 38-55-540 (Proposed Legislation)](https://insurancefraud.org/statutes/south-carolina-range-of-criminal-penalties-code-1976-¤-38-55-540-proposed-legislation/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (A) A person who knowingly makes a false statement or misrepresentation, and any other person knowingly, with an intent to injure, defraud, or deceive, or who assists, abets, solicits, or conspires with a person to make a false statement or misrepresentation, is guilty of a: (1) misdemeanor, for a first offense violation, if the amount of the economic advantage or benefit received is less than one thousand dollars. Upon conviction, the person must be fined not less than one hundred nor more than five hundred dollars or imprisoned not more than thirty days; (2) misdemeanor, for a first offense violation, if the amount of the economic advantage or benefit received is one thousand dollars or more but less than ten thousand dollars. Upon conviction, the person must be fined not less than two thousand nor more than ten thousand dollars or imprisoned not more than three years, or both; (3) felony, for a first offense violation, if the amount of the economic advantage or benefit received is ten thousand dollars or more but less than fifty thousand dollars. Upon conviction, the person must be fined not less than ten thousand nor more than fifty thousand dollars or imprisoned not more than five years, or both; (4) felony, for a first offense violation, if the amount of the economic advantage or benefit received is fifty thousand dollars or more. Upon conviction, the person must be fined not less than twenty thousand nor more than one hundred thousand dollars or imprisoned not more than ten years, or both; (5) felony, for a second or subsequent violation, regardless of the amount of the economic advantage or benefit received. Upon conviction, the person must be fined not less than twenty thousand nor more than one hundred thousand dollars or imprisoned not more than ten years, or both. (B) In addition to the criminal penalties set forth in subsection (A), a person convicted pursuant to the provisions of this section must be ordered by the court to make full restitution to a victim for any economic advantage or benefit which has been obtained by the person as a result of that violation, and to pay the difference between any taxes owed and any taxes the person paid, if applicable. **State:** South Carolina **Statute Areas:** Range of Criminal Penalties --- ### [South Carolina-Range of Civil Penalties-Code 1976 ¤ 38-55-550](https://insurancefraud.org/statutes/south-carolina-range-of-civil-penalties-code-1976-¤-38-55-550/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (A) In addition to any criminal liability, any person who is found by a court of competent jurisdiction to have violated any provision of this article, including Section 38-55-170, is subject to a civil penalty for each violation as follows: (1) for a first offense, a fine not to exceed five thousand dollars; (2) for a second offense, a fine of not less than five thousand dollars but not to exceed ten thousand dollars; (3) for a third and subsequent offense, a fine of not less than ten thousand dollars but not to exceed fifteen thousand dollars. (B) The civil penalty must be paid to the director of the Insurance Fraud Division to be used in accordance with subsection (D) of this section. The court may also award court costs and reasonable attorneys’ fees to the director. When requested by the director, the Attorney General may assign one or more deputies attorneys general to assist the bureau in any civil court proceedings against the person. (C) Nothing in subsections (A) and (B) shall be construed to prohibit the director of the Insurance Fraud Division and the person alleged to be guilty of a violation of this article from entering into a written agreement in which the person does not admit or deny the charges but consents to payment of the civil penalty. A consent agreement may not be used in a subsequent civil or criminal proceeding relating to any violation of this article. (D) All revenues from the civil penalties imposed pursuant to this section must be used to provide funds for the costs of enforcing and administering the provisions of this article. **State:** South Carolina **Statute Areas:** Range of Civil Penalties --- ### [South Carolina-Rating of an Insurance Policy-Code 1976 ¤ 38-73-430](https://insurancefraud.org/statutes/south-carolina-rating-of-an-insurance-policy-code-1976-¤-38-73-430/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Rates must be made in accordance with the following provisions: (1) Due consideration must be given to past and prospective loss experience within and outside this State, to catastrophe hazards, if any, to a reasonable margin for underwriting profit and contingencies, to dividends, savings, or unabsorbed premium deposits allowed or returned by insurers to their policyholders, members, or subscribers, to past and prospective expenses, both countrywide and those specially applicable to this State, and to all other relevant factors within and outside of this State. (2) The systems of expense provisions included in the rates for use by any insurer or group of insurers may differ from those of other insurers or groups of insurers to reflect the requirements of the operating methods of the insurer or group with respect to any kind of insurance or with respect to any subdivision or combination thereof for which subdivision or combination separate expense provisions are applicable. (3) Risks may be grouped by classifications for the establishment of rates and minimum premiums, and classification rates may be modified to produce rates for individual risks in accordance with rating plans which establish standards for measuring any variations in hazards or expense provisions, or both, that can be demonstrated to have a probable effect upon losses or expenses. (4) Rates may not be excessive, inadequate, or unfairly discriminatory. (5) Due consideration must be given to assessments for purposes such as the guaranty fund, wind and hail joint underwriting association, and similar mechanisms. Except to the extent necessary to meet the provisions of item (4) of this section, uniformity among insurers in any matters within the scope of this section is neither required nor prohibited. **State:** South Carolina --- ### [South Carolina-Underwriting Fraud-Code 1976 ¤ 38-55-530](https://insurancefraud.org/statutes/south-carolina-underwriting-fraud-code-1976-¤-38-55-530/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (D) “False statement or misrepresentation” means a statement or representation made by a person that is false, material, made with the person’s knowledge of the falsity of the statement and made with the intent of obtaining or causing another to obtain or attempting to obtain or causing another to obtain an undeserved economic advantage or benefit or made with the intent to deny or cause another to deny any benefit or payment in connection with an insurance transaction, and such shall constitute fraud. “False statement or misrepresentation” specifically includes, but is not limited to, an intentional: (1) false report of business activities; (2) miscount or misclassification by an employer of its employees; (3) failure to timely reduce reserves; (4) failure to account for Second Injury Fund reimbursements or subrogation reimbursements; or (5) failure to provide verifiable information to public or private rating bureaus and the Department of Insurance. An undeserved economic benefit or advantage includes, but is not limited to, a favorable insurance premium, payment schedule, insurance award, or insurance settlement. **State:** South Carolina **Statute Areas:** Underwriting Fraud --- ### [South Carolina-Unauthorized Entities-Code 1976 ¤ 38-25-110](https://insurancefraud.org/statutes/south-carolina-unauthorized-entities-code-1976-¤-38-25-110/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** It is unlawful for an insurer to transact insurance business in this State without a certificate of authority from the director or his designee. Any of the acts listed in items (1) through (8) in this State effected by mail or otherwise by or on behalf of an unauthorized insurer is considered to constitute the transaction of an insurance business in this State. The venue of an act committed by mail is at the point where the matter transmitted by mail is delivered and takes effect. Unless otherwise indicated, the term “insurer” as used in this section includes all corporations, associations, partnerships, and individuals engaged as principals in the business of insurance and also includes interinsurance exchanges and mutual benefit societies. (1) The making of or proposing to make, as an insurer, an insurance contract. (2) The making of or proposing to make, as guarantor or surety, any contract of guaranty or suretyship as a vocation and not merely incidental to any other legitimate business or activity of the guarantor or surety. (3) The taking or receiving of any application for insurance. (4) The receiving or collection of any premium, commission, membership fees, assessments, dues, or other consideration for any insurance or any part thereof. (5) The issuance or delivery of contracts of insurance to residents of this State or to persons authorized to do business in this State. (6) Directly or indirectly acting as an agent for or otherwise representing or aiding on behalf of another, any person or insurer in the solicitation, negotiation, procurement, or effectuation of insurance or renewals thereof or in the dissemination of information as to coverage or rates, or forwarding of applications, or delivery of policies or contracts, or inspection of risks, a fixing of rates or investigation or adjustment of claims or losses or in the transaction of matters after effectuation of the contract and arising out of it, or in any other manner representing or assisting a person or insurer in the transaction of insurance with respect to subjects of insurance resident, located, or to be performed in this State. This section does not prohibit full-time salaried employees of a corporate insured from acting in the capacity of an insurance manager or buyer in placing insurance in behalf of their employer. (7) The transaction of any kind of insurance business specifically recognized as transacting an insurance business within the meaning of the statutes relating to insurance. (8) The transacting or proposing to transact any insurance business in substance equivalent to any of the foregoing in a manner designed to evade the insurance laws of this State. **State:** South Carolina --- ### [Rhode Island-Aiding & Abetting-Gen.Laws 1956, ¤ 27-54.1-1](https://insurancefraud.org/statutes/rhode-island-aiding-abetting-gen-laws-1956-¤-27-54-1-1/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (3) “Fraudulent insurance act” means an act or omission committed by a person who, knowingly and with intent to defraud, commits, or conceals any material information concerning, one or more of the following: (i) Presenting, causing to be presented or preparing with knowledge or belief that it will be presented to or by an insurer, a reinsurer, broker or its agent, false information as part of, in support of or concerning a fact material to one or more of the following: (A) An application for the issuance or renewal of an insurance policy or reinsurance contract; (B) The rating of an insurance policy or reinsurance contract; (C) A claim for payment or benefit pursuant to an insurance policy or reinsurance contract; (D) Premiums paid on an insurance policy or reinsurance contract; (E) Payments made in accordance with the terms of an insurance policy or reinsurance contract; (F) A document filed with the commissioner or the chief insurance regulatory official of another jurisdiction; (G) The financial condition of an insurer or reinsurer; (H) The formation, acquisition, merger, reconsolidation, dissolution or withdrawal from one or more lines of insurance or reinsurance in all or part of this state by an insurer or reinsurer; (I) The issuance of written evidence of insurance; or (J) The reinstatement of an insurance policy; (ii) Solicitation of acceptance of new or renewal insurance risks on behalf of an insurer, reinsurer or other person engaged in the business of insurance by a person who knows or should know that the insurer or other person responsible for the risk is insolvent at the time of the transaction; (iii) Removal, concealment, alteration or destruction of the assets or records of an insurer, reinsurer or other person engaged in the business of insurance; (iv) Willful embezzlement, abstracting, purloining, or conversion of monies, funds, premiums, credits or other property of an insurer, reinsurer or person engaged in the business of insurance; (v) Transaction of the business of insurance in violation of laws requiring a license, certificate of authority or other legal authority for the transaction of the business of insurance; or (vi) Attempt to commit, aiding or abetting in the commission of, or conspiracy to commit the acts or omissions specified in this subsection. **State:** Rhode Island --- ### [Rhode Island-Anti-Runner Provisions-n/a](https://insurancefraud.org/statutes/rhode-island-anti-runner-provisions-n-a/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** No statute found **State:** Rhode Island **Statute Areas:** Anti-Runner Provisions --- ### [Rhode Island-Attempted Fraud-Gen.Laws 1956, ¤ 27-54.1-1](https://insurancefraud.org/statutes/rhode-island-attempted-fraud-gen-laws-1956-¤-27-54-1-1/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (3) “Fraudulent insurance act” means an act or omission committed by a person who, knowingly and with intent to defraud, commits, or conceals any material information concerning, one or more of the following: (i) Presenting, causing to be presented or preparing with knowledge or belief that it will be presented to or by an insurer, a reinsurer, broker or its agent, false information as part of, in support of or concerning a fact material to one or more of the following: (A) An application for the issuance or renewal of an insurance policy or reinsurance contract; (B) The rating of an insurance policy or reinsurance contract; (C) A claim for payment or benefit pursuant to an insurance policy or reinsurance contract; (D) Premiums paid on an insurance policy or reinsurance contract; (E) Payments made in accordance with the terms of an insurance policy or reinsurance contract; (F) A document filed with the commissioner or the chief insurance regulatory official of another jurisdiction; (G) The financial condition of an insurer or reinsurer; (H) The formation, acquisition, merger, reconsolidation, dissolution or withdrawal from one or more lines of insurance or reinsurance in all or part of this state by an insurer or reinsurer; (I) The issuance of written evidence of insurance; or (J) The reinstatement of an insurance policy; (ii) Solicitation of acceptance of new or renewal insurance risks on behalf of an insurer, reinsurer or other person engaged in the business of insurance by a person who knows or should know that the insurer or other person responsible for the risk is insolvent at the time of the transaction; (iii) Removal, concealment, alteration or destruction of the assets or records of an insurer, reinsurer or other person engaged in the business of insurance; (iv) Willful embezzlement, abstracting, purloining, or conversion of monies, funds, premiums, credits or other property of an insurer, reinsurer or person engaged in the business of insurance; (v) Transaction of the business of insurance in violation of laws requiring a license, certificate of authority or other legal authority for the transaction of the business of insurance; or (vi) Attempt to commit, aiding or abetting in the commission of, or conspiracy to commit the acts or omissions specified in this subsection. **State:** Rhode Island **Statute Areas:** Attempted Fraud --- ### [Rhode Island-Claims Fraud-Gen.Laws 1956, ¤ 27-54.1-1](https://insurancefraud.org/statutes/rhode-island-claims-fraud-gen-laws-1956-¤-27-54-1-1/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (3) “Fraudulent insurance act” means an act or omission committed by a person who, knowingly and with intent to defraud, commits, or conceals any material information concerning, one or more of the following: (i) Presenting, causing to be presented or preparing with knowledge or belief that it will be presented to or by an insurer, a reinsurer, broker or its agent, false information as part of, in support of or concerning a fact material to one or more of the following: (C) A claim for payment or benefit pursuant to an insurance policy or reinsurance contract; **State:** Rhode Island **Statute Areas:** Claims Fraud --- ### [Rhode Island-Failing to Remit Premium-Gen.Laws 1956, ¤ 27-54.1-1](https://insurancefraud.org/statutes/rhode-island-failing-to-remit-premium-gen-laws-1956-¤-27-54-1-1/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (3) “Fraudulent insurance act” means an act or omission committed by a person who, knowingly and with intent to defraud, commits, or conceals any material information concerning, one or more of the following: (i) Presenting, causing to be presented or preparing with knowledge or belief that it will be presented to or by an insurer, a reinsurer, broker or its agent, false information as part of, in support of or concerning a fact material to one or more of the following: (iv) Willful embezzlement, abstracting, purloining, or conversion of monies, funds, premiums, credits or other property of an insurer, reinsurer or person engaged in the business of insurance; **State:** Rhode Island --- ### [Rhode Island-Fraud Bureau-Gen.Laws 1956, ¤ 31-50-1](https://insurancefraud.org/statutes/rhode-island-fraud-bureau-gen-laws-1956-¤-31-50-1/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) There is established an office of automobile theft and insurance fraud. (b) The scope and purpose of the office of automobile theft and insurance fraud shall be to investigate and prosecute crimes involving the theft or other unauthorized use of motor vehicles and to investigate and prosecute all forms of automobile insurance-related fraud. (c) The office of automobile theft and insurance fraud shall consist of a director, and not less than five (5) nor more than eight (8) investigators, who shall be selected and who shall be specially-trained to investigate instances of automobile theft and automobile claim insurance fraud. The director shall be a member of the Rhode Island state police with at least the rank of sergeant, and shall remain on the personnel rolls of the Rhode Island state police, with the same salary and benefits schedule, and shall retain all powers of a member of the Rhode Island state police of that rank. (d) The office of automobile theft and insurance fraud shall be under the jurisdiction of the superintendent of the state police. He or she shall appoint the director of that office from amongst the members of state police who have attained the rank of sergeant or above. The director, with the approval of the superintendent, shall have the authority to appoint and to remove, if necessary, the investigators and staff of the office. (e) The director and the investigators shall have the following powers: (1) To arrest independently or in conjunction with local, state or federal law enforcement agencies. (2) To apply for and execute search warrants; (3) To serve civil and criminal process. (f) No person shall be appointed as an investigator in the office unless he or she has successfully completed the basic course of instruction for police officers at the Providence Police Training Academy, the Rhode Island Municipal Police Training Academy, or the Rhode Island State Police Training Academy, and has at least three (3) years of active law enforcement experience, or has served as a member of the United States Marshal’s Service or as a special agent of the Federal Bureau of Investigation, a criminal law enforcement agency of the United States Department of Justice, the United States Department of State, the United States Department of the Treasury or the United States Postal Inspection Service and has at least three (3) years of active law enforcement experience, or has been certified as a police officer by the duly-constituted state commission on police officer standards and training of another state, and has at least three (3) years of active law enforcement experience. Prior to the appointment of any individuals, a background examination shall be conducted utilizing federal, state and local law enforcement agencies, bureau of criminal identification, national crime information center, and any and all relevant records existing within the federal and state court systems. (g) The attorney general shall designate one assistant or special assistant attorney general to the office whose duties shall be exclusively devoted to the office of automobile theft and insurance fraud. That assistant shall be funded from the account established in ¤ 31-50-4. (h) The state shall hold the director and each investigator harmless and indemnify them to the extent provided under ¤ 9-31-12 for acts committed within the scope of their employment. **State:** Rhode Island **Statute Areas:** Fraud Bureau --- ### [Rhode Island-Immunity-Gen.Laws 1957, 27-49-5; 27-49-5.1](https://insurancefraud.org/statutes/rhode-island-immunity-gen-laws-1957-27-49-5-27-49-5-1/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** No insurer, or agent authorized by an insurer to act on its behalf, authorized governmental agency or their respective employees shall be subject to any civil or criminal liability in a cause of action of any kind for releasing or receiving any factually accurate information pursuant to ÌÙ 27- 49-3 or ÌÙ 27-49-4. Nothing herein is intended to or does in any way or manner abrogate or lessen the common and statutory law, privileges and immunities of an insurer, agent authorized by an insurer to act on its behalf, or authorized governmental agency or any of their respective employees. \*\*\* (a) An insurer and an agent authorized to act on its behalf, upon written request, may provide to another insurer or insurance industry related organization whose purpose it is to investigate or assist in the prosecution of motor vehicle insurance fraud any and all relevant factually accurate information which the insurer may possess as to any motor vehicle claim or other information which may relate to whether a motor vehicle theft or motor vehicle insurance fraud has occurred. (b) No insurer, organization or agent authorized to act under subsection (a) of this section shall be subjected to any civil or criminal liability in any cause of action of any kind for releasing or receiving any relevant factually accurate information pursuant to subsection (a) of this section if it acts in good faith and with due care solely for the purpose of facilitating the discovery and prosecution of the theft or fraud. **State:** Rhode Island **Statute Areas:** Immunity --- ### [Rhode Island-Insurance Fraud - Definition-Gen.Laws 1956, ¤ 27-54.1-1](https://insurancefraud.org/statutes/rhode-island-insurance-fraud-definition-gen-laws-1956-¤-27-54-1-1/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (3) “Fraudulent insurance act” means an act or omission committed by a person who, knowingly and with intent to defraud, commits, or conceals any material information concerning, one or more of the following: (i) Presenting, causing to be presented or preparing with knowledge or belief that it will be presented to or by an insurer, a reinsurer, broker or its agent, false information as part of, in support of or concerning a fact material to one or more of the following: (A) An application for the issuance or renewal of an insurance policy or reinsurance contract; (B) The rating of an insurance policy or reinsurance contract; (C) A claim for payment or benefit pursuant to an insurance policy or reinsurance contract; (D) Premiums paid on an insurance policy or reinsurance contract; (E) Payments made in accordance with the terms of an insurance policy or reinsurance contract; (F) A document filed with the commissioner or the chief insurance regulatory official of another jurisdiction; (G) The financial condition of an insurer or reinsurer; (H) The formation, acquisition, merger, reconsolidation, dissolution or withdrawal from one or more lines of insurance or reinsurance in all or part of this state by an insurer or reinsurer; (I) The issuance of written evidence of insurance; or (J) The reinstatement of an insurance policy; (ii) Solicitation of acceptance of new or renewal insurance risks on behalf of an insurer, reinsurer or other person engaged in the business of insurance by a person who knows or should know that the insurer or other person responsible for the risk is insolvent at the time of the transaction; (iii) Removal, concealment, alteration or destruction of the assets or records of an insurer, reinsurer or other person engaged in the business of insurance; (iv) Willful embezzlement, abstracting, purloining, or conversion of monies, funds, premiums, credits or other property of an insurer, reinsurer or person engaged in the business of insurance; (v) Transaction of the business of insurance in violation of laws requiring a license, certificate of authority or other legal authority for the transaction of the business of insurance; or (vi) Attempt to commit, aiding or abetting in the commission of, or conspiracy to commit the acts or omissions specified in this subsection. **State:** Rhode Island **Statute Areas:** Insurance Fraud - Definition --- ### [Rhode Island-Looting & diverting-Gen.Laws 1956, ¤ 27-54.1-1](https://insurancefraud.org/statutes/rhode-island-looting-diverting-gen-laws-1956-¤-27-54-1-1/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (3) “Fraudulent insurance act” means an act or omission committed by a person who, knowingly and with intent to defraud, commits, or conceals any material information concerning, one or more of the following: (i) Presenting, causing to be presented or preparing with knowledge or belief that it will be presented to or by an insurer, a reinsurer, broker or its agent, false information as part of, in support of or concerning a fact material to one or more of the following: (iv) Willful embezzlement, abstracting, purloining, or conversion of monies, funds, premiums, credits or other property of an insurer, reinsurer or person engaged in the business of insurance; **State:** Rhode Island --- ### [Rhode Island-Practitioner Penalites-Gen.Laws 1956, ¤ 27-54.1-6](https://insurancefraud.org/statutes/rhode-island-practitioner-penalites-gen-laws-1956-¤-27-54-1-6/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** A person who violates this chapter is subject to suspension or revocation of license or certificate of authority or administrative penalties per Rhode Island general laws ¤ 42-14-16 or both. Suspension or revocation of license or certificate of authority and imposition of administrative penalties shall be pursuant to an order of the commissioner issued under Rhode Island general laws ¤ 42-35-9 and/or 42-35-12. The commissioner’s order may require a person found to be in violation of this chapter to make restitution to persons aggrieved by violations of this chapter. **State:** Rhode Island **Statute Areas:** Practitioner Penalites --- ### [Rhode Island-Premium Fraud-Gen.Laws 1956, ¤ 27-54.1-1](https://insurancefraud.org/statutes/rhode-island-premium-fraud-gen-laws-1956-¤-27-54-1-1/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (3) “Fraudulent insurance act” means an act or omission committed by a person who, knowingly and with intent to defraud, commits, or conceals any material information concerning, one or more of the following: (i) Presenting, causing to be presented or preparing with knowledge or belief that it will be presented to or by an insurer, a reinsurer, broker or its agent, false information as part of, in support of or concerning a fact material to one or more of the following: (D) Premiums paid on an insurance policy or reinsurance contract; **State:** Rhode Island **Statute Areas:** Premium Fraud --- ### [Rhode Island-Range of Criminal Penalties-Gen.Laws 1956, ¤ 27-54-1](https://insurancefraud.org/statutes/rhode-island-range-of-criminal-penalties-gen-laws-1956-¤-27-54-1/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) Any person who knowingly and with intent to deceive the director of business regulation (referred to in this section as “director”) about the financial condition of an insurance company, makes any false statement, representation or report to the director concerning an insurance company; or who knowingly and with intent to deceive the director about the financial condition of the company testifies or affirms falsely under oath or affirmation to any material fact relative to an insurance company in any matter which would materially affect the financial condition of the company; or who knowingly and with intent to deceive the director about the financial condition of the company makes any false entry or memorandum upon any book, paper, report or statement of any insurance company; or, who, knowingly and with intent to deceive the director or his or her designee or any agent appointed to examine the affairs of an insurance company, or knowingly and with intent to deceive, defraud or injure the stockholders, policyholders or any officer or director of an insurance company about the financial condition of the company makes a statement, representation or report to the director or the director’s designee which the individual knows materially overvalues any asset, property or security of an insurance company; or who knowingly and with intent to deceive the director about the financial condition of the company fails to disclose material information, and any person who, with like intent, aids or abets another in any violation of any provision of this section, shall upon conviction, be fined not exceeding fifty thousand dollars ($50,000) or imprisoned not exceeding twenty (20) years, or both. **State:** Rhode Island **Statute Areas:** Range of Criminal Penalties --- ### [Rhode Island-Range of Civil Penalties-Gen.Laws 1956, ¤ 27-54-2](https://insurancefraud.org/statutes/rhode-island-range-of-civil-penalties-gen-laws-1956-¤-27-54-2/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** In addition to the criminal penalties set forth in ¤ 27-54-1, the attorney general or the director or his or her designee may bring a civil action against any person who engages in conduct constituting an offense under this chapter and, upon proof of that conduct by a preponderance of the evidence, the person shall be subject, for each violation, to a civil penalty not exceeding fifty thousand dollars ($50,000) or the amount of damages caused by that conduct, whichever is greater. If the insurance company is placed in conservation, rehabilitation, or liquidation, the conservator or receiver shall also be entitled to bring a civil action, and the penalty shall be paid to the conservator or receiver for the benefit of the policyholders, claimants, and creditors of the insurer. The imposition of a civil penalty under this subsection does not preclude any other criminal or civil statutory, common law, or administrative remedy, which is available by law to the state of Rhode Island or any other person. **State:** Rhode Island **Statute Areas:** Range of Civil Penalties --- ### [Rhode Island-Rating of an Insurance Policy-Gen.Laws 1956, ¤ 27-6-4](https://insurancefraud.org/statutes/rhode-island-rating-of-an-insurance-policy-gen-laws-1956-¤-27-6-4/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Rates shall be made in accordance with the following provisions: (1) Manual, minimum, or class rates, rating schedules, or rating plans shall be made and adopted, except in the case of specific inland marine rates, on risks specially rated; (2) Rates shall not be excessive, inadequate, or unfairly discriminatory; and (3) Due consideration shall be given to past and prospective loss experience within and outside of this state, to the conflagration and catastrophe hazards, to a reasonable margin for underwriting profit and contingencies, to dividends savings or unabsorbed premium deposits allowed or returned by insurers to their policyholders, members, or subscribers, to past and prospective expenses both country-wide and those specially applicable to this state, and to all other relevant factors within and outside of this state. In the case of fire insurance rates consideration shall be given to the experience of the fire insurance business during a period of not less than the most recent five (5) year period for which that experience is available. **State:** Rhode Island --- ### [Rhode Island-Underwriting Fraud-n/a](https://insurancefraud.org/statutes/rhode-island-underwriting-fraud-n-a/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (3) “Fraudulent insurance act” means an act or omission committed by a person who, knowingly and with intent to defraud, commits, or conceals any material information concerning, one or more of the following: (E) Payments made in accordance with the terms of an insurance policy or reinsurance contract; (F) A document filed with the commissioner or the chief insurance regulatory official of another jurisdiction; (G) The financial condition of an insurer or reinsurer; (H) The formation, acquisition, merger, reconsolidation, dissolution or withdrawal from one or more lines of insurance or reinsurance in all or part of this state by an insurer or reinsurer; (I) The issuance of written evidence of insurance; or (J) The reinstatement of an insurance policy; (ii) Solicitation of acceptance of new or renewal insurance risks on behalf of an insurer, reinsurer or other person engaged in the business of insurance by a person who knows or should know that the insurer or other person responsible for the risk is insolvent at the time of the transaction; (iii) Removal, concealment, alteration or destruction of the assets or records of an insurer, reinsurer or other person engaged in the business of insurance; (iv) Willful embezzlement, abstracting, purloining, or conversion of monies, funds, premiums, credits or other property of an insurer, reinsurer or person engaged in the business of insurance; (v) Transaction of the business of insurance in violation of laws requiring a license, certificate of authority or other legal authority for the transaction of the business of insurance; or (vi) Attempt to commit, aiding or abetting in the commission of, or conspiracy to commit the acts or omissions specified in this subsection. **State:** Rhode Island **Statute Areas:** Underwriting Fraud --- ### [Rhode Island-Unauthorized Entities-Gen.Laws 1956, ¤ 27-16-1.2](https://insurancefraud.org/statutes/rhode-island-unauthorized-entities-gen-laws-1956-¤-27-16-1-2/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) It shall be unlawful for any insurer to transact insurance business in this state as set forth in subsection (b) of this section without a certificate of compliance from the commissioner; provided, that this section shall not apply to: (1) The lawful transaction of surplus lines insurance; (2) The lawful transaction of reinsurance by insurers; (3) Transactions in this state involving a policy lawfully solicited, written, and delivered outside of this state covering only subjects of insurance not resident, located, or expressly to be performed in this state at the time of issuance, and which transactions are subsequent to the issuance of the policy; (4) Attorneys acting in the ordinary relation of attorney and client in the adjustment of claims or losses; (5) Transactions in this state involving group life and group sickness and accident or blanket sickness and accident insurance or group annuities where the master policy of the groups was lawfully issued and delivered in and pursuant to the laws of a state in which the insurer was authorized to do an insurance business, to a group organized for purposes other than the procurement of insurance, and where the policyholder is domiciled or has a bona fide situs; (6) Transactions in this state involving any policy of insurance or annuity contract issued prior to May 15, 1973; (7) Transactions in this state relative to a policy issued outside of this state involving insurance on vessels, craft, or hulls, cargoes, marine protection, and indemnity or other risk, including strikes and war risks commonly insured under ocean or wet marine forms of policy; (8) Transactions in this state involving contracts of insurance issued to one or more industrial insured. An industrial insured is defined as an insured: (i) Which procures the insurance of any risk by the use of the services of a full-time employee acting as insurance manager or buyer or the services of a regularly and continuously retained qualified insurance consultant; (ii) Whose aggregate annual premiums on all risks excluding workers’ compensation and group total at least twenty-five thousand dollars ($25,000); and (iii) Which has at least twenty-five (25) full-time employees; and (9)(i) Transactions in this state involving life insurance, health insurance, or annuities provided to educational or religious or charitable institutions organized and operated without profit to any private shareholder or individual for the benefit of the institutions and individuals engaged in the service of the institutions; (ii) This exemption shall be conditional upon the company complying with the following requirements: (A) Payment of an annual registration fee of five hundred dollars ($500); (B) Filing a copy of any policy or contract form, including annuities issued to any Rhode Island residents with the commissioner of insurance. Each policy and contract form, including annuities, shall contain (on its front and declaration page) in at least twelve (12) point type the following notice: NOTICE TO RHODE ISLAND RESIDENTS THIS CONTRACT HAS BEEN PLACED WITH AN INSURER NOT LICENSED TO DO BUSINESS IN THE STATE OF RHODE ISLAND BUT ELIGIBLE AS AN UNLICENSED REGISTERED INSURER PURSUANT TO THE UNAUTHORIZED BUSINESS STATUTE. THE INSURER IS NOT A MEMBER OF THE RHODE ISLAND LIFE AND HEALTH GUARANTY ASSOCIATION. SHOULD THE INSURER BECOME INSOLVENT, THE PROTECTION AND BENEFITS OF THE ASSOCIATION ARE NOT AVAILABLE. (C) Filing a copy of its annual statement, prepared pursuant to the laws of its state of domicile, and any other financial material that may be requested by the commissioner; and (D) The company agrees to appoint the commissioner of insurance, and his or her successors in office, as its attorney to receive service of legal process issued against it in Rhode Island. The appointment is to be irrevocable and to bind the commissioner, and any successors in interest, and to remain in effect as long as there is in force in this state any contract issued by the company or any obligations arising from a contract. (10) Rental car companies and their employees principally engaged in the rental of motor vehicles and which offer in connection with and incidental to the rental of motor vehicles various optional insurance coverage during the term of the rental, which shall be no more than sixty (60) days. (11) Transactions that are insurance securitization or reinsurance transactions entered into by a protected cell of a protected cell company organized under the Protected Cell Companies Act, chapter 64 of this title, as those terms are defined or utilized in that chapter. (b) Any of the following acts in this state effected by mail or otherwise, by or on behalf of an insurer, is deemed to constitute the transaction of an insurance business in this state. The venue of an act committed by mail is at the point where the matter transmitted by mail is delivered and takes effect. Unless indicated, “insurer,” as used in this section, includes all corporations, associations, partnerships, and individuals engaged as principals in the business of insurance and also includes interinsurance exchanges and mutual benefit societies: (1) The making or proposing to make, as an insurer an insurance contract; (2) The making of or proposing to make, as guarantor or surety, any contract of guaranty or suretyship as a vocation and not merely incidental to any other legitimate business or activity of the guarantor or surety; (3) The taking or receiving of any application for insurance; (4) The receiving or collection of any premium, commission, membership fees, assessments, dues, or other consideration for an insurance or any part of an insurance; (5) The issuance or delivery of contracts of insurance to residents of this state or to persons authorized to do business in this state; (6) Directly or indirectly acting as an agent or insurance producer for or representing or aiding on behalf of another any person or insurer in the solicitation, negotiation, procurement, or effectuation of insurance or renewals of insurance or in the dissemination of information as to coverage or rates, forwarding of applications, delivery of policies or contracts, inspection of risks, fixing of rates or investigation or adjustment of claims or losses, or in the transaction of matters subsequent to effectuation of the contract and arising out of it, or in any other manner representing or assisting a person or insurer in the transaction of insurance with respect to subjects of insurance, resident, located, or to be performed in this state. The provisions of this subsection shall not operate to prohibit full-time salaried employees of a corporate insured from acting in the capacity of an insurance manager or buyer in placing insurance in behalf of the employer; (7) The transaction of any kind of insurance business specifically recognized as transacting an insurance business within the meaning of the statutes relating to insurance; or (8) The transacting or proposing to transact any insurance business in substance equivalent to any of these in a manner designed to evade the provisions of the statutes. (c) The failure of an insurer transacting insurance business in this state to obtain a certificate of compliance shall not impair the validity of any act or contract of the insurer and shall not prevent the insurer from defending any action at law or suit in equity in any court of this state, but no insurer transacting insurance business in this state without a certificate of authority shall be permitted to maintain an action in any court of this state to enforce any right, claim, or demand arising out of the transaction of insurance business until the insurer shall have obtained a certificate of authority. (d) In the event of the failure of any unauthorized insurer to pay any claim or loss within the provisions of the insurance contract, any person who assisted or in any manner aided directly or indirectly in the procurement of the insurance contract shall be liable to the insured for the full amount of the claim or loss in the manner provided by the provisions of the insurance contract. **State:** Rhode Island --- ### [Pennsylvania-Aiding & Abetting-18 Pa.C.S.A. ¤ 4117](https://insurancefraud.org/statutes/pennsylvania-aiding-abetting-18-pa-c-s-a-¤-4117/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) Offense defined.–A person commits an offense if the person does any of the following: (3) Knowingly and with the intent to defraud any insurer or self-insured, assists, abets, solicits or conspires with another to prepare or make any statement that is intended to be presented to any insurer or self-insured in connection with, or in support of, a claim that contains any false, incomplete or misleading information concerning any fact or thing material to the claim, including information which documents or supports an amount claimed in excess of the actual loss sustained by the claimant. **State:** Pennsylvania --- ### [Pennsylvania-Anti-Runner Provisions-18 Pa.C.S.A. ¤ 4117](https://insurancefraud.org/statutes/pennsylvania-anti-runner-provisions-18-pa-c-s-a-¤-4117/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) Offense defined.–A person commits an offense if the person does any of the following: (5) Knowingly benefits, directly or indirectly, from the proceeds derived from a violation of this section due to the assistance, conspiracy or urging of any person. (6) Is the owner, administrator or employee of any health care facility and knowingly allows the use of such facility by any person in furtherance of a scheme or conspiracy to violate any of the provisions of this section. (7) Borrows or uses another person’s financial responsibility or other insurance identification card or permits his financial responsibility or other insurance identification card to be used by another, knowingly and with intent to present a fraudulent claim to an insurer. **State:** Pennsylvania **Statute Areas:** Anti-Runner Provisions --- ### [Pennsylvania-Claims Fraud-18 Pa.C.S.A. ¤ 4117](https://insurancefraud.org/statutes/pennsylvania-claims-fraud-18-pa-c-s-a-¤-4117/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) Offense defined.–A person commits an offense if the person does any of the following: (2) Knowingly and with the intent to defraud any insurer or self-insured, presents or causes to be presented to any insurer or self-insured any statement forming a part of, or in support of, a claim that contains any false, incomplete or misleading information concerning any fact or thing material to the claim. (3) Knowingly and with the intent to defraud any insurer or self-insured, assists, abets, solicits or conspires with another to prepare or make any statement that is intended to be presented to any insurer or self-insured in connection with, or in support of, a claim that contains any false, incomplete or misleading information concerning any fact or thing material to the claim, including information which documents or supports an amount claimed in excess of the actual loss sustained by the claimant. **State:** Pennsylvania **Statute Areas:** Claims Fraud --- ### [Pennsylvania-Failing to Remit Premium-n/a](https://insurancefraud.org/statutes/pennsylvania-failing-to-remit-premium-n-a/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** No statute found.. **State:** Pennsylvania --- ### [Pennsylvania-Fraud Bureau-40 P.S. ¤ 325.21](https://insurancefraud.org/statutes/pennsylvania-fraud-bureau-40-p-s-¤-325-21/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) Establishment.–There is hereby established a body corporate and politic to be known as the Insurance Fraud Prevention Authority. The purposes, powers and duties of the authority shall be vested in and exercised by a board of directors. (b) Composition.–The board of the authority shall consist of seven members composed and appointed in accordance with the following: (1) The Attorney General or his designee. (2) A representative of the Philadelphia Federal Insurance Fraud Task Force. (3) Four representatives of insurers, one of whom shall be appointed by the President pro tempore of the Senate, one of whom shall be appointed by the Minority Leader of the Senate, one of whom shall be appointed by the Speaker of the House of Representatives and one of whom shall be appointed by the Minority Leader of the House of Representatives. Each of the four members shall be, respectively, a representative of an insurer writing workers’ compensation, accident and health, automobile or general commercial liability insurance in this Commonwealth. (4) One representative of purchasers of insurance in this Commonwealth who is not employed by or connected with the business of insurance and is appointed by the Governor. (c) Terms.–With the exception of the Attorney General and the representative of the Philadelphia Federal Insurance Fraud Task Force, members of the board shall serve for terms of four years. (d) Compensation.–Members of the board shall serve without compensation but shall receive reimbursement for all reasonable and necessary expenses incurred in connection with their duties in accordance with the rules of the Executive Board. (e) Quorum.–A majority of the members of the board shall constitute a quorum for the transaction of business at a meeting or the exercise of a power or function of the authority. Notwithstanding any other provision of law, action may be taken by the board at a meeting upon a vote of the majority of its members present in person or through the use of amplified telephonic equipment if authorized by the bylaws of the board. The board shall meet at the call of the chairperson or as may be provided in the bylaws of the board. The board shall meet at least quarterly. Meetings of the board may be held anywhere within this Commonwealth. The board shall elect its own chairperson. **State:** Pennsylvania **Statute Areas:** Fraud Bureau --- ### [Pennsylvania-Immunity-18 Pa.C.S.A. ¤ 4117; 40 P.S. ¤ 325.47](https://insurancefraud.org/statutes/pennsylvania-immunity-18-pa-c-s-a-¤-4117-40-p-s-¤-325-47/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (f) Immunity. “Ó An insurer, and any agent, servant or employee thereof acting in the course and scope of his employment, shall be immune from civil or criminal liability arising from the supply or release of written or oral information to any entity duly authorized to receive such information by Federal or State law, or by Insurance Department regulations. \*\*\* (a) GENERAL RULE.”Ó In the absence of malice, persons or organizations providing information to or otherwise cooperating with the section, its employees, agents or designees shall not be subject to civil or criminal liability for supplying the information. (b) CIVIL AND CRIMINAL LIABILITY.”Ó (1) In the absence of malice, persons or organizations shall not be subject to civil or criminal liability for complying with an order issued by a court of competent jurisdiction acting in response to a request by the section. (2) In the absence of malice, the Attorney General and any employee, agent or designee of the Office of Attorney General and the section shall not be subject to civil or criminal liability for the execution of official activities or duties of the section by virtue of the publication of any report or bulletin related to the official activities or duties of the section. (c) CONSTRUCTION OF SECTION.”Ó This section does not abrogate or modify in any way any common law or statutory privilege or immunity heretofore enjoyed by any person. **State:** Pennsylvania **Statute Areas:** Immunity --- ### [Pennsylvania-Insurance Fraud - Definition-](https://insurancefraud.org/statutes/pennsylvania-insurance-fraud-definition/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) Offense defined.–A person commits an offense if the person does any of the following: (1) Knowingly and with the intent to defraud a State or local government agency files, presents or causes to be filed with or presented to the government agency a document that contains false, incomplete or misleading information concerning any fact or thing material to the agency’s determination in approving or disapproving a motor vehicle insurance rate filing, a motor vehicle insurance transaction or other motor vehicle insurance action which is required or filed in response to an agency’s request. (2) Knowingly and with the intent to defraud any insurer or self-insured, presents or causes to be presented to any insurer or self-insured any statement forming a part of, or in support of, a claim that contains any false, incomplete or misleading information concerning any fact or thing material to the claim. (3) Knowingly and with the intent to defraud any insurer or self-insured, assists, abets, solicits or conspires with another to prepare or make any statement that is intended to be presented to any insurer or self-insured in connection with, or in support of, a claim that contains any false, incomplete or misleading information concerning any fact or thing material to the claim, including information which documents or supports an amount claimed in excess of the actual loss sustained by the claimant. (4) Engages in unlicensed agent, broker or unauthorized insurer activity as defined by the act of May 17, 1921 (P.L. 789, No. 285), known as The Insurance Department Act of one thousand nine hundred and twenty-one,1 knowingly and with the intent to defraud an insurer, a self-insured or the public. (5) Knowingly benefits, directly or indirectly, from the proceeds derived from a violation of this section due to the assistance, conspiracy or urging of any person. (6) Is the owner, administrator or employee of any health care facility and knowingly allows the use of such facility by any person in furtherance of a scheme or conspiracy to violate any of the provisions of this section. (7) Borrows or uses another person’s financial responsibility or other insurance identification card or permits his financial responsibility or other insurance identification card to be used by another, knowingly and with intent to present a fraudulent claim to an insurer. (8) If, for pecuniary gain for himself or another, he directly or indirectly solicits any person to engage, employ or retain either himself or any other person to manage, adjust or prosecute any claim or cause of action against any person for damages for negligence or, for pecuniary gain for himself or another, directly or indirectly solicits other persons to bring causes of action to recover damages for personal injuries or death, provided, however, that this paragraph shall not apply to any conduct otherwise permitted by law or by rule of the Supreme Court. (b) Additional offenses defined.– (1) A lawyer may not compensate or give anything of value to a nonlawyer to recommend or secure employment by a client or as a reward for having made a recommendation resulting in employment by a client; except that the lawyer may pay: (i) the reasonable cost of advertising or written communication as permitted by the rules of professional conduct; or (ii) the usual charges of a not-for-profit lawyer referral service or other legal service organization. Upon a conviction of an offense provided for by this paragraph, the prosecutor shall certify such conviction to the disciplinary board of the Supreme Court for appropriate action. Such action may include a suspension or disbarment. (2) With respect to an insurance benefit or claim covered by this section, a health care provider may not compensate or give anything of value to a person to recommend or secure the provider’s service to or employment by a patient or as a reward for having made a recommendation resulting in the provider’s service to or employment by a patient; except that the provider may pay the reasonable cost of advertising or written communication as permitted by rules of professional conduct. Upon a conviction of an offense provided for by this paragraph, the prosecutor shall certify such conviction to the appropriate licensing board in the Department of State which shall suspend or revoke the health care provider’s license. (3) A lawyer or health care provider may not compensate or give anything of value to a person for providing names, addresses, telephone numbers or other identifying information of individuals seeking or receiving medical or rehabilitative care for accident, sickness or disease, except to the extent a referral and receipt of compensation is permitted under applicable professional rules of conduct. A person may not knowingly transmit such referral information to a lawyer or health care professional for the purpose of receiving compensation or anything of value. Attempts to circumvent this paragraph through use of any other person, including, but not limited to, employees, agents or servants, shall also be prohibited. (4) A person may not knowingly and with intent to defraud any insurance company, self-insured or other person file an application for insurance containing any false information or conceal for the purpose of misleading information concerning any fact material thereto. (c) Electronic claims submission.–If a claim is made by means of computer billing tapes or other electronic means, it shall be a rebuttable presumption that the person knowingly made the claim if the person has advised the insurer in writing that claims will be submitted by use of computer billing tapes or other electronic means. (d) Grading.–An offense under subsection (a)(1) through (8) is a felony of the third degree. An offense under subsection (b) is a misdemeanor of the first degree. (e) Restitution.–The court may, in addition to any other sentence authorized by law, sentence a person convicted of violating this section to make restitution. (f) Immunity.–An insurer, and any agent, servant or employee thereof acting in the course and scope of his employment, shall be immune from civil or criminal liability arising from the supply or release of written or oral information to any entity duly authorized to receive such i **State:** Pennsylvania **Statute Areas:** Insurance Fraud - Definition --- ### [Pennsylvania-Licensing Board Notification-75 Pa.C.S.A. ¤ 1817](https://insurancefraud.org/statutes/pennsylvania-licensing-board-notification-75-pa-c-s-a-¤-1817/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Every insurer licensed to do business in this Commonwealth, and its employees, agents, brokers, motor vehicle physical damage appraisers and public adjusters, or public adjuster solicitors, who has a reasonable basis to believe insurance fraud has occurred shall be required to report the incidence of suspected insurance fraud to Federal, State or local criminal law enforcement authorities. Licensed insurance agents and physical damage appraisers may elect to report suspected fraud through the affected insurer with which they have a contractual relationship. All reports of insurance fraud to law enforcement authorities shall be made in writing. Where insurance fraud involves agents, brokers, motor vehicle physical damage appraisers, public adjusters or public adjuster solicitors, a copy of the report shall also be sent to the department. **State:** Pennsylvania --- ### [Pennsylvania-Looting & diverting-18 Pa.C.S.A. ¤ 4117](https://insurancefraud.org/statutes/pennsylvania-looting-diverting-18-pa-c-s-a-¤-4117/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (5) Knowingly benefits, directly or indirectly, from the proceeds derived from a violation of this section due to the assistance, conspiracy or urging of any person. (6) Is the owner, administrator or employee of any health care facility and knowingly allows the use of such facility by any person in furtherance of a scheme or conspiracy to violate any of the provisions of this section. (7) Borrows or uses another person’s financial responsibility or other insurance identification card or permits his financial responsibility or other insurance identification card to be used by another, knowingly and with intent to present a fraudulent claim to an insurer. **State:** Pennsylvania --- ### [Pennsylvania-Mandatory Restitution-18 Pa.C.S.A. ¤ 4117](https://insurancefraud.org/statutes/pennsylvania-mandatory-restitution-18-pa-c-s-a-¤-4117/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) Offense defined.–A person commits an offense if the person does any of the following: (e) Restitution.–The court may, in addition to any other sentence authorized by law, sentence a person convicted of violating this section to make restitution. **State:** Pennsylvania **Statute Areas:** Mandatory Restitution --- ### [Pennsylvania-Range of Criminal Penalties-¤ 4117. Insurance fraud](https://insurancefraud.org/statutes/pennsylvania-range-of-criminal-penalties-¤-4117-insurance-fraud/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) Offense defined.–A person commits an offense if the person does any of the following: (1) Knowingly and with the intent to defraud a State or local government agency files, presents or causes to be filed with or presented to the government agency a document that contains false, incomplete or misleading information concerning any fact or thing material to the agency’s determination in approving or disapproving a motor vehicle insurance rate filing, a motor vehicle insurance transaction or other motor vehicle insurance action which is required or filed in response to an agency’s request. (2) Knowingly and with the intent to defraud any insurer or self-insured, presents or causes to be presented to any insurer or self-insured any statement forming a part of, or in support of, a claim that contains any false, incomplete or misleading information concerning any fact or thing material to the claim. (3) Knowingly and with the intent to defraud any insurer or self-insured, assists, abets, solicits or conspires with another to prepare or make any statement that is intended to be presented to any insurer or self-insured in connection with, or in support of, a claim that contains any false, incomplete or misleading information concerning any fact or thing material to the claim, including information which documents or supports an amount claimed in excess of the actual loss sustained by the claimant. (4) Engages in unlicensed agent, broker or unauthorized insurer activity as defined by the act of May 17, 1921 (P.L. 789, No. 285), known as The Insurance Department Act of one thousand nine hundred and twenty-one,1 knowingly and with the intent to defraud an insurer, a self-insured or the public. (5) Knowingly benefits, directly or indirectly, from the proceeds derived from a violation of this section due to the assistance, conspiracy or urging of any person. (6) Is the owner, administrator or employee of any health care facility and knowingly allows the use of such facility by any person in furtherance of a scheme or conspiracy to violate any of the provisions of this section. (7) Borrows or uses another person’s financial responsibility or other insurance identification card or permits his financial responsibility or other insurance identification card to be used by another, knowingly and with intent to present a fraudulent claim to an insurer. (8) If, for pecuniary gain for himself or another, he directly or indirectly solicits any person to engage, employ or retain either himself or any other person to manage, adjust or prosecute any claim or cause of action against any person for damages for negligence or, for pecuniary gain for himself or another, directly or indirectly solicits other persons to bring causes of action to recover damages for personal injuries or death, provided, however, that this paragraph shall not apply to any conduct otherwise permitted by law or by rule of the Supreme Court. (d) Grading.–An offense under subsection (a)(1) through (8) is a felony of the third degree. An offense under subsection (b) is a misdemeanor of the first degree. **State:** Pennsylvania **Statute Areas:** Range of Criminal Penalties --- ### [Pennsylvania-Range of Civil Penalties-18 Pa.C.S.A. ¤ 4117](https://insurancefraud.org/statutes/pennsylvania-range-of-civil-penalties-18-pa-c-s-a-¤-4117/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (j) Violations, penalties, etc.– (1) If a person is found by court of competent jurisdiction, pursuant to a claim initiated by a prosecuting authority, to have violated any provision of this section, the person shall be subject to civil penalties of not more than $5,000 for the first violation, $10,000 for the second violation and $15,000 for each subsequent violation. The penalty shall be paid to the prosecuting authority to be used to defray the operating expenses of investigating and prosecuting insurance fraud. The court may also award court costs and reasonable attorney fees to the prosecuting authority. (2) Nothing in this subsection shall be construed to prohibit a prosecuting authority and the person accused of violating this section from entering into a written agreement in which that person does not admit or deny the charges but consents to payment of the civil penalty. A consent agreement may not be used in a subsequent civil or criminal proceeding, but notification thereof shall be made to the licensing authority if the person is licensed by a licensing authority of the Commonwealth so that the licensing authority may take appropriate administrative action. Penalties paid under this section shall be deposited into the Insurance Fraud Prevention Trust Fund created under the act of December 28, 1994 (P.L. 1414, No. 166), known as the Insurance Fraud Prevention Act. (3) The imposition of any fine or other remedy under this section shall not preclude prosecution for a violation of the criminal laws of this Commonwealth. (g) Civil action.–An insurer damaged as a result of a violation of this section may sue therefor in any court of competent jurisdiction to recover compensatory damages, which may include reasonable investigation expenses, costs of suit and attorney fees. An insurer may recover treble damages if the court determines that the defendant has engaged in a pattern of violating this section. **State:** Pennsylvania **Statute Areas:** Range of Civil Penalties --- ### [Pennsylvania-Unauthorized Entities-18 Pa.C.S.A. ¤ 4117](https://insurancefraud.org/statutes/pennsylvania-unauthorized-entities-18-pa-c-s-a-¤-4117/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) Offense defined.–A person commits an offense if the person does any of the following: (4) Engages in unlicensed agent, broker or unauthorized insurer activity as defined by the act of May 17, 1921 (P.L.789, No.285), known as The Insurance Department Act of one thousand nine hundred and twenty-one, knowingly and with the intent to defraud an insurer, a self-insured or the public. **State:** Pennsylvania --- ### [Oregon-Immunity-O.R.S. ¤ 731.594; 731.737](https://insurancefraud.org/statutes/oregon-immunity-o-r-s-¤-731-594-731-737/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Unless it is shown that the person, including an insurer, acted with actual malice, a person who discloses or provides information under ORS 731.592 has immunity from any civil liability that might otherwise be incurred or imposed with respect to the disclosure or provision of the information. A person has the same immunity with respect to participating in any judicial proceeding resulting from the disclosure or provision of information. \*\*\* (1) A person or other entity described in this subsection acting without malice, fraudulent intent or bad faith is not subject to civil liability, and no cause of action of any nature may exist against such a person or entity, when the person is performing authorized functions, including publication or dissemination of information, regarding any activity described in subsection (3) of this section. This subsection applies to the following persons and entities: (a) Law enforcement officials and their agents and employees. (b) The National Association of Insurance Commissioners, the Department of Consumer and Business Services, a federal or state governmental agency established to detect and prevent activities described in subsection (3) of this section and any other organization established for the same purpose, and agents, employees or designees of any such person or entity. (2) A person acting without malice, fraudulent intent or bad faith is not subject to liability by virtue of filing reports or furnishing information regarding any activity described in subsection (3) of this section with or to any person or other entity described in subsection (1) of this section. (3) The activities referred to in subsections (1) and (2) of this section include but are not limited to the following, whether any activity is suspected or anticipated or has occurred: (a) Acts or omissions by a person who presents a statement described in this paragraph to or by an insurer or an insurance producer, causes such a statement to be presented to or by an insurer or an insurance producer, or prepares such a statement with knowledge or belief that it will be presented to or by an insurer or an insurance producer. This paragraph applies to any statement that the person knows to contain false information as part of, in support of or concerning any fact relating to the following, or conceals relevant information relating to the following: (A) An application for the issuance of insurance. (B) The rating of insurance. (C) A claim for payment or benefit pursuant to any insurance. (D) Premiums paid on insurance. (E) Payments made in accordance with the terms of insurance coverage. (F) An application for a certificate of authority. (G) The financial condition of an insurer. (H) The acquisition of any insurer. (b) Solicitation or an attempt to solicit new or renewal insurance by or for an insolvent insurer or other person subject to regulation under the Insurance Code. (c) Removal or an attempt to remove assets or any record of assets, transactions and affairs from the home office or other place of business of the insurer or other person subject to regulation under the Insurance Code, or from the place of safekeeping of such a person, or who conceals or attempts to conceal the assets or record from the Director of the Department of Consumer and Business Services. (d) Diversion, an attempt to divert or a conspiracy to divert funds of an insurer or other person subject to regulation under the Insurance Code, or of any other person, in connection with: (A) The transaction of insurance. (B) The conduct of business activities by an insurer or other person subject to regulation under the Insurance Code. (C) The formation, acquisition or dissolution of an insurer or other person subject to regulation under the Insurance Code. (4) This section does not abrogate or modify in any way any common law or statutory privilege or immunity otherwise enjoyed by a person or entity made immune from liability under this section. (5) The court may award reasonable attorney fees to the prevailing party in any tort action against a person who claims immunity under the provisions of this section. **State:** Oregon **Statute Areas:** Immunity --- ### [Oregon-Licensing Board Notification-O.R.S. ¤ 731.592](https://insurancefraud.org/statutes/oregon-licensing-board-notification-o-r-s-¤-731-592/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (1) Notwithstanding ORS 746.665, an insurer shall cooperate with any law enforcement agency or other state or federal agency that is investigating or prosecuting suspected criminal conduct involving insurance. The insurer shall provide any information requested by the agency unless the information is subject to a legal privilege that would prohibit disclosure. (2) If an insurer has reason to believe that criminal conduct involving insurance has been, is being or is about to be committed, the insurer shall notify the appropriate agency of that fact. The insurer is not required to notify the agency if the information or any part of the information upon which the belief is based is protected from disclosure by legal privilege. (3) An insurer providing information under this section may request information relating to the investigation that is in the possession or control of the agency. The agency may not provide an insurer with information that is privileged or confidential. Otherwise, the agency shall disclose requested information unless disclosure would jeopardize an ongoing investigation or prosecution. The agency may require that the insurer not disclose the information to any other person. (4) A person who has reason to believe criminal conduct involving insurance has been, is being or is about to be committed, or who collects, reviews or analyzes information concerning suspected criminal conduct involving insurance, may furnish any unprivileged information in the person’s possession concerning the suspected criminal conduct to an insurer who requests the information for the purpose of detecting, prosecuting or preventing criminal conduct involving insurance. (5) If an insurer or agency does not provide information as required by this section and the suspected criminal conduct results in a conviction, the insurer or agency is not eligible for any compensation to which the insurer or agency might otherwise be entitled from any award under ORS 137.106. **State:** Oregon --- ### [Oregon-Mandatory Restitution-O.R.S. ¤ 744.991](https://insurancefraud.org/statutes/oregon-mandatory-restitution-o-r-s-¤-744-991/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (1) Violation of ORS 744.369, in addition to any applicable prescribed denial, suspension or revocation of any license or civil forfeiture, shall be punishable upon conviction as for the crime of theft under ORS 164.015 to 164.135 or the crime of forgery or related offenses under ORS 165.002 to 165.070. (2) A person convicted of a violation of ORS 744.369 may be ordered to pay restitution to persons aggrieved by the violation of ORS 744.369. Restitution may be ordered in addition to a fine or imprisonment, but not in lieu of a fine or imprisonment. (3) Except for an act under ORS 744.369 (8) to (16), the penalties of this section shall not apply to an owner. **State:** Oregon **Statute Areas:** Mandatory Restitution --- ### [Oregon-Practitioner Penalites-O.R.S. ¤ 731.988](https://insurancefraud.org/statutes/oregon-practitioner-penalites-o-r-s-¤-731-988/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (1) A person that violates any provision of the Insurance Code, any lawful rule or final order of the Director of the Department of Consumer and Business Services or any judgment that a court makes in response to the director’s application, shall forfeit and pay to the General Fund of the State Treasury a civil penalty in an amount determined by the director that does not exceed $10,000 for each offense. The civil penalty for individual insurance producers, adjusters or insurance consultants may not exceed $1,000 for each offense. Each violation is a separate offense. (2) In addition to the civil penalty specified in subsection (1) of this section, a person that violates any provision of the Insurance Code, any lawful rule or final order of the director or any judgment that a court makes in response to the director’s application, may be required to forfeit and pay to the General Fund of the State Treasury a civil penalty in an amount determined by the director that does not exceed the amount by which the person profited in any transaction that violates the provision, rule, order or judgment. (3) In addition to the civil penalties specified in subsections (1) and (2) of this section, an insurer that must submit a report under ORS 742.400 and that fails to do so within the specified time may be required to pay to the General Fund of the State Treasury a civil penalty in an amount determined by the director that does not exceed $10,000. (4) In addition to the penalties specified in subsection (1), (2), (5) and (6) of this section, a director or officer of an insurance holding company system who engages in a transaction or makes an investment that has not been properly reported under, or does not otherwise comply with, ORS 732.517 to 732.596, who knowingly participates in or assents to the transaction or investment, or who permits another officer or an agent of the insurance holding company system to engage in the transaction or make the investment, shall pay, in the director or officer’s individual capacity, a civil penalty in an amount determined by the director that does not exceed $10,000. (5) In addition to the penalties specified in subsections (1), (2), (4) and (6) of this section, an insurer or other person that fails to make a required filing or demonstrate a good faith effort to comply with a filing requirement under ORS 732.527, 732.537, 732.539, 732.542 or 732.544 shall pay a civil penalty in an amount determined by the director that does not exceed $50,000. (6) In addition to the penalties specified in subsections (1), (2), (4) and (5) of this section, an insurer or other person that violates a cease and desist order the director has issued under ORS 731.252 in connection with a violation of a provision of ORS 732.517 to 732.596 may be subject to a civil penalty in an amount determined by the director that does not exceed $10,000 for each day of the violation. (7) A civil penalty imposed under this section may be recovered either as provided in subsection (8) of this section or in an action brought in the name of the State of Oregon in any court of appropriate jurisdiction. (8) Civil penalties under this section must be imposed and enforced in accordance with ORS 183.745. (9) The provisions of this section are in addition to and not in lieu of any other enforcement provisions specified in the Insurance Code. **State:** Oregon **Statute Areas:** Practitioner Penalites --- ### [Oregon-Range of Criminal Penalties-O.R.S. ¤ 731.992](https://insurancefraud.org/statutes/oregon-range-of-criminal-penalties-o-r-s-¤-731-992/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (1) A violation of ORS 731.260 is a Class A misdemeanor. (2) A violation of a provision of ORS 732.517 to 732.596 is a Class C felony. (3) An officer, director or employee of an insurance holding company system who willfully and knowingly makes, causes to be made, or subscribes to, a false statement, report or filing with the intent to deceive the Director of the Department of Consumer and Business Services in the performance of the director’s duties under ORS 732.517 to 732.596 is guilty of a Class C misdemeanor. The officer, director or employee shall pay any fines imposed under this subsection in the officer’s, director’s or employee’s individual capacity. (4) A violation of any provision of the Insurance Code for which the Insurance Code or other applicable laws of this state do not provide a greater penalty, in addition to any applicable prescribed denial, suspension or revocation of any certificate or license or any civil forfeiture, is a Class A misdemeanor. **State:** Oregon **Statute Areas:** Range of Criminal Penalties --- ### [Oregon-Range of Civil Penalties-O.R.S. ¤ 731.988](https://insurancefraud.org/statutes/oregon-range-of-civil-penalties-o-r-s-¤-731-988/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (1) A person that violates any provision of the Insurance Code, any lawful rule or final order of the Director of the Department of Consumer and Business Services or any judgment that a court makes in response to the director’s application, shall forfeit and pay to the General Fund of the State Treasury a civil penalty in an amount determined by the director that does not exceed $10,000 for each offense. The civil penalty for individual insurance producers, adjusters or insurance consultants may not exceed $1,000 for each offense. Each violation is a separate offense. (2) In addition to the civil penalty specified in subsection (1) of this section, a person that violates any provision of the Insurance Code, any lawful rule or final order of the director or any judgment that a court makes in response to the director’s application, may be required to forfeit and pay to the General Fund of the State Treasury a civil penalty in an amount determined by the director that does not exceed the amount by which the person profited in any transaction that violates the provision, rule, order or judgment. (3) In addition to the civil penalties specified in subsections (1) and (2) of this section, an insurer that must submit a report under ORS 742.400 and that fails to do so within the specified time may be required to pay to the General Fund of the State Treasury a civil penalty in an amount determined by the director that does not exceed $10,000. (4) In addition to the penalties specified in subsection (1), (2), (5) and (6) of this section, a director or officer of an insurance holding company system who engages in a transaction or makes an investment that has not been properly reported under, or does not otherwise comply with, ORS 732.517 to 732.596, who knowingly participates in or assents to the transaction or investment, or who permits another officer or an agent of the insurance holding company system to engage in the transaction or make the investment, shall pay, in the director or officer’s individual capacity, a civil penalty in an amount determined by the director that does not exceed $10,000. (5) In addition to the penalties specified in subsections (1), (2), (4) and (6) of this section, an insurer or other person that fails to make a required filing or demonstrate a good faith effort to comply with a filing requirement under ORS 732.527, 732.537, 732.539, 732.542 or 732.544 shall pay a civil penalty in an amount determined by the director that does not exceed $50,000. (6) In addition to the penalties specified in subsections (1), (2), (4) and (5) of this section, an insurer or other person that violates a cease and desist order the director has issued under ORS 731.252 in connection with a violation of a provision of ORS 732.517 to 732.596 may be subject to a civil penalty in an amount determined by the director that does not exceed $10,000 for each day of the violation. (7) A civil penalty imposed under this section may be recovered either as provided in subsection (8) of this section or in an action brought in the name of the State of Oregon in any court of appropriate jurisdiction. (8) Civil penalties under this section must be imposed and enforced in accordance with ORS 183.745. (9) The provisions of this section are in addition to and not in lieu of any other enforcement provisions specified in the Insurance Code. **State:** Oregon **Statute Areas:** Range of Civil Penalties --- ### [Oregon-Rating of an Insurance Policy-O.R.S. ¤ 737.310](https://insurancefraud.org/statutes/oregon-rating-of-an-insurance-policy-o-r-s-¤-737-310/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** The following standards shall apply to the making and use of rates: (1) Rates shall not be excessive, inadequate or unfairly discriminatory. (2) As to all classes of insurance, other than workers’ compensation and title insurance: (a) No rate shall be held to be excessive unless: (A) Such rate is unreasonably high for the insurance provided; and (B) A reasonable degree of competition does not exist in the area with respect to the classification to which such rate is applicable. (b) No rate shall be held inadequate unless such rate is unreasonably low for the insurance provided and: (A) Use or continued use of such rate endangers the solvency of the insurer; or (B) The use of such rate by the insurer has, or if continued will have, the effect of destroying competition or creating a monopoly. (3) Rates for each classification of coverage shall be based on the claims experience of insurers within Oregon on that classification of coverage unless that experience provides an insufficient base for actuarially sound rates. (4) Due consideration shall be given to past and prospective loss experience within this state, to the hazards of conflagration and catastrophe, to a reasonable margin for profit and to contingencies, to dividends, savings or unabsorbed premium deposits allowed or returned by insurers to their policyholders, members or subscribers, to past and prospective expenses specially applicable to this state, and to all other relevant factors, including judgment factors deemed relevant, within this state. (5) In addition to subsection (4) of this section, rates for home protection insurance may include provision for unreimbursed costs of risk inspection and for loss costs under policies which are terminated without premium because the related home sale is not made. (6) In the case of fire insurance rates, consideration may be given to the experience of the fire insurance business during the most recent five-year period for which such experience is available. (7) The systems of expense provisions included in the rates for use by any insurer or group of insurers may differ from those of other insurers or groups of insurers to reflect the requirements of the operating methods of any such insurer or group of insurers with respect to any class of insurance, or with respect to any subdivision or combination thereof for which subdivision or combination separate expenses are applicable. (8) Risks may be grouped by classifications for the establishment of rates and minimum premiums. Classification rates for casualty, surety or inland marine risks may be modified to produce rates for individual risks in accordance with rating plans which establish standards for measuring variations in hazards or expense provisions or both. Such standards may measure any differences among risks that can be demonstrated to have a probable effect upon losses or expenses. (9) Due consideration shall be given, in the making and use of rates for all insurance, to investment income earned by the insurer, to insurer profits and to accumulated reserves for vocational rehabilitation services and for claim costs related to orders or awards made pursuant to ORS 656.278. (10) The Director of the Department of Consumer and Business Services, by rule, shall prescribe the conditions under which a division of payroll between different manual classifications is permitted for purposes of computing workers’ compensation premiums. (11)(a) The director shall not approve any workers’ compensation rating system that does not include a plan for rewarding employers, however small, that have good loss experience or programs likely to improve accident prevention. However, this paragraph is not intended to require that all employers be experience rated. (b) The director shall not approve any workers’ compensation rating system that does not allow the insurer to include potential third party recovery as one of the variables in the claims reserving process. (12) At the time an insurer issues a workers’ compensation insurance policy to an insured for the first time, the insurer shall give written notice to the insured of the rating classifications to which the insured’s employees are to be assigned and shall provide an adequate description of work activities in each classification. In the event an insurer recommences coverage following its termination, the notice required under this subsection must be given only if the gap in coverage exceeds six months. (13) If an insurer determines the workers’ compensation insurance policy of an insured needs reclassification, the insurer: (a) May bill an additional premium for the revised classification after the insurer has provided the insured at least 60 days’ written notice of the reclassification. (b) Shall bill retroactively to policy inception or date of change in insured’s operations for any reclassification that results in a net reduction of premium. (c) May, notwithstanding paragraph (a) of this subsection, retroactively bill an insured for reclassification during the policy year without prior notice of reclassification if the insurer shows by a preponderance of the evidence that: (A) The insured knew that the employees were misclassified, or the insured was adequately informed by the insurer of the proper classification for the insured’s employees; (B) The insured provided improper or inaccurate information concerning its operations; or (C) The insured’s operations changed after the date information on the employees was obtained from the insured. (14) In consultation with system participants, the director shall analyze the rating classification system to investigate changes that simplify the system and reduce costs for employers and insurers while preserving rate equity and minimizing the potential for abuse. The director shall give particular emphasis to the method of allocating payroll to rating classifications and to alternatives to methods that require verifiable payroll records. Upon completion of this analysis, the director shall implement appropriate changes to the system. (15) The director shall adopt rules to carry out the provisions of this section and may by rule specify procedures relating to rating and ratemaking by workers’ compensation insurers. (16) A rate increase based solely upon an insured’s attaining or exceeding 65 years of age shall be presumed to be unfairly discriminatory unless the increase is clearly based on sound actuarial principles or is related to actual or reasonably anticipated experience. **State:** Oregon --- ### [Oregon-Unauthorized Entities-O.R.S. ¤ 731.362](https://insurancefraud.org/statutes/oregon-unauthorized-entities-o-r-s-¤-731-362/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (1) A foreign or alien insurer may be authorized to transact insurance in this state when it has complied with the following requirements: (a) It shall file with the Director of the Department of Consumer and Business Services a certified copy of its charter, articles of incorporation or deed of settlement and a statement of its financial condition and business in all states in such form and detail as the director may require, signed and sworn to by at least two of its executive officers or the United States manager. (b) It shall satisfy the director that it is fully and legally organized under the laws of its state or government to do the business it proposes to transact. (c) It shall satisfy the director that it is possessed of and will maintain at all times its required capitalization. (d) It shall make such deposits with the Department of Consumer and Business Services as are required by the provisions of the Insurance Code. (2) Upon compliance with the requirements of this section and all other requirements imposed on such insurer by the Insurance Code, the director shall issue to it a certificate of authority. **State:** Oregon --- ### [Oklahoma-Claims Fraud-21 Okl.St.Ann. ¤ 1662](https://insurancefraud.org/statutes/oklahoma-claims-fraud-21-okl-st-ann-¤-1662/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Any person who presents or causes to be presented any false or fraudulent claim, or any proof in support of any such claim, upon any contract of insurance, for the payment of any loss, or who prepares, makes or subscribes any account, certificate, survey affidavit, proof of loss, or other book, paper or writing, with intent to present or use the same, or to allow it to be presented or used in support of any such claim, shall be guilty of a felony punishable by imprisonment in the State Penitentiary not exceeding three (3) years, or by a fine not exceeding twice the amount of the aggregated loss sum, or both. **State:** Oklahoma **Statute Areas:** Claims Fraud --- ### [Oklahoma-Fraud Bureau-74 Okl.St.Ann. ¤ 18n-1](https://insurancefraud.org/statutes/oklahoma-fraud-bureau-74-okl-st-ann-¤-18n-1/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** A. There is hereby created within the Office of the Attorney General an Insurance Fraud Unit. B. The Insurance Fraud Unit, upon inquiry or complaint or upon referral from the Insurance Department, shall determine the extent, if any, to which a violation has occurred of any statute or administrative rule of this state pertaining to insurance fraud and may initiate any necessary investigation, civil action, criminal action, referral to the Insurance Commissioner or Insurance Department, referral to a district attorney, or referral to any appropriate official of this or any other state or of the federal government. C. In the absence of fraud, bad faith, reckless disregard for the truth, or actual malice, no person, insurer, or agent of an insurer shall be liable for damages in a civil action or subject to criminal prosecution for supplying information about suspected insurance fraud to the Insurance Fraud Unit of the Office of the Attorney General or any other agency involved in the investigation or prosecution of suspected insurance fraud. D. The Attorney General and the Office of the Attorney General, the Insurance Commissioner, the Insurance Department, every district attorney, and every law enforcement agency shall cooperate and coordinate efforts for the investigation and prosecution of suspected insurance fraud. **State:** Oklahoma **Statute Areas:** Fraud Bureau --- ### [Oklahoma-Immunity-36 Okl.St.Ann. ¤ 363](https://insurancefraud.org/statutes/oklahoma-immunity-36-okl-st-ann-¤-363/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** A. Any insurer, employee or agent of any insurer who has reason to believe that a person or entity has engaged in or is engaging in an act or practice that violates any statute or administrative rule of this state related to insurance fraud shall immediately notify the Anti-Fraud Unit of the Insurance Department and, in the case of an allegation of claimant fraud, the Workers’ Compensation and Insurance Fraud Unit of the Office of the Attorney General. B. No insurer, employee or agent of an insurer, or any other person acting in the absence of fraud, bad faith, reckless disregard for the truth, or actual malice shall be subject to civil liability for libel, slander or any other relevant tort or subject to criminal prosecution by virtue of filing of reports or furnishing other information either orally or in writing, concerning suspected, anticipated or completed fraudulent insurance acts to the Anti-Fraud Division of the Insurance Department or the Workers’ Compensation and Insurance Fraud Unit of the Office of the Attorney General pursuant to subsection A of this section or to any other agency involved in the investigation or prosecution of suspected insurance fraud. C. No civil or criminal cause of action of any nature shall exist against the person or entity by virtue of filing of reports or furnishing other information, either orally or in writing, concerning suspected, anticipated or completed fraudulent insurance acts to the Anti-Fraud Division of the Insurance Department pursuant to subsection A of this section or to any other agency involved in the investigation or prosecution of suspected insurance fraud. The immunity provided in this subsection shall extend to the act of providing or receiving information or reports to or from: 1. Law enforcement officials, their agents and employees; 2. The National Association of Insurance Commissioners, any state department of insurance, any federal or state agency or bureau established to detect and prevent fraudulent insurance activities, as well as any other organization established for the same purpose, their agents, employees or designees; and 3. Any organization or person involved in the prevention and detection of fraudulent insurance activities or that organization or person’s employees, agents, or representatives. The immunity provided in this subsection shall not extend to any person, insurer, or agent of an insurer for communications or publications about suspected insurance fraud to any other person or entity. **State:** Oklahoma **Statute Areas:** Immunity --- ### [Oklahoma-Practitioner Penalites-36 Okl.St.Ann. ¤ 6220](https://insurancefraud.org/statutes/oklahoma-practitioner-penalites-36-okl-st-ann-¤-6220/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** A. The Commissioner may censure, suspend, revoke, or refuse to issue or renew a license after hearing for any of the following causes: 1. Material misrepresentation or fraud in obtaining an adjuster’s license; 2. Any cause for which original issuance of a license could have been refused; 3. Misappropriation, conversion to the personal use of the licensee, or illegal withholding of monies required to be held by the licensee in a fiduciary capacity; 4. Material misrepresentation of the terms and effect of any insurance contract, with intent to deceive, or engaging in, or attempting to engage in, any fraudulent transaction with respect to a claim or loss that the licensee or the trainee is adjusting and, in the case of a public adjuster, misrepresentation of the services offered or the fees or commission to be charged; 5. Conviction of or pleading guilty or nolo contendere to a felony pursuant to the laws of this state, any other state, the United States, or any foreign country; 6. If in the conduct of business affairs, the licensee or trainee has shown himself to be, and is so deemed by the Commissioner, incompetent, untrustworthy or a source of injury to the public; 7. Refusal to comply with any lawful order of the Commissioner; 8. Violation of any provision of the Insurance Adjusters Licensing Act;1 9. Adjusting losses or negotiating claim settlements arising pursuant to provisions of insurance contracts on behalf of an insurer or insured without proper licensing from the Commissioner and authority from the licensed insurer or the insured party; 10. Failing to respond to any inquiry (including electronic communications) from the Department within thirty (30) calendar days of receipt of such inquiry; 11. Forging another’s name to any document; 12. Obtaining or attempting to obtain a license through misrepresentation or fraud; 13. Having admitted or been found to have committed any insurance unfair trade practice or insurance fraud; 14. Having an insurance adjuster license or its equivalent denied, suspended, censured, placed on probation or revoked in any other state, province, district or territory; 15. Failing to inform the Department, by any means acceptable to the Department, of a change of address, change of legal name or change of information submitted on the application within thirty (30) days of the change; or 16. Providing services as a public adjuster, company adjuster or independent adjuster on the same claim. B. In addition to or in lieu of any applicable denial, suspension, or revocation of a license, any person violating the provisions of the Insurance Adjusters Licensing Act may be subject to a civil fine of not more than One Thousand Dollars ($1,000.00) for each violation. This fine may be enforced in the same manner in which civil judgment may be enforced. C. If the license of an adjuster is suspended, revoked, or not renewed, the licensee shall surrender said license to the Commissioner. D. The Commissioner shall not reinstate a license to any person whose license has been suspended, revoked, or refused renewal until the Commissioner determines that the cause or causes for the suspension, revocation, or nonrenewal of said license no longer exist. E. The Department shall retain the authority to enforce the provisions of and impose any penalty or remedy authorized by this title against any person who is under investigation for or charged with a violation even if the person’s license or registration has been surrendered or has lapsed by operation of law. F. It shall be unlawful for any person, firm, association, company or corporation to act as an adjuster without first obtaining a license pursuant to the Insurance Adjusters Licensing Act. Any person convicted of violating the provisions of this subsection shall be guilty of a misdemeanor and shall be punished as set forth in Section 10 of Title 21 of the Oklahoma Statutes. **State:** Oklahoma **Statute Areas:** Practitioner Penalites --- ### [Oklahoma-Range of Criminal Penalties-21 Okl.St.Ann. ¤ 1662](https://insurancefraud.org/statutes/oklahoma-range-of-criminal-penalties-21-okl-st-ann-¤-1662/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Any person who presents or causes to be presented any false or fraudulent claim, or any proof in support of any such claim, upon any contract of insurance, for the payment of any loss, or who prepares, makes or subscribes any account, certificate, survey affidavit, proof of loss, or other book, paper or writing, with intent to present or use the same, or to allow it to be presented or used in support of any such claim, shall be guilty of a felony punishable by imprisonment in the State Penitentiary not exceeding three (3) years, or by a fine not exceeding twice the amount of the aggregated loss sum, or both. **State:** Oklahoma **Statute Areas:** Range of Criminal Penalties --- ### [Oklahoma-Unauthorized Entities-36 Okl.St.Ann. ¤ 1101](https://insurancefraud.org/statutes/oklahoma-unauthorized-entities-36-okl-st-ann-¤-1101/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** A. No person in Oklahoma shall in any manner: 1. Represent or assist any nonadmitted insurer in the soliciting, procuring, placing, or maintenance of any nonadmitted insurance coverage upon or with relation to any subject of insurance resident, located, or to be performed in Oklahoma without being a surplus lines licensee or broker as defined in the Unauthorized Insurers and Surplus Lines Insurance Act; or 2. Inspect or examine any risk or collect or receive any premium on behalf of any nonadmitted insurer without being a surplus lines broker or licensee as defined in the Unauthorized Insurers and Surplus Lines Insurance Act. B. Any person transacting insurance or acting as a surplus lines broker or licensee in violation of this section shall be liable to the insured for the performance of any contract between the insured and the insurer resulting from the transaction. C. This section shall not apply as to reinsurance, to surplus line insurance lawfully procured pursuant to the Unauthorized Insurers and Surplus Lines Insurance Act, to transactions exempt under Section 606 of this title (Authorization of Insurers and General Qualifications),1 or to professional services of an adjuster or attorney-at-law from time to time with respect to claims under policies lawfully solicited, issued, and delivered outside of Oklahoma. D. The investigation and adjustment of any claim in this state arising under an insurance contract issued by a nonadmitted insurer shall not be deemed to constitute the transacting of the business of insurance in this state. E. Nonadmitted insurers shall contract with the trustees of any fund which will insure residents in this state in a manner consistent with the requirements, nature and scope of the Unauthorized Insurers and Surplus Lines Insurance Act. **State:** Oklahoma --- ### [Ohio-Aiding & Abetting-R.C. ¤ 2913.47](https://insurancefraud.org/statutes/ohio-aiding-abetting-r-c-¤-2913-47/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (B) No person, with purpose to defraud or knowing that the person is facilitating a fraud, shall do either of the following: (1) Present to, or cause to be presented to, an insurer any written or oral statement that is part of, or in support of, an application for insurance, a claim for payment pursuant to a policy, or a claim for any other benefit pursuant to a policy, knowing that the statement, or any part of the statement, is false or deceptive; (2) Assist, aid, abet, solicit, procure, or conspire with another to prepare or make any written or oral statement that is intended to be presented to an insurer as part of, or in support of, an application for insurance, a claim for payment pursuant to a policy, or a claim for any other benefit pursuant to a policy, knowing that the statement, or any part of the statement, is false or deceptive. (C) Whoever violates this section is guilty of insurance fraud. Except as otherwise provided in this division, insurance fraud is a misdemeanor of the first degree. If the amount of the claim that is false or deceptive is one thousand dollars or more and is less than seven thousand five hundred dollars, insurance fraud is a felony of the fifth degree. If the amount of the claim that is false or deceptive is seven thousand five hundred dollars or more and is less than one hundred fifty thousand dollars, insurance fraud is a felony of the fourth degree. If the amount of the claim that is false or deceptive is one hundred fifty thousand dollars or more, insurance fraud is a felony of the third degree. **State:** Ohio --- ### [Ohio-Attempted Fraud-R.C. ¤ 2913.47](https://insurancefraud.org/statutes/ohio-attempted-fraud-r-c-¤-2913-47/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (B) No person, with purpose to defraud or knowing that the person is facilitating a fraud, shall do either of the following: (1) Present to, or cause to be presented to, an insurer any written or oral statement that is part of, or in support of, an application for insurance, a claim for payment pursuant to a policy, or a claim for any other benefit pursuant to a policy, knowing that the statement, or any part of the statement, is false or deceptive; (2) Assist, aid, abet, solicit, procure, or conspire with another to prepare or make any written or oral statement that is intended to be presented to an insurer as part of, or in support of, an application for insurance, a claim for payment pursuant to a policy, or a claim for any other benefit pursuant to a policy, knowing that the statement, or any part of the statement, is false or deceptive. (C) Whoever violates this section is guilty of insurance fraud. Except as otherwise provided in this division, insurance fraud is a misdemeanor of the first degree. If the amount of the claim that is false or deceptive is one thousand dollars or more and is less than seven thousand five hundred dollars, insurance fraud is a felony of the fifth degree. If the amount of the claim that is false or deceptive is seven thousand five hundred dollars or more and is less than one hundred fifty thousand dollars, insurance fraud is a felony of the fourth degree. If the amount of the claim that is false or deceptive is one hundred fifty thousand dollars or more, insurance fraud is a felony of the third degree. **State:** Ohio **Statute Areas:** Attempted Fraud --- ### [Ohio-Claims Fraud-R.C. ¤ 2913.47](https://insurancefraud.org/statutes/ohio-claims-fraud-r-c-¤-2913-47/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (B) No person, with purpose to defraud or knowing that the person is facilitating a fraud, shall do either of the following: (1) Present to, or cause to be presented to, an insurer any written or oral statement that is part of, or in support of, an application for insurance, a claim for payment pursuant to a policy, or a claim for any other benefit pursuant to a policy, knowing that the statement, or any part of the statement, is false or deceptive; (2) Assist, aid, abet, solicit, procure, or conspire with another to prepare or make any written or oral statement that is intended to be presented to an insurer as part of, or in support of, an application for insurance, a claim for payment pursuant to a policy, or a claim for any other benefit pursuant to a policy, knowing that the statement, or any part of the statement, is false or deceptive. (C) Whoever violates this section is guilty of insurance fraud. Except as otherwise provided in this division, insurance fraud is a misdemeanor of the first degree. If the amount of the claim that is false or deceptive is one thousand dollars or more and is less than seven thousand five hundred dollars, insurance fraud is a felony of the fifth degree. If the amount of the claim that is false or deceptive is seven thousand five hundred dollars or more and is less than one hundred fifty thousand dollars, insurance fraud is a felony of the fourth degree. If the amount of the claim that is false or deceptive is one hundred fifty thousand dollars or more, insurance fraud is a felony of the third degree. **State:** Ohio **Statute Areas:** Claims Fraud --- ### [Ohio-Immunity-R.C. ¤ 3999.31](https://insurancefraud.org/statutes/ohio-immunity-r-c-¤-3999-31/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (A) As used in this section: (1) “Fraudulent insurance act” means an act committed by a person who, knowingly and with intent to defraud, presents, causes to be presented, or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker, or any agent thereof, any written statement as part of, or in support of, an application for the issuance of, or the rating of a policy or contract for property insurance, casualty insurance, life insurance, sickness and accident insurance, or an annuity, or a claim for payment or other benefit pursuant to such a policy or contract, that the person knows to contain materially false information concerning any fact material thereto, or conceals, for the purpose of misleading, information concerning any fact material thereto. “Fraudulent insurance act” also includes any such written statement, claim, or concealment in relation to such an insurance policy or contract that constitutes a criminal offense under Title XXIX or XXXIX of the Revised Code. (2) “Person” includes, but is not limited to, the superintendent of insurance, the national association of insurance commissioners, any insurer, any organization established to detect or prevent fraudulent insurance acts, and any officer, director, trustee, representative, agent, broker, or employee of the superintendent, association, insurer, organization, or person. (B) In the absence of fraud or bad faith, no person is subject to liability for damages or any other civil liability for libel, slander, or other relevant tort cause of action by virtue of filing reports, without malice, or furnishing other information, without malice, required under Title XXXIX of the Revised Code or required by the superintendent under authority granted by that title, and no liability for damages or any other civil cause of action of any nature arises against a person for providing or receiving information relating to suspected fraudulent insurance acts that is furnished to or received from any of the following: (1) Any law enforcement official, or any agent or employee of such official; (2) Other persons subject to the provisions of Title XXXIX of the Revised Code; (3) The superintendent and any designee of the superintendent, any insurance frauds bureau, the national association of insurance commissioners, or any organization established to detect and prevent fraudulent insurance acts; (4) Any other person involved in the detection or prevention of fraudulent insurance acts. (C) The superintendent and any designee of the superintendent, or any insurance frauds bureau, in the absence of malice, fraud, or bad faith, is not subject to civil liability for libel, slander, or other relevant tort and no civil cause of action of any nature arises against such a person by virtue of the publication of any report or bulletin related to the official activities of the superintendent or of any insurance frauds bureau in relation to fraudulent insurance acts. (D) Nothing in this section is intended to abrogate or modify in any way any common law or statutory privilege or immunity enjoyed by any person. (E) Nothing in this section shall be construed to negate, supersede, or otherwise affect section 3911.06, 3911.07, 3915.05, or 3923.04 of the Revised Code. (F) This section may be cited as the conference of insurance legislators/national association of insurance commissioners model immunity act. **State:** Ohio **Statute Areas:** Immunity --- ### [Ohio-Insurance Fraud - Definition-R.C. ¤ 2913.47](https://insurancefraud.org/statutes/ohio-insurance-fraud-definition-r-c-¤-2913-47/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (B) No person, with purpose to defraud or knowing that the person is facilitating a fraud, shall do either of the following: (1) Present to, or cause to be presented to, an insurer any written or oral statement that is part of, or in support of, an application for insurance, a claim for payment pursuant to a policy, or a claim for any other benefit pursuant to a policy, knowing that the statement, or any part of the statement, is false or deceptive; (2) Assist, aid, abet, solicit, procure, or conspire with another to prepare or make any written or oral statement that is intended to be presented to an insurer as part of, or in support of, an application for insurance, a claim for payment pursuant to a policy, or a claim for any other benefit pursuant to a policy, knowing that the statement, or any part of the statement, is false or deceptive. (C) Whoever violates this section is guilty of insurance fraud. Except as otherwise provided in this division, insurance fraud is a misdemeanor of the first degree. If the amount of the claim that is false or deceptive is one thousand dollars or more and is less than seven thousand five hundred dollars, insurance fraud is a felony of the fifth degree. If the amount of the claim that is false or deceptive is seven thousand five hundred dollars or more and is less than one hundred fifty thousand dollars, insurance fraud is a felony of the fourth degree. If the amount of the claim that is false or deceptive is one hundred fifty thousand dollars or more, insurance fraud is a felony of the third degree. (D) This section shall not be construed to abrogate, waive, or modify division (A) of section 2317.02 of the Revised Code. CREDIT(S) **State:** Ohio **Statute Areas:** Insurance Fraud - Definition --- ### [Ohio-Licensing Board Notification-R.C. ¤ 3999.42](https://insurancefraud.org/statutes/ohio-licensing-board-notification-r-c-¤-3999-42/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (A) If an insurer, as defined in division (A) of section 3999.36 of the Revised Code, has a reasonable belief that a person is perpetrating or facilitating an insurance fraud, as established by section 2913.47 of the Revised Code, or has done so, the insurer shall notify the department of insurance. (B) The notification required by division (A) of this section shall be made in accordance with rules adopted by the department of insurance. (C) Division (A) of this section does not require notification of the department of insurance if the insurance fraud involves a claim of an amount less than one thousand dollars. (D) This section applies to insurance fraud perpetrated or facilitated by any person, including, but not limited to, any applicant, policyholder, subscriber, or enrollee, or any officer, director, manager, employee, representative, or agent of the insurer. **State:** Ohio --- ### [Ohio-Mandatory Restitution-R.C. ¤ 3999.99](https://insurancefraud.org/statutes/ohio-mandatory-restitution-r-c-¤-3999-99/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (I) If a person is found guilty under this section, the court may award restitution in accordance with section 2929.18 of the Revised Code. **State:** Ohio **Statute Areas:** Mandatory Restitution --- ### [Ohio-Range of Criminal Penalties-R.C. ¤ 3999.99](https://insurancefraud.org/statutes/ohio-range-of-criminal-penalties-r-c-¤-3999-99/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (A) Whoever violates section 3999.02 of the Revised Code is guilty of a misdemeanor of the second degree. (B) Whoever violates section 3999.03, 3999.07, 3999.13, 3999.14, or 3999.15 of the Revised Code is guilty of a misdemeanor of the first degree. (C) Whoever violates section 3999.04, 3999.05, 3999.08, or 3999.09 of the Revised Code is guilty of a misdemeanor of the fourth degree. (D) Whoever violates section 3999.10 or 3999.11 of the Revised Code shall be fined five hundred dollars for a first offense and shall be fined one thousand dollars for each subsequent offense. (E) Whoever violates section 3999.12 of the Revised Code shall be fined not less than ten nor more than one thousand dollars. (F) Whoever violates division (F) of section 3999.32, division (B) of section 3999.36, or section 3999.37 or 3999.38 of the Revised Code is guilty of a felony of the fourth degree. (G) Whoever violates division (A) of section 3999.18 of the Revised Code is guilty of a felony of the fourth degree. (H) Whoever violates division (B) of section 3999.18 of the Revised Code is guilty of a misdemeanor of the first degree on a first offense and a felony of the fifth degree on each subsequent offense. (I) If a person is found guilty under this section, the court may award restitution in accordance with section 2929.18 of the Revised Code. **State:** Ohio **Statute Areas:** Range of Criminal Penalties --- ### [Ohio-Range of Civil Penalties-3999.99 Penalties](https://insurancefraud.org/statutes/ohio-range-of-civil-penalties-3999-99-penalties/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (D) Whoever violates section 3999.10 or 3999.11 of the Revised Code shall be fined five hundred dollars for a first offense and shall be fined one thousand dollars for each subsequent offense. (E) Whoever violates section 3999.12 of the Revised Code shall be fined not less than ten nor more than one thousand dollars. **State:** Ohio **Statute Areas:** Range of Civil Penalties --- ### [Ohio-Rating of an Insurance Policy-R.C. ¤ 3935.03](https://insurancefraud.org/statutes/ohio-rating-of-an-insurance-policy-r-c-¤-3935-03/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Rates shall be made as follows: (A) Manual, minimum class rates, rating schedules, or rating plans shall be made and adopted, except in the case of specific inland marine rates on risks specially rated. (B) Rates shall not be excessive, inadequate, or unfairly discriminatory. (C) Consideration shall be given to: (1) Past and prospective loss experience within and outside this state; (2) Conflagration and catastrophe hazards; (3) A reasonable margin for underwriting profit and contingencies; (4) Dividends, savings, or unabsorbed premium deposits allowed or returned by insurers to their policyholders, members, or subscribers; (5) Past and prospective expenses both countrywide and those specially applicable to this state; (6) All other relevant factors within and outside this state; (7) In the case of fire insurance rates, the experience of the fire insurance business during a period of not less than the most recent five year period for which such experience is available. Except to the extent necessary to comply with division (B) of this section, uniformity among insurers in any matters within the scope of this section is neither required nor prohibited. Rates made in accordance with this section may be used subject to sections 3935.01 to 3935.17, inclusive, of the Revised Code. **State:** Ohio --- ### [Ohio-Unauthorized Entities-R.C. ¤ 3905.33](https://insurancefraud.org/statutes/ohio-unauthorized-entities-r-c-¤-3905-33/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (A) No person licensed under section 3905.30 of the Revised Code shall solicit, procure an application for, bind, issue, renew, or deliver a policy with any insurer that is not eligible to write insurance on an unauthorized basis in this state. Pursuant to the “Nonadmitted and Reinsurance Reform Act of 2010,” 15 U.S.C. 8201 et seq., 124 Stat. 1589, or any successor or replacement law, where this state is the home state of the insured, an insurer shall be considered eligible to write insurance on an unauthorized basis in this state if either of the following are true: (1) The insurer meets the requirements and criteria in sections 5A(2) and 5C(2)(a) of the nonadmitted insurance model act adopted by the national association of insurance commissioners, or alternative nationwide uniform eligibility requirements adopted by this state through participation in a compact or other nationwide system pursuant to 15 U.S.C. 8201 et seq., 124 Stat. 1589. (2) For unauthorized insurance placed with, or procured from an unauthorized insurer domiciled outside the United States, the insurer is listed on the quarterly listing of alien insurers maintained by the international insurers department of the national association of insurance commissioners. (B)(1) No surplus lines broker shall solicit, procure, place, or renew any insurance with an unauthorized insurer unless an agent or the surplus lines broker has complied with the due diligence requirements of this section and is unable to procure the requested insurance from an authorized insurer. Due diligence requires an agent to contact at least five of the authorized insurers the agent represents, or as many insurers as the agent represents, that customarily write the kind of insurance required by the insured. Due diligence is presumed if declinations are received from each authorized insurer contacted. If any authorized insurer fails to respond within ten days after the initial contact, the agent may assume the insurer has declined to accept the risk. (2) Due diligence shall only be performed by an agent licensed in this state that holds an active property and casualty insurance agent license. (3) An insurance agent or surplus lines broker is exempt from the due diligence requirements of this section if the agent or surplus lines broker is procuring insurance from a risk purchasing group or risk retention group as provided in Chapter 3960. of the Revised Code. (4) An insurance agent or surplus lines broker is exempt from the due diligence requirements of this section if the agent or surplus lines broker is seeking to procure or place unauthorized insurance for a person that qualifies as an exempt commercial purchaser under section 3905.331 of the Revised Code and both of the following are true: (a) The surplus lines broker procuring or placing the surplus lines insurance has disclosed to the exempt commercial purchaser that the insurance may or may not be available from the authorized market that may provide greater protection with more regulatory oversight. (b) After receipt of the disclosure required under division (B)(4)(a) of this section, the exempt commercial purchaser has requested in writing that the insurance agent or broker procure or place the insurance from an unauthorized insurer. (C) Except when exempt from due diligence requirements under division (B) of this section, an insurance agent who procures or places insurance through a surplus lines broker shall obtain a signed statement from the insured acknowledging that the insurance policy is to be placed with a company or insurer not authorized to do business in this state and acknowledging that, in the event of the insolvency of the insurer, the insured is not entitled to any benefits or proceeds from the Ohio insurance guaranty association. The statement must be on a form prescribed by the superintendent and need not be notarized. The agent shall submit the original signed statement to the surplus lines broker within thirty days after the effective date of the policy. If no other agent is involved, the surplus lines broker shall obtain the statement from the insured. The surplus lines broker shall maintain the original signed statement or a copy of the statement, and the originating agent shall keep a copy of the statement, for at least five years after the effective date of the policy to which the statement pertains. A copy of the signed statement shall be given to the insured at the time the insurance is bound or a policy is delivered. (D) For the purpose of carrying out the “Nonadmitted and Reinsurance Reform Act of 2010,” 124 Stat. 1589, 15 U.S.C. 8201 et seq., or any successor or replacement law, the superintendent shall conduct a fiscal analysis of the impact of entering into a multistate agreement or compact for determining eligibility for placement of unauthorized insurance and for payment, reporting, collection, and allocation of the tax on unauthorized insurance. If the fiscal analysis indicates that entering into a multistate agreement or compact is advantageous to this state, the superintendent may enter into the surplus lines insurance multistate compliance compact adopted by the national conference of insurance legislators and known as “SLIMPACT,” as amended on December 21, 2010, and including any subsequent amendment; or, if it is in this state’s financial best interest, the superintendent shall request that the general assembly authorize the superintendent to enter into a different multistate agreement or compact. (E) The superintendent may adopt rules in accordance with Chapter 119. of the Revised Code to carry out the purposes of sections 3905.30 to 3905.38 of the Revised Code. **State:** Ohio --- ### [North Dakota-Aiding & Abetting-NDCC, 26.1-02.1-01](https://insurancefraud.org/statutes/north-dakota-aiding-abetting-ndcc-26-1-02-1-01/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** 5\. “Fraudulent insurance act” includes the following acts or omissions committed by a person knowingly and with intent to defraud: a. Presenting, causing to be presented, or preparing with knowledge or belief that it will be presented to or by an insurer, reinsurer, insurance producer, or any agent thereof, false or misleading information as part of, in support of, or concerning a fact material to one or more of the following: (1) An application for the issuance or renewal of an insurance policy or reinsurance contract; (2) The rating of an insurance policy or reinsurance contract; (3) A claim for payment or benefit pursuant to an insurance policy or reinsurance contract; (4) Premiums paid on an insurance policy or reinsurance contract; (5) Payments made in accordance with the terms of an insurance policy or reinsurance contract; (6) A document filed with the commissioner or the chief insurance regulatory official of another jurisdiction; (7) The financial condition of an insurer or reinsurer; (8) The formation, acquisition, merger, reconsolidation, dissolution, or withdrawal from one or more lines of insurance or reinsurance in all or part of this state by an insurer or reinsurer; (9) The issuance of written evidence of insurance; (10) The reinstatement of an insurance policy; or (11) The formation of an agency, brokerage, or insurance producer contract. b. Solicitation or acceptance of new or renewal insurance risks on behalf of an insurer, reinsurer, or other person engaged in the business of insurance by a person who knows or should know that the insurer or other person responsible for the risk is insolvent at the time of the transaction. c. Removal, concealment, alteration, or destruction of the assets or records of an insurer, reinsurer, or other person engaged in the business of insurance. d. Theft by deception or otherwise, or embezzlement, abstracting, purloining, or conversion of moneys, funds, premiums, credits, or other property of an insurer, reinsurer, or person engaged in the business of insurance. e. Attempting to commit, aiding or abetting in the commission of, or conspiring to commit the acts or omissions specified in this section. **State:** North Dakota --- ### [North Dakota-Attempted Fraud-NDCC, 26.1-02.1-01](https://insurancefraud.org/statutes/north-dakota-attempted-fraud-ndcc-26-1-02-1-01/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** 5\. “Fraudulent insurance act” includes the following acts or omissions committed by a person knowingly and with intent to defraud: a. Presenting, causing to be presented, or preparing with knowledge or belief that it will be presented to or by an insurer, reinsurer, insurance producer, or any agent thereof, false or misleading information as part of, in support of, or concerning a fact material to one or more of the following: (1) An application for the issuance or renewal of an insurance policy or reinsurance contract; (2) The rating of an insurance policy or reinsurance contract; (3) A claim for payment or benefit pursuant to an insurance policy or reinsurance contract; (4) Premiums paid on an insurance policy or reinsurance contract; (5) Payments made in accordance with the terms of an insurance policy or reinsurance contract; (6) A document filed with the commissioner or the chief insurance regulatory official of another jurisdiction; (7) The financial condition of an insurer or reinsurer; (8) The formation, acquisition, merger, reconsolidation, dissolution, or withdrawal from one or more lines of insurance or reinsurance in all or part of this state by an insurer or reinsurer; (9) The issuance of written evidence of insurance; (10) The reinstatement of an insurance policy; or (11) The formation of an agency, brokerage, or insurance producer contract. b. Solicitation or acceptance of new or renewal insurance risks on behalf of an insurer, reinsurer, or other person engaged in the business of insurance by a person who knows or should know that the insurer or other person responsible for the risk is insolvent at the time of the transaction. c. Removal, concealment, alteration, or destruction of the assets or records of an insurer, reinsurer, or other person engaged in the business of insurance. d. Theft by deception or otherwise, or embezzlement, abstracting, purloining, or conversion of moneys, funds, premiums, credits, or other property of an insurer, reinsurer, or person engaged in the business of insurance. e. Attempting to commit, aiding or abetting in the commission of, or conspiring to commit the acts or omissions specified in this section. **State:** North Dakota **Statute Areas:** Attempted Fraud --- ### [North Dakota-Claims Fraud-NDCC, 26.1-02.1-01](https://insurancefraud.org/statutes/north-dakota-claims-fraud-ndcc-26-1-02-1-01/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** 5\. “Fraudulent insurance act” includes the following acts or omissions committed by a person knowingly and with intent to defraud: a. Presenting, causing to be presented, or preparing with knowledge or belief that it will be presented to or by an insurer, reinsurer, insurance producer, or any agent thereof, false or misleading information as part of, in support of, or concerning a fact material to one or more of the following: (3) A claim for payment or benefit pursuant to an insurance policy or reinsurance contract; **State:** North Dakota **Statute Areas:** Claims Fraud --- ### [North Dakota-Failing to Remit Premium-NDCC, 26.1-02.1-01](https://insurancefraud.org/statutes/north-dakota-failing-to-remit-premium-ndcc-26-1-02-1-01/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** 5\. “Fraudulent insurance act” includes the following acts or omissions committed by a person knowingly and with intent to defraud: d. Theft by deception or otherwise, or embezzlement, abstracting, purloining, or conversion of moneys, funds, premiums, credits, or other property of an insurer, reinsurer, or person engaged in the business of insurance. **State:** North Dakota --- ### [North Dakota-Fraud Bureau-NDCC, 26.1-02.1-08](https://insurancefraud.org/statutes/north-dakota-fraud-bureau-ndcc-26-1-02-1-08/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** 1\. The North Dakota insurance fraud unit is established within the insurance department. The commissioner may appoint the full-time supervisory and investigative personnel of the insurance fraud unit, who must be qualified by training and experience to perform the duties of their positions. The commissioner may also appoint clerical and other staff necessary for the insurance fraud unit to carry out its duties and responsibilities under this chapter. 2. The insurance fraud unit shall: a. Initiate independent inquiries and conduct independent investigations when the insurance fraud unit has cause to believe that a fraudulent insurance act may be, is being, or has been committed; b. Review reports or complaints of alleged fraudulent insurance activities from federal, state, and local law enforcement and regulatory agencies, persons engaged in the business of insurance, and the public to determine whether the reports require further investigation and to conduct these investigations; and c. Conduct independent examinations of alleged fraudulent insurance acts and undertake independent studies to determine the extent of fraudulent insurance acts. 3. The insurance fraud unit may: a. Inspect, copy, or collect records and evidence; b. Serve subpoenas; c. Administer oaths and affirmations; d. Share records and evidence with federal, state, or local law enforcement or regulatory agencies; e. Execute search warrants and arrest warrants for criminal violations of this chapter; f. Arrest upon probable cause without warrant a person found in the act of violating or attempting to violate a provision of this chapter; g. Make criminal referrals to prosecuting authorities; and h. Conduct investigations outside of this state. If the information the insurance fraud unit seeks to obtain is located outside this state, the person from whom the information is sought may make the information available to the insurance fraud unit to examine at the place where the information is located. The insurance fraud unit may designate a representative, including an official of the state in which the matter is located, to inspect the information on behalf of the insurance fraud unit, and the insurance fraud unit may respond to a similar request from an official of another state. **State:** North Dakota **Statute Areas:** Fraud Bureau --- ### [North Dakota-Immunity-NDCC, 26.1-02-24.2; 26.1-02.1-04](https://insurancefraud.org/statutes/north-dakota-immunity-ndcc-26-1-02-24-2-26-1-02-1-04/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** In the absence of fraud or bad faith, no person is subject to civil liability of any kind, including for libel and slander, by virtue of filing reports, without malice, or furnishing other information, without malice, required by the insurance laws of this state or required by the commissioner, and no civil cause of action of any nature may arise against such person for any of the following: 1. Any information relating to suspected fraudulent insurance acts furnished to or received from law enforcement officials, their agents and employees. 2. Any information relating to suspected fraudulent insurance acts furnished to or received from other persons subject to the provisions of section 26.1-02-24.1 and this section. 3. Any such information furnished in reports to the insurance fraud bureau, national association of insurance commissioners, or any organization established to detect and prevent fraudulent insurance acts, their agents, employees or designees, nor is the commissioner or any employee of the insurance fraud bureau, in the absence of fraud or bad faith, subject to civil liability and no civil cause of actions of any nature may arise against such person by virtue of the publication of any report or bulletin related to the official activities of the insurance fraud bureau. Nothing herein is intended to abrogate or modify in any way any common law or statutory privilege or immunity heretofore enjoyed by any person. \*\*\* 1. A person when acting without malice is not subject to liability by virtue of filing reports, or furnishing orally or in writing other information concerning any suspected, anticipated, or completed fraudulent insurance act, when the reports or information are provided to or received from any authorized agency, the national association of insurance commissioners, or any other not-for-profit organization established to detect and prevent insurance fraud, and their agents, employees, or designees. 2. Except in prosecution for perjury or insurance fraud, and in the absence of malice, an insurer, or any officer, employee, or agent thereof, or any licensed producer or private person who cooperates with, furnishes evidence, or provides or receives information regarding any suspected fraudulent insurance act to or from an authorized agency, the national association of insurance commissioners, or any not for- profit organization established to detect and prevent fraudulent insurance acts or who complies with an order issued by a court of competent jurisdiction acting in response to a request by any of these entities to provide evidence or testimony is not subject to a criminal proceeding or to a civil penalty with respect to any act concerning which the person testifies to or produces relevant matter. 3. In the absence of malice, an insurer, or any officer, employee, or agent thereof, or any licensed producer or private person who cooperates with, furnishes evidence, or provides information regarding any suspected fraudulent insurance act to an authorized agency, the national association of insurance commissioners, or any not for- profit organization established to detect and prevent fraudulent insurance acts or who complies with an order issued by a court of competent jurisdiction acting in response to a request by any of these entities to furnish evidence or provide testimony, is not subject to civil liability for libel, slander, or any other relevant tort, and no civil cause of action of any nature exists against the person, for filing reports, providing information, or otherwise cooperating with an investigation or examination of any of these entities. 4. The authorized agency, the national association of insurance commissioners, or any not-for profit organization established to detect and prevent fraudulent insurance acts and any employee or agent of any of these entities, when acting without malice is not subject to civil liability for libel, slander, or any other relevant tort, and no civil cause of action of any nature will lie against the person by virtue of the execution of official activities or duties of the entity by virtue of the publication of any report or bulletin related to the official activities or duties of the entity. 5. This section does not abrogate or modify in any way common law or statutory privilege or immunity heretofore enjoyed by any person or entity. **State:** North Dakota **Statute Areas:** Immunity --- ### [North Dakota-Insurance Fraud - Definition-NDCC, 26.1-02.1-01](https://insurancefraud.org/statutes/north-dakota-insurance-fraud-definition-ndcc-26-1-02-1-01/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** 5\. “Fraudulent insurance act” includes the following acts or omissions committed by a person knowingly and with intent to defraud: a. Presenting, causing to be presented, or preparing with knowledge or belief that it will be presented to or by an insurer, reinsurer, insurance producer, or any agent thereof, false or misleading information as part of, in support of, or concerning a fact material to one or more of the following: (1) An application for the issuance or renewal of an insurance policy or reinsurance contract; (2) The rating of an insurance policy or reinsurance contract; (3) A claim for payment or benefit pursuant to an insurance policy or reinsurance contract; (4) Premiums paid on an insurance policy or reinsurance contract; (5) Payments made in accordance with the terms of an insurance policy or reinsurance contract; (6) A document filed with the commissioner or the chief insurance regulatory official of another jurisdiction; (7) The financial condition of an insurer or reinsurer; (8) The formation, acquisition, merger, reconsolidation, dissolution, or withdrawal from one or more lines of insurance or reinsurance in all or part of this state by an insurer or reinsurer; (9) The issuance of written evidence of insurance; (10) The reinstatement of an insurance policy; or (11) The formation of an agency, brokerage, or insurance producer contract. b. Solicitation or acceptance of new or renewal insurance risks on behalf of an insurer, reinsurer, or other person engaged in the business of insurance by a person who knows or should know that the insurer or other person responsible for the risk is insolvent at the time of the transaction. c. Removal, concealment, alteration, or destruction of the assets or records of an insurer, reinsurer, or other person engaged in the business of insurance. d. Theft by deception or otherwise, or embezzlement, abstracting, purloining, or conversion of moneys, funds, premiums, credits, or other property of an insurer, reinsurer, or person engaged in the business of insurance. e. Attempting to commit, aiding or abetting in the commission of, or conspiring to commit the acts or omissions specified in this section. **State:** North Dakota **Statute Areas:** Insurance Fraud - Definition --- ### [North Dakota-Licensing Board Notification-NDCC, 26.1-02.1-06](https://insurancefraud.org/statutes/north-dakota-licensing-board-notification-ndcc-26-1-02-1-06/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** 1\. A person engaged in the business of insurance having knowledge or a reasonable belief that a fraudulent insurance act is being, will be, or has been committed shall provide to the commissioner the information required by, and in a manner prescribed by, the commissioner. 2. Any other person having knowledge or a reasonable belief that a fraudulent insurance act is being, will be, or has been committed may provide to the commissioner the information required by, and in a manner prescribed by, the commissioner. 3. A person who provides nonpublic personal information to the commissioner pursuant to this section does not violate the insurance privacy law under section 26.1-02-27. **State:** North Dakota --- ### [North Dakota-Looting & diverting-NDCC, 26.1-02.1-01](https://insurancefraud.org/statutes/north-dakota-looting-diverting-ndcc-26-1-02-1-01/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** 5\. “Fraudulent insurance act” includes the following acts or omissions committed by a person knowingly and with intent to defraud: a. Presenting, causing to be presented, or preparing with knowledge or belief that it will be presented to or by an insurer, reinsurer, insurance producer, or any agent thereof, false or misleading information as part of, in support of, or concerning a fact material to one or more of the following: d. Theft by deception or otherwise, or embezzlement, abstracting, purloining, or conversion of moneys, funds, premiums, credits, or other property of an insurer, reinsurer, or person engaged in the business of insurance. **State:** North Dakota --- ### [North Dakota-Mandatory Restitution-NDCC, 26.1-02.1-05](https://insurancefraud.org/statutes/north-dakota-mandatory-restitution-ndcc-26-1-02-1-05/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** 3\. In addition to any other punishment, a person who violates section 26. 1-02.1-02.1 must be ordered to make restitution to the insurer or to any other person for any financial loss sustained as a result of the violation of section 26.1-02.1-02.1. The court shall determine the extent and method of restitution. **State:** North Dakota **Statute Areas:** Mandatory Restitution --- ### [North Dakota-Placing Bogus Coverage-NDCC, 26.1-02.1-01](https://insurancefraud.org/statutes/north-dakota-placing-bogus-coverage-ndcc-26-1-02-1-01/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** 5\. “Fraudulent insurance act” includes the following acts or omissions committed by a person knowingly and with intent to defraud: a. Presenting, causing to be presented, or preparing with knowledge or belief that it will be presented to or by an insurer, reinsurer, insurance producer, or any agent thereof, false or misleading information as part of, in support of, or concerning a fact material to one or more of the following: (1) An application for the issuance or renewal of an insurance policy or reinsurance contract; b. Solicitation or acceptance of new or renewal insurance risks on behalf of an insurer, reinsurer, or other person engaged in the business of insurance by a person who knows or should know that the insurer or other person responsible for the risk is insolvent at the time of the transaction. **State:** North Dakota --- ### [North Dakota-Premium Fraud-NDCC, 26.1-02.1-01](https://insurancefraud.org/statutes/north-dakota-premium-fraud-ndcc-26-1-02-1-01/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** 5\. “Fraudulent insurance act” includes the following acts or omissions committed by a person knowingly and with intent to defraud: a. Presenting, causing to be presented, or preparing with knowledge or belief that it will be presented to or by an insurer, reinsurer, insurance producer, or any agent thereof, false or misleading information as part of, in support of, or concerning a fact material to one or more of the following: (4) Premiums paid on an insurance policy or reinsurance contract; **State:** North Dakota **Statute Areas:** Premium Fraud --- ### [North Dakota-Range of Criminal Penalties-NDCC, 26.1-02.1-05](https://insurancefraud.org/statutes/north-dakota-range-of-criminal-penalties-ndcc-26-1-02-1-05/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** 1\. a. A violation of section 26.1-02.1-02.1 is: (1) A class A felony if the value of any property or services retained exceeds fifty thousand dollars; (2) A class B felony if the value of any property or services attempted to be obtained exceeds fifty thousand dollars; (3) A class B felony if the value of any property or services retained exceeds ten thousand dollars but does not exceed fifty thousand dollars; (4) A class C felony if the value of any property or services attempted to be obtained exceeds ten thousand dollars but does not exceed fifty thousand dollars; (5) A class C felony if the value of any property or services retained exceeds one thousand dollars but does not exceed ten thousand dollars; and (6) A class A misdemeanor in all other cases. b. For purposes of this section, the value of any property and services must be determined in accordance with section 12.1-23-05. 2. In the event that a practitioner is adjudicated guilty of a violation of section 26.1-02.1-02.1, the court shall notify the appropriate licensing authority of this state of the adjudication. The appropriate licensing authority shall hold an administrative hearing to consider the imposition of administrative sanctions as provided by law against the practitioner. **State:** North Dakota **Statute Areas:** Range of Criminal Penalties --- ### [North Dakota-Rating of an Insurance Policy-NDCC, 26.1-02.1-01](https://insurancefraud.org/statutes/north-dakota-rating-of-an-insurance-policy-ndcc-26-1-02-1-01/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** 5\. “Fraudulent insurance act” includes the following acts or omissions committed by a person knowingly and with intent to defraud: a. Presenting, causing to be presented, or preparing with knowledge or belief that it will be presented to or by an insurer, reinsurer, insurance producer, or any agent thereof, false or misleading information as part of, in support of, or concerning a fact material to one or more of the following: (2) The rating of an insurance policy or reinsurance contract; **State:** North Dakota --- ### [North Dakota-Underwriting Fraud-NDCC, 26.1-02.1-01](https://insurancefraud.org/statutes/north-dakota-underwriting-fraud-ndcc-26-1-02-1-01/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** 5\. “Fraudulent insurance act” includes the following acts or omissions committed by a person knowingly and with intent to defraud: a. Presenting, causing to be presented, or preparing with knowledge or belief that it will be presented to or by an insurer, reinsurer, insurance producer, or any agent thereof, false or misleading information as part of, in support of, or concerning a fact material to one or more of the following: (5) Payments made in accordance with the terms of an insurance policy or reinsurance contract; (6) A document filed with the comissioner or the chief insurance regulatory official of another jurisdiction; (7) The financial condition of an insurer or reinsurer; (8) The formation, acquisition, merger, reconsolidation, dissolution, or withdrawal from one or more lines of insurance or reinsurance in all or part of this state by an insurer or reinsurer; (9) The issuance of written evidence of insurance; (10) The reinstatement of an insurance policy; or (11) The formation of an agency, brokerage, or insurance producer contract. b. Solicitation or acceptance of new or renewal insurance risks on behalf of an insurer, reinsurer, or other person engaged in the business of insurance by a person who knows or should know that the insurer or other person responsible for the risk is insolvent at the time of the transaction. c. Removal, concealment, alteration, or destruction of the assets or records of an insurer, reinsurer, or other person engaged in the business of insurance. d. Theft by deception or otherwise, or embezzlement, abstracting, purloining, or conversion of moneys, funds, premiums, credits, or other property of an insurer, reinsurer, or person engaged in the business of insurance. e. Attempting to commit, aiding or abetting in the commission of, or conspiring to commit the acts or omissions specified in this section. **State:** North Dakota **Statute Areas:** Underwriting Fraud --- ### [North Dakota-Unauthorized Entities-NDCC, 26.1-02-06](https://insurancefraud.org/statutes/north-dakota-unauthorized-entities-ndcc-26-1-02-06/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Any of the following acts in this state effected by mail or otherwise by or on behalf of an unauthorized insurance company constitutes the transaction of an insurance business in this state: 1. Making or proposing to make, as an insurance company, an insurance contract. 2. Making or proposing to make, as guarantor or surety, any contract of guaranty or suretyship as a vocation and not merely incidental to any other legitimate business or activity of the guarantor or surety. 3. Taking or receiving of any application for insurance. 4. Receiving or collecting any premium, commission, membership fees, assessments, dues, or other consideration for any insurance or any part thereof. 5. Issuing or delivering an insurance contract to residents of this state or to persons authorized to do business in this state. 6. Directly or indirectly acting as an insurance producer for or otherwise representing or aiding on behalf of another, any person or insurance company in the solicitation, negotiation, procurement, or effectuation of insurance or renewals thereof or in the dissemination of information as to coverage or rates, or forwarding of applications, or delivery of policies or contracts, or inspection of risks, or fixing of rates, or investigation or adjustment of claims or losses, or in the transaction of matters subsequent to effectuation of the contract and arising out of it, or in any other manner representing or assisting a person or insurance company in the transaction of insurance with respect to subjects of insurance resident, located, or to be performed, in this state. This subsection does not prohibit full-time salaried employees of a corporate insured from acting in the capacity of an insurance manager or buyer in placing insurance on behalf of the employer. 7. Transacting any kind of insurance business specifically recognized as transacting an insurance business within the meaning of the statutes relating to insurance. 8. Transacting or proposing to transact any insurance business in substance equivalent to any of the foregoing in a manner designed to evade these statutes. The venue of an act committed by mail is at the point where the matter transmitted by mail is delivered and takes effect. **State:** North Dakota --- ### [North Carolina-Aiding & Abetting-N.C.G.S.A. ¤ 58-2-161](https://insurancefraud.org/statutes/north-carolina-aiding-abetting-n-c-g-s-a-¤-58-2-161/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (b) Any person who, with the intent to injure, defraud, or deceive an insurer or insurance claimant: (2) Assists, abets, solicits, or conspires with another person to prepare or make any written or oral statement that is intended to be presented to an insurer or insurance claimant in connection with, in support of, or in opposition to, a claim for payment or other benefit pursuant to an insurance policy, knowing that the statement contains false or misleading information concerning a fact or matter material to the claim is guilty of a Class H felony. Each claim shall be considered a separate count. Upon conviction, if the court imposes probation, the court may order the defendant to pay restitution as a condition of probation. In determination of the amount of restitution pursuant to G.S. 15A-1343(d), the reasonable costs and attorneys’ fees incurred by the victim in the investigation of, and efforts to recover damages arising from, the claim, may be considered part of the damage caused by the defendant arising out of the offense. **State:** North Carolina --- ### [North Carolina-Claims Fraud-N.C.G.S.A. ¤ 58-2-161](https://insurancefraud.org/statutes/north-carolina-claims-fraud-n-c-g-s-a-¤-58-2-161/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (b) Any person who, with the intent to injure, defraud, or deceive an insurer or insurance claimant: (1) Presents or causes to be presented a written or oral statement, including computer-generated documents as part of, in support of, or in opposition to, a claim for payment or other benefit pursuant to an insurance policy, knowing that the statement contains false or misleading information concerning any fact or matter material to the claim, or (2) Assists, abets, solicits, or conspires with another person to prepare or make any written or oral statement that is intended to be presented to an insurer or insurance claimant in connection with, in support of, or in opposition to, a claim for payment or other benefit pursuant to an insurance policy, knowing that the statement contains false or misleading information concerning a fact or matter material to the claim is guilty of a Class H felony. Each claim shall be considered a separate count. Upon conviction, if the court imposes probation, the court may order the defendant to pay restitution as a condition of probation. In determination of the amount of restitution pursuant to G.S. 15A-1343(d), the reasonable costs and attorneys’ fees incurred by the victim in the investigation of, and efforts to recover damages arising from, the claim, may be considered part of the damage caused by the defendant arising out of the offense. In a civil cause of action for recovery based upon a claim for which a defendant has been convicted under this section, the conviction may be entered into evidence against the defendant. The court may award the prevailing party compensatory damages, attorneys’ fees, costs, and reasonable investigative costs. If the prevailing party can demonstrate that the defendant has engaged in a pattern of violations of this section, the court may award treble damages. **State:** North Carolina **Statute Areas:** Claims Fraud --- ### [North Carolina-Failing to Remit Premium-N.C.G.S.A. ¤ 58-2-162](https://insurancefraud.org/statutes/north-carolina-failing-to-remit-premium-n-c-g-s-a-¤-58-2-162/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** If any insurance agent, broker, or administrator embezzles or fraudulently converts to his own use, or, with intent to use or embezzle, takes, secretes, or otherwise disposes of, or fraudulently withholds, appropriates, lends, invests, or otherwise uses or applies any money, negotiable instrument, or other consideration received by him in his performance as an agent, broker, or administrator, he shall be guilty of a felony. If the value of the money, negotiable instrument, or other consideration is one hundred thousand dollars ($100,000) or more, violation of this section is a Class C felony. If the value of the money, negotiable instrument, or other consideration is less than one hundred thousand dollars ($100,000), violation of this section is a Class H felony. **State:** North Carolina --- ### [North Carolina-Immunity-N.C.G.S.A. ¤ 58-2-160](https://insurancefraud.org/statutes/north-carolina-immunity-n-c-g-s-a-¤-58-2-160/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) As used in this section, “Commissioner” includes an employee, agent, or designee of the Commissioner. A person, or an employee or agent of that person, acting without actual malice, is not subject to civil liability for libel, slander, or any other cause of action by virtue of furnishing to the Commissioner under the requirements of law or at the direction of the Commissioner reports or other information relating to (i) any known or suspected fraudulent insurance or reinsurance claim, transaction, or act or (ii) the financial condition of any licensee. In the absence of actual malice, members of the NAIC, their duly authorized committees, subcommittees, task forces, delegates, and employees, and all other persons charged with the responsibility of collecting, reviewing, analyzing, or disseminating the information developed from filings of financial statements or examinations of licensees are not subject to civil liability for libel, slander, or any other cause of action by virtue of their collection, review, analysis, or dissemination of the data and information collected from such filings or examinations.. **State:** North Carolina **Statute Areas:** Immunity --- ### [North Carolina-Insurance Fraud - Definition-N.C.G.S.A. ¤ 58-2-161](https://insurancefraud.org/statutes/north-carolina-insurance-fraud-definition-n-c-g-s-a-¤-58-2-161/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (b) Any person who, with the intent to injure, defraud, or deceive an insurer or insurance claimant: (1) Presents or causes to be presented a written or oral statement, including computer-generated documents as part of, in support of, or in opposition to, a claim for payment or other benefit pursuant to an insurance policy, knowing that the statement contains false or misleading information concerning any fact or matter material to the claim, or (2) Assists, abets, solicits, or conspires with another person to prepare or make any written or oral statement that is intended to be presented to an insurer or insurance claimant in connection with, in support of, or in opposition to, a claim for payment or other benefit pursuant to an insurance policy, knowing that the statement contains false or misleading information concerning a fact or matter material to the claim is guilty of a Class H felony. Each claim shall be considered a separate count. Upon conviction, if the court imposes probation, the court may order the defendant to pay restitution as a condition of probation. In determination of the amount of restitution pursuant to G.S. 15A-1343(d), the reasonable costs and attorneys’ fees incurred by the victim in the investigation of, and efforts to recover damages arising from, the claim, may be considered part of the damage caused by the defendant arising out of the offense. In a civil cause of action for recovery based upon a claim for which a defendant has been convicted under this section, the conviction may be entered into evidence against the defendant. The court may award the prevailing party compensatory damages, attorneys’ fees, costs, and reasonable investigative costs. If the prevailing party can demonstrate that the defendant has engaged in a pattern of violations of this section, the court may award treble damages. **State:** North Carolina **Statute Areas:** Insurance Fraud - Definition --- ### [North Carolina-Looting & diverting-N.C.G.S.A. ¤ 58-2-161](https://insurancefraud.org/statutes/north-carolina-looting-diverting-n-c-g-s-a-¤-58-2-161/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (b) Any person who, with the intent to injure, defraud, or deceive an insurer or insurance claimant: (1) Presents or causes to be presented a written or oral statement, including computer-generated documents as part of, in support of, or in opposition to, a claim for payment or other benefit pursuant to an insurance policy, knowing that the statement contains false or misleading information concerning any fact or matter material to the claim, or (2) Assists, abets, solicits, or conspires with another person to prepare or make any written or oral statement that is intended to be presented to an insurer or insurance claimant in connection with, in support of, or in opposition to, a claim for payment or other benefit pursuant to an insurance policy, knowing that the statement contains false or misleading information concerning a fact or matter material to the claim is guilty of a Class H felony. Each claim shall be considered a separate count. Upon conviction, if the court imposes probation, the court may order the defendant to pay restitution as a condition of probation. In determination of the amount of restitution pursuant to G.S. 15A-1343(d), the reasonable costs and attorneys’ fees incurred by the victim in the investigation of, and efforts to recover damages arising from, the claim, may be considered part of the damage caused by the defendant arising out of the offense. In a civil cause of action for recovery based upon a claim for which a defendant has been convicted under this section, the conviction may be entered into evidence against the defendant. The court may award the prevailing party compensatory damages, attorneys’ fees, costs, and reasonable investigative costs. If the prevailing party can demonstrate that the defendant has engaged in a pattern of violations of this section, the court may award treble damages. **State:** North Carolina --- ### [North Carolina-Mandatory Restitution-N.C.G.S.A. ¤ 58-2-70](https://insurancefraud.org/statutes/north-carolina-mandatory-restitution-n-c-g-s-a-¤-58-2-70/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) This section applies to any person who is subject to licensure or certification under this Chapter. (b) Whenever the Commissioner has reason to believe that any person has violated any of the provisions of this Chapter, and the violation subjects the license or certification of that person to suspension or revocation, the Commissioner may, after notice and opportunity for a hearing, proceed under the appropriate subsections of this section. (c) If, under subsection (b) of this section, the Commissioner finds a violation of this Chapter, the Commissioner may, in addition to or instead of suspending or revoking the license or certification, order the payment of a monetary penalty as provided in subsection (d) of this section or petition the Superior Court of Wake County for an order directing payment of restitution as provided in subsection (e) of this section, or both. Each day during which a violation occurs constitutes a separate violation. (d) If the Commissioner orders the payment of a monetary penalty pursuant to subsection (c) of this section, the penalty shall not be less than one hundred dollars ($100.00) nor more than one thousand dollars ($1,000). In determining the amount of the penalty, the Commissioner shall consider the degree and extent of harm caused by the violation, the amount of money that inured to the benefit of the violator as a result of the violation, whether the violation was committed willfully, and the prior record of the violator in complying or failing to comply with laws, rules, or orders applicable to the violator. The clear proceeds of the penalty shall be remitted to the Civil Penalty and Forfeiture Fund in accordance with G.S. 115C-457.2. Payment of the civil penalty under this section shall be in addition to payment of any other penalty for a violation of the criminal laws of this State. (e) Upon petition of the Commissioner the court may order the person who committed a violation specified in subsection (c) of this section to make restitution in an amount that would make whole any person harmed by the violation. The petition may be made at any time and also in any appeal of the Commissioner’s order. **State:** North Carolina **Statute Areas:** Mandatory Restitution --- ### [North Carolina-Placing Bogus Coverage-N.C.G.S.A. ¤ 58-2-161](https://insurancefraud.org/statutes/north-carolina-placing-bogus-coverage-n-c-g-s-a-¤-58-2-161/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (b) Any person who, with the intent to injure, defraud, or deceive an insurer or insurance claimant: (1) Presents or causes to be presented a written or oral statement, including computer-generated documents as part of, in support of, or in opposition to, a claim for payment or other benefit pursuant to an insurance policy, knowing that the statement contains false or misleading information concerning any fact or matter material to the claim, or (2) Assists, abets, solicits, or conspires with another person to prepare or make any written or oral statement that is intended to be presented to an insurer or insurance claimant in connection with, in support of, or in opposition to, a claim for payment or other benefit pursuant to an insurance policy, knowing that the statement contains false or misleading information concerning a fact or matter material to the claim is guilty of a Class H felony. Each claim shall be considered a separate count. Upon conviction, if the court imposes probation, the court may order the defendant to pay restitution as a condition of probation. In determination of the amount of restitution pursuant to G.S. 15A-1343(d), the reasonable costs and attorneys’ fees incurred by the victim in the investigation of, and efforts to recover damages arising from, the claim, may be considered part of the damage caused by the defendant arising out of the offense. In a civil cause of action for recovery based upon a claim for which a defendant has been convicted under this section, the conviction may be entered into evidence against the defendant. The court may award the prevailing party compensatory damages, attorneys’ fees, costs, and reasonable investigative costs. If the prevailing party can demonstrate that the defendant has engaged in a pattern of violations of this section, the court may award treble damages. **State:** North Carolina --- ### [North Carolina-Practitioner Penalites-N.C.G.S.A. ¤ 58-41-55; N.C.G.S.A. ¤ 58-2-162](https://insurancefraud.org/statutes/north-carolina-practitioner-penalites-n-c-g-s-a-¤-58-41-55-n-c-g-s-a-¤-58-2-162/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** In addition to criminal penalties for acts declared unlawful by this Article, any violation of this Article subjects an insurer to revocation or suspension of its license, or monetary penalties or payment of restitution as provided in G.S. 58-2-70.; If any insurance agent, broker, or administrator embezzles or fraudulently converts to his own use, or, with intent to use or embezzle, takes, secretes, or otherwise disposes of, or fraudulently withholds, appropriates, lends, invests, or otherwise uses or applies any money, negotiable instrument, or other consideration received by him in his performance as an agent, broker, or administrator, he shall be guilty of a felony. If the value of the money, negotiable instrument, or other consideration is one hundred thousand dollars ($100,000) or more, violation of this section is a Class C felony. If the value of the money, negotiable instrument, or other consideration is less than one hundred thousand dollars ($100,000), violation of this section is a Class H felony. **State:** North Carolina **Statute Areas:** Practitioner Penalites --- ### [North Carolina-Premium Fraud-n/a](https://insurancefraud.org/statutes/north-carolina-premium-fraud-n-a/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** No staute found. **State:** North Carolina **Statute Areas:** Premium Fraud --- ### [North Carolina-Range of Civil Penalties-N.C.G.S.A. ¤ 58-2-70](https://insurancefraud.org/statutes/north-carolina-range-of-civil-penalties-n-c-g-s-a-¤-58-2-70/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) This section applies to any person who is subject to licensure or certification under this Chapter. (b) Whenever the Commissioner has reason to believe that any person has violated any of the provisions of this Chapter, and the violation subjects the license or certification of that person to suspension or revocation, the Commissioner may, after notice and opportunity for a hearing, proceed under the appropriate subsections of this section. (c) If, under subsection (b) of this section, the Commissioner finds a violation of this Chapter, the Commissioner may, in addition to or instead of suspending or revoking the license or certification, order the payment of a monetary penalty as provided in subsection (d) of this section or petition the Superior Court of Wake County for an order directing payment of restitution as provided in subsection (e) of this section, or both. Each day during which a violation occurs constitutes a separate violation. (d) If the Commissioner orders the payment of a monetary penalty pursuant to subsection (c) of this section, the penalty shall not be less than one hundred dollars ($100.00) nor more than one thousand dollars ($1,000). In determining the amount of the penalty, the Commissioner shall consider the degree and extent of harm caused by the violation, the amount of money that inured to the benefit of the violator as a result of the violation, whether the violation was committed willfully, and the prior record of the violator in complying or failing to comply with laws, rules, or orders applicable to the violator. The clear proceeds of the penalty shall be remitted to the Civil Penalty and Forfeiture Fund in accordance with G.S. 115C-457.2. Payment of the civil penalty under this section shall be in addition to payment of any other penalty for a violation of the criminal laws of this State. (e) Upon petition of the Commissioner the court may order the person who committed a violation specified in subsection (c) of this section to make restitution in an amount that would make whole any person harmed by the violation. The petition may be made at any time and also in any appeal of the Commissioner’s order. (f) Restitution to any State agency for extraordinary administrative expenses incurred in the investigation and hearing of the violation may also be ordered by the court in such amount that would reimburse the agency for the expenses. (g) Nothing in this section prevents the Commissioner from negotiating a mutually acceptable agreement with any person as to the status of the person’s license or certificate or as to any civil penalty or restitution. (h) Unless otherwise specifically provided for, all administrative proceedings under this Chapter are governed by Chapter 150B of the General Statutes. Appeals of the Commissioner’s orders under this section shall be governed by G.S. 58-2-75. **State:** North Carolina **Statute Areas:** Range of Civil Penalties --- ### [North Carolina-Rating of an Insurance Policy-N.C.G.S.A. ¤ 58-40-25](https://insurancefraud.org/statutes/north-carolina-rating-of-an-insurance-policy-n-c-g-s-a-¤-58-40-25/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** In determining whether rates comply with the standards under G.S. 58-40-20, the following criteria shall be applied: (1) Due consideration shall be given to past and prospective loss and expense experience within this State, to catastrophe hazards, to a reasonable margin for underwriting profit and contingencies, to trends within this State, to dividends or savings to be allowed or returned by insurers to their policyholders, members, or subscribers, and to all other relevant factors, including judgment factors; however, regional or countrywide expense or loss experience and other regional or countrywide data may be considered only when credible North Carolina expense or loss experience or other data is not available. (2) Risks may be grouped by classifications for the establishment of rates and minimum premiums. Classification rates may be modified to produce rates for individual risks in accordance with rating plans which establish standards for measuring variations in hazards or expense provisions, or both. Those standards may measure any differences among risks that have probable effect upon losses or expenses. Classifications or modifications of classifications of risks may be established based upon size, expense, management, individual experience, location or dispersion of hazard, or any other reasonable considerations. Those classifications and modifications shall apply to all risks under the same or substantially the same circumstances or conditions. (3) The expense provisions included in the rates to be used by an insurer may reflect the operating methods of the insurer and, as far as it is credible, its own expense experience. (4) In the case of property insurance rates under this Article, consideration shall be given to the insurance public protection classifications of fire districts established by the Commissioner. The Commissioner shall establish and modify from time to time insurance public protection districts for all rural areas of the State and for cities with populations of 100,000 or fewer, according to the most recent annual population estimates certified by the State Budget Officer. In establishing and modifying these districts, the Commissioner shall use standards at least equivalent to those used by the Insurance Services Office, Inc., or any successor organization. The standards developed by the Commissioner are subject to Article 2A of Chapter 150B of the General Statutes. The insurance public protection classifications established by the Commissioner issued pursuant to the provisions of this Article shall be subject to appeal as provided in G.S. 58-2-75, et seq. The exceptions stated in G.S. 58-2-75(a) do not apply. **State:** North Carolina --- ### [North Carolina-Underwriting Fraud-N.C.G.S.A. ¤ 58-2-161](https://insurancefraud.org/statutes/north-carolina-underwriting-fraud-n-c-g-s-a-¤-58-2-161/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (b) Any person who, with the intent to injure, defraud, or deceive an insurer or insurance claimant: (1) Presents or causes to be presented a written or oral statement, including computer-generated documents as part of, in support of, or in opposition to, a claim for payment or other benefit pursuant to an insurance policy, knowing that the statement contains false or misleading information concerning any fact or matter material to the claim, or (2) Assists, abets, solicits, or conspires with another person to prepare or make any written or oral statement that is intended to be presented to an insurer or insurance claimant in connection with, in support of, or in opposition to, a claim for payment or other benefit pursuant to an insurance policy, knowing that the statement contains false or misleading information concerning a fact or matter material to the claim is guilty of a Class H felony. Each claim shall be considered a separate count. Upon conviction, if the court imposes probation, the court may order the defendant to pay restitution as a condition of probation. In determination of the amount of restitution pursuant to G.S. 15A-1343(d), the reasonable costs and attorneys’ fees incurred by the victim in the investigation of, and efforts to recover damages arising from, the claim, may be considered part of the damage caused by the defendant arising out of the offense. **State:** North Carolina **Statute Areas:** Underwriting Fraud --- ### [North Carolina-Unauthorized Entities-N.C.G.S.A. ¤ 58-14-15](https://insurancefraud.org/statutes/north-carolina-unauthorized-entities-n-c-g-s-a-¤-58-14-15/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** When any domestic insurer knowingly engages in the practice of soliciting, advertising or making contracts for insurance in states or jurisdictions in which it is not licensed, the Commissioner may issue an order requiring the company to cease and desist from engaging in such activities and, for the purposes of this section, the acts prohibited by G.S. 58-14-10 and the foregoing sections, are declared to be an unfair trade practice within the meaning of G.S. 58-63-15 and G.S. 58-63-40. When the Commissioner has reason to believe that any domestic company has been engaged or is engaging in the practice of knowingly soliciting, advertising or writing contracts of insurance on risks within a state or jurisdiction in which it is not licensed, the Commissioner shall serve the company with notice of hearing and the hearing shall conform with the hearing procedure set forth in G.S. 58-63-25. Any action taken by the Commissioner after the hearing shall comply with G.S. 58-63-32, and any company aggrieved by an order of the Commissioner is entitled to the judicial review provided in G.S. 58-63-35. **State:** North Carolina --- ### [New York-Fraud Bureau-McKinney's Executive Law ¤ 846-l (Proposed Law)](https://insurancefraud.org/statutes/new-york-fraud-bureau-mckinneys-executive-law-¤-846-l-proposed-law/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** 1\. There is hereby created in the division of criminal justice services the New York motor vehicle theft and insurance fraud prevention board (hereinafter “board”), which shall consist of the following members: (a) The commissioner of criminal justice services (hereinafter “commissioner”), or his designee, who shall serve as the voting chairperson of the board; (b) Three voting members appointed by the governor on the recommendation of the speaker of the assembly provided, however, that no more than two such appointments made pursuant to this paragraph shall be from the same category of members as provided for in subdivision two of this section. (c) Three voting members appointed by the governor on the recommendation of the temporary president of the senate provided, however, that no more than two such appointments made pursuant to this paragraph shall be from the same category of members as provided for in subdivision two of this section; and (d) Five voting members appointed by the governor provided, however, that no more than two such appointments made pursuant to this paragraph shall be from the same category of members as provided for in subdivision two of this section. 2. The members of the board appointed on the recommendation of the speaker of the assembly and the temporary president of the senate, and the members of the board appointed by the governor pursuant to paragraph (d) of subdivision one of this section, shall be representative of consumers of motor vehicle insurance, motor vehicle insurance companies, law enforcement agencies and the judicial system. The appointments shall be made not later than one hundred eighty days after the date on which this section shall have become law. Members of the board who are not public officials shall serve for a term of four years. Members of the board shall serve without compensation, except that members of the board who are not public officials shall be entitled to receive reasonable reimbursement for expenses incurred by them in performance of their duties as members of the board. A majority of the members of the board shall constitute a quorum for the transaction of business at a meeting. Action may be taken by the board at a meeting upon a vote of the majority of its members present. Every member of the board shall be entitled to designate a representative to attend, in his or her place, a meeting of the board and to vote or otherwise act in his or her behalf, provided, however, that a member may not designate such a representative more than once each year. Written notice of such designation shall be furnished to the board by the designating member prior to any meeting attended by his or her representative. Any such representative shall serve at the pleasure of the designating member. No such representative shall be authorized to delegate any of his or her duties or functions to any other person. The board shall meet at least four times each year, and at other times at the call of the chairperson or upon the written request of two-thirds of the members of the board. 3. The commissioner shall, pursuant to the recommendation of the board, have the power and duty to: (a) Make, execute, and deliver contracts, conveyances, and other instruments necessary to effect the purposes and objectives of the program; (b) Accept any grant, including federal grants, or any other contributions for the purposes of the program. Any moneys so received shall be expended by the commissioner for the program’s purposes, pursuant to appropriation and subject to the applicable provisions of the state finance law; (c) Make grants pursuant to a request for proposals process; (d) Appoint such employees and agents as the commissioner may deem necessary, fix their compensation within the limitations provided by law, and prescribe their duties; (e) Request from the division of state police, from county or municipal police departments and agencies, from the department of financial services, from the department of motor vehicles, from the office of court administration, from any other state department or agency or public authority, or from any insurer which offers motor vehicle insurance such assistance and data as are useful for the purposes and objectives of the program; (f) Cooperate with and assist political subdivisions of the state in the development of local programs to prevent motor vehicle theft and insurance fraud; (g) Advise and assist the superintendent of financial services pursuant to section two thousand three hundred forty-eight of the insurance law; and (h) Submit, no later than February fifteenth of each year to the governor and the chairperson of the senate finance committee and the chairperson of the assembly ways and means committee, a written report on the board’s activities, the activities of grant recipients, the results achieved by the grant recipients in improving the detection, prevention or reduction of motor vehicle theft and insurance fraud and the impact such efforts may have on motor vehicle insurance rates. **State:** New York **Statute Areas:** Fraud Bureau --- ### [New York-Insurance Fraud - Definition-](https://insurancefraud.org/statutes/new-york-insurance-fraud-definition/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** A fraudulent insurance act is committed by any person who, knowingly and with intent to defraud presents, causes to be presented, or prepares with knowledge or belief that it will be presented to or by an insurer, self insurer, or purported insurer, or purported self insurer, or any agent thereof: 1. any written statement as part of, or in support of, an application for the issuance of, or the rating of a commercial insurance policy, or certificate or evidence of self insurance for commercial insurance or commercial self insurance, or a claim for payment or other benefit pursuant to an insurance policy or self insurance program for commercial or personal insurance that he or she knows to: (a) contain materially false information concerning any fact material thereto; or (b) conceal, for the purpose of misleading, information concerning any fact material thereto; or 2. any written statement or other physical evidence as part of, or in support of, an application for the issuance of a health insurance policy, or a policy or contract or other authorization that provides or allows coverage for, membership or enrollment in, or other services of a public or private health plan, or a claim for payment, services or other benefit pursuant to such policy, contract or plan that he or she knows to: (a) contain materially false information concerning any material fact thereto; or (b) conceal, for the purpose of misleading, information concerning any fact material thereto. Such policy or contract or plan or authorization shall include, but not be limited to, those issued or operating pursuant to any public or governmentally-sponsored or supported plan for health care coverage or services or those otherwise issued or operated by entities authorized pursuant to the public health law. For purposes of this subdivision an “application for the issuance of a health insurance policy” shall not include (i) any application for a health insurance policy or contract approved by the superintendent of financial services pursuant to the provisions of sections three thousand two hundred sixteen, four thousand three hundred four, four thousand three hundred twenty-one or four thousand three hundred twenty-two of the insurance law or any other application for a health insurance policy or contract approved by the superintendent of financial services in the individual or direct payment market; or (ii) any application for a certificate evidencing coverage under a self-insured plan or under a group contract approved by the superintendent of financial services. **State:** New York **Statute Areas:** Insurance Fraud - Definition --- ### [New York-Placing Bogus Coverage-](https://insurancefraud.org/statutes/new-york-placing-bogus-coverage/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** A fraudulent insurance act is committed by any person who, knowingly and with intent to defraud presents, causes to be presented, or prepares with knowledge or belief that it will be presented to or by an insurer, self insurer, or purported insurer, or purported self insurer, or any agent thereof: 1. any written statement as part of, or in support of, an application for the issuance of, or the rating of a commercial insurance policy, or certificate or evidence of self insurance for commercial insurance or commercial self insurance, or a claim for payment or other benefit pursuant to an insurance policy or self insurance program for commercial or personal insurance that he or she knows to: (a) contain materially false information concerning any fact material thereto; or (b) conceal, for the purpose of misleading, information concerning any fact material thereto; or 2. any written statement or other physical evidence as part of, or in support of, an application for the issuance of a health insurance policy, or a policy or contract or other authorization that provides or allows coverage for, membership or enrollment in, or other services of a public or private health plan, or a claim for payment, services or other benefit pursuant to such policy, contract or plan that he or she knows to: (a) contain materially false information concerning any material fact thereto; or (b) conceal, for the purpose of misleading, information concerning any fact material thereto. Such policy or contract or plan or authorization shall include, but not be limited to, those issued or operating pursuant to any public or governmentally-sponsored or supported plan for health care coverage or services or those otherwise issued or operated by entities authorized pursuant to the public health law. For purposes of this subdivision an “application for the issuance of a health insurance policy” shall not include (i) any application for a health insurance policy or contract approved by the superintendent of financial services pursuant to the provisions of sections three thousand two hundred sixteen, four thousand three hundred four, four thousand three hundred twenty-one or four thousand three hundred twenty-two of the insurance law or any other application for a health insurance policy or contract approved by the superintendent of financial services in the individual or direct payment market; or (ii) any application for a certificate evidencing coverage under a self-insured plan or under a group contract approved by the superintendent of financial services. **State:** New York --- ### [New York-Range of Criminal Penalties-](https://insurancefraud.org/statutes/new-york-range-of-criminal-penalties/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** A person is guilty of insurance fraud in the fifth degree when he commits a fraudulent insurance act. Insurance fraud in the fifth degree is a class A misdemeanor. A person is guilty of insurance fraud in the fourth degree when he commits a fraudulent insurance act and thereby wrongfully takes, obtains or withholds, or attempts to wrongfully take, obtain or withhold property with a value in excess of one thousand dollars. Insurance fraud in the fourth degree is a class E felony. A person is guilty of insurance fraud in the third degree when he commits a fraudulent insurance act and thereby wrongfully takes, obtains or withholds, or attempts to wrongfully take, obtain or withhold property with a value in excess of three thousand dollars. Insurance fraud in the third degree is a class D felony. A person is guilty of insurance fraud in the second degree when he commits a fraudulent insurance act and thereby wrongfully takes, obtains or withholds, or attempts to wrongfully take, obtain or withhold property with a value in excess of fifty thousand dollars. Insurance fraud in the second degree is a class C felony. A person is guilty of insurance fraud in the first degree when he commits a fraudulent insurance act and thereby wrongfully takes, obtains or withholds, or attempts to wrongfully take, obtain or withhold property with a value in excess of one million dollars. Insurance fraud in the first degree is a class B felony. A person is guilty of aggravated insurance fraud in the fourth degree when he commits a fraudulent insurance act, and has been previously convicted within the preceding five years of any offense, an essential element of which is the commission of a fraudulent insurance act. Aggravated insurance fraud in the fourth degree is a class D felony. **State:** New York **Statute Areas:** Range of Criminal Penalties --- ### [New York-Range of Civil Penalties-McKinney's Insurance Law ¤ 403](https://insurancefraud.org/statutes/new-york-range-of-civil-penalties-mckinneys-insurance-law-¤-403/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (c) In addition to any criminal liability arising under the provisions of this section, the superintendent shall be empowered to levy a civil penalty not exceeding five thousand dollars and the amount of the claim for each violation upon any person, including those persons and their employees licensed pursuant to this chapter, who is found to have: (i) committed a fraudulent insurance act, fraudulent life settlement act or otherwise violates the provisions of this section; or (ii) knowingly and with intent to defraud files, makes, or assists, solicits or conspires with another to file or make an application for a premium reduction, pursuant to subsection (a) of section two thousand three hundred thirty-six of this chapter, containing any materially false information or which, for the purpose of misleading, conceals information concerning any fact material thereto. **State:** New York **Statute Areas:** Range of Civil Penalties --- ### [New York-Rating of an Insurance Policy-](https://insurancefraud.org/statutes/new-york-rating-of-an-insurance-policy/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Rates shall not be excessive, inadequate, unfairly discriminatory, destructive of competition or detrimental to the solvency of insurers. In determining whether rates comply with the foregoing standards, the superintendent shall include all income earned by such insurer and any insurer controlling or controlled by such insurer or under common control by or with such insurer on all its investments of any kind and wherever located. The superintendent shall further determine whether any component of such rates represent an effort on the part of the insurer to recover losses incurred in another state due to any referendum, law or regulation which requires a general reduction in rates for the kinds of insurance described in section two thousand three hundred two of this article. Such a finding shall be deemed unfairly discriminatory for the purposes of this article. **State:** New York --- ### [New York-Unauthorized Entities-](https://insurancefraud.org/statutes/new-york-unauthorized-entities/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) In this article: (1) “Insurance contract” means any agreement or other transaction whereby one party, the “insurer”, is obligated to confer benefit of pecuniary value upon another party, the “insured” or “beneficiary”, dependent upon the happening of a fortuitous event in which the insured or beneficiary has, or is expected to have at the time of such happening, a material interest which will be adversely affected by the happening of such event. (2) “Fortuitous event” means any occurrence or failure to occur which is, or is assumed by the parties to be, to a substantial extent beyond the control of either party. (3) “Contract of warranty, guaranty or suretyship” means an insurance contract only if made by a warrantor, guarantor or surety who or which, as such, is doing an insurance business. (b)(1) Except as otherwise provided in this subsection, any of the following acts in this state, effected by mail from outside this state or otherwise, by any person, firm, association, corporation or joint-stock company shall constitute doing an insurance business in this state and shall constitute doing business in the state within the meaning of section three hundred two of the civil practice law and rules: (A) making, or proposing to make, as insurer, any insurance contract, including either issuance or delivery of a policy or contract of insurance to a resident of this state or to any firm, association, or corporation authorized to do business herein, or solicitation of applications for any such policies or contracts; (B) making, or proposing to make, as warrantor, guarantor or surety, any contract of warranty, guaranty or suretyship as a vocation and not as merely incidental to any other legitimate business or activity of the warrantor, guarantor or surety; (C) collecting any premium, membership fee, assessment or other consideration for any policy or contract of insurance; (D) doing any kind of business, including a reinsurance business, specifically recognized as constituting the doing of an insurance business within the meaning of this chapter; or (E) doing or proposing to do any business in substance equivalent to any of the foregoing in a manner designed to evade the provisions of this chapter. (2) Notwithstanding the foregoing, the following acts or transactions, if effected by mail from outside this state by an unauthorized foreign or alien insurer duly licensed to transact the business of insurance in and by the laws of its domicile, shall not constitute doing an insurance business in this state, but section one thousand two hundred thirteen of this chapter shall nevertheless be applicable to such insurers: (A) transactions by any life insurance company organized and operated, without profit to any private shareholder or individual, exclusively for the purpose of aiding any charitable, religious, educational or scientific institution organized and operated, without profit to any private shareholder or individual, by issuing insurance or annuity contracts directly from its home office, without agents or representatives in this state, only to or for the benefit of such institutions and to individuals engaged in their service; (B) transactions with respect to group life, group annuity, group accident and health or blanket accident and health insurance (other than any transaction with respect to a group annuity contract funding individual retirement accounts or individual retirement annuities, as defined in section four hundred eight of the Internal Revenue Code,1 funding annuities in accordance with subdivision (b) of section four hundred three of such code2 or providing a plan of retirement annuities under which the payments are derived wholly from funds contributed by the persons covered): (i) where such groups conform to the definitions of eligibility contained in; (I) the following paragraphs of subsection (b) of section four thousand two hundred sixteen of this chapter: (aa) paragraph (1) or (2); (bb) paragraph (3), if, with respect to those credit transactions entered into in this state, the policy fully conforms with the requirements of sections three thousand two hundred one, three thousand two hundred twenty and four thousand two hundred sixteen of this chapter; (cc) paragraphs (4), (5), (6), (7), (8), (9) and (10). (II) the following subparagraphs of paragraph (1) of subsection (c) of section four thousand two hundred thirty-five of this chapter: (aa) subparagraph (A), (B), (C) or (D); (bb) subparagraph (E), if, with respect to those credit transactions entered into in this state, the policy fully conforms with the requirements of sections three thousand two hundred one, three thousand two hundred twenty-one and four thousand two hundred thirty-five of this chapter; (cc) subparagraphs (F), (G) and (H). (III) section four thousand two hundred thirty-seven (except subparagraph (F) of paragraph three of subsection (a) thereof) or four thousand two hundred thirty-eight (except paragraphs six and seven of subsection (b) thereof) of this chapter; and (ii) where the master policies or contracts were lawfully issued without this state in a jurisdiction where the insurer was authorized to do an insurance business; (C) transactions involving the continuance or servicing of life or accident and health insurance policies or annuity contracts lawfully issued or delivered in this state by an authorized insurer and occurring subsequent to the termination of such insurer’s authority to do an insurance business in this state; (D) transactions with respect to policies or annuity contracts lawfully issued without this state occurring subsequent to issue, if, at the time of issue, such policies or contracts covered subjects of insurance or risks not resident or located in this state; (E) transactions with respect to policies of insurance on risks located or resident within or without this state (except master policies or contracts of group insurance which are subject to the requirements of subparagraph (B) hereof), which policies are principally negotiated, issued and delivered without this state in a jurisdiction in which the insurer is authorized to do an insurance business; (F) transactions authorized by section two thousand one hundred five of this chapter with respect to excess lines insurance; (G) transactions with respect to the reinsurance of risks of authorized insurers to the extent that such reinsurance is permitted by this chapter; (H) transactions with respect to insurance contracts negotiated or placed pursuant or otherwise subject to subsection (b), (c), (j) or (k) of section two thousand one hundred seventeen of this chapter; (I) transactions with respect to any policy of insurance or annuity contract issued prior to September first, nineteen hundred seventy. (3) Notwithstanding the foregoing, the making of an agreement pursuant **State:** New York --- ### [New Mexico-Claims Fraud-N. M. S. A. 1978, ¤ 59A-16-23](https://insurancefraud.org/statutes/new-mexico-claims-fraud-n-m-s-a-1978-¤-59a-16-23/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** A. An agent, broker, solicitor, examining physician, applicant or other person shall not knowingly or willfully: (1) make a false or fraudulent statement or representation as to a material fact in or with reference to an application for insurance or other coverage; (2) for the purpose of obtaining money or benefit, present or cause to be presented a false or fraudulent claim or proof in support of such a claim for payment of loss under a policy; (3) prepare, make or subscribe a false or fraudulent account, certificate, affidavit or proof of loss or other document with intent that the same may be presented or used in support of such a claim; or (4) make a false or fraudulent statement or representation on or relative to an application for a policy for the purpose of obtaining a fee, commission or benefit from an insurer, agent, broker or individual. B. A false statement or representation made under oath shall constitute and be punishable as perjury. A violation of the provisions of this section when the purported loss or potential loss to the victim insurer is: (1) two hundred fifty dollars ($250) or less is a petty misdemeanor; (2) over two hundred fifty dollars ($250) but not more than five hundred dollars ($500) is a misdemeanor; (3) over five hundred dollars ($500) but not more than two thousand five hundred dollars ($2,500) is a fourth degree felony; (4) over two thousand five hundred dollars ($2,500) but not more than twenty thousand dollars ($20,000) is a third degree felony; or (5) over twenty thousand dollars ($20,000) is a second degree felony. **State:** New Mexico **Statute Areas:** Claims Fraud --- ### [New Mexico-Failing to Remit Premium-N. M. S. A. 1978, ¤ 59A-16-24](https://insurancefraud.org/statutes/new-mexico-failing-to-remit-premium-n-m-s-a-1978-¤-59a-16-24/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** A. No person shall wilfully collect any sum as premium or charge for insurance or other coverage, which insurance or coverage is not then provided or in due course to be provided (subject to acceptance of the risk by the insurer) by a policy issued by an insurer as authorized by the Insurance Code. B. No person shall wilfully collect as premium, administration fee or other charge for insurance or coverage any sum in excess of the premium or charge applicable thereto as specified in the policy, in accordance with the insurer’s applicable classifications and rates then lawfully in effect. This subsection shall not be deemed to prohibit: (1) the charging and collection by surplus line brokers licensed as such under Article 14 of the Insurance Code, of the amount of applicable taxes, if any, and policy fee, if any, in addition to the premium required by the insurer; or (2) the charging and collection by a life insurer of amounts actually to be expended for medical examination of an applicant for life insurance or for reinstatement of a life insurance policy. **State:** New Mexico --- ### [New Mexico-Immunity-N. M. S. A. 1978, ¤ 59A-16C-7](https://insurancefraud.org/statutes/new-mexico-immunity-n-m-s-a-1978-¤-59a-16c-7/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** A. The provisions of Section 59A-4-21 NMSA 1978 regarding immunity from civil liability for enforcement actions performed in good faith by the superintendent, his authorized representatives and examiners shall apply to the Insurance Fraud Act. B. Except when a person intentionally communicates false information he actually believes to be false, a person shall not be subject to liability by virtue of reporting or furnishing, orally or in writing, information concerning suspected, anticipated or completed insurance fraud acts when the report or information is provided to: (1) the department of insurance, the superintendent or law enforcement agencies, their officials, agents or employees; (2) the national association of insurance commissioners, a federal or state governmental agency or office established to detect and prevent insurance fraud, any other organization established for the same purpose and their agents, employees or designees; or (3) the anti-fraud unit of an insurer. C. A person identified in Subsection B of this section or any of the person’s officers, employees or agents when performing authorized activities, including the publication or dissemination of any related bulletin or reports, shall not be subject to civil liability for libel, slander or any other relevant tort or a civil cause of action of any nature, except if the person, officer, employee or agent intentionally communicates false information he actually believes to be false. D. This section shall not abrogate or modify in any way any privilege or immunity recognized by common law or statute. E. The court shall award attorney fees and costs to any person identified in Subsection B of this section or any of that person’s officers, employees or agents who is a prevailing party in a civil cause of action against him for libel, slander or any other relevant tort arising out of conduct pursuant to the Insurance Fraud Act if the party bringing the action was not substantially justified in bringing such action. For the purposes of this subsection, “substantially justified” means having a reasonable basis in law or fact at the time a proceeding was initiated. F. The relief provided in this section is in addition to remedies otherwise available against the same conduct under the common law or other laws of this state. **State:** New Mexico **Statute Areas:** Immunity --- ### [New Mexico-Insurance Fraud - Definition-N. M. S. A. 1978, ¤ 59A-16-23](https://insurancefraud.org/statutes/new-mexico-insurance-fraud-definition-n-m-s-a-1978-¤-59a-16-23/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** A. An agent, broker, solicitor, examining physician, applicant or other person shall not knowingly or willfully: (1) make a false or fraudulent statement or representation as to a material fact in or with reference to an application for insurance or other coverage; (2) for the purpose of obtaining money or benefit, present or cause to be presented a false or fraudulent claim or proof in support of such a claim for payment of loss under a policy; (3) prepare, make or subscribe a false or fraudulent account, certificate, affidavit or proof of loss or other document with intent that the same may be presented or used in support of such a claim; or (4) make a false or fraudulent statement or representation on or relative to an application for a policy for the purpose of obtaining a fee, commission or benefit from an insurer, agent, broker or individual. B. A false statement or representation made under oath shall constitute and be punishable as perjury. A violation of the provisions of this section when the purported loss or potential loss to the victim insurer is: (1) two hundred fifty dollars ($250) or less is a petty misdemeanor; (2) over two hundred fifty dollars ($250) but not more than five hundred dollars ($500) is a misdemeanor; (3) over five hundred dollars ($500) but not more than two thousand five hundred dollars ($2,500) is a fourth degree felony; (4) over two thousand five hundred dollars ($2,500) but not more than twenty thousand dollars ($20,000) is a third degree felony; or (5) over twenty thousand dollars ($20,000) is a second degree felony. **State:** New Mexico **Statute Areas:** Insurance Fraud - Definition --- ### [New Mexico-Placing Bogus Coverage-N. M. S. A. 1978, ¤ 59A-16-4](https://insurancefraud.org/statutes/new-mexico-placing-bogus-coverage-n-m-s-a-1978-¤-59a-16-4/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** No person shall make, publish, issue or circulate any estimate, illustration, circular, statement, sales presentation or comparison which: A. misrepresents the benefits, advantages, conditions or terms of any policy; B. misrepresents the premium overcharge commonly called dividends or share of the surplus to be received on any policy; C. makes any false or misleading statement as to dividends or share of surplus previously paid on any policy; D. is misleading or a misrepresentation as to the financial condition of any person, or as to the reserve system upon which any life insurer operates; E. uses any name or title of any policy or class of policies misrepresenting the true nature thereof; F. misrepresents any policy as being shares of stock; or G. fails to disclose material facts reasonably necessary to prevent other statements made from being misleading. **State:** New Mexico --- ### [New Mexico-Practitioner Penalites-N. M. S. A. 1978, ¤ 59A-1-18](https://insurancefraud.org/statutes/new-mexico-practitioner-penalites-n-m-s-a-1978-¤-59a-1-18/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** A. Unless the same is defined as a felony under any other law of this state or punishment therefor classifies it otherwise, every violation of the Insurance Code is a petty misdemeanor punishable by a fine not to exceed five hundred dollars ($500). B. Where other monetary penalty is not expressly provided for, an administrative penalty may be assessed for violations of the Insurance Code. The administrative penalty shall be not over five thousand dollars ($5,000) for each violation, except that if the violation is to be found willful and intentional, the penalty may be up to ten thousand dollars ($10,000) for each violation. Every administrative penalty shall be imposed by written order of the superintendent made after hearing held as provided in Chapter 59A, Article 4 NMSA 1978. C. A monetary penalty imposed may be additional to any applicable suspension, revocation or denial of a license or certificate of authority. D. In addition to the authority of the insurance department to bring an action to recover statutory fines and assessments, the insurance department may bring civil actions for penalties in sums not to exceed the criminal fine for each violation of the Insurance Code, in lieu of criminal prosecution. E. The penalties contained in Subsections A through D of this section shall be in addition to any other penalty provided by law. **State:** New Mexico **Statute Areas:** Practitioner Penalites --- ### [New Mexico-Range of Civil Penalties-N. M. S. A. 1978, ¤ 59A-1-18](https://insurancefraud.org/statutes/new-mexico-range-of-civil-penalties-n-m-s-a-1978-¤-59a-1-18/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** A. Unless the same is defined as a felony under any other law of this state or punishment therefor classifies it otherwise, every violation of the Insurance Code is a petty misdemeanor punishable by a fine not to exceed five hundred dollars ($500). B. Where other monetary penalty is not expressly provided for, an administrative penalty may be assessed for violations of the Insurance Code. The administrative penalty shall be not over five thousand dollars ($5,000) for each violation, except that if the violation is to be found willful and intentional, the penalty may be up to ten thousand dollars ($10,000) for each violation. Every administrative penalty shall be imposed by written order of the superintendent made after hearing held as provided in Chapter 59A, Article 4 NMSA 1978. C. A monetary penalty imposed may be additional to any applicable suspension, revocation or denial of a license or certificate of authority. D. In addition to the authority of the insurance department to bring an action to recover statutory fines and assessments, the insurance department may bring civil actions for penalties in sums not to exceed the criminal fine for each violation of the Insurance Code, in lieu of criminal prosecution. E. The penalties contained in Subsections A through D of this section shall be in addition to any other penalty provided by law. **State:** New Mexico **Statute Areas:** Range of Civil Penalties --- ### [New Mexico-Rating of an Insurance Policy-N. M. S. A. 1978, ¤ 59A-17-7](https://insurancefraud.org/statutes/new-mexico-rating-of-an-insurance-policy-n-m-s-a-1978-¤-59a-17-7/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** In determining whether rates comply with the rate standards, the following criteria shall be applied: A. due consideration shall be given to past and prospective loss and expense experience within and without this state, to catastrophic hazards and contingencies, to trends within and without this state, to loadings for leveling premium rates over time or for dividends or savings to be allowed or returned by insurers to their policyholders, members or subscribers and to all other relevant factors, including the judgment of technical personnel; B. risks may be classified in any reasonable way for the establishment of rates and minimum premiums, except that classifications may not be based on race, color, creed or national origin; C. the expense provisions included in the rates to be used by an insurer may reflect the operating methods of the insurer and, so far as it is credible, its own expense experience; and D. the rates may contain an allowance permitting a profit that is not unreasonable in relation to the riskiness of the line, kind or class of business. Profit shall include investment income attributable to such rates. **State:** New Mexico --- ### [New Mexico-Underwriting Fraud-N. M. S. A. 1978, ¤ 59A-16-4](https://insurancefraud.org/statutes/new-mexico-underwriting-fraud-n-m-s-a-1978-¤-59a-16-4/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** No person shall make, publish, issue or circulate any estimate, illustration, circular, statement, sales presentation or comparison which: A. misrepresents the benefits, advantages, conditions or terms of any policy; B. misrepresents the premium overcharge commonly called dividends or share of the surplus to be received on any policy; C. makes any false or misleading statement as to dividends or share of surplus previously paid on any policy; D. is misleading or a misrepresentation as to the financial condition of any person, or as to the reserve system upon which any life insurer operates; E. uses any name or title of any policy or class of policies misrepresenting the true nature thereof; F. misrepresents any policy as being shares of stock; or G. fails to disclose material facts reasonably necessary to prevent other statements made from being misleading. **State:** New Mexico **Statute Areas:** Underwriting Fraud --- ### [New Mexico-Unauthorized Entities-N. M. S. A. 1978, ¤ 59A-15-2](https://insurancefraud.org/statutes/new-mexico-unauthorized-entities-n-m-s-a-1978-¤-59a-15-2/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** A. No person shall in this state directly or indirectly act as agent for, or otherwise represent or aid on behalf of another, any unauthorized insurer in solicitation, negotiation, procurement or effectuation of insurance or renewals thereof, or forwarding of applications, or delivery of policies or contracts, or inspection of risks, or fixing of rates, or investigation or adjustment of claims or losses, or collection or forwarding of premiums, or in any other manner represent or assist such insurer in transaction of insurance in this state. B. This section shall not apply as to: (1) matters authorized to be done by the superintendent under service of process provisions of Chapter 59A, Article 15 NMSA 1978; (2) transactions for which certificate of authority is not required of an insurer under Section 59A-5-11 NMSA 1978; (3) subject to Subsection B of Section 59A-5-10 NMSA 1978, insurances exempt from the surplus line law under Section 59A-14-1 NMSA 1978; (4) insurance policies and annuity contracts in force in this state prior to the effective date of the Insurance Code, transactions as to which shall be governed by laws in force immediately prior to such effective date; or (5) a transaction or transactions in this state involving contracts of insurance to one or more industrial insureds. For the purposes of this section, an industrial insured is an insured: (a) which procures the insurance of any risk by the use of the services of a full-time employee acting as a risk manager or insurance manager or by utilizing the services of a regularly and continuously qualified insurance consultant; (b) which has aggregate annual premiums for insurance on all risks of at least twenty-five thousand dollars ($25,000); and (c) which has at least twenty-five full-time employees. C. Violation of this section shall be subject to the general penalty provided under Section 59A-1-18 NMSA 1978. **State:** New Mexico --- ### [New Jersey-Aiding & Abetting-N.J.S.A. 17:33A-4 (Proposed Legislation)](https://insurancefraud.org/statutes/new-jersey-aiding-abetting-n-j-s-a-1733a-4-proposed-legislation/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (6) Prepares, presents or causes to be presented to any insurer or other person, or demands or requires the issuance of, a certificate of insurance that contains any false or misleading information concerning the policy of insurance to which the certificate makes reference, or assists, abets, solicits or conspires with another to do any of these acts. As used in this paragraph, “certificate of insurance” means a document or instrument, regardless of how titled or described, that is, or purports to be, prepared or issued by an insurer or insurance producer as evidence of property or casualty insurance coverage. The term shall not include a policy of insurance, insurance binder, policy endorsement, or automobile insurance identification or information card. b. A person or practitioner violates this act if he knowingly assists, conspires with, or urges any person or practitioner to violate any of the provisions of this act. **State:** New Jersey --- ### [New Jersey-Anti-Runner Provisions-N.J.S.A. 17:33A-4 (Proposed Legislation)](https://insurancefraud.org/statutes/new-jersey-anti-runner-provisions-n-j-s-a-1733a-4-proposed-legislation/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (6) Prepares, presents or causes to be presented to any insurer or other person, or demands or requires the issuance of, a certificate of insurance that contains any false or misleading information concerning the policy of insurance to which the certificate makes reference, or assists, abets, solicits or conspires with another to do any of these acts. As used in this paragraph, “certificate of insurance” means a document or instrument, regardless of how titled or described, that is, or purports to be, prepared or issued by an insurer or insurance producer as evidence of property or casualty insurance coverage. The term shall not include a policy of insurance, insurance binder, policy endorsement, or automobile insurance identification or information card. e. A person or practitioner violates this act if, for pecuniary gain, for himself or another, he directly or indirectly solicits any person or practitioner to engage, employ or retain either himself or any other person to manage, adjust or prosecute any claim or cause of action, against any person, for damages for negligence, or, for pecuniary gain, for himself or another, directly or indirectly solicits other persons to bring causes of action to recover damages for personal injuries or death, or for pecuniary gain, for himself or another, directly or indirectly solicits other persons to make a claim for personal injury protection benefits pursuant to P.L.1972, c. 70 (C.39:6A-1 et seq.); provided, however, that this subsection shall not apply to any conduct otherwise permitted by law or by rule of the Supreme Court. **State:** New Jersey **Statute Areas:** Anti-Runner Provisions --- ### [New Jersey-Claims Fraud-N.J.S.A. 17:33A-3](https://insurancefraud.org/statutes/new-jersey-claims-fraud-n-j-s-a-1733a-3/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** a. A person or a practitioner violates this act if he: (1) Presents or causes to be presented any written or oral statement as part of, or in support of or opposition to, a claim for payment or other benefit pursuant to an insurance policy or the “Unsatisfied Claim and Judgment Fund Law,” P.L.1952, c. 174 (C.39:6-61 et seq.), knowing that the statement contains any false or misleading information concerning any fact or thing material to the claim; or (2) Prepares or makes any written or oral statement that is intended to be presented to any insurance company, the Unsatisfied Claim and Judgment Fund or any claimant thereof in connection with, or in support of or opposition to any claim for payment or other benefit pursuant to an insurance policy or the “Unsatisfied Claim and Judgment Fund Law,” P.L.1952, c. 174 (C.39:6-61 et seq.), knowing that the statement contains any false or misleading information concerning any fact or thing material to the claim; or **State:** New Jersey **Statute Areas:** Claims Fraud --- ### [New Jersey-Failing to Remit Premium-n/a](https://insurancefraud.org/statutes/new-jersey-failing-to-remit-premium-n-a/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** No staute found. **State:** New Jersey --- ### [New Jersey-Fraud Bureau-N.J.S.A. 17:33A-16](https://insurancefraud.org/statutes/new-jersey-fraud-bureau-n-j-s-a-1733a-16/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** There is established in the Division of Criminal Justice in the Department of Law and Public Safety the Office of the Insurance Fraud Prosecutor. The Insurance Fraud Prosecutor shall be appointed by, and serve at the pleasure of, the Governor with the advice and consent of the Senate and be under the direction and supervision of the Attorney General. Any person appointed as Insurance Fraud Prosecutor shall have had prosecutorial experience, including experience in the litigation of civil and criminal cases. The Attorney General shall establish standards of performance for the Office of Insurance Fraud Prosecutor, which shall include standards of accountability. **State:** New Jersey **Statute Areas:** Fraud Bureau --- ### [New Jersey-Immunity-N.J.S.A. 17:33A-9 (Proposed legislation)](https://insurancefraud.org/statutes/new-jersey-immunity-n-j-s-a-1733a-9-proposed-legislation/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** a. (1) Any person who believes that a violation of this act has been or is being made shall notify the bureau and the Office of the Insurance Fraud Prosecutor1 immediately after discovery of the alleged violation of this act and shall send to the bureau and office, on a form and in a manner jointly prescribed by the commissioner and the Insurance Fraud Prosecutor, the information requested and such additional information relative to the alleged violation as the bureau or office may require. The bureau and the office shall jointly review the reports and select those alleged violations as may require further investigation by the office for possible criminal prosecution, and those that may warrant investigation and possible civil action or enforcement proceeding by the bureau in lieu of or in addition to criminal prosecution. The Insurance Fraud Prosecutor and the assistant commissioner shall meet monthly to ensure that reports are handled in an expedited fashion. (2) Whenever the Bureau of Fraud Deterrence or any employee of the bureau obtains information or evidence of a reasonable possibility of criminal wrongdoing not previously known or disclosed to the Office of the Insurance Fraud Prosecutor, the bureau shall immediately refer that information or evidence to that office. In determining whether a referral to the office is appropriate, the bureau shall utilize appropriate levels of internal review, which shall include but not be limited to approval at the assistant commissioner level. Upon referral, the bureau shall provide the office with all documents related to the referral consistent with section 39 of P.L.1998, c. 21 (C.17:33A-23). b. No person shall be subject to civil liability for libel, violation of privacy or otherwise by virtue of the filing of reports or furnishing of other information, in good faith and without malice, required by this section or required by the bureau or the Office of the Insurance Fraud Prosecutor as a result of the authority conferred upon it by law. c. The commissioner may, by regulation, require insurance companies licensed to do business in this State to keep such records and other information as he deems necessary for the effective enforcement of this act. **State:** New Jersey **Statute Areas:** Immunity --- ### [New Jersey-Insurance Fraud - Definition-](https://insurancefraud.org/statutes/new-jersey-insurance-fraud-definition/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** a. A person is guilty of the crime of insurance fraud if that person knowingly makes, or causes to be made, a false, fictitious, fraudulent, or misleading statement of material fact in, or omits a material fact from, or causes a material fact to be omitted from, any record, bill, claim or other document, in writing, electronically, orally or in any other form, that a person attempts to submit, submits, causes to be submitted, or attempts to cause to be submitted as part of, in support of or opposition to or in connection with: (1) a claim for payment, reimbursement or other benefit pursuant to an insurance policy, or from an insurance company or the “Unsatisfied Claim and Judgment Fund Law,” P.L.1952, c. 174 (C.39:6-61 et seq.); (2) an application to obtain or renew an insurance policy; (3) any payment made or to be made in accordance with the terms of an insurance policy or premium finance transaction; or (4) an affidavit, certification, record or other document used in any insurance or premium finance transaction. b. A person who operates a motor vehicle on the public highways of this State, which motor vehicle is insured by a policy issued under the laws of another state, is guilty of the crime of insurance fraud if that person maintains a principal residence in this State or has his motor vehicle principally garaged in this State and he has knowingly prepared or made any written, electronic or oral statement, presented to any insurance company or producer licensed to transact the business of insurance under the laws of that other state, and which resulted in obtaining a motor vehicle insurance policy for his motor vehicle in that other state, that the person to be insured: (1) maintains a principal residence in the other state when, in fact, that person’s principal residence is in this State; or (2) has his motor vehicle principally garaged in the other state, when, in fact, that person has his motor vehicle principally garaged in this State. This subsection shall not apply to a person who insures a vehicle in another state, as permitted by and in accordance with the laws of that state, based on a second residence, or attendance at an educational institution, in that other state, if in obtaining the policy the person truthfully discloses to the insurance company or producer the state of the person’s principal residence and the state where the vehicle is principally garaged. c. Insurance fraud constitutes a crime of the second degree if the person knowingly commits five or more acts of insurance fraud, including acts of health care claims fraud pursuant to section 2 of P.L.1997, c. 353 (C.2C:21-4.2) and if the aggregate value of property, services or other benefit wrongfully obtained or sought to be obtained is at least $1,000. Otherwise, insurance fraud in violation of subsection a. of this section is a crime of the third degree and insurance fraud in violation of subsection b. of this section is a crime of the fourth degree. Each act of insurance fraud shall constitute an additional, separate and distinct offense, except that five or more separate acts may be aggregated for the purpose of establishing liability pursuant to this subsection. Multiple acts of insurance fraud which are contained in a single record, bill, claim, application, payment, affidavit, certification or other document shall each constitute an additional, separate and distinct offense for purposes of this section. d. Proof that a person has signed or initialed an application, bill, claim, affidavit, certification, record or other document may give rise to an inference that the person has read and reviewed the application, bill, claim, affidavit, certification, record or other document. e. In order to promote the uniform enforcement of this act, the Attorney General shall develop insurance fraud prosecution guidelines and disseminate them to county prosecutors within 180 days of the effective date of this act. f. Nothing in this act shall preclude an indictment and conviction for any other offense defined by the laws of this State. g. Nothing in this act shall preclude an assignment judge from dismissing a prosecution of insurance fraud if the assignment judge determines, pursuant to N.J.S.2C:2-11, the conduct charged to be a de minimis infraction.\*\*\*a. A person or a practitioner violates this act if he: (1) Presents or causes to be presented any written or oral statement as part of, or in support of or opposition to, a claim for payment or other benefit pursuant to an insurance policy or the “Unsatisfied Claim and Judgment Fund Law,” P.L.1952, c. 174 (C.39:6-61 et seq.), knowing that the statement contains any false or misleading information concerning any fact or thing material to the claim; or (2) Prepares or makes any written or oral statement that is intended to be presented to any insurance company, the Unsatisfied Claim and Judgment Fund or any claimant thereof in connection with, or in **State:** New Jersey **Statute Areas:** Insurance Fraud - Definition --- ### [New Jersey-Licensing Board Notification-N.J.S.A. 17:33A-9 (Proposed legislation)](https://insurancefraud.org/statutes/new-jersey-licensing-board-notification-n-j-s-a-1733a-9-proposed-legislation/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** a. (1) Any person who believes that a violation of this act has been or is being made shall notify the bureau and the Office of the Insurance Fraud Prosecutor1 immediately after discovery of the alleged violation of this act and shall send to the bureau and office, on a form and in a manner jointly prescribed by the commissioner and the Insurance Fraud Prosecutor, the information requested and such additional information relative to the alleged violation as the bureau or office may require. The bureau and the office shall jointly review the reports and select those alleged violations as may require further investigation by the office for possible criminal prosecution, and those that may warrant investigation and possible civil action or enforcement proceeding by the bureau in lieu of or in addition to criminal prosecution. The Insurance Fraud Prosecutor and the assistant commissioner shall meet monthly to ensure that reports are handled in an expedited fashion. (2) Whenever the Bureau of Fraud Deterrence or any employee of the bureau obtains information or evidence of a reasonable possibility of criminal wrongdoing not previously known or disclosed to the Office of the Insurance Fraud Prosecutor, the bureau shall immediately refer that information or evidence to that office. In determining whether a referral to the office is appropriate, the bureau shall utilize appropriate levels of internal review, which shall include but not be limited to approval at the assistant commissioner level. Upon referral, the bureau shall provide the office with all documents related to the referral consistent with section 39 of P.L.1998, c. 21 (C.17:33A-23). b. No person shall be subject to civil liability for libel, violation of privacy or otherwise by virtue of the filing of reports or furnishing of other information, in good faith and without malice, required by this section or required by the bureau or the Office of the Insurance Fraud Prosecutor as a result of the authority conferred upon it by law. c. The commissioner may, by regulation, require insurance companies licensed to do business in this State to keep such records and other information as he deems necessary for the effective enforcement of this act. **State:** New Jersey --- ### [New Jersey-Mandatory Restitution-N.J.S.A. 17:33A-26](https://insurancefraud.org/statutes/new-jersey-mandatory-restitution-n-j-s-a-1733a-26/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** The Insurance Fraud Prosecutor shall consider the restitution of moneys to insurers and others who are defrauded as a major priority, in order that policyholders may benefit from the prosecution of those persons guilty of insurance fraud, and to that end, any assets of any person guilty of fraud shall be subject to seizure. **State:** New Jersey **Statute Areas:** Mandatory Restitution --- ### [New Jersey-Placing Bogus Coverage-N.J.S.A. 17:29A-4 (Proposed legislation)](https://insurancefraud.org/statutes/new-jersey-placing-bogus-coverage-n-j-s-a-1729a-4-proposed-legislation/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (1) Presents or causes to be presented any written or oral statement as part of, or in support of or opposition to, a claim for payment or other benefit pursuant to an insurance policy or the “Unsatisfied Claim and Judgment Fund Law,” P.L.1952, c. 174 (C.39:6-61 et seq.), knowing that the statement contains any false or misleading information concerning any fact or thing material to the claim; or (2) Prepares or makes any written or oral statement that is intended to be presented to any insurance company, the Unsatisfied Claim and Judgment Fund or any claimant thereof in connection with, or in support of or opposition to any claim for payment or other benefit pursuant to an insurance policy or the “Unsatisfied Claim and Judgment Fund Law,” P.L.1952, c. 174 (C.39:6-61 et seq.), knowing that the statement contains any false or misleading information concerning any fact or thing material to the claim; or (3) Conceals or knowingly fails to disclose the occurrence of an event which affects any person’s initial or continued right or entitlement to (a) any insurance benefit or payment or (b) the amount of any benefit or payment to which the person is entitled; (6) Prepares, presents or causes to be presented to any insurer or other person, or demands or requires the issuance of, a certificate of insurance that contains any false or misleading information concerning the policy of insurance to which the certificate makes reference, or assists, abets, solicits or conspires with another to do any of these acts. As used in this paragraph, “certificate of insurance” means a document or instrument, regardless of how titled or described, that is, or purports to be, prepared or issued by an insurer or insurance producer as evidence of property or casualty insurance coverage. The term shall not include a policy of insurance, insurance binder, policy endorsement, or automobile insurance identification or information card. b. A person or practitioner violates this act if he knowingly assists, conspires with, or urges any person or practitioner to violate any of the provisions of this act. c. A person or practitioner violates this act if, due to the assistance, conspiracy or urging of any person or practitioner, he knowingly benefits, directly or indirectly, from the proceeds derived from a violation of this act. d. A person or practitioner who is the owner, administrator or employee of any hospital violates this act if he knowingly allows the use of the facilities of the hospital by any person in furtherance of a scheme or conspiracy to violate any of the provisions of this act. **State:** New Jersey --- ### [New Jersey-Practitioner Penalites-N.J.S.A. 17:29A-4 (Proposed legislation)](https://insurancefraud.org/statutes/new-jersey-practitioner-penalites-n-j-s-a-1729a-4-proposed-legislation/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** c. Insurance fraud constitutes a crime of the second degree if the person knowingly commits five or more acts of insurance fraud, including acts of health care claims fraud pursuant to section 2 of P.L.1997, c. 353 (C.2C:21-4.2) and if the aggregate value of property, services or other benefit wrongfully obtained or sought to be obtained is at least $1,000. Otherwise, insurance fraud in violation of subsection a. of this section is a crime of the third degree and insurance fraud in violation of subsection b. of this section is a crime of the fourth degree. Each act of insurance fraud shall constitute an additional, separate and distinct offense, except that five or more separate acts may be aggregated for the purpose of establishing liability pursuant to this subsection. Multiple acts of insurance fraud which are contained in a single record, bill, claim, application, payment, affidavit, certification or other document shall each constitute an additional, separate and distinct offense for purposes of this section. **State:** New Jersey **Statute Areas:** Practitioner Penalites --- ### [New Jersey-Premium Fraud-N.J.S.A. 17:29A-4 (Proposed legislation)](https://insurancefraud.org/statutes/new-jersey-premium-fraud-n-j-s-a-1729a-4-proposed-legislation/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** a. A person or a practitioner violates this act if he:(3) Conceals or knowingly fails to disclose the occurrence of an event which affects any person’s initial or continued right or entitlement to (a) any insurance benefit or payment or (b) the amount of any benefit or payment to which the person is entitled; **State:** New Jersey **Statute Areas:** Premium Fraud --- ### [New Jersey-Range of Criminal Penalties-N.J.S.A. 17:29A-4 (Proposed legislation)](https://insurancefraud.org/statutes/new-jersey-range-of-criminal-penalties-n-j-s-a-1729a-4-proposed-legislation/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** c. Insurance fraud constitutes a crime of the second degree if the person knowingly commits five or more acts of insurance fraud, including acts of health care claims fraud pursuant to section 2 of P.L.1997, c. 353 (C.2C:21-4.2) and if the aggregate value of property, services or other benefit wrongfully obtained or sought to be obtained is at least $1,000. Otherwise, insurance fraud in violation of subsection a. of this section is a crime of the third degree and insurance fraud in violation of subsection b. of this section is a crime of the fourth degree. Each act of insurance fraud shall constitute an additional, separate and distinct offense, except that five or more separate acts may be aggregated for the purpose of establishing liability pursuant to this subsection. Multiple acts of insurance fraud which are contained in a single record, bill, claim, application, payment, affidavit, certification or other document shall each constitute an additional, separate and distinct offense for purposes of this section. **State:** New Jersey **Statute Areas:** Range of Criminal Penalties --- ### [New Jersey-Range of Civil Penalties-N.J.S.A. 17:33A-5](https://insurancefraud.org/statutes/new-jersey-range-of-civil-penalties-n-j-s-a-1733a-5/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** a. Whenever the commissioner 1 determines that a person has violated any provision of P.L.1983, c. 320 (C.17:33A-1 et seq.), the commissioner may either: (1) bring a civil action in accordance with subsection b. of this section; or (2) levy a civil administrative penalty and order restitution in accordance with subsection c. of this section. In addition to or as an alternative to the remedies provided in this section, the commissioner may request the Attorney General to bring a criminal action under applicable criminal statutes. Additionally, nothing in this section shall be construed to preclude the commissioner from referring the matter to appropriate state licensing authorities, including the insurance producer licensing section in the Department of Banking and Insurance, for consideration of licensing actions, including license suspension or revocation. b. Any person who violates any provision of P.L.1983, c. 320 (C.17:33A-1 et seq.) shall be liable, in a civil action brought by the commissioner in a court of competent jurisdiction, for a penalty of not more than $5,000 for the first violation, $10,000 for the second violation and $15,000 for each subsequent violation. The penalty shall be paid to the commissioner to be used in accordance with subsection e. of this section. The court shall also award court costs and reasonable attorneys’ fees to the commissioner. c. The commissioner is authorized to assess a civil and administrative penalty of not more than $5,000 for the first violation, $10,000 for the second violation and $15,000 for each subsequent violation of any provision of P.L.1983, c. 320 (C.17:33A-1 et seq.) and to order restitution to any insurance company or other person who has suffered a loss as a result of a violation of P.L.1983, c. 320 (C.17:33A-1 et seq.). No assessment shall be levied pursuant to this subsection until the violator has been notified by certified mail or personal service. The notice shall contain a concise statement of facts providing the basis for the determination of a violation of P.L.1983, c. 320 (C.17:33A-1 et seq.), the provisions of that act violated, a statement of the amount of civil penalties assessed and a statement of the party’s right to a hearing in accordance with the “Administrative Procedure Act,” P.L.1968, c. 410 (C.52:14B-1 et seq.). The noticed party shall have 20 calendar days from receipt of the notice within which to deliver to the commissioner a written request for a hearing containing an answer to the statement of facts contained in the notice. After the hearing and upon a finding that a violation has occurred, the commissioner may issue a final order assessing up to the amount of the penalty in the notice, restitution, and costs of prosecution, including attorneys’ fees. If no hearing is requested, the notice shall become a final order after the expiration of the 20-day period. Payment of the assessment is due when a final order is issued or the notice becomes a final order. Any penalty imposed pursuant to this subsection may be collected with costs in a summary proceeding pursuant to “the penalty enforcement law,” N.J.S.2A:58-1 et seq. The Superior Court shall have jurisdiction to enforce the provisions of the “the penalty enforcement law” in connection with P.L.1983, c. 320 (C.17:33A-1 et seq.). Any penalty collected pursuant to this subsection shall be used in accordance with subsection e. of this section. d. Nothing in this section shall be construed to prohibit the commissioner and the person or practitioner alleged to be guilty of a violation of this act from entering into a written agreement in which the person or practitioner does not admit or deny the charges but consents to payment of the civil penalty. A consent agreement may contain a provision that it shall not be used in a subsequent civil or criminal proceeding relating to any violation of this act, but notification thereof shall be made to a licensing authority in the same manner as required pursuant to subsection c. of section 10 of P.L.1983, c. 320 (C.17:33A-10). The existence of a consent agreement under this subsection shall not preclude any licensing authority from taking appropriate administrative action against a licensee over which it has regulatory authority, nor shall such a consent agreement preclude referral to law enforcement for consideration of criminal prosecution. e. The New Jersey Automobile Full Insurance Underwriting Association and Market Transition Facility Auxiliary Fund (hereinafter referred to as the “fund”) is established as a nonlapsing, revolving fund into which shall be deposited all revenues from the civil penalties imposed pursuant to this section. Interest received on moneys in the fund shall be credited to the fund. The fund shall be administered by the Commissioner of Banking and Insurance and shall be used to help defray the operating expenses of the New Jersey Automobile Full Insurance Underwriting Association created pursuant to P.L.1983, c. 65 (C.17:30E-1 et seq.) or shall be used to help defray the operating expenses of the Market Transition Facility created pursuant to section 88 of P.L.1990, c. 8 (C.17:33B-11). **State:** New Jersey **Statute Areas:** Range of Civil Penalties --- ### [New Jersey-Rating of an Insurance Policy-N.J.S.A. 17:29A-4 (Proposed legislation)](https://insurancefraud.org/statutes/new-jersey-rating-of-an-insurance-policy-n-j-s-a-1729a-4-proposed-legislation/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Every rating organization, and every insurer which makes its own rates, shall make rates that are not unreasonably high or inadequate for the safety and soundness of the insurer, and which do not unfairly discriminate between risks in this State involving essentially the same hazards and expense elements, and shall, in rate-making, and in making rating systems: (a) Adopt basic classifications, which shall be used as the basis of all manual, minimum, class, schedule, experience or merit rates; (b) Adopt reasonable standards for construction, for protective facilities, and for other conditions that materially affect the hazard or peril, which shall be applied in the determination or fixing of rates; (c) Give consideration to past and prospective loss experience, including where pertinent, the conflagration and catastrophe hazards, if any, both within and without the State; to all factors reasonably related to the kind of insurance involved; to a reasonable profit for the insurer; and, in the case of participating insurers, to policyholders’ dividends. In the case of fire insurance, consideration shall be given to the latest available experience of the fire insurance business during a period of not less than 5 years preceding the year in which rates are made or revised; (d) Give a rate reduction, to be approved by the commissioner, for fire insurance on structures equipped with operative smoke detection devices of a design approved by the Commissioner of Insurance. **State:** New Jersey --- ### [New Jersey-Unauthorized Entities-N.J.S.A. 17:51-1](https://insurancefraud.org/statutes/new-jersey-unauthorized-entities-n-j-s-a-1751-1/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) Any of the following acts in this State, by an insurer not authorized to transact business in this State: (1) the issuance or delivery of contracts of insurance to residents of this State or to corporations authorized to do business therein, (2) the solicitation of applications for such contracts, (3) the collection of premiums, membership fees, assessments or other considerations for such contracts, or (4) any other transaction of business in relation to such contracts of insurance, is equivalent to and shall constitute an appointment by such insurer of the Commissioner of Insurance and his successor or successors in office, to be its true and lawful attorney, upon whom may be served all lawful process and a complaint in any action or proceeding instituted by or on behalf of an insured or beneficiary arising out of any such contracts of insurance, and any such act shall be signification of its agreement that such service of process and a complaint is of the same legal force and validity as personal service of the same in this State upon such insurer. (b) Such service of process and a complaint upon the commissioner shall be made by leaving two copies thereof, with the fee prescribed by law, in the hands of the commissioner or someone designated by him in his office, or the clerk of the court may serve the commissioner by mailing such papers to him by registered mail, with the said fee. The commissioner shall forthwith mail by registered mail one of the copies of such process and complaint to the defendant at its last-known principal place of business, and shall keep a record of all papers so served upon him. The commissioner, upon giving notice to the defendant of the service of process as required by this act, shall file with the clerk of the court his certificate of the notice given. Such service of process and a complaint is sufficient, provided notice of such service and a copy of the papers are sent within ten days thereafter by registered mail by plaintiff or plaintiff’s attorney to the defendant at its last-known principal place of business, and the defendant’s receipt, or receipt issued by the post office with which the letter is registered, showing the name of the sender of the letter and the name and address of the person to whom the letter is addressed, and the affidavit of the plaintiff or plaintiff’s attorney showing a compliance herewith are filed with the clerk of the court in which such action is pending on or before the date the defendant is required to appear, or within such further time as the court may allow. (c) Service of process and a complaint in any such action or proceeding shall in addition to the manner provided in subsection (b) of this section be valid if served upon any person within this State who, in this State on behalf of such insurer, is (1) soliciting insurance, or (2) making, issuing or delivering any contract of insurance, or (3) collecting or receiving any premium, membership fee, assessment or other consideration for insurance; and a copy of such process and complaint is sent within ten days thereafter by registered mail by the plaintiff or plaintiff’s attorney to the defendant at the last-known principal place of business of the defendant, and the defendant’s receipt, or the receipt issued by the post office with which the letter is registered, showing the name of the sender of the letter and the name and address of the person to whom the letter is addressed, and the affidavit of the plaintiff or plaintiff’s attorney showing a compliance herewith are filed with the clerk of the court in which such action is pending on or before the date the defendant is required to appear, or within such further time as the court may allow. (d) No plaintiff shall be entitled to a judgment by default under this section until the expiration of thirty days from date of the filing of the affidavit of compliance. (e) Nothing in this section contained shall limit or abridge the right to serve any process, complaint, notice or demand upon any insurer in any other manner now or hereafter permitted by law. **State:** New Jersey --- ### [New Hampshire-Aiding & Abetting-N.H. Rev. Stat. ¤ 638:20](https://insurancefraud.org/statutes/new-hampshire-aiding-abetting-n-h-rev-stat-¤-63820/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** III. A person is guilty as an accomplice to insurance fraud, if, with a purpose to injure, defraud or deceive any insurer, the person assists, abets, solicits or conspires with another to commit insurance fraud, as defined in paragraph II of this section. **State:** New Hampshire --- ### [New Hampshire-Anti-Runner Provisions-n/a](https://insurancefraud.org/statutes/new-hampshire-anti-runner-provisions-n-a/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** No statute found **State:** New Hampshire **Statute Areas:** Anti-Runner Provisions --- ### [New Hampshire-Claims Fraud-N.H. Rev. Stat. ¤ 638:20](https://insurancefraud.org/statutes/new-hampshire-claims-fraud-n-h-rev-stat-¤-63820/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** I. A person is guilty of insurance fraud, if, such person knowingly and with intent to injure, defraud or deceive any insurer, conceals or causes to be concealed from any insurer a material statement, or presents or causes to be presented to any insurer, or prepares with knowledge or belief that it will be so presented, any written or oral statement including computer-generated documents, knowing that such statement contains any false, incomplete or misleading information which is material to: ((c) A claim for payment or benefit pursuant to any insurance policy. **State:** New Hampshire **Statute Areas:** Claims Fraud --- ### [New Hampshire-Fraud Bureau-N.H. Rev. Stat. ¤ 417:23](https://insurancefraud.org/statutes/new-hampshire-fraud-bureau-n-h-rev-stat-¤-41723/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** There is established in the department of insurance the insurance fraud investigation unit. The unit shall assist the commissioner, or any law enforcement agency, in investigating insurance fraud or other insurance-related criminal activity and in developing and implementing programs to prevent insurance fraud and abuse. The unit shall have the power to subpoena witnesses and administer oaths in any investigation it conducts, and to compel the production of any books, papers or other memoranda or documents by subpoena duces tecum. The unit shall promptly notify the attorney general of any insurance application, claim, or activity which involves criminal conduct. When required by the commissioner and the attorney general, the unit shall cooperate with the attorney general in the investigation and prosecution of criminal violations. **State:** New Hampshire **Statute Areas:** Fraud Bureau --- ### [New Hampshire-Immunity-N.H. Rev. Stat. ¤ 400-A:36-b](https://insurancefraud.org/statutes/new-hampshire-immunity-n-h-rev-stat-¤-400-a36-b/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** I. In the absence of actual malice, members of the National Association of Insurance Commissioners, their duly authorized committees, subcommittees, and task forces, their delegates, employees, and all others charged with the responsibility of collecting, reviewing, analyzing, and disseminating the information developed from the filing of the annual statement convention blanks shall be acting as agents of the commissioner under the authority of RSA 400-A:36-a and shall not be subject to civil liability for libel, slander, or any other cause of action by virtue of their collection, review, and analysis or dissemination of the data and information collected from the filings required under such section. II. In the absence of actual malice, no person shall be subject to civil liability for libel, slander or any other cause of action arising from filing reports or furnishing information concerning any activity that may constitute insurance fraud as defined in RSA 638:20, if such reports or information is provided to or received from the commissioner, law enforcement officials, the National Association of Insurance Commissioners, any state or federal agency established to detect, prevent or prosecute insurance fraud, or an insurance company authorized to do business in the state. The immunity conferred by this section applies unless the person seeking to impose civil liability proves actual malice. Any person against whom a civil action is brought, and who is found to be entitled to immunity from liability under this section, shall be entitled to recover reasonable attorney’s fees and costs from the person who brought the civil action. **State:** New Hampshire **Statute Areas:** Immunity --- ### [New Hampshire-Insurance Fraud - Definition-N.H. Rev. Stat. ¤ 638:20](https://insurancefraud.org/statutes/new-hampshire-insurance-fraud-definition-n-h-rev-stat-¤-63820/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** I. In this section: (a) “Bidding” includes a bid made as any contractor, general contractor, or subcontractor. (b) “Financial interest” means any direct or indirect interest in the entity, whether as an owner, partner, officer, manager, employee, agent, consultant, advisor, or representative, but does not include an employee who does not participate in management of the entity and ownership in a mutual or common investment fund that holds securities unless the person participates in the management of the fund. (c) “Insurance policy” includes an actual or purported insurance policy. (d) “Insurer” includes any insurance company, health maintenance organization, or reinsurance company, or broker or agent thereof, or insurance claims adjuster. (e) “Participating in public works projects” means bidding or working on any public works project or holding any financial interest in any entity bidding or working on any public works project. (f) “Public works project” means any construction project financed by public funds. (g) “Statement” includes, but is not limited to, any notice, statement, proof of loss, bill of lading, receipt of payment, invoice, account, estimate of property damages, bill for service, diagnosis, prescription, hospital or doctor records, x-rays, test results, or other evidence of loss, injury, or expense. I-a. \[Repealed.\] II. A person is guilty of insurance fraud, if, such person knowingly and with intent to injure, defraud or deceive any insurer, conceals or causes to be concealed from any insurer a material statement, or presents or causes to be presented to any insurer, or prepares with knowledge or belief that it will be so presented, any written or oral statement including computer-generated documents, knowing that such statement contains any false, incomplete or misleading information which is material to: (a) An application for the issuance of any insurance policy. (b) The rating of any insurance policy. (c) A claim for payment or benefit pursuant to any insurance policy. (d) Premiums on any insurance policy. (e) Payments made in accordance with the terms of any insurance policy. III. A person is guilty as an accomplice to insurance fraud, if, with a purpose to injure, defraud or deceive any insurer, the person assists, abets, solicits or conspires with another to commit insurance fraud, as defined in paragraph II of this section. IV. (a) Insurance fraud is: (1) A class A felony if the value of the fraudulent portion of the claim for payment or other benefit pursuant to an insurance policy is more than $1,500. (2) A class B felony if the value of the fraudulent portion of the claim for payment or other benefit pursuant to an insurance policy is more than $1,000, but not more than $1,500. (3) A misdemeanor in all other cases. (b) The value shall be determined according to the provisions of RSA 637:2, V. V. \[Repealed.\] VI. In addition to any other penalty authorized by law, any person convicted of violating subparagraphs II(a), (b), or (d) relative to a workers’ compensation insurance policy shall, as a condition of his or her sentence, be prohibited from participating in any public works projects for a period of no less than one year and no more than 3 years and shall be ordered to pay restitution to its workers’ compensation carrier, as determined by the sentencing court. Any person convicted of a third or subsequent violation may, as a condition of his or her sentence, be permanently banned from participating in any public works projects. For the purposes of this paragraph, “restitution” means the difference between the premium actually charged and the premium amount that would have been charged if accurate information had been provided to the carrier, provided that the carrier is not compensated by the offender more than once. VII. The commissioner of the department of administrative services shall maintain a list of persons who have been banned from participating in public works projects under this section. Such list shall be a public record under 91-A. **State:** New Hampshire **Statute Areas:** Insurance Fraud - Definition --- ### [New Hampshire-Licensing Board Notification-N.H. Rev. Stat. ¤ 417:28](https://insurancefraud.org/statutes/new-hampshire-licensing-board-notification-n-h-rev-stat-¤-41728/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Any person or entity regulated under title XXXVII which has reason to believe that an insurance fraud or insurance-related criminal activity has been committed shall make a report to the unit within 60 days or within a shorter period under such circumstances as the commissioner may prescribe by rule. No waiver of any such regulated person’s or entity’s applicable privilege or claim of confidentiality in the documents, materials or information shall occur as a result of such disclosure to the unit. Such report shall be made on a form prescribed by the unit and shall contain the information requested and such additional information as the unit may require. The unit shall review such report and select such claims as, in its judgment, warrant further investigation. In the absence of fraud or malice, no public official or insurance company or person who furnishes information on behalf of the insurance company shall be liable for damages in a civil action or subject to criminal prosecution for any oral or written statement made or any other action taken that is necessary to supply information required pursuant to this section. **State:** New Hampshire --- ### [New Hampshire-Mandatory Restitution-N.H. Rev. Stat. ¤ 638:20](https://insurancefraud.org/statutes/new-hampshire-mandatory-restitution-n-h-rev-stat-¤-63820/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** VI. In addition to any other penalty authorized by law, any person convicted of violating subparagraphs II(a), (b), or (d) relative to a workers’ compensation insurance policy shall, as a condition of his or her sentence, be prohibited from participating in any public works projects for a period of no less than one year and no more than 3 years and shall be ordered to pay restitution to its workers’ compensation carrier, as determined by the sentencing court. Any person convicted of a third or subsequent violation may, as a condition of his or her sentence, be permanently banned from participating in any public works projects. For the purposes of this paragraph, “restitution” means the difference between the premium actually charged and the premium amount that would have been charged if accurate information had been provided to the carrier, provided that the carrier is not compensated by the offender more than once. **State:** New Hampshire **Statute Areas:** Mandatory Restitution --- ### [New Hampshire-Placing Bogus Coverage-n/a](https://insurancefraud.org/statutes/new-hampshire-placing-bogus-coverage-n-a/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** No statute found **State:** New Hampshire --- ### [New Hampshire-Premium Fraud-N.H. Rev. Stat. ¤ 638:20](https://insurancefraud.org/statutes/new-hampshire-premium-fraud-n-h-rev-stat-¤-63820/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** II. A person is guilty of insurance fraud, if, such person knowingly and with intent to injure, defraud or deceive any insurer, conceals or causes to be concealed from any insurer a material statement, or presents or causes to be presented to any insurer, or prepares with knowledge or belief that it will be so presented, any written or oral statement including computer-generated documents, knowing that such statement contains any false, incomplete or misleading information which is material to:(d) Premiums on any insurance policy. **State:** New Hampshire **Statute Areas:** Premium Fraud --- ### [New Hampshire-Range of Criminal Penalties-N.H. Rev. Stat. ¤ 638:20](https://insurancefraud.org/statutes/new-hampshire-range-of-criminal-penalties-n-h-rev-stat-¤-63820/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** IV. (a) Insurance fraud is: (1) A class A felony if the value of the fraudulent portion of the claim for payment or other benefit pursuant to an insurance policy is more than $1,500. (2) A class B felony if the value of the fraudulent portion of the claim for payment or other benefit pursuant to an insurance policy is more than $1,000, but not more than $1,500. (3) A misdemeanor in all other cases. (b) The value shall be determined according to the provisions of RSA 637:2, V. **State:** New Hampshire **Statute Areas:** Range of Criminal Penalties --- ### [New Hampshire-Range of Civil Penalties-N.H. Rev. Stat. ¤ 638:20](https://insurancefraud.org/statutes/new-hampshire-range-of-civil-penalties-n-h-rev-stat-¤-63820/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** IV. (a) Insurance fraud is: (1) A class A felony if the value of the fraudulent portion of the claim for payment or other benefit pursuant to an insurance policy is more than $1,500. (2) A class B felony if the value of the fraudulent portion of the claim for payment or other benefit pursuant to an insurance policy is more than $1,000, but not more than $1,500. (3) A misdemeanor in all other cases. (b) The value shall be determined according to the provisions of RSA 637:2, V. **State:** New Hampshire **Statute Areas:** Range of Civil Penalties --- ### [New Hampshire-Rating of an Insurance Policy-N.H. Rev. Stat. ¤ 412:15](https://insurancefraud.org/statutes/new-hampshire-rating-of-an-insurance-policy-n-h-rev-stat-¤-41215/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Rates shall be made in accordance with the following provisions: I. Rates shall not be excessive, inadequate, or unfairly discriminatory. (a) A rate in a competitive market shall not be disapproved for being excessive. (b) A rate in a noncompetitive market is excessive if it is likely to produce a profit that is unreasonably high for the insurance provided or if expenses are unreasonably high in relation to services rendered. (c) A rate is inadequate if: (1) The rate is unreasonably low for the insurance provided and the continued use of the rate endangers the solvency of the insurer using it; or unless (2) The rate is unreasonably low for the insurance provided and the use of the rate by the insurer has, or if continued will have, the effect of substantially lessening competition or the tendency to create monopoly in any market. (d) Unfair discrimination exists if, after allowing for practical limitations, price differentials fail to reflect equitably the differences in expected losses and expenses. A rate is not unfairly discriminatory if it is averaged broadly among persons insured under a group, franchise or blanket policy or a mass marketed plan. In this paragraph, a mass marketed plan means a method of selling property-liability insurance wherein: (1) The insurance is offered to employees of particular employers or to members of particular associations or organizations or to persons grouped in other ways, except groupings formed principally for the purpose of obtaining such insurance; and (2) The employer, association or other organization, if any, has agreed to, or otherwise affiliated itself with, the sale of such insurance to its employees or members. II. In determining whether rates comply with the excessiveness standard in a noncompetitive market under subparagraph I(b), the inadequacy standards under subparagraph I(c) and the unfair discrimination standard under subparagraph I(d), the following criteria shall apply: (a) Due consideration shall be given to past and prospective loss experience within and outside this state; to the conflagration and catastrophe hazards; to a reasonable margin for profit and contingencies; to dividends, savings, or unabsorbed premium deposits allowed or returned by insurers to their policyholders, members or subscribers; to past and prospective expenses both countrywide and those specifically applicable to this state; and to provisions for special assessments and to all other relevant factors within and outside the state. (b) Risks may be grouped by classifications for the establishment of rates and minimum premiums. Classification rates may be modified to produce rates for individual risks in accordance with rating plans that establish standards for measuring variations in hazards or expense provisions, or both. Such standards may measure any differences among risks that can be demonstrated to have a probable effect upon losses or expenses. No risk classification, however, may be based upon race, creed, national origin or the religion of the insured. (c) The expense provisions included in the rates to be used by an insurer shall reflect the operating methods of the insurer and its anticipated expenses. (d) The rates may contain provision for contingencies and an allowance permitting a reasonable profit. In determining the reasonableness of the profit, consideration shall be given to all investment income attributable to the line of insurance. III. (a) The use of any information from credit reports, credit histories, and credit scoring models for underwriting and rating purposes for homeowners insurance and private passenger automobile insurance shall be based upon objective, documented, and measurable standards and shall be used in a manner which provides for appropriate consumer protections, including adequate and clear consumer notice, procedures to promptly correct and adjust underwriting or rating decisions based on incorrect credit information, and confidentiality protections. (b) The insurance commissioner shall, pursuant to RSA 541-A, adopt such rules as may be necessary to regulate the obligations of insurers with respect to the use of such information in the underwriting and rating of homeowners insurance and private passenger automobile insurance. Information that explains and justifies underwriting rules, credit scoring models or rating plans that rely upon credit reports, credit histories, or credit scoring mechanisms shall be included in the rate filing required pursuant to RSA 412:16. IV. For commercial risks, except for workers’ compensation which is governed by RSA 412:34, the commissioner may permit insurers to use appropriate systems of schedule rating filed by any insurer or rating bureau approved by the commissioner, subject to rules adopted under RSA 541-A, to assure the uniform and impartial application of such rating. Insurers shall retain supporting documentation for such ratings. Such ratings shall be: (a) Based on an insured’s management, safety, and loss control policies and record; (b) No greater than plus or minus 40 percent of the insurer’s base rates. V. In order to further uniform administration of rate regulatory laws, the commissioner and every insurer, advisory organization and statistical agent may exchange information and experience data with insurance supervisory officials, insurers and advisory organizations in other states and may consult with them with respect to the application of rating systems and the collection of statistical data. **State:** New Hampshire --- ### [New Hampshire-Unauthorized Entities-N.H. Rev. Stat. ¤ 406-B:2](https://insurancefraud.org/statutes/new-hampshire-unauthorized-entities-n-h-rev-stat-¤-406-b2/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Any of the following acts in this state effected by mail or otherwise by or on behalf of an unlicensed insurer is deemed to constitute the transaction or doing of an insurance business in this state. The venue of an act committed by mail is at the point where the matter transmitted by mail is delivered and takes effect. Unless otherwise indicated, the term “insurer” as used in this section includes all corporations, associations, partnerships and individuals, engaged as principals in the business of insurance and also includes interinsurance exchanges and mutual benefit societies. The word “commissioner” shall mean the insurance commissioner. I. The making of or proposing to make, as an insurer, an insurance contract. II. The making of or proposing to make, as guarantor or surety, any contract of guaranty or suretyship as a vocation and not merely incidental to any other legitimate business or activity of the guarantor or surety. III. The taking or receiving of any application for insurance. IV. The receiving or collection of any premium, commission, membership fees, assessments, dues or other consideration for any insurance or any part thereof. V. The issuance or delivery of contracts or certificates of insurance to residents of this state or to persons authorized to do business in this state. VI. Directly or indirectly acting as an agent for or otherwise representing or aiding on behalf of another any person or insurer in the solicitation, negotiation, procurement, or effectuation of insurance or renewals thereof, or in the dissemination of information as to coverage or rates, or forwarding of applications, or delivery of policies or contracts, or inspection of risks, a fixing of rates or investigation or adjustment of claims or losses or in the transaction of matters subsequent to effectuation of the contract and arising out of it, or in any other manner representing or assisting a person or insurer in the transaction of insurance with respect to subjects of insurance resident, located or to be performed in this state. The provisions of this section shall not operate to prohibit full-time salaried employees of a corporate insured from acting in the capacity of an insurance manager or buyer in placing insurance in behalf of such employer. VII. The doing of any kind of insurance business specifically recognized as constituting the doing of an insurance business within the meaning of the statutes relating to insurance. VIII. The doing or proposing to do any insurance business in substance equivalent to any of the foregoing in a manner designed to evade the provisions of the statutes. IX. Any other transactions of business in this state by an insurer. **State:** New Hampshire --- ### [Nevada-Aiding & Abetting-N.R.S. 686A.2815](https://insurancefraud.org/statutes/nevada-aiding-abetting-n-r-s-686a-2815/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** 1\. “Insurance fraud” means knowingly and willfully: (c) Assisting, abetting, soliciting or conspiring with another person to present or cause to be presented any statement to an insurer, a reinsurer, a producer, a broker or any agent thereof, if the person who assists, abets, solicits or conspires knows that the statement conceals or omits facts, or contains false or misleading information concerning any fact material to an application for the issuance of a policy of insurance or a claim for payment or other benefits under such a policy. (h) Participating in, aiding, abetting, conspiring to commit, soliciting another person to commit, or permitting an employee or agent to commit any act or omission specified in this section. **State:** Nevada --- ### [Nevada-Anti-Runner Provisions-N.R.S. 686A.2815](https://insurancefraud.org/statutes/nevada-anti-runner-provisions-n-r-s-686a-2815/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** 1\. “Insurance fraud” means knowingly and willfully: (g) Employing a person to procure clients, patients or other persons who obtain services or benefits under a policy of insurance for the purpose of engaging in any act or omission specified in this section, except that such insurance fraud does not include contact or communication by an insurer or an agent or representative of the insurer with a client, patient or other person if the contact or communication is made for a lawful purpose, including, without limitation, communication by an insurer with a holder of a policy of insurance issued by the insurer or with a claimant concerning the settlement of any claims against the policy. **State:** Nevada **Statute Areas:** Anti-Runner Provisions --- ### [Nevada-Claims Fraud-N.R.S. 686A.2815](https://insurancefraud.org/statutes/nevada-claims-fraud-n-r-s-686a-2815/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** 1\. “Insurance fraud” means knowingly and willfully: (b) Presenting or causing to be presented any statement as a part of, or in support of, a claim for payment or other benefits under a policy of insurance, if the person who presents or causes the presentation of the statement knows that the statement conceals or omits facts, or contains false or misleading information concerning any fact material to that claim. **State:** Nevada **Statute Areas:** Claims Fraud --- ### [Nevada-Fraud Bureau-N.R.S. 228.412](https://insurancefraud.org/statutes/nevada-fraud-bureau-n-r-s-228-412/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** 2\. The Attorney General shall establish within his or her office a Fraud Control Unit for Insurance. The Fraud Control Unit must consist of such persons as are necessary to carry out the duties set forth in this section, NRS 679B.600 to 679B.700, inclusive, and NRS 686A.281 to 686A.292, inclusive, including, without limitation, attorneys and investigators. 3. The Attorney General, acting through the Fraud Control Unit: (a) Is the single state agency responsible for the criminal prosecution of insurance fraud; (b) Shall cooperate with the Commissioner of Insurance, insurers, and investigators and prosecutors of other states and the Federal Government in coordinating state and federal criminal investigations and criminal prosecutions involving insurance fraud; (c) Shall protect the privacy of insurers and insured persons who are eligible to receive benefits pursuant to the provisions of title 57 of NRS and shall establish procedures to prevent the misuse of information obtained in carrying out this section; and (d) May, upon written request, inspect the records of any insurer, the Commissioner of Insurance and the Division of Insurance of the Department of Business and Industry to conduct a criminal investigation into any act alleged to be insurance fraud. 4. To investigate any act alleged to be insurance fraud, the Attorney General and members of the Fraud Control Unit may conduct investigations into any activity related thereto occurring outside of this State, if necessary. To conduct these investigations, the Attorney General and members of the Fraud Control Unit may: (a) Travel outside of this State; (b) Cooperate with appropriate agencies or persons outside of this State; and (c) Designate those agencies or persons to conduct investigations for the Attorney General. 5. When acting pursuant to this section, the Attorney General may commence an investigation and file a criminal action without leave of court, and has exclusive charge of the conduct of the prosecution. The Attorney General may conduct preliminary hearings or grand juries for the purposes of filing an information or indictment. 6. The Attorney General shall report the name of each person who has been convicted of insurance fraud to the Commissioner of Insurance. 7. The provisions of this section must not be construed to limit or diminish the jurisdiction of the Commissioner of Insurance to regulate persons transacting insurance in this State. 8. As used in this section, “insurance fraud” has the meaning ascribed to it in NRS 686A.2815. **State:** Nevada **Statute Areas:** Fraud Bureau --- ### [Nevada-Immunity-N.R.S."679B.670](https://insurancefraud.org/statutes/nevada-immunity-n-r-s-679b-670/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Liability for disclosure of information on fraudulent claim or suspicious fire.””Any person, governmental entity, insurer, employee or representative of an insurer, official of an investigative or law enforcement agency, employee of the Division, the Commissioner, the Attorney General or a member of the Fraud Control Unit is not subject to a criminal penalty or subject to civil liability for libel, slander or any similar cause of action in tort if he or she, without malice, discloses information on a fraudulent claim or suspicious fire. **State:** Nevada **Statute Areas:** Immunity --- ### [Nevada-Insurance Fraud - Definition-N.R.S. 686A.2815](https://insurancefraud.org/statutes/nevada-insurance-fraud-definition-n-r-s-686a-2815/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** 1\. “Insurance fraud” means knowingly and willfully: (a) Presenting or causing to be presented any statement to an insurer, a reinsurer, a producer, a broker or any agent thereof, if the person who presents or causes the presentation of the statement knows that the statement conceals or omits facts, or contains false or misleading information concerning any fact material to an application for the issuance of a policy of insurance. (b) Presenting or causing to be presented any statement as a part of, or in support of, a claim for payment or other benefits under a policy of insurance, if the person who presents or causes the presentation of the statement knows that the statement conceals or omits facts, or contains false or misleading information concerning any fact material to that claim. (c) Assisting, abetting, soliciting or conspiring with another person to present or cause to be presented any statement to an insurer, a reinsurer, a producer, a broker or any agent thereof, if the person who assists, abets, solicits or conspires knows that the statement conceals or omits facts, or contains false or misleading information concerning any fact material to an application for the issuance of a policy of insurance or a claim for payment or other benefits under such a policy. (d) Acting or failing to act with the intent of defrauding or deceiving an insurer, a reinsurer, a producer, a broker or any agent thereof, to obtain a policy of insurance or any proceeds or other benefits under such a policy. (e) As a practitioner, an insurer or any agent thereof, acting to assist, conspire with or urge another person to commit any act or omission specified in this section through deceit, misrepresentation or other fraudulent means. (f) Accepting any proceeds or other benefits under a policy of insurance, if the person who accepts the proceeds or other benefits knows that the proceeds or other benefits are derived from any act or omission specified in this section. (g) Employing a person to procure clients, patients or other persons who obtain services or benefits under a policy of insurance for the purpose of engaging in any act or omission specified in this section, except that such insurance fraud does not include contact or communication by an insurer or an agent or representative of the insurer with a client, patient or other person if the contact or communication is made for a lawful purpose, including, without limitation, communication by an insurer with a holder of a policy of insurance issued by the insurer or with a claimant concerning the settlement of any claims against the policy. (h) Participating in, aiding, abetting, conspiring to commit, soliciting another person to commit, or permitting an employee or agent to commit any act or omission specified in this section. 2. As used in this section, “policy of insurance” means: (a) Any policy issued in this State by an authorized insurer; and (b) Any policy issued outside this State by an authorized insurer which relates to property that: (1) Is located in this State when any act or omission specified in this section occurs; or (2) Was located in this State when the incident that gave rise to the act or omission specified in this section occurred. **State:** Nevada **Statute Areas:** Insurance Fraud - Definition --- ### [Nevada-Looting & diverting-N.R.S. 686A.2815](https://insurancefraud.org/statutes/nevada-looting-diverting-n-r-s-686a-2815/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** 1\. “Insurance fraud” means knowingly and willfully: (f) Accepting any proceeds or other benefits under a policy of insurance, if the person who accepts the proceeds or other benefits knows that the proceeds or other benefits are derived from any act or omission specified in this section. (g) Employing a person to procure clients, patients or other persons who obtain services or benefits under a policy of insurance for the purpose of engaging in any act or omission specified in this section, except that such insurance fraud does not include contact or communication by an insurer or an agent or representative of the insurer with a client, patient or other person if the contact or communication is made for a lawful purpose, including, without limitation, communication by an insurer with a holder of a policy of insurance issued by the insurer or with a claimant concerning the settlement of any claims against the policy. (h) Participating in, aiding, abetting, conspiring to commit, soliciting another person to commit, or permitting an employee or agent to commit any act or omission specified in this section. **State:** Nevada --- ### [Nevada-Mandatory Restitution-N.R.S. 686A.292](https://insurancefraud.org/statutes/nevada-mandatory-restitution-n-r-s-686a-292/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** 1\. A court may, in addition to imposing the penalties set forth in NRS 193.130, order a person who is convicted of, or who pleads guilty, guilty but mentally ill or nolo contendere to, insurance fraud to pay: 3. An insurer or other organization, or any other person, subject to the jurisdiction of the Commissioner pursuant to this title shall be deemed to be a victim for the purposes of restitution in a case that involves insurance fraud or that is related to a claim of insurance fraud. **State:** Nevada **Statute Areas:** Mandatory Restitution --- ### [Nevada-Placing Bogus Coverage-N.R.S. 686A.2815](https://insurancefraud.org/statutes/nevada-placing-bogus-coverage-n-r-s-686a-2815/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** 1\. “Insurance fraud” means knowingly and willfully: (a) Presenting or causing to be presented any statement to an insurer, a reinsurer, a producer, a broker or any agent thereof, if the person who presents or causes the presentation of the statement knows that the statement conceals or omits facts, or contains false or misleading information concerning any fact material to an application for the issuance of a policy of insurance. (b) Presenting or causing to be presented any statement as a part of, or in support of, a claim for payment or other benefits under a policy of insurance, if the person who presents or causes the presentation of the statement knows that the statement conceals or omits facts, or contains false or misleading information concerning any fact material to that claim. (c) Assisting, abetting, soliciting or conspiring with another person to present or cause to be presented any statement to an insurer, a reinsurer, a producer, a broker or any agent thereof, if the person who assists, abets, solicits or conspires knows that the statement conceals or omits facts, or contains false or misleading information concerning any fact material to an application for the issuance of a policy of insurance or a claim for payment or other benefits under such a policy. (d) Acting or failing to act with the intent of defrauding or deceiving an insurer, a reinsurer, a producer, a broker or any agent thereof, to obtain a policy of insurance or any proceeds or other benefits under such a policy. (e) As a practitioner, an insurer or any agent thereof, acting to assist, conspire with or urge another person to commit any act or omission specified in this section through deceit, misrepresentation or other fraudulent means. (f) Accepting any proceeds or other benefits under a policy of insurance, if the person who accepts the proceeds or other benefits knows that the proceeds or other benefits are derived from any act or omission specified in this section. (g) Employing a person to procure clients, patients or other persons who obtain services or benefits under a policy of insurance for the purpose of engaging in any act or omission specified in this section, except that such insurance fraud does not include contact or communication by an insurer or an agent or representative of the insurer with a client, patient or other person if the contact or communication is made for a lawful purpose, including, without limitation, communication by an insurer with a holder of a policy of insurance issued by the insurer or with a claimant concerning the settlement of any claims against the policy. (h) Participating in, aiding, abetting, conspiring to commit, soliciting another person to commit, or permitting an employee or agent to commit any act or omission specified in this section. 2. As used in this section, “policy of insurance” means: (a) Any policy issued in this State by an authorized insurer; and (b) Any policy issued outside this State by an authorized insurer which relates to property that: (1) Is located in this State when any act or omission specified in this section occurs; or (2) Was located in this State when the incident that gave rise to the act or omission specified in this section occurred. **State:** Nevada --- ### [Nevada-Practitioner Penalites-N.R.S. 686A.295](https://insurancefraud.org/statutes/nevada-practitioner-penalites-n-r-s-686a-295/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** If a person who is licensed or registered under the laws of the State of Nevada to engage in a business or profession is convicted of, or pleads guilty or guilty but mentally ill to, engaging in an act of insurance fraud, the Commissioner and the Attorney General shall forward to each agency by which the convicted person is licensed or registered a copy of the conviction or plea and all supporting evidence of the act of insurance fraud. **State:** Nevada **Statute Areas:** Practitioner Penalites --- ### [Nevada-Range of Criminal Penalties-N.R.S. 686A.291; N.R.S. 193.130](https://insurancefraud.org/statutes/nevada-range-of-criminal-penalties-n-r-s-686a-291-n-r-s-193-130/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** A person who commits insurance fraud is guilty of a category D felony and shall be punished as provided in NRS 193.130.\*\*\*1. Except when a person is convicted of a category A felony, and except as otherwise provided by specific statute, a person convicted of a felony shall be sentenced to a minimum term and a maximum term of imprisonment which must be within the limits prescribed by the applicable statute, unless the statute in force at the time of commission of the felony prescribed a different penalty. The minimum term of imprisonment that may be imposed must not exceed 40 percent of the maximum term imposed. 2. Except as otherwise provided by specific statute, for each felony committed on or after July 1, 1995: (a) A category A felony is a felony for which a sentence of death or imprisonment in the state prison for life with or without the possibility of parole may be imposed, as provided by specific statute. (b) A category B felony is a felony for which the minimum term of imprisonment in the state prison that may be imposed is not less than 1 year and the maximum term of imprisonment that may be imposed is not more than 20 years, as provided by specific statute. (c) A category C felony is a felony for which a court shall sentence a convicted person to imprisonment in the state prison for a minimum term of not less than 1 year and a maximum term of not more than 5 years. In addition to any other penalty, the court may impose a fine of not more than $10,000, unless a greater fine is authorized or required by statute. (d) A category D felony is a felony for which a court shall sentence a convicted person to imprisonment in the state prison for a minimum term of not less than 1 year and a maximum term of not more than 4 years. In addition to any other penalty, the court may impose a fine of not more than $5,000, unless a greater fine is authorized or required by statute. (e) A category E felony is a felony for which a court shall sentence a convicted person to imprisonment in the state prison for a minimum term of not less than 1 year and a maximum term of not more than 4 years. Except as otherwise provided in paragraph (b) of subsection 1 of NRS 176A.100, upon sentencing a person who is found guilty of a category E felony, the court shall suspend the execution of the sentence and grant probation to the person upon such conditions as the court deems appropriate. Such conditions of probation may include, but are not limited to, requiring the person to serve a term of confinement of not more than 1 year in the county jail. In addition to any other penalty, the court may impose a fine of not more than $5,000, unless a greater penalty is authorized or required by statute. **State:** Nevada **Statute Areas:** Range of Criminal Penalties --- ### [Nevada-Range of Civil Penalties-N.R.S. 686A.292](https://insurancefraud.org/statutes/nevada-range-of-civil-penalties-n-r-s-686a-292/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** 1\. A court may, in addition to imposing the penalties set forth in NRS 193.130, order a person who is convicted of, or who pleads guilty, guilty but mentally ill or nolo contendere to, insurance fraud to pay: (a) Court costs; and (b) The cost of the investigation and prosecution of the insurance fraud for which the person was convicted or to which the person pleaded guilty, guilty but mentally ill or nolo contendere. 2. Any money received by the Attorney General pursuant to paragraph (b) of subsection 1 must be accounted for separately and used to pay the expenses of the Fraud Control Unit for Insurance established pursuant to NRS 228.412, and is hereby authorized for expenditure for that purpose. The money in the account does not revert to the State General Fund at the end of any fiscal year and must be carried forward to the next fiscal year. 3. An insurer or other organization, or any other person, subject to the jurisdiction of the Commissioner pursuant to this title shall be deemed to be a victim for the purposes of restitution in a case that involves insurance fraud or that is related to a claim of insurance fraud. **State:** Nevada **Statute Areas:** Range of Civil Penalties --- ### [Nevada-Rating of an Insurance Policy-n/a](https://insurancefraud.org/statutes/nevada-rating-of-an-insurance-policy-n-a/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** No statute found **State:** Nevada --- ### [Nevada-Underwriting Fraud-N.R.S. 686A.2815](https://insurancefraud.org/statutes/nevada-underwriting-fraud-n-r-s-686a-2815/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (e) As a practitioner, an insurer or any agent thereof, acting to assist, conspire with or urge another person to commit any act or omission specified in this section through deceit, misrepresentation or other fraudulent means. (f) Accepting any proceeds or other benefits under a policy of insurance, if the person who accepts the proceeds or other benefits knows that the proceeds or other benefits are derived from any act or omission specified in this section. (g) Employing a person to procure clients, patients or other persons who obtain services or benefits under a policy of insurance for the purpose of engaging in any act or omission specified in this section, except that such insurance fraud does not include contact or communication by an insurer or an agent or representative of the insurer with a client, patient or other person if the contact or communication is made for a lawful purpose, including, without limitation, communication by an insurer with a holder of a policy of insurance issued by the insurer or with a claimant concerning the settlement of any claims against the policy. (h) Participating in, aiding, abetting, conspiring to commit, soliciting another person to commit, or permitting an employee or agent to commit any act or omission specified in this section. **State:** Nevada **Statute Areas:** Underwriting Fraud --- ### [Nevada-Unauthorized Entities-N.R.S. 685B.030](https://insurancefraud.org/statutes/nevada-unauthorized-entities-n-r-s-685b-030/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** 1\. As used in this section unless otherwise indicated, “insurer” includes: (a) All corporations, associations, partnerships and natural persons engaged as principals in the business of insurance, including a fraternal benefit society, a nonprofit corporation offering dental, hospital and medical services, a health maintenance organization, a prepaid limited health service organization, an organization for dental care, a dental plan, an optometric plan or a similar health service plan; and (b) Interinsurance exchanges and mutual benefit societies. 2. It is unlawful for any insurer to transact an insurance business in this State as set forth in subsection 3, without a certificate of authority from the Commissioner. This section does not apply to: (a) Any transaction for which a certificate of authority is not required pursuant to NRS 680A.070. (b) Attorneys at law acting in the ordinary relation of attorney and client in the adjustment of claims or losses. (c) Transactions in this State involving any policy of insurance or annuity contract issued before January 1, 1972. (d) Transactions in this State relative to a policy issued or to be issued outside this State involving insurance on vessels, craft or hulls, cargoes, marine builder’s risk, marine protection and indemnity or other risk, including strikes and war risks commonly insured under ocean or wet marine forms of policy. 3. Any of the following acts in this State effected by mail or otherwise by or on behalf of an unauthorized insurer constitutes the transaction of an insurance business in this State: (a) The making of or proposing to make, as an insurer, an insurance contract. (b) The making of or proposing to make, as guarantor or surety, any contract of guaranty or suretyship as a vocation and not merely incidental to any other legitimate business or activity of the guarantor or surety. (c) The taking or receiving of any application for insurance. (d) The receiving or collection of any premium, commission, membership fees, assessments, dues or other consideration for any insurance or any part thereof. (e) The issuance or delivery of contracts of insurance to residents of this State or to persons authorized to do business in this State. (f) Directly or indirectly acting as an agent for or otherwise representing or aiding on behalf of another any person or insurer in the solicitation, negotiation, procurement or effectuation of insurance or renewals thereof or in the dissemination of information as to coverage or rates, or forwarding of applications, or delivery of policies or contracts, or inspection of risks, a fixing of rates or investigation or adjustment of claims or losses or in the transaction of matters after effectuation of the contract and arising out of it, or in any other manner representing or assisting a person or insurer in the transaction of insurance with respect to subjects of insurance that are resident, located or to be performed in this State. The provisions of this paragraph do not prohibit full-time salaried employees of a corporate insured from acting in the capacity of an insurance manager or buyer in placing insurance on behalf of such an employer. (g) The transaction of any kind of insurance business specifically recognized as transacting an insurance business within the meaning of the statutes relating to insurance. (h) The transacting or proposing to transact any insurance business in substance equivalent to any of the provisions of paragraphs (a) to (g), inclusive, in a manner designed to evade the provisions of the statutes. 4. The venue of an act committed by mail is at the point where the matter transmitted by mail is delivered and takes effect. 5. The failure of an insurer transacting insurance business in this State to obtain a certificate of authority does not impair the validity of any act or contract of the insurer and does not prevent the insurer from defending any action at law or suit in equity in any court of this State, except that no insurer transacting insurance business in this State without a certificate of authority may maintain an action in any court of this State to enforce any right, claim or demand arising out of the transaction of such business until the insurer has obtained a certificate of authority. In the event of a failure by an unauthorized insurer to pay any claim or loss within the provisions of an insurance contract, any person who assisted or in any manner aided directly or indirectly in the procurement of the insurance contract is liable to the insured for the full amount of the claim or loss in the manner provided by the provisions of the insurance contract. **State:** Nevada --- ### [Nebraska-Aiding & Abetting-Neb.Rev.St. ¤ 44-6604](https://insurancefraud.org/statutes/nebraska-aiding-abetting-neb-rev-st-¤-44-6604/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** For purposes of the Insurance Fraud Act, a person or entity commits a fraudulent insurance act if he or she:(2) Assists, abets, solicits, or conspires with another to prepare or make any statement that is intended to be presented to or by an insurer or person in connection with or in support of any claim for payment or other benefit from an insurer or pursuant to an insurance policy knowing that the statement contains any false, incomplete, or misleading information concerning any fact or thing material to the claim; **State:** Nebraska --- ### [Nebraska-Claims Fraud-Neb.Rev.St. ¤ 44-6604](https://insurancefraud.org/statutes/nebraska-claims-fraud-neb-rev-st-¤-44-6604/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** For purposes of the Insurance Fraud Act, a person or entity commits a fraudulent insurance act if he or she: (1) Knowingly and with intent to defraud or deceive presents, causes to be presented, or prepares with knowledge or belief that it will be presented to or by an insurer, or any agent of an insurer, any statement as part of, in support of, or in denial of a claim for payment or other benefit from an insurer or pursuant to an insurance policy knowing that the statement contains any false, incomplete, or misleading information concerning any fact or thing material to a claim; (2) Assists, abets, solicits, or conspires with another to prepare or make any statement that is intended to be presented to or by an insurer or person in connection with or in support of any claim for payment or other benefit from an insurer or pursuant to an insurance policy knowing that the statement contains any false, incomplete, or misleading information concerning any fact or thing material to the claim; (3) Makes any false or fraudulent representations as to the death or disability of a policy or certificate holder or a covered person in any statement or certificate for the purpose of fraudulently obtaining money or benefit from an insurer; **State:** Nebraska **Statute Areas:** Claims Fraud --- ### [Nebraska-Failing to Remit Premium-Neb.Rev.St. ¤ 44-6604](https://insurancefraud.org/statutes/nebraska-failing-to-remit-premium-neb-rev-st-¤-44-6604/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** For purposes of the Insurance Fraud Act, a person or entity commits a fraudulent insurance act if he or she: (6) Willfully embezzles, abstracts, purloins, misappropriates, or converts money, funds, premiums, credits, or other property of an insurer or person engaged in the business of insurance; **State:** Nebraska --- ### [Nebraska-False Claims Act-n/a](https://insurancefraud.org/statutes/nebraska-false-claims-act-n-a/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** No statute found **State:** Nebraska **Statute Areas:** False Claims Act --- ### [Nebraska-Fraud Bureau-Neb.Rev.St. ¤ 44-6606](https://insurancefraud.org/statutes/nebraska-fraud-bureau-neb-rev-st-¤-44-6606/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (1) In order to investigate activities involving insurance fraud, the director shall appoint a sufficient staff to be known as the Insurance Fraud Prevention Division. (2)(a) As specified by the director, division investigators who are certified law enforcement officers of the State of Nebraska shall be vested with the authority and power of a peace officer to carry out the laws of this state administered by the director. The general laws of this state applicable to peace officers shall be applicable to such investigators. Such investigators shall be empowered, among other powers, to search and arrest with or without a warrant, file and serve any lien, seize property, serve and return a summons, warrant, or subpoena issued by a court of law or the director, and bring an offender before any court with jurisdiction in this state, except that such investigators shall not be authorized to enforce any laws other than laws administered by the director. (b) Subdivision (a) of this subsection shall not be construed to restrict any other law enforcement officer of this state from enforcing any state law, insurance or otherwise. (3) The division shall: (a) Initiate independent inquiries and conduct independent investigations when the division has cause to believe that an act of insurance fraud has been or is currently being committed; (b) Review reports or complaints of alleged insurance fraud to determine whether such reports require further investigation and to conduct such investigation; (c) Conduct independent examinations of alleged fraudulent insurance acts and undertake independent studies to determine the extent of fraudulent insurance acts; and (d) Cooperate with federal, state, and local law enforcement, prosecuting attorneys, and the Attorney General in the investigation and prosecution of insurance fraud violations. At the request of the division, through the director, the Attorney General shall prosecute fraudulent insurance acts through criminal or civil proceedings as authorized by the Insurance Fraud Act if, after investigation, the Attorney General is convinced that there is sufficient legal merit to justify the proceeding. The Attorney General, after consultation with the director, may refer cases of fraudulent insurance acts to a special assistant attorney general or county attorney for prosecution. Any costs directly associated with the prosecution and attorney’s fees for any special assistant attorney general shall be paid by the division. (4)(a) The director or his or her designee may: Administer oaths and affirmations; subpoena witnesses; compel attendance of witnesses; take evidence; and require the production of any books, papers, correspondence, memoranda, agreements, documents, records, and other tangible things which constitute or contain evidence that is deemed relevant or material to an investigation or enforcement of the Insurance Fraud Act, when it shall appear that such action is necessary and proper. The attendance of witnesses and the production of records shall be required from any place within the State of Nebraska. Witnesses summoned by the director or by his or her designee shall be paid the same fees that are paid witnesses in the courts of the State of Nebraska and mileage at the rate provided in section 81-1176. (b) A subpoena of the director or of his or her designee may be served by any person designated in the subpoena to serve it. Service upon a natural person may be made by certified mail or personal delivery of the subpoena to him or her. Service may be made upon a domestic or foreign insurer, corporation, or partnership, upon a domestic or foreign limited liability company, or upon any other unincorporated association which is subject to suit under a common name, or any other entity by delivering the subpoena to an officer, a managing or general agent, a member, or any other agent authorized by appointment or by law to receive service of process. The affidavit of the person serving the subpoena entered on a true copy thereof by the person serving it shall be proof of service. (c) If any person refuses to obey a subpoena issued by the director or by his or her designee, the director or his or her designee may invoke the aid of any court of the State of Nebraska within the jurisdiction of which the investigation is carried on or of which the subpoenaed person is an inhabitant, carries on business, or may otherwise be found, to compel compliance with such subpoena. (d) The court may issue an order requiring the subpoenaed person to appear before the director or his or her designee to produce records, if so ordered, or to give testimony concerning the matter under investigation. Nothing in this section shall be con **State:** Nebraska **Statute Areas:** Fraud Bureau --- ### [Nebraska-Immunity-Neb.Rev.St. ¤ 44-6605](https://insurancefraud.org/statutes/nebraska-immunity-neb-rev-st-¤-44-6605/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (1) Any person or entity, including the department, an insurer, or a person employed by or authorized by an insurer whose activities include the investigation of or reporting of suspected insurance fraud, acting without malice, fraudulent intent, or bad faith shall be immune from civil liability for furnishing any information relating to suspected fraudulent insurance acts to: (a) The director or his or her agents or employees; (b) Law enforcement officials or their agents or employees; (c) The Nebraska Workers’ Compensation Court or its agents or employees; (d) Persons or entities subject to Chapter 44 or their agents or employees; or (e) The National Association of Insurance Commissioners or any organization established to detect and prevent fraudulent insurance acts or its agents, employees, or designees. (2) This section does not abrogate or modify in any way any common-law or statutory privilege or immunity. **State:** Nebraska **Statute Areas:** Immunity --- ### [Nebraska-Insurance Fraud - Definition-Neb.Rev.St. ¤ 44-6604](https://insurancefraud.org/statutes/nebraska-insurance-fraud-definition-neb-rev-st-¤-44-6604/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** For purposes of the Insurance Fraud Act, a person or entity commits a fraudulent insurance act if he or she: (1) Knowingly and with intent to defraud or deceive presents, causes to be presented, or prepares with knowledge or belief that it will be presented to or by an insurer, or any agent of an insurer, any statement as part of, in support of, or in denial of a claim for payment or other benefit from an insurer or pursuant to an insurance policy knowing that the statement contains any false, incomplete, or misleading information concerning any fact or thing material to a claim; (2) Assists, abets, solicits, or conspires with another to prepare or make any statement that is intended to be presented to or by an insurer or person in connection with or in support of any claim for payment or other benefit from an insurer or pursuant to an insurance policy knowing that the statement contains any false, incomplete, or misleading information concerning any fact or thing material to the claim; (3) Makes any false or fraudulent representations as to the death or disability of a policy or certificate holder or a covered person in any statement or certificate for the purpose of fraudulently obtaining money or benefit from an insurer; (4) Knowingly and willfully transacts any contract, agreement, or instrument which violates this section; (5) Receives money for the purpose of purchasing insurance and converts the money to the person’s own benefit; (6) Willfully embezzles, abstracts, purloins, misappropriates, or converts money, funds, premiums, credits, or other property of an insurer or person engaged in the business of insurance; (7) Knowingly and with intent to defraud or deceive issues or possesses fake or counterfeit insurance policies, certificates of insurance, insurance identification cards, or insurance binders; (8) Knowingly and with intent to defraud or deceive makes any false entry of a material fact in or pertaining to any document or statement filed with or required by the department; (9) Knowingly and with intent to defraud or deceive removes, conceals, alters, diverts, or destroys assets or records of an insurer or person engaged in the business of insurance or attempts to remove, conceal, alter, divert, or destroy assets or records of an insurer or person engaged in the business of insurance; (10) Knowingly and with the intent to defraud or deceive provides false, incomplete, or misleading information to an insurer concerning the number, location, or classification of employees for the purpose of lessening or reducing the premium otherwise chargeable for workers’ compensation insurance coverage; (11) Willfully operates as or aids and abets another operating as a discount medical plan organization in violation of subsection (1) of section 44-8306; or (12) Willfully collects fees for purported membership in a discount medical plan but purposefully fails to provide the promised benefits. **State:** Nebraska **Statute Areas:** Insurance Fraud - Definition --- ### [Nebraska-Looting & diverting-Neb.Rev.St. ¤ 44-6604](https://insurancefraud.org/statutes/nebraska-looting-diverting-neb-rev-st-¤-44-6604/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** For purposes of the Insurance Fraud Act, a person or entity commits a fraudulent insurance act if he or she: (5) Receives money for the purpose of purchasing insurance and converts the money to the person’s own benefit; (6) Willfully embezzles, abstracts, purloins, misappropriates, or converts money, funds, premiums, credits, or other property of an insurer or person engaged in the business of insurance; **State:** Nebraska --- ### [Nebraska-Mandatory Restitution-n/a](https://insurancefraud.org/statutes/nebraska-mandatory-restitution-n-a/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** No statute found **State:** Nebraska **Statute Areas:** Mandatory Restitution --- ### [Nebraska-Placing Bogus Coverage-Neb.Rev.St. ¤ 44-6604](https://insurancefraud.org/statutes/nebraska-placing-bogus-coverage-neb-rev-st-¤-44-6604/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** For purposes of the Insurance Fraud Act, a person or entity commits a fraudulent insurance act if he or she: (1) Knowingly and with intent to defraud or deceive presents, causes to be presented, or prepares with knowledge or belief that it will be presented to or by an insurer, or any agent of an insurer, any statement as part of, in support of, or in denial of a claim for payment or other benefit from an insurer or pursuant to an insurance policy knowing that the statement contains any false, incomplete, or misleading information concerning any fact or thing material to a claim; (2) Assists, abets, solicits, or conspires with another to prepare or make any statement that is intended to be presented to or by an insurer or person in connection with or in support of any claim for payment or other benefit from an insurer or pursuant to an insurance policy knowing that the statement contains any false, incomplete, or misleading information concerning any fact or thing material to the claim; (3) Makes any false or fraudulent representations as to the death or disability of a policy or certificate holder or a covered person in any statement or certificate for the purpose of fraudulently obtaining money or benefit from an insurer; **State:** Nebraska --- ### [Nebraska-Premium Fraud-Neb.Rev.St. ¤ 44-6604](https://insurancefraud.org/statutes/nebraska-premium-fraud-neb-rev-st-¤-44-6604/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** For purposes of the Insurance Fraud Act, a person or entity commits a fraudulent insurance act if he or she: (6) Willfully embezzles, abstracts, purloins, misappropriates, or converts money, funds, premiums, credits, or other property of an insurer or person engaged in the business of insurance; **State:** Nebraska **Statute Areas:** Premium Fraud --- ### [Nebraska-Range of Criminal Penalties-Neb.Rev.St. ¤ 28-631](https://insurancefraud.org/statutes/nebraska-range-of-criminal-penalties-neb-rev-st-¤-28-631/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (2)(a) A violation of subdivisions (1)(a) through (f) of this section is a Class III felony when the amount involved is five thousand dollars or more. (b) A violation of subdivisions (1)(a) through (f) of this section is a Class IV felony when the amount involved is one thousand five hundred dollars or more but less than five thousand dollars. (c) A violation of subdivisions (1)(a) through (f) of this section is a Class I misdemeanor when the amount involved is five hundred dollars or more but less than one thousand five hundred dollars. (d) A violation of subdivisions (1)(a) through (f) of this section is a Class II misdemeanor when the amount involved is less than five hundred dollars. (e) For any second or subsequent conviction under subdivision (2)(c) of this section, the violation is a Class IV felony. (f) A violation of subdivisions (1)(g), (i), (j), (k), (l), and (m) of this section is a Class IV felony. (g) A violation of subdivision (1)(h) of this section is a Class I misdemeanor. (3) Amounts taken pursuant to one scheme or course of conduct from one person, entity, or insurer may be aggregated in the indictment or information in determining the classification of the offense, except that amounts may not be aggregated into more than one offense. (4) In any prosecution under this section, if the amounts are aggregated pursuant to subsection (3) of this section, the amount involved in the offense shall be an essential element of the offense that must be proved beyond a reasonable doubt. (5) A prosecution under this section shall be in lieu of an action under section 44-6607. **State:** Nebraska **Statute Areas:** Range of Criminal Penalties --- ### [Nebraska-Range of Civil Penalties-Neb.Rev.St. ¤ 44-6607](https://insurancefraud.org/statutes/nebraska-range-of-civil-penalties-neb-rev-st-¤-44-6607/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (1) A person or entity who is found by a court of competent jurisdiction, pursuant to an action initiated by the Director of Insurance, to have committed a fraudulent insurance act set forth in section 44-6604 is subject to a civil penalty not to exceed five thousand dollars for the first violation, ten thousand dollars for the second violation, and fifteen thousand dollars for each subsequent violation. An action under this section shall be in lieu of a prosecution under section 28-631. (2) Costs and expenses incurred in any investigation or other action arising out of a violation under the Insurance Fraud Act may be sought in any judgment, court decree, or other final result. Any recovered costs, except civil or criminal penalties, shall be deposited by the director in the fund from which the costs were expended. The court may make such additional orders or judgments as may be necessary to restore to any person in interest any compensation which may have been acquired by means of any act prohibited in section 44-6604. (3) This section shall not be construed to prohibit the director and the alleged violator from entering into a written agreement upon commencement of a civil action in which the alleged violator does not admit or deny the charges but consents to payment of the civil penalty. A consent agreement may not be used in a subsequent civil or criminal proceeding relating to any violation of the act. **State:** Nebraska **Statute Areas:** Range of Civil Penalties --- ### [Nebraska-Rating of an Insurance Policy-Neb.Rev.St. ¤ 44-7510](https://insurancefraud.org/statutes/nebraska-rating-of-an-insurance-policy-neb-rev-st-¤-44-7510/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (1) Rating systems shall not produce premiums that are excessive. A premium level is excessive if it is likely to produce a profit that is unreasonably high for the insurance provided or if expenses are unreasonably high in relation to services rendered. In the evaluation of a premium level, due consideration shall be given to loss experience within and outside this state; reasonably anticipated trends; investment income; special assessments, conflagration, and catastrophe hazards; a reasonable margin for profit; dividends, savings, or unabsorbed premium deposits allowed or returned by insurers to policyholders, members, or subscribers; expense experience both countrywide and specially applicable to this state; and other relevant factors. (2) Rating systems shall not produce premiums that are inadequate. A premium level is inadequate only if (a) it would endanger the solvency of the insurer or (b) it would not be expected to generate a profit on a direct basis and would be likely to have the effect of diminishing competition. (3)(a) Rating systems shall not produce premiums that are unfairly discriminatory. Premiums are unfairly discriminatory if, after allowing for practical limitations, price differentials fail to equitably reflect differences in expense requirements or expected losses. (b) Risks may be grouped by classification groupings that identify objective risk differences for the establishment of rates and prospective loss costs and for the use of rating systems. (c) Rates and premiums may be modified for individual risks or groups of risks in accordance with objective standards for measuring differences among risks or groups of risks that can be demonstrated to have a probable effect upon losses or expenses. The fact that experience rating plans use loss reserves shall not be interpreted as making experience rating plans subjective. (d) Notwithstanding subdivisions (3)(b) and (c) of this section, fire insurance rating plans applying to commercial risks for the sole use by advisory organizations that contain reasonable subjective rating factors, but that otherwise meet the standards contained in the Property and Casualty Insurance Rate and Form Act, shall be approved. (e) A rate is not unfairly discriminatory if it is averaged broadly among persons insured under a group, franchise, or blanket policy or a mass marketed plan. Mass marketed plan means a method of selling property liability insurance wherein: (i) The insurance is offered to employees of particular employers, members of particular associations or organizations, or stockholders of publicly held corporations or to persons grouped in other ways, except groupings formed principally for the purpose of obtaining such insurance; and (ii) The employer or other organization has agreed to, or otherwise affiliated itself with, the sale of such insurance to its employees or other groupings of persons affiliated with it. (f) An insurer may have different rate levels for otherwise similar insureds based on expense differences between coverage sold: (i) Through direct sales using employees of the insurer; (ii) Through direct sales by the insurer using the Internet; and (iii) Through agents that are not employees of the insurer. (g) No risk classification or grouping may be based upon the race, creed, national origin, or religion of the insured. (h) No rating system may violate the Unfair Discrimination Against Subjects of Abuse in Insurance Act. (4) Prospective loss costs shall be as near as is practical to the expected cost of future losses, including loss adjustment expenses. Anticipated special assessments may be included with prospective loss costs. **State:** Nebraska --- ### [Nebraska-Underwriting Fraud-Neb.Rev.St. ¤ 44-6604](https://insurancefraud.org/statutes/nebraska-underwriting-fraud-neb-rev-st-¤-44-6604/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** For purposes of the Insurance Fraud Act, a person or entity commits a fraudulent insurance act if he or she:(4) Knowingly and willfully transacts any contract, agreement, or instrument which violates this section; (5) Receives money for the purpose of purchasing insurance and converts the money to the person’s own benefit; (6) Willfully embezzles, abstracts, purloins, misappropriates, or converts money, funds, premiums, credits, or other property of an insurer or person engaged in the business of insurance; (7) Knowingly and with intent to defraud or deceive issues or possesses fake or counterfeit insurance policies, certificates of insurance, insurance identification cards, or insurance binders; (8) Knowingly and with intent to defraud or deceive makes any false entry of a material fact in or pertaining to any document or statement filed with or required by the department; (9) Knowingly and with intent to defraud or deceive removes, conceals, alters, diverts, or destroys assets or records of an insurer or person engaged in the business of insurance or attempts to remove, conceal, alter, divert, or destroy assets or records of an insurer or person engaged in the business of insurance; **State:** Nebraska **Statute Areas:** Underwriting Fraud --- ### [Nebraska-Unauthorized Entities-Neb.Rev.St. ¤ 44-2002](https://insurancefraud.org/statutes/nebraska-unauthorized-entities-neb-rev-st-¤-44-2002/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (1) It shall be unlawful for any insurer to transact insurance business in this state, as set forth in subsection (2) of this section, without a certificate of authority from the director. This section shall not apply to: (a) The lawful transaction of surplus lines insurance; (b) The lawful transaction of reinsurance by insurers; (c) Transactions in this state involving a policy lawfully solicited, written, and delivered outside of this state covering only subjects of insurance not resident, located, or expressly to be performed in this state at the time of issuance, and which transactions are subsequent to the issuance of such policy; (d) Attorneys acting in the ordinary relation of attorney and client in the adjustment of claims or losses; (e) Transactions in this state involving group life and group sickness and accident or blanket sickness and accident insurance or group annuities when the master policy of such groups was lawfully issued and delivered in and pursuant to the laws of a state in which the insurer was authorized to do an insurance business, to a group organized for purposes other than the procurement of insurance, and when the policyholder is domiciled or otherwise has a bona fide situs; or (f) Transactions in this state relative to a policy issued or to be issued outside this state involving insurance on vessels, craft or hulls, cargoes, marine builder’s risk, marine protection, and indemnity or other risk, including strikes and war risks commonly insured under ocean or wet marine forms of policy. (2) Any of the following acts in this state effected by mail or otherwise by or on behalf of an unauthorized insurer shall constitute the transaction of an insurance business in this state. The venue of an act committed by mail shall be at the point where the matter transmitted by mail is delivered and takes effect. For purposes of this section, unless the context otherwise requires, insurer shall include all corporations, associations, partnerships, and individuals engaged as principals in the business of insurance and shall also include interinsurance exchanges and mutual benefit societies: (a) The making of or proposing to make, as an insurer, an insurance contract; (b) The making of or proposing to make, as guarantor or surety, any contract of guaranty or suretyship as a vocation and not merely incidental to any other legitimate business or activity of the guarantor or surety; (c) The taking or receiving of any application for insurance; (d) The receiving or collection of any premium, commission, membership fees, assessments, dues, or other consideration for any insurance or any part thereof; (e) The issuance or delivery of contracts of insurance to residents of this state or to persons authorized to do business in this state; (f) Directly or indirectly acting as an agent for or otherwise representing or aiding on behalf of another any person or insurer in the solicitation, negotiation, procurement, or effectuation of insurance or renewals thereof or in the dissemination of information as to coverage or rates, or forwarding of applications, or delivery of policies or contracts, or inspection of risks, a fixing of rates or investigation or adjustment of claims or losses or in the transaction of matters subsequent to effectuation of the contract and arising out of it, or in any other manner representing or assisting a person or insurer in the transaction of insurance with respect to subjects of insurance resident, located, or to be performed in this state. This subsection shall not operate to prohibit full-time salaried employees of a corporate insured from acting in the capacity of an insurance manager or buyer in placing insurance in behalf of such employer; (g) The transaction of any kind of insurance business specifically recognized as transacting an insurance business within the meaning of the statutes relating to insurance; or (h) The transacting or proposing to transact any insurance business in substance equivalent to any of the provisions of subdivisions (a) through (g) of this subsection in a manner designed to evade the provisions of the statutes. (3)(a) The failure of an insurer transacting insurance business in this state to obtain a certificate of authority shall not impair the validity of any act or contract of such insurer and shall not prevent such insurer from defending any action at law or suit in equity in any court of this state, but no insurer transacting insurance business in this state without a certificate of authority shall be permitted to maintain an action in any court of this state to enforce any right, claim, or demand arising out of the transaction of such business until such insurer shall have obtained a certificate of authority. (b) In the event of failure of any such unauthorized insurer to pay any claim or loss within the provisions of any insurance contract, any person who assisted or in any manner aided directly or indirectly in the procurement of such insurance contract shall be liable to the insured for the full amount of the claim or loss in the manner provided by the provisions of such insurance contract. **State:** Nebraska --- ### [Montana-Aiding & Abetting-MCA 33-1-1202](https://insurancefraud.org/statutes/montana-aiding-abetting-mca-33-1-1202/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (2) assists, abets, solicits, or conspires with another to prepare or make any written or oral statement containing false, incomplete, or misleading information concerning any fact that is intended to be presented to any insurer or purported insurer or in connection with, material to, or in support of any claim for payment or other benefit pursuant to an insurance policy or contract; **State:** Montana --- ### [Montana-Anti-Runner Provisions-n/a](https://insurancefraud.org/statutes/montana-anti-runner-provisions-n-a/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **State:** Montana **Statute Areas:** Anti-Runner Provisions --- ### [Montana-Claims Fraud-MCA 33-1-1202](https://insurancefraud.org/statutes/montana-claims-fraud-mca-33-1-1202/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** A person commits the act of administrative or civil insurance fraud when the person: (1) for the purpose of obtaining any money or benefit, presents or causes to be presented to any insurer, purported insurer, producer, or administrator, as defined in 33-17-102, any written or oral statement, including computer-generated documents, containing false, incomplete, or misleading information concerning any fact or thing material to, as part of, or in support of a claim for payment or other benefit pursuant to an insurance policy; (2) assists, abets, solicits, or conspires with another to prepare or make any written or oral statement containing false, incomplete, or misleading information concerning any fact that is intended to be presented to any insurer or purported insurer or in connection with, material to, or in support of any claim for payment or other benefit pursuant to an insurance policy or contract; (6) offers or accepts a direct or indirect inducement to file a false statement of claim with the intent of deceiving an insurer; or **State:** Montana **Statute Areas:** Claims Fraud --- ### [Montana-Failing to Remit Premium-MCA 33-1-1202](https://insurancefraud.org/statutes/montana-failing-to-remit-premium-mca-33-1-1202/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** A person commits the act of administrative or civil insurance fraud when the person: (4) accepts premium money knowing that coverage will not be provided; **State:** Montana --- ### [Montana-Fraud Bureau-MCA 33-1-1203](https://insurancefraud.org/statutes/montana-fraud-bureau-mca-33-1-1203/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (1) The commissioner may: (a) initiate independent inquiries and conduct independent investigations when the commissioner has reason to believe that insurance fraud may be, has been, or is currently being committed; (b) respond to notice or complaints generated by federal, state, county, and local law enforcement officers, other entities with law enforcement responsibilities, or governmental agencies or units; (c) review and respond to notices or reports of insurance fraud submitted by any person, select the incidents of suspected fraud that in the commissioner’s judgment require further and more detailed investigation, and conduct the investigations; (d) conduct independent examinations of insurance fraud to determine the extent of insurance fraud, deceit, or intentional misrepresentation; (e) after investigation, report any meritorious alleged violation of the law to the appropriate prosecuting authority or licensing agencies; and (f) assemble evidence, prepare charges, and prosecute, if requested, or otherwise assist any prosecuting authority that has jurisdiction, including the attorney general. (2) Papers, records, documents, reports, materials, or other evidence relative to the subject of an insurance fraud investigation must remain confidential and must be treated as confidential criminal justice information as defined in 44-5-103. Evidence procured pursuant to this section may not be disseminated, except as provided in 44-5-303. (3) The commissioner shall notify the person who or the entity that has given notice of an alleged insurance fraud pursuant to 33-1-1205(2) of receipt of the notice by the commissioner and of the disposition of the notice and any resulting investigation. **State:** Montana **Statute Areas:** Fraud Bureau --- ### [Montana-Immunity-MCA 33-1-1210](https://insurancefraud.org/statutes/montana-immunity-mca-33-1-1210/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (1) In the absence of malice, an insurer, an officer, employee, or producer of the insurer, an independent adjuster, an administrator, a consultant, or any private person is not subject to civil liability for filing reports, providing information, or otherwise cooperating with an investigation or examination of insurance fraud conducted by the commissioner. (2) A person listed in subsection (1) receives immunity if the person: (a) cooperates with, furnishes evidence to, or provides information regarding any suspected insurance fraud to the commissioner, the national association of insurance commissioners, any nonprofit organization established to detect and prevent insurance fraud, or other insurer or producer; or (b) complies with an order issued by a court of competent jurisdiction acting in response to a request by the commissioner to furnish evidence or provide testimony. **State:** Montana **Statute Areas:** Immunity --- ### [Montana-Insurance Fraud - Definition-MCA 33-1-1202; MCA 33-1-1504](https://insurancefraud.org/statutes/montana-insurance-fraud-definition-mca-33-1-1202-mca-33-1-1504/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** A person commits the act of administrative or civil insurance fraud when the person: (1) for the purpose of obtaining any money or benefit, presents or causes to be presented to any insurer, purported insurer, producer, or administrator, as defined in 33-17-102, any written or oral statement, including computer-generated documents, containing false, incomplete, or misleading information concerning any fact or thing material to, as part of, or in support of a claim for payment or other benefit pursuant to an insurance policy; (2) assists, abets, solicits, or conspires with another to prepare or make any written or oral statement containing false, incomplete, or misleading information concerning any fact that is intended to be presented to any insurer or purported insurer or in connection with, material to, or in support of any claim for payment or other benefit pursuant to an insurance policy or contract; (3) presents or causes to be presented to or by an insurer, purported insurer, producer, or administrator, as defined in 33-17-102, a materially false or altered application of insurance; (4) accepts premium money knowing that coverage will not be provided; (5) as a health care provider, submits a false or altered bill or report of physical condition to an insurer; (6) offers or accepts a direct or indirect inducement to file a false statement of claim with the intent of deceiving an insurer; or (7) presents or causes to be presented counterfeit insurance documents to any person. \*\*\*(1) A person commits the offense of insurance fraud when the person purposely or knowingly: (a) for the purpose of obtaining any money or benefit, presents or causes to be presented to any person any written or oral statement, including computer-generated documents, containing false, incomplete, or misleading information concerning any fact or thing material to, as part of, or in support of a claim for payment or other benefit pursuant to an insurance policy; (b) presents or causes to be presented to or by an insurer, as defined in 33-1-201, or to an insurance producer or administrator, as defined in 33-17-102, a materially false or altered application of insurance; (c) as a health care provider as defined in 33-38-102, submits a false or altered bill or report of physical condition to an insurer; or (d) presents or causes to be presented false, incomplete, or misleading insurance documents to any person. (2)(a) A person convicted of criminal insurance fraud involving a benefit or benefits with a value not exceeding $1,500 shall be fined not more than $1,500 or be imprisoned in the county detention center for not more than 6 months, or both. (b) A person convicted of the offense of insurance fraud involving a benefit or benefits with a value exceeding $1,500 shall be fined an amount not to exceed $50,000 or be imprisoned in a state prison for a term not to exceed 10 years, or both. (c) A person convicted of the offense of insurance fraud involving a common scheme as defined in 45-2-101 shall be fined an amount not to exceed $50,000 or be imprisoned in a state prison for a term not to exceed 10 years, or both. **State:** Montana **Statute Areas:** Insurance Fraud - Definition --- ### [Montana-Licensing Board Notification-MCA 33-1-1205](https://insurancefraud.org/statutes/montana-licensing-board-notification-mca-33-1-1205/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (1) Each insurer, independent adjuster, independent administrator, independent consultant, and independent producer shall cooperate fully with the commissioner with respect to the provisions of this part. (2) Except as provided in subsection (4), an insurer, an officer, or an employee of the insurer, an independent adjuster, an independent administrator, an independent consultant, or an independent producer who has reason to believe that an insurance fraud has been or is being committed shall provide notice of the alleged insurance fraud to the commissioner within 60 days. A producer of an insurer who has reason to believe that an insurance fraud has been or is being committed shall report the alleged fraud to the insurer within 60 days of discovery of the alleged insurance fraud. The insurer shall review the report. If the insurer determines that there is reasonable likelihood that fraud has occurred, the insurer shall forward the report to the commissioner within 30 days of receipt of the report. (3) Notice to the commissioner by an insurer who has reason to believe that an insurance fraud has been committed in connection with an insurance claim, application, or policy tolls any applicable time period, for the commissioner, in any applicable insurance statute or related insurance regulation, or any applicable provisions of Title 33, chapter 1, part 15, and tolls any time period arising under 33-18-232 or 33-18-242 regarding unfair claims settlement practices. (4) Notice of an alleged insurance fraud involving an insurance claim or application submitted to the state compensation insurance fund or a policy issued by the state compensation insurance fund must be made within 60 days to the fraud detection and prevention unit established pursuant to 39-71-211. **State:** Montana --- ### [Montana-Mandatory Restitution-MCA 33-1-1211](https://insurancefraud.org/statutes/montana-mandatory-restitution-mca-33-1-1211/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (1) If, after a hearing conducted under 33-1-701, the commissioner determines that a person has committed administrative or civil insurance fraud, the commissioner may: (a) impose any penalty provided for in 33-1-317; or (b) require the person to pay the costs of the proceeding. (2) In addition to any other penalties, the commissioner shall require a person who commits administrative or civil insurance fraud to make restitution to the insurer or to any other person for all financial loss sustained as a result of the insurance fraud. **State:** Montana **Statute Areas:** Mandatory Restitution --- ### [Montana-Practitioner Penalites-MCA 33-1-317](https://insurancefraud.org/statutes/montana-practitioner-penalites-mca-33-1-317/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** The commissioner may, after having conducted a hearing pursuant to 33-1-701, impose a fine not to exceed the sum of $25,000 upon a person found to have violated a provision of this code or regulation promulgated by the commissioner, except that the fine imposed upon insurance producers or adjusters may not exceed $5,000 per violation. The fine is in addition to all other penalties imposed by the laws of this state and must be collected by the commissioner in the name of the state of Montana. Imposition of a fine under this section is an order from which an appeal may be taken, pursuant to the provisions of 33-1-711. **State:** Montana **Statute Areas:** Practitioner Penalites --- ### [Montana-Premium Fraud-MCA 33-1-1202](https://insurancefraud.org/statutes/montana-premium-fraud-mca-33-1-1202/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** A person commits the act of administrative or civil insurance fraud when the person: (4) accepts premium money knowing that coverage will not be provided; **State:** Montana **Statute Areas:** Premium Fraud --- ### [Montana-Range of Criminal Penalties-MCA 33-1-1504](https://insurancefraud.org/statutes/montana-range-of-criminal-penalties-mca-33-1-1504/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (2)(a) A person convicted of criminal insurance fraud involving a benefit or benefits with a value not exceeding $1,500 shall be fined not more than $1,500 or be imprisoned in the county detention center for not more than 6 months, or both. (b) A person convicted of the offense of insurance fraud involving a benefit or benefits with a value exceeding $1,500 shall be fined an amount not to exceed $50,000 or be imprisoned in a state prison for a term not to exceed 10 years, or both. (c) A person convicted of the offense of insurance fraud involving a common scheme as defined in 45-2-101 shall be fined an amount not to exceed $50,000 or be imprisoned in a state prison for a term not to exceed 10 years, or both. **State:** Montana **Statute Areas:** Range of Criminal Penalties --- ### [Montana-Range of Civil Penalties-MCA 33-1-1211; MCA 33-1-317](https://insurancefraud.org/statutes/montana-range-of-civil-penalties-mca-33-1-1211-mca-33-1-317/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (1) If, after a hearing conducted under 33-1-701, the commissioner determines that a person has committed administrative or civil insurance fraud, the commissioner may: (a) impose any penalty provided for in 33-1-317; or (b) require the person to pay the costs of the proceeding. (2) In addition to any other penalties, the commissioner shall require a person who commits administrative or civil insurance fraud to make restitution to the insurer or to any other person for all financial loss sustained as a result of the insurance fraud.\*\*The commissioner may, after having conducted a hearing pursuant to 33-1-701, impose a fine not to exceed the sum of $25,000 upon a person found to have violated a provision of this code or regulation promulgated by the commissioner, except that the fine imposed upon insurance producers or adjusters may not exceed $5,000 per violation. The fine is in addition to all other penalties imposed by the laws of this state and must be collected by the commissioner in the name of the state of Montana. Imposition of a fine under this section is an order from which an appeal may be taken, pursuant to the provisions of 33-1-711. **State:** Montana **Statute Areas:** Range of Civil Penalties --- ### [Montana-Rating of an Insurance Policy-MCA 33-16-201](https://insurancefraud.org/statutes/montana-rating-of-an-insurance-policy-mca-33-16-201/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** The following standards apply to the making and use of rates pertaining to all classes of insurance to which the provisions of this chapter are applicable: (1)(a) Rates may not be excessive or inadequate, and they may not be unfairly discriminatory. (b) A rate may not be held to be excessive unless the rate is unreasonably high for the insurance provided and a reasonable degree of competition does not exist in the area with respect to the classification to which the rate is applicable. (c) A rate may not be held to be inadequate unless the rate is unreasonably low for the insurance provided and the continued use of the rate endangers the solvency of the insurer using the rate or unless the rate is unreasonably low for the insurance provided and the use of the rate by the insurer has, or if continued will have, the effect of destroying competition or creating a monopoly. (2)(a) Consideration must be given, when applicable, to past and prospective loss experience within and outside this state, to revenue and profits from reserves, to conflagration and catastrophe hazards, if any, to a reasonable margin for underwriting profit and contingencies, to past and prospective expenses, both countrywide and those specially applicable to this state, and to all other factors, including judgment factors, considered relevant within and outside this state. In the case of fire insurance rates, consideration may be given to the experience of the fire insurance business during the most recent 5-year period for which experience is available. (b) Consideration may also be given in the making and use of rates to dividends, savings, or unabsorbed premium deposits allowed or returned by insurers to their policyholders, members, or subscribers. (3) The systems of expense provisions included in the rates for use by any insurer or group of insurers may differ from those of other insurers or groups of insurers to reflect the operating methods of the insurer or group with respect to any kind of insurance or with respect to any subdivision or combination of insurance. (4)(a) Risks may be grouped by classifications for the establishment of rates and minimum premiums. Classification rates may be modified to produce rates for separate risks in accordance with rating plans that establish standards for measuring variations in hazards or expense provisions, or both. The standards may measure any difference among risks that have a probable effect upon losses or expenses. Classifications or modifications of classifications of risks may be established, based upon size, expense, management, individual experience, location or dispersion of hazard, or any other reasonable considerations. (b) Special risk classifications may be established for private passenger automobile policies. Special risk classifications may be based upon favorable aspects of an insured individual’s claims history that is 3 years old or older. Special risk classifications may not be established based on adverse information contained in an insured individual’s driving record that is 3 years old or older. (c) Special risk classifications may be established for commercial automobile policies. Special risk classifications for commercial automobile policies may be based upon favorable aspects of an insured’s claims history that is 5 years old or older. Special risk classifications for commercial automobile policies established for an insured’s adverse loss experience may not use more than the most recent 5 years of claims history that is available. (d) Classifications and modifications apply to all risks under the same or substantially the same circumstances or conditions. (e) As used in subsection (4)(b), “private passenger automobile policy” means an automobile insurance policy issued to individuals or families but does not include policies known as commercial automobile policies. **State:** Montana --- ### [Montana-Underwriting Fraud-MCA 33-1-1202](https://insurancefraud.org/statutes/montana-underwriting-fraud-mca-33-1-1202/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** A person commits the act of administrative or civil insurance fraud when the person: (4) accepts premium money knowing that coverage will not be provided; (5) as a health care provider, submits a false or altered bill or report of physical condition to an insurer; (6) offers or accepts a direct or indirect inducement to file a false statement of claim with the intent of deceiving an insurer; or (7) presents or causes to be presented counterfeit insurance documents to any person. **State:** Montana **Statute Areas:** Underwriting Fraud --- ### [Missouri-Claims Fraud-V.A.M.S. 375.991](https://insurancefraud.org/statutes/missouri-claims-fraud-v-a-m-s-375-991/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** 2\. For the purposes of sections 375.991 to 375.994, a person commits a “fraudulent insurance act” if such person knowingly presents, causes to be presented, or prepares with knowledge or belief that it will be presented, to or by an insurer, purported insurer, broker, or any agent thereof, any oral or written statement including computer generated documents as part of, or in support of, an application for the issuance of, or the rating of, an insurance policy for commercial or personal insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance, which such person knows to contain materially false information concerning any fact material thereto or if such person conceals, for the purpose of misleading another, information concerning any fact material thereto. **State:** Missouri **Statute Areas:** Claims Fraud --- ### [Missouri-Immunity-V.A.M.S. 375.993](https://insurancefraud.org/statutes/missouri-immunity-v-a-m-s-375-993/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** 1\. The department’s papers, documents, reports, or evidence relative to the subject of an investigation under this section shall not be subject to public inspection for so long as the department deems reasonably necessary to complete the investigation and any subsequent legal action. Further, such papers, documents, reports, or evidence relative to the subject of an investigation under sections 375.991 to 375.994 shall not be subject to subpoena until opened for public inspection by the department, unless the department consents, or until, after notice to the department and a hearing, the court determines the department would not be unnecessarily hindered by such subpoena. Department investigators shall not be subject to subpoena in civil actions by any court of this state to testify concerning any matter of which they have knowledge pursuant to a pending insurance fraud investigation by the department. 2. No insurer, employees or agents of any insurer, or any other person acting without malice, shall be subject to civil liability of any kind, including for libel and slander by virtue of the filing of reports or furnishing other information required by sections 375.991 to 375.994 or required by the department of insurance, financial institutions and professional registration as a result of the authority granted in sections 375.991 to 375.994. In addition, except when a person knowingly and intentionally communicates false information, no civil cause of action of any nature may arise against such person for any of the following: (1) Any information relating to suspected or anticipated fraudulent insurance acts furnished to or received from law enforcement officials, their agents, and employees; (2) Any information relating to suspected or anticipated fraudulent insurance acts furnished to or received from other persons subject to the provisions of sections 375.991 to 375.994 and this section; (3) Any information relating to suspected or anticipated fraudulent insurance acts furnished in reports to a federal or state governmental agency or office, the National Association of Insurance Commissioners, the National Insurance Crime Bureau, or any other organization established to detect and prevent fraudulent insurance acts, or to their agents, employees, or designees, or a recognized comprehensive database system recognized by the department. Nothing herein is intended to abrogate or modify in any way any common law or statutory privilege or immunity heretofore enjoyed by any person. **State:** Missouri **Statute Areas:** Immunity --- ### [Missouri-Insurance Fraud - Definition-V.A.M.S. 375.991](https://insurancefraud.org/statutes/missouri-insurance-fraud-definition-v-a-m-s-375-991/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** 1\. As used in sections 375.991 to 375.994, the term “statement” means any communication, notice statement, proof of loss, bill of lading, receipt for payment, invoice, account, estimate of damages, bills for services, diagnosis, prescription, hospital or doctor records, x-rays, test results or other evidence of loss, injury or expense. 2. For the purposes of sections 375.991 to 375.994, a person commits a “fraudulent insurance act” if such person knowingly presents, causes to be presented, or prepares with knowledge or belief that it will be presented, to or by an insurer, purported insurer, broker, or any agent thereof, any oral or written statement including computer generated documents as part of, or in support of, an application for the issuance of, or the rating of, an insurance policy for commercial or personal insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance, which such person knows to contain materially false information concerning any fact material thereto or if such person conceals, for the purpose of misleading another, information concerning any fact material thereto. 3. A “fraudulent insurance act” shall also include but not be limited to knowingly filing false insurance claims with an insurer, health services corporation, or health maintenance organization by engaging in any one or more of the following false billing practices: (1) “Unbundling”, an insurance claim by claiming a number of medical procedures were performed instead of a single comprehensive procedure; (2) “Upcoding”, an insurance claim by claiming that a more serious or extensive procedure was performed than was actually performed; (3) “Exploding”, an insurance claim by claiming a series of tests was performed on a single sample of blood, urine, or other bodily fluid, when actually the series of tests was part of one battery of tests; or (4) “Duplicating”, a medical, hospital or rehabilitative insurance claim made by a health care provider by resubmitting the claim through another health care provider in which the original health care provider has an ownership interest. Nothing in sections 375.991 to 375.994 shall prohibit providers from making good faith efforts to ensure that claims for reimbursement are coded to reflect the proper diagnosis and treatment. 4. If, by its own inquiries or as a result of complaints, the department of insurance, financial institutions and professional registration has reason to believe that a person has engaged in, or is engaging in, any fraudulent insurance act or has violated any provision of chapters 375 to 385, it may administer oaths and affirmations, serve subpoenas ordering the attendance of witnesses or proffering of matter, and collect evidence. The director may refer such evidence as is available concerning violations of this chapter to the proper prosecuting attorney or circuit attorney who may, with or without such reference, initiate the appropriate criminal proceedings. 5. If the matter that the department of insurance, financial institutions and professional registration seeks to obtain by request is located outside the state, the person so requested may make it available to the department or its representative to examine the matter at the place where it is located. The department may designate representatives, including officials of the state in which the matter is located, to inspect the matter on its behalf, and it may respond to similar requests from officials of other states. 6. A fraudulent insurance act for a first offense is a class E felony. Any person who is found guilty of a fraudulent insurance act who has previously been found guilty of a fraudulent insurance act shall be guilty of a class D felony. 7. Any person who pleads guilty or is found guilty of a fraudulent insurance act shall be ordered by the court to make restitution to any person or insurer for any financial loss sustained as a result of such violation. The court shall determine the extent and method of restitution. 8. Nothing in this section shall limit the power of the state to punish any person for any conduct that constitutes a crime by any other state statute. **State:** Missouri **Statute Areas:** Insurance Fraud - Definition --- ### [Missouri-Mandatory Restitution-V.A.M.S. 375.991](https://insurancefraud.org/statutes/missouri-mandatory-restitution-v-a-m-s-375-991/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** 7\. Any person who pleads guilty or is found guilty of a fraudulent insurance act shall be ordered by the court to make restitution to any person or insurer for any financial loss sustained as a result of such violation. The court shall determine the extent and method of restitution. **State:** Missouri **Statute Areas:** Mandatory Restitution --- ### [Missouri-Placing Bogus Coverage-V.A.M.S. 375.991](https://insurancefraud.org/statutes/missouri-placing-bogus-coverage-v-a-m-s-375-991/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** 2\. For the purposes of sections 375.991 to 375.994, a person commits a “fraudulent insurance act” if such person knowingly presents, causes to be presented, or prepares with knowledge or belief that it will be presented, to or by an insurer, purported insurer, broker, or any agent thereof, any oral or written statement including computer generated documents as part of, or in support of, an application for the issuance of, or the rating of, an insurance policy for commercial or personal insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance, which such person knows to contain materially false information concerning any fact material thereto or if such person conceals, for the purpose of misleading another, information concerning any fact material thereto. **State:** Missouri --- ### [Missouri-Practitioner Penalites-V.A.M.S. 375.991](https://insurancefraud.org/statutes/missouri-practitioner-penalites-v-a-m-s-375-991/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** 6\. A fraudulent insurance act for a first offense is a class E felony. Any person who is found guilty of a fraudulent insurance act who has previously been found guilty of a fraudulent insurance act shall be guilty of a class D felony. 7. Any person who pleads guilty or is found guilty of a fraudulent insurance act shall be ordered by the court to make restitution to any person or insurer for any financial loss sustained as a result of such violation. The court shall determine the extent and method of restitution. 8. Nothing in this section shall limit the power of the state to punish any person for any conduct that constitutes a crime by any other state statute. **State:** Missouri **Statute Areas:** Practitioner Penalites --- ### [Missouri-Premium Fraud-V.A.M.S. 375.991](https://insurancefraud.org/statutes/missouri-premium-fraud-v-a-m-s-375-991/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** 2\. For the purposes of sections 375.991 to 375.994, a person commits a “fraudulent insurance act” if such person knowingly presents, causes to be presented, or prepares with knowledge or belief that it will be presented, to or by an insurer, purported insurer, broker, or any agent thereof, any oral or written statement including computer generated documents as part of, or in support of, an application for the issuance of, or the rating of, an insurance policy for commercial or personal insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance, which such person knows to contain materially false information concerning any fact material thereto or if such person conceals, for the purpose of misleading another, information concerning any fact material thereto. **State:** Missouri **Statute Areas:** Premium Fraud --- ### [Missouri-Range of Criminal Penalties-V.A.M.S. 375.991](https://insurancefraud.org/statutes/missouri-range-of-criminal-penalties-v-a-m-s-375-991/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** 6\. A fraudulent insurance act for a first offense is a class E felony. Any person who is found guilty of a fraudulent insurance act who has previously been found guilty of a fraudulent insurance act shall be guilty of a class D felony. **State:** Missouri **Statute Areas:** Range of Criminal Penalties --- ### [Missouri-Range of Civil Penalties-V.A.M.S. 375.991](https://insurancefraud.org/statutes/missouri-range-of-civil-penalties-v-a-m-s-375-991/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** 7\. Any person who pleads guilty or is found guilty of a fraudulent insurance act shall be ordered by the court to make restitution to any person or insurer for any financial loss sustained as a result of such violation. The court shall determine the extent and method of restitution. **State:** Missouri **Statute Areas:** Range of Civil Penalties --- ### [Missouri-Underwriting Fraud-V.A.M.S. 375.991](https://insurancefraud.org/statutes/missouri-underwriting-fraud-v-a-m-s-375-991/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** 2\. For the purposes of sections 375.991 to 375.994, a person commits a “fraudulent insurance act” if such person knowingly presents, causes to be presented, or prepares with knowledge or belief that it will be presented, to or by an insurer, purported insurer, broker, or any agent thereof, any oral or written statement including computer generated documents as part of, or in support of, an application for the issuance of, or the rating of, an insurance policy for commercial or personal insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance, which such person knows to contain materially false information concerning any fact material thereto or if such person conceals, for the purpose of misleading another, information concerning any fact material thereto. 3. A “fraudulent insurance act” shall also include but not be limited to knowingly filing false insurance claims with an insurer, health services corporation, or health maintenance organization by engaging in any one or more of the following false billing practices: (1) “Unbundling”, an insurance claim by claiming a number of medical procedures were performed instead of a single comprehensive procedure; (2) “Upcoding”, an insurance claim by claiming that a more serious or extensive procedure was performed than was actually performed; (3) “Exploding”, an insurance claim by claiming a series of tests was performed on a single sample of blood, urine, or other bodily fluid, when actually the series of tests was part of one battery of tests; or (4) “Duplicating”, a medical, hospital or rehabilitative insurance claim made by a health care provider by resubmitting the claim through another health care provider in which the original health care provider has an ownership interest. **State:** Missouri **Statute Areas:** Underwriting Fraud --- ### [Missouri-Unauthorized Entities-V.A.M.S. 375.310](https://insurancefraud.org/statutes/missouri-unauthorized-entities-v-a-m-s-375-310/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** 1\. It is unlawful for any person, association of individuals, or any corporation to transact in this state any insurance business unless the person, association, or corporation is duly authorized by the director under a certificate of authority or appropriate licensure, or is an insurance company exempt from certification under section 375.786. 2. If the director determines that a person has engaged, is engaging in, or has taken a substantial step toward engaging in an act, practice or course of business constituting a violation of this section or a rule adopted or order issued pursuant thereto, or that a person has materially aided or is materially aiding an act, practice, omission, or course of business constituting a violation of this section or a rule adopted or order issued pursuant thereto, the director may issue such administrative orders as authorized under section 374.046. A violation of this section is a level four violation under section 374.049. 3. If the director believes that a person has engaged, is engaging in, or has taken a substantial step toward engaging in an act, practice or course of business constituting a violation of this section or a rule adopted or order issued pursuant thereto, or that a person has materially aided or is materially aiding an act, practice, omission, or course of business constituting a violation of this section or a rule adopted or order issued pursuant thereto, the director may maintain a civil action for relief authorized under section 374.048. A violation of this section is a level four violation under section 374.049. 4. Any person who knowingly engages in any act, practice, omission, or course of business in violation of this section is guilty of a class E felony. 5. The director may refer such evidence as is available concerning violations of this chapter to the proper prosecuting attorney, who with or without a criminal reference, or the attorney general under section 27.030, may institute the appropriate criminal proceedings. 6. Nothing in this section shall limit the power of the state to punish any person for any conduct that constitutes a crime under any other state statute. **State:** Missouri --- ### [Mississippi-Aiding & Abetting-Miss. Code Ann. ¤ 7-5-303 (Proposed Legislation)](https://insurancefraud.org/statutes/mississippi-aiding-abetting-miss-code-ann-¤-7-5-303-proposed-legislation/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (2) A person or entity shall not, with the intent to appropriate to himself or to another any benefit, knowingly execute, collude or conspire to execute or attempt to execute a scheme or artifice: (a) To defraud any insurance plan in connection with the delivery of, or payment for, insurance benefits, items, services or claims; or (b) To obtain by means of false or fraudulent pretense, representation, statement or promise money, or anything of value, in connection with the delivery of or payment for insurance claims under any plan or program or state law, items or services which are in whole or in part paid for, reimbursed, subsidized by, or are a required benefit of, an insurance plan or an insurance company or any other provider. **State:** Mississippi --- ### [Mississippi-Anti-Runner Provisions-n/a](https://insurancefraud.org/statutes/mississippi-anti-runner-provisions-n-a/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** No statute found **State:** Mississippi **Statute Areas:** Anti-Runner Provisions --- ### [Mississippi-Attempted Fraud-n/a](https://insurancefraud.org/statutes/mississippi-attempted-fraud-n-a/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** No staute found. **State:** Mississippi **Statute Areas:** Attempted Fraud --- ### [Mississippi-Claims Fraud-Miss. Code Ann. ¤ 7-5-303 (Proposed Legislation)](https://insurancefraud.org/statutes/mississippi-claims-fraud-miss-code-ann-¤-7-5-303-proposed-legislation/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (2) A person or entity shall not, with the intent to appropriate to himself or to another any benefit, knowingly execute, collude or conspire to execute or attempt to execute a scheme or artifice: (a) To defraud any insurance plan in connection with the delivery of, or payment for, insurance benefits, items, services or claims; or (b) To obtain by means of false or fraudulent pretense, representation, statement or promise money, or anything of value, in connection with the delivery of or payment for insurance claims under any plan or program or state law, items or services which are in whole or in part paid for, reimbursed, subsidized by, or are a required benefit of, an insurance plan or an insurance company or any other provider. **State:** Mississippi **Statute Areas:** Claims Fraud --- ### [Mississippi-Fraud Bureau-Miss. Code Ann. ¤ 7-5-301](https://insurancefraud.org/statutes/mississippi-fraud-bureau-miss-code-ann-¤-7-5-301/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** There is created within the Office of the Attorney General an Insurance Integrity Enforcement Bureau. The duty of the bureau is to investigate and prosecute claims of insurance abuses and crimes involving insurance. The Attorney General may employ the necessary personnel to carry out the provisions of Sections 7-5-301 through 7-5-311. **State:** Mississippi **Statute Areas:** Fraud Bureau --- ### [Mississippi-Insurance Fraud - Definition-Miss. Code Ann. ¤ 7-5-303 (Proposed Legislation)](https://insurancefraud.org/statutes/mississippi-insurance-fraud-definition-miss-code-ann-¤-7-5-303-proposed-legislation/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (2) A person or entity shall not, with the intent to appropriate to himself or to another any benefit, knowingly execute, collude or conspire to execute or attempt to execute a scheme or artifice: (a) To defraud any insurance plan in connection with the delivery of, or payment for, insurance benefits, items, services or claims; or (b) To obtain by means of false or fraudulent pretense, representation, statement or promise money, or anything of value, in connection with the delivery of or payment for insurance claims under any plan or program or state law, items or services which are in whole or in part paid for, reimbursed, subsidized by, or are a required benefit of, an insurance plan or an insurance company or any other provider. (3) A person or entity shall not directly or indirectly give, offer or promise anything of value to an insurance official, or offer or promise an insurance official to give anything of value to another person, with intent to influence such official’s decision in carrying out any of his duties or laws or regulations. (4) Except as otherwise allowed by law, a person or entity shall not knowingly pay, offer, deliver, receive, solicit or accept any remuneration, as an inducement for referring or for refraining from referring a patient, client, customer or service in connection with an insurance plan. (5) A person or entity shall not, in any matter related to any insurance plan, knowingly and willfully falsify, conceal or omit by any trick, scheme, artifice or device a material fact, make any false, fictitious or fraudulent statement or representation or make or use any false writing or document, knowing or having reason to know that the writing or document contains any false or fraudulent statement or entry in connection with the provision of insurance programs. (6) A person or entity shall not fraudulently deny the payment of an insurance claim. **State:** Mississippi **Statute Areas:** Insurance Fraud - Definition --- ### [Mississippi-Mandatory Restitution-n/a](https://insurancefraud.org/statutes/mississippi-mandatory-restitution-n-a/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** No statute found **State:** Mississippi **Statute Areas:** Mandatory Restitution --- ### [Mississippi-Placing Bogus Coverage-Miss. Code Ann. ¤ 7-5-303 (Proposed Legislation)](https://insurancefraud.org/statutes/mississippi-placing-bogus-coverage-miss-code-ann-¤-7-5-303-proposed-legislation/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (2) A person or entity shall not, with the intent to appropriate to himself or to another any benefit, knowingly execute, collude or conspire to execute or attempt to execute a scheme or artifice: (a) To defraud any insurance plan in connection with the delivery of, or payment for, insurance benefits, items, services or claims; or (b) To obtain by means of false or fraudulent pretense, representation, statement or promise money, or anything of value, in connection with the delivery of or payment for insurance claims under any plan or program or state law, items or services which are in whole or in part paid for, reimbursed, subsidized by, or are a required benefit of, an insurance plan or an insurance company or any other provider. (3) A person or entity shall not directly or indirectly give, offer or promise anything of value to an insurance official, or offer or promise an insurance official to give anything of value to another person, with intent to influence such official’s decision in carrying out any of his duties or laws or regulations. (4) Except as otherwise allowed by law, a person or entity shall not knowingly pay, offer, deliver, receive, solicit or accept any remuneration, as an inducement for referring or for refraining from referring a patient, client, customer or service in connection with an insurance plan. (5) A person or entity shall not, in any matter related to any insurance plan, knowingly and willfully falsify, conceal or omit by any trick, scheme, artifice or device a material fact, make any false, fictitious or fraudulent statement or representation or make or use any false writing or document, knowing or having reason to know that the writing or document contains any false or fraudulent statement or entry in connection with the provision of insurance programs. (6) A person or entity shall not fraudulently deny the payment of an insurance claim. **State:** Mississippi --- ### [Mississippi-Practitioner Penalites-Miss. Code Ann. ¤ 7-5-309](https://insurancefraud.org/statutes/mississippi-practitioner-penalites-miss-code-ann-¤-7-5-309/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (1) A person who violates any provision of Section 7-5-303 shall be guilty of a felony and, upon conviction thereof, shall be punished by imprisonment for not more than three (3) years, or by a fine of not more than Five Thousand Dollars ($5,000.00) or double the value of the fraud, whichever is greater, or both. Sentences imposed for convictions of separate offenses under Sections 7-5-301 through 7-5-311 may run consecutively. (2) If the defendant found to have violated any provisions of Section 7-5-303 is an organization, then it shall be subject to a fine of not more than One Hundred Fifty Thousand Dollars ($150,000.00) for each violation. “Organization” for purposes of this subsection means a person other than an individual. The term includes corporations, partnerships, associations, joint-stock companies, unions, trusts, pension funds, unincorporated organizations, governments and political subdivisions thereof and nonprofit organizations. (3) In a proceeding for violations under Section 7-5-303, the court, in addition to the criminal penalties imposed under this section, shall assess against the defendant convicted of such violation double those reasonable costs that are expended by the Insurance Integrity Enforcement Bureau of the Office of Attorney General or the district attorney’s office in the investigation of such case, including, but not limited to, the cost of investigators, process service, court reporters, expert witnesses and attorney’s fees. A monetary penalty assessed and levied under this section shall be deposited to the credit of the State General Fund, and the Attorney General may institute and maintain proceedings in his name for enforcement of payment in the circuit court of the county of residence of the defendant and, if the defendant is a nonresident, such proceedings shall be in the Circuit Court of the First Judicial District of Hinds County, Mississippi. **State:** Mississippi **Statute Areas:** Practitioner Penalites --- ### [Mississippi-Range of Criminal Penalties-Miss. Code Ann. ¤ 7-5-309](https://insurancefraud.org/statutes/mississippi-range-of-criminal-penalties-miss-code-ann-¤-7-5-309/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (1) A person who violates any provision of Section 7-5-303 shall be guilty of a felony and, upon conviction thereof, shall be punished by imprisonment for not more than three (3) years, or by a fine of not more than Five Thousand Dollars ($5,000.00) or double the value of the fraud, whichever is greater, or both. Sentences imposed for convictions of separate offenses under Sections 7-5-301 through 7-5-311 may run consecutively. (2) If the defendant found to have violated any provisions of Section 7-5-303 is an organization, then it shall be subject to a fine of not more than One Hundred Fifty Thousand Dollars ($150,000.00) for each violation. “Organization” for purposes of this subsection means a person other than an individual. The term includes corporations, partnerships, associations, joint-stock companies, unions, trusts, pension funds, unincorporated organizations, governments and political subdivisions thereof and nonprofit organizations. (3) In a proceeding for violations under Section 7-5-303, the court, in addition to the criminal penalties imposed under this section, shall assess against the defendant convicted of such violation double those reasonable costs that are expended by the Insurance Integrity Enforcement Bureau of the Office of Attorney General or the district attorney’s office in the investigation of such case, including, but not limited to, the cost of investigators, process service, court reporters, expert witnesses and attorney’s fees. A monetary penalty assessed and levied under this section shall be deposited to the credit of the State General Fund, and the Attorney General may institute and maintain proceedings in his name for enforcement of payment in the circuit court of the county of residence of the defendant and, if the defendant is a nonresident, such proceedings shall be in the Circuit Court of the First Judicial District of Hinds County, Mississippi. **State:** Mississippi **Statute Areas:** Range of Criminal Penalties --- ### [Mississippi-Range of Civil Penalties-Miss. Code Ann. ¤ 7-5-309](https://insurancefraud.org/statutes/mississippi-range-of-civil-penalties-miss-code-ann-¤-7-5-309/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (1) A person who violates any provision of Section 7-5-303 shall be guilty of a felony and, upon conviction thereof, shall be punished by imprisonment for not more than three (3) years, or by a fine of not more than Five Thousand Dollars ($5,000.00) or double the value of the fraud, whichever is greater, or both. Sentences imposed for convictions of separate offenses under Sections 7-5-301 through 7-5-311 may run consecutively. (2) If the defendant found to have violated any provisions of Section 7-5-303 is an organization, then it shall be subject to a fine of not more than One Hundred Fifty Thousand Dollars ($150,000.00) for each violation. “Organization” for purposes of this subsection means a person other than an individual. The term includes corporations, partnerships, associations, joint-stock companies, unions, trusts, pension funds, unincorporated organizations, governments and political subdivisions thereof and nonprofit organizations. (3) In a proceeding for violations under Section 7-5-303, the court, in addition to the criminal penalties imposed under this section, shall assess against the defendant convicted of such violation double those reasonable costs that are expended by the Insurance Integrity Enforcement Bureau of the Office of Attorney General or the district attorney’s office in the investigation of such case, including, but not limited to, the cost of investigators, process service, court reporters, expert witnesses and attorney’s fees. A monetary penalty assessed and levied under this section shall be deposited to the credit of the State General Fund, and the Attorney General may institute and maintain proceedings in his name for enforcement of payment in the circuit court of the county of residence of the defendant and, if the defendant is a nonresident, such proceedings shall be in the Circuit Court of the First Judicial District of Hinds County, Mississippi. **State:** Mississippi **Statute Areas:** Range of Civil Penalties --- ### [Mississippi-Rating of an Insurance Policy-Miss. Code Ann. ¤ 83-2-3 (Proposed Legislation)](https://insurancefraud.org/statutes/mississippi-rating-of-an-insurance-policy-miss-code-ann-¤-83-2-3-proposed-legislation/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (1) Rates shall comply with the following standards: (a) Rates shall not be excessive, inadequate or unfairly discriminatory. (b) A rate is excessive if it is likely to produce a profit that is unreasonably high for the insurance provided or if the expense provision included therein is unreasonably high in relation to the services rendered. (c) A rate is inadequate if it threatens the solvency of the insurance company or tends to create a monopoly. (d) Unfair discrimination exists if, after allowing for practical limitations, price differentials fail to reflect equitably the differences in expected losses and expenses. A rate is not unfairly discriminatory because different premiums result for policyholders with like loss exposures with different expenses, or like expenses but different loss exposures, so long as the rate reflects the differences with reasonable accuracy. (2) In determining whether rates comply with the standards set forth in subsection (1), the following criteria shall apply: (a) Due consideration shall be given to past and prospective loss and expense experience within and outside this state; to catastrophe hazards; to any residual market loss redistributions and other similar obligations; to a reasonable provision for profit and contingencies; to trends within and outside this state; to loadings for leveling premium rates over a reasonable period of time or for dividends or savings to be allowed or returned by insurers to their policyholders, members or subscribers; and to all other relevant factors, including the judgment of the filer. (b) Risks may be classified in any reasonable way for the establishment of rates except that no risks may be grouped by classifications based, in whole or in part, on race, color, creed, or national origin of the risk. Rates may be modified for individual risks in accordance with rating plans or schedules which provide for recognition of probable variations in hazards, expenses or both. (c) The systems of expense provisions included in rates for use by an insurer or group of insurers may differ from those of other insurers or group of insurers to reflect the operating methods of such insurer or group with respect to any kind of insurance, or with respect to any subdivision or combination thereof. (d) Any homeowners’ insurance policy filed with the Commissioner of Insurance that offers a percentage deductible for the peril of windstorm from a named storm shall offer a buy-back provision for that deductible which is actuarially sound; however, the Commissioner of Insurance may grant a waiver from the mandatory buy-back provision in accordance with the following procedure and criteria: (i) An insurance company shall make a formal filing requesting a waiver from the buy-back provision requirement with the Commissioner of Insurance. (ii) An insurance company shall submit written proof in its formal filing as to why it is in the best interest of Mississippi policyholders to receive a waiver from the buy-back provision requirement and shall provide any supporting documentation requested by the commissioner deemed appropriate to make his decision. (iii) All expenses incurred by the Commissioner of Insurance or his designee in determining the validity of the waiver request shall be borne by the petitioning insurer. Such expenses may include, but not be limited to, the cost of reviewing the filing by actuaries, and if the commissioner deems a public hearing appropriate, the cost of a facility, the cost of publicity and the cost of a court reporter for the hearing. (e) The commissioner shall establish by regulation uniform policy language regarding the applicability of hurricane deductibles and the form of notice to be provided to an insured under a homeowner’s insurance policy by an insurer utilizing a hurricane deductible program or programs. The term “hurricane,” for the purpose of a hurricane deductible program, means a storm system that has been declared to be a hurricane by the National Hurricane Center of the National Weather Service. The duration of the hurricane includes the time period, in Mississippi: (i) Beginning at the time a hurricane watch or hurricane warning is issued for any part of Mississippi by the National Hurricane Center of the National Weather Service; (ii) Continuing for the time period during which the hurricane conditions exist anywhere in Mississippi; and (iii) Ending twenty-four (24) hours following the termination of the last hurricane watch or hurricane warning issued for any part of Mississippi by the National Hurricane Center of the National Weather Service. **State:** Mississippi --- ### [Mississippi-Underwriting Fraud-Miss. Code Ann. ¤ 7-5-303 (Proposed Legislation)](https://insurancefraud.org/statutes/mississippi-underwriting-fraud-miss-code-ann-¤-7-5-303-proposed-legislation/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (2) A person or entity shall not, with the intent to appropriate to himself or to another any benefit, knowingly execute, collude or conspire to execute or attempt to execute a scheme or artifice: (a) To defraud any insurance plan in connection with the delivery of, or payment for, insurance benefits, items, services or claims; or (b) To obtain by means of false or fraudulent pretense, representation, statement or promise money, or anything of value, in connection with the delivery of or payment for insurance claims under any plan or program or state law, items or services which are in whole or in part paid for, reimbursed, subsidized by, or are a required benefit of, an insurance plan or an insurance company or any other provider. (3) A person or entity shall not directly or indirectly give, offer or promise anything of value to an insurance official, or offer or promise an insurance official to give anything of value to another person, with intent to influence such official’s decision in carrying out any of his duties or laws or regulations. (4) Except as otherwise allowed by law, a person or entity shall not knowingly pay, offer, deliver, receive, solicit or accept any remuneration, as an inducement for referring or for refraining from referring a patient, client, customer or service in connection with an insurance plan. (5) A person or entity shall not, in any matter related to any insurance plan, knowingly and willfully falsify, conceal or omit by any trick, scheme, artifice or device a material fact, make any false, fictitious or fraudulent statement or representation or make or use any false writing or document, knowing or having reason to know that the writing or document contains any false or fraudulent statement or entry in connection with the provision of insurance programs. (6) A person or entity shall not fraudulently deny the payment of an insurance claim. **State:** Mississippi **Statute Areas:** Underwriting Fraud --- ### [Minnesota-Anti-Runner Provisions-M.S.A. ¤ 609.612](https://insurancefraud.org/statutes/minnesota-anti-runner-provisions-m-s-a-¤-609-612/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Subdivision 1. Definitions. (a) As used in this section, the following terms have the meanings given. (b) “Public media” means telephone directories, professional directories, newspapers and other periodicals, radio and television, billboards, and mailed or electronically transmitted written communications that do not involve in-person contact with a specific prospective patient or client. (c) “Runner,” “capper,” or “steerer” means a person who for a pecuniary gain directly procures or solicits prospective patients through telephonic, electronic, or written communication, or in-person contact, at the direction of, or in cooperation with, a health care provider when the person knows or has reason to know that the provider’s purpose is to perform or obtain services or benefits under or relating to a contract of motor vehicle insurance. The term runner, capper, or steerer does not include a person who solicits or procures clients either through public media, or consistent with the requirements of section 65B.54, subdivision 6. Subd. 2. Act constituting. Whoever employs, uses, or acts as a runner, capper, or steerer is guilty of a felony and may be sentenced to imprisonment for not more than three years or to a payment of a fine of not more than $6,000, or both. Charges for any services rendered by a health care provider, who violated this section in regard to the person for whom such services were rendered, are noncompensable and unenforceable as a matter of law. **State:** Minnesota **Statute Areas:** Anti-Runner Provisions --- ### [Minnesota-Claims Fraud-M.S.A. ¤ 609.611](https://insurancefraud.org/statutes/minnesota-claims-fraud-m-s-a-¤-609-611/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) Presents, causes to be presented, or prepares with knowledge or reason to believe that it will be presented, by or on behalf of an insured, claimant, or applicant to an insurer, insurance professional, or premium finance company in connection with an insurance transaction or premium finance transaction, any information that contains a false representation as to any material fact, or that conceals a material fact concerning any of the following: (2) a claim for payment or benefit under an insurance policy; **State:** Minnesota **Statute Areas:** Claims Fraud --- ### [Minnesota-Fraud Bureau-M.S.A. ¤ 45.0135 (Proposed Legislation)](https://insurancefraud.org/statutes/minnesota-fraud-bureau-m-s-a-¤-45-0135-proposed-legislation/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Subd. 2a. Authorization. The commissioner may appoint peace officers, as defined in section 626.84, subdivision 1, paragraph (c), and establish a law enforcement agency, as defined in section 626.84, subdivision 1, paragraph (f), known as the Commerce Fraud Bureau, to conduct investigations, and to make arrests under sections 629.30 and 629.34. The jurisdiction of the law enforcement agency is limited to offenses related to insurance fraud. Subd. 2b. Duties. The Commerce Fraud Bureau shall: (1) review notices and reports of insurance fraud submitted by authorized insurers, their employees, and agents or producers; (2) respond to notifications or complaints of suspected insurance fraud generated by other law enforcement agencies, state or federal governmental units, or any other person; (3) initiate inquiries and conduct investigations when the bureau has reason to believe that insurance fraud has been or is being committed; and (4) report incidents of alleged insurance fraud disclosed by its investigations to appropriate law enforcement agencies, including, but not limited to, the attorney general, county attorneys, or any other appropriate law enforcement or regulatory agency, and shall assemble evidence, prepare charges, and otherwise assist any law enforcement authority having jurisdiction. Subd. 2c. Arrests and investigations. The initial processing of a person arrested by the Commerce Fraud Bureau for an offense within its jurisdiction is the responsibility of the bureau unless otherwise directed by the law enforcement agency with primary jurisdiction. Subsequent investigation shall be the responsibility of the bureau unless otherwise directed by the law enforcement agency with primary jurisdiction. At the request of the primary jurisdiction, the bureau may assist in a subsequent investigation being carried out by the primary jurisdiction. Subd. 2d. Policy for notice of investigations. The Commerce Fraud Bureau must develop a policy for notifying the law enforcement agency with primary jurisdiction when it has initiated investigation of any person within the jurisdiction of that agency. Subd. 2e. Chief law enforcement officer. The commissioner shall appoint a peace officer employed full time to be the chief law enforcement officer and to be responsible for the management of the Commerce Fraud Bureau. The chief law enforcement officer shall possess the necessary police and management experience to manage a law enforcement agency. The chief law enforcement officer may appoint, discipline, and discharge all employees of the bureau. All police managerial and supervisory personnel must be full-time employees of the bureau. Supervisory personnel must be on duty and available any time peace officers of the bureau are on duty. Subd. 2f. Compliance. Except as otherwise provided in this section, the Commerce Fraud Bureau shall comply with all statutes and administrative rules relating to the operation and management of a law enforcement agency. Subd. 3. Evidence, documentation, and related materials. If the bureau seeks evidence, documentation, and related materials pertinent to an investigation, and the matter is located outside of this state, the bureau may designate representatives, including officials of the state where the matter is located, to secure the matter or inspect the matter on its behalf. Subd. 4. Confidentiality and immunity. The provisions of chapter 13, including, but not limited to, section 13.82, apply to the classification, disclosure, and collection of data relating to the Commerce Fraud Bureau. Subd. 5. Annual report on activities and cost-effectiveness. The Commerce Fraud Bureau shall maintain records and information in order to produce an annual report of its activities as may be prescribed by the commissioner of commerce. The commissioner shall report annually to the house of representatives and senate standing committees with jurisdiction over insurance issues as to the activities of the bureau and the cost-effectiveness of the programs established by the bureau. Subd. 6. Insurance fraud prevention account. The insurance fraud prevention account is created in the state treasury. Money received from assessments under subdivision 7 and transferred from the automobile theft prevention account in sections 65B.84, subdivision 1, and 297I.11, subdivision 2, is deposited in the account. Money in this fund is appropriated to the commissioner of commerce for the purposes specified in this section and sections 60A.951 to 60A.956. Subd. 7. Assessment. Each insurer authorized to sell insurance in the state of Minnesota, including surplus lines carriers, and having Minnesota earned premium the previous calendar year shall remit an assessment to the commissioner for deposit in the insurance fraud prevention account on or before June 1 of each year. The amount of the assessment shall be based on the insurer’s total assets and on the insurer’s total written Minnesota premium, for the preceding fiscal year, as reported pursuant to section 60A.13. The assessment is calculated to be an amount up to the following: Total Assets Assessment Less than $100,000,000 $ 200 $100,000,000 to $1,000,000,000 $ 750 Over $1,000,000,000 $ 2,000 Minnesota Written Premium Assessment Less than $10,000,000 $ 200 $10,000,000 to $100,000,000 $ 750 Over $100,000,000 $ 2,000 For purposes of this subdivision, the following entities are not considered to be insurers authorized to sell insurance in the state of Minnesota: risk retention groups; or township mutuals organized under chapter 67A. Subd. 8. Investigations; health-related boards. (a) The Commerce Fraud Bureau may consult with the appropriate health-related board when a licensee, licensed under chapter 144E, 147, 148, 148B, or 150A, is suspected of insurance fraud. (b) The bureau shall, for any conviction involving or related to insurance, send copies of all public data in its possession to the appropriate health-related licensing board. Subd. 9. Administrative penalty for insurance fraud. (a) The commissioner may: (1) impose an administrative penalty against any person in an amount as set forth in paragraph (b) for each intentional act of insurance fraud or substantiated acts of attempted insurance fraud as defined in section 60A.951, subdivision 4, committed by that person; (2) order restitution to any person suffering loss as a result of the insurance fraud; and (3) order restitution to a company for the reasonable documented cost of any investigation in connection with the insurance fraud. (b) The administrative penalty for each violation described in paragraph (a) may be no more than: (1) $20,000 if the funds or the value of the property or services wrongfully obtained exceeds $5,000; (2) $10,000 if the funds or value of the property or services wrongfully obtained exceeds $1,000, but not more than $5,000; (3) $3,000 if the funds or value of the property or services wrongfully obtained is more than $500, but not more than $1,000; and (4) $1,000 if the funds or value of the property or services wrongfully obtained is $500 or less. (c) If an administrative penalty is not paid after all rights of appeal have been waived or exhausted, the commissioner may bring a civil action in a court of competent jurisdiction to collect the administrative penalty, including expenses and litigation costs, reasonable attorney fees, and interest. (d) This section does not affect a person’s right to seek recovery, including expenses and litigation costs, reasonable attorney fees, and interest, against any person that commits insurance fraud. (e) For purposes of this subdivision, “insurance fraud” has the meaning given in section 60A.951, subdivision 4. (f) Hearings under this subdivision must be conducted in accordance with chapter 14 and any other applicable law. (g) All revenues from penalties, expenses, costs, fees, and interest collected under paragraphs (a) to (c) shall be deposited in the insurance fraud prevention account under subdivision 6. **State:** Minnesota **Statute Areas:** Fraud Bureau --- ### [Minnesota-Immunity-M.S.A. ¤ 60A.952](https://insurancefraud.org/statutes/minnesota-immunity-m-s-a-¤-60a-952/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Subd. 3. Immunity from liability. If insurers, insurance support organizations as defined in section 72A.491, subdivision 12, agents acting on the insurers’ behalf, or authorized persons release information in good faith under this section, whether orally or in writing, they are immune from any liability, civil or criminal, for the release or reporting of the information. **State:** Minnesota **Statute Areas:** Immunity --- ### [Minnesota-Insurance Fraud - Definition-M.S.A. ¤ 609.611](https://insurancefraud.org/statutes/minnesota-insurance-fraud-definition-m-s-a-¤-609-611/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Subdivision 1. Insurance fraud prohibited. Whoever with the intent to defraud for the purpose of depriving another of property or for pecuniary gain, commits, or permits its employees or its agents to commit any of the following acts, is guilty of insurance fraud and may be sentenced as provided in subdivision 3: (a) Presents, causes to be presented, or prepares with knowledge or reason to believe that it will be presented, by or on behalf of an insured, claimant, or applicant to an insurer, insurance professional, or premium finance company in connection with an insurance transaction or premium finance transaction, any information that contains a false representation as to any material fact, or that conceals a material fact concerning any of the following: (1) an application for, rating of, or renewal of, an insurance policy; (2) a claim for payment or benefit under an insurance policy; (3) a payment made according to the terms of an insurance policy; (4) an application used in a premium finance transaction; (b) Presents, causes to be presented, or prepares with knowledge or reason to believe that it will be presented, to or by an insurer, insurance professional, or a premium finance company in connection with an insurance transaction or premium finance transaction, any information that contains a false representation as to any material fact, or that conceals a material fact, concerning any of the following: (1) a solicitation for sale of an insurance policy or purported insurance policy; (2) an application for certificate of authority; (3) the financial condition of an insurer; or (4) the acquisition, formation, merger, affiliation, or dissolution of an insurer; (c) Solicits or accepts new or renewal insurance risks by or for an insolvent insurer; (d) Removes the assets or any record of assets, transactions, and affairs or any material part thereof, from the home office or other place of business of an insurer, or from the place of safekeeping of an insurer, or destroys or sequesters the same from the Department of Commerce. (e) Diverts, misappropriates, converts, or embezzles funds of an insurer, insured, claimant, or applicant for insurance in connection with: (1) an insurance transaction; (2) the conducting of business activities by an insurer or insurance professional; or (3) the acquisition, formation, merger, affiliation, or dissolution of any insurer. Subd. 2. Statute of limitations. The applicable statute of limitations provision under section 628.26 shall not begin to run until the insurance company or law enforcement agency is aware of the fraud, but in no event may the prosecution be commenced later than seven years after the act has occurred. Subd. 3. Sentence. Whoever violates this provision may be sentenced as provided in section 609.52, subdivision 3, based on the greater of (i) the value of property, services, or other benefit wrongfully obtained or attempted to obtain, or (ii) the aggregate economic loss suffered by any person as a result of the violation. A person convicted of a violation of this section must be ordered to pay restitution to persons aggrieved by the violation. Restitution must be ordered in addition to a fine or imprisonment but not in lieu of a fine or imprisonment. Subd. 4. Definitions. (a) “Insurance policy” means the written instrument in which are set forth the terms of any certificate of insurance, binder of coverage, or contract of insurance (including a certificate, binder, or contract issued by a state-assigned risk plan); benefit plan; nonprofit hospital service plan; motor club service plan; or surety bond, cash bond, or any other alternative to insurance authorized by a state’s Financial Responsibility Act. (b) “Insurance professional” means sales agents, agencies, managing general agents, brokers, producers, claims representatives, adjusters, and third-party administrators. (c) “Insurance transaction” means a transaction by, between, or among: (1) an insurer or a person who acts on behalf of an insurer; and (2) an insured, claimant, applicant for insurance, public adjuster, insurance professional, practitioner, or any person who acts on behalf of any of the foregoing, for the purpose of obtaining insurance or reinsurance, calculating insurance premiums, submitting a claim, negotiating or adjusting a claim, or otherwise obtaining insurance, self-insurance, or reinsurance or obtaining the benefits thereof or therefrom. (d) “Insurer” means a person purporting to engage in the business of insurance or authorized to do business in the state or subject to regulation by the state, who undertakes to indemnify another against loss, damage, or liability arising from a contingent or unknown event. Insurer includes, but is not limited to, an insurance company; self-insurer; reinsurer; reciprocal exchange; interinsurer; risk retention group; Lloyd’s insurer; fraternal benefit society; surety; medical service, dental, optometric, or any other similar health service plan; and any other legal entity engaged or purportedly engaged in the business of insurance, including any person or entity that falls within the definition of insurer found within section 60A.951, subdivision 5. (e) “Premium” means consideration paid or payable for coverage under an insurance policy. Premium includes any payment, whether due within the insurance policy term or otherwise, and any deductible payment, whether advanced by the insurer or insurance professional and subject to reimbursement by the insured or otherwise, any self-insured retention or payment, whether advanced by the insurer or insurance professional and subject to reimbursement by the insured or otherwise, and any collateral or security to be provided to collateralize obligations to pay any of the above. (f) “Premium finance company” means a person engaged or purporting to engage in the business of advancing money, directly or indirectly, to an insurer or producer at the request of an insured under the terms of a premium finance agreement, including but not limited to, loan contracts, notes, agreements or obligations, wherein the insured has assigned the unearned premiums, accrued dividends, or loss payments as security for such advancement in payment of premiums on insurance policies only, but does not include the financing of insurance premiums purchased in connection with the financing of goods or services. (g) “Premium finance transaction” means a transaction by, between, or among an insured, a producer or other party claiming to act on behalf of an insured and a third-party premium finance company, for the purposes of purportedly or actually advancing money directly or indirectly to an insurer or producer at the request of an insured under the terms of a premium finance agreement, wherein the insured has assigned the unearned premiums, accrued dividends, or loan payments as security for such advancement in payment of premiums on insurance policies only, but does not include the financing of insurance premiums purchased in connection with the financing of goods or services. **State:** Minnesota **Statute Areas:** Insurance Fraud - Definition --- ### [Minnesota-Licensing Board Notification-M.S.A. ¤ 60A.952](https://insurancefraud.org/statutes/minnesota-licensing-board-notification-m-s-a-¤-60a-952/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Subdivision 1. Request. After receiving a written request from an authorized person stating that the authorized person has reason to believe that a crime or civil fraud has been committed in connection with an insurance claim, insurance transaction, payment, or application, an insurer must release to the authorized person all relevant information in the insurer’s possession. Subd. 2. Notice to and cooperation with the Commerce Fraud Bureau. Any insurer or insurance professional that has reasonable belief that an act of insurance fraud will be, is being, or has been committed, shall furnish and disclose all relevant information to the Commerce Fraud Bureau or to any authorized person and cooperate fully with any investigation conducted by the Commerce Fraud Bureau. Any person that has a reasonable belief that an act of insurance fraud will be, is being, or has been committed, or any person who collects, reviews, or analyzes information concerning insurance fraud may furnish and disclose any information in its possession concerning the act to the Commerce Fraud Bureau, any authorized person, or to an authorized representative of an insurer that requests the information for the purpose of detecting, prosecuting, or preventing insurance fraud. The insurer may also release relevant information to any person authorized to receive the information under section 72A.502, subdivision 2. If disclosure is made to an authorized person other than the Commerce Fraud Bureau, a copy of the disclosure must be sent to the Commerce Fraud Bureau. Subd. 3. Immunity from liability. If insurers, insurance support organizations as defined in section 72A.491, subdivision 12, agents acting on the insurers’ behalf, or authorized persons release information in good faith under this section, whether orally or in writing, they are immune from any liability, civil or criminal, for the release or reporting of the information. Subd. 4. Tolling of time periods. If an insurer has a reasonable or probable cause to believe that an insurance fraud has been committed in connection with an insurance claim, and has properly notified the Commerce Fraud Bureau of its suspicions according to subdivision 2, the notification tolls any applicable time period in any unfair claims practices statute or related regulations, or any action on the claim against the insurer to whom the claim had been presented for bad faith, until 30 days after determination by the Commerce Fraud Bureau and notice to the insurer that the division will not recommend action on the claim. Subd. 5. Reward for information. The Commerce Fraud Bureau, in cooperation with authorized insurers and insurance professionals, may establish a voluntary fund to reward persons not connected with the insurance industry who provide information or furnish evidence leading to the arrest and conviction of persons responsible for insurance fraud. **State:** Minnesota --- ### [Minnesota-Looting & diverting-M.S.A. ¤ 609.611](https://insurancefraud.org/statutes/minnesota-looting-diverting-m-s-a-¤-609-611/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Subdivision 1. Insurance fraud prohibited. Whoever with the intent to defraud for the purpose of depriving another of property or for pecuniary gain, commits, or permits its employees or its agents to commit any of the following acts, is guilty of insurance fraud and may be sentenced as provided in subdivision 3: (e) Diverts, misappropriates, converts, or embezzles funds of an insurer, insured, claimant, or applicant for insurance in connection with: (1) an insurance transaction; (2) the conducting of business activities by an insurer or insurance professional; or (3) the acquisition, formation, merger, affiliation, or dissolution of any insurer. **State:** Minnesota --- ### [Minnesota-Mandatory Restitution-M.S.A. ¤ 609.611](https://insurancefraud.org/statutes/minnesota-mandatory-restitution-m-s-a-¤-609-611/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Subd. 3. Sentence. Whoever violates this provision may be sentenced as provided in section 609.52, subdivision 3, based on the greater of (i) the value of property, services, or other benefit wrongfully obtained or attempted to obtain, or (ii) the aggregate economic loss suffered by any person as a result of the violation. A person convicted of a violation of this section must be ordered to pay restitution to persons aggrieved by the violation. Restitution must be ordered in addition to a fine or imprisonment but not in lieu of a fine or imprisonment. **State:** Minnesota **Statute Areas:** Mandatory Restitution --- ### [Minnesota-Placing Bogus Coverage-M.S.A. ¤ 609.611](https://insurancefraud.org/statutes/minnesota-placing-bogus-coverage-m-s-a-¤-609-611/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Subdivision 1. Insurance fraud prohibited. Whoever with the intent to defraud for the purpose of depriving another of property or for pecuniary gain, commits, or permits its employees or its agents to commit any of the following acts, is guilty of insurance fraud and may be sentenced as provided in subdivision 3: (a) Presents, causes to be presented, or prepares with knowledge or reason to believe that it will be presented, by or on behalf of an insured, claimant, or applicant to an insurer, insurance professional, or premium finance company in connection with an insurance transaction or premium finance transaction, any information that contains a false representation as to any material fact, or that conceals a material fact concerning any of the following: (1) an application for, rating of, or renewal of, an insurance policy; (2) a claim for payment or benefit under an insurance policy; (3) a payment made according to the terms of an insurance policy; (4) an application used in a premium finance transaction; **State:** Minnesota --- ### [Minnesota-Premium Fraud-M.S.A. ¤ 609.611](https://insurancefraud.org/statutes/minnesota-premium-fraud-m-s-a-¤-609-611/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Subdivision 1. Insurance fraud prohibited. Whoever with the intent to defraud for the purpose of depriving another of property or for pecuniary gain, commits, or permits its employees or its agents to commit any of the following acts, is guilty of insurance fraud and may be sentenced as provided in subdivision 3: (a) Presents, causes to be presented, or prepares with knowledge or reason to believe that it will be presented, by or on behalf of an insured, claimant, or applicant to an insurer, insurance professional, or premium finance company in connection with an insurance transaction or premium finance transaction, any information that contains a false representation as to any material fact, or that conceals a material fact concerning any of the following: (1) an application for, rating of, or renewal of, an insurance policy; (2) a claim for payment or benefit under an insurance policy; (3) a payment made according to the terms of an insurance policy; (4) an application used in a premium finance transaction; **State:** Minnesota **Statute Areas:** Premium Fraud --- ### [Minnesota-Range of Criminal Penalties-M.S.A. ¤ 609.52 (Proposed Legislation)](https://insurancefraud.org/statutes/minnesota-range-of-criminal-penalties-m-s-a-¤-609-52-proposed-legislation/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Subd. 3. Sentence. Whoever commits theft may be sentenced as follows: (1) to imprisonment for not more than 20 years or to payment of a fine of not more than $100,000, or both, if the property is a firearm, or the value of the property or services stolen is more than $35,000 and the conviction is for a violation of subdivision 2, clause (3), (4), (15), or (16), or section 609.2335, subdivision 1, clause (1) or (2), item (i); or (2) to imprisonment for not more than ten years or to payment of a fine of not more than $20,000, or both, if the value of the property or services stolen exceeds $5,000, or if the property stolen was an article representing a trade secret, an explosive or incendiary device, or a controlled substance listed in Schedule I or II pursuant to section 152.02 with the exception of marijuana; or (3) to imprisonment for not more than five years or to payment of a fine of not more than $10,000, or both, if any of the following circumstances exist: (a) the value of the property or services stolen is more than $1,000 but not more than $5,000; or (b) the property stolen was a controlled substance listed in Schedule III, IV, or V pursuant to section 152.02; or (c) the value of the property or services stolen is more than $500 but not more than $1,000 and the person has been convicted within the preceding five years for an offense under this section, section 256.98; 268.182; 609.24; 609.245; 609.53; 609.582, subdivision 1, 2, or 3; 609.625; 609.63; 609.631; or 609.821, or a statute from another state, the United States, or a foreign jurisdiction, in conformity with any of those sections, and the person received a felony or gross misdemeanor sentence for the offense, or a sentence that was stayed under section 609.135 if the offense to which a plea was entered would allow imposition of a felony or gross misdemeanor sentence; or **State:** Minnesota **Statute Areas:** Range of Criminal Penalties --- ### [Minnesota-Range of Civil Penalties-M.S.A. ¤ 609.611](https://insurancefraud.org/statutes/minnesota-range-of-civil-penalties-m-s-a-¤-609-611/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Subd. 3. Sentence. Whoever violates this provision may be sentenced as provided in section 609.52, subdivision 3, based on the greater of (i) the value of property, services, or other benefit wrongfully obtained or attempted to obtain, or (ii) the aggregate economic loss suffered by any person as a result of the violation. A person convicted of a violation of this section must be ordered to pay restitution to persons aggrieved by the violation. Restitution must be ordered in addition to a fine or imprisonment but not in lieu of a fine or imprisonment. **State:** Minnesota **Statute Areas:** Range of Civil Penalties --- ### [Minnesota-Rating of an Insurance Policy-M.S.A. ¤ 70A.04](https://insurancefraud.org/statutes/minnesota-rating-of-an-insurance-policy-m-s-a-¤-70a-04/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Subdivision 1. Prohibitions. Rates shall not be excessive, inadequate or unfairly discriminatory, nor shall an insurer use rates to engage in unfair price competition. Subd. 2. Excessiveness; market test. (a) Rates are presumed not to be excessive if a reasonable degree of price competition exists at the consumer level with respect to the class of business to which they apply. In determining whether a reasonable degree of price competition exists, the commissioner shall consider all relevant tests. In addition to any other manner of determining whether a reasonable degree of price competition exists with respect to any class of insurance, it is presumed that a reasonable degree of competition does not exist if less than five insurers write more than 75 percent of the direct written premiums. (b) If such competition does not exist, rates are excessive if they are likely to produce a long-run profit that is unreasonably high in relation to the riskiness of the class of business, or if expenses are unreasonably high in relation to the services rendered. In determining whether an excessive rate is being charged by an individual insurer for a class of insurance where a reasonable degree of competition does not exist, the commissioner shall determine whether the rate charged produces a rate of return that is not in excess of a reasonable rate of return. To determine what is a reasonable rate of return, the riskiness of the class of insurance, the profitability of the insurer in that class of business, and other relevant factors shall be considered. Subd. 3. Solidity of insurer. Rates are inadequate only if they will endanger the solidity of an insurer that uses them or if they are insufficient to sustain projected losses and expenses within the state. Rates are conclusively presumed to be adequate if they are sufficient to sustain projected losses and expenses within the state. Subd. 4. Discriminatory rates. One rate is unfairly discriminatory in relation to another if it clearly fails to reflect equitably the differences in expected losses, expenses and the degree of risk. Rates are not unfairly discriminatory because different premiums result for policyholders with like loss exposures but different expense factors, or like expense factors but different loss exposures, so long as the rates reflect the differences with reasonable accuracy. Rates are not unfairly discriminatory if they attempt to spread risk broadly among persons insured under a group, franchise or blanket policy. Subd. 5. Unfair price competition. Unfair price competition exists if an insurer charges any rate for the purpose of securing an unfair competitive advantage, or if the use of the rate has or tends to have or if continued will have or tend to have the effect of destroying competition or creating a monopoly. **State:** Minnesota --- ### [Minnesota-Underwriting Fraud-M.S.A. ¤ 609.611](https://insurancefraud.org/statutes/minnesota-underwriting-fraud-m-s-a-¤-609-611/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (b) Presents, causes to be presented, or prepares with knowledge or reason to believe that it will be presented, to or by an insurer, insurance professional, or a premium finance company in connection with an insurance transaction or premium finance transaction, any information that contains a false representation as to any material fact, or that conceals a material fact, concerning any of the following: (1) a solicitation for sale of an insurance policy or purported insurance policy; (2) an application for certificate of authority; (3) the financial condition of an insurer; or (4) the acquisition, formation, merger, affiliation, or dissolution of an insurer; (c) Solicits or accepts new or renewal insurance risks by or for an insolvent insurer; (d) Removes the assets or any record of assets, transactions, and affairs or any material part thereof, from the home office or other place of business of an insurer, or from the place of safekeeping of an insurer, or destroys or sequesters the same from the Department of Commerce. (e) Diverts, misappropriates, converts, or embezzles funds of an insurer, insured, claimant, or applicant for insurance in connection with: (1) an insurance transaction; (2) the conducting of business activities by an insurer or insurance professional; or (3) the acquisition, formation, merger, affiliation, or dissolution of any insurer. **State:** Minnesota **Statute Areas:** Underwriting Fraud --- ### [Minnesota-Unauthorized Entities-M.S.A. ¤ 72A.41](https://insurancefraud.org/statutes/minnesota-unauthorized-entities-m-s-a-¤-72a-41/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Subdivision 1. Prohibition; exception. It is unlawful for any company to enter into a contract of insurance as an insurer or to transact insurance business in this state, as set forth in subdivision 2, without a certificate of authority from the commissioner; provided that this subdivision does not apply to: (a) contracts of insurance procured by agents under the authority of sections 60A.195 to 60A.209; (b) contracts of reinsurance and contracts of ocean or wet marine and transportation insurance; (c) transactions in this state involving a policy lawfully solicited, written and delivered outside of this state covering only subjects of insurance not resident, located, or expressly to be performed in this state at the time of issuance and which transactions are subsequent to the issuance of the policy; (d) transactions in this state involving a policy of insurance or annuity issued prior to July 1, 1967; (e) contract of insurance procured under the authority of section 60A.198, subdivision 8; or (f) transactions in this state involving contracts of insurance covering property or risks not located in this state. Subd. 2. Acts constituting. Any of the following acts in this state, effected by mail or otherwise by an unauthorized insurer, shall be included among those deemed to constitute transacting insurance business in this state: (a) the issuance or delivery of a contract of insurance or annuity to a resident of this state; (b) the solicitation of an application for such a contract; (c) the collection of a premium, membership fee, assessment or other consideration for such a contract; or (d) the transaction of any matter subsequent to the execution of such a contract and arising out of it. Subd. 3. Failure to obtain certificate. The failure of a company to obtain a certificate of authority shall not impair the validity of any act or contract of such company and shall not prevent such company from defending any action in any court of this state, but no company transacting insurance business in this state without a certificate of authority shall be permitted to maintain an action in any court of this state to enforce any right, claim or demand arising out of the transaction of such business until such company shall have obtained a certificate of authority. Nor shall an action be maintained in any court of this state by any successor or assignee of such company on any such right, claim or demand originally held by such company until a certificate of authority shall have been obtained by such company or by a company which has acquired all or substantially all of its assets. **State:** Minnesota --- ### [Michigan-Aiding & Abetting-M.C.L.A. 500.4503 (Proposed Legislation)](https://insurancefraud.org/statutes/michigan-aiding-abetting-m-c-l-a-500-4503-proposed-legislation/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Sec. 4503. A fraudulent insurance act includes, but is not limited to, acts or omissions committed by any person who knowingly, and with an intent to injure, defraud, or deceive: (b) Prepares or assists, abets, solicits, or conspires with another to prepare or make an oral or written statement that is intended to be presented to or by any insurer in connection with, or in support of, any application for the issuance of an insurance policy, knowing that the statement contains any false information concerning any fact or thing material to the application. (d) Assists, abets, solicits, or conspires with another to prepare or make any oral or written statement including computer-generated documents that is intended to be presented to or by any insurer in connection with, or in support of, any claim for payment or other benefit pursuant to an insurance policy, knowing that the statement contains any false information concerning any fact or thing material to the claim. **State:** Michigan --- ### [Michigan-Anti-Runner Provisions-M.C.L.A. 500.4503 (Proposed Legislation)](https://insurancefraud.org/statutes/michigan-anti-runner-provisions-m-c-l-a-500-4503-proposed-legislation/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Sec. 4503. A fraudulent insurance act includes, but is not limited to, acts or omissions committed by any person who knowingly, and with an intent to injure, defraud, or deceive: (h) Employs, uses, or acts as a runner, capper, or steerer with the intent to falsely or fraudulently obtain benefits under a contract of insurance or to falsely or fraudulently assert a claim against an insured or an insurer for providing services to the client, patient, or customer. **State:** Michigan **Statute Areas:** Anti-Runner Provisions --- ### [Michigan-Attempted Fraud-M.C.L.A. 500.4503 (Proposed Legislation)](https://insurancefraud.org/statutes/michigan-attempted-fraud-m-c-l-a-500-4503-proposed-legislation/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Sec. 4503. A fraudulent insurance act includes, but is not limited to, acts or omissions committed by any person who knowingly, and with an intent to injure, defraud, or deceive: (f) Removes or attempts to remove the assets or records of assets, transactions, and affairs, or a material part of the assets or records, from the home office or other place of business of the insurer or from the place of safekeeping of the insurer, or who conceals or attempts to conceal the assets or record of assets, transactions, and affairs, or a material part of the assets or records, from the commissioner. (g) Diverts, attempts to divert, or conspires to divert funds of an insurer or of other persons in connection with any of the following: (i) The transaction of insurance or reinsurance. (ii) The conduct of business activities by an insurer. (iii) The formation, acquisition, or dissolution of an insurer. **State:** Michigan **Statute Areas:** Attempted Fraud --- ### [Michigan-Claims Fraud-M.C.L.A. 500.4503 (Proposed Legislation)](https://insurancefraud.org/statutes/michigan-claims-fraud-m-c-l-a-500-4503-proposed-legislation/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Sec. 4503. A fraudulent insurance act includes, but is not limited to, acts or omissions committed by any person who knowingly, and with an intent to injure, defraud, or deceive: (a) Presents, causes to be presented, or prepares with knowledge or belief that it will be presented to or by an insurer or any agent of an insurer, or any agent of an insurer, reinsurer, or broker any oral or written statement knowing that the statement contains any false information concerning any fact material to an application for the issuance of an insurance policy. (b) Prepares or assists, abets, solicits, or conspires with another to prepare or make an oral or written statement that is intended to be presented to or by any insurer in connection with, or in support of, any application for the issuance of an insurance policy, knowing that the statement contains any false information concerning any fact or thing material to the application. (c) Presents or causes to be presented to or by any insurer, any oral or written statement including computer-generated information as part of, or in support of, a claim for payment or other benefit pursuant to an insurance policy, knowing that the statement contains false information concerning any fact or thing material to the claim. (d) Assists, abets, solicits, or conspires with another to prepare or make any oral or written statement including computer-generated documents that is intended to be presented to or by any insurer in connection with, or in support of, any claim for payment or other benefit pursuant to an insurance policy, knowing that the statement contains any false information concerning any fact or thing material to the claim. **State:** Michigan **Statute Areas:** Claims Fraud --- ### [Michigan-Immunity-M.C.L.A. 500.4509](https://insurancefraud.org/statutes/michigan-immunity-m-c-l-a-500-4509/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Sec. 4509. (1) A person acting without malice is not subject to liability for filing a report or requesting or furnishing orally or in writing other information concerning suspected or completed insurance fraud, if the reports or information are provided to or received from the insurance bureau, the national association of insurance commissioners, any federal, state, or governmental agency established to detect and prevent insurance fraud, as well as any other organization, and their agents, employees, or designees, unless that person knows that the report or other information contains false information pertaining to any material fact or thing. (2) In a prosecution for perjury or insurance fraud, and in the absence of malice, an insurer, or any officer, employee, or agent of an insurer, or any private person who cooperates with, furnishes evidence, or provides or receives information regarding suspected insurance fraud to or from an authorized agency, the national association of insurance commissioners, or any organization, or who complies with an order issued by a court acting in response to a request by any of these entities to provide evidence or testimony, is not subject to civil liability with respect to any act concerning the suspected insurance fraud that the person testifies to or produces relevant matter, unless that person knows that the evidence, information, testimony, or matter contains false information pertaining to any material fact or thing. (3) In the absence of malice, an insurer, or any officer, employee, or agent of an insurer, or any person who cooperates with, furnishes evidence, or provides information regarding suspected insurance fraud to an authorized agency, the national association of insurance commissioners, or any organization, or who complies with an order issued by a court of competent jurisdiction acting in response to a request by any of these entities to furnish evidence or provide testimony, is not subject to civil liability for libel, slander, or any other tort, and a civil cause of action of any nature does not exist against the person, for filing a report, providing information, or otherwise cooperating with an investigation or examination of any of these entities, unless that person knows that the evidence, information, testimony, or matter contains false information pertaining to any material fact or thing. (4) The authorized agency, the national association of insurance commissioners, or any organization, and any employee or agent of any of these entities, when acting without malice, is not subject to civil liability for libel, slander, or any other tort, and a civil cause of action of any nature does not exist against the person for official activities or duties of the entity because of the publication of any report or bulletin related to the entity’s official activities or duties, unless the report or bulletin contains false information concerning any material fact or thing and the authorized agency, the national association of insurance commissioners, an organization, or an employee or agent of these entities knows that the information is false. (5) This section does not abrogate or modify in any way common law or statutory privilege or immunity otherwise available to any person or entity. **State:** Michigan **Statute Areas:** Immunity --- ### [Michigan-Insurance Fraud - Definition-M.C.L.A. 500.4503 (Proposed Legislation)](https://insurancefraud.org/statutes/michigan-insurance-fraud-definition-m-c-l-a-500-4503-proposed-legislation/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Sec. 4503. A fraudulent insurance act includes, but is not limited to, acts or omissions committed by any person who knowingly, and with an intent to injure, defraud, or deceive: (a) Presents, causes to be presented, or prepares with knowledge or belief that it will be presented to or by an insurer or any agent of an insurer, or any agent of an insurer, reinsurer, or broker any oral or written statement knowing that the statement contains any false information concerning any fact material to an application for the issuance of an insurance policy. (b) Prepares or assists, abets, solicits, or conspires with another to prepare or make an oral or written statement that is intended to be presented to or by any insurer in connection with, or in support of, any application for the issuance of an insurance policy, knowing that the statement contains any false information concerning any fact or thing material to the application. (c) Presents or causes to be presented to or by any insurer, any oral or written statement including computer-generated information as part of, or in support of, a claim for payment or other benefit pursuant to an insurance policy, knowing that the statement contains false information concerning any fact or thing material to the claim. (d) Assists, abets, solicits, or conspires with another to prepare or make any oral or written statement including computer-generated documents that is intended to be presented to or by any insurer in connection with, or in support of, any claim for payment or other benefit pursuant to an insurance policy, knowing that the statement contains any false information concerning any fact or thing material to the claim. (e) Solicits or accepts new or renewal insurance risks by or for an insolvent insurer. (f) Removes or attempts to remove the assets or records of assets, transactions, and affairs, or a material part of the assets or records, from the home office or other place of business of the insurer or from the place of safekeeping of the insurer, or who conceals or attempts to conceal the assets or record of assets, transactions, and affairs, or a material part of the assets or records, from the commissioner. (g) Diverts, attempts to divert, or conspires to divert funds of an insurer or of other persons in connection with any of the following: (i) The transaction of insurance or reinsurance. (ii) The conduct of business activities by an insurer. (iii) The formation, acquisition, or dissolution of an insurer. (h) Employs, uses, or acts as a runner, capper, or steerer with the intent to falsely or fraudulently obtain benefits under a contract of insurance or to falsely or fraudulently assert a claim against an insured or an insurer for providing services to the client, patient, or customer. (i) Knowingly and willfully assists, conspires with, or urges any person to fraudulently violate this act, or any person who due to that assistance, conspiracy, or urging knowingly and willfully benefits from the proceeds derived from the fraud. **State:** Michigan **Statute Areas:** Insurance Fraud - Definition --- ### [Michigan-Licensing Board Notification-M.C.L.A. 500.4507](https://insurancefraud.org/statutes/michigan-licensing-board-notification-m-c-l-a-500-4507/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Sec. 4507. (1) Upon written request by an authorized agency to an insurer, the insurer or an agent authorized by the insurer to act on its behalf may release to the authorized agency, at the authorized agency’s expense, any or all information that is considered important relating to any suspected insurance fraud. An authorized agency may release information on suspected insurance fraud to an insurer or an agent authorized by an insurer to act on its behalf upon a showing of good cause by the insurer or the insurer’s authorized agent. This information may include, but is not limited to, the following: (a) Insurance policy information relevant to an investigation, including any application for a policy. (b) Policy premium payment records that are available. (c) History of previous claims made by the insured. (d) Information relating to the investigation of the suspected insurance fraud, including statements of any person, proofs of loss, and notice of loss. (2) If an insurer knows or reasonably believes it knows the identity of a person who it has reason to believe committed a fraudulent insurance act or has knowledge of a suspected fraudulent insurance act that is reasonably believed not to have been reported to an authorized agency, then for the purpose of notification and investigation, the insurer or an agent authorized by an insurer to act on its behalf may notify an authorized agency of the knowledge or belief and provide any additional information in accordance with subsection (1). (3) An insurer providing information to an authorized agency pursuant to subsection (2) has the right to request in writing information in the possession or control of the authorized agency relating to the same suspected fraudulent insurance act of which the insurer notifies the authorized agency under subsection (2). Upon a showing of good cause by the insurer, the authorized agency may provide the requested information at the insurer’s expense within 30 days of the request. (4) In addition to providing information to an insurer under subsection (3), the authorized agency provided with information pursuant to subsection (1) or (2) may release or provide the information to any other authorized agency. (5) Nothing in this chapter impairs a person’s right, as of the effective date of this chapter, to submit to the insurer or the insurer’s representative a statement fully explaining the basis of the claim and to have that statement placed in the claim file. (6) An authorized agency, insurer, or an agent authorized by an insurer to act on its behalf shall not request or release information under subsection (1) for any purpose other than for the investigation of suspected insurance fraud. **State:** Michigan --- ### [Michigan-Looting & diverting-M.C.L.A. 500.4503 (Proposed Legislation)](https://insurancefraud.org/statutes/michigan-looting-diverting-m-c-l-a-500-4503-proposed-legislation/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Sec. 4503. A fraudulent insurance act includes, but is not limited to, acts or omissions committed by any person who knowingly, and with an intent to injure, defraud, or deceive: (g) Diverts, attempts to divert, or conspires to divert funds of an insurer or of other persons in connection with any of the following: (i) The transaction of insurance or reinsurance. (ii) The conduct of business activities by an insurer. (iii) The formation, acquisition, or dissolution of an insurer. (h) Employs, uses, or acts as a runner, capper, or steerer with the intent to falsely or fraudulently obtain benefits under a contract of insurance or to falsely or fraudulently assert a claim against an insured or an insurer for providing services to the client, patient, or customer. (i) Knowingly and willfully assists, conspires with, or urges any person to fraudulently violate this act, or any person who due to that assistance, conspiracy, or urging knowingly and willfully benefits from the proceeds derived from the fraud. **State:** Michigan --- ### [Michigan-Placing Bogus Coverage-M.C.L.A. 500.4503 (Proposed Legislation)](https://insurancefraud.org/statutes/michigan-placing-bogus-coverage-m-c-l-a-500-4503-proposed-legislation/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Sec. 4503. A fraudulent insurance act includes, but is not limited to, acts or omissions committed by any person who knowingly, and with an intent to injure, defraud, or deceive: (a) Presents, causes to be presented, or prepares with knowledge or belief that it will be presented to or by an insurer or any agent of an insurer, or any agent of an insurer, reinsurer, or broker any oral or written statement knowing that the statement contains any false information concerning any fact material to an application for the issuance of an insurance policy. (b) Prepares or assists, abets, solicits, or conspires with another to prepare or make an oral or written statement that is intended to be presented to or by any insurer in connection with, or in support of, any application for the issuance of an insurance policy, knowing that the statement contains any false information concerning any fact or thing material to the application. (c) Presents or causes to be presented to or by any insurer, any oral or written statement including computer-generated information as part of, or in support of, a claim for payment or other benefit pursuant to an insurance policy, knowing that the statement contains false information concerning any fact or thing material to the claim. (d) Assists, abets, solicits, or conspires with another to prepare or make any oral or written statement including computer-generated documents that is intended to be presented to or by any insurer in connection with, or in support of, any claim for payment or other benefit pursuant to an insurance policy, knowing that the statement contains any false information concerning any fact or thing material to the claim. **State:** Michigan --- ### [Michigan-Range of Criminal Penalties-M.C.L.A. 500.4511](https://insurancefraud.org/statutes/michigan-range-of-criminal-penalties-m-c-l-a-500-4511/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Sec. 4511. (1) A person who commits a fraudulent insurance act under section 45031 is guilty of a felony punishable by imprisonment for not more than 4 years or a fine of not more than $50,000.00, or both, and shall be ordered to pay restitution as provided in section 1a of chapter IX of the code of criminal procedure, Act No. 175 of the Public Acts of 1927, being section 769.1a of the Michigan Compiled Laws, and in the crime victim’s rights act, Act No. 87 of the Public Acts of 1985, being sections 780.751 to 780.834 of the Michigan Compiled Laws. (2) A person who enters into an agreement or conspiracy to commit a fraudulent insurance act under section 4503 is guilty of a felony, punishable by imprisonment for not more than 10 years or by a fine of not more than $50,000.00, or both, and shall be ordered to pay restitution as provided in section 1a of chapter IX of the code of criminal procedure, Act No. 175 of the Public Acts of 1927, being section 769.1a of the Michigan Compiled Laws, and in the crime victim’s rights act, Act No. 87 of the Public Acts of 1985, being sections 780.751 to 780.834 of the Michigan Compiled Laws. (3) If the court finds a practitioner or insurer responsible for or guilty of a fraudulent insurance act under section 4503, the court shall notify the appropriate licensing authority in this state of the adjudication. **State:** Michigan **Statute Areas:** Range of Criminal Penalties --- ### [Michigan-Range of Civil Penalties-M.C.L.A. 500.4511](https://insurancefraud.org/statutes/michigan-range-of-civil-penalties-m-c-l-a-500-4511/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Sec. 4511. (1) A person who commits a fraudulent insurance act under section 45031 is guilty of a felony punishable by imprisonment for not more than 4 years or a fine of not more than $50,000.00, or both, and shall be ordered to pay restitution as provided in section 1a of chapter IX of the code of criminal procedure, Act No. 175 of the Public Acts of 1927, being section 769.1a of the Michigan Compiled Laws, and in the crime victim’s rights act, Act No. 87 of the Public Acts of 1985, being sections 780.751 to 780.834 of the Michigan Compiled Laws. (2) A person who enters into an agreement or conspiracy to commit a fraudulent insurance act under section 4503 is guilty of a felony, punishable by imprisonment for not more than 10 years or by a fine of not more than $50,000.00, or both, and shall be ordered to pay restitution as provided in section 1a of chapter IX of the code of criminal procedure, Act No. 175 of the Public Acts of 1927, being section 769.1a of the Michigan Compiled Laws, and in the crime victim’s rights act, Act No. 87 of the Public Acts of 1985, being sections 780.751 to 780.834 of the Michigan Compiled Laws. (3) If the court finds a practitioner or insurer responsible for or guilty of a fraudulent insurance act under section 4503, the court shall notify the appropriate licensing authority in this state of the adjudication. **State:** Michigan **Statute Areas:** Range of Civil Penalties --- ### [Michigan-Rating of an Insurance Policy-M.C.L.A. 500.2403](https://insurancefraud.org/statutes/michigan-rating-of-an-insurance-policy-m-c-l-a-500-2403/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Sec. 2403. (1) All rates shall be made in accordance with this section and all of the following: (a) Due consideration shall be given to past and prospective loss experience within and outside this state; to catastrophe hazards; to a reasonable margin for underwriting profit and contingencies; to dividends, savings, or unabsorbed premium deposits allowed or returned by insurers to their policyholders, members, or subscribers; to past and prospective expenses, both countrywide and those specially applicable to this state; to underwriting practice, judgment, and to all other relevant factors within and outside this state. For worker’s compensation insurance, in determining the reasonableness of the margin for underwriting profit and contingencies, consideration shall be given to all after-tax investment profit or loss from unearned premium and loss reserves attributable to worker’s compensation insurance, as well as the factors used to determine the amount of reserves. For all other kinds of insurance to which this chapter applies, all factors to which due consideration is given under this subdivision shall be treated in a manner consistent with the laws of this state that existed on December 28, 1981. (b) The systems of expense provisions included in the rates for use by any insurer or group of insurers may differ from those of other insurers or groups of insurers to reflect the requirements of the operating methods of the insurer or group with respect to any kind of insurance, or with respect to any subdivision or combination thereof for which subdivision or combination separate expense provisions are applicable. (c) Risks may be grouped by classifications for the establishment of rates and minimum premiums. Classification rates may be modified to produce rates for individual risks in accordance with rating plans that measure variations in hazards, expense provisions, or both. The rating plans may measure any differences among risks that may have a probable effect upon losses or expenses as provided for in subdivision (a). (d) Rates shall not be excessive, inadequate, or unfairly discriminatory. A rate shall not be held to be excessive unless the rate is unreasonably high for the insurance coverage provided and a reasonable degree of competition does not exist with respect to the classification, kind, or type of risks to which the rate is applicable. Except as otherwise provided in this subdivision, a rate shall not be held to be inadequate unless the rate is unreasonably low for the insurance coverage provided and the continued use of the rate endangers the solvency of the insurer; or unless the rate is unreasonably low for the insurance coverage provided and the use of the rate has or will have the effect of destroying competition among insurers, creating a monopoly, or causing a kind of insurance to be unavailable to a significant number of applicants who are in good faith entitled to procure the insurance through ordinary methods. For commercial liability insurance a rate shall not be held to be inadequate unless the rate, after consideration of investment income and marketing programs and underwriting programs, is unreasonably low for the insurance coverage provided and is insufficient to sustain projected losses and expenses; or unless the rate is unreasonably low for the insurance coverage provided and the use of the rate has or will have the effect of destroying competition among insurers, creating a monopoly, or causing a kind of insurance to be unavailable to a significant number of applicants who are in good faith entitled to procure the insurance through ordinary methods. As used in this subdivision, “commercial liability insurance” means insurance that provides indemnification for commercial, industrial, professional, or business liabilities. For worker’s compensation insurance provided by an insurer that is controlled by a nonprofit health care corporation formed pursuant to the nonprofit health care corporation reform act, Act No. 350 of the Public Acts of 1980, being sections 550.1101 to 550.1704 of the Michigan Compiled Laws, a rate shall not be held to be inadequate unless the rate is unreasonably low for the insurance coverage provided. A rate for a coverage is unfairly discriminatory in relation to another rate for the same coverage, if the differential between the rates is not reasonably justified by differences in losses, expenses, or both, or by differences in the uncertainty of loss for the individuals or risks to which the rates apply. A reasonable justification shall be supported by a reasonable classification system; by sound actuarial principles when applicable; and by actual and credible loss and expense statistics or, in the case of new coverages and classifications, by reasonably anticipated loss and expense experience. A rate is not unfairly discriminatory because the rate reflects differences in expenses for individuals or risks with similar anticipated losses, or because the rate reflects differences in losses for individuals or risks with similar expenses. Rates are not unfairly discriminatory if they are averaged broadly among persons insured on a group, franchise, blanket policy, or similar basis. (2) Except to the extent necessary to meet the provisions of subsection (1)(d), uniformity among insurers in any matters within the scope of this section is neither required nor prohibited. **State:** Michigan --- ### [Michigan-Underwriting Fraud-M.C.L.A. 500.4503 (Proposed Legislation)](https://insurancefraud.org/statutes/michigan-underwriting-fraud-m-c-l-a-500-4503-proposed-legislation/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Sec. 4503. A fraudulent insurance act includes, but is not limited to, acts or omissions committed by any person who knowingly, and with an intent to injure, defraud, or deceive: (e) Solicits or accepts new or renewal insurance risks by or for an insolvent insurer. (f) Removes or attempts to remove the assets or records of assets, transactions, and affairs, or a material part of the assets or records, from the home office or other place of business of the insurer or from the place of safekeeping of the insurer, or who conceals or attempts to conceal the assets or record of assets, transactions, and affairs, or a material part of the assets or records, from the commissioner. (g) Diverts, attempts to divert, or conspires to divert funds of an insurer or of other persons in connection with any of the following: (i) The transaction of insurance or reinsurance. (ii) The conduct of business activities by an insurer. (iii) The formation, acquisition, or dissolution of an insurer. **State:** Michigan **Statute Areas:** Underwriting Fraud --- ### [Michigan-Unauthorized Entities-M.C.L.A. 500.451](https://insurancefraud.org/statutes/michigan-unauthorized-entities-m-c-l-a-500-451/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Sec. 451. Any unauthorized insurer transacting insurance in this state shall be subject to a tax of 2% of premiums written in this state and to an additional regulatory fee of 0.5% on premiums written in this state. The tax required by this section shall be considered delinquent if not paid within 30 days after a copy of the computation of the tax by the commissioner is delivered to the insurer in the manner prescribed by law for the service of process. **State:** Michigan --- ### [Massachusetts-Aiding & Abetting-M.G.L.A. 266 ¤ 111A](https://insurancefraud.org/statutes/massachusetts-aiding-abetting-m-g-l-a-266-¤-111a/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Whoever, in connection with or in support of any claim under any policy of insurance issued by any company, as defined in section one of chapter one hundred and seventy-five, and with intent to injure, defraud or deceive such company, presents to it, or aids or abets in or procures the presentation to it of, any notice, statement, proof of loss, bill of lading, bill of parcels, invoice, schedule, account or other written document, whether or not the same is under oath or is required or authorized by law or by the terms of such policy, knowing that such notice, statement, proof of loss, bill of lading, bill of parcels, invoice, schedule, account or other written document contains any false or fraudulent statement or representation of any fact or thing material to such claim, or whoever with intent as aforesaid makes, prepares or subscribes, or aids or abets in or procures the making, preparation or subscription of, any such notice, statement, proof of loss, bill of lading, bill of parcels, invoice, schedule, account or other written document intended to be presented to any such company in connection with or in support of any claim under any such policy issued by it knowing that such notice, statement, proof of loss, bill of lading, bill of parcels, invoice, schedule, account or other written document contains any false or fraudulent statement or representation as aforesaid, shall, except as provided in section one hundred and ten or one hundred and eleven, be punished by imprisonment in the state prison for not more than five years or by imprisonment in jail for not less than six months nor more than two and one half years or by a fine of not less than $500 nor more than $10,000, or by both such fine and imprisonment in jail. **State:** Massachusetts --- ### [Massachusetts-Anti-Runner Provisions-M.G.L.A. 266 ¤ 111C](https://insurancefraud.org/statutes/massachusetts-anti-runner-provisions-m-g-l-a-266-¤-111c/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) As used in this section, the following words shall have the following meanings:– “Provider”, an attorney, a health care professional licensed pursuant to chapter 112, an owner or operator of a health care practice or facility, any person who creates the impression that he or his practice or facility can provide legal or health care services, or any person employed or acting on behalf of any of the aforementioned persons. “Public media”, telephone directories, professional directories, newspapers and other periodicals, radio and television, billboards and mailed or electronically transmitted written communications that do not involve in-person contact with a specific prospective client, patient or customer. “Runner”, a person who, for a pecuniary benefit, procures or attempts to procure a client, patient or customer at the direction of, request of, or in cooperation with a provider whose purpose is to seek to fraudulently obtain benefits under a contract of insurance or fraudulently assert a claim against an insured or an insurance carrier for providing services to the client, patient or customer. “Runner” shall not include a person who procures or attempts to procure clients, patients or customers for a provider through public media or a person who refers clients, patients or customers to a provider as otherwise authorized by law. (b) Whoever knowingly acts as a runner or uses, solicits, directs, hires or employs another to act as a runner for the purpose of defrauding an insured or an insurance carrier shall be punished by imprisonment in the state prison for not more than 5 years, by imprisonment in a jail or house of correction for not less than 6 months nor more than 2 \_ years or by a fine of not less than $1,000 nor more than $4,000. **State:** Massachusetts **Statute Areas:** Anti-Runner Provisions --- ### [Massachusetts-Claims Fraud-M.G.L.A. 266 ¤ 111A](https://insurancefraud.org/statutes/massachusetts-claims-fraud-m-g-l-a-266-¤-111a/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Whoever, in connection with or in support of any claim under any policy of insurance issued by any company, as defined in section one of chapter one hundred and seventy-five, and with intent to injure, defraud or deceive such company, presents to it, or aids or abets in or procures the presentation to it of, any notice, statement, proof of loss, bill of lading, bill of parcels, invoice, schedule, account or other written document, whether or not the same is under oath or is required or authorized by law or by the terms of such policy, knowing that such notice, statement, proof of loss, bill of lading, bill of parcels, invoice, schedule, account or other written document contains any false or fraudulent statement or representation of any fact or thing material to such claim, or whoever with intent as aforesaid makes, prepares or subscribes, or aids or abets in or procures the making, preparation or subscription of, any such notice, statement, proof of loss, bill of lading, bill of parcels, invoice, schedule, account or other written document intended to be presented to any such company in connection with or in support of any claim under any such policy issued by it knowing that such notice, statement, proof of loss, bill of lading, bill of parcels, invoice, schedule, account or other written document contains any false or fraudulent statement or representation as aforesaid, shall, except as provided in section one hundred and ten or one hundred and eleven, be punished by imprisonment in the state prison for not more than five years or by imprisonment in jail for not less than six months nor more than two and one half years or by a fine of not less than $500 nor more than $10,000, or by both such fine and imprisonment in jail. **State:** Massachusetts **Statute Areas:** Claims Fraud --- ### [Massachusetts-Failing to Remit Premium-n/a](https://insurancefraud.org/statutes/massachusetts-failing-to-remit-premium-n-a/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** No statute found **State:** Massachusetts --- ### [Massachusetts-Fraud Bureau-M.G.L.A. 26 ¤ 8B](https://insurancefraud.org/statutes/massachusetts-fraud-bureau-m-g-l-a-26-¤-8b/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** There shall be in the division of insurance a fraudulent claims board, hereinafter called the board, consisting of the commissioner of insurance or his designee, the registrar of motor vehicles or his designee, and the director of the state rating bureau or his designee. The commissioner of insurance or his designee shall be the chairman of the board. The board shall have authority to investigate all claims alleging loss or damages arising out of the ownership, operation, maintenance or use of a motor vehicle anywhere within the commonwealth, filed by a claimant against any person insured by an insurance company which has issued a policy of insurance providing protection or indemnity to the insured owner and to any other person operating, maintaining or using the motor vehicle with the consent, express or implied, of the insured; and any other claim covered by insurance resulting from the operation of a motor vehicle. Any company notified that such a claim is being made shall, within sixty days of the receipt of such notice, send to the board on a form prescribed by the board the information requested and such additional information relative to the accident and the parties claiming loss or damages because of the accident as the board may require. The board shall review such reports and select such claims as, in its judgment, may require further investigation. It shall then cause an independent examination of the facts surrounding such claim to be made to determine the extent, if any, to which fraud, deceit, misrepresentation or exaggeration of any kind exists in the submission of the claim and the extent to which improper practices on the part of insurance companies contribute to or encourage the making of fraudulent or exaggerated claims, or result in fraud, misrepresentation or deceit on the part of such companies, leading to higher costs of insurance or public dissatisfaction with the insurance laws of the commonwealth. The board shall report its findings annually on or before December the first, to the governor and the attorney general, and may recommend legislation as in its judgment will best eliminate such fraud, deceit, misrepresentation or exaggeration, or improper practices as it finds exists. The board may submit interim reports at such other times as it deems necessary and shall report any violations of law which its investigations disclose to the attorney general, or to the proper district attorney who shall cause the offender to be prosecuted therefor. The board, with the approval of the governor, may appoint and remove a chief of accident claims investigations. The board may expend for expenses and for such legal, investigative, clerical and other assistance such sums as may be appropriated therefor; provided, however, that all costs of administration and operation of said board shall be borne by liability insurance companies doing business within the commonwealth. The commissioner shall apportion such costs among all such companies and shall assess them for the same on a fair and reasonable basis. Investigators employed by the board shall have access to all records kept by the registry of motor vehicles and to such records kept by insurance companies as may be pertinent to the processing of such claims as are within the investigatory powers of the board. Whoever is convicted of a fraudulent claim as a result of a court judgment shall automatically lose his privilege to operate a motor vehicle for a period of one year. **State:** Massachusetts **Statute Areas:** Fraud Bureau --- ### [Massachusetts-Immunity-M.G.L.A 175I ¤ 21](https://insurancefraud.org/statutes/massachusetts-immunity-m-g-l-a-175i-¤-21/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** No cause of action in the nature of defamation, invasion of privacy or negligence shall arise against any person for disclosing personal or privileged information in accordance with this chapter; provided, however, this section shall provide no immunity: (1) for any person who discloses false information with malice or willful intent to injure any person; or (2) for any person who misidentifies an individual as the subject of information and who discloses such misidentified information to others. **State:** Massachusetts **Statute Areas:** Immunity --- ### [Massachusetts-Insurance Fraud - Definition-M.G.L.A. 266 ¤ 111A](https://insurancefraud.org/statutes/massachusetts-insurance-fraud-definition-m-g-l-a-266-¤-111a/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Whoever, in connection with or in support of any claim under any policy of insurance issued by any company, as defined in section one of chapter one hundred and seventy-five, and with intent to injure, defraud or deceive such company, presents to it, or aids or abets in or procures the presentation to it of, any notice, statement, proof of loss, bill of lading, bill of parcels, invoice, schedule, account or other written document, whether or not the same is under oath or is required or authorized by law or by the terms of such policy, knowing that such notice, statement, proof of loss, bill of lading, bill of parcels, invoice, schedule, account or other written document contains any false or fraudulent statement or representation of any fact or thing material to such claim, or whoever with intent as aforesaid makes, prepares or subscribes, or aids or abets in or procures the making, preparation or subscription of, any such notice, statement, proof of loss, bill of lading, bill of parcels, invoice, schedule, account or other written document intended to be presented to any such company in connection with or in support of any claim under any such policy issued by it knowing that such notice, statement, proof of loss, bill of lading, bill of parcels, invoice, schedule, account or other written document contains any false or fraudulent statement or representation as aforesaid, shall, except as provided in section one hundred and ten or one hundred and eleven, be punished by imprisonment in the state prison for not more than five years or by imprisonment in jail for not less than six months nor more than two and one half years or by a fine of not less than $500 nor more than $10,000, or by both such fine and imprisonment in jail. **State:** Massachusetts **Statute Areas:** Insurance Fraud - Definition --- ### [Massachusetts-Mandatory Restitution-M.G.L.A. 266 ¤ 111B (Proposed Legislation)](https://insurancefraud.org/statutes/massachusetts-mandatory-restitution-m-g-l-a-266-¤-111b-proposed-legislation/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** The court shall, after conviction, conduct an evidentiary hearing to ascertain the extent of the damages or financial loss suffered as a result of the defendant’s crime. A person found guilty of violating this section shall, in all cases, upon conviction, in addition to any other punishment, be ordered to make restitution to the insurer for any financial loss sustained as a result of the commission of the crime; provided, however, that restitution shall not be ordered to a party whom the court determines to be aggrieved without that party’s consent. Restitution shall be imposed in addition to incarceration or fine, and not in lieu thereof; provided, however, the court shall consider the defendant’s present and future ability to pay in its determinations regarding a fine; provided, further, that, whenever possible subject to the constraints of this paragraph and the first paragraph of this section, the amount of a fine imposed for a violation of this section shall equal twice the amount of damages or financial loss suffered as a result of the defendant’s crime. <\[ Fourth paragraph effective until April 13, 2018. For text effective April 13, 2018, see below.\]> In determining the amount, time and method of payment of restitution, the court shall consider the financial resources of the defendant and the burden restitution will impose on the defendant. Upon a real or impending change in financial circumstances, a defendant ordered to pay restitution may petition the court for a modification of the amount, time or method of payment of restitution. If the court finds that because of any such change the payment of restitution will impose an undue financial hardship on the defendant or his family, the court may modify the amount, time or method of payment, but may not grant complete remission from payment of restitution. <\[ Fourth paragraph as amended by 2018, 69, Sec. 151 effective April 13, 2018. For text effective until April 13, 2018, see above.\]> In determining the amount, time and method of payment of restitution, the court shall consider the financial resources of the defendant and the burden restitution will impose on the defendant. Upon a real or impending change in financial circumstances, a defendant ordered to pay restitution may petition the court for a modification of the amount, time or method of payment of restitution. If the court finds that because of any such change the payment of restitution will cause a substantial financial hardship to the defendant or the defendant’s immediate family or the defendant’s dependents, the court may grant remission from any payment of restitution or modify the amount, time or method of payment. If a defendant who is required to make restitution defaults in any payment of restitution or installment thereof, the court shall hold him in contempt unless said defendant has made a good faith effort to pay such restitution. If said defendant has made a good faith effort to pay such restitution, the court may modify the amount, time or method of payment, but may not grant complete remission from payment of restitution. Credits **State:** Massachusetts **Statute Areas:** Mandatory Restitution --- ### [Massachusetts-Practitioner Penalites-M.G.L.A. 175 ¤ 223D](https://insurancefraud.org/statutes/massachusetts-practitioner-penalites-m-g-l-a-175-¤-223d/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) If a person is found guilty of committing a fraudulent life settlement act, that person shall also be guilty of committing insurance fraud and shall be subject to additional penalties. (b) The commissioner may levy a civil penalty, not to exceed $10,000 for each violation, upon any person, including those persons and their employees licensed pursuant to sections 213 to 223E, inclusive, who is found to have committed a fraudulent life settlement act or violated any other provision of sections 213 to 223E, inclusive. (c) The license of a person licensed under sections 213 to 223E, inclusive, that has committed a fraudulent life settlement act shall be revoked for at least 1 year. **State:** Massachusetts **Statute Areas:** Practitioner Penalites --- ### [Massachusetts-Premium Fraud-M.G.L.A. 175 ¤ 170](https://insurancefraud.org/statutes/massachusetts-premium-fraud-m-g-l-a-175-¤-170/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** An insurance agent or broker who knowingly procures by fraudulent representations payment or the obligation for the payment of any premium on any policy of insurance or any annuity or pure endowment contract shall be punished by a fine of not less than one hundred nor more than one thousand dollars or by imprisonment for not more than one year. **State:** Massachusetts **Statute Areas:** Premium Fraud --- ### [Massachusetts-Range of Criminal Penalties-M.G.L.A. 266 ¤ 111A](https://insurancefraud.org/statutes/massachusetts-range-of-criminal-penalties-m-g-l-a-266-¤-111a/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Whoever, in connection with or in support of any claim under any policy of insurance issued by any company, as defined in section one of chapter one hundred and seventy-five, and with intent to injure, defraud or deceive such company, presents to it, or aids or abets in or procures the presentation to it of, any notice, statement, proof of loss, bill of lading, bill of parcels, invoice, schedule, account or other written document, whether or not the same is under oath or is required or authorized by law or by the terms of such policy, knowing that such notice, statement, proof of loss, bill of lading, bill of parcels, invoice, schedule, account or other written document contains any false or fraudulent statement or representation of any fact or thing material to such claim, or whoever with intent as aforesaid makes, prepares or subscribes, or aids or abets in or procures the making, preparation or subscription of, any such notice, statement, proof of loss, bill of lading, bill of parcels, invoice, schedule, account or other written document intended to be presented to any such company in connection with or in support of any claim under any such policy issued by it knowing that such notice, statement, proof of loss, bill of lading, bill of parcels, invoice, schedule, account or other written document contains any false or fraudulent statement or representation as aforesaid, shall, except as provided in section one hundred and ten or one hundred and eleven, be punished by imprisonment in the state prison for not more than five years or by imprisonment in jail for not less than six months nor more than two and one half years or by a fine of not less than $500 nor more than $10,000, or by both such fine and imprisonment in jail. **State:** Massachusetts **Statute Areas:** Range of Criminal Penalties --- ### [Massachusetts-Range of Civil Penalties-M.G.L.A. 266 ¤ 111A](https://insurancefraud.org/statutes/massachusetts-range-of-civil-penalties-m-g-l-a-266-¤-111a/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Whoever, in connection with or in support of any claim under any policy of insurance issued by any company, as defined in section one of chapter one hundred and seventy-five, and with intent to injure, defraud or deceive such company, presents to it, or aids or abets in or procures the presentation to it of, any notice, statement, proof of loss, bill of lading, bill of parcels, invoice, schedule, account or other written document, whether or not the same is under oath or is required or authorized by law or by the terms of such policy, knowing that such notice, statement, proof of loss, bill of lading, bill of parcels, invoice, schedule, account or other written document contains any false or fraudulent statement or representation of any fact or thing material to such claim, or whoever with intent as aforesaid makes, prepares or subscribes, or aids or abets in or procures the making, preparation or subscription of, any such notice, statement, proof of loss, bill of lading, bill of parcels, invoice, schedule, account or other written document intended to be presented to any such company in connection with or in support of any claim under any such policy issued by it knowing that such notice, statement, proof of loss, bill of lading, bill of parcels, invoice, schedule, account or other written document contains any false or fraudulent statement or representation as aforesaid, shall, except as provided in section one hundred and ten or one hundred and eleven, be punished by imprisonment in the state prison for not more than five years or by imprisonment in jail for not less than six months nor more than two and one half years or by a fine of not less than $500 nor more than $10,000, or by both such fine and imprisonment in jail. **State:** Massachusetts **Statute Areas:** Range of Civil Penalties --- ### [Massachusetts-Unauthorized Entities-M.G.L.A. 175 ¤ 3](https://insurancefraud.org/statutes/massachusetts-unauthorized-entities-m-g-l-a-175-¤-3/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** No company shall make a contract of insurance or annuity, including any such insurance or annuity contract which is a contract on a variable basis, upon or relative to any property or interests or lives in the commonwealth, or with any resident thereof, and no person shall negotiate, solicit, sell or in any manner aid in the transaction of such contracts, or of their continuance or renewal, except as authorized by this chapter or chapter one hundred and seventy-six, or except as otherwise expressly authorized by law; and any such contract and the negotiation, solicitation, sale or transaction thereof by any person shall not be subject to the provisions of chapter one hundred and ten A. **State:** Massachusetts --- ### [Maryland-Claims Fraud-MD Code, Insurance, ¤ 27-403](https://insurancefraud.org/statutes/maryland-claims-fraud-md-code-insurance-¤-27-403/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** It is a fraudulent insurance act for a person: (1) knowingly to fail to return any money or premiums paid for a policy to an insured, designee of the insured, or another person entitled to the money or premiums if the insurance contracted for is not ultimately provided; (2) to present or cause to be presented to an insurer documentation or an oral or written statement made in support of a claim, including a claim that alleges the theft of a motor vehicle, with knowledge that the documentation or statement contains false or misleading information about a matter material to the claim; (3) except for the prepayment of periodic payments or excess contributions allowed under the terms of the policy, willfully to collect as a premium a sum in excess of the premium applicable to the insurance under approved classifications and rates or, for cases in which classifications and rates are not subject to approval, the premiums and charges applicable to the insurance as specified in the policy and set by the insurer; (4) to misappropriate or withhold unreasonably funds received or held if the funds represent premiums or return premiums; (5) to misappropriate benefits under a policy; and (6) knowingly or willfully to present, or cause to be presented, documentation or an oral or written statement made in, with reference to, or in support of an application for a viatical settlement contract, the financing of a viatical settlement contract, the transfer of a viatical settlement contract, or the settlement in support of a claim made under a viatical settlement contract with knowledge that the documentation or statement contains false or misleading information about matters material to the application, financing, transfer, settlement, or claim. **State:** Maryland **Statute Areas:** Claims Fraud --- ### [Maryland-Failing to Remit Premium-MD Code, Insurance, ¤ 27-403](https://insurancefraud.org/statutes/maryland-failing-to-remit-premium-md-code-insurance-¤-27-403/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** It is a fraudulent insurance act for a person: (1) knowingly to fail to return any money or premiums paid for a policy to an insured, designee of the insured, or another person entitled to the money or premiums if the insurance contracted for is not ultimately provided; (2) to present or cause to be presented to an insurer documentation or an oral or written statement made in support of a claim, including a claim that alleges the theft of a motor vehicle, with knowledge that the documentation or statement contains false or misleading information about a matter material to the claim; (3) except for the prepayment of periodic payments or excess contributions allowed under the terms of the policy, willfully to collect as a premium a sum in excess of the premium applicable to the insurance under approved classifications and rates or, for cases in which classifications and rates are not subject to approval, the premiums and charges applicable to the insurance as specified in the policy and set by the insurer; (4) to misappropriate or withhold unreasonably funds received or held if the funds represent premiums or return premiums; (5) to misappropriate benefits under a policy; and (6) knowingly or willfully to present, or cause to be presented, documentation or an oral or written statement made in, with reference to, or in support of an application for a viatical settlement contract, the financing of a viatical settlement contract, the transfer of a viatical settlement contract, or the settlement in support of a claim made under a viatical settlement contract with knowledge that the documentation or statement contains false or misleading information about matters material to the application, financing, transfer, settlement, or claim. **State:** Maryland --- ### [Maryland-Fraud Bureau-MD Code, Insurance, ¤ 2-405](https://insurancefraud.org/statutes/maryland-fraud-bureau-md-code-insurance-¤-2-405/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** The Fraud Division: (1) has the authority to investigate each person suspected of engaging in insurance fraud; (2) if appropriate after an investigation: (i) shall refer suspected cases of insurance fraud to the Office of the Attorney General or appropriate local State’s Attorney to prosecute the person criminally for insurance fraud; (ii) shall notify the appropriate professional licensing board or disciplinary body of evidence of insurance fraud that involves professionals; (iii) shall notify the appropriate professional licensing board of evidence of gross overutilization of health care services; (iv) shall notify the Workers’ Compensation Commission of suspected cases of insurance fraud referred to the Office of the Attorney General or appropriate local State’s Attorney under subparagraph (i) of this paragraph that involve the payment of compensation, fees, or expenses under the Workers’ Compensation Law;1 and (v) shall assist local and State law enforcement agencies in the prosecution of automobile theft; (3) shall compile and abstract information that includes the number of confirmed acts of insurance fraud and the type of acts of insurance fraud; (4) in exercising its authority under this subtitle, shall cooperate with the Department of State Police, Office of the Attorney General, local State’s Attorney in the jurisdiction in which the alleged acts of insurance fraud took place, and appropriate federal and local law enforcement authorities; (5) shall operate or provide for a toll-free insurance fraud hot line to receive and record information about alleged acts of insurance fraud; (6) in cooperation with the Office of the Attorney General and Department of State Police, shall conduct public outreach and awareness programs on the costs of insurance fraud to the public; and (7) shall investigate allegations of civil fraud and, if appropriate after investigation, impose administrative penalties and order restitution in accordance with ¤ 27-408 of this article. **State:** Maryland **Statute Areas:** Fraud Bureau --- ### [Maryland-Immunity-MD Code, Insurance, ¤ 27-802](https://insurancefraud.org/statutes/maryland-immunity-md-code-insurance-¤-27-802/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a)(1) An authorized insurer, its employees, fund producers, insurance producers, a viatical settlement provider, or a viatical settlement broker who in good faith has cause to believe that insurance fraud has been or is being committed shall report the suspected insurance fraud in writing to the Commissioner, the Fraud Division, or the appropriate federal, State, or local law enforcement authorities. (2) An independent insurance producer shall meet the reporting requirement of this subsection by reporting the suspected insurance fraud in writing to the Fraud Division. (3) A registered premium finance company shall meet the requirement of this subsection by reporting suspected insurance fraud in writing to the Fraud Division. (4) A governmental self-insurance group formed in accordance with ¤ 9-404 of the Labor and Employment Article or an employer who self-insures or participates in a self-insurance group in accordance with ¤ 9-405 of the Labor and Employment Article shall meet the reporting requirement of this subsection by reporting suspected insurance fraud in writing to the Fraud Division. Information, documentation, or other evidence not subject to public inspection (b) In addition to any protection provided under Title 4, Subtitle 4, Part IV of the General Provisions Article, any information, documentation, or other evidence provided under this section by an insurer, its employees, fund producers, or insurance producers, a viatical settlement provider, a viatical settlement broker, an independent insurance producer, a registered premium finance company, a governmental self-insurance group, or an employer who self-insures or participates in a self-insurance group to the Commissioner, the Fraud Division, or a federal, State, or local law enforcement authority in connection with an investigation of suspected insurance fraud is not subject to public inspection for as long as the Commissioner, Fraud Division, or law enforcement authority considers the withholding to be necessary to complete an investigation of the suspected fraud or to protect the person investigated from unwarranted injury. Persons not subject to civil liability for reporting suspected insurance fraud (c) A person is not subject to civil liability for a cause of action by virtue of reporting suspected insurance fraud, or furnishing or receiving information relating to suspected, anticipated, or completed fraudulent insurance acts, if: (1) the report was made, or the information was furnished to or received from: (i) the Commissioner, Fraud Division, or an appropriate federal, State, or local law enforcement authority; (ii) the National Association of Insurance Commissioners or its agent, employee, or designee; (iii) a nonprofit organization established to detect and prevent fraudulent insurance acts or its agent, employee, or designee; (iv) a person that contracts to provide special investigative unit services to an insurer; or (v) a provider of a recognized comprehensive database system that the Commissioner approves to monitor activities involving insurance fraud or an employee of the provider; and (2) the person that reported the suspected insurance fraud, or furnished or received the information, acted in good faith when making the report or furnishing or receiving the information. **State:** Maryland **Statute Areas:** Immunity --- ### [Maryland-Insurance Fraud - Definition-MD Code, Insurance, ¤ 27-406](https://insurancefraud.org/statutes/maryland-insurance-fraud-definition-md-code-insurance-¤-27-406/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** It is a fraudulent insurance act for a person: (1) knowingly or willfully to make a false or fraudulent statement or representation in or with reference to an application for insurance; (2) to place insurance with an unauthorized insurer not regulated by the Commissioner and refuse to obey an order of the Commissioner to produce for examination all policies and other documents that evidence the insurance and the amount of premiums paid or agreed to be paid for the insurance; (3) if a certificate of authority is required, to operate an insurer or conduct an insurance business without obtaining a certificate of authority issued by the Commissioner; (4) to make a false sworn statement that the person does not believe to be true about matter material to an examination, investigation, or hearing conducted by the Commissioner; or (5) with intent to deceive, knowingly to exhibit a false account, document, or advertisement about the affairs of an insurer. **State:** Maryland **Statute Areas:** Insurance Fraud - Definition --- ### [Maryland-Licensing Board Notification-MD Code, Insurance, ¤ 27-802](https://insurancefraud.org/statutes/maryland-licensing-board-notification-md-code-insurance-¤-27-802/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a)(1) An authorized insurer, its employees, fund producers, insurance producers, a viatical settlement provider, or a viatical settlement broker who in good faith has cause to believe that insurance fraud has been or is being committed shall report the suspected insurance fraud in writing to the Commissioner, the Fraud Division, or the appropriate federal, State, or local law enforcement authorities. (2) An independent insurance producer shall meet the reporting requirement of this subsection by reporting the suspected insurance fraud in writing to the Fraud Division. (3) A registered premium finance company shall meet the requirement of this subsection by reporting suspected insurance fraud in writing to the Fraud Division. (4) A governmental self-insurance group formed in accordance with ¤ 9-404 of the Labor and Employment Article or an employer who self-insures or participates in a self-insurance group in accordance with ¤ 9-405 of the Labor and Employment Article shall meet the reporting requirement of this subsection by reporting suspected insurance fraud in writing to the Fraud Division. Information, documentation, or other evidence not subject to public inspection (b) In addition to any protection provided under Title 4, Subtitle 4, Part IV of the General Provisions Article, any information, documentation, or other evidence provided under this section by an insurer, its employees, fund producers, or insurance producers, a viatical settlement provider, a viatical settlement broker, an independent insurance producer, a registered premium finance company, a governmental self-insurance group, or an employer who self-insures or participates in a self-insurance group to the Commissioner, the Fraud Division, or a federal, State, or local law enforcement authority in connection with an investigation of suspected insurance fraud is not subject to public inspection for as long as the Commissioner, Fraud Division, or law enforcement authority considers the withholding to be necessary to complete an investigation of the suspected fraud or to protect the person investigated from unwarranted injury. Persons not subject to civil liability for reporting suspected insurance fraud (c) A person is not subject to civil liability for a cause of action by virtue of reporting suspected insurance fraud, or furnishing or receiving information relating to suspected, anticipated, or completed fraudulent insurance acts, if: (1) the report was made, or the information was furnished to or received from: (i) the Commissioner, Fraud Division, or an appropriate federal, State, or local law enforcement authority; (ii) the National Association of Insurance Commissioners or its agent, employee, or designee; (iii) a nonprofit organization established to detect and prevent fraudulent insurance acts or its agent, employee, or designee; (iv) a person that contracts to provide special investigative unit services to an insurer; or (v) a provider of a recognized comprehensive database system that the Commissioner approves to monitor activities involving insurance fraud or an employee of the provider; and (2) the person that reported the suspected insurance fraud, or furnished or received the information, acted in good faith when making the report or furnishing or receiving the information. **State:** Maryland --- ### [Maryland-Mandatory Restitution-MD Code, Insurance, ¤ 27-408](https://insurancefraud.org/statutes/maryland-mandatory-restitution-md-code-insurance-¤-27-408/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a)(1) A person that violates ¤ 27-407 of this subtitle, or another provision of this subtitle in which the claim or act that is the subject of the fraud has a value of $300 or more is guilty of a felony and on conviction, for each violation, is subject to: Administrative penalties and restitution (c)(1) In addition to any criminal penalties that may be imposed under this section, on a showing by clear and convincing evidence that a violation of this subtitle has occurred, the Commissioner may: (i) impose an administrative penalty not exceeding $25,000 for each act of insurance fraud; and (ii) order restitution to an insurer or self-insured employer of any insurance proceeds paid relating to a fraudulent insurance claim. (2) In determining the amount of an administrative penalty, the Commissioner shall consider: (i) the nature, circumstances, extent, gravity, and number of violations; (ii) the degree of culpability of the violator; (iii) prior offenses and repeated violations of the violator; and (iv) any other matter that the Commissioner considers appropriate and relevant. (3) If an administrative penalty is not paid after all rights of appeal have been waived or exhausted, the Commissioner may bring a civil action in a court of competent jurisdiction to collect the administrative penalty, including expenses and litigation costs, reasonable attorney’s fees, and interest. **State:** Maryland **Statute Areas:** Mandatory Restitution --- ### [Maryland-Placing Bogus Coverage-MD Code, Insurance, ¤ 27-406](https://insurancefraud.org/statutes/maryland-placing-bogus-coverage-md-code-insurance-¤-27-406/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** It is a fraudulent insurance act for a person: (1) knowingly or willfully to make a false or fraudulent statement or representation in or with reference to an application for insurance; (2) to place insurance with an unauthorized insurer not regulated by the Commissioner and refuse to obey an order of the Commissioner to produce for examination all policies and other documents that evidence the insurance and the amount of premiums paid or agreed to be paid for the insurance; **State:** Maryland --- ### [Maryland-Range of Criminal Penalties-MD Code, Insurance, ¤ 2-406](https://insurancefraud.org/statutes/maryland-range-of-criminal-penalties-md-code-insurance-¤-2-406/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Criminal prosecution for insurance fraud (a) Notwithstanding any other provision of law, a criminal prosecution for engaging in insurance fraud may be brought in any county in the State in which: (1) an element of the insurance fraud was committed; (2) the purported insured loss occurred; (3) the insurance policy in question provides coverage; (4) the insurer or an agent of the insurer received a false or misleading statement or document; (5) the defendant or respondent resides; or (6) money or other benefit was received as a result of the insurance fraud. **State:** Maryland **Statute Areas:** Range of Criminal Penalties --- ### [Maryland-Range of Civil Penalties-MD Code, Insurance, ¤ 27-408](https://insurancefraud.org/statutes/maryland-range-of-civil-penalties-md-code-insurance-¤-27-408/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a)(1) A person that violates ¤ 27-407 of this subtitle, or another provision of this subtitle in which the claim or act that is the subject of the fraud has a value of $300 or more is guilty of a felony and on conviction, for each violation, is subject to: (i) liability for restoring to the victim the property taken or the value of the property taken; and (ii) 1. for a violation of any provision of ¤ 27-403 of this subtitle, a fine, the maximum of which is the greater of three times the value of the claim or act that is the subject of the fraud and $10,000 and the minimum of which is $500, or imprisonment not exceeding 15 years or both; and 2. for a violation of any provision of ¤ 27-404, ¤ 27-405, ¤ 27-406, ¤ 27-406.1, ¤ 27-407, ¤ 27-407.1, or ¤ 27-407.2 of this subtitle, a fine not exceeding $10,000 or imprisonment not exceeding 15 years or both. (2) A person that violates a provision of this subtitle in which the claim or act that is the subject of the fraud has a value of less than $300 is guilty of a misdemeanor and on conviction, for each violation, is subject to: (i) liability for restoring to the victim the property taken or the value of the property taken; and (ii) 1. for a violation of any provision of ¤ 27-403 of this subtitle, a fine, the maximum of which is the greater of three times the value of the claim or act that is the subject of the fraud and $10,000 and the minimum of which is $500, or imprisonment not exceeding 18 months or both; and 2. for a violation of any provision of ¤ 27-404, ¤ 27-405, ¤ 27-406, ¤ 27-406.1, ¤ 27-407, ¤ 27-407.1, or ¤ 27-407.2 of this subtitle, a fine not exceeding $10,000 or imprisonment not exceeding 18 months or both. Construction with other sentences (b)(1) The penalties imposed under this section may be imposed separately from and consecutively to or concurrently with a sentence for another offense based on the act that constitutes a violation of this subtitle. (2) Each act of solicitation under ¤ 27-407 of this subtitle constitutes a separate violation for purposes of the penalties imposed under this section. (3) Notwithstanding any other provision of law, a fine imposed under subsection (a) of this section is mandatory and not subject to suspension. Administrative penalties and restitution (c)(1) In addition to any criminal penalties that may be imposed under this section, on a showing by clear and convincing evidence that a violation of this subtitle has occurred, the Commissioner may: (i) impose an administrative penalty not exceeding $25,000 for each act of insurance fraud; and (ii) order restitution to an insurer or self-insured employer of any insurance proceeds paid relating to a fraudulent insurance claim. (2) In determining the amount of an administrative penalty, the Commissioner shall consider: (i) the nature, circumstances, extent, gravity, and number of violations; (ii) the degree of culpability of the violator; (iii) prior offenses and repeated violations of the violator; and (iv) any other matter that the Commissioner considers appropriate and relevant. (3) If an administrative penalty is not paid after all rights of appeal have been waived or exhausted, the Commissioner may bring a civil action in a court of competent jurisdiction to collect the administrative penalty, including expenses and litigation costs, reasonable attorney’s fees, and interest. Independent actions to seek recovery (d) This section does not affect an insurer’s right to take any independent action to seek recovery against a person that violates this subtitle. **State:** Maryland **Statute Areas:** Range of Civil Penalties --- ### [Maryland-Rating of an Insurance Policy-MD Code, Insurance, ¤ 11-306](https://insurancefraud.org/statutes/maryland-rating-of-an-insurance-policy-md-code-insurance-¤-11-306/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** In general (a) The standards set forth in this section apply to the making and use of rates under this subtitle. Excessive, inadequate, or unfairly discriminatory rates prohibited (b)(1) Rates may not be: (i) excessive or inadequate, as defined under this subtitle; or (ii) unfairly discriminatory. (2) Except as provided in paragraph (4) of this subsection, a rate may not be held to be excessive unless: (i) the rate is unreasonably high for the insurance provided; and (ii) the Commissioner has issued a ruling under ¤ 11-308(c) of this subtitle that a reasonable degree of competition does not exist in a market to which the rate is applicable. (3) A rate may not be held to be inadequate unless: (i) the rate is unreasonably low for the insurance provided and continued use of the rate would endanger the solvency of the insurer; or (ii) the rate is unreasonably low for the insurance provided and the use of the rate by the insurer has had, or if continued will have, the effect of destroying competition or of creating monopoly. (4) For personal lines property insurance and casualty insurance, the Commissioner may hold a statewide rate or a rate in a particular jurisdiction or geographic territory to be excessive without determining whether a reasonable degree of competition exists under ¤ 11-308(c) of this subtitle if the Commissioner determines that the rate: (i) is unreasonably high for the insurance provided; and (ii) is not actuarially justified based on commonly accepted actuarial principles. (5) If the Commissioner determines that a rate is excessive under paragraph (4) of this subsection and disapproves the rate, the disapproval is subject to ¤ 11-308(c)(4), (d), and (e) of this subtitle. Factors given due consideration (c) In determining whether rates comply with the standards set forth in subsection (b) of this section, due consideration shall be given to: (1) past and prospective loss experience within and outside the State; (2) conflagration or catastrophe hazards; (3) a reasonable margin for underwriting profit and contingencies; (4) dividends, savings, or unabsorbed premium deposits allowed or returned by insurers to their policyholders, members, or subscribers; (5) past and prospective expenses, both countrywide and those specially applicable to the State; (6) investment income earned or realized by insurers both from their unearned premium and from their loss reserve funds; and (7) all relevant factors within and outside the State. Systems of expense provisions included in rates (d) The systems of expense provisions included in the rates for use by an insurer or group of insurers may differ from those of other insurers or groups of insurers to reflect the requirements of the operating methods of the insurer or group of insurers with respect to a kind of insurance, or with respect to a subdivision or combination of insurance for which separate expense provisions are applicable. Risks grouped by classifications (e)(1) Risks may be grouped by classifications for the establishment of rates and minimum premiums. (2) Classification rates may be modified to produce rates for individual risks in accordance with rating plans that establish standards for measuring variations in hazards or expense provisions, or both. (3) The standards may measure any difference among risks that have had a direct and substantial effect on losses or expenses. (4) Notwithstanding any other provision of this subsection, a rate may not be based wholly or partly on geographic area itself, as opposed to underlying risk considerations, even though expressed in geographic terms. **State:** Maryland --- ### [Maryland-Underwriting Fraud-MD Code, Insurance, ¤ 27-406](https://insurancefraud.org/statutes/maryland-underwriting-fraud-md-code-insurance-¤-27-406/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** It is a fraudulent insurance act for a person: (1) knowingly or willfully to make a false or fraudulent statement or representation in or with reference to an application for insurance; (2) to place insurance with an unauthorized insurer not regulated by the Commissioner and refuse to obey an order of the Commissioner to produce for examination all policies and other documents that evidence the insurance and the amount of premiums paid or agreed to be paid for the insurance; (3) if a certificate of authority is required, to operate an insurer or conduct an insurance business without obtaining a certificate of authority issued by the Commissioner; (4) to make a false sworn statement that the person does not believe to be true about matter material to an examination, investigation, or hearing conducted by the Commissioner; or (5) with intent to deceive, knowingly to exhibit a false account, document, or advertisement about the affairs of an insurer. **State:** Maryland **Statute Areas:** Underwriting Fraud --- ### [Maryland-Unauthorized Entities-MD Code, Insurance, ¤ 4-203](https://insurancefraud.org/statutes/maryland-unauthorized-entities-md-code-insurance-¤-4-203/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Application of section (a) This section does not apply to: (1) acceptance of service of process; (2) surplus lines insurance; (3) a transaction for which a certificate of authority is not required under ¤ 4-101(b) of this title; (4) reinsurance, as authorized under Title 5, Subtitle 9 of this article; (5) an adjuster while providing services with respect to a claim under a policy lawfully solicited, issued, and delivered outside of the State; or (6) the professional services of an attorney at law. Acting as insurance producer for unauthorized insurers prohibited (b) With respect to a subject of insurance resident, located, or to be performed in the State, a person may not in the State directly or indirectly act as an insurance producer for, or otherwise represent or help on behalf of another, an unauthorized insurer to: (1) solicit, negotiate, or effect insurance or an annuity contract; (2) inspect risks; (3) fix rates; (4) investigate or adjust losses; (5) collect premiums; or (6) transact insurance business in any other manner. **State:** Maryland --- ### [Maine-Aiding & Abetting-24-A M.R.S.A. ¤ 2186](https://insurancefraud.org/statutes/maine-aiding-abetting-24-a-m-r-s-a-¤-2186/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** A. “Fraudulent insurance act” means any of the following acts or omissions when committed knowingly and with intent to defraud: (7) Attempting to commit, aiding or abetting in the commission of, or conspiring to commit the acts or omissions described in this subsection. **State:** Maine --- ### [Maine-Attempted Fraud-24-A M.R.S.A. ¤ 2186](https://insurancefraud.org/statutes/maine-attempted-fraud-24-a-m-r-s-a-¤-2186/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** A. “Fraudulent insurance act” means any of the following acts or omissions when committed knowingly and with intent to defraud: (7) Attempting to commit, aiding or abetting in the commission of, or conspiring to commit the acts or omissions described in this subsection. **State:** Maine **Statute Areas:** Attempted Fraud --- ### [Maine-Claims Fraud-24-A M.R.S.A. ¤ 2186](https://insurancefraud.org/statutes/maine-claims-fraud-24-a-m-r-s-a-¤-2186/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** A. “Fraudulent insurance act” means any of the following acts or omissions when committed knowingly and with intent to defraud: (1) Presenting, or causing to be presented, or preparing any information containing false representations as to a material fact with knowledge or belief that the information will be presented by or on behalf of an insured, claimant or applicant to an insurer, insurance producer or other person engaged in the business of insurance concerning any of the following: (c) A claim for payment or benefit pursuant to an insurance policy; **State:** Maine **Statute Areas:** Claims Fraud --- ### [Maine-Failing to Remit Premium-24-A M.R.S.A. ¤ 2186](https://insurancefraud.org/statutes/maine-failing-to-remit-premium-24-a-m-r-s-a-¤-2186/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** A. “Fraudulent insurance act” means any of the following acts or omissions when committed knowingly and with intent to defraud: (2) Presenting, or causing to be presented, or preparing any information containing false representations as to a material fact with knowledge or belief that the information will be presented to or by an insurer, insurance producer or other person engaged in the business of insurance concerning any of the following: (5) Embezzling, abstracting, purloining or converting money, funds, premiums, credits or other property of an insurer or other person engaged in the business of insurance; **State:** Maine --- ### [Maine-Immunity-24-A M.R.S.A. ¤ 2187](https://insurancefraud.org/statutes/maine-immunity-24-a-m-r-s-a-¤-2187/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** 1\. Definitions. As used in this section, unless the context otherwise indicates, the following terms have the following meanings. A. “Action” includes nonaction or the failure to take action. B. “Authorized agency” or “authorized agencies” means: (1) The Attorney General; (2) A district attorney responsible for prosecution in the municipality where the fraud occurred; (3) The Federal Bureau of Investigation, or any other federal agency, only for the purposes of subsection 2; (4) The State Fire Marshal; (5) The Superintendent of Insurance; (6) The Superintendent of Financial Institutions; (7) The United States Attorney’s office when authorized or charged with investigation or prosecution of the insurance fraud in question, only for the purposes of subsection 2; (8) The State Police, state law enforcement officials or local law enforcement officials; or (9) The National Association of Insurance Commissioners. C. “Fraudulent insurance act” has the same meaning as in section 2186, subsection 1, paragraph A. D. “Insurer” has the same meaning as in section 2186, subsection 1, paragraph B. 2. Information disclosed. An authorized agency investigating insurance fraud may, in writing, require the insurance company at interest to release to the requesting agency any relevant information or evidence determined to be important to the authorized agency that the company may have in its possession relating to the insurance fraud in question. This information includes, but is not limited to: A. A history of previous claims made by the insured; B. Insurance policy information relevant to fraud under investigation and any application for that policy; C. Material relating to the investigation of the loss including statements and proof of loss; and D. Policy premium payment records. 3. Exchange of information. An authorized agency or insurer provided with information pursuant to this section may release or provide that information to any other authorized agency or insurer with an interest in the insurance fraud under investigation. 4. Right to receive upon request. Any insurer providing information to an authorized agency pursuant to this section has the right, upon request, to receive other information relevant to the fraud from that authorized agency within 30 days. 5. Immunity. In the absence of fraud, malice or bad faith, any person, including, but not limited to, an insurer or authorized agency, that furnished information relating to suspected, anticipated or completed fraudulent insurance acts is not liable for any damages in any civil action for furnishing the information if that information is furnished to or received from an authorized agency. Nothing in this subsection is intended to abrogate or modify in any way any common law or statutory privilege or immunity previously enjoyed by any person. 6. Confidentiality. An authorized agency or insurer that receives any information pursuant to this section shall hold it in confidence and may not release the information, except to another authorized agency, until its release is required for a criminal or civil proceeding. **State:** Maine **Statute Areas:** Immunity --- ### [Maine-Insurance Fraud - Definition-24-A M.R.S.A. ¤ 2186](https://insurancefraud.org/statutes/maine-insurance-fraud-definition-24-a-m-r-s-a-¤-2186/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** 1\. Definitions. As used in this section, unless the context otherwise indicates, the following terms have the following meanings. A. “Fraudulent insurance act” means any of the following acts or omissions when committed knowingly and with intent to defraud: (1) Presenting, or causing to be presented, or preparing any information containing false representations as to a material fact with knowledge or belief that the information will be presented by or on behalf of an insured, claimant or applicant to an insurer, insurance producer or other person engaged in the business of insurance concerning any of the following: (a) An application for the issuance or renewal of an insurance policy; (b) The rating of an insurance policy; (c) A claim for payment or benefit pursuant to an insurance policy; (d) Payments made in accordance with an insurance policy; or (e) Premiums paid on an insurance policy; (2) Presenting, or causing to be presented, or preparing any information containing false representations as to a material fact with knowledge or belief that the information will be presented to or by an insurer, insurance producer or other person engaged in the business of insurance concerning any of the following: (a) A document filed with the superintendent or the insurance regulatory official or agency of another jurisdiction; (b) The financial condition of an insurer; (c) The formation, acquisition, merger, reconsolidation, dissolution or withdrawal from one or more lines of insurance in all or part of this State by an insurer; (d) The issuance of written evidence of insurance; or (e) The reinstatement of an insurance policy; (3) Soliciting or accepting new or renewal insurance risks on behalf of an insurer or other person engaged in the business of insurance by a person who knows or should know that the insurer or other person responsible for the risk is insolvent at the time of the transaction; (4) Removing, concealing, altering or destroying the assets or records of an insurer or other person engaged in the business of insurance; (5) Embezzling, abstracting, purloining or converting money, funds, premiums, credits or other property of an insurer or other person engaged in the business of insurance; (6) Transacting the business of insurance in violation of laws requiring a license, certificate of authority or other legal authority for the transaction of the business of insurance; or (7) Attempting to commit, aiding or abetting in the commission of, or conspiring to commit the acts or omissions described in this subsection. B. “Insurer” means an authorized insurance company, fraternal benefit society, reinsurer, surplus lines insurer, unauthorized insurer, nonprofit hospital and medical service organization, health maintenance organization, risk retention group or multiple employer welfare organization. “Insurer” also includes an insurance producer or other person acting on the behalf of an insurer. For the purposes of this section, “insurer” also means the state Medicaid program. 2. Fraudulent insurance acts prohibited. A person may not commit a fraudulent insurance act. **State:** Maine **Statute Areas:** Insurance Fraud - Definition --- ### [Maine-Licensing Board Notification-24-A M.R.S.A. ¤ 2186](https://insurancefraud.org/statutes/maine-licensing-board-notification-24-a-m-r-s-a-¤-2186/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** 4\. Reporting of fraudulent insurance acts. Fraudulent insurance acts must be reported in accordance with this subsection. A. An insurer shall, annually on or before March 1st or within any reasonable extension of time granted by the superintendent, file with the superintendent a report relating to fraudulent insurance acts that the insurer knew or reasonably believed had been committed during the previous calendar year. The report must contain information required by the superintendent in the manner prescribed by the superintendent. The information must be reported on an aggregate basis and may not contain any information identifying any individuals or entities. The superintendent shall adopt by January 1, 1999 rules necessary to define the information that must be reported. Rules adopted pursuant to this subsection are routine technical rules as defined in Title 5, chapter 375, subchapter II-A. B. On the July 1st following the filing of the initial reports required by paragraph A, and annually thereafter, the superintendent shall report to the joint standing committee of the Legislature having jurisdiction over insurance matters. The report must include aggregate information detailing the fraudulent insurance activity experienced by insurers in this State. **State:** Maine --- ### [Maine-Looting & diverting-24-A M.R.S.A. ¤ 2186](https://insurancefraud.org/statutes/maine-looting-diverting-24-a-m-r-s-a-¤-2186/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** A. “Fraudulent insurance act” means any of the following acts or omissions when committed knowingly and with intent to defraud: (2) Presenting, or causing to be presented, or preparing any information containing false representations as to a material fact with knowledge or belief that the information will be presented to or by an insurer, insurance producer or other person engaged in the business of insurance concerning any of the following: (5) Embezzling, abstracting, purloining or converting money, funds, premiums, credits or other property of an insurer or other person engaged in the business of insurance; **State:** Maine --- ### [Maine-Mandatory Restitution-24-A M.R.S.A. ¤ 2186](https://insurancefraud.org/statutes/maine-mandatory-restitution-24-a-m-r-s-a-¤-2186/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** 6\. Restitution. The superintendent may order restitution for any insured or applicant for insurance injured by a violation for which a civil penalty may be assessed pursuant to this section. **State:** Maine **Statute Areas:** Mandatory Restitution --- ### [Maine-Practitioner Penalites-24-A M.R.S.A. ¤ 12-A](https://insurancefraud.org/statutes/maine-practitioner-penalites-24-a-m-r-s-a-¤-12-a/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** 1\. Civil penalty. Civil penalties may be assessed against any person who: A. Violates any provision of this Title, Title 24 or any other law enforced by the superintendent; B. Violates any rule lawfully adopted by the superintendent; or C. Violates any lawful order of the superintendent that has not been stayed by order of the superintendent or the Superior Court. The Superior Court, upon an action brought by the Attorney General, may assess a civil penalty of not less than $500 and not more than $5,000 for each violation in the case of an individual and not less than $2,000 and not more than $15,000 for each violation in the case of a corporation or other entity other than an individual, unless the applicable law specifies a different civil penalty. The superintendent, following an adjudicatory hearing, may assess a civil penalty of up to $500 for each violation in the case of an individual and a civil penalty of up to $10,000 for each violation in the case of a corporation or other entity other than an individual, unless the applicable law specifies a different civil penalty. The superintendent shall notify the Attorney General or the Attorney General’s designee of any such adjudicatory hearing at the time that the notice of hearing is issued by the superintendent. The superintendent may not assess a civil penalty if the Attorney General notifies the superintendent that the Attorney General intends to pursue an action in Superior Court to seek civil penalties for the same conduct. If the Attorney General elects to pursue the noticed action in Superior Court, the Attorney General shall notify the superintendent of that decision no later than 7 days prior to the hearing. 1-A. Equitable relief; actual damages. In addition to a civil penalty awarded pursuant to subsection 1, the Superior Court may award to any injured insured or applicant for insurance who is represented by the Attorney General reasonable equitable relief and actual damages. 2. Cease and desist orders. The superintendent may issue a cease and desist order following an adjudicatory hearing held in conformance with Title 5, chapter 375, subchapter IV,1 if the superintendent finds that any person has engaged in or is engaging in any act or practice in violation of any law administered or enforced by the superintendent, any rules promulgated under that law or any lawful order of the superintendent. A. A cease and desist order is effective when issued, unless the order specifies a later effective date or is stayed pursuant to Title 5, section 11004. B. In the event an appeal is taken, the court shall issue its own order for compliance to the extent that the superintendent’s order is affirmed. C. Violation of any cease and desist order shall be punishable as a violation of this Title in accordance with this section. 2-A. Emergency cease and desist. The superintendent may issue an emergency cease and desist order, without prior notice and hearing, if the complaint shows that a person is engaging in unlicensed insurance activities or is engaging in conduct that creates an immediate danger to the public safety or is causing or is reasonably expected to cause significant, imminent and irreparable public injury. A. A request for an emergency cease and desist order must be in writing in the form of a verified complaint. B. An emergency cease and desist order is effective immediately and will continue in force and effect until further order by the superintendent or unless stayed by the superintendent or by a court of competent jurisdiction. C. Upon issuance of an emergency cease and desist order, the superintendent shall serve on the person affected by the order, by registered or certified mail to the person’s last known address, an order that contains a statement of the charges and a notice of hearing. The hearing, held in conformance with Title 5, chapter 375, subchapter IV,1 must be held within 10 days of the effective date of the emergency order, unless a later time is agreed upon by all parties. D. At the hearing, the superintendent shall affirm, modify or set aside, in whole or in part, the emergency cease and desist order and may combine and employ any other enforcement or penalty provisions available to the superintendent to arrive at a final order. E. The superintendent’s order after hearing is a final order in all respects and is subject to subsection 2, paragraph A and section 236. 3. Reprimand or censure. The superintendent may issue a letter of reprimand or censure to any licensee, but only after opportunity for hearing has been provided to any and all persons who are subjects of the reprimand. 4. Refunds of overcharges. In the event that any insurer, fraternal benefit society, nonprofit hospital service plan, nonprofit medical service plan, nonprofit health care plan, health maintenance organization or preferred provider organization makes charges to any person that are not in conformity with a filing that it is required to submit for approval or disapproval by this Title or Title 24, the superintendent may order that refunds of any overcharges be made. 5. Election of enforcement options. The superintendent may elect to utilize any or all of the enforcement options provided by this section, in combination or in sequence, as the superintendent deems appropriate. The penalties and provisions of this section are in addition to any other penalty provided by law. 6. Restitution. The superintendent may order restitution for any insured or applicant for insurance injured by a violation for which a civil penalty may be assessed pursuant to this section. **State:** Maine **Statute Areas:** Practitioner Penalites --- ### [Maine-Premium Fraud-24-A M.R.S.A. ¤ 2186](https://insurancefraud.org/statutes/maine-premium-fraud-24-a-m-r-s-a-¤-2186/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** A. “Fraudulent insurance act” means any of the following acts or omissions when committed knowingly and with intent to defraud: (1) Presenting, or causing to be presented, or preparing any information containing false representations as to a material fact with knowledge or belief that the information will be presented by or on behalf of an insured, claimant or applicant to an insurer, insurance producer or other person engaged in the business of insurance concerning any of the following: (e) Premiums paid on an insurance policy; **State:** Maine **Statute Areas:** Premium Fraud --- ### [Maine-Range of Civil Penalties-24-A M.R.S.A. ¤ 12-A](https://insurancefraud.org/statutes/maine-range-of-civil-penalties-24-a-m-r-s-a-¤-12-a/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** 1\. Civil penalty. Civil penalties may be assessed against any person who: A. Violates any provision of this Title, Title 24 or any other law enforced by the superintendent; B. Violates any rule lawfully adopted by the superintendent; or C. Violates any lawful order of the superintendent that has not been stayed by order of the superintendent or the Superior Court. The Superior Court, upon an action brought by the Attorney General, may assess a civil penalty of not less than $500 and not more than $5,000 for each violation in the case of an individual and not less than $2,000 and not more than $15,000 for each violation in the case of a corporation or other entity other than an individual, unless the applicable law specifies a different civil penalty. The superintendent, following an adjudicatory hearing, may assess a civil penalty of up to $500 for each violation in the case of an individual and a civil penalty of up to $10,000 for each violation in the case of a corporation or other entity other than an individual, unless the applicable law specifies a different civil penalty. The superintendent shall notify the Attorney General or the Attorney General’s designee of any such adjudicatory hearing at the time that the notice of hearing is issued by the superintendent. The superintendent may not assess a civil penalty if the Attorney General notifies the superintendent that the Attorney General intends to pursue an action in Superior Court to seek civil penalties for the same conduct. If the Attorney General elects to pursue the noticed action in Superior Court, the Attorney General shall notify the superintendent of that decision no later than 7 days prior to the hearing. 1-A. Equitable relief; actual damages. In addition to a civil penalty awarded pursuant to subsection 1, the Superior Court may award to any injured insured or applicant for insurance who is represented by the Attorney General reasonable equitable relief and actual damages. 2. Cease and desist orders. The superintendent may issue a cease and desist order following an adjudicatory hearing held in conformance with Title 5, chapter 375, subchapter IV,1 if the superintendent finds that any person has engaged in or is engaging in any act or practice in violation of any law administered or enforced by the superintendent, any rules promulgated under that law or any lawful order of the superintendent. A. A cease and desist order is effective when issued, unless the order specifies a later effective date or is stayed pursuant to Title 5, section 11004. B. In the event an appeal is taken, the court shall issue its own order for compliance to the extent that the superintendent’s order is affirmed. C. Violation of any cease and desist order shall be punishable as a violation of this Title in accordance with this section. 2-A. Emergency cease and desist. The superintendent may issue an emergency cease and desist order, without prior notice and hearing, if the complaint shows that a person is engaging in unlicensed insurance activities or is engaging in conduct that creates an immediate danger to the public safety or is causing or is reasonably expected to cause significant, imminent and irreparable public injury. A. A request for an emergency cease and desist order must be in writing in the form of a verified complaint. B. An emergency cease and desist order is effective immediately and will continue in force and effect until further order by the superintendent or unless stayed by the superintendent or by a court of competent jurisdiction. C. Upon issuance of an emergency cease and desist order, the superintendent shall serve on the person affected by the order, by registered or certified mail to the person’s last known address, an order that contains a statement of the charges and a notice of hearing. The hearing, held in conformance with Title 5, chapter 375, subchapter IV,1 must be held within 10 days of the effective date of the emergency order, unless a later time is agreed upon by all parties. D. At the hearing, the superintendent shall affirm, modify or set aside, in whole or in part, the emergency cease and desist order and may combine and employ any other enforcement or penalty provisions available to the superintendent to arrive at a final order. E. The superintendent’s order after hearing is a final order in all respects and is subject to subsection 2, paragraph A and section 236. 3. Reprimand or censure. The superintendent may issue a letter of reprimand or censure to any licensee, but only after opportunity for hearing has been provided to any and all persons who are subjects of the reprimand. 4. Refunds of overcharges. In the event that any insurer, fraternal benefit society, nonprofit hospital service plan, nonprofit medical service plan, nonprofit health care plan, health maintenance organization or preferred provider organization makes charges to any person that are not in conformity with a filing that it is required to submit for approval or disapproval by this Title or Title 24, the superintendent may order that refunds of any overcharges be made. 5. Election of enforcement options. The superintendent may elect to utilize any or all of the enforcement options provided by this section, in combination or in sequence, as the superintendent deems appropriate. The penalties and provisions of this section are in addition to any other penalty provided by law. 6. Restitution. The superintendent may order restitution for any insured or applicant for insurance injured by a violation for which a civil penalty may be assessed pursuant to this section. **State:** Maine **Statute Areas:** Range of Civil Penalties --- ### [Maine-Rating of an Insurance Policy-24-A M.R.S.A. ¤ 2303](https://insurancefraud.org/statutes/maine-rating-of-an-insurance-policy-24-a-m-r-s-a-¤-2303/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** 1\. Rates shall be made in accordance with the following provisions. A. Manual, minimum, class rates, rating schedules or rating plans shall be made and adopted, except in the case of specific inland marine rates on risks specially rated. B. Rates shall not be excessive, inadequate or unfairly discriminatory. C. Due consideration must be given: (1) To past and prospective loss experience within and outside this State; (2) To the conflagration and catastrophe hazards; (3) To a reasonable margin for underwriting profit and contingencies; (4) To dividends, savings or unabsorbed premium deposits allowed or returned by insurers to their policyholders, members or subscribers; (5) To past and prospective expenses both countrywide and those specially applicable to this State; (6) To all other relevant factors within and outside this State; (6-A) Deleted. Laws 1991, c. 885, ¤ B-2, eff. Jan. 1, 1993. (7) In the case of fire insurance rates, to the experience of the fire insurance business during a period of not less than the most recent 5-year period for which such experience is available; and (8) In the case of title insurance rates, to the reasonableness of commission levels and other acquisition costs both countrywide and those specifically applicable to this State. D, E. Repealed. Laws 1989, c. 797, ¤ 3, eff. Jan. 1, 1991. F. Repealed. Laws 1985, c. 372, Pt. B, ¤ 4, eff. Jan. 1, 1986. G. Risks may be grouped by classifications for the establishment of rates and minimum premiums. Classification rates may be modified to produce rates for individual risks in accordance with rating plans that establish standards for measuring variations in hazards or expense provisions, or both. These standards may measure any differences among risks that may have a probable effect upon losses or expenses. No risk classification may be based upon race, creed, national origin or the religion of the insured. H. The expense provisions included in the rates to be used by an insurer must reflect the operating methods of the insurer and its anticipated expenses. I. Rates may contain a provision for contingencies and an allowance permitting a reasonable profit. In determining the reasonableness of the profit allowance, consideration must be given to investment income. 2. Nothing in this section shall be taken to prohibit as unreasonable or unfairly discriminatory the establishment of classifications or modifications of classifications or risks based upon size, expense, management, individual experience, purpose of insurance, location or dispersion of hazard, or any other reasonable considerations, provided such classifications and modifications apply to all risks under the same or substantially similar circumstances or conditions. **State:** Maine --- ### [Maine-Underwriting Fraud-24-A M.R.S.A. ¤ 2186](https://insurancefraud.org/statutes/maine-underwriting-fraud-24-a-m-r-s-a-¤-2186/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** 1\. Definitions. As used in this section, unless the context otherwise indicates, the following terms have the following meanings. A. “Fraudulent insurance act” means any of the following acts or omissions when committed knowingly and with intent to defraud: (2) Presenting, or causing to be presented, or preparing any information containing false representations as to a material fact with knowledge or belief that the information will be presented to or by an insurer, insurance producer or other person engaged in the business of insurance concerning any of the following: (a) A document filed with the superintendent or the insurance regulatory official or agency of another jurisdiction; (b) The financial condition of an insurer; (c) The formation, acquisition, merger, reconsolidation, dissolution or withdrawal from one or more lines of insurance in all or part of this State by an insurer; (d) The issuance of written evidence of insurance; or (e) The reinstatement of an insurance policy; (3) Soliciting or accepting new or renewal insurance risks on behalf of an insurer or other person engaged in the business of insurance by a person who knows or should know that the insurer or other person responsible for the risk is insolvent at the time of the transaction; (4) Removing, concealing, altering or destroying the assets or records of an insurer or other person engaged in the business of insurance; (5) Embezzling, abstracting, purloining or converting money, funds, premiums, credits or other property of an insurer or other person engaged in the business of insurance; (6) Transacting the business of insurance in violation of laws requiring a license, certificate of authority or other legal authority for the transaction of the business of insurance; or (7) Attempting to commit, aiding or abetting in the commission of, or conspiring to commit the acts or omissions described in this subsection. **State:** Maine **Statute Areas:** Underwriting Fraud --- ### [Maine-Unauthorized Entities-24-A M.R.S.A. ¤ 2101](https://insurancefraud.org/statutes/maine-unauthorized-entities-24-a-m-r-s-a-¤-2101/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** 1\. No person shall in this State directly or indirectly act as agent for, or otherwise represent or aid on behalf of another, any insurer not then authorized to transact such business in this State, in the solicitation, negotiation, procurement or effectuation of insurance or annuity contracts, or renewal thereof, or forwarding of applications for insurance or annuities, or the dissemination of information as to coverage or rates, or inspection of risks, or fixing of rates, or investigation or adjustment of claims or losses, or collection or forwarding of premiums, or in any other manner represent or assist such an insurer in the transaction of insurance with respect to subjects of insurance resident, located or to be performed in this State. 2. This section does not apply to: A. Matters authorized to be done by the superintendent under the Unauthorized Insurers Process Act, sections 2102 to 2108; B. Transactions as to which the insurer is not required to have a certificate of authority pursuant to section 405 (exceptions to certificate of authority requirement); C. A licensed adjuster or attorney at law representing such an insurer from time to time in his professional capacity; D. Transactions in this State relating to a policy of wet marine and transportation insurance delivered or issued for delivery outside this State; E. The employee, compensated on salary only, of a Maine employer who on behalf of the employer assists in the procurement or administration of insurance coverages on the property, risks and insurable interests of the employer; or F. Transactions outside this State arising from the unsolicited application of the insured, if the transaction is lawful in the jurisdiction in which it occurs and the applicable premium tax has been paid in compliance with Title 36, section 2513. 3. If the superintendent has reason to believe that any insurer or other person is acting in violation of this section or section 404, the superintendent shall commence proceedings in accordance with sections 12-A and 404. Section 2105 applies to all process, notices and statements of charges to be served on the unauthorized insurer or insurers. **State:** Maine --- ### [Louisiana-Claims Fraud-LSA-R.S. 22:1923](https://insurancefraud.org/statutes/louisiana-claims-fraud-lsa-r-s-221923/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** As used in this Part, the following terms shall have the meanings indicated in this Section: (1) “Claim” shall mean any request or demand for payment or benefit, whether paid or not, made by a person either in writing or filed electronically. (2) “Fraudulent insurance act” shall include but not be limited to acts or omissions committed by any person who, knowingly and with intent to defraud: (a) Presents, causes to be presented, or prepares with knowledge or belief that it will be presented to or by an insurer, reinsurer, purported insurer or reinsurer, producer, or any agent thereof, any oral or written statement which he knows to contain materially false information as part of, or in support of, or denial of, or concerning any fact material to or conceals any information concerning any fact material to the following: (i) An application for the issuance of any insurance policy. (ii) The rating of any insurance policy. (iii) A claim for payment or benefit pursuant to any insurance policy. **State:** Louisiana **Statute Areas:** Claims Fraud --- ### [Louisiana-Fraud Bureau-LSA-R.S. 40:1422](https://insurancefraud.org/statutes/louisiana-fraud-bureau-lsa-r-s-401422/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** A. There is hereby created an insurance fraud investigation unit in the Department of Public Safety and Corrections, public safety services, office of state police, and the unit shall be solely dedicated to the investigation of property and casualty, worker’s compensation, life, and health insurance fraud. The purposes of this unit shall be to: (1) Initiate independent inquiries and conduct independent investigations into allegations of insurance fraud in any municipality or parish of the state of Louisiana and perform other related law enforcement duties. (2) Respond to notification or complaints alleging insurance fraud generated by federal, state, and local police, other law enforcement authorities, governmental agencies or units, and any other person. (3) Review notices and reports of insurance fraud, select the incidents of suspected fraud that, in its judgment, require further detailed investigation, and conduct the investigations. B. The insurance fraud investigation unit shall have the authority to: (1) Issue subpoenas to examine any person under oath and to compel the production of records, books, papers, contracts, and other documents. Subpoenas shall be served in the same manner as if issued by a district court. If any person fails to obey a subpoena issued and served pursuant to this Subsection, upon application of the insurance fraud investigation unit, the Nineteenth Judicial District Court or the district court in the judicial district where the subpoena was served may issue an order requiring the person to comply with the subpoena. Any failure to obey the order of the court may be punished by the court as contempt. (2) Administer oaths and affirmation. (3) Share records and evidence with federal, state, or local law enforcement or regulatory agencies. (4) Make criminal referrals to prosecuting authorities. The district attorney of the judicial district where a criminal referral has been made shall, for the purpose of assisting in such prosecution, have the authority to appoint as special deputy district attorneys, licensed attorneys in the employment of the insurance fraud investigation unit. The district attorney shall have the right and discretion to proceed against any person or organization on criminal referrals. (5) Conduct investigations outside of this state. If the information the fraud unit seeks to obtain is located outside this state, the person from whom the information is sought may make the information available to the fraud unit to examine at the place where the information is located. The fraud unit may designate representatives, including officials of the state in which the matter is located, to inspect the information on behalf of the fraud unit, and the fraud unit may respond to similar requests from officials of other states. C. The police employees of the unit shall have the same duties and powers as are provided for other police employees of the office in R.S. 40:1379 and such other duties as are assigned by the deputy secretary of public safety services of the Department of Public Safety and Corrections. The police employees of the unit shall complete the National Insurance Crime Training Academy, phases 1, 2, and 3, and Fraud Claims Law Specialist program, within the first two years of assignment to the unit. **State:** Louisiana **Statute Areas:** Fraud Bureau --- ### [Louisiana-Immunity-LSA-R.S. 22:1928](https://insurancefraud.org/statutes/louisiana-immunity-lsa-r-s-221928/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** A. No insurer, employees, or agents of any insurer, or any other person acting without malice, fraudulent intent, or bad faith, shall be subject to civil liability for libel, slander, or any other relevant tort, and no civil cause of action of any nature shall exist against such person or entity by virtue of the filing of reports or furnishing other information, either orally or in writing, concerning suspected, anticipated, or completed fraudulent insurance acts when such reports or information are required by this Part or required by the division of insurance fraud as a result of the authority herein granted or when such reports or information are provided to or received from: (1) Law enforcement officials, their agents, and employees. (2) The National Association of Insurance Commissioners, the state Department of Insurance, a federal or state agency or bureau established to detect and prevent fraudulent insurance acts, as well as any other organization established for the same purpose, their agents, employees, or designees. (3) A person involved in the prevention and detection of fraudulent insurance acts or that person’s employees, agents, or representatives. B. This Section does not abrogate or modify in any way any statutory or other privilege or immunity enjoyed by such person or entity. C. Any person or entity covered by the provisions of this Section shall be entitled to an award of attorney fees and costs if they are the prevailing party in a civil suit and the party bringing the action was not substantially justified in doing so. For the purposes of this Section, a proceeding is “substantially justified” if it had a reasonable basis in law or fact at the time that it was initiated. **State:** Louisiana **Statute Areas:** Immunity --- ### [Louisiana-Insurance Fraud - Definition-LSA-R.S. 22:1923](https://insurancefraud.org/statutes/louisiana-insurance-fraud-definition-lsa-r-s-221923/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (2) “Fraudulent insurance act” shall include but not be limited to acts or omissions committed by any person who, knowingly and with intent to defraud: (a) Presents, causes to be presented, or prepares with knowledge or belief that it will be presented to or by an insurer, reinsurer, purported insurer or reinsurer, producer, or any agent thereof, any oral or written statement which he knows to contain materially false information as part of, or in support of, or denial of, or concerning any fact material to or conceals any information concerning any fact material to the following: (i) An application for the issuance of any insurance policy. (ii) The rating of any insurance policy. (iii) A claim for payment or benefit pursuant to any insurance policy. (iv) Premiums paid on any insurance policy. (v) Payments made in accordance with the terms of any insurance policy. (vi) An application for certificate of authority or the application for a certificate of authority by a health insurer that has ceased writing health and accident insurance in the state within the prior five years. (vii) The financial condition of any insurer, reinsurer, purported insurer or reinsurer. (viii) The acquisition of any insurer or reinsurer. (b) Solicits or accepts new or renewal insurance risks by or for an insolvent insurer, reinsurer, or other entity regulated under the insurance laws of this state. (c) Removes or attempts to remove the assets or record of assets, transactions, and affairs of such material part thereof, from the home office or other place of business of the insurer, reinsurer, or other entity regulated under the insurance laws of this state, or from the place of safekeeping of the insurer, reinsurer, or other entity regulated under the laws of this state, or who conceals or attempts to conceal the same from the department. (d) Diverts, attempts to divert, or conspires to divert funds of an insurer, reinsurer, or other entity regulated under the laws of this state, or other persons in connection with: (i) The transaction of insurance or reinsurance. (ii) The conduct of business activities by an insurer, reinsurer, or other entity regulated by the insurance laws of this state. (iii) The formation, acquisition, or dissolution of an insurer, reinsurer, or other entity regulated under the insurance laws of this state. (e) Supplies false or fraudulent material information pertaining to any document or statement required by the Department of Insurance. (f) Commits any fraudulent viatical settlement act, as defined by R.S. 22:1791. (g) Solicits or accepts new or renewal insurance risks by or for an unauthorized insurer, except as provided by Subpart O of Part I of Chapter 2 of this Title, R.S. 22:431 et seq., and Part III of this Chapter, R.S. 22:1941 et seq. (h) Manufactures, sells, distributes, presents, or causes to be presented a fraudulent proof of insurance card or document. (i) Alters a legitimate proof of insurance card or document. (j) Presents, causes to be presented, or prepares with the knowledge or belief that it will be presented to a self-insured governmental entity any oral or written statement which he knows to contain materially false information as part of, in support of, denial of, or concerning any fact material to or conceals any information concerning any fact material to any claim for payment under such self-insured governmental entity’s loss fund or risk pool. For the purposes of this Subparagraph, “self-insured governmental entity” shall mean any agency of the state, political subdivision of the state, or agency thereof, or consortium of governmental entities that maintains a self-insured loss fund or risk pool. (k) Impersonates an insurance company, or a representative of an insurance company, without the authorization or consent of the insurance company for the purpose of executing a scheme or artifice to defraud a person. (l) Impersonates another person or entity, whether real or fictitious, and purports himself to have the authority to direct healthcare treatment for the purpose of executing a scheme or artifice to defraud a person. (m) Receives money or any other thing of value from any person, firm, or entity as a means of compensation for the acts of solicitation or criminal conspiracy done for the purpose of executing a scheme or artifice to defraud a person. (n) Presents, causes to be presented, or prepares with knowledge or belief that it will be presented to the Property Insurance Association of Louisiana, any written statement which he knows to contain materially false information in connection with the grading by the Property Insurance Association of Louisiana of a municipality or fire district. (3) “Statement” includes but is not limited to any notice, statement, proof of loss, bill of lading, receipt for payment, invoice, account, estimate of property damages, bill for services, diagnosis, prescription, hospital or doctor records, test results, x-rays, or other evidence of loss, injury, or expense. **State:** Louisiana **Statute Areas:** Insurance Fraud - Definition --- ### [Louisiana-Licensing Board Notification-LSA-R.S. 22:1926](https://insurancefraud.org/statutes/louisiana-licensing-board-notification-lsa-r-s-221926/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** A. Any person, company, or other legal entity including but not limited to those engaged in the business of insurance, including producers and adjusters, that suspects that a fraudulent insurance act will be, is being, or has been committed shall, within sixty days of the receipt of such notice, send to the division of insurance fraud, on a form prescribed by the commissioner, the information requested and such additional information relative to the insurance act and the parties claiming loss or damages because of an occurrence or accident as the commissioner may require. The division of insurance fraud shall review such reports and select such insurance acts as, in its judgment, may require further investigation. It shall then cause an independent examination of the facts surrounding such insurance act to be made to determine the extent, if any, to which fraud, deceit, or intentional misrepresentation of any kind exists in the submission of the insurance act. B. The division of insurance fraud shall report any alleged violations of law which its investigations disclose to the appropriate licensing agency, the insurance fraud investigation unit of the office of state police, the insurance fraud support unit of the Department of Justice, and the prosecutive authority having jurisdiction with respect to any such violation. These units shall work jointly on criminal referrals. **State:** Louisiana --- ### [Louisiana-Looting & diverting-LSA-R.S. 22:1923](https://insurancefraud.org/statutes/louisiana-looting-diverting-lsa-r-s-221923/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (2) “Fraudulent insurance act” shall include but not be limited to acts or omissions committed by any person who, knowingly and with intent to defraud: (a) Presents, causes to be presented, or prepares with knowledge or belief that it will be presented to or by an insurer, reinsurer, purported insurer or reinsurer, producer, or any agent thereof, any oral or written statement which he knows to contain materially false information as part of, or in support of, or denial of, or concerning any fact material to or conceals any information concerning any fact material to the following: (d) Diverts, attempts to divert, or conspires to divert funds of an insurer, reinsurer, or other entity regulated under the laws of this state, or other persons in connection with: (i) The transaction of insurance or reinsurance. (ii) The conduct of business activities by an insurer, reinsurer, or other entity regulated by the insurance laws of this state. (iii) The formation, acquisition, or dissolution of an insurer, reinsurer, or other entity regulated under the insurance laws of this state. **State:** Louisiana --- ### [Louisiana-Mandatory Restitution-LSA-R.S. 22:1924](https://insurancefraud.org/statutes/louisiana-mandatory-restitution-lsa-r-s-221924/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** A. (1) Any person who, with the intent to injure, defraud, or deceive any insurance company, or the Department of Insurance, or any insured or other party in interest, or any third-party claimant commits any of the acts specified in Paragraph (2) or (3) of this Subsection is guilty of a felony and shall be subjected to a term of imprisonment, with or without hard labor, not to exceed five years, or a fine not to exceed five thousand dollars, or both, on each count and payment of restitution to the victim company of any insurance payments to the defendant that the court determines was not owed and the costs incurred by the victim company associated with the evaluation and defense of the fraudulent claim, including but not limited to the investigative costs, attorney fees, and court costs. However, if the benefit pursued does not exceed one thousand dollars, the term of imprisonment shall not exceed six months, or the fine shall not exceed one thousand dollars, or both, on each count. **State:** Louisiana **Statute Areas:** Mandatory Restitution --- ### [Louisiana-Practitioner Penalites-LSA-R.S. 22:2007](https://insurancefraud.org/statutes/louisiana-practitioner-penalites-lsa-r-s-222007/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** A. Any officer, manager, director, trustee, owner, employee, or agent of any insurer, or any other persons with authority over or in charge of any segment of the insurer’s affairs, shall cooperate with the commissioner in any proceeding under this Chapter or any investigation preliminary to the proceeding. B. No person shall obstruct or interfere with the commissioner in the conduct of any delinquency proceeding or any investigation preliminary or incidental thereto. C. No person shall provide to the commissioner statements, documents, or records, which are fraudulent or materially false. D. The court having jurisdiction over a proceeding under this Chapter shall have the authority to issue such orders, including injunctive relief, as appropriate, for the enforcement of this Section. E. Failure to comply with such court order shall subject the violator to incarceration for civil contempt until compliance with the order has been obtained, and a fine not to exceed one hundred thousand dollars, or both. F. Whosoever shall knowingly and intentionally violate any provisions of this Section shall be guilty of a felony. For each violation of which such person is convicted, the offender shall be punished by imprisonment at hard labor for not more than five years, or a fine not to exceed one hundred thousand dollars, or both. **State:** Louisiana **Statute Areas:** Practitioner Penalites --- ### [Louisiana-Premium Fraud-LSA-R.S. 22:1923](https://insurancefraud.org/statutes/louisiana-premium-fraud-lsa-r-s-221923/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (2) “Fraudulent insurance act” shall include but not be limited to acts or omissions committed by any person who, knowingly and with intent to defraud: (a) Presents, causes to be presented, or prepares with knowledge or belief that it will be presented to or by an insurer, reinsurer, purported insurer or reinsurer, producer, or any agent thereof, any oral or written statement which he knows to contain materially false information as part of, or in support of, or denial of, or concerning any fact material to or conceals any information concerning any fact material to the following: (iv) Premiums paid on any insurance policy. **State:** Louisiana **Statute Areas:** Premium Fraud --- ### [Louisiana-Range of Criminal Penalties-LSA-R.S. 22:1924](https://insurancefraud.org/statutes/louisiana-range-of-criminal-penalties-lsa-r-s-221924/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** A. (1) Any person who, with the intent to injure, defraud, or deceive any insurance company, or the Department of Insurance, or any insured or other party in interest, or any third-party claimant commits any of the acts specified in Paragraph (2) or (3) of this Subsection is guilty of a felony and shall be subjected to a term of imprisonment, with or without hard labor, not to exceed five years, or a fine not to exceed five thousand dollars, or both, on each count and payment of restitution to the victim company of any insurance payments to the defendant that the court determines was not owed and the costs incurred by the victim company associated with the evaluation and defense of the fraudulent claim, including but not limited to the investigative costs, attorney fees, and court costs. However, if the benefit pursued does not exceed one thousand dollars, the term of imprisonment shall not exceed six months, or the fine shall not exceed one thousand dollars, or both, on each count. (2) The following acts shall be punishable as provided in Paragraph (1) of this Subsection: (a) Committing any fraudulent insurance act as defined in R.S. 22:1923. (b) Presenting or causing to be presented any written or oral statement including computer-generated documents as part of or in support of or denial of a claim for payment or other benefit pursuant to an insurance policy, knowing that such statement contains any false, incomplete, or fraudulent information concerning any fact or thing material to such claim or insurance policy. (c) Assisting, abetting, soliciting, or conspiring with another to prepare or make any written or oral statement that is intended to be presented to any insurance company, insured, the Department of Insurance, or other party in interest or third-party claimant in connection with, or in support of or denial, or any claim for payment of other benefit pursuant to an insurance policy, knowing that such statement contains any false, incomplete, or fraudulent information concerning any fact or thing material to such claim or insurance policy. (3)(a) Knowingly and willfully committing health care fraud shall be punishable as provided in Paragraph (1) of this Subsection. (b) “Health care fraud” shall mean, in conjunction with the delivery of or payment for health care benefits, items, or services: (i) To execute a scheme or artifice to defraud any health care benefit program. (ii) To obtain, by means of fraudulent claims, or false or fraudulent pretenses, representations, or promises, any of the money or property owned by, or under the custody or control of, any health care benefit program. (c) For the purposes of this Paragraph, “knowingly and willfully” shall mean to continue with a practice, after written notice to cease such practice from a health care benefit program by certified mail, return receipt requested, except when the health care provider reasonably believes that such practice materially complies with coding or billing standards as issued by the American Medical Association, the United States Department of Health and Human Services, the Centers for Medicare and Medicaid Services, or the Louisiana Medicaid Program. B. The criminal provisions of this Section shall be investigated, enforced, or prosecuted only by the proper law enforcement and prosecutorial agencies. **State:** Louisiana **Statute Areas:** Range of Criminal Penalties --- ### [Louisiana-Range of Civil Penalties-n/a](https://insurancefraud.org/statutes/louisiana-range-of-civil-penalties-n-a/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** No statute fou nd. **State:** Louisiana **Statute Areas:** Range of Civil Penalties --- ### [Louisiana-Underwriting Fraud-LSA-R.S. 22:1923](https://insurancefraud.org/statutes/louisiana-underwriting-fraud-lsa-r-s-221923/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (2) “Fraudulent insurance act” shall include but not be limited to acts or omissions committed by any person who, knowingly and with intent to defraud: (b) Solicits or accepts new or renewal insurance risks by or for an insolvent insurer, reinsurer, or other entity regulated under the insurance laws of this state. (c) Removes or attempts to remove the assets or record of assets, transactions, and affairs of such material part thereof, from the home office or other place of business of the insurer, reinsurer, or other entity regulated under the insurance laws of this state, or from the place of safekeeping of the insurer, reinsurer, or other entity regulated under the laws of this state, or who conceals or attempts to conceal the same from the department. **State:** Louisiana **Statute Areas:** Underwriting Fraud --- ### [Louisiana-Unauthorized Entities-LSA-R.S. 22:1902](https://insurancefraud.org/statutes/louisiana-unauthorized-entities-lsa-r-s-221902/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** A. Any of the following acts in this state, effected by mail or otherwise, by an unauthorized insurer or by any person acting with actual or apparent authority of the insurer, on behalf of the insurer, is deemed to constitute the transaction of an insurance business in or from this state: (1) The making of or proposing to make, as an insurer, an insurance contract. (2) The solicitation, taking, or receiving of any application for insurance contract. (3) The receiving or collection of any premiums, commissions, membership fees, assessment, dues, or other considerations for any insurance contract or any part thereof. (4) The issuance or delivery of contracts of insurance to residents of this state or to corporations or persons authorized to do business in this state. (5) The transaction of any matter subsequent to the execution of such a contract and arising out of it. (6) The doing or proposing to do any insurance business in substance equivalent to any of the foregoing in a manner designed to evade the provisions of the insurance laws of this state. (7) The solicitation, negotiation, procurement, or effectuation of insurance or renewals thereof. (8) The transaction of any kind of insurance business specifically recognized as transacting business within the meaning of the statutes relating to insurance. (9) The dissemination of information as to coverage or rates, or forwarding applications, or delivery of policies or contracts, or inspection of risks, the fixing of rates, or investigation or adjustment of claims or losses, or the transaction of matters subsequent to effectuation of the contract and arising out of it, or any other manner of representing or assisting a person or insurer in the transaction of risks with respect to properties, risks, or exposures located or to be performed in this state. (10) The making or proposing to make, as guarantor or surety, any contract of guaranty or suretyship as a vocation and not merely incidental to any other legitimate business or activity of the guarantor or surety. (11) The offering of insurance or the transacting of insurance business, or the offering of an agreement or contract which purports to alter, amend, or void coverage of an insurance contract. B. The venue of an act committed by mail shall be at the point where the matter transmitted by mail is delivered or issued for delivery or takes effect. **State:** Louisiana --- ### [Kentucky-Aiding & Abetting-KRS ¤ 304.47-020 (Proposed Legislation)](https://insurancefraud.org/statutes/kentucky-aiding-abetting-krs-¤-304-47-020-proposed-legislation/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (1) For the purposes of this subtitle, a person or entity commits a “fraudulent insurance act” if he or she engages in any of the following, including but not limited to matters relating to workers’ compensation: (a) Knowingly and with intent to defraud or deceive presents, causes to be presented, or prepares with knowledge or belief that it will be presented to an insurer, Kentucky Claims Commission, Special Fund, or any agent thereof: 1. Any written or oral statement as part of, or in support of, a claim for payment or other benefit pursuant to an insurance policy or from a “self-insurer” as defined by KRS Chapter 342, knowing that the statement contains any false, incomplete, or misleading information concerning any fact or thing material to a claim; or 2. Any statement as part of, or in support of, an application for an insurance policy, for renewal, reinstatement, or replacement of insurance, or in support of an application to a lender for money to pay a premium, knowing that the statement contains any false, incomplete, or misleading information concerning any fact or thing material to the application; (b) Knowingly and willfully transacts any contract, agreement, or instrument which violates this title; (c) Knowingly and with intent to defraud or deceive: 1. Receives money for the purpose of purchasing insurance, and fails to obtain insurance; 2. Fails to make payment or disposition of money or voucher as defined in KRS 304.17A-750, as required by agreement or legal obligation, that comes into his or her possession while acting as a licensee under this chapter; 3. Presents, causes to be presented, or prepares with knowledge or belief that it will be presented to or by an insurer, or to the commissioner, any statement, knowing that the statement contains any false, incomplete, or misleading information concerning any material fact or thing, as part of, or in support of one (1) or more of the following: a. The rating of an insurance policy; b. The financial condition of an insurer; c. The formation, acquisition, merger, reconsolidation, dissolution, or withdrawal from one (1) or more lines of insurance in all or part of this Commonwealth by an insurer; or d. A document filed with the commissioner; or 4. Engages in any of the following: a. Solicitation or acceptance of new or renewal insurance risks on behalf of an insolvent insurer; or b. Removal, concealment, alteration, tampering, or destruction of money, records, or any other property or assets of an insurer; (d) Issues or knowingly presents fake or counterfeit insurance policies, certificates of insurance, insurance identification cards, insurance binders, or any other documents that purport to evidence insurance; (e) Makes any false or fraudulent representation as to the death or disability of a policy or certificate holder in any written statement or certificate for the purpose of fraudulently obtaining money or benefit from an insurer; (f) Engages in unauthorized insurance, as set forth in KRS 304.11-030; or (g) Assists, abets, solicits, or conspires with another to commit a fraudulent insurance act in violation of this subtitle. **State:** Kentucky --- ### [Kentucky-Attempted Fraud-KRS ¤ 304.47-020 (Proposed Legislation)](https://insurancefraud.org/statutes/kentucky-attempted-fraud-krs-¤-304-47-020-proposed-legislation/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (1) For the purposes of this subtitle, a person or entity commits a “fraudulent insurance act” if he or she engages in any of the following, including but not limited to matters relating to workers’ compensation: (a) Knowingly and with intent to defraud or deceive presents, causes to be presented, or prepares with knowledge or belief that it will be presented to an insurer, Kentucky Claims Commission, Special Fund, or any agent thereof: 1. Any written or oral statement as part of, or in support of, a claim for payment or other benefit pursuant to an insurance policy or from a “self-insurer” as defined by KRS Chapter 342, knowing that the statement contains any false, incomplete, or misleading information concerning any fact or thing material to a claim; or 2. Any statement as part of, or in support of, an application for an insurance policy, for renewal, reinstatement, or replacement of insurance, or in support of an application to a lender for money to pay a premium, knowing that the statement contains any false, incomplete, or misleading information concerning any fact or thing material to the application; **State:** Kentucky **Statute Areas:** Attempted Fraud --- ### [Kentucky-Claims Fraud-KRS ¤ 304.47-020 (Proposed Legislation)](https://insurancefraud.org/statutes/kentucky-claims-fraud-krs-¤-304-47-020-proposed-legislation/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (1) For the purposes of this subtitle, a person or entity commits a “fraudulent insurance act” if he or she engages in any of the following, including but not limited to matters relating to workers’ compensation: (a) Knowingly and with intent to defraud or deceive presents, causes to be presented, or prepares with knowledge or belief that it will be presented to an insurer, Kentucky Claims Commission, Special Fund, or any agent thereof: 1. Any written or oral statement as part of, or in support of, a claim for payment or other benefit pursuant to an insurance policy or from a “self-insurer” as defined by KRS Chapter 342, knowing that the statement contains any false, incomplete, or misleading information concerning any fact or thing material to a claim; or 2. Any statement as part of, or in support of, an application for an insurance policy, for renewal, reinstatement, or replacement of insurance, or in support of an application to a lender for money to pay a premium, knowing that the statement contains any false, incomplete, or misleading information concerning any fact or thing material to the application; **State:** Kentucky **Statute Areas:** Claims Fraud --- ### [Kentucky-Fraud Bureau-KRS ¤ 304.47-040](https://insurancefraud.org/statutes/kentucky-fraud-bureau-krs-¤-304-47-040/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (1) There is created within the Department of Insurance a Division of Insurance Fraud Investigation. (2) (a) The commissioner shall appoint qualified persons to serve as special investigators for the Division of Insurance Fraud Investigation who shall have general police powers including the power to arrest, and they shall possess all of the common law and statutory powers, privileges, and immunities of sheriffs, and their jurisdiction shall be coextensive with the state. (b) The division staff also shall include, at a minimum, three (3) special investigators, one (1) attorney, and one (1) administrative assistant. The positions authorized by this paragraph shall be in addition to the staff employed by the division as of December 12, 1996. (3) The special investigator may: (a) Administer oaths and affirmations; (b) Order the attendance of witnesses or proffering of information and documentation; (c) Collect evidence; and (d) Make arrests for criminal violations established as a result of its investigations. The general laws applicable to arrests by sheriffs of the Commonwealth shall also be applicable to special investigators, who may: 1. Execute arrest warrants and search warrants for the criminal violations revealed as a result of their investigations; 2. Serve subpoenas issued for the examination, investigation, and trial of all offenses determined by their investigations; and 3. Arrest upon probable cause without warrant any person found in the act of violating any of the provisions of applicable laws. (4) The division may implement its powers if, based upon its own inquiries or as a result of information received, it has reason to believe that a person has engaged in, is engaging in, or is about to engage in a fraudulent insurance act. (5) If the information the division seeks to obtain is located outside the state, the person so requested may make it available to the division or its representative to examine at the place where it is located. The division may designate representatives, including officials of the state in which the matter is located, to inspect the information on the division’s behalf, and it may respond to similar requests from officials of other states. (6) It shall be unlawful for any person to resist an arrest authorized by this subtitle or in any manner to interfere, either by abetting or assisting this resistance or otherwise interfering, with special investigators employed by the commissioner under this subtitle in the duties imposed upon them by law, and shall be punishable as provided in KRS 520.090. (7) The commissioner may obtain any evidence for use in criminal investigations according to KRS 304.2-340. **State:** Kentucky **Statute Areas:** Fraud Bureau --- ### [Kentucky-Immunity-KRS ¤ 304.47-060](https://insurancefraud.org/statutes/kentucky-immunity-krs-¤-304-47-060/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (1) In the absence of malice, fraud, or gross negligence, a person shall not be subject to civil liability for libel, slander, or any other relevant tort by virtue of filing reports or furnishing other information required by this chapter or requested by the division or its authorized representative. No civil cause of action of any nature shall arise against the person: (a) For any information relating to suspected fraudulent insurance acts furnished to or received from law enforcement officials, their agents, or employees; (b) For any information relating to suspected fraudulent insurance acts furnished to or received from other persons subject to the provisions of this subtitle, including those designated by KRS 304.47-080; (c) For any information furnished to or received from the Department of Workers’ Claims, its agents, or employees; or (d) For any information furnished in reports to the commissioner or the National Association of Insurance Commissioners. (2) The commissioner or any employee or agent of the Department of Insurance shall not be subject to civil liability for libel, slander, or any other relevant tort. No civil cause of action shall exist against these persons by virtue of the execution of official activities or duties of the commissioner or the division or by virtue of the publication of any report or bulletin related to the official activities or duties of the commissioner. (3) This subtitle shall not abrogate or modify any common law or statutory privilege or immunity enjoyed by any person. **State:** Kentucky **Statute Areas:** Immunity --- ### [Kentucky-Insurance Fraud - Definition-KRS ¤ 304.47-020 (Proposed Legislation)](https://insurancefraud.org/statutes/kentucky-insurance-fraud-definition-krs-¤-304-47-020-proposed-legislation/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (1) For the purposes of this subtitle, a person or entity commits a “fraudulent insurance act” if he or she engages in any of the following, including but not limited to matters relating to workers’ compensation: (a) Knowingly and with intent to defraud or deceive presents, causes to be presented, or prepares with knowledge or belief that it will be presented to an insurer, Kentucky Claims Commission, Special Fund, or any agent thereof: 1. Any written or oral statement as part of, or in support of, a claim for payment or other benefit pursuant to an insurance policy or from a “self-insurer” as defined by KRS Chapter 342, knowing that the statement contains any false, incomplete, or misleading information concerning any fact or thing material to a claim; or 2. Any statement as part of, or in support of, an application for an insurance policy, for renewal, reinstatement, or replacement of insurance, or in support of an application to a lender for money to pay a premium, knowing that the statement contains any false, incomplete, or misleading information concerning any fact or thing material to the application; (b) Knowingly and willfully transacts any contract, agreement, or instrument which violates this title; (c) Knowingly and with intent to defraud or deceive: 1. Receives money for the purpose of purchasing insurance, and fails to obtain insurance; 2. Fails to make payment or disposition of money or voucher as defined in KRS 304.17A-750, as required by agreement or legal obligation, that comes into his or her possession while acting as a licensee under this chapter; 3. Presents, causes to be presented, or prepares with knowledge or belief that it will be presented to or by an insurer, or to the commissioner, any statement, knowing that the statement contains any false, incomplete, or misleading information concerning any material fact or thing, as part of, or in support of one (1) or more of the following: a. The rating of an insurance policy; b. The financial condition of an insurer; c. The formation, acquisition, merger, reconsolidation, dissolution, or withdrawal from one (1) or more lines of insurance in all or part of this Commonwealth by an insurer; or d. A document filed with the commissioner; or 4. Engages in any of the following: a. Solicitation or acceptance of new or renewal insurance risks on behalf of an insolvent insurer; or b. Removal, concealment, alteration, tampering, or destruction of money, records, or any other property or assets of an insurer; (d) Issues or knowingly presents fake or counterfeit insurance policies, certificates of insurance, insurance identification cards, insurance binders, or any other documents that purport to evidence insurance; (e) Makes any false or fraudulent representation as to the death or disability of a policy or certificate holder in any written statement or certificate for the purpose of fraudulently obtaining money or benefit from an insurer; (f) Engages in unauthorized insurance, as set forth in KRS 304.11-030; or (g) Assists, abets, solicits, or conspires with another to commit a fraudulent insurance act in violation of this subtitle. (2) (a) Except as provided in paragraphs (b) and (c) of this subsection, a person convicted of a violation of subsection (1) of this section shall be guilty of a misdemeanor where the aggregate of the claim, benefit, or money referred to in subsection (1) of this section is less than or equal to five hundred dollars ($500), and shall be punished by: 1. Imprisonment for not more than one (1) year; 2. A fine, per occurrence, of not more than one thousand dollars ($1,000) per individual nor five thousand dollars ($5,000) per corporation or twice the amount of gain received as a result of the violation, whichever is greater; or 3. Both imprisonment and a fine as set forth in subparagraphs 1. and 2. of this paragraph. (b) Except as provided in paragraph (c) of this subsection, where the claim, benefit, or money referred to in subsection (1) of this section exceeds an aggregate of five hundred dollars ($500), a person convicted of a violation of subsection (1) of this section shall be guilty of a felony and shall be punished by: 1. Imprisonment for not less than one (1) nor more than five (5) years; 2. A fine, per occurrence, of not more than ten thousand dollars ($10,000) per individual nor one hundred thousand dollars ($100,000) per corporation or twice the amount of gain received as a result of the violation, whichever is greater; or 3. Both imprisonment and a fine as set forth in subparagraphs 1. and 2. of this paragraph. (c) Any person, with the purpose to establish or maintain a criminal syndicate, or to facilitate any of its activities, as set forth in KRS 506.120(1), shall be guilty of engaging in organized crime, a Class B felony, and shall be punished by: 1. Imprisonment for not less than ten (10) years nor more than twenty (20) years; 2. A fine, per occurrence, of not more than ten thousand dollars ($10,000) per individual nor one hundred thousand dollars ($100,000) per corporation, or twice the amount of gain received as a result of the violation; whichever is greater; or 3. Both imprisonment and a fine, as set forth in subparagraphs 1. and 2. of this paragraph. (d) In addition to imprisonment, the assessment of a fine, or both, a person convicted of a violation of paragraph (a), (b), or (c) of subsection (2) of this section may be ordered to make restitution to any victim who suffered a monetary loss due to any actions by that person which resulted in the adjudication of guilt, and to the division for the cost of any investigation. The amount of restitution shall equal the monetary value of the actual loss or twice the amount of gain received as a result of the violation, whichever is greater. (3) Any person damaged as a result of a violation of any provision of this section shall have a cause of action to recover compensatory damages, plus all reasonable investigation and litigation expenses, including attorneys’ fees, at the trial and appellate courts. (4) The provisions of this section shall also apply to any agent, unauthorized insurer or its agents or representatives, or surplus lines carrier who, with intent, injures, defrauds, or deceives any claimant with regard to any claim. The claimant shall have the right to recover the damages provided in subsection (3) of this section. **State:** Kentucky **Statute Areas:** Insurance Fraud - Definition --- ### [Kentucky-Licensing Board Notification-KRS ¤ 304.47-050](https://insurancefraud.org/statutes/kentucky-licensing-board-notification-krs-¤-304-47-050/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (1) Any person, other than those specified in subsection (2) of this section, having knowledge or believing that a fraudulent insurance act or any other act or practice which, upon conviction, constitutes a felony or misdemeanor under the subtitle is being or has been committed may send to the division a report of information pertinent to this knowledge of or belief and any additional relevant information the commissioner may request. (2) The following individuals having knowledge or believing that a fraudulent insurance act or any other act or practice which may constitute a felony or misdemeanor under this subtitle is being or has been committed shall send to the division a report or information pertinent to the knowledge or belief and additional relevant information that the commissioner or the commissioner’s employees or agents may require: (a) Any professional practitioner licensed or regulated by the Commonwealth, except as provided by law; (b) Any private medical review committee; (c) Any insurer, agent, or other person licensed under this chapter; and (d) Any employee of the persons named in paragraphs (a) to (c) of this subsection. (3) The division or its employees or agents shall review this information or these reports and select the information or reports that, in the judgment of the division, may require further investigation. The division shall then cause an investigation of the facts surrounding the information or report to be made to determine the extent, if any, to which a fraudulent insurance act or any other act or practice which, upon conviction, constitutes a felony or misdemeanor under this subtitle is being committed. (4) The Department of Workers’ Claims shall provide the division access to all relevant information the commissioner may request. (5) The division shall report any alleged violations of law which the investigations disclose to the appropriate licensing agency and the Commonwealth’s attorney, Attorney General, or other prosecuting agency having jurisdiction with respect to a violation. If prosecution by the Commonwealth’s attorney, Attorney General, or other prosecuting agency is not begun within sixty (60) days of the report, the prosecuting attorney shall inform the division of the reasons for the lack of prosecution. In addition to filing a report with the appropriate prosecuting agency, the commissioner may, through the Attorney General, prosecute violations of this subtitle in the Circuit Court of the county in which the alleged wrongdoer resides or has his or her principal place of business, in the Circuit Court of the county in which the fraudulent insurance act has been committed, or, with consent of the parties, in the Franklin Circuit Court. (6) Notwithstanding the provisions of subsections (1) to (5) of this section, any person having knowledge or believing that a fraudulent insurance act or any other act that may be prohibited under this subtitle is being or has been committed, may notify any law enforcement agency of his or her knowledge or belief and provide information relevant to the act, as may be requested by that agency, including, but not limited to, insurance policy information including the application for insurance, policy premium payment records, history of previous claims made by the insured, and other information relating to the investigation of the claim, including statements of any person, proofs of loss, and notice of loss. Reporting to any other agency does not relieve those listed in subsection (2) of this section of their mandatory duty to report to the division. (7) If the information referred to in this section is specifically requested by the division, any other law enforcement agency, or a prosecuting attorney, the insurer shall provide certified copies of the requested information within ten (10) business days of the request or as soon thereafter as reasonable. (8) In the absence of malice, fraud, or gross negligence, no insurer or agent authorized by an insurer to act on its behalf, law enforcement agency, the Department of Workers’ Claims, their respective employees, or an insured shall be subject to any civil liability for libel, slander, or related cause of action by virtue of filing reports or for releasing or receiving any information pursuant to this subsection. **State:** Kentucky --- ### [Kentucky-Mandatory Restitution-KRS ¤ 304.47-020 (Proposed Legislation)](https://insurancefraud.org/statutes/kentucky-mandatory-restitution-krs-¤-304-47-020-proposed-legislation/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (2) (a) Except as provided in paragraphs (b) and (c) of this subsection, a person convicted of a violation of subsection (1) of this section shall be guilty of a misdemeanor where the aggregate of the claim, benefit, or money referred to in subsection (1) of this section is less than or equal to five hundred dollars ($500), and shall be punished by: (d) In addition to imprisonment, the assessment of a fine, or both, a person convicted of a violation of paragraph (a), (b), or (c) of subsection (2) of this section may be ordered to make restitution to any victim who suffered a monetary loss due to any actions by that person which resulted in the adjudication of guilt, and to the division for the cost of any investigation. The amount of restitution shall equal the monetary value of the actual loss or twice the amount of gain received as a result of the violation, whichever is greater. **State:** Kentucky **Statute Areas:** Mandatory Restitution --- ### [Kentucky-Placing Bogus Coverage-KRS ¤ 304.47-020 (Proposed Legislation)](https://insurancefraud.org/statutes/kentucky-placing-bogus-coverage-krs-¤-304-47-020-proposed-legislation/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (1) For the purposes of this subtitle, a person or entity commits a “fraudulent insurance act” if he or she engages in any of the following, including but not limited to matters relating to workers’ compensation: (c) Knowingly and with intent to defraud or deceive: 1. Receives money for the purpose of purchasing insurance, and fails to obtain insurance; 2. Fails to make payment or disposition of money or voucher as defined in KRS 304.17A-750, as required by agreement or legal obligation, that comes into his or her possession while acting as a licensee under this chapter; 3. Presents, causes to be presented, or prepares with knowledge or belief that it will be presented to or by an insurer, or to the commissioner, any statement, knowing that the statement contains any false, incomplete, or misleading information concerning any material fact or thing, as part of, or in support of one (1) or more of the following: a. The rating of an insurance policy; b. The financial condition of an insurer; c. The formation, acquisition, merger, reconsolidation, dissolution, or withdrawal from one (1) or more lines of insurance in all or part of this Commonwealth by an insurer; or d. A document filed with the commissioner; or 4. Engages in any of the following: a. Solicitation or acceptance of new or renewal insurance risks on behalf of an insolvent insurer; or b. Removal, concealment, alteration, tampering, or destruction of money, records, or any other property or assets of an insurer; (d) Issues or knowingly presents fake or counterfeit insurance policies, certificates of insurance, insurance identification cards, insurance binders, or any other documents that purport to evidence insurance; (e) Makes any false or fraudulent representation as to the death or disability of a policy or certificate holder in any written statement or certificate for the purpose of fraudulently obtaining money or benefit from an insurer; **State:** Kentucky --- ### [Kentucky-Practitioner Penalites-KRS ¤ 304.99-126](https://insurancefraud.org/statutes/kentucky-practitioner-penalites-krs-¤-304-99-126/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (1) When a license issued under KRS 304.15-700 is suspended or revoked, the licensee, if the commissioner directs, shall proceed, immediately following the effective date of the suspension or revocation to conclude the affairs it is transacting under its license. The licensee shall not solicit, negotiate, advertise, or effectuate new contracts. The department shall retain jurisdiction over the licensee and trust until all life contracts have been fulfilled or canceled or have expired. (2) During the suspension or revocation period in which the licensee is concluding existing contracts, the licensee shall continue to comply with KRS 304.15-020, 304.15-700 to 304.15-720, and 304.42-190 and this section as if the license were in force. (3) Any person who violates any provisions of KRS 304.15-020, 304.15-700 to 304.15-720, and 304.42-190 and this section shall be subject to civil fines by the commissioner in an amount not less than one thousand dollars ($1,000) and not more than twenty-five thousand dollars ($25,000). Each violation shall constitute a separate offense. (4) The department shall refer violations to the Division of Insurance Fraud Investigation for further investigation, and, if appropriate, the Division of Insurance Fraud Investigation shall proceed as set forth in KRS 304.47-050(5). **State:** Kentucky **Statute Areas:** Practitioner Penalites --- ### [Kentucky-Range of Criminal Penalties-KRS ¤ 304.47-020 (Proposed Legislation)](https://insurancefraud.org/statutes/kentucky-range-of-criminal-penalties-krs-¤-304-47-020-proposed-legislation/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (2) (a) Except as provided in paragraphs (b) and (c) of this subsection, a person convicted of a violation of subsection (1) of this section shall be guilty of a misdemeanor where the aggregate of the claim, benefit, or money referred to in subsection (1) of this section is less than or equal to five hundred dollars ($500), and shall be punished by: 1. Imprisonment for not more than one (1) year; 2. A fine, per occurrence, of not more than one thousand dollars ($1,000) per individual nor five thousand dollars ($5,000) per corporation or twice the amount of gain received as a result of the violation, whichever is greater; or 3. Both imprisonment and a fine as set forth in subparagraphs 1. and 2. of this paragraph. (b) Except as provided in paragraph (c) of this subsection, where the claim, benefit, or money referred to in subsection (1) of this section exceeds an aggregate of five hundred dollars ($500), a person convicted of a violation of subsection (1) of this section shall be guilty of a felony and shall be punished by: 1. Imprisonment for not less than one (1) nor more than five (5) years; 2. A fine, per occurrence, of not more than ten thousand dollars ($10,000) per individual nor one hundred thousand dollars ($100,000) per corporation or twice the amount of gain received as a result of the violation, whichever is greater; or 3. Both imprisonment and a fine as set forth in subparagraphs 1. and 2. of this paragraph. (c) Any person, with the purpose to establish or maintain a criminal syndicate, or to facilitate any of its activities, as set forth in KRS 506.120(1), shall be guilty of engaging in organized crime, a Class B felony, and shall be punished by: 1. Imprisonment for not less than ten (10) years nor more than twenty (20) years; 2. A fine, per occurrence, of not more than ten thousand dollars ($10,000) per individual nor one hundred thousand dollars ($100,000) per corporation, or twice the amount of gain received as a result of the violation; whichever is greater; or 3. Both imprisonment and a fine, as set forth in subparagraphs 1. and 2. of this paragraph. (d) In addition to imprisonment, the assessment of a fine, or both, a person convicted of a violation of paragraph (a), (b), or (c) of subsection (2) of this section may be ordered to make restitution to any victim who suffered a monetary loss due to any actions by that person which resulted in the adjudication of guilt, and to the division for the cost of any investigation. The amount of restitution shall equal the monetary value of the actual loss or twice the amount of gain received as a result of the violation, whichever is greater. (3) Any person damaged as a result of a violation of any provision of this section shall have a cause of action to recover compensatory damages, plus all reasonable investigation and litigation expenses, including attorneys’ fees, at the trial and appellate courts. **State:** Kentucky **Statute Areas:** Range of Criminal Penalties --- ### [Kentucky-Range of Civil Penalties-KRS ¤ 304.47-020 (Proposed Legislation)](https://insurancefraud.org/statutes/kentucky-range-of-civil-penalties-krs-¤-304-47-020-proposed-legislation/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (2) (a) Except as provided in paragraphs (b) and (c) of this subsection, a person convicted of a violation of subsection (1) of this section shall be guilty of a misdemeanor where the aggregate of the claim, benefit, or money referred to in subsection (1) of this section is less than or equal to five hundred dollars ($500), and shall be punished by: 1. Imprisonment for not more than one (1) year; 2. A fine, per occurrence, of not more than one thousand dollars ($1,000) per individual nor five thousand dollars ($5,000) per corporation or twice the amount of gain received as a result of the violation, whichever is greater; or 3. Both imprisonment and a fine as set forth in subparagraphs 1. and 2. of this paragraph. (b) Except as provided in paragraph (c) of this subsection, where the claim, benefit, or money referred to in subsection (1) of this section exceeds an aggregate of five hundred dollars ($500), a person convicted of a violation of subsection (1) of this section shall be guilty of a felony and shall be punished by: 1. Imprisonment for not less than one (1) nor more than five (5) years; 2. A fine, per occurrence, of not more than ten thousand dollars ($10,000) per individual nor one hundred thousand dollars ($100,000) per corporation or twice the amount of gain received as a result of the violation, whichever is greater; or 3. Both imprisonment and a fine as set forth in subparagraphs 1. and 2. of this paragraph. (c) Any person, with the purpose to establish or maintain a criminal syndicate, or to facilitate any of its activities, as set forth in KRS 506.120(1), shall be guilty of engaging in organized crime, a Class B felony, and shall be punished by: 1. Imprisonment for not less than ten (10) years nor more than twenty (20) years; 2. A fine, per occurrence, of not more than ten thousand dollars ($10,000) per individual nor one hundred thousand dollars ($100,000) per corporation, or twice the amount of gain received as a result of the violation; whichever is greater; or 3. Both imprisonment and a fine, as set forth in subparagraphs 1. and 2. of this paragraph. (d) In addition to imprisonment, the assessment of a fine, or both, a person convicted of a violation of paragraph (a), (b), or (c) of subsection (2) of this section may be ordered to make restitution to any victim who suffered a monetary loss due to any actions by that person which resulted in the adjudication of guilt, and to the division for the cost of any investigation. The amount of restitution shall equal the monetary value of the actual loss or twice the amount of gain received as a result of the violation, whichever is greater. (3) Any person damaged as a result of a violation of any provision of this section shall have a cause of action to recover compensatory damages, plus all reasonable investigation and litigation expenses, including attorneys’ fees, at the trial and appellate courts. **State:** Kentucky **Statute Areas:** Range of Civil Penalties --- ### [Kentucky-Rating of an Insurance Policy-n/a](https://insurancefraud.org/statutes/kentucky-rating-of-an-insurance-policy-n-a/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Statute repealed. KRS ¤ 304.13-030. **State:** Kentucky --- ### [Kentucky-Underwriting Fraud-KRS ¤ 304.47-020 (Proposed Legislation)](https://insurancefraud.org/statutes/kentucky-underwriting-fraud-krs-¤-304-47-020-proposed-legislation/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (c) Knowingly and with intent to defraud or deceive: 1. Receives money for the purpose of purchasing insurance, and fails to obtain insurance; 2. Fails to make payment or disposition of money or voucher as defined in KRS 304.17A-750, as required by agreement or legal obligation, that comes into his or her possession while acting as a licensee under this chapter; 3. Presents, causes to be presented, or prepares with knowledge or belief that it will be presented to or by an insurer, or to the commissioner, any statement, knowing that the statement contains any false, incomplete, or misleading information concerning any material fact or thing, as part of, or in support of one (1) or more of the following: a. The rating of an insurance policy; b. The financial condition of an insurer; c. The formation, acquisition, merger, reconsolidation, dissolution, or withdrawal from one (1) or more lines of insurance in all or part of this Commonwealth by an insurer; or d. A document filed with the commissioner; or 4. Engages in any of the following: a. Solicitation or acceptance of new or renewal insurance risks on behalf of an insolvent insurer; or b. Removal, concealment, alteration, tampering, or destruction of money, records, or any other property or assets of an insurer; (d) Issues or knowingly presents fake or counterfeit insurance policies, certificates of insurance, insurance identification cards, insurance binders, or any other documents that purport to evidence insurance; (e) Makes any false or fraudulent representation as to the death or disability of a policy or certificate holder in any written statement or certificate for the purpose of fraudulently obtaining money or benefit from an insurer; (f) Engages in unauthorized insurance, as set forth in KRS 304.11-030; or (g) Assists, abets, solicits, or conspires with another to commit a fraudulent insurance act in violation of this subtitle. **State:** Kentucky **Statute Areas:** Underwriting Fraud --- ### [Kentucky-Unauthorized Entities-KRS ¤ 304.11-030 (Proposed Legislation)](https://insurancefraud.org/statutes/kentucky-unauthorized-entities-krs-¤-304-11-030-proposed-legislation/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (1) It shall be unlawful for any company to enter into a contract of insurance as an insurer or to transact insurance business in this state, as set forth in subsection (2) of this section without a certificate of authority from the commissioner; provided, that this subsection shall not apply to: (a) The lawful transaction of surplus lines insurance; (b) The lawful transaction of reinsurance by insurers; (c) Transactions in this state involving a policy lawfully solicited, written, and delivered outside of this state covering only subjects of insurance not resident, located, or expressly to be performed in this state at the time of issuance, and which transactions are subsequent to the issuance of such policy; (d) Transactions involving contracts of insurance independently procured through negotiations occurring entirely outside of this state which are reported and on which premium tax is paid; (e) Attorneys acting in the ordinary relation of attorney and client in the adjustment of claims or losses; (f) Transactions in this state involving group life and group health or blanket health insurance or group annuities where the master policy of such groups was lawfully issued and delivered in a state in which the company was authorized to do an insurance business; (g) Transactions in this state involving any policy of insurance issued prior to July 1, 1968; and (h) Insurance on vessels, craft or hulls, cargoes, marine builder’s risk, marine protection and indemnity or other risk, including strikes and war risks commonly insured under ocean or wet marine forms of policy. (2) Any of the following acts in this state effected by mail or otherwise is defined to be doing an insurance business in this state. The venue of an act committed by mail is at the point where the matter transmitted by mail is delivered and takes effect. Unless otherwise indicated, the term “insurer” as used in this section includes all corporations, associations, partnerships, and individuals, engaged as principals in the business of insurance and also includes interinsurance exchanges and mutual benefit societies: (a) The making of or proposing to make, as an insurer, an insurance contract; (b) The making of or proposing to make, as guarantor or surety, any contract of guaranty or suretyship as a vocation and not merely incidental to any other legitimate business or activity of the guarantor or surety; (c) The taking or receiving of any application for insurance; (d) The receiving or collection of any premiums, commissions, membership fees, assessments, dues or other consideration for any insurance or any part thereof; (e) The issuance or delivery of contracts of insurance to residents of this state or to persons authorized to do business in this state; (f) Directly or indirectly acting as an agent for, or otherwise representing or aiding on behalf of another, any person or insurer in the solicitation, negotiation, procurement or effectuation of insurance or renewals thereof or in the dissemination of information as to coverage or rates, or forwarding of applications, or delivery of policies or contracts, or inspection of risks, or fixing of rates or investigation or adjustment of claims or losses, or in the transaction of matters subsequent to effectuation of the contract and arising out of it, or in any other manner representing or assisting a person or insurer in the transaction of insurance with respect to subjects of insurance resident, located or to be performed in this state. The provisions of this subsection shall not operate to prohibit full-time salaried employees of a corporate insured from acting in the capacity of an insurance manager or buyer in placing insurance in behalf of such employer; (g) The doing of any kind of insurance business specifically recognized as constituting the doing of an insurance business within the meaning of the statutes relating to insurance; (h) The doing or proposing to do any insurance business in substance equivalent to any of the foregoing in a manner designed to evade the provisions of this code; and (i) Any other transactions of business in this state by an insurer. (3) (a) The failure of a company transacting insurance business in Kentucky to obtain a certificate of authority shall not impair the validity of any act or contract of such company and shall not prevent such company from defending any action at law or suit in equity in any court of this state. (b) In event of failure of any such unauthorized insurer to pay any claim or loss within the provisions of such insurance contract, any person who assisted or in any manner aided directly or indirectly in the procurement of such insurance contract shall be liable to the insured for the full amount of the claim or loss in the manner provided by the provisions of such insurance contract. (4) Whenever the commissioner believes, from evidence satisfactory to him or her, that any company is violating or about to violate the provisions of these sections, the commissioner may, through the Attorney General of this state, cause a complaint to be filed in the Circuit Court of Franklin County to enjoin and restrain such company from continuing such violation or engaging therein or doing any act in furtherance thereof. The court shall have jurisdiction of the proceeding and shall have the power to make and enter an order or judgment awarding such preliminary or final injunctive relief as in its judgment is proper. **State:** Kentucky --- ### [Kansas-Claims Fraud-K.S.A. 40-2,118](https://insurancefraud.org/statutes/kansas-claims-fraud-k-s-a-40-2118/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** a) For purposes of this act a “fraudulent insurance act” means an act committed by any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written, electronic, electronic impulse, facsimile, magnetic, oral, or telephonic communication or statement as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance which such person knows to contain materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto. (b) An insurer that has knowledge or a good faith belief that a fraudulent insurance act is being or has been committed shall provide to the commissioner, on a form prescribed by the commissioner, any and all information and such additional information relating to such fraudulent insurance act as the commissioner may require. (c) Any other person that has knowledge or a good faith belief that a fraudulent insurance act is being or has been committed may provide to the commissioner, on a form prescribed by the commissioner, any and all information and such additional information relating to such fraudulent insurance act as the commissioner may request. (d)(1) Each insurer shall have antifraud initiatives reasonably calculated to detect fraudulent insurance acts. Antifraud initiatives may include fraud investigators, who may be insurer employees or independent contractors and an antifraud plan submitted to the commissioner no later than July 1, 2007. Each insurer that submits an antifraud plan shall notify the commissioner of any material change in the information contained in the antifraud plan within 30 days after such change occurs. Such insurer shall submit to the commissioner in writing the amended antifraud plan. The requirement for submitting any antifraud plan, or any amendment thereof, to the commissioner shall expire on the date specified in subsection (d)(2) unless the legislature reviews and reenacts the provisions of subsection (d)(2) prior to such date. (2) Any antifraud plan, or any amendment thereof, submitted to the commissioner for informational purposes only shall be confidential and not be a public record and shall not be subject to discovery or subpoena in a civil action unless following an in camera review, the court determines that the antifraud plan is relevant and otherwise admissible under the rules of evidence set forth in article 4 of chapter 60 of the Kansas Statutes Annotated, and amendments thereto. The provisions of this paragraph shall expire on July 1, 2021, unless the legislature reviews and reenacts this provision prior to July 1, 2021. (e) Except as otherwise specifically provided in K.S.A. 21-5812(a), and amendments thereto, and K.S.A. 44-5,125, and amendments thereto, a fraudulent insurance act shall constitute a severity level 6, nonperson felony if the amount involved is $25,000 or more; a severity level 7, nonperson felony if the amount is at least $5,000 but less than $25,000; a severity level 8, nonperson felony if the amount is at least $1,000 but less than $5,000; and a class C nonperson misdemeanor if the amount is less than $1,000. Any combination of fraudulent acts as defined in subsection (a) which occur in a period of six consecutive months which involves $25,000 or more shall have a presumptive sentence of imprisonment regardless of its location on the sentencing grid block. (f) In addition to any other penalty, a person who violates this statute shall be ordered to make restitution to the insurer or any other person or entity for any financial loss sustained as a result of such violation. An insurer shall not be required to provide coverage or pay any claim involving a fraudulent insurance act. (g) This act shall apply to all insurance applications, ratings, claims and other benefits made pursuant to any insurance policy. **State:** Kansas **Statute Areas:** Claims Fraud --- ### [Kansas-Fraud Bureau-K.S.A. 40-113](https://insurancefraud.org/statutes/kansas-fraud-bureau-k-s-a-40-113/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) There is hereby established within the insurance department a criminal anti-fraud division of the Kansas insurance department. The criminal anti-fraud division shall accept information and complaints regarding possible insurance fraud. The criminal anti-fraud division shall also investigate possible violations of Kansas criminal statutes pertaining to and related to insurance fraud. The criminal anti-fraud division shall prepare and refer criminal cases to the attorney general, or in consultation with the attorney general to the proper county or district attorney, who may, in such prosecutor’s discretion, with or without such a reference, institute the appropriate criminal proceedings under the laws of this state. The commissioner may pay extradition and witness expenses and other costs associated with the case. (b) Complaints of insurance fraud shall be accepted from Kansas consumers, other divisions within the insurance department, other state and federal law enforcement agencies, and insurance companies. The criminal anti-fraud division’s investigators shall prepare clear and concise reports concerning investigations and preserve evidence. (c) The criminal anti-fraud division shall assist in the preparation and presentation of criminal cases as requested by the attorney general or county or district attorney. The criminal anti-fraud division shall perform other such duties in the prevention, detection, investigation and prosecution of insurance fraud as may be necessary. Such preparation may include affidavits, interviews, preservation of evidence and securing the attendance of individuals involved in the case. In presenting the prosecution’s case, members of the criminal anti-fraud division may testify as to the facts of the case. **State:** Kansas **Statute Areas:** Fraud Bureau --- ### [Kansas-Immunity-K.S.A. 40-2,119](https://insurancefraud.org/statutes/kansas-immunity-k-s-a-40-2119/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** In the absence of fraud, bad faith or malice, no person or insurer shall be subject to civil liability for libel, slander or any other relevant cause of action: (a) For filing reports or furnishing other information required by chapter 40 of the Kansas Statutes Annotated, and amendments thereto, or required by the commissioner under the authority granted in chapter 40 of the Kansas Statutes Annotated, and amendments thereto; (b) for any information relating to suspected fraudulent insurance acts furnished to or received from law enforcement officials, their agents and employees; (c) for any information relating to suspected fraudulent insurance acts furnished to or received from other persons subject to the provisions of chapter 40 of the Kansas Statutes Annotated, and amendments thereto; (d) for any such information furnished in reports to the insurance department, regulatory agencies of any other state, the national association of insurance commissioners or any organization established to detect and prevent fraudulent insurance acts, their agents, employees or designees; or (e) for the publication of any report or bulletin related to the official activities of the insurance department by the commissioner or any employee of the insurance department. Nothing herein is intended to abrogate or modify in any way any common law or statutory privilege or immunity heretofore enjoyed by any person. **State:** Kansas **Statute Areas:** Immunity --- ### [Kansas-Insurance Fraud - Definition-K.S.A. 40-2,118](https://insurancefraud.org/statutes/kansas-insurance-fraud-definition-k-s-a-40-2118/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) For purposes of this act a “fraudulent insurance act” means an act committed by any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written, electronic, electronic impulse, facsimile, magnetic, oral, or telephonic communication or statement as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance which such person knows to contain materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto. (b) An insurer that has knowledge or a good faith belief that a fraudulent insurance act is being or has been committed shall provide to the commissioner, on a form prescribed by the commissioner, any and all information and such additional information relating to such fraudulent insurance act as the commissioner may require. (c) Any other person that has knowledge or a good faith belief that a fraudulent insurance act is being or has been committed may provide to the commissioner, on a form prescribed by the commissioner, any and all information and such additional information relating to such fraudulent insurance act as the commissioner may request. (d)(1) Each insurer shall have antifraud initiatives reasonably calculated to detect fraudulent insurance acts. Antifraud initiatives may include fraud investigators, who may be insurer employees or independent contractors and an antifraud plan submitted to the commissioner no later than July 1, 2007. Each insurer that submits an antifraud plan shall notify the commissioner of any material change in the information contained in the antifraud plan within 30 days after such change occurs. Such insurer shall submit to the commissioner in writing the amended antifraud plan. The requirement for submitting any antifraud plan, or any amendment thereof, to the commissioner shall expire on the date specified in subsection (d)(2) unless the legislature reviews and reenacts the provisions of subsection (d)(2) prior to such date. (2) Any antifraud plan, or any amendment thereof, submitted to the commissioner for informational purposes only shall be confidential and not be a public record and shall not be subject to discovery or subpoena in a civil action unless following an in camera review, the court determines that the antifraud plan is relevant and otherwise admissible under the rules of evidence set forth in article 4 of chapter 60 of the Kansas Statutes Annotated, and amendments thereto. The provisions of this paragraph shall expire on July 1, 2021, unless the legislature reviews and reenacts this provision prior to July 1, 2021. (e) Except as otherwise specifically provided in K.S.A. 21-5812(a), and amendments thereto, and K.S.A. 44-5,125, and amendments thereto, a fraudulent insurance act shall constitute a severity level 6, nonperson felony if the amount involved is $25,000 or more; a severity level 7, nonperson felony if the amount is at least $5,000 but less than $25,000; a severity level 8, nonperson felony if the amount is at least $1,000 but less than $5,000; and a class C nonperson misdemeanor if the amount is less than $1,000. Any combination of fraudulent acts as defined in subsection (a) which occur in a period of six consecutive months which involves $25,000 or more shall have a presumptive sentence of imprisonment regardless of its location on the sentencing grid block. (f) In addition to any other penalty, a person who violates this statute shall be ordered to make restitution to the insurer or any other person or entity for any financial loss sustained as a result of such violation. An insurer shall not be required to provide coverage or pay any claim involving a fraudulent insurance act. (g) This act shall apply to all insurance applications, ratings, claims and other benefits made pursuant to any insurance policy. **State:** Kansas **Statute Areas:** Insurance Fraud - Definition --- ### [Kansas-Looting & diverting-n/a](https://insurancefraud.org/statutes/kansas-looting-diverting-n-a/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** No statue found. **State:** Kansas --- ### [Kansas-Mandatory Restitution-K.S.A. 40-2,118](https://insurancefraud.org/statutes/kansas-mandatory-restitution-k-s-a-40-2118/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (f) In addition to any other penalty, a person who violates this statute shall be ordered to make restitution to the insurer or any other person or entity for any financial loss sustained as a result of such violation. An insurer shall not be required to provide coverage or pay any claim involving a fraudulent insurance act. **State:** Kansas **Statute Areas:** Mandatory Restitution --- ### [Kansas-Practitioner Penalites-K.S.A. 40-2406](https://insurancefraud.org/statutes/kansas-practitioner-penalites-k-s-a-40-2406/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) Whenever the commissioner has reason to believe that any such person has been engaged or is engaging in this state in any unfair method of competition or any unfair or deceptive act or practice, whether or not defined in K.S.A. 40-2404, and amendments thereto, and that a proceeding by the commissioner in respect thereto would be in the interest of the public, the commissioner shall issue and serve upon such person a statement of the charges in that respect and conduct a hearing thereon in accordance with the provisions of the Kansas administrative procedure act. (b) If, after such hearing, the commissioner determines that the person charged has engaged in any unfair method of competition or any unfair or deceptive act or practice, any costs incurred as a result of conducting any administrative hearing authorized under the provisions of this section shall be assessed against such person or the company or companies represented by such person as an agent, broker or adjuster who is a participating party to the matters giving rise to the hearing. As used in this subsection, “costs” shall include witness fees, mileage allowances, any costs associated with reproduction of documents which become a part of the hearing record and the expense of making a record of the hearing. **State:** Kansas **Statute Areas:** Practitioner Penalites --- ### [Kansas-Range of Criminal Penalties-K.S.A. 40-2,118](https://insurancefraud.org/statutes/kansas-range-of-criminal-penalties-k-s-a-40-2118/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (e) Except as otherwise specifically provided in K.S.A. 21-5812(a), and amendments thereto, and K.S.A. 44-5,125, and amendments thereto, a fraudulent insurance act shall constitute a severity level 6, nonperson felony if the amount involved is $25,000 or more; a severity level 7, nonperson felony if the amount is at least $5,000 but less than $25,000; a severity level 8, nonperson felony if the amount is at least $1,000 but less than $5,000; and a class C nonperson misdemeanor if the amount is less than $1,000. Any combination of fraudulent acts as defined in subsection (a) which occur in a period of six consecutive months which involves $25,000 or more shall have a presumptive sentence of imprisonment regardless of its location on the sentencing grid block. (f) In addition to any other penalty, a person who violates this statute shall be ordered to make restitution to the insurer or any other person or entity for any financial loss sustained as a result of such violation. An insurer shall not be required to provide coverage or pay any claim involving a fraudulent insurance act. **State:** Kansas **Statute Areas:** Range of Criminal Penalties --- ### [Kansas-Unauthorized Entities-K.S.A. 40-2001](https://insurancefraud.org/statutes/kansas-unauthorized-entities-k-s-a-40-2001/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** The purpose of this act is to subject certain insurers to the jurisdiction of courts of this state in suits by or on behalf of insureds or beneficiaries under insurance contracts. The legislature declares that it is a subject of concern that many residents of this state hold policies of insurance issued or delivered in this state by insurers while not authorized to do business in this state, thus presenting to such residents the often insuperable obstacle of resorting to distant forums for the purpose of asserting legal rights under such policies. In furtherance of such state interest, the legislature herein provides a method of substituted service of process upon such insurers and declares that in so doing it exercises its powers to protect its residents and to define, for the purpose of this statute, what constitutes doing business in this state, and also exercises powers and privileges available to the state by virtue of Public Law 15, 79th Congress of the United States, Chapter 20, 1st Session, S. 3401, which declares that the business of insurance and every person engaged therein shall be subject to the laws of the several states. **State:** Kansas --- ### [Iowa-Aiding & Abetting-I.C.A. ¤ 507E.3](https://insurancefraud.org/statutes/iowa-aiding-abetting-i-c-a-¤-507e-3/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** 2\. A person commits a class “D” felony if the person, with the intent to defraud an insurer, does any of the following: b. Assists, abets, solicits, or conspires with another to present or cause to be presented to an insurer, any written document or oral statement, including a computer-generated document, that is intended to be presented to any insurer in connection with, or in support of, any claim for payment or other benefit pursuant to an insurance policy, knowing that such document or statement contains any false information concerning a material fact. **State:** Iowa --- ### [Iowa-Claims Fraud-I.C.A. ¤ 507E.3](https://insurancefraud.org/statutes/iowa-claims-fraud-i-c-a-¤-507e-3/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** 2\. A person commits a class “D” felony if the person, with the intent to defraud an insurer, does any of the following: a. Presents or causes to be presented to an insurer, any written document or oral statement, including a computer-generated document, as part of, or in support of, a claim for payment or other benefit pursuant to an insurance policy, knowing that such document or statement contains any false information concerning a material fact. **State:** Iowa **Statute Areas:** Claims Fraud --- ### [Iowa-Fraud Bureau-I.C.A. ¤ 507E.2](https://insurancefraud.org/statutes/iowa-fraud-bureau-i-c-a-¤-507e-2/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** An insurance fraud bureau is created within the insurance division. Upon a reasonable determination by the division, by its own inquiries or as a result of complaints filed with the division, that a person has engaged in, is engaging in, or may be engaging in an act or practice that violates this chapter or any other provision of the insurance code, the division may administer oaths and affirmations, serve subpoenas ordering the attendance of witnesses, and collect evidence related to such act or practice. **State:** Iowa **Statute Areas:** Fraud Bureau --- ### [Iowa-Immunity-I.C.A. ¤ 507E.7](https://insurancefraud.org/statutes/iowa-immunity-i-c-a-¤-507e-7/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** 1\. A person acting without malice, fraudulent intent, or bad faith is not liable civilly as a result of filing a report or furnishing, orally or in writing, other information concerning alleged acts in violation of this chapter, if the report or information is provided to or received from any of the following: a. Law enforcement officials, their agents and employees. b. The national association of insurance commissioners, the insurance division, a federal or state governmental agency or bureau established to detect and prevent fraudulent insurance acts, or any other organization established for such purpose, and their agents, employees, or designees. c. An authorized representative of an insurer. 2. This section does not affect in any way any common law or statutory privilege or immunity applicable to such person or entity. **State:** Iowa **Statute Areas:** Immunity --- ### [Iowa-Insurance Fraud - Definition-I.C.A. ¤ 507E.3](https://insurancefraud.org/statutes/iowa-insurance-fraud-definition-i-c-a-¤-507e-3/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** 2\. A person commits a class “D” felony if the person, with the intent to defraud an insurer, does any of the following: a. Presents or causes to be presented to an insurer, any written document or oral statement, including a computer-generated document, as part of, or in support of, a claim for payment or other benefit pursuant to an insurance policy, knowing that such document or statement contains any false information concerning a material fact. b. Assists, abets, solicits, or conspires with another to present or cause to be presented to an insurer, any written document or oral statement, including a computer-generated document, that is intended to be presented to any insurer in connection with, or in support of, any claim for payment or other benefit pursuant to an insurance policy, knowing that such document or statement contains any false information concerning a material fact. c. Presents or causes to be presented to an insurer, any written document or oral statement, including a computer-generated document, as part of, or in, an application for insurance coverage, knowing that such document or statement contains false information concerning a material fact. **State:** Iowa **Statute Areas:** Insurance Fraud - Definition --- ### [Iowa-Licensing Board Notification-I.C.A. ¤ 507E.6](https://insurancefraud.org/statutes/iowa-licensing-board-notification-i-c-a-¤-507e-6/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** An insurer which believes that a claim or application for insurance coverage is being made which is a violation of section 507E.3 shall provide, within sixty days of the receipt of such claim or application, written notification to the bureau of the claim or application on a form prescribed by the bureau, including any additional information requested by the bureau related to the claim or application or the party making the claim or application. The fraud bureau shall review each notification and determine whether further investigation is warranted. If the bureau determines that further investigation is warranted, the bureau shall conduct an independent investigation of the facts surrounding the claim or application for insurance coverage to determine the extent, if any, to which fraud occurred in the submission of the claim or application. The bureau shall report any alleged violation of law disclosed by the investigation to the appropriate licensing agency or prosecuting authority having jurisdiction with respect to such violation. **State:** Iowa --- ### [Iowa-Placing Bogus Coverage-n/a](https://insurancefraud.org/statutes/iowa-placing-bogus-coverage-n-a/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** No statute found **State:** Iowa --- ### [Iowa-Practitioner Penalites-I.C.A. ¤ 507E.3A](https://insurancefraud.org/statutes/iowa-practitioner-penalites-i-c-a-¤-507e-3a/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** 1\. A person commits the offense of fraudulent sales practices if the person, with the intent to defraud another person in connection with any sale, solicitation, or negotiation of insurance in this state, willfully does any of the following: a. Employs any deception, device, scheme, or artifice to defraud. b. Misrepresents, conceals, or suppresses any material fact. c. Engages in any act, practice, or course of business which operates as a fraud or deceit upon any person. 2. A person who violates subsection 1 commits a class “D” felony. 3. Notwithstanding subsection 2, a person commits a class “C” felony if the person violates subsection 1, and such violation results in a loss of more than ten thousand dollars. **State:** Iowa **Statute Areas:** Practitioner Penalites --- ### [Iowa-Range of Criminal Penalties-I.C.A. ¤ 507E.3](https://insurancefraud.org/statutes/iowa-range-of-criminal-penalties-i-c-a-¤-507e-3/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** 1\. For purposes of this chapter, “statement” includes, but is not limited to, any notice, statement, proof of loss, bill of lading, receipt for payment, invoice, account, estimate of property damage, bill for services, diagnosis, prescription, hospital or physician record, X ray, test result, or other evidence of loss, injury, or expense. 2. A person commits a class “D” felony if the person, with the intent to defraud an insurer, does any of the following: a. Presents or causes to be presented to an insurer, any written document or oral statement, including a computer-generated document, as part of, or in support of, a claim for payment or other benefit pursuant to an insurance policy, knowing that such document or statement contains any false information concerning a material fact. b. Assists, abets, solicits, or conspires with another to present or cause to be presented to an insurer, any written document or oral statement, including a computer-generated document, that is intended to be presented to any insurer in connection with, or in support of, any claim for payment or other benefit pursuant to an insurance policy, knowing that such document or statement contains any false information concerning a material fact. c. Presents or causes to be presented to an insurer, any written document or oral statement, including a computer-generated document, as part of, or in, an application for insurance coverage, knowing that such document or statement contains false information concerning a material fact. Credits **State:** Iowa **Statute Areas:** Range of Criminal Penalties --- ### [Iowa-Range of Civil Penalties-I.C.A. ¤ 505.7A](https://insurancefraud.org/statutes/iowa-range-of-civil-penalties-i-c-a-¤-505-7a/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Unless specifically provided for in this subtitle, penalties imposed under this subtitle by order of the commissioner of insurance after hearing shall not exceed one thousand dollars for each act or violation of this subtitle, up to an aggregate of ten thousand dollars, unless the person knew or reasonably should have known the person was in violation of this subtitle, in which case the penalty shall not exceed five thousand dollars for each act or violation, up to an aggregate of fifty thousand dollars in any one six-month period. **State:** Iowa **Statute Areas:** Range of Civil Penalties --- ### [Iowa-Rating of an Insurance Policy-I.C.A. ¤ 515F.4](https://insurancefraud.org/statutes/iowa-rating-of-an-insurance-policy-i-c-a-¤-515f-4/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Rates shall be made in accordance with the following: 1. Rates shall not be excessive, inadequate, or unfairly discriminatory. 2. Due consideration may be given to past and prospective loss experience within and outside this state; to the conflagration and catastrophe hazards; to a reasonable margin for profit and contingencies; to dividends, savings, or unabsorbed premium deposits allowed or returned by insurers to their policyholders, members, or subscribers; to past and prospective expenses both within and outside this state; and to all other relevant factors within and outside this state; and in the case of fire insurance rates, consideration shall be given to the experience of the fire insurance business during a period of not less than the most recent five-year period for which experience data is available. 3. Risks may be grouped by classifications for the establishment of rates and minimum premiums. Classification rates may be modified to produce rates for individual risks in accordance with rating plans which establish standards for measuring variations in hazards or expense provisions, or both. Standards may measure any differences among risks that can be demonstrated to have a probable effect upon losses or expenses. A risk classification, however, shall not be based upon race, creed, national origin, or the religion of the insured. 4. The expense provisions included in the rates to be used by an insurer shall reflect to the extent possible the operating methods of the insurer and its anticipated expenses. 5. The rates may contain a provision for contingencies and an allowance permitting a reasonable profit. In determining the reasonableness of the profit, consideration shall be given to investment income attributable to unearned premium and loss reserves. **State:** Iowa --- ### [Iowa-Underwriting Fraud-I.C.A. ¤ 507E.3A](https://insurancefraud.org/statutes/iowa-underwriting-fraud-i-c-a-¤-507e-3a/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** 1\. A person commits the offense of fraudulent sales practices if the person, with the intent to defraud another person in connection with any sale, solicitation, or negotiation of insurance in this state, willfully does any of the following: a. Employs any deception, device, scheme, or artifice to defraud. b. Misrepresents, conceals, or suppresses any material fact. c. Engages in any act, practice, or course of business which operates as a fraud or deceit upon any person. 2. A person who violates subsection 1 commits a class “D” felony. 3. Notwithstanding subsection 2, a person commits a class “C” felony if the person violates subsection 1, and such violation results in a loss of more than ten thousand dollars. **State:** Iowa **Statute Areas:** Underwriting Fraud --- ### [Iowa-Unauthorized Entities-I.C.A. ¤ 507A.3](https://insurancefraud.org/statutes/iowa-unauthorized-entities-i-c-a-¤-507a-3/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** 1\. Unless otherwise indicated, “insurer” as used in this section includes all corporations, associations, partnerships and individuals engaged in the business of insurance. Any of the following acts in this state, effected by mail or otherwise, by an unauthorized insurer is defined to be doing an insurance business in this state: a. The making of or proposing to make, as an insurer, an insurance contract. b. The taking or receiving of any application for insurance. c. The receiving or collection of any premiums, membership fees, assessments, dues or other considerations for any insurance. d. The issuance or delivery of contracts of insurance to residents of this state or to corporations or persons authorized to do business in this state. e. The doing of any kind of insurance business specifically recognized as constituting the doing of an insurance business within the meaning of the statutes relating to insurance. f. The doing or proposing to do any insurance business in substance equivalent to any of the foregoing in a manner designed to evade the provisions of the insurance laws of this state. g. Any other transactions of business relating directly to insurance in this state by an insurer. 2. The venue of an act committed by mail is at the point where the matter transmitted by mail is delivered and takes effect. **State:** Iowa --- ### [Indiana-Attempted Fraud-n/a](https://insurancefraud.org/statutes/indiana-attempted-fraud-n-a/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** No statute found **State:** Indiana **Statute Areas:** Attempted Fraud --- ### [Indiana-Claims Fraud-IC 35-43-5-4.5](https://insurancefraud.org/statutes/indiana-claims-fraud-ic-35-43-5-4-5/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Sec. 4.5. (a) A person who, knowingly and with intent to defraud: (2) presents, causes to be presented, or prepares with knowledge or belief that it will be presented to or by an insurer, an oral, a written, or an electronic statement that the person knows to contain materially false information as part of, in support of, or concerning a fact that is material to: (B) a claim for payment or benefit under an insurance policy; **State:** Indiana **Statute Areas:** Claims Fraud --- ### [Indiana-Immunity-IC 27-1-3-22](https://insurancefraud.org/statutes/indiana-immunity-ic-27-1-3-22/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (c) A person who acts without malice, fraudulent intent, or bad faith is not subject to civil liability for filing a report or furnishing, orally or in writing, other information concerning a suspected, anticipated, or completed fraudulent insurance act if the report or other information is provided to or received from any of the following: (1) The department or an agent, an employee, or a designee of the department. (2) Law enforcement officials or an agent or employee of a law enforcement official. (3) The National Association of Insurance Commissioners. (4) Any agency or bureau of federal or state government established to detect and prevent fraudulent insurance acts. (5) Any other organization established to detect and prevent fraudulent insurance acts. (6) An agent, an employee, or a designee of an entity referred to in subdivisions (3) through (5). (d) This section does not abrogate or modify in any way any common law or statutory privilege or immunity. **State:** Indiana **Statute Areas:** Immunity --- ### [Indiana-Insurance Fraud - Definition-IC 35-43-5-4.5](https://insurancefraud.org/statutes/indiana-insurance-fraud-definition-ic-35-43-5-4-5/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Sec. 4.5. (a) A person who, knowingly and with intent to defraud: (1) makes, utters, presents, or causes to be presented to an insurer or an insurance claimant, a claim statement that contains false, incomplete, or misleading information concerning the claim; (2) presents, causes to be presented, or prepares with knowledge or belief that it will be presented to or by an insurer, an oral, a written, or an electronic statement that the person knows to contain materially false information as part of, in support of, or concerning a fact that is material to: (A) the rating of an insurance policy; (B) a claim for payment or benefit under an insurance policy; (C) premiums paid on an insurance policy; (D) payments made in accordance with the terms of an insurance policy; (E) an application for a certificate of authority; (F) the financial condition of an insurer; or (G) the acquisition of an insurer; or conceals any information concerning a subject set forth in clauses (A) through (G); (3) solicits or accepts new or renewal insurance risks by or for an insolvent insurer or other entity regulated under IC 27; (4) removes: (A) the assets; (B) the record of assets, transactions, and affairs; or (C) a material part of the assets or the record of assets, transactions, and affairs; of an insurer or another entity regulated under IC 27, from the home office, other place of business, or place of safekeeping of the insurer or other regulated entity, or conceals or attempts to conceal from the department of insurance assets or records referred to in clauses (A) through (B); or (5) diverts funds of an insurer or another person in connection with: (A) the transaction of insurance or reinsurance; (B) the conduct of business activities by an insurer or another entity regulated under IC 27; or (C) the formation, acquisition, or dissolution of an insurer or another entity regulated under IC 27; commits insurance fraud. Except as provided in subsection (b), insurance fraud is a Level 6 felony. (b) An offense described in subsection (a) is a Level 5 felony if: (1) the person who commits the offense has a prior unrelated conviction under this section; or (2) the: (A) value of property, services, or other benefits obtained or attempted to be obtained by the person as a result of the offense; or (B) economic loss suffered by another person as a result of the offense; is at least two thousand five hundred dollars ($2,500). (c) A person who knowingly and with intent to defraud makes a material misstatement in support of an application for the issuance of an insurance policy commits insurance application fraud, a Class A misdemeanor. **State:** Indiana **Statute Areas:** Insurance Fraud - Definition --- ### [Indiana-Licensing Board Notification-IC 33-23-8-4](https://insurancefraud.org/statutes/indiana-licensing-board-notification-ic-33-23-8-4/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Sec. 4. If a practitioner is convicted under IC 35-43-5-4.5 of: (1) insurance fraud; (2) an attempt to commit insurance fraud; or (3) conspiracy to commit insurance fraud; the sentencing court shall provide notice of the conviction to each governmental body that has issued a license to the practitioner. **State:** Indiana --- ### [Indiana-Looting & diverting-IC 35-43-5-4.5](https://insurancefraud.org/statutes/indiana-looting-diverting-ic-35-43-5-4-5/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Sec. 4.5. (a) A person who, knowingly and with intent to defraud: (5) diverts funds of an insurer or another person in connection with: (A) the transaction of insurance or reinsurance; (B) the conduct of business activities by an insurer or another entity regulated under IC 27; or (C) the formation, acquisition, or dissolution of an insurer or another entity regulated under IC 27; commits insurance fraud. **State:** Indiana --- ### [Indiana-Practitioner Penalites-IC 27-1-3-20](https://insurancefraud.org/statutes/indiana-practitioner-penalites-ic-27-1-3-20/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (c) No company shall transact any business of insurance or hold itself out as a company in the business of insurance in Indiana until it shall have received a certificate of authority as prescribed in this section. (d) No company shall make, issue, deliver, sell, or advertise any kind or kinds of insurance not specified in the company’s certificate of authority. (f) The commissioner shall impose a civil penalty of not more than twenty-five thousand dollars ($25,000) on a director or officer of a company that violates subsection (c) or (d). The amount imposed must be proportionate to the costs incurred by the department of insurance, other governmental entities, and the courts in regulating the activity of the director, officer, or company who violates subsection (c) or (d). A civil penalty imposed under this subsection may be enforced in the same manner as a civil judgment. **State:** Indiana **Statute Areas:** Practitioner Penalites --- ### [Indiana-Premium Fraud-IC 27-1-3-22](https://insurancefraud.org/statutes/indiana-premium-fraud-ic-27-1-3-22/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Sec. 4.5. (a) A person who, knowingly and with intent to defraud: (2) presents, causes to be presented, or prepares with knowledge or belief that it will be presented to or by an insurer, an oral, a written, or an electronic statement that the person knows to contain materially false information as part of, in support of, or concerning a fact that is material to: (C) premiums paid on an insurance policy; **State:** Indiana **Statute Areas:** Premium Fraud --- ### [Indiana-Range of Criminal Penalties-IC 35-50-2-7](https://insurancefraud.org/statutes/indiana-range-of-criminal-penalties-ic-35-50-2-7/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Sec. 7. (a) A person who commits a Class D felony (for a crime committed before July 1, 2014) shall be imprisoned for a fixed term of between six (6) months and three (3) years, with the advisory sentence being one and one-half (1 \_ ) years. In addition, the person may be fined not more than ten thousand dollars ($10,000). (b) A person who commits a Level 6 felony (for a crime committed after June 30, 2014) shall be imprisoned for a fixed term of between six (6) months and two and one-half (2 \_ ) years, with the advisory sentence being one (1) year. In addition, the person may be fined not more than ten thousand dollars ($10,000). **State:** Indiana **Statute Areas:** Range of Criminal Penalties --- ### [Indiana-Rating of an Insurance Policy-IC 27-1-22-3](https://insurancefraud.org/statutes/indiana-rating-of-an-insurance-policy-ic-27-1-22-3/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Sec. 3. (a) Rates shall be made in accordance with the following provisions: (1) Due consideration shall be given to the past and prospective loss experience within and outside this state, to conflagration and catastrophe hazards, if any, to a reasonable margin for underwriting profit and contingencies, to dividends or savings allowed or returned by insurers to their policyholders or members, to past and prospective expenses both countrywide and those specifically applicable to this state, to all other relevant factors, including trend factors, within and outside this state, and in the case of fire insurance rates, to the underwriting experience of the fire insurance business during a period of not less than the most recent five (5) year period for which such experience is available and relevant. (2) Risks may be grouped by classifications, by rating schedules, or by any other reasonable methods, for the establishment of rates and minimum premiums. Classification rates may be modified to produce rates for individual risks in accordance with rating plans which establish standards for measuring variations in hazards or expense provisions, or both. Such standards may measure any difference among risks that can be demonstrated to have a probable effect upon losses or expenses. (3) The systems of expense provisions included in the rates for use by any insurer or group of insurers may differ from those of other insurers or groups of insurers to reflect the requirements of the operating methods of any such insurer or group with respect to any kind of insurance, or with respect to any subdivision or combination thereof for which subdivision or combination separate expense provisions are applicable. (4) Rates shall not be excessive, inadequate, or unfairly discriminatory. No rate shall be held to be excessive unless such rate is unreasonably high for the insurance coverage provided and a reasonable degree of competition does not exist in the area with respect to the classification to which such rate is applicable. No rate shall be held to be inadequate unless such rate is unreasonably low for the insurance coverage provided and is insufficient to sustain projected losses and expenses, or unless such rate is unreasonably low for the insurance coverage provided and the use of such rate has, or if continued, will have, the effect of destroying competition or creating a monopoly. A rating difference that results from application of a rating plan that is intended to control rate changes applicable to a current policyholder upon renewal of the policy or the transfer of a policy in force among insurers is not unfairly discriminatory, is not an unfair or deceptive act or practice in the business of insurance under IC 27-4-1-4, and is not a violation of IC 27-1-20-30. (b) Except to the extent necessary to meet the provisions of subsection (a)(4), uniformity among insurers in any matters within the scope of this section is neither required nor prohibited. (c) For the purpose of making rates upon automobiles and other motor vehicles under the provisions of this chapter, the terms “fleet” or “fleet policy” shall mean an insurance risk of five (5) or more automobiles and other vehicles of any kind, all owned by one (1) insured and all under one (1) direct operating management; provided, that automobiles and other motor vehicles owned by employees may not be included or insured under a fleet policy of an employer under any circumstances. **State:** Indiana --- ### [Indiana-Underwriting Fraud-n/a](https://insurancefraud.org/statutes/indiana-underwriting-fraud-n-a/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** No statute found **State:** Indiana **Statute Areas:** Underwriting Fraud --- ### [Indiana-Unauthorized Entities-IC 27-4-5-2](https://insurancefraud.org/statutes/indiana-unauthorized-entities-ic-27-4-5-2/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Sec. 2. (a) It is a Class A infraction for an insurer to transact insurance business in this state, as set forth in subsection (b), without a certificate of authority from the commissioner. However, this section does not apply to the following: (1) The lawful transaction of surplus lines insurance. (2) The lawful transaction of reinsurance by insurers. (3) Transactions in this state involving a policy lawfully solicited, written, and delivered outside of this state covering only subjects of insurance not resident, located, or expressly to be performed in this state at the time of issuance, and which transactions are subsequent to the issuance of such policy. (4) Attorneys acting in the ordinary relation of attorney and client in the adjustment of claims or losses. (5) Transactions in this state involving group life and group sickness and accident or blanket sickness and accident insurance or group annuities where the master policy of such groups was lawfully issued and delivered in and pursuant to the laws of a state in which the insurer was authorized to do an insurance business, to a group organized for purposes other than the procurement of insurance, and where the policyholder is domiciled or otherwise has a bona fide situs. (6) Transactions in this state relative to a policy issued or to be issued outside this state involving insurance on vessels, craft or hulls, cargos, marine builder’s risk, marine protection and indemnity or other risk, including strikes and war risks commonly insured under ocean or wet marine forms of policy. (7) Transactions in this state involving life insurance, health insurance, or annuities provided to religious or charitable institutions organized and operated without profit to any private shareholder or individual for the benefit of such institutions and individuals engaged in the service of such institutions. (8) Transactions in this state involving contracts of insurance not readily obtainable in the ordinary insurance market and issued to one (1) or more industrial insureds. For purposes of this section, an “industrial insured” means an insured: (A) who procures the insurance of any risk or risks by use of the services of a full-time employee acting as an insurance manager or buyer or the services of a regularly retained and continuously qualified insurance consultant; (B) whose aggregate annual premium for insurance on all risks totals at least twenty-five thousand dollars ($25,000); (C) who has at least twenty-five (25) full-time employees; (D) who, on or before February 1 (for the preceding six (6) month period ending December 31) and August 1 (for the preceding six (6) month period ending June 30) of each year, remits to the department an amount equal to two and one-half percent (2.5%) of all gross premiums upon all policies and contracts procured by the insured under this section, plus: (i) ten percent (10%) of the amount due for the first month after the date specified in this clause, during which the amount described in this clause is not remitted in compliance with this clause; and (ii) an additional one percent (1%) of the amount due for each additional month during which the amount due under this clause is unpaid; and (E) who files with the department, with the amount remitted under clause (D), an affidavit specifying all transactions undertaken and policies and contracts procured during the preceding calendar year, including the following: (i) The description and location of the insured property or risk and the name of the insured. (ii) The gross premiums charged for the policy or contract. (iii) The name and home office address of the insurer that issues the policy or contract and the kind of insurance affected. (iv) A statement that the insured, after diligent effort, was unable to procure from any insurer authorized to transact the particular kind of insurance business in Indiana the full amount of insurance coverage required to protect the insured. (9) Transactions in Indiana involving the rendering of any service by any ambulance service provider and all fees, costs, and membership payments charged for the service. To qualify under this subdivision, the ambulance service provider: (A) must have its ambulance service program approved by an ordinance of the legislative body of the county or city in which it operates; and (B) may not offer any membership program that includes benefits exceeding one (1) year in duration. (b) Any of the following acts in this state effected by mail or otherwise by or on behalf of an unauthorized insurer constitutes the transaction of an insurance business in this state. The venue of an act committed by mail is at the point where the matter transmitted by mail is delivered and takes effect. Unless otherwise indicated, the term “insurer” as used in this section includes all persons engaged as principals in the business of insurance and also includes interinsurance exchanges and mutual benefit societies. (1) The making of or proposing to make, as an insurer, an insurance contract. (2) The making of or proposing to make, as guarantor or surety, any contract of guaranty or suretyship as a vocation and not merely incidental to any other legitimate business or activity of the guarantor or surety. (3) The taking or receiving of any application for insurance. (4) The receiving or collection of any premium, commission, membership fees, assessments, dues, or other consideration for any insurance or any part thereof. (5) The issuance or delivery of contracts of insurance to residents of this state or to persons authorized to do business in this state. (6) Acting as an agent for or otherwise representing or aiding on behalf of another person or insurer in the solicitation, negotiation, procurement, or effectuation of insurance or renewals thereof or in the dissemination of information as to coverage or rates, or forwarding of applications, or delivery of policies or contracts, or inspection of risks, a fixing of rates or investigation or adjustment of claims or losses or in the transaction of matters subsequent to effectuation of the contract and arising out of it, or representing or assisting a person or an insurer in the transaction of insurance with respect to subjects of insurance resident, located, or to be performed in this state. This subdivision does not prohibit full-time salaried employees of a corporate insured from acting in the capacity of an insurance manager or buyer in placing insurance in behalf of the employer. (c)(1) The failure of an insurer transacting insurance business in this state to obtain a certificate of authority does not impair the validity of any act or contract of such insurer and does not prevent such insurer from defending any action at law or suit in equity in any court of this state, but no insurer transacting insurance business in this state without a certificate of authority may maintain an action in any court of this state to enforce any right, claim, or demand arising out of the transaction of such business until such insurer obtains a certificate of authority. (2) In the event of failure of any such unauthorized insurer to pay any claim or loss within the provisions of such insurance contract, any person who assisted or in any manner aided directly or indirectly in the procurement of such insurance contract is liable to the insured for the full amount of the claim or loss in the manner provided by the insurance contract. **State:** Indiana --- ### [Illinois-Attempted Fraud-720 ILCS 5/17-10.5 (Proposed Legislation)](https://insurancefraud.org/statutes/illinois-attempted-fraud-720-ilcs-5-17-10-5-proposed-legislation/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** ¤ 17-10.5. Insurance fraud. (a) Insurance fraud. (1) A person commits insurance fraud when he or she knowingly obtains, attempts to obtain, or causes to be obtained, by deception, control over the property of an insurance company or self-insured entity by the making of a false claim or by causing a false claim to be made on any policy of insurance issued by an insurance company or by the making of a false claim or by causing a false claim to be made to a self-insured entity, intending to deprive an insurance company or self-insured entity permanently of the use and benefit of that property. (2) A person commits health care benefits fraud against a provider, other than a governmental unit or agency, when he or she knowingly obtains or attempts to obtain, by deception, health care benefits and that obtaining or attempt to obtain health care benefits does not involve control over property of the provider. (b) Aggravated insurance fraud. (1) A person commits aggravated insurance fraud on a private entity when he or she commits insurance fraud 3 or more times within an 18-month period arising out of separate incidents or transactions. (2) A person commits being an organizer of an aggravated insurance fraud on a private entity conspiracy if aggravated insurance fraud on a private entity forms the basis for a charge of conspiracy under Section 8-2 of this Code and the person occupies a position of organizer, supervisor, financer, or other position of management within the conspiracy. (c) Conspiracy to commit insurance fraud. If aggravated insurance fraud on a private entity forms the basis for charges of conspiracy under Section 8-2 of this Code, the person or persons with whom the accused is alleged to have agreed to commit the 3 or more violations of this Section need not be the same person or persons for each violation, as long as the accused was a part of the common scheme or plan to engage in each of the 3 or more alleged violations. If aggravated insurance fraud on a private entity forms the basis for a charge of conspiracy under Section 8-2 of this Code, and the accused occupies a position of organizer, supervisor, financer, or other position of management within the conspiracy, the person or persons with whom the accused is alleged to have agreed to commit the 3 or more violations of this Section need not be the same person or persons for each violation as long as the accused occupied a position of organizer, supervisor, financer, or other position of management in each of the 3 or more alleged violations. (d) Sentence. (1) A violation of paragraph (a)(1) in which the value of the property obtained, attempted to be obtained, or caused to be obtained is $300 or less is a Class A misdemeanor. (2) A violation of paragraph (a)(1) in which the value of the property obtained, attempted to be obtained, or caused to be obtained is more than $300 but not more than $10,000 is a Class 3 felony. (3) A violation of paragraph (a)(1) in which the value of the property obtained, attempted to be obtained, or caused to be obtained is more than $10,000 but not more than $100,000 is a Class 2 felony. (4) A violation of paragraph (a)(1) in which the value of the property obtained, attempted to be obtained, or caused to be obtained is more than $ 100,000 is a Class 1 felony. (5) A violation of paragraph (a)(2) is a Class A misdemeanor. (6) A violation of paragraph (b)(1) is a Class 1 felony, regardless of the value of the property obtained, attempted to be obtained, or caused to be obtained. (7) A violation of paragraph (b)(2) is a Class X felony. (8) A person convicted of insurance fraud, vendor fraud, or a federal criminal violation associated with defrauding the Medicaid program shall be ordered to pay monetary restitution to the insurance company or self-insured entity or any other person for any financial loss sustained as a result of a violation of this Section, including any court costs and attorney’s fees. An order of restitution shall include expenses incurred and paid by the State of Illinois or an insurance company or self-insured entity in connection with any medical evaluation or treatment services. (9) Notwithstanding Section 8-5 of this Code, a person may be convicted and sentenced both for the offense of conspiracy to commit insurance fraud or the offense of being an organizer of an aggravated insurance fraud conspiracy and for any other offense that is the object of the conspiracy. (e) Civil damages for insurance fraud. (1) A person who knowingly obtains, attempts to obtain, or causes to be obtained, by deception, control over the property of any insurance company by the making of a false claim or by causing a false claim to be made on a policy of insurance issued by an insurance company, or by the making of a false claim or by causing a false claim to be made to a self-insured entity, intending to deprive an insurance company or self-insured entity permanently of the use and benefit of that property, shall be civilly liable to the insurance company or self-insured entity that paid the claim or against whom the claim was made or to the subrogee of that insurance company or self- insured entity in an amount equal to either 3 times the value of the property wrongfully obtained or, if no property was wrongfully obtained, twice the value of the property attempted to be obtained, whichever amount is greater, plus reasonable attorney’s fees. (2) An insurance company or self-insured entity that brings an action against a person under paragraph (1) of this subsection in bad faith shall be liable to that person for twice the value of the property claimed, plus reasonable attorney’s fees. In determining whether an insurance company or self-insured entity acted in bad faith, the court shall relax the rules of evidence to allow for the introduction of any facts or other information on which the insurance company or self-insured entity may have relied in bringing an action under paragraph (1) of this subsection. (f) Determination of property value. For the purposes of this Section, if the exact value of the property attempted to be obtained is either not alleged by the claimant or not specifically set by the terms of a policy of insurance, the value of the property shall be the fair market replacement value of the property claimed to be lost, the reasonable costs of reimbursing a vendor or other claimant for services to be rendered, or both. (g) Actions by State licensing agencies. (1) All State licensing agencies, the Illinois State Police, and the Department of Financial and Professional Regulation shall coordinate enforcement efforts relating to acts of insurance fraud. (2) If a person who is licensed or registered under the laws of the State of Illinois to engage in a business or profession is convicted of or pleads guilty to engaging in forward to each State agency by which the person is licensed or registered a copy of the conviction or plea and all supporting evidence. (3) Any agency that receives information under this Section shall, not later than 6 months after the date on which it receives the information, publicly report the final action taken against the convicted person, including but not limited to the revocation or suspension of the license or any other disciplinary action taken. (h) Definitions. For the purposes of this Section, “obtain”, “obtains control”, “deception”, “property”, and “permanent deprivation” have the meanings ascribed to those terms in Article 15 of this Code. **State:** Illinois **Statute Areas:** Attempted Fraud --- ### [Illinois-Claims Fraud-720 ILCS 5/17-10.5 (Proposed Legislation)](https://insurancefraud.org/statutes/illinois-claims-fraud-720-ilcs-5-17-10-5-proposed-legislation/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** ¤ 17-10.5. Insurance fraud. (a) Insurance fraud. (1) A person commits insurance fraud when he or she knowingly obtains, attempts to obtain, or causes to be obtained, by deception, control over the property of an insurance company or self-insured entity by the making of a false claim or by causing a false claim to be made on any policy of insurance issued by an insurance company or by the making of a false claim or by causing a false claim to be made to a self-insured entity, intending to deprive an insurance company or self-insured entity permanently of the use and benefit of that property. **State:** Illinois **Statute Areas:** Claims Fraud --- ### [Illinois-Immunity-215 ILCS 5/132.7; 215 ILCS 5/1022](https://insurancefraud.org/statutes/illinois-immunity-215-ilcs-5-132-7-215-ilcs-5-1022/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** ¤ 132.7. Immunity from liability. (a) No cause of action shall arise nor shall any liability be imposed against the Director, the Director’s authorized representatives, or any examiner appointed by the Director for any statements made or conduct performed in good faith while carrying out the provisions of this Code. (b) No cause of action shall arise, nor shall any liability be imposed against any person for the act of communicating or delivering information or data to the Director or the Director’s authorized representative or examiner in the course of an examination if the act of communication or delivery was performed in good faith and without fraudulent intent or the intent to deceive. (c) This Section does not abrogate or modify in any way any common law or statutory privilege or immunity heretofore enjoyed by any person identified in subsection (a). (d) Persons identified in subsection (a) shall be entitled to an award of attorney’s fees and costs if they are a prevailing party in a civil action for libel, slander, or any other relevant tort arising out of their activities in carrying out the provisions of this Code and the party bringing the action was not substantially justified in doing so. For purposes of this Section a proceeding is “substantially justified” if it has a reasonable basis in law or fact at the time that it was initiated.\*\*\*No cause of action in the nature of defamation, invasion of privacy or negligence shall arise against any person for disclosing personal or privileged information in accordance with this Article, nor shall such a cause of action arise against any person for furnishing personal or privileged information to an insurance institution, agent or insurance-support organization; provided, however, this Section shall provide no immunity for disclosing or furnishing false information with malice or willful intent to injure any person. **State:** Illinois **Statute Areas:** Immunity --- ### [Illinois-Insurance Fraud - Definition-720 ILCS 5/17-10.5 (Proposed Legislation)](https://insurancefraud.org/statutes/illinois-insurance-fraud-definition-720-ilcs-5-17-10-5-proposed-legislation/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) Insurance fraud. (1) A person commits insurance fraud when he or she knowingly obtains, attempts to obtain, or causes to be obtained, by deception, control over the property of an insurance company or self-insured entity by the making of a false claim or by causing a false claim to be made on any policy of insurance issued by an insurance company or by the making of a false claim or by causing a false claim to be made to a self-insured entity, intending to deprive an insurance company or self-insured entity permanently of the use and benefit of that property. (2) A person commits health care benefits fraud against a provider, other than a governmental unit or agency, when he or she knowingly obtains or attempts to obtain, by deception, health care benefits and that obtaining or attempt to obtain health care benefits does not involve control over property of the provider. (b) Aggravated insurance fraud. (1) A person commits aggravated insurance fraud on a private entity when he or she commits insurance fraud 3 or more times within an 18-month period arising out of separate incidents or transactions. (2) A person commits being an organizer of an aggravated insurance fraud on a private entity conspiracy if aggravated insurance fraud on a private entity forms the basis for a charge of conspiracy under Section 8-2 of this Code and the person occupies a position of organizer, supervisor, financer, or other position of management within the conspiracy. (c) Conspiracy to commit insurance fraud. If aggravated insurance fraud on a private entity forms the basis for charges of conspiracy under Section 8-2 of this Code, the person or persons with whom the accused is alleged to have agreed to commit the 3 or more violations of this Section need not be the same person or persons for each violation, as long as the accused was a part of the common scheme or plan to engage in each of the 3 or more alleged violations. If aggravated insurance fraud on a private entity forms the basis for a charge of conspiracy under Section 8-2 of this Code, and the accused occupies a position of organizer, supervisor, financer, or other position of management within the conspiracy, the person or persons with whom the accused is alleged to have agreed to commit the 3 or more violations of this Section need not be the same person or persons for each violation as long as the accused occupied a position of organizer, supervisor, financer, or other position of management in each of the 3 or more alleged violations. (d) Sentence. (1) A violation of paragraph (a)(1) in which the value of the property obtained, attempted to be obtained, or caused to be obtained is $300 or less is a Class A misdemeanor. (2) A violation of paragraph (a)(1) in which the value of the property obtained, attempted to be obtained, or caused to be obtained is more than $300 but not more than $10,000 is a Class 3 felony. (3) A violation of paragraph (a)(1) in which the value of the property obtained, attempted to be obtained, or caused to be obtained is more than $10,000 but not more than $100,000 is a Class 2 felony. (4) A violation of paragraph (a)(1) in which the value of the property obtained, attempted to be obtained, or caused to be obtained is more than $ 100,000 is a Class 1 felony. (5) A violation of paragraph (a)(2) is a Class A misdemeanor. (6) A violation of paragraph (b)(1) is a Class 1 felony, regardless of the value of the property obtained, attempted to be obtained, or caused to be obtained. (7) A violation of paragraph (b)(2) is a Class X felony. (8) A person convicted of insurance fraud, vendor fraud, or a federal criminal violation associated with defrauding the Medicaid program shall be ordered to pay monetary restitution to the insurance company or self-insured entity or any other person for any financial loss sustained as a result of a violation of this Section, including any court costs and attorney’s fees. An order of restitution shall include expenses incurred and paid by the State of Illinois or an insurance company or self-insured entity in connection with any medical evaluation or treatment services. (9) Notwithstanding Section 8-5 of this Code, a person may be convicted and sentenced both for the offense of conspiracy to commit insurance fraud or the offense of being an organizer of an aggravated insurance fraud conspiracy and for any other offense that is the object of the conspiracy. (e) Civil damages for insurance fraud. (1) A person who knowingly obtains, attempts to obtain, or causes to be obtained, by deception, control over the property of any insurance company by the making of a false claim or by causing a false claim to be made on a policy of insurance issued by an insurance company, or by the making of a false claim or by causing a false claim to be made to a self-insured entity, intending to deprive an insurance company or self-insured entity permanently of the use and benefit of that property, shall be civilly liable to the insurance company or self-insured entity that paid the claim or against whom the claim was made or to the subrogee of that insurance company or self- insured entity in an amount equal to either 3 times the value of the property wrongfully obtained or, if no property was wrongfully obtained, twice the value of the property attempted to be obtained, whichever amount is greater, plus reasonable attorney’s fees. (2) An insurance company or self-insured entity that brings an action against a person under paragraph (1) of this subsection in bad faith shall be liable to that person for twice the value of the property claimed, plus reasonable attorney’s fees. In determining whether an insurance company or self-insured entity acted in bad faith, the court shall relax the rules of evidence to allow for the introduction of any facts or other information on which the insurance company or self-insured entity may have relied in bringing an action under paragraph (1) of this subsection. (f) Determination of property value. For the purposes of this Section, if the exact value of the property attempted to be obtained is either not alleged by the claimant or not specifically set by the terms of a policy of insurance, the value of the property shall be the fair market replacement value of the property claimed to be lost, the reasonable costs of reimbursing a vendor or other claimant for services to be rendered, or both. (g) Actions by State licensing agencies. (1) All State licensing agencies, the Illinois State Police, and the Department of Financial and Professional Regulation shall coordinate enforcement efforts relating to acts of insurance fraud. (2) If a person who is licensed or registered under the laws of the State of Illinois to engage in a business or profession is convicted of or pleads guilty to engaging in forward to each State agency by which the person is licensed or registered a copy of the conviction or plea and all supporting evidence. (3) Any agency that receives information under this Section shall, not later than 6 months after the date on which it receives the information, publicly report the final action taken against the convicted person, including but not limited to the revocation or suspension of the license or any other disciplinary action taken. (h) Definitions. For the purposes of this Section, “obtain”, “obtains control”, “deception”, “property”, and “permanent deprivation” have the meanings ascribed to those terms in Article 15 of this Code. **State:** Illinois **Statute Areas:** Insurance Fraud - Definition --- ### [Illinois-Placing Bogus Coverage-n/a](https://insurancefraud.org/statutes/illinois-placing-bogus-coverage-n-a/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** No statute found **State:** Illinois --- ### [Illinois-Practitioner Penalites-720 ILCS 5/17-10.5 (Proposed Legislation)](https://insurancefraud.org/statutes/illinois-practitioner-penalites-720-ilcs-5-17-10-5-proposed-legislation/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (g) Actions by State licensing agencies. (1) All State licensing agencies, the Illinois State Police, and the Department of Financial and Professional Regulation shall coordinate enforcement efforts relating to acts of insurance fraud. (2) If a person who is licensed or registered under the laws of the State of Illinois to engage in a business or profession is convicted of or pleads guilty to engaging in forward to each State agency by which the person is licensed or registered a copy of the conviction or plea and all supporting evidence. (3) Any agency that receives information under this Section shall, not later than 6 months after the date on which it receives the information, publicly report the final action taken against the convicted person, including but not limited to the revocation or suspension of the license or any other disciplinary action taken. **State:** Illinois **Statute Areas:** Practitioner Penalites --- ### [Illinois-Range of Criminal Penalties-720 ILCS 5/17-10.5 (Proposed Legislation)](https://insurancefraud.org/statutes/illinois-range-of-criminal-penalties-720-ilcs-5-17-10-5-proposed-legislation/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** ¤ 17-10.5. Insurance fraud. (a) Insurance fraud. (1) A person commits insurance fraud when he or she knowingly obtains, attempts to obtain, or causes to be obtained, by deception, control over the property of an insurance company or self-insured entity by the making of a false claim or by causing a false claim to be made on any policy of insurance issued by an insurance company or by the making of a false claim or by causing a false claim to be made to a self-insured entity, intending to deprive an insurance company or self-insured entity permanently of the use and benefit of that property. (2) A person commits health care benefits fraud against a provider, other than a governmental unit or agency, when he or she knowingly obtains or attempts to obtain, by deception, health care benefits and that obtaining or attempt to obtain health care benefits does not involve control over property of the provider. (b) Aggravated insurance fraud. (1) A person commits aggravated insurance fraud on a private entity when he or she commits insurance fraud 3 or more times within an 18-month period arising out of separate incidents or transactions. (2) A person commits being an organizer of an aggravated insurance fraud on a private entity conspiracy if aggravated insurance fraud on a private entity forms the basis for a charge of conspiracy under Section 8-2 of this Code and the person occupies a position of organizer, supervisor, financer, or other position of management within the conspiracy. (c) Conspiracy to commit insurance fraud. If aggravated insurance fraud on a private entity forms the basis for charges of conspiracy under Section 8-2 of this Code, the person or persons with whom the accused is alleged to have agreed to commit the 3 or more violations of this Section need not be the same person or persons for each violation, as long as the accused was a part of the common scheme or plan to engage in each of the 3 or more alleged violations. If aggravated insurance fraud on a private entity forms the basis for a charge of conspiracy under Section 8-2 of this Code, and the accused occupies a position of organizer, supervisor, financer, or other position of management within the conspiracy, the person or persons with whom the accused is alleged to have agreed to commit the 3 or more violations of this Section need not be the same person or persons for each violation as long as the accused occupied a position of organizer, supervisor, financer, or other position of management in each of the 3 or more alleged violations. (d) Sentence. (1) A violation of paragraph (a)(1) in which the value of the property obtained, attempted to be obtained, or caused to be obtained is $300 or less is a Class A misdemeanor. (2) A violation of paragraph (a)(1) in which the value of the property obtained, attempted to be obtained, or caused to be obtained is more than $300 but not more than $10,000 is a Class 3 felony. (3) A violation of paragraph (a)(1) in which the value of the property obtained, attempted to be obtained, or caused to be obtained is more than $10,000 but not more than $100,000 is a Class 2 felony. (4) A violation of paragraph (a)(1) in which the value of the property obtained, attempted to be obtained, or caused to be obtained is more than $ 100,000 is a Class 1 felony. (5) A violation of paragraph (a)(2) is a Class A misdemeanor. (6) A violation of paragraph (b)(1) is a Class 1 felony, regardless of the value of the property obtained, attempted to be obtained, or caused to be obtained. (7) A violation of paragraph (b)(2) is a Class X felony. (8) A person convicted of insurance fraud, vendor fraud, or a federal criminal violation associated with defrauding the Medicaid program shall be ordered to pay monetary restitution to the insurance company or self-insured entity or any other person for any financial loss sustained as a result of a violation of this Section, including any court costs and attorney’s fees. An order of restitution shall include expenses incurred and paid by the State of Illinois or an insurance company or self-insured entity in connection with any medical evaluation or treatment services. (9) Notwithstanding Section 8-5 of this Code, a person may be convicted and sentenced both for the offense of conspiracy to commit insurance fraud or the offense of being an organizer of an aggravated insurance fraud conspiracy and for any other offense that is the object of the conspiracy. **State:** Illinois **Statute Areas:** Range of Criminal Penalties --- ### [Illinois-Range of Civil Penalties-720 ILCS 5/17-10.5 (Proposed Legislation)](https://insurancefraud.org/statutes/illinois-range-of-civil-penalties-720-ilcs-5-17-10-5-proposed-legislation/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (e) Civil damages for insurance fraud. (1) A person who knowingly obtains, attempts to obtain, or causes to be obtained, by deception, control over the property of any insurance company by the making of a false claim or by causing a false claim to be made on a policy of insurance issued by an insurance company, or by the making of a false claim or by causing a false claim to be made to a self-insured entity, intending to deprive an insurance company or self-insured entity permanently of the use and benefit of that property, shall be civilly liable to the insurance company or self-insured entity that paid the claim or against whom the claim was made or to the subrogee of that insurance company or self- insured entity in an amount equal to either 3 times the value of the property wrongfully obtained or, if no property was wrongfully obtained, twice the value of the property attempted to be obtained, whichever amount is greater, plus reasonable attorney’s fees. (2) An insurance company or self-insured entity that brings an action against a person under paragraph (1) of this subsection in bad faith shall be liable to that person for twice the value of the property claimed, plus reasonable attorney’s fees. In determining whether an insurance company or self-insured entity acted in bad faith, the court shall relax the rules of evidence to allow for the introduction of any facts or other information on which the insurance company or self-insured entity may have relied in bringing an action under paragraph (1) of this subsection. **State:** Illinois **Statute Areas:** Range of Civil Penalties --- ### [Illinois-Rating of an Insurance Policy-n/a](https://insurancefraud.org/statutes/illinois-rating-of-an-insurance-policy-n-a/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** No statue found. Many provisions repealed. **State:** Illinois --- ### [Illinois-Unauthorized Entities-215 ILCS 5/121](https://insurancefraud.org/statutes/illinois-unauthorized-entities-215-ilcs-5-121/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** ¤ 121. Transacting Business Without Certificate of Authority Prohibited. (1) It shall be unlawful for any company to enter into a contract of insurance as an insurer or to transact insurance business in this State, without a certificate of authority from the Director; provided that this subsection shall not apply to contracts procured by agents under the authority of section 445, nor to contracts of reinsurance. (2) The following acts, if performed in this State, shall be included among those deemed to constitute transacting insurance business in this State: (a) maintaining an agency or office where contracts are executed which are or purport to be contracts of insurance with citizens of this or any other State; (b) maintaining files or records of contracts of insurance; or (c) receiving payment of premiums for contracts of insurance. (3) Any company that violates any of the provisions of subsections (1) and (2) of this section shall be guilty of a business offense and shall be required to pay a penalty of not less than $100 nor more than $1000 for each offense, to be recovered in the name of the People of the State of Illinois by the State’s Attorney of the county in which the violation occurs and the penalty so recovered shall be paid into the county treasury. Each day in which a violation occurs shall constitute a separate offense. (4) The failure of a company to obtain a certificate of authority shall not impair the validity of any act or contract of such company and shall not prevent such company from defending any action in any court of this State, but no company transacting insurance business in this State without a certificate of authority shall be permitted to maintain an action in any court of this State to enforce any right, claim or demand arising out of the transaction of such business until such company shall have obtained a certificate of authority. Nor shall an action be maintained in any court of this State by any successor or assignee of such company on any such right, claim or demand originally held by such company until a certificate of authority shall have been obtained by such company or by a company which has acquired all or substantially all of its assets. **State:** Illinois --- ### [Idaho-Aiding & Abetting-I.C. ¤ 41-293](https://insurancefraud.org/statutes/idaho-aiding-abetting-i-c-¤-41-293/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (b) Any person who, with intent to defraud or deceive an insurer assists, abets, solicits, or conspires with another to prepare or make any statement that is intended to be presented to any insurer, producer, practitioner or other person, in connection with, or in support of, any claim for payment or other benefit, knowing that such statement contains false, incomplete, or misleading information concerning any fact or thing material to such claim; **State:** Idaho --- ### [Idaho-Anti-Runner Provisions-I.C. ¤ 41-293](https://insurancefraud.org/statutes/idaho-anti-runner-provisions-i-c-¤-41-293/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (i) Any practitioner or any other person who, with intent to defraud or deceive, employs, uses or acts as a runner for the purpose of submitting a claim containing false, incomplete, or misleading information concerning any fact or thing material to such claim; **State:** Idaho **Statute Areas:** Anti-Runner Provisions --- ### [Idaho-Attempted Fraud-I.C. ¤ 41-293](https://insurancefraud.org/statutes/idaho-attempted-fraud-i-c-¤-41-293/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (b) Any person who, with intent to defraud or deceive an insurer assists, abets, solicits, or conspires with another to prepare or make any statement that is intended to be presented to any insurer, producer, practitioner or other person, in connection with, or in support of, any claim for payment or other benefit, knowing that such statement contains false, incomplete, or misleading information concerning any fact or thing material to such claim; **State:** Idaho **Statute Areas:** Attempted Fraud --- ### [Idaho-Claims Fraud-I.C. ¤ 41-293*](https://insurancefraud.org/statutes/idaho-claims-fraud-i-c-¤-41-293/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Insurance fraud includes: (1)(a) Any person who, with the intent to defraud or deceive an insurer for the purpose of obtaining any money or benefit, presents or causes to be presented to any insurer, producer, practitioner or other person, any statement as part of, or in support of, a claim for payment or other benefit, knowing that such statement contains false, incomplete, or misleading information concerning any fact or thing material to such claim; or (b) Any person who, with intent to defraud or deceive an insurer assists, abets, solicits, or conspires with another to prepare or make any statement that is intended to be presented to any insurer, producer, practitioner or other person, in connection with, or in support of, any claim for payment or other benefit, knowing that such statement contains false, incomplete, or misleading information concerning any fact or thing material to such claim; (c) Any person who, with intent to defraud or deceive, presents or causes to be presented to or by an insurer, a producer, practitioner or other person, a false or altered statement material to an insurance transaction; (d) Any insurance producer or other person who, with intent to defraud or deceive, willfully takes premium money knowing that insurance coverage will not be effected; (e) Any practitioner or other person who willfully submits a false or altered statement, with the intent of deceiving an insurer or other person in connection with an insurance transaction or claim; (f) Anyone willfully making a false statement or material misrepresentation to an insurer, employer, practitioner or other person, with the intent to defraud or deceive an insurer or other person, to obtain or extend worker’s compensation benefits; (g) Anyone who offers or accepts a direct or indirect inducement to file or solicits another person to file a false statement, with intent to defraud or deceive an insurer; (h) Any person who, with intent to defraud or deceive, transacts insurance of any kind or character, or transmits for a person other than himself an application for a policy of insurance, without proper licensing or after such license has been suspended or revoked; **State:** Idaho **Statute Areas:** Claims Fraud --- ### [Idaho-Failing to Remit Premium-I.C. ¤ 41-293*](https://insurancefraud.org/statutes/idaho-failing-to-remit-premium-i-c-¤-41-293/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (d) Any insurance producer or other person who, with intent to defraud or deceive, willfully takes premium money knowing that insurance coverage will not be effected; **State:** Idaho --- ### [Idaho-Immunity-I.C. ¤ 41-292*](https://insurancefraud.org/statutes/idaho-immunity-i-c-¤-41-292/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (1) The director of the department of insurance, state fire marshal or any authorized agency may, in writing, require the insurance company at interest to release to the requesting agency any or all relevant information or evidence deemed important to the authorized agency, director or state fire marshal which the company may have in its possession, relating to the loss in question. Relevant information may include, without limitation herein: (a) Pertinent insurance policy information relevant to a loss under investigation and any application for such a policy; (b) Policy premium payment records which are available; (c) History of previous claims made by the insured; (d) Material relating to the investigation of the loss, including statements of any person, proof of loss, and any other evidence relevant to the investigation. (2) (a) When an insurance company has facts to support a belief that a loss in which it has an interest may be of other than accidental cause, then, for the purpose of notification and for having such loss investigated, the company shall, in writing, notify the director of the department of insurance, or the state fire marshal, and provide any or all material developed from the company’s inquiry into the loss. (b) When an insurance company provides the director of the department of insurance or the state fire marshal with notice of a loss, it shall be sufficient notice for the purpose of this chapter. (c) Nothing in section 41-292(1), Idaho Code, shall abrogate or impair the rights or powers created under section 41-292(2), Idaho Code. (3) The director of the department of insurance, the state fire marshal or an authorized agency provided with information pursuant to section 41-248, 41-258, 41-290 or 41-292(1) or (2), Idaho Code, and in furtherance of its own purposes, may release or provide such information to any of the other authorized agencies. (4) Any insurance company providing information to an authorized agency or agencies pursuant to section 41-258, 41-290 or 41-292(1) or (2), Idaho Code, shall have the right to request relevant information relative to the loss in question and to receive, within a reasonable time, not to exceed thirty (30) days, the information requested, if the information is not otherwise privileged by law. (5) In the absence of fraud or malice, no person shall be subject to civil liability for libel, slander or any other relevant tort cause of action by virtue of filing reports or furnishing other information required by this chapter or required by the director of the department of insurance under the authority granted in this chapter, and no civil cause of action of any nature shall arise against such person: (a) For any information relating to suspected fraudulent insurance acts furnished to or received from authorized agencies, their agents and employees; or (b) For any information relating to suspected fraudulent insurance acts furnished to or received from other persons subject to the provisions of this chapter; or (c) For any such information furnished in reports to the department of insurance, national association of insurance commissioners, national insurance crime bureau or any organization established to detect and prevent fraudulent insurance acts, their agents, employees or designees, nor shall the director or any employee of the department of insurance, acting without malice in the absence of fraud, be subject to civil liability for libel, slander or any other relevant tort and no civil cause of action of any nature shall arise against such person by virtue of the publication of any report or bulletin related to the official activities of the department of insurance. Nothing herein is intended to abrogate or modify in any way any common law or statutory privilege or immunity heretofore enjoyed by any person. (6) For purposes of subsection (5) of this section, there shall exist a rebuttable presumption that the person has acted without fraud or malice. **State:** Idaho **Statute Areas:** Immunity --- ### [Idaho-Insurance Fraud - Definition-I.C. ¤ 41-293](https://insurancefraud.org/statutes/idaho-insurance-fraud-definition-i-c-¤-41-293/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Insurance fraud includes: (1)(a) Any person who, with the intent to defraud or deceive an insurer for the purpose of obtaining any money or benefit, presents or causes to be presented to any insurer, producer, practitioner or other person, any statement as part of, or in support of, a claim for payment or other benefit, knowing that such statement contains false, incomplete, or misleading information concerning any fact or thing material to such claim; or (b) Any person who, with intent to defraud or deceive an insurer assists, abets, solicits, or conspires with another to prepare or make any statement that is intended to be presented to any insurer, producer, practitioner or other person, in connection with, or in support of, any claim for payment or other benefit, knowing that such statement contains false, incomplete, or misleading information concerning any fact or thing material to such claim; (c) Any person who, with intent to defraud or deceive, presents or causes to be presented to or by an insurer, a producer, practitioner or other person, a false or altered statement material to an insurance transaction; (d) Any insurance producer or other person who, with intent to defraud or deceive, willfully takes premium money knowing that insurance coverage will not be effected; (e) Any practitioner or other person who willfully submits a false or altered statement, with the intent of deceiving an insurer or other person in connection with an insurance transaction or claim; (f) Anyone willfully making a false statement or material misrepresentation to an insurer, employer, practitioner or other person, with the intent to defraud or deceive an insurer or other person, to obtain or extend worker’s compensation benefits; (g) Anyone who offers or accepts a direct or indirect inducement to file or solicits another person to file a false statement, with intent to defraud or deceive an insurer; (h) Any person who, with intent to defraud or deceive, transacts insurance of any kind or character, or transmits for a person other than himself an application for a policy of insurance, without proper licensing or after such license has been suspended or revoked; (i) Any practitioner or any other person who, with intent to defraud or deceive, employs, uses or acts as a runner for the purpose of submitting a claim containing false, incomplete, or misleading information concerning any fact or thing material to such claim; (j) Any employer or other person who, with intent to defraud or deceive, presents or causes to be presented to an insurer, producer or any other person or governmental agency any statement containing the number of employees, amount of payroll, job description or job title or any other statement material to worker’s compensation insurance which contains false, misleading or incomplete information; or (k) Any person who, with intent to defraud or deceive, obstructs the director in the conduct of any authorized examination. (2) A fact, statement or representation is “material” if it includes any of the following: (a) Any fact which, if communicated to the producer, insurer, adjuster or representative thereof, would induce him to either decline insurance altogether or not accept it unless a higher premium is paid by the insured; (b) Any fact relating to a claim for insurance benefits which, if disclosed, would be a fair reason for rejecting a claim for insurance benefits; (c) Any fact, the knowledge or ignorance of which would naturally influence the insurer in making or refusing the contract, in estimating the degree or character of the risk, or in fixing the rate of premium; (d) Any fact, the knowledge or ignorance of which would naturally influence the insurer in accepting or rejecting a claim for insurance benefits or compensation, or in determining the amount of compensation or insurance benefits to be paid to the insured; or (e) Any fact that necessarily has some bearing on the subject matter of the insurance coverage or claim for benefits under an insurance contract. (3) Any offense committed by use of a telephone, any means of electronic communication or mail as provided by this chapter may be deemed to have been committed at the place from which the telephone call or electronic communication was made, or mail was sent, or the offense may be deemed to have been committed at the place at which the telephone call, electronic communication or mail was received. (4) Any violator of this section is guilty of a felony and shall be subject to a term of imprisonment not to exceed fifteen (15) years, or a fine not to exceed fifteen thousand dollars ($15,000), or both and shall be ordered to make restitution to the insurer or any other person for any financial loss sustained as a result of a violation of this section. Each instance of violation may be considered a separate offense. **State:** Idaho **Statute Areas:** Insurance Fraud - Definition --- ### [Idaho-Licensing Board Notification-I.C. ¤ 41-292*](https://insurancefraud.org/statutes/idaho-licensing-board-notification-i-c-¤-41-292/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (1) The director of the department of insurance, state fire marshal or any authorized agency may, in writing, require the insurance company at interest to release to the requesting agency any or all relevant information or evidence deemed important to the authorized agency, director or state fire marshal which the company may have in its possession, relating to the loss in question. Relevant information may include, without limitation herein: (a) Pertinent insurance policy information relevant to a loss under investigation and any application for such a policy; (b) Policy premium payment records which are available; (c) History of previous claims made by the insured; (d) Material relating to the investigation of the loss, including statements of any person, proof of loss, and any other evidence relevant to the investigation. (2) (a) When an insurance company has facts to support a belief that a loss in which it has an interest may be of other than accidental cause, then, for the purpose of notification and for having such loss investigated, the company shall, in writing, notify the director of the department of insurance, or the state fire marshal, and provide any or all material developed from the company’s inquiry into the loss. (b) When an insurance company provides the director of the department of insurance or the state fire marshal with notice of a loss, it shall be sufficient notice for the purpose of this chapter. (c) Nothing in section 41-292(1), Idaho Code, shall abrogate or impair the rights or powers created under section 41-292(2), Idaho Code. (3) The director of the department of insurance, the state fire marshal or an authorized agency provided with information pursuant to section 41-248, 41-258, 41-290 or 41-292(1) or (2), Idaho Code, and in furtherance of its own purposes, may release or provide such information to any of the other authorized agencies. (4) Any insurance company providing information to an authorized agency or agencies pursuant to section 41-258, 41-290 or 41-292(1) or (2), Idaho Code, shall have the right to request relevant information relative to the loss in question and to receive, within a reasonable time, not to exceed thirty (30) days, the information requested, if the information is not otherwise privileged by law. (5) In the absence of fraud or malice, no person shall be subject to civil liability for libel, slander or any other relevant tort cause of action by virtue of filing reports or furnishing other information required by this chapter or required by the director of the department of insurance under the authority granted in this chapter, and no civil cause of action of any nature shall arise against such person: (a) For any information relating to suspected fraudulent insurance acts furnished to or received from authorized agencies, their agents and employees; or (b) For any information relating to suspected fraudulent insurance acts furnished to or received from other persons subject to the provisions of this chapter; or (c) For any such information furnished in reports to the department of insurance, national association of insurance commissioners, national insurance crime bureau or any organization established to detect and prevent fraudulent insurance acts, their agents, employees or designees, nor shall the director or any employee of the department of insurance, acting without malice in the absence of fraud, be subject to civil liability for libel, slander or any other relevant tort and no civil cause of action of any nature shall arise against such person by virtue of the publication of any report or bulletin related to the official activities of the department of insurance. Nothing herein is intended to abrogate or modify in any way any common law or statutory privilege or immunity heretofore enjoyed by any person. (6) For purposes of subsection (5) of this section, there shall exist a rebuttable presumption that the person has acted without fraud or malice. **State:** Idaho --- ### [Idaho-Looting & diverting-I.C. ¤ 41-293](https://insurancefraud.org/statutes/idaho-looting-diverting-i-c-¤-41-293/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (g) Anyone who offers or accepts a direct or indirect inducement to file or solicits another person to file a false statement, with intent to defraud or deceive an insurer; (h) Any person who, with intent to defraud or deceive, transacts insurance of any kind or character, or transmits for a person other than himself an application for a policy of insurance, without proper licensing or after such license has been suspended or revoked; **State:** Idaho --- ### [Idaho-Mandatory Restitution-I.C. ¤ 41-293](https://insurancefraud.org/statutes/idaho-mandatory-restitution-i-c-¤-41-293/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (4) Any violator of this section is guilty of a felony and shall be subject to a term of imprisonment not to exceed fifteen (15) years, or a fine not to exceed fifteen thousand dollars ($15,000), or both and shall be ordered to make restitution to the insurer or any other person for any financial loss sustained as a result of a violation of this section. Each instance of violation may be considered a separate offense. **State:** Idaho **Statute Areas:** Mandatory Restitution --- ### [Idaho-Placing Bogus Coverage-I.C. ¤ 41-293*](https://insurancefraud.org/statutes/idaho-placing-bogus-coverage-i-c-¤-41-293/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (d) Any insurance producer or other person who, with intent to defraud or deceive, willfully takes premium money knowing that insurance coverage will not be effected; (e) Any practitioner or other person who willfully submits a false or altered statement, with the intent of deceiving an insurer or other person in connection with an insurance transaction or claim; **State:** Idaho --- ### [Idaho-Practitioner Penalites-I.C. ¤ 41-117](https://insurancefraud.org/statutes/idaho-practitioner-penalites-i-c-¤-41-117/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Each violation of this code for which a greater penalty is not provided by another provision of this code or by other applicable laws of this state, shall in addition to any applicable prescribed denial, suspension, or revocation of certificate of authority or license be punishable by an administrative penalty of not more than one thousand dollars ($1,000) for any individual or natural person and not more than five thousand dollars ($5,000) for any other person, imposed by the director, and upon conviction by a fine of not more than one thousand dollars ($1,000) or by imprisonment in the county jail for a period not to exceed six (6) months, or by both such fine and imprisonment in the discretion of the court. Each instance of violation may be considered a separate offense. **State:** Idaho **Statute Areas:** Practitioner Penalites --- ### [Idaho-Premium Fraud-I.C. ¤ 41-293](https://insurancefraud.org/statutes/idaho-premium-fraud-i-c-¤-41-293/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (d) Any insurance producer or other person who, with intent to defraud or deceive, willfully takes premium money knowing that insurance coverage will not be effected; **State:** Idaho **Statute Areas:** Premium Fraud --- ### [Idaho-Range of Criminal Penalties-I.C. ¤ 41-293](https://insurancefraud.org/statutes/idaho-range-of-criminal-penalties-i-c-¤-41-293/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (4) Any violator of this section is guilty of a felony and shall be subject to a term of imprisonment not to exceed fifteen (15) years, or a fine not to exceed fifteen thousand dollars ($15,000), or both and shall be ordered to make restitution to the insurer or any other person for any financial loss sustained as a result of a violation of this section. Each instance of violation may be considered a separate offense. **State:** Idaho **Statute Areas:** Range of Criminal Penalties --- ### [Idaho-Range of Civil Penalties-I.C. ¤ 41-293](https://insurancefraud.org/statutes/idaho-range-of-civil-penalties-i-c-¤-41-293/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (4) Any violator of this section is guilty of a felony and shall be subject to a term of imprisonment not to exceed fifteen (15) years, or a fine not to exceed fifteen thousand dollars ($15,000), or both and shall be ordered to make restitution to the insurer or any other person for any financial loss sustained as a result of a violation of this section. Each instance of violation may be considered a separate offense. **State:** Idaho **Statute Areas:** Range of Civil Penalties --- ### [Idaho-Rating of an Insurance Policy-I.C. ¤ 41-1437](https://insurancefraud.org/statutes/idaho-rating-of-an-insurance-policy-i-c-¤-41-1437/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (1) As to all rates which are subject to this chapter, due consideration shall be given to past and prospective loss experience within and outside this state, to the conflagration and catastrophe hazards, to a reasonable margin for underwriting profit and contingencies, to dividends, savings or unabsorbed premium deposits allowed or returned by insurers to their policy holders, members or subscribers, to past and prospective expenses both countrywide and those specifically applicable to this state, and to all other relevant factors, including judgment factors, within and outside this state; and in the case of fire insurance rates, consideration shall be given to the experience of the fire insurance business during a period of not less than the most recent five (5) year period for which such experience is available. (2) The systems of expense provisions included in the rates for use by an insurer or group of insurers may differ from those of other insurers or groups of insurers to reflect the requirements of the operating methods of any such insurer or group with respect to any kind of insurance, or with respect to any subdivision or combination thereof for which subdivision or combination separate expense provisions are applicable. (3) Risks may be grouped by classification for the establishment of rates and minimum premiums. Classification rates may be modified to produce rates for individual risks in accordance with rating plans which establish standards for measuring variations in hazards or expense provisions, or both. Such standards may measure any difference among risks that can be demonstrated to have a probable effect upon losses or expenses. Such classifications and modifications shall apply to all risks under the same or substantially the same circumstances or conditions. **State:** Idaho --- ### [Idaho-Underwriting Fraud-I.C. ¤ 41-293](https://insurancefraud.org/statutes/idaho-underwriting-fraud-i-c-¤-41-293/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (d) Any insurance producer or other person who, with intent to defraud or deceive, willfully takes premium money knowing that insurance coverage will not be effected; (e) Any practitioner or other person who willfully submits a false or altered statement, with the intent of deceiving an insurer or other person in connection with an insurance transaction or claim; **State:** Idaho **Statute Areas:** Underwriting Fraud --- ### [Idaho-Unauthorized Entities-I.C. ¤ 41-1201](https://insurancefraud.org/statutes/idaho-unauthorized-entities-i-c-¤-41-1201/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (1) No person shall in this state directly or indirectly act as agent for, or otherwise represent or aid on behalf of another, any insurer not then authorized to transact such insurance in this state, in the solicitation, negotiation, procurement or effectuation of insurance or annuity contracts, or renewal thereof, or forwarding of applications for insurance, or in the dissemination of information as to coverage or rates, or inspection of risks, or fixing of rates, or investigation or adjustment of claims or losses, or collection or forwarding of premiums, or in any other manner represent or assist such an insurer in the transaction of insurance with respect to subjects of insurance resident, located or to be performed in this state. (2) This section does not apply to: (a) Matters authorized to be done by the director under the Unauthorized Insurers Process Act, sections 41-1204 through 41-1210\[, Idaho Code\]. (b) Surplus line insurance when written pursuant to the Surplus Line Law, sections 41-1211 through 41-1232, \[Idaho Code,\] and coverages specified in section 41-1212\[, Idaho Code,\] (exemptions from Surplus Line Law). (c) Any transaction with respect to which the insurer is not required to have a certificate of authority pursuant to section 41-306\[, Idaho Code,\] (exceptions to certificate of authority requirement). (d) A licensed adjuster or attorney at law representing such an insurer from time to time in his professional capacity. **State:** Idaho --- ### [Hawaii-Aiding & Abetting-HRS ¤ 431:2-403](https://insurancefraud.org/statutes/hawaii-aiding-abetting-hrs-¤-4312-403/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) A person commits the offense of insurance fraud if the person: (2) Intentionally or knowingly aids, agrees, or attempts to aid, solicit, or conspire with any person who engages in anunlawful act as defined under this section; **State:** Hawaii --- ### [Hawaii-Attempted Fraud-HRS ¤ 431:2-403](https://insurancefraud.org/statutes/hawaii-attempted-fraud-hrs-¤-4312-403/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) A person commits the offense of insurance fraud if the person: (2) Intentionally or knowingly aids, agrees, or attempts to aid, solicit, or conspire with any person who engages in anunlawful act as defined under this section; **State:** Hawaii **Statute Areas:** Attempted Fraud --- ### [Hawaii-Claims Fraud-HRS ¤ 431:2-403](https://insurancefraud.org/statutes/hawaii-claims-fraud-hrs-¤-4312-403/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) A person commits the offense of insurance fraud if the person: (1) Intentionally or knowingly misrepresents or conceals material facts, opinions, intention, or law to obtain or attempt to obtain coverage, benefits, recovery, or compensation: (B) When presenting, or causing or permitting to be presented, false information on a claim for payment; (C) When presenting, or causing or permitting to be presented, a claim for the payment of a loss; (D) When presenting, or causing or permitting to be presented, multiple claims for the same loss or injury, including knowingly presenting such multiple and duplicative claims to more than one insurer; (E) When presenting, or causing or permitting to be presented, any claim for payment of a health care benefit; (F) When presenting, or causing or permitting to be presented, a claim for a health care benefit that was not used by, or provided on behalf of, the claimant; (G) When presenting, or causing or permitting to be presented, improper multiple and duplicative claims for payment of the same health care benefit; **State:** Hawaii **Statute Areas:** Claims Fraud --- ### [Hawaii-Fraud Bureau-HRS ¤ 431:2-402](https://insurancefraud.org/statutes/hawaii-fraud-bureau-hrs-¤-4312-402/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) There is established in the insurance division the insurance fraud investigations branch for the purposes set forth in this part. (b) The branch shall: (1) Conduct a statewide program for the prevention of insurance fraud under title 24, including chapters 431, 432, and 432D; provided that the branch shall not have jurisdiction over workers’ compensation under chapter 386; (2) Notwithstanding any other law to the contrary, investigate and prosecute in administrative hearings and courts of competent jurisdiction all persons involved in insurance fraud violations; and (3) Promote public and industry-wide education about insurance fraud. (c) The branch may review and take appropriate action on complaints of fraud relating to insurance under title 24, including chapters 431, 432, and 432D, but excluding workers’ compensation insurance under chapter 386. (d) The commissioner shall employ or retain, by contract or otherwise, attorneys, investigators, investigator assistants, auditors, accountants, physicians, health care professionals, paralegals, consultants, experts, and other professional, technical, and support staff as necessary to promote the effective and efficient conduct of the branch’s activities. The commissioner may hire these employees without regard to chapters 76 or 89. (e) Notwithstanding any other law to the contrary, an attorney employed or retained by the branch may represent the State in any criminal, civil, or administrative proceeding to enforce all applicable state laws relating to insurance fraud, including criminal prosecutions, disciplinary actions, and actions for declaratory and injunctive relief. The attorney general may designate an attorney as a special deputy attorney general for purposes of this subsection. (f) Investigators appointed and commissioned under this part shall have and may exercise all of the powers and authority of a police officer or of a deputy sheriff. (g) Funding for the branch shall come from the compliance resolution fund established by section 26-9(o). **State:** Hawaii **Statute Areas:** Fraud Bureau --- ### [Hawaii-Immunity-HRS ¤ 431:2-301.8](https://insurancefraud.org/statutes/hawaii-immunity-hrs-¤-4312-301-8/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) No cause of action shall arise nor shall any liability be imposed against any examiner appointed or otherwise designated as an examiner by the commissioner for any statements made or conduct performed in good faith while carrying out the provisions of the insurance code. (b) No cause of action shall arise, nor shall any liability be imposed against any person, for the act of communicating or delivering information or data to the commissioner or the commissioner’s authorized representative or examiner pursuant to an examination made under the insurance code, if the act of communication or delivery was performed in good faith and without fraudulent intent or the intent to deceive. (c) This section does not abrogate nor modify in any way common law or statutory privilege or immunity heretofore enjoyed by any person identified in subsection (a). (d) A person identified in subsection (a) shall be entitled to an award of attorneys’ fees and costs if the person is the prevailing party in a civil cause of action for libel, slander, or any other relevant tort arising out of activities in carrying out the insurance code, and the party bringing action is not substantially justified to do so. For the purposes of this section, a proceeding is substantially justified if it has a reasonable basis in law or fact at the time that it is initiated. **State:** Hawaii **Statute Areas:** Immunity --- ### [Hawaii-Insurance Fraud - Definition-HRS ¤ 431:2-403](https://insurancefraud.org/statutes/hawaii-insurance-fraud-definition-hrs-¤-4312-403/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) A person commits the offense of insurance fraud if the person: (1) Intentionally or knowingly misrepresents or conceals material facts, opinions, intention, or law to obtain or attempt to obtain coverage, benefits, recovery, or compensation: (A) When presenting, or causing or permitting to be presented, an application, whether written, typed, or transmitted through electronic media, for the issuance or renewal of an insurance policy or reinsurance contract; (B) When presenting, or causing or permitting to be presented, false information on a claim for payment; (C) When presenting, or causing or permitting to be presented, a claim for the payment of a loss; (D) When presenting, or causing or permitting to be presented, multiple claims for the same loss or injury, including knowingly presenting such multiple and duplicative claims to more than one insurer; (E) When presenting, or causing or permitting to be presented, any claim for payment of a health care benefit; (F) When presenting, or causing or permitting to be presented, a claim for a health care benefit that was not used by, or provided on behalf of, the claimant; (G) When presenting, or causing or permitting to be presented, improper multiple and duplicative claims for payment of the same health care benefit; (H) When presenting, or causing or permitting to be presented, for payment any undercharges for benefits on behalf of a specific claimant unless any known overcharges for benefits under this article for that claimant are presented for reconciliation at the same time; (I) When fabricating, altering, concealing, making an entry in, or destroying a document whether typed, written, or through an audio or video tape or electronic media; (J) When presenting, or causing or permitting to be presented, to a person, insurer, or other licensee false, incomplete, or misleading information to obtain coverage or payment otherwise available under an insurance policy; (K) When presenting, or causing or permitting to be presented, to a person or producer, information about a person’s status as a licensee that induces a person or insurer to purchase an insurance policy or reinsurance contract; and (L) When making, or causing or permitting to be made, any statement, either typed, written, or through audio or video tape or electronic media, or claims by the person or on behalf of a person with regard to obtaining legal recovery or benefits; (2) Intentionally or knowingly aids, agrees, or attempts to aid, solicit, or conspire with any person who engages in an unlawful act as defined under this section; or (3) Intentionally or knowingly makes, causes, or permits to be presented, any false statements or claims by any person or on behalf of any person during an official proceeding as defined by section 710-1000. (b) Violation of subsection (a) is a criminal offense and shall constitute: (1) A class B felony if the value of the benefits, recovery, or compensation obtained or attempted to be obtained exceeds $20,000; (2) A class C felony if the value of the benefits, recovery, or compensation obtained or attempted to be obtained exceeds $750; or (3) A misdemeanor if the value of the benefits, recovery, or compensation obtained or attempted to be obtained is not in excess of $750. (c) This section shall not supersede any other law relating to theft, fraud, or deception. Insurance fraud may be prosecuted under this part, or any other applicable statute or common law, and all such remedies shall be cumulative. Credits **State:** Hawaii **Statute Areas:** Insurance Fraud - Definition --- ### [Hawaii-Licensing Board Notification-HRS ¤ 431:2-409](https://insurancefraud.org/statutes/hawaii-licensing-board-notification-hrs-¤-4312-409/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) Within sixty days of an insurer or other licensee’s employee or agent discovering credible information indicating a violation of section 431:2-403, or as soon thereafter as practicable, the insurer or licensee shall provide to the branch information, including documents and other evidence, regarding the alleged violation of section 431:2-403. The insurance fraud investigations branch shall work with the insurer or licensee to determine what information shall be provided. (b) Information provided pursuant to this section shall be protected from public disclosure to the extent authorized by chapter 92F and section 431:2-209; provided that the branch may release the information in an administrative or judicial proceeding to enforce this part to federal, state, or local law enforcement or regulatory authorities, the National Association of Insurance Commissioners, the National Insurance Crime Bureau, or an insurer or other licensee aggrieved by the alleged violation of section 431:2-403. **State:** Hawaii --- ### [Hawaii-Mandatory Restitution-HRS ¤ 431:2-404](https://insurancefraud.org/statutes/hawaii-mandatory-restitution-hrs-¤-4312-404/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Any person convicted under this part shall be ordered by a court to make restitution to any insurer, person, or licensee for any financial loss sustained by that insurer, person, or licensee that was caused by the act or acts for which the person was convicted. **State:** Hawaii **Statute Areas:** Mandatory Restitution --- ### [Hawaii-Placing Bogus Coverage-HRS ¤ 431:2-403*](https://insurancefraud.org/statutes/hawaii-placing-bogus-coverage-hrs-¤-4312-403/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) A person commits the offense of insurance fraud if the person: (1) Intentionally or knowingly misrepresents or conceals material facts, opinions, intention, or law to obtain or attempt to obtain coverage, benefits, recovery, or compensation: (A) When presenting, or causing or permitting to be presented, an application, whether written, typed, or transmitted through electronic media, for the issuance or renewal of an insurance policy or reinsurance contract; (B) When presenting, or causing or permitting to be presented, false information on a claim for payment; (C) When presenting, or causing or permitting to be presented, a claim for the payment of a loss; (D) When presenting, or causing or permitting to be presented, multiple claims for the same loss or injury, including knowingly presenting such multiple and duplicative claims to more than one insurer; (E) When presenting, or causing or permitting to be presented, any claim for payment of a health care benefit; (F) When presenting, or causing or permitting to be presented, a claim for a health care benefit that was not used by, or provided on behalf of, the claimant; (G) When presenting, or causing or permitting to be presented, improper multiple and duplicative claims for payment of the same health care benefit; (H) When presenting, or causing or permitting to be presented, for payment any undercharges for benefits on behalf of a specific claimant unless any known overcharges for benefits under this article for that claimant are presented for reconciliation at the same time; (I) When fabricating, altering, concealing, making an entry in, or destroying a document whether typed, written, or through an audio or video tape or electronic media; (J) When presenting, or causing or permitting to be presented, to a person, insurer, or other licensee false, incomplete, or misleading information to obtain coverage or payment otherwise available under an insurance policy; (K) When presenting, or causing or permitting to be presented, to a person or producer, information about a person’s status as a licensee that induces a person or insurer to purchase an insurance policy or reinsurance contract; and (L) When making, or causing or permitting to be made, any statement, either typed, written, or through audio or video tape or electronic media, or claims by the person or on behalf of a person with regard to obtaining legal recovery or benefits; **State:** Hawaii --- ### [Hawaii-Premium Fraud-HRS ¤ 431:2-403*](https://insurancefraud.org/statutes/hawaii-premium-fraud-hrs-¤-4312-403/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) A person commits the offense of insurance fraud if the person: (1) Intentionally or knowingly misrepresents or conceals material facts, opinions, intention, or law to obtain or attempt to obtain coverage, benefits, recovery, or compensation: (A) When presenting, or causing or permitting to be presented, an application, whether written, typed, or transmitted through electronic media, for the issuance or renewal of an insurance policy or reinsurance contract; (B) When presenting, or causing or permitting to be presented, false information on a claim for payment; (C) When presenting, or causing or permitting to be presented, a claim for the payment of a loss; (D) When presenting, or causing or permitting to be presented, multiple claims for the same loss or injury, including knowingly presenting such multiple and duplicative claims to more than one insurer; (E) When presenting, or causing or permitting to be presented, any claim for payment of a health care benefit; (F) When presenting, or causing or permitting to be presented, a claim for a health care benefit that was not used by, or provided on behalf of, the claimant; (G) When presenting, or causing or permitting to be presented, improper multiple and duplicative claims for payment of the same health care benefit; (H) When presenting, or causing or permitting to be presented, for payment any undercharges for benefits on behalf of a specific claimant unless any known overcharges for benefits under this article for that claimant are presented for reconciliation at the same time; (I) When fabricating, altering, concealing, making an entry in, or destroying a document whether typed, written, or through an audio or video tape or electronic media; (J) When presenting, or causing or permitting to be presented, to a person, insurer, or other licensee false, incomplete, or misleading information to obtain coverage or payment otherwise available under an insurance policy; (K) When presenting, or causing or permitting to be presented, to a person or producer, information about a person’s status as a licensee that induces a person or insurer to purchase an insurance policy or reinsurance contract; and (L) When making, or causing or permitting to be made, any statement, either typed, written, or through audio or video tape or electronic media, or claims by the person or on behalf of a person with regard to obtaining legal recovery or benefits; **State:** Hawaii **Statute Areas:** Premium Fraud --- ### [Hawaii-Range of Criminal Penalties-HRS ¤ 431:2-403](https://insurancefraud.org/statutes/hawaii-range-of-criminal-penalties-hrs-¤-4312-403/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (b) Violation of subsection (a) is a criminal offense and shall constitute: (1) A class B felony if the value of the benefits, recovery, or compensation obtained or attempted to be obtained exceeds $20,000; (2) A class C felony if the value of the benefits, recovery, or compensation obtained or attempted to be obtained exceeds $750; or (3) A misdemeanor if the value of the benefits, recovery, or compensation obtained or attempted to be obtained is not in excess of $750. (c) This section shall not supersede any other law relating to theft, fraud, or deception. Insurance fraud may be prosecuted under this part, or any other applicable statute or common law, and all such remedies shall be cumulative. Credits **State:** Hawaii **Statute Areas:** Range of Criminal Penalties --- ### [Hawaii-Range of Civil Penalties-HRS ¤ 431:2-405](https://insurancefraud.org/statutes/hawaii-range-of-civil-penalties-hrs-¤-4312-405/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) In addition to or in lieu of criminal penalties under section 431:2-403(b), any person who commits insurance fraud as defined under section 431:2-403, may be subject to the administrative penalties in this section. (b) If a person is found to have knowingly committed insurance fraud under this part, the commissioner may assess any or all of the following penalties: (1) Restitution to any insurer or any other person of benefits or payments fraudulently received or other damages or costs incurred; (2) A fine of not more than $10,000 for each violation; and (3) Reimbursement of attorneys’ fees and costs of the party sustaining a loss under this part; provided that the State shall be exempt from paying attorneys’ fees and costs to other parties. (c) Administrative actions brought for insurance fraud under this part shall be brought within six years after the insurance fraud is discovered or by exercise of reasonable diligence should have been discovered and, in any event, no more than ten years after the date on which a violation of this part is committed. **State:** Hawaii **Statute Areas:** Range of Civil Penalties --- ### [Hawaii-Rating of an Insurance Policy-HRS ¤ 431:14-103](https://insurancefraud.org/statutes/hawaii-rating-of-an-insurance-policy-hrs-¤-43114-103/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) Rates shall be made in accordance with the following provisions: (1) Rates shall not be excessive, inadequate, or unfairly discriminatory. (2) Due consideration shall be given to: (A) Past and prospective loss experience within and outside this State; provided that if the claim does not exceed the selected deductible amount pursuant to section 386-100, and the employer reimburses the insurer for the amount, the claims shall not be calculated in the employer’s experience rating or risk category; (B) The conflagration and catastrophe hazards, if any; (C) A reasonable margin for underwriting profit and contingencies; (D) Dividends, savings, or unabsorbed premium deposits allowed or returned by insurers to their policyholders, members, or subscribers; (E) Past and prospective expenses both country-wide and those specially applicable to this State; (F) Investment income from unearned premium and loss reserve funds; and (G) All other relevant factors within and outside this State. (3) In the case of fire insurance rates, consideration shall be given to the experience of the fire insurance business during a period of not less than the most recent five-year period for which that experience is available. (4) The systems of expense provisions included in the rates for use by any insurer or group of insurers may differ from those of other insurers or groups of insurers to reflect the requirements of the operating methods of any insurer or group with respect to any class of insurance, or with respect to any subdivision or combination thereof for which subdivision or combination separate expense provisions are applicable. (5) Risks may be grouped by classifications for the establishment of rates and minimum premiums. Classification rates may be modified to produce rates for individual risks in accordance with rating plans that establish standards for measuring variations in hazards or expense provisions, or both. These standards may measure any differences among risks that can be demonstrated to have a probable effect upon losses or expenses. No risk classification may be based upon race, creed, national origin, or the religion of the insured. (6) Manual, minimum, class rates, rating schedules, or rating plans shall be made and adopted, except in the case of: (A) Special rates where manual, minimum, class rates, rating schedules, or rating plans are not applicable; and (B) Specifically rated inland marine risks. (7) No insurer authorized to do business in this State shall issue any policy that provides or makes available to any risks preferred rates based upon any grouping of persons, firms, or corporations by way of membership, license, franchise, contract, agreement, or any other means, other than common majority ownership of the risks, or except where: (A) A common stock ownership in and management control of the risks are held by the same person, corporation, or firm; (B) Permitted or authorized by filings in existence as of January 1, 1988, under the casualty rating law and the fire rating law, as these filings may be amended from time to time; (C) Health care providers, as defined in section 671-1 that could have joined the patients’ compensation fund as it existed in chapter 671, part III, prior to May 31, 1984, joined together with one or more groups of related or unrelated health care providers; (D) Permitted under article 12; or (E) Otherwise expressly provided by law. (b) In cases of workers’ compensation insurance, all rates made in accordance with this section shall be given due consideration for good safety records of employers. By premium reductions, dividends, or both, insurance carriers shall recognize good safety performance records of employers in this State. (c) Upon the issuance of a certificate by a certified safety and health professional to an employer that the employer has an effective safety and health program pursuant to section 396-4.5, the insurer shall provide the employer with a workers’ compensation insurance premium discount of at least five per cent; provided that the employer shall maintain the effective safety and health program throughout the policy period. Standards for the issuance of certificates shall be included in rules adopted by the department of labor and industrial relations pursuant to chapter 91. (d) For the purpose of ratemaking, all insurers shall treat a volunteer firefighter the same as a firefighter employed by a county fire department; provided that the volunteer firefighters are attached to a station where a firefighter or volunteer firefighter who has been trained and certified to drive a commercial motor vehicle by either the state or county government, as appropriate, and who maintains a category (3) license as defined by section 286-102(b)(3) is on duty at all times or at least four firefighters or volunteer firefighters who have been trained and certified to drive a commercial motor vehicle by either the state or county government, as appropriate, and who maintain a category (3) license as defined by section 286-102(b)(3) are members of the volunteer unit. (e) Except to the extent necessary to meet the provisions of subsection (a)(1), uniformity among insurers in any matters within the scope of this section is neither required nor prohibited. **State:** Hawaii --- ### [Hawaii-Unauthorized Entities-HRS ¤ 431:8-201](https://insurancefraud.org/statutes/hawaii-unauthorized-entities-hrs-¤-4318-201/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** It shall be unlawful for any insurer to transact an insurance business in this State, as defined in section 431:1-215, without a certificate of authority; provided that this section shall not apply to: (1) The lawful transaction of surplus lines insurance; (2) The lawful transaction of reinsurance by insurers; (3) Transactions in this State involving a policy lawfully solicited, written, and delivered outside of this State covering only subjects of insurance not resident, located, or expressly to be performed in this State at the time of issuance, and subsequent to the issuance of the policy; (4) Attorneys acting in the ordinary relation of attorney and client in the adjustment of claims or losses; (5) Transactions in this State involving group life and group accident and health or sickness or blanket accident and health or sickness insurance or group annuities where the master policy of the groups was lawfully issued in and delivered pursuant to the laws of a state in which the insurer was authorized to do an insurance business; (6) Transactions in this State involving any policy of insurance or annuity contract issued prior to July 1, 1988; (7) Transactions in this State involving ocean marine insurance; and (8) Transactions of contracts of insurance for property and casualty multi-state risks; provided that the producer is licensed to sell, solicit, or negotiate that insurance in the home state of the insured. **State:** Hawaii --- ### [Georgia-Aiding & Abetting-Ga. Code Ann., ¤ 33-1-9](https://insurancefraud.org/statutes/georgia-aiding-abetting-ga-code-ann-¤-33-1-9/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) Any natural person who knowingly or willfully: (1) Makes or aids in the making of any false or fraudulent statement or representation of any material fact or thing: (A) In any written statement or certificate; (B) In the filing of a claim; (C) In the making of an application for a policy of insurance; (D) In the receiving of such an application for a policy of insurance; or (E) In the receiving of money for such application for a policy of insurance for the purpose of procuring or attempting to procure the payment of any false or fraudulent claim or other benefit by an insurer; (2) Receives money for the purpose of purchasing insurance and converts such money to such person’s own benefit; (3) Issues fake or counterfeit insurance policies, certificates of insurance, insurance identification cards, or insurance binders; or (4) Makes any false or fraudulent representation as to the death or disability of a policy or certificate holder in any written statement or certificate for the purpose of fraudulently obtaining money or benefit from an insurer commits the crime of insurance fraud. **State:** Georgia --- ### [Georgia-Claims Fraud-Ga. Code Ann., ¤ 33-1-9](https://insurancefraud.org/statutes/georgia-claims-fraud-ga-code-ann-¤-33-1-9/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) Any natural person who knowingly or willfully: (1) Makes or aids in the making of any false or fraudulent statement or representation of any material fact or thing: (A) In any written statement or certificate; (B) In the filing of a claim; (C) In the making of an application for a policy of insurance; (D) In the receiving of such an application for a policy of insurance; or (E) In the receiving of money for such application for a policy of insurance for the purpose of procuring or attempting to procure the payment of any false or fraudulent claim or other benefit by an insurer; (2) Receives money for the purpose of purchasing insurance and converts such money to such person’s own benefit; (3) Issues fake or counterfeit insurance policies, certificates of insurance, insurance identification cards, or insurance binders; or (4) Makes any false or fraudulent representation as to the death or disability of a policy or certificate holder in any written statement or certificate for the purpose of fraudulently obtaining money or benefit from an insurer **State:** Georgia **Statute Areas:** Claims Fraud --- ### [Georgia-Immunity-Ga. Code Ann., ¤ 33-39-22; ¤ 33-1-16](https://insurancefraud.org/statutes/georgia-immunity-ga-code-ann-¤-33-39-22-¤-33-1-16/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** No cause of action in the nature of defamation, invasion of privacy, or negligence shall arise against any person for disclosing personal or privileged information in accordance with this chapter, nor shall such a cause of action arise against any person for furnishing personal or privileged information to an insurance institution, agent, or insurance-support organization; provided, however, this Code section shall provide no immunity for disclosing or furnishing false information with malice or willful intent to injure any person.\*\*\*(3) In the absence of fraud or bad faith, a person is not subject to civil liability for libel, slander, or any other relevant tort by virtue of filing reports, without malice, or furnishing other information, without malice, required by this Code section or required by the Commissioner under the authority granted in this Code section, and no civil cause of action of any nature shall arise against such person: (A) For any information relating to suspected fraudulent insurance acts furnished to or received from law enforcement officials, their agents, or employees; (B) For any such information relating to suspected fraudulent insurance acts furnished to or received from other persons subject to the provisions of this title; or (C) For any such information furnished in reports to the Commissioner or the National Association of Insurance Commissioners. (4) The Commissioner or any employee or agent is not subject to civil liability for libel, slander, or any other relevant tort, and no civil cause of action of any nature exists against such persons by virtue of the execution of activities or duties of the Commissioner under this Code section or by virtue of the publication of any report or bulletin related to the activities or duties of the Commissioner under this Code section. (5) This Code section does not abrogate or modify in any way any common law or statutory privilege or immunity heretofore enjoyed by any person. **State:** Georgia **Statute Areas:** Immunity --- ### [Georgia-Insurance Fraud - Definition-Ga. Code Ann., ¤ 33-1-9](https://insurancefraud.org/statutes/georgia-insurance-fraud-definition-ga-code-ann-¤-33-1-9/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) Any natural person who knowingly or willfully: (1) Makes or aids in the making of any false or fraudulent statement or representation of any material fact or thing: (A) In any written statement or certificate; (B) In the filing of a claim; (C) In the making of an application for a policy of insurance; (D) In the receiving of such an application for a policy of insurance; or (E) In the receiving of money for such application for a policy of insurance for the purpose of procuring or attempting to procure the payment of any false or fraudulent claim or other benefit by an insurer; (2) Receives money for the purpose of purchasing insurance and converts such money to such person’s own benefit; (3) Issues fake or counterfeit insurance policies, certificates of insurance, insurance identification cards, or insurance binders; or (4) Makes any false or fraudulent representation as to the death or disability of a policy or certificate holder in any written statement or certificate for the purpose of fraudulently obtaining money or benefit from an insurer commits the crime of insurance fraud. (b) Any natural person who knowingly and willfully or with reckless disregard engages in the following activities, either directly or indirectly, as an agent for, as a representative of, or on behalf of an insurer not authorized to transact insurance in this state commits the crime of insurance fraud: (1) Soliciting, negotiating, procuring, or effectuating insurance or annuity contracts or renewals thereof; (2) Soliciting, negotiating, procuring, or effectuating any contract relating to benefits or services; (3) Disseminating information as to coverage or rates; (4) Forwarding applications; (5) Delivering policies or contracts; (6) Inspecting or assessing risk; (7) Fixing of rates; (8) Investigating or adjusting claims or losses; (9) Collecting or forwarding of premiums; or (10) In any other manner representing or assisting such an insurer in the transaction of insurance with respect to subjects of insurance resident, located, or to be performed in this state. (c) Any natural person who knowingly and willfully with intent to defraud subscribes, makes, or concurs in making any annual or other statement required by law to be filed with the Commissioner containing any material statement which is false commits the crime of insurance fraud. (d) In any prosecution under this Code section, the crime shall be considered as having been committed in the county of the purported loss, in the county in which the insurer or the insurer’s agent received the fraudulent or false claim or application, in the county in which money was received for the fraudulent application, or in any county where any act in furtherance of the criminal scheme was committed. (e) A natural person convicted of a violation of this Code section shall be guilty of a felony and shall be punished by imprisonment for not less than two nor more than ten years, or by a fine of not more than $10,000.00, or both. (f) Subsection (b) of this Code section shall not apply to a contract of insurance entered into in accordance with Article 2 of Chapter 5 of this title. **State:** Georgia **Statute Areas:** Insurance Fraud - Definition --- ### [Georgia-Licensing Board Notification-n/a](https://insurancefraud.org/statutes/georgia-licensing-board-notification-n-a/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** No Statute found **State:** Georgia --- ### [Georgia-Looting & diverting-Ga. Code Ann., ¤ 33-1-9](https://insurancefraud.org/statutes/georgia-looting-diverting-ga-code-ann-¤-33-1-9/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) Any natural person who knowingly or willfully: (1) Makes or aids in the making of any false or fraudulent statement or representation of any material fact or thing: (A) In any written statement or certificate; (B) In the filing of a claim; (C) In the making of an application for a policy of insurance; (D) In the receiving of such an application for a policy of insurance; or (E) In the receiving of money for such application for a policy of insurance for the purpose of procuring or attempting to procure the payment of any false or fraudulent claim or other benefit by an insurer; (2) Receives money for the purpose of purchasing insurance and converts such money to such person’s own benefit; (3) Issues fake or counterfeit insurance policies, certificates of insurance, insurance identification cards, or insurance binders; or (4) Makes any false or fraudulent representation as to the death or disability of a policy or certificate holder in any written statement or certificate for the purpose of fraudulently obtaining money or benefit from an insurer **State:** Georgia --- ### [Georgia-Placing Bogus Coverage-Ga. Code Ann., ¤ 33-1-9](https://insurancefraud.org/statutes/georgia-placing-bogus-coverage-ga-code-ann-¤-33-1-9/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (b) Any natural person who knowingly and willfully or with reckless disregard engages in the following activities, either directly or indirectly, as an agent for, as a representative of, or on behalf of an insurer not authorized to transact insurance in this state commits the crime of insurance fraud: (1) Soliciting, negotiating, procuring, or effectuating insurance or annuity contracts or renewals thereof; (2) Soliciting, negotiating, procuring, or effectuating any contract relating to benefits or services; (3) Disseminating information as to coverage or rates; (4) Forwarding applications; (5) Delivering policies or contracts; (6) Inspecting or assessing risk; (7) Fixing of rates; (8) Investigating or adjusting claims or losses; (9) Collecting or forwarding of premiums; or (10) In any other manner representing or assisting such an insurer in the transaction of insurance with respect to subjects of insurance resident, located, or to be performed in this state. **State:** Georgia --- ### [Georgia-Practitioner Penalites-Ga. Code Ann., ¤ 33-1-7 (Proposed legislation)](https://insurancefraud.org/statutes/georgia-practitioner-penalites-ga-code-ann-¤-33-1-7-proposed-legislation/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Any insurer, or any officer or agent thereof, issuing or delivering to any person in this state any policy in violation of any provision of this title shall be guilty of a misdemeanor. **State:** Georgia **Statute Areas:** Practitioner Penalites --- ### [Georgia-Premium Fraud-Ga. Code Ann., ¤ 33-1-9](https://insurancefraud.org/statutes/georgia-premium-fraud-ga-code-ann-¤-33-1-9/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) Any natural person who knowingly or willfully: (1) Makes or aids in the making of any false or fraudulent statement or representation of any material fact or thing: (A) In any written statement or certificate; (B) In the filing of a claim; (C) In the making of an application for a policy of insurance; (D) In the receiving of such an application for a policy of insurance; or (E) In the receiving of money for such application for a policy of insurance for the purpose of procuring or attempting to procure the payment of any false or fraudulent claim or other benefit by an insurer; (2) Receives money for the purpose of purchasing insurance and converts such money to such person’s own benefit; (3) Issues fake or counterfeit insurance policies, certificates of insurance, insurance identification cards, or insurance binders; or (4) Makes any false or fraudulent representation as to the death or disability of a policy or certificate holder in any written statement or certificate for the purpose of fraudulently obtaining money or benefit from an insurer **State:** Georgia **Statute Areas:** Premium Fraud --- ### [Georgia-Range of Criminal Penalties-Ga. Code Ann., ¤ 33-1-9](https://insurancefraud.org/statutes/georgia-range-of-criminal-penalties-ga-code-ann-¤-33-1-9/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (e) A natural person convicted of a violation of this Code section shall be guilty of a felony and shall be punished by imprisonment for not less than two nor more than ten years, or by a fine of not more than $10,000.00, or both. **State:** Georgia **Statute Areas:** Range of Criminal Penalties --- ### [Georgia-Range of Civil Penalties-Ga. Code Ann., ¤ 33-1-9](https://insurancefraud.org/statutes/georgia-range-of-civil-penalties-ga-code-ann-¤-33-1-9/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (e) A natural person convicted of a violation of this Code section shall be guilty of a felony and shall be punished by imprisonment for not less than two nor more than ten years, or by a fine of not more than $10,000.00, or both. **State:** Georgia **Statute Areas:** Range of Civil Penalties --- ### [Georgia-Rating of an Insurance Policy-Ga. Code Ann., ¤ 33-9-4 (Proposed legislation)](https://insurancefraud.org/statutes/georgia-rating-of-an-insurance-policy-ga-code-ann-¤-33-9-4-proposed-legislation/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** The following standards shall apply to the making and use of rates pertaining to all classes of insurance to which this chapter is applicable: (1) Rates shall not be excessive or inadequate, as defined in this Code section, nor shall they be unfairly discriminatory; (2) No rate shall be held to be excessive unless such rate is unreasonably high for the insurance provided and a reasonable degree of competition does not exist in the area with respect to the classification to which such rate is applicable; provided, however, with respect to rate filings involving an increase in rates, no rate for personal private passenger motor vehicle insurance shall be held to be excessive unless such rate is unreasonably high for the insurance provided and a reasonable degree of competition does not exist; (3) No rate shall be held inadequate unless it is unreasonably low for the insurance provided and continued use of it would endanger solvency of the insurer, or unless the use of such rate by the insurer using such rate has, or will, if continued, tend to destroy competition or create a monopoly; (4) Consideration shall be given to the extent applicable to past and prospective loss experience within and outside this state, to conflagration and catastrophe hazards, to a reasonable margin for underwriting profit and contingencies, to past and prospective expenses both country wide and those specially applicable to this state, to the insurer’s average yield from investment income, and to all other factors, including judgment factors, deemed relevant within and outside this state; and, in the case of fire insurance rates, consideration may be given to the experience of the fire insurance business during the most recent five-year period; (5) Consideration may also be given, in the making and use of rates, to dividends, savings, or unabsorbed premium deposits allowed or returned by insurers to their policyholders, members, or subscribers; (6) The systems of expense provisions included in the rates for use by any insurer or group of insurers may differ from those of other insurers or groups of insurers to reflect the operating methods of any such insurer or group with respect to any kind of insurance or with respect to any subdivision or combination thereof; (7) Risks may be grouped by classifications for the establishment of rates and minimum premiums. Classification rates may be modified to produce rates for individual risks in accordance with rating plans which establish standards for measuring variations in hazards or expense provisions, or both. Such standards may measure any difference among risks that have a probable effect upon losses or expenses. Classifications or modifications of classifications of risks may be established based upon size, expense, management, individual experience, location or dispersion of hazard, or any other reasonable considerations. Such classifications and modifications shall apply to all risks under the same or substantially the same circumstances or conditions; provided, however, the Commissioner shall establish the maximum amount of any such modification; (8) Nothing contained in this Code section or elsewhere in this chapter shall be construed to repeal or modify Chapter 6 of this title, relating to unfair trade practices, and any rate, rating classification, rating plan or schedule, or variation thereof established in violation of Chapter 6 of this title shall, in addition to the consequences stated in Chapter 6 of this title or elsewhere, be deemed violative of this Code section; (9) No insurer shall base any standard or rating plan on vehicle insurance, in whole or in part, directly or indirectly, upon race, creed, or ethnic extraction; and (10) No insurer shall base any standard or rating plan on vehicle insurance, in whole or in part, directly or indirectly, upon any physical disability of an insured unless the disability directly impairs the ability of the insured to drive a motor vehicle. **State:** Georgia --- ### [Georgia-Underwriting Fraud-Ga. Code Ann., ¤ 33-1-9](https://insurancefraud.org/statutes/georgia-underwriting-fraud-ga-code-ann-¤-33-1-9/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (b) Any natural person who knowingly and willfully or with reckless disregard engages in the following activities, either directly or indirectly, as an agent for, as a representative of, or on behalf of an insurer not authorized to transact insurance in this state commits the crime of insurance fraud: (1) Soliciting, negotiating, procuring, or effectuating insurance or annuity contracts or renewals thereof; (2) Soliciting, negotiating, procuring, or effectuating any contract relating to benefits or services; (3) Disseminating information as to coverage or rates; (4) Forwarding applications; (5) Delivering policies or contracts; (6) Inspecting or assessing risk; (7) Fixing of rates; (8) Investigating or adjusting claims or losses; (9) Collecting or forwarding of premiums; or (10) In any other manner representing or assisting such an insurer in the transaction of insurance with respect to subjects of insurance resident, located, or to be performed in this state. **State:** Georgia **Statute Areas:** Underwriting Fraud --- ### [Georgia-Unauthorized Entities-Ga. Code Ann., ¤ 33-5-1](https://insurancefraud.org/statutes/georgia-unauthorized-entities-ga-code-ann-¤-33-5-1/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) No person in this state shall: (1) Represent an insurer who is not at the time duly authorized to transact insurance in this state in the solicitation, negotiation, or effectuation of insurance, inspection of risks, fixing of rates, investigation or adjustment of losses, collection of premiums, or in any other manner in the transaction of insurance with respect to subjects of insurance, resident, located, or to be performed in this state; or (2) Represent any person in the procuring of insurance with an unauthorized insurer upon or with relation to any subject of insurance. (b) This Code section shall not apply to: (1) Surplus line insurance which is authorized by this chapter and transactions as to which a certificate of authority is not required of an insurer under Code Section 33-3-2; (2) Reinsurance as authorized by Code Section 33-7-14; (3) The services of an adjuster with respect to claims under policies lawfully solicited, issued, and delivered outside of Georgia; (4) Acceptance of service by the Commissioner pursuant to this title; (5) The professional services of an attorney; or (6) Any insurance company or underwriter issuing contracts of insurance to nuclear insureds, nor to any contract of insurance issued to any one or more nuclear insureds, provided that such nuclear insured under a contract procured from an unauthorized insurer shall pay to the Commissioner of Insurance before March 1 of the succeeding calendar year following the year in which the insurance was so effectuated, continued, or renewed, a premium receipts tax of 4 percent of the gross premiums charged for such insurance. For the purposes of this paragraph, a “nuclear insured” is an insured purchasing policies of insurance on risks on its own nuclear generating plants and other facilities at such plants in this state. **State:** Georgia --- ### [Florida-Claims Fraud-West's F.S.A. ¤ 817.234*](https://insurancefraud.org/statutes/florida-claims-fraud-wests-f-s-a-¤-817-234/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (1)(a) A person commits insurance fraud punishable as provided in subsection (11) if that person, with the intent to injure, defraud, or deceive any insurer: 1. Presents or causes to be presented any written or oral statement as part of, or in support of, a claim for payment or other benefit pursuant to an insurance policy or a health maintenance organization subscriber or provider contract, knowing that such statement contains any false, incomplete, or misleading information concerning any fact or thing material to such claim; 2. Prepares or makes any written or oral statement that is intended to be presented to any insurer in connection with, or in support of, any claim for payment or other benefit pursuant to an insurance policy or a health maintenance organization subscriber or provider contract, knowing that such statement contains any false, incomplete, or misleading information concerning any fact or thing material to such claim; 3. a. Knowingly presents, causes to be presented, or prepares or makes with knowledge or belief that it will be presented to any insurer, purported insurer, servicing corporation, insurance broker, or insurance agent, or any employee or agent thereof, any false, incomplete, or misleading information or written or oral statement as part of, or in support of, an application for the issuance of, or the rating of, any insurance policy, or a health maintenance organization subscriber or provider contract; or b. Knowingly conceals information concerning any fact material to such application; or 4. Knowingly presents, causes to be presented, or prepares or makes with knowledge or belief that it will be presented to any insurer a claim for payment or other benefit under a personal injury protection insurance policy if the person knows that the payee knowingly submitted a false, misleading, or fraudulent application or other document when applying for licensure as a health care clinic, seeking an exemption from licensure as a health care clinic, or demonstrating compliance with part X of chapter 400. **State:** Florida **Statute Areas:** Claims Fraud --- ### [Florida-Fraud Bureau-West's F.S.A. ¤ 626.989](https://insurancefraud.org/statutes/florida-fraud-bureau-wests-f-s-a-¤-626-989/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Investigation by department or Division of Insurance Fraud; compliance; immunity; confidential information; reports to division; division investigator’s power of arrest (1) For the purposes of this section, a person commits a “fraudulent insurance act” if the person knowingly and with intent to defraud presents, causes to be presented, or prepares with knowledge or belief that it will be presented, to or by an insurer, self-insurer, self-insurance fund, servicing corporation, purported insurer, broker, or any agent thereof, any written statement as part of, or in support of, an application for the issuance of, or the rating of, any insurance policy, or a claim for payment or other benefit pursuant to any insurance policy, which the person knows to contain materially false information concerning any fact material thereto or if the person conceals, for the purpose of misleading another, information concerning any fact material thereto. For the purposes of this section, the term “insurer” also includes any health maintenance organization and the term “insurance policy” also includes a health maintenance organization subscriber contract. 817.234. False and fraudulent insurance claims 3. a. Knowingly presents, causes to be presented, or prepares or makes with knowledge or belief that it will be presented to any insurer, purported insurer, servicing corporation, insurance broker, or insurance agent, or any employee or agent thereof, any false, incomplete, or misleading information or written or oral statement as part of, or in support of, an application for the issuance of, or the rating of, any insurance policy, or a health maintenance organization subscriber or provider contract; or b. Who knowingly conceals information concerning any fact material to such application. 817.236. False and fraudulent motor vehicle insurance application Any person who, with intent to injure, defraud, or deceive any motor vehicle insurer, including any statutorily created underwriting association or pool of motor vehicle insurers, presents or causes to be presented any written application, or written statement in support thereof, for motor vehicle insurance knowing that the application or statement contains any false, incomplete, or misleading information concerning any fact or matter material to the application commits a felony of the third degree, punishable as provided in s. 775.082, s. 775.083, or s. 775.084. **State:** Florida **Statute Areas:** Fraud Bureau --- ### [Florida-Immunity-West's F.S.A. ¤ 626.989](https://insurancefraud.org/statutes/florida-immunity-wests-f-s-a-¤-626-989/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** 4\) (c) In the absence of fraud or bad faith, a person is not subject to civil liability for libel, slander, or any other relevant tort by virtue of filing reports, without malice, or furnishing other information, without malice, required by this section or required by the department or division under the authority granted in this section, and no civil cause of action of any nature shall arise against such person: 1. For any information relating to suspected fraudulent insurance acts furnished to or received from law enforcement officials, their agents, or employees; 2. For any information relating to suspected fraudulent insurance acts furnished to or received from other persons subject to the provisions of this chapter; or 3. For any such information furnished in reports to the department, division, the National Insurance Crime Bureau, or the National Association of Insurance Commissioners. (d) In addition to the immunity granted in paragraph (c), persons identified as designated employees whose responsibilities include the investigation and disposition of claims relating to suspected fraudulent insurance acts may share information relating to persons suspected of committing fraudulent insurance acts with other designated employees employed by the same or other insurers whose responsibilities include the investigation and disposition of claims relating to fraudulent insurance acts, provided the department has been given written notice of the names and job titles of such designated employees prior to such designated employees sharing information. Unless the designated employees of the insurer act in bad faith or in reckless disregard for the rights of any insured, neither the insurer nor its designated employees are civilly liable for libel, slander, or any other relevant tort, and a civil action does not arise against the insurer or its designated employees: 1. For any information related to suspected fraudulent insurance acts provided to an insurer; or 2. For any information relating to suspected fraudulent insurance acts provided to the National Insurance Crime Bureau or the National Association of Insurance Commissioners. Provided, however, that the qualified immunity against civil liability conferred on any insurer or its designated employees shall be forfeited with respect to the exchange or publication of any defamatory information with third persons not expressly authorized by this paragraph to share in such information. (e) The Insurance Commissioner and any employee or agent of the department or division, when acting without malice and in the absence of fraud or bad faith, is not subject to civil liability for libel, slander, or any other relevant tort, and no civil cause of action of any nature exists against such person by virtue of the execution of official activities or duties of the department under this section or by virtue of the publication of any report or bulletin related to the official activities or duties of the department or division under this section. (f) This section does not abrogate or modify in any way any common-law or statutory privilege or immunity heretofore enjoyed by any person. **State:** Florida **Statute Areas:** Immunity --- ### [Florida-Insurance Fraud - Definition-West's F.S.A. ¤ 817.234](https://insurancefraud.org/statutes/florida-insurance-fraud-definition-wests-f-s-a-¤-817-234/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (1)(a) A person commits insurance fraud punishable as provided in subsection (11) if that person, with the intent to injure, defraud, or deceive any insurer: 1. Presents or causes to be presented any written or oral statement as part of, or in support of, a claim for payment or other benefit pursuant to an insurance policy or a health maintenance organization subscriber or provider contract, knowing that such statement contains any false, incomplete, or misleading information concerning any fact or thing material to such claim; 2. Prepares or makes any written or oral statement that is intended to be presented to any insurer in connection with, or in support of, any claim for payment or other benefit pursuant to an insurance policy or a health maintenance organization subscriber or provider contract, knowing that such statement contains any false, incomplete, or misleading information concerning any fact or thing material to such claim; 3. a. Knowingly presents, causes to be presented, or prepares or makes with knowledge or belief that it will be presented to any insurer, purported insurer, servicing corporation, insurance broker, or insurance agent, or any employee or agent thereof, any false, incomplete, or misleading information or written or oral statement as part of, or in support of, an application for the issuance of, or the rating of, any insurance policy, or a health maintenance organization subscriber or provider contract; or b. Knowingly conceals information concerning any fact material to such application; or 4. Knowingly presents, causes to be presented, or prepares or makes with knowledge or belief that it will be presented to any insurer a claim for payment or other benefit under a personal injury protection insurance policy if the person knows that the payee knowingly submitted a false, misleading, or fraudulent application or other document when applying for licensure as a health care clinic, seeking an exemption from licensure as a health care clinic, or demonstrating compliance with part X of chapter 400. (b) All claims and application forms must contain a statement that is approved by the Office of Insurance Regulation of the Financial Services Commission which clearly states in substance the following: “Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.” This paragraph does not apply to reinsurance contracts, reinsurance agreements, or reinsurance claims transactions. (2)(a) Any physician licensed under chapter 458, osteopathic physician licensed under chapter 459, chiropractic physician licensed under chapter 460, or other practitioner licensed under the laws of this state who knowingly and willfully assists, conspires with, or urges any insured party to fraudulently violate any of the provisions of this section or part XI of chapter 627, or any person who, due to such assistance, conspiracy, or urging by said physician, osteopathic physician, chiropractic physician, or practitioner, knowingly and willfully benefits from the proceeds derived from the use of such fraud, commits insurance fraud, punishable as provided in subsection (11). In the event that a physician, osteopathic physician, chiropractic physician, or practitioner is adjudicated guilty of a violation of this section, the Board of Medicine as set forth in chapter 458, the Board of Osteopathic Medicine as set forth in chapter 459, the Board of Chiropractic Medicine as set forth in chapter 460, or other appropriate licensing authority shall hold an administrative hearing to consider the imposition of administrative sanctions as provided by law against said physician, osteopathic physician, chiropractic physician, or practitioner. (b) In addition to any other provision of law, systematic upcoding by a provider, as defined in s. 641.19(14), with the intent to obtain reimbursement otherwise not due from an insurer is punishable as provided in s. 641.52(5). (3) Any attorney who knowingly and willfully assists, conspires with, or urges any claimant to fraudulently violate any of the provisions of this section or part XI of chapter 627, or any person who, due to such assistance, conspiracy, or urging on such attorney’s part, knowingly and willfully benefits from the proceeds derived from the use of such fraud, commits insurance fraud, punishable as provided in subsection (11). (4) Any person or governmental unit licensed under chapter 395 to maintain or operate a hospital, and any administrator or employee of any such hospital, who knowingly and willfully allows the use of the facilities of said hospital by an insured party in a scheme or conspiracy to fraudulently violate any of the provisions of this section or part XI of chapter 627 commits insurance fraud, punishable as provided in subsection (11). Any adjudication of guilt for a violation of this subsection, or the use of business practices demonstrating a pattern indicating that the spirit of the law set forth in this section or part XI of chapter 627 is not being followed, shall be grounds for suspension or revocation of the license to operate the hospital or the imposition of an administrative penalty of up to $5,000 by the licensing agency, as set forth in chapter 395. (5) Any insurer damaged as a result of a violation of any provision of this section when there has been a criminal adjudication of guilt shall have a cause of action to recover compensatory damages, plus all reasonable investigation and litigation expenses, including attorneys’ fees, at the trial and appellate courts. (6) For the purposes of this section, “statement” includes, but is not limited to, any notice, statement, proof of loss, bill of lading, invoice, account, estimate of property damages, bill for services, diagnosis, prescription, hospital or doctor records, X ray, test result, or other evidence of loss, injury, or expense. (7)(a) It shall constitute a material omission and insurance fraud, punishable as provided in subsection (11), for any service provider, other than a hospital, to engage in a general business practice of billing amounts as its usual and customary charge, if such provider has agreed with the insured or intends to waive deductibles or copayments, or does not for any other reason intend to collect the total amount of such charge. With respect to a determination as to whether a service provider has engaged in such general **State:** Florida **Statute Areas:** Insurance Fraud - Definition --- ### [Florida-Licensing Board Notification-West's F.S.A. ¤ 626.989](https://insurancefraud.org/statutes/florida-licensing-board-notification-wests-f-s-a-¤-626-989/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Investigation by department or Division of Insurance Fraud; compliance; immunity; confidential information; reports to division; division investigator’s power of arrest (1) For the purposes of this section, a person commits a “fraudulent insurance act” if the person knowingly and with intent to defraud presents, causes to be presented, or prepares with knowledge or belief that it will be presented, to or by an insurer, self-insurer, self-insurance fund, servicing corporation, purported insurer, broker, or any agent thereof, any written statement as part of, or in support of, an application for the issuance of, or the rating of, any insurance policy, or a claim for payment or other benefit pursuant to any insurance policy, which the person knows to contain materially false information concerning any fact material thereto or if the person conceals, for the purpose of misleading another, information concerning any fact material thereto. For the purposes of this section, the term “insurer” also includes any health maintenance organization and the term “insurance policy” also includes a health maintenance organization subscriber contract. 817.234. False and fraudulent insurance claims 3. a. Knowingly presents, causes to be presented, or prepares or makes with knowledge or belief that it will be presented to any insurer, purported insurer, servicing corporation, insurance broker, or insurance agent, or any employee or agent thereof, any false, incomplete, or misleading information or written or oral statement as part of, or in support of, an application for the issuance of, or the rating of, any insurance policy, or a health maintenance organization subscriber or provider contract; or b. Who knowingly conceals information concerning any fact material to such application. 817.236. False and fraudulent motor vehicle insurance application Any person who, with intent to injure, defraud, or deceive any motor vehicle insurer, including any statutorily created underwriting association or pool of motor vehicle insurers, presents or causes to be presented any written application, or written statement in support thereof, for motor vehicle insurance knowing that the application or statement contains any false, incomplete, or misleading information concerning any fact or matter material to the application commits a felony of the third degree, punishable as provided in s. 775.082, s. 775.083, or s. 775.084. **State:** Florida --- ### [Florida-Mandatory Restitution-West's F.S.A. ¤ 817.234](https://insurancefraud.org/statutes/florida-mandatory-restitution-wests-f-s-a-¤-817-234/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (5) Any insurer damaged as a result of a violation of any provision of this section when there has been a criminal adjudication of guilt shall have a cause of action to recover compensatory damages, plus all reasonable investigation and litigation expenses, including attorneys’ fees, at the trial and appellate courts. **State:** Florida **Statute Areas:** Mandatory Restitution --- ### [Florida-Placing Bogus Coverage-West's F.S.A. ¤ 817.234*](https://insurancefraud.org/statutes/florida-placing-bogus-coverage-wests-f-s-a-¤-817-234/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (1)(a) A person commits insurance fraud punishable as provided in subsection (11) if that person, with the intent to injure, defraud, or deceive any insurer: 1. Presents or causes to be presented any written or oral statement as part of, or in support of, a claim for payment or other benefit pursuant to an insurance policy or a health maintenance organization subscriber or provider contract, knowing that such statement contains any false, incomplete, or misleading information concerning any fact or thing material to such claim; 2. Prepares or makes any written or oral statement that is intended to be presented to any insurer in connection with, or in support of, any claim for payment or other benefit pursuant to an insurance policy or a health maintenance organization subscriber or provider contract, knowing that such statement contains any false, incomplete, or misleading information concerning any fact or thing material to such claim; 3. a. Knowingly presents, causes to be presented, or prepares or makes with knowledge or belief that it will be presented to any insurer, purported insurer, servicing corporation, insurance broker, or insurance agent, or any employee or agent thereof, any false, incomplete, or misleading information or written or oral statement as part of, or in support of, an application for the issuance of, or the rating of, any insurance policy, or a health maintenance organization subscriber or provider contract; or b. Knowingly conceals information concerning any fact material to such application; or 4. Knowingly presents, causes to be presented, or prepares or makes with knowledge or belief that it will be presented to any insurer a claim for payment or other benefit under a personal injury protection insurance policy if the person knows that the payee knowingly submitted a false, misleading, or fraudulent application or other document when applying for licensure as a health care clinic, seeking an exemption from licensure as a health care clinic, or demonstrating compliance with part X of chapter 400. **State:** Florida --- ### [Florida-Practitioner Penalites-West's F.S.A. ¤ 817.234](https://insurancefraud.org/statutes/florida-practitioner-penalites-wests-f-s-a-¤-817-234/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (2)(a) Any physician licensed under chapter 458, osteopathic physician licensed under chapter 459, chiropractic physician licensed under chapter 460, or other practitioner licensed under the laws of this state who knowingly and willfully assists, conspires with, or urges any insured party to fraudulently violate any of the provisions of this section or part XI of chapter 627, or any person who, due to such assistance, conspiracy, or urging by said physician, osteopathic physician, chiropractic physician, or practitioner, knowingly and willfully benefits from the proceeds derived from the use of such fraud, commits insurance fraud, punishable as provided in subsection (11). In the event that a physician, osteopathic physician, chiropractic physician, or practitioner is adjudicated guilty of a violation of this section, the Board of Medicine as set forth in chapter 458, the Board of Osteopathic Medicine as set forth in chapter 459, the Board of Chiropractic Medicine as set forth in chapter 460, or other appropriate licensing authority shall hold an administrative hearing to consider the imposition of administrative sanctions as provided by law against said physician, osteopathic physician, chiropractic physician, or practitioner. (b) In addition to any other provision of law, systematic upcoding by a provider, as defined in s. 641.19(14), with the intent to obtain reimbursement otherwise not due from an insurer is punishable as provided in s. 641.52(5). (3) Any attorney who knowingly and willfully assists, conspires with, or urges any claimant to fraudulently violate any of the provisions of this section or part XI of chapter 627, or any person who, due to such assistance, conspiracy, or urging on such attorney’s part, knowingly and willfully benefits from the proceeds derived from the use of such fraud, commits insurance fraud, punishable as provided in subsection (11). (4) Any person or governmental unit licensed under chapter 395 to maintain or operate a hospital, and any administrator or employee of any such hospital, who knowingly and willfully allows the use of the facilities of said hospital by an insured party in a scheme or conspiracy to fraudulently violate any of the provisions of this section or part XI of chapter 627 commits insurance fraud, punishable as provided in subsection (11). Any adjudication of guilt for a violation of this subsection, or the use of business practices demonstrating a pattern indicating that the spirit of the law set forth in this section or part XI of chapter 627 is not being followed, shall be grounds for suspension or revocation of the license to operate the hospital or the imposition of an administrative penalty of up to $5,000 by the licensing agency, as set forth in chapter 395. **State:** Florida **Statute Areas:** Practitioner Penalites --- ### [Florida-Range of Criminal Penalties-West's F.S.A. ¤ 817.234](https://insurancefraud.org/statutes/florida-range-of-criminal-penalties-wests-f-s-a-¤-817-234/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (11) If the value of any property involved in a violation of this section: (a) Is less than $20,000, the offender commits a felony of the third degree, punishable as provided in s. 775.082, s. 775.083, or s. 775.084. (b) Is $20,000 or more, but less than $100,000, the offender commits a felony of the second degree, punishable as provided in s. 775.082, s. 775.083, or s. 775.084. (c) Is $100,000 or more, the offender commits a felony of the first degree, punishable as provided in s. 775.082, s. 775.083, or s. 775.084. **State:** Florida **Statute Areas:** Range of Criminal Penalties --- ### [Florida-Range of Civil Penalties-West's F.S.A. ¤ 817.234](https://insurancefraud.org/statutes/florida-range-of-civil-penalties-wests-f-s-a-¤-817-234/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (12) In addition to any criminal liability, a person convicted of violating any provision of this section for the purpose of receiving insurance proceeds from a motor vehicle insurance contract is subject to a civil penalty. (a) Except for a violation of subsection (9), the civil penalty shall be: 1. A fine up to $5,000 for a first offense. 2. A fine greater than $5,000, but not to exceed $10,000, for a second offense. 3. A fine greater than $10,000, but not to exceed $15,000, for a third or subsequent offense. (b) The civil penalty for a violation of subsection (9) must be at least $15,000 but may not exceed $50,000. (c) The civil penalty shall be paid to the Insurance Regulatory Trust Fund within the Department of Financial Services and used by the department for the investigation and prosecution of insurance fraud. **State:** Florida **Statute Areas:** Range of Civil Penalties --- ### [Florida-Rating of an Insurance Policy-West's F.S.A. ¤ 627.062](https://insurancefraud.org/statutes/florida-rating-of-an-insurance-policy-wests-f-s-a-¤-627-062/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (1) The rates for all classes of insurance to which the provisions of this part are applicable may not be excessive, inadequate, or unfairly discriminatory. (2) As to all such classes of insurance: (a) Insurers or rating organizations shall establish and use rates, rating schedules, or rating manuals that allow the insurer a reasonable rate of return on the classes of insurance written in this state. A copy of rates, rating schedules, rating manuals, premium credits or discount schedules, and surcharge schedules, and changes thereto, must be filed with the office under one of the following procedures: 1. If the filing is made at least 90 days before the proposed effective date and is not implemented during the office’s review of the filing and any proceeding and judicial review, such filing is considered a “file and use” filing. In such case, the office shall finalize its review by issuance of a notice of intent to approve or a notice of intent to disapprove within 90 days after receipt of the filing. The notice of intent to approve and the notice of intent to disapprove constitute agency action for purposes of the Administrative Procedure Act. Requests for supporting information, requests for mathematical or mechanical corrections, or notification to the insurer by the office of its preliminary findings does not toll the 90-day period during any such proceedings and subsequent judicial review. The rate shall be deemed approved if the office does not issue a notice of intent to approve or a notice of intent to disapprove within 90 days after receipt of the filing. 2. If the filing is not made in accordance with subparagraph 1., such filing must be made as soon as practicable, but within 30 days after the effective date, and is considered a “use and file” filing. An insurer making a “use and file” filing is potentially subject to an order by the office to return to policyholders those portions of rates found to be excessive, as provided in paragraph (h). 3. For all property insurance filings made or submitted after January 25, 2007, but before May 1, 2012, an insurer seeking a rate that is greater than the rate most recently approved by the office shall make a “file and use” filing. For purposes of this subparagraph, motor vehicle collision and comprehensive coverages are not considered property coverages. (b) Upon receiving a rate filing, the office shall review the filing to determine if a rate is excessive, inadequate, or unfairly discriminatory. In making that determination, the office shall, in accordance with generally accepted and reasonable actuarial techniques, consider the following factors: 1. Past and prospective loss experience within and without this state. 2. Past and prospective expenses. 3. The degree of competition among insurers for the risk insured. 4. Investment income reasonably expected by the insurer, consistent with the insurer’s investment practices, from investable premiums anticipated in the filing, plus any other expected income from currently invested assets representing the amount expected on unearned premium reserves and loss reserves. The commission may adopt rules using reasonable techniques of actuarial science and economics to specify the manner in which insurers calculate investment income attributable to classes of insurance written in this state and the manner in which investment income is used to calculate insurance rates. Such manner must contemplate allowances for an underwriting profit factor and full consideration of investment income that produces a reasonable rate of return; however, investment income from invested surplus may not be considered. 5. The reasonableness of the judgment reflected in the filing. 6. Dividends, savings, or unabsorbed premium deposits allowed or returned to policyholders, members, or subscribers in this state. 7. The adequacy of loss reserves. 8. The cost of reinsurance. The office may not disapprove a rate as excessive solely due to the insurer having obtained catastrophic reinsurance to cover the insurer’s estimated 250-year probable maximum loss or any lower level of loss. 9. Trend factors, including trends in actual losses per insured unit for the insurer making the filing. 10. Conflagration and catastrophe hazards, if applicable. 11. Projected hurricane losses, if applicable, which must be estimated using a model or method found to be acceptable or reliable by the Florida Commission on Hurricane Loss Projection Methodology, and as further provided in s. 627.0628. 12. Projected flood losses for personal residential property insurance, if applicable, which may be estimated using a model or method, or a straight average of model results or output ranges, independently found to be acceptable or reliable by the Florida Commission on Hurricane Loss Projection Methodology and as further provided in s. 627.0628. 13. A reasonable margin for underwriting profit and contingencies. 14. The cost of medical services, if applicable. 15. Other relevant factors that affect the frequency or severity of claims or expenses. (c) In the case of fire insurance rates, consideration must be given to the availability of water supplies and the experience of the fire insurance business during a period of not less than the most recent 5-year period for which such experience is available. (d) If conflagration or catastrophe hazards are considered by an insurer in its rates or rating plan, including surcharges and discounts, the insurer shall establish a reserve for that portion of the premium allocated to such hazard and maintain the premium in a catastrophe reserve. Removal of such premiums from the reserve for purposes other than paying claims associated with a catastrophe or purchasing reinsurance for catastrophes must be approved by the office. Any ceding commission received by an insurer purchasing reinsurance for catastrophes must be placed in the catastrophe reserve. (e) After consideration of the rate factors provided in paragraphs (b), (c), and (d), the office may find a rate to be excessive, inadequate, or unfairly discriminatory based upon the following standards: 1. Rates shall be deemed excessive if they are likely to produce a profit from Florida business which is unreasonably high in relation to the risk involved in the class of business or if expenses are unreasonably high in relation to services rendered. 2. Rates shall be deemed excessive if, among other things, the rate structure established by a stock insurance company provides for replenishment of surpluses from premiums, if the replenishment is attributable to investment losses. 3. Rates shall be deemed inadequate if they are clearly insufficient, together with the investment income attributable to them, to sustain projected losses and expenses in the class of business to which they apply. 4. A rating plan, including discounts, credits, or surcharges, shall be deemed unfairly discriminatory if it fails to clearly and equitably reflect consideration of the policyholder’s participation in a risk management program adopted pursuant to s. 627.0625. 5. A rate shall be deemed inadequate as to the premium charged to a risk or group of risks if discounts or credits are allowed which exceed a reasonable reflection of expense savings and reasonably expected loss experience from the risk or group of risks. 6. A rate shall be deemed unfairly discriminatory as to a risk or group of risks if the application of premium discounts, credits, or surcharges among such risks does not bear a reasonable relationship to the expected loss and expense experience among the various risks. (f) In reviewing a rate filing, the office may require the insurer to provide, at the insurer’s expense, all information necessary to evaluate the condition of the company and the reasonableness of the filing according to the criteria enumerated in this section. (g) The office may at any time review a rate, rating schedule, rating manual, or rate change; the pertinent records of the insurer; and market conditions. If the office finds on a preliminary basis that a rate may be excessive, inadequate, or unfairly discriminatory, the office shall initiate proceedings to disapprove the rate and shall so notify the insurer. However, the office may not disapprove as excessive any rate for which it has given final approval or which has been deemed approved for 1 year after the effective date of the filing unless the office finds that a material misrepresentation or material error was made by the insurer or was contained in the filing. Upon being notified, the insurer or rating organization shall, within 60 days, file with the office all information that, in the belief of the insurer or organization, proves the reasonableness, adequacy, and fairness of the rate or rate change. The office shall issue a notice of intent to approve or a notice of intent to disapprove pursuant to paragraph (a) within 90 days after receipt of the insurer’s initial response. In such instances and in any administrative proceeding relating to the legality of the rate, the insurer or rating organization shall carry the burden of proof by a preponderance of the evidence to show that the rate is not excessive, inadequate, or unfairly discriminatory. After the office notifies an insurer that a rate may be excessive, inadequate, or unfairly discriminatory, unless the office withdraws the notification, the insurer may not alter the rate except to conform to the office’s notice until the earlier of 120 days after the date the notification was provided or 180 days after the date of implementing the rate. The office, subject to chapter 120, may disapprove without the 60-day notification any rate increase filed by an insurer within the prohibited time period or during the time that the legality of the increased rate is being contested. (h) If the office finds that a rate or rate change is excessive, inadequate, or unfairly discriminatory, the office shall issue an order of disapproval specifying that a new rate or rate schedule, which responds to the findings of the office, be filed by the insurer. The office shall further order, for any “use and file” filing made in accordance with subparagraph (a)2., that premiums charged each policyholder constituting the portion of the rate above that which was actuarially justified be returned to the policyholder in the form of a credit or refund. If the office finds that an insurer’s rate or rate change is inadequate, the new rate or rate schedule filed with the office in response to such a finding is applicable only to new or renewal business of the insurer written on or after the effective date of the responsive filing. (i) Except as otherwise specifically provided in this chapter, for property and casualty insurance the office may not directly or indirectly: 1. Prohibit any insurer, including any residual market plan or joint underwriting association, from paying acquisition costs based on the full amount of premium, as defined in s. 627.403, applicable to any policy, or prohibit any such insurer from including the full amount of acquisition costs in a rate filing; or 2. Impede, abridge, or otherwise compromise an insurer’s right to acquire policyholders, advertise, or appoint agents, including the calculation, manner, or amount of such agent commissions, if any. (j) With respect to residential property insurance rate filings, the rate filing must account for mitigation measures undertaken by policyholders to reduce hurricane losses. (k) 1. A residential property insurer may make a separate filing limited solely to an adjustment of its rates for reinsurance, the cost of financing products used as a replacement for reinsurance, financing costs incurred in the purchase of reinsurance, and the actual cost paid due to the application of the cash build-up factor pursuant to s. 215.555(5)(b) if the insurer: a. Elects to purchase financing products such as a liquidity instrument or line of credit, in which case the cost included in filing for the liquidity instrument or line of credit may not result in a premium increase exceeding 3 percent for any individual policyholder. All costs contained in the filing may not result in an overall premium increase of more than 15 percent for any individual policyholder. b. Includes in the filing a copy of all of its reinsurance, liquidity instrument, or line of credit contracts; proof of the billing or payment for the contracts; and the calculation upon which the proposed rate change is based demonstrating that the costs meet the criteria of this section. 2. An insurer that purchases reinsurance or financing products from an affiliated company may make a separate filing only if the costs for such reinsurance or financing products are charged at or below charges made for comparable coverage by nonaffiliated reinsurers or financial entities making such coverage or financing products available in this state. 3. An insurer may make only one filing per 12-month period under this paragraph. 4. An insurer that elects to implement a rate change under this paragraph must file its rate filing with the office at least 45 days before the effe **State:** Florida --- ### [Florida-Unauthorized Entities-West's F.S.A. ¤ 624.401](https://insurancefraud.org/statutes/florida-unauthorized-entities-wests-f-s-a-¤-624-401/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (1) No person shall act as an insurer, and no insurer or its agents, attorneys, subscribers, or representatives shall directly or indirectly transact insurance, in this state except as authorized by a subsisting certificate of authority issued to the insurer by the office, except as to such transactions as are expressly otherwise provided for in this code. (2) No insurer shall from offices or by personnel or facilities located in this state solicit insurance applications or otherwise transact insurance in another state or country unless it holds a subsisting certificate of authority issued to it by the office authorizing it to transact the same kind or kinds of insurance in this state. (3) This state hereby preempts the field of regulating insurers and their agents and representatives; and no county, city, municipality, district, school district, or political subdivision shall require of any insurer, agent, or representative regulated under this code any authorization, permit, or registration of any kind for conducting transactions lawful under the authority granted by the state under this code. (4)(a) Any person who acts as an insurer, transacts insurance, or otherwise engages in insurance activities in this state without a certificate of authority in violation of this section commits a felony of the third degree, punishable as provided in s. 775.082, s. 775.083, or s. 775.084. (b) However, any person acting as an insurer without a valid certificate of authority who violates this section commits insurance fraud, punishable as provided in this paragraph. If the amount of any insurance premium collected with respect to any violation of this section: 1. Is less than $20,000, the offender commits a felony of the third degree, punishable as provided in s. 775.082, s. 775.083, or s. 775.084, and the offender shall be sentenced to a minimum term of imprisonment of 1 year. 2. Is $20,000 or more, but less than $100,000, the offender commits a felony of the second degree, punishable as provided in s. 775.082, s. 775.083, or s. 775.084, and the offender shall be sentenced to a minimum term of imprisonment of 18 months. 3. Is $100,000 or more, the offender commits a felony of the first degree, punishable as provided in s. 775.082, s. 775.083, or s. 775.084, and the offender shall be sentenced to a minimum term of imprisonment of 2 years. **State:** Florida --- ### [District of Columbia-Anti-Runner Provisions-DC ST ¤ 22-3225.02](https://insurancefraud.org/statutes/district-of-columbia-anti-runner-provisions-dc-st-¤-22-3225-02/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** A person commits the offense of insurance fraud in the first degree if that person knowingly engages in the following conduct with the intent to defraud or to fraudulently obtain property of another and thereby obtains property of another or causes another to lose property and the value of the property obtained or lost is $1,000 or more: (1) Presenting false information or knowingly conceals information regarding a material fact in any of the following transactions:(6) Employing or using any other person or acting as the agent of any other person to procure a client, patient, or customer for the purpose of falsely or fraudulently obtaining benefits under a contract of insurance or asserting a false or fraudulent claim against an insured or insurer. **State:** District of Columbia **Statute Areas:** Anti-Runner Provisions --- ### [District of Columbia-Claims Fraud-DC ST ¤ 22-3225.02](https://insurancefraud.org/statutes/district-of-columbia-claims-fraud-dc-st-¤-22-3225-02/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** A person commits the offense of insurance fraud in the first degree if that person knowingly engages in the following conduct with the intent to defraud or to fraudulently obtain property of another and thereby obtains property of another or causes another to lose property and the value of the property obtained or lost is $1,000 or more: (1) Presenting false information or knowingly conceals information regarding a material fact in any of the following transactions: (B) Claim for payment or benefit pursuant to an insurance policy or reinsurance contract; **State:** District of Columbia **Statute Areas:** Claims Fraud --- ### [District of Columbia-Failing to Remit Premium-DC ST ¤ 22-3225.02](https://insurancefraud.org/statutes/district-of-columbia-failing-to-remit-premium-dc-st-¤-22-3225-02/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** A person commits the offense of insurance fraud in the first degree if that person knowingly engages in the following conduct with the intent to defraud or to fraudulently obtain property of another and thereby obtains property of another or causes another to lose property and the value of the property obtained or lost is $1,000 or more: (1) Presenting false information or knowingly conceals information regarding a material fact in any of the following transactions: (C) Premiums paid on an insurance policy or reinsurance contract; (E) Application used in a premium finance transaction; **State:** District of Columbia --- ### [District of Columbia-Fraud Bureau-DC ST ¤ 31-103](https://insurancefraud.org/statutes/district-of-columbia-fraud-bureau-dc-st-¤-31-103/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) The functions and duties contained and referenced herein are transferred to the Department and shall be performed by the following major organizational components of the Department. (1) All duties and responsibilities in respect to the regulation of life and health and property and casualty insurance, insurers, and health maintenance organizations that heretofore have been given to the Mayor, the Superintendent of Insurance, or the Insurance Administrator, by virtue of various District of Columbia laws, shall be assumed by the Commissioner of Insurance and Securities who shall exercise those regulatory responsibilities through the Insurance Bureau. (2) All functions and duties assigned to the Public Service Commission in Chapter 36 of Title 3 and Chapter 37 of Title 3, shall be assumed by the Commissioner who shall exercise those regulatory responsibilities through the Securities and Banking Bureau. (3) Pursuant to ¤¤ 26-551.03 and 26-551.05, the Commissioner, through the Securities and Banking Bureau, shall administer the District of Columbia Banking Code, as defined in ¤ 26-551.02(14). (b) The Mayor, at his or her discretion, may transfer the regulatory functions and duties of other executive offices and agencies to the Department. **State:** District of Columbia **Statute Areas:** Fraud Bureau --- ### [District of Columbia-Immunity-DC ST ¤ 22-3225.13](https://insurancefraud.org/statutes/district-of-columbia-immunity-dc-st-¤-22-3225-13/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** No person shall be subject to civil liability or criminal prosecution for reporting any suspected insurance fraud if: (1) The report was made to: (A) The Department of Insurance, Securities, and Banking, the Metropolitan Police Department, or any other law enforcement authority; or (B) Any insurer, insurance agent, or other person who collects, reviews, or analyzes information concerning insurance fraud; and (2) The person or entity reporting the suspected fraud acted without malice when making the report. **State:** District of Columbia **Statute Areas:** Immunity --- ### [District of Columbia-Insurance Fraud - Definition-](https://insurancefraud.org/statutes/district-of-columbia-insurance-fraud-definition/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** A person commits the offense of insurance fraud in the first degree if that person knowingly engages in the following conduct with the intent to defraud or to fraudulently obtain property of another and thereby obtains property of another or causes another to lose property and the value of the property obtained or lost is $1,000 or more: (1) Presenting false information or knowingly conceals information regarding a material fact in any of the following transactions: (A) Application for, rating of, or renewal of an insurance policy or reinsurance contract; (B) Claim for payment or benefit pursuant to an insurance policy or reinsurance contract; (C) Premiums paid on an insurance policy or reinsurance contract; (D) Payment made in accordance with the terms of an insurance policy or reinsurance contract; (E) Application used in a premium finance transaction; (F) Solicitation for sale of an insurance policy; (G) Application for a license or certificate of authority filed with the Commissioner or the chief insurance regulatory official of another jurisdiction; (H) Financial statement or condition of any insurer or reinsurer; (I) Acquisition, formation, merger, affiliation, reconsolidation, dissolution, or withdrawal from one or more lines of insurance or reinsurance in the District by an insurer or reinsurer; (J) Issuance of written evidence of insurance; or (K) Application for reinstatement of an insurance policy; (2) Soliciting or accepting insurance or renewal of insurance by or for an insurer which the person knows is insolvent or has a strong likelihood of insolvency; (3) Removal or tampering with the records of transaction, documentation, and other material assets of an insurer from the insurer or from the Department of Insurance and Securities Regulation; (4) Diversion, misappropriation, conversion, or embezzlement of funds of an insurer, an insured, claimant or applicant regarding any of the following: (A) Insurance transaction; (B) Other insurance business activities by an insurer or insurance professional; or (C) Acquisition, formation, merger, affiliation or dissolution of an insurer. (5) Transaction of the business of insurance in violation of laws requiring a license, certificate of authority, or other legal authority for the transaction of the business of insurance; or (6) Employing or using any other person or acting as the agent of any other person to procure a client, patient, or customer for the purpose of falsely or fraudulently obtaining benefits under a contract of insurance or asserting a false or fraudulent claim against an insured or insurer.\*\*\* A person commits the offense of insurance fraud in the second degree if that person knowingly engages in conduct specified in ¤ 22-3225.02 with the intent to defraud or to fraudulently obtain property of another and the value of the property which is sought to be obtained is $1,000 or more.\*\*\*A person commits the offense of misdemeanor insurance fraud if that person knowingly engages in conduct specified in ¤ 22-3225.02 with the intent to defraud or to fraudulently obtain property of another. **State:** District of Columbia **Statute Areas:** Insurance Fraud - Definition --- ### [District of Columbia-Licensing Board Notification-DC ST ¤ 22-3225.08](https://insurancefraud.org/statutes/district-of-columbia-licensing-board-notification-dc-st-¤-22-3225-08/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) Based upon a reasonable belief, an insurer, insurance professional, and any other pertinent person, shall report to the Metropolitan Police Department or the Department of Insurance, Securities, and Banking, actions that may constitute the commission of insurance fraud, and assist in the investigation of insurance fraud by reasonably providing information when required by an investigating authority. (b) The Commissioner may investigate suspected fraudulent insurance acts and persons engaged in the business of insurance. Nothing in this subchapter shall preempt the authority or relieve the duty of other law enforcement or regulatory agencies to investigate, examine, and prosecute suspected violations of law. (c) An insurer, insurance professional, or any other pertinent person who fails to reasonably assist the investigation of an insurance fraud or fails to report an insurance fraud, and who is injured by that insurance fraud, shall be estopped from receiving restitution as provided in ¤ 22-3225.05. (d) Any information, documentation, or other evidence provided under this section by an insurer, its employees, producers, or agents, or by any other person, to the Department of Insurance, Securities, and Banking, the Metropolitan Police Department, or any other law enforcement agency in connection with any investigation of suspected fraud is not subject to public inspection as long as the Commissioner or law enforcement agency deems the withholding to be necessary to complete an investigation of the suspected fraud or to protect the person or entity investigated from unwarranted injury. **State:** District of Columbia --- ### [District of Columbia-Looting & diverting-DC ST ¤ 22-3225.02](https://insurancefraud.org/statutes/district-of-columbia-looting-diverting-dc-st-¤-22-3225-02/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** A person commits the offense of insurance fraud in the first degree if that person knowingly engages in the following conduct with the intent to defraud or to fraudulently obtain property of another and thereby obtains property of another or causes another to lose property and the value of the property obtained or lost is $1,000 or more: (4) Diversion, misappropriation, conversion, or embezzlement of funds of an insurer, an insured, claimant or applicant regarding any of the following: (A) Insurance transaction; (B) Other insurance business activities by an insurer or insurance professional; or (C) Acquisition, formation, merger, affiliation or dissolution of an insurer. **State:** District of Columbia --- ### [District of Columbia-Mandatory Restitution-DC ST ¤ 22-3225.05](https://insurancefraud.org/statutes/district-of-columbia-mandatory-restitution-dc-st-¤-22-3225-05/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) In addition to the penalties provided under ¤ 22-3225.04, a person convicted under this subchapter shall make monetary restitution for any loss caused by the offense. The court shall determine the form and method of payment which, if by installment, shall not exceed 5 years. (b) Any person, including the District, injured as the result of an insurance fraud in the first degree may bring suit in the appropriate court to recover ordinary damages including attorney’s fees and other costs and punitive damages which shall not be less than $500 nor more than $50,000. Except where punitive damages are sought, the court shall award treble damages where the offense is proven by clear and convincing evidence to be in accordance with an established pattern or practice. (c) Notwithstanding any action that may be brought by the United States Attorney’s office to recoup its costs in prosecuting these cases, the Corporation Counsel may bring a civil suit against any person convicted under this subchapter in order to recover investigation and prosecution-related costs incurred by the District. (d) A suit under subsection (b) of this section must be filed within 3 years of the act constituting the offense or within 3 years of the time the plaintiff discovered or with reasonable diligence could have discovered the act, whichever is later. This 3 year statute of limitations shall not apply to the District. (e) Remedies provided in this section shall be exclusive and may not be claimed in conjunction with any other remedies available under the law. **State:** District of Columbia **Statute Areas:** Mandatory Restitution --- ### [District of Columbia-Placing Bogus Coverage-DC ST ¤ 22-3225.02*](https://insurancefraud.org/statutes/district-of-columbia-placing-bogus-coverage-dc-st-¤-22-3225-02/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** A person commits the offense of insurance fraud in the first degree if that person knowingly engages in the following conduct with the intent to defraud or to fraudulently obtain property of another and thereby obtains property of another or causes another to lose property and the value of the property obtained or lost is $1,000 or more: (1) Presenting false information or knowingly conceals information regarding a material fact in any of the following transactions: (A) Application for, rating of, or renewal of an insurance policy or reinsurance contract; (B) Claim for payment or benefit pursuant to an insurance policy or reinsurance contract; (C) Premiums paid on an insurance policy or reinsurance contract; (D) Payment made in accordance with the terms of an insurance policy or reinsurance contract; (E) Application used in a premium finance transaction; (F) Solicitation for sale of an insurance policy; (G) Application for a license or certificate of authority filed with the Commissioner or the chief insurance regulatory official of another jurisdiction; (H) Financial statement or condition of any insurer or reinsurer; (I) Acquisition, formation, merger, affiliation, reconsolidation, dissolution, or withdrawal from one or more lines of insurance or reinsurance in the District by an insurer or reinsurer; (J) Issuance of written evidence of insurance; or (K) Application for reinstatement of an insurance policy; (2) Soliciting or accepting insurance or renewal of insurance by or for an insurer which the person knows is insolvent or has a strong likelihood of insolvency; (3) Removal or tampering with the records of transaction, documentation, and other material assets of an insurer from the insurer or from the Department of Insurance and Securities Regulation; (4) Diversion, misappropriation, conversion, or embezzlement of funds of an insurer, an insured, claimant or applicant regarding any of the following: (A) Insurance transaction; (B) Other insurance business activities by an insurer or insurance professional; or (C) Acquisition, formation, merger, affiliation or dissolution of an insurer. (5) Transaction of the business of insurance in violation of laws requiring a license, certificate of authority, or other legal authority for the transaction of the business of insurance; or (6) Employing or using any other person or acting as the agent of any other person to procure a client, patient, or customer for the purpose of falsely or fraudulently obtaining benefits under a contract of insurance or asserting a false or fraudulent claim against an insured or insurer **State:** District of Columbia --- ### [District of Columbia-Practitioner Penalites-DC ST ¤ 22-3225.07](https://insurancefraud.org/statutes/district-of-columbia-practitioner-penalites-dc-st-¤-22-3225-07/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) Notwithstanding any other provisions of law, the offenses of insurance fraud in the first degree or the second degree shall be deemed a crime of moral turpitude for the purposes of professional or trade license. (b) The Commissioner, court, or prosecutor shall notify the appropriate licensing authority, and the person who is injured by the offense may notify the appropriate licensing authority of any conviction. **State:** District of Columbia **Statute Areas:** Practitioner Penalites --- ### [District of Columbia-Premium Fraud-DC ST ¤ 22-3225.02](https://insurancefraud.org/statutes/district-of-columbia-premium-fraud-dc-st-¤-22-3225-02/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** A person commits the offense of insurance fraud in the first degree if that person knowingly engages in the following conduct with the intent to defraud or to fraudulently obtain property of another and thereby obtains property of another or causes another to lose property and the value of the property obtained or lost is $1,000 or more: (1) Presenting false information or knowingly conceals information regarding a material fact in any of the following transactions:(C) Premiums paid on an insurance policy or reinsurance contract; **State:** District of Columbia **Statute Areas:** Premium Fraud --- ### [District of Columbia-Range of Criminal Penalties-DC ST ¤ 22-3225.04; DC ST ¤ 22-3571.01](https://insurancefraud.org/statutes/district-of-columbia-range-of-criminal-penalties-dc-st-¤-22-3225-04-dc-st-¤-22-3571-01/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) Any person convicted of insurance fraud in the first degree shall be fined not more than the amount set forth in ¤ 22-3571.01 or imprisoned for not more than 15 years, or both. (b)(1) Except as provided in paragraph (2) of this subsection, any person convicted of insurance fraud in the second degree shall be fined not more than the amount set forth in ¤ 22-3571.01 or imprisoned for not more than 5 years, or both. (2) Any person convicted of insurance fraud in the second degree who has been convicted previously of insurance fraud pursuant to ¤ 22-3225.02 or ¤ 22-3225.03, or a felony conviction based on similar grounds in any other jurisdiction, shall be fined not more than the amount set forth in ¤ 22-3571.01 or imprisoned for not more than 10 years, or both. (c) Any person convicted of misdemeanor insurance fraud shall be fined not more than the amount set forth in ¤ 22-3571.01 or imprisoned for not more than 180 days, or both. (d) A person convicted of a felony violation of this subchapter shall be disqualified from engaging in the business of insurance, subject to 18 U.S.C. ¤ 1033(e)(2).\*\*\*(a) Notwithstanding any other provision of the law, and except as provided in ¤ 22-3571.02, a defendant who has been found guilty of an offense under the District of Columbia Official Code punishable by imprisonment may be sentenced to pay a fine as provided in this section. (b) An individual who has been found guilty of such an offense may be fined not more than the greatest of: (1) $100 if the offense is punishable by imprisonment for 10 days or less; (2) $250 if the offense is punishable by imprisonment for 30 days, or one month, or less but more than 10 days; (3) $500 if the offense is punishable by imprisonment for 90 days, or 3 months, or less but more than 30 days; (4) $1,000 if the offense is punishable by imprisonment for 180 days, or 6 months, or less but more than 90 days; (5) $2,500 if the offense is punishable by imprisonment for one year or less but more than 180 days; (6) $12,500 if the offense is punishable by imprisonment for 5 years or less but more than one year; (7) $25,000 if the offense is punishable by imprisonment for 10 years or less but more than 5 years; (8) $37,500 if the offense is punishable by imprisonment for 15 years or less but more than 10 years; (9) $50,000 if the offense is punishable by imprisonment for 20 years or less but more than 15 years; (10) $75,000 if the offense is punishable by imprisonment for 30 years or less but more than 20 years; (11) $125,000 if the offense is punishable by imprisonment for more than 30 years; or (12) $250,000 if the offense resulted in death. (c) An organization that has been found guilty of an offense punishable by imprisonment for 6 months or more may be fined not more than the greatest of: (1) Twice the maximum amount specified in the law setting forth the penalty for the offense; (2) Twice the applicable amount under subsection (b) of this section; or (3) Twice the applicable amount under ¤ 22-3571.02(a). **State:** District of Columbia **Statute Areas:** Range of Criminal Penalties --- ### [District of Columbia-Range of Civil Penalties-DC ST ¤ 22-3225.04.](https://insurancefraud.org/statutes/district-of-columbia-range-of-civil-penalties-dc-st-¤-22-3225-04/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** a) Any person convicted of insurance fraud in the first degree shall be fined not more than the amount set forth in ¤ 22-3571.01 or imprisoned for not more than 15 years, or both. (b) (1) Except as provided in paragraph (2) of this subsection, any person convicted of insurance fraud in the second degree shall be fined not more than the amount set forth in ¤ 22-3571.01 or imprisoned for not more than 5 years, or both. (2) Any person convicted of insurance fraud in the second degree who has been convicted previously of insurance fraud pursuant to ¤ 22-3225.02 or ¤ 22-3225.03, or a felony conviction based on similar grounds in any other jurisdiction, shall be fined not more than the amount set forth in ¤ 22-3571.01 or imprisoned for not more than 10 years, or both. (c) Any person convicted of misdemeanor insurance fraud shall be fined not more than the amount set forth in ¤ 22-3571.01 or imprisoned for not more than 180 days, or both. (d) A person convicted of a felony violation of this subchapter shall be disqualified from engaging in the business of insurance, subject to 18 U.S.C. ¤”1033(e)(2). https://beta.code.dccouncil.us/dc/council/code/sections/22-3225.04.html **State:** District of Columbia **Statute Areas:** Range of Civil Penalties --- ### [District of Columbia-Rating of an Insurance Policy-DC ST ¤ 31-2703](https://insurancefraud.org/statutes/district-of-columbia-rating-of-an-insurance-policy-dc-st-¤-31-2703/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) Rates for insurance within the scope of this chapter shall not be excessive, inadequate, or unfairly discriminatory. (b) Due consideration shall be given to past and prospective loss experience within and outside the District, to physical hazards, to safety and loss prevention factors, to underwriting practice and judgment, to catastrophe hazards, if any, to a reasonable margin for underwriting profit and contingencies; to dividends, savings, or unabsorbed premium deposits allowed or returned by companies to their policyholders, members, or subscribers; to past and prospective expenses both country-wide and those specially applicable to the District; to whether classification rates exist generally for the risks under consideration; to the rarity or peculiar characteristics of the risks; and to all other relevant factors within and outside the District. Due consideration shall be given to the net investment income (including the realized capital gains) on all cash and invested assets held against all unearned premium reserves and loss reserves of any nature. Unrealized capital gains or losses shall not be considered in the rate-making process. (c) Nothing in this section shall be taken to prohibit as unfairly discriminatory the establishment of classifications or modifications of classifications of risks based upon the size, expense, management, individual experience, location or dispersion of hazard, or any other reasonable considerations attributable to such risks provided such classifications and modifications apply to all risks under the same or substantially similar circumstances or conditions. (d) Nothing in this chapter shall be construed to require uniformity in insurance rates, classifications, rating plans, or practices. (e) Nothing in this chapter shall abridge or restrict the freedom of contract of companies, agents, brokers, or employees with reference to the commissions or salaries to be paid to such agents, brokers, or employees by companies. (f)(1) Every classification plan fixed, established, and promulgated by the Commissioner shall be so structured as to produce rates or premium charges which are adequate, not excessive, and not unfairly discriminatory. (2) Every final rate or premium charge proposed to be used by any motor vehicle insurer shall be filed with the Commissioner and shall be adequate, not excessive, and not unfairly discriminatory. A motor vehicle insurance rate may be held by the Commissioner to be excessive if the rate is unreasonably high for the insurance provided and is not actuarially justified based on the commonly accepted actuarial principles. In determining whether rates comply with standards under this subsection, due consideration shall be given for past and prospective loss experience within and outside the District, a reasonable margin for underwriting profit and contingencies, dividends, savings, or unabsorbed premium deposits allowed or returned by insurers to their policyholders or members or subscribers, past and prospective expenses, both countrywide and in the District, and investment income earned or realized by insurers both from their unearned premiums and from their loss reserve funds. If the Commissioner finds after a hearing that a rate is not in compliance with this subsection, he shall order that its use be discontinued for any policy issued or renewed after a date specified in the order and the order may prospectively provide for premium adjustment of any policy then in force. (f-1)(1)(A) Every final rate or premium charge proposed to be used by a medical malpractice insurer shall be filed with the Commissioner and shall be adequate, not excessive, and not unfairly discriminatory. A medical malpractice rate shall be excessive if the rate is unreasonably high for the insurance provided. In determining whether rates are adequate, not excessive, and not unfairly discriminatory, due consideration shall be given to: (i) Past and prospective loss experience within the District; (ii) A reasonable margin for underwriting profit and contingencies; (iii) Dividends, savings, or unabsorbed premium deposits allowed or returned by insurers to their policyholders, members, or subscribers; (iv) Past and prospective expenses in the District; (v) All investment income reasonably attributable to medical malpractice insurance in the District. (B) If District experience is not credible, the Commissioner may consider experience outside the District. The Commissioner shall promulgate rules setting forth the extent to which and the circumstances under which an insurer may rely on experience outside the District. (2) If a medical malpractice insurer wishes to change a rate, it shall file a complete rate application with the Commissioner. A complete rate application shall include all information, including all actuarial data, projections, and assumptions, that the medical malpractice insurer has relied on in calculating its proposed rates. All such information shall be made available when filed in accordance with subchapter II of Chapter 5 of Title 2. (3) The Commissioner shall notify the public of any application by a medical malpractice insurer for a rate change increase. The application shall be deemed approved 60 days after public notice unless the proposed rate change increase exceeds 10%. If the proposed rate change increase exceeds 10%, the Commissioner shall hold a hearing on the proposed change and shall issue an order approving, denying, or modifying the proposed change within 90 days after public notice of the proposed change. Any person shall have a right to testify in a hearing held by the Commissioner. The Commissioner shall promulgate rules governing the public hearing. (4) If the Commissioner finds, after a hearing, that a rate used by a medical malpractice insurer does not comply with this subsection, the Commissioner shall order the insurer to discontinue using the rate and to issue a refund to any policyholder who has paid the rate to the extent that the Commissioner has found it excessive. (g) No company, agent, or broker shall make, issue, or deliver, or knowingly permit the making, issuance, or delivery of any policy of insurance within the scope of this chapter contrary to pertinent filings which are in effect for the company as provided in this chapter, except that upon the written application of the insured stating his reasons therefor, filed with and approved by the Commissioner, a rate in excess of that provided by a filing otherwise applicable may be used on any specific risk. (h) Every insurer writing motor vehicle insurance in the District shall file with the Commissioner, in such form as he shall order, complete financial records showing the amount of profit on every line of motor vehicle insurance during the previous year. (i) The Office of the People’s Counsel shall serve as advocate for consumers in rate hearings before the Commissioner and the costs associated with such advocacy shall be borne by the insurer or insurers requesting the rate hearing. **State:** District of Columbia --- ### [District of Columbia-Underwriting Fraud-DC ST ¤ 22-3225.02*](https://insurancefraud.org/statutes/district-of-columbia-underwriting-fraud-dc-st-¤-22-3225-02/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** A person commits the offense of insurance fraud in the first degree if that person knowingly engages in the following conduct with the intent to defraud or to fraudulently obtain property of another and thereby obtains property of another or causes another to lose property and the value of the property obtained or lost is $1,000 or more: (1) Presenting false information or knowingly conceals information regarding a material fact in any of the following transactions: (A) Application for, rating of, or renewal of an insurance policy or reinsurance contract; (B) Claim for payment or benefit pursuant to an insurance policy or reinsurance contract; (C) Premiums paid on an insurance policy or reinsurance contract; (D) Payment made in accordance with the terms of an insurance policy or reinsurance contract; (E) Application used in a premium finance transaction; (F) Solicitation for sale of an insurance policy; (G) Application for a license or certificate of authority filed with the Commissioner or the chief insurance regulatory official of another jurisdiction; (H) Financial statement or condition of any insurer or reinsurer; (I) Acquisition, formation, merger, affiliation, reconsolidation, dissolution, or withdrawal from one or more lines of insurance or reinsurance in the District by an insurer or reinsurer; (J) Issuance of written evidence of insurance; or (K) Application for reinstatement of an insurance policy; (2) Soliciting or accepting insurance or renewal of insurance by or for an insurer which the person knows is insolvent or has a strong likelihood of insolvency; (3) Removal or tampering with the records of transaction, documentation, and other material assets of an insurer from the insurer or from the Department of Insurance and Securities Regulation; (4) Diversion, misappropriation, conversion, or embezzlement of funds of an insurer, an insured, claimant or applicant regarding any of the following: (A) Insurance transaction; (B) Other insurance business activities by an insurer or insurance professional; or (C) Acquisition, formation, merger, affiliation or dissolution of an insurer. (5) Transaction of the business of insurance in violation of laws requiring a license, certificate of authority, or other legal authority for the transaction of the business of insurance; or (6) Employing or using any other person or acting as the agent of any other person to procure a client, patient, or customer for the purpose of falsely or fraudulently obtaining benefits under a contract of insurance or asserting a false or fraudulent claim against an insured or insurer **State:** District of Columbia **Statute Areas:** Underwriting Fraud --- ### [District of Columbia-Unauthorized Entities-DC ST ¤ 31-231 (Proposed legislation)](https://insurancefraud.org/statutes/district-of-columbia-unauthorized-entities-dc-st-¤-31-231-proposed-legislation/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** No person shall act as an insurer, or engage in any other activity, directly or indirectly, which is regulated in acts codified in Chapters 1 through 55 of this title unless performed within the scope of a certificate of authority issued by the Commissioner as provided by this chapter. The prohibitions in this chapter shall not apply to persons or entities engaging in activity pursuant to ¤¤ 31-2502.39 and 31-2502.40. **State:** District of Columbia --- ### [Delaware-Aiding & Abetting-18 Del.C. ¤ 2407](https://insurancefraud.org/statutes/delaware-aiding-abetting-18-del-c-¤-2407/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) It shall be a fraudulent insurance act for a person to knowingly, by act or omission, with intent to injure, defraud or deceive: (3) Assist, abet, solicit or conspire with another to prepare or present any oral or written statement, including computer-generated documents, that is intended to be presented to any insurer in connection with, or in support of, any claim for payment or other benefit pursuant to an insurance policy, which contains false, incomplete or misleading information concerning any fact material to the claim; **State:** Delaware --- ### [Delaware-Attempted Fraud-n/a](https://insurancefraud.org/statutes/delaware-attempted-fraud-n-a/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** No statute found **State:** Delaware **Statute Areas:** Attempted Fraud --- ### [Delaware-Claims Fraud-18 Del.C. ¤ 2407](https://insurancefraud.org/statutes/delaware-claims-fraud-18-del-c-¤-2407/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) It shall be a fraudulent insurance act for a person to knowingly, by act or omission, with intent to injure, defraud or deceive: (2) Prepare, present or cause to be presented to any insurer, any oral or written statement including computer-generated documents as part of, or in support of, a claim for payment or other benefit pursuant to an insurance policy, containing false, incomplete or misleading information concerning any fact material to such claims; **State:** Delaware **Statute Areas:** Claims Fraud --- ### [Delaware-Fraud Bureau-18 Del.C. ¤ 2404](https://insurancefraud.org/statutes/delaware-fraud-bureau-18-del-c-¤-2404/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) The Delaware Insurance Fraud Prevention Bureau is hereby established within the Department of Insurance and authorized to employ investigators and appropriate support staff as is necessary to carry out its mandate. (b) The Commissioner shall appoint the full-time supervisory and investigative personnel of the Bureau including the Director and Chief Investigator, who shall hold their employment at the pleasure of the Commissioner and who shall be qualified by training and experience to perform the duties of their positions. The Commissioner shall also appoint the clerical and other staff necessary for the Bureau to fulfill its responsibilities under this chapter. (c) It shall be the duty of the Bureau: (1) To initiate independent inquiries and conduct independent investigations when the Bureau has cause to believe that an act of insurance fraud has been, or is currently being committed; (2) To review reports or complaints of alleged insurance fraud from federal, state and local police, other law-enforcement authorities, governmental agencies or units, insurers and the general public and to determine whether such reports require further investigation and to conduct such investigations; (3) To conduct independent examinations of insurance fraud, and undertake independent studies to determine the extent of insurance fraud; and (4) To enforce ¤ 2118(q)(4) of Title 21 by confiscating license plates of uninsured motorists who have failed to provide proof of insurance after being afforded an opportunity to prove proof of insurance as required in ¤ 2118(q)(4) of Title 21. (d) There is hereby created within the Bureau a special revolving fund to be designated as the Delaware Insurance Fraud Auxiliary Fund which shall be used by the Bureau in the performance of the various functions and duties required of the Bureau by law. **State:** Delaware **Statute Areas:** Fraud Bureau --- ### [Delaware-Immunity-18 Del.C. ¤ 2409](https://insurancefraud.org/statutes/delaware-immunity-18-del-c-¤-2409/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** In the absence of fraud or bad faith, no person shall be subject to civil liability (for libel, slander or any other relevant tort cause of action by virtue of filing reports, without malice, or furnishing other information, written or oral, without malice, required by this chapter or required by the Commissioner under the authority granted in this title), and no civil cause of action of any nature shall arise against such person: (1) For any information relating to suspected fraudulent insurance acts furnished to or received from law-enforcement officials, their agents and employees; or (2) For any information relating to the suspected fraudulent insurance acts furnished to or received from other persons in this title; or (3) For any such information furnished in reports to the Insurance Department, the National Association of Insurance Commissioners or any organization established to detect and prevent fraudulent insurance acts, their agents, employees or designees, nor shall the Commissioner or any employee of the Insurance Department, (acting without malice) in the absence of fraud or bad faith, be subject to civil liability (for libel, slander or any other relevant tort) and no civil cause of action of any nature shall arise against such person by virtue of publication of any report or bulletin related to the official activities of the Insurance Department. Nothing herein is intended to abrogate or modify in any way any common law or statutory privilege or immunity heretofore enjoyed by any person. **State:** Delaware **Statute Areas:** Immunity --- ### [Delaware-Insurance Fraud - Definition-18 Del.C. ¤ 2407](https://insurancefraud.org/statutes/delaware-insurance-fraud-definition-18-del-c-¤-2407/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) It shall be a fraudulent insurance act for a person to knowingly, by act or omission, with intent to injure, defraud or deceive: (1) Present, cause to be presented, prepare, assist, abet, solicit or conspire with another to prepare or make any oral or written statement with knowledge or belief that it will be presented to an insurer in connection with, or in support of, any application for the issuance of an insurance policy, containing false, incomplete or misleading information concerning any fact material to the application for issuance of an insurance policy; (2) Prepare, present or cause to be presented to any insurer, any oral or written statement including computer-generated documents as part of, or in support of, a claim for payment or other benefit pursuant to an insurance policy, containing false, incomplete or misleading information concerning any fact material to such claims; (3) Assist, abet, solicit or conspire with another to prepare or present any oral or written statement, including computer-generated documents, that is intended to be presented to any insurer in connection with, or in support of, any claim for payment or other benefit pursuant to an insurance policy, which contains false, incomplete or misleading information concerning any fact material to the claim; or (4) Prepare, present or cause to be presented to any insurer or other person, or demand or require the issuance of, a certificate of insurance that contains any false or misleading information concerning the policy of insurance to which the certificate makes reference, or assist, abet, solicit or conspire with another to do any of the acts described in this sentence. As used in this section, “certificate of insurance” means a document or instrument, regardless of how titled or described, that is, or purports to be, prepared or issued by an insurer or insurance producer as evidence of property or casualty insurance coverage. The term does not include a policy of insurance, insurance binder, policy endorsement, or automobile insurance identification or information card. (b) It shall be a fraudulent insurance act for a practitioner to knowingly and wilfully assist, conspire with, or urge any person to violate any of the provisions of this chapter, or for any person who due to such assistance, conspiracy or urging by said practitioner, knowingly and wilfully benefits from the proceeds derived from the use of the fraud. (c) It shall be a fraudulent insurance act for any insurer or any person acting on behalf of such insurer to knowingly, by act or omission, with intent to injure, defraud or deceive: (1) Present or cause to be presented to an insurance claimant false, incomplete or misleading information regarding the nature, extent and terms of insurance coverage which may or might be available to such claimant under any policy of insurance, whether first or third party. (2) Present or cause to be presented to any insurance claimant false, incomplete or misleading information regarding or affecting in any fashion the extent of any claimant’s right to benefit under, or to make a claim against, any policy of insurance whether first or third party. **State:** Delaware **Statute Areas:** Insurance Fraud - Definition --- ### [Delaware-Mandatory Restitution-18 Del.C. ¤ 2411](https://insurancefraud.org/statutes/delaware-mandatory-restitution-18-del-c-¤-2411/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (d) Any person who is found to have committed an act of insurance fraud, or violated an order of the Commissioner pursuant to a hearing, shall be liable for costs incurred by the Bureau. The assessment for costs shall be 15% of each penalty assessed pursuant to this section. (e) In addition to the above, the Commissioner shall have authority to order restitution to the insurer, or self-insured employer of any insurance proceeds paid pursuant to a fraudulent claim. **State:** Delaware **Statute Areas:** Mandatory Restitution --- ### [Delaware-Placing Bogus Coverage-18 Del.C. ¤ 2407](https://insurancefraud.org/statutes/delaware-placing-bogus-coverage-18-del-c-¤-2407/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (c) It shall be a fraudulent insurance act for any insurer or any person acting on behalf of such insurer to knowingly, by act or omission, with intent to injure, defraud or deceive: (1) Present or cause to be presented to an insurance claimant false, incomplete or misleading information regarding the nature, extent and terms of insurance coverage which may or might be available to such claimant under any policy of insurance, whether first or third party. **State:** Delaware --- ### [Delaware-Practitioner Penalites-18 Del.C. ¤ 4507](https://insurancefraud.org/statutes/delaware-practitioner-penalites-18-del-c-¤-4507/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) The Commissioner shall have the power to examine and investigate the activities of any person that the Commissioner reasonably believes has been or is engaged in an act or practice prohibited by this chapter. (b) The Commissioner shall have the power to enforce the provisions of this chapter, including the authority to issue orders to cease and desist and to impose a fine of up to $1,000 per violation against any person who violates this chapter. This subsection shall not be construed to limit the Commissioner’s authority to investigate, enforce and issue penalties pursuant to any other applicable provision in this title including, without limitation, Chapters 17, 23 and 24 of this title. (c) The Commissioner may adopt reasonable rules and regulations as are necessary or proper to carry out the provisions of this chapter. **State:** Delaware **Statute Areas:** Practitioner Penalites --- ### [Delaware-Premium Fraud-18 Del.C. ¤ 2407*](https://insurancefraud.org/statutes/delaware-premium-fraud-18-del-c-¤-2407/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) It shall be a fraudulent insurance act for a person to knowingly, by act or omission, with intent to injure, defraud or deceive: (1) Present, cause to be presented, prepare, assist, abet, solicit or conspire with another to prepare or make any oral or written statement with knowledge or belief that it will be presented to an insurer in connection with, or in support of, any application for the issuance of an insurance policy, containing false, incomplete or misleading information concerning any fact material to the application for issuance of an insurance policy; (2) Prepare, present or cause to be presented to any insurer, any oral or written statement including computer-generated documents as part of, or in support of, a claim for payment or other benefit pursuant to an insurance policy, containing false, incomplete or misleading information concerning any fact material to such claims; (3) Assist, abet, solicit or conspire with another to prepare or present any oral or written statement, including computer-generated documents, that is intended to be presented to any insurer in connection with, or in support of, any claim for payment or other benefit pursuant to an insurance policy, which contains false, incomplete or misleading information concerning any fact material to the claim; or (4) Prepare, present or cause to be presented to any insurer or other person, or demand or require the issuance of, a certificate of insurance that contains any false or misleading information concerning the policy of insurance to which the certificate makes reference, or assist, abet, solicit or conspire with another to do any of the acts described in this sentence. As used in this section, “certificate of insurance” means a document or instrument, regardless of how titled or described, that is, or purports to be, prepared or issued by an insurer or insurance producer as evidence of property or casualty insurance coverage. The term does not include a policy of insurance, insurance binder, policy endorsement, or automobile insurance identification or information card. (b) It shall be a fraudulent insurance act for a practitioner to knowingly and wilfully assist, conspire with, or urge any person to violate any of the provisions of this chapter, or for any person who due to such assistance, conspiracy or urging by said practitioner, knowingly and wilfully benefits from the proceeds derived from the use of the fraud. (c) It shall be a fraudulent insurance act for any insurer or any person acting on behalf of such insurer to knowingly, by act or omission, with intent to injure, defraud or deceive: (1) Present or cause to be presented to an insurance claimant false, incomplete or misleading information regarding the nature, extent and terms of insurance coverage which may or might be available to such claimant under any policy of insurance, whether first or third party. (2) Present or cause to be presented to any insurance claimant false, incomplete or misleading information regarding or affecting in any fashion the extent of any claimant’s right to benefit under, or to make a claim against, any policy of insurance whether first or third party. **State:** Delaware **Statute Areas:** Premium Fraud --- ### [Delaware-Range of Criminal Penalties-11 Del.C. ¤ 913 (Proposed)](https://insurancefraud.org/statutes/delaware-range-of-criminal-penalties-11-del-c-¤-913-proposed/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Insurance fraud is a class G felony. (b) All insurance claims forms shall contain a statement that clearly states in substance the following: “Any person who knowingly, and with intent to injure, defraud or deceive any insurer, files a statement of claim containing any false, incomplete or misleading information is guilty of a felony.” The lack of such a statement shall not constitute a defense against prosecution under this section. (c) For the purposes of this section, “statement” includes, but is not limited to, a police report, any notice, statement, proof of loss, bill of lading, receipt for payment, invoice, account, estimate of property damages, bill for services, diagnosis, prescription, hospital or doctor records, X rays, test result or other evidence of loss, injury or expense; “insurer” shall include, but is not limited to, a health service corporation or health maintenance organization; and “insurance policy” shall include, but is not limited to, the subscriber and members contracts of health service corporations and health maintenance organizations. **State:** Delaware **Statute Areas:** Range of Criminal Penalties --- ### [Delaware-Range of Civil Penalties-18 Del.C. ¤ 2411](https://insurancefraud.org/statutes/delaware-range-of-civil-penalties-18-del-c-¤-2411/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) The matters of enforcement, investigations, hearings, administrative penalties and appeals shall be conducted in accordance with Chapter 3 of this title and Chapter 101 of Title 29 to the extent that such provisions are not in conflict with the provisions set forth in this chapter. (b) Upon a showing by a preponderance of evidence that a violation of this chapter has occurred, the Commissioner may impose an administrative penalty of not more than $10,000 for each act of insurance fraud. An act of insurance fraud may be 1 of several such acts which taken together comprise a fraudulent insurance scheme. Assessment of the administrative penalty shall be determined by the nature, circumstances, extent and gravity of the act or acts of insurance fraud, any prior history of such act or acts, the degree of culpability and such other matters as justice may require. (c) In the event of nonpayment of the administrative penalty after all rights of appeal have been waived or exhausted, a civil action may be brought by the Commissioner in Superior Court for the collection of the administrative penalty, including interest, attorneys’ fees and costs, in the following manner: (1) A praecipe and complaint shall be filed setting forth that administrative action was taken against the defendant in accordance with this chapter, that the defendant either voluntarily entered into a consent order which called for the payment of a specified monetary penalty, or in the alternative, that after proper notice and hearing, the defendant was determined to be in violation of this chapter and that by order of the Commissioner a specified monetary penalty had been assessed against the defendant, that all rights of appeal have been waived or exhausted, and that payment in full has not been made in accordance with the terms of the consent order or other order of the Commissioner. The Department shall attach to the complaint a certified copy of that consent order or other order of the Commissioner. (2) The Court shall enter judgment in favor of the Department for the amount specified in the complaint upon the Department establishing the following: a. The defendant is the same person against whom the consent order or other order of the Commissioner applies; and b. Payment in full has not been made by or on behalf of the defendant according to the terms of the consent or other order of the Commissioner. (3) Any judgment entered shall be final to the same extent as a judgment entered after trial. (4) Except as otherwise provided in this section the Superior Court Civil Rules shall govern these proceedings. (d) Any person who is found to have committed an act of insurance fraud, or violated an order of the Commissioner pursuant to a hearing, shall be liable for costs incurred by the Bureau. The assessment for costs shall be 15% of each penalty assessed pursuant to this section. (e) In addition to the above, the Commissioner shall have authority to order restitution to the insurer, or self-insured employer of any insurance proceeds paid pursuant to a fraudulent claim. **State:** Delaware **Statute Areas:** Range of Civil Penalties --- ### [Delaware-Rating of an Insurance Policy-18 Del.C. ¤ 2503](https://insurancefraud.org/statutes/delaware-rating-of-an-insurance-policy-18-del-c-¤-2503/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) Rates shall be made in accordance with the following provisions: (1) Manual, minimum, class rates, rating schedules or rating plans shall be made and adopted, except in the case of specific inland marine rates on risks specially rated; (2) Rates shall not be excessive, inadequate or unfairly discriminatory; (3) Due consideration shall be given: a. To past and prospective loss experience within and outside this State; b. To the conflagration and catastrophe hazards; c. To a reasonable margin for underwriting profit and contingencies; d. To dividends, savings or unabsorbed premium deposits allowed or returned by insurers to their policyholders, members or subscribers; e. To past and prospective expenses both countrywide and those specially applicable to this State; f. To all other relevant factors within and outside this State; and g. In the case of fire insurance rates, consideration shall be given to the experience of the fire insurance business during a period of not less than the most recent 5-year period for which such experience is available; (4) The systems of expense provisions included in the rates for use by any insurer or group of insurers may differ from those of other insurers or groups of insurers to reflect the requirements of the operating methods of any such insurer or group with respect to any kind of insurance, or with respect to any subdivision or combination thereof for which subdivision or combination separate expense provisions are applicable; (5) Risks may be grouped by classifications for the establishment of rates and minimum premiums. Classification rates may be modified to produce rates for individual risks in accordance with rating plans which establish standards for measuring variations in hazards or expense provisions or both. Such standards may measure any differences among risks which may have a probable effect upon losses or expenses; (6) The Commissioner shall require a reduction in rates for a 3-year period for any person who voluntarily attends and successfully completes a motor vehicle accident prevention course which is approved by the Division of Motor Vehicles. Motor vehicle accident prevention course instructors that have been certified by the Division of Motor Vehicles shall be entitled to the same reduction in rates as those individuals that have successfully completed a motor vehicle accident prevention course, in the manner set forth in regulations promulgated pursuant to this section. The reduction shall be for any individually owned vehicle classified as a private passenger vehicle and shall be in proportion to the number who have completed the course in the event that not all members of a group have completed the course. Voluntary attendance shall not include any attendance ordered as permitted by a court or required by the Division of Motor Vehicles pursuant to any violations of Title 21; (7) The Commissioner shall require a reduction in rates for a 3-year period for any person who voluntarily attends and successfully completes a motorcycle rider course which as approved by the Division of Motor Vehicles. Motorcycle rider course instructors that have been certified by the Division of Motor Vehicles shall be entitled to the same reduction in rates as those individuals that have successfully completed a motorcycle rider course, in the manner set forth in regulations promulgated pursuant to this section. The reduction shall be for any individually owned vehicle classified as a motorcycle and licensed for use on the streets and highways of this State. Voluntary attendance shall not include any attendance ordered as permitted by a court or required by the Division of Motor Vehicles pursuant to any violations of Title 21; (8) The Commissioner shall require insurers to file an actuarially justified reduction in rates for a 3-year period if all operators of a vessel voluntarily attend and successfully complete a boating safety education course which is approved by the Department of Natural Resources and Environmental Control for the purposes of ¤ 2221 of Title 23. The reduction shall be for any individually owned vessel used exclusively for noncommercial purposes. Voluntary attendance shall not include any attendance ordered as permitted by a court or required by the Department of Natural Resources and Environmental Control pursuant to any violations of Title 23; (9) Rate filings concerning automobile collision insurance shall provide for a credit of 5 percent of annual premiums for such coverage for any individually owned vehicle classified as a private passenger vehicle owned by employees participating in an approved Travelink Traffic Mitigation Act program created pursuant to subchapter IV of Chapter 20 of Title 30; (10) An insurer authorized to do business in Delaware cannot increase a renewal rate for a personal automobile insurance policy based solely on an insured having attained the age of 75 or older; (11) With respect to personal automobile insurance for an existing insured, an insurer authorized to do business in Delaware may not charge the insured a higher rate solely based upon a change in his or her marital status due to the death of a spouse. (b) Nothing in this section shall be taken to prohibit as unreasonable or unfairly discriminatory the establishment of classifications or modifications of classifications or risks based upon size, expense, management, individual experience, purpose of insurance location or dispersion of hazard or any other reasonable considerations provided such classifications and modifications apply to all risks under the same or substantially similar circumstances or conditions. (c) Except to the extent necessary to meet the provisions of paragraphs (a)(2) and (9) of this section, uniformity among insurers in any matters within the scope of this section is neither required nor prohibited. **State:** Delaware --- ### [Delaware-Underwriting Fraud-18 Del.C. ¤ 2407](https://insurancefraud.org/statutes/delaware-underwriting-fraud-18-del-c-¤-2407/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (c) It shall be a fraudulent insurance act for any insurer or any person acting on behalf of such insurer to knowingly, by act or omission, with intent to injure, defraud or deceive: (1) Present or cause to be presented to an insurance claimant false, incomplete or misleading information regarding the nature, extent and terms of insurance coverage which may or might be available to such claimant under any policy of insurance, whether first or third party. (2) Present or cause to be presented to any insurance claimant false, incomplete or misleading information regarding or affecting in any fashion the extent of any claimant’s right to benefit under, or to make a claim against, any policy of insurance whether first or third party. **State:** Delaware **Statute Areas:** Underwriting Fraud --- ### [Delaware-Unauthorized Entities-18 Del.C. ¤ 2101](https://insurancefraud.org/statutes/delaware-unauthorized-entities-18-del-c-¤-2101/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) No person shall in this State directly or indirectly act as agent for, or otherwise represent or aid on behalf of another, any insurer not then authorized to transact such business in this State in the solicitation, negotiation, procurement or effectuation of insurance or annuity contracts, or renewal thereof, or forwarding of applications for insurance or annuities, or the dissemination of information as to coverage or rates, or inspection of risks, or fixing of rates, or investigation or adjustment of claims or losses, or collection or forwarding of premiums, or in any other manner represent or assist such an insurer in the transaction of insurance with respect to subjects of insurance resident, located or to be performed in this State. (b) This section does not apply to: (1) Matters authorized to be done by the Commissioner under the Unauthorized Insurers Process Act, ¤¤ 2103-2108 of this title; (2) Transactions as to which the insurer is not required to have a certificate of authority pursuant to ¤ 506 (exceptions to certificate of authority requirement) of this title; (3) A licensed adjuster or attorney-at-law representing such an insurer from time to time in his or her professional capacity; (4) Persons in this State who secure and furnish information for the purposes of group life insurance, group or blanket health insurance or annuity coverages, or for enrolling individuals under such plans or issuing certificates thereunder or otherwise assisting in administering such plans where no commission is paid for such services and the master policy or contract was lawfully solicited, issued and delivered in and pursuant to the laws of a state in which the insurer was then authorized to transact insurance; (5) The employee, compensated on salary only, of a Delaware employer who on behalf of the employer assists in the procurement or administration of insurance coverages on the property, risks and insurable interests of the employer. **State:** Delaware --- ### [Connecticut-Aiding & Abetting-C.G.S.A. ¤ 53a-215](https://insurancefraud.org/statutes/connecticut-aiding-abetting-c-g-s-a-¤-53a-215/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) A person is guilty of insurance fraud when the person, with the intent to injure, defraud or deceive any insurance company: (2) assists, abets, solicits, or conspires with another to prepare or make any written or oral statement that is intended to be presented to any insurance company in connection with, or in support of, any application for any policy of insurance or any claim for payment or other benefit pursuant to such policy of insurance, knowing that such statement contains any false, incomplete, or misleading information concerning any fact or thing material to such application or claim for the purposes of defrauding such insurance company. **State:** Connecticut --- ### [Connecticut-Anti-Runner Provisions-n/a](https://insurancefraud.org/statutes/connecticut-anti-runner-provisions-n-a/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** No statute found. Proposed legislation under HB 6642 **State:** Connecticut **Statute Areas:** Anti-Runner Provisions --- ### [Connecticut-Claims Fraud-C.G.S.A. ¤ 53a-215](https://insurancefraud.org/statutes/connecticut-claims-fraud-c-g-s-a-¤-53a-215/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) A person is guilty of insurance fraud when the person, with the intent to injure, defraud or deceive any insurance company: (1) Presents or causes to be presented to any insurance company, any written or oral statement including computer-generated documents as part of, or in support of, any application for any policy of insurance or a claim for payment or other benefit pursuant to such policy of insurance, knowing that such statement contains any false, incomplete, or misleading information concerning any fact or thing material to such application or claim; or (2) assists, abets, solicits, or conspires with another to prepare or make any written or oral statement that is intended to be presented to any insurance company in connection with, or in support of, any application for any policy of insurance or any claim for payment or other benefit pursuant to such policy of insurance, knowing that such statement contains any false, incomplete, or misleading information concerning any fact or thing material to such application or claim for the purposes of defrauding such insurance company. (b) For the purposes of this section, “statement” includes, but is not limited to, any notice, statement, invoice, account, estimate of property damages, bill for services, test result, or other evidence of loss, injury, or expense. (c) For the purposes of this section, “insurance company” has the same meaning as provided in section 38a-1. (d) Insurance fraud is a class D felony. **State:** Connecticut **Statute Areas:** Claims Fraud --- ### [Connecticut-Failing to Remit Premium-C.G.S.A. ¤ 38a-712](https://insurancefraud.org/statutes/connecticut-failing-to-remit-premium-c-g-s-a-¤-38a-712/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) Each insurance company authorized or permitted to do business in this state and each residual market mechanism established pursuant to section 38a-329 shall report to the Insurance Commissioner (1) any failure on the part of an insurance producer or surplus lines broker to remit premiums for policies or endorsements issued to insureds directly or through the producer within thirty days following the due date of the account of the producer with the company, its state agent or managing general agent, or (2) whenever a check issued by such producer to the company or residual market mechanism is returned for insufficient funds or otherwise dishonored and remains outstanding fifteen days following receipt of such return. (b) If, upon investigation of a report concerning a failure to remit premiums, the commissioner determines that a producer has received premiums directly or indirectly from insureds and has failed to remit them to the proper company, its state agent or managing general agent, he may, following a hearing as specified in section 38a-774, suspend or revoke the license of the producer. Upon receipt of a report concerning a dishonored check or upon dishonor of any check, draft or other remittance upon presentment of payment, from a producer to the Insurance Department, the commissioner shall notify the producer issuing such check, draft or other remittance of the report. If an arrangement for payment of such funds is not made to the satisfaction of the commissioner by the producer within fifteen days of receipt of such notice, the license of the producer shall be automatically suspended. Within sixty days of receipt of such notice the producer may make written demand upon the commissioner for a hearing to show cause why the suspension should be terminated. Such hearing shall be held within thirty days from the date of receipt of the written demand. If by the end of the sixty-day demand period no hearing has been demanded, the license of the producer shall be revoked. The commissioner may institute procedures for the restoration of the licensee’s insurance accounts to best protect the interests of all parties concerned. (c) The commissioner may adopt such reasonable regulations as the commissioner deems necessary for the implementation of this section and specifically to provide procedures for continuing, terminating or restoring the licenses affected. **State:** Connecticut --- ### [Connecticut-Immunity-C.G.S.A. ¤ 38a-318a](https://insurancefraud.org/statutes/connecticut-immunity-c-g-s-a-¤-38a-318a/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) Notwithstanding any provision of the general statutes, each insurer authorized to issue policies of liability insurance in the state shall, upon the filing of any claim for damages because of bodily injury or death for a resident of this state, provide notice of such claim to the Commissioner of Administrative Services for the purposes of identifying potential liabilities to the state that the commissioner is authorized to collect pursuant to the general statutes. The content of such notice and the manner of its transmission shall be determined by the department in consultation with the insurers, except that insurers may provide such required notification directly to the commissioner or through a central reporting organization to which the insurer subscribes. (b) The state shall maintain, as confidential, any information obtained, collected, prepared or received pursuant to this section. The state shall not store or maintain any information provided pursuant to this section unless the state identifies the claimant as having a potential liability to the state. (c) The commissioner shall reimburse insurers or central reporting organizations, as applicable, for the reasonable documented costs, as determined by the commissioner, incurred for compliance with this section. (d) Each insurer, its directors, agents, and employees and each central reporting organization, its agents and employees, authorized by an insurer to act on its behalf, that provide or attempt to provide data pursuant to the provisions of this section shall be immune from any liability under any law to any person or entity for any alleged or actual damages that occur as a result of providing or attempting to provide data pursuant to this section, provided said damages are not caused by intentional, wilful or wanton misconduct. Compliance with the requirements of this section shall not subject any insurer, its directors, agents, employees and insureds, or any central reporting organization, its agents and employees, authorized by an insurer to act on its behalf, to any claims brought pursuant to sections 38a-816, 38a-975 to 38a-999a, inclusive, or section 42-110b, or any penalty pursuant to section 38a-15. (e) Information provided by or obtained from an insurer or the central reporting organization pursuant to this section shall not be subject to disclosure under section 1-210. **State:** Connecticut **Statute Areas:** Immunity --- ### [Connecticut-Insurance Fraud - Definition-C.G.S.A. ¤ 53a-215](https://insurancefraud.org/statutes/connecticut-insurance-fraud-definition-c-g-s-a-¤-53a-215/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) A person is guilty of insurance fraud when the person, with the intent to injure, defraud or deceive any insurance company: (1) Presents or causes to be presented to any insurance company, any written or oral statement including computer-generated documents as part of, or in support of, any application for any policy of insurance or a claim for payment or other benefit pursuant to such policy of insurance, knowing that such statement contains any false, incomplete, or misleading information concerning any fact or thing material to such application or claim; or (2) assists, abets, solicits, or conspires with another to prepare or make any written or oral statement that is intended to be presented to any insurance company in connection with, or in support of, any application for any policy of insurance or any claim for payment or other benefit pursuant to such policy of insurance, knowing that such statement contains any false, incomplete, or misleading information concerning any fact or thing material to such application or claim for the purposes of defrauding such insurance company. (b) For the purposes of this section, “statement” includes, but is not limited to, any notice, statement, invoice, account, estimate of property damages, bill for services, test result, or other evidence of loss, injury, or expense. (c) For the purposes of this section, “insurance company” has the same meaning as provided in section 38a-1. (d) Insurance fraud is a class D felony. **State:** Connecticut **Statute Areas:** Insurance Fraud - Definition --- ### [Connecticut-Mandatory Restitution-C.G.S.A. ¤ 53-443](https://insurancefraud.org/statutes/connecticut-mandatory-restitution-c-g-s-a-¤-53-443/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Any person who violates any provision of sections 53-440 to 53-443, inclusive, shall be subject to the penalties for larceny under sections 53a-122 to 53a-125b, inclusive. Each act shall be considered a separate offense. In addition to any fine or term of imprisonment imposed, including any order of probation, any such person shall make restitution to an aggrieved insurer, including reasonable attorneys’ fees and investigation costs. **State:** Connecticut **Statute Areas:** Mandatory Restitution --- ### [Connecticut-Placing Bogus Coverage-C.G.S.A. ¤ 38a-275.](https://insurancefraud.org/statutes/connecticut-placing-bogus-coverage-c-g-s-a-¤-38a-275/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Contracts entered into by unauthorized insurers are unenforceable. Any contract effective in this state and entered into by an unauthorized insurer in violation of sections 38a-27 and 38a-271 to 38a-278, inclusive, shall be unenforceable by such insurer. If any such unauthorized insurer fails to pay any claim or loss within the provisions of such insurance contract, any person who assisted or in any manner aided directly or indirectly in the procurement of such insurance contract shall be liable to the insured for the full amount of such claim or loss pursuant to the provisions of such insurance **State:** Connecticut --- ### [Connecticut-Premium Fraud-C.G.S.A. ¤ 53a-215](https://insurancefraud.org/statutes/connecticut-premium-fraud-c-g-s-a-¤-53a-215/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) A person is guilty of insurance fraud when the person, with the intent to injure, defraud or deceive any insurance company: (1) Presents or causes to be presented to any insurance company, any written or oral statement including computer-generated documents as part of, or in support of, any application for any policy of insurance or a claim for payment or other benefit pursuant to such policy of insurance, knowing that such statement contains any false, incomplete, or misleading information concerning any fact or thing material to such application or claim; or (2) assists, abets, solicits, or conspires with another to prepare or make any written or oral statement that is intended to be presented to any insurance company in connection with, or in support of, any application for any policy of insurance or any claim for payment or other benefit pursuant to such policy of insurance, knowing that such statement contains any false, incomplete, or misleading information concerning any fact or thing material to such application or claim for the purposes of defrauding such insurance company. (b) For the purposes of this section, “statement” includes, but is not limited to, any notice, statement, invoice, account, estimate of property damages, bill for services, test result, or other evidence of loss, injury, or expense. (c) For the purposes of this section, “insurance company” has the same meaning as provided in section 38a-1. (d) Insurance fraud is a class D felony. **State:** Connecticut **Statute Areas:** Premium Fraud --- ### [Connecticut-Range of Criminal Penalties-C.G.S.A. ¤ 53a-215](https://insurancefraud.org/statutes/connecticut-range-of-criminal-penalties-c-g-s-a-¤-53a-215/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (d) Insurance fraud is a class D felony. **State:** Connecticut **Statute Areas:** Range of Criminal Penalties --- ### [Connecticut-Range of Civil Penalties-C.G.S.A. ¤ 38a-2.](https://insurancefraud.org/statutes/connecticut-range-of-civil-penalties-c-g-s-a-¤-38a-2/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Any person or corporation violating any provision of this title for the violation of which no other penalty is provided shall be fined not more than fifteen thousand dollars. **State:** Connecticut **Statute Areas:** Range of Civil Penalties --- ### [Connecticut-Rating of an Insurance Policy-C.G.S.A. ¤ 38a-668 C.G.S.A. ¤ 38a-668](https://insurancefraud.org/statutes/connecticut-rating-of-an-insurance-policy-c-g-s-a-¤-38a-668-c-g-s-a-¤-38a-668/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Members and subscribers of rating or advisory organizations may use the rates, rating systems, underwriting rules or policy or bond form of such organizations, either consistently or intermittently, but, except as provided in sections 38a-667, 38a-670 and 38a-672, shall not agree with each other or rating organizations or others to adhere thereto. The fact that two or more admitted insurers, whether or not members or subscribers of a rating or advisory organization, use, either consistently or intermittently, the rates or rating systems made or adopted by a rating organization, or policy or bond forms prepared by a rating or advisory organization, shall not be sufficient in itself to support a finding that an agreement to so adhere exists and may be used only for the purpose of supplementing or explaining any competent evidence of the existence of any such agreement. **State:** Connecticut --- ### [Connecticut-Unauthorized Entities-C.G.S.A. ¤ 38a-278](https://insurancefraud.org/statutes/connecticut-unauthorized-entities-c-g-s-a-¤-38a-278/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) Any unauthorized insurer who does any act of an insurance business as set forth in section 38a-271 shall be fined not more than fifty thousand dollars. (b) In addition to the penalty provided in subsection (a) of this section or otherwise provided by law, any person or insurer violating section 38a-27 or 38a-271 to 38a-278, inclusive, shall be fined two thousand five hundred dollars for the first offense and an additional two thousand five hundred dollars for each month during which any such person or insurer continues such violation. **State:** Connecticut --- ### [Colorado-Claims Fraud-C.R.S.A. ¤ 18-5-211](https://insurancefraud.org/statutes/colorado-claims-fraud-c-r-s-a-¤-18-5-211/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (1) A person commits insurance fraud if the person does any of the following: (b) With an intent to defraud presents or causes to be presented any insurance claim, which claim contains false material information or withholds material information; (d) With an intent to defraud presents or causes to be presented an insurance claim where the loss or damage claimed occurred outside of the period of time that coverage was in effect for the applicable contract of insurance or policy unless otherwise permitted under the contract of insurance or policy **State:** Colorado **Statute Areas:** Claims Fraud --- ### [Colorado-Failing to Remit Premium-C.R.S.A. ¤ 18-5-211](https://insurancefraud.org/statutes/colorado-failing-to-remit-premium-c-r-s-a-¤-18-5-211/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (2) A person commits insurance fraud if he or she knowingly moves, diverts, or misappropriates premium funds belonging to an insurer or unearned premium funds belonging to an insured or applicant for insurance from a trust or other account without the authorization of the owner of the funds or other lawful justification. **State:** Colorado --- ### [Colorado-Fraud Bureau-C.R.S.A. ¤ 24-31-104.5](https://insurancefraud.org/statutes/colorado-fraud-bureau-c-r-s-a-¤-24-31-104-5/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (1) (a) For the purpose of providing adequate funds to the Colorado department of law for the investigation and prosecution of allegations of insurance fraud, in addition to any other fee collected pursuant to section 10-3-207 (1), C.R.S., each entity regulated by the division of insurance shall pay to the division a nonrefundable annual fee. Based upon the appropriations made to the department of law from the insurance fraud cash fund and the recommendation of the attorney general, the commissioner of insurance shall set the fee so that the revenue generated from the fee approximates the direct and indirect costs of the investigation and prosecution of allegations of insurance fraud. The fee shall not exceed three thousand dollars and is payable on or before March 1 of each year. (b) The commissioner of insurance shall establish a tiered fee schedule that sets the annual fee required by paragraph (a) of this subsection (1) based upon the prior year’s direct written premiums, gross contract funds, or charges received in Colorado by each regulated entity. The regulated entities with direct written premiums, gross contract funds, or charges received in Colorado in excess of one million dollars shall pay one fee, and the regulated entities with one million dollars or less shall pay a lesser fee. (2) The division of insurance shall transmit fees collected pursuant to subsection (1) of this section to the state treasurer for deposit in the insurance fraud cash fund, which fund is hereby created in the state treasury. The fund consists of fees collected pursuant to this section and any other moneys deposited into the fund. Interest derived from the deposit and investment of moneys in the fund shall be credited to the fund. The moneys in the fund are subject to annual appropriation by the general assembly to the department of law for use in investigating and prosecuting allegations of insurance fraud. Any unexpended and unencumbered moneys remaining in the fund at the end of any fiscal year remain in the fund and do not revert to the general fund. (3) The attorney general shall provide annual reports to the joint budget committee, the senate business, labor, and technology committee, and the house economic and business development committee, or any successor committees, and shall post on the attorney general’s web site a statistical report of the number of full-time employees dedicated to insurance fraud, referrals, open investigations, convictions, arrests, and actions initiated, and the number of restitutions, fines, costs, and forfeitures obtained, from the investigation and prosecution of insurance fraud as provided in this section. In the report, the attorney general shall make his or her best effort to delineate between the types of cases prosecuted by line of insurance. **State:** Colorado **Statute Areas:** Fraud Bureau --- ### [Colorado-Immunity-C.R.S.A. ¤ 10-1-128; C.R.S.A. ¤ 10-4-1005](https://insurancefraud.org/statutes/colorado-immunity-c-r-s-a-¤-10-1-128-c-r-s-a-¤-10-4-1005/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (4)(a) Each insurance company licensed to do business in this state that, in a lawsuit involving a fraudulent insurance act, obtains a judgment or settlement against a person who is licensed by the state of Colorado and whose services are compensated in whole or in part, directly or indirectly, by insurance claim proceeds shall send notice of such settlement or judgment to the appropriate Colorado state licensing board, in the form prescribed by the executive director of the department of regulatory agencies. No cause of action shall arise against any insurance company or individual for providing information as provided in this subsection (4). (c) Every person who obtains a judgment or settlement involving a fraudulent insurance act by an insurance company or an agent of an insurance company may send to the Colorado division of insurance within the department of regulatory agencies notice of such judgment or settlement, including any evidence of a fraudulent insurance act. No cause of action shall arise against any person for providing information as provided in this subsection (4).\*\*\*(1) In the case of actions taken under this part 10, and except where information is furnished with knowledge that the information is false or with reckless disregard for its truth or falsity, there may be no civil penalty or damages on the part of, and no claim for relief may be brought against, any person, insurer, or authorized agency or secondary agency for furnishing information or taking other action pursuant to the provisions of this part 10. (2) Every person, insurer, and authorized agency and secondary agency is immune from civil liability when acting in good faith to cooperate with, furnish evidence to or on behalf of, provide information to, or solicit or receive information from, any of the following with regard to an actual or suspected fraudulent insurance act: (a) An agency of the federal or any state, county, or municipal government that is involved in the detection, prosecution, or prevention of arson or insurance fraud; (a.5) Any secondary agency; (b) Any employee or agent of an agency listed in subsection (2)(a) or (2)(a.5) of this section; and (c) Another insurer, if acting in accordance with section 10-4-1003 (8)(c) solely for the purpose of detecting, investigating, preventing, or prosecuting an actual or suspected fraudulent insurance act. Information so provided may not be used for underwriting or rating purposes except in connection with an application or policy under which a fraudulent insurance act was committed. (3) Every person, insurer, and authorized agency and secondary agency is immune from civil liability when acting in good faith to comply with a court order to provide evidence or testimony with regard to an actual or suspected fraudulent insurance act; except that such immunity does not apply to a person or insurer that has committed, or has conspired in or aided and abetted the commission of, such fraudulent insurance act. (4) The immunity granted by this section shall be in addition to, and not in lieu of, any right, privilege, or immunity available under the common law or any other applicable statute or rule. **State:** Colorado **Statute Areas:** Immunity --- ### [Colorado-Insurance Fraud - Definition-C.R.S.A. ¤ 18-5-211](https://insurancefraud.org/statutes/colorado-insurance-fraud-definition-c-r-s-a-¤-18-5-211/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (1) A person commits insurance fraud if the person does any of the following: (a) With an intent to defraud presents or causes to be presented in written, verbal, or digital form an application or request for the issuance, modification, or renewal of an insurance policy, which application or request, or documentation in support of such application or request, contains false material information or withholds material information that is requested by the insurer and results in the issuance of an insurance policy or insurance coverage for the applicant or another; (b) With an intent to defraud presents or causes to be presented any insurance claim, which claim contains false material information or withholds material information; (c) With an intent to defraud causes or participates, or purports to be involved, in a vehicular collision, or any other vehicular accident, for the purpose of presenting any false or fraudulent insurance claim; (d) With an intent to defraud presents or causes to be presented an insurance claim where the loss or damage claimed occurred outside of the period of time that coverage was in effect for the applicable contract of insurance or policy unless otherwise permitted under the contract of insurance or policy; or (e) With an intent to defraud presents or causes to be presented any written, verbal, or digital material or statement as part of, in support of or in opposition to, a claim for payment or other benefit pursuant to an insurance policy, knowing that the material or statement contains false material information or withholds material information. (2) A person commits insurance fraud if he or she knowingly moves, diverts, or misappropriates premium funds belonging to an insurer or unearned premium funds belonging to an insured or applicant for insurance from a trust or other account without the authorization of the owner of the funds or other lawful justification. (3) A person commits insurance fraud if he or she with an intent to defraud makes, alters, presents, or causes to be presented a certificate or other evidence of the existence of insurance in any form that contains false material information or omits material information. (4) Insurance fraud committed in violation of paragraph (a) of subsection (1) of this section is a class 1 misdemeanor. Insurance fraud committed in violation of paragraphs (b) to (e) of subsection (1) of this section or subsection (2) or (3) of this section is a class 5 felony. (5) The commissioner of insurance shall revoke the license to conduct business in this state of any licensed insurance producer under article 2 of title 10, C.R.S., who is convicted of any provision under this section. (6) No provision of this article 5 may be interpreted to supersede, limit, abrogate, or impair the ability of the prosecuting authority to concurrently bring charges for any other state criminal offense that is otherwise applicable in addition to any offenses described by this section. (7) As used in this section, unless the context otherwise requires: (a) “Claim” means a demand for money, property, or services pursuant to a contract of insurance as well as any documentation in support of such claim whether submitted contemporaneously with the claim or at a different time. A claim and any supporting information may be in written, verbal, or digital form. (b) “Insurance” has the same meaning as defined in section 10-1-102(12), C.R.S. (c) “Insurance producer” has the same meaning as defined in section 10-2-103(6), C.R.S. (d) “Insurer” has the same meaning as defined in section 10-1-102(13),C.R.S. (e) “Material information” is a statement or assertion directly pertaining to an application for insurance or an insurance claim that a reasonable person making such an assertion knows or should know will affect the action, conduct, or decision of the person who receives or is intended to receive the asserted information in a manner that would directly or indirectly benefit the person making the assertion. **State:** Colorado **Statute Areas:** Insurance Fraud - Definition --- ### [Colorado-Licensing Board Notification-C.R.S.A. ¤ 10-1-128](https://insurancefraud.org/statutes/colorado-licensing-board-notification-c-r-s-a-¤-10-1-128/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (4)(a) Each insurance company licensed to do business in this state that, in a lawsuit involving a fraudulent insurance act, obtains a judgment or settlement against a person who is licensed by the state of Colorado and whose services are compensated in whole or in part, directly or indirectly, by insurance claim proceeds shall send notice of such settlement or judgment to the appropriate Colorado state licensing board, in the form prescribed by the executive director of the department of regulatory agencies. No cause of action shall arise against any insurance company or individual for providing information as provided in this subsection (4). (b) Every person who, in a lawsuit involving a fraudulent insurance act, obtains a judgment or settlement against a person who is licensed by the state of Colorado and whose services are compensated in whole or in part, directly or indirectly, by insurance claim proceeds, may send to the appropriate Colorado state licensing board notice of such settlement or judgment. No cause of action shall arise against any person for providing information as provided in this subsection (4). **State:** Colorado --- ### [Colorado-Looting & diverting-C.R.S.A. ¤ 18-5-211](https://insurancefraud.org/statutes/colorado-looting-diverting-c-r-s-a-¤-18-5-211/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (2) A person commits insurance fraud if he or she knowingly moves, diverts, or misappropriates premium funds belonging to an insurer or unearned premium funds belonging to an insured or applicant for insurance from a trust or other account without the authorization of the owner of the funds or other lawful justification. **State:** Colorado --- ### [Colorado-Mandatory Restitution-C.R.S.A. ¤ 10-3-105](https://insurancefraud.org/statutes/colorado-mandatory-restitution-c-r-s-a-¤-10-3-105/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (4)(a) The commissioner may order an insurer to pay restitution to a person, if, after notice to the insurer and after a hearing held in accordance with sections 24-4-104 and 24-4-105, C.R.S., the commissioner finds that the insurer has violated this title or that the insurer is financially responsible for the unfair business practices of an insurance producer pursuant to section 10-3-131. **State:** Colorado **Statute Areas:** Mandatory Restitution --- ### [Colorado-Placing Bogus Coverage-C.R.S.A. ¤ 18-5-211](https://insurancefraud.org/statutes/colorado-placing-bogus-coverage-c-r-s-a-¤-18-5-211/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (1) A person commits insurance fraud if the person does any of the following: (d) With an intent to defraud presents or causes to be presented an insurance claim where the loss or damage claimed occurred outside of the period of time that coverage was in effect for the applicable contract of insurance or policy unless otherwise permitted under the contract of insurance or policy **State:** Colorado --- ### [Colorado-Practitioner Penalites-C.R.S.A. ¤ 18-5-211](https://insurancefraud.org/statutes/colorado-practitioner-penalites-c-r-s-a-¤-18-5-211/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (5) The commissioner of insurance shall revoke the license to conduct business in this state of any licensed insurance producer under article 2 of title 10, C.R.S., who is convicted of any provision under this section. **State:** Colorado **Statute Areas:** Practitioner Penalites --- ### [Colorado-Premium Fraud-C.R.S.A. ¤ 18-5-211](https://insurancefraud.org/statutes/colorado-premium-fraud-c-r-s-a-¤-18-5-211/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (2) A person commits insurance fraud if he or she knowingly moves, diverts, or misappropriates premium funds belonging to an insurer or unearned premium funds belonging to an insured or applicant for insurance from a trust or other account without the authorization of the owner of the funds or other lawful justification. **State:** Colorado **Statute Areas:** Premium Fraud --- ### [Colorado-Range of Criminal Penalties-C.R.S.A. ¤ 18-5-211](https://insurancefraud.org/statutes/colorado-range-of-criminal-penalties-c-r-s-a-¤-18-5-211/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (4) Insurance fraud committed in violation of paragraph (a) of subsection (1) of this section is a class 1 misdemeanor. Insurance fraud committed in violation of paragraphs (b) to (e) of subsection (1) of this section or subsection (2) or (3) of this section is a class 5 felony. **State:** Colorado **Statute Areas:** Range of Criminal Penalties --- ### [Colorado-Rating of an Insurance Policy-C.R.S.A. ¤ 10-4-403](https://insurancefraud.org/statutes/colorado-rating-of-an-insurance-policy-c-r-s-a-¤-10-4-403/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (1) Rates shall not be excessive, inadequate, or unfairly discriminatory. The following rate standards shall apply: (a) Rates are excessive if they are likely to produce a long run profit that is unreasonably high for the insurance provided or if expenses are unreasonably high in relation to services rendered. (b) Concerning inadequacy, rates are not inadequate unless clearly insufficient to sustain projected losses and expenses, or the use of such rates, if continued, will tend to create a monopoly in the market. (c) Concerning unfair discrimination, unfair discrimination exists if, after allowing for practical limitations, price differentials fail to reflect equitably the differences in expected losses and expenses. A rate is not unfairly discriminatory solely if different premiums result for policyholders with like loss exposures but different expenses, or like expenses but different loss exposures, so long as the rate reflects the differences with reasonable accuracy. Additionally, the provisions of section 10-3-1104(1)(f) shall apply. (2)(a) In determining whether rates comply with the excessiveness standard, the inadequacy standard, and the unfair discrimination standard, the following criteria shall apply: (I) Concerning basic factors in rates, due consideration shall be given to past and prospective loss and expense experience, to catastrophe hazards and contingencies, to events or trends, to loadings for leveling premium rates over time or for dividends or savings to be allowed or returned by insurers to their policyholders, members, or subscribers, and to all other relevant factors, including judgment; (II) Concerning expenses, the expense provisions included in the rates to be used by an insurer shall reflect the operating methods of the insurer and, so far as it is credible, its own actual and anticipated expenses experience; (III) Concerning profits, the rate shall contain provisions for contingencies and an allowance permitting a reasonable profit. In determining the reasonableness of profit, consideration should be given to all investment income attributable to premiums and the reserves associated with those premiums. (b) In setting rates, insurers shall consider past and prospective loss experience and catastrophic hazards, if any, solely within the state of Colorado. However, if there is insufficient experience within Colorado upon which a rate can be based, the insurer may consider experiences within any other state or states which have a similar cost of claim and frequency of claim experience as the state of Colorado; and, if insufficient experience is available, the insurer may use a countrywide experience. The insurer, in its rate filing or in its records, shall expressly state and describe what rate experience it is using, and for Colorado business other than workers’ compensation insurance, the insurer shall specify the state or states from which experiences were drawn and the considerations used in setting the rates. In considering experience outside the state of Colorado, as much weight as possible shall be given to the Colorado experience. The rates shall allow a reasonable margin for profit, as allowed in subparagraph (III) of paragraph (a) of this subsection (2), and contingencies. (2.1)(a) In setting rates for medical malpractice insurance, rates shall not be excessive or inadequate, as defined in this section, nor shall they be unfairly discriminatory. No rate shall be held to be excessive unless such rate is unreasonably high for the insurance provided and a reasonable degree of competition does not exist in the area with respect to the classification to which such rate is applicable. No rate shall be held to be inadequate unless such rate is unreasonably low for the insurance provided and the continued use of such rate endangers the solvency of the insurer using the same, or unless such rate is unreasonably low for the insurance provided and the use of rate by the insurer using the same has, or if continued will have, the effect of destroying competition or creating a monopoly. (b) In setting rates, medical malpractice insurers shall consider past and prospective loss experience and catastrophic hazards, if any, solely within the state of **State:** Colorado --- ### [Colorado-Unauthorized Entities-C.R.S.A. ¤ 10-3-104](https://insurancefraud.org/statutes/colorado-unauthorized-entities-c-r-s-a-¤-10-3-104/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Except for reinsurance by an authorized insurer or insurance effected pursuant to the provisions of article 5 or article 15 of this title, it is unlawful for any person, company, or corporation in this state to procure, receive, or forward applications for insurance in, or to issue or to deliver policies for, any company not legally authorized to do business in this state, as provided in this title and article 14 of title 24, C.R.S. Any person violating the provisions of this section commits a class 1 misdemeanor and shall be punished as provided in section 18-1.3-501, C.R.S. **State:** Colorado --- ### [California-Aiding & Abetting-West's Ann.Cal.Ins.Code ¤ 1871.4](https://insurancefraud.org/statutes/california-aiding-abetting-wests-ann-cal-ins-code-¤-1871-4/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) It is unlawful to do any of the following: (a) It is unlawful to do any of the following: (3) Knowingly assist, abet, conspire with, or solicit a person in an unlawful act under this section. **State:** California --- ### [California-Anti-Runner Provisions-West's Ann.Cal.Ins.Code ¤ 1871.7](https://insurancefraud.org/statutes/california-anti-runner-provisions-wests-ann-cal-ins-code-¤-1871-7/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) It is unlawful to knowingly employ runners, cappers, steerers, or other persons to procure clients or patients to perform or obtain services or benefits pursuant to Division 4 (commencing with Section 3200) of the Labor Code or to procure clients or patients to perform or obtain services or benefits under a contract of insurance or that will be the basis for a claim against an insured individual or his or her insurer. (b) Every person who violates any provision of this section or Section 549, 550, or 551 of the Penal Code shall be subject, in addition to any other penalties that may be prescribed by law, to a civil penalty of not less than five thousand dollars ($5,000) nor more than ten thousand dollars ($10,000), plus an assessment of not more than three times the amount of each claim for compensation, as defined in Section 3207 of the Labor Code or pursuant to a contract of insurance. The court shall have the power to grant other equitable relief, including temporary injunctive relief, as is necessary to prevent the transfer, concealment, or dissipation of illegal proceeds, or to protect the public. The penalty prescribed in this paragraph shall be assessed for each fraudulent claim presented to an insurance company by a defendant and not for each violation. **State:** California **Statute Areas:** Anti-Runner Provisions --- ### [California-Attempted Fraud-West's Ann.Cal.Ins.Code ¤ 1871.4](https://insurancefraud.org/statutes/california-attempted-fraud-wests-ann-cal-ins-code-¤-1871-4/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) It is unlawful to do any of the following: (3) Knowingly assist, abet, conspire with, or solicit a person in an unlawful act under this section. **State:** California **Statute Areas:** Attempted Fraud --- ### [California-Claims Fraud-West's Ann.Cal.Ins.Code ¤ 1871.4](https://insurancefraud.org/statutes/california-claims-fraud-wests-ann-cal-ins-code-¤-1871-4/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (2) Present or cause to be presented a knowingly false or fraudulent written or oral material statement in support of, or in opposition to, a claim for compensation for the purpose of obtaining or denying any compensation, as defined in Section 3207 of the Labor Code. **State:** California **Statute Areas:** Claims Fraud --- ### [California-Fraud Bureau-West's Ann.Cal.Ins.Code ¤ 1872](https://insurancefraud.org/statutes/california-fraud-bureau-wests-ann-cal-ins-code-¤-1872/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** There is created within the department the Fraud Division to enforce the provisions of Sections 549,1 and 550 of the Penal Code, and to administer the provisions of Article 3 (commencing with Section 1873). **State:** California **Statute Areas:** Fraud Bureau --- ### [California-Immunity-](https://insurancefraud.org/statutes/california-immunity/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** In the absence of fraud or malice, no insurer, or any employee or agent authorized by an insurer to act on behalf of the insurer, and no authorized governmental agency or its respective employees, shall be subject to any civil liability for libel, slander, or any other relevant cause of action by virtue of releasing or receiving any information pursuant to Section 1873 or 1873.1. Nothing in this article is intended to, nor does in any way or manner, abrogate or lessen the existing common law or statutory privileges and immunities of an insurer, or any employee or agent authorized by the insurer to act on behalf of the insurer, or of any authorized governmental agency or its respective employees. \*\*\*No insurer, or the employees or agents of any insurer, shall be subject to civil liability for libel, slander, or any other relevant tort cause of action by virtue of providing any of the following without malice: (a) Any information or reports relating to suspected fraudulent insurance transaction furnished to law enforcement officials, or licensing officials governed by the Business and Professions Code. (b) Any reports or information relating to suspected fraudulent insurance transaction furnished to other persons subject to this chapter. (c) Any information or reports required by this article or required by the commissioner under the authority granted in this chapter. **State:** California **Statute Areas:** Immunity --- ### [California-Insurance Fraud - Definition-West's Ann.Cal.Ins.Code ¤ 1871.4](https://insurancefraud.org/statutes/california-insurance-fraud-definition-wests-ann-cal-ins-code-¤-1871-4/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) It is unlawful to do any of the following: (1) Make or cause to be made a knowingly false or fraudulent material statement or material representation for the purpose of obtaining or denying any compensation, as defined in Section 3207 of the Labor Code. (2) Present or cause to be presented a knowingly false or fraudulent written or oral material statement in support of, or in opposition to, a claim for compensation for the purpose of obtaining or denying any compensation, as defined in Section 3207 of the Labor Code. (3) Knowingly assist, abet, conspire with, or solicit a person in an unlawful act under this section. (4) Make or cause to be made a knowingly false or fraudulent statement with regard to entitlement to benefits with the intent to discourage an injured worker from claiming benefits or pursuing a claim. For the purposes of this subdivision, “statement” includes, but is not limited to, a notice, proof of injury, bill for services, payment for services, hospital or doctor records, X-ray, test results, medical-legal expense as defined in Section 4620 of the Labor Code, other evidence of loss, injury, or expense, or payment. (5) Make or cause to be made a knowingly false or fraudulent material statement or material representation for the purpose of obtaining or denying any of the benefits or reimbursement provided in the Return-to-Work Program established under Section 139.48 of the Labor Code. (6) Make or cause to be made a knowingly false or fraudulent material statement or material representation for the purpose of discouraging an employer from claiming any of the benefits or reimbursement provided in the Return-to-Work Program established under Section 139.48 of the Labor Code. **State:** California **Statute Areas:** Insurance Fraud - Definition --- ### [California-Licensing Board Notification-West's Ann.Cal.Ins.Code ¤ 1873](https://insurancefraud.org/statutes/california-licensing-board-notification-wests-ann-cal-ins-code-¤-1873/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) Upon written request to an insurer by officers designated in subdivisions (a) and (b) of Section 830.1 and subdivision (a) of Section 830.2, and subdivisions (a), (c), and (i) of Section 830.3 of the Penal Code, an insurer, or agent authorized by that insurer to act on behalf of the insurer, shall release to the requesting authorized governmental agency any or all relevant information deemed important to the authorized governmental agency that the insurer may possess relating to any specific insurance fraud. Relevant information may include, but is not limited to, all of the following: (1) Insurance policy information relevant to the insurance fraud under investigation, including, but not limited to, any application for a policy. (2) Policy premium payment records which are available. (3) History of previous claims made by the insured. (4) Information relating to the investigation of the insurance fraud, including statements of any person, proof of loss, and notice of loss. (5) Complete copies of both sides of payment drafts. (b) The provisions of subdivision (a) shall not operate to authorize disclosure of medical information not otherwise authorized for disclosure pursuant to law. **State:** California --- ### [California-Mandatory Restitution-West's Ann.Cal.Ins.Code ¤ 1871.4](https://insurancefraud.org/statutes/california-mandatory-restitution-wests-ann-cal-ins-code-¤-1871-4/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (b) Every person who violates subdivision (a) shall be punished by imprisonment in a county jail for one year, or pursuant to subdivision (h) of Section 1170 of the Penal Code, for two, three, or five years, or by a fine not exceeding one hundred fifty thousand dollars ($150, 000) or double the value of the fraud, whichever is greater, or by both that imprisonment and fine. Restitution shall be ordered, including restitution for any medical evaluation or treatment services obtained or provided. The court shall determine the amount of restitution and the person or persons to whom the restitution shall be paid. A person convicted under this section may be charged the costs of investigation at the discretion of the court. **State:** California **Statute Areas:** Mandatory Restitution --- ### [California-Practitioner Penalites-West's Ann.Cal.Ins.Code ¤ 804](https://insurancefraud.org/statutes/california-practitioner-penalites-wests-ann-cal-ins-code-¤-804/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Any insurer willfully violating any provision of this article is guilty of a misdemeanor and is punishable by a fine not exceeding one thousand dollars ($1,000) for each violation thereof, or the commissioner may suspend the certificate of authority of such insurer for the remainder of the term thereof. **State:** California **Statute Areas:** Practitioner Penalites --- ### [California-Premium Fraud-West's Ann.Cal.Ins.Code ¤ 1871.4](https://insurancefraud.org/statutes/california-premium-fraud-wests-ann-cal-ins-code-¤-1871-4/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) It is unlawful to do any of the following: (1) Make or cause to be made a knowingly false or fraudulent material statement or material representation for the purpose of obtaining or denying any compensation, as defined in Section 3207 of the Labor Code. (2) Present or cause to be presented a knowingly false or fraudulent written or oral material statement in support of, or in opposition to, a claim for compensation for the purpose of obtaining or denying any compensation, as defined in Section 3207 of the Labor Code. (3) Knowingly assist, abet, conspire with, or solicit a person in an unlawful act under this section. (4) Make or cause to be made a knowingly false or fraudulent statement with regard to entitlement to benefits with the intent to discourage an injured worker from claiming benefits or pursuing a claim. **State:** California **Statute Areas:** Premium Fraud --- ### [California-Range of Criminal Penalties-West's Ann.Cal.Penal Code ¤ 550](https://insurancefraud.org/statutes/california-range-of-criminal-penalties-wests-ann-cal-penal-code-¤-550/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (c)(1) Every person who violates paragraph (1), (2), (3), (4), or (5) of subdivision (a) is guilty of a felony punishable by imprisonment pursuant to subdivision (h) of Section 1170 for two, three, or five years, and by a fine not exceeding fifty thousand dollars ($50,000), or double the amount of the fraud, whichever is greater. **State:** California **Statute Areas:** Range of Criminal Penalties --- ### [California-Rating of an Insurance Policy-West's Ann.Cal.Ins.Code ¤ 1852](https://insurancefraud.org/statutes/california-rating-of-an-insurance-policy-wests-ann-cal-ins-code-¤-1852/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Repealed. **State:** California --- ### [California-Underwriting Fraud-West's Ann.Cal.Ins.Code ¤ 804](https://insurancefraud.org/statutes/california-underwriting-fraud-wests-ann-cal-ins-code-¤-804/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Any insurer willfully violating any provision of this article is guilty of a misdemeanor and is punishable by a fine not exceeding one thousand dollars ($1,000) for each violation thereof, or the commissioner may suspend the certificate of authority of such insurer for the remainder of the term thereof. **State:** California **Statute Areas:** Underwriting Fraud --- ### [Arkansas-Aiding & Abetting-A.C.A. ¤ 23-66-501](https://insurancefraud.org/statutes/arkansas-aiding-abetting-a-c-a-¤-23-66-501/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (4) “Fraudulent insurance act” means an act or omission committed by a person who, knowingly and with intent to defraud, deceive, conceal, or misrepresent: (F) Attempts to commit, aids or abets the commission of, or conspires to commit the acts or omissions specified in this subsection; **State:** Arkansas --- ### [Arkansas-Attempted Fraud-A.C.A. ¤ 23-66-501](https://insurancefraud.org/statutes/arkansas-attempted-fraud-a-c-a-¤-23-66-501/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (4) “Fraudulent insurance act” means an act or omission committed by a person who, knowingly and with intent to defraud, deceive, conceal, or misrepresent: (F) Attempts to commit, aids or abets the commission of, or conspires to commit the acts or omissions specified in this subsection; **State:** Arkansas **Statute Areas:** Attempted Fraud --- ### [Arkansas-Claims Fraud-A.C.A. ¤ 23-66-501](https://insurancefraud.org/statutes/arkansas-claims-fraud-a-c-a-¤-23-66-501/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (4) “Fraudulent insurance act” means an act or omission committed by a person who, knowingly and with intent to defraud, deceive, conceal, or misrepresent: (A) Presents, causes to be presented, or prepares with knowledge or belief that it will be presented to an insurer, a reinsurer, broker or its agent, or by a broker or agent, false information as part of, in support of, or concerning a fact material to one (1) or more of the following: (iii) A claim for payment or benefit pursuant to an insurance policy or reinsurance contract; **State:** Arkansas **Statute Areas:** Claims Fraud --- ### [Arkansas-Failing to Remit Premium-A.C.A. ¤ 23-66-501](https://insurancefraud.org/statutes/arkansas-failing-to-remit-premium-a-c-a-¤-23-66-501/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (4) “Fraudulent insurance act” means an act or omission committed by a person who, knowingly and with intent to defraud, deceive, conceal, or misrepresent: (D) Embezzles, abstracts, purloins, or converts moneys, funds, premiums, credits, or other property of an insurer, reinsurer, or person engaged in the business of insurance; **State:** Arkansas --- ### [Arkansas-Fraud Bureau-A.C.A. ¤ 23-66-508](https://insurancefraud.org/statutes/arkansas-fraud-bureau-a-c-a-¤-23-66-508/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** There is created within the department the Fraud Division to enforce the provisions of Sections 549,1 and 550 of the Penal Code, and to administer the provisions of Article 3 (commencing with Section 1873). **State:** Arkansas **Statute Areas:** Fraud Bureau --- ### [Arkansas-Immunity-A.C.A. ¤ 23-60-111; A.C.A. 23-66-506](https://insurancefraud.org/statutes/arkansas-immunity-a-c-a-¤-23-60-111-a-c-a-23-66-506/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) In the absence of fraud or bad faith, no civil cause of action of any nature shall arise against the person for supplying any information: (1) Relating to suspected fraudulent insurance acts furnished to or received from law enforcement officials or their agents and employees; (2) Relating to suspected fraudulent insurance acts furnished to or received from other persons subject to the provisions of the insurance laws of this state; or (3) Furnished in reports to the State Insurance Department, National Association of Insurance Commissioners, or any organization established to detect and prevent fraudulent insurance acts or their agents, employees, or designees. (b) Neither the Insurance Commissioner nor any employee of the department, in the absence of fraud or bad faith, shall be subject to civil liability, and no civil cause of action of any nature shall arise against the person by virtue of the publication of any report or bulletin related to the official activities of the department. (c) Nothing in this section is intended to abrogate or modify in any way any common law or statutory privilege or immunity heretofore enjoyed by any person.\*\*\*(a) There shall be no civil liability for libel, slander, or any other cause of action imposed on, and no cause of action shall arise from a person’s furnishing information concerning suspected, anticipated, or completed fraudulent insurance acts, if the information is provided to or received from: (1) The Insurance Commissioner or the commissioner’s employees, agents, or representatives; (2) Federal, state, or local law enforcement or regulatory officials or their employees, agents, or representatives; (3) A person employed by or authorized by an insurer whose activities include the investigation or reporting of suspected fraudulent insurance acts when furnishing, disclosing, or requesting information on such suspected fraudulent insurance acts to or from a person employed by or authorized by other insurers or insurer organizations acting in the same capacity; or (4) The National Association of Insurance Commissioners or its employees, agents, or representatives. (b) Subsection (a) of this section shall not apply to statements made with actual malice. In an action brought against a person for filing a report or furnishing other information concerning a fraudulent insurance act, the party bringing the action shall plead specifically any allegation that subsection (a) of this section does not apply because the person filing the report or furnishing the information did so with actual malice. (c) This section does not abrogate or modify common law or statutory privileges or immunities enjoyed by a person described in subsection (a) of this section. **State:** Arkansas **Statute Areas:** Immunity --- ### [Arkansas-Insurance Fraud - Definition-A.C.A. ¤ 23-66-501](https://insurancefraud.org/statutes/arkansas-insurance-fraud-definition-a-c-a-¤-23-66-501/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (4) “Fraudulent insurance act” means an act or omission committed by a person who, knowingly and with intent to defraud, deceive, conceal, or misrepresent: (A) Presents, causes to be presented, or prepares with knowledge or belief that it will be presented to an insurer, a reinsurer, broker or its agent, or by a broker or agent, false information as part of, in support of, or concerning a fact material to one (1) or more of the following: (i) An application for the issuance or renewal of an insurance policy or reinsurance contract; (ii) The rating of an insurance policy or reinsurance contract; (iii) A claim for payment or benefit pursuant to an insurance policy or reinsurance contract; (iv) Premiums paid on an insurance policy or reinsurance contract; (v) Payments made in accordance with the terms of an insurance policy or reinsurance contract; (vi) A document filed with the commissioner or the chief insurance regulatory official of another jurisdiction; (vii) The financial condition of an insurer or reinsurer; (viii) The formation, acquisition, merger, reconsolidation, dissolution, or withdrawal from one (1) or more lines of insurance or reinsurance in all or part of this state by an insurer or reinsurer; (ix) The issuance of written evidence of insurance; or (x) The reinstatement of an insurance policy; (B) Solicits or accepts new or renewal insurance risks on behalf of an insurer, reinsurer, or other person engaged in the business of insurance by a person who knows or should know that the insurer or other person responsible for the risk is insolvent at the time of the transaction; (C) Removes, conceals, alters, or destroys the assets or records of an insurer, reinsurer, or other person engaged in the business of insurance; (D) Embezzles, abstracts, purloins, or converts moneys, funds, premiums, credits, or other property of an insurer, reinsurer, or person engaged in the business of insurance; (E) Transacts the business of insurance in violation of laws requiring a license, certificate of authority, or other legal authority for the transaction of the business of insurance; (F) Attempts to commit, aids or abets the commission of, or conspires to commit the acts or omissions specified in this subsection; (G) Issues false, fake, or counterfeit insurance policies, certificates of insurance, insurance identification cards, policy declaration pages or policy covers, or insurance binders or other temporary contracts of insurance; (H) Possesses or possesses in order to distribute, solicit, sell, negotiate or effectuate false, fake, or counterfeit insurance policies, certificates of insurance, insurance identification cards, policy declaration pages or policy covers, or insurance binders or other temporary contracts of insurance to consumers, lienholders or loss payees, insurance agents or producers, or other persons or entities; (I) Possesses any device, software, or printing supplies utilized to manufacture false, fake, or counterfeit insurance policies, certificates of insurance, insurance identification cards, policy declaration pages or policy covers, or insurance binders or other temporary contracts of insurance; or (J) Falsely holds himself, herself, or itself out as a representative of an insurance company or assists another in furtherance of that misrepresentation to receive a benefit under an insurance claim, contract, or policy; **State:** Arkansas **Statute Areas:** Insurance Fraud - Definition --- ### [Arkansas-Mandatory Restitution-A.C.A. ¤ 23-66-512](https://insurancefraud.org/statutes/arkansas-mandatory-restitution-a-c-a-¤-23-66-512/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (2)(A) A person convicted of a violation of ¤ 23-66-502 by a court of competent jurisdiction shall be guilty of a Class D felony. (B) A person convicted of a violation of ¤ 23-66-502 shall be ordered to pay restitution to persons aggrieved by the violation of this subchapter. (C) Restitution shall be ordered in addition to a fine or imprisonment; and (3) A person convicted of a felony violation of this subchapter pursuant to subdivision (2) of this section shall be disqualified from engaging in the business of insurance. **State:** Arkansas **Statute Areas:** Mandatory Restitution --- ### [Arkansas-Placing Bogus Coverage-A.C.A. ¤ 23-66-501](https://insurancefraud.org/statutes/arkansas-placing-bogus-coverage-a-c-a-¤-23-66-501/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (4) “Fraudulent insurance act” means an act or omission committed by a person who, knowingly and with intent to defraud, deceive, conceal, or misrepresent:(G) Issues false, fake, or counterfeit insurance policies, certificates of insurance, insurance identification cards, policy declaration pages or policy covers, or insurance binders or other temporary contracts of insurance; (H) Possesses or possesses in order to distribute, solicit, sell, negotiate or effectuate false, fake, or counterfeit insurance policies, certificates of insurance, insurance identification cards, policy declaration pages or policy covers, or insurance binders or other temporary contracts of insurance to consumers, lienholders or loss payees, insurance agents or producers, or other persons or entities; (I) Possesses any device, software, or printing supplies utilized to manufacture false, fake, or counterfeit insurance policies, certificates of insurance, insurance identification cards, policy declaration pages or policy covers, or insurance binders or other temporary contracts of insurance; or (J) Falsely holds himself, herself, or itself out as a representative of an insurance company or assists another in furtherance of that misrepresentation to receive a benefit under an insurance claim, contract, or policy; **State:** Arkansas --- ### [Arkansas-Practitioner Penalites-A.C.A. ¤ 23-66-512](https://insurancefraud.org/statutes/arkansas-practitioner-penalites-a-c-a-¤-23-66-512/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** A person who violates this subchapter is subject to the following: (1)(A) Suspension or revocation of license, civil penalties of up to ten thousand dollars ($10,000) per violation, or both. (B) Suspension or revocation of license and imposition of civil penalties shall be pursuant to an order of the Insurance Commissioner issued under ¤ 23-61-301 et seq. (C) The commissioner’s order may require a person found to be in violation of this subchapter to make restitution to persons aggrieved by violations of this subchapter; **State:** Arkansas **Statute Areas:** Practitioner Penalites --- ### [Arkansas-Premium Fraud-A.C.A. ¤ 23-66-501](https://insurancefraud.org/statutes/arkansas-premium-fraud-a-c-a-¤-23-66-501/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (4) “Fraudulent insurance act” means an act or omission committed by a person who, knowingly and with intent to defraud, deceive, conceal, or misrepresent: (A) Presents, causes to be presented, or prepares with knowledge or belief that it will be presented to an insurer, a reinsurer, broker or its agent, or by a broker or agent, false information as part of, in support of, or concerning a fact material to one (1) or more of the following: (iv) Premiums paid on an insurance policy or reinsurance contract; **State:** Arkansas **Statute Areas:** Premium Fraud --- ### [Arkansas-Range of Criminal Penalties-A.C.A. ¤ 23-66-512](https://insurancefraud.org/statutes/arkansas-range-of-criminal-penalties-a-c-a-¤-23-66-512/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (2)(A) A person convicted of a violation of ¤ 23-66-502 by a court of competent jurisdiction shall be guilty of a Class D felony. (B) A person convicted of a violation of ¤ 23-66-502 shall be ordered to pay restitution to persons aggrieved by the violation of this subchapter. **State:** Arkansas **Statute Areas:** Range of Criminal Penalties --- ### [Arkansas-Range of Civil Penalties-A.C.A. ¤ 23-60-108](https://insurancefraud.org/statutes/arkansas-range-of-civil-penalties-a-c-a-¤-23-60-108/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Unless a greater penalty is provided by another law of this state, a violation of a statute or regulation enforceable by the Insurance Commissioner is punishable: (1) By the refusal, suspension, revocation, or nonrenewal of a license or certificate of authority; and (2) A fine no greater than one thousand dollars ($1,000) per violation, not to exceed fifty thousand dollars ($50,000) in any six-month period. **State:** Arkansas **Statute Areas:** Range of Civil Penalties --- ### [Arkansas-Rating of an Insurance Policy-A.C.A. ¤ 23-67-208](https://insurancefraud.org/statutes/arkansas-rating-of-an-insurance-policy-a-c-a-¤-23-67-208/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) Rates shall not be excessive, inadequate, or unfairly discriminatory. (b) A rate in a competitive market is assumed not to be excessive. A rate is excessive in a competitive or noncompetitive market if it is likely to produce a profit from Arkansas business that is unreasonably high in relation to past and prospective loss experience for that class of business which the filing affects or if expenses are unreasonably high in relation to services rendered. (c) A rate is clearly inadequate if, together with the investment income attributable to it, it fails to satisfy projected losses and expenses in the class of business to which it applies. (d)(1) A rate is not unfairly discriminatory in relation to another in the same class of business if it reflects equitably the differences in expected losses and expenses. Rates are not unfairly discriminatory because different premiums result for policyholders with like loss exposures but different expense factors, or with like expense factors but different loss exposures, if the rates reflect the differences with reasonable accuracy. (2) A rate shall be deemed unfairly discriminatory as to a risk or group of risks if the application of premium discounts, credits, or surcharges among the risks does not bear a reasonable relationship to the expected loss and expense experience among the various risks. **State:** Arkansas --- ### [Arkansas-Underwriting Fraud-A.C.A. ¤ 23-66-501](https://insurancefraud.org/statutes/arkansas-underwriting-fraud-a-c-a-¤-23-66-501/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (4) “Fraudulent insurance act” means an act or omission committed by a person who, knowingly and with intent to defraud, deceive, conceal, or misrepresent: (A) Presents, causes to be presented, or prepares with knowledge or belief that it will be presented to an insurer, a reinsurer, broker or its agent, or by a broker or agent, false information as part of, in support of, or concerning a fact material to one (1) or more of the following: (i) An application for the issuance or renewal of an insurance policy or reinsurance contract; (ii) The rating of an insurance policy or reinsurance contract; (iii) A claim for payment or benefit pursuant to an insurance policy or reinsurance contract; (iv) Premiums paid on an insurance policy or reinsurance contract; (v) Payments made in accordance with the terms of an insurance policy or reinsurance contract; (vi) A document filed with the commissioner or the chief insurance regulatory official of another jurisdiction; (vii) The financial condition of an insurer or reinsurer; (viii) The formation, acquisition, merger, reconsolidation, dissolution, or withdrawal from one (1) or more lines of insurance or reinsurance in all or part of this state by an insurer or reinsurer; (ix) The issuance of written evidence of insurance; or (x) The reinstatement of an insurance policy; (B) Solicits or accepts new or renewal insurance risks on behalf of an insurer, reinsurer, or other person engaged in the business of insurance by a person who knows or should know that the insurer or other person responsible for the risk is insolvent at the time of the transaction; (C) Removes, conceals, alters, or destroys the assets or records of an insurer, reinsurer, or other person engaged in the business of insurance; (D) Embezzles, abstracts, purloins, or converts moneys, funds, premiums, credits, or other property of an insurer, reinsurer, or person engaged in the business of insurance; (E) Transacts the business of insurance in violation of laws requiring a license, certificate of authority, or other legal authority for the transaction of the business of insurance; **State:** Arkansas **Statute Areas:** Underwriting Fraud --- ### [Arkansas-Unauthorized Entities-A.C.A ¤ 23-65-101.](https://insurancefraud.org/statutes/arkansas-unauthorized-entities-a-c-a-¤-23-65-101/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a)(1) No person or entity in this state shall act as agent or broker for or otherwise represent or aid any insurer, health maintenance organization, multiple employer welfare arrangement, multiple employer trust, association, or any other person or entity in the solicitation, negotiation, or effectuation of insurance, inspection of risks, fixing of rates, investigation or adjustment of losses, collection of premiums, or in any other manner in the transaction of insurance with respect to subjects of insurance resident, located, or to be performed in this state if that person or entity is not authorized or licensed by the State Insurance Department for those purposes. (2)(A) No person or entity shall act as a producer, adjuster, or consultant without first obtaining appropriate licensure or registration as required by the insurance laws of this state for the transaction of insurance with respect to subjects of insurance or self-insurance resident, located, or to be performed in this state. (B) No person or entity shall act as a multiple employer trust or multiple employer welfare arrangement without first obtaining appropriate registration or licensing as required by ¤ 23-92-101. (C) No person or entity shall act as a third-party administrator for a multiple employer trust, multiple employer welfare arrangement, collectively bargained trust, self-insurance plan, or any other plan providing accident and health insurance benefits to the citizens of this state without first obtaining appropriate registration as required by ¤ 23-92-201 et seq. (D) Any producer who knows or has reason to know that a health plan is not licensed in accordance with the Arkansas Insurance Code shall immediately report the health plan to the department. (b)(1)(A) The Insurance Commissioner may summarily order a person or entity to cease and desist from an act or practice when the commissioner has reason to believe that the person or entity has not complied with the requirements of this section or any other provision of the Arkansas Insurance Code. (B) Upon the entry of the cease and desist order, the commissioner shall promptly notify the person or entity named: (i) That the order has been entered; (ii) The reasons for the order; and (iii) Of the person’s or entity’s right to a hearing on the order. (2)(A) A hearing shall be held on the written request of the person or entity named in the cease and desist order if the commissioner receives the request within thirty (30) days of the date of the entry of the order or if otherwise ordered by the commissioner. (B) If no hearing is requested and none is ordered by the commissioner, the order will remain in effect until it is modified or vacated by the commissioner. (C) If a hearing is requested or ordered and after notice of an opportunity for hearing, the commissioner may affirm, modify, or vacate the cease and desist order. (D) The person or entity named in the cease and desist order shall have the burden of proving: (i) That the actions, methods, or practices described in the order are not in violation of the Arkansas Insurance Code; and (ii) The grounds upon which the commissioner should modify or vacate an order issued under this section. (3)(A) After issuance of an order under subdivision (b)(1)(B) of this section, the commissioner may apply to Pulaski County Circuit Court to temporarily or permanently enjoin the act or practice and to enforce compliance with the Arkansas Insurance Code or any rule or order under the Arkansas Insurance Code. (B) However, the commissioner may apply directly to Pulaski County Circuit Court for a temporary or permanent injunction under subdivision (b)(3)(A) of this section. (C) Upon a proper showing, the court shall enter a permanent or temporary injunction, restraining order, or writ of mandamus. (D) The commissioner shall not be required to post a bond. (c) The commissioner may also seek and the appropriate court may grant any other ancillary relief which may be in the public interest, including the appointment of a receiver, temporary receiver, conservator, or declaratory judgment, obtaining an accounting, disgorgement, assessment of a fine, or other relief as may be appropriate in the public interest. (d) This section does not prohibit or restrict the informal disposition of a proceeding by stipulation, settlement, consent, or default. (e) Any insurance producer licensed in this state, or any other person, who knowingly sells, solicits, or negotiates a product of an unauthorized person or entity in violation of this section or who knowingly represents or aids an unauthorized person or entity in violation of this section shall be guilty of a Class D felony. (f) Any insurance producer licensed in this state, or any other person, who sells, solicits, or negotiates a product of an unauthorized person or entity in violation of this section or who represents or aids an unauthorized person or entity in violation of this section may be personally liable for all damages caused by the unauthorized person or entity, including claims unpaid by the unauthorized person or entity. (g) Any person or entity who violates or otherwise fails to comply with a cease and desist order of the commissioner under this section while that order is in effect may be subject, at the discretion of the commissioner, to any one (1) or more of the following: (1) A monetary penalty of not more than ten thousand dollars ($10,000); (2) Suspension or revocation of the person’s or entity’s license or registration; and (3) Upon the commissioner’s petition filed in Pulaski County Circuit Court and upon good cause shown, that court may order injunctive relief. (h) The following shall be applicable to hearings held, orders issued, and penalties levied by the commissioner under this section: (1) The provisions of ¤ 23-61-301, as to witnesses and evidence; (2) Section 23-61-302, as to immunity from prosecution; (3) The provisions of ¤¤ 23-61-303–23-61-305, as to hearings; (4) The provisions of ¤¤ 23-61-306 and 23-61-307, as to orders on hearings and appeals of orders; (5) The provisions of ¤ 23-66-210(a)(1), as to monetary penalties; and (6) The provisions of ¤ 23-66-212, as to judicial review of cease and desist orders. (i) The commissioner may promulgate such reasonable rules and regulations as are necessary to carry out the provisions of this section. (j)(1) The commissioner shall have the power to examine and investigate the affairs of every person or entity suspected of engaging in activities which are prohibited by this section or by any other provision of the Arkansas Insurance Code. (2) All licensees of the commissioner shall assist the commissioner in examinations and investigations conducted under this section. (k) The powers vested in the commissioner by this section shall be additional to any other powers to enforce any penalties, fines, or forfeitures authorized by law or other provisions of the Arkansas Insurance Code with respect to activities that are prohibited by this section or the Arkansas Insurance Code. (l) This section shall not apply to: (1) Acceptance of service of process by the commissioner under ¤ 23-65-203; and (2) Surplus lines insurance and other transactions as to which a certificate of authority is not required of an insurer, as stated in ¤ 23-63-201. **State:** Arkansas --- ### [Arizona-Aiding & Abetting-A.R.S. ¤ 20-463](https://insurancefraud.org/statutes/arizona-aiding-abetting-a-r-s-¤-20-463/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** A. It is a fraudulent practice and unlawful for a person to knowingly: 1. Present, cause to be presented or prepare with the knowledge or belief that it will be presented an oral or written statement, including computer generated documents, to or by an insurer, reinsurer, purported insurer or reinsurer, insurance producer or agent of a reinsurer that contains untrue statements of material fact or that fails to state any material fact with respect to any of the following: 5. Assist, abet, solicit or conspire with another person to violate paragraph 1 of this subsection. **State:** Arizona --- ### [Arizona-Anti-Runner Provisions-A.R.S. ¤ 20-463](https://insurancefraud.org/statutes/arizona-anti-runner-provisions-a-r-s-¤-20-463/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** A. It is a fraudulent practice and unlawful for a person to knowingly: 1. Present, cause to be presented or prepare with the knowledge or belief that it will be presented an oral or written statement, including computer generated documents, to or by an insurer, reinsurer, purported insurer or reinsurer, insurance producer or agent of a reinsurer that contains untrue statements of material fact or that fails to state any material fact with respect to any of the following: 6. Employ, use or act as a runner, capper or steerer for the purposes of violating paragraph 1 of this subsectio **State:** Arizona **Statute Areas:** Anti-Runner Provisions --- ### [Arizona-Attempted Fraud-A.R.S. ¤ 20-463](https://insurancefraud.org/statutes/arizona-attempted-fraud-a-r-s-¤-20-463/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** A. It is a fraudulent practice and unlawful for a person to knowingly: 3. Conceal or attempt to conceal from the department or remove or attempt to remove from the home office, place of safekeeping or other place of business of any insurer, reinsurer or other entity licensed to transact insurance business in this state part or all of the assets or records of the assets, transactions and affairs. 4. Divert or attempt or conspire to divert the monies of an insurer, reinsurer, entity licensed to transact insurance business in this state or other person in connection with: (a) The transaction of insurance or reinsurance. (b) The conduct of business activities by any insurer, reinsurer or other entity licensed to transact insurance business in this state. (c) The formation, acquisition or dissolution of any insurer, reinsurer or other entity licensed to transact insurance business in this state. **State:** Arizona **Statute Areas:** Attempted Fraud --- ### [Arizona-Claims Fraud-A.R.S. ¤ 20-463](https://insurancefraud.org/statutes/arizona-claims-fraud-a-r-s-¤-20-463/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** A. It is a fraudulent practice and unlawful for a person to knowingly: 1. Present, cause to be presented or prepare with the knowledge or belief that it will be presented an oral or written statement, including computer generated documents, to or by an insurer, reinsurer, purported insurer or reinsurer, insurance producer or agent of a reinsurer that contains untrue statements of material fact or that fails to state any material fact with respect to any of the following: (c) A claim for payment or benefit pursuant to an insurance policy. **State:** Arizona **Statute Areas:** Claims Fraud --- ### [Arizona-Failing to Remit Premium-A.R.S. ¤ 20-463](https://insurancefraud.org/statutes/arizona-failing-to-remit-premium-a-r-s-¤-20-463/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** A. It is a fraudulent practice and unlawful for a person to knowingly: 1. Present, cause to be presented or prepare with the knowledge or belief that it will be presented an oral or written statement, including computer generated documents, to or by an insurer, reinsurer, purported insurer or reinsurer, insurance producer or agent of a reinsurer that contains untrue statements of material fact or that fails to state any material fact with respect to any of the following:(d) Premiums paid on any insurance policy. **State:** Arizona --- ### [Arizona-Fraud Bureau-A.R.S. ¤ 20-466](https://insurancefraud.org/statutes/arizona-fraud-bureau-a-r-s-¤-20-466/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** A. A fraud unit is established in the department of insurance. B. The fraud unit shall work in conjunction with the department of public safety. C. The director may investigate any act or practice of fraud prohibited by ¤ 20-466.01 and any other act or practice of fraud against an insurer or entity licensed under this title. The director shall administer the fraud unit. D. The director may employ investigators for the fraud unit. A fraud unit investigator has and shall exercise the law enforcement powers of a peace officer of this state but only while acting in the course and scope of employment for the department. The director shall adopt guidelines for the conduct of investigations that are substantially similar to the investigative policy and procedural guidelines of the department of public safety for peace officers. Fraud unit investigators shall not preempt the authority and jurisdiction of other law enforcement agencies of this state or its political subdivisions. Fraud unit investigators: 1. Shall have at least the qualifications prescribed by the Arizona peace officer standards and training board pursuant to ¤ 41-1822. 2. Are not eligible to participate in the public safety personnel retirement system established by title 38, chapter 5, article 41 due solely to employment as fraud unit investigators. E. The director may request the submission of papers, documents, reports or other evidence relating to an investigation under this section. The director may issue subpoenas and take other actions pursuant to ¤ 20-160. The materials are privileged and confidential until the director completes the investigation. Any documents, materials or other information that is provided to the director pursuant to this section is not subject to discovery or subpoena until opened for public inspection by the director or, after notice and a hearing, a court determines that the director would not be unduly burdened by compliance with the subpoena. The director shall keep the identity of an informant confidential, including any information that might identify the informant, unless the request for information is made by a law enforcement agency, the attorney general or a county attorney for purposes of a criminal investigation or prosecution. The director may use the documents, materials or other information in the furtherance of any regulatory or legal action brought as a part of the director’s official duties. F. If the documents, materials or other information the director seeks to obtain by request is located outside this state, the person requested to provide the documents, materials or other information shall arrange for the fraud unit or a representative, including an official of the state in which the documents, materials or other information is located, to examine the documents, materials or other information where it is located. The director may respond to similar requests from other states. G. An insurer that believes a fraudulent claim has been or is being made shall send to the director, on a form prescribed by the director, information relative to the claim including the identity of parties claiming loss or damage as a result of an accident and any other information the fraud unit may require. The director shall review the report and determine if further investigation is necessary. If the director determines that further investigation is necessary, the director may conduct an independent investigation to determine if fraud, deceit or intentional misrepresentation in the submission of the claim exists. If the director is satisfied that fraud, deceit or intentional misrepresentation of any kind has been committed in the submission of a claim, the director may report the violations of the law to the reporting insurer, to the appropriate licensing agency as defined in ¤ 20-466.04 and to the appropriate county attorney or the attorney general for prosecution. H. The director may: 1. Share nonpublic documents, materials or other information with other state, federal and international regulatory agencies, with the national association of insurance commissioners and its affiliates and subsidiaries and with state, federal and international law enforcement authorities if the recipient agrees and warrants that it has the authority to maintain the confidentiality and privileged status of the documents, materials or other information. 2. Receive documents, materials and other information from the national association of insurance commissioners and its affiliates and subsidiaries and from regulatory and law enforcement officials of other jurisdictions and shall maintain as confidential or privileged any document, material or other information received with notice or the understanding that it is confidential or privileged under the laws of the jurisdiction that is the source of the document, material or other information. 3. Enter into agreements that govern the sharing and use of documents, materials and other information and that are consistent with this section. I. A disclosure to or by the director pursuant to this section or as a result of sharing information pursuant to subsection G of this section is not a waiver of any applicable privilege or claim of confidentiality in the documents, materials or other information disclosed or shared. J. The director shall annually assess each insurer as defined in ¤ 20-441, subsection B authorized to transact business in this state up to one thousand fifty dollars, as annually adjusted pursuant to this subsection for the administration and operation of the fraud unit and the prosecution of fraud pursuant to this section. Monies collected shall be deposited, pursuant to ¤¤ 35-146 and 35-147, in the state general fund. The director shall annually revise the assessment amount in such a manner that the revenue derived from the assessment equals at least ninety-five per cent but not more than one hundred ten per cent of the appropriated budget of the fraud unit for the prior fiscal year. K. A person, or an officer, employee or agent of the person acting within the scope of employment or agency of that officer, employee or agent, who in good faith files a report or provides other information to the fraud unit pursuant to this section is not subject to civil or criminal liability for reporting that information to the fraud unit. **State:** Arizona **Statute Areas:** Fraud Bureau --- ### [Arizona-Immunity-A.R.S. ¤ 20-463](https://insurancefraud.org/statutes/arizona-immunity-a-r-s-¤-20-463/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** B. A person who acts without malice, fraudulent intent or bad faith is not subject to liability for filing reports or furnishing orally or in writing other information concerning suspected, anticipated or completed fraudulent insurance acts if the reports or information is provided to or received from: 1. The director or the department. 2. Law enforcement officials and their agents and employees. 3. The national association of insurance commissioners, other state insurance departments, a federal or state agency or bureau established to detect and prevent fraudulent insurance acts, and the agency’s or bureau’s agents, employees or designees, or an organization established by insurers to assist in the detection and prevention of fraudulent insurance acts, and the organization’s agents, employees or designees. C. A person, or an officer, employee or agent of the person acting within the scope of employment or agency of that officer, employee or agent, identified under subsection B, paragraph 1, 2 or 3 when performing authorized activities without malice, fraudulent intent or bad faith is not subject to civil liability for libel, slander or another relevant tort. No civil cause of action may be brought against the person or entity. D. A person or entity under subsection B or C is entitled to an award of attorney fees and costs if the person or entity is a prevailing party in a civil cause of action for libel, slander or other relevant tort and the action is not substantially justified. For purposes of this subsection, “substantially justified” means a proceeding that has a reasonable basis in law or fact at the time that it is initiated. E. Nothing in this section limits any common law right of the person or entity. F. Nothing in this section is intended to prohibit contact or communication with clients or patients for any lawful purpose, including communication by and between insurers, the insurers’ policyholders and claimants under policies issued to the insurers’ policyholders regarding the investigation or settlement of any claim. **State:** Arizona **Statute Areas:** Immunity --- ### [Arizona-Insurance Fraud - Definition-A.R.S. ¤ 20-463](https://insurancefraud.org/statutes/arizona-insurance-fraud-definition-a-r-s-¤-20-463/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** A. It is a fraudulent practice and unlawful for a person to knowingly: 1. Present, cause to be presented or prepare with the knowledge or belief that it will be presented an oral or written statement, including computer generated documents, to or by an insurer, reinsurer, purported insurer or reinsurer, insurance producer or agent of a reinsurer that contains untrue statements of material fact or that fails to state any material fact with respect to any of the following: (a) An application for the issuance or renewal of an insurance policy. (b) The rating of an insurance policy. (c) A claim for payment or benefit pursuant to an insurance policy. (d) Premiums paid on any insurance policy. (e) Payments made pursuant to the terms of any insurance policy. (f) An application for a certificate of authority. (g) The financial condition of an insurer, reinsurer or purported insurer or reinsurer. (h) The acquisition of an insurer or reinsurer or the concealing of any information concerning any fact material to the acquisition. 2. Solicit or accept new or renewal insurance risks by or for any insolvent insurer, reinsurer or other entity licensed to transact insurance business in this state. 3. Conceal or attempt to conceal from the department or remove or attempt to remove from the home office, place of safekeeping or other place of business of any insurer, reinsurer or other entity licensed to transact insurance business in this state part or all of the assets or records of the assets, transactions and affairs. 4. Divert or attempt or conspire to divert the monies of an insurer, reinsurer, entity licensed to transact insurance business in this state or other person in connection with: (a) The transaction of insurance or reinsurance. (b) The conduct of business activities by any insurer, reinsurer or other entity licensed to transact insurance business in this state. (c) The formation, acquisition or dissolution of any insurer, reinsurer or other entity licensed to transact insurance business in this state. 5. Assist, abet, solicit or conspire with another person to violate paragraph 1 of this subsection. 6. Employ, use or act as a runner, capper or steerer for the purposes of violating paragraph 1 of this subsection. B. A person who acts without malice, fraudulent intent or bad faith is not subject to liability for filing reports or furnishing orally or in writing other information concerning suspected, anticipated or completed fraudulent insurance acts if the reports or information is provided to or received from: 1. The director or the department. 2. Law enforcement officials and their agents and employees. 3. The national association of insurance commissioners, other state insurance departments, a federal or state agency or bureau established to detect and prevent fraudulent insurance acts, and the agency’s or bureau’s agents, employees or designees, or an organization established by insurers to assist in the detection and prevention of fraudulent insurance acts, and the organization’s agents, employees or designees. C. A person, or an officer, employee or agent of the person acting within the scope of employment or agency of that officer, employee or agent, identified under subsection B, paragraph 1, 2 or 3 when performing authorized activities without malice, fraudulent intent or bad faith is not subject to civil liability for libel, slander or another relevant tort. No civil cause of action may be brought against the person or entity. D. A person or entity under subsection B or C is entitled to an award of attorney fees and costs if the person or entity is a prevailing party in a civil cause of action for libel, slander or other relevant tort and the action is not substantially justified. For purposes of this subsection, “substantially justified” means a proceeding that has a reasonable basis in law or fact at the time that it is initiated. E. Nothing in this section limits any common law right of the person or entity. F. Nothing in this section is intended to prohibit contact or communication with clients or patients for any lawful purpose, including communication by and between insurers, the insurers’ policyholders and claimants under policies issued to the insurers’ policyholders regarding the investigation or settlement of any claim. G. For the purposes of this section: 1. “Runner”, “capper” or “steerer” means a person who procures clients at the direction of, or in cooperation with, a person who intends to perform or obtain services or benefits under a contract of insurance or who intends to assert a claim against an insured. 2. “Statement” includes any notice, proof of injury, bill for services, payment for services, hospital or doctor records, x-rays, test reports, medical or legal expenses, or other evidence of loss or injury, or other expense or payment. **State:** Arizona **Statute Areas:** Insurance Fraud - Definition --- ### [Arizona-Looting & diverting-A.R.S. ¤ 20-463](https://insurancefraud.org/statutes/arizona-looting-diverting-a-r-s-¤-20-463/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** A. It is a fraudulent practice and unlawful for a person to knowingly: 4. Divert or attempt or conspire to divert the monies of an insurer, reinsurer, entity licensed to transact insurance business in this state or other person in connection with: (a) The transaction of insurance or reinsurance. (b) The conduct of business activities by any insurer, reinsurer or other entity licensed to transact insurance business in this state. (c) The formation, acquisition or dissolution of any insurer, reinsurer or other entity licensed to transact insurance business in this state. **State:** Arizona --- ### [Arizona-Mandatory Restitution-A.R.S. ¤ 20-466.02](https://insurancefraud.org/statutes/arizona-mandatory-restitution-a-r-s-¤-20-466-02/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** A. On request by the director, the attorney general may seek and obtain in an action in the superior court an injunction that prohibits a person from engaging in practices or doing any acts that violate ¤ 20-463, 20-463.01 or 23-1028. The court may enter any order or judgment that is necessary to: 2. Return any monies, interest or real or personal property that was acquired by an act or practice that is unlawful under ¤ 20-463, 20-463.01 or 23-1028. B. An order of restitution may also include expenses incurred and paid by an insurer in connection with any medical evaluation or treatment services. C. If the court finds that a person has violated ¤ 20-463, 20-463.01 or 23-1028, the attorney general on petition or complaint to the court may recover from that person on behalf of the state a civil penalty of not more than five thousand dollars for each violation. D. In any action pursuant to this section, the court may award the attorney general costs including reasonable attorney fees and investigative costs for the services rendered. **State:** Arizona **Statute Areas:** Mandatory Restitution --- ### [Arizona-Placing Bogus Coverage-A.R.S. ¤ 20-463](https://insurancefraud.org/statutes/arizona-placing-bogus-coverage-a-r-s-¤-20-463/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** A. It is a fraudulent practice and unlawful for a person to knowingly: 1. Present, cause to be presented or prepare with the knowledge or belief that it will be presented an oral or written statement, including computer generated documents, to or by an insurer, reinsurer, purported insurer or reinsurer, insurance producer or agent of a reinsurer that contains untrue statements of material fact or that fails to state any material fact with respect to any of the following: (c) A claim for payment or benefit pursuant to an insurance policy; (e) Payments made pursuant to the terms of any insurance policy. **State:** Arizona --- ### [Arizona-Practitioner Penalites-A.R.S. ¤ 20-220](https://insurancefraud.org/statutes/arizona-practitioner-penalites-a-r-s-¤-20-220/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** A. The director may after a hearing refuse to renew or may revoke or suspend an insurer’s certificate of authority, in addition to other grounds therefor in this title, if the insurer: 1. Violates any provision of this title other than a provision as to which refusal, suspension or revocation is mandatory. 2. Knowingly fails to comply with any lawful rule or order of the director. 3. Is found by the director to be in unsound condition or in such condition as to render its further transaction of insurance in this state hazardous to its policyholders or to the people of this state. 4. Usually compels claimants under its policies to accept less than the amount due them or to bring suit against it to secure full payment thereof. 5. Refuses to be examined or to produce its accounts, records and files for examination by the director when required. 6. Fails to pay any final judgment rendered against it in this state within thirty days after the judgment becomes final. 7. Is affiliated with and under the same general management or interlocking directorate or ownership as another insurer which transacts direct insurance in this state without having a certificate of authority therefor, except as permitted to a surplus lines insurer under article 5 of this chapter.1 B. If after a hearing the director finds grounds pursuant to subsection A to suspend or revoke an insurer’s certificate of authority, the director may impose, in lieu of or in addition to such suspension or revocation, the following civil penalties: 1. A penalty not to exceed one thousand dollars for each violation and not to exceed an aggregate of ten thousand dollars within any six-month period with respect to unintentional violations. 2. A penalty not to exceed five thousand dollars for each violation and not to exceed an aggregate of fifty thousand dollars within any six-month period with respect to intentional violations. The insurer shall pay the civil penalty to the director who shall deposit it, pursuant to ¤¤ 35-146 and 35-147, in the state general fund. The civil penalty is in addition to any other penalty imposed by law. C. The director may adopt rules to provide the criteria to be used for identifying insurers who are found to be in a condition that would render the continuance of their business hazardous to their policyholders or the people of this state. **State:** Arizona **Statute Areas:** Practitioner Penalites --- ### [Arizona-Premium Fraud-A.R.S. ¤ 20-463](https://insurancefraud.org/statutes/arizona-premium-fraud-a-r-s-¤-20-463/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** A. It is a fraudulent practice and unlawful for a person to knowingly: 1. Present, cause to be presented or prepare with the knowledge or belief that it will be presented an oral or written statement, including computer generated documents, to or by an insurer, reinsurer, purported insurer or reinsurer, insurance producer or agent of a reinsurer that contains untrue statements of material fact or that fails to state any material fact with respect to any of the following: (d) Premiums paid on any insurance policy. **State:** Arizona **Statute Areas:** Premium Fraud --- ### [Arizona-Range of Civil Penalties-A.R.S. ¤ 20-466.02](https://insurancefraud.org/statutes/arizona-range-of-civil-penalties-a-r-s-¤-20-466-02/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** A. On request by the director, the attorney general may seek and obtain in an action in the superior court an injunction that prohibits a person from engaging in practices or doing any acts that violate ¤ 20-463, 20-463.01 or 23-1028. The court may enter any order or judgment that is necessary to: 1. Prevent any act or practice that is unlawful under ¤ 20-463, 20-463.01 or 23-1028. 2. Return any monies, interest or real or personal property that was acquired by an act or practice that is unlawful under ¤ 20-463, 20-463.01 or 23-1028. B. An order of restitution may also include expenses incurred and paid by an insurer in connection with any medical evaluation or treatment services. C. If the court finds that a person has violated ¤ 20-463, 20-463.01 or 23-1028, the attorney general on petition or complaint to the court may recover from that person on behalf of the state a civil penalty of not more than five thousand dollars for each violation. D. In any action pursuant to this section, the court may award the attorney general costs including reasonable attorney fees and investigative costs for the services rendered. **State:** Arizona **Statute Areas:** Range of Civil Penalties --- ### [Arizona-Rating of an Insurance Policy-A.R.S. ¤ 20-356](https://insurancefraud.org/statutes/arizona-rating-of-an-insurance-policy-a-r-s-¤-20-356/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** All rates subject to this article shall be made in accordance with the following provisions: 1. Rates shall not be excessive, inadequate or unfairly discriminatory. No rate shall be held to be inadequate unless the director finds that the loss experience of the insurer in the classification covered by the rate has been adverse for a continuous period of not less than two years immediately preceding the date of such finding. 2. Due consideration shall be given to past and prospective loss experience within and outside this state, to catastrophe hazards, if any, to a reasonable margin for underwriting profit and contingencies, to dividends, savings or unabsorbed premium deposits allowed or returned by insurers to their policyholders, members or subscribers, to past and prospective expenses within and outside this state and to all other relevant factors within and outside this state. 3. The systems of expense provisions included in the rates for use by any insurer or group of insurers may differ from those of other insurers or groups of insurers to reflect the requirements of the operating methods of any such insurer or group with respect to any kind of insurance, or with respect to any subdivision or combination thereof for which subdivision or combination separate expense provisions are applicable. 4. Risks may be grouped by classifications for the establishment of rates and minimum premiums. Classification rates may be modified to produce rates for individual risks in accordance with rating plans which establish standards for measuring variations in hazards or expense provisions, or both. Such standards may measure any differences among risks that can be demonstrated to have a probable effect upon losses or expenses. 5. Nothing in this article shall be construed to prohibit payment of dividends by insurers issuing policies on the participating plan, or by mutual or reciprocal insurers, but in the payment of such dividends there shall be no unfair discrimination between policyholders. 6. Except to the extent necessary to meet the provisions of paragraph 1, uniformity among insurers in any matters within the scope of this section is neither required nor prohibited. **State:** Arizona --- ### [Arizona-Unauthorized Entities-A.R.S. ¤ 20-401.01](https://insurancefraud.org/statutes/arizona-unauthorized-entities-a-r-s-¤-20-401-01/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** A. It is unlawful for any insurer to transact insurance business, as provided by ¤ 20-106, in this state without a certificate of authority from the director. B. The provisions of subsection A of this section do not apply to: 1. The lawful transaction of surplus lines insurance. 2. The lawful transaction of reinsurance by insurers. 3. Transactions in this state involving a policy lawfully solicited, written and delivered outside of this state covering only subjects of insurance not resident, located or expressly to be performed in this state at the time of issuance, and which transactions are subsequent to the issuance of such policy. 4. Attorneys acting in the ordinary relation of attorney and client in the adjustment of claims or losses. 5. Transactions in this state involving group annuities where the master policy of such groups was lawfully issued and delivered in and pursuant to the laws of a state in which the insurer was authorized to do an insurance business, to a group organized for purposes other than the procurement of insurance, and where the policyholder is domiciled or otherwise has a bona fide situs. 6. Transactions in this state involving any policy of insurance or annuity contract issued prior to August 13, 1972. 7. Transactions in this state relative to a policy issued or to be issued outside this state involving insurance on vessels, craft or hulls, cargoes, marine builder’s risk, marine protection and indemnity or other risk, including strikes and war risks commonly insured under ocean or wet marine forms of policy. 8. Transactions in this state involving contracts of insurance not readily obtainable from insurers authorized to transact insurance in this state issued to one or more industrial insureds, as defined in ¤ 20-401.07. **State:** Arizona --- ### [Alaska-Aiding & Abetting-¤ 21.36.360](https://insurancefraud.org/statutes/alaska-aiding-abetting-¤-21-36-360/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** \*(b) A fraudulent insurance act is committed by a person who, with intent to injure, defraud, or deceive; (3) assists or conspires with another to prepare or make a written or oral statement that is presented to an insurer in support of a claim for a benefit under an insurance policy, knowing that the statement contains false, incomplete, or misleading information concerning a matter material to the claim; **State:** Alaska --- ### [Alaska-Claims Fraud-AS ¤ 21.36.360](https://insurancefraud.org/statutes/alaska-claims-fraud-as-¤-21-36-360/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** \*(b) A fraudulent insurance act is committed by a person who, with intent to injure, defraud, or deceive; (2) presents to an insurer a written or oral statement in support of a claim for payment or other benefit under an insurance policy, knowing that the statement contains false, incomplete, or misleading information or omits information concerning a matter material to the claim; (7) makes a written or oral statement in response to an insurer’s inquiries related to another person’s claim for payment or other benefit under an insurance policy, knowing that the statement contains false, incomplete, or misleading information or omits information concerning a matter material to the claim. **State:** Alaska **Statute Areas:** Claims Fraud --- ### [Alaska-Failing to Remit Premium-AS ¤ 21.36.360](https://insurancefraud.org/statutes/alaska-failing-to-remit-premium-as-¤-21-36-360/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (b) A fraudulent insurance act is committed by a person who, with intent to injure, defraud, or deceive,(5) fails to make disposition of funds received or held or misappropriates funds received or held representing premiums or return premiums; **State:** Alaska --- ### [Alaska-False Claims Act-n/a](https://insurancefraud.org/statutes/alaska-false-claims-act-n-a/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** No statute found. Legislation pending under HB 347. **State:** Alaska **Statute Areas:** False Claims Act --- ### [Alaska-Immunity-AS ¤ 21.36.365](https://insurancefraud.org/statutes/alaska-immunity-as-¤-21-36-365/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) A person is not liable for civil damages for filing a report with or furnishing other information whether written or oral, concerning suspected, anticipated, or completed fraudulent acts to (1) law enforcement officials, their agents, and employees; (2) the National Association of Insurance Commissioners, the division of insurance, an agency in a state that regulates insurance, or an organization established to detect and prevent fraudulent insurance acts, their agents, employees, or designees; (3) a person involved in the prevention and detection of fraudulent insurance acts or that person’s employees, agents, or representatives. (b) This section does not preclude liability for civil damages as a result of reckless, wilful, or intentional misconduct. **State:** Alaska **Statute Areas:** Immunity --- ### [Alaska-Insurance Fraud - Definition-AS ¤ 21.36.360](https://insurancefraud.org/statutes/alaska-insurance-fraud-definition-as-¤-21-36-360/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (b) A fraudulent insurance act is committed by a person who, with intent to injure, defraud, or deceive, (1) collects a sum as premium or charge for insurance if the insurance has not been provided or is not in due course to be provided, subject to acceptance of the risk by the insurer, by an insurance policy authorized under this title; (2) presents to an insurer a written or oral statement in support of a claim for payment or other benefit under an insurance policy, knowing that the statement contains false, incomplete, or misleading information or omits information concerning a matter material to the claim; (3) assists or conspires with another to prepare or make a written or oral statement that is presented to an insurer in support of a claim for a benefit under an insurance policy, knowing that the statement contains false, incomplete, or misleading information or omits information concerning a matter material to the claim; (4) wilfully collects as premium or charge for insurance a sum in excess of the premium or charge applicable to the insurance as specified in the policy by the insurer in accordance with the applicable classifications and rates approved by the director, or in cases where classifications and rates are not subject to approval, the premiums and charges applicable to the insurance as specified in the policy and fixed by the insurer; (5) fails to make disposition of funds received or held or misappropriates funds received or held representing premiums or return premiums; (6) fails to pay its tax liability under this title when due; or (7) makes a written or oral statement in response to an insurer’s inquiries related to another person’s claim for payment or other benefit under an insurance policy, knowing that the statement contains false, incomplete, or misleading information or omits information concerning a matter material to the claim. (c) A fraudulent insurance act is committed by a person forming or proposing to form an insurer, an insurance holding corporation, a stock corporation to finance an insurer or insurance production, a corporation to manage an insurer, a corporation to be attorney-in-fact for a reciprocal insurer, or a syndicate for any of these purposes that advertises, or solicits or receives funds, agreement, stock subscription, or membership on account unless the person has applied for and has received from the director a solicitation permit as required by AS 21.69. (d) A fraudulent insurance act is committed by a person who makes a false sworn statement that the person does not believe to be true as to matter material to an examination, investigation, or hearing of the division. (e) A fraudulent insurance act is committed by a person if (1) as to a matter material to an examination, investigation, or hearing by the division, the person makes two or more sworn statements that are irreconcilably inconsistent to the degree that one of them is necessarily false; and (2) the person does not believe one of the statements to be true at the time the statement is made. (f) A fraudulent insurance act is committed by a person who with intent to deceive, knowingly exhibits a false account, document, or advertisement, relative to the affairs of an insurer, a corporation, or syndicate of the kind described in AS 21.69.060, formed or proposed to be formed. (g) A fraudulent insurance act is committed by a person who wrongfully removes or attempts to remove records from the place where they are required to be kept under AS 21.69.390(a) or who conceals or attempts to conceal records from the director. (h) Repealed by SLA 2015, ch. 34, ¤ 52, eff. July 1, 2015. (i) A criminal insurance act is committed by a person doing business in this state or relative to a subject resident, located, or to be performed in this state who knowingly (1) writes, places, or causes to be written or placed in this state or relative to a subject resident, located, or to be performed in this state a policy, duplicate policy, or contract of insurance of any kind or character, or general or floating policy upon persons or property resident, situated, or located in this state, from or through a person not authorized to transact business under AS 21.27 or a risk retention group or purchasing group not registered under AS 21.96.090; or (2) pays a commission or other form of remuneration to a person, firm, or organization for the writing or placing of insurance coverage in this state or relative to a subject resident, located, or to be performed in this state unless that person, firm, or organization is authorized under AS 21.27 to transact the kind or class of insurance written or placed, or, in the case of a risk retention group or purchasing group, is registered under AS 21.96.090. (j) A criminal insurance act is committed by a person in this state or relative to a subject resident, located, or to be performed in this state who acts as an insurance producer, managing general agen **State:** Alaska **Statute Areas:** Insurance Fraud - Definition --- ### [Alaska-Licensing Board Notification-AS ¤ 21.36.390.](https://insurancefraud.org/statutes/alaska-licensing-board-notification-as-¤-21-36-390/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) An insurer or licensee that has reason to believe that a fraudulent claim has been made against it shall send the director a report disclosing information that the director may require. (b) An insurer or licensee that has reason to believe that an insurance producer with which it is doing business is involved in a defalcation, embezzlement, or violation of the provisions of AS 21.36.030, 21.36.050, or 21.36.360 shall immediately send the director a report disclosing the basis for that belief and any other information that the director may require. (c) An insurer or licensee, its employee or agent, or another person acting in good faith is not civilly liable for damages resulting from the filing of the report or the furnishing of information required by this section or by the director. (d) The director shall investigate facts reported under this section and shall refer facts indicating a violation of law to the appropriate prosecutor or agency. **State:** Alaska --- ### [Alaska-Looting & diverting-AS ¤ 21.36.360.](https://insurancefraud.org/statutes/alaska-looting-diverting-as-¤-21-36-360/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** \*(b) A fraudulent insurance act is committed by a person who, with intent to injure, defraud, or deceive;(4) wilfully collects as premium or charge for insurance a sum in excess of the premium or charge applicable to the insurance as specified in the policy by the insurer in accordance with the applicable classifications and rates approved by the director, or in cases where classifications and rates are not subject to approval, the premiums and charges applicable to the insurance as specified in the policy and fixed by the insurer; **State:** Alaska --- ### [Alaska-Mandatory Restitution-AS ¤ 12.55.045](https://insurancefraud.org/statutes/alaska-mandatory-restitution-as-¤-12-55-045/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Section 12.55.045 (a) The court shall, when presented with credible evidence, unless the victim or other person expressly declines restitution, order a defendant convicted of an offense to make restitution as provided in this section, including restitution to the victim or other person injured by the offense, to a public, private, or private nonprofit organization that has provided or is or will be providing counseling, medical, or shelter services to the victim or other person injured by the offense, or as otherwise authorized by law. The court shall, when presented with credible evidence, unless the victim expressly declines restitution, also order a defendant convicted of an offense to compensate a victim that is a nonprofit organization for the value of labor or goods provided by volunteers if the labor or goods were necessary to alleviate or mitigate the effects of the defendant’s crime. In determining the amount and method of payment of restitution or compensation, the court shall take into account the (1) public policy that favors requiring criminals to compensate for damages and injury to their victims; and (2) financial burden placed on the victim and those who provide services to the victim and other persons injured by the offense as a result of the criminal conduct of the defendant. **State:** Alaska **Statute Areas:** Mandatory Restitution --- ### [Alaska-Placing Bogus Coverage-n/a](https://insurancefraud.org/statutes/alaska-placing-bogus-coverage-n-a/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** Nostatute found. **State:** Alaska --- ### [Alaska-Practitioner Penalites-AS ¤ 21.09.260](https://insurancefraud.org/statutes/alaska-practitioner-penalites-as-¤-21-09-260/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** An insurer that the director determines, following an appropriate hearing as provided in AS 21.06.170 – 21.06.230, has violated the provisions of AS 21.09.250 is subject to a civil penalty of not more than $2,500 for each violation. The director may suspend or revoke the license of the insurer for a violation of AS 21.09.250, but violation does not invalidate the insurance contract. **State:** Alaska **Statute Areas:** Practitioner Penalites --- ### [Alaska-Premium Fraud-AS ¤ 21.36.360](https://insurancefraud.org/statutes/alaska-premium-fraud-as-¤-21-36-360/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (b) A fraudulent insurance act is committed by a person who, with intent to injure, defraud, or deceive, (1) collects a sum as premium or charge for insurance if the insurance has not been provided or is not in due course to be provided, subject to acceptance of the risk by the insurer, by an insurance policy authorized under this title; **State:** Alaska **Statute Areas:** Premium Fraud --- ### [Alaska-Range of Criminal Penalties-AS¤ 21.22.175](https://insurancefraud.org/statutes/alaska-range-of-criminal-penalties-as¤-21-22-175/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (q) A fraudulent or criminal insurance act described in (1) (b) of this section that is committed to obtain $10,000 or more is a class B felony; (2) (c), (d), or (p)(4) of this section is a class B felony; (3) (b) of this section that is committed to obtain $500 or more but less than $10,000 is a class C felony; (4) (e), (f), (g), or (p)(2) or (3) of this section is a class C felony; (5) (b) of this section that is committed to obtain less than $500 is a class A misdemeanor; (6) (i), (j), (k), (l), (m), or (n) of this section is a class A misdemeanor; (7) (o) of this section is a class B misdemeanor; and (8) (p)(1) of this section is a class B misdemeanor unless another specific penalty is provided for the violation of the provision. **State:** Alaska **Statute Areas:** Range of Criminal Penalties --- ### [Alaska-Range of Civil Penalties-AS ¤ 21.33.065](https://insurancefraud.org/statutes/alaska-range-of-civil-penalties-as-¤-21-33-065/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) A person other than an insured, who in this state represents or aids a nonadmitted insurer in violation of AS 21.33.037, is subject to a civil penalty of not more than $50,000 in addition to applicable criminal penalties and other penalties prescribed in this title. (b) In addition to any other penalty provided, a person who violates a provision of this chapter is subject to a civil penalty of not more than $10,000 for the first offense and not more than $100,000 for each succeeding violation. **State:** Alaska **Statute Areas:** Range of Civil Penalties --- ### [Alaska-Rating of an Insurance Policy-AS ¤ 21.39.030](https://insurancefraud.org/statutes/alaska-rating-of-an-insurance-policy-as-¤-21-39-030/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) Rates, including loss costs under AS 21.39.043 or any other provision of law, shall be made in accordance with the following provisions: (1) rates shall not be excessive, inadequate, or unfairly discriminatory; (2) consideration shall be given to past and prospective loss experience inside and outside this state; to the conflagration and catastrophe hazards; to a reasonable margin for underwriting profit and contingencies; to dividends, savings, or unabsorbed premium deposits allowed or returned by insurers to their policyholders, members, or subscribers; to past and prospective expenses both countrywide and those specially applicable to this state; and to all other relevant factors inside and outside this state; (3) the systems of expense provisions included in the rates for use by an insurer or group of insurers may differ from those of other insurers or group of insurers to reflect the requirements of the operating methods of the insurer or group of insurers with respect to any kind of insurance, or with respect to a subdivision or combination thereof for which subdivision or combination separate expense provisions are applicable; (4) risks may be grouped by classifications for the establishment of rates and minimum premiums; classification rates may be modified to produce rates for individual risks in accordance with rating plans that establish standards for measuring variations in hazards or expense provisions, or both; the standards may measure any differences among risks that can be demonstrated to have a probable effect upon losses or expenses; (5) in the case of fire insurance rates, consideration may be given to the experience of the fire insurance business during a period of not more than the most recent five-year period for which experience is available; (6) when there is an established program to inspect new and existing dwellings and the program has been certified by the director as likely to reduce the incidence of fires in inspected dwellings, then in any rate plan used in this state, dwellings that have been found by the inspection to meet the standards established by the program shall have credits applied to the rate in amounts approved by the director. (b) Except to the extent necessary to meet the provisions of (a)(1) of this section, uniformity among insurers in matters within the scope of this section is neither required nor prohibited. (c) In this section “dwelling” means a residential structure containing not more than four family living units. **State:** Alaska --- ### [Alaska-Underwriting Fraud-AS ¤ 21.36.360](https://insurancefraud.org/statutes/alaska-underwriting-fraud-as-¤-21-36-360/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (o) A fraudulent insurance act is committed by a person who, with intent to injure, defraud, or deceive, knowingly makes a false or fraudulent statement or representation in or with reference to an application for insurance **State:** Alaska **Statute Areas:** Underwriting Fraud --- ### [Alaska-Unauthorized Entities-AS ¤ 21.33.011](https://insurancefraud.org/statutes/alaska-unauthorized-entities-as-¤-21-33-011/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** The legislature declares that insurance transactions with nonadmitted insurers are so affected with a public interest as to require regulation, taxation, supervision, and control of the transactions and matters relating to nonadmitted insurance as provided in this chapter in order to (1) protect the insureds and claimants of this state in transactions involving the purchase of insurance from nonadmitted insurers; (2) avoid the obstacle of resorting to distant forums for the purpose of asserting legal rights under policies issued by nonadmitted insurers; (3) provide a method of substituted service of process upon nonadmitted insurers for proceedings before the director and in the courts in this state; (4) provide for the public the ability to self-procure insurance directly from nonadmitted insurers; (5) protect the revenue of the state; (6) protect regulated, admitted insurers from unregulated and unfair competition by nonadmitted insurers; (7) regulate and supervise the effectuation of nonadmitted insurance under the laws of this state and 15 U.S.C. 1011; and (8) maintain reliable insurance markets. **State:** Alaska --- ### [Alabama-Aiding & Abetting-¤ 27-12A-2](https://insurancefraud.org/statutes/alabama-aiding-abetting-¤-27-12a-2/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** A person commits the crime of insurance fraud if, knowingly and with intent to defraud, he or she commits, or conceals any material information concerning, one or more of the following acts: (1) The solicitation or acceptance of new or renewal insurance risks on behalf of an insurer, reinsurer, or other person engaged in the transaction of the business of insurance, by a person who knows the insurer, reinsurer, or other person responsible for the risk is financially unable to pay its claims at the time of the transaction. (4) Presenting, causing to be presented, or preparing with knowledge or belief that it will be presented to or by an insurer, reinsurer, producer, or any of their respective agents, false information as part of, in support of, or concerning a fact material to, one or more of the following: a. An application for the issuance or renewal of an insurance policy or reinsurance agreement. b. The rating of an insurance policy or reinsurance agreement. c. A claim for payment or benefit pursuant to an insurance policy or reinsurance agreement. d. A claim for payment or benefit based on an advertisement or promises to provide a good or service under an insurance policy. e. Premiums paid on an insurance policy or reinsurance agreement. f. Payments made in accordance with the terms of an insurance policy or reinsurance agreement. g. A document filed with the commissioner. i. Audit information submitted to the commissioner or an insurer. j. The formation, acquisition, merger, reconsolidation, or dissolution of one or more insurance entities, or the withdrawal from one or more lines of insurance in all or part of this state by an insurer or reinsurer. k. The issuance of written evidence of insurance. l. The reinstatement of an insurance policy. m. Issuance, acceptance, change, endorsement, or continuance of an insurance policy or reinsurance agreement. n. A construction or structure mitigation inspection report provided for the issuance or renewal of an insurance policy or discounts or credits related to an insurance policy. **State:** Alabama --- ### [Alabama-Anti-Runner Provisions-¤ 27-12A-2](https://insurancefraud.org/statutes/alabama-anti-runner-provisions-¤-27-12a-2/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** A person commits the crime of insurance fraud if, knowingly and with intent to defraud, he or she commits, or conceals any material information concerning, one or more of the following acts: (1) The solicitation or acceptance of new or renewal insurance risks on behalf of an insurer, reinsurer, or other person engaged in the transaction of the business of insurance, by a person who knows the insurer, reinsurer, or other person responsible for the risk is financially unable to pay its claims at the time of the transaction. (2) The removal, concealment, alteration, or destruction of the assets or records relating to the transaction of the business of insurance of an insurer, reinsurer, or other person engaged in the transaction of the business of insurance. This section does not prohibit an insurer, reinsurer, or other person engaged in the transaction of the business of insurance from destroying records or documents relating to the transaction of the business of insurance in accordance with record retention and destruction standards set forth in state or federal law or the record retention policy of the insurer, reinsurer, or other person. (3) The embezzlement, abstraction, theft, or conversion of monies, funds, premiums, credits, or other property relating to the transaction of the business of insurance of an insurer, reinsurer, or other person engaged in the transaction of the business of insurance. (4) Presenting, causing to be presented, or preparing with knowledge or belief that it will be presented to or by an insurer, reinsurer, producer, or any of their respective agents, false information as part of, in support of, or concerning a fact material to, one or more of the following: a. An application for the issuance or renewal of an insurance policy or reinsurance agreement. b. The rating of an insurance policy or reinsurance agreement. c. A claim for payment or benefit pursuant to an insurance policy or reinsurance agreement. d. A claim for payment or benefit based on an advertisement or promises to provide a good or service under an insurance policy. e. Premiums paid on an insurance policy or reinsurance agreement. f. Payments made in accordance with the terms of an insurance policy or reinsurance agreement. g. A document filed with the commissioner. i. Audit information submitted to the commissioner or an insurer. j. The formation, acquisition, merger, reconsolidation, or dissolution of one or more insurance entities, or the withdrawal from one or more lines of insurance in all or part of this state by an insurer or reinsurer. k. The issuance of written evidence of insurance. l. The reinstatement of an insurance policy. m. Issuance, acceptance, change, endorsement, or continuance of an insurance policy or reinsurance agreement. n. A construction or structure mitigation inspection report provided for the issuance or renewal of an insurance policy or discounts or credits related to an insurance policy. (5) The failure to decline or refusal to return an insurance payment for a loss or a recovery to which the person is not entitled by reason of an insurer’s mistake or other facts or circumstances connected with the person’s claim or the coverage provided by an applicable insurance policy. (6) Overcharging an insurer or insured an amount for a good or service that exceeds the usual and customary charge by the person providing the good or performing the service as a part of an insurance claim for damage. **State:** Alabama **Statute Areas:** Anti-Runner Provisions --- ### [Alabama-Claims Fraud-¤ 27-12A-2](https://insurancefraud.org/statutes/alabama-claims-fraud-¤-27-12a-2/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** A person commits the crime of insurance fraud if, knowingly and with intent to defraud, he or she commits, or conceals any material information concerning, one or more of the following acts: (4) Presenting, causing to be presented, or preparing with knowledge or belief that it will be presented to or by an insurer, reinsurer, producer, or any of their respective agents, false information as part of, in support of, or concerning a fact material to, one or more of the following: c. A claim for payment or benefit pursuant to an insurance policy or reinsurance agreement. d. A claim for payment or benefit based on an advertisement or promises to provide a good or service under an insurance policy. **State:** Alabama **Statute Areas:** Claims Fraud --- ### [Alabama-Failing to Remit Premium-¤ 27-12A-2](https://insurancefraud.org/statutes/alabama-failing-to-remit-premium-¤-27-12a-2/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** A person commits the crime of insurance fraud if, knowingly and with intent to defraud, he or she commits, or conceals any material information concerning, one or more of the following acts: (4) Presenting, causing to be presented, or preparing with knowledge or belief that it will be presented to or by an insurer, reinsurer, producer, or any of their respective agents, false information as part of, in support of, or concerning a fact material to, one or more of the following: e. Premiums paid on an insurance policy or reinsurance agreement. (5) The failure to decline or refusal to return an insurance payment for a loss or a recovery to which the person is not entitled by reason of an insurer’s mistake or other facts or circumstances connected with the person’s claim or the coverage provided by an applicable insurance policy. **State:** Alabama --- ### [Alabama-Fraud Bureau-¤ 27-12A-40](https://insurancefraud.org/statutes/alabama-fraud-bureau-¤-27-12a-40/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) There is hereby established within the department the Insurance Fraud Unit. The commissioner shall appoint the necessary full-time supervisory and investigative personnel of the unit who shall be qualified by training and experience to perform the duties of their positions. The commissioner shall furnish offices, equipment, operating expenses, and necessary personnel to maintain and operate the unit. (b) The unit shall perform all of the following duties: (1) Initiate independent inquiries and conduct independent investigations when the unit has cause to believe that any insurance fraud may be, is being, or has been, committed. (2) Review reports or complaints of alleged insurance fraud from federal, state, and local law enforcement and regulatory agencies, persons engaged in the business of insurance, and the public to determine whether the reports or complaints require further investigation and, if so, to conduct these investigations. (3) Conduct independent examinations of alleged insurance fraud and undertake independent studies to determine the extent of insurance fraud. (c) In performing its duties, the unit shall have the powers to do all of the following: (1) Inspect, copy, or collect records and evidence. (2) Issue and serve subpoenas. (3) Administer oaths and affirmations. (4) Share records and evidence with federal, state, or local law enforcement and regulatory agencies. (5) Execute arrest warrants for criminal violations of this chapter. (6) Arrest upon probable cause without warrant a person found in the act of violating or attempting to violate this chapter. (7) Make criminal referrals to the Attorney General. (8) Conduct investigations outside of this state. If the information the unit seeks to obtain is located outside of this state, the person from whom the information is sought may make the information available to the unit to examine at the place where the information is located. The unit may designate representatives, including officials of the state in which the matter is located, to inspect the information on behalf of the unit, and the unit may respond to similar requests from officials of other states. (d) Investigators of the unit shall have all the powers vested in law enforcement officers of the State of Alabama, including, but not limited to, the powers of arrest and the power to serve process, but only as necessary to enforce this chapter, and shall perform the duties, responsibilities, and functions as may be required for the unit to carry out its duties and responsibilities pursuant to this chapter. No person shall serve as investigator of the unit who has not met the minimum standards established for law enforcement officers by the Alabama Peace Officers’ Standards and Training Commission, or other standards as may be provided hereafter by law. (e) Information relating to criminal activity discovered in the course of an investigation by the unit shall be provided to the Department of Public Safety. **State:** Alabama **Statute Areas:** Fraud Bureau --- ### [Alabama-Immunity-¤ 27-12A-22](https://insurancefraud.org/statutes/alabama-immunity-¤-27-12a-22/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) Except as otherwise provided in subsection (b), there shall be no civil liability imposed on and no cause of action shall arise against a person for furnishing or receiving information concerning suspected, anticipated, or completed insurance fraud. This shall not abrogate or modify common law or statutory privileges or immunities enjoyed by a person, and the limit on civil liability applies only to the act of reporting and does not limit civil liability against a person for committing fraud or other tortuous conduct. (b) Subsection (a) shall not apply to false statements made with actual malice by a person furnishing or receiving information concerning suspected, anticipated, or completed insurance fraud. In any action brought against a person for filing a report or furnishing other information concerning insurance fraud, the party bringing the action shall plead specifically any allegations that subsection (a) shall not apply because the person filing the report or furnishing the information did so with actual malice. **State:** Alabama **Statute Areas:** Immunity --- ### [Alabama-Insurance Fraud - Definition-¤ 27-12A-2](https://insurancefraud.org/statutes/alabama-insurance-fraud-definition-¤-27-12a-2/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** A person commits the crime of insurance fraud if, knowingly and with intent to defraud, he or she commits, or conceals any material information concerning, one or more of the following acts: (1) The solicitation or acceptance of new or renewal insurance risks on behalf of an insurer, reinsurer, or other person engaged in the transaction of the business of insurance, by a person who knows the insurer, reinsurer, or other person responsible for the risk is financially unable to pay its claims at the time of the transaction. (2) The removal, concealment, alteration, or destruction of the assets or records relating to the transaction of the business of insurance of an insurer, reinsurer, or other person engaged in the transaction of the business of insurance. This section does not prohibit an insurer, reinsurer, or other person engaged in the transaction of the business of insurance from destroying records or documents relating to the transaction of the business of insurance in accordance with record retention and destruction standards set forth in state or federal law or the record retention policy of the insurer, reinsurer, or other person. (3) The embezzlement, abstraction, theft, or conversion of monies, funds, premiums, credits, or other property relating to the transaction of the business of insurance of an insurer, reinsurer, or other person engaged in the transaction of the business of insurance. (4) Presenting, causing to be presented, or preparing with knowledge or belief that it will be presented to or by an insurer, reinsurer, producer, or any of their respective agents, false information as part of, in support of, or concerning a fact material to, one or more of the following: a. An application for the issuance or renewal of an insurance policy or reinsurance agreement. b. The rating of an insurance policy or reinsurance agreement. c. A claim for payment or benefit pursuant to an insurance policy or reinsurance agreement. d. A claim for payment or benefit based on an advertisement or promises to provide a good or service under an insurance policy. e. Premiums paid on an insurance policy or reinsurance agreement. f. Payments made in accordance with the terms of an insurance policy or reinsurance agreement. g. A document filed with the commissioner. i. Audit information submitted to the commissioner or an insurer. j. The formation, acquisition, merger, reconsolidation, or dissolution of one or more insurance entities, or the withdrawal from one or more lines of insurance in all or part of this state by an insurer or reinsurer. k. The issuance of written evidence of insurance. l. The reinstatement of an insurance policy. m. Issuance, acceptance, change, endorsement, or continuance of an insurance policy or reinsurance agreement. n. A construction or structure mitigation inspection report provided for the issuance or renewal of an insurance policy or discounts or credits related to an insurance policy. (5) The failure to decline or refusal to return an insurance payment for a loss or a recovery to which the person is not entitled by reason of an insurer’s mistake or other facts or circumstances connected with the person’s claim or the coverage provided by an applicable insurance policy. (6) Overcharging an insurer or insured an amount for a good or service that exceeds the usual and customary charge by the person providing the good or performing the service as a part of an insurance claim for damage. **State:** Alabama **Statute Areas:** Insurance Fraud - Definition --- ### [Alabama-Licensing Board Notification-¤ 27-12A-8](https://insurancefraud.org/statutes/alabama-licensing-board-notification-¤-27-12a-8/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (c) The commissioner shall also notify the proper licensing authority of a practitioner for the appropriate disciplinary action including the revocation or suspension of any professional license when a practitioner is convicted of a violation of this chapter and whose services are compensated in whole or in part, directly or indirectly, by insurance proceeds. **State:** Alabama --- ### [Alabama-Mandatory Restitution-¤ 27-12A-20](https://insurancefraud.org/statutes/alabama-mandatory-restitution-¤-27-12a-20/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** \*(a) A fraud warning shall be included on at least one of the following: Claim release forms, applications, reinstatements for insurance, participation agreements, declaration pages, and claim documents, regardless of the method or form of transmission and shall contain the following statement or a substantially similar statement: “Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution, fines, or confinement in prison, or any combination thereof.” **State:** Alabama **Statute Areas:** Mandatory Restitution --- ### [Alabama-Placing Bogus Coverage-¤ 27-12A-2](https://insurancefraud.org/statutes/alabama-placing-bogus-coverage-¤-27-12a-2/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** \*A person commits the crime of insurance fraud if, knowingly and with intent to defraud, he or she commits, or conceals any material information concerning, one or more of the following acts: (1) The solicitation or acceptance of new or renewal insurance risks on behalf of an insurer, reinsurer, or other person engaged in the transaction of the business of insurance, by a person who knows the insurer, reinsurer, or other person responsible for the risk is financially unable to pay its claims at the time of the transaction. (2) The removal, concealment, alteration, or destruction of the assets or records relating to the transaction of the business of insurance of an insurer, reinsurer, or other person engaged in the transaction of the business of insurance. This section does not prohibit an insurer, reinsurer, or other person engaged in the transaction of the business of insurance from destroying records or documents relating to the transaction of the business of insurance in accordance with record retention and destruction standards set forth in state or federal law or the record retention policy of the insurer, reinsurer, or other person. (3) The embezzlement, abstraction, theft, or conversion of monies, funds, premiums, credits, or other property relating to the transaction of the business of insurance of an insurer, reinsurer, or other person engaged in the transaction of the business of insurance. (4) Presenting, causing to be presented, or preparing with knowledge or belief that it will be presented to or by an insurer, reinsurer, producer, or any of their respective agents, false information as part of, in support of, or concerning a fact material to, one or more of the following: a. An application for the issuance or renewal of an insurance policy or reinsurance agreement. b. The rating of an insurance policy or reinsurance agreement. c. A claim for payment or benefit pursuant to an insurance policy or reinsurance agreement. d. A claim for payment or benefit based on an advertisement or promises to provide a good or service under an insurance policy. e. Premiums paid on an insurance policy or reinsurance agreement. f. Payments made in accordance with the terms of an insurance policy or reinsurance agreement. g. A document filed with the commissioner. i. Audit information submitted to the commissioner or an insurer. j. The formation, acquisition, merger, reconsolidation, or dissolution of one or more insurance entities, or the withdrawal from one or more lines of insurance in all or part of this state by an insurer or reinsurer. k. The issuance of written evidence of insurance. l. The reinstatement of an insurance policy. m. Issuance, acceptance, change, endorsement, or continuance of an insurance policy or reinsurance agreement. n. A construction or structure mitigation inspection report provided for the issuance or renewal of an insurance policy or discounts or credits related to an insurance policy. (5) The failure to decline or refusal to return an insurance payment for a loss or a recovery to which the person is not entitled by reason of an insurer’s mistake or other facts or circumstances connected with the person’s claim or the coverage provided by an applicable insurance policy. (6) Overcharging an insurer or insured an amount for a good or service that exceeds the usual and customary charge by the person providing the good or performing the service as a part of an insurance claim for damage. **State:** Alabama --- ### [Alabama-Practitioner Penalites-¤ 27-12A-8](https://insurancefraud.org/statutes/alabama-practitioner-penalites-¤-27-12a-8/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) A producer who violates this chapter may be subject to the suspension or revocation of any insurance license held by the producer or civil penalties of up to five thousand dollars ($5,000) per violation, or both. Suspension or revocation of an insurance license or certificate of authority and the imposition of civil penalties shall be pursuant to action brought before the commissioner. Suspension or revocation of any insurance licenses and the imposition of civil penalties shall be pursuant to action brought before the commissioner in accordance with this title. (b) An insurer who, with such frequency as to indicate its general business practice in this state, is in violation of this chapter may be subject to the suspension or revocation of any certificate of authority held by insurer or civil penalties of up to five thousand dollars ($5,000) per violation, or both. Suspension or revocation of a certificate of authority and the imposition of civil penalties shall be pursuant to action brought before the commissioner in accordance with Section 27-3-21 and subject to the right of appeal in accordance with Section 27-2-32. (c) The commissioner shall also notify the proper licensing authority of a practitioner for the appropriate disciplinary action including the revocation or suspension of any professional license when a practitioner is convicted of a violation of this chapter and whose services are compensated in whole or in part, directly or indirectly, by insurance proceeds. **State:** Alabama **Statute Areas:** Practitioner Penalites --- ### [Alabama-Premium Fraud-¤ 27-12A-2](https://insurancefraud.org/statutes/alabama-premium-fraud-¤-27-12a-2/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** A person commits the crime of insurance fraud if, knowingly and with intent to defraud, he or she commits, or conceals any material information concerning, one or more of the following acts: (4) Presenting, causing to be presented, or preparing with knowledge or belief that it will be presented to or by an insurer, reinsurer, producer, or any of their respective agents, false information as part of, in support of, or concerning a fact material to, one or more of the following: e. Premiums paid on an insurance policy or reinsurance agreement. **State:** Alabama **Statute Areas:** Premium Fraud --- ### [Alabama-Range of Criminal Penalties-¤ 27-12A-6](https://insurancefraud.org/statutes/alabama-range-of-criminal-penalties-¤-27-12a-6/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) No prosecution may be commenced under this article more than two years after the alleged violation was detected. (b) An individual who has been convicted of insurance fraud in the first degree or insurance fraud in the second degree shall be disqualified from engaging in the business of insurance in this state. (c) A person may not willfully permit another person who has been convicted of insurance fraud in the first degree or insurance fraud in the second degree to transact in the business of insurance in this state. (d) For the purposes of Article 4A of Chapter 18 of Title 15, insurance fraud shall be considered criminal activity. **State:** Alabama **Statute Areas:** Range of Criminal Penalties --- ### [Alabama-Rating of an Insurance Policy-¤ 27-13-1](https://insurancefraud.org/statutes/alabama-rating-of-an-insurance-policy-¤-27-13-1/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** The purpose of this chapter is to promote the public welfare by regulating insurance rates to the end that they shall not be excessive, inadequate or unfairly discriminatory and to authorize and regulate cooperative action among insurers in rate-making and in other matters within the scope of this chapter. Nothing in this chapter is intended: (1) To prohibit or discourage reasonable competition; or (2) Prohibit or encourage, except to the extent necessary to accomplish the aforementioned purpose, uniformity in insurance rates, rating systems, rating plans, or practices. This chapter shall be liberally interpreted to carry into effect the provisions of this section. **State:** Alabama --- ### [Alabama-Unauthorized Entities-¤ 27-10-1l](https://insurancefraud.org/statutes/alabama-unauthorized-entities-¤-27-10-1l/) **Published:** July 21, 2020 **Author:** Coalition Against Insurance Fraud **Content:** (a) No person shall in this state, directly or indirectly, act as agent for, or otherwise represent or aid on behalf of another, any insurer not then authorized to transact such insurance in this state in the solicitation, negotiation, or effectuation of insurance or annuity contracts, forwarding of applications, delivery of policies or contracts, inspection of risks, fixing of rates, investigation or adjustment of losses, collection of premiums, or in any other manner in the transaction of insurance with respect to subjects of insurance resident, located or to be performed in this state. (b) This section shall not apply to: (1) Acceptance of service of process by the commissioner under Section 27-10-52; (2) Surplus lines insurance or coverage specified in Section 27-10-34 and other transactions as to which a certificate of authority is not required of an insurer; (3) Adjustment of losses as authorized in Section 27-10-35; (4) Transactions for which a certificate of authority to do business is not required of an insurer under the laws of this state; (5) Reinsurance effectuated in accordance with this title; or (6) The property and operations of the shipbuilding and/or ship repair industry engaged in interstate or foreign commerce and vessels, cargoes, watercraft, piers, wharves, graven docks, drydocks, marine railways and building ways, commonly known as wet marine. (c) This section shall not be deemed to render invalid, as between the parties thereto, any insurance contract entered into in violation of this section. Credits **State:** Alabama --- ## Current Legislation ### [Counterfeit Airbags](https://insurancefraud.org/current_legislation/counterfeit-airbags-2/) **Published:** May 2, 2025 **Author:** Brent Walker **Content:** 2026 Carryover: AK HB 74 establishes the crime of airbag fraud. **Date introduced:** 1/29/2025 **Key Sponsor**: Frank Tomaszewski **Committee**: Judiciary **State:** Alaska **Categories:** Counterfeit Airbags --- ### [Workers Compensation](https://insurancefraud.org/current_legislation/workers-compensation-4/) **Published:** July 21, 2025 **Author:** Brent Walker **Content:** CA AB 1331 would limit the use of workplace surveillance tools by employers, including by prohibiting an employer from monitoring or surveilling workers in employee-only, employer-designated areas. Would subject an employer who violates the bill to a specified civil penalty and authorizes a public prosecutor to bring specified enforcement actions. **Passed Assembly on 6/5/12025 to Senate.** **Date introduced:** 02/21/2025 **Key Sponsor**: Sade Elhawary **Committee**: Senate Appropriations **State:** California **Categories:** Workers Compensation --- ### [Towing](https://insurancefraud.org/current_legislation/towing-11/) **Published:** May 8, 2025 **Author:** Brent Walker **Content:** CA AB 987 provides that existing law makes an insurer that is responsible for reasonable storage and towing charges liable to the person providing those services when a vehicle is towed and stored as a result of an accident or stolen recovery. Expands the list of presumptively unreasonable fees to include storage fees charged for certain State holidays and towing fees charged when the owner is directed by a law enforcement officer to remove their vehicle at the scene of a State or local emergency. **Passed Assembly to Senate 5/19/2025.** **Date introduced:** 2/20/2025 **Key Sponsor**: LaShae Sharp-Collins **Committee**: Fiscal **State:** California **Categories:** Towing --- ### [Fraud Bureau Authority](https://insurancefraud.org/current_legislation/fraud-bureau-authority-2/) **Published:** April 29, 2025 **Author:** Brent Walker **Content:** MN HB 2432 transfers financial crimes and fraud investigations to the Financial Crimes and Fraud Section in the Bureau of Criminal Apprehension. **Passed House to Senate 4/25/2025.** Substituted for SB 1417. **Passed House to Senate on 4/25/2025. Passed Senate and to House for concurrence. House concurred and eligible for Governor on 5/18/2025.** **Date introduced:** 3/17/2025 **Key Sponsor**: Paul Novotny **Committee**: Insurance **State:** Minnesota **Categories:** Fraud Bureau Authority --- ### [Telematics](https://insurancefraud.org/current_legislation/telematics/) **Published:** April 29, 2025 **Author:** Brent Walker **Content:** LA HB 549 provides a premium discount for commercial motor vehicles with dashboard cameras and telematics systems to enhance public safety, reduce insurance fraud, and lower costs of claims. **Passed House to Senate on 4/28/2025. Passed Senate to Governor on 5/20/2025.** **Date introduced:** 4/14/2025 **Key Sponsor**: Rodney Schamerhorn **Committee**: Pending **State:** Louisiana **Categories:** Telematics --- ### [Towing](https://insurancefraud.org/current_legislation/towing-12/) **Published:** May 19, 2025 **Author:** Brent Walker **Content:** ME SB 572 convenes a working group to evaluate potential regulation of the vehicle towing industry and the impact on state agencies and industries, stating that deceptive, irresponsible and predatory towing practices impose financial burdens and logistical hardships on those who rely on their vehicles for everyday use and that the towing industry affects many different industries and state agencies. **Date introduced:** 3/28/2025 **Key Sponsor**: Timothy Nangle **Committee**: Joint Committee on Transportation. **State:** Maine **Categories:** Towing --- ### [Disaster Claims](https://insurancefraud.org/current_legislation/disaster-claims/) **Published:** May 9, 2025 **Author:** Brent Walker **Content:** HI SB 417 establishes as a class B felony the unlicensed performance of contractor work, during or within a specified year following a national emergency, state of emergency, or disaster proclamation, in an affected political subdivision. **Date introduced:** 1/15/2025 **Key Sponsor**: Angus McKelvey **Committee**: Judiciary **State:** Hawaii **Categories:** Disaster Claims --- ### [Immunity](https://insurancefraud.org/current_legislation/immunity/) **Published:** May 9, 2025 **Author:** Brent Walker **Content:** NJ SB 4225 broadens scope of information sharing and civil immunity therefor, related to insurance fraud. **Date introduced:** prefiled 3/3/2025 **Key Sponsor**: Joseph Lagana **Committee**: Commerce **State:** New Jersey **Categories:** Immunity --- ### [Runners](https://insurancefraud.org/current_legislation/runners-2/) **Published:** May 7, 2025 **Author:** Brent Walker **Content:** NY SB 4874 criminalizes acting as a runner or soliciting or employing a runner to procure patients or clients. **Date introduced:** 2/13/2025 **Key Sponsor**: Patricia Fahy **Committee**: Codes **State:** New York **Categories:** Runners --- ### [Runners](https://insurancefraud.org/current_legislation/runners/) **Published:** May 7, 2025 **Author:** Brent Walker **Content:** NY AB 7392 criminalizes acting as a runner or soliciting or employing a runner to procure patients or clients. **Date introduced:** 3/25/2025 **Key Sponsor**: J. Garry Petlow **Committee**: Codes **State:** New York **Categories:** Runners --- ### [Staged Accidents](https://insurancefraud.org/current_legislation/staged-accidents-6/) **Published:** May 7, 2025 **Author:** Brent Walker **Content:** NY AB 7322 permits an insurer to rescind or retroactively cancel a policy in circumstance involving an accident staged to defraud an insurer. **Date introduced:** 3/25/2025 **Key Sponsor**: J. Garry Petlow **Committee**: Insurance **State:** New York **Categories:** Staged Accidents --- ### [Staged Accidents](https://insurancefraud.org/current_legislation/staged-accidents-5/) **Published:** May 7, 2025 **Author:** Brent Walker **Content:** NY SB 5052 permits an insurer to rescind or retroactively cancel a policy in circumstance involving an accident staged to defraud an insurer. **Date introduced:** 2/18/2025 **Key Sponsor**: Jamaal Bailey **Committee**: Insurance **State:** New York **Categories:** Staged Accidents --- ### [Counterfeit Airbags](https://insurancefraud.org/current_legislation/counterfeit-airbags/) **Published:** May 2, 2025 **Author:** Brent Walker **Content:** AK SB 17 establishes the crime of airbag fraud. **Date introduced:** 1/21/2025 **Key Sponsor**: Matt Claman **Committee**: Judiciary **State:** Alaska **Categories:** Counterfeit Airbags --- ### [Staged Accidents](https://insurancefraud.org/current_legislation/staged-accidents-4/) **Published:** May 2, 2025 **Author:** Brent Walker **Content:** NY AB 3800 (Crime of Staging Construction Site Accident) establishes the crime of staging a construction site accident which is a class E felony. **Date introduced:** 1/30/2025 **Key Sponsor**: David Weprin **Committee**: Codes **State:** New York **Categories:** Staged Accidents --- ### [Staged Accidents](https://insurancefraud.org/current_legislation/staged-accidents-3/) **Published:** May 2, 2025 **Author:** Brent Walker **Content:** NY AB 3851 (Expanded Liability for Orchestrating Illegal Acts) provides that anyone who directs, hires, requests, encourages, orchestrates or invites another individual to cause a collision involving a motor vehicle shall be guilty of staging a motor vehicle accident in the second degree. **Date introduced:** 1/30/2025 **Key Sponsor**: David Weprin **Committee**: Codes **State:** New York **Categories:** Staged Accidents --- ### [Bail Bond Antifraud Regulation](https://insurancefraud.org/current_legislation/bail-bond-antifraud-regulation/) **Published:** May 2, 2025 **Author:** Brent Walker **Content:** NC HB 718 revises the Laws related to bail bondsmen. Introduce new oversight tools by extending provisional licensing periods for new bondsmen, tightening supervisory responsibilities, and modernizing reporting and address requirements to help prevent underreporting bond amounts, failing to remit premium payments to surety companies, etc. **The Coalition submitted a letter of support on 4/16/2025.** **Date introduced:** 4/3/2025 **Key Sponsor**: Chris Humphrey **Committee**: Insurance **State:** North Carolina **Categories:** Bail Bond Antifraud Regulations --- ### [Bail Bond Antifraud Regulation](https://insurancefraud.org/current_legislation/fraud-bureau-authority-3/) **Published:** May 2, 2025 **Author:** Brent Walker **Content:** NC SB 251 revises the Laws related to bail bondsmen. Introduce new oversight tools by extending provisional licensing periods for new bondsmen, tightening supervisory responsibilities, and modernizing reporting and address requirements to help prevent underreporting bond amounts, failing to remit premium payments to surety companies, etc. **The Coalition submitted a letter of support on 4/16/2025.** **Date introduced:** 3/10/2025 **Key Sponsor**: Todd Johnson **Committee**: Rules and Operation **State:** North Carolina **Categories:** Bail Bond Antifraud Regulations --- ### [Staged Accidents](https://insurancefraud.org/current_legislation/staged-accidents-2/) **Published:** May 1, 2025 **Author:** Brent Walker **Content:** NY SB 5232 provides that anyone who directs, hires, requests, encourages, orchestrates or invites another individual to cause a collision involving a motor vehicle shall be guilty of staging a motor vehicle accident in the second degree. **Date introduced:** 2/19/2025 **Key Sponsor**: Leroy Comrie **Committee**: Codes **State:** New York **Categories:** Staged Accidents --- ### [Staged Accidents](https://insurancefraud.org/current_legislation/staged-accidents/) **Published:** May 1, 2025 **Author:** Brent Walker **Content:** NY SB 5231 establishes the crime of staging a construction site accident which is a class E felony. **Date introduced:** 2/19/2025 **Key Sponsor**: Leroy Comrie **Committee**: Codes **State:** New York **Categories:** Staged Accidents --- ### [Consumer Privacy](https://insurancefraud.org/current_legislation/consumer-privacy-3/) **Published:** April 29, 2025 **Author:** Brent Walker **Content:** PA HB 78 adds new types of data to the list of “sensitive data” and provides for the Consumer Data Privacy Act; provides that a consumer shall have specified rights; specifies the duties of controllers, defined as certain entities that sell consumer personal information; provides that a controller shall establish and describe in a privacy notice a secure and reliable means for consumers to submit a request to exercise such rights, including allowing a consumer to opt out of the processing of their data; defines sensitive data; provides for private rights of action. Does contain an antifraud exemption. **Date introduced:** 1/14/2025 **Key Sponsor**: Ed Neilson **Committee**: Appropriations **State:** Pennsylvania **Categories:** Consumer Privacy --- ### [Towing](https://insurancefraud.org/current_legislation/towing-10/) **Published:** April 29, 2025 **Author:** Brent Walker **Content:** OK HB 1753 provides that the Corporation Commission shall review the rates wrecker and tow services companies may charge for nonconsensual tows and, if necessary, change the rates, following notice and hearing; relates to motor vehicles; relates to maximum fees and charges; relates to rate calculations; relates to vehicle weight; relates to ees and charges for storage; relates to expert witness. **Date introduced:** 2/3/2025 **Key Sponsor**: Dell Kerbs **Committee**: Public Safety **State:** Oklahoma **Categories:** Towing --- ### [Towing](https://insurancefraud.org/current_legislation/towing-8/) **Published:** April 29, 2025 **Author:** Brent Walker **Content:** IL SB 2040 amends the Vehicle Code; provides that any personal property belonging to the vehicle owner in a vehicle subject to a lien shall be subject to that lien, except for the specified items, which may be claimed by immediate family members at the authorization of the vehicle owner; establishes registration requirements for commercial vehicle safety relocators and tasks the Commerce Commission with oversight duties and the imposition of penalties. **Passed Senate to House** **on 4/3/2025.** **Date introduced:** 2/6/2025 **Key Sponsor**: Celina Villanueva **Committee**: Transportation **State:** Illinois **Categories:** Towing --- ### [Price Gouging](https://insurancefraud.org/current_legislation/price-gouging/) **Published:** April 29, 2025 **Author:** Brent Walker **Content:** CA SB 368 provides that under existing law, upon the proclamation of a state of emergency, it is a misdemeanor for a person, contractor, business, or other entity to sell or offer to sell certain goods or services for a price of more than a specified percent greater than the price charged by that person immediately prior to the proclamation or declaration of emergency. Requires the Department of Justice and local prosecutors to establish partnerships to enforce those provisions. **Date introduced:** 2/13/2024 **Key Sponsor**: Lola Smallwood-Cuevas **Committee**: Appropriations **State:** California **Categories:** Disaster Claims --- ### [Price Gouging](https://insurancefraud.org/current_legislation/towing-5/) **Published:** April 29, 2025 **Author:** Brent Walker **Content:** CA SB 36 provides that the Unfair Competition Law makes various practices unlawful and provides that a person who engages in unfair competition is liable for a civil penalty. Makes a person who violates those provisions, if the act or acts of unfair competition are perpetrated against one or more persons displaced due to a state of emergency or local emergency, liable for a civil penalty not to exceed a certain amount for each violation. Makes it unlawful to engage in price gouging during a State or local emergency. **Date introduced:** 12/3/2024 **Key Sponsor**: Thomas Umberg **Committee**: Appropriations **State:** California **Categories:** Disaster Claims --- ### [Fraud Bureau Authority](https://insurancefraud.org/current_legislation/fraud-bureau-authority/) **Published:** April 28, 2025 **Author:** Brent Walker **Content:** LA SB 199 provides for the authority of the Department of Insurance, in instances of fraud, to take action against unlicensed persons engaged in the business of insurance. **Date introduced:** 4/15/2025 **Key Sponsor**: Brach Myers **Committee**: Insurance **State:** Louisiana **Categories:** Fraud Bureau Authority --- ### [Consumer Privacy](https://insurancefraud.org/current_legislation/consumer-privacy-2/) **Published:** April 10, 2025 **Author:** Brent Walker **Content:** CA SB 354 would enact the Insurance Consumer Privacy Protection Act of 2025 to establish new standards for the collection, processing, retaining, or sharing of consumers’ personal information by insurance licensees and their third party service providers. Requires a licensee or third party service provider to obtain a consumer’s consent to take specified actions, and sets forth the means by which consent is obtained. Defines an “Insurance support organization” as an entity that processes personal information from licensees or other insurance support organizations to detect or prevent insurance fraud and insurance crime, material misrepresentation, or material nondisclosure in connection with the business of insurance. Also defines an “Insurance transaction” that includes the detection or prevention of insurance fraud, crime related to insurance claims, material misrepresentation, or material nondisclosure. The bill does contain the following antifraud exemption, “A licensee shall not be required to furnish specific privileged information if it has a reasonable suspicion, based upon specific information available for review by the commissioner, that the consumer has engaged in criminal activity, fraud, material misrepresentation, or a material nondisclosure, and the information withheld relates to the suspected criminal activity, fraud, material misrepresentation, or a material nondisclosure.” **Date introduced:** 2/12/2025 **Key Sponsor**: Monique Limon **Committee**: Senate Judiciary Committee **State:** California **Categories:** Consumer Privacy --- ### [Staged Accidents](https://insurancefraud.org/current_legislation/insurer-practices-3/) **Published:** April 10, 2025 **Author:** Brent Walker **Content:** US HR 2662 would amend title 49, United States Code, to prohibit staged collisions with commercial motor vehicles. **Date introduced:** 4/7/2025 **Key Sponsor**: Michael Collins **Committee**: House Judiciary Committee **State:** Federal **Categories:** Staged Accidents --- ### [Fraud Reporting](https://insurancefraud.org/current_legislation/fraud-reporting-3/) **Published:** March 17, 2025 **Author:** Brent Walker **Content:** NY SB 6364 relates to insurance fraud; provides a provision for compensation to a person that reports insurance fraud to the authorities; establishes crimes of unlawful procurement of clients, patients or customers; aggravated insurance fraud in the second degree; aggravated insurance fraud in the first degree; provides that this act also increases the penalty for insurance fraud; appropriates a specified amount therefor. **Date introduced:** 3/11/2025 **Key Sponsor**: Pamela Helming **Committee**: Finance Committee **State:** New York **Categories:** Fraud Reporting --- ### [Healthcare Fraud](https://insurancefraud.org/current_legislation/healthcare-fraud/) **Published:** March 17, 2025 **Author:** Brent Walker **Content:** AZ HB 2874 provides that if a health insurer notices a trend in the number of health care insurance claims that are filed by a health care provider for services provided to patients on any given workday exceeds the number of patients that the health care provider could reasonably be expected to treat on that given workday, the health insurer shall notify the department and the board that licenses, registers or certifies the health care provider. Also requires a property & casualty insurer to notify the department if insurance fraud or health care fraud is suspected. **Date introduced:** 2/10/2025 **Key Sponsor**: Sarah Liguori **Committee**: House Third Reading **State:** Arizona **Categories:** Medical Fraud --- ### [Towing](https://insurancefraud.org/current_legislation/towing-4/) **Published:** March 17, 2025 **Author:** Brent Walker **Content:** MO HB 745 enacts provisions relating to towing of commercial vehicles and establishes civil penalties for violations. **Date introduced:** 1/8/2025 **Key Sponsor**: Dave Griffith **Committee**: Pending **State:** Missouri **Categories:** Towing --- ### [Towing](https://insurancefraud.org/current_legislation/towing-3/) **Published:** March 17, 2025 **Author:** Brent Walker **Content:** MA HB 3516 provides that the Department of Utilities establish a list of approved charges for towing and storage services provided by towing companies contracted by state or local police departments. Specifies penalties for towing companies in violation of. **Date introduced:** 2/27/2025 **Key Sponsor**: Michael Kushmerek **Committee**: Pending **State:** Massachusetts **Categories:** Towing --- ### [Artificial Intelligence](https://insurancefraud.org/current_legislation/artificial-intelligence-2/) **Published:** March 17, 2025 **Author:** Brent Walker **Content:** MA HB 97 relates to consumers interactions with artificial intelligence systems. Specifies that high-risk AI systems do not include anti-fraud technology that does not use facial recognition technology and does not, when deployed, make, or are a substantial factor in making, a consequential decision. The bill does not restrict the ability to prevent, detect, protect against, or respond to fraud. **Date introduced:** 2/27/2025 **Key Sponsor**: David Rogers **Committee**: Pending **State:** Massachusetts **Categories:** Artificial Intelligence --- ### [Towing](https://insurancefraud.org/current_legislation/towing-2/) **Published:** March 17, 2025 **Author:** Brent Walker **Content:** IL HB 3430 creates the Nonconsensual Towing Act; creates the Commercial Vehicle Towing Advisory Committee; sets forth members, terms, compensation, meetings, and record keeping; provides that the Committee shall establish rules and standards for the inclusion of a towing and recovery service on the tow list; establishes statewide maximum towing and storage rates for nonconsensual tows; requires the towing and recovery service to ban the use of per pound billing for nonconsensual towing. **Date introduced:** 2/7/2025 **Key Sponsor**: Norma Herenandez **Committee**: Transportation: Vehicles and Safety **State:** Illinois **Categories:** Towing --- ### [Workers Compensation](https://insurancefraud.org/current_legislation/workers-compensation-3/) **Published:** March 12, 2025 **Author:** Brent Walker **Content:** NY SB 1514 empowers the commissioner of labor to issue stop-work orders against employers for misclassification of employees as independent contractors or for providing false, incomplete, or misleading information to an insurance company on the number of employees of such employer. **Date introduced:** 1/10/2025 **Key Sponsor**: Peter Harckham **Committee**: Assembly Labor Committee **State:** New York **Categories:** Workers Compensation --- ### [Fraud Reporting](https://insurancefraud.org/current_legislation/fraud-reporting-7-2-2-2/) **Published:** February 25, 2025 **Author:** Brent Walker **Content:** WA HB 1793 modifies reports of fire losses, within 90 days of closing a claim related to a fire loss or damage. **Date introduced:** 1/31/2025 **Key Sponsor**: Dan Griffey **Committee**: Rules **State:** Washington **Categories:** Fraud Reporting --- ### [Fraud Reporting](https://insurancefraud.org/current_legislation/fraud-reporting-7-2-2-2-2/) **Published:** February 27, 2025 **Author:** Brent Walker **Content:** CA SB 536 would require an insurer or licensed rating organization to notify the Employment Development Department, in addition to the local district attorney’s office and Fraud Division on the Department of Insurance, of suspected fraud when the fraudulent act relates to premium fraud. **Date introduced:** 2/20/2025 **Key Sponsor**: Bob Archuleta **Committee**: Fiscal Committee **State:** California **Categories:** Fraud Reporting --- ### [Artificial Intelligence](https://insurancefraud.org/current_legislation/artificial-intelligence-8-3-2-3-2/) **Published:** February 25, 2025 **Author:** Brent Walker **Content:** NY SB 1169 regulates the development and use of certain artificial intelligence systems to prevent algorithmic discrimination; requires independent audits of high risk ai systems; provides for enforcement by the attorney general as well as a private right of action. **Date introduced:** 1/8/2025 **Key Sponsor**: Kristen Gonzalez **Committee**: Internet and Technology Committee **State:** New York **Categories:** Artificial Intelligence --- ### [Consumer Privacy](https://insurancefraud.org/current_legislation/state-anti-fraud-authority-2-2-2-2-4-2-2/) **Published:** February 25, 2025 **Author:** Brent Walker **Content:** OK SB 488 relates to unmanned aerial systems; defines term; prohibits certain purchase by state agencies after certain date; prohibits certain purchase by political subdivisions after certain date; directs the Office of Homeland Security; maintains certain list; relates to the State Open Records Act; provides for certain assessment to be confidential; updates statutory language; provides for codification; provides an effective date. **Date introduced:** 02/03/2025 **Key Sponsor**: Michael Bergstrom **Committee**: Aeronautics and Transportation Committee **State:** Oklahoma **Categories:** Consumer Privacy --- ### [Consumer Privacy](https://insurancefraud.org/current_legislation/state-anti-fraud-authority-2-2-2-2-4-2/) **Published:** February 25, 2025 **Author:** Brent Walker **Content:** TN SB 663 authorizes a consumer to designate an authorized agent who may opt the consumer out of the processing of the consumer’s personal data; requires a controller to comply with an opt-out request from an authorized agent if certain conditions are met. **Date introduced:** 01/31/2025 **Key Sponsor**: Heidi Campbell **Committee**: Commerce and Labor Committee **State:** Tennessee **Categories:** Consumer Privacy --- ### [Workers Compensation](https://insurancefraud.org/current_legislation/workers-compensation-2/) **Published:** February 25, 2025 **Author:** Brent Walker **Content:** OR SB 606 adds certain health care employees to the list of workers for whom certain stress disorders give rise to a presumption that a workers’ compensation claim is compensable as an occupational disease. **Date introduced:** 1/21/2025 **Key Sponsor**: Winsvey Campos **Committee**: Labor and Business Committee **State:** Oregon **Categories:** Workers Compensation --- ### [Assignment of Benefits](https://insurancefraud.org/current_legislation/assignment-of-benefits/) **Published:** February 12, 2025 **Author:** Coalition Fraud **Content:** CT HB 6967 concerns the assignment of post-loss homeowners and commercial property insurance benefits and home improvement contractors and salespersons; strengthens regulations for home improvement contractors by enhancing registration requirements, prohibiting fraudulent practices, and ensuring consumer protections in contracts. **Date introduced:** 02/13/2025 **Key Sponsor**: Joint Committee on Insurance and Real Estate **Committee**: Joint Committee on Insurance and Real Estate **State:** Connecticut **Categories:** Assignment of Benefits, Assignment of Benefits - Property --- ### [Policy Misrepresentations](https://insurancefraud.org/current_legislation/policy-misrepresentations/) **Published:** February 12, 2025 **Author:** Coalition Fraud **Content:** IL HB 3795 amends the Insurance Code; removes provisions concerning the duties of the Director of Insurance to promulgate reasonable rules requiring insurers doing business in the state to report factual information in their possession that is pertinent to suspected fraudulent insurance claims, fraudulent insurance applications, or premium fraud after the Director has made a determination that the information is necessary to detect fraud or arson; requires insurers to report fraudulent activity. **Date introduced:** 02/7/2025 **Key Sponsor**: Jeff Keicher **Committee**: House **State:** Illinois **Categories:** Policy Misrepresentations --- ### [Fraud Reporting](https://insurancefraud.org/current_legislation/fraud-reporting/) **Published:** February 13, 2025 **Author:** Coalition Fraud **Content:** NJ AB 5254 establishes Car Insurance Reduction Act; modifies current law addressing requirements of automobile insurers for underwriting, rate calculations and reductions, and reporting requirements to State. The bill requires insurers to report fraud-related data to the Department of Banking and Insurance and the Office of the Insurance Fraud Prosecutor. **Date introduced:** 01/30/2025 **Key Sponsor**: Heather Simmons **Committee**: Assembly Financial Institutions and Insurance **State:** New Jersey **Categories:** Fraud Reporting --- ### [Fraud Act Updates](https://insurancefraud.org/current_legislation/fraud-act-updates/) **Published:** February 13, 2025 **Author:** Coalition Fraud **Content:** NY AB 3321 enacts the New York automobile insurance fraud and premium reduction act; provides that this act is aimed at reducing insurance fraud and thus lowering the cost of insurance premiums; provides a provision for compensation to a person that reports insurance fraud to the authorities; further provides that this act also increases the penalty for insurance fraud. **Date introduced:** 1/27/2025 **Key Sponsor**: Ken Blankenbush **Committee**: Assembly Insurance Committee **State:** New York **Categories:** Fraud Act Updates --- ### [Workers Compensation](https://insurancefraud.org/current_legislation/workers-compensation/) **Published:** February 13, 2025 **Author:** Coalition Fraud **Content:** NY AB 3418 relates to providing access to the workers’ compensation system, timely and meaningful wage replacement benefits, and medical treatment; relates to improving efficiency of the system and cost savings. The amendment to Section 112-a defines knowingly understating payroll, misclassifying employees, or concealing relevant information as fraudulent practices, and imposes stricter penalties for employers who fail to provide audit access, including a surcharge of twice the estimated annual premium and mandatory reporting to the New York Compensation Insurance Rating Board. **Date introduced:** 1/27/2025 **Key Sponsor**: Harry B. Bronson **Committee**: Assembly Labor Committee **State:** New York **Categories:** Workers Compensation --- ### [Fraud Act Updates](https://insurancefraud.org/current_legislation/fraud-act-updates-2/) **Published:** February 13, 2025 **Author:** Coalition Fraud **Content:** NY AB 3690 authorizes the investigation of fraudulent activities; regards to individuals operating motor vehicles without insurance; increases the civil penalty for forging insurance documents; creates the crime of offering a false application for motor vehicle insurance or registration. **Date introduced:** 1/30/2025 **Key Sponsor**: David I. Weprin **Committee**: Assembly Insurance Committee **State:** New York **Categories:** Fraud Act Updates --- ### [Fraud Act Updates](https://insurancefraud.org/current_legislation/fraud-act-updates-3/) **Published:** February 13, 2025 **Author:** Coalition Fraud **Content:** NY AB 3785 grants the superintendent of financial services authority to investigate fraudulent activities, such as motor vehicle operators who drive with no insurance coverage, and those who misrepresent their principal place of residence or where their motor vehicle is principally garaged and operated; authorizes such superintendent to accept reports of suspected fraudulent insurance actions; requires insurance companies and self-insurers to report incidents of insurance fraud to the department. **Date introduced:** 1/30/2025 **Key Sponsor**: David I. Weprin **Committee**: Assembly Insurance Committee **State:** New York **Categories:** Fraud Act Updates --- ### [Fraud Warnings](https://insurancefraud.org/current_legislation/fraud-warnings/) **Published:** February 13, 2025 **Author:** Coalition Fraud **Content:** PA HB 392 amends the act known as The Insurance Company Law, in casualty insurance; provides for billing. It establishes new notification requirements when an insurer reimburses a nonnetwork EMS agency and issues payment directly to the policyholder rather than the EMS provider. The amendment introduces a fraud warning by explicitly stating that misuse of EMS reimbursement funds by a policyholder—using the money for anything other than paying the EMS provider—may result in an insurance fraud claim. **Date introduced:** 1/28/2025 **Key Sponsor**: Seth M. Grove **Committee**: House Insurance Committee **State:** Pennsylvania **Categories:** Fraud Warnings --- ### [Insurance Fraud Prevention Act](https://insurancefraud.org/current_legislation/insurance-fraud-prevention-act-3-2/) **Published:** January 21, 2025 **Author:** Brent Walker **Content:** IL HB 266 makes a technical change in a section concerning the short title of the Illinois Insurance Fraud Prevention Act. **Date introduced:** 01/09/2025 **Key Sponsor**: Chris Welch **Committee**: Rules **State:** Illinois **Categories:** Insurance Fraud Prevention Act --- ### [Insurance Fraud Prevention Act](https://insurancefraud.org/current_legislation/insurance-fraud-prevention-act-3/) **Published:** January 21, 2025 **Author:** Brent Walker **Content:** IL HB 265 makes a technical change in a section concerning the short title of the Illinois Insurance Fraud Prevention Act. **Date introduced:** 01/09/2025 **Key Sponsor**: Chris Welch **Committee**: Rules **State:** Illinois **Categories:** Insurance Fraud Prevention Act --- ### [Insurance Fraud](https://insurancefraud.org/current_legislation/insurance-fraud-prevention-act-2/) **Published:** January 21, 2025 **Author:** Brent Walker **Content:** DE SB 45 would add a new crime of application insurance fraud under the Delaware criminal code. **Date introduced:** 01/16/2025 **Key Sponsor**: Spiros Mantzavinos **Committee**: Banking, Business, Insurance & Technology **State:** Delaware **Categories:** Insurance Fraud Prevention Act --- ### [Data Privacy](https://insurancefraud.org/current_legislation/data-privacy-34-2/) **Published:** January 21, 2025 **Author:** Brent Walker **Content:** IL HB 1252 would amend the Illinois Insurance Code. that the Amendatory Act may be referred to as the Motor Vehicle Insurance Fairness Act; provides that no insurer shall refuse to issue or renew a policy of automobile insurance based in whole or in part on specified prohibited underwriting or rating factors; sets forth factors that are prohibited with respect to underwriting and rating a policy of automobile insurance; sets forth provisions concerning the use of Territorial factors; provides that every insurer. Every insurer shall demonstrate that its marketing, underwriting, rating, claims handling, fraud investigations, and any algorithm or model used for those business practices do not disparately impact any group of customers based on race, color, national or ethnic origin, religion, sex, sexual orientation, disability, gender identity, or gender expression. **Date introduced:** 01/10/2025 **Key Sponsor**: Will Guzzardi **Committee**: Pending **State:** Illinois **Categories:** Consumer Privacy --- ### [Dental Fraud](https://insurancefraud.org/current_legislation/dental-fraud/) **Published:** January 29, 2025 **Author:** Brent Walker **Content:** NY SB 229 establishes an elderly dental insurance coverage program; specifies eligibility requirements; specifies penalties for fraud and abuse. **Date Introduced:** 01/08/2025 **Key Sponsor:** James Tedisco **Committee:** Finance Committee **State:** New York **Categories:** Dental Fraud --- ### [Health Insurance](https://insurancefraud.org/current_legislation/insurance-fraud-prevention-act-2-2-2/) **Published:** January 29, 2025 **Author:** Brent Walker **Content:** WA SB 5477 improves access to appropriate mental health and substance use disorder services. Does not prevent a health carrier from denying coverage based on insurance fraud. Provides that a health carrier may not request a refund of amounts paid to a provider from that provider for mental health services more than 180 days after the date of payment, except in cases of fraud. **Date introduced:** 01/23/2025 **Key Sponsor**: Jessica Bateman **Committee**: Health & Long Term Care **State:** Washington **Categories:** Health Insurance --- ### [Data Privacy](https://insurancefraud.org/current_legislation/data-privacy-34-2-2/) **Published:** January 29, 2025 **Author:** Brent Walker **Content:** NY AB 974 enacts the New York privacy act to require companies to disclose their methods of de-identifying personal information, to place special safeguards around data sharing and to allow consumers to obtain the names of all entities with whom their information is shared. Does not apply to any nonprofit entity to the extent such organization collects, processes, uses, or shares data solely in relation to identifying, investigating, or assisting law enforcement agencies in connection with suspected insurance-related criminal or fraudulent acts or first responders in connection with catastrophic events. Does not restrict the ability to prevent, detect, protect against, or respond to security incidents, identity theft, fraud, harassment, malicious or deceptive activities, or any illegal activity; preserve the integrity or security of systems; or investigate, report, or prosecute those responsible for any such action. **Date introduced:** 01/08/2025 **Key Sponsor**: Nily Rozic **Committee**: Consumer Affairs and Protection **State:** New York **Categories:** Consumer Privacy --- ### [Data Privacy](https://insurancefraud.org/current_legislation/state-anti-fraud-authority-2-2-2-2-3-2/) **Published:** January 29, 2025 **Author:** Brent Walker **Content:** NY SB 3044 enacts the New York privacy act to require companies to disclose their methods of de-identifying personal information, to place special safeguards around data sharing and to allow consumers to obtain the names of all entities with whom their information is shared. Does not apply to any nonprofit entity to the extent such organization collects, processes, uses, or shares data solely in relation to identifying, investigating, or assisting law enforcement agencies in connection with suspected insurance-related criminal or fraudulent acts or first responders in connection with catastrophic events. Does not restrict the ability to prevent, detect, protect against, or respond to security incidents, identity theft, fraud, harassment, malicious or deceptive activities, or any illegal activity; preserve the integrity or security of systems; or investigate, report, or prosecute those responsible for any such action. **Date introduced:** 01/238/2025 **Key Sponsor**: Kristen Gonzalez **Committee**: Internet and Technology Committee **State:** New York **Categories:** Consumer Privacy --- ### [Vehicle Photo Inspections](https://insurancefraud.org/current_legislation/insurer-practices-2-3/) **Published:** January 29, 2025 **Author:** Brent Walker **Content:** NY SB 1591 authorizes insurers to allow the insured to take and submit photographs of their automobile for purposes of the issuance or renewal of a policy of automobile physical damage insurance. The insured must certify the accuracy and completeness of the information recorded on the inspection form prescribed by the superintendent, under penalty of perjury. Any knowing misrepresentation shall constitute a “fraudulent insurance act”. If, upon inspection of the insured’s digital photographs and/or review of the inspection form prescribed by the superintendent, the insurer identifies evidence of a fraudulent insurance act, the insurer may cancel or rescind the insured’s physical damage coverage, and may report such evidence of a fraudulent insurance act to law enforcement authorities. **Date introduced:** 01/10/2025 **Key Sponsor**: Andrew Lanza **Committee**: Insurance Committee **State:** New York **Categories:** Vehicle Photo Inspections --- ### [Identity Theft](https://insurancefraud.org/current_legislation/artificial-intelligence-8-6/) **Published:** January 29, 2025 **Author:** Brent Walker **Content:** NY SB 74 relates to offenses involving theft of identity by knowingly and with intent to defraud assumes the identity of another; creates five tiers of crimes, based on the financial loss to the victim(s) and the number of people victimized. **Date introduced:** 01/08/2025 **Key Sponsor**: Brian Kavanagh **Committee**: Codes **State:** New York **Categories:** Identity Theft --- ### [Artificial Intelligence](https://insurancefraud.org/current_legislation/artificial-intelligence-8-5/) **Published:** January 29, 2025 **Author:** Brent Walker **Content:** NY AB 768 enacts the “New York artificial intelligence consumer protection act”, in relation to preventing the use of artificial intelligence algorithms to discriminate against protected classes. High-risk artificial intelligence decision system does not include any anti-fraud technology that does not make use of facial recognition technology. Does not restrict, by any means other than facial recognition technology, prevent, detect, protect against, or respond to a malicious or deceptive activity or identity theft, fraud, harassment or any other illegal activity. **Date introduced:** 01/08/2025 **Key Sponsor**: Alex Bores **Committee**: Consumer Affairs and Protection **State:** New York **Categories:** Artificial Intelligence --- ### [Consumer Privacy](https://insurancefraud.org/current_legislation/state-anti-fraud-authority-2-2-2-2-4/) **Published:** January 29, 2025 **Author:** Brent Walker **Content:** NY AB 219 relates to the furnishing of registration information by the commissioner of the Department of Motor Vehicles. Exempts the deletion requirement from use by any insurer or by a self-insured entity, or its agents, employees, or contractors, in connection with motor vehicle claims investigation activities, antifraud activities, rating or underwriting. **Date introduced:** 01/08/2025 **Key Sponsor**: William Magnarelli **Committee**: Transportation Committee **State:** New York **Categories:** Consumer Privacy --- ### [Data Privacy](https://insurancefraud.org/current_legislation/data-privacy-27-2/) **Published:** January 29, 2025 **Author:** Brent Walker **Content:** NJ AB 5017 exempts certain personal information collected by insurance support organizations from certain requirements concerning notification and disclosure of personal data. **Date introduced:** 01/23/2025 **Key Sponsor**: Ellen Park **Committee**: Assembly Financial Institutions and Insurance **State:** New Jersey **Categories:** Data Privacy --- ### [Artificial Intelligence](https://insurancefraud.org/current_legislation/artificial-intelligence-8-3/) **Published:** January 29, 2025 **Author:** Brent Walker **Content:** NE LB 642 adopts the Artificial Intelligence Consumer Protection Act. Specifies that a high-risk artificial intelligence system does not include antifraud technology and does not restrict the ability to prevent, detect, protect against, or respond to any security incident, identity theft, fraud, harassment, malicious or deceptive activity, or illegal activity. **Date introduced:** 1/22/2025 **Key Sponsor**: Eliot Bostar **Committee**: Judiciary **State:** Nebraska **Categories:** Artificial Intelligence --- ### [Insurer Practices](https://insurancefraud.org/current_legislation/insurer-practices-2-2/) **Published:** January 29, 2025 **Author:** Brent Walker **Content:** CT HB 6437 would remove the requirement for insurance companies to provide the Insurance Commissioner annual reports detailing all information received or investigations conducted by such company during the past year concerning insurance fraud in any claim under a motor vehicle insurance policy. **Date introduced:** 01/22/2025 **Key Sponsor**: Joint Committee on Insurance and Real Estate **Committee**: Joint Committee on Insurance and Real Estate **State:** Connecticut **Categories:** Insurer Practices --- ### [Workers Compensation](https://insurancefraud.org/current_legislation/insurer-practices-2-2-2/) **Published:** January 29, 2025 **Author:** Brent Walker **Content:** CT SB 828 establishes a working group to examine the Workers Compensation Program and to make recommendations for streamlining the program, including, but not limited to, updating the electronic filing system, including the reporting triggers and mechanisms, reducing prior authorization delays and reducing fraudulent claims. **Date introduced:** 01/21/2025 **Key Sponsor**: Paul Cicarella **Committee**: Joint Committee on Labor and Public Employees **State:** Connecticut **Categories:** Workers Compensation --- ### [Data Privacy](https://insurancefraud.org/current_legislation/data-privacy-27/) **Published:** January 30, 2024 **Author:** Brent Walker **Content:** NJ AB 1902 relates to the New Jersey Disclosure and Accountability Transparency Act (DATA); establishes certain requirements for disclosure and processing of personally identifiable information; establishes Office of Data Protection and Responsible Use in Division of Consumer Affairs. 2024/2025 bill. **Date introduced:** 01/09/2023 **Key Sponsor**: Ellen Park **Committee**: Science, Innovation, Technology **State:** New Jersey **Categories:** Data Privacy --- ### [Insurer Practices](https://insurancefraud.org/current_legislation/insurer-practices-6/) **Published:** January 30, 2024 **Author:** Brent Walker **Content:** NJ AB 2592 revises New Jersey law concerning physical damage inspection of vehicle by automobile insurer. **Date introduced:** 01/09/2023 **Key Sponsor**: Jessica Ramirez **Committee**: Financial Institutions and Insurance **State:** New Jersey **Categories:** Auto Damage Appraisals, Auto Damage Estimates --- ### [Insurance Fraud Penalties](https://insurancefraud.org/current_legislation/insurance-fraud-penalties/) **Published:** January 30, 2024 **Author:** Brent Walker **Content:** NJ AB 3109 would create a New Jersey White Collar Crime Registry. Includes the offense of insurance fraud. **Date introduced:** 01/09/2023 **Key Sponsor**: Craig Coughlin **Committee**: Judiciary **State:** New Jersey **Categories:** Insurance Fraud Penalties --- ### [Public Adjusters](https://insurancefraud.org/current_legislation/public-adjusters-5/) **Published:** January 30, 2024 **Author:** Brent Walker **Content:** NJ SB 1320 is a New Jersey carryover into 2025. Requires certain information be included in certain contracts with licensed public adjusters. **Has support** **and labeled as a 2024-2025 bill.** **Date introduced:** 01/09/2023 **Key Sponsor**: Nellie Pou **Committee**: Commerce **State:** New Jersey **Categories:** Public Adjusters --- ### [State Anti-Fraud Authority](https://insurancefraud.org/current_legislation/state-anti-fraud-authority/) **Published:** January 30, 2024 **Author:** Brent Walker **Content:** NJ SB 1463 clarifies that a violation of New Jersey State Insurance Fraud Prevention Act would result in loss of motor vehicle liability insurance coverage in certain circumstances; also provides coverage for innocent persons in certain situations involving insurance fraud. **Date introduced:** 01/09/2023 **Key Sponsor**: Joseph Lagana **Committee**: Commerce **State:** New Jersey **Categories:** Fraud Bureau Authority --- ### [Insurance Fraud Prevention Act](https://insurancefraud.org/current_legislation/insurance-fraud-prevention-act/) **Published:** February 6, 2024 **Author:** Brent Walker **Content:** NJ SB 2558 would add self-insured entities and plans under certain provisions to the New Jersey Insurance Fraud Prevention Act. **Date introduced:** 02/05/2024 **Key Sponsor**: Robert Singer **Committee**: Pending **State:** New Jersey **Categories:** Insurance Fraud Prevention Act --- ### [Towing](https://insurancefraud.org/current_legislation/state-anti-fraud-authority-2-2/) **Published:** January 29, 2025 **Author:** Brent Walker **Content:** AZ HB 2283 relates to towing price regulations and unlawful practices during emergencies. **Date introduced:** 01/15/2025 **Key Sponsor**: Cesar Aguilar **Committee**: Commerce Committee **State:** Arizona **Categories:** Towing --- ### [Towing](https://insurancefraud.org/current_legislation/state-anti-fraud-authority-2-2-2/) **Published:** January 29, 2025 **Author:** Brent Walker **Content:** AZ SB 1127 relates to vehicle towing rates; relates to regulation. **On monitor only, relates to private property tows.** **Date introduced:** 01/15/2025 **Key Sponsor**: Kevin Payne **Committee**: Government Committee **State:** Arizona **Categories:** Towing --- ## News Archives ### [Richmond Man Gets 42 Years to Life for Killing, Burning Body Near Oakland Zoo](https://insurancefraud.org/news_archives/richmond-man-gets-42-years-to-life-for-killing-burning-body-near-oakland-zoo/) **Published:** October 20, 2026 **Author:** Diane Beauchamp **Content:** A Richmond man was sentenced to 42 years to life in prison, with no chance of parole for 42 years, for shooting a 25-year-old man and then having his body dumped and burned inside a pickup truck near the Oakland Zoo. Jose Vazquez-Cano, 45, was sentenced in Martinez after a jury convicted him of second-degree murder and arson of a corpse in the June 2023 killing of Bryan Barrios-Marroquin. The sentence, handed down this week, folds together the murder and arson convictions with a 25-year firearm-use enhancement that the judge declined to strike, according to The Mercury News. A jury found that Vazquez-Cano killed Barrios-Marroquin and then burned his body, capping a prosecution that began when investigators traced a burning truck in the Oakland hills back to a shooting scene in Richmond. Barrios-Marroquin was killed in a June 3, 2023 shooting in Richmond, and his body was found later that same day inside a burning pickup truck parked on the 9500 block of Mountain Boulevard in the Oakland hills, near the Oakland Zoo, according to a separate mercurynews.com report from 2023. The report described gunshot wounds. Vazquez-Cano was arrested and charged about a month after the body was discovered. Judge Rejects Self-Defense and Accident Claims At trial, Vazquez-Cano testified that Barrios-Morales had handled the firearm irresponsibly and that he grabbed it out of fear before it went off, and that the gun then discharged 11 times by accident in what he described as self-defense. Judge Terri Mockler, who presided over the case, acknowledged that testimony in her ruling but was unmoved by it. “Had it been a single shot, perhaps. But there were 11 shots,” Mockler said, according to the same report. Mockler also said that burning the body made it harder for a forensic pathologist to trace the trajectories of the victim’s gunshot wounds, a factor she weighed in declining to run the arson sentence concurrently with the murder conviction. Police said two other people witnessed the shooting and that Vazquez-Cano pressured them into dumping the body in Oakland and setting it on fire. Defense Cited Trauma, Prosecution Cited Jail Record The defense argued that Vazquez-Cano’s childhood trauma and a PTSD diagnosis warranted a more lenient sentence, and attorneys urged Mockler not to add the 25-year firearm enhancement on top of the underlying charges. The judge declined to strike that enhancement, leaving the full weight of the gun-use allegation intact. Deputy District Attorney Kabu Adodoadji, who prosecuted the case, told the court that Vazquez-Cano had accumulated 22 jail discipline write-ups since his 2023 arrest. Adodoadji also claimed in court that Vazquez-Cano admitted he was a former gang member and had given conflicting statements about having once been shot in El Salvador, details the prosecution used to argue against leniency. Shortly before sentencing, Vazquez-Cano tried unsuccessfully to fire his public defender through a legal motion, a last attempt that did not delay the outcome. Under the California Penal Code’s general sentencing framework for homicide, second-degree murder alone is punishable by 15 years to life in state prison, according to California Legislative Information — a baseline the firearm enhancement and arson conviction substantially extended in this case. A Father’s Grief Submitted to the Court Barrios-Marroquin’s father, Reno Barrios-Morales, submitted a letter to the court describing the pain that has followed his son’s death. “I go to sleep crying and I wake up crying,” he wrote, a statement that underscored the human toll behind the legal proceedings as the case reached its conclusion. **Topics:** Auto arson **Categories:** Conviction --- ### [Former Vermont therapist convicted of Medicaid fraud](https://insurancefraud.org/news_archives/former-vermont-therapist-convicted-of-medicaid-fraud/) **Published:** October 20, 2026 **Author:** Diane Beauchamp **Content:** A former Vermont psychotherapist won’t practice for five years after being convicted of Medicaid fraud. Amy Siegel, 49, of Moretown, admitted to falsely billing the state for more than $4,000 in treatment services she never provided. Washington County Superior Court Judge Michael Kainen deferred sentencing for five years. During that period, Siegel cannot provide psychotherapy. If she complies with the terms, the court may vacate her conviction after the five years. Siegel was also ordered to pay $4,551.62 in restitution for 48 fraudulent claims. **Topics:** Medicare/Medicaid **Categories:** Conviction --- ### [Bristol police give update on odometer fraud investigation](https://insurancefraud.org/news_archives/bristol-police-give-update-on-odometer-fraud-investigation/) **Published:** October 20, 2026 **Author:** Diane Beauchamp **Content:** The Bristol Police Department gave an update on a multi-agency [odometer fraud investigation](https://www.wndu.com/2026/10/15/multi-agency-investigation-into-odometer-fraud-underway-elkhart-county/) on Friday. On Thursday at around 1:30 p.m., Bristol police executed three search warrants related to an ongoing criminal investigation into odometer fraud and corrupt business practices, the department said. Bristol police said they were assisted by Indiana State Police, National Insurance Crime Bureau and U.S. Immigration and Customs Enforcement. Nine people with immigration warrants were taken into custody by ICE and five vehicles were impounded, Bristol police said. Two of the search warrants were for locations in Bristol, in the 200 block of St. Joseph Street and 300 block of Washington Street. The third was for a residence in the City of Elkhart along the 1200 block of County Road 15. The investigation is still active. **Topics:** Auto fraud, Public Awareness --- ### [3 Connecticut business owners arrested for alleged workers’ comp violations](https://insurancefraud.org/news_archives/3-connecticut-business-owners-arrested-for-alleged-workers-comp-violations/) **Published:** October 19, 2026 **Author:** Diane Beauchamp **Content:** Three Connecticut business owners were arrested on Thursday related to alleged workers’ compensation law violations, according to the Office of the Chief State’s Attorney. Luis Pomaquiza, 42, the owner of LA Roofing, LLC in Middletown, was charged with defrauding a workers’ compensation insurance carrier. He is accused of conducting roof-replacement site visits in Southington with employees who were not reported ot the company’s insurance carrier. Jordan Tyler, 36, the owner of J.A.T. Builders, LLC in East Hartford, was charged with noncompliance with insurance requirements. According to the Office of the Chief State’s Attorney, an investigation revealed that an employee sustained an injury while working for Tyler’s company when it did not have an active workers’ compensation insurance policy. As a result of this incident, the State of Connecticut’s Second Injury Fund was ordered to pay more than $25,000 in combined benefits to the injured worker and medical providers, according to the Office of the Chief State’s Attorney. Solomon Sade, 47, the owner of the Baxter & The Blondinit restaurant in Westport, is accused of operating his business without a workers’ compensation insurance policy on two separate occasions. He was charged with two counts of noncompliance with insurance requirements. All three individuals were processed on their arrest warrants and released on $10,000 non-surety bonds. **Topics:** Work comp - employer **Categories:** Arrest --- ### [National Fraud Enforcement Division and the Department of Health and Human Services Announce Self-Disclosure Protocol for Criminal Health Care Fraud](https://insurancefraud.org/news_archives/national-fraud-enforcement-division-and-the-department-of-health-and-human-services-announce-self-disclosure-protocol-for-criminal-health-care-fraud/) **Published:** October 19, 2026 **Author:** Diane Beauchamp **Content:** One disclosure to the Fraud Division’s Health Care Fraud Section now earns companies the benefits of both DOJ’s Corporate Enforcement Policy and HHS-OIG’s Self-Disclosure Protocol The Justice Department’s National Fraud Enforcement Division (Fraud Division) and the Department of Health and Human Services Office of Inspector General (HHS-OIG) today issued a policy that clarifies that companies seeking to voluntarily self-disclose potential criminal conduct related to health care need only to disclose to the Fraud Division to receive the benefit of both the Department’s Corporate Enforcement Policy and HHS-OIG’s Health Care Fraud Self-Disclosure Protocol (SDP). HHS-OIG separately updated the SDP to clarify that criminal health care matters should be disclosed to the Department of Justice. “Companies that discover fraud within their own operations should not have to navigate a maze of agencies before reporting it,” said Assistant Attorney General Colin M. McDonald of the Justice Department’s National Fraud Enforcement Division. “Today, together with our partners at HHS-OIG, we are eliminating unnecessary bureaucratic barriers that have caused confusion about whether companies must make multiple disclosures of potentially criminal conduct. There is now one clear point of contact: DOJ’s Fraud Division. If a company comes forward, cooperates fully, and remedies the misconduct, the benefits are clear and predictable. If a company conceals what it knows, it should expect a very different conversation.” “We encourage companies to come forward and disclose criminal conduct to the Justice Department, and we are committed to extending the benefits of the HHS-OIG Self-Disclosure Protocol to those who do.” said Department of Health and Human Services Inspector General T. March Bell. “The OIG Self-Disclosure Protocol is a critical tool for promoting accountability, transparency, and integrity across the health care system, providing organizations with a clear pathway to voluntarily report potential misconduct and address compliance concerns. This process helps strengthen trust in federally funded health care programs by encouraging timely corrective action, reducing future risk, and demonstrating a commitment to ethical conduct.” The Policy announced today is designed to eliminate obstacles that may slow disclosures. A single arrangement – an illegal kickback, a scheme to bill Medicare for medically unnecessary services, a scheme concealing an excluded provider – routinely may result in potential criminal, civil, or administrative consequences. Companies facing that overlap have had to decide not only whether to come forward, but also where to make that disclosure. Under the Policy announced today, a company that voluntarily self-discloses criminal conduct affecting a federal health care program to the Fraud Division’s Health Care Fraud Section will receive the benefits of HHS-OIG’s SDP – automatically, with no additional direct submission necessary through the HHS-OIG portal. HHS-OIG separately updated the SDP today to settle the reverse question. The SDP covers conduct that may violate civil or administrative law, and the SDP was updated today to clarify that criminal conduct should be disclosed to the Department of Justice. A company that discloses only to HHS-OIG generally will not have made a voluntary self-disclosure to the Department and generally will not qualify for a declination on that basis. Companies seeking the benefits of both programs should bring potentially criminal conduct to the Fraud Division first. The policy announced today may be found [here](https://urldefense.us/v3/__https:/links-1.govdelivery.com/CL0/https:%2A2F%2A2Fwww.justice.gov%2A2Fopa%2A2Fmedia%2A2F1466291%2A2Fdl%2A3Finline=%2A26utm_medium=email%2A26utm_source=govdelivery/1/010001a14123003f-c0d32897-68a7-4284-9d2f-0d8219329b05-000000/Cpf3J-snNqq_aDkg5YbxkcMUXQlUBwlLxlRROotrJ70=452__;JSUlJSUlJSUl!!KDHJTnLT9htas3gmAhw!YeeiqXpj3VDb7EZK40Wnh3V-nsl-wWcsLx97vT2yvm4EhYRdpBFxpDaa0ReNK6US-UsdraTGbd3RLTNhgmnsneyUBuCTpMnT3dJRBsroWw$). HHS-OIG’s updated protocol may be found [here](https://urldefense.us/v3/__https:/links-1.govdelivery.com/CL0/https:%2A2F%2A2Foig.hhs.gov%2A2Fdocuments%2A2Fself-disclosure-info%2A2F11951%2A2Fhhs-oig-self-disclosure-protocol.pdf%2A3Futm_medium=email%2A26utm_source=govdelivery/1/010001a14123003f-c0d32897-68a7-4284-9d2f-0d8219329b05-000000/xUpQUMlPWBYatzo876I4mJ5d10-BHGdYmy6FBQLXKvY=452__;JSUlJSUlJSU!!KDHJTnLT9htas3gmAhw!YeeiqXpj3VDb7EZK40Wnh3V-nsl-wWcsLx97vT2yvm4EhYRdpBFxpDaa0ReNK6US-UsdraTGbd3RLTNhgmnsneyUBuCTpMnT3dL7V_qWZA$). Self-disclosures may be reported to the Fraud Division at: <corporate.enforcement@usdoj.gov>. On April 7, the Department of Justice announced the creation of the Fraud Division. The Fraud Division is laser-focused on investigating and prosecuting those who commit fraud against the American people. The Department’s work to combat fraud supports President Trump’s Task Force to Eliminate Fraud, a whole-of-government effort chaired by Vice President J.D. Vance to eliminate fraud, waste, and abuse within Federal benefit programs. The Fraud Division’s Health Care Fraud Section, currently comprised of nine strike forces operating in federal districts across the country, has charged more than 6,200 defendants who collectively billed federal health care programs and private insurers more than $45 billion since 2007. In addition, the Centers for Medicare & Medicaid Services, working in conjunction with the Office of the Inspector General for the Department of Health and Human Services, are taking steps to hold providers accountable for their involvement in health care fraud schemes. More information can be found at [www.justice.gov/criminal-fraud/health-care-fraud-unit](https://urldefense.us/v3/__https:/links-1.govdelivery.com/CL0/http:%2A2F%2A2Fwww.justice.gov%2A2Fcriminal-fraud%2A2Fhealth-care-fraud-unit%2A3Futm_medium=email%2A26utm_source=govdelivery/1/010001a14123003f-c0d32897-68a7-4284-9d2f-0d8219329b05-000000/6ciKplSBHQfWwan749fccLpeULziNNmwYIZD0vVZudA=452__;JSUlJSUl!!KDHJTnLT9htas3gmAhw!YeeiqXpj3VDb7EZK40Wnh3V-nsl-wWcsLx97vT2yvm4EhYRdpBFxpDaa0ReNK6US-UsdraTGbd3RLTNhgmnsneyUBuCTpMnT3dIW23IsnQ$). **Topics:** Healthcare Fraud, Public Awareness, Regulatory actions --- ### [Connecticut Physician and His Practices Pay More Than $860K to Settle False Claims Act Allegations](https://insurancefraud.org/news_archives/connecticut-physician-and-his-practices-pay-more-than-860k-to-settle-false-claims-act-allegations/) **Published:** October 19, 2026 **Author:** Diane Beauchamp **Content:** STEVEN MURPHY, M.D. and his practices, MURPHY MEDICAL ASSOCIATES, LLC and DIAGNOSTIC AND MEDICAL SPECIALISTS OF GREENWICH, LLC, located in Stamford, have entered into a civil settlement agreement with the federal and state governments in which they will pay $866,539 to settle allegations of COVID-19 related fraud and health care fraud. As part of the settlement, Murphy and his practices agreed to be excluded from all federal health care programs for a period of three years. The government alleges that Murphy and his practices submitted false and fraudulent claims to the Health Resources Services Administration (HRSA), which is a sub-agency of the U.S. Department of Health and Human Services, to reimburse Murphy for “uninsured” patients treated during the COVID-19 pandemic. The government also alleges that Murphy submitted false claims to Medicaid and Medicare for blood testing “panels” allegedly performed by Murphy’s in-house lab. *COVID-19 Uninsured Program Fraud* In response to the COVID-19 pandemic, Congress passed a series of bills to provide funds to health care providers for COVID-19 testing and treatment for uninsured individuals (the “Uninsured Program”). The Uninsured Program reimbursed eligible health care providers for COVID-19 testing, treatment, and vaccine administration provided to uninsured individuals. HRSA was selected to provide oversight and management of the Uninsured Program. An uninsured individual was defined as someone who was “not enrolled” in a government or private health insurance program as of the date of service in question. Prior to seeking reimbursement from the Uninsured Program, health care providers were required to attest to the government that they had confirmed that the patients for whom they were seeking reimbursement were uninsured. Murphy and his practices participated in the Uninsured Program, attested that the patients for whom they sought payment were uninsured, and received reimbursement from the Uninsured Program for those patients. The government alleges that Murphy and his practices had information, including copies of insurance cards and other documents, in their files indicating that certain patients for which they made attestations and submitted claims for reimbursement to the Uninsured Program were, in fact, enrolled in government or private health insurance programs. In addition, Murphy and his practices changed the patient’s insurance identifying information to “Covid19 HRSA Uninsured” in their internal electronic medical records system and then submitted claims and received reimbursement from the Uninsured Program for those patients. *Blood Testing Fraud* Murphy had an in-house lab that performed blood tests on patients. The lab performed blood tests on patients who had possible exposure to COVID-19 or were presenting with COVID-19 symptoms, and also performed blood tests on non-COVID patients, including those who were having an annual physical exam. Murphy and his practices utilized blood testing panels in their in-house lab. The blood testing panels were not billed and paid at one price per panel. Each blood test that made up the panel was billed separately to Medicare or Medicaid. Reagents were used to run the specific blood tests that made up the panel, but there were times when Murphy and his practices failed to purchase certain reagents or otherwise did not have certain reagents, so they could not run the complete blood testing panel. The government alleges that Murphy and his practices billed Medicare and Medicaid for specific blood tests that were part of their standard panel, but which were never actually performed, because they did not have the reagents necessary to perform the specific blood tests that were billed. To resolve the governments’ federal and state False Claims Act allegations, Murphy and his practices have agreed to pay $866,539, which covers the time-period from September 2019 through April 2022. Murphy and his practices also agreed to be excluded from all federal health care programs for a period of three years. This matter was investigated by the Office of Inspector General for the Department of Health and Human Services and the Federal Bureau of Investigation. The matter was handled by Assistant U.S. Attorney Richard M. Molot, with the assistance of Auditor Susan Spiegel, and by Deputy Associate Attorney General Gregory O’Connell of the Connecticut Office of the Attorney General. People who suspect health care fraud are encouraged to report it by calling 1-800-HHS-TIPS or the Health Care Fraud Task Force at (203) 777-6311. **Topics:** COVID-19, Judicial/courts --- ### [Two Florida defendants sentenced to prison for nearly $900,000 health care scam](https://insurancefraud.org/news_archives/two-florida-defendants-sentenced-to-prison-for-nearly-900000-health-care-scam/) **Published:** October 19, 2026 **Author:** Diane Beauchamp **Content:** Two defendants received prison sentences following an $897,405 health care scheme where they used their pharmaceutical service to bill Medicare for thousands of unnecessary and illegal prescriptions. On April 7, the Department of Justice announced the creation of the National Fraud Enforcement Division (Fraud Division). The Fraud Division is laser-focused on investigating and prosecuting those who commit fraud against the American people. The Department’s work to combat fraud supports President Trump’s Task Force to Eliminate Fraud, a whole-of-government effort chaired by Vice President J.D. Vance to eliminate fraud, waste, and abuse within Federal benefit programs. According to court documents, the following defendants pleaded guilty to one count of conspiracy to commit health care fraud, mail fraud, and wire fraud: Steven Anthony Churchill, 39, of Boca Raton, Florida, was sentenced to 24 months in prison; Samson Kollelil Solomon, 28, of Pompano Beach, Florida, was sentenced to 24 months in prison; and Fawn Lickteig, 46, of Lawrence, Kansas, will be sentenced on November 10, 2026. In March 2020, Steven Churchill bought Free State Pharmacy (FSP) in Lawrence, Kansas, but under the name of a now deceased, accused coconspirator. FSP operated as a mail-order pharmacy despite representing itself to Medicare as a retail pharmacy. FSP contracted with Fawn Lickteig’s company, Pharmacy Consulting, to complete and submit its applications to Medicare and other health care related government entities. As part of the scheme, FSP acquired information from telemedicine companies, including names and addresses of patients. FSP employees then filled and shipped medications to these people even though the doctors who wrote the prescriptions had not physically examined or conducted proper telemedicine visits with the patients. FSP received calls from patients unexpectedly receiving medical products, and some patients returned the products to FSP. FSP prioritized the filling of prescriptions based on the amount of profit Medicare would ultimately pay the pharmacy. The majority of the medications prescribed were high-dollar dermatological products. Although FSP was based in Kansas, most of the beneficiaries were Floridians, with 948 claims for Florida residents and 381 claims for Kansas residents. Of the 40 prescribing physicians who worked with FSP, 15 were under investigation at the time for referring medically unnecessary services. Between September 2020 and February 2021, Churchill, Solomon, and Lickteig submitted 2,699 false claims causing Medicare to make fraudulent payments to FSP totaling $897,405. “Medicare exists to help senior citizens obtain the medical services and supplies they need,” said U.S. Attorney Ryan A. Kriegshauser. “Those who pillage government programs for their own enrichment will pay a heavy price when brought to justice. The agency Inspectors General under this administration are hard at work rooting out this type of fraud, and the Department of Justice stands ready to prosecute when it is found.” The Federal Bureau of Investigation (FBI) and Health and Human Services Office of Inspector General (OIG) investigated the case. Assistant U.S. Attorneys Sara Walton and Lindsey Debenham prosecuted the case. **Topics:** Drug Diversion, Medicare/Medicaid **Categories:** Conviction --- ### [Somerset Lifesciences Inc. Agrees to Pay $4M to Resolve Allegations of Causing Medicare to Pay Claims for its Mislabeled Generic Drug](https://insurancefraud.org/news_archives/somerset-lifesciences-inc-agrees-to-pay-4m-to-resolve-allegations-of-causing-medicare-to-pay-claims-for-its-mislabeled-generic-drug/) **Published:** October 19, 2026 **Author:** Diane Beauchamp **Content:** Somerset Lifesciences Inc. (Somerset) has [agreed](https://www.justice.gov/opa/media/1466581/dl) to pay $4 million to resolve common law claims for causing Medicare Part D (Medicare) to pay for its prescription-only (Rx-only) generic drug Olopatadine when it was no longer eligible for Medicare coverage. Medicare does not cover drugs that can be purchased by retail customers over-the-counter (OTC) without a prescription. In 2020, the brand name version of Olopatadine switched from Rx-only to OTC, and Somerset was required to change Olopatadine’s label from Rx-only to OTC as well. Instead, Somerset continued to label and sell Olopatadine as Rx-only and caused Medicare to wrongfully pay claims for an OTC drug. “Today’s resolution underscores the Department’s commitment to safeguarding federal healthcare programs,” said Assistant Attorney General Brett A. Shumate of the Justice Department’s Civil Division. “When companies cause Medicare to pay for products that are not eligible for coverage, the Department will act decisively to remedy that misconduct.” Olopatadine (olopatadine hydrochloride ophthalmic solution USP, 0.1%) is the generic drug version of the brand name eyedrop Pataday Twice Daily Relief (olopatadine hydrochloride) ophthalmic solution, 0.1% (Pataday). Before February 2020, Pataday and Olopatadine were covered by Medicare and only available with a prescription. In February 2020, the U.S. Food and Drug Administration approved the sale of Pataday OTC. Generally, a generic drug’s label must mirror the label for its brand name drug. When Pataday’s label switched from Rx-only to OTC, Somerset was required to change Olopatadine’s label to OTC as well. Somerset, however, did not and continued to label and sell Olopatadine as Rx-only. By continuing to label and sell Olopatadine as Rx-only, Somerset caused Medicare to pay for Olopatadine claims by mistake. This action unjustly enriched Somerset. This year the Administration launched the Task Force to Eliminate Fraud and the National Fraud Enforcement Division to enhance the administration’s war on fraud, waste, and abuse in federal programs. When unscrupulous actors exploit these programs for their own financial gain, they defraud the government, harm the people these programs are designed to aid and protect, and undermine American businesses that play by the rules. The Civil Division’s False Claims Act (FCA) enforcement plays a critical role in combatting such fraudulent schemes, recovering billions of dollars for the American taxpayers, and holding wrongdoers accountable. FCA matters will continue to be on the forefront of the battle against fraud, and the Civil Division’s FCA work will support and advance the mission of the Task Force to Eliminate Fraud and the National Fraud Enforcement Division. The investigation and resolution of this matter illustrate the government’s emphasis on combating healthcare fraud. One of the most powerful tools in this effort is the FCA. Tips and complaints from all sources about potential fraud, waste, abuse, and mismanagement, can be reported to the Department of Health and Human Services at 800-HHS-TIPS (800-447-8477). This matter is being handled by Fraud Section Trial Attorney Vince Vaccarella. **Topics:** Drug Diversion, Judicial/courts, Medicare/Medicaid --- ### [Husband, wife accused of arson, insurance fraud](https://insurancefraud.org/news_archives/husband-wife-accused-of-arson-insurance-fraud/) **Published:** October 19, 2026 **Author:** Diane Beauchamp **Content:** A couple was arrested Thursday after police say they set fire to their Fell Township home in July for insurance money. Salvatore Carovinci, 42, and Holly Carovinci, 41, both of Ocala, Florida, face arson and fraud charges for allegedly starting a July 25 fire at their Shannon Street home. According to the criminal affidavit, the Carovincis put the house up for sale earlier in the month and filed an insurance claim for the house less than four days after the fire. They received $10,000 for the contents of the home and living expenses, according to court records. Although the Carovincis said they left for South Carolina the night before the fire, their cell phones place them at the scene and the neighbor saw a truck identified as Holly’s leave the house approximately 30 minutes before first responders were called to the scene, police said. Once on scene, police said they found three gas cans and a K-9 indicated the presence of an accelerant. Both are in Lackawanna County Prison, unable to post $100,000 bails. Preliminary hearings are scheduled for Oct. 26. **Topics:** Homeowners - arson **Categories:** Arrest --- ### [Driver charged with insurance fraud after leaving obvious signs that he set fire to his own truck](https://insurancefraud.org/news_archives/driver-charged-with-insurance-fraud-after-leaving-obvious-signs-that-he-set-fire-to-his-own-truck/) **Published:** October 19, 2026 **Author:** Diane Beauchamp **Content:** A truck driver has been charged with insurance fraud after investigators discovered several obvious signs that he had set fire to the semi truck himself. The truck caught fire on September 29th, 2025 in Cuyahoga County, Ohio. According to The Chronicle, a passing trucker contacted authorities when he noticed a semi truck on fire at the Columbia Mini Storage on Royalton Road just after 6 p.m. Firefighters arrived and extinguished the blaze before determining that the fire had started in two places – the passenger seat and the sleeper berth. Investigators say that two points of origin for one fire is a common sign of arson, and “concluded it was intentionally set.” When questioned, 58-year-old truck owner Ashraf Khan told police that he was trying to sell the truck in preparation for moving out of state, but later made an insurance claim on the truck worth about $30,275. Investigators also determined that Khan had purchased lighter fluid the day before the fire. Khan has been charged with two felonies – arson and insurance fraud. **Topics:** Auto - staged **Categories:** Arrest --- ### [Video: Comp Spotlight with Pranay Mittal of Travelers](https://insurancefraud.org/news_archives/video-comp-spotlight-with-pranay-mittal-of-travelers/) **Published:** October 19, 2026 **Author:** Diane Beauchamp **Content:** Pranay Mittal, who leads investigative services with Travelers, discusses the changing landscape of fraud detection in workers compensation. <https://www.businessinsurance.com/video-post/video-comp-spotlight-with-pranay-mittal-of-travelers> **Topics:** Public Awareness, Workers Comp --- ### [New Orleans attorney sentenced in staged 18-wheeler crash trial](https://insurancefraud.org/news_archives/new-orleans-attorney-sentenced-in-staged-18-wheeler-crash-trial/) **Published:** October 19, 2026 **Author:** Diane Beauchamp **Content:** New Orleans personal injury attorney Danny Patrick Keating, who pleaded guilty to his role in a fraud scheme, has been sentenced to 32 months in prison. Federal prosecutors say dozens of drivers intentionally crashed into 18-wheelers between 2015 and 2020, hoping to secure large insurance payouts through bogus lawsuits. The staged crashes, many of which took place in New Orleans East and Gentilly, became the focus of a years-long federal investigation that exposed a network involving drivers, passengers, attorneys and medical claims. Following an FBI investigation into those kinds of accidents, the plaintiffs pleaded guilty to staging the wreck. In 2021, Danny Patrick Keating, the personal injury attorney for their lawsuit, pleaded guilty to conspiracy to commit wire fraud. Keating admitted to paying another cooperating government witness, Damien Labeaud, to stage 31 accidents. Keating told investigators he represented 77 plaintiffs in subsequent lawsuits. Federal authorities say the fake crashes mostly took place in New Orleans East and Gentilly, often near a truck stop. In March, a jury convicted personal injury attorneys Jason Giles and Vanessa Motta of numerous charges, including conspiracy to commit wire and mail fraud. Prosecutors said Giles and Motta orchestrated years’ worth of crashes, paying drivers and passengers willing to risk a collision and then cashing in through bogus lawsuits. Members of the U.S. Attorney’s Office in the Eastern District of Louisiana say Vanessa Motta and Giles tarnished their own profession. **Topics:** Auto - staged **Categories:** Conviction --- ### [The Trump administration is doubling down on health care fraud investigations](https://insurancefraud.org/news_archives/the-trump-administration-is-doubling-down-on-health-care-fraud-investigations/) **Published:** October 19, 2026 **Author:** Diane Beauchamp **Content:** The Department of Justice has a warning for health care executives: Don’t be another Theranos. As the Trump administration continues its fight against Medicare and Medicaid fraud, it is also [expanding its investigations into corporate wrongdoing](https://www.statnews.com/pharmalot/2026/10/07/trump-administration-adds-pharma-to-list-priorities-combating-white-collar-fraud/), DOJ officials announced this month. A key part of that plan is making it easier for companies themselves to report potential criminal activity, and encouraging whistleblowing, Jacob Foster, deputy assistant attorney general in the National Fraud Enforcement division, said Thursday at the STAT Summit in Boston. Foster oversees the unit that investigates health care fraud. “There’s nothing more that we want to know when a compliance failure occurs than to hear about the great efforts to remediate it, and reward that,” he said. Going forward, companies in the health care sector looking to file voluntary self-disclosures will find a one-stop shop at the DOJ, Foster said. They previously would’ve had to navigate a separate process at the Department of Health and Human Services, but that is now being consolidated under the health care fraud section at the DOJ. “What do you do? Who do you call? That is a question that industry should not have to ask,” Foster said. Under the new policy, companies that report potential criminal misconduct can reap the benefits — such as a limited cap on financial damages — from both agencies at once. The health care fraud section at the DOJ brings a range of expertise under one roof to handle issues like the emerging field of digital health technology, Foster said. DOJ will make use of data analytics and artificial intelligence algorithms to try and suss out instances of corporate wrongdoing, like providers billing for unneeded services, companies fabricating patient records, or health tech companies adding redundant diagnoses. The department will also design new programs that “appropriately incentivize” whistleblowers to report fraud, according to [an Oct. 1 memo](https://www.justice.gov/opa/media/1463571/dl?inline) from Assistant Attorney General Colin M. McDonald. Health care investigators also look at social media, news reports, and other sources of information to learn about companies possibly breaking the law, Foster said. Prosecutors will place extra emphasis on schemes involving health care, controlled substances, and violations of the federal Food, Drug, and Cosmetic Act, the McDonald memo said. They will also place “great weight” on factors like whether corporate executives knew about or tried to conceal fraud, ran a scheme for over three years or across various states, or affected taxpayer-funded programs, new guidance said. “No one, irrespective of party, likes the government being ripped off by wrongdoers,” Foster said Thursday. “These cases not only involve the theft of all of our tax dollars, \[but\] involve the theft from a program, a trust fund — Medicare — that could run out.” **Topics:** Healthcare Fraud, Public Awareness, Regulatory actions --- ### [Owner of Health Care Software Company Sentenced to 19 Years in Prison for $1B Medicare Fraud](https://insurancefraud.org/news_archives/owner-of-health-care-software-company-sentenced-to-19-years-in-prison-for-1b-medicare-fraud/) **Published:** October 19, 2026 **Author:** Diane Beauchamp **Content:** A Kansas CEO and owner of an internet platform was sentenced yesterday to 19 years in prison for his role in operating a platform that generated false doctors’ orders and prescriptions to defraud Medicare and other federal health care benefit programs out of more than $1 billion. “The Department of Justice and our agency partners dismantled one of the largest telemedicine fraud schemes ever, and yesterday’s lengthy prison sentence holds the orchestrator of that scheme accountable,” said Assistant Attorney General Colin M. McDonald of the Justice Department’s National Fraud Enforcement Division. “The defendant’s fraud scheme lured hundreds of thousands of elderly and disabled Americans into a sophisticated international telemarketing system with one goal: stealing as much as possible from the Medicare trust fund. The Fraud Division will continue to leverage its resources to take down complex fraud operations like Blackman’s DMERx.” “This sentence delivers a decisive warning: anyone who exploits VA programs and services for personal profit will be found and held fully accountable,” said Inspector General Cheryl L. Mason of the Department of Veterans Affairs. “The VA OIG remains committed to working alongside our law enforcement partners to uncover complex fraud schemes and protect our nation’s veterans.” “This 19-year sentence sends an unmistakable message: those who exploit federal health care programs for personal enrichment will face serious consequences,” said Acting Deputy Inspector General for Investigations Miranda L. Bennett of the U.S. Department of Health and Human Services, Office of Inspector General (HH-OIG). “Schemes that corrupt medical decision-making and siphon taxpayer dollars from programs serving vulnerable Americans undermine trust in our health care system. HHS-OIG and its law enforcement partners will continue to pursue those responsible and hold them accountable.” “This sentencing sends a clear message that those who exploit federal health care programs for personal gain will be held accountable,” said Special Agent in Charge Brett D. Skiles of the FBI Miami Field Office. “This scheme undermined the integrity of our health care system and defrauded taxpayer-funded programs designed to serve those in need. The FBI remains committed to working alongside our law enforcement partners to investigate complex health care fraud schemes, protect taxpayer dollars, and hold those responsible accountable. Through these efforts, we remain focused on defending the homeland and protecting the American people from those who seek to exploit our nation’s systems for personal gain.” “This investigation reinforces DCIS’s steadfast commitment to protecting the integrity of the TRICARE program and ensuring that taxpayer-funded military health benefits are used appropriately,” said Acting Special Agent in Charge Nakia Martin Alexander of the DCIS Southeast Field Office. “Fraud schemes that divert TRICARE resources erode the support promised to our service members and their families. As the criminal investigative arm of the DoD Office of Inspector General, DCIS remains focused on identifying these schemes and holding those responsible fully accountable.” According to court documents and evidence presented at trial, Brett Blackman, 43, of Johnson County, Kansas, and his co-conspirators aggressively targeted hundreds of thousands of Medicare beneficiaries across the United States to get them to accept medically unnecessary orthotic braces and other items. They then arranged for purported telemedicine doctors to sign bogus prescription orders for these items so that their co-conspirators could bill Medicare for them. All told, Blackman and his co-conspirators billed Medicare and other federal health care benefit programs over $1 billion for this unnecessary equipment. Blackman owned, controlled, and was the CEO of HealthSplash, which acquired Power Mobility Doctor Rx, LLC (DMERx) in Sept. 2017. DMERx was an internet-based platform that generated false and fraudulent doctors’ orders for durable medical equipment (DME) and prescriptions for other items. As part of the scheme, Blackman and his co-conspirators connected pharmacies, DME suppliers, and marketers with telemedicine companies that would accept illegal kickbacks and bribes in exchange for signed doctors’ orders created using the DMERx platform. Blackman and his co-conspirators took a cut for themselves in exchange for the referrals. The fraudulent doctors’ orders and prescriptions generated by DMERx falsely represented that a doctor had actually examined and treated the Medicare beneficiaries when, in fact, the doctors were simply paid to sign orders and prescriptions without any meaningful interaction with the beneficiary, and in some cases, no interaction at all. Testimony and evidence presented at trial from an undercover agent who posed as a Medicare beneficiary showed the scheme in action — starting with a foreign call center that pushed the undercover agent to agree to multiple braces to a doctor signing bogus orders for the braces using Blackman’s DMERx platform. The doctor’s order for one of these undercover agent beneficiaries claimed that the doctor conducted various tests that can only be performed in person even though the doctor never even spoke with the undercover agent “patient.” The DME suppliers and pharmacies that were paying illegal kickbacks for these orders billed Medicare and other insurers more than $1 billion. Medicare and the other insurers paid more than $450 million based on these claims. According to evidence presented at trial, Blackman and his co-conspirators concealed the scheme through sham contracts and by manipulating the doctors’ orders to avoid Medicare audits, including by removing references to telemedicine in the doctors’ orders. As a result of Blackman’s scheme, Medicare was fraudulently billed for orthotic braces for more than 346,000 Medicare beneficiaries. On average, Medicare was billed for four braces per beneficiary, with Medicare being billed for at least 21 orthotics prescribed through Blackman’s DMERx platform to over 1,200 beneficiaries. After a 23-day jury trial ending in Apr. 2026, Blackman was convicted of conspiracy to commit health care fraud and wire fraud, conspiracy to pay and receive kickbacks, and conspiracy to defraud the United States and to make false statements in connection with health care matters. Blackman’s restitution and forfeiture obligations will be determined by the Court at a later date. In Dec. 2025, Blackman’s co-defendant, Gary Cox, was sentenced to 15 years in prison. HHS-OIG, FBI, VA-OIG, and DCIS investigated the case. Assistant Deputy Chief Darren C. Halverson and Trial Attorney Reginald Cuyler Jr. of the Fraud Division’s Health Care Fraud Section prosecuted the case. On April 7, the Department of Justice announced the creation of the Fraud Division. The Fraud Division is laser-focused on investigating and prosecuting those who commit fraud against the American people. The Department’s work to combat fraud supports President Trump’s Task Force to Eliminate Fraud, a whole-of-government effort chaired by Vice President J.D. Vance to eliminate fraud, waste, and abuse within Federal benefit programs. The Department of Justice’s Health Care Fraud Strike Force Program, currently comprised of nine strike forces operating in federal districts across the country, has charged more than 6,200 defendants who collectively billed federal health care programs and private insurers more than $45 billion since 2007. In addition, the Centers for Medicare & Medicaid Services, working in conjunction with the Office of the Inspector General for the Department of Health and Human Services, are taking steps to hold providers accountable for their involvement in health care fraud schemes. More information can be found at [www.justice.gov/criminal-fraud/health-care-fraud-unit](http://www.justice.gov/criminal-fraud/health-care-fraud-unit). **Topics:** Medicare/Medicaid, Technology **Categories:** Conviction --- ### [Abbott Signs Vance Pledge To Crack Down on Government Benefits Fraud](https://insurancefraud.org/news_archives/abbott-signs-vance-pledge-to-crack-down-on-government-benefits-fraud/) **Published:** October 19, 2026 **Author:** Diane Beauchamp **Content:** Twenty-two Republican governors, including Texas Gov. [Greg Abbott](https://texasscorecard.com/directory/officials/greg-abbott/), have signed a pledge supporting Vice President JD Vance’s efforts to combat fraud in taxpayer-funded benefit programs. The [document](https://www.rga.org/wp-content/uploads/2026/10/The-Vice-Presidents-Pledge-to-Protect-Americans-from-Fraud-10.15.26-1.pdf), titled “The Vice President’s Pledge to Protect Americans from Fraud,” outlines six commitments aimed at preventing fraudulent payments, protecting vulnerable Americans, and holding those who abuse government assistance programs accountable. Among the commitments is a pledge to ensure taxpayer-funded programs serve law-abiding Americans rather than illegal aliens or fraudsters. The governors also pledged to prevent fraudulent benefits from being used to purchase luxury cars or mansions and to strengthen coordination between government agencies to stop improper payments before they are distributed. The document calls for convicted fraudsters to be imprisoned and permanently barred from receiving taxpayer funds. It also calls for illegal aliens convicted of fraud to be prosecuted, imprisoned, and deported. “Although previous administrations turned a blind eye to fraud, President Trump and Vice President Vance are aggressively fighting fraudsters nationwide,” the pledge states. Vance has also raised concerns about fraud during recent campaign appearances in Texas. At a rally in Tyler earlier this week, he referenced criminals defrauding Texas Medicaid while praising Attorney General [Ken Paxton](https://texasscorecard.com/directory/officials/ken-paxton/)’s record. During a September rally in Harlingen, Vance also criticized politicians who he said prioritize fraudsters over ordinary Americans. The pledge comes as Abbott has already directed state agencies to increase scrutiny of fraud in Texas. In January, Abbott ordered a [review](https://texasscorecard.com/state/after-minnesota-scandal-abbott-orders-review-of-texas-child-care-program/) of the state’s subsidized child care program following reports of widespread fraud in Minnesota. “Fraud has no place in Texas,” Abbott spokesman Andrew Mahaleris told *Texas Scorecard*. “Earlier this year, Governor Abbott directed the TWC and HHSC to conduct a thorough review of the Child Care Services program to ensure robust protections against any potential misuse of taxpayer dollars.” Mahaleris said the review found that Texas already had strong safeguards in place. “Their review confirmed that Texas maintains strong anti-fraud measures that have kept improper payments extraordinarily low compared to other states,” he said. “Taxpayer-funded programs must serve eligible Texans, not fraudsters or illegal aliens. Those who steal from these programs face investigation and prosecution.” In August, Abbott [directed the Texas Department of Insurance](https://gov.texas.gov/news/post/governor-abbott-directs-tdi-to-take-action-to-make-property-insurance-more-affordable) to establish an Insurance Fraud Task Force as part of a broader effort to reduce property insurance costs. The task force is intended to bring together law enforcement agencies, anti-fraud organizations, consumers, and other stakeholders to combat insurance fraud that contributes to higher premiums. At the federal level, President Donald Trump established a Task Force to Eliminate Fraud in March, chaired by Vance, to coordinate efforts to prevent fraud across federal benefit programs, including those administered by state governments. **Topics:** Legislative, Public Awareness --- ### [Washington fines USAA, Allstate over claims violations and 86,705 home policies](https://insurancefraud.org/news_archives/washington-fines-usaa-allstate-over-claims-violations-and-86705-home-policies/) **Published:** October 19, 2026 **Author:** Diane Beauchamp **Content:** The Washington Office of the Insurance Commissioner fined USAA and Allstate a combined $230,000 for claims-handling violations and missing premium-change language on homeowners policies. The OIC also said USAA made $88,241 in additional payments on 158 auto claims. The OIC fined USAA Casualty Insurance Co. $140,000 for its handling of auto claims and Allstate Vehicle and Property Insurance Co. $90,000 for claims-handling violations and failing to follow the state’s premium-change transparency rule. “We take our role as a consumer protection agency seriously,” Insurance Commissioner Patty Kuderer said in announcing the fines. “These orders, and the actions we’ve taken against insurers for failing to meet their obligations to policyholders when processing their claims, are a testament to that work.” USAA paid $88,241 on additional claims The OIC received 445 complaints involving USAA between April 2019 and April 2024. The agency reviewed 125 complaints filed between January 2023 and April 2024 and found at least one potential violation of state law or rules in 31 associated auto claims. USAA confirmed 19 violations. The findings included delays in responding to consumers, failures to investigate claims within required timeframes, investigations that were not completed within 30 days and refusals to pay claims without a reasonable investigation. One finding involved a total-loss settlement that did not include applicable taxes and fees. After reviewing a complaint in March 2024, the OIC asked USAA to examine its total-loss settlements from the previous two years. USAA reviewed its records and made additional payments on 158 claims totaling $88,241 within two months. The company also reported that it corrected the issue to prevent it from happening again. Allstate claims review found 16 violations The OIC reviewed 108 claims from a database of 3,040 Allstate claims after receiving complaints about the company’s claims handling. The agency found nine claims with a total of 16 violations. The findings included failures to use reasonable standards for processing and paying claims, delays in responding to consumers and investigations that were not completed within the required 30-day period. The OIC also identified one instance in which it found that Allstate misrepresented important facts when issuing a payment substantially below its own estimate. According to the consumer complaint memo, Allstate’s initial claim payment was $20,000, while its estimate of the property’s actual cash value was $22,390.14 — a difference of $2,390.14. Separately, the agency found that 86,705 Allstate homeowners policies lacked required language explaining premium changes. Of those policies, 86,136 had a premium increase at renewal. The policies were issued between April 15, 2024, and April 22, 2025. The OIC’s premium-change transparency rule took effect June 1, 2024, and the renewal-notice period was extended from 45 days to 60 days in 2025. Washington updates claims-handling rules In a separate enforcement action, the OIC reported fining Integon National Insurance Co. $50,000 after finding claims-handling violations in 14 of 108 randomly selected claims. The agency cited delayed payments, delays in investigating claims and responding to policyholders, and total-loss vehicle settlements that omitted licensing fees or taxes. Washington adopted updated minimum claims-handling rules on Aug. 18, with an effective date of Oct. 18. The changes address claim investigations, insurer communications with claimants and the evaluation of covered losses. In its rulemaking documents, the OIC said auto and homeowners claim volumes had remained relatively consistent over the preceding six years while consumer complaints and Insurance Fair Conduct Act notices had increased. Those notices indicate a consumer’s dissatisfaction with claims handling and may signal an intent to sue an insurer. The revised standards include requirements for insurers to provide more information about investigations that remain unresolved and to explain certain decisions involving vehicle repair estimates. **Topics:** Homeowners Fraud, Insider Fraud, Public Awareness, Regulatory actions --- ### [MetLife Brings Pet Insurance to ChatGPT, Expanding How Consumers Research, Quote and Fetch Coverage Through AI](https://insurancefraud.org/news_archives/metlife-brings-pet-insurance-to-chatgpt-expanding-how-consumers-research-quote-and-fetch-coverage-through-ai/) **Published:** October 19, 2026 **Author:** Diane Beauchamp **Content:** MetLife today announced that MetLife Pet Insurance has integrated its insurance portal through [a ChatGPT plugin](https://cts.businesswire.com/ct/CT?id=smartlink&url=https%3A%2F%2Fchatgpt.com%2Fplugins%2Fplugin_asdk_app_6a506d95f91881919312f54e15bea507%3Fq%3DMetLife&esheet=54621509&newsitemid=20261014577288&lan=en-US&anchor=a+ChatGPT+plugin&index=1&md5=1a5608b67cca9015c776d281f51bffff), enabling pet parents who use ChatGPT to easily link to MetLife Pet’s personalized quotes, walk through their application and simply connect to the MetLife Pet website to purchase a policy. MetLife is the first major pet insurer to support conversational input of pet insurance applications through a ChatGPT plugin, reflecting the growing role of AI-powered platforms in how consumers discover, evaluate and buy products and services. Through the ChatGPT experience, consumers can answer questions about their pets needed to complete an application, review options and obtain a binding quote from MetLife Pet, all within a natural conversation, and connect to the MetLife Pet Insurance website to review the quote based on their completed application then complete their purchase. “This is about using innovation to remove friction from an important financial decision,” said Todd Katz, head of Group Benefits at MetLife. “We believe conversational experiences can make it easier for people to understand their options and take action when they’re ready. By bringing MetLife Pet Insurance to ChatGPT, we’re creating a simpler, more intuitive path to coverage for pet parents.” Rising costs are putting pressure on household budgets, and pet care is increasingly becoming a source of financial stress. MetLife data shows that one-third of employees worry about affording pet care, yet fewer than one in 10 have pet insurance. At the same time, seven in 10 pet owners say they’ve delayed or skipped veterinary care because of cost, and more than one-third report their pet’s condition worsened as a result. By making pet insurance more accessible through [a ChatGPT plugin](https://cts.businesswire.com/ct/CT?id=smartlink&url=https%3A%2F%2Fchatgpt.com%2Fplugins%2Fplugin_asdk_app_6a506d95f91881919312f54e15bea507%3Fq%3DMetLife&esheet=54621509&newsitemid=20261014577288&lan=en-US&anchor=a+ChatGPT+plugin&index=2&md5=aebbdee9fbd31bbacf2cfe1555bb751a), MetLife is helping consumers easily explore coverage options and prepare for unexpected veterinary expenses. As consumer expectations continue to evolve, MetLife remains focused on meeting customers where they are with simpler, more convenient ways to protect the health and well-being of their pets. **Availability** MetLife Pet Insurance through a ChatGPT plugin is now available. For more information, search “MetLife Pet Insurance” in the ChatGPT Plugin Library. **About MetLife** MetLife, Inc. (NYSE: MET), through its subsidiaries and affiliates (“MetLife”), is one of the world’s leading financial services companies, providing insurance, annuities, employee benefits and asset management to help individual and institutional customers build a more confident future. Founded in 1868, MetLife has operations in more than 40 markets globally and holds leading positions in the United States, Asia, Latin America, Europe and the Middle East. For more information, visit [www.metlife.com](https://cts.businesswire.com/ct/CT?id=smartlink&url=http%3A%2F%2Fwww.metlife.com&esheet=54621509&newsitemid=20261014577288&lan=en-US&anchor=www.metlife.com&index=3&md5=951df4d562ca93323d2398598d864862). **Topics:** Pet insurance fraud, Public Awareness --- ### [Cape Cod man pleads guilty to $6 million Medicare fraud scheme](https://insurancefraud.org/news_archives/cape-cod-man-pleads-guilty-to-6-million-medicare-fraud-scheme/) **Published:** October 19, 2026 **Author:** Diane Beauchamp **Content:** [The White House Fraud Task Force](https://thenationaldesk.com/news/americas-news-now/vance-fraud-task-force-uncovers-billions-229b-new-website-claims-white-house-vp-president-trump-administration-money) announced that it would be stopping welfare handouts for individuals who were double-dipping on government healthcare payouts under the last administration. The Fraud Task Force said Wednesday that the Centers for Medicare & Medicaid Services stopped Obamacare subsidies for over 180,000 people who were deceased. Under the Biden administration, White House officials in the Trump administration said that CMS didn’t check for duplicate enrollment in Obamacare and Medicaid. ## *“When it comes to program integrity, the Biden Administration was sleeping on the job,” CMS Administrator Dr. Mehmet Oz said in an exclusive interview with The Daily Wire. “They paused looking for duplicate Medicaid and Obamacare coverage for four years, creating a backlog of hundreds of thousands of duplicate enrollments.”* Oz stated that the task focusing on combatting fraud has already saved taxpayers $6 billion. ## *“We’ve already saved nearly $6 billion, and we will continue to work hard to restore taxpayers’ confidence that the programs they fund are spending their hard-earned dollars wisely and efficiently,” he said.* This report comes one month after the task force said that it shut down [750,000 Obamacare enrollments that were fraudulent.](https://thenationaldesk.com/news/americas-news-now/vance-led-task-force-targets-760k-obamacare-enrollments-in-22b-anti-fraud-push-report-white-house-task-force-to-eliminate-fraud-centers-for-medicare-medicaid-services-affordable-care-act-dr-oz-immigration-status-former-president-joe-biden-donald-trump) “We’re actually making sure that people receiving Obamacare subsidies are actually entitled to receive them,” Vice President JD Vance said at the time of the announcement. “Amazingly, we weren’t doing that before.” **Topics:** Healthcare Fraud, Medicare/Medicaid, Public Awareness, Regulatory actions --- ### [NJ family accused of $138,000 insurance fraud scheme involving fake claims on property not theirs](https://insurancefraud.org/news_archives/nj-family-accused-of-138000-insurance-fraud-scheme-involving-fake-claims-on-property-not-theirs/) **Published:** October 19, 2026 **Author:** Diane Beauchamp **Content:** Three family members from Gloucester County have been accused of taking part in a massive homeowners’ insurance fraud scheme and stealing well more than $100,000 through phony claims. Husband and wife, 65-year-old Donald Feldman and 61-year-old Carolyn Feldman each face charges that include second-degree counts of conspiracy to commit insurance fraud, insurance fraud and theft by deception, as well as third-degree commercial bribery, insurance fraud, and theft by deception. They were arrested on Tuesday. West Deptford family faces insurance fraud charges Their 34-year-old daughter, Brittany Feldman, faced third-degree insurance fraud and theft by deception. All three Feldmans, who are West Deptford residents, were additionally charged with third-degree conspiracy to commit insurance fraud and theft by deception. Former insurance examiner allegedly approved phony claims State prosecutors said the Feldmans carried out the scheme with help from John Philbin, already convicted of a broader insurance fraud scam. Philbin was a former claims examiner with Assurant Insurance Company. In May, he pleaded guilty to third-degree insurance fraud. The state will recommend five years of probation with restitution, when he is sentenced. Investigators have said that over the span of about a year, Philbin got cash kickbacks from the Feldmans after approving the family’s phony insurance claims. Fake construction company allegedly used in insurance claims Between April 2022 and May 2023, Donald Feldman worked with Carolyn Feldman and Philbin to create or submit about 10 made-up Assurant insurance claims. Among those phony scams, Donald Feldman took out an Assurant policy for a Camden County property owned by another person and submitted multiple claims on the Sicklerville site. Claims included made-up estimates and invoices for emergency mitigation or restoration work, which Donald Feldman said was performed by “American Construction and Restoration,” prosecutors said. The company appeared to be made-up, too, as a search of statewide business records found no filings or registrations for it. Donald Feldman is also accused of submitting invoices for mitigation services at other properties — where the actual insurance policy holders said he did not complete. For each claim, Donald Feldman notified Philbin, who at the time was a field claims examiner. Philbin then reassigned the claims to himself and approved about $108,000 in payments to Donald Feldman for work that was never done. In exchange, Philbin received about 20% of the cash, which prosecutors say was carried out by Carolyn Feldman. She is accused of coordinating claim information and cashing insurance claim checks, before delivering a cut to Philbin. Daughter accused in separate Mantua property claims The role that Brittany Feldman is accused of playing was connected to two phony insurance claims involving a Mantua property, despite not living there or owning the residence. In addition, all three Feldmans were also charged in connection with two allegedly fraudulent claims involving a property in Mantua that Brittany Feldman neither owned nor occupied. Brittany Feldman secured an Assurant policy for the property and submitted claims of windstorm-related and animal-related damages, between March 2023 and May 2023. Those claims were supported by made-up estimates and invoices from Feldman Construction, a family business in which she held an ownership interest. Philbin assigned the claims to himself and approved $30,000 in payments directed to Brittany Feldman — of which he also got about 20% of the money, prosecutors said. State officials condemn accused insurance fraud “New Jersey families pay for homeowners’ insurance to protect what they have worked hard to build,” state Attorney General Jennifer Davenport said in a written statement on Wednesday. “The defendants in this case allegedly defrauded an insurance company for their own gain. These cases reflect our commitment to protecting honest policyholders and holding those responsible accountable.” “An insurance claim should be paid because it is legitimate, not because the person approving it stands to receive a share of the proceeds,” Acting Insurance Fraud Prosecutor Bernard J. Cooney said in the same release. As of Wednesday, attorneys were not yet listed for any of the Feldman defendants. **Topics:** Homeowners - fake, Insider - agent **Categories:** Arrest --- ### [DC contractors to pay $1.7M over worker misclassification scheme](https://insurancefraud.org/news_archives/dc-contractors-to-pay-1-7m-over-worker-misclassification-scheme/) **Published:** October 19, 2026 **Author:** Diane Beauchamp **Content:** A major District construction contractor will pay more than $1.7 million to settle a lawsuit accusing it of running a widespread payroll fraud scheme that denied hundreds of local workers their hard-earned wages and benefits. District Attorney General Brian Schwalb announced the settlement with W.G./Welch Mechanical Contractors, LLC (Welch) and general contractor Whiting-Turner Contracting Company. The agreement resolves a 2024 lawsuit brought by the city, which claimed the businesses illegally classified employees as independent contractors to slash labor costs and gain an unfair advantage when bidding on major local projects. Under the terms of the consent order, Welch must pay $1 million in penalties directly to the District, alongside $691,450 earmarked for roughly 500 harmed construction workers. Over half of the affected employees worked on the massive City Ridge mixed-use development on Wisconsin Avenue NW, where Welch handled mechanical services like plumbing and HVAC installation. By classifying these workers as independent contractors via third-party labor brokers, the city argued that Welch bypassed mandatory workplace protections. Affected workers were left without minimum wage guarantees, overtime pay, sick leave, or access to workers’ compensation insurance. A third-party administrator will handle the payouts and is expected to contact eligible workers within 60 days. Beyond the financial penalties, the settlement forces a massive overhaul of how both companies operate in the District. Welch is now required to implement random audits and demand certified payroll reports from its subcontractors. Additionally, the company is barred from doing business with specific subcontractors previously tied to worker misclassification unless those entities prove to the city that they have cleaned up their practices. Whiting-Turner reached a separate agreement to enforce stricter record-keeping and oversight across its entire subcontracting chain. The settlement marks another major victory for the OAG’s Workers’ Rights and Antifraud Section, which has clawed back more than $28.5 million for workers and the city since 2023. Local workers who suspect they have been victims of wage theft or misclassification can file a report by calling the OAG at (202) 724-7730 or emailing <workers@dc.gov>. **Topics:** Employment fraud, Judicial/courts, Work comp - employer --- ### [Cape Cod Man Pleads Guilty to Conspiring to Launder Proceeds of $6M Medicare Fraud Scheme](https://insurancefraud.org/news_archives/cape-cod-man-pleads-guilty-to-conspiring-to-launder-proceeds-of-6m-medicare-fraud-scheme/) **Published:** October 19, 2026 **Author:** Diane Beauchamp **Content:** A Cape Cod man pleaded guilty today to a money laundering conspiracy for laundering proceeds in connection with a more than $6 million health care fraud scheme. According to court documents and statements made in court, Leo Anzivino Jr., 35, of Falmouth, Massachusetts, conspired with others to launder health care fraud proceeds. Specifically, Anzivino agreed to be the straw or nominee owner of Advanced Medical Supply Corp. (Advanced), located in Rochester, New Hampshire, even though his co-conspirators were in fact the beneficial owners and managers of Advanced. Advanced submitted more than $6 million in claims to Medicare for durable medical equipment (DME) — such as knee braces and back braces — that Medicare beneficiaries did not need and that doctors did not prescribe. Instead, Advanced supported these claims using fake orders from physicians who did not actually write or submit those orders. Medicare paid more than $3 million as a result of these false and fraudulent claims. Medicare beneficiaries returned boxes of DME to Advanced with notes stating that they had not ordered the products and alleging a fraud or scam, as depicted below. ![Note from Medicare Beneficiary Accompanying DME Return Stating that the Beneficiary “Did Not Order” the Medical Products and that it was a “FRAUD!!”](https://www.justice.gov/sites/default/files/styles/banner/public/2026-10/picture2_1_5.png?itok=jIXlU5y5)*Note from Medicare Beneficiary Accompanying DME Return Stating that the Beneficiary “Did Not Order” the Medical Products and that it was a “FRAUD!!”* ![Note from Medicare Beneficiary Accompanying DME Return Stating that the Medical Products Were Sent “Without Prior Consent of My Physician or Myself”](https://www.justice.gov/sites/default/files/styles/banner/public/2026-10/picture3_for_pp.png?itok=lxp7M7HA)*Note from Medicare Beneficiary Accompanying DME Return Stating that the Medical Products Were Sent “Without Prior Consent of My Physician or Myself”* ![Note from Medicare Beneficiary Accompanying DME Return Stating that “This Must Be Some Type of Medicare Scam”](https://www.justice.gov/sites/default/files/styles/banner/public/2026-10/picture4_for_pp.png?itok=GGpbj3Q1)*Note from Medicare Beneficiary Accompanying DME Return Stating that “This Must Be Some Type of Medicare Scam”* Anzivino helped hide his co-conspirator’s involvement with Advanced by being listed as the owner of Advanced on the Medicare enrollment paperwork. He also submitted false and fraudulent bank account opening documents to a bank in New Hampshire, falsely certifying that he was the sole owner of 25 percent or more of the equity interests of Advanced when others, including a co-conspirator, were Advanced’s true owners. Anzivino then laundered the fraud proceeds by, at his co-conspirator’s direction, seeking to transfer more than $1 million from the Advanced bank account in New Hampshire to companies that were affiliated with the co-conspirator. When told by a bank employee that the bank had not reached a level of confidence that the other companies were legitimate, and that Anzivino should do his own research into these companies, Anzivino instead opened a bank account at another bank with branches in Massachusetts. In addition, Anzivino learned that Advanced’s ability to bill Medicare would be revoked for various deficiencies, including an inability to verify proof of his ownership of Advanced. Anzivino then sent messages to another individual discussing that revocation, explaining that “All the ppl who gave me money are going to come back for it now my shits revoked,” stating that his co-conspirator “still wants me to wire him money,” and claiming that “I ain’t wiring shit.” Despite this, over the next five weeks, Anzivino proceeded to wire $1,494,938.09 across three separate transactions, each in excess of $10,000. In 2024, the government seized approximately $353,768.29 in assets tied to the alleged scheme from Advanced’s bank account. Anzivino pleaded guilty to one count of money laundering conspiracy. He is scheduled to be sentenced Jan. 21, 2027 and faces a maximum penalty of 10 years in years in prison. A federal district court judge will determine any sentence after considering the U.S. Sentencing Guidelines and other statutory factors. Assistant Attorney General Colin M. McDonald of the Justice Department’s National Fraud Enforcement Division; U.S. Attorney Erin Creegan for the District of New Hampshire; Special Agent in Charge Roberto Coviello of the U.S. Department of Health and Human Services, Office of the Inspector General (HHS-OIG); and Special Agent in Charge Ted E. Docks of the FBI Boston Field Office made the announcement. HHS-OIG and FBI investigated the case with valuable assistance from IRS-Criminal Investigation and the Department of War Office of Inspector General’s Defense Criminal Investigative Services. Trial Attorneys John Howard and Tiffany Wynn of the National Fraud Enforcement Division’s Health Care Fraud Section and Assistant U.S. Attorneys Matthew Hunter and Matthew Vicinanzo for the District of New Hampshire are prosecuting the case. On April 7, the Department of Justice announced the creation of the Fraud Division. The Fraud Division is laser-focused on investigating and prosecuting those who commit fraud against the American people. The Department’s work to combat fraud supports President Trump’s Task Force to Eliminate Fraud, a whole-of-government effort chaired by Vice President J.D. Vance to eliminate fraud, waste, and abuse within Federal benefit programs. The Department of Justice’s Health Care Fraud Strike Force Program, currently comprised of nine strike forces operating in federal districts across the country, has charged more than 6,200 defendants who collectively billed federal health care programs and private insurers more than $45 billion since 2007. In addition, the Centers for Medicare & Medicaid Services, working in conjunction with the Office of the Inspector General for the Department of Health and Human Services, are taking steps to hold providers accountable for their involvement in health care fraud schemes. More information can be found at [www.justice.gov/criminal-fraud/health-care-fraud-unit](http://www.justice.gov/criminal-fraud/health-care-fraud-unit). **Topics:** Medicare/Medicaid **Categories:** Conviction --- ### [Traveling nurse from Florida charged for drug diversion](https://insurancefraud.org/news_archives/traveling-nurse-from-florida-charged-for-drug-diversion/) **Published:** October 19, 2026 **Author:** Diane Beauchamp **Content:** The Vermont Attorney General’s Office announced that Anneka Brooks, 46, of Titusville, Florida, was arraigned today on two felony counts of Fraud or Deceit Involving a Regulated Drug. The charges are the result of an investigation conducted by the Vermont Secretary of State’s Office of Professional Regulation (OPR) and the Attorney General’s Medicaid Fraud and Residential Abuse Unit (MFRAU). According to the affidavit of probable cause, Ms. Brooks was employed as a Licensed Practical Nurse at Union House Nursing Home, a long-term care facility in Glover, Vermont. On or about November 8, 2025, Ms. Brooks is alleged to have fraudulently obtained Oxycodone, a controlled substance, intended for administration to medical patients, for her own personal use. Ms. Brooks, currently residing in Florida, pleaded not guilty by remote appearance at her arraignment today in Vermont Superior Court, Orleans Criminal Division. The Court, Judge Michael Harris presiding, ordered Ms. Brooks released on conditions, including that she attend future hearings and that she provide fingerprints. Ms. Brooks’ license as a Licensed Practice Nurse was suspended by OPR pursuant to a stipulation and consent order on August 11, 2026. The Attorney General’s Office emphasizes that individuals charged with a crime are legally presumed innocent until their guilt is proven beyond a reasonable doubt in a court of law. If you suspect Medicaid fraud, please submit a report using MFRAU’s online reporting form. The Medicaid Fraud and Residential Abuse Unit receives 75 percent of its funding from the U.S. Department of Health and Human Services under a grant award totaling $1,621,775 for Federal fiscal year (FY) 2027. The remaining 25 percent, totaling $540,425 for FY 2027, is funded by the State of Vermont. **Topics:** Drug Diversion **Categories:** Arrest --- ### [Man defrauds Central Pennsylvania insurance provider of almost $1M in ‘elaborate scheme,’ AG’s Office says](https://insurancefraud.org/news_archives/man-defrauds-central-pennsylvania-insurance-provider-of-almost-1m-in-elaborate-scheme-ags-office-says/) **Published:** October 19, 2026 **Author:** Diane Beauchamp **Content:** An Indiana man is accused of defrauding a Central Pennsylvania insurance provider out of nearly $1 million in an “elaborate scheme”, according to Attorney General Dave Sunday’s Office. The AG’s Office said a Grand Jury presentment found that Glenn Allen Johnson was employed as a claims adjuster by Donegal Insurance when he “facilitated a payment” to Elite Injury Representatives, LLC, “under a guise that Elite was a law firm representing a client in an accident claim.” However, Elite was Johnson’s business that he opened in 2025, the AG’s Office said. “This kind of criminal conduct is theft and fraud that leads to higher insurance premiums for law-abiding citizens,” Attorney General Sunday said in a statement Tuesday. “I commend our investigators, the grand jurors, and our out-of-state partners for holding the defendant accountable for this elaborate scheme.” Johnson was employed as a claims adjuster for Donegal in 2024 and 2025. Sunday’s Office said, Johnson allegedly submitted fraudulent documents, that included falsified medical records and conversation notes with the alleged injured party for the accident claim. Donegal issued a $949,639.54 payment to Elite, according to the AG’s Office. He faces charges of corrupt organizations, dealing in proceeds of unlawful activities, theft by deception, insurance fraud and forgery. Johnson was arrested in Indiana and is awaiting extradition to Pennsylvania, Sunday’s Office said. **Topics:** Insider Fraud **Categories:** Arrest --- ### [Former New Hampshire Doctor Sentenced to Year in Prison for Role in $1.9 Million Medicare Fraud Scheme](https://insurancefraud.org/news_archives/former-new-hampshire-doctor-sentenced-to-year-in-prison-for-role-in-1-9-million-medicare-fraud-scheme/) **Published:** October 19, 2026 **Author:** Diane Beauchamp **Content:** Former New Hampshire physician Steven Powell, 56, was sentenced to 12 months and a day in federal prison on one count of health care fraud, in connection with a scheme to defraud Medicare by prescribing medical equipment without ever seeing, speaking to, or otherwise examining patients. Powell, who now lives in Georgia, was sentenced today by U.S. District Court Judge Paul Barbadoro. According to court documents and statements made in court, Powell, a licensed psychiatrist, signed hundreds of medically unnecessary orders for durable medical equipment (DME), including knee, wrist, back, and shoulder braces. He did not examine, speak with, or meaningfully evaluate the Medicare beneficiaries for whom he purported to prescribe these devices. Instead, he approved large volumes of pre‑populated brace orders within minutes, making meaningful medical review impossible. These orders enabled DME suppliers to submit approximately 1,400 fraudulent claims to Medicare totaling more than $1.9 million in claims, of which Medicare paid $761,202.75. Between December 2018 and March 2019, Powell signed brace orders for more than 500 Medicare beneficiaries, often approving multiple braces per patient. In one instance, he completed more than 100 pages requiring 75 signatures in just over a minute, further demonstrating the absence of any legitimate medical assessment. In addition to the prison sentence, Powell was ordered to pay $761,202.75 in restitution to the Medicare program. “This defendant abused his position and his medical license in order to defraud taxpayers with nearly $2 million in bogus medical bills, and will now spend time behind bars,” said Erin Creegan, U.S. Attorney for the District of New Hampshire. “The U.S. Attorney’s office will continue to pursue accountability for those who commit fraud and steal from the taxpayers, and strict penalties for those siphon precious healthcare resources meant to help elderly and low-income patients.” “Dr. Steven Powell abandoned all pretense of professional ethics when he caused nearly $2 million in false Medicare bills from bogus prescriptions for medical equipment,” said Ted E. Docks, Special Agent in Charge of the FBI’s Boston Division. “By looting these funds, this physician not only strained the system, but cheated the taxpayers who fund it. Know that your FBI is committed to fighting health care fraud, one case at a time, because every dollar lost to bogus billing is a dollar less to use for legitimate treatments and services.” “Powell used his medical license as a tool to facilitate fraud, signing orders for medically unnecessary equipment without examining patients and helping to fuel a scheme that sought to defraud Medicare of millions of dollars,” said Special Agent in Charge Roberto Coviello of the U.S. Department of Health and Human Services Office of Inspector General. “Today’s sentence reflects the seriousness of that conduct and reinforces our commitment to protecting the integrity of federal health care programs and the taxpayers who fund them.” The Federal Bureau of Investigation and U.S Department of Health and Human Services – Office of the Inspector General led the investigation. Assistant U.S. Attorney John Kennedy prosecuted the case. **Topics:** Medicare/Medicaid **Categories:** Conviction --- ### [CVS Agrees to Pay $315M for Illegally Filling Unlawful Opioid Prescriptions and for Submitting False Claims to the Federal Government](https://insurancefraud.org/news_archives/cvs-agrees-to-pay-315m-for-illegally-filling-unlawful-opioid-prescriptions-and-for-submitting-false-claims-to-the-federal-government/) **Published:** October 19, 2026 **Author:** Diane Beauchamp **Content:** CVS Pharmacy Inc., a Rhode Island-based pharmacy chain, and its related corporate entities (collectively, CVS) have agreed to pay $315 million to resolve allegations that, from October 17, 2013 through December 2, 2025, CVS illegally filled prescriptions for opioids and other controlled substances [in violation of the Controlled Substances Act (CSA)](https://www.justice.gov/opa/media/1465561/dl?inline), and then sought payment for many of those invalid prescriptions from Medicare and other federal healthcare programs [in violation of the False Claims Act (FCA).](https://www.justice.gov/opa/media/1465566/dl?inline) “Not only does this settlement hold bad actors accountable for their fraudulent activities, but Americans are safer because of it,” said Associate Attorney General Stanley E. Woodward Jr. “Today’s settlement is a significant milestone in the Justice Department’s efforts to combat the opioid epidemic by cracking down on pharmacies who unlawfully fulfill prescriptions for controlled substances.” “Today’s settlement requires CVS to implement additional safeguards to ensure that prescriptions for opioids and other controlled substances are dispensed only when medically appropriate,” said Assistant Attorney General Brett A. Shumate of the Justice Department’s Civil Division. “The remedial measures in this agreement — including proactive monitoring of opioid prescribing patterns — will provide critical protections for patients and federal healthcare programs. The Department of Justice will continue to take steps to prevent the unlawful dispensing of opioids.” “The opioid epidemic has affected families and communities across Rhode Island and throughout the nation,” said First Assistant U.S. Attorney Charles C. Calenda for the District of Rhode Island. “Pharmacies that dispense controlled substances must maintain effective compliance systems to identify and respond to warning signs that prescriptions may be unlawful or medically unnecessary. This settlement demonstrates the importance of those obligations and the consequences of failing to implement safeguards designed to prevent the improper dispensing of controlled substances.” The settlement resolves allegations in the government’s complaint, which the United States filed on Dec. 13, 2024, in the U.S. District Court for the District of Rhode Island, that CVS knowingly filled prescriptions for controlled substances that lacked a legitimate medical purpose, were not valid, and/or were not issued in the usual course of professional practice. The United States alleged that CVS dispensed prescriptions for dangerous and excessive quantities of opioids, opioid prescriptions filled too early, and “trinity” prescriptions, a dangerous and abused combination of an opioid, a benzodiazepine, and a muscle relaxant. CVS also allegedly filled prescriptions for controlled substances from “pill mill” prescribers who issued large numbers of controlled substance prescriptions without any medical purpose. Further, the United States alleged that CVS pharmacists filled these prescriptions despite clear red flags indicating that there was a high likelihood that the prescriptions lacked a legitimate medical purpose, were not valid, or were not issued in the course of professional practice. Many of these prescriptions were ultimately billed to and reimbursed by federal healthcare programs. The complaint further alleged that CVS’s violations stemmed from corporate-imposed performance metrics, incentive compensation, and staffing policies that prioritized corporate profits over patient safety. CVS failed to employ enough pharmacists to serve patients, comply with CVS’s legal obligations, and meet corporate performance metrics. In addition, CVS’s policies allegedly prevented pharmacists from warning one another about certain problematic prescribers. In addition to the monetary payment announced today, CVS has entered into a memorandum of agreement with DEA to address its future obligations in dispensing controlled substances. This agreement requires CVS to establish a hotline for both employees and the public to report suspected illegal dispensing of controlled substances, proactively monitor the dispensing patterns of its pharmacies to identify and address potentially illegal dispensing, and establish a process to evaluate prescribers suspected of illegal prescribing. “This settlement agreement highlights DEA’s commitment to protecting the health and safety of Americans while holding CVS accountable for dispensing unlawful prescriptions and endangering the public,” said DEA Assistant Administrator Cheri Oz. “DEA is unwavering in its commitment to protect public health and ensuring pharmacies adhere to the highest standards of responsible dispensing. We will continue to work closely with law enforcement, regulatory agencies, and the healthcare community to prevent the misuse of controlled substances, and we will hold those who jeopardize the safety of our citizens accountable.” “Behind every unlawful prescription is a patient who could be put in harm’s way,” said Acting Deputy Inspector General for Investigations Miranda L. Bennett of the U.S. Department of Health and Human Services, Office of Inspector General (HHS OIG). “The allegations in this case point to warning signs that should never be overlooked. HHS OIG will not tolerate conduct that jeopardizes lives, and we will continue to pursue those who betray the trust placed in them.” The civil settlement resolves a civil lawsuit filed by Hillary Estright, a former CVS employee, under the whistleblower provision of the FCA, which authorizes private parties to sue on behalf of the United States and receive a share of any recovery. It also permits the United States to intervene and take over such lawsuits, as it did here. The amount to be recovered by the private whistleblower has not yet been determined. The *qui tam* case is captioned *United States ex rel. Hillary Estright v. CVS Health Corporation, et al*., No. 22-cv-00222 (D.R.I.). This year the Administration launched the Task Force to Eliminate Fraud and the National Fraud Enforcement Division to enhance the Administration’s war on fraud, waste, and abuse in federal programs. When unscrupulous actors exploit these programs for their own financial gain, they defraud the government, harm the people these programs are designed to aid and protect, and undermine American businesses that play by the rules. The Civil Division’s FCA enforcement plays a critical role in combatting such fraudulent schemes, recovering billions of dollars for the American taxpayers, and holding wrongdoers accountable. FCA matters will continue to be on the forefront of the battle against fraud, and the Civil Division’s FCA work will support and advance the mission of the Task Force to Eliminate Fraud and the National Fraud Enforcement Division. The resolution obtained in this matter was the result of a coordinated effort between the Civil Division’s Commercial Litigation Branch, Fraud Section, and the Enforcement & Affirmative Litigation Branch, along with the U.S. Attorneys’ Offices for the District of Rhode Island, Eastern District of Virginia, Eastern District of Texas, and District of Hawaii. The DEA’s Office of Diversion Control, Los Angeles Field Division, Richmond District Office, and Office of Chief Counsel led this case with substantial assistance from Health and Human Services Office of Inspector General, Defense Criminal Investigative Service, Defense Health Agency (DHA), Office of Personnel Management (OPM), Department of Labor (DOL) Office of Inspector General, and the Department of Veterans Affairs (VA). The investigation and resolution of this matter illustrate the government’s emphasis on combating healthcare fraud. One of the most powerful tools in this effort is the False Claims Act. Tips and complaints from all sources about potential fraud, waste, abuse, and mismanagement, can be reported to the Department of Health and Human Services at 800-HHS-TIPS (800-447-8477). The United States is represented in this matter by attorneys from the Justice Department’s Civil Division Commercial Litigation Branch, Fraud Section (Assistant Director Natalie Waites and Trial Attorneys Claire Norsetter and Megan Engel) and Enforcement & Affirmative Litigation Branch (Deputy Director Lisa Hsiao and Trial Attorneys Kathleen Brunson and Katherine Ho), as well as from the U.S. Attorneys’ Offices for the District of Rhode Island (Assistant U.S. Attorney Rachna Vyas), Eastern District of Virginia (Assistant U.S. Attorney John Beerbower), Eastern District of Texas (Assistant U.S. Attorney James Gillingham), and District of Hawaii (Assistant U.S. Attorney Tracy J. Weinstein). **Topics:** Drug Diversion, Judicial/courts, Medicare/Medicaid, Veterans Benefits Fraud --- ### [Lexington County woman charged with insurance fraud, accused of submitting fake medical bills](https://insurancefraud.org/news_archives/lexington-county-woman-charged-with-insurance-fraud-accused-of-submitting-fake-medical-bills/) **Published:** October 19, 2026 **Author:** Diane Beauchamp **Content:** A 38-year-old Lexington County woman is facing seven charges after state investigators say she submitted falsified medical bills and other documents to an insurance company in an attempt to collect money for medical expenses and lost wages. The South Carolina Law Enforcement Division (SLED) announced Tuesday, Oct. 13, that Charyada Onetder Davis, 38, was charged Oct. 8 with six counts of forgery involving values less than $10,000 and one count of presenting a false claim for insurance payment valued at $10,000 or more. The South Carolina Department of Insurance requested the investigation. According to arrest warrants, Davis submitted a false insurance claim to Progressive Insurance Company on or about Feb. 13, 2026, in Richland County. Investigators allege the claim totaled $17,636.06 and included documents seeking reimbursement for medical expenses and lost wages. The warrants allege Davis submitted an altered or fictitious medical bill from Prisma Health, along with other medical documentation, in an attempt to obtain insurance funds. The documents also reference a medical bill from Carolina Pediatrics, a false work excuse from a previous employer and a document described as an audio/video-recorded voluntary statement. According to the warrants, Davis admitted submitting the documents to obtain additional funds. The warrants state that the allegations are supported by Davis’ admissions, electronic communications and other records. SLED said Davis was booked into the Alvin S. Glenn Detention Center in Richland County. The case will be prosecuted by the South Carolina Department of Insurance. **Topics:** Auto - padding/false claim, Healthcare Fraud **Categories:** Arrest --- ### [Q&A: What roofing contractors should know about insurer fraud](https://insurancefraud.org/news_archives/qa-what-roofing-contractors-should-know-about-insurer-fraud/) **Published:** October 19, 2026 **Author:** Diane Beauchamp **Content:** In conversation with Brad Quinn, executive director at the American Policyholders Association With [State Farm](https://homepros.news/additional-documents-released-in-homeowners-roofing-claim-fight-against-state-farm/) in the news — and roofing contractors engaged in [legal battles](https://www.insurancebusinessmag.com/us/news/risk-compliance-legal/tower-hill-faces-malicious-prosecution-suit-after-fraud-case-collapses-590016.aspx) — contractors have become frustrated with roof replacement claims, with many pivoting to retail. To advise contractors on working in the insurance market, Homepros chatted with Doug Quinn, executive director at the [American Policyholders Association](https://apassociation.org/), a nonprofit focused on property insurance fraud. Below is our conversation, lightly edited for brevity and clarity. **Most contractors have a pretty cynical view of insurance. But is there anything you think roofing contractors don’t understand about how it works?** They should understand that they’re a target. If you’re a contractor, and you’re charging decent prices so you can feed your family, and your employees can feed their families, and you’re winning cases \[against insurance carriers\], eventually, you will be targeted. We tell all of our members: You do every piece of paperwork as though there’s a regulator looking over your shoulder, because one day there will be. You talk to every person as though it’s an undercover investigator, because one day it will be. Everybody’s jaded on all sides. But there are some tactics for establishing good relationships. Make sure that you’ve established yourself as somebody who has honesty and who has integrity. **How has roofing contractor fraud contributed to the current insurance environment?** There’s no zip code that makes you exempt from fraud. There’s no job title that makes you exempt from fraud. The problem is this: You have this tiny little voice saying, ‘Hey, look, the insurance companies are committing fraud.’ The insurance industry has the wall of sound. They’re one of the most dominant advertisers in the media. Try to watch something without running into five insurance commercials. They’re one of the top lobbies in the country, so their tentacles reach into so many different spaces, and their message is this: ‘These contractors are committing fraud.’ Fraud happens on all sides, but they have much bigger megaphones. **What would you say to a contractor who hears this — but wants to stay out of politics?** You don’t have to be involved in politics — but understand that the insurance industry is. They have a huge bankroll; something like 60 percent of insurance lobbyists are former federal or state employees. They have huge connections. So you can stick your head in the sand and say, ‘Hey, I don’t want to be involved.’ Be involved in running your business, make the money, run your business, but take some time and energy and some money and support the people who are standing up here. That’s the one problem I see with contractors. They don’t work together. They don’t support the people out there fighting for them as much as they should be. And trust me, I go to the insurance industry meetings; they work together very well. On TV, it looks like they’re competing. Behind the scenes, they work together for their common interests very well. Contractors don’t do that, and it is the oldest military tactic in the book: Divide and conquer. **Contractors feel that it’s hard for insurers to have the same accountability. Is that true, and if so, why?** Public prosecutors do not look for fraud cases. They sit at their desk, and insurance companies walk \[cases\] into them. And by the way, insurance companies never seem to turn themselves in. If you’re a prosecutor, all you’ve seen your whole career are cases of people stealing from the insurance company. ​​We’ve actually had to coin the term \[insurer fraud\]. I just testified to the Texas state legislature on Monday; we call them a one-way state. Their insurance fraud law only defines insurance fraud as somebody stealing from the insurance company. The law doesn’t even define the insurance company stealing from you as fraud. We’ve got our work cut out for us. **How do you think the prevalence of AI in the claims process will impact contractors?** AI takes the human factor out, but I can turn it up and tweak AI to pay everybody a little less. AI has to be programmed. Right now, they use third-party administrators to process claims. And then they’re like, ‘Oh, it wasn’t us. It was that third party. That gives \[them\] plausible deniability. Now it’s a function of: ‘How did you train your AI?’ As a roofer, can you go on there and argue with AI? Probably not, but we hope they have some form of appeals process. **How would you advise a contractor who’s in the midst of a legal dispute with an insurance carrier?** Document everything. Your first conversation is with an attorney, and it can’t be the guy who did your will. It can’t be the guy who did the closing on your house. As long as you’ve been documenting your evidence all the way across the board \[and\] you have really good, clean files. That’s important. Then, you wanna fight and counterpunch. You cannot allow somebody to throw four, five, six punches at you without counterpunching, because eventually, they’re gonna land something. **Topics:** Contractor fraud --- ### [‘Pure evil’: Convicted cancer doctor Farid Fata seeks early release again, outraging victims](https://insurancefraud.org/news_archives/pure-evil-convicted-cancer-doctor-farid-fata-seeks-early-release-again-outraging-victims/) **Published:** October 19, 2026 **Author:** Diane Beauchamp **Content:** Fata is making another attempt to get out of prison, but victims who say they’re still suffering from his treatments are determined to keep him behind bars What to know: Former Michigan oncologist Farid Fata has filed another motion for compassionate release, more than a decade after he was sentenced to 45 years in federal prison. Survivors and family members of people treated by Fata say they continue to suffer from the consequences of his actions and oppose his release. Patty Hester, 72, said Fata treated her for cancer she never had. She now requires weekly infusions to survive, she told Local 4. Fata was arrested in 2013 on federal health care fraud charges involving unnecessary cancer treatments. He pleaded guilty to 16 federal charges in 2014 and was sentenced to 45 years in prison in 2015. Over a decade after disgraced Michigan oncologist Farid Fata was sentenced to 45 years in federal prison, he’s once again asking for compassionate release. His victims aren’t having it. “I don’t look at him as even being human — It’s just pure evil,” said 72-year-old Patty Hester of Clarkston. She said Fata treated her for cancer she never even had. Now, Hester says she requires weekly infusions just to survive, and she’s far from the only victim still dealing with the consequences. “People are still hurting,” Hester said. “People are struggling. Everyone that I know that’s alive that was treated by him are struggling physically.” ‘We all felt cheated by the system’ Hester is among hundreds of people who recently received a letter from the U.S. Department of Justice notifying them that Fata is once again seeking early release from prison. The letter, dated Sept. 29, said Fata filed the motion Sept. 15. “Are you kidding? Nothing will stop me from — I mean, until I’m dead — to fight him from ever getting out because he destroyed people,” Hester said. Another man, who said his father died while under Fata’s care, called the former doctor a murderer and told Local 4, “We all felt cheated by the system.” “Fata was arrested for insurance fraud… People need to remember that the crimes that Fata committed were not insurance fraud but premeditated murder,” Jeff Berz told Local 4. “The DOJ did its best, and we appreciate that, but it still stings to know that this killer was charged with fraud instead of murder. He deserves absolutely no compassion.” “He did his own genocide… He decided who lived and who died,” Hester added. Farid Fata’s repeated attempts at release Fata’s case dates back to 2013, when he was arrested on federal health care fraud charges involving unnecessary cancer treatments. In 2014, he pleaded guilty to 16 federal charges. A year later, he was sentenced to 45 years in prison. In 2016, federal officials announced a restitution plan for his victims. Fata unsuccessfully challenged his guilty pleas and sought a reduced sentence years later, and his previous request for compassionate release was denied in March 2025. His current projected prison release date is Dec. 11, 2050. Federal prosecutors oppose his latest request, and no hearing had been scheduled as of Sept. 29. There is currently no limit on how many times Fata can request compassionate release. Local 4 reached out to those representing Fata but has not received a response. What is the deadline for submissions? Victims and their families have until 5 p.m. Friday, Oct. 23, to submit written statements to U.S. District Judge Jonathan Grey about Fata’s latest request. Statements can be emailed to <alexandra.wyatt@usdoj.gov> or <sherri.holloway@usdoj.gov>. **Topics:** Healthcare Fraud **Categories:** Conviction --- ### [Craven County Man Charged With Insurance Fraud In Roofing Scam](https://insurancefraud.org/news_archives/craven-county-man-charged-with-insurance-fraud-in-roofing-scam/) **Published:** October 15, 2026 **Author:** Diane Beauchamp **Content:** North Carolina Insurance Commissioner Mike Causey announced Monday the arrest of Cameron Alexander Hammond, 34, of Vanceboro. Hammond was charged with one count of insurance fraud, one count of attempting to obtain property by false pretense, and one count of damage to residential property, all felonies. Special agents with the Department of Insurance Criminal Investigations Division allege that, while employed by Carolina Trophy Roofs, Hammond intentionally damaged roofing shingles at a residence in Washington, then made false statements to North Carolina Farm Bureau and the North Carolina Joint Underwriters Association (NCJUA), claiming the roof sustained weather-related damage. Investigators allege Hammond lied to obtain insurance proceeds and commission for a roof replacement. The offense occurred on Aug. 18. Hammond was released under a $5,000 secured bond and is scheduled to appear in Beaufort County district court on Dec. 17. Commissioner Causey encourages North Carolinians to help keep insurance premiums low by reporting suspicious fraud. “Property and casualty insurance fraud costs insurance customers an estimated $120 billion a year in increased premiums,” said Commissioner Causey. “The Department of Insurance has beefed up its fraud-fighting staff in an effort to make more arrests to keep fraud from driving up insurance costs.” **Topics:** Contractor fraud **Categories:** Arrest --- ### [FTC warns Medicare scammers are buying their way into search results](https://insurancefraud.org/news_archives/ftc-warns-medicare-scammers-are-buying-their-way-into-search-results/) **Published:** October 15, 2026 **Author:** Diane Beauchamp **Content:** Every scam has its season. And the scammers are ready to go for the Medicare Open Enrollment period that runs from Oct. 15 through Dec. 7. It is the same time each year when those on Medicare can make changes to their coverage. The changes you make during this window would be effective Jan. 1. Read more at: <https://www.centredaily.com/news/nation-world/national/article317589049.html#storylink=cpy> The open enrollment period for the Health Insurance Marketplace under the Affordable Care Act begins Nov. 1. And scammers can target those consumers shopping for coverage, too. This year, it’s essential for many consumers to realize that scams don’t always start with just a call out of the blue. Sometimes, you can connect with the bad actors simply by trying to research the best medical plan for you online. Medicare scammers hope you’ll find them online The Federal Trade Commission put out an alert in late September warning that consumers shouldn’t just simply click on link for a search result. “Remember: Scammers and dishonest businesses sometimes pay to appear at the top,” the FTC stated. The crooks make themselves appear legitimate by hiding behind keywords and official-looking logos. Their goal, according to the FTC, is to trick you into believing that you’re on the real Healthcare.gov or Medicare.gov. The web address can seem similar to a government website when it’s not. “If you use the link or phone number in the ad, you might end up paying for a scammy plan that’s not health insurance, or expose yourself to medical identity theft,” the FTC said. Scammers play into the uncertainty that surrounds Medicare open enrollment season when Medicare beneficiaries are encouraged to review their health care coverage and make any necessary changes before the Dec. 7 deadline. During this window, those with Medicare can change their Medicare health insurance plans, such as Medicare Advantage or stand-alone Part D Prescription Drug plans, for 2027. It’s also time to compare what’s offered under current plans. Medicare scammers may pose as Medicare representatives, health care providers, medical supply vendors or insurance agents, according to an online blog written by Ryan Ramsey, the National Council on Aging associate director of health coverage and benefits. “Scammers can sound very professional and persuasive over the phone,” he wrote. And many fraudsters, he noted, use AI technology to create convincing websites, emails and print materials that appear to be from trustworthy organizations. Some scammers might wrongly warn that you’ll lose benefits unless you verify information or change plans immediately. Others may claim you’re owed a “refund” as a ruse to get your banking information. What Medicare crooks want beyond your money Mary Johnson, an independent Social Security and Medicare policy analyst, told the Detroit Free Press, part of the USA TODAY Network, that Medicare scam victims face risks that go beyond losing money. “Scams can cost not only financially but could put one’s health care and health at risk,” Johnson said. If your Social Security number and Medicare numbers end up being stolen, she said, you’re likely to be a victim of identity theft. Fraudsters may use stolen or inappropriately obtained information from Medicare beneficiaries to submit fraudulent claims for unneeded or never provided services, according to a report by the U.S. Government Accountability Office. In 2023 and 2024, for example, the Centers for Medicare & Medicaid Services, which oversees Medicare, suspended payments to 15 providers involved in a scheme that allegedly billed Medicare for more than $4 billion in urinary catheters that were never supplied. In some cases, fraudulent medical care, even some surgery that you didn’t have, can show up on your record. As a result, Johnson said, the ID theft victim could be rejected for some treatment down the line when prior authorizations are required. You also could face longer waits for care, surprise bills and extra stress as you try to correct the record. According to the FTC, once you give your Medicare number to a scammer, the scammer can use it to order things like neck braces and other medical equipment, which can result in denied benefits later if you need them or unexpected bills. That Medicare call about a new card is fake One common scam already being reported to the AARP Fraud Watch Network Helpline involves someone calling and claiming that Medicare is issuing new cards. “Scammers may say something like, ‘Medicare cards are being replaced with hard plastic cards, like credit cards, and we need your Medicare number to send you one,” said Amy Nofziger, senior director of victim support for the AARP Fraud Watch Network. It’s not true. Some claim that Medicare is switching to a card with a chip in it. Or they say you now need a black-and-white card instead of one that is red, white and blue. Scammers want to trick you into handing over your Medicare number. “Be extremely cautious of anyone who contacts you unexpectedly and asks for your Medicare number,” Nofziger said. Medicare does not need to call you to verify your Medicare number because they already have that information, she noted. The AARP Fraud Watch Network Helpline also receives many calls from consumers who lost their wallets or had their wallets stolen, Nofziger said. The senior is at wit’s end when their Medicare card is in that missing wallet. Nofziger said it’s best to keep your Medicare card in a secure place at home rather than carrying it in your wallet every day. Bring it with you only when you know you’ll need it. Nofziger warns that consumers need to re-evaluate any information they might receive out of the blue about Medicare coverage, too. In some cases, consumers complain that someone on the phone called and told them that Medicare would cover their “knee braces” fully. “However, when Medicare stopped the transaction, the sham company would try and bill the beneficiaries for those braces, often times at prices that far outweighed standard costs,” Nofziger said. Health insurance open enrollment already can be confusing Much can be confusing when you’re dealing with health insurance, and crooks know how to take advantage of the Medicare muddle. “Scams can seem super legit at the time, and scammers count on confusion and the natural human tendency to choose quick and easy rather than to take time to check things out,” Johnson warned. Johnson said it doesn’t help consumers that algorithms enable advertisers and others to track what you are doing online, what you’re reading, researching and buying. “We are literally being followed,” she said. As we become more concentrated with digital online tools, she said, older consumers can become easy pickings for scams, Johnson said. Johnson noted that outright scams aren’t the only risks during open enrollment season. “One danger that older consumers encounter is incomplete information even from established insurers – which can lead to losing Medigap coverage when one leaps into a Medicare Advantage plan without first looking into the details of whether it would be a good match for your needs,” Johnson said. It’s possible to get help to compare costs, coverage and plans through your State Health Insurance Assistance Program at shiphelp.org or call 877-839-2675. How to avoid scams If you did not initiate the call, be extra cautious and do not respond. Block spam calls. Type Medicare.gov directly into the search engine, or you can call 800-633-4227. You can research options for coverage here. If searching for coverage under the Affordable Care Act, you’d go to the Health Insurance Marketplace at HealthCare.gov or call 800-318-2596 to compare health insurance plans, including checking out your coverage or finding out if you qualify for extra savings. You don’t want to be confused and think you’re dealing with a government site when you’re not. Take a careful look to spot a paid advertisement. Look for small “Ad” or “Sponsored” labels next to search results to identify paid ads. Only share your Medicare card and other health care identification cards and numbers with trusted sources such as your health care providers. Protect your Medicare card like a credit card or banking information. Don’t hand it over to someone who simply appears friendly. Do not provide your Medicare number to a stranger who calls, visits or approaches you in a public setting. Medicare already has your Medicare number. They will not call you and ask you for it over the phone. If you suspect a health insurance scam, you can report it to the FTC at ReportFraud.ftc.gov and your state attorney general. If the scam involves Medicare, report it at Medicare.gov or 800-633-4227. Only share your Medicare card and other health care identification cards and numbers with trusted sources such as your health care providers. **Topics:** Medicare/Medicaid, Public Awareness, Technology --- ### [The Human Cost of Insurance Claim Fraud](https://insurancefraud.org/news_archives/the-human-cost-of-insurance-claim-fraud/) **Published:** October 13, 2026 **Author:** Diane Beauchamp **Content:** Insurance fraud carries a human cost, making early detection and prevention critical to protecting employees, supporting recovery and reducing harm. Picture someone injured in an accident that wasn’t their fault: a slip and fall, a car crash, an incident on someone else’s property. The injury is real, the pain is real, and their need for care is real. But, when seeking medical treatment, they encounter a medical provider who intentionally recommends unnecessary surgery to inflate the value of the claim. Months later, the person — now a “claimant” in the system — hasn’t recovered and may be worse off, both physically and financially. Insurance fraud is usually framed in terms of numbers — inflated claims, fraudulent billing, dollars lost. But behind those numbers, there are real victims, and in this case the fraud costs a person their recovery. So how do we stop this? Insurance carriers can be a key line of defense between a fraudulent provider and the claimant they’re targeting. ### **Fraud’s Ripple Effects on Real People** The Coalition Against Insurance Fraud estimates that insurance fraud costs the United States more than $308 billion annually. This figure is usually cited as an insurance industry expense. In reality, the impact shows up in places that are far more personal: household budgets, business overhead and culture, and trust in the institutions people depend on when something goes wrong. **Consider a few scenarios:** - **Employees drawn into staged incidents.** Organized fraud rings recruit real employees into staged fall schemes or accidents to generate fraudulent claims. An employee might be told, “Everyone does this,” or promised quick cash. When people are pressured or incentivized to participate, the damage extends beyond any single claim. It can follow them in the form of higher premiums, employment consequences, and a lingering sense that they were complicit in doing something wrong. - **Patients treated like revenue, not people.** Within the medical system, a durable medical equipment provider who bills claimants for supplies they don’t need is not just misusing insurance dollars. They are consuming limited resources and potentially derailing a patient’s recovery. Time, trust and health are all on the line. - **Families already under stress, facing dishonest contractors.** Insurance fraud isn’t limited to businesses. Homeowners can face the same dynamic after a severe weather event. When families are displaced and eager to return to normal, fraudulent contractors move quickly, using high-pressure tactics and promises of fast repairs to inflate claims. This can lead to financial loss, improperly repaired properties, delayed recovery and skepticism of legitimate contractors long after the storm has passed. Taken together, these examples make the case that fraud of any kind is not a victimless crime against a faceless industry. It takes a toll on employees, patients, and families. ### **Protecting Employees is Protecting People** In a business setting, the human cost of fraud can be easy to overlook. Claims are coded, tracked and reported, and it is tempting to see fraud purely as a matter of loss control. For a risk manager, though, fraud prevention can and should be viewed as part of your employee care structure. That means approaching it with the same rigor as any other safety program. The goal is the same: to protect people when something goes wrong. While risk managers depend on their insurers to detect suspicious claim activity quickly, there are practical steps they can take to make a meaningful difference: - **Train and educate employees**. Ongoing training helps employees recognize and report suspicious activity, such as an unusually aggressive treatment recommendation, an unfamiliar recruiter approaching them about “easy money,” or a provider relationship that doesn’t feel right. - **Establish strong post-incident practices**. Quick, factual documentation – what happened, who was present, what was observed, what changed afterward – protects a legitimate claim just as effectively as it defends against fraud. - **Know what your carrier can see that you can’t.** A carrier managing claims across an entire portfolio spanning industries, geographies, and lines of coverage can see patterns that are invisible from any single vantage point. At scale, it makes it possible to identify patterns across claims and distinguish between a legitimate claimant who needs care and a network systematically steering patients toward unnecessary treatment. That perspective is not abstract data. It is a way to keep people from being harmed by repeat offenders. - **Engage your carrier early and share what you observe.** The combination of your on-the-ground context and your carrier’s analytical capabilities is more powerful than either of you working alone. A concern that seems anecdotal to you may confirm a pattern already forming in the data. Raising these concerns early can prevent others from being hurt. ### **The Most Important Question** Remember the injured claimant we met at the start? Now imagine a different outcome. This time, when they seek care, they are guided to appropriate treatment. They recover without unnecessary procedures, because the system worked the way it was supposed to. The suspicious activity was caught by the insurance carrier before it happened. That’s why an insurer’s early claim fraud detection capabilities matter. Not merely to catch wrongdoing after the fact, but to interrupt harm before it reaches the person the system exists to protect. Each claim resolved correctly is more than a clean outcome on a spreadsheet; it is a person’s life and livelihood back on track. The claimant’s recovery isn’t just a personal outcome. It’s a small proof point for a larger assertion: that fighting fraud protects the integrity of a system. The next time your organization reviews its fraud prevention practices, it is worth asking one additional question alongside the usual ones about controls and loss ratios: Are these practices designed only to protect our financial results, or are they also designed to protect our employees from becoming victims of fraud? The strongest programs are built to do both. When they are, fraud prevention becomes not just a cost-saving measure, but a tangible expression of how an organization cares for its people. **Topics:** Coalition Against Insurance Fraud, Public Awareness --- ### [Cuyahoga Jail Sergeant Accused of Workers' Comp Fraud While Running BBQ Joint](https://insurancefraud.org/news_archives/cuyahoga-jail-sergeant-accused-of-workers-comp-fraud-while-running-bbq-joint/) **Published:** October 13, 2026 **Author:** Diane Beauchamp **Content:** A Cuyahoga County Jail sergeant is facing felony workers’ compensation fraud and grand theft charges after investigators say he collected disability benefits for a shoulder injury while working strenuous shifts at his own barbecue restaurant. William Brewer, who has worked at the jail since 1997, is now on unpaid leave and free on bond after pleading not guilty. According to News 5 Cleveland, investigators say Brewer fraudulently received benefits he was not entitled to after sustaining a shoulder injury during an altercation with an inmate in April 2023. He began collecting workers’ compensation tied to that injury, the station reports, even as his bosses grew suspicious about how he was spending his time away from the jail. A Grand Opening Raises Red Flags The following month, jail staff attended the grand opening of Brewer’s barbecue restaurant, where he was seen cooking and serving customers himself, per the station’s report. The jail warden described Brewer as performing more strenuous work at his restaurant than he ever did at the jail, according to the same account. By August 2023, the warden told News 5 Cleveland he had received inquiries about when Brewer would return to work, and people reported witnessing him continuing to perform physically demanding labor at his other job. The warden said reports of Brewer doing that work continued, the station’s report states. State Investigators Step In The Ohio Bureau of Workers’ Compensation opened an investigation into Brewer in November 2023. The agency’s Special Investigations Department investigates suspected workers’ compensation fraud, according to the Ohio Bureau of Workers’ Compensation. Even as that investigation proceeded, workers’ compensation paid Brewer $18,712.89 in benefits in January 2024, with Brewer still listed as injured and on leave at the time, per the station’s report. He has since returned to duty at the Cuyahoga County Jail, though he is now on unpaid leave amid the criminal case. Charges Filed in Franklin County The charges against Brewer were filed in Franklin County rather than Cuyahoga County, a venue choice that aligns with standard state procedure. State workers’ compensation fraud cases evaluated by BWC investigators may be presented to grand juries in Franklin County, where the bureau is headquartered, or referred to local county prosecutors, according to the Ohio Attorney General’s Office. The indictment alleges Brewer fraudulently received between $7,500 and $150,000, covering the period from late December 2023 through the end of February 2024, the station’s report notes. Under Ohio Revised Code Section 2913.48, workers’ compensation fraud in that dollar range is a fourth-degree felony carrying 6 to 18 months in prison and fines up to $5,000. The grand theft count, charged under Section 2913.02 for the same dollar range, carries an identical potential sentence. A spokesperson for the state Bureau of Workers’ Compensation did not respond to a request for more details, and Brewer’s attorney did not respond to a request for comment, per the station’s reporting. Part of a Broader Enforcement Push Brewer’s case lands amid an active statewide crackdown on claimant fraud. The Ohio Bureau of Workers’ Compensation’s Special Investigations Department reported securing 56 fraud convictions and saving the State Insurance Fund nearly $92 million during fiscal year 2025. Within that total, the bureau’s claimant fraud unit alone closed 1,044 cases, leading to 74 criminal referrals, 35 indictments, 34 convictions, and $66.6 million in savings for the state fund. Similar cases have surfaced elsewhere involving public-safety employees accused of exploiting injury benefits. In a case Hoodline covered last month, a former California sheriff’s deputy was charged with workers’ compensation fraud after surveillance video caught him heavy weightlifting at a gym despite reporting severe physical limitations to medical providers. And in March 2025, an Illinois State Police employee was charged with workers’ compensation fraud and theft for allegedly accepting disability benefits while secretly working a second job. Brewer’s case adds to a run of recent legal scrutiny touching Cuyahoga County’s justice system. Earlier this month, former Cuyahoga County assistant prosecutor Carl Sullivan was indicted on two felony obstruction of justice counts and given a $10,000 bond. In August, a federal judge sided with Cuyahoga County in a class-action lawsuit over inmate overdetention, ruling that officials had taken timely corrective action regarding release delays from 2021 to 2023. **Topics:** Work comp - worker **Categories:** Arrest --- ### [NYC’s RICO-Complaint Accuses Manhattan Injury Firm of Turning Real Injuries Into Bogus City Claims](https://insurancefraud.org/news_archives/nycs-rico-complaint-accuses-manhattan-injury-firm-of-turning-real-injuries-into-bogus-city-claims/) **Published:** October 13, 2026 **Author:** Diane Beauchamp **Content:** ### What the City Says Was Happening - New York City says Asher & Associates repeatedly blamed potholes and defective streets for injuries that medical records tied to fights, crashes and other events. - The federal civil case seeks triple damages under RICO and New York false-claims laws, potentially turning disputed injury suits into a much larger fraud case. - The complaint does not accuse doctors or clinics of participating in the alleged scheme — but it does accuse unnamed client *“runners”* and litigation funders, while alleging some clients knowingly backed false stories. A Manhattan personal injury law firm that has spent years suing New York City is now on the other side of the caption. The City of New York filed an 80-page federal complaint against **Asher & Associates, P.C., Ryan H.** **Asher and Roberta D.** **Asher**, accusing them of operating a years-long scheme that took genuine injuries and allegedly changed one crucial fact — **who caused them**. The case is **[City of New York v.](https://dockets.justia.com/docket/new-york/nysdce/1%3A2026cv08753/674321)** **[Ryan H. Asher, et al., No. 1:26-cv-08753 (S.D.N.Y. filed Oct.](https://dockets.justia.com/docket/new-york/nysdce/1%3A2026cv08753/674321)** **[4, 2026)](https://dockets.justia.com/docket/new-york/nysdce/1%3A2026cv08753/674321)**. It is assigned to U.S. District Judge Edgardo Ramos, with Magistrate Judge Sarah Netburn designated for referred matters. According to the complaint, some clients really were hurt. That distinction matters. The City is not simply alleging fake injuries. Instead, city lawyers say injuries allegedly caused by assaults, hit-and-run drivers, vehicle collisions or even a claimant’s own actions were later presented as accidents caused by defective New York roadways. The complaint identifies 15 examples and alleges they may represent only a fraction of the firm’s cases. [New York City Government](https://www.nyc.gov/assets/law/downloads/pdf/Asher-Complaint-as-filed.pdf) One claim sought $3 million after a client allegedly suffered injuries because of a defective Brooklyn roadway. Medical records, according to the City, instead described injuries connected to a fight. Another $3 million claim blamed a Manhattan street hole for an electric-scooter accident even though hospital personnel were allegedly told about an automobile accident. That difference is enormous legally. A broken bone can be completely real while the claim for who must pay for it can still be fraudulent. The City alleges Asher attorneys possessed medical records containing conflicting accident histories while submitting notices of claim and litigation documents asserting City liability. It alleges the conduct amounted to mail and wire fraud forming a pattern of racketeering under federal RICO, along with violations of the New York State and New York City False Claims Acts. [New York City Government](https://www.nyc.gov/assets/law/downloads/pdf/Asher-Complaint-as-filed.pdf) Asher & Associates is fighting back. Attorney Matthew Laroche of Milbank, now representing the firm, told a reporter that the City is improperly trying to turn legitimate personal injury litigation into a racketeering case and characterized the lawsuit as an attack on injured New Yorkers and the lawyers who represent them. There is an important insurance story here as well. New York City effectively bears much of its own tort risk rather than simply forwarding these cases to a conventional liability insurer; City materials have long described New York as self-insured for personal-injury and property-damage risks, meaning settlements and judgments can ultimately reach public funds. The Comptroller investigates claims before litigation and can settle them when liability appears justified. [New York City Government](https://www.nyc.gov/html/records/pdf/govpub/2911insidethebudget147.pdf?utm_source=chatgpt.com) But the alleged scheme also could affect private insurers. The City says Asher routinely filed parallel actions against utilities and paving contractors whose work allegedly contributed to roadway defects. Those companies may have commercial liability insurers paying defense costs or settlements. A fabricated accident theory can spread costs well beyond City Hall. [New York City Government](https://www.nyc.gov/site/law/news/26-3/city-new-york-sues-manhattan-law-firm-asher-associates-orchestrating-personal-injury-fraud) What about doctors or clinics routinely treating the firm’s clients? **So far, the City’s complaint does not allege that any preferred physician, medical clinic or treatment provider participated in the scheme.** In fact, medical records often play the opposite role in the complaint — they are the evidence the City says exposed discrepancies between what patients originally reported and what later appeared in legal claims. That is materially different from other New York insurance-fraud cases in which medical providers themselves are accused of participating. The complaint does, however, identify unnamed **“runners”** who allegedly supplied potential clients and unnamed **litigation funders** who advanced expenses. The City alleges those participants knew certain claims relied on false narratives. [New York City Government](https://www.nyc.gov/assets/law/downloads/pdf/Asher-Complaint-as-filed.pdf) And the clients themselves could become a major issue. If a claimant knowingly agreed to a fabricated account, signed a false notice of claim, repeated it during sworn testimony or knowingly participated in obtaining money through that story, potential exposure could extend beyond losing the personal injury case. Depending on the evidence, knowingly false sworn testimony can raise perjury concerns, while intentional participation in a scheme to obtain money could create civil or potentially criminal fraud exposure. The City goes further than merely blaming attorneys: its complaint alleges runners provided clients willing to give false testimony and claims that clients were induced to repeat false causation accounts during municipal hearings and depositions. Those remain **allegations**, not findings, and the 15 personal-injury clients are not presently named as defendants in this federal action. [New York City Government](https://www.nyc.gov/assets/law/downloads/pdf/Asher-Complaint-as-filed.pdf) The procedural posture is still early. The complaint was filed Oct. 4 and summonses were issued Oct. 5. As of the publicly available docket reviewed by USA Herald, no proof of service establishing a specific answer deadline had appeared. Under the normal federal rule, a defendant generally has **21 days after service** to answer or file a Rule 12 response. [Justia Dockets & Filings](https://dockets.justia.com/docket/new-york/nysdce/1%3A2026cv08753/674321) The stakes are substantial. The City seeks treble damages under RICO, treble damages under state and city false-claims laws, statutory penalties, attorneys’ fees and an injunction that could require medical records to accompany future notices of claim. **Topics:** Healthcare Fraud, Judicial/courts --- ### [Patient disputed an $85,000 hospital bill, then an AI sweep added nearly $20,000 more](https://insurancefraud.org/news_archives/patient-disputed-an-85000-hospital-bill-then-an-ai-sweep-added-nearly-20000-more/) **Published:** October 13, 2026 **Author:** Diane Beauchamp **Content:** A hospital bill already at $85,000 allegedly got even worse after a patient challenged it. The optics got even worse when the hospital appeared to use artificial intelligence tools to increase the amount the patient owed. ### Here’s what to know In a [TikTok video](https://www.tiktok.com/@aaronthesocialworker/video/7693577934275185933), a social worker who posts as [Aaron the Social Worker](https://www.tiktok.com/@aaronthesocialworker) (@aaronthesocialworker) said the hospital used AI to revisit the patient’s visit, identified almost $20,000 in extra charges, and increased the revised total to $102,000. The video centers on a call Aaron says he made about the updated bill. In his account, the patient challenged the original charges; the hospital reviewed the account again and said some charges had been left off the first bill. Along with asking whether the added charges had been sent to insurance and processed, Aaron also demands specifics in the video: “OK, what charges? For what services and for what days.” After saying the hospital “did an AI sweep of her visit,” Aaron adds: “The bill was already $85,000. Now the revised bill, it’s driven it up to $102,000.” Reaction in the comments was critical, with many wondering if the practice was legal or constituted a “massive \[HIPAA\] violation.” “If AI finds an additional 20k, someone did not do their job in the first place,” a user weighed in. ### More background Aaron describes the situation as especially difficult because the patient already couldn’t pay. During the call, he says the patient “already can’t afford the bill” and questions why speaking up led to a response of: “Congratulations. Here’s a larger financial bill.” Aaron also raises a broader concern: “Also, what is the ethics of using AI to sweep a patient’s bill?” Commenters on TikTok suggested this is far from being the old misuse of the tech. “AI is in doctors offices,” one declared. “It’s been a nightmare.” Other commenters suggested the higher bill was “punishment” and an intentional deterrent to patients questioning high medical bills. ### What can be done? In the video, Aaron seeks more detailed accounting instead of simply accepting the new total. He asks what the added charges were tied to and which dates in the patient’s care they covered. He also presses for clarity on insurance, asking whether the hospital submitted those extra charges and whether that process was completed. After being told the increase came from an AI sweep, he asks, “Is that a standard practice?” He argues that patients should be able to question a hospital bill without fearing a higher price afterward: “Patients should not have to question a hospital bill without wondering whether the price is going to be, you know, jacked up after.” “We already can’t afford medical care as it is,” a TikTok viewer lamented. “We don’t need AI adding more.” ### Where can I learn more? Some of the same issues Aaron and viewers raised pervade AI’s infiltration of the healthcare and insurance industries. • In Congress, lawmakers pushed [to stop AI claim denials](https://learn.thecooldown.com/green-tech/health-insurance-regulations-bill-artificial-intelligence-discounts/) after patients were reportedly left behind. • Researchers found that [very small words changed](https://learn.thecooldown.com/green-tech/chatgpt-health-assistant-researchers-discovery/) health chatbot answers in disturbing ways. **Topics:** Public Awareness, Technology --- ### [Allstate alleges $1.3 mn no-fault insurance fraud by Titan Diagnostic Imaging](https://insurancefraud.org/news_archives/allstate-alleges-1-3-mn-no-fault-insurance-fraud-by-titan-diagnostic-imaging/) **Published:** October 13, 2026 **Author:** Diane Beauchamp **Content:** - Allstate accuses Titan Diagnostic Imaging of submitting more than $1.3 mn in fraudulent no-fault insurance bills across more than 9,000 claims involving 59 clinic locations. - The insurer alleges that medical necessity letters, diagnostic interpretations and test results were virtually identical across patients, with services performed through an improperly licensed operation. - Allstate seeks to recover $179,689.87 already paid, obtain triple damages under RICO and eliminate liability for approximately $1.12 mn in outstanding bills. > Allstate has filed a federal racketeering lawsuit against Titan Diagnostic Imaging Services and its sole owner, alleging that the company submitted more than $1.3 mn in fraudulent medical bills for diagnostic procedures performed on New York no-fault auto insurance claimants. The complaint, filed October 7 in the US District Court for the Eastern District of New York, accuses Titan of billing for tests described as “medically unnecessary, illusory, unlawfully rendered.” According to Allstate, the alleged scheme involved more than 9,000 claims processed through 59 clinic locations, with medical documentation and diagnostic findings repeatedly showing identical language and results. The lawsuit contains five causes of action, including two federal claims under the Racketeer Influenced and Corrupt Organizations Act (RICO), common law fraud, unjust enrichment and a request for declaratory relief concerning Titan’s pending and future billing. > Allstate says it paid Titan $179.7K before identifying the suspected irregularities. The insurer is seeking reimbursement of those payments and a judicial declaration that it has no obligation to pay approximately $1.12 bn in outstanding bills that Titan continues to pursue. A central allegation concerns Titan’s legal authority to provide and bill for medical services in New York. According to the complaint, Titan was not organized as a professional medical corporation and had never registered with the New York State Education Department, a requirement for entities providing professional medical services. Allstate also alleges that the company’s sole owner was not a licensed healthcare professional. Despite these alleged deficiencies, Titan billed the insurer for musculoskeletal ultrasound examinations, videonystagmography and transcranial Doppler studies. > Videonystagmography evaluates vestibular function by measuring eye movements, while transcranial Doppler examinations use ultrasound to assess blood flow in the brain. The complaint questions both the medical necessity of these procedures and the circumstances under which they were performed. Allstate points to extensive similarities in the documentation used to justify the tests. According to the filing, Titan submitted “Letters of Medical Necessity” containing the same referral language regardless of the claimant’s injuries, symptoms or clinical circumstances. Each letter stated that the patient “has been referred for musculoskeletal diagnostic sonogram to evaluate his/her acute/subacute/chronic pain and segmental dysfunction of the joints and muscles of the back.” > The insurer alleges that this uniformity extended to the diagnostic findings themselves. Interpretations of vestibular examinations reportedly contained identical summaries, clinical impressions and recommendations across virtually every patient, with almost all results reported as negative. Transcranial Doppler examinations allegedly produced the same conclusions and normal findings in every case. Allstate argues that such consistency is medically implausible given the differences in patients’ accident histories, reported injuries and individual medical circumstances. The complaint further describes an operation distributed across 59 clinics in New York, including locations in the Bronx, Brooklyn and Buffalo, rather than a single diagnostic facility. In October, [Allstate also has filed three federal lawsuits](https://beinsure.com/news/allstate-sues-three-new-york-pharmacies-over-no-fault-insurance-claims/) against New York pharmacies, alleging they used similar arrangements with no-fault medical clinics to bill hundreds of thousands of dollars for expensive prescription pain treatments. > The complaints were filed Sept. 30, 2026, in the U.S. District Court for the Eastern District of New York against Narrow Pharmacy Inc. in Brooklyn, Redfern Drugs Inc. in Far Rockaway and Punjab Rx Pharmacy Inc. in South Richmond Hill. The plaintiffs are Allstate Insurance Company, Allstate Fire and Casualty Insurance Company, Allstate Indemnity Company and Allstate Property and Casualty Insurance Company. Allstate characterizes the participating clinics as “medical mills established for the sole purpose of submitting inflated, fraudulent billing.” > In certain cases, as many as 23 separate entities allegedly billed Allstate for services provided to the same patient at the same clinic following a single motor vehicle accident. The insurer also challenges the clinical justification for performing musculoskeletal ultrasounds on patients who had already undergone magnetic resonance imaging of the same anatomical regions. Some ultrasound examinations allegedly occurred on the same day as the corresponding MRI scans. The complaint maintains that performing an ultrasound shortly after an MRI of the same area “virtually never provides any additional information.” > The timing of other examinations raised further concerns. Allstate identifies examples of ultrasounds performed on the day of an accident, three days afterward or during the first week following an injury. According to the insurer, these procedures occurred before the 30-day period of conservative treatment that legitimate medical providers would typically allow before ordering additional diagnostic testing. Allstate contends that the recurring documentation, consistently normal results, questionable testing practices and alleged licensing violations support its claims that Titan improperly sought reimbursement under New York’s no-fault insurance system. **Topics:** Auto fraud, Judicial/courts --- ### [Rockville man indicted in alleged $100 million COVID-19 testing fraud scheme](https://insurancefraud.org/news_archives/rockville-man-indicted-in-alleged-100-million-covid-19-testing-fraud-scheme/) **Published:** October 13, 2026 **Author:** Diane Beauchamp **Content:** A Rockville man has been indicted on federal charges alleging he and his co-conspirators submitted more than $100 million in fraudulent health insurance claims for at-home COVID-19 tests, according to the U.S. Attorney’s Office for the District of Maryland. Marc Aaron Potash, 57, faces one count of conspiracy to commit health care fraud, seven counts of health care fraud and five counts of conducting transactions involving criminally derived proceeds, federal prosecutors announced Friday. Bethesda Today could not immediately reach Potash or an attorney for comment Friday. According to the indictment, Potash, the founder and CEO of Tiero LLC, a Gaithersburg-based company, conspired with others between January 2022 and May 2026 to submit false claims to Medicare, Medicaid, the Federal Employees Health Benefits Program and other insurers. Prosecutors allege that Potash and his co-conspirators obtained a federal laboratory certification for Tiero by submitting false documents to the Maryland Department of Health. The documents allegedly misrepresented how and where medical providers conducted COVID-19 testing. The indictment alleges that Tiero then used the certification to submit insurance claims containing false service dates, locations and provider information for COVID-19 tests. In reality, the company shipped over-the-counter COVID-19 tests for individuals to administer themselves, rather than providing the testing services described in the claims, according to prosecutors. The alleged scheme resulted in more than $100 million in fraudulent claims and more than $50 million in insurance payments to Tiero, the indictment states. Potash is also accused of conducting financial transactions involving proceeds from the alleged scheme. Prosecutors allege that he purchased a Range Rover, a Mercedes-Benz and real estate in the Beallsville area of Montgomery County, valued at $4 million. The indictment also cites two securities transfers totaling more than $12 million. The case is part of a federal effort to investigate and prosecute health care fraud, according to the U.S. Attorney’s Office. If convicted, Potash faces a maximum sentence of 10 years in federal prison for the conspiracy charge and for each count of health care fraud and conducting transactions involving criminally derived proceeds. A federal judge would determine any sentence after considering federal sentencing guidelines and other factors. **Topics:** COVID-19, Medicare/Medicaid **Categories:** Arrest --- ### [Dobbs Ferry woman allegedly bilked insurance companies out of $100,000](https://insurancefraud.org/news_archives/dobbs-ferry-woman-allegedly-bilked-insurance-companies-out-of-100000/) **Published:** October 13, 2026 **Author:** Diane Beauchamp **Content:** A Dobbs Ferry woman allegedly stole more than $100,000 after making false medical insurance claims, the Westchester District Attorney’s Office said. Jackie Crino, 46, was arrested Thursday, Oct. 8, and arraigned in Dobbs Ferry Village Court on multiple felony charges. The top charges – second-degree grand larceny, second-degree insurance fraud and second-degree health care fraud – are each punishable by up to 15 years in prison. Crino told The Journal News/lohud that the allegations were untrue but declined to comment further as she had not yet hired a lawyer. Between May 2022 and February 2025 Crino allegedly used false invoices for medical services that were never performed to support insurance claims. She received $103,007 in total after making claims for $16,737 from UnitedHealthcare in 2022 and 2023 and $86,270.02 from Cigna Health and Life Insurance in 2024 and 2025, according to an investigation by the DA’s forensic accountant Michael Frenza. District Attorney Susan Cacace said in a news release that Crino’s alleged scheme helped her unlawfully profit off the insurance companies and their customers. UnitedHealthcare’s Special Investigative Unit referred the case to the DA’s Economic Crimes Bureau, which investigated along with the New York State Department of Financial Services. In addition to the top charges, Crino was charged with third- and fourth-degree health care fraud, third-degree grand larceny, third-degree insurance fraud, second-degree forgery, second-degree criminal possession of a forged instrument and first-degree scheme to defraud, all felonies. None of the charges are bail eligible so Village Justice David Koenigsberg released Crino and scheduled her next court appearance for Oct. 22. **Topics:** Healthcare Fraud **Categories:** Arrest --- ### [Takeda Agrees to Pay $13.6M to Resolve False Claims Allegations Relating to Improper Payments to Physicians](https://insurancefraud.org/news_archives/takeda-agrees-to-pay-13-6m-to-resolve-false-claims-allegations-relating-to-improper-payments-to-physicians/) **Published:** October 13, 2026 **Author:** Diane Beauchamp **Content:** Attorney General William Tong today announced that Connecticut joined a coalition of states and the federal government to settle allegations against Takeda Pharmaceuticals, U.S.A., Inc. The settlement resolves allegations that the pharmaceutical company knowingly caused the submission of false claims to Medicare, Medicaid, and other federal health care programs by paying kickbacks to healthcare providers to include prescriptions of Trintellix, an antidepressant medication that Takeda marketed and sold to treat major depressive disorder. Takeda, a Delaware corporation with its principal place of business in Cambridge, Massachusetts, paid the federal government and states $13,670,921 in addition to accrued interest, of which $1,703,572 is allocated to the participating states’ Medicaid programs. The portion of the settlement attributable to the Connecticut Medicaid program is $213,674. “Takeda paid illegal kickbacks to doctors to boost prescriptions of their drug, undermining trust in our healthcare system and abusing public funds. In coordination with our state and federal partners, we will continue to aggressively pursue companies who break the law to line their pockets,” said Attorney General Tong. The Anti-Kickback Statute prohibits offering or paying anything of value to induce the referral of items or services covered by Medicare, Medicaid, TRICARE, and other federal health care programs. The statue is intended to ensure that the judgments of healthcare professionals are not compromised by improper financial incentives. The national federal and state civil settlement resolves allegations that, from January 2014 to October 2020, Takeda paid improper remuneration, including in the form of speaker honoraria and meals at high-end restaurants, to healthcare professionals to induce them to prescribe the antidepressant medication Trintellix in violation of the Anti-Kickback Statute. The States contend that Takeda selected certain healthcare providers to be part of the Trintellix speaker bureau and provided them with paid speaking opportunities with the intend that the speaker honoraria and meals would induce them to prescribe Trintellix. The States further contend that certain prescribers who attended multiple programs on the same topic and received meals and drinks from Takeda received no educational benefit from attending duplicate programs, in violation of state false claims statutes. A National Association of Medicaid Fraud Control Units (NAMFCU) Team participated in the investigation and conducted settlement negotiations with Takeda on behalf of the states. The Team included representatives from the Offices of the Attorneys General for the states of California, Florida, Illinois, and New Jersey. Paralegal Specialist Orlean Woodham and Deputy Associate Attorney General Gregory O’Connell, Chief of the Government Fraud Section, assisted the Attorney General Tong in this matter. **Topics:** Drug Diversion, Judicial/courts, Medicare/Medicaid, Veterans Benefits Fraud --- ### [Woman arrested in connection with insurance fraud investigation](https://insurancefraud.org/news_archives/woman-arrested-in-connection-with-insurance-fraud-investigation/) **Published:** October 13, 2026 **Author:** Diane Beauchamp **Content:** A 49-year-old woman was arrested in connection with insurance fraud involving a car fire along I-110 North near the Capitol Access Road exit in Baton Rouge on Friday, according to the Louisiana State Fire Marshal’s Office. On April 13, the Baton Rouge Fire Department, along with the Baton Rouge Police, responded to a car fire on the side of I-110 around 5:16 a.m. involving 49-year-old Chastity Lewis. The Louisiana Department of Insurance later contacted the State Fire Marshall in reference to an insurance claim Lewis allegedly filed for a 2011 Nissan, with investigators determining the insurance claim to be fraudulent. Lewis was arrested in connection with the alleged fraud. **Topics:** Auto - padding/false claim **Categories:** Arrest --- ### [Chiropractor Gets 14 Years in $30M Medicare Fraud](https://insurancefraud.org/news_archives/chiropractor-gets-14-years-in-30m-medicare-fraud/) **Published:** October 13, 2026 **Author:** Diane Beauchamp **Content:** An Oklahoma chiropractor and medical supply company owner has been sentenced to 14 years in federal prison for participating in a multimillion-dollar health care fraud conspiracy that submitted more than $30 million in fraudulent claims to Medicare, TRICARE, and a federal health benefits program serving eligible veterans’ families. Mark Loftis, 39, of Cushing, Oklahoma, was sentenced October 8 following his conviction in July on a charge of conspiracy to commit health care fraud and wire fraud, according to the U.S. Department of Justice. Federal prosecutors established that Loftis and his co-conspirators used illegal kickbacks, misleading marketing operations, concealed business relationships, and fraudulent medical orders to bill government insurance programs for medical equipment beneficiaries did not want or need. The operation generated more than $8 million in payments from federal health care programs. In addition to the prison sentence, the court ordered Loftis to pay more than $8 million in restitution and forfeit more than $560,000. The investigation exposed a scheme involving medical equipment suppliers, purported telemedicine businesses, marketers, and a call center that obtained personal information from elderly and disabled Americans. The case also highlighted concerns about the misuse of sensitive medical information and the vulnerability of patients who depend on federal health insurance programs. Federal Jury Convicted Oklahoma Chiropractor Loftis owned Back Pain Home Supplies LLC, which operated under the business name EZ Medical Supply. Evidence presented at trial showed that Loftis and his co-conspirators concealed information about the company’s ownership and management from Medicare. They also failed to disclose that the medical equipment company was submitting claims for businesses not enrolled in Medicare. The arrangement let outside participants use the company’s billing operations while hiding their involvement from federal regulators. Prosecutors established that Loftis paid more than $1 million in illegal kickbacks to marketers, purported telemedicine companies, and a call center. Some payments were routed through a shell marketing company. The payments helped generate medical equipment orders and insurance claims that were not supported by legitimate medical evaluations. Following a 12-day jury trial that concluded in July 2026, Loftis was convicted of conspiracy to commit health care fraud and wire fraud. The Justice Department announced the prison sentence on October 9. The sentencing represents a significant federal prosecution involving fraudulent medical equipment billing and illegal financial arrangements designed to generate government insurance payments. Chiropractor – How the $30 Million Fraud Scheme Operated The conspiracy relied on obtaining patient information and using it to generate medical equipment orders that could be billed to federal insurance programs. According to the Justice Department, marketers and call center representatives persuaded elderly and disabled Americans to disclose personal information, including health insurance details. They then used the information to obtain orders for orthopedic braces, continuous glucose monitors, and other durable medical equipment. Instead of relying on legitimate medical examinations, the conspirators purchased fraudulent orders generated by telemedicine physicians and nurse practitioners. Federal authorities reported that these practitioners had never examined the beneficiaries and often never spoke with them. The conspirators then used the orders to support claims submitted to Medicare, TRICARE, and CHAMPVA. In many instances, the medical equipment was unnecessary or unwanted. The conspirators also concealed business relationships that would have revealed other suppliers’ participation in the billing operation. According to the Justice Department, the operation submitted more than $30 million in fraudulent claims and received more than $8 million in payments. The distinction matters: The $30 million represents fraudulent claims submitted, not the amount government programs actually paid. The payments received totaled more than $8 million, while the restitution and forfeiture orders represent separate financial consequences imposed by the court. Chiropractor – Elderly and Disabled Americans Affected The fraudulent operation involved marketing practices directed toward elderly and disabled Americans, according to evidence presented at trial. Call center representatives persuaded beneficiaries to provide information that the operation later used to generate medical equipment orders. The government’s investigation established that some beneficiaries received equipment they did not need. The operation also relied on medical orders that were not based on appropriate patient examinations. Such arrangements can create significant risks for individuals who believe they are communicating with legitimate health care representatives. Medical insurance information can be used to submit claims without beneficiaries fully understanding how their information will be handled. The Justice Department’s sentencing announcement did not provide a complete count of the beneficiaries affected by the conspiracy. Nor did it establish that every individual whose information was used suffered a direct financial loss. However, the evidence demonstrated that the conspirators exploited federal insurance billing procedures to obtain millions of dollars in payments. The case underscores the importance of protecting personal medical information and investigating questionable equipment claims, particularly when beneficiaries receive unsolicited offers for medical products. Oklahoma – Eight Orthopedic Braces Billed for One Beneficiary Federal investigators identified examples of excessive medical equipment billing during the conspiracy. In one instance, the operation submitted claims for eight orthopedic braces for a single beneficiary. According to the Justice Department, the conspirators frequently billed for multiple braces at the same time. Orthopedic braces can serve legitimate medical purposes, including supporting injured joints, stabilizing affected areas, and assisting patients recovering from certain conditions. However, federal insurance reimbursement generally requires documentation establishing medical necessity and compliance with applicable coverage requirements. The Loftis conspiracy involved medical orders obtained through fraudulent arrangements rather than legitimate medical evaluations. The example involving eight braces shows how excessive claims can drive substantial fraudulent billing totals. It also demonstrates why unusual patterns involving multiple medical devices for the same beneficiary can warrant closer examination. Oklahoma – Original Indictment Included COVID-19 Relief Allegations The original federal indictment also contained allegations involving pandemic-related government assistance. In January 2026, the Justice Department announced charges related to the medical equipment conspiracy and the alleged misuse of federal COVID-19 relief funds. Prosecutors alleged that Loftis received more than $133,000 through the Provider Relief Fund established under the Coronavirus Aid, Relief, and Economic Security Act. The program was designed to help eligible health care providers address pandemic-related financial losses and expenses. According to the indictment, Loftis falsely certified compliance with requirements governing the use of those funds. Prosecutors further alleged that Loftis diverted some money to personal expenses and activities connected to the medical equipment operation. The original indictment included a conspiracy charge to commit health care fraud and wire fraud; a separate conspiracy charge alleging an agreement to defraud the United States and to offer, pay, solicit, and receive illegal kickbacks; and two counts of theft of government property. However, the Justice Department’s subsequent conviction and sentencing announcements identify the conviction as conspiracy to commit health care fraud and wire fraud. Those announcements do not explain the final disposition of the additional original charges. Consequently, the pandemic relief fund allegations must be distinguished from the conduct established by the jury conviction. The available official announcements do not establish that Loftis was convicted of stealing Provider Relief Fund money. Chiropractor – Medicare, TRICARE and Veterans’ Health Benefits Affected The fraudulent claims involved three federal health care programs serving different groups of Americans. Medicare provides health insurance primarily to people age 65 and older and certain younger individuals with qualifying disabilities or medical conditions. TRICARE provides coverage to eligible military personnel, retirees, and their families. CHAMPVA, the Civilian Health and Medical Program of the Department of Veterans Affairs, provides health benefits to certain spouses, surviving spouses and children of qualifying veterans. The conspiracy exploited billing arrangements involving these programs to obtain reimbursement for unnecessary or improperly ordered medical equipment. The Justice Department has not publicly provided a breakdown establishing how much each program paid as a result of the conspiracy. Accordingly, the more than $8 million in payments represents the combined amount reported by federal authorities. The involvement of military and veterans’ benefits also brought additional investigative agencies into the case. Federal Officials Address the Fraud Conviction Assistant Attorney General Colin M. McDonald of the Justice Department’s National Fraud Enforcement Division said the sentence reflected the government’s determination to prosecute individuals who misuse federal health care programs. McDonald criticized illegal kickbacks, false claims, and treating sensitive patient information as a commercial commodity. Acting Deputy Inspector General for Investigations Miranda L. Bennett of the Department of Health and Human Services Office of Inspector General emphasized the importance of protecting vulnerable beneficiaries and safeguarding taxpayer funds. FBI Tampa Field Office Special Agent in Charge Rodney Crawford said health care fraud harms the public financially and pledged continued enforcement against fraudulent billing operations. Representatives of the Defense Criminal Investigative Service and the Department of Veterans Affairs Office of Inspector General also emphasized the need to protect benefits intended for service members, veterans, and their families. The investigation involved HHS-OIG, the FBI, the Defense Criminal Investigative Service and VA-OIG. Assistant Deputy Chief Catherine Wagner and Trial Attorney Raymond Beckering III of the Justice Department’s National Fraud Enforcement Division Health Care Fraud Section prosecuted the case. Chirpractor – Broader Federal Health Care Fraud Enforcement The Loftis prosecution comes amid continued federal efforts to investigate fraudulent medical billing, illegal kickback arrangements and the misuse of government insurance programs. According to the Justice Department, its Health Care Fraud Strike Force Program has charged more than 6,200 defendants since 2007. Those defendants collectively billed federal health care programs and private insurers more than $45 billion. The figures represent aggregate billed amounts associated with charged defendants, not the amount actually paid by government programs or insurers. The program currently operates through nine strike forces in federal districts across the country. Federal investigators also work with the Centers for Medicare & Medicaid Services to identify suspicious billing activity and address provider misconduct. The Loftis case illustrates how concealed business relationships, purchased medical orders, and third-party marketing arrangements can combine to generate fraudulent claims. It also demonstrates the importance of distinguishing legitimate telemedicine services from operations that produce medical orders without meaningful patient evaluations. Chiropractor – Fourteen-Year Sentence Concludes Major Fraud Trial The 14-year prison sentence follows a federal jury conviction, not a guilty plea. In addition to incarceration, Loftis faces more than $8 million in restitution and forfeiture, including more than $560,000. The Justice Department has not publicly stated how much restitution it has collected or whether it will ultimately recover the full amount. Its sentencing announcement also does not fully account for the legal status of every alleged co-conspirator. For beneficiaries, the case underscores the importance of questioning unsolicited medical equipment offers and reviewing insurance statements for unfamiliar charges. For federal investigators, the conviction demonstrates the consequences of using fraudulent medical orders, illegal financial arrangements, and concealed billing relationships to obtain government payments. The prosecution also highlights the importance of protecting elderly and disabled Americans whose personal information can be exploited by deceptive marketing operations. Although the sentence addresses Loftis’s criminal conduct, the broader issues extend to oversight of medical equipment suppliers, telemedicine arrangements, and federal health insurance billing. The case shows how fraudulent operations can generate millions of dollars in claims before investigators stop them. **Topics:** COVID-19, Medicare/Medicaid, Veterans Benefits Fraud **Categories:** Conviction --- ### [Advantage Investigations Acquires NorStar](https://insurancefraud.org/news_archives/advantage-investigations-acquires-norstar/) **Published:** October 10, 2026 **Author:** Diane Beauchamp **Content:** A**dvantage Investigations**, the insurance investigative services platform backed by **Align Capital Partners** (ACP), has acquired **NorStar Investigations**, a founder-owned surveillance and claims-investigation firm serving insurers and law firms across the Northeast. [**Advantage Investigations**](http://www.advantageinvestigations.com/) examines insurance claims for the carriers and employers who pay them. Working for property and casualty insurers, third-party administrators that run claims on behalf of self-insured employers, and defense law firms, the company sets out to confirm whether a claim is what it appears to be. Its field investigators conduct surveillance — discreetly observing a claimant over the course of a day to document whether a reported injury matches the person’s actual activity — while its desktop researchers comb public records and social media toward the same end, a service the company markets as **NetSweep**. Other assignments include recorded statements, background checks and activity checks that establish a claimant is alive, at a given address and doing what they say they are doing. The company staffs assignments with investigators it employs directly rather than subcontractors, a model it says keeps evidence consistent and defensible when a claim decision is contested or reaches a courtroom. Cases are routed and tracked through a proprietary case-management system, and the in-house investigator network reaches across 45 states, giving a national carrier a single vendor in place of a patchwork of local firms. Alongside its live surveillance capabilities, Advantage offers remote camera monitoring and analysis of vehicle event-data recorders to help insurers judge liability. Charlotte, North Carolina-headquartered Advantage, led by CEO **Shelly Kummings**, was founded in 1998 and employs about 300 people across its investigator network. [**NorStar Investigations**](http://www.norstarinvestigations.com/) works for general liability carriers, third-party administrators and law firms, handling surveillance, insurance-fraud and claims investigations, background checks and legal investigations across New York, New Jersey and Pennsylvania. NorStar is based about 60 miles north of New York City in Fishkill, New York. “The acquisition enhances NorStar’s value proposition by providing access to the expanded national resources, technology and operational support of Advantage Investigations,” said **Bill Troiano**, the founder of NorStar. “We’re excited about the future as our team joins forces with Advantage to offer clients continuity with the same experienced personnel and investigative resources that have supported their results for years.” NorStar is the second add-on for Advantage under ACP ownership. In June 2026, it acquired **Lange Technical Services**, a Long Island-based provider of forensic vehicle investigation services including fire origin and cause determinations, collision damage analysis, accident reconstruction and event data recorder retrieval for auto and property and casualty insurers and law enforcement. For Advantage, NorStar deepens its Northeast coverage and adds a book of carrier, administrator and law-firm relationships in three contiguous states to a network that already reaches 45 states. ACP acquired Advantage from [**MD Holdings**](https://www.mdholdings.com/), a Texas-based private equity firm that makes control investments in US-based business-to-business companies with $1.5 million to $5 million of EBITDA. MD Holdings had acquired a majority interest in Advantage in 2019 and added four investigation businesses to it before selling the platform to ACP in November 2025. Insurance fraud is a large and persistent cost. The Coalition Against Insurance Fraud puts the annual price of fraud across all lines of US insurance at about **$309 billion**, a figure that gives carriers a direct financial reason to scrutinize suspicious claims rather than simply pay them. Workers’ compensation, disability, auto and general-liability claims are the most frequently contested, and insurers increasingly outsource the field work to specialist firms. The investigation industry that serves them is fragmented, built largely of small, founder-owned firms licensed state by state. That structure favors buyers able to offer carriers national coverage, uniform compliance and shared technology, and it has drawn private equity into a wave of consolidation. The broader market for insurance fraud detection, which spans investigative services and analytics software, was about $8.5 billion worldwide in 2026 and is projected to reach $20.2 billion by 2031, a compound annual growth rate of roughly 18.9%, according to Mordor Intelligence, with North America the largest regional market. Cleveland and Dallas-based [**ACP**](https://aligncp.com/) makes control investments in lower-middle-market business-to-business companies, typically investing $20 million to $60 million of equity in businesses with enterprise values up to $150 million and EBITDA of $3 million to $15 million. Its sectors of interest are professional business services, tech-enabled services, industrial services, and specialty manufacturing and distribution. The ACP transaction team was led by Partner **Matt Iodice**, Co-Founder and Managing Partner **Rob Langley**, Operating Partner **Stuart Schardin**, Vice President **Sarah Whitney** and Managing Director of Portfolio M&A **Joe Vitale**. **Topics:** Coalition Against Insurance Fraud, Public Awareness, Technology --- ### [Report: RICO statute used to crack down on staged accidents](https://insurancefraud.org/news_archives/report-rico-statute-used-to-crack-down-on-staged-accidents/) **Published:** October 10, 2026 **Author:** Diane Beauchamp **Content:** New York City is increasingly turning to a federal mafia-busting law in a crackdown on organized crime rings staging bogus auto accidents that drive up costs for consumers. That’s according to a report released Thursday by American Tort Reform Foundation, which found that since 2024 businesses and insurers have filed nearly 300 civil lawsuits under the Racketeer Influenced and Corrupt Organizations Act – a 1970 federal statute meant to dismantle organized crime – a majority of which been filed in New York. “New York is in a league of its own,” Tiger Joyce, president of the American Tort Reform Association, said in a statement. “Every kind of scheme shows up here: staged construction accidents, trip-and-falls, auto accidents, even fraud-driven class actions. Now even New York City is fighting back on behalf of taxpayers.” The report’s release comes days after New York City Mayor Zohran Mamdani’s law department filed a RICO lawsuit accusing the personal injury law firm Asher & Associates P.C. rewrote clients’ accounts of how they were hurt so the city would be on the hook for the maximum payout in court. “With so many RICO claims filed there, and no sign of slowing, the Eastern District of New York well deserves the title of ‘America’s insurance fraud court,'” Joyce added. The foundation’s report said New York’s no-fault law makes the state a “prime target” by limiting accident victims to $50,000 in medical costs and lost income unless they can show a “serious” injury, which “gives schemers a reason to inflate injuries so they can file lawsuits seeking far larger payouts, including pain and suffering damages.” Construction sites are a favorite target, according to the report. Contractors, insurers and reinsurers have filed at least nine RICO suits alleging that law firms staged falls to cash in on New York’s outdated Scaffold Law, an 1885 law that imposes “absolute liability” on New York property owners and contractors for injuries on construction sites, the report’s authors said. The stakes are high for New Yorkers, who pay an estimated $2,684 per person each year in “tort tax” due to excessive litigation – the second-highest burden in the nation, according to the foundation. New York’s legal system is consistently ranked among the worst in the nation in the American Tort Reform Foundation’s annual “judicial hellholes” report over frivolous litigation in the court system. Meanwhile, trial lawyer groups have ramped up spending on lawsuit ads and aggressive marketing campaigns that critics say are fueling a “fraudemic” of bogus litigation. Gov. Kathy Hochul, a Democrat who is seeking another term in office in the November elections, made auto insurance reform a key plank of her legislative agenda for the year, often tying it to broader efforts to reduce the state’s high cost of living. In May, Hochul signed legislation that seeks to crack down on staged accidents setting limits on court-ordered damages for drivers engaging in “criminal behavior” at the time of crash, such as uninsured motorists, drunk drivers and fraudsters, with the goal of preventing “jackpot” payouts. Tort reform advocates have welcomed the changes, but say New York needs to continue to push to eliminate laws that are contributing to bogus slip-and-fall lawsuits and staged car accidents. “This report should be required reading for every lawmaker and enforcement agency in Albany,” said Tom Stebbins, executive director of the Lawsuit Reform Alliance of New York. “New York sits firmly at the center of the lawsuit abuse and fraudulent activity draining working families of their hard-earned dollars.” **Topics:** Auto - staged, Healthcare Fraud, Judicial/courts --- ### [GEICO sues Brooklyn supplier over alleged $733K no-fault equipment fraud](https://insurancefraud.org/news_archives/geico-sues-brooklyn-supplier-over-alleged-733k-no-fault-equipment-fraud/) **Published:** October 10, 2026 **Author:** Diane Beauchamp **Content:** **What happened:** [GEICO](https://www.insurancebusinessmag.com/us/companies/geico/116487/) alleges a Brooklyn medical supply company billed more than $733,000 for laser devices and cold therapy units prescribed to fender-bender victims through a kickback-fueled scheme. **Who’s involved:** GEICO (four entities) as plaintiff; a Brooklyn-based DME supplier and its owner as defendants. **What’s at stake:** Over $200,000 in damages already paid, more than $450,000 in pending claims GEICO wants voided, plus treble damages under RICO. **Why it matters:** The complaint maps a full no-fault DME fraud playbook – photocopied prescriptions, boilerplate forms, clinic kickbacks – that SIU and claims teams across the industry confront daily. **Where it stands:** Complaint filed October 7, 2026. A $3,750 laser therapy device for a minor sprain. The same prescription for virtually every patient. And a company that allegedly started billing insurers nine days after it was incorporated. Those are the allegations at the center of a federal lawsuit filed by GEICO in the US District Court for the Eastern District of New York on October 7, 2026, targeting a Brooklyn-based durable medical equipment supplier and its owner. The complaint accuses the supplier of exploiting New York’s no-fault auto insurance system to bill GEICO more than $733,000 for equipment the filing calls medically unnecessary, prescribed through what it describes as a “fraudulent scheme” built on kickbacks, photocopied prescriptions, and pre-printed boilerplate forms. GEICO says it has already paid out more than $200,000 on the claims. It wants that money back, a court order voiding more than $450,000 in pending bills, and treble damages under RICO, the federal racketeering statute. The insurer is a wholly owned subsidiary of [Berkshire Hathaway](https://www.insurancebusinessmag.com/us/companies/berkshire-hathaway/535041/). ## **Identical prescriptions, every patient** According to the complaint, virtually all of the policyholders who received the disputed equipment had been in minor, low-impact collisions – what the filing calls “fender-bender” accidents – and suffered nothing more serious than a sprain or strain. Many never went to a hospital. Yet the filing alleges that nearly every one of them was prescribed an almost identical set of equipment: laser therapy devices billed at $3,750 or $3,756 each, and cold compression therapy systems at $3,100 each. All were billed under a catch-all code reserved for items not individually priced in the state’s fee schedule. The complaint says the prescriptions were not driven by medical need but by “predetermined fraudulent protocols” at several clinics across the Bronx, Brooklyn, and Yonkers. Different ages. Different accidents. Different physical conditions. Same equipment. ## **The prescription pipeline** The filing describes a pipeline in which unlicensed clinic operators – the complaint calls them “Clinic Controllers” – directed prescriptions to the supplier rather than handing them to patients. The complaint alleges this was deliberate: routing prescriptions through a legitimate retail channel would have invited questions about why so many patients were being prescribed the same expensive devices. Instead, the complaint says, prescriptions were generated on pre-printed template forms, many carrying photocopied physician signatures. GEICO includes side-by-side comparisons of signatures from multiple prescriptions in the filing, alleging they are identical copies. Some prescriptions were allegedly issued on dates the prescribing provider never treated the patient. Others were undated entirely. One clinic location alone, the complaint says, cycled through more than 110 different healthcare providers – a “revolving door” that the filing attributes to efforts to dodge insurer investigations rather than any genuine change in practice ownership. There were also significant gaps between when prescriptions were allegedly issued and when equipment showed up. The complaint cites one case where a laser device was prescribed in May 2024 and delivered more than three and a half months later. ## **The devices** The complaint takes aim at both types of equipment. The filing alleges the laser therapy devices are “not FDA cleared or approved” and notes that commercial insurer policy bulletins have described low-level light therapy as “experimental and investigational,” with “no legitimate body of evidence” supporting its use for back, neck, or shoulder pain. On the cold compression therapy systems, the complaint is more direct. The filing states the devices “essentially provide compression and cold therapy to a part of the patient’s body, which is not more effective than using a standard ice pack and bandage.” The complaint adds that cold therapy is generally most effective in the first few days after an acute injury – yet the devices were routinely prescribed weeks after the accidents. A $3,100 device that does the same job as an ice pack. That is the allegation. ## **The price gap** Beyond medical necessity, the complaint alleges the supplier deliberately inflated what it charged. Under New York’s no-fault rules, items not on the state fee schedule can only be reimbursed at the lower of 150% of what the supplier paid for them, or what they cost the general public. The filing alleges the supplier used cheap, low-quality equipment but billed as though it had purchased high-end devices – and never included purchase invoices with its claims, which the complaint says would have exposed the gap. GEICO brings six legal claims: it wants the court to declare the pending bills void, alleges two counts of federal racketeering (one for running the scheme, one for conspiracy), and adds common-law fraud, unjust enrichment, and aiding and abetting fraud against unnamed co-conspirators. The insurer is seeking a jury trial. The case maps a fraud pattern that no-fault claims teams and SIU investigators across the industry have been flagging for years: high-volume DME billing tied to clinic networks, cookie-cutter prescriptions, and catch-all billing codes used to inflate charges for low-cost equipment. The allegations in the complaint have not been tested in court, and no judge has ruled on the merits. **Topics:** Healthcare Fraud, Judicial/courts --- ### [Minnesota Woman Convicted in $3.6M Scheme to Defraud Medicaid Housing Services Program](https://insurancefraud.org/news_archives/minnesota-woman-convicted-in-3-6m-scheme-to-defraud-medicaid-housing-services-program/) **Published:** October 10, 2026 **Author:** Diane Beauchamp **Content:** A federal jury in St. Paul convicted a Minnesota woman yesterday for executing a scheme to steal $3.6 million from the now-defunct Minnesota Medicaid Housing Stabilization Services (HSS) Program. “The Fraud Division has arrived in Minnesota — and we are here to stay,” said Assistant Attorney General Colin M. McDonald of the Justice Department’s National Fraud Enforcement Division. “The jury’s guilty verdict in this case sends a clear message that those who steal from programs meant to help our most vulnerable will be held accountable. As proven at trial, Meadows falsified records to enrich herself while preventing critical services from reaching those in need. Her fraud scheme — and others like it — forced Minnesota’s Housing Stabilization Services Program to shut down entirely after costs of the program outran estimates by four thousand percent. I commend the dedicated prosecutors, agents, and support staff who worked tirelessly to deliver justice in this case.” “The defendant chose to defraud millions from a program meant to help vulnerable Minnesotans,” said U.S. Attorney Daniel N. Rosen for the District of Minnesota. “My office is committed to prosecuting those who steal from the American taxpayer.” According to court documents and evidence presented at trial, Sharmaine Meadows, 45, of Lake Elmo, Minnesota, orchestrated a scheme to bill the HSS Program for housing services that were meant to transition the unhoused and assist them in sustaining that housing. Instead, these services were not actually provided. The HSS Program permitted providers to bill up to 150 hours for transitional services and 150 hours for sustaining services per eligible Medicaid beneficiary. Meadows routinely emphasized to her employees that they were required to maximize the billings to that 150-hour cap, even if the hours of services were never provided. ![Agenda from Meadows’ company staff meeting in July 2022 at which “Maximizing of Hours” was discussed](https://www.justice.gov/sites/default/files/styles/banner/public/2026-10/pic_1_for_pp_0.png?itok=yy0RxgkB)*Agenda from Meadows’ company staff meeting in July 2022 at which “Maximizing of Hours” was discussed* The evidence presented at trial also proved that Meadows and her company billed the HSS Program for in-person hours supposedly provided by employees who were in other states, like Illinois, and in other countries, like the Philippines, where the defendant paid only $6.00 per hour and explicitly offered no benefits. ![Employment Offer Letter from Meadows’ Company to Individual in the Philippines ](https://www.justice.gov/sites/default/files/styles/banner/public/2026-10/pic_for_pp_2.png?itok=y9I7iX6-)*Employment Offer Letter from Meadows’ Company to Individual in the Philippines* She also submitted claims for services that could not have been provided because beneficiaries were in the hospital. And through data analysis, evidence showed that Meadows billed as if her employees were working more than 20 hours per day, every day, for weeks. ![Summary of billing for “Impossible Days” by Meadows’ company](https://www.justice.gov/sites/default/files/styles/banner/public/2026-10/picture13.png?itok=gGYGy1Bf "Summary of billing for “Impossible Days” by Meadows’ company")*Summary of billing for “Impossible Days” by Meadows’ company* ![Summaries of billing for “Impossible Days” by Meadows’ company](https://www.justice.gov/sites/default/files/styles/banner/public/2026-10/screenshot_2026-10-08_134934.png?itok=tj6d6jF-)*Summaries of billing for “Impossible Days” by Meadows’ company* At the same time, Medicaid beneficiaries testified that they received little to no services from Meadows’ company. These beneficiaries testified that they were routinely told by Meadows’ employees that despite having received no assistance, they had run out of available hours in the HSS Program. As a result of the fraud scheme, the HSS Program paid Meadows’ company over $3.6 million between 2020 and 2025 into accounts that Meadows exclusively controlled. The jury convicted Meadows of three counts of health care fraud. She is scheduled to be sentenced at a later date and faces a maximum penalty of 10 years in prison on each count. A federal district court judge will determine any sentence after considering the U.S. Sentencing Guidelines and other statutory factors. Assistant Attorney General Colin M. McDonald of the Justice Department’s Fraud Division; U.S. Attorney Daniel N. Rosen for the District of Minnesota; Special Agent in Charge Christopher D. Dotson of the FBI Minneapolis Field Office; Special Agent in Charge Thomas Ethridge of the Department of Health and Human Services, Office of Inspector General (HHS-OIG); and Special Agent in Charge Adam Jobes of the IRS Criminal Investigation (IRS-CI), Chicago Field Office, made the announcement FBI, HHS-OIG, and IRS-CI investigated the case. Trial Attorneys Brant Cook and Emily Reeder-Ricchetti of the Fraud Division’s Health Care Fraud Section, with the assistance of Health Care Fraud Section Trial Attorney Jody King and Assistant U.S. Attorney Matthew Murphy for the District of Minnesota, are prosecuting the case. On April 7, the Department of Justice announced the creation of the Fraud Division. The Fraud Division is laser-focused on investigating and prosecuting those who commit fraud against the American people. The Department’s work to combat fraud supports President Trump’s Task Force to Eliminate Fraud, a whole-of-government effort chaired by Vice President J.D. Vance to eliminate fraud, waste, and abuse within Federal benefit programs. The Department of Justice’s Health Care Fraud Strike Force Program, currently comprised of nine strike forces operating in federal districts across the country, has charged more than 6,200 defendants who collectively billed federal health care programs and private insurers more than $45 billion since 2007. In addition, the Centers for Medicare & Medicaid Services, working in conjunction with the Office of the Inspector General for the Department of Health and Human Services, are taking steps to hold providers accountable for their involvement in health care fraud schemes. More information can be found at [www.justice.gov/criminal-fraud/health-care-fraud-unit](http://www.justice.gov/criminal-fraud/health-care-fraud-unit). **Topics:** Medicare/Medicaid **Categories:** Conviction --- ### [Salt Lake City woman charged with 7 felonies, accused of insurance fraud](https://insurancefraud.org/news_archives/salt-lake-city-woman-charged-with-7-felonies-accused-of-insurance-fraud/) **Published:** October 10, 2026 **Author:** Diane Beauchamp **Content:** A woman has been charged with insurance fraud after her company allegedly failed to pay off multiple clients’ mortgages after they sold their homes. Kimberly Mosby, 54, was charged with pattern of unlawful activity, four counts of unlawful dealing of property by a fiduciary worth more than $5,000, and two counts of insurance fraud. All of these are felony charges. According to the charging document, in 2011, Mosby obtained a license for Gateway Title Company from the Utah Insurance Department. She began operating as a fiduciary and opened a bank account at First Utah Bank, which was Gateway Title Company’s primary bank account for almost 15 years. The investigation into Mosby began in April 2025 when the Utah Insurance Department received a complaint. The complaint alleged that Mosby took $81,720.53 into escrow for a construction site bond, and that once the project was completed, she failed to return the remaining $6,822.32 in funds, which she was obligated to do. The charging documents detail several more alleged incidents from 2024 and 2025. In one incident, a man sold his home in Provo in Oct. 2024, and the escrow funding was handled by Gateway, but Gateway allegedly failed to satisfy the $325,000 mortgage. First American Title Company was forced to step in and pay off the mortgage per his title insurance policy. In another incident, a woman bought a home in Midvale in November 2024, and in October 2025, she saw a foreclosure notice for her condo posted in the complex. Allegedly, Gateway failed to pay off the previous homeowner’s mortgage. Luckily for the homeowner, the issue was resolved through her title insurance, but First American had to pay off the seller’s $345,000 mortgage. Investigators spoke with an employee at First American, who reportedly confirmed that both cases resulted in First American paying off the remaining balances on those mortgages, paying nearly $700,000 because Gateway failed to forward the funds it held in trust to the mortgage companies. Another First American employee told investigators that they no longer do business with Gateway because the company failed to pay the premiums for previously issued title insurance policies. Then, in February 2025, Mosby allegedly visited a First Utah Bank branch and obtained a cashier’s check for more than $37,000, which effectively emptied Gateway’s fiduciary account, all while others were waiting on payment from Gateway. Mosby was not arrested, but a summons was proposed for future court dates. **Topics:** Financial Fraud, Insider Fraud, Title Insurance --- ### [Owings Mills insurance agent pleads guilty to stealing over $100,000 in commissions](https://insurancefraud.org/news_archives/owings-mills-insurance-agent-pleads-guilty-to-stealing-over-100000-in-commissions/) **Published:** October 10, 2026 **Author:** Diane Beauchamp **Content:** An Owings Mills insurance agent pleaded guilty to stealing more than $100,000 in life insurance commissions, according to the Maryland Attorney General’s Office. On October 2, Baltimore County insurance agent Gregory A. Maslow, 72, pleaded guilty to a four-year scheme to steal more than $100,000 in life insurance commissions from policy sales. Authorities reported that Maslow carried out the scheme from May 2015 through May 2019, defrauding insurance companies of commissions by using the identities of other agents and customers. After various insurance companies terminated Maslow’s agency contracts, he submitted more than 75 life insurance applications, falsely claiming other licensed insurance agents had solicited, sold, and submitted them, officials said. These applications were for life insurance policies for Maslow’s friends, family members, and even Maslow himself, officials wrote. Maslow convinced these individuals to apply for life insurance by offering to pay all or part of their premiums, but he did not intend to pay them for long. In some cases, officials said he submitted applications without the applicants’ knowledge or permission. Officials reported that he also impersonated the agents and applicants in phone calls to the insurance companies. Once applications were approved, insurance companies paid significant upfront commissions designated for the agent that Maslow named on the application. Maslow then sent those commissions to joint accounts that he set up. Once the commissions were deposited into the joint accounts, Maslow transferred the funds to another account he controlled. After receiving the commissions, officials said Maslow stopped paying the premiums, causing the policies to lapse due to nonpayment. Maslow is scheduled to be sentenced on November 23, 2026. Officials said the binding plea agreement will sentence Maslow to 30 days in prison and, upon his release, five years of supervised probation. Maslow must also pay restitution and consent to the revocation of his insurance producer’s license, officials said. **Topics:** Insider - agent, Life Insurance **Categories:** Conviction --- ### [Five sentenced in Mississippi Medicaid, wire fraud cases](https://insurancefraud.org/news_archives/five-sentenced-in-mississippi-medicaid-wire-fraud-cases/) **Published:** October 10, 2026 **Author:** Diane Beauchamp **Content:** Five people convicted of Medicaid and wire fraud have been sentenced in Mississippi, Attorney General Lynn Fitch announced. The cases involved more than $120,000 in fraud, according to Fitch’s office. Since taking office, Fitch said her office has secured 65 criminal convictions and 62 civil settlements related to fraud, recovering more than $105 million for Mississippi taxpayers. “These convictions serve as a reminder that here in Mississippi, we are taking fraudsters head-on,” Fitch said. “The strong partnership between our Medicaid Fraud Control Unit and Mississippi’s Division of Medicaid stops you from being fleeced and ensures the money for this program gets to those it was meant to help.” The individuals were sentenced for fraudulent billing, wire fraud, and/or submitting false documentation to defraud the government: Ahyana Nicole Crosby, 34, of Laurel — sentenced Oct. 2 by Madison County Circuit Court Judge Dewey K. Arthur. Angela Nannette Crosby, 51, of Laurel — sentenced Oct. 2 by Judge Arthur. Taylor Christian Rushing, 34, of Gautier — sentenced Sept. 28 by Madison County Circuit Court Judge M. Bradley Mills. Yolanda Evette Blackman, 54, of Hattiesburg — sentenced Oct. 2 by Judge Arthur. Linda Jenkins, 46, of Hermanville — sentenced Sept. 14 by Hinds County Circuit Court Judge Damon R. Stevenson. The cases were part of Fitch’s work during the U.S. Department of Justice’s NationCrosbyal Health Care Fraud Takedown this summer. The nationwide operation resulted in criminal charges against 455 defendants in 45 states and territories for alleged health care fraud schemes involving more than $6.5 billion in intended losses. Fitch announced 11 indictments tied to the takedown, involving more than $12.3 million. Anyone who suspects Medicaid fraud can file a complaint with the Mississippi Attorney General’s Office Medicaid Fraud Control Unit. **Topics:** Medicare/Medicaid **Categories:** Conviction --- ### [New York Health Care Provider Sentenced to 32 Months in Prison for Role in $11 Million Health Care Fraud Scheme Targeting Amtrak, Drug Distribution, and Unlawful Possession of Firearm](https://insurancefraud.org/news_archives/new-york-health-care-provider-sentenced-to-32-months-in-prison-for-role-in-11-million-health-care-fraud-scheme-targeting-amtrak-drug-distribution-and-unlawful-possession-of-firearm/) **Published:** October 10, 2026 **Author:** Diane Beauchamp **Content:** A podiatrist formerly based in New York was sentenced today for his role in a health care fraud scheme targeting Amtrak’s health care plan, as well as for unlawful distribution of opioids and unlawful possession of a firearm, U.S. Attorney Robert Frazer announced. Michael DeNicola, 64, pleaded guilty on June 29, 2022, before U.S. District Judge Madeline Cox Arleo in Newark federal court to conspiracy to commit health care fraud, unlawful distribution of controlled substances, and unlawful possession of a firearm. DeNicola was sentenced today to 32 months’ imprisonment, three years’ supervised release, and ordered to pay over $1.6 million in restitution and over $1.3 million in forfeiture. According to documents filed in this case and statements made in court: From 2019 to August 2021, DeNicola and his conspirators agreed to engage in a scheme to bill the Amtrak health care plan for fraudulent claims for services that either were never provided or were medically unnecessary. They would recruit Amtrak employees to participate in the scheme by paying them to allow the conspirators to use their patient and insurance information to submit false and fraudulent claims. DeNicola and his conspirators submitted false and fraudulent claims that caused Amtrak losses of more than $1.6 million. DeNicola also provided oxycodone prescriptions to an individual in return for the individual’s agreement to allow his patient and insurance information to be used for the submission of fraudulent insurance claims. DeNicola provided oxycodone prescription to others at the direction of this individual and did so outside of the usual course of professional treatment and without legitimate medical purpose. From April 2017 through February 2018, DeNicola issued 64 oxycodone prescriptions in this manner. DeNicola also unlawfully possessed a firearm on Sept. 1, 2019, after previously having been convicted in a court of a crime punishable by a term of imprisonment exceeding one year. The overall scheme targeting the Amtrak health care plan involved dozens of Amtrak employees and multiple health care providers, who paid hundreds of thousands of dollars in cash kickbacks to Amtrak employees over the course of the scheme. In total, the Amtrak health care plan paid over $11 million in fraudulent claims associated with providers connected to the scheme. The Amtrak health care plan paid out over $1.6 million for claims associated with DeNicola. The investigation has resulted in the prosecution of nineteen individuals, including DeNicola. All have pleaded guilty to conspiracy to commit health care fraud. U.S. Attorney Frazer credited special agents of the Amtrak Office of Inspector General, under the direction of Special Agent in Charge James Harper, the Amtrak Police Department, under the direction of Chief of Police James Cook, and special agents of the Drug Enforcement Administration, under the direction of Special Agent in Charge Frank A. Tarentino III in New York, with the investigation. The government is represented by Assistant U.S. Attorney Katherine M. Romano, Deputy Chief of the Bank Integrity, Money Laundering, and Recovery Unit in Newark. On April 7, the Department of Justice announced the creation of the National Fraud Enforcement Division (Fraud Division). The Fraud Division is investigating and prosecuting those who commit fraud against the American people. The Department’s work to combat fraud supports President Trump’s Task Force to Eliminate Fraud, a whole-of-government effort chaired by Vice President J.D. Vance to eliminate fraud, waste, and abuse within Federal benefit programs. **Topics:** Drug Diversion **Categories:** Conviction --- ### [Heal 360 Clinics and Owner Agree to Pay $20M to Resolve False Claims Act Allegations of Billing False Claims to the COVID-19 Uninsured Program for Services Not Rendered](https://insurancefraud.org/news_archives/heal-360-clinics-and-owner-agree-to-pay-20m-to-resolve-false-claims-act-allegations-of-billing-false-claims-to-the-covid-19-uninsured-program-for-services-not-rendered/) **Published:** October 10, 2026 **Author:** Diane Beauchamp **Content:** Heal 360 Urgent Care PLLC, Heal 360 Primary Care PLLC (together “Heal 360”) and their owner, Dr. Mohammed Amer Mohiuddin (Mohiuddin), have agreed to pay the United States $20 million to resolve False Claims Act allegations that they knowingly submitted or caused the submission of false claims to the Health Resources & Services Administration COVID-19 Claims Reimbursement to Health Care Providers and Facilities for Testing, Treatment, and Vaccine Administration for the Uninsured Program (the “Uninsured Program”) for evaluation and management services that were not performed. “The Department is committed to rooting out fraud by healthcare providers who bill for services they did not provide,” said Assistant Attorney General Brett A. Shumate of the Justice Department’s Civil Division. “Today’s settlement demonstrates that we will hold accountable those providers who exploit federal healthcare programs for their own financial gain.” “We are dedicated to protecting healthcare resources from fraud,” said U.S. Attorney Jay R. Combs for the Eastern District of Texas. “When medical providers bill federal healthcare payers for unnecessary or unprovided services to increase revenue, we will use every possible tool to hold medical providers accountable and recover those funds. This case emphasizes our District’s commitment to justice by pursuing anyone who attempts to steal through misrepresentations.” “This settlement is a great example of this Administration’s commitment to using all available tools at its disposal to combat waste, fraud, and abuse in federal healthcare programs,” said U.S. Attorney Ryan Raybould for the Northern District of Texas. “Through the combined efforts of civil fraud and asset forfeiture prosecutors from my office, civil fraud prosecutors in the Eastern District of Texas and at Main Justice, and outstanding investigative work by our agency partners at the HHS Office of Inspector General, we were able to secure this substantial recovery for the benefit of the American taxpayer. The message should be crystal clear to anyone seeking to defraud federal healthcare programs — we will find you, we will find the money and assets, and we will do everything within our power to hold you accountable.” “Ensuring federal funds dedicated to public health emergency response are used appropriately is a core oversight priority for HHS‑OIG,” said Acting Deputy Inspector General for Investigations Miranda L. Bennett of the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG). “Billing for services that were never provided undermines trust in the health care system and diverts resources from patients who need them. HHS‑OIG will continue working alongside law‑enforcement partners to hold anyone who attempts to exploit federal healthcare programs accountable.” Between approximately May 2020 and April 2022, the Uninsured Program reimbursed eligible providers for COVID-19 tests, testing-related items and services, treatment, and vaccines performed on uninsured individuals. Mohiuddin is a physician who owns the Heal 360 entities, which are medical clinics in Plano, Texas. During the COVID-19 Public Health Emergency (PHE), Heal 360 provided healthcare services, including specimen collection for COVID-19 tests. The settlement announced today resolves allegations that from Jan. 1, 2021 through March 23, 2022, Heal 360 and Mohiuddin knowingly submitted or caused the submission of false claims to the Uninsured Program by billing evaluation and management services (E/M Services) that were not performed. As alleged by United States, claims for E/M Services, sometimes referred to as “office visits,” are submitted under Current Procedural Terminology (CPT) Codes, and vary in level of complexity. Higher level codes reflect increased complexity, such as a higher level of decision-making, more detailed history, or longer duration of time. During the COVID Public Health Emergency (PHE), CMS approved the use of CPT Code 99211 for COVID-19 test specimen collection. Physicians and non-physician practitioners, such as nurse practitioners (NPs) were required to use CPT Code 99211 to bill for COVID-19 specimen collection billed by clinical staff incident to their services. By contrast, Levels 3 and 4 E/M Services (i.e. CPT Codes 99203 and 99204 for new patients, and 99213 and 99214 for established patients) are codes for higher level E/M services (the “Higher Level E/M Services”) that could not be used for mere specimen collection. The United States contends that during the PHE, under Mohiuddin’s oversight and direction, the Heal 360 entities operated and provided services at dozens of COVID-19 testing sites in Texas, the vast majority of which were walk up or drive through testing sites (the “COVID test sites”). Patients could register online or at the site to receive a COVID-19 test, and at the COVID test sites, patients remained in their vehicles while Heal 360 staff checked them in and performed specimen collection services through nasal swabs for COVID-19 tests. No other medical treatment was rendered. The United States alleges that Heal 360 and Mohiuddin knew that the appropriate CPT Codes for the services provided at the COVID test sites were specimen collection codes, but nevertheless submitted claims under CPT Codes for Higher Level E/M Services that were reimbursed at substantially higher rates than reimbursements for specimen collection. In order to create the appearance that Higher Level E/M Services were being performed, Heal 360 and Mohiuddin created fictitious, template-generated medical records to correspond to the dates of service for testing that made it appear as if E/M services occurred, for example by including sections for “past medical history” and “examination.” The charts were generated by remote scribes located overseas who input information collected at the COVID test sites into the records. Although Mohiuddin did not visit or treat patients at the COVID tests sites, he was listed on the majority of the claims as the rendering physician. Heal 360 and Mohiuddin submitted hundreds of thousands of claims by the Heal 360 entities to the Uninsured Program for Higher Level E/M Services, and as a result received payment to which they were not entitled. The civil settlement resolves two cases pending in the Eastern District of Texas and Northern District of Texas filed under the qui tam or whistleblower provisions of the False Claims Act, which permit private parties to file an action for false claims on behalf of the United States and share any recovery. The qui tam cases are captioned U.S. ex rel. Hooper at al. v. Heal 360 Primary Care, PLLC et al., Case No. 4:21-cv-00569 (E.D. Tex.) and U.S. ex rel. Hasan v. Heal 360 Urgent Care, PLLC et al., Case No. 3:22-cv-1333-E (N.D. Tex.). Relators will receive $3,400,000 of the proceeds from the settlement. In addition, the government and Mohiuddin have reached an agreement to resolve a related asset forfeiture proceeding initiated in the Northern District of Texas against certain real properties purchased by Mohiuddin, with proceeds from the sales of those properties being credited to the civil settlement. The asset forfeiture proceeding is captioned United States v. Real Property Known as 3300 State Highway 78, Garland, TX et al., No. 3:23-cv-2784-X. The resolution obtained in this matter was the result of a coordinated effort between the Justice Department’s Civil Division, Commercial Litigation Branch, Fraud Section, the U.S. Attorney’s Offices for the Eastern District of Texas and Northern District of Texas, with substantial assistance from HHS-OIG. This matter was handled by Civil Division Fraud Section Trial Attorney Elizabeth J. Kappakas and by Assistant U.S. Attorneys James Gillingham and Kevin McClendon for the Eastern District of Texas, Brian Stoltz and Najib Gazi for the Northern District of Texas, and John Penn for the forfeiture proceeding in the Northern District of Texas. This year the Administration launched the Task Force to Eliminate Fraud and the National Fraud Enforcement Division to enhance the Administration’s war on fraud, waste, and abuse in federal programs. When unscrupulous actors exploit these programs for their own financial gain, they defraud the government, harm the people these programs are designed to aid and protect, and undermine American businesses that play by the rules. The Civil Division’s FCA enforcement plays a critical role in combatting such fraudulent schemes, recovering billions of dollars for the American taxpayers, and holding wrongdoers accountable. FCA matters will continue to be on the forefront of the battle against fraud, and the Civil Division’s FCA work will support and advance the mission of the Task Force to Eliminate Fraud and the National Fraud Enforcement Division. **Topics:** COVID-19, Judicial/courts --- ### [East Hartford woman charged with double-dipping from Medicaid caregiver programs](https://insurancefraud.org/news_archives/east-hartford-woman-charged-with-double-dipping-from-medicaid-caregiver-programs/) **Published:** October 10, 2026 **Author:** Diane Beauchamp **Content:** An East Hartford woman is accused of double-dipping into state Medicaid programs. Carmen Rivera-Rivera, 52, was arrested last week by inspectors from the Medicaid Fraud Control Unit of the Office of the Chief State’s Attorney and charged with health insurance fraud and first-degree larceny by defrauding a public community. The Personal Care Assistant Waiver (PCA) program and Adult Family Living Waiver (AFL) program are Medicaid-funded programs meant to help people with severe disabilities stay in their homes. Duties include preparing meals, helping with personal hygiene and doing household chores. On May 20, the fraud control unit received a complaint that Rivera-Rivera, an employee of the AFL program, had enrolled in the PCA program and was being paid by both programs for providing services to the same person, an arrest warrant says. Rivera-Rivera initially told investigators she did not know she was being paid by both programs, the warrant says. Investigators, however, found that she transferred funds between two checking accounts, indicating she was aware of the prohibited double-dipping, the warrant says. **Topics:** Medicare/Medicaid **Categories:** Arrest --- ### [Texas Insurance Broker Gets 160 Months for Fraud — Now the Feds Will Sell the 90-Plus Exotic Cars He Agreed To Forfeit](https://insurancefraud.org/news_archives/texas-insurance-broker-gets-160-months-for-fraud-now-the-feds-will-sell-the-90-plus-exotic-cars-he-agreed-to-forfeit/) **Published:** October 10, 2026 **Author:** Diane Beauchamp **Content:** Clayton Iley, a 41-year-old businessman from Stephenville, Texas, was sentenced Oct. 1 to 160 months in federal prison for wire fraud and aggravated identity theft, and the vehicles he agreed to forfeit number more than 90. The U.S. Attorney’s Office for the Northern District of Texas said in an Oct. 2 release that U.S. District Judge Mark Pittman imposed the sentence after Iley pleaded guilty June 17. According to the release, which cites court records, Iley ran an insurance brokerage, Clayton Texas Legacy Insurance Group, LLC, from Cross Plains, Texas, selling home, auto, life, health, farm and ranch, and commercial policies. From January 2020 through May 2026 he also used two other companies he controlled, Texas Legacy Holdings and Enterprises, LLC and Spartan Global Security, LLC, which did business as “Black Eagle PMC,” to move money. Prosecutors described three methods. Iley told victims he could invest their money in a “Bonded Note” loan program run by the U.S. Department of Defense for private military contractors; the release says the program did not exist and that he knew it did not, and that he collected more than $2 million on the claim. He took premium payments from insurance clients, did not open the policies they asked for, and spent the money on himself and on the scheme. And he gave clients’ personal information to financial institutions to get credit cards in their names without their knowledge, then used those cards to deposit money into Spartan Global’s bank accounts, reported the transactions as business receipts, and paid personal expenses and for exotic collector vehicles. Why the identity theft count adds time by law Federal law sets a fixed price on the identity theft count. Under 18 U.S.C. § 1028A, a person convicted of aggravated identity theft receives two years on top of the sentence for the underlying felony, cannot be placed on probation for it, and generally cannot serve it at the same time as another prison term. Wire fraud under 18 U.S.C. § 1343 carries up to 20 years per count. The release does not say how many counts Iley pleaded to or how Pittman divided the 160 months, which works out to 13 years and 4 months. The statute does mean at least 24 of those months were stacked on the fraud sentence by requirement, not by the judge’s choice. Seventeen cars named, more than 90 agreed Under his plea agreement, Iley agreed to forfeit more than 90 exotic collector vehicles that the release says were obtained with funds from the scheme. So far, the release says, investigators have seized 17 and obtained a preliminary forfeiture order on them: three 2022 Maserati MC20s, a 2016 and a 2018 Ferrari 488, four Lamborghini entries (a 2012 “Model Ave,” a 2012 Aventador, and a 2015 Huracan listed twice), a 2021 Porsche Taycan, a 2014 Dodge SRT Viper, a 2013 Toyota Tundra, a 2023 Jeep Gladiator, a 1968 Pontiac, and three entries written as a 1989 “AM G M99,” a 1990 BMY M923A and a 1993 AM General. That is fewer than one in five of the 90-plus. The release says those vehicles will be sold to fund restitution owed to victims. It gives no restitution total, no number of victims, and no sale date, and it carries no response from Iley or his attorney. A preliminary order is not a sale Under Federal Rule of Criminal Procedure 32.2, a preliminary forfeiture order names specific property and is entered without regard to any third party’s interest in it. It becomes final as to the defendant at sentencing, which was Oct. 1. Anyone else who claims an interest in a car can file a petition in a separate ancillary proceeding, and the order stays preliminary as to those people until that proceeding ends. The release does not say whether any of the 17 vehicles carries a lien or a competing claim. It also does not say who will run the sales. The U.S. Marshals Service, which manages many federal forfeitures, says on its asset forfeiture page that proceeds from asset sales go to operating the program, compensating victims and supporting law enforcement efforts. Whether that applies here is not stated, and the split between those uses decides how much of the sale money reaches the people whose names were on the credit cards. Garages as restitution funds Prosecutors turning a defendant’s garage into a victims’ fund has shown up in other cases The Auto Wire has covered, including an Atlanta woman’s $10 million Amazon fraud case that ended with a Lamborghini, a Tesla, a Porsche and a Dodge Durango seized, and a $245 million crypto theft that paid for 28 supercars. In the Iley case the order of events is the reverse of what the sentence suggests: the 160 months ended the criminal case on Oct. 1, while the repayment still depends on a sale schedule and a restitution figure that have not been made public. A final restitution number and the Marshals’ or the court’s sale notices are the next things to watch for. If a fraud defendant forfeits a garage full of exotic cars, should the government sell them quickly, even at a discount, or hold out for top collector prices to get victims more money? **Topics:** Financial Fraud, Insider - insurer, Synthetic Identity Theft **Categories:** Conviction --- ### [Psychologist loses bid to end probation after comp fraud conviction](https://insurancefraud.org/news_archives/psychologist-loses-bid-to-end-probation-after-comp-fraud-conviction/) **Published:** October 10, 2026 **Author:** Diane Beauchamp **Content:** A California appeals court on Tuesday upheld the denial of a psychologist’s request to end her licensing probation early, finding she had not demonstrated rehabilitation after a workers compensation fraud conviction. Morella Bombardini pleaded no contest in 2018 to misdemeanor workers comp fraud involving a claim connected to her work as a psychologist. She was ordered to perform community service and pay more than $11,000 in restitution to her employer, according to Morella Bombardini v. Board of Psychology, filed in California’s 3rd District Court of Appeal. Although the conviction was dismissed in 2019, it remained a basis for licensing discipline. The Board of Psychology revoked her license in 2021, stayed the revocation and imposed five years of probation. Conditions included practice and billing monitoring, an ethics examination, coursework and quarterly reports. Ms. Bombardini sought early termination in 2023. She maintained that she had carpal tunnel syndrome, never intended to commit fraud and pleaded no contest on her attorneys’ advice without fully understanding the consequences. She also cited her payment of investigative costs, required reports, and absence of further misconduct. The board denied the request, finding she continued to minimize her conduct and portray herself as unfairly punished. They paused her probation because she moved out of California and did not resume practicing after returning, leaving key practice-related conditions unfulfilled. The appeals court found sufficient evidence to support the board’s decision. It said acknowledging wrongdoing and accepting responsibility were central to rehabilitation, and that compliance with reporting and payment requirements did not establish those qualities. The court also found her challenge to the original 2021 discipline untimely. It affirmed the judgment rejecting her challenge to the board’s decisions. **Topics:** Workers Comp **Categories:** Conviction --- ### [5 fires ignite at Carolina woman’s home in 11 years](https://insurancefraud.org/news_archives/5-fires-ignite-at-carolina-womans-home-in-11-years-2/) **Published:** September 24, 2020 **Author:** Coalition Against Insurance Fraud **Content:** A woman accused of setting fires at both her own home and her parents’ home had five fires at her house in the Grace Chapel area in less than 11 years, the Caldwell County Fire Marshal’s Office said. Grecia Leann Barlowe, 48, was indicted Monday on charges stemming from two fires — one at her own home and another at her parents’ home — but the State Bureau of Investigation has been investigating fires at her home since late 2007, when there were three fires during a span of about two weeks, Fire Marshal Kevin Brown said. According to reports from firefighters and the fire marshal’s office, the first fire at 5025 Grace Chapel Road was on Nov. 26, 2007, when someone left the oven on and a fire started on top of the range. The flames damaged the stove, the counter top and the splash guard behind the stove, according to the report. Tat fire was believed to have been an accident, the report said. The second fire started in a dryer less than a week later, on Dec. 2, 2007, according to a report. Firefighters said that the fire was in and around the dryer, and they did not determine a cause. The third fire was on Dec. 10, 2007, when the house burned to the ground shortly after 6 a.m., leaving behind only the basement walls, Brown said. It then that county officials called the State Bureau of Investigation, and investigators now think that the fire was intentionally set, but charges have not been filed, he said. “We know it’s a set fire. We just don’t know who, so we’re still waiting for leads to come in,” he said. The house was later rebuilt. There were no other fires at 5025 Grace Chapel Road until Sept. 26, 2012, when there was a fire in the garage and the basement about 1:30 a.m., according to a report. Brown said that the flames appeared to have been ignited in three places — one in the basement and two in the garage — and vehicles at the home had been vandalized. He thinks that fire also was intentionally set. The final fire at 5025 Grace Chapel Road was on July 3, 2018, when fires ignited in a front bedroom, an adjacent bedroom and in the basement, Brown said. Barlowe was charged with second-degree arson and insurance fraud in that fire. The fire at her parents’ home on Log Cabin Place in eastern Caldwell County on May 23 was the sixth fire at a place where she was living. Both Barlowe and her parents, Gregory and Patricia Fox, were there. Barlowe was charged with first-degree arson and two counts of attempted murder in that fire. Gregory Fox told a reporter from WSOC-TV that he believes his daughter is innocent. “I just don’t believe she done it,” he said. “I don’t think she’s capable of that. We love our daughter, and we don’t think she done it.” Fox said that Barlowe was asleep inside the home when the fire started. **Topics:** Homeowners - arson **Categories:** Arrest --- ### [North Dakota cattle broker pleads guilty in $220 million Agridime fraud case](https://insurancefraud.org/news_archives/north-dakota-cattle-broker-pleads-guilty-in-220-million-agridime-fraud-case/) **Published:** October 7, 2026 **Author:** Diane Beauchamp **Content:** A North Dakota cattle broker has pleaded guilty to a federal charge tied to the collapse of Agridime, a cattle investment company that authorities determined operated as a Ponzi scheme and left investors and cattle producers owed hundreds of millions of dollars. Taylor Bang of Killdeer pleaded guilty last month to one count of conspiracy to commit wire fraud in U.S. District Court in Texas, according to court records. His sentencing is scheduled for Jan. 7. The charge carries a maximum penalty of five years in prison, along with potential fines and restitution. Following the plea, the North Dakota Department of Agriculture moved to stop Bang and Taylor Bang Cattle Sales LLC from conducting livestock dealer activities. Agriculture Commissioner Doug Goehring issued a cease-and-desist order that prohibits the business from buying or selling livestock and moves to revoke Bang’s livestock dealer license. A hearing on the state action is scheduled for Oct. 28 in Bismarck unless Bang waives it. Bang was one of five people charged earlier this year in connection with Agridime, a Texas-based company that marketed cattle investments to customers across several states. Agridime launched in 2017 and promoted a model in which investors could purchase cattle on paper, with the company handling feeding, finishing and eventual beef sales. Investors were told they could purchase a heifer or steer for $2,000 per head, while bred cows were offered for $4,500 plus feed costs. The company operated in Texas, Arizona, Kansas, North Dakota, and other states before federal authorities shut it down in December 2023. A federal judge determined in August 2024 that Agridime had operated as a Ponzi scheme by using money from new investors to make payments to earlier investors instead of paying returns from legitimate business profits. Court records alleged the company owed investors approximately $220 million when the operation collapsed. North Dakota was among the states hardest hit. The North Dakota Securities Department previously estimated that investors in the state were owed about $40 million when federal authorities took control of the business. Bang worked as a cattle broker for Agridime and purchased cattle in western North Dakota. State securities officials have said he earned approximately $6 million in commissions from the company, though Bang disputed that figure in a 2023 interview with the North Dakota Monitor, calling it “way high.” Federal prosecutors initially charged Bang in February with eight counts of wire fraud, one count of conspiracy to commit wire fraud and one count of money laundering. The indictment alleged that $240,000 was sent to an account controlled by Bang rather than an Agridime account in an effort to conceal the transaction. Prosecutors also alleged that Bang falsified dates on records and provided investors with false information about cattle identification tags. In a March court filing, Bang’s attorney argued that Bang had not knowingly participated in fraud or a Ponzi scheme. His guilty plea to the conspiracy charge now moves the federal case toward sentencing while North Dakota regulators pursue action against his livestock dealer license. **Topics:** Commercial Fraud, Financial Fraud **Categories:** Conviction --- ### [AIDS Healthcare Foundation Agrees to Pay $1.44M to Settle False Claims Act Allegations](https://insurancefraud.org/news_archives/aids-healthcare-foundation-agrees-to-pay-1-44m-to-settle-false-claims-act-allegations/) **Published:** October 7, 2026 **Author:** Diane Beauchamp **Content:** AIDS Healthcare Foundation, a non-profit organization based in Los Angeles, California, has [agreed](https://www.justice.gov/opa/media/1464401/dl) to pay $1.44 million to resolve allegations that it violated the False Claims Act by submitting or failing to delete false or invalid diagnosis codes in order to increase payments that it received from the Medicare Advantage program. “The government relies on Medicare Advantage participants to submit accurate, substantiated diagnosis codes that are adequately documented in a medical record to ensure proper payment,” said Assistant Attorney General Brett A. Shumate of the Justice Department’s Civil Division. “The Justice Department will continue to protect the public fisc and hold accountable those who receive inflated payments by knowingly providing or failing to correct false information.” “The integrity of our federal healthcare programs, including Medicare Advantage, must be preserved,” said First Assistant U.S. Attorney Bill Essayli for the Central District of California. “We will not tolerate companies undermining the interests of Medicare patients for financial gain.” “Medicare Advantage organizations have a responsibility to ensure the accuracy of diagnosis codes they submit for payment. When entities fail to correct information they know is wrong, they undermine the integrity of a program millions of seniors rely on,” said Acting Deputy Inspector General for Investigations Miranda L. Bennett of the U.S. Department of Health and Human Services Office of Inspector General (HHS‑OIG). “HHS‑OIG will continue to safeguard taxpayer funds by holding organizations accountable when their failures inflate federal payments and compromise program trust.” Under the Medicare Advantage (MA) Program, also known as Medicare Part C, Medicare beneficiaries may opt out of traditional Medicare and enroll in private health plans offered by insurance companies known as Medicare Advantage Organizations, or MAOs. The Centers for Medicare & Medicaid Services (CMS) pays the MAOs a fixed monthly amount for each Medicare beneficiary enrolled in their plans. CMS adjusts these monthly payments to account for various “risk” factors that affect expected health expenditures for the beneficiary. In general, CMS pays MAOs more for sicker beneficiaries expected to incur higher healthcare costs and less for healthier beneficiaries expected to incur lower costs. To calculate the payment amounts, CMS uses a health-based risk adjustment model — the Hierarchical Conditions Category (HCC) model — that takes into account diagnoses reported by healthcare providers. In general, the more severe the diagnosis or costly the associated treatment, the higher the risk score and the higher the corresponding payments to the MAO. Diagnosis codes submitted to CMS must be supported by the beneficiaries’ medical records and be accurate, complete, and truthful, based on the best knowledge, information, and belief of the MAO making the submission. AIDS Healthcare Foundation (AHF) provides care and services to HIV patients in the United States and other countries. AHF’s Managed Care Division (doing business as Positive Healthcare Partners) operated special needs MA plans for Medicare beneficiaries who have HIV and lived in Florida, Georgia, or California. The settlement announced today resolves allegations that, for payment years 2017 to 2023, AHF failed to timely investigate and delete diagnosis codes that were either inaccurate or not documented in medical records. Beginning in around 2017, AHF’s risk adjustment coders conducted chart reviews to identify inaccurate or unsupported diagnosis codes for deletion. As part of this process, AHF’s risk adjustment coders maintained “Delete Research” spreadsheets, which listed diagnosis codes they identified as potentially lacking support in the medical record but needing further research. Although AHF knew that it was required to investigate and delete inaccurate and unsupported diagnosis codes within 60 days, AHF failed to timely investigate and delete the codes. AHF did not delete most of the inaccurate or unsupported diagnosis codes in the “Delete Research” spreadsheets until 2024 or 2025 — well after AHF was on notice that the codes potentially lacked support and only after being notified of the United States’ investigation. The United States further alleges that, for payment year 2017, AHF knowingly submitted diagnosis codes for HIV (ICD-10 B20) where the diagnosis was not documented in any medical record for a face-to-face visit, in violation of CMS requirements that all diagnosis code submissions must be documented as a result of a face-to-face visit. The civil settlement resolves claims brought under the *qui tam* or whistleblower provisions of the False Claims Act by Donna Irons, a former risk adjustment coder at AHF. Under the *qui tam* provisions, a private party can file an action on behalf of the United States and receive a portion of any recovery. The *qui tam* case is captioned *United States ex rel. Irons v. AIDS Healthcare Foundation d/b/a Positive Healthcare Partners*, Civil Action No. 23-cv-2160 (C.D. Cal.). Ms. Irons will receive $259,200 as her share of the federal recovery. AHF received credit under the Department of Justice’s guidelines for taking disclosure, cooperation, and remediation into account in False Claims Act resolutions, Justice Manual § 4-4.112. In addition to cooperating in the government’s investigation and enhancing its compliance program, AHF proactively remediated its conduct during the course of Department’s investigation by submitting deletes for diagnosis codes that, based on review of medical records, were not supported. The resolution obtained in this matter was the result of a coordinated effort between the Justice Department’s Civil Division, Commercial Litigation Branch, Fraud Section and the U.S. Attorney’s Office for the Central District of California, with assistance from the Department of Health and Human Services, Office of Inspector General. The investigation and resolution of this matter illustrate the government’s emphasis on combating healthcare fraud. One of the most powerful tools in this effort is the False Claims Act. Tips and complaints from all sources about potential fraud, waste, abuse, and mismanagement, can be reported to the Department of Health and Human Services at 800-HHS-TIPS (800-447-8477). This year the Administration launched the Task Force to Eliminate Fraud and the National Fraud Enforcement Division to enhance the Administration’s war on fraud, waste, and abuse in federal programs. When unscrupulous actors exploit these programs for their own financial gain, they defraud the government, harm the people these programs are designed to aid and protect, and undermine American businesses that play by the rules. The Civil Division’s FCA enforcement plays a critical role in combatting such fraudulent schemes, recovering billions of dollars for the American taxpayers, and holding wrongdoers accountable. FCA matters will continue to be on the forefront of the battle against fraud, and the Civil Division’s FCA work will support and advance the mission of the Task Force to Eliminate Fraud and the National Fraud Enforcement Division. Trial Attorney Tiffany L. Ho of the Civil Division’s Commercial Litigation Branch, Fraud Section and Assistant U.S. Attorney S. Desmond Jui for the Central District of California handled this case. **Topics:** Judicial/courts, Medicare/Medicaid --- ### [DeSantis boasts about Medicaid fraud crackdown efforts](https://insurancefraud.org/news_archives/desantis-boasts-about-medicaid-fraud-crackdown-efforts/) **Published:** October 7, 2026 **Author:** Diane Beauchamp **Content:** Gov. Ron DeSantis appeared in West Palm Beach Tuesday to announce the fruits of the state’s Medicaid fraud and abuse crackdown efforts, including more than 150 referrals to the state’s attorney general’s Medicaid fraud unit to investigate and potentially prosecute. DeSantis said the state also has restricted or suspended payments to more than 260 providers suspected of Medicaid fraud and has, since the beginning of the year, terminated 220 providers from the state’s program. “These actions are focused on bad actors who exploit the program, not legitimate providers delivering necessary care to Floridians,” DeSantis said. He added that the data underscore “exactly why the heightened oversight is essential.” He said the referrals and suspensions were the first “salvo” and promised more to come. SentiLink is assisting the state with its fraud and abuse efforts, DeSantis [announced in June](https://ahca.myflorida.com/file/press_releases/6.12.26%20Medicaid%20Integrity%20Initiative.pdf), and is conducting a “large-scale identity intelligence analysis covering millions of individuals and entities enrolled in the Florida Medicaid program.” The goal of the contract, according to the [press release](https://resources.sentilink.com/media/sentilink-partners-with-floridas-agency-for-health-care-administration-to-combat-medicaid-fraud) announcing the agreement between the state and the company, is “to detect sophisticated fraud schemes — not just individual bad actors — including organized networks operating through concealed ownerships, fictitious entities, and compromised credentials.” The DeSantis administration announced enhanced Medicaid fraud and abuse efforts after the Centers for Medicare and Medicaid Services sent a letter to Florida ( as well as California, Maine, and New York) seeking information about Medicaid integrity and oversight — and after CMS Director Mehmet Oz said on social media that “Florida has been a hotspot for health care fraud for years.” The Florida Agency for Health Care Administration has conducted more than 400 onsite provider visits with the focus on those that provide people access to durable medical equipment, adult day care, and applied behavioral analysis, a therapy provided to children with autism and people with intellectual and developmental disabilities. “We’re knocking on more doors, conducting site visits. We’re not leaving if the provider does not produce the records requested,” AHCA Secretary Shevaun Harris said. “We’re not accepting, ‘I didn’t know the requirements,’ as an answer.” Harris said the agency has required Medicaid providers to verify their credentials and identities as part of its beefed-up fraud efforts. She acknowledged it can be bothersome but insisted it’s necessary. “These fraudsters have sophisticated schemes. It’s forcing us to be nimble and agile and to use every tool at our disposal to combat this issue,” she said. ## Structured interventions ABA represents structured interventions to decrease maladaptive behaviors and reinforce appropriate ones. It is common in treatment of children diagnosed with autism spectrum disorder and used for people with attention deficit hyperactivity disorder (ADHD), traumatic brain injuries, and intellectual and developmental disabilities. Shena Grantham, Florida’s deputy secretary for Medicaid policy and quality, said in August that about 60,000 low-income children in Florida receive ABA, although she didn’t cite the year. The protocol has been a focus of the state’s fraud and abuse efforts for years, and past efforts to better control costs and detect fraud included pilot programs and a moratorium on ABA provider enrollments. But costs kept increasing. Then Florida switched its ABA delivery model to require managed care plans to cover services for children. Previously, patients, once authorized, saw the Medicaid ABA provider of their choice and the state paid for the services. Since 2025, the care must be provided by the state-contracted plans and the ABA providers who want to continue working with their clients are having to negotiate contracts in their regions. Before the switch to managed care, economists predicted ABA services would reach $3.86 billion in state FY 26-27, the governor said. ABA expenditures are now projected to come in at $2.88 billion, he continued. Some ABA providers have been dropped from the managed care networks and others have chosen to stop treating Medicaid clients. Families and providers have been complaining about interruptions in ABA services since the transition to managed care. When asked about difficulties parents have been reporting in getting care for their children since then, DeSantis was stern. “You know, to the extent that those services get interrupted, that’s not AHCA’s fault. That’s the providers’ fault for what they’re doing and putting those families in that situation,” DeSantis said. “And, unfortunately, you know, we’ve seen that.” Harris said state contracted managed care plans “have staff on deck who are providing care coordination services, reaching out to these families, and helping them pick a new provider so there are no gaps or interruption in services.” Parents struggling to secure services for their children can contact AHCA. “We will help help them ourselves or connect them with with their managed care plan,” she said. The Florida Legislature this spring created a 10-member task force and directed it to review the delivery model “to improve care experience and service continuity for enrollees and families receiving ABA services, while safeguarding long term program sustainability.” The panel has met four times and is expected to hold an additional two meetings before finalizing its recommendations. **Topics:** Medicare/Medicaid, Regulatory actions --- ### [Missouri AG Secures $42K Judgment Against Contractor Accused of Fraud](https://insurancefraud.org/news_archives/missouri-ag-secures-42k-judgment-against-contractor-accused-of-fraud/) **Published:** October 7, 2026 **Author:** Diane Beauchamp **Content:** Missouri Attorney General Catherine Hanaway announced that her office secured a jury conviction against Daniel Eschliman for scamming an elderly couple out of more than $42,000. Eschliman allegedly stole from the victims over the course of six months. During those six months, Eschliman allegedly repeatedly promised the victims he would complete a home addition, all while spending the money on himself. On September 29, a Jackson County jury convicted Eschliman of Financial Exploitation of an Elderly Person, Stealing by Deceit, and Deceptive Business Practices. Upon finding Eschliman guilty, the jury recommended a sentence of ten years in prison. The case was investigated by the Attorney General’s Office’s Consumer Protection Section after the victims filed a complaint against Eschliman. Assistant Attorneys General Joe Bliss and Jared Johnstone successfully prosecuted the case. Eschliman is scheduled to be sentenced on December 8 in Jackson County. Eschliman was criminally charged in one other contractor fraud case and has been sued civilly numerous times. **Topics:** Contractor fraud, Elderly Fraud **Categories:** Conviction --- ### [ALTA CEO discusses fraud, AI and advocating for title insurance](https://insurancefraud.org/news_archives/alta-ceo-discusses-fraud-ai-and-advocating-for-title-insurance/) **Published:** October 7, 2026 **Author:** Diane Beauchamp **Content:** The title insurance industry finds itself in a pivotal moment. Businesses are tackling challenges such as reducing fraud, narrowing the requirements of the Financial Crimes Enforcement Network’s (FinCEN) residential rule and determining how artificial intelligence (AI) can best be used to enhance their operations. American Land Title Association (ALTA) CEO Chris Morton spoke with *The Title Report* about these topics and offered a preview of the upcoming ALTA ONE conference. **Elevating members’ work** Since being named ALTA’s CEO in June 2025, Morton said his main priority has been to elevate the work done by ALTA members and ensure both policymakers and consumers “understand the expertise that’s behind secure real estate transactions.” ALTA is also spreading the word that they support the use of technological innovation mainly as a complement to rather than as a replacement for the expertise and the judgment of the title professional. In the past 15 months, Morton said he is most proud of “making sure that our members and our industry has the strongest voice possible.” The organization has also worked to ensure that the people shaping policy decisions and discussion around housing affordability understand the work that ALTA’s “members do to protect property rights and keep transactions secure,” Morton said. **Focal points of advocacy** According to Morton, ALTA is primarily focused on three categories of advocacy: fraud, unregulated title alternatives and affordability. “On the fraud front, our focus has been on building awareness of the problem, ensuring that we’re sharing research and data around trends that we’re seeing … for our industry to understand what’s coming at them, and from a policy side, making sure that policymakers understand the critical role that we play in preventing and protecting against fraud,” Morton said. That data includes [ALTA’s recently released Seller Impersonation Fraud study](https://www.thetitlereport.com/articles/alta-ceo-details-efforts-to-combat-seller-imperson-98173.aspx), sponsored by CertifID, which found that 59 percent of firms reported at least one seller impersonation fraud attempt in the previous calendar year, more than double the 28 percent reported in ALTA’s 2024 survey. On unregulated title alternatives such as attorney opinion letters (AOLs), Morton emphasized the discussion centers on “risk and risk transfer to consumers, to lenders, to the housing finance marketplace.” In line with this thinking, ALTA is supportive of the Protecting America’s Property Rights Act legislation, which has been introduced in the U.S. House of Representatives with a few dozen bipartisan co-sponsors. A companion piece in the Senate is being worked on and Morton noted ALTA and other interested parties are looking for opportunities to attach that bill to a larger piece of legislation. “What (the Protecting America’s Property Rights Act) says is … if you propose a product in the marketplace that is purporting to cover the same risks and have the same coverages as title insurance, you should be subject to the same rules and regulations,” Morton explained. The legislation would require alternative products such as an AOL or government-sponsored enterprises (GSEs) such as Fannie Mae and Freddie Mac to follow the same state consumer protection laws that title insurers have to abide by. On the affordability issue, Morton said his organization spent a lot of time advocating for the passage and enactment of the [21st Century ROAD to Housing Act](https://www.thetitlereport.com/articles/21st-century-road-to-housing-act-becomes-law-witho-97661.aspx), which recently became law. ALTA representatives are now working with lawmakers and regulators to implement the provisions in the bill. Morton also discussed how fraud, unregulated title alternatives and affordability overlap in the broader industry landscape. “Part of our message around the affordability question has been that affordable housing discussions must take into account property rights, protection against fraud and sustainability, and that’s what we provide as an industry,” he said. “When you’re looking at things like waiving title insurance or introducing alternatives that are not as comprehensive and don’t cover fraud, you may purport to be able to save a few dollars at closing, but that can mean shifting a potentially six-figure risk to the homeowner, the lender or the housing finance system on the back end because you don’t have coverage. We’re trying to make sure lawmakers understand that when you remove those protections, you don’t eliminate risk; you just shift it somewhere else.” Morton noted the average fraud and forgery claim is more than $143,000, overall, and $207,000 on a refinancing transaction. “That’s a massive number for a homeowner to shoulder, or a lender (to shoulder). … People then are looking at losing their home, which is why I talk about sustainability,” he explained. “We’re trying to communicate what title does and what title professionals do to account for that risk.” He noted that ALTA leadership has had a number of discussions with the current presidential administration and federal regulators about fraud in the mortgage space. They’ve also submitted letters to legislative leaders informing them about the data they’ve gathered, the trends they’re seeing with regard to fraud and what they’re doing to attack the problem. Methods to attack the problem include spreading awareness and the 49 series endorsements, which Morton explained is “post-policy fraud coverage that we now have available in the marketplace post-closing for some of the issues that we’re seeing.” **Thoughts on AI in title industry** Morton said ALTA representatives have explained to policymakers that the title industry is using AI to improve its processes and workflows, as well as automation to handle redundant tasks. Using automation for those predictable, routine tasks will, Morton explained, “free up time for title professionals in their firms… to use their expertise and judgment on decision making. We don’t have AI making decisions in our (business). “AI can help in creating efficiencies and time and space so that title professionals can better use their higher level expertise and judgment on items that can’t be automated,” Morton stated. While noting ALTA has not taken a formal policy position on whether they would like to see more guardrails around the use of AI, Morton observed, “I think … it’s always important to have protections in place for things that could go wrong. … We always take that protection and guardrail conversation really seriously when it comes to property ownership. … It’s important for policymakers to look at these larger questions about risk and what the risk-reward tradeoff (is), and … I’m hopeful that that’s what is going to take place with this larger conversation about AI and technology.” **Narrowing FinCEN rule** Morton said ALTA supports the goal of the FinCEN residential real estate rule and the approach to stopping money laundering, but noted that title professionals and customers have raised a number of concerns. “We did a survey (when the rule was in effect) that showed there was significant burden on not only small title companies, but also confusion by consumers about why this information is necessary. They’re concerned about privacy and security, and ultimately, they feel reluctant to share the information,” Morton said. He noted ALTA filed an amicus brief in Fidelity National Financial’s fight against FinCEN’s residential real estate rule that discusses the findings of the survey and the challenges faced by title agencies, particularly smaller ones. “My concern is… even if this court case wins on the title side, that (FinCEN) comes back and does something broader and more intrusive,” Morton said. “We’re trying to use the time wisely to make (the rule) more tailored.” Morton emphasized that ALTA favors “substantially” narrowing the FinCEN rule so that title agencies are providing “the most relevant information” that FinCEN needs to achieve its goal “without burdening those (title) agencies from a cost perspective.” ALTA leaders also hope the rule is altered so that title agents don’t have to provide data that could be obtained from public sources or other private data sources, he explained. Morton also commented on how some of the information being sought through the FinCEN rule contradicts the title industry’s message to consumers to be cautious about releasing sensitive data. “For years we’ve been telling consumers to be mindful of the information they are putting in email. We’ve encouraged consumers to be suspicious and be careful, so it’s counterintuitive when we then ask them for their sensitive banking information. … On the one hand, we’re trying to do right by consumers. On the other hand, we’re being told by government agencies you’ve got to ask all these probing and deep questions,” he said. “And there’s not been a set of data or experiences that they’ve publicly shared where the data has actually worked to go after bad actors.” **Preview of ALTA ONE** Morton also shared a preview of the annual ALTA ONE conference, scheduled for Oct. 12-15 in Scottsdale, Ariz. Fraud, AI, automation, technology and security are some of the major topics that will be tackled at the conference from, Morton said, two separate perspectives. “One’s really around what’s the future of the industry look like, and the other one is how can you operationalize your business in a way that deals with the here and now as well as the future. … We’re trying to be intentional.” Morton added ALTA ONE’s theme centers on encouraging companies to take a proactive approach to the numerous changes happening in the industry. “The theme of the conference is ‘Powered By You,’ driving change so that you take control of what the future looks like and shape that future for the industry, as opposed to react to that future coming at you. What is important for us is that our members are prepared and excited and embracing what’s coming,” he explained. Innovation around each component of the industry will also be a focal point of the conference. Morton explained there will be discussions centered on “thinking differently about not only how we do business, but the products that we provide, the need of consumers and customers in the marketplace, and what they’re asking for, and whether or not we’re responding effectively to their desires, so that we shape it not based on what we think is best, but what they demand as consumers of our services.” The program entitled, “Omni Session: What’s Next For Real Estate?” will feature Daryl Fairweather, chief economist of Redfin; Mark Fleming, senior vice president for decision science and chief economist for First American Financial Corp.; Craig Haskins, CEO and president of Knight Barry Title Inc.; and Oscar Nieves, equity research analyst with Stephens. Morton said these industry economists and analysts will discuss the future and the trends that are going to shape that future. He anticipates the panelists will have differing perspectives about upcoming issues in the real estate industry. “It’s really going to be more of a debate versus a consensus based on where they sit,” Morton said. “That one’s going to be really interesting.” The conference will close with a presentation entitled, “Smart Bets: Where Real Estate Innovation and Investment Are Headed.” Morton will be on the panel and be joined by Elizabeth Blosser, chief strategy, communications and innovation officer for ALTA; Zachary Kammerdeiner, vice president, chief of innovation and strategy at Connecticut Attorneys Title Insurance Co. (CATIC); and Carolyn Kwon, managing director at Moderne Ventures. Morton said the discussion will examine “what some firms have been doing to change their business to think about AI and automation in particular, as well as the traditional business model of the industry versus new entrants. That one will also be really helpful to educate our members about what is new and different out there. They’re going to be talking from their perspective on what investments are coming into the industry, what’s driving change, and how we’re adapting.” **Topics:** Public Awareness, Regulatory actions, Technology, Title Insurance --- ### [Owner of CT company pleads guilty to nearly $1.3M healthcare fraud](https://insurancefraud.org/news_archives/owner-of-ct-company-pleads-guilty-to-nearly-1-3m-healthcare-fraud/) **Published:** October 7, 2026 **Author:** Diane Beauchamp **Content:** The owner of a Connecticut health resources company pleaded guilty to healthcare fraud Tuesday after billing insurers nearly $1.3 million for products she never provided, federal prosecutors said. Jacqueline Pelphrey, 50, of Freedom, Pa., entered the plea in Hartford federal court after waiving her right to be indicted, according to a news release from U.S. Attorney for the District of Connecticut David X. Sullivan. Sullivan said Pelphrey, formerly of Manchester, was accused of defrauding Medicaid, private insurers and healthcare benefit programs by submitting fraudulent claims while running the business Women’s Health Resources Inc. Sullivan said the Vernon-based company sold post-mastectomy items and products, including custom breast prostheses. He said Pelphrey submitted $1,299,633 in fraudulent insurance claims for prostheses that her clients did not order, purchase or receive. Pelphrey was released on a $10,000 bond pending a Dec. 29 sentencing hearing that will be held in Bridgeport federal court. The offense carries a maximum sentence of 10 years in prison. **Topics:** Healthcare Fraud, Medicare/Medicaid **Categories:** Conviction --- ### [Minnesota challenges CMS over Medicaid fraud claims, $550M funding freeze](https://insurancefraud.org/news_archives/minnesota-challenges-cms-over-medicaid-fraud-claims-550m-funding-freeze/) **Published:** October 7, 2026 **Author:** Diane Beauchamp **Content:** Minnesota’s top human services official is defending the state’s efforts to combat fraud, while also demanding more transparency from the federal government as the Centers for Medicare & Medicaid Services (CMS) continues to withhold nearly $550 million in Medicaid funding. In a five-page letter sent Friday to CMS administrator Mehmet Oz, Temporary DHS Commissioner John Connolly argued the state has aggressively pursued anti-fraud efforts but has not received the evidence federal officials say justifies the funding deferrals. Connolly wrote that Minnesota and CMS share a commitment to combating Medicaid fraud and protecting taxpayer money, but said effective oversight requires a transparent federal-state partnership. The letter marks the latest chapter in Minnesota’s effort to get the Trump administration to release hundreds of millions of dollars in federal funding for the state’s Medicaid program that’s been deferred three separate times this year. In February, the Trump administration [halted nearly $260 million](https://kstp.com/kstp-news/top-news/federal-government-halts-260m-medicaid-funds-to-minnesota-over-fraud/) in Medicaid funding to Minnesota, citing concerns about fraud in 14 Medicaid programs and demanding additional documentation from the state. Vice President JD Vance called the action part of a national crackdown on healthcare fraud, while Oz said the federal government would hold the money until Minnesota implemented a corrective action plan. Federal officials later froze [an additional $91 million in April](https://kstp.com/kstp-news/top-news/federal-government-freezes-another-91m-in-minnesota-medicaid-funding-over-fraud-concerns/), saying concerns remained about Minnesota’s management of Medicaid funds despite the state’s corrective action plan. Then in July, the administration announced [another deferral](https://kstp.com/kstp-news/top-news/trump-administration-says-its-deferring-1b-in-medicaid-payments-to-california-and-minnesota-2/) affecting approximately $199 million owed to Minnesota for Medicaid services, part of more than $1 billion in deferred payments to both Minnesota and California over what federal officials described as “suspected fraud and noncompliance.” DHS confirmed Monday that the total amount is now $550 million. At the center of the dispute is how CMS identified providers it considers high-risk. State officials say CMS has identified 870 Minnesota providers as high-risk but has not explained the methodology used to flag them. The state also disputes whether provider disenrollments cited by federal officials should be treated as evidence of fraud. Connolly wrote that many providers lost enrollment during a large-scale revalidation effort due to documentation or administrative issues. He argued disenrollment does not necessarily establish fraud, waste or abuse. In the letter, Connolly writes that state officials have repeatedly requested information from CMS and federal law enforcement regarding alleged fraud but have not received documentation identifying providers or supporting the allegations. 5 INVESTIGATES reached out to CMS for its response to the letter and also asked if the federal government is considering withholding even more Medicaid funding before the end of the year. The agency has yet to respond to the request. **Topics:** Medicare/Medicaid, Regulatory actions --- ### [US President Trump urges Congress to double sentences for repeat fraud offenders](https://insurancefraud.org/news_archives/us-president-trump-urges-congress-to-double-sentences-for-repeat-fraud-offenders/) **Published:** October 7, 2026 **Author:** Diane Beauchamp **Content:** **United States President Donald Trump has called on Congress to impose mandatory minimum prison sentences on people convicted of defrauding Medicare, Medicaid and Social Security, proposing a major change in federal sentencing policy that would eliminate probation for covered offenders and impose increasingly severe punishment as the amount stolen rises.** Mr Trump announced the proposal on Saturday in a video posted to his Truth Social account, saying Congress should also double sentences for repeat fraud offenders and create potential personal financial liability for state and local politicians who knowingly allow fraud to continue when they have the authority to stop it. The proposal is not currently law. Congress would have to enact legislation before the mandatory minimum sentences or the proposed liability for government officials could take effect. Mr Trump did not identify specific mandatory prison terms or dollar thresholds in his announcement. He made clear, however, the direction he wants Congress to take, namely imprisonment rather than probation for people convicted of whatever federal benefit-fraud offences ultimately fall under the legislation. “Today, I’m calling on Congress to pass legislation to address fraud in Medicare, Medicaid, and Social Security programs,” he said. The first component of the proposal would fundamentally change sentencing for at least some federal benefit-fraud convictions. Mr Trump called for mandatory minimum sentences for people who steal from programmes intended to provide health care, assistance and retirement benefits. “Under our proposal, probation is no longer an option for the fraudsters,” he said. He said sentences would increase according to the amount stolen, although he did not specify the proposed dollar brackets or corresponding prison terms. He also proposed a repeat-offender provision under which the sentence of a person convicted of another qualifying fraud offence would be doubled. Those details matter because current federal sentencing for fraud is considerably more complicated. Federal judges sentence defendants under statutes enacted by Congress while considering the advisory United States Sentencing Guidelines and the circumstances of individual cases. Factors including financial loss, criminal history, number of victims, sophisticated conduct, leadership roles, obstruction and abuse of a position of trust can affect the guideline calculation. Federal law already allows substantial prison sentences for health care fraud. Under the relevant statute, knowingly and wilfully executing or attempting a scheme to defraud a health care benefit programme generally carries a maximum sentence of ten years in prison. The maximum increases to twenty years if the violation results in serious bodily injury, and if the violation results in death, a defendant can be imprisoned for any term of years or for life. Statutory maximums, however, should not be confused with typical sentences. Sentencing Commission data for the 2025 fiscal year show that 340 federal cases involved health care fraud, with an average sentence of 21 months, and 68 per cent of those sentenced received prison terms. Only three per cent were convicted of an offence carrying a mandatory minimum penalty. Government-benefits fraud produced similar numbers, with 965 cases reported in the 2025 fiscal year, an average prison sentence of 16 months and 66 per cent of defendants sentenced to prison. Again, only three per cent were convicted of an offence carrying a mandatory minimum penalty. Another portion of the proposal, imposing progressively longer punishment as the amount stolen increases, has a partial counterpart in existing federal sentencing policy. Financial loss already plays a major role in calculating advisory sentences for fraud, and health care fraud involving government programmes receives additional treatment under the guidelines. Mr Trump’s proposal would go further by making at least some imprisonment mandatory rather than leaving the ultimate sentence entirely within the existing statutory and judicial framework. The proposed repeat-offender provision could also have substantial consequences. “If you’re a convicted fraudster who gets caught stealing from the American people a second time, your sentence will be doubled,” he said. Exactly how that provision would work remains unclear, as he did not say whether the doubling would apply to the mandatory minimum, the guideline sentence, the sentence ultimately imposed by a judge or some other statutory sentencing calculation. He also did not specify which prior fraud convictions would qualify. The second major component of the announcement could prove even more legally complicated. Mr Trump called for consequences for state and local politicians who know about fraud, possess the ability to stop it and fail to act. Under the proposal, such officials could become personally liable for taxpayer losses they could have prevented. He did not provide details about the proposed cause of action, required state of mind, enforcement mechanism, defences or evidentiary standard, characterising the proposal as applying to politicians who “willfully turn a blind eye” to fraud. The announcement did not emerge in isolation. Mr Trump established the Task Force to Eliminate Fraud through Executive Order 14395 on March 16, chaired by Vice President JD Vance, to coordinate federal efforts against fraud, waste and abuse involving federal benefit programmes. The order directed agencies to identify transactions and processes particularly susceptible to fraud, develop stronger eligibility and identity verification systems, improve pre-payment controls, expand data sharing and consider audit, suspension, repayment, exclusion and debarment measures. The administration subsequently created a public fraud-tracking initiative. According to the White House’s current Fraud Ledger, the administration estimates its task force has identified about US$260.7 billion in fraud since January 2025 and reports about US$72 billion per year in fraud stopped. Those numbers are White House estimates and should be understood as administration figures, not independent judicial findings. The Justice Department has simultaneously expanded criminal enforcement. On June 23, it announced what it described as the 2026 National Health Care Fraud Takedown, with federal prosecutors charging 455 defendants, including 90 doctors and other licensed medical professionals, in cases alleging more than US$6.5 billion in false claims. The cases were brought in 56 federal districts and involved 45 states and United States territories, with 50 state Medicaid Fraud Control Units participating. The defendants are presumed innocent unless and until proven guilty in court. The administration has also established a National Fraud Enforcement Division within the Justice Department to concentrate resources on fraud involving taxpayer money and government-funded programmes. The announcement also follows earlier administration advocacy for tougher sentencing. In an August opinion article in the Washington Post, Vice President Vance wrote that Congress could strengthen fraud enforcement by establishing mandatory minimum sentences for what he described as the most serious fraud cases. The largest unanswered question is now what Congress does with the request. The Constitution gives Congress authority to establish federal criminal offences and statutory sentencing ranges, while the president can propose legislation and sign or veto legislation passed by Congress. Mr Trump therefore cannot establish the mandatory minimum sentences described on Saturday through the video announcement alone. Congress would have to pass legislation answering questions the announcement did not resolve, including which offences would carry mandatory minimum sentences, what the minimum sentence would be, what financial thresholds would trigger longer mandatory terms, how repeat offences would be defined, whether defendants who provide substantial assistance could receive relief and how personal liability for state and local officials would be established and enforced. Mandatory minimum statutes also change the traditional allocation of sentencing discretion. When Congress establishes a mandatory minimum, judges generally cannot sentence below the statutory floor unless a legally authorised exception applies. According to the Sentencing Commission, 21 per cent of all federal cases in the 2025 fiscal year involved an offence carrying a statutory mandatory minimum, with 68 per cent of those involving drug trafficking and only three per cent involving fraud. The practical significance of the announcement is therefore not that fraud against Medicare, Medicaid or Social Security is currently lightly regulated, as it is already criminal conduct carrying potentially substantial penalties. The proposed change concerns how much discretion remains after conviction. The next development to watch is legislative text. Until Congress introduces and acts on a bill, the proposal remains a policy proposal rather than a change in federal criminal law. Mr Trump closed his announcement with a direct warning to people committing fraud against federal programmes. “So from now on, fraudsters, we’re watching you,” he said. **Topics:** Legislative, Medicare/Medicaid --- ### [She was convicted in Hertel & Brown case in '25. Sentencing is in '27.](https://insurancefraud.org/news_archives/she-was-convicted-in-hertel-brown-case-in-25-sentencing-is-in-27/) **Published:** October 7, 2026 **Author:** Diane Beauchamp **Content:** The only defendant yet to be sentenced in the sprawling Hertel & Brown health care billing fraud is not scheduled to learn her fate until the middle of 2027, two years after she was convicted at trial in federal court in Erie. The sentencing hearing for physical therapist Julie A. Johnson has been rescheduled from Nov. 6 to April 29, according to a court order filed Oct. 2. U.S. District Judge Robert Colville, who presided at trial, granted the defense’s request to postpone the sentencing hearing. Johnson’s court-appointed lawyers, Efrem Grail and Julia Gitelman, of Pittsburgh, asked for the delay because of scheduling issues. They also said they need more time because they are “engaging an expert to analyze the relevant billing records and to prepare an independent assessment of any loss properly attributed to Ms. Johnson,” according to a defense motion. The motion states that the prosecutor, Assistant U.S. Attorney Christian Trabold, took “no position” on the defense’s request to postpone the hearing. Johnson and two others chose trial Johnson, 45, of Millcreek Township, has been free on a $10,000 unsecured bond since she and 20 other defendants were indicted in November 2021 in the case against the Erie-based Hertel & Brown Physical & Aquatic Therapy. Also charged were the lead defendants, Hertel & Brown as a corporation and owners Aaron W. Hertel and Michael R. Brown, as well as 17 other employees. The indictment listed Johnson seventh out of the 21 defendants. The defendants were accused of conspiring in an overbilling scheme that cost Medicare, Medicaid and other public and private insurers as much as $22 million over 14 years. The scam included Hertel & Brown using unlicensed and low-paid techs to perform physical therapy and billing as if physical therapists did the work. Except for Johnson and two other defendants, all the defendants pleaded guilty to the felony of conspiracy to commit wire fraud and health care fraud. Johnson and two other defendants went to a joint trial. Two of the defendants were acquitted of all charges, and Johnson was acquitted of the conspiracy count and convicted of health care fraud. The jury delivered its verdict on April 23, 2025. Colville initially set sentencing for Sept. 3, 2025, though the sentencing hearing was later rescheduled. Judge rejected Johnson’s claims of ‘miscarriage of justice’ Colville, based in Pittsburgh, handled the trial at the federal courthouse in Erie. Erie-based U.S. District Judge Susan Paradise Baxter handled the cases of all the other Hertel & Brown defendants, and she completed her final sentence in the case on Aug. 4. With the exception of Hertel & Brown’s owners, Baxter sentenced all the defendants to probation and ordered them to pay large amounts of restitution to health care providers they overbilled. Baxter in February sentenced owners Hertel and Brown to six years in federal prison and fined them each the maximum of $250,000. Hertel and Brown in August reached a deal with the U.S. Attorney’s Office to pay $15 million each in restitution. Johnson is disputing the amount of restitution the U.S. Attorney’s Office has requested in her case, according to her lawyers’ motion to delay the sentencing. The motion does not include the proposed amount, and the prosecution has not disclosed it in a filing. Johnson did not testify at her trial. She appealed her conviction over a number of claims, including that the U.S. Attorney’s Office presented insufficient evidence. Johnson also argued that the verdict was legally inconsistent because she was acquitted of conspiracy but found guilty of health care fraud. Her lawyers called the verdict a “grave miscarriage of justice” in a court filing. Colville in July rejected Johnson’s lawyers’ request to set aside the verdict. “Viewing the record in the light most favorable to the prosecution,” Colville wrote in a 55-page opinion, “the Court has no difficulty concluding that a rational trier of fact could have found Johnson guilty of health care fraud beyond a reasonable doubt.” **Topics:** Healthcare Fraud, Unlicensed entities **Categories:** Conviction --- ### [Medicaid provider allegedly billed $165K for dead patient's rides among fraud exposed in explosive report](https://insurancefraud.org/news_archives/medicaid-provider-allegedly-billed-165k-for-dead-patients-rides-among-fraud-exposed-in-explosive-report/) **Published:** October 7, 2026 **Author:** Diane Beauchamp **Content:** A House GOP-led report details schemes exploiting Medicare and Medicaid across multiple states A Colorado resident was charged with trying to steal hundreds of thousands of taxpayer dollars by billing the state’s Medicaid program for transporting a patient to doctor’s appointments — rides that would have taken place after that person had already died. A new report by the House Energy and Commerce Committee revealed that taxpayer-funded healthcare programs, specifically Medicare and Medicaid, are rife with vulnerabilities that allow them to be exploited on the local, state and federal levels. “Medicare and Medicaid fraud occurs nationwide and costs American taxpayers billions of dollars a year. Fraud is prevalent in all sectors of health care and is especially egregious in taxpayer-funded health care programs that are intended to serve vulnerable populations, including the elderly, disabled, children, and pregnant women,” the report said. “Patients are suffering from identity theft, long waiting lists, substandard health care, and, in some cases, a lack of health care services due to fraudulent claims to Medicare and Medicaid.” Fox News Digital highlighted some of the most egregious examples below. Hundreds of thousands billed for a dead patient Wesam Yassin was one of two providers of non-emergency medical transportation, a Medicaid benefit for helping patients get to doctor’s appointments, charged by state and local prosecutors for fraudulent billing in Colorado in February 2026. Yassin is accused of charging Colorado Medicaid a total of $3.3 million in questionable bills under a company called Sama Limo, according to the report. Yassin is accused of charging $283,000 for 64 rides for one person, coming out to over $4,000 per ride. Roughly $165,000 of those charges came after the patient in question had already died, the report said. “Proceeds from this scheme were allegedly used for personal gain, including the purchase of a home, furnishings, luxury vehicles, jewelry, and cosmetic surgery,” a federal release announcing the charges said. It also pointed to charges against Ashley Marie Stevens, who is accused of trying to bilk the state for over $1 million in taxpayer dollars. She is accused of billing the state some $400,000 for non-medical rides for herself and her family in addition to “ghost rides,” which never even took place. “Fraudulent” hospice practices in Los Angeles County The report also accused the hospice industry in California of raising suspicions of fraud. “Investigators observed nearly 500 hospices operating in a three-mile radius in L.A. County, 137 hospices operating on Van Nuys Boulevard alone, and 89 companies registered to a single address in Van Nuys,” the report said. The document also noted that House lawmakers raised concerns with the Department of Health and Human Services (HHS) that an increase in home health and hospice providers raised red flags about possible healthcare fraud tied to foreign criminal groups earlier this year. “The Committees were concerned about data from a March 2022 California State Auditor’s Report and HHS hospice ownership data, showing that L.A. County had more than 31 percent of the hospice agencies in the U.S. in 2022,” the report said. The California Department of Public Health had placed a freeze on new hospice licenses in January 2022. Despite that, however, the report found that 15 new hospices — located in a single Los Angeles County building — still got Medicare certification in 2023. U.S. taxpayer dollars ending up in foreign criminals’ hands House Republicans are worried that potential hospice fraud is not the only area being targeted by international criminal groups. The report highlighted allegations from 2024 in which “years-long, large-scale” schemes targeted as much as $3 billion in American taxpayer dollars via fake bills for urinary catheters. Members of Russian organized crime groups bought 30 small medical supply companies already receiving federal dollars, and billed the Medicare system nearly $11 billion for urinary catheters, the report said. More than 99% of those funds never went out the door, however. Similar medical equipment fraud schemes ensnared bad actors in Estonia, Pakistan, Georgia and Hong Kong. The California Department of Public Health had placed a freeze on new hospice licenses in January 2022. Despite that, however, the report found that 15 new hospices — located in a single Los Angeles County building — still got Medicare certification in 2023. U.S. taxpayer dollars ending up in foreign criminals’ hands House Republicans are worried that potential hospice fraud is not the only area being targeted by international criminal groups. The report highlighted allegations from 2024 in which “years-long, large-scale” schemes targeted as much as $3 billion in American taxpayer dollars via fake bills for urinary catheters. Members of Russian organized crime groups bought 30 small medical supply companies already receiving federal dollars, and billed the Medicare system nearly $11 billion for urinary catheters, the report said. More than 99% of those funds never went out the door, however. Similar medical equipment fraud schemes ensnared bad actors in Estonia, Pakistan, Georgia and Hong Kong. He and his co-defendants are accused of hiring unqualified people as behavior counselors and getting children to enroll by bribing their parents, the report said. Yussuf admitted during his plea hearing that he did not actually know anyone with autism, the report said. House Energy and Commerce Committee Chairman Brett Guthrie told Fox News Digital that “combating fraud is a coast-to-coast battle.” “Every instance of fraud we uncover represents money stolen from taxpayers and care taken away from the patients who depend on it most,” Guthrie said. **Topics:** Medicare/Medicaid, Regulatory actions **Categories:** Arrest --- ### [House Committee Report on Fraud Against Medicare and Medicaid: Oversight Done Wrong](https://insurancefraud.org/news_archives/house-committee-report-on-fraud-against-medicare-and-medicaid-oversight-done-wrong/) **Published:** October 7, 2026 **Author:** Diane Beauchamp **Content:** On September 29, exactly five weeks before the mid-term elections, Republicans on the House Energy & Commerce Committee released a [Majority Staff Report](https://d1dth6e84htgma.cloudfront.net/EC_Fraud_Staff_Report_9_29_26_468cdcbe40.pdf) on fraud against Medicare and Medicaid. The same day the Committee’s Chairman [announced](https://energycommerce.house.gov/posts/e-and-c-republicans-introduce-critical-fraud-fighting-package-to-protect-vulnerable-americans-and-safeguard-taxpayer-dollars) a package of 14 bills, 13 of which would amend the Medicaid statute to address fraud against the program. At this late date, it seems highly unlikely that these bills will find their way to the President’s desk for signature before the end of this Congress. The Majority Staff Report, however, is a final product worth examining. The report characterizes itself as a “comprehensive” investigation of fraud against Medicare and Medicaid (p. 6). In fact, it focuses largely on Medicaid programs in Democratic-led states. The findings of the report are based on “over 100,000 pages of documents and information” and three Subcommittee hearings. The documents and information produced in response to [letters sent to 11 states](https://energycommerce.house.gov/posts/e-and-c-leaders-expand-investigation-into-medicaid-fraud-nationwide): California, Colorado, Massachusetts, Maine, Minnesota, Nebraska, New York, Oregon, Pennsylvania, Vermont, and Washington. All but two of these states have Democratic governors. One of the Subcommittee hearings involved [four state Medicaid directors](https://energycommerce.house.gov/posts/o-and-i-subcommittee-holds-hearing-with-state-medicaid-directors-as-part-of-committee-s-extensive-probe-into-medicaid-programs-nationwide), three of which were from states with Democratic governors (California, Minnesota, and New York). So, it is hardly surprising that in the section of the report titled “Deficiencies in State Medicaid Program Integrity,” the only examples provided are from Democratic-led states: New York, California, and Oregon (“Insufficiency of Provider Risk Assessments”) and Minnesota, Colorado, Maine, and California (“Utilization of Audits”). Bad actors have demonstrably committed fraud against the Medicaid programs in each of these states. But does the Majority Staff actually believe that their investigation is “comprehensive”? That there are no “Deficiencies in State Medicaid Program Integrity” in [Florida](https://www.justice.gov/usao-sdfl/pr/national-health-care-fraud-takedown-results-455-defendants-charged-connection-over-65) or [Ohio](https://oversight.house.gov/release/hearing-wrap-up-rampant-fraud-in-medicaid-waiver-program/) or any of the other 24 states with Republican governors? The report states that “The Committee picked a sample of states after looking at a variety of publicly available reports and data…recent cases of Medicaid fraud occurring in certain services…and recent audits and reports that identified certain Medicaid programs of concern.” (p. 30). In selecting the sample, the Majority Staff apparently overlooked the publicly available data in the [2026 National Health Care Fraud Takedown](https://www.justice.gov/opa/pr/national-health-care-fraud-takedown-results-455-defendants-charged-connection-over-65) released by the Department of Justice in June. The “Takedown” includes [cases](https://www.justice.gov/criminal/criminal-fraud/health-care-fraud-unit/2026-national-hcf-case-summaries) alleging fraud against Medicaid programs filed in federal or state court in 42 states: Alaska, Arizona, Arkansas, California, Colorado, Connecticut, Delaware, Florida, Georgia, Illinois, Iowa, Kansas, Kentucky, Louisiana, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, Tennessee, Texas, Utah, Vermont, Virginia, Washington, West Virginia, and Wisconsin. The most coherent explanation for the sample selected by the Majority Staff is partisan targeting. Along the same partisan lines, the report credits—without qualification—the Trump Administration with having “uncovered $96.4 billion in fraud, stopped $46.2 billion of fraud, and recovered $33.1 billion of fraud through enforcement actions since January 2025” in HHS programs. These are the [unsourced, unexplained, and unverifiable](https://ccf.georgetown.edu/2026/09/21/fact-checking-the-white-house-fraud-ledger-trusted-numbers-or-legerdemain/) numbers posted on the White House [Fraud Ledger](https://www.whitehouse.gov/fraud/). There’s no indication that the Majority Staff did its due diligence to assess the accuracy of at least the Medicare and Medicaid components of these figures. Despite its partisan targeting, the Report does manage to get a few things right. It characterizes fraud against Medicare and Medicaid as a “serious” problem but doesn’t make up numbers of amounts lost to fraud. Instead, it states correctly that “no precise estimate of annual fraud rates in Medicare or Medicaid exists…”(p. 11). It also acknowledges that [improper payments](https://ccf.georgetown.edu/2025/03/13/medicaid-fraud-the-improper-use-of-improper-payments/) are not a measure of fraud: “…improper payments only capture some fraud and also include payment errors, insufficient documentation, or administrative processing failures.” (p. 11) The Report also provides one piece of new information: the risk levels assigned by the 11 states targeted by the investigation to providers of four different services (Adult Day Care, Applied Behavioral Analysis, Non-Emergency Medical Transportation, and Personal Care Services) that the Report identifies as presenting a high risk of fraud. (Table 1, p. 56). By way of background, anti-fraud provisions [enacted in the ACA in 2010](https://www.macpac.gov/key-legislative-milestones-and-statutory-provisions-in-program-integrity/) require that state Medicaid agencies screen providers before allowing them to enroll in the program and bill for services. The extent of the screening, ranging from database checks to site visits to fingerprinting and criminal background checks, depends on the provider’s risk level; the higher the risk level, the more extensive the screening. Under [Centers for Medicare & Medicaid Services (CMS) regulations](https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-455/subpart-E/section-455.450), states must assign providers one of three risk levels: limited, moderate, or high. For services covered only by Medicaid, and not also by Medicare, each state makes its own determination of risk. The four services highlighted in the report are Medicaid-only services, three of which (ADC, ABA, and PCS) CMS considers “[the biggest risks to the Medicaid program](https://www.cms.gov/fraud).” The report finds that two of the states—Minnesota and New York—classified all four service types as “high” risk, which would subject providers to the most extensive screening at initial enrollment and upon revalidation. Five of the states—California, Massachusetts, Oregon, Pennsylvania, and New York—classified all four service types as “limited” risk. The remaining four states applied a mix of levels to the four service types. Each of the service types had at least one state classifying it as “limited” risk and one state classifying it as “high” risk. Three of the service types—ABA, ADC, and NEMT—were designated as “limited” risk by a majority of the targeted states. Even allowing for state-to-state variation, these data raise some interesting questions. What criteria and what claims data did the 11 targeted states use in determining their classifications? How do the states not targeted by the investigation classify these services, and how did they arrive at their risk levels? Are the patterns similar to those observed with the 11 targeted states? If most states consider ADC and ABA services to present “limited” risk to their Medicaid programs, why does CMS consider those services two of the three “biggest risks”? Here is where the report’s partisanship degrades its ability to inform. The Majority Staff’s conclusion from the data it presents is not to explore the questions the data raise but to criticize many of the targeted states for not applying an “enhanced risk designation, despite recent patterns of fraud within these programs, including in these states.” (p. 56). The report then launches into an attack on New York for “not complying with federal law by designating provider risk levels” (p. 57) and on California and Oregon for “doing the bare minimum to comply with federal requirements” (p. 58). It is altogether appropriate for the Majority Staff to ask whether states are complying with federal requirements for provider screening. It is rank partisanship to ask those questions of only a subset of states, the overwhelming majority of which are led by Democratic Governors. And it is thoroughly inappropriate to take two of those Democratic-led states to task for “doing the bare minimum” to comply with federal regulations—compliance is, after all, what is required, and that is what the report acknowledges they are doing. States may choose to go above and beyond, and perhaps some have; the sample size is too small to know. But no state is required to do so. If the Majority Staff believes that the current federal regulations on provider screening are too lax, it should recommend that CMS Administrator Dr. Mehmet Oz revise them, not call out two of its partisan targets for not doing more than what is required. Oversight is an important responsibility that Congress should take seriously. When done right, [Congressional oversight](https://levin-center.org/what-is-oversight/portraits/) has the potential to improve the operation of federal programs by identifying problems and holding federal (and in the case of Medicaid, state agencies) accountable for addressing them. Medicaid is a [hugely important program](https://ccf.georgetown.edu/2026/06/29/medicaid-connections-webinar-series/) for tens of millions of children and families as well as individuals with disabilities and low-income elderly. [Fraud against Medicaid](https://ccf.georgetown.edu/2025/01/10/the-truth-about-fraud-against-medicaid/) is a major challenge and one that CMS and state Medicaid agencies should work together to address. The program and its enrollees would benefit from a bipartisan, fact-based investigation that is actually comprehensive and gathers and analyzes data from all states, not just a partisan subset. Regrettably, this Majority Staff Report is not that investigation. **Topics:** Medicare/Medicaid, Regulatory actions --- ### [Pottsville Man Accused of Submitting False Wage Information in $4,500 Insurance Claim](https://insurancefraud.org/news_archives/pottsville-man-accused-of-submitting-false-wage-information-in-4500-insurance-claim/) **Published:** October 6, 2026 **Author:** Diane Beauchamp **Content:** A Pottsville man is facing felony charges following a Pennsylvania Office of Attorney General investigation into allegations that he submitted false employment and wage information as part of an insurance claim. Corey Michael McCabe, 52, of Pottsville, was charged on October 1, 2026, with felony counts of presenting a false or fraudulent insurance claim and theft by deception. He also faces a misdemeanor count of tampering with records or identification. The Pennsylvania Office of Attorney General filed the charges before Magisterial District Judge James Reiley. Insurance Claim Followed Pottsville Vehicle Incident According to an affidavit of probable cause filed by the Attorney General’s Bureau of Criminal Investigations, the case stems from an August 17, 2024, incident involving a State Farm-insured vehicle in Pottsville. Investigators said the vehicle’s owner reported that she was dropping McCabe off at a relative’s home when she began pulling away without realizing he was retrieving items from the vehicle. McCabe allegedly suffered a dislocated left shoulder and sprained left foot and later sought compensation through State Farm. As part of the claim, authorities allege McCabe submitted a Wage and Salary Verification form stating that he was employed by “Prestine Landscaping” in Pottsville and had earned $27,509 in 2024. According to the affidavit, the document purported to contain the signature of the company’s CEO. Investigators said State Farm settled McCabe’s bodily injury claim on August 30, 2024, for $4,500. Tip Leads to Insurance Fraud Investigation The affidavit states that State Farm received information in November 2024 alleging that the wage-verification form had been forged and that the landscaping company identified on the document did not exist. The matter eventually led to an investigation by the Pennsylvania Office of Attorney General after information was provided by a special agent with the National Insurance Crime Bureau. In April 2026, investigators checked Pennsylvania Department of Labor and Industry records and allegedly found that McCabe’s last reported wages were from the second quarter of 2024 and did not correspond with the employment information provided to State Farm. A search of Pennsylvania Department of State business records also allegedly failed to locate a company matching “Prestine Landscaping,” as the name was spelled on the form. Investigators also searched a similar spelling of the company’s name and reported finding no matching Pottsville-area business associated with McCabe. Attorney General’s Office Speaks With McCabe According to the affidavit, an investigator with the Attorney General’s Office spoke with McCabe by telephone on April 25, 2026. Authorities said McCabe acknowledged the insurance claim and confirmed receiving the $4,500 settlement. When asked about the landscaping company, McCabe allegedly told the investigator that a friend owned the business. After the investigator told McCabe that authorities believed the wage-verification form was false, the signature had been forged and the business did not exist, McCabe declined to answer additional questions, according to the affidavit. The following day, McCabe sent a message indicating that he had not been an employee but had instead been helping a friend with “some simple side work,” according to the complaint. The affidavit states that McCabe expressed an interest in providing clarification, but investigators subsequently did not receive another call or message from him. $2,550 of Settlement Allegedly Represented Lost Wages Investigators contacted a State Farm representative in August 2026 to determine what portion of the settlement was based on the disputed wage information. According to the affidavit, State Farm reported that McCabe did not receive workers’ compensation or monthly benefit payments. However, $2,550 of the $4,500 settlement represented lost wages calculated using the wage-verification form. Charges Filed in Schuylkill County Court records show that the criminal complaint was filed October 1. The docket lists the case as awaiting a preliminary hearing. **Topics:** Auto - padding/false claim **Categories:** Arrest --- ### [Officials investigating nor'easter insurance fraud](https://insurancefraud.org/news_archives/officials-investigating-noreaster-insurance-fraud/) **Published:** October 4, 2026 **Author:** Diane Beauchamp **Content:** The [nor’easter that hit the East Coast](https://www.propertycasualty360.com/2026/09/29/hurricane-nolo-noreaster-caused-weekend-damage/) with heavy rain and strong winds last weekend didn’t keep fraudsters inside. Police in Edgewater, N.J., are investigating potential insurance fraud caught on camera. A River Road parking lot flooded during the storm due to a tidal surge that filled the area with water from the Hudson River. Video taken on Saturday showed several cars parked in the lot were submerged in deep water. However, video taken on Monday showed even more cars in the lot, after it had flooded. Those vehicles included a BMW 7 Series and a $130,000 Mercedes-Benz S580. Officials say there’s evidence that people were driving and pushing cars into the flooded area, and those people are being investigated by police. New Jersey investigates more than 5,000 cases of insurance fraud every year. Insurance fraud drives up rates, costing the average New Jersey family about $1,300 per year. That amounts to about $2.6 billion statewide annually. **Topics:** Auto fraud, Public Awareness, Regulatory actions --- ### [Investigation reveals Russian connection to Medicare billing scheme](https://insurancefraud.org/news_archives/investigation-reveals-russian-connection-to-medicare-billing-scheme/) **Published:** October 4, 2026 **Author:** Diane Beauchamp **Content:** A WSMV4 investigation has uncovered a Medicare fraud scheme that billed the federal program tens of thousands of dollars for medical supplies that Tennessee recipients never needed or received. Our investigation found the billing is connected to a Russian citizen living in Texas, accused in a $3 billion Medicare fraud scheme. Penny Vaughan, a retired nurse in College Grove, and her husband received their quarterly Medicare statements showing Medicare had been billed more than $11,000 for urinary catheters for both of them over five months. “We did not need, did not buy, did not order,” Vaughan said. “The price was just extraordinary.” The billing showed 300 catheters per month for five months. “Three hundred a month would mean you were catheterizing yourself 10 times a day. Nobody does that. Nobody does that,” Vaughan said. In Kingston Springs, Larry Welch’s mother-in-law received a similar quarterly report showing Medicare was billed for urinary catheters she never needed or received, totaling more than $11,000. Several other Medicare recipients shared their quarterly reports, showing identical Medicare billing for hundreds of catheters they never needed. “I knew it was fraud,” Vaughan said. Despite the large number of catheters and high costs, Medicare paid the claims each time. Russian citizen indicted The billing for the catheters came from two medical equipment suppliers in Coral Springs, Florida, and Austin, Texas. In Texas, the billing came from Centurion Superior Medical. Texas Secretary of State records show the company’s managing member is Nika Machutadze, a Russian citizen living in Austin. Federal criminal complaints show Machutadze was indicted in federal court two-and-a-half weeks ago. The complaint shows Machutadze’s company submitted claims to more than 221,000 Medicare beneficiaries across the United States, billing Medicare more than $3 billion, including for 752,281 urinary catheters. “This could be pretty major,” Welch said. Data breach may explain access Questions remain about how Medicare recipients’ information in Tennessee reached the criminals. Penny Vaughan recently received a letter from a billing service that works for health care providers stating there had been a data breach that may include identifying Medicare beneficiary identifiers. Brandy Bauer with Senior Medicare Patrol, which helps Medicare recipients report fraud, said Medicare doesn’t have the ability to look at all 68 million enrollees and question claims. “Medicare isn’t going to necessarily know what, on a day-to-day basis, what your prescribing physician has ordered for you,” Bauer said. “Medicare doesn’t have the ability to necessarily look at all 68 million enrollees and sort of question that. They’re going to sort of take the benefit of the doubt and go ahead and try and pay those claims until you realize, wait a second, I don’t need that supplies or I didn’t get those supplies.” A spokesperson for the Centers for Medicare and Medicaid Services said in an emailed statement that they “do not confirm or comment on ongoing or potential investigations.” Senior Medicare Patrol says all people interviewed for this story now need to reach out to Medicare to get new Medicare ID numbers. Medicare recipients should review their quarterly reports to see what they were billed for and watch for notifications from hospitals and doctors about data breaches. Experts also warn of scammers sending out fake plastic Medicare cards to Medicare recipients in Alabama. Activating one of these cards could give criminals access to your social security number, bank account, or allow them to make claims, according to AARP. A real card you don’t need to activate nor pay for. These cards are never made of plastic, instead they are made with paper. **Topics:** Medicare/Medicaid **Categories:** Arrest --- ### [Texas woman pleads guilty to $478K Medicaid fraud using NP’s identity](https://insurancefraud.org/news_archives/texas-woman-pleads-guilty-to-478k-medicaid-fraud-using-nps-identity/) **Published:** October 4, 2026 **Author:** Diane Beauchamp **Content:** A 34-year-old woman has pleaded guilty to healthcare fraud and aggravated identity theft for billing Medicaid for mental health therapy services that were never provided, according to the U.S. Attorney’s Office for the Southern District of Texas. Tekiyah McLeod served as the registered agent for nLove Community Services, which purported to provide mental health therapy to Medicaid beneficiaries. Ms. McLeod admitted billing Medicaid about $477,872 for services that never took place, including services she purportedly provided to herself. She also used a nurse practitioner’s name and National Provider Identifier to submit claims without the practitioner’s knowledge or consent, and received about $453,323 from Medicaid. U.S. District Judge Keith Ellison will sentence Ms. McLeod on Dec. 16. She faces up to 10 years in federal prison for healthcare fraud, a mandatory consecutive two-year sentence for aggravated identity theft and a possible fine of up to $250,000. She remains on bond pending sentencing. **Topics:** Medicare/Medicaid, Unlicensed --- ### [Attorney General Mayes Announces Conviction and Sentencing of Yuma Physician in $36.5 Million Medicaid Fraud Case](https://insurancefraud.org/news_archives/attorney-general-mayes-announces-conviction-and-sentencing-of-yuma-physician-in-36-5-million-medicaid-fraud-case/) **Published:** October 4, 2026 **Author:** Diane Beauchamp **Content:** Attorney General Kris Mayes announced today the conviction of Irfan Fazil, M.D., on four felony counts for orchestrating a massive fraud scheme against the Arizona Health Care Cost Containment System (AHCCCS). Fazil was convicted on September 4, 2026, of Fraudulent Schemes and Artifices (class 2 felony), Illegal Control of an Enterprise (class 3 felony), Theft (class 2 felony), and Illegal Procurement of a Dangerous Drug (class 3 felony) after entering a guilty plea. A State Grand Jury had indicted him on six felony counts on June 8, 2026. Fazil was sentenced in Yuma County Superior Court on October 2, 2026. “Dr. Fazil abused his position as a physician to steal more than $36 million from a taxpayer funded program that exists to provide health care to Arizona’s most vulnerable residents,” said Attorney General Mayes. “He billed for thousands of X-rays and other medical treatments that could not possibly have been performed and treated AHCCCS as his personal bank account. My office will continue to aggressively prosecute fraud in government programs to protect tax dollars.” As part of his plea deal entered by the court, Fazil will serve 7.5 years in the Arizona Department of Corrections followed by 7.0 years of probation. He will forfeit all of his assets — including real estate, medical facilities, vehicles, multiple aircraft, jewelry, luxury handbags, U.S. currency, cryptocurrency, and gold bars — surrender his medical license and DEA registration, and pay $36,542,901.45 in restitution to AHCCCS. Between July 1 and December 31, 2025, Fazil used three business entities — Bio Family Clinic, Inc., Yuma Mobile X-Ray, and Yuma Kidney & Dialysis — to bill AHCCCS for tens of thousands of radiology services, including X-rays, ECGs, CT scans, medical treatments, and ultrasounds. His entities collected $36.5 million in AHCCCS payments in that six-month period, compared to $4.7 million over the preceding two and a half years — a 671% increase in paid claims. Investigators focused on the 27 patients with the highest billing volumes. In one case, a single patient’s account was billed for more than 1,700 X-rays in six months — a physically impossible number that would have caused serious harm from radiation exposure — along with hundreds of other radiology services. Fazil also wrote his wife, Nadia Hanif, multiple prescriptions for drugs like Clonazepam while she was outside the United States, then picked up the prescriptions himself from the pharmacy. The case was investigated by Special Agents of the Arizona Attorney General’s Office Special Investigations Section. Fazil was indicted by the Attorney General’s Office in a major medicaid fraud crackdown in June 2026. The Attorney General’s Office thanks its law enforcement partners from the DEA, FAA, Yuma Police Department. Yuma County Sheriff’s Office, AHCCCS OIG, HHS OIG for their assistance on this investigation. **Topics:** Medicare/Medicaid **Categories:** Conviction --- ### [Six Insane Fraud Schemes the Trump Administration Has Uncovered](https://insurancefraud.org/news_archives/six-insane-fraud-schemes-the-trump-administration-has-uncovered/) **Published:** October 4, 2026 **Author:** Diane Beauchamp **Content:** From the Department of Government Efficiency to Vice President JD Vance’s task force, the Trump administration has made combatting fraud a top priority. Here are just a few of the most astonishing fraud schemes uncovered so far. ## **750,000 fraudsters stealing $2.2 billion from Obamacare** Since its passage in 2010, Obamacare has been a magnet for scammers, resulting in higher tax bills for Americans and higher premiums in the private insurance market. But the Trump administration is finally doing something about it. On September 21, Vice President Vance [announced](https://www.foxnews.com/politics/white-house-yank-750000-fraudsters-obamacare-save-taxpayers-2-2-billion-vance-says) that the White House Fraud Task Force would be removing 750,000 enrollees from the program, saving taxpayers an estimated $2.2 billion. While elected Democrats and the liberal media have claimed that the administration is simply ripping people off their insurance, that hardly appears to be the case. According to Vance, brokers have been enrolling people in Obamacare who do not qualify for subsidies or in some cases do not even exist. The brokers then collect lucrative commission payments from insurance companies. “In one case we found a fraud ring that had 40 agents, 40 brokerage agents who had funneled 50,000 people into the Obamacare system fraudulently,” Vance said. CMS Administrator Dr. Mehmet Oz also revealed that more than one million people who enrolled in Obamacare this year had no Social Security number. Democrats never had an incentive to root out fraud; in fact, the Biden administration relaxed verification safeguards that would have caught most of the scammers. But Democrats benefit when more people appear to be enrolled in Obamacare, because that makes it more politically risky for Republicans to roll back subsidies or reduce eligibility. ## **250+ fake trucking schools** Unqualified migrant truckers have become the [terror of American roads](https://amac.us/newsline/death-toll-climbs-as-illegal-alien-truck-drivers-terrorize-american-roadways), with one heartbreaking story after another showing the deadly consequences of allowing poorly trained drivers to operate big rigs. There are two primary culprits in this ongoing tragedy: Democrat states granting a commercial driver’s license to virtually anyone who wants one, and fraudulent trucking schools churning out certifications to drivers who in some cases can’t even speak or read English. The Trump administration has gone after both the states and the schools, suspending more than 110 schools and completely shutting down another 150 so far, according to [*Center Square*](https://www.thecentersquare.com/illinois/article_a121fd45-c3ed-4234-98ec-e7cbcecd462c.html). The case to prove fraud is simple. The 110 schools currently suspended are linked to more than 5,000 drivers who failed English language proficiency tests. Meanwhile, the 150 schools that have been shut down entirely “claim to be certified but have unlicensed instructors and don’t have adequate space to allow drivers to get behind the wheel and drive.” **Hundreds of fake hospice centers in Los Angeles** Following an investigation from independent journalist and YouTuber Nick Shirley, CMS Administrator Dr. Mehmet Oz announced an investigation into hospice care centers in Los Angeles. What he found was truly shocking. Roughly one-third of the nation’s hospice providers are based in Los Angeles – despite the city only being home to 2.5 percent of the U.S. elderly population. In just one three-mile stretch of the city, there were [500 registered hospice companies](https://13wham.com/news/nation-world/hospice-fraud-report-los-angeles-cbs-report-la-county-empty-offices-piled-mail), including 89 in a single building. A CBS News investigation found “empty offices, piled-up mail, and phone lines dead” when they attempted to contact the companies. In total, CMS projects that there is [$3.5 billion](https://x.com/DrOzCMS/status/2016150183868878882?s=20) of hospice and home care fraud in Los Angeles every year. In one particularly appalling [case](https://www.foxnews.com/media/doctor-faces-scrutiny-over-ties-medicare-claims-thousands-hospice-patients), a single physician was linked to Medicare claims for nearly 2,800 patients across 126 California hospices in 2024 – accounting for an eye-popping $71 million in billings to the government. Most hospice doctors care for only about 140 patients annually. Perhaps most tellingly of all, CMS received [zero complaints](https://nypost.com/2026/04/22/us-news/dr-oz-touts-fraud-war-room-ending-payments-to-400-calif-hospices-over-fears-of-100b-fraud/) after shutting down more than 400 hospices in Los Angeles. ## **Minnesota scammers use ChatGPT to steal $2 million** Shirley’s investigative journalism kicked off the fraud frenzy in Minnesota, where he uncovered hundreds of millions of dollars of fraud linked to the state’s large Somali population. As the Trump administration has continued to investigate there, what they’ve found has only become more jaw-dropping. In one particularly shocking case, the Department of Justice [announced](https://www.justice.gov/opa/pr/four-men-plead-guilty-2m-minnesota-medicaid-fraud?) in July that four individuals had “pleaded guilty to defrauding Minnesota’s Housing Stabilization Services (HSS) program out of approximately $2.2 million and concealing the scheme by using artificial intelligence to create fake records when questioned by insurance companies.” Specifically, the defendants “fabricated records using ChatGPT in an attempt to conceal their theft.” The DOJ called the criminals “Minnesota men,” but it’s doubtful that “Moktar Hassan Aden,” “Mustafa Dayib Ali,” “Khalid Ahmed Dayib,” and “Abdifitah Mohamud Mohamed” feel any sense of loyalty to Minnesota or the United States. ## **Gang members paid addicts in fentanyl and heroin to steal $12 million from Medicaid** One of the reasons there is so much fraud is that the federal government doles out cash for basically every cause. In August, the Department of Justice charged four gang members with “$12 million of fraudulent Medicaid claims” for billing the government for “fake rides for Medicaid patients to and from methadone clinics in the Bronx.” The defendants allegedly “paid recurring kickbacks to Medicaid patients in cash and drugs, and laundered millions of dollars in fraud proceeds obtained from the scheme.” The four individuals also [reportedly](https://www.justice.gov/opa/pr/four-members-war-room-charged-connection-12m-medicaid-fraud-scheme) “engaged in violence against their rivals.” In other words, fraud has become so easy and rampant that gangs are now turning to ripping off taxpayers instead of good-old-fashioned robberies and racketeering. As a result, American taxpayer dollars are being used to fund gang warfare. ## **Homeless services executive spends $12 million on nightclubs, cars, and exotic vacations** In September, the Department of Justice [announced](https://www.justice.gov/opa/pr/two-defendants-employed-la-area-homeless-nonprofits-arrested-federal-charges-alleging-misuse) federal fraud charges against California nonprofit executive Michael Young for allegedly “misappropriating” (read: stealing) $12 million. Young received more than $100 million in funds meant to help address the out-of-control homelessness problem in California. Instead, he diverted millions to “a high-end nightclub, a nearly $50,000 trip to Tahiti, and a $140,000 restoration of a vintage Chevy Impala,” according to *CalMatters*. Federal authorities charged at least two other people with defrauding taxpayers by stealing homeless funds. At least one has already pleaded guilty. Authorities expect more charges to come, as a scathing 2025 report “found L.A. city officials failed to properly track $2.3 billion in homeless funds.” “We have not seen the results you would expect for billions of dollars being spent,” Los Angeles County District Attorney Nathan Hochman announced. He said “many more” prosecutions are expected. Federal California district attorney Bill Essayli made a similar comment. “There’s no vetting. There’s no auditing. There’s no accounting. It was just a rush to push as much money out the door as possible,” he said. As critics have pointed out, nonprofits that are supposed to help the homeless have no incentive to do so. The worse the homelessness crisis gets, the more money the scammers can expect from the government. \*\*\* While these are a few of the most shocking examples of fraud uncovered so far during the Trump administration, they’re hardly the only ones. Taken together, they make abundantly clear that stealing from the taxpayer has become a multi-billion-dollar industry in America. The most infuriating part of this saga for everyday Americans may be that the fraudsters are not particularly clever. They make virtually no effort to hide their schemes because, until now, no one in power has bothered to look under the hood and see where the money is really going. Now, Trump is cleaning up the mess and putting the thieves on notice. But the question remains: is this a permanent change, or will the next administration allow a return to the broken status quo? It ultimately will be up to voters to decide. **Topics:** Medicare/Medicaid, Regulatory actions, Testing Fraud --- ### [Las Vegas Business Owner Pleads Guilty to $90,000 Insurance Fraud Scheme](https://insurancefraud.org/news_archives/las-vegas-business-owner-pleads-guilty-to-90000-insurance-fraud-scheme/) **Published:** October 4, 2026 **Author:** Diane Beauchamp **Content:** A Las Vegas business owner pleaded guilty today to arranging a fake armed robbery of his cell phone repair store to collect money from his insurance company. “When a business owner chooses to engineer a $90,000 fraud scheme, they are not engaging in a victimless crime,” said First Assistant United States Attorney Sigal Chattah for the District of Nevada. “They are driving up premium costs for honest, hardworking business owners who play by the rules every day. Our office, in lockstep with our federal and state law enforcement partners, will continue to vigorously investigate and prosecute individuals who prioritize corporate greed over legal accountability. This guilty plea underscores our unwavering commitment to safeguarding the integrity of our financial systems and protecting insurance providers from deceptive exploitation.” “Erwin Lanada ran a calculated scheme of deception, involving a co-conspirator to fake a robbery at gunpoint for financial gain,” said Special Agent in Charge Christopher S. Delzotto for the FBI Las Vegas Field Office. “The FBI, working alongside local law enforcement, successfully thwarted his scheme. His guilty plea highlights law enforcement’s commitment to protecting financial systems from fraud, which directly impacts the insurance premiums for many Americans. Insurance is a tool American families depend on to safeguard their assets and finances. That tool has become more and more expensive for every American family due to fraud and fraud’s impact on skyrocketing premiums.” According to court documents, Erwin Lanada owned CPR Cellphone Repair, a store in Las Vegas that repaired and sold cell phones and other electronic devices. On October 25, 2023, Lanada hired and gave Marco Antonio Capistran a revolver to use during a fake robbery of CPR Cellphone Repair, and he promised to pay Capistran for his participation. On October 26, 2023, during the fake robbery, Capistran pointed the revolver at Lanada, he demanded electronic devices, parts, and cash, and he tied Lanada with zip ties, then fled the store. On October 28, 2023, Lanada filed fraudulent insurance claims with his insurance company for property loss and loss of income purportedly resulting from the fake robbery. In December 2023, the insurance company sent Lanada checks totaling approximately $88,611.23 for his claims. Lanada pleaded guilty to one count of mail fraud. He faces the statutory maximum penalty of 20 years in prison at sentence before United States District Judge Richard F. Boulware II on January 5, 2027. A federal district court judge will determine the sentence after considering the U.S. Sentencing Guidelines and other statutory factors. This case was investigated by the FBI and Las Vegas Metropolitan Police Department. Assistant United States Attorney Daniel R. Schiess is prosecuting the case. **Topics:** Business - padding/faking **Categories:** Conviction --- ### [Four Sentenced for Conspiring with Annandale-Based Doctor to Illegally Distribute Oxycodone and other Controlled Substances](https://insurancefraud.org/news_archives/four-sentenced-for-conspiring-with-annandale-based-doctor-to-illegally-distribute-oxycodone-and-other-controlled-substances/) **Published:** October 4, 2026 **Author:** Diane Beauchamp **Content:** Four Maryland residents who conspired with Dr. Rotimi Iluyomade, an Annandale-based doctor convicted of distributing more than 7,000 oxycodone pills, 34,000 milliliters of hydrocodone-chlorpheniramine solution (also known as “Tussionex”), and 107,000 milliliters of promethazine-codeine solution (also known as “lean”) were sentenced today in federal court. Yared Michael Tesfaye, a.k.a. “Yar” 29, of Montgomery Village, Maryland, was sentenced today to 60 months in federal prison. Elhadj Malick Diallo, 32, of Silver Spring, Maryland, was sentenced to time served (approximately 13 months) in federal prison. Cameron Isaiah Lewis, 24, and Raymono Alfonzo Russell II, 25, both of Bowie, Maryland, were sentenced to 8 months and 10 months respectively. All four defendants previously pleaded guilty to conspiracy to distribute and possess with the intent to distribute Schedule II controlled substances and to acquire promethazine-codeine solution by fraud. “Any physician and anyone who conspires with a physician to facilitate the illegal distribution of drugs will be aggressively prosecuted in the Western District of Virginia,” First Assistant United States Attorney Robert N. Tracci said today. “I applaud the outstanding work of the FBI and the DEA in this case.” “The defendants paid a doctor to issue fraudulent prescriptions for opioid medications and then trafficked those drugs to buyers across multiple states,” said Darren Cox, Assistant Director in Charge of the FBI Washington Field Office. “We are grateful to our federal, state, and local partners for their help in ensuring these defendants are held accountable for profiting from the illegal distribution of controlled substances.” “Patient care is a privilege. Patient safety is a responsibility. When responsibility is betrayed through the unlawful prescribing of controlled substances, DEA and other law enforcement partners will act decisively and with one purpose: protecting American lives,” said DEA Special Agent in Charge Cindy Marx of the Washington Division. According to court documents, in at least 2023 and 2024, Iluyomade and the co-conspirators entered into an agreement to distribute oxycodone pills, promethazine-codeine solution, and Tussionex to pharmacies in multiple states, including California, Colorado, Nebraska, Arizona, Missouri, Florida, Pennsylvania, Maryland, New Jersey, Delaware, Rhode Island, Georgia, Wisconsin, Texas, West Virginia, and in the Eastern and Western Districts of Virginia. At least 70 of the illegal controlled substance prescriptions were transmitted to and/or filled at pharmacies in the Western District of Virginia. As part of the conspiracy, multiple individuals visited Iluyomade’s medical clinic to obtain fraudulent prescriptions. The individuals provided Iluyomade with lists of multiple “patients” addresses and identify information or different variations of names and false addresses, and requested prescriptions be sent to pharmacies throughout the United States for the “patients” on the lists. Tesfaye was the first co-conspirator to visit Iluyomade at Crossover Medical Center in Annandale, Virginia to obtain fraudulent prescriptions. In addition to obtaining his own fraudulent prescriptions, he sold “slots” with Iluyomade to other co-conspirators that they used to obtain fraudulent prescriptions. Lewis and Diallo traveled to various pharmacies to pick up fraudulent prescriptions written by Iluyomade, which they then distributed for profit, often posting pictures on social media to facilitate drug sales. Lewis and Diallo paid Iluyomade $300 per fraudulent prescription. The investigation began on September 2, 2023, when Russell attempted to pick up a fraudulent prescription transmitted by Iluyomade at a pharmacy in Honaker, Virginia. Russell was arrested and a search of his vehicle revealed multiple controlled substance prescription bottles in various “patient” names, all from Iluyomade, filled at pharmacies in Roanoke, Radford, Tazewell, and Floyd, Virginia. The Drug Enforcement Administration, Federal Bureau of Investigation, Virginia State Police, Russell County Sheriff’s Office, Salisbury, Maryland Police Department, Loudoun County Sheriff’s Office, Nebraska State Police, HHS-OIG, and the Food and Drug Administration (FDA) are investigating the case. Assistant U.S. Attorneys Lena Busscher and Randy Ramseyer are prosecuting the case. **Topics:** Drug Diversion **Categories:** Conviction --- ### [Social Adult Day Care Owner Pleads Guilty to $65M Medicaid Fraud](https://insurancefraud.org/news_archives/social-adult-day-care-owner-pleads-guilty-to-65m-medicaid-fraud/) **Published:** October 4, 2026 **Author:** Diane Beauchamp **Content:** A Brooklyn man pleaded guilty today to defrauding New York State Medicaid of approximately $65 million through claims for social adult day care services and home health care services that were not provided. According to court documents, Ahsan Ijaz, 29, of Brooklyn, New York, was an owner of Happy Family Social Adult Day Care Center, Inc. and Family Social Adult Day Care Center Inc., social adult day care centers located in Brooklyn, and Responsible Care Staffing Inc., a home health care fiscal intermediary in Brooklyn. Over approximately seven years, Ijaz’s businesses paid cash kickbacks and bribes to Medicaid recipients to induce them to enroll with the businesses and billed Medicaid for services that were not provided, including when certain Medicaid recipients were not in the United States at the time of service. Ijaz is the 10th defendant to plead guilty in connection with the scheme. Ijaz pleaded guilty to conspiracy to commit health care fraud. He is scheduled to be sentenced on March 10, 2027 and faces a maximum penalty of 10 years in prison. A federal district court judge will determine any sentence after considering the U.S. Sentencing Guidelines and other statutory factors. Assistant Attorney General Colin M. McDonald of the Justice Department’s National Fraud Enforcement Division (Fraud Division); U.S. Attorney Joseph Nocella Jr. for the Eastern District of New York; Acting Deputy Inspector General for Investigations Miranda L. Bennett of the U.S. Department of Health and Human Services, Office of Inspector General (HHS-OIG); Acting Special Agent in Charge Pete Gizas of Homeland Security Investigations (HSI) New York; and Commissioner Jessica S. Tisch of the New York City Police Department (NYPD), made the announcement. HHS-OIG, HSI New York, and NYPD investigated the case. Deputy Chief Patrick J. Campbell and Trial Attorney Leonid Sandlar of the National Fraud Enforcement Division’s Health Care Fraud Section are prosecuting the case, with the assistance of Assistant U.S. Attorney Claire Kedeshian for the Eastern District of New York, who is assisting with forfeiture matters. On April 7, the Department of Justice announced the creation of the Fraud Division. The Fraud Division is laser-focused on investigating and prosecuting those who commit fraud against the American people. The Department’s work to combat fraud supports President Trump’s Task Force to Eliminate Fraud, a whole-of-government effort chaired by Vice President J.D. Vance to eliminate fraud, waste, and abuse within Federal benefit programs. The Department of Justice’s Health Care Fraud Strike Force Program, currently comprised of nine strike forces operating in federal districts across the country, has charged more than 6,200 defendants who collectively billed federal health care programs and private insurers more than $45 billion since 2007. In addition, the Centers for Medicare & Medicaid Services, working in conjunction with HHS-OIG, are taking steps to hold providers accountable for their involvement in health care fraud schemes. More information can be found at [www.justice.gov/criminal-fraud/health-care-fraud-unit](http://www.justice.gov/criminal-fraud/health-care-fraud-unit). **Topics:** Medicare/Medicaid **Categories:** Conviction --- ### [Governor Hochul Announces New Regulation Proposed by the Department of Financial Services Increasing Transparency for Policyholders in the Auto Insurance Market](https://insurancefraud.org/news_archives/governor-hochul-announces-new-regulation-proposed-by-the-department-of-financial-services-increasing-transparency-for-policyholders-in-the-auto-insurance-market/) **Published:** October 3, 2026 **Author:** Diane Beauchamp **Content:** Governor Kathy Hochul today announced that the New York State Department of Financial Services (DFS) has proposed a regulation amending the process for filing private passenger auto insurance rates, implementing reforms enacted in the Fiscal Year 2027 Budget to help bring down the cost of auto insurance in New York State. The regulation will increase transparency by requiring insurers to receive prior approval for any private passenger automobile rate increase requests. The enacted FY27 Budget delivers sweeping reforms to address key factors driving up auto insurance premiums, including insurance fraud and excessive litigation costs. The proposed regulation issued by DFS is an important step in enacting these reforms. “New Yorkers deserve a transparent, fair and accountable auto insurance market that puts customers first,” **Governor Hochul said.** “This regulation delivers on our commitment to strengthen consumer protections and give policyholders greater confidence that insurance companies are being held to clear standards. As we continue to work to lower costs, combat fraud and make New York State more affordable, we are helping families and businesses make informed decisions and ensuring insurers remain accountable to their customers.” **New York State Department of Financial Services Acting Superintendent Kaitlin Asrow said,** “This regulation strengthens transparency for New York policyholders by ensuring that any increase in private passenger auto rates is subject to comprehensive and independent review.” **Assemblymember David Weprin said,** “New Yorkers deserve relief from rising auto insurance costs, as well as greater transparency and accountability when rates change. Requiring insurers to receive prior approval before raising private passenger auto rates is an important consumer protection and a key part of the reforms we enacted in this year’s State Budget. I commend Governor Hochul and the Department of Financial Services for moving swiftly to implement these measures, and I look forward to continuing our work to combat insurance fraud, reduce unnecessary costs and make auto insurance more affordable for New York drivers.” The regulation published today implements new regulatory safeguards and transparency measures for drivers in New York. Currently, insurers may implement no more than two overall average private passenger auto rate increases without the Department’s prior approval if the cumulative effect of the rate increases are within 5%. The proposed regulation requires insurers to seek express prior approval from DFS before *any* upward rate changes. Additionally, the regulation ensures insurers notify policyholders about rate decreases taken without prior approval resulting from Fiscal Year 2027 budget reforms and explain why the changes are happening. This announcement builds on New York’s efforts to address property/casualty insurance costs, including [guidance on rate filings and mandatory premium discounts](https://www.dfs.ny.gov/reports_and_publications/press_releases/pr20260701), [specialized auto insurance fraud prevention training](https://www.dfs.ny.gov/reports_and_publications/press_releases/pr20260722), and DFS’s [Insurance Discounts and Savings webpage](https://www.dfs.ny.gov/consumer-insurance-discounts-savings). A 60-day public comment period will commence today upon the proposed regulation’s publication in the State Register. The law and regulation will take effect on November 27, 2026. Visit the DFS [website](https://www.dfs.ny.gov/industry_guidance/regulatory_activity/insurance) to review the proposed regulation or submit feedback. **Topics:** Legislation --- ### [SLED Charges Dorchester County Man with Insurance Fraud](https://insurancefraud.org/news_archives/sled-charges-dorchester-county-man-with-insurance-fraud-2/) **Published:** October 3, 2026 **Author:** Diane Beauchamp **Content:** The South Carolina Law Enforcement Division (SLED) charged Forrest Sanders Smith IV, also known as Chip Smith, 61, with five counts of Forgery – Value $10,000 or more, two counts of Fraud Regarding Payment of Insurance Premium, and Fraudulent Insurance Application by an Agent on Tuesday, September 29, 2026. The South Carolina Department of Insurance requested the SLED investigation. Smith was booked into the Florence County Detention Center. Details can be found in the attached warrants. The case will be prosecuted by the South Carolina Department of Insurance. **Topics:** Insider - agent **Categories:** Arrest --- ### [Why cybersecurity is a team sport](https://insurancefraud.org/news_archives/why-cybersecurity-is-a-team-sport/) **Published:** October 3, 2026 **Author:** Diane Beauchamp **Content:** # Key takeaways: AI can make fraud and scams harder to spot and detect Verify unexpected messages and calls through a separate, trusted channel. For instance, if your bank calls you, hang up and call back using the number on the back of your debit card Use strong, unique passwords for every account Learn about how AI is changing cybersecurity and why this might matter for you. Share what you learn with friends and loved ones so everyone can be better prepared Cybersecurity is a team sport. And that’s even more true today, said Chuck Kennedy, Vice President, Global Security and Defence at TD. Artificial intelligence is rapidly changing the cybersecurity landscape. Not only can powerful AI models help expose cybersecurity flaws within organizations, but these tools can also be used by bad actors to gain access to systems and perpetrate fraud and scams. Kennedy said organizations across Canada, and throughout the world, are working together to help bolster security for all. At TD, teams – often with the assistance of AI tools – work to help keep clients and colleagues safe. “If you think of the world of security, of any organization, as an onion, the different layers are the types of security we rely on to ensure that you can’t get down to the middle, which is the area we’re trying to protect,” said Kennedy. While artificial intelligence can work to try and break through those layers, Kennedy said teams at TD, are working at a never-before-seen pace to help manage this risk. That team sport analogy extends beyond an organization like TD. Individuals have a role to play when it comes to protecting themselves, too. ## 3 ways to help protect against frauds and scams AI can make it more difficult to spot fraud. With AI, scammers can write better, more convincing phishing and smishing (phishing via text) messages and can even convincingly impersonate friends, family, and famous people via phone calls, images, and videos. AI has also made it easier for scammers to generate and distribute large volumes of increasingly sophisticated (and easier-to-fall-for) phishing and smishing messages at scale. But, even as technology advances, we can still heed tried and true fraud prevention advice to help stay safe. **1. Verify everything** 1. “Always try to verify on a different communications channel,” said Kennedy. That means, if you receive a fishy or unexpected phone call or message from a loved one or an institution, like a government agency or your bank, try to confirm its authenticity using an alternative mode of communication. For instance, if you get an unexpected call or text from your bank, even if it sounds legitimate, hang up and call back using a verified number, like the one on the back of your debit card. Receive an email from your boss asking you to purchase something slightly unusual, such as gift cards? Receive a call from your bank telling you someone will come to your home to pick up your debit or credit card? Verify their request over the phone, or even, in-person. Many of us are familiar with two-factor authentication emails and text messages. But now, many organizations, including TD, are moving towards in-app verification. For instance, when you make an online purchase with a TD-issued credit card, you might be prompted to verify the purchase in-app. “You’re going to see more of that because you will have opened that app up yourself and you’ll be in control,” Kennedy said. **2. Choose strong passwords** 1. This might seem like the oldest piece of advice, but strong passwords remain important. It’s equally important to avoid reusing passwords across different platforms. “I’m making sure that I’m doing upper and lower case, I’m throwing in special characters, I’m meeting or exceeding the requirements of the password that I’m asked to enter,” said Kennedy. An easy way to create a strong password is to think of an easy-to-remember phrase, like Go Jays. To make it a strong password, you could try: G0-J@y5. Can’t keep track of all of your passwords? You can try using a secure password management system. **3. Learn about the changing cybersecurity landscape** 1. While stories about AI-enabled frauds and scams make their way into the regular news cycle, Kennedy said, the average Canadian has a lot to learn about the ever-changing cybersecurity landscape. He recommends doing some basic research about the threats – and opportunities – posed by new AI models, and what organizations and governments around the world are doing to prepare. It’s also important to share knowledge about cybersecurity with family and friends. Not only can this help boost fraud prevention, but it can begin to make those around you more comfortable verifying everything and sharing if they’ve fallen – or almost fallen – for a scam. It’s a team sport, after all. **Topics:** Public Awareness, Technology --- ### [Insurance agent pleads guilty to fraud, shaves 43 years off possible sentence](https://insurancefraud.org/news_archives/insurance-agent-pleads-guilty-to-fraud-shaves-43-years-off-possible-sentence/) **Published:** October 3, 2026 **Author:** Diane Beauchamp **Content:** A Pensacola insurance agent pleaded guilty Thursday to three charges related to his insurance fraud case. Daniel Raney pleaded guilty to organized fraud, misappropriation of insurance funds and using a two-way device to facilitate a felony for fraudulently obtaining insurance funds during an Oct. 1 hearing. As part of the plea, the Office of the State Attorney plans to drop the rest of Raney’s charges at his sentencing hearing. The charges expected to be dropped are racketeering, money laundering, two counts of grand theft over $100,000 and one count of grand theft between $20,000 and $100,000. Raney owns Raney Ventures LLC and signed two premium finance agreements with AFCO Credit Corp. to fund insureds through his own company despite not purchasing insurance. According to law enforcement, AFCO received “a few” premium installments before the payments ceased. An investigator with the Florida Department of Financial Services’ Bureau of Insurance Fraud said AFCO issued $237,580.20 to Gulf Coast Management LLC and $80,504.82 to I-10 Investments. Both companies are owned by Raney, and the Bureau of Insurance Fraud got involved after AFCO determined the two companies ‘may not be legitimate.'” Despite Raney’s three charges typically coming with a maximum prison sentence of 50 years, his plea agreement caps his prison sentence to seven years, according to Judge Amy Brodersen. Raney is scheduled to be sentenced Nov. 10. **Topics:** Insider - agent **Categories:** Conviction --- ### [Minidoka County jury convicts Rupert man of felony insurance fraud in house fire claim](https://insurancefraud.org/news_archives/minidoka-county-jury-convicts-rupert-man-of-felony-insurance-fraud-in-house-fire-claim/) **Published:** October 3, 2026 **Author:** Diane Beauchamp **Content:** The Idaho Department of Insurance (DOI) announced that Justin Tate of Rupert, Idaho, was convicted of felony insurance fraud following an investigation by the Department’s Fraud Unit. A Minidoka County jury found Tate guilty on July 8, 2026. DOI states the case began on Aug. 5, 2023, when Tate filed a house fire claim with Farm Bureau Mutual Insurance Company after the total loss of his Rupert home. As part of the claims process, Tate later provided Farm Bureau with an invoice for $10,657.19, which he claimed was issued by “Tates Rents” and covered tractor rental, labor, fuel, consumable items and related charges. Farm Bureau raised concerns about the invoice’s authenticity, prompting the DOI Fraud Unit to investigate. On Sept. 26, 2024, investigators contacted Tates Rents to verify the document. The company confirmed the invoice was not theirs, provided a sample of legitimate invoices and stated no rental account existed for Tate or the property address listed. The investigation further determined that Tate had not rented any equipment from the company. Following Tate’s conviction, he was sentenced on Sept. 22, 2026, in Minidoka County. The court imposed a three-year prison sentence, which was suspended in favor of three years of supervised probation. Tate was ordered to serve 10 days in jail and must pay restitution and associated fines. **Topics:** Homeowners - arson **Categories:** Conviction --- ### [San Mateo Co.: Former Deputy Sentenced To 5 Months In Jail For Workers' Comp Fraud](https://insurancefraud.org/news_archives/san-mateo-co-former-deputy-sentenced-to-5-months-in-jail-for-workers-comp-fraud/) **Published:** October 3, 2026 **Author:** Diane Beauchamp **Content:** A former San Mateo County sheriff’s deputy was sentenced to five months in county jail after pleading no contest earlier this year to felony workers’ compensation fraud charges, prosecutors announced Wednesday. Jorden Faatiga, 35, entered a no contest plea in April to felony charges of workers’ compensation fraud and filing a false document and on Tuesday was sentenced to the county jail term starting in January, along with two years’ probation and paying restitution of more than $61,000 to the county, according to the San Mateo County District Attorney’s Office. Prosecutors said that Faatiga reported an injury to his right elbow suffered while on duty and filed a workers’ compensation claim, then received benefits while working a modified role. However, investigators found surveillance footage that showed Faatiga lifting weights, driving and engaging in intense gym workouts in contradiction to the restrictions he reported to his treating physician, and regularly misrepresented the symptoms of his injury to doctors, according to the District Attorney’s Office. Following his conviction, he was deemed ineligible by the state Commission on Peace Officer Standards and Training to serve as a law enforcement officer in California. Faatiga’s defense attorney was not immediately available Wednesday to comment on the case. Faatiga remains out of custody but prosecutors said a judge ordered him to surrender at the county jail on Jan. 9 to serve his sentence. **Topics:** Work comp - worker **Categories:** Conviction --- ### [Gulf coast physician faces False Claims Act lawsuit in alleged Medicare fraud](https://insurancefraud.org/news_archives/gulf-coast-physician-faces-false-claims-act-lawsuit-in-alleged-medicare-fraud/) **Published:** October 3, 2026 **Author:** Diane Beauchamp **Content:** A Bay City physician faces a False Claims Act lawsuit alleging he fraudulently billed Medicare nearly $500,000 for surgical neurostimulator electrode implantations. Dr. Michael Neret owns and manages Neret MD Medical Clinic and practices in Bay City and Lake Jackson. According to the complaint, Neret billed Medicare for surgical neurostimulator electrode implantations. These complex procedures require an operating room, and Medicare pays thousands of dollars for each procedure. However, the complaint alleges Neret did not perform the surgeries he billed to Medicare. Instead, non-physician practitioners and non-clinical staff allegedly used inexpensive electro-acupuncture devices during brief, in-office sessions. They inserted small electrode wires into patients’ skin and secured the devices behind their ears with adhesive. The complaint further alleges Neret encouraged staff to use the electro-acupuncture devices without explaining how the procedures would benefit patients. Neret allegedly knew the devices were non-billable and used the procedures to justify prescribing narcotics for pain management. The Department of Health and Human Services Office of Inspector General assisted with the investigation. Assistant U.S. Attorneys Laura E. Collins and Michelle Luong are handling the matter. **Topics:** Drug Diversion, Judicial/courts, Medicare/Medicaid, Unlicensed entities --- ### [FinCEN Identifies $17.5 Billion in Suspected Healthcare Fraud, Reinforces Prior Warning to Financial Institutions](https://insurancefraud.org/news_archives/fincen-identifies-17-5-billion-in-suspected-healthcare-fraud-reinforces-prior-warning-to-financial-institutions/) **Published:** October 3, 2026 **Author:** Diane Beauchamp **Content:** **Key Takeaways** - A recent FinCEN report identified approximately **$17.5 billion in suspicious financial activities potentially linked to healthcare fraud** between March 1, 2025 and February 28, 2026 - **Home healthcare providers were the most frequently named provider type**, while FinCEN also indicated hospice, behavioral health and addiction treatment, medical equipment, and daycare providers are recurring areas of concern. - The findings build on FinCEN’s **March 2026 healthcare fraud advisory**, which summarized common fraud and money laundering schemes and provided financial institutions with specific red flags for detecting suspicious activity. - **Healthcare fraud remains an enforcement priority for FinCEN and Treasury**, and Bank Secrecy Act (BSA) reporting is another source for identifying potential fraud. On September 9, the U.S. Department of the Treasury [announced that the Financial Crimes Enforcement Network (FinCEN) had identified approximately $17.5 billion in suspicious financial activity](https://home.treasury.gov/news/press-releases/sb0625/) potentially connected to healthcare fraud. Part of the Treasury Department, FinCEN has primary responsibility for administering and enforcing U.S. anti-money laundering laws such as the Bank Secrecy Act (BSA). The finding is from a new FinCEN Financial Trend Analysis (FTA) examining BSA reports related to suspected healthcare fraud. In addition to summarizing the volume and amount of suspicious payments, the FTA details providers, patterns, and fund flows most often involved in such payments. The FTA is FinCEN’s second major publication focused on healthcare fraud this year. In March, FinCEN [issued an advisory warning financial institutions](https://www.fincen.gov/resources/advisories/fincen-advisory-fin-2026-a001) (the Advisory) about fraud schemes targeting Medicare, Medicaid, and other federal and state healthcare benefit programs. For more information about that action, please review [this April 2026 article](https://www.bassberrygovcontrade.com/fincen-advisory-warns-healthcare-fraud-targeting-medicare-medicaid/). Together, the publications paint a clear picture of the financial activity on which FinCEN and law enforcement are focused and underscore the extent to which – as we discussed in this [September 2026 article](https://www.insidethefalseclaimsact.com/medicare-advantage-false-claims-act-data-driven-fraud-enforcement-2026/) – the government is using data-driven initiatives to further enforcement efforts. **FinCEN Finds $17.5 Billion in Potentially Fraudulent Activity** The FTA reflects FinCEN’s analysis of a large dataset: 5,702 BSA reports, from 471 financial institutions, filed between March 1, 2025, and February 28, 2026. The reports identified approximately $17.5 billion in suspicious activity, including both completed and attempted transactions. The average reported amount was approximately $3.3 million per filing, while the median was approximately $600,000. Depository institutions, *e.g.*, banks and financial cooperatives such as credit unions, are front and center, as they filed approximately 89% of the reports in the dataset FinCEN reviewed and accounted for nearly 87% of the reported suspicious activity amounts. Two large depository institutions alone filed 29% of all healthcare fraud-related reports. FinCEN also found that suspected fraud frequently involved payments from multiple sources. Potentially fraudulent providers often received funds from some or all of Medicare, Medicaid, state programs, and/or private insurers, rather than simply from one single payment program. Medicare payments frequently originated from Medicare Administrative Contractors, while Medicaid payments generally originated from state-level administrators. The activity was overwhelmingly domestic, and involved all 50 states, Puerto Rico, Guam, and the U.S. Virgin Islands. FinCEN did not observe any instance of money being sent from a U.S. government health agency directly to a recipient outside the United States. **Home Healthcare Is Significant But Not the Only Area of Concern** In the FTA, home healthcare is the most frequently reported line of business: such businesses were identified as the suspected fraudulent provider in 20% of all healthcare fraud-related BSA reports. Most home healthcare businesses identified in the FTA were registered at residential addresses. In terms of frequency, home healthcare was followed by hospice providers (identified in approximately 8% of BSA reports), mental and behavioral health and addiction treatment providers (in approximately 7% of reports), medical equipment providers (in approximately 5% of reports), and adult and child daycare providers (in approximately 3% of reports). The FTA cites Centers for Medicare & Medicaid Services (CMS) data estimating a 9.5% improper payment rate for home health and hospice payments in 2025, totaling approximately $2.8 billion. Notably, CMS’ underlying data shows that the vast majority of these “improper payments” stem from insufficient documentation, medical necessity questions, and other administrative errors. **How Do Fraudulent Healthcare Payments Move Through the Financial System?** The flow of funds after providers receive healthcare reimbursements was another major focus. FinCEN observed suspected proceeds being transferred among related companies; moved through circular transactions; paid to individuals; or spent on personal items such as real estate, travel, luxury purchases, and other expenses unrelated to legitimate healthcare operations. In a small number of cases, funds were transferred internationally, though in many cases funds may have been transferred internationally after initial receipt. In its review, FinCEN identified potential connections to larger fraud rings or criminal networks in a small portion of Suspicious Activity Reports (SARs). Importantly, however, the FTA states that most filers did not specifically identify connections to known transnational criminal organizations, even where the reported activity suggested broader criminal networks or foreign connections. **Findings Build on FinCEN’s Healthcare Fraud Advisory, Underscore Compliance Red Flags** The FTA augments the Advisory, which urged financial institutions to identify and report suspicious transactions involving government healthcare benefit programs. The Advisory also noted that BSA reporting associated with healthcare fraud had increased 330% between 2020 and 2025, with a record of more than 3,800 initial SARs identifying healthcare- or health insurance-related suspicious activity in 2025. The Advisory identified several recurring schemes. These included using straw owners and shell companies to establish or acquire healthcare providers; submitting claims for nonexistent, unnecessary, or substandard services; and paying kickbacks or bribes for patient referrals or prescriptions. The Advisory also highlighted means of money laundering of fraud proceeds through domestic and international financial channels, including transfers to shell companies, virtual asset service providers, broker-dealers, online betting platforms, money mule accounts, and foreign financial institutions, as well as cash withdrawals and purchases of real estate and luxury goods. The Advisory also detailed red flags, including the following: - Established providers receiving unusually large reimbursements. - Significant increases in reimbursement following changes in ownership. - Providers receiving large government payments with little evidence of legitimate operating expenses. - Rapid transfers of reimbursements to related shell companies. - Sudden spikes in billing. - Unexplained cash withdrawals. - Significant transfers to foreign jurisdictions. It is important to recognize that a red flag by itself does not mean that fraud or money laundering has occurred. Likewise, the filing of a SAR does not establish that a crime has occurred. Criminal money laundering requires proof of additional elements, including connection to criminal proceeds and the requisite knowledge and purpose. But these red flags mean further investigation is warranted. Notably, the FTA does not directly reflect any impact of the Advisory, since the data underpinning the FTA was collected until February 28, 2026, about one month before the Advisory was issued. FinCEN nevertheless stated that trends observed in BSA reports filed after issuance of the Advisory have been consistent with those identified in the FTA. **What FinCEN’s Healthcare Fraud Report Means for Providers and Banks** The FTA offers clear evidence that BSA reporting is increasingly being used to identify potentially fraudulent healthcare providers and trace payments after they enter the financial system. The FTA emphasizes that BSA reports provide law enforcement with valuable financial intelligence that might not otherwise be available. For financial institutions, the findings in the FTA matched with the red flags identified in the Advisory underscore the importance of special scrutiny of customers operating in home healthcare, hospice, behavioral health, addiction treatment, medical equipment, and other high-risk segments. At the same time, these indicators are starting points, not conclusions. An unusual fact or pattern alone does not establish that underlying claims were fraudulent or that the funds were criminal proceeds. Assessing potential fraud or money laundering requires examining the services, claims, business purpose, and surrounding facts, as well as the elements of the particular offense. Healthcare providers and other companies receiving Medicare, Medicaid, or similar government payments should also take notice. Transaction patterns that do not match a provider’s stated business, rapid transfers to affiliated entities, unexplained changes in reimbursement volumes, limited evidence of ordinary healthcare expenses, and payments for personal or unrelated purposes may not only create traditional fraud or False Claims Act concerns but also generate suspicious activity reporting that can provide federal investigators with additional leads. FinCEN’s latest analysis adds another dimension to the government’s broader focus on identifying and pursuing fraud involving taxpayer-funded healthcare programs. **Topics:** Healthcare Fraud, Public Awareness, Regulatory actions --- ### [76-Year-Old Utah Man Tried To Dodge a $7,319 Repair Bill. Now He Could Face a $10,000 Fine](https://insurancefraud.org/news_archives/76-year-old-utah-man-tried-to-dodge-a-7319-repair-bill-now-he-could-face-a-10000-fine/) **Published:** October 3, 2026 **Author:** Diane Beauchamp **Content:** A driver who decides to carry only the minimum insurance on an older car is making a fairly ordinary financial calculation: pay less every month and accept that a bad day could leave a repair bill sitting squarely in his own lap. That calculation becomes considerably more expensive if, after the bad day arrives, someone tries to move the calendar. Utah insurance investigators say that is what happened after a 2015 Chevrolet Sonic sustained heavy front-end damage. The resulting case is also an unusually clean example of a fraud pattern the Utah Insurance Department tracks as “Crash & Buy”: obtaining coverage after a loss and then representing that the loss occurred later. Then The Dates Shift Harold Leroy Carter, 75, obtained a liability-only Progressive policy for his 2015 Chevrolet Sonic on Jan. 6, 2026, according to a criminal Information filed by the Utah Attorney General’s Office. Liability generally covers losses a driver causes to other people rather than collision damage to his own vehicle, so Carter was effectively carrying that repair risk himself when Troy’s Custom Body & Paint prepared a $7,319.10 estimate for the Sonic at 9:27 a.m. on May 27. Six days later, Progressive’s records show Carter changed the policy from liability-only to comprehensive and collision coverage, which could protect against future losses but could not retroactively insure existing damage. At 1:11 p.m. on July 10, Carter filed a claim reporting that the Sonic had sustained heavy front-end damage on June 26 at 11 a.m., placing the reported accident more than three weeks after the coverage change. Progressive found the May 27 body-shop estimate. That sequence fits what Utah’s Insurance Fraud Division calls auto-accident “past posting,” or “Crash & Buy”: obtaining coverage after damage occurs, then presenting the loss as though it happened after the policy took effect. The insurer referred the matter for investigation, and Dennis Barrera of the Utah Department of Insurance Fraud Division reviewed Progressive’s claim file and audio recordings supplied by Loretta Horton-Moore, identified in the filing as an SIU investigator. Barrera said the records confirmed both the June 3 policy change and that Carter had represented the accident as happening later. On Sept. 8, he obtained the body-shop estimate and supporting timestamped records, confirming that they predated the accident date reported to Progressive. When Barrera contacted Carter the next day, the investigator said Carter confirmed that the accident occurred May 27, while he still had liability-only coverage. Carter said he had “panicked,” added comprehensive and collision coverage, and then made the report. Barrera wrote that Carter admitted he was trying to gain coverage. The Bill Gets Bigger The Utah Attorney General’s Office charged Carter with one count of insurance fraud, and the $7,319.10 estimate affects more than the size of the disputed claim. Under the version of Utah’s insurance-fraud statute cited in the charging document, seeking $5,000 or more through this type of fraudulent claim can make the offense a second-degree felony, carrying a possible prison term of one to 15 years and a fine of up to $10,000. So a $7,319 repair bill has become a criminal case carrying substantially greater financial and legal exposure. Recent Utah car-insurance cases show what similar schemes have cost defendants even when the final convictions were misdemeanors. In one case documented by Utah’s Insurance Fraud Division, a driver bought insurance for a 2024 Hyundai Elantra after the vehicle had already been damaged, then reported the accident as occurring after the policy began. The $4,219 case was initially filed as felony insurance fraud before the defendant pleaded guilty to a Class A misdemeanor and received 18 months of probation, a $500 fine, $451 in investigative costs and a required thinking-errors class. Another case involved an uninsured driver who crashed and then had someone else add the vehicle to an insurance policy. Investigators said the pair changed the timing of the accident while seeking $38,538 from Progressive. Both pleaded guilty to Class A misdemeanor insurance fraud and each received 18 months of probation, a $750 fine and $606 in investigative costs. Dropping collision coverage on an older car can still make financial sense when the premium is high relative to the vehicle’s value, but the savings only work if the owner can absorb the loss personally. Someone who saves $50 a month by declining collision coverage saves $600 a year. Put aside, that money becomes a reserve for the risk the driver chose to keep. Spent elsewhere, the premium disappears while the risk remains. One Stop Before Court Carter’s case was filed in Washington County’s Fifth Judicial District Court under case No. 261501898, where Judge Bryan Pattison ordered him to appear Oct. 29 at 1:30 p.m. Before that appearance, the summons requires Carter to report to the Purgatory Facility, Washington County Jail in Hurricane, to be booked and then released on his own recognizance. Failure to complete the booking process could result in an arrest warrant. All parties are presumed innocent unless and until proven guilty in a court of law. **Topics:** Auto - padding/false claim, Auto - underwriting **Categories:** Arrest --- ### [Lowell Man Sentenced to Prison for Hiding More Than $6 Million in Payroll](https://insurancefraud.org/news_archives/lowell-man-sentenced-to-prison-for-hiding-more-than-6-million-in-payroll/) **Published:** October 3, 2026 **Author:** Diane Beauchamp **Content:** A Lowell man was sentenced today in federal court in Boston for his involvement in payroll tax avoidance and workers’ compensation insurance fraud. Henry Lam, 68, was sentenced by U.S. District Court Chief Judge Denise J. Casper to 13 months in prison, to be followed by two years of supervised release. Lam was also ordered to pay $1,652,573 in restitution. Lam was arrested in July 2025, following his June 2025 indictment, and pleaded guilty to failure to collect and pay over taxes and mail fraud in May 2026. Between 2016 and 2023, Lam owned and operated HL Temporary Services – a temporary employment agency in Lowell that served client companies in New England. The client companies paid HL Temporary Services for the temporary employees’ work on an hourly basis. Lam cashed these client’s checks at check cashing businesses in Massachusetts and paid the temporary employees primarily in cash. By using cash payments, Lam hid over $6.2 million in payroll and avoided paying more than $1.5 million in required payroll taxes. Lam also used HL Temporary Services’ false payroll numbers to obtain worker’s compensation insurance at lower premium rates. United States Attorney Leah B. Foley and Thomas Demeo, Special Agent in Charge of the Internal Revenue Service’s Criminal Investigations in Boston made the announcement. Valuable assistance was provided by the Insurance Fraud Bureau of Massachusetts. Assistant U.S. Attorney Kristen A. Kearney of the Securities, Financial & Cyber Fraud Unit prosecuted the case. **Topics:** Financial Fraud, Work comp - employer **Categories:** Conviction --- ### [Kansas Woman Sentenced to Probation for Insurance Fraud](https://insurancefraud.org/news_archives/kansas-woman-sentenced-to-probation-for-insurance-fraud-3/) **Published:** October 3, 2026 **Author:** Diane Beauchamp **Content:** A Leavenworth County, Kansas woman has been sentenced to 12 months of probation for insurance fraud, Insurance Commissioner Vicki Schmidt announced. Jennifer Walker, aged 48, pleaded guilty on July 29, 2026, in Leavenworth County District Court to one felony count of attempted insurance fraud. Following a collision, Walker misrepresented the date of the event during her auto claim to obtain coverage of loss that occurred prior to the inception of her new policy. She was sentenced on September 9, 2026, to 12 months of probation. “Every time someone commits insurance fraud, it causes families and businesses across Kansas to pay more,” said Schmidt. “The Department will continue to hold these individuals accountable.” The Kansas Department of Insurance investigated this case which was prosecuted by the Kansas Attorney General’s Office. **Topics:** Auto - underwriting **Categories:** Conviction --- ### [Insurance agent charged with multiple felonies following 18-month investigation](https://insurancefraud.org/news_archives/insurance-agent-charged-with-multiple-felonies-following-18-month-investigation/) **Published:** October 3, 2026 **Author:** Diane Beauchamp **Content:** A 41-year-old Iosco County man has been charged with embezzlement and other felonies following an 18-month investigation. Oscoda Township police said investigators had been looking into alleged criminal activity involving a local insurance agent, serving a search warrant, reviewing financial documents and interviewing witnesses. An eight-count felony warrant was issued for the suspect. Police said the charges include embezzlement and illegal use of a financial transaction device. The man turned himself in Wednesday at the Iosco County Jail. **Topics:** Insider - agent **Categories:** Arrest --- ### [Attorney General’s office charges nine people with Medicaid fraud totaling $3 million](https://insurancefraud.org/news_archives/attorney-generals-office-charges-nine-people-with-medicaid-fraud-totaling-3-million/) **Published:** October 3, 2026 **Author:** Diane Beauchamp **Content:** **For the third time this year —** **[there’s a proposed merger involving major healthcare systems in Minnesota](https://www.mprnews.org/story/2026/09/29/healthpartners-and-essentia-health-announce-plan-to-merge)**. This time it’s Twin Cities-based HealthPartners and Duluth-based Essentia Health that are planning to combine under the HealthPartners name. **The Minnesota Attorney General’s office has** **[charged nine people with Medicaid fraud totaling $3 million](https://www.mprnews.org/story/2026/09/29/minnesota-attorney-general-keith-ellisons-office-charges-9-people-with-medicaid-fraud)**. Of that money allegedly stolen from Minnesota’s Medicaid programs, $2 million is connected to Peter Meilahn. He’s a Duluth resident who provided psychotherapy and mental health services through his own practice and worked as an independent contracted therapist for Franklin Family Services. **Starting Thursday, thousands of immigrants in Minnesota will lose access to Medicaid benefits.** Refugees and asylees used to have those benefits while they awaited a green card, but a new federal law taking effect Thursday makes them ineligible. **A Roosevelt High School teacher in Minneapolis who was violently detained by federal agents outside the school in January has** **[filed a claim against the government](https://www.mprnews.org/story/2026/09/29/roosevelt-teacher-quentin-williams-files-federal-claim-over-violent-detention-by-agents).** The claim alleges that federal agents lied about what happened. It’s the first step in the long process of suing the federal government for violating Quentin Williams’ constitutional rights. The government has six months to respond. **A pilot project in St. Cloud to remove PFAS — or forever chemicals — from sewage is showing success**. [Researchers say the technology destroyed more than 99 percent of PFAS in bio-solids pulled from wastewater in the city](https://www.mprnews.org/episode/2026/09/28/pfas-pilot-in-st-cloud-finds-success-in-destroying-forever-chemicals). Such waste has been used as fertilizer in the past, but led to soil contamination as PFAS levels grew. **The** **[Minnesota Lynx had their season come to an end Tuesday](https://www.mprnews.org/story/2026/09/29/minnesota-lynx-lose-to-new-york-liberty-eliminated-from-wnba-playoffs)**, losing to the New York Liberty 87-71. New York swept the best-of-three series. **Topics:** Medicare/Medicaid **Categories:** Arrest --- ### [Montana Department of Justice uncovers $2.4 million Medicaid fraud scheme](https://insurancefraud.org/news_archives/montana-department-of-justice-uncovers-2-4-million-medicaid-fraud-scheme/) **Published:** October 3, 2026 **Author:** Diane Beauchamp **Content:** The Montana Department of Justice’s Medicaid Fraud Control Unit (MFCU) recently uncovered nearly $2.4 million in fraudulent Medicaid claims, the largest scheme the unit has uncovered in its history, Attorney General Austin Knudsen announced today. On Sept. 15, a judge ordered Kevin Patrick Maxwell, a licensed clinical social worker and the former owner of Providence Mental Health Services (PMH) in Bozeman, to pay the state $2,391,277.55 for defrauding Montana taxpayers. MFCU’s investigation found that from January 2022 to November 2024, interns and non-licensed PMH staff, who were not authorized to bill Medicaid, provided mental health sessions that PMH then billed Medicaid. Additionally, PMH was not a licensed mental health center during a portion of that period, which is a requirement for mental health professionals seeking their licensure to bill Medicaid. Maxwell closed PMH in June 2025 and later moved to Texas. MFCU filed a civil complaint against him for violations of the Montana False Claims Act. MFCU Agent Gary Herbst investigated the case, and Assistant Attorney General Alexandra van Belle litigated. MFCU is part of the Montana Department of Justice’s Division of Criminal Investigation, which is overseen by Attorney General Knudsen and is responsible for investigating and prosecuting healthcare providers who defraud the Montana Medicaid program or who abuse, neglect, or exploit patients in Medicaid-funded care facilities. Montanans can report suspected cases of Medicaid fraud and patient abuse, neglect, or exploitation by calling the Medicaid Fraud hotline at 800-376-1115. Stevens Amendment Compliance Statement The Montana Medicaid Fraud Control Unit receives 75 percent of its funding from the U.S. Department of Health and Human Services under a grant award totaling $939,984 for the federal fiscal year (FY) 2026. The remaining 25 percent, totaling $313,325 for FY 2026, is funded by the State of Montana. **Topics:** Judicial/courts, Medicare/Medicaid, Unlicensed --- ### [Defendant Convicted of Workers’ Comp Fraud While Working for SacRT](https://insurancefraud.org/news_archives/defendant-convicted-of-workers-comp-fraud-while-working-for-sacrt/) **Published:** October 3, 2026 **Author:** Diane Beauchamp **Content:** On September 14, 2026, Rona Christina Means was convicted by a jury of felony presenting a false or fraudulent insurance claim; misdemeanor presenting false or misleading information in support of an insurance claim; and misdemeanor making a knowingly false or fraudulent statement to obtain workers’ compensation benefits. Rona Christina Means was working as a SacRT bus operator. Means claimed she was assaulted and repeatedly punched by a passenger on July 25, 2018, and later sought workers’ compensation benefits for her injuries. The California Department of Insurance investigated the case, including interviewing Means, other SacRT employees, doctors and the insurance company. There was also bus surveillance video from multiple camera angles that did not support Means’ claim that she was repeatedly punched or otherwise attacked. Means faces a maximum potential sentence of 5 years in prison and 2 years in county jail. Means also faces approximately $45,500 in victim restitution. Sentencing is set for October 23, 2026, at 1:30 PM in Department 9D before the Honorable Allison Williams. CASE: Rona Christina Means (Case #20FE017775) PROSECUTOR: Deputy District Attorney Sohrab Haze, Insurance Fraud Unit **Topics:** Work comp - worker **Categories:** Conviction --- ### [Causey: Watch out for insurance fraud’s red flags](https://insurancefraud.org/news_archives/causey-watch-out-for-insurance-frauds-red-flags/) **Published:** October 3, 2026 **Author:** Diane Beauchamp **Content:** “Insurance fraud is a felony. Since ignorance of the law is not a defense, I thought it’d be a good idea to let you know some important things about insurance fraud.” Receiving a payout from an insurance company based on a lie is insurance fraud. Exaggerating the loss of an insurance claim to get more money from an insurance company is insurance fraud. Insurance fraud is a felony. Since ignorance of the law is not a defense, I thought it’d be a good idea to let you know some important things about insurance fraud. According to a 2022 study conducted for the Coalition Against Insurance Fraud, this crime costs Americans $308.6 billion annually. That’s about $3,800 a year for a family of four. Some estimates suggest that 20 cents of every premium dollar go to cover the cost of fraud. Here are a few things to remember about insurance fraud: – Don’t ignore red flags. If you’re suspicious about anything dealing with insurance, stop and call the Department of Insurance at 855-408-1212. We have consumer experts available to answer your questions weekdays from 8 a.m. to 5 p.m. You may also find us online at [www.ncdoi.gov](http://www.ncdoi.gov/). – If you see or suspect fraud, report it. You may anonymously report fraud by calling our Criminal Investigations Division at 919-807-6840 or toll free from anywhere in North Carolina at 888-680-7684. You may also report it online at [www.ncdoi.gov/fraud-control](http://www.ncdoi.gov/fraud-control). We have 50 special agents investigating insurance fraud in North Carolina, along with a team of special prosecutors to assist local district attorneys with fraud cases. – Insurance fraud is a crime which leads to higher rates for all consumers. All businesses must take fraud into account when setting rates. For example, stores take shoplifting and other forms of theft into account when setting prices. The cost of fraud is passed along to consumers in the form of higher premiums. Insurance fraud is a form of theft. It comes in various shapes and sizes. While some insurance fraud acts are intended to defraud consumers, others are committed by consumers. Fake insurance companies or agents defraud consumers by taking money for premiums on bogus policies with no intention of paying claims. Here are some examples: – Scammers may offer fake policies at costs that are significantly lower than competitors’ prices. – Companies may sell non-insurance products marketed to look like insurance. For example, an agent working for a company may sell health discount plans, calling the plan “insurance” when it is an unregulated, non-insurance product. – A dishonest agent may collect a premium from a consumer without forwarding the payment to the company. The consumer believes premiums are paid, while the insurance company has no record of payment and cancels or does not renew the policy. Consumers can also commit fraud. Here are some examples of consumer-initiated insurance fraud: – A motorist may deliberately stage an automobile crash, claim injury and make an insurance claim. – A consumer may exaggerate a legitimate claim, hoping to obtain a larger settlement than he or she is entitled to receive. – A consumer may falsify documents or provide false information on a claim. – A motorist may have allowed an insurance policy to lapse and have a crash. After the crash, the consumer will get the policy reinstated and claim the crash occurred after the policy was reinstated. I hope these tips help you avoid becoming a victim of fraud. Together, we can work to fight insurance fraud and slow the increase in premiums. *Mike Causey is the insurance commissioner for North Carolina.* **Topics:** Coalition Against Insurance Fraud, Fraud General, Public Awareness --- ### [Seven indicted in arson insurance fraud case](https://insurancefraud.org/news_archives/seven-indicted-in-arson-insurance-fraud-case/) **Published:** October 3, 2026 **Author:** Diane Beauchamp **Content:** Several suspects, including family members and associates, were indicted Tuesday in connection to an allegedly years-long arson insurance fraud conspiracy in Ouachita Parish. U.S. Attorney Zachary Keller announced the indictment Tuesday at the Monroe Public Safety Center while warning that arson-insurance fraud was becoming more prevalent across northeastern Louisiana. “What we’re here to do is highlight this case—this case where these defendants were arrested last week—to show that we will not tolerate this type of fraud,” Keller said. “This type of fraud is dangerous, and this type of fraud is a trend that we’re seeing in northeast Louisiana, including in Rayville and Caldwell Parish.” On Sept. 23, seven defendants were indicted for allegedly burning houses down in Monroe and West Monroe to defraud insurance companies and charitable organizations over the course of seven years. Defendants include Lashaundalyn Whitlock Brown, 41, of West Monroe; LaQuadra Whitlock, 26, of West Monroe; Latricia Whitlock, 20 of Monroe; Romenique Whitlock, 37, of Monroe; Jonika James, 25, of Monroe; Iesha Alexander, 26, of Monroe; and Travericka Williams, 27, of Dallas, Texas. “These defendants, as alleged in the indictment, over the course of seven years, burned 13 houses in this community to the ground in order to make over $1 million in fraud proceeds,” Keller said. “Our office has charged these defendants with serious federal crimes.” All defendants are charged with conspiracy to commit wire fraud, wire fraud and use of fire to commit a federal felony. Lashaundalyn, LaQuadra and Latricia Whitlock were additionally charged with conspiracy to commit money laundering, concealment money laundering and structuring. If convicted on all charges, the defendants could serve decades in federal prison. State Fire Marshal (SFM) Chad P. Sonnier explained that the state Department of Insurance (LDI), LDI’s Crime Bureau and the SFM’s Fire Investigation Unit (FIU) began investigating the Whitlocks for potential fraudulent, fire-related insurance claims in May. “A review of multiple claims revealed patterns and common elements, prompting a deeper investigation,” Sonnier said. “Our FIU investigators examined nearly a decade’s worth of fire claims, collected and analyzed fire reports, executed search warrants, reviewed digital records, and conducted numerous witness interviews. This extensive work resulted in the arrest of multiple individuals involved in fraudulent insurance claims, identity theft and other related crimes.” The indictment alleged that between 2019 and 2026, the defendants routinely rented homes, obtained homeowners insurance policies and caused some 13 fires at those rental homes to submit false insurance claims seeking payments for fabricated personal property losses and extended-stay hotel reimbursements. The defendants also submitted fake relief claims with a national humanitarian organization and received cash payments under false pretenses, according to the indictment. From January to August, the FIU investigated over 400 fire incidents and determined 100 to be arson, according to Sonnier. “To date, 78 arrests have been made in connection with 56 of those intentionally set fires,” Sonnier said. “The team has a current case clearance rate of 52 percent, which is double the national FBI statistics. These numbers highlight the efficiency of specialized training, modern equipment and dedicated personnel.” Jonathan Tapp, special agent in charge of the FBI’s New Orleans Field Office, warned that an increased number of insurance fraud schemes could cause insurance companies to raise the cost of premiums. He urged residents to report potential insurance fraud to 1-800-CALL-FBI or local law enforcement agencies. “The cost to Louisiana policy holders is impossible to calculate but every single one of us pays the price when criminals take advantage of programs that are meant to help actual victims,” Tapp said. “There’s also real damage done to businesses who invest in our communities.” Dominique Jones, deputy commissioner for the LDI’s Office of Insurance Fraud, said Insurance Commissioner Tim Temple invested additional resources into the Office of Insurance Fraud. She noted that preventing insurance fraud could strengthen the state’s insurance market. “Today, the LDI uses advanced technology, including artificial intelligence, to help identify suspicious claims, reveal connections and uncover organized fraud that might otherwise go undetected,” Jones said. “We are proud to do this work alongside our law enforcement partners at the local, state and federal level. These efforts are producing results.” **Topics:** Homeowners - arson **Categories:** Arrest --- ### [Inspektlabs Announces AI-Powered Vehicle Damage Assessment for Insurance Claims](https://insurancefraud.org/news_archives/inspektlabs-announces-ai-powered-vehicle-damage-assessment-for-insurance-claims/) **Published:** October 3, 2026 **Author:** Diane Beauchamp **Content:** Inspektlabs has announced an AI-powered vehicle inspection approach designed to help insurers convert vehicle photos and videos into structured damage data for faster and more consistent claims processing. The company’s computer vision technology analyzes vehicle images, identifies visible damage and vehicle parts, and generates information that can be integrated into existing insurance claims workflows. As image-based assessment becomes increasingly common in auto insurance, insurers are looking for ways to use photographs and video beyond simple documentation. Structured information about damaged parts, damage types, and repair requirements can help claims teams evaluate vehicle condition and move eligible claims toward settlement more efficiently. Industry adoption of artificial intelligence is already expanding across insurance operations. A 2022 National Association of Insurance Commissioners (NAIC) survey of private passenger auto insurers found that 88% of 193 responding insurers either used, planned to use, or planned to explore artificial intelligence or machine learning. Claims operations represented the highest reported area of use, at 70%. Repair timelines have also increased attention on claims efficiency. J.D. Power’s 2025 U.S. Auto Claims Satisfaction Study reported an average repair cycle of 19.3 days, compared with 22.3 days the previous year. Vehicles from model year 2019 onward equipped with three or more advanced driver assistance systems recorded an average repair cycle of 21.5 days. Total losses represented 27% of claims in the study. AI-Powered Vehicle Damage Detection Inspektlabs’ inspection process begins when a policyholder, insurer, fleet operator, or other user captures vehicle photos or video using a smartphone. Its AI damage detection software analyzes the visual information using computer vision technology. According to Inspektlabs, its system identifies 21 damage types across 163 vehicle parts, with reported detection accuracy of 90% to 95%, excluding rare corner cases. The platform also evaluates image quality, including blur, lighting, camera angle, and whether relevant vehicle areas are covered. Images that do not meet quality requirements can be identified for retaking. The resulting information is structured into fields describing the affected vehicle part, identified damage, and potential repair decision. These fields can then be mapped against local parts pricing and labor rates to support repair estimates. The company recognizes that image-based inspection has limitations. Minor damage may not always be detected, while internal damage that cannot be seen externally may require additional assessment. As a result, the appropriate level of automation can depend on the complexity of each claim. Supporting Multiple Claims Workflows Inspektlabs has developed its insurance claim automation approach around different levels of claim complexity. Simple and clearly identifiable damage, such as a cracked windshield or broken tail light, can move through an automated process when predefined conditions are satisfied. For claims involving multiple components, an AI-generated estimate can be compared with a repair garage estimate. Inspektlabs states that when the two estimates remain within an agreed variance of approximately 5%, the claim can qualify for automated approval. When the difference between estimates is larger, the claim can be routed to an adjuster. The adjuster can review the available evidence, revise repair costs, and add damage that may not have been identified through image analysis. The technology can also support closed-file review. Settled claims can be analyzed after completion to identify patterns such as inconsistent assessments or potentially inflated repair costs, giving insurers another way to review claims data. Connecting Inspection Data with Existing Systems Inspektlabs has announced that its AI damage detection platform can connect with claims management, fleet and dealer systems through APIs. This allows structured inspection information, estimates and damage records to move into existing operational workflows rather than remaining in a standalone inspection application. The approach also supports post-claim analysis by maintaining structured information that can be reviewed after a claim has been settled. Evidence verification remains an important consideration as insurers increase their use of image-based claims processing. The Coalition Against Insurance Fraud, as summarized by the NAIC, has estimated significant annual costs associated with insurance fraud across insurance lines, including property and casualty insurance. In a January 2026 publication, Debevoise & Plimpton also noted that generative image technology can be used to fabricate or exaggerate vehicle damage in submitted insurance photographs. Suggested safeguards include multiple image angles, reference objects for scale, image-analysis tools, and live video inspection. Inspektlabs’ inspection workflow places image assessment and verification within the same technology environment, supporting insurers as they balance automation with evidence quality. Supporting Human Review and Regulatory Oversight Inspektlabs’ approach does not require every claim to be handled entirely by automation. Clear-cut claims can be processed automatically, while more complex cases can be directed to human adjusters for additional judgment. Regulatory oversight remains an important part of insurance AI adoption. The NAIC Model Bulletin on the Use of Artificial Intelligence Systems by Insurers, adopted in December 2023, calls for insurers to maintain a written AI program. Insurers also remain responsible for applicable claims-handling requirements when technology is supplied by a third-party provider. For insurers adopting automated inspection, this creates an ongoing need for documentation, defined review points, and monitoring of automated outcomes. Model performance on uncommon damage types, acceptable variance between AI and repair-shop estimates, and regulatory expectations remain important considerations as claims automation develops. Through its AI-powered computer vision technology, Inspektlabs is supporting insurers, fleets and dealers in converting vehicle inspection images and videos into structured information that can be used throughout the claims process. About Inspektlabs Inspektlabs is an AI-powered computer vision company focused on vehicle inspection. Its software converts photos and videos into structured vehicle damage data for use by insurers, fleets, and dealers through existing systems. The company also applies its computer vision approach to the inspection of other physical assets. **Topics:** Public Awareness, Technology --- ### [Trainer Ruis Charged With Navy Contracting Fraud](https://insurancefraud.org/news_archives/trainer-ruis-charged-with-navy-contracting-fraud/) **Published:** October 3, 2026 **Author:** Diane Beauchamp **Content:** Owner and trainer Mick Ruis Sr. is one of three scaffolding executives indicted by San Diego federal prosecutors for allegedly conspiring to defraud the United States by using deceptive tactics to secure construction contracts with the U.S. Navy, according to the San Diego Union-Tribune. Ruis is best known for training multiple grade 1 winner and Kentucky Derby (G1) participant Bolt d’Oro. Ruis, who is the lead defendant, was indicted alongside two co-defendants—Isaiah Levi Diehl and Shawn Peilun Huang on federal charges of conspiracy to commit wire fraud and major fraud against the U.S. All three men pleaded not guilty earlier this month in U.S. District Court in San Diego, Calif., according to the Union-Tribune. According to the indictment, the three co-defendants orchestrated two separate contracting fraud schemes across parts of 2020 and 2021 involving Navy Sea Systems Command, commonly known as NAVSEA. The purported scheme, involving a contract with a ceiling of $17.6 million, was allegedly successful when government personnel in 2021 awarded the contract to Vertical Horizon Marine— a supposed small business owned by co-defendant Huang that was eligible for certain contracts the Navy sets aside for small businesses—which was not a small business eligible to win the contract, instead of Vertical Horizon Scaffold, the small business that initially bid on the contract. The second scheme allegedly took aim at NAVSEA’s Southeast Regional Maintenance Center in Florida. Prosecutors state the defendants used Huang’s company, Vertical Horizon Scaffold, to apply for a small-business contract worth up to $7 million. This time, however, they allegedly intended to use the small firm as a front to win the bid before outsourcing the work to two larger companies that were ineligible for the contract. The indictment did not name those companies, but government records showed they were Vertical Horizon Marine and American Scaffold. Ruis’ attorney Jan Ronis told the Union-Tribune, “My only response at this time is that Mr. Ruis has only been given a copy of the indictment and has made an appearance in court in which a plea of not guilty has been entered. Keeping in mind the American tradition that an indictment is not evidence, and a person charged is presumed to be innocent, it would be inappropriate to comment further in this very early stage of the proceedings.” Anthony Colombo Jr., Diehl’s lawyer, also reminded the public that his client is entitled to the presumption of innocence. “It is important to note what the indictment does not allege—there are no allegations that any financial loss occurred,” Colombo said in a statement provided by the Union-Tribune. “The contracts were awarded and completed to satisfaction. Additionally, the indictment, although within the statute of limitations of five years, was filed right before the time expired. The staleness of the timing casts doubt on the accuracy of the allegations.” Ruis trained Bolt d’Oro to a trio of grade 1 victories, including wins in the Del Mar Futurity (G1) and FrontRunner Stakes (G1) in 2017. The son of Medaglia d’Oro would cross the wire second behind eventual Triple Crown winner Justify in the 2018 Santa Anita Derby (G1) but was later promoted to the win in 2024 when California stewards disqualified Justify from the win due to a positive test for scopolamine. Ruis has started limited horses in recent years. According to Equibase, he saddled one winner from 11 starters thus far in 2026. His most recent starter came at Del Mar on Sept. 6 when he sent out Gordon’s Legacy to a sixth-place finish in a starter optional claiming race. Ruis has 69 winners from 596 starts with earnings of $4,499,393 for his career. **Topics:** Contractor fraud **Categories:** Arrest --- ### [Minnesota fraud: Therapist charged in $2.25M Medicaid scheme](https://insurancefraud.org/news_archives/minnesota-fraud-therapist-charged-in-2-25m-medicaid-scheme/) **Published:** October 3, 2026 **Author:** Diane Beauchamp **Content:** The Brief - A Minnesota therapist is accused of receiving more than $2.25 million through fraudulent Medicaid claims. - Charges allege he submitted 27,430 claims for psychotherapy services that were not provided. - He faces 13 felony charges, including theft by false representation and identity theft. A Minnesota therapist is accused of receiving more than $2.25 million in Medicaid payments after allegedly submitting more than 27,400 claims for services that were never provided. Medicaid fraud charges: Peter Jason Meilahn, 50, is facing 13 felony charges, including 11 counts of theft by false representation over $35,000, one count of identity theft involving eight or more victims and one count of identity theft involving more than $35,000. According to the criminal complaint, Meilahn worked as an independent contractor with Franklin Family Services and operated his own practice, Individual Services, providing psychotherapy and behavioral health services. Between October 2019 and March 2026, Meilahn reportedly submitted 27,430 claims for psychotherapy services that were not provided, resulting in more than $2.25 million in Medicaid payments. Patients billed for services they never received The backstory: Investigators said claims involving at least 117 Medicaid recipients lacked required documentation supporting the services he billed. Of those recipients, investigators determined 15 allegedly never had a single session with Meilahn. Eight told investigators they had never provided Meilahn with their insurance information. The complaint alleges Meilahn may have used his access to Franklin Family’s billing system to obtain identifying information for additional Medicaid recipients and submit claims using their information. What they’re saying: Some recipients told investigators they attended between one and four sessions with Meilahn before discontinuing services, yet he allegedly continued submitting claims for services for up to four years afterward. Others said they never received services from him. In one case, Meilahn reportedly submitted more than $127,000 in claims for psychotherapy services for two of a woman’s children between July 2019 and June 2024. The woman told investigators that another of her sons had received services from the Franklin Family about a decade earlier, but the two children named in the claims had never received services from Meilahn. In another case, a woman planned to have her seven children see Meilahn for psychotherapy services and emailed him copies of their UCare insurance cards and birthdates. The children never ended up receiving services from Meilahn, but charges allege he submitted claims for all seven between January 2021 and October 2023 and received more than $150,000 in Medicaid payments. Search warrant for bank accounts Dig deeper: Meilahn opened accounts for Individual Services and himself at several financial institutions, according to the complaint. Search warrants at these financial institutions allegedly revealed that Meilahn transferred money to “law firms, several non-bank financial technology companies and dozens of website building and artificial intelligence companies.” What’s next: Prosecutors charged Meilahn via warrant on Monday. He has yet to make his first court appearance. **Topics:** Medicare/Medicaid, Synthetic Identity Theft **Categories:** Arrest --- ### [Woman accused of pocketing customers’ insurance payments](https://insurancefraud.org/news_archives/woman-accused-of-pocketing-customers-insurance-payments/) **Published:** October 3, 2026 **Author:** Diane Beauchamp **Content:** A woman is facing insurance fraud charges after investigators said she took customers’ cash payments and used the money to pay her own bills. Kelsi Mercer, 36, of Jonesboro, is being held in the Greene County Detention Center after District Court Judge Curtis Hitt found probable cause Sept. 24 to charge her with two counts of fraudulent insurance acts, a Class D felony. Court documents allege that while employed last year at the Arkansas Farm Bureau’s Greene County branch, Mercer took cash payments from customers to pay her bills. Investigation details Dylan Hawkins, with the state’s Insurance Fraud Investigation Division, said in the affidavit that between April 2023 and August 2025, Mercer would collect insurance premiums and enter the payments into the company’s system. Following her termination in August 2025 for “continuous no-call/no-show absences,” Hawkins said irregularities related to the processing of cash on insurance premium payments were found after customers came in and reported they had received documents saying they were “short on their premiums when they knew they paid the full amount and had receipts.” A review of the transactions showed Mercer reversed the cash payment amounts on the days they were made, the affidavit said. “On some of these transactions, the balance would be reapplied later, usually within three weeks,” Hawkins said. “Four transactions were located showing the amount reversed by Ms. Mercer was never reapplied back to the account.” Hawkins said this resulted in an unpaid balance totaling $650.03 that was never paid back. Investigators say Mercer confirmed the scheme During an interview at her residence, Hawkins said Mercer confirmed she accepted cash payments from customers. At the time, she said she was living near Greene County while maintaining another residence in Jonesboro. When asked about the missing money, Hawkins said Mercer stated, “It was me.” “Mercer said she was unable to afford everything and began to take money from the cash payments which she was given by customers so she could use to pay her bills,” Hawkins said. “Mercer said at first she would eventually pay the amount back.” But Mercer said she did not have the money she took and did not pay it back, Hawkins said. **Topics:** Financial Fraud, Insider Fraud **Categories:** Arrest --- ### [2 women charged in $601,000 Connecticut Medicaid fraud investigation](https://insurancefraud.org/news_archives/2-women-charged-in-601000-connecticut-medicaid-fraud-investigation/) **Published:** October 3, 2026 **Author:** Diane Beauchamp **Content:** Two women have been arrested and charged with allegedly defrauding the Connecticut Medicaid program of more than $600,000 through fraudulent billing for autism therapy services, according to the Office of the chief State’s attorney. Alyse Enderle, 39, of Ludlow Mass. and Carmen Wynter, 47, of Hartford, were arrested separately this month by inspectors with the Medicaid Fraud Control Unit. Enderle, who formerly lived in Connecticut, is the owner of Autism Sparkles, an autism specialist group that provides Applied Behavior Analysis therapy. Wynter worked for the company as a behavioral technician. According to investigators, Enderle and Wynter conspired between Dec. 2021 and Sept. of 2023 to submit or cause to be submitted, claims to Connecticut Medicaid for services that were either not provided or not fully provided to clients. The alleged scheme resulted in $353,805.99 in improper Medicaid payments, prosecutors said. Investigators also allege that Enderle separately submitted or caused additional claims to be submitted for other clients for services that were not rendered or were only partially rendered. Those claims resulted in another $248,164.91 in improper payments. In total, Prosecutors allege Enderle’s fraudulent billing resulted in $601,970.90 in improper Medicaid payments. Enderle was charged with: First Degree Larceny Defrauding a Public Community, Health insurance Fraud (2 counts) Conspiracy to Commit First Degree Larceny (2 counts) Wynter was charged with: First Degree Larceny Defrauding a Public Community, Health insurance Fraud Conspiracy to Commit First Degree Larceny Both women were released on $150,000 non-surety bonds. Enderle is scheduled to be arraigned on Tuesday at New Britain Superior Court, Wynter is scheduled for arraignment on Wednesday also at New Britain Superior Court. First-degree larceny by defrauding a public community and health insurance fraud are both Class B felonies, punishable by up to 20 years in prison. The investigation was conducted by the Connecticut Medicaid Fraud Control Unit, which will also prosecute the case. investigators received assistance from the Connecticut Department of Social Services Office of Quality Assurance, the U.S. Department of Health and Human Services, Office of Inspector General, the Connecticut attorney General’s Office and the New Britain Police Department. The Medicaid Fraud Control Unit receives 75% of its funding through a federal grant from the U.S. Department of Health and Human Services, with the remaining 25% funded by Connecticut. Anyone with information about suspected fraud or abuse involving the public health care system can contact the Medicaid fraud Control Unit at (860)-258-5986. The charges are allegations and both defendants are presumed innocent unless and until proven guilty in a court of law. **Topics:** Medicare/Medicaid **Categories:** Arrest --- ### [Luxury Car Rental Company Owner Sentenced to Four Years in Prison for Insurance Fraud Scheme Involving Staged Crash](https://insurancefraud.org/news_archives/luxury-car-rental-company-owner-sentenced-to-four-years-in-prison-for-insurance-fraud-scheme-involving-staged-crash/) **Published:** October 3, 2026 **Author:** Diane Beauchamp **Content:** Attorney General Jennifer Davenport and the Office of the Insurance Fraud Prosecutor (OIFP) announced today that an owner of a high-end car rental company has been sentenced to four years in state prison for insurance fraud involving a staged car crash and fraudulent insurance claim. Bozena A. Kolc, 47, of Edgewater, New Jersey, was sentenced on September 28, 2026 by New Jersey Superior Court Judge James M. Doyle in Bergen County. The court also ordered Kolc to pay approximately $314,000 in restitution for additional losses associated with the broader case. Kolc pleaded guilty on July 21, 2026, to one count of second-degree insurance fraud. “Insurance fraud can drive up expenses for motorists across our state, and it also carries significant costs for perpetrators, as this sentence shows,” said Attorney General Davenport. “As people around our state and nation bear the weight of rising costs, we are committed to holding those who cheat the system accountable.” “This defendant tried to turn a staged crash into a substantial insurance payout,” said Acting Insurance Fraud Prosecutor Bernard J. Cooney. “Kolc insured a luxury vehicle after it had already been damaged and then made several misrepresentations in support of the claim. The claim was never paid, and this sentence holds the defendant accountable for that conduct.” According to documents filed in the case and statements made in court, Kolc was an owner of Imperial Exotics, a luxury car rental business that operated in North Bergen. In December 2024, Kolc and five other defendants were charged in a 33-count indictment following an investigation into the business. Kolc’s guilty plea stemmed from an insurance claim involving a 2021 Bentley Bentayga registered to Kolc and valued at approximately $274,000. The vehicle had already been damaged when Kolc added it to a Geico Insurance Company policy in January 2022. Approximately one month later, in February 2022, the Bentley was reported as having been involved in an accident. As part of her guilty plea, Kolc admitted to several acts of insurance fraud in connection with the claim, including adding the Bentley to the Geico policy after it had already been damaged, submitting a police report detailing a staged accident, making false statements under oath to the insurer, and submitting a forged foreign bank account statement in furtherance of the false claim. Kolc also admitted that the fraudulent claim sought $273,864 from Geico, which did not ultimately pay the claim. Of the five other defendants charged in the indictment, defendants Braden Tyson Brown and Edwyn Macelus are awaiting trial. Defendant Everet Lake was admitted into the Pretrial Intervention program in January 2026 after being indicted on several fourth-degree charges, including conspiracy, forgery, and falsifying or tampering with records. Defendant Terrance Everett pleaded guilty to possession of a false government-issued identification document and was sentenced on May 15, 2026, to one year of probation. Defendant Damian Slezak pleaded guilty to third-degree insurance fraud on April 2, 2026, and is awaiting sentencing. The charges against Brown and Macelus are merely accusations, and they are presumed innocent unless and until proven guilty in court. The case was prosecuted by Deputy Attorneys General Alyssa Pelardis and Crystal Callahan of the Office of the Insurance Fraud Prosecutor. Lt. Amy Carson led the investigation along with Civil Investigator Gabrielle Kane. Acting Insurance Fraud Prosecutor Cooney thanked the Geico Insurance Company and the National Insurance Crime Bureau (NICB) for their assistance in the investigation. OIFP’s mission includes coordination of all anti-insurance fraud activities statewide, and many successful prosecutions are a result of initial anonymous tips. If you suspect insurance fraud or have information about a potential case, OIFP wants to hear from you. You can report fraud anonymously by calling the toll-free hotline at 1-877-55-FRAUD or visiting [www.NJInsurancefraud.org](http://www.NJInsurancefraud.org). State regulations permit a reward to be paid to eligible persons who provide information that leads to an arrest, prosecution, and conviction for insurance fraud. **Topics:** Auto - staged **Categories:** Conviction --- ### [Florida shuts down The Wave Insurance after alleged $100,000 premium scheme](https://insurancefraud.org/news_archives/florida-shuts-down-the-wave-insurance-after-alleged-100000-premium-scheme/) **Published:** October 3, 2026 **Author:** Diane Beauchamp **Content:** Florida Insurance Commissioner Mike Yaworsky ordered an immediate cease-and-desist against Hydrogen Deep LLC, doing business as The Wave Insurance, after regulators determined the company operated without the required license. The action follows a market conduct investigation by the Florida Office of Insurance Regulation and the Florida Department of Financial Services. Investigators said the company sold insurance, collected premiums, issued insurance binders and failed to pay claims without state authorization. “Operating without a required license and soliciting consumers is not only unacceptable, but it can also cause immediate danger to public health and safety,” Yaworsky said. According to regulators, Christopher Jason Brossett, owner of Hydrogen Deep, was arrested in June on charges including grand theft while acting as an insurer and transacting insurance without a certificate of authority. In July, authorities arrested Brady Allen Howard, owner of The Wave Insurance, on allegations of conspiring with Brossett to commit grand theft and operate a business without proper authorization. State investigators said the pair targeted watersports and marine-livery businesses in the Destin area, providing insurance quotes, issuing insurance binders and certificates of insurance, and collecting premiums under various business names. Regulators allege they collected more than $100,000 in premiums and diverted the funds for personal use. The immediate final order states that the respondents’ activities constituted a danger to public health, safety and welfare and requires them to cease insurance operations in Florida. The case is the latest enforcement action involving unauthorized insurance activity in Florida. Earlier this year, regulators ordered American Dream Auto Protect to stop conducting business in the state after determining it operated without the required authorization. Florida officials warn that unlicensed insurance entities may lack the financial oversight and reserves required of authorized insurers, potentially leaving consumers without coverage when claims arise. The Office of Insurance Regulation encourages consumers and businesses to verify that insurers and agents are properly licensed before purchasing coverage. **Topics:** Public Awareness, Regulatory actions, Unlicensed **Categories:** Arrest --- ### [DiNapoli: Brothers Plead Guilty to Defrauding Medicaid Out of $1.6 Million](https://insurancefraud.org/news_archives/dinapoli-brothers-plead-guilty-to-defrauding-medicaid-out-of-1-6-million/) **Published:** October 3, 2026 **Author:** Diane Beauchamp **Content:** New York State Comptroller Thomas P. DiNapoli, Albany County District Attorney Lee C. Kindlon, New York State Police Superintendent Steven G. James, and Acting Medicaid Inspector General Frank T. Walsh, Jr. today announced that two brothers pleaded guilty to grand larceny in the second degree for using three Medicaid transportation companies to systematically defraud the program out of more than $1.6 million. Jawad Choudhary, 44, and Junaid Choudhary, 45, both of Clifton Park, will pay full restitution. “Jawad and Junaid Choudhary sought to defraud New York’s Medicaid system out of over $1.6 million by billing for non-existent services, inflating charges, and paying kickbacks,” DiNapoli said. “They have now been held accountable for their crimes. Medicaid is a vital program that millions of New Yorkers rely on to get the health care they need. My office will continue to work with our law enforcement partners to protect New York’s program from those who try to abuse the system. I thank District Attorney Kindlon, the State Police and the Office of the Medicaid Inspector General for their continued partnership in fighting Medicaid fraud.” “The defendants in this case were bilking the state and lying about services provided to those who truly rely on Medicaid funding to live a healthy life,” Kindlon said. “I applaud the work of the Office of the New York State Comptroller, the Medicaid Inspector General, New York State Police and our Financial Crimes Bureau, who will always work together tirelessly to detect, investigate, and dismantle these health care fraud schemes that drain critical resources from programs intended for those who need medical care the most.” “These two individuals perpetuated a dishonest scheme to financially take advantage of medical transportation people rely on. Financial fraud of any kind is a serious crime that causes all those victimized far-reaching and devastating hardship. We will continue to work with our law enforcement partners to end these illegal acts and hold accountable those who think they can get away with them. I thank the Comptroller’s Office, Albany County District Attorney’s Office, and Office of the Medicaid Inspector General for their continued partnerships,” James said. “This joint effort sends an unmistakable message to those who seek to line their pockets by defrauding the Medicaid program: You will be held accountable,” Walsh said. “Medicaid fraud threatens the health and safety of beneficiaries, wastes taxpayer dollars, and drains essential resources from the health care delivery system. My office is committed to working closely with our state and law enforcement partners to protect the integrity of the Medicaid program, hold wrong doers fully accountable, and preserve precious health care resources.” In October 2024, the New York State Police contacted DiNapoli’s office regarding several related Medicaid providers who were allegedly submitting fake bills to the program. The joint investigation and forensic audit that followed determined that three Medicaid transportation companies, A1 Rides Inc., NY Jet Transport Inc. and Ride to Recovery Corp., allegedly stole more than $1.6 million in total from Medicaid. Under Medicaid regulations, patients may use transportation services for legitimate appointments, which are billed to the Medicaid program by the provider. Group rides are not allowed without prior authorization and approved providers can only bill for mileage once for the group. Junaid Choudhary, the owner of A1 Rides, submitted over $1 million in false claims to the Medicaid program. Jawad Choudhary, owner of NY Jet Transport, submitted over $400,000 in false claims. These claims were submitted from 2021 through 2025. The investigation revealed the Choudhary brothers fraudulently billed the Medicaid program by claiming payment for individual rides which were actually unauthorized group rides, and fraudulently boosted the amount the companies were paid. The defendants also billed for rides that never occurred. The investigation also determined that the defendants allegedly paid kickbacks to the patients. The defendants used the money for mortgage and credit card payments, cash withdrawals, and other personal and business bank accounts. Both defendants pleaded guilty to grand larceny in the second degree before Judge William T. Little in Albany County Court. They are due back in court for sentencing on Dec. 14. Since taking office in 2007, DiNapoli has committed to fighting public corruption and encourages the public to help fight fraud and abuse. New Yorkers can report allegations of fraud involving taxpayer money by calling the toll-free Fraud Hotline at 1-888-672-4555, by filing a complaint online at <https://www.osc.ny.gov/investigations>, or by mailing a complaint to: Office of the State Comptroller, Division of Investigations, 8th Floor, 110 State St., Albany, NY 12236. **Topics:** Medicare/Medicaid **Categories:** Conviction --- ### [Iowa Attorney Sent to Federal Prison in Medicaid Fraud Scheme Involving His Rolls-Royce Vehicle Collection](https://insurancefraud.org/news_archives/iowa-attorney-sent-to-federal-prison-in-medicaid-fraud-scheme-involving-his-rolls-royce-vehicle-collection/) **Published:** October 3, 2026 **Author:** Diane Beauchamp **Content:** Provided False Value for a 1961 Rolls Royce in Elderly Man’s Application for Nursing Home Benefits An Iowa attorney who made a false statement to Iowa Medicaid was sentenced on September 11, 2026, to six months in federal prison. Timothy Mark Anderson, age 67, from Garner, Iowa, received the prison term after an October 30, 2025, guilty plea to one count of false statement relating to a health care matter. Evidence at Anderson’s plea and sentencing hearings showed that Anderson is an attorney licensed to practice in Iowa. Anderson offers financial, tax, and estate planning services from his law office in Garner. Anderson’s legal services have included assisting elderly clients with Medicaid eligibility. Anderson is also an avid collector of Rolls-Royce and other luxury vehicles. Medicaid is a cooperative federal-state health care benefit program for low-income persons and others, including the elderly. As part of his legal practice, Anderson prepared and submitted applications for Iowa Medicaid-funded nursing home care. Iowa Medicaid has rules for eligibility, including an evaluation of the financial resources available to the applicant. In determining the resources of an individual, one automobile is exempt, regardless of value, if it is used for the transportation of the Medicaid applicant or a member of the applicant’s household. Between 2017 and 2022, Anderson told elderly individuals and their heirs to engage in a series of purported transactions with his vehicle collection. Anderson directed families to have the elderly person purportedly “buy” one of his Rolls-Royce or other luxury vehicles before applying for Medicaid benefits. Later, Anderson told the families to have the elderly persons “gift” the same vehicles to the heirs, who then “sold” the vehicles back to Anderson at a lower price. The purported purchasers of Anderson’s vehicles never drove the vehicles and, for the most part, never saw them. For example, in 2021, an elderly couple had over $400,000 assets, including a 2020 Chevrolet Equinox valued at $30,000. The couple wanted to become eligible for Iowa Medicaid, have Iowa Medicaid pay for nursing home expenses, and pass on their assets to their heirs. The husband in the couple was receiving nursing home care at the time without public assistance. In October 2021, Anderson deposited a $186,000 check from the wife into his personal savings account and provided her a certificate of title to a 1961 Rolls-Royce Phantom V. Anderson signed the title for the Phantom V over to her. Anderson also created a bill of sale for the transaction, stating that the car was transferred on October 18, 2021. Two days earlier, on October 16, 2021, Anderson had driven the Phantom V and got into an accident. The car suffered front-end damage, was inoperable, and was towed to a farm shop. On November 4, 2021, Anderson wrote Iowa Medicaid and provided a series of documents to qualify the husband for Iowa Medicaid benefits. Anderson provided a document that stated that the Phantom V had a fair market value of $194,000. At the time Anderson submitted the form to Iowa Medicaid, he knew that the fair market value of the car was not $194,000. Anderson was sentenced in Cedar Rapids by United States District Court Judge Leonard T. Strand. Anderson was sentenced to six months’ imprisonment and fined $25,000. He was ordered to make $184,274.36 in restitution to Iowa Medicaid. He must also serve a two-year term of supervised release after the prison term. There is no parole in the federal system. In sentencing Anderson, Judge Strand found that Anderson’s luxury vehicle sales to the elderly Medicaid applicants were “obviously fraudulent and illegal.” On April 7, the Department of Justice announced the creation of the National Fraud Enforcement Division. The core mission of the Fraud Division is to zealously investigate and prosecute those who steal or fraudulently misuse taxpayer dollars. Department of Justice efforts to combat fraud support President Trump’s Task Force to Eliminate Fraud, a whole-of-government effort chaired by Vice President J.D. Vance to eliminate fraud, waste, and abuse within Federal benefit programs. Anderson was released on the bond previously set and is to surrender to the Bureau of Prisons on a date yet to be set. The case was prosecuted by Assistant United States Attorney Timothy L. Vavricek and investigated by the Federal Bureau of Investigation. Court file information at <https://ecf.iand.uscourts.gov/cgi-bin/login.pl>. The case file number is 25-CR-3053. **Topics:** Medicare/Medicaid **Categories:** Conviction --- ### [U.S. Assistant Special Agent in Charge Accused of Stealing Thousands in Fraudulent Disability Payments](https://insurancefraud.org/news_archives/u-s-assistant-special-agent-in-charge-accused-of-stealing-thousands-in-fraudulent-disability-payments/) **Published:** October 3, 2026 **Author:** Diane Beauchamp **Content:** Defendant received $51,571.73 in disability compensation while allegedly living an active and athletic lifestyle hiking and traveling abroad. A federal grand jury in Salt Lake City, Utah, returned a four-count indictment charging an Assistant Special Agent in Charge for the United States Department of Agriculture Office of the Inspector General (USDA-OIG), with defrauding the United States out of more than $50,000 in disability pay. According to court documents, Michelle L. Bouziden, 44, of Ogden, Utah, suffered a concussion on the job in March 2026 but then, beginning around May 14, 2026, she falsely reported that ongoing symptoms left her totally disabled and unable to work. In filings with the Department of Labor Office of Workers’ Compensation Program, Bouziden sought disability pay claiming she was completely unable to engage in “arduous physical activity” and cognitive reasoning,” and could not perform any required work tasks such as: sitting, walking, standing, twisting, bending, squatting, kneeling, climbing, and operating a motor vehicle. Yet, Bouziden received disability payments as she simultaneously traveled internationally and actively pursued a high-endurance, athletic lifestyle. Court filings allege Bouziden submitted documents to the Department of Labor indicating she was totally disabled and too symptomatic to return to work on the same day she flew to Italy to hike the Dolomites. Bouziden allegedly remained in Italy for two weeks, hiking over 50 miles and documenting her experience on social media. Prior to leaving, Bouziden allegedly canceled a Department of Labor appointment for a mandatory, independent second opinion medical evaluation claiming it conflicted with a “wellness retreat.” The indictment alleges Bouziden received $51,571.73 in disability compensation. United States Attorney Melissa Holyoak of the District of Utah thanked federal law enforcement partners for their work on the case and emphasized her Office’s commitment to prosecuting fraud in federal benefits programs. “Our federal law enforcement is filled with hardworking, dedicated employees who sacrifice to keep the people of Utah and this country safe,” said U.S. Attorney Melissa Holyoak of the District of Utah. “Bouziden’s alleged fraud not only cheats taxpayers but is an affront to those hardworking federal employees who show up every day to fight fraud. My Office remains committed to working with our law enforcement partners to stamp out corruption and waste.” Bouziden is charged with wire fraud, false reports for federal workers’ compensation benefits, obstruction of federal department and agency proceedings, and theft of government property. A four-day jury trial is scheduled for November 30, 2026, at the Orrin G. Hatch United States Courthouse in downtown Salt Lake City. The case is being investigated jointly by the U.S. Department of Agriculture Office of Inspector General (USDA-OIG), and U.S. Department of Labor – Office of Inspector General (DOL-OIG). Assistant United States Attorney Luisa Gough of the U.S. Attorney’s Office for the District of Utah is prosecuting the case. On April 7, the Department of Justice announced the creation of the National Fraud Enforcement Division (“Fraud Division”). The Fraud Division is laser-focused on investigating and prosecuting those who commit fraud against the American people. The Department’s work to combat fraud supports President Trump’s Task Force to Eliminate Fraud, a whole-of-government effort chaired by Vice President J.D. Vance to eliminate fraud, waste, and abuse within Federal benefit programs. **Topics:** Work comp - worker **Categories:** Arrest --- ### [Medicare Advantage and Medicare Prescription Drug Programs Expected to Remain Stable in 2027](https://insurancefraud.org/news_archives/medicare-advantage-and-medicare-prescription-drug-programs-expected-to-remain-stable-in-2027/) **Published:** October 3, 2026 **Author:** Diane Beauchamp **Content:** The Centers for Medicare & Medicaid Services (CMS) today announced significant premium savings for millions of Medicare beneficiaries in 2027, with weighted average MA premiums projected to fall more than 16% from 2026 to 2027, and average prescription drug premiums in Medicare Advantage projected to plummet 38%. Additionally, average premium for stand-alone Part D prescription drug plans is projected to rise by less than $1 per month in 2027. Despite speculation and misleading reports related to the appropriate sunsetting of the Part D Stabilization Demonstration Project, there is broad pricing stability across the Part D market. The strong 2027 outlook means Medicare beneficiaries will continue to have access to affordable coverage and broad plan choice without relying on billions of dollars in temporary subsidies to insurance companies. More than 99% of Medicare beneficiaries will have access to at least one Medicare Advantage Plan, while 97% will have access to 10 or more options. CMS is releasing this key information ahead of the upcoming Medicare Open Enrollment, which runs from October 15, 2026, through December 7, 2026. “CMS is fighting to keep high-quality care options affordable and accessible for the millions of beneficiaries who rely on Medicare Advantage and Part D prescription drug plans,” said **CMS Administrator Dr. Mehmet Oz**. “By slashing handouts to big insurance companies, CMS is keeping premiums stable while ensuring that 97% of Medicare beneficiaries have access to 10 or more MA plans and that 93% of non-low-income beneficiaries can get an enhanced Part D plan for less than $6 a month. We urge beneficiaries to use Open Enrollment as an opportunity to review their coverage, compare options, and pick the plan that best suits their needs and budget.” **Medicare Advantage** The weighted average monthly premium across all MA plans, including plans with prescription drug including plans with prescription drug coverage and Special Needs Plans, is projected to decrease from $14.37 in 2026 to $12.00 in 2027, a decline of 16.5%. Supplemental benefit offerings, including hearing, dental, and vision benefits, are expected to remain stable. Based on plan projections, enrollment in MA is estimated to be 34 million in 2027, representing approximately 47.4% of all people enrolled in Medicare. Plan enrollment projections have historically understated actual enrollment, and CMS expects actual 2027 MA enrollment to again be more robust than current plan projections indicate. Access to MA plans remains broad in 2027, with more than 99% of Medicare beneficiaries having access to at least one MA plan, and 97% having access to 10 or more MA plan choices. The total number of available MA plans nationally is expected to remain relatively stable, changing from 5,553 in 2026 to approximately 5,532 in 2027. Beneficiaries will continue to have a wide range of choices, and approximately eight in 10 MA beneficiaries will be able to remain in their current plan with the same or a lower premium in 2027. **Medicare Part D** CMS is committed to keeping prescription drug coverage affordable for people with Medicare while preserving beneficiary choice and access and safeguarding taxpayer dollars. There are encouraging signs that, as expected, the Part D program is returning to normal market conditions following the narrowing of the voluntary Part D Premium Stabilization Demonstration for CY 2026 and its planned discontinuation in 2027. The total average monthly Part D premium for stand-alone prescription drug plans is projected to increase less than $1, from $35.09 in 2026 to $36 in 2027. 88% of non-low-income beneficiaries will have access to a basic Part D plan that is $10.30 or less, and 93% of non-low-income beneficiaries will have access to an enhanced Part D plan at less than $6. For MA plans that include prescription drug coverage, after application of MA rebates, the average monthly Part D total premium is projected to decrease from $11.32 in 2026 to $7 in 2027, a decrease of $4.32 or 38%. **Medicare Open Enrollment Resources** Medicare Open Enrollment begins October 15, 2026, and ends December 7, 2026. During this time, people with Medicare can compare 2027 coverage options at [Medicare.gov](https://www.medicare.gov/). The [Medicare Plan Finder](https://www.medicare.gov/plan-compare/#/?lang=en&year=2026) allows beneficiaries to compare Medicare health and drug plans, including premiums, costs, benefits, and other coverage information. Because plan costs and benefits can change from year to year, CMS encourages beneficiaries to review their current coverage and compare their options for 2027. CMS continues to improve the user experience on Medicare.gov and the Medicare Plan Finder to help people with Medicare compare their options and make informed decisions. Since the last Open Enrollment period, users can now sign in to Medicare accounts more securely using Login.gov, ID.me and CLEAR®, and easily find and save providers to help them compare plans. Starting in October, users will be able to review more details about preventive services offered by health plans, easily connect from Medicare.gov to important plan documents like formularies and Summary of Benefits, and see clear, prominent messages about changes impacting their current plans in 2027. Beneficiaries can also call 1-800-MEDICARE for help comparing plans and costs. 1-800-MEDICARE is available 24 hours a day, seven days a week, to provide help. People who want to keep their current Medicare coverage generally do not need to re-enroll. People with limited income and resources may also qualify for programs that help lower their Medicare costs. Medicare Savings Programs (MSP) may help pay Medicare premiums and may also pay deductibles, coinsurance, and copayments for eligible individuals. Learn more at: [www.medicare.gov/basics/costs/help/medicare-savings-programs](https://www.medicare.gov/basics/costs/help/medicare-savings-programs). Extra Help is a Medicare program that helps qualifying individuals pay Part D premiums, deductibles, coinsurance, and other costs. Individuals who enroll in MSP automatically qualify for Extra Help. Learn more at: [Medicare.gov/extrahelp](https://www.medicare.gov/basics/costs/help/drug-costs). To view premiums and costs for 2027 MA and Part D plans, visit: [www.cms.gov/medicare/coverage/prescription-drug-coverage](https://www.cms.gov/medicare/coverage/prescription-drug-coverage), and select the 2027 landscape source file under “Downloads.” For state-by-state information, important dates, and enrollment resources for MA and Part D in 2027, visit: <https://www.cms.gov/files/document/2027-medicare-advantage-part-d-landscape-state-state-fact-sheets.pdf>. **Topics:** Medicare/Medicaid, Public Awareness --- ### [Understanding the Role of Medicaid Fraud Control Units (MFCUs)](https://insurancefraud.org/news_archives/understanding-the-role-of-medicaid-fraud-control-units-mfcus/) **Published:** October 3, 2026 **Author:** Diane Beauchamp **Content:** Federal law [requires](https://www.ssa.gov/OP_Home/ssact/title19/1902.htm#ft46:~:text=(61)%5B46,such%20a%20unit%3B) every state to [operate](https://oig.hhs.gov/fraud/medicaid-fraud-control-units-mfcu/terms-conditions/) a Medicaid Fraud Control Unit (MFCU) that investigates and prosecutes provider fraud and patient abuse and neglect. MFCUs are typically housed within the state Attorney General’s office and are required to operate independently from the state Medicaid agency that runs the Medicaid program. MFCUs are one component in the Medicaid program integrity system, which includes many different state and federal agencies with shared and distinct responsibilities defined by state and federal law. Ensuring Medicaid [program](https://medicaiddirectors.org/wp-content/uploads/2025/06/NAMD-Why-did-they-do-it-that-way-program-integrity-06-27-25.pdf#page=2) [integrity](https://medicaiddirectors.org/resource/building-on-what-works-in-medicaid-program-integrity/) (i.e., the appropriate use of federal and state Medicaid funds) involves a range of activities from fraud prevention to enforcement activities—the primary responsibility of MFCUs. While MFCUs are a key part of the program integrity system, it can be difficult to compare MFCU data across states or to put fraud recovery dollars into the context of overall Medicaid spending because recovery data only capture a portion of Medicaid program integrity efforts (e.g., leaving out the value of fraud prevention or stopped payments) and don’t capture fraud that goes undetected. As the Trump Administration continues to [focus](https://www.whitehouse.gov/presidential-actions/2026/03/establishing-the-task-force-to-eliminate-fraud/) on addressing [fraud](https://www.cms.gov/fraud), waste, and abuse in federal programs, including [Medicaid](https://www.kff.org/medicaid/what-to-know-about-recent-federal-actions-involving-state-medicaid-program-integrity/), MFCUs are facing increased federal scrutiny. In May 2026, CMS [announced](https://www.youtube.com/watch?v=lJoCAk9r8xw) the HHS Office of the Inspector General (HHS-OIG) would be initiating a review of every state’s MFCU before its next annual recertification. In June 2026, the HHS-OIG [denied recertification](https://www.kff.org/medicaid/medicaid-program-integrity-tracking-state-specific-and-nationwide-federal-action/) and suspended federal funding for Hawaii’s and New York’s Medicaid Fraud Control Units. Within this context, this brief provides an overview of the role of MFCUs, examines caseload and case outcome data, and current issues facing MFCUs. ## What are MFCUs and how do they work? **MFCUs are law enforcement entities that investigate and prosecute provider fraud and patient abuse and neglect.** [MFCUs](https://www.ecfr.gov/current/title-42/chapter-V/subchapter-B/part-1007/subpart-A/section-1007.1) investigate and prosecute, or refer to prosecution, provider fraud (in all settings) and complaints of patient abuse in certain health care settings, such as nursing homes and hospitals receiving Medicaid funds.[1](https://www.kff.org/medicaid/understanding-the-role-of-medicaid-fraud-control-units-mfcus/#bfc043de-d3cc-4be3-82d0-f8e936a531b0) MFCUs do not investigate fraud or program abuse committed by beneficiaries (these cases are the responsibility of the state Medicaid agency), although [evidence](https://www.macpac.gov/wp-content/uploads/2026/07/Issue-Brief-Medicaid-Program-Integrity.pdf) of beneficiary fraud is low.[2](https://www.kff.org/medicaid/understanding-the-role-of-medicaid-fraud-control-units-mfcus/#09e4e539-e632-462e-83bf-76549967167f) MFCUs must operate independently from the state Medicaid agency and are often part of the State Attorney General’s office, employing teams of investigators, attorneys, and auditors. The HHS-OIG [oversees](https://oig.hhs.gov/fraud/medicaid-fraud-control-units-mfcu/terms-conditions/) MFCUs, annually recertifying each MFCU, assessing performance and compliance with federal requirements, and administering federal grant awards (which cover 75% of MFCU operating costs). **MFCUs open investigations after receiving referrals of suspected provider fraud or complaints involving patient abuse or neglect.** A MFCU case typically begins with a referral from the state Medicaid agency (including program integrity or auditing offices), managed care organization (MCO), or from a complaint filed by a patient or former employee. The state Medicaid agency or MCO may initially detect [fraud](https://www.naag.org/about-naag/namfcu/about-the-medicaid-fraud-control-units/#:~:text=health%20care%20cases.-,Medicaid%20Fraud,-MFCUs%20conduct%20statewide) through monitoring Medicaid data and using data mining or analytics to identify billing pattern anomalies (e.g., billing spikes, upcoding, double billing, or unusual hours). All state Medicaid agencies have authority to conduct data mining, but some MFCUs have also specifically been granted permission by HHS-OIG to [mine](https://www.ecfr.gov/current/title-42/chapter-V/subchapter-B/part-1007/subpart-C/section-1007.20) Medicaid data directly for evidence of fraud as part of their regular activities. More MFCUs may begin to conduct data mining or analytics as HHS-OIG in August 2026 [waived](https://oig.hhs.gov/documents/medicaid-fraud-control-units/11852/2026-1_Permissible_Data_Mining_Activities.pdf) the requirement that MFCUs obtain prior approval for these activities to identify suspected Medicaid fraud. While patient abuse or neglect may fall under the jurisdiction of [several](https://acl.gov/programs/protection-and-advocacy-systems/what-if-i-suspect-abuse-neglect-or-exploitation) different law enforcement agencies, MFCUs may investigate patient [abuse or neglect](https://www.naag.org/about-naag/namfcu/about-the-medicaid-fraud-control-units/) in health care facilities receiving Medicaid funds.[3](https://www.kff.org/medicaid/understanding-the-role-of-medicaid-fraud-control-units-mfcus/#045db173-00d0-4b1b-9f37-e90db3b62e95) **MFCU cases vary in duration and scope, but investigations generally follow a standard process starting with an investigation and ending with potential financial recoveries (Figure 1).** **Investigation.** When a case is opened, the investigative team researches the alleged fraud or abuse by analyzing the evidence. Investigations may take months or years before charges are filed against providers. **Criminal Indictments & Civil Cases.** Fraud and abuse can violate state and/or federal criminal law, civil law, or both. If a MFCU’s investigation team determines there is sufficient evidence of wrongdoing, the MFCU can bring criminal charges and/or civil lawsuits against the provider. **Criminal Convictions & Civil Judgments.** Criminal convictions can result in a criminal record, financial penalties, and/or incarceration. Civil judgments can establish liability and/or impose financial penalties and other court-ordered remedies. Providers who are convicted or liable for criminal fraud or patient abuse/neglect (along with other crimes) legally must be [excluded](https://www.ssa.gov/OP_Home/ssact/title11/1128.htm) from participating in federally funded health care programs. HHS-OIG or [state Medicaid agencies](https://www.ecfr.gov/current/title-42/section-1002.3) [may also decide](https://oig.hhs.gov/documents/exclusions/11247/1128b7exclusion-criteria.pdf) to exclude providers beyond these minimum standards. **Recoveries.** HHS-OIG defines recoveries as the amount of money that defendants are required to pay as a result of a settlement, judgment, or prefiling settlement in criminal and civil cases. Recoveries may not reflect the amounts actually collected from defendants (e.g., if the defendant is a company that dissolved before collections could be obtained). MFCUs work with state Medicaid agencies to return the state and federal share of any recovered Medicaid payments. **Note:** Throughout the lifecycle of a case, MFCUs may collaborate with other state and federal program integrity and law enforcement partners. State entities include state inspectors general and state health departments and federal entities include the U.S. Department of Justice (DOJ) (including Federal Bureau of Investigation (FBI)) and the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG). Some investigations or cases may be transferred to (or handled by) federal law enforcement agencies. Box 1. Example Cases Active MFCU investigations are typically confidential. When MFCUs secure criminal convictions and civil judgments or settlements, the case is described in an announcement published by the state or the DOJ. To illustrate the variety of cases that may be processed by a MFCU, this box describes examples from a range of states, types of wrongdoing, and recovery amounts. **Criminal Fraud:** Between 2004 and 2019, the McKinsey consulting firm provided OxyContin sales and marketing advice to Purdue Pharmaceuticals. The Virginia MFCU participated in a lengthy and complex [investigation into alleged criminal wrongdoing](https://www.justice.gov/archives/opa/pr/justice-department-announces-resolution-criminal-and-civil-investigations-mckinsey-companys) resulting in false or fraudulent OxyContin prescriptions paid by Medicaid and other health insurers. The December 2024 resolution of criminal charges against McKinsey resulted in $650 million in recoveries, which contribute to the high total MFCU recoveries reported in FY 2025 (as seen in Figure 4). **Civil Fraud:** As part of the 2018 [National Health Care Fraud Takedown](https://oig.ssa.gov/news-releases/2018-07-02-audits-and-investigations-investigations-june28-health-care-takedown-ga/), the Georgia MFCU investigated false claims for non-emergency medical transportation (NEMT) and adult day health services. More than $1 million in Medicaid payments were implicated in the investigation. The case was [decided](https://www.justice.gov/usao-sdga/pr/government-obtains-101-million-judgments-resolve-medicaid-fraud-claims-false-claims-act) in 2019, with state and federal civil judgments resulting in a $10.1 million settlement paid to Georgia and the federal government. **Patient Abuse and Neglect**: In 2021, the Massachusetts MFCU received a [referral](https://www.mass.gov/news/springfield-home-health-aide-pleads-guilty-to-abusing-elderly-patient) into alleged patient abuse by a home health aide. In 2023 the MFCU obtained a criminal [conviction](https://oig.hhs.gov/fraud/enforcement/springfield-home-health-aide-pleads-guilty-to-abusing-elderly-patient/) of abuse, neglect, or mistreatment of an elder by a caretaker. ![](https://insurancefraud.org/wp-content/uploads/image-21.png)## What data do MFCUs report? **Annually, MFCUs report investigation, enforcement, and financial recoveries data to HHS-OIG.** Each year, HHS-OIG releases a [summary report](https://www.oig.hhs.gov/reports/all/2026/medicaid-fraud-control-units-annual-report-fiscal-year-2025/) of MFCU activities that provides an annual snapshot of aggregated case outcomes from all MFCUs and certain case outcome trends. In addition to the summary report, HHS-OIG releases individual (state) MFCU case activity and outcomes [data](https://www.oig.hhs.gov/fraud/medicaid-fraud-control-units-mfcu/#expenditures-statistics). **At the end of FY 2025, there were 15,810 *open* investigations across all state MFCUs.** While MFCUs investigate both provider fraud and patient abuse and neglect, data show most MFCU investigations are related to provider fraud (Figure 2). A subset of investigations leads to criminal indictments or civil cases / complaints. MFCU investigations can take months to years, depending on various factors, including the types of allegations involved, volume of records, and agencies involved. ![](https://insurancefraud.org/wp-content/uploads/most-investigations-were-cases-of-suspected-fraud-1024x955.png)**In FY 2025, MFCUs obtained 1,180 criminal convictions and reached 661 civil settlements and judgements (Figure 3).** Most criminal convictions were for provider fraud. HHS-OIG uses information it receives from MFCUs to exclude individuals and entities from participating in federal health programs. In FY 2025, 900 individuals or entities were excluded because of criminal convictions obtained by MFCUs—accounting for nearly one-third (32%) of all OIG exclusions that year (data not shown). ![](https://insurancefraud.org/wp-content/uploads/mfcus-obtained-1-841-case-resolutions-in-fy-2025-1024x497.png)**On average, MFCUs recover more than $1 billion each year from fraud investigations.** Nationally, MFCUs recovered $1.97 billion in [FY 2025](https://www.oig.hhs.gov/reports/all/2026/medicaid-fraud-control-units-annual-report-fiscal-year-2025/). While recoveries include other financial penalties in addition to Medicaid funds recouped from providers due to MFCU investigations (and may not reflect amounts actually collected[4](https://www.kff.org/medicaid/understanding-the-role-of-medicaid-fraud-control-units-mfcus/#b7cf89f5-b75e-463a-abbd-99f4ad3cc071)), the total amount of recoveries is small compared to [total Medicaid spending](https://www.kff.org/medicaid/state-indicator/total-medicaid-spending/?currentTimeframe=0&selectedRows=%7B%22wrapups%22:%7B%22united-states%22:%7B%7D%7D%7D&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D). Recoveries [vary](https://oig.hhs.gov/documents/evaluation/11553/OEI-09-26-00140.pdf#page=5) each year and can be skewed by factors, including timing of settlements and large multi-year cases. Recoveries typically vary substantially from year to year and have averaged $1.48 billion per year over the period 2016 to 2025. A 5-year rolling average accounts for periodic variation and shows that recoveries decreased during the COVID-19 Public Health Emergency and are returning to pre-COVID levels. Recoveries, after accounting for year-to-year variation, have remained generally steady over time while total Medicaid [spending](https://www.kff.org/medicaid/medicaid-financing-the-basics/#a22eb71c-7430-4f33-9736-4fa655793e28) has increased. Recoveries are not a comprehensive measure of enforcement (because they may not include Medicaid-related enforcement actions that occurred outside of MFCU actions) and do not include the possible financial impacts of other program integrity efforts, such as preventing fraud before it occurs. Of the $1.97 billion in recoveries, two-thirds (64%) were due to criminal convictions and one-third (36%) were due to civil judgments or settlements (data not shown). This is proportionate to the share of criminal and civil case resolutions in FY 2025 (Figure 3). ![](https://insurancefraud.org/wp-content/uploads/annual-recoveries-vary-but-on-average-mfcus-recover-more-than-1-billion-in-medicaid-funds-each-year-through-fraud-investigations-1024x499.png)**Comparing data across states or considering recovery dollars in the context of overall Medicaid spending can be challenging.** Comparing MFCU data across states or years can be difficult due to differences in state law (that impact the handling of cases) and varying duration, scope, or complexity of cases, among other factors. Comparing MFCU recoveries to overall Medicaid spending can also be challenging to interpret as a hypothetical indicator of MFCU performance because these data only capture a portion of Medicaid program integrity efforts and include amounts other than recouped Medicaid payments. States can also make policy decisions that might impact state spending and MFCU recoveries differently. For example, states that spend more on prevention or early detection may see fewer recoveries (if these activities are successful), while states that invest less in fraud prevention may see higher levels of enforcement action and recoveries. There are no estimates of fraud that may have been successfully prevented or fraud that went undetected/unrecovered; however, over time there has been a shift in focus from efforts to recover misspent funds (“pay and chase”) to prevention and early detection. A higher level of MFCU recoveries could indicate more fraud, more aggressive enforcement, or less effective prevention. ## What are current issues involving MFCUs? **MFCUs continue to** [**work**](https://www.justice.gov/opa/pr/national-health-care-fraud-takedown-results-455-defendants-charged-connection-over-65) **with state and federal agencies to stop fraud and abuse but also face increased federal scrutiny.** On May 13, 2026, HHS Investigator General Bell sent a [letter](https://ccf.georgetown.edu/wp-content/uploads/2026/05/HHS-OIG-letter-to-Attorney-General-of-California-re-MFCU-Oversight-1.pdf) to every state Attorney General communicating a stance of “insistence on rigid MFCU compliance” with requirements and performance standards that will be enforced through “robust review” by the HHS-OIG. MFCUs are [recertified](https://www.ecfr.gov/current/title-42/chapter-V/subchapter-B/part-1007/subpart-B/section-1007.17) annually on a rolling schedule, based on each specific state or territory’s original certification date.[5](https://www.kff.org/medicaid/understanding-the-role-of-medicaid-fraud-control-units-mfcus/#13751446-db7b-4c46-a044-add01a9891a0) As of September 17, 2026, HHS-OIG has followed release of the May 2026 letter by [issuing](https://oig.hhs.gov/fraud/medicaid-fraud-control-units-mfcu/mfcu-certifications/mfcu-recertification-letters/) standard recertifications to 3 states and “conditionally recertifying” 11 state MFCUs, a designation which accompanies a set of corrective actions recommended by HHS-OIG. It does not appear that HHS-OIG regularly issued conditional recertifications prior to 2026. **In June 2026, Hawaii’s and New York’s MFCUs were notified that HHS-OIG was denying their annual recertification in letters citing insufficient case outcomes in both states.** HHS announced that it was denying [Hawaii](https://oig.hhs.gov/documents/medicaid-fraud-control-units/11679/Hawaii_Denial_of_Recertification_Letter.pdf)’s and [New York’s](https://oig.hhs.gov/documents/medicaid-fraud-control-units/11727/NY_MFCU.pdf) annual MFCU recertifications, discontinuing federal funding for the fraud control units. In each state’s recertification denial letter, HHS cites insufficient case outcomes (particularly low production of criminal indictments and convictions) and recoveries that are disproportionately low relative to the staffing and budget of the state MFCU (New York) or relative to the growth in the state’s Medicaid spending (Hawaii). States that have their MFCU recertification denied can appeal the decision and [request](https://www.ecfr.gov/current/title-42/chapter-V/subchapter-B/part-1007/subpart-C/section-1007.21#:~:text=Procedures%20for%20reconsideration%20of%20a%20disallowance.) that HHS-OIG reconsider; Hawaii [indicated](https://ag.hawaii.gov/wp-content/uploads/2026/06/News-Release-2026-30.pdf) they intended to seek reconsideration. [Hawaii](https://governor.hawaii.gov/newsroom/office-of-the-governor-news-release-gov-green-takes-action-addressing-federal-medicaid-fraud-unit-decision/) and [New York](https://ag.ny.gov/press-release/2026/attorney-general-james-condemns-trump-administration-slashing-new-yorks) have responded to their denied MFCU certifications by reiterating their states’ commitment to Medicaid program integrity and highlighting ongoing actions to prevent and detect suspected Medicaid fraud. It is unclear if HHS-OIG may deny the recertification of other state MFCUs, but the discontinuation of federal funding could hamper states’ ability to continue ongoing operations or initiate new investigations. 1. MFCUs can also elect to investigate and prosecute patient abuse and neglect in non-institutional settings (e.g., home and community-based settings). [↩︎](https://www.kff.org/medicaid/understanding-the-role-of-medicaid-fraud-control-units-mfcus/#bfc043de-d3cc-4be3-82d0-f8e936a531b0-link) 2. While states may have their own laws defining responsibilities around investigating beneficiary fraud or program abuse, MFCUs cannot use federal funding to investigate alleged beneficiary fraud unless it is in relation to suspected provider fraud. [↩︎](https://www.kff.org/medicaid/understanding-the-role-of-medicaid-fraud-control-units-mfcus/#09e4e539-e632-462e-83bf-76549967167f-link) 3. Ibid. [↩︎](https://www.kff.org/medicaid/understanding-the-role-of-medicaid-fraud-control-units-mfcus/#045db173-00d0-4b1b-9f37-e90db3b62e95-link) 4. Recoveries may not reflect the amounts actually collected from defendants (e.g., if the defendant is a company that dissolved before collections could be obtained). MFCUs work with state Medicaid agencies to return the state and federal share of any recovered Medicaid payments. [↩︎](https://www.kff.org/medicaid/understanding-the-role-of-medicaid-fraud-control-units-mfcus/#b7cf89f5-b75e-463a-abbd-99f4ad3cc071-link) 5. Federal requirements and performance standards serve as the basis for MFCU annual recertification by HHS-OIG. When a MFCU applies for annual recertification, the MFCU submits performance and budget data, including staffing, costs, case numbers and outcomes, and other information requested by HHS-OIG. HHS-OIG may conduct an onsite review of the MFCU. [↩︎](https://www.kff.org/medicaid/understanding-the-role-of-medicaid-fraud-control-units-mfcus/#13751446-db7b-4c46-a044-add01a9891a0-link) **Topics:** Medicare/Medicaid, Public Awareness, Regulatory actions --- ### [Insurance fraud prevention takes a village](https://insurancefraud.org/news_archives/insurance-fraud-prevention-takes-a-village/) **Published:** September 29, 2026 **Author:** Diane Beauchamp **Content:** [Insurance fraud](https://www.propertycasualty360.com/2023/03/15/youll-never-believe-some-of-the-claims-ive-handled/) occurs in about 10% of insurance claims and costs the United States around $308.6 billion each year, according to the latest data from the **[Coalition Against Insurance Fraud](https://insurancefraud.org/)**. Tactics of these fraudsters are varied, and [insurance scams](https://www.propertycasualty360.com/2023/02/22/business-rules-alone-are-not-enough-to-fight-insurance-fraud/) can involve anything from contractors, to auto repair, to workers’ compensation fraud, and it’s imperative insureds and insurers alike know what to look out for in order to avoid falling victim to a scheme. Tracy Thompson, deputy executive director of the Coalition Against Insurance Fraud, offered her expertise in a keynote address at the recent Complex Claims and Litigation Forum in Las Vegas. In this episode of Insurance Speak – recorded live at the forum – she recaps some of the high points of her address and offers advice for insurers and communities for keeping [fraud at bay](https://www.propertycasualty360.com/2023/02/21/how-can-insurers-protect-against-deepfake-fraud/). Thompson has over three decades of experience in criminal justice, formerly serving as an Assistant Prosecutor in the Mercer County Prosecutor’s Office, then as a Deputy Attorney General and Assistant Attorney General in the Division of Criminal Justice (DCJ) in the New Jersey Attorney General’s Office. She recently retired from her position as the New Jersey Insurance Fraud Prosecutor, where she supervised a team that investigated and prosecuted all types of insurance fraud. To hear from Tracy Thompson about strategies for identifying and preventing fraud, listen to the podcast above or subscribe to [**Insurance Speak**](https://www.propertycasualty360.com/podcastcenter/) on [***Spotify***](https://open.spotify.com/show/2d7uvzduyn11MFeh6g7fMP), ***Apple Music*** or [***Libsyn***](http://insurancespeak.libsyn.com/). [https://assets.libsyn.com/item/26086707?width=471&height=360&overlay=true&player\_time=1790714469930](https://assets.libsyn.com/item/26086707?width=471&height=360&overlay=true&player_time=1790714469930) **Topics:** Coalition Against Insurance Fraud, Public Awareness --- ### [Insurance fraud, YouTube & a series of intentional auto accidents](https://insurancefraud.org/news_archives/insurance-fraud-youtube-a-series-of-intentional-auto-accidents/) **Published:** September 29, 2026 **Author:** Diane Beauchamp **Content:** If you’re going to make [insurance fraud](https://www.propertycasualty360.com/2023/03/22/insurance-fraud-prevention-takes-a-village/) a regular thing, a side hustle is crucial for making ends meet during the lull between schemes. For three Californians — charged in unrelated but similar incidents of insurance fraud — chasing down those ad dollars on YouTube was a way to supplement their fraud-derived income, while leveraging footage of their crimes, according to the California Department of Insurance. On March 22, 2023, Eliu Canales was arraigned on March 22, 2023, on 54 felony counts of insurance fraud, assault with a deadly weapon and reckless driving, the [state’s insurance department reported](http://www.insurance.ca.gov/0400-news/0100-press-releases/2023/release010-2023.cfm). Canales, who worked as a tow truck driver for AAA and taught defensive driving, is alleged to have claimed more than $86,000 in damages, and collected more than $35,000 from insurance companies, following staged accidents. From 2017-2022, he perpetrated approximately 22 vehicle collisions in and around Stockton, California. According to the insurance department, Canales would ride in the blind spot of an unsuspecting motorist and wait for the driver to change lanes, at which time Canales would accelerate and sometimes turn into the other vehicle. Immediately following the collisions, Canales would file claims against the other driver’s insurance company. The alleged scammer from Stockton would record the incidents and upload them to his YouTube channel, which was titled “Stockton Drivers” and highlighted the area’s “bad drivers.” Most of the videos have now been removed from the site, the California Department of Insurance reported. Canales is scheduled to return to court on March 29, 2023. ## With child in tow Meanwhile, some 390 miles south of Stockton in San Bernardino, Christopher Phelps and his wife Kimberly were causing similar mayhem and capturing it on video. To make matters worse, the couple’s child was present in the vehicle during a number of the incidents, according to the [state’s insurance department](http://www.insurance.ca.gov/0400-news/0100-press-releases/2023/release011-2023.cfm). The pair were arrested on March 23, 2023. According to the California Department of Insurance, Phelps’ YouTube channel featured approximately 162 videos of collisions, attempted or near collisions, road rage incidents and other content involving the couple. Around 23 of the collisions documented in the videos were linked to 17 insurance claims filed by Christopher Phelps. More than 40 of the videos related to road rage incidents and attempted collisions involving Phelps. In February 2023, Christopher Phelps was also arrested for insurance fraud. In that instance, the San Bernardino Sheriff notified the insurance department that Phelps was involved in a suspicious collision, in which he stopped for no apparent reason and caused a truck pulling a trailer to rear-end his vehicle. Shortly after that collision, a rear-facing dashcam video of the accident was posted on YouTube. Insurance department detectives searched the area near the accident for surveillance camera footage and witnesses, which lead to Phelps’ February arrest. He had posted bond and was released following that incident. After his March 2023 arrest, Christopher Phelps was charged with 11 felony counts of insurance fraud, six counts of assault with a deadly weapon and five felony counts of child endangerment. Kimberly Phelps has been charged with two counts of felony child endangerment and one count of insurance fraud. As of March 24, 2023, both were being held on $500,000 bail. **Topics:** Auto - staged --- ### [Cities that saw the most insurance fraud in 2023](https://insurancefraud.org/news_archives/cities-that-saw-the-most-insurance-fraud-in-2023/) **Published:** September 29, 2026 **Author:** Diane Beauchamp **Content:** About 10% or more of P&C claims could be fraudulent, according to the National Insurance Crime Bureau. Many of these claims involve workers’ compensation and [auto theft](https://www.propertycasualty360.com/2023/10/16/these-states-are-seeing-the-most-auto-thefts-with-u-s-on-pace-to-set-record/), says the Coalition Against Insurance Fraud ([CAIF](https://insurancefraud.org/)). Overall, CAIF estimates insurance fraud amounts to $308.6 billion annually in the U.S. and costs policyholders about $900 in higher premiums and other expenses. [Insurance fraud](https://www.propertycasualty360.com/2023/07/05/who-commits-insurance-fraud-and-why/) is a growing problem across the country. It can happen anywhere and to anyone, but some areas across the U.S. are more prone to insurance fraud than others. The Zebra analyzed the 50 most-populated cities to evaluate the rates of insurance fraud in 2023, looking at the number of fraud laws enacted by the state, the number of spam calls per capita and the number of white-collar crimes committed per 10,000 people. **Topics:** Coalition Against Insurance Fraud, Public Awareness --- ### [Man staged road accident, roped in whole family to commit insurance fraud](https://insurancefraud.org/news_archives/man-staged-road-accident-roped-in-whole-family-to-commit-insurance-fraud-2/) **Published:** September 29, 2026 **Author:** Diane Beauchamp **Content:** After staging a road accident, he roped in his entire family to commit insurance fraud. Tan Lek Keong, 28, was jailed for eight months and 12 weeks and fined $4,400 on Thursday. He was also disqualified from driving for 10 months from the date of his release. He pleaded guilty to one count each of abetment by conspiracy to do a rash act and abetment by conspiracy to give false information, and two counts of abetment by conspiracy to cheat. Another four charges of engaging in a conspiracy to cheat were taken into consideration during sentencing. Tan worked for Teamwork Garage from February to May 2021 and was responsible for finding customers involved in accidents and explaining to them the benefits of getting their cars repaired at his workshop instead of authorised workshops. In March 2021, Tan and two colleagues from the workshop – Chew Kuo Choon, 25, and Koh Yi Ming, 28 – agreed to stage an accident using Tan’s car and lodge fraudulent insurance claims. **Topics:** Auto - staged, Auto fraud **Categories:** Conviction --- ### [Cybersecurity Threats to Health Services: Why We Should Be Concerned](https://insurancefraud.org/news_archives/cybersecurity-threats-to-health-services-why-we-should-be-concerned/) **Published:** September 29, 2026 **Author:** Diane Beauchamp **Content:** [Hospitals](https://hackread.com/cybersecurity-threats-health-services-concern/#) and medical facilities are [lucrative targets for hackers](https://hackread.com/hackers-demand-ransom-in-bitcoin-after-taking-over-hospital-servers/). It’s not enough anymore to keep software updated and make backups once a week. Instead, [ hospitals](https://hackread.com/cybersecurity-threats-health-services-concern/#) should ask questions like: “what is a VPN” and “what does a VPN do” to kick-start their journey to safer patient data. Hospitals& Treatment Centers Would you enjoy hearing about your most intimate medical issues on the evening news? It’s [already happening](https://hackread.com/planned-parenthood-data-breach-hackers-steal-patients-data/). It will [keep happening](https://www.nbcnews.com/tech/security/hackers-post-detailed-patient-medical-records-two-hospitals-dark-web-n1256887) until hospitals, and medical service providers stop underestimating the cybersecurity threat landscape. The [statistics](https://www.zdnet.com/article/data-breach-costs-record-4-3m-with-firms-passing-buck-to-customers/) and news headlines are clear: hospitals and medical facilities are choice targets for hackers. Patients are starting to demand that medical services providers do everything they can to keep personal data safe. Hospitals should be googling questions like “[VPN meaning](https://nordvpn.com/what-is-a-vpn/)” and “what does a VPN do” to kick start their journey to safer patient data and privacy. ### Why do hackers target hospitals? The healthcare industry is highly vulnerable at five pressure points. Hackers know this. They design their attacks to push these buttons to get rapid economic rewards: 1. A shutdown of medical appliances could kill patients and delay urgent medical Treatment. 2. The loss of patient medical history could delay the treatment of medical Conditions. 3. Public backlash and loss of patients’ trust. 4. The possibility of facing federal and criminal investigations and fines or sanctions. Some medical providers are not equipped to install better security controls, but many simply underestimate the risks. 5. Hackers can make quick cash from selling Personal Health Information (PHI), which is worth more than ‘ordinary’ Personally Identifiable Information (PII). You can change your credit card or even SSN, but you can’t change your medical history of illnesses, treatments, or surgeries. [According to our sources](https://hackread.com/hacking-tools-ready-made-phishing-pages-sold-on-dark-web/), Credit cards and related information sell for $1-$2 on the dark web, but PHI can sell for more than $350. Hackers use these detailed medical records to falsify insurance claims, buy high-value drugs, or get medical procedures. ### How do hackers threaten healthcare services? Most of the healthcare industry’s cybersecurity woes start with the weakest link: phishing attacks aimed at everyday workers. MedicalFacilities & Services ### Phishing The first step to ransomware attacks and data breaches is to gain access to an employee’s login credentials. And they do this by [carrying out phishing attacks](https://hackread.com/zoom-phishing-scam-ms-exchange-credentials/). Cybercriminals bombard mailboxes with unsuspecting emails that contain malicious attachments or links that can download malware or steal login credentials. They often use the hacked account of one employee to work their way up to someone in the organization that has access to the entire IT system. ### Data breaches A careless or overburdened [employee may unintentionally click on a malicious link](https://hackread.com/cisco-confirms-breach-employee-google-account-hacked/) or even lose a device. In today’s work-from-everywhere environment, hackers can steal user credentials if an employee logs into the hospital’s system via a home or public Wi-Fi link without the protection of a virtual private network (VPN). Once hackers gain access to a system, they can download patients’ healthcare and financial information, steal proprietary research, infiltrate the company’s finance system, divert funds or medical equipment and drugs, or even shut down the entire operation. MedicalFacilities & Services ### Ransomware attacks A ransomware infection locks down your files and system and makes it completely inaccessible. The attacker then demands a ransom to unlock the files. The healthcare industry is particularly vulnerable to this type of attack because ransomware attacks can bring medical services to a complete halt. [Medical emergencies can’t wait](https://hackread.com/ransomware-attack-on-hospital-causes-patient-death/). The urgency of this situation sometimes forces hospitals to pay the ransom despite the FBI’s advice to the contrary. ### DDoS Attacks A Distributed-Denial-of-Service attack ([DDoS attack)](https://hackread.com/tag/DDoS/) is when hackers bombard a targeted server with fake connection requests to overwhelm and force the server offline. DDoS attacks can bring every operation in a hospital to an abrupt halt and could even put lives at risk. The criminals usually demand a ransom to stop the attack. ### How can hospitals protect themselves? Cyberattacks on hospitals can halt clinical procedures, threaten the quality of patient care, and result in very serious [ data](https://hackread.com/cybersecurity-threats-health-services-concern/#) breaches. Clearly, standard [ security](https://hackread.com/cybersecurity-threats-health-services-concern/#) advice is not good enough. Hospitals should adopt a structured plan to invest in cybersecurity to defend their electronic infrastructure. Hospitals& Treatment Centers ### Address the weakest link with cybersecurity Awareness training Train staff to view electronic communications as a potential attack surface. [Cyber Threat Awareness programs](https://hackread.com/hoxhunt-gamified-phishing-awareness-enterprise/) can help to protect staff from phishing attacks and social engineering attempts. ### Enforce Password Security In a [ hospital](https://hackread.com/cybersecurity-threats-health-services-concern/#)’s high-pressure environment where staff often share devices and machines, users should have access to a [sophisticated password management system](https://learn.microsoft.com/en-us/windows/security/threat-protection/security-policy-settings/enforce-password-history) to keep unauthorized users out. ### Install a Multi-Factor Authentication system Multi-Factor Authentication (MFA) is a secure, simple access control measure that could thwart most hacking attempts. ### Migrate to Ultra-Secure Cloud Computing Cloud computing is reliable, cheap, and easy to put in place, especially if outsourced. Reputable cloud storage providers meet [HIPAA minimum requirements](https://www.hhs.gov/hipaa/for-professionals/special-topics/health-information-technology/cloud-computing/index.html) and can be tailored to meet specific storage and access control needs. ### Enforce data encryption Criminals can hijack unencrypted data flying between storage and endpoint terminals. All data should be protected from input to the endpoint. A VPN can encrypt everything that enters and leaves a hospital’s digital system so that hackers can’t decipher the contents. DataManagement ### What is a VPN, and what does it do? [VPN technology](https://hackread.com/a-guide-to-using-vpns-on-your-smartphone/) creates a secure, private tunnel to pass data between, for example, your computer or mobile device and the hospital system’s storage device. It encrypts everything by turning it into an unreadable, useless data salad. That private communication tunnel protects the data from prying eyes, and the encryption makes the data useless, even if someone manages to intercept it. ### What can a VPN do for hospitals? A VPN is critical to data protection, especially under HIPAA rules. A VPN can encrypt data, block unauthorized access, [protect IoT equipment](https://hackread.com/feds-dismantle-russia-rsocks-botnet-iot-devices-hack/) and IoT endpoints, block malware, improve email filtering and ensure that patient data remains protected during transit. ### Conclusion Hospitals and other health service providers are prime cybercrime targets. At the same time, HIPAA requires that they put in place a range of measures to protect patient data. It’s a tall and challenging order. Hospitals & Treatment Centers Fortunately, digital tools offer extraordinary solutions and safety features, and data encryption is a good place to start. You can use a VPN on iPhone, Android, all Windows and Linux devices, and all IoT devices like monitors, cameras, alarm systems, and other smart tech devices across the entire organization. **Topics:** Public Awareness, Technology --- ### [New York StateWide Senior Action Council (www.nysenior.org) Announces It's October Medicare Fraud of the Month:](https://insurancefraud.org/news_archives/new-york-statewide-senior-action-council-www-nysenior-org-announces-its-october-medicare-fraud-of-the-month/) **Published:** September 29, 2026 **Author:** Diane Beauchamp **Content:** New York StateWide Senior Action Council (StateWide), an organization dedicated to advocacy for the rights of seniors in New York State today announced its Medicare Fraud of the Month for October; **Identity Theft.** “The annual Medicare enrollment period begins October 15 and runs through December 7. This time of year, it is critical to beware of Medicare fraudsters looking to steal your personal information,” stated Maria Alvarez, Executive Director of StateWide in announcing this month’s Medicare Fraud of the Month. The StateWide Fraud of the Month is a component of the **Senior Medical Patrol**, the definitive resource for New York State’s senior citizens and caregivers to help detect, prevent, and report Medicare fraud and waste. StateWide is New York’s grantee/administrator for this Federal Program. Alvarez added, “This is the time of year when you can compare health insurance plans to make sure you have the right health and prescription coverage for your needs. “Every year, plans change or end, the doctors no longer work with that insurance company, the lab only works with this plan, or maybe the plan no longer pays for your medication. It is important to take advantage of this time to make sure you have the right plan for you.” Here are some of the more prevalent scams seniors should be on the lookout for: - Scammers claim they work with Medicare, are an “official Medicare agent” or “represent Medicare” - There are no Medicare representatives and Medicare will never cold-call you - Scammers say you must join a Medicare prescription plan (also known as Part D) - It is voluntary to join a Medicare prescription drug plan - They ask for personal information, such as your Medicare number, Social Security number and/or bank information - These fraudsters threaten or pressure you to enroll in their plan - You will not lose your benefits and have the entire Open Enrollment Period to decide - They may offer you gifts to enroll in their plan — it’s illegal It is estimated that Medicare fraud costs New York taxpayers over $5 billion dollars a year. To help combat this illicit industry StateWide earlier this year announced its **Fraud of the Month** program to highlight these scams being perpetrated on the State’s seniors. **Topics:** Medicare/Medicaid, Public Awareness --- ### [The health care company at the center of D.C.'s Medicaid saga](https://insurancefraud.org/news_archives/the-health-care-company-at-the-center-of-d-c-s-medicaid-saga/) **Published:** September 29, 2026 **Author:** Diane Beauchamp **Content:** Meet Amerigroup. It’s a Fortune 500 company that manages state-run health plans for low-income people. Its subsidiaries also have a history of fines and allegations over the handling of patients in multiple states. Amerigroup is now set to get back part of the District’s $1.5 billion Medicaid contract. Welcome to D.C.’s Medicaid saga. **Why it matters:** There has been a painfully long battle royale over management of the city’s Medicaid services. Since 2017, four companies, including Amerigroup, have engaged in finger-pointing and contract appeals as they compete for the three open contract slots. - One in three D.C. residents, including the poorest and most vulnerable patients, receive health insurance through Medicaid. They are caught in the middle of being shuffled between different health care providers over recent years. **Driving the news:** The District selects three contractors to run its Medicaid program through a competitive bidding process, and the D.C. Council is now set to act on the contract for Amerigroup and the other awardees, MedStar and AmeriHealth. - Amerigroup is at the center of this conflict. - Since losing out on the contract, CareFirst, which is one of the current Medicaid contractors, is publicly lobbying to push the D.C. Council to intervene. **State of play:** Council member Vincent Gray, who chairs the Health Committee, and other critics are pointing out that Amerigroup and its subsidiaries have a history of paying out fines and facing allegations of bad patient care across the nation. - Gray wrote to colleagues last Monday that he was considering disapproving the new contractors, known as managed care organizations (MCO). - “We are poised to bring back an MCO with a checkered history in the District and a well-known reputation for denying care to vulnerable Medicaid members,” Gray wrote in the letter, acquired by Axios. **Zoom in:** An Amerigroup subsidiary previously served the District over two separate periods, most recently from 2017 to 2020. In their final year, the deputy mayor for health, Wayne Turnage, told a D.C. Council committee that patients left Amerigroup in droves to seek coverage from other providers. - At that July 2020 hearing, Turnage was flabbergasted by Amerigroup’s 30% profit margin, compared to 4% for its competitor. - “I have never seen a public funded health plan have a margin of 30%,” Turnage testified. “In Virginia, when we had plans make more than 6%, they came back and voluntarily cut us checks.” Turnage declined to comment to Axios last Friday on the contracts, citing the ongoing process. He referred to his public comments from 2020 about Amerigroup. **The other side:** In response, Amerigroup says that patients left its services for other companies because MedStar, the D.C. region health giant, refused to offer its services for Amerigroup patients. (D.C. later began requiring that all Medicaid providers offer their services to each other.) Amerigroup D.C. president Adrian Jordan wrote his own letter to lawmakers. He dismissed Gray’s criticisms as “the product of a broader campaign of disinformation that is being waged by an unsuccessful offeror,” referring to CareFirst’s lobbying efforts. He echoed similar sentiments in a statement to Axios, adding “Amerigroup D.C. is committed to providing no or low-cost access to healthcare for D.C. residents enrolled in Medicaid.” One black eye for Amerigroup is a $225 million fine in 2008 to [settle](https://www.justice.gov/archive/opa/pr/2008/August/08-civ-723.html) accusations of federal and state Medicaid fraud claims. A central allegation was that the company systematically denied pregnancy care in Illinois. - More recently, in Texas, Amerigroup told state lawmakers in 2018 that it paid $20 million in fines after allegations of denying medical care to disabled patients. In Iowa, a 2021 [audit](https://www.auditor.iowa.gov/reports/file/66425/embed) faulted Amerigroup for denying some patients care. **What’s next:** Several council members on Tuesday told me they were still waiting for the contracts to be formally transmitted by Mayor Muriel Bowser, who had promised they would be out last week. - The waiting game is fueling last-minute jitters in a bureaucratic process that feels like a comedy of errors, with serious consequences. **Topics:** Medicare/Medicaid, Public Awareness --- ### [Amerigroup Settles Federal & State Medicaid Fraud Claims for $225 Million](https://insurancefraud.org/news_archives/amerigroup-settles-federal-state-medicaid-fraud-claims-for-225-million/) **Published:** September 29, 2026 **Author:** Diane Beauchamp **Content:** Amerigroup Corporation has agreed to pay $225 million to resolve claims that it defrauded the Illinois Medicaid program, the Justice Department and the Attorney General of Illinois announced today. Amerigroup, which is headquartered in Virginia Beach, Va., operates managed health care plans throughout the United States. Today’s settlement resolves allegations that Amerigroup and its Illinois subsidiary systematically avoided enrolling pregnant women, and unhealthy patients in their managed care program in Illinois. Amerigroup was paid by the United States and the state to operate a Medicaid managed care health plan in Illinois to provide health care to low income people. Amerigroup was required by law to enroll all eligible beneficiaries. The United States and the state of Illinois brought claims against the company alleging that it violated this requirement and avoided enrolling unhealthy patients, as well as pregnant women, who were more costly to treat and would have eroded Amerigroup’s profit margin. In October 2006, a jury found Amerigroup liable under the federal False Claims Act and the Illinois Whistleblower Reward and Protection Act. The court entered a $334 million judgment against Amerigroup, which then filed an appeal with the U.S. Court of Appeals for the Seventh Circuit in Chicago seeking a reversal of the judgment. As part of the settlement, Amerigroup will dismiss its appeal and has agreed to enter into a Corporate Integrity Agreement (CIA) with the Office of Inspector General for the U.S. Department of Health and Human Services (HHS). “The Justice Department is committed to ensuring that recipients of federal health care funds adhere to the law, so that appropriate health care services are provided to all eligible patients,” said Gregory G. Katsas, Assistant Attorney General for the Civil Division. “A settlement of this magnitude sends the clear message that this office takes health care fraud very seriously,” said Patrick J. Fitzgerald, U.S. Attorney for the Northern District of Illinois. “This case also illustrates the perils a defendant faces in taking a case such as this to trial.” “This settlement should send a clear message that the state of Illinois will not tolerate illegal conduct in the provision of healthcare for Illinoisans,” said Illinois Attorney General Lisa Madigan. “I am pleased that our work on this case will bring millions of dollars to the State of Illinois.” The CIA between Amerigroup and its subsidiary health plans and the Office of Inspector General requires the company to adopt policies and procedures, and a code of conduct designed to prevent improper discrimination against federal health care program beneficiaries in its marketing and enrollment practices. The CIA applies to Amerigroup’s managed care plans in all the states – currently 11 – in which the company does business during the term of the agreement. In addition, Amerigroup must hire an independent organization to annually review its marketing practices and enrollment initiatives, and its board of directors must certify the effectiveness of its compliance program each year. “The Office of Inspector General is committed to protecting Medicaid beneficiaries from fraud and discrimination” said HHS Inspector General Daniel R. Levinson. “This Corporate Integrity Agreement will help ensure that our most vulnerable beneficiaries have access to needed Medicaid HMO plans in the future.” The lawsuit against Amerigroup was originally filed by Cleveland Tyson, a former company employee. Under the federal False Claims Act and the Illinois Whistleblower Reward and Protection Act, a private party, known as a relator, is entitled to file suit alleging fraud on behalf of the federal or state government, respectively, and receive a share of any recovery. As a result of today’s recovery, Tyson will receive $56.25 million. The case was handled by the U.S. Attorney’s Office for the Northern District of Illinois and the Illinois State Attorney General’s Office, with assistance from the Justice Department’s Civil Division and the Office of Inspector General for HHS, as well as by private counsel for the relator. **Topics:** Judicial/courts, Medicare/Medicaid --- ### [Florida man gets 4 1/2 years for $2.2M Medicare fraud scheme](https://insurancefraud.org/news_archives/florida-man-gets-4-1-2-years-for-2-2m-medicare-fraud-scheme/) **Published:** September 29, 2026 **Author:** Diane Beauchamp **Content:** A federal judge sentenced a Florida medical equipment supply company owner to spend more than four-and-a-half years in prison after prosecutors said he defrauded Medicare out of more than $2.2 million. Ariel Madero Paez, 56, was the owner of Always Medical Supply in Stuart, according to prosecutors. Madero submitted $2.2 million in claims to Medicare for equipment that the company never provided and that Medicare beneficiaries never requested, the U.S. Department of Justice said. Always Medical Supply got $1.4 million as a result. Federal agents arrested Madero May 6 at Miami International Airport. In addition to the prison term and three years supervised release, U.S. District Judge Donald M. Middlebrooks ordered Madero to pay $1.5 million in restitution to Medicare and entered a forfeiture judgment of nearly $1.5 million. Federal agents already seized funds from Madero’s bank accounts. **Topics:** Medicare/Medicaid **Categories:** Conviction --- ### [Hospitals Continue to Suffer Impacts of CommonSpirit IT Security Incident](https://insurancefraud.org/news_archives/hospitals-continue-to-suffer-impacts-of-commonspirit-it-security-incident/) **Published:** September 29, 2026 **Author:** Diane Beauchamp **Content:** IT outages, appointment cancellations, and suspended patient portal access remain challenges for hospitals across the country as CommonSpirit deals with a cyberattack. Hospitals across the country are experiencing IT outages, delays, and appointment cancellations as CommonSpirit Health works to resolve an IT security incident. As [previously reported](https://www.techtarget.com/healthtechsecurity/news/366594594/CommonSpirit-Health-Suffers-IT-Outages-EHR-Downtime-at-Multiple-Hospitals), CommonSpirit Health [confirmed](https://www.commonspirit.org/news-and-perspectives/news/Statement-IT-Security-Issue) that it has been suffering IT outages as a result of an unspecified IT security incident that began on or around October 3. The incident has impacted multiple facilities within the health system, forcing some hospitals to take their EHR systems offline. The incident impacted CommonSpirit itself, not its EHR vendor. In 2019, CHI Health and Dignity Health merged to form CommonSpirit Health. CommonSpirit is one of the largest nonprofit healthcare systems in the US, with more than 1,000 care sites and 140 hospitals in 21 states. It is unclear at this time how many of CommonSpirit’s locations were impacted by the incident, but multiple CHI Health locations have reported impacts from the incident. At the time of publication, CHI Health’s [website](https://www.chihealth.com/en/patients-visitors/patient-portals/it-issue-impacting-some-facilities.html) stated that its facilities were following existing protocols for system outages and had taken certain systems offline temporarily. “As a result of this issue, we have canceled or rescheduled some patient appointments,” CHI Health’s website notice continued. “If your appointment was not able to be rescheduled immediately, you will be contacted when we are able to reschedule your appointment.” In addition, CHI Health temporarily suspended access to its patient portal and is following offline processes to manage prescriptions. “Patients who have a prescription on file with a pharmacy can continue to fill/refill their prescription. If a patient is out of refills for a medication, the patient should contact their pharmacy first and the pharmacy will contact the prescriber to obtain a new prescription with additional refills,” the notice explained. “CHI providers have the ability to write new prescriptions for patients who may require a new medicine.” MercyOne Central Iowa [said](https://www.mercyone.org/about-us/news-events/mercyone-central-iowa-it-issue-affects-online-scheduling) that the incident was impacting its online scheduling capabilities. Other hospitals across Iowa, Nebraska, Washington, and Tennessee have reported similar impacts. **Topics:** Public Awareness, Technology --- ### [Don’t Waste Your Money: Home insurance warning](https://insurancefraud.org/news_archives/dont-waste-your-money-home-insurance-warning/) **Published:** September 29, 2026 **Author:** Diane Beauchamp **Content:** Hurricane Ian should be a reminder to everyone that it is a good idea to check up on your homeowner’s insurance every now and then. Because your coverage may be much less than you think. Josiah Jouett watched as a tree fell on her neighbor’s home. “I saw the tree fall and I knew people lived in there, and wanted to make sure everyone was okay,” Jouett said. The good news is that everyone is fine. But, after Hurricane Ian and in many cases, homeowners are discovering they have to pay thousands of dollars for storm cleanup. That is because most insurance policies do not cover trees downed by wind, according to Jennifer Pike of the Insurance Board. “If a tree comes down in your yard and it causes no damage, but just falls in your yard, unfortunately, that falls on you,” Pike said. Pike always says if a tree hit your roof or the wind ripped off shingles, your homeowner’s insurance should cover cleanup and repair costs. However, if a tree hit your roof without damaging anything else, you are typically not covered. Unless you have a “rider” for trees and landscaping. Even if your policy will pick up the pieces after a storm, what kind of coverage you have makes a difference. Because, a basic policy may not want to pay for top-quality windows, real wood siding or granite counters. You should try to have full replacement coverage, which will restore everything in today’s dollars. Finally, many Hurricane Ian victims are discovering they weren’t covered for the water damage to their homes, because flood insurance is a totally different policy, and it is only mandatory if you live in a flood zone. Your best bet is to give your agent a call and see if you bare covered for floods, fallen trees, and full replacement costs, so you don’t waste your money. **Topics:** Public Awareness --- ### [Pharmacist sent to prison for fraudulent compounding cream scheme](https://insurancefraud.org/news_archives/pharmacist-sent-to-prison-for-fraudulent-compounding-cream-scheme/) **Published:** September 29, 2026 **Author:** Diane Beauchamp **Content:** A Houston woman has been ordered to federal prison following her conviction of conspiracy to commit health care fraud, announced U.S. Attorney Jennifer B. Lowery. Kyhati Undavia pleaded guilty Oct. 12, 2021. Today, U.S. District Judge Hanen ordered Undavia to serve 27 months in federal prison to be immediately followed by three years of supervised release. In handing down the sentence, the court considered the $12 million dollar restitution she paid at the time of the sentencing. In handing down the sentence, Judge Hanen noted restitution goes a long way to show acceptance but you cannot buy your way out of prison. At the time of her plea, Undavia admitted to submitting claims to federal health benefit programs such as TRICARE, Department of Labor Office of Workers’ Compensation Programs (DOL-OWCP) and Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) for compounded medication prescriptions. Undavia has a professional background as a pharmacist who controlled and operated Memorial Pharmacy. From December 2012 to December of 2018, Undavia hired employees to market Memorial Pharmacy to physicians as a place to submit compounded drug prescriptions. Undavia paid kickbacks through the marketers to physicians in efforts to persuade them to write prescriptions and send them to Memorial on behalf of their patients. Instead of providing pain medication prescriptions directly to the patients who could select a pharmacy of their choice, the bribed physicians sent the prescriptions directly to Memorial. In some instances, patients were never seen by an actual physician. Instead, physicians authorized prescriptions for beneficiaries that a marketer provided to them. The marketer paid the physician an illegal kickback for the prescriptions or Undavia would directly pay them. Beneficiaries often received medicated creams that they did not need or want. Undavia received approximately $22 million from Tricare, DOL-OWCP and CHAMPVA for the prescriptions. “Today’s sentencing is a testament to the dedication and determination of the investigative and legal teams,” said Special Agent in Charge Scott Pierce, U.S. Postal Service – Office of Inspector General (USPS-OIG), Southern Area Field Office. “The Postal Service spends hundreds of millions of dollars annually on health care related costs and these monies are critical to those who legitimately require medical services. As in this case, our criminal investigators will diligently pursue any individual or organization intent on defrauding the Postal Service with an eye on both federal prosecution and returning lost monies to the affected program.” Undavia was permitted to remain on bond and voluntarily surrender to a U.S. Bureau of Prisons facility to be determined in the near future. The Defense Criminal Investigative Services, DOL – Office of Inspector General (OIG), USOS-OIG, Veterans Affairs – OIG and FBI conducted the investigation. Assistant U.S. Attorney Tina Ansari prosecuted the case. **Topics:** Veterans Benefits Fraud **Categories:** Conviction --- ### [DermaTran and three other pharmacies pay over $6.8 million to settle civil claims](https://insurancefraud.org/news_archives/dermatran-and-three-other-pharmacies-pay-over-6-8-million-to-settle-civil-claims/) **Published:** September 29, 2026 **Author:** Diane Beauchamp **Content:** DermaTran Health Solutions, LLC; Pharmacy Insurance Administrators, LLC; Legends Pharmacy; TriadRx; and the former owners of Lake Side Pharmacy and related entities, agreed to pay $6,876,564 to resolve allegations that they violated the False Claims Act by waiving copays, charging the government higher prices than permitted, and trading federal healthcare business with other pharmacies. “Waiving copays and charging the government higher prices leads to overutilization and costs federal programs millions of dollars in unnecessary spending,” said U.S. Attorney Ryan Buchanan. “Our office will continue to enforce the False Claims Act to recover government payments that result from such misconduct.” “Health care fraud abuse like this case erodes the trust patients have in the health care system,” said Keri Farley, Special Agent in Charge of FBI Atlanta. “The FBI will not stand by when there are allegations of companies operating corporate wide schemes to illegally line their pockets.” “Fraud through compounding pharmacies bilked billions out of TRICARE and undermined the integrity of our healthcare system designed to care for our service members and their families,” stated Cynthia Bruce, Special Agent in Charge of the Department of Defense, Office of Inspector General, Defense Criminal Investigative Service (DCIS). “I appreciate the partnership among involved law enforcement agencies and the U.S. Attorney’s Office to bring this matter to justice.” “The OPM OIG has no tolerance for businesses that knowingly take advantage of FEHBP, violating the rules to make a profit,” said Amy K. Parker, Special Agent in Charge, OPM OIG. “I am extremely proud of the hard work of our investigators, analysts, and other law enforcement partners because overcharging the government is not a victimless crime – it contributes to higher premium prices and harms the financial integrity of the FEHBP.” “The U.S. Postal Service, Office of Inspector General, will continue to tirelessly investigate those who commit frauds against federal benefit programs and the U.S. Postal Service. This settlement is a clear message that the USPS OIG is dedicated to rooting out corruption and bringing to justice those responsible for these crimes, said Special Agent in Charge Matthew Modafferi of the U.S. Postal Service, Office of Inspector General Northeast Area Field Office. The USPS OIG would like to thank our law enforcement partners and the Department of Justice for their efforts in this investigation”. “Health care providers that try to boost their profits by submitting fraudulent claims to Federal health care programs threaten the integrity of those programs and drive up prices for everyone,” said Tamala E. Miles, Special Agent in Charge with the U.S. Department of Health and Human Services Office of Inspector General. “We work tirelessly alongside our law enforcement partners to protect the integrity of Federal health care programs and to ensure the appropriate use of taxpayer dollars.” The government alleged that in 2012, pharmacy DermaTran Health Solutions, LLC (“DermaTran”), opened in Rome, Georgia, for the purpose of making and selling custom “compound” pain creams. DermaTran’s owners during the relevant time include DIII Consulting, LLC; SRM Holdings, LLC; Gussenhoven Holdings, LLC; Sam Moss; and Robert Gussenhoven. At the same time, another company named Pharmacy Insurance Administrators, LLC (“PIA”), was created to handle the billing for DermaTran. During the relevant time, PIA was a subsidiary of Insurance Administrative Solutions, LLC; which was a subsidiary of Gulfcoast Administrators, LLC; which was majority-owned by Life & Health Holdings, Inc.; which was a subsidiary of State Mutual Insurance Company. Compound pain creams were very lucrative. Government-backed health insurance programs such as TRICARE (for the military) and the Federal Employees Health Benefits Program (for federal workers) would reimburse hundreds of dollars for these prescriptions. But the government programs imposed certain restrictions to limit spending. For example, patients were required to contribute to the cost of the prescription in the form of copays. The government programs also limited payments to the “usual and customary price”—the price charged to a cash-paying, uninsured patient. The Government alleged that DermaTran and PIA found ways to avoid these restrictions. DermaTran and PIA created a copay-waiver program where patients would have their copays waived based on a brief, unverified statement of economic need. DermaTran and PIA also misled the government programs about the price being charged to uninsured, cash-paying patients by falsely stating that that price was high when, in fact, it was only $30. As a result, there were days that veterans were charged $600+ for pain creams, while uninsured patients were charged only $30. Eventually, various auditors uncovered these problems and began to terminate DermaTran from their networks. The Government alleged that DermaTran, looking for a way to continue to earn money, began selling its out-of-network prescriptions to other pharmacies. The other pharmacies could fill the prescriptions because they were still in network. After filling the lucrative prescriptions, the other pharmacies remitted a portion of the proceeds to DermaTran and PIA. The government alleged that this arrangement constituted an illegal kickback. The other pharmacies that participated in this prescriptions-for-money scheme included Legends Pharmacy (in Texas), Lake Side Pharmacy (in Alabama), and TriadRx (in Alabama). The Government’s False Claims Act claims based on the above allegations are being settled. PIA will contribute $6.5 million to the settlement. DermaTran is no longer operating and was sold in an arm’s-length transaction to a third-party buyer last year for the price of $40,000. That amount will be turned over to the government as part of the settlement. MLDP of Texas, LP (a/k/a “Legends Pharmacy”) will pay $59,293. TRIAD Rx, Inc. will pay $166,547. Lake Side Pharmacy is no longer in business, but former owners of Lake Side Pharmacy will pay $110,724. The former owners include Titan Medical Marketing, LLC; Donald Wayne Bogue; George Takashi Elkins; James Bernard Bogue, Jr.; Robert Joseph Puckett, Jr.; Robert Joseph Puckett, Sr.; Stephen Weston Wilson; and Charles Franklin Taylor, Jr. This civil settlement resolves a lawsuit filed in the U.S. District Court for the Northern District of Georgia by a former accountant for DermaTran, under the qui tam, or whistleblower provisions, of the False Claims Act. United States ex rel. Doe v. DermaTran Health Solutions, LLC, et al., Civil Action No. 1:17-CV-1765. Under the False Claims Act, private citizens may bring suit for false claims on behalf of the United States and share in any recovery obtained by the government. The whistleblower will receive $1,434,775 from the settlements. PIA will also pay her attorney’s fees. The claims resolved by the settlement are allegations only, and there has been no determination of liability. This case was investigated by the U.S. Attorney’s Office for the Northern District of Georgia, the FBI, the Defense Criminal Investigative Service, the US Office of Personnel Management – Office of the Inspector General, the U.S. Postal Service – Office of Inspector General, and the Health and Human Services – Office of Inspector General. The civil settlement was reached by Assistant U.S. Attorney Anthony DeCinque. **Topics:** Judicial/courts, Veterans Benefits Fraud --- ### [Scammers targeting elderly as Medicare open enrollment period set to begin](https://insurancefraud.org/news_archives/scammers-targeting-elderly-as-medicare-open-enrollment-period-set-to-begin/) **Published:** September 29, 2026 **Author:** Diane Beauchamp **Content:** With [Medicare open enrollment](https://www.medicare.gov/sign-up-change-plans/joining-a-health-or-drug-plan) just days away, scammers are targeting the elderly in an effort to commit insurance fraud. “If someone says that they’re calling from Medicare or from Social Security and they ask you for your Social Security Number or your Medicare number, it might be a scam,” Chapter Co-Founder Ari Parker said. But there are a [lot of moving pieces](https://thenationaldesk.com/news/americas-news-now/medicare-premium-drop-a-once-in-a-retirement-moment-for-older-americans-part-b-prescription-drugs-insulin-vaccines-social-security-retirees-seniors-benefits) this year: the first round of relief from the Inflation Reduction Act begins in 2023 and the $35 cap on cost-sharing for insulin under Part D begins on the first of the new year. “That’s a huge thing because we all know that insulin can be very expensive for people,” PA MEDI Director Susan Neff said. For beneficiaries taking insulin through a traditional pump under Part B, the benefit begins in July. “Your specific insulin that you use must be on your plan’s formularies,” Neff explained. “So it’s a really good idea to confirm that before you decide to enroll in a different plan.” Enrollees will see other changes as they choose their coverage plan for 2023. Here’s the breakdown of cost changes: **PART A PREMIUMS** - 2022 – $1,556 - 2023 – $1,600 **PART B PREMIUMS** - 2022 – $170.10 - 2023 – $164.90 **PART B DEDUCTIBLE** - 2022 – $233 - 2023 – $226 **PART D PREMIUMS** - 2022 – $32.08 - 2023 – $31.50 Part A premiums are up $44. This covers inpatient hospital stays, skilled nursing facilities, hospice and inpatient rehab. “Healthcare costs are on the rise,” Parker added. “Medicare premiums are actually going down.” Notably different are Part B costs, which cover doctors’ appointments and outpatient hospital services. These prices are falling for the first time in nearly a decade. “People will be able to save a little bit more money,” Neff said. Part D premiums, which cover prescription drug costs, are also trending downward. > “This coincides with an increase in Social Security, which should be announced this week,” Parker continued. “The Social Security cost of living adjustment should be going up so that means there actually should be more money in seniors’ pockets.” Advisors say beneficiaries need to check their doctors, pharmacies and prescriptions to ensure they’re on the best plan. The rest of the Inflation Reduction Act will roll out in the next few years. This time next year, Medicare will be able to start negotiating prices for the 10 most commonly prescribed drugs. **Topics:** Medicare/Medicaid, Public Awareness --- ### [Iowa City man pleads to killing his wife before she found out about his risky finances](https://insurancefraud.org/news_archives/iowa-city-man-pleads-to-killing-his-wife-before-she-found-out-about-his-risky-finances/) **Published:** September 29, 2026 **Author:** Diane Beauchamp **Content:** An Iowa City man pleaded guilty to stabbing his wife multiple times in 2019 before she was scheduled to speak to a banking official who would have told her about his risky high-interest loans, falsified accounting records and that he emptied one of her savings accounts. Roy Carl Browning Jr., 70, of Iowa City, originally charged with first-degree murder, made an Alford plea to second-degree murder. He still faces a life sentence because a second-degree conviction is 50 years in prison. He will have to serve a mandatory 35 years before being eligible for parole. Under the Alford plea, Browning, who appeared in an orange jumpsuit, didn’t admit guilt but admitted that the prosecution had enough evidence for a likely conviction in the murder of his wife, JoEllen Browning, 65, who died April 5, 2019. Johnson County Attorney Janet Lyness said after the plea that more information about the crime will be released later at a sentencing hearing. Lyness did say she conferred with JoEllen Browning’s family about the plea, and they agreed to it. None of JoEllen’s family was in the courtroom Wednesday. Sixth Judicial District Judge Kevin McKeever set sentencing for Dec. 2 in Johnson County District Court. After Roy Browning’s murder trial was rescheduled several times and then set to begin Nov. 1, he filed a motion to exclude testimony that he declined to be questioned by police or asked for a lawyer; testimony by law enforcement regarding his wife’s activities; their relationship and statements made by others about him; or his wife’s financial information. The motion also wanted the court to exclude “opinion testimony” about any possible motive and of any concealment of funds or how they were used. The defense also asked that any testimony be excluded alleging Roy Browning was seen with “younger women or beliefs he had one night stands” because it’s irrelevant, according to the motion. After Roy Browning was arrested six months after the murder in October 2019, investigators said they had determined JoEllen Browning, a University of Iowa Hospitals and Clinics budget executive, was going to learn April 5, 2019, about her husband falsifying banking records and his numerous high-interest loans. Investigators said she had scheduled a meeting with a financial representative that day and would have learned her husband had depleted one of her savings accounts and taken out loans without her knowledge, according to court documents. During the investigation, law enforcement learned JoEllen Browning had emailed her husband that April 1, asking about the discrepancies in their bank accounts, according to court documents. She told her husband to contact their bank to ensure he could log into their account so the couple could review the accounts that night. Authorities said about 20 minutes after Roy Browning responded to his wife that he was aware of the April 5, 2019, meeting, he was at a paint supply store buying rubber gloves and towels, which police said they never found. Investigators did find a text message from JoEllen Browning to her husband that said they were to meet with their financial institution at 8 a.m. that day — an hour after she was found dead in her home, according to a search warrant affidavit. Roy Browning called 911 at 6:59 a.m. April 5, 2019, reporting his wife was “unresponsive.” Police found her on the bedroom floor with multiple stab wounds to her front and back torso and on her left hand, according to court documents. A forensic pathologist determined the cause of death was “sharp-force injuries” — stab wounds — and her death was ruled a homicide. During the investigation, authorities learned JoEllen Browning had a retirement account and life insurance policy worth more than $2 million, according to court documents. Her husband had no source of income. According to court documents, Roy Browning is the executor of his wife’s will, which is in probate pending the outcome of the case. Browning will remain in jail on a $5 million bail pending his sentencing. **Topics:** Financial Fraud, Life Insurance **Categories:** Conviction --- ### [Acuity Reports Increase in Cyber Liability Insurance Claims as Cybercrime Skyrockets](https://insurancefraud.org/news_archives/acuity-reports-increase-in-cyber-liability-insurance-claims-as-cybercrime-skyrockets/) **Published:** September 29, 2026 **Author:** Diane Beauchamp **Content:** In recognition of Cybersecurity Awareness Month, Acuity Insurance — the sole regional insurance provider rated A+ by both AM Best and Standard & Poor’s, with over $6 billion in assets — is reporting an increased need for cyber liability insurance across both personal and business policyholders. From June 2021 to June 2022, Acuity Insurance saw cyber liability insurance claims on its commercial insurance policies increase by more than 50%. For personal policies, Acuity saw more than a 90% increase in cyber claims being reported in 2021 compared with 2020. “Our lives, homes and businesses are more connected than ever before,” said Steve Maliborski, general manager of commercial products at Acuity Insurance. “Being connected leads to a greater risk of cyberattacks, which aren’t covered under standard homeowners or business insurance policies.” Acuity experts caution that everyone is at risk — whether you are a small business owner or an individual — as cyberattacks continue to pose a serious financial threat. From 2019 to 2021, cyberattacks were up 50% from the previous year, according to recent research. Wire fraud and gift card scams are two of the most common types of cyberattacks impacting both businesses and individuals, Acuity found. “Scams involving social engineering are some of the easiest to fall for, as fraudsters exploit a person’s trust to obtain money or personal information, which can then be used for unauthorized withdrawals of money,” said Bob Hertel, director of personal lines product development at Acuity Insurance. “Cyber insurance can protect you from financial loss caused by wire transfer fraud, phishing attacks, cyber extortion, cyberbullying and more.” While all cybercrimes have a financial impact, fraudulent wire transfers often come with greater losses. Banks are typically not responsible for funds lost as a result of a fraudulent wire transfer inadvertently authorized by the customer. Whether it’s a wrongful money transfer by a business or an individual, cyber insurance will help mitigate some of the financial loss caused by these scams. Although many individuals and companies look to keep their insurance costs as low as possible, adding a cyber endorsement will cost you far less than any cybercrime loss would. At Acuity, the personal lines identity fraud expense and cyber protection endorsement cost just $35 per year, while the average commercial line policy starts at approximately $260 per year. While the best defense is prevention, you can have peace of mind knowing you are properly covered. Acuity’s personal and commercial cyber protection policies contain resources to help minimize cyber risks and protect individuals and businesses. For more information, visit [www.acuity.com](https://c212.net/c/link/?t=0&l=en&o=3676384-1&h=1313267464&u=http%3A%2F%2Fwww.acuity.com%2F&a=www.acuity.com). **Topics:** Public Awareness, Technology --- ### [Props to BWC workers who find fraud](https://insurancefraud.org/news_archives/props-to-bwc-workers-who-find-fraud/) **Published:** September 29, 2026 **Author:** Diane Beauchamp **Content:** It’s easy to spot all the ways in which those working in state government tend to be less careful with taxpayer dollars than we’d like. It’s not so easy to spot the ways in which some of those folks are working hard to stop fraud, waste and abuse of the system. But at the Ohio Bureau of Workers Compensation, the special investigations department is doing just that. During the most recent fiscal year, the department closed 1,431 cases, which resulted in 69 convictions and “identified $90 million in savings to our system,” the bureau reports. “Protecting the state insurance fund, ensuring the workforce is receiving the best care possible, and employers pay their share to help keep premiums low, has been a driving force for the SID specialists,” according to a news release announcing the notably high success rate of the department last year. Among the examples given by the department are a doctor who was caught billing for services not rendered, a man who had managed to steal a check meant for an employer and a man who tried to collect money without fulfilling the requirements set forth by the bureau. Run-of-the-mill stuff, perhaps, but not when there is so much of it going on that tens of millions of dollars of taxpayer money is at risk. Those in the special investigations department who continue to work hard on behalf of Ohioans are to be commended for their efforts — particularly as last year’s savings to the system were the second highest annual savings for a fiscal year since 2007. It would be nice to hope the kinds of people who would attempt to defraud the BWC will learn their lesson. But as that seems unlikely, Buckeye State residents can be assured there is a group of people working diligently to save our money and bring those criminals to justice. **Topics:** Public Awareness, Workers Comp --- ### [Medicare Advantage Fraud Cases Pile Up; COVID Origins Settled? Nurse's Murder Trial](https://insurancefraud.org/news_archives/medicare-advantage-fraud-cases-pile-up-covid-origins-settled-nurses-murder-trial/) **Published:** September 29, 2026 **Author:** Diane Beauchamp **Content:** Welcome to the latest edition of Investigative Roundup, highlighting some of the best investigative reporting on healthcare each week. Medicare Advantage Is Being Exploited for Big Profits Major health insurers are exploiting the Medicare Advantage program to “inflate their profits by billions of dollars,” the New York Times reported, citing their review of dozens of fraud lawsuits, inspector general audits, and investigations by watchdogs. By 2023, more than half of Medicare beneficiaries are expected to have a private Medicare Advantage plan, according to the Times. Although Medicare Advantage was meant to encourage better care at lower costs and to improve upon the traditional program, it has become more costly. “The government pays Medicare Advantage insurers a set amount for each person who enrolls, with higher rates for sicker patients,” the Times reporters wrote. “And the insurers, among the largest and most prosperous American companies, have developed elaborate systems to make their patients appear as sick as possible, often without providing additional treatment, according to the lawsuits.” In response, most of the largest Medicare Advantage insurers contested the allegations, and have said that federal audits have been subpar. They have also said their goal has been to improve care by accurately describing patients’ health. “Medicare Advantage is an important option for America’s seniors, but as Medicare Advantage adds more patients and spends billions of dollars of taxpayer money, aggressive oversight is needed,” Sen. Charles Grassley (R-Iowa), who has investigated the industry, said, according to the Times. He added that abuses of the program, such as making patients look sicker than they are, have “resulted in billions of dollars in improper payments.” Many of the fraud lawsuits have been brought by former health insurers’ employees, and most have been joined by the Department of Justice. However, regulators at CMS have been more lax. “Some critics say the lack of oversight has encouraged the industry to compete over who can most effectively game the system rather than who can provide the best care,” the Times reporters noted. Zoonosis or Lab Leak — The Debate Over COVID-19’s Origins Rages On A new report from an expert panel published in Proceedings of the National Academy of Sciences (PNAS) on COVID-19’s origins points to a spillover from animals to humans, rather than a laboratory leak, Science reported. “Our paper recognizes that there are different possible origins, but the evidence towards zoonosis is overwhelming,” co-author Danielle Anderson, PhD, of the University of Melbourne, told Science. Even so, the debate continues. Science noted that the history of the expert panel itself “reflects the intensity of the debate.” The panel was first put together as a task force for The Lancet COVID-19 Commission, which was disbanded after the commission’s chair, Jeffrey Sachs, PhD, of Columbia University, alleged that several members had conflicts of interest that would bias them against the hypothesis that COVID originated in a lab. Sachs and other researchers aren’t convinced by the argument for zoonosis, according to Science. “What we’ve seen is mostly reanalysis and reinterpretation of existing evidence,” Jesse Bloom, PhD, of the Fred Hutchinson Cancer Research Center in Seattle, told the publication. However, the authors of the report said that their literature search found “considerable scientific peer-reviewed evidence” that COVID-19 moved from bats to other animals and then to people in the wildlife trade, leading to an outbreak at the Huanan Seafood Market in Wuhan, China, adding that relatively few peer-reviewed studies back the lab-leak theory. Last month, The Lancet published a report from Sachs and other authors, which gave equal weight to either a zoonotic or laboratory origin of COVID-19, Science noted. Trial for British Nurse Accused of Murdering Infants Reveals Disturbing Details Lucy Letby, a 32-year-old neonatal nurse who is accused of killing seven babies and attempting to kill 10 more, deliberately poisoned two infants with insulin, a prosecutor said during trial this week, the AP reported. Letby has pleaded not guilty to the charges against her. However, in opening her trial at Manchester Crown Court, prosecutor Nick Johnson said that beginning in 2015, the Countess of Chester Hospital in northwest England, where Letby worked, saw a significant increase in the number of infants who were dying or experiencing “serious catastrophic collapses,” according to the AP. “Babies who had not been unstable at all suddenly deteriorated,” Johnson told the jury. “Sometimes babies who had been sick, but then been on the mend suddenly deteriorated for no apparent reason.” In addition to allegedly using insulin to poison infants, the prosecutor described an instance in which Letby injected air into the bloodstream of another young victim, AP reported. The killings allegedly took place between 2015 and 2016, during Letby’s time working at the hospital. She was previously arrested three times in connection with the deaths, but was not charged until November 2020. Other horrifying allegations against Letby described during the ongoing trial include that she smiled as a grieving mother bathed her dead baby daughter after the nurse fatally poisoned the 11-week-old on her fourth attempt, The Guardian reported. In another instance, when a mother walked in on Letby allegedly trying to murder a baby boy, Letby is reported to have said, “Trust me, I’m a nurse.” **Topics:** Medicare/Medicaid, Public Awareness --- ### [Data increases efficiency in the detection of fraud, waste and abuse](https://insurancefraud.org/news_archives/data-increases-efficiency-in-the-detection-of-fraud-waste-and-abuse/) **Published:** September 29, 2026 **Author:** Diane Beauchamp **Content:** The OIG has focused the evolution of fraud, waste and abuse (FWA) detection on a foundation of data analytics. Capitalizing on the power of data drives the agency to more efficient and comprehensive investigations, reviews, audits and inspections. Each year, the OIG team uses emerging technology used for data analytics to assess the billing trends and patterns of providers, clients, retailers, and contractors participating in HHS programs. This information enables investigators to increase the recognition of potential risks and move quickly against possible misuse of taxpayer funds. Fraud Detection Operations To support fraud detection operations (FDOs), the OIG’s data team created more than 25 new algorithms throughout fiscal year 2022. OIG Investigations and Reviews use these tools to detect potential waste or wrongdoing by identifying providers with unusual billing patterns compared to their peers. The creation of the new algorithms helped identify potential policy violations and suspicious billing behaviors for Non-Local Mental Health Authorities and durable medical equipment providers. The graphic below highlights providers billing for significantly higher amounts when seeing fewer clients than their peers. Outlier status is not an automatic indicator of wrongdoing; it only identifies providers who may warrant a closer look due to unusual billing activity. The initiatives are in various stages of review and investigation. In the span of a few years, the OIG’s provider investigation inventory has evolved from approximately 95 percent traditional referral cases with a few self-initiated cases to approximately 60 percent now being based on data analytics, almost all of which are data initiatives project team cases. By harnessing the power of data analytics, the OIG can handle cases more efficiently from the moment they begin until each investigation reaches its final resolution. Data Initiatives Project Team Fiscal year 2022 has seen the OIG broaden the use of data analytics to uncover improper billing trends in Medicaid delivery through the OIG’s Data Initiatives Project Team. This team specializes in expanding previously developed algorithms from reviewing one provider – whether it comes from data analytics or a referral from an MCO or the public – to examining statewide data to locate Medicaid providers with similar issues in need of review. This process identified a repeated issue with emergency room injection and infusion reimbursements. The data indicated outpatient hospital facilities were billing for administering injections or infusions in the emergency department when the ER evaluation and management reimbursement already covered those services. The team has settled 21 ER injection/infusion cases for more than $30 million in overpayments. The OIG is also working to develop education and outreach to help providers and MCOs prevent future overpayments. Advancing analysis To further develop the OIG analytics-based review methods, the agency contracted with a vendor. The contract is assisting the OIG to create more advanced analytical tools to help identify FWA’s potential indicators throughout state health and human services. The work performed over the past fiscal year with the contractor will enhance the agency’s ability to perform highly complex data analysis, increase operational efficiencies, and advance its analytical capabilities. Sharing data and information The OIG’s data team facilitates a cross-divisional data analytics information-sharing session with data analytics staff throughout HHS. The quarterly meetings include OIG and HHS Medicaid/CHIP Services representatives, Actuarial Analysis, and the Office of Data, Analytics, and Performance. During these meetings, staff share data anomalies, utilization trends, and program and financial updates that may impact Medicaid services. The information exchanged during these collaborative meetings is considered by the OIG when performing any data analysis on topics of interest and can lead to recommendations for reviews by OIG staff in the future. Going forward The OIG has found data analytics to be the most effective use of state resources to detect fraud waste and abuse. While referrals to the OIG identify potential risks in specific circumstances with an individual provider contracting with one managed care organization, a data-driven approach can identify risks program-wide by identifying if the referred provider and other providers are behaving similarly across other MCOs. This approach helps the agency focus on areas of high risk, increases recoveries and ensures better compliance across the Texas health and human services system. **Topics:** Public Awareness, Regulatory actions, Technology --- ### [Public adjusters, contractors knocking on doors post-Hurricane Ian, homeowners say](https://insurancefraud.org/news_archives/public-adjusters-contractors-knocking-on-doors-post-hurricane-ian-homeowners-say/) **Published:** September 29, 2026 **Author:** Diane Beauchamp **Content:** Southwest Florida homeowners say hundreds of public adjusters and contractors have been knocking on their doors asking to help with insurance claims after Hurricane Ian. The Insurance Information Institute said natural disasters like this attract scammers looking to take advantage of people when they’re most vulnerable. “They’re out here like vultures, you know, and they are taking advantage of everybody,” Cape Coral Homeowner Ron Scalzo told ABC Action News. “As you can see, we’ve got a lot of wind damage because the eye of the storm ran right parallel to us,” he said, showing us the tree debris lining his street. As soon as the hurricane passed, he went outside to start cleaning the debris in his neighborhood. “The most disturbing thing was within half an hour of us just starting to clean up to get to our cars, we had 40, 50 public adjusters running through the neighborhood talking about how they could do our claims for us… they could handle it for us, it’s what they do,” he said. To homeowners in a time of distress, it sounds like a good idea, but Scalzo knew better because he’s the COO of Flagler Insurance agency. “I said, ‘I’m a licensed adjuster. I’m an insurance agent. I don’t need any help, we just call the carrier and they’ll take care of the claim,’ and they said, ‘Oh no, that’s not how it works.’ I said, ‘What do you mean that’s not how it works?’ ‘No, you have to know how to navigate through this because the carrier’s not going to want to pay you,’” Scalzo described one of the conversations he had hours after the hurricane. Scalzo said he knows at least 15 people who agreed to sign with these door knockers — either a public adjuster who will adjust their claim for a percentage of the payout or an [assignment of benefits](https://floir.com/consumers/assignment-of-benefits-resources) (AOB) — allowing a third party, often a roofer, to take over with the insurance company. According to the Florida Office of Insurance Regulation, the abuse of AOBs has fueled runaway litigation, putting millions of dollars from insurance companies into the pockets of roofers and their attorneys. “They were going through here like it was Halloween, and they were trick or treating,” Scalzo exclaimed. “We probably had 40, 60 within an hour coming through here, and then they continue to just keep coming in over days and days.” As many are facing some of the hardest weeks of their lives, Florida’s Chief Financial Officer Jimmy Patronis told residents on October 6 to beware of scammers waiting to take advantage. “The bad actors will be high-pressure salesmen going door to door trying to coerce you to sign documents. Never sign anything,” Patronis said in a [press release video](https://myfloridacfo.com/news/pressreleases/details/2022/10/06/public-service-announcement-cfo-jimmy-patronis-beware-of-bad-actors-and-don-t-sign-anything). “Our advice always is don’t even answer your door,” said Mark Friedlander, spokesperson for the Insurance Information Institute. He adds that this happens after every natural disaster, and it won’t change until the laws do. “We’re hoping, at some point, the legislature will take strong enough action to basically ban AOBs because all they are, are roadmaps for fraud,” Friedlander said. “Many states have banned them or greatly restricted them. Florida is still very open season when it comes to AOBs, and it is the first step towards being scammed by a contractor.” The institute also predicts $10-20 billion in lawsuits against insurance companies to come out of Hurricane Ian. Florida Association of Insurance Agents (FAIA) also warns that not only will a third party slow down a payout, but homeowners will lose money as well. “Public adjusters are paid, you know, as a portion of the claim, so after a catastrophe, their fees are limited to 10% of the claim,” explained Kyle Ulrich, President and CEO for FAIA. “But, if a customer signs an agreement with a public adjuster now before giving their insurance company the opportunity to adjust the claim, they’re giving away 10% of their claim for no reason whatsoever.” In Florida, you have 10 days to rescind signing a public adjuster and 14 days to rescind an assignment of benefits to make sure no one gets paid out from your loss. “I think they take advantage of people because they’re completely lost,” Scalzo concluded. Insurance fraud costs each Florida family an additional $1,500 a year in increased premiums, according to the CFO’s office. **Here are a few important tips to avoid falling victim:** - Always call your insurance agent before signing anything - Verify anyone you hire has a valid license by asking for information and [searching it on this site.](https://licenseesearch.fldfs.com/) - If you have any questions or concerns, call 1-877-MY-FL-CFO (1-877-693-5236) **Topics:** Public Awareness --- ### [Cybersecurity: Key threats endangering insurers](https://insurancefraud.org/news_archives/cybersecurity-key-threats-endangering-insurers/) **Published:** September 29, 2026 **Author:** Diane Beauchamp **Content:** Like most businesses, insurers are smarting from the relentless attacks on their computer networks by hackers — which are increasing in number and sophistication with each passing year. Currently, 82% of the world’s largest insurers are vulnerable to phishing — which occurs when trusting employees unknowingly give hackers access to IDs and passwords or other ways to penetrate the company network, according to Black Kite’s “A Fight for Coverage: Cyber Insurance Risk in 2022.” The same report found that 18% of insurance companies open their doors each day extremely susceptible to ransomware. “Most security and risk leaders now recognize that major disruption is only one crisis away,” said Richard Addiscott, senior director analyst, Gartner — a technology advisement firm. “We can’t control it, but we can evolve our thinking, our philosophy, our program and our architecture.” Unfortunately, insurers are especially desirable for hackers given they have deep pockets — as well as that catnip-of-catnip for cybercrooks: The personally identifiable information (PII) of sometimes millions of customers. Granted, we’d all like to believe that every business on the planet has the grit to tell hackers where to go when such crooks compromise their data and computer systems. But as guardians of customers’ PII, insurers face a tough choice: Standing up to hackers, or paying them off to hopefully protect the PII of their customers. PII theft statistics are among the scariest for those charged with guarding such personal data. During 2021 alone, hackers exposed the PII of 1.5 billion users during the course of their exploits, according to the Black Kite report. Equally troublesome, insurers specializing in cybersecurity insurance find they are of even greater interest to hackers, given that the stolen details of cyber insurance policies also offer hackers insight into the amount of ransom an insurer has agreed to pay for its insured, according to the “2022 Insurance Industry Cyber Threat Landscape Report,” from IntSights. Observed Bob Maley, chief security officer, Black Kite: “The cyber insurance landscape has never been more volatile.” As in previous years, one cyberthreat troubling insurers as of late is ransomware, which saw an 82% jump in incidents in 2021 over the prior year, according to Crowdstrike, an IT security firm. The industry also saw disturbing growth in attacks on personal computing devices used by remote workers last year — as well as increased hacker penetration into giant companies via the poorly secured networks of smaller, third-party vendors. “Year after year, the increasing risk lies with your most vulnerable partners and suppliers,” said Paul Paget, CEO of Black Kite. Add an increase in hacker break-ins to cloud-based systems, a jump in hacking attacks orchestrated by nation-states and increasing hacker access to tricks and techniques powered by artificial intelligence, and it becomes clear that nothing less than 24/7 vigilance will be needed by insurers to thwart the cybercriminals in coming years. Here’s a deeper look at threats that are especially dangerous to the industry: Remote worker vulnerability: One of the downsides of all the remote working opportunities many workers are enjoying lately is the significantly increased vulnerability of their employers. The reason? Many of the personal smartphones, home laptops, on-the-go personal digital assistants and similar technologies workers are using from home are completely devoid of cybersecurity software. That gaping vulnerability translates into open season for hackers, who can often penetrate an unsecured personal computerized device faster than a remote worker can say “oops,” and then leapfrog from that personal device onto the company’s mainframe. Sarah Pavlak, a security industry principal at business consulting firm Frost & Sullivan, explained: “Due to the pandemic and remote working requirements, the world witnessed a significant increase in endpoint security needs. To mitigate attacks, endpoint security solutions — endpoint protection platform and endpoint detection and response — are vital as they help identify unprotected assets.” Added Michael Sentonas, chief technology officer at CrowdStrike: “Stopping breaches requires a modern approach to security that relies on continuous, comprehensive endpoint visibility that spans detection, response and forensics — to ensure nothing is missed.” Ransomware and ransomware-as-a-Service: Few industries have been gouged more deeply by ransomware than the insurance industry — a form of malware that seizes control of a computer’s data and demands a ransom before the data can be accessed again. Last year, industry giant CNA Financial, for example, reportedly paid one of the largest ransoms ever – $40 million – to a hacker gang that wreaked havoc on its computer network, according to Black Kite’s report. Currently, nearly 20% of the world’s top 99 insurers have a high susceptibility to the scourge, according to Black Kite, and 82% of the globe’s largest insurance companies are also prime targets for cybercriminals. Worldwide, across all industries, a ransomware attack occurs every 11 seconds, with an average payout to the crooks of $130,000, according to Black Kite’s report. Adding insult to injury is the growing availability of ransomware-as-a-Service kits, which sophisticated hacker gangs license-out to less-tech-savvy criminals in exchange for a cut of any ransoms secured. Nation-state-sponsored hacking: Insurers and others have been targets of state-sanctioned hacking for years, and they can expect more of the same for the foreseeable future, according to the 2022 CrowdStrike Global Threat Report. The “Big Four” perpetrators in this space are Iran, China, Russia and North Korea. For the insurance industry, nation-state extortion included the exposure of PII from customers of the Israeli insurance company Shirbit, according to IntSights’ report. Insurance data hackers released to the world during the caper included driver’s license photos, identity documents, and forms featuring the names and addresses of the insurer’s customers. The leading culprit among the Big Four by far is China, which is increasingly penetrating companies and organizations by finding vulnerabilities in internet-facing software like Microsoft Exchange, according to Crowdstrike. Adam Meyers, senior vice president of intelligence, CrowdStrike, said: “As cybercriminals and nation-states around the world continue to adapt in the changing, interconnected landscape, it’s critical that businesses evolve to defend against these threats.” Back-door & third-party attacks: Sadly, too many insurers and others discover the hard way that the even most sophisticated cybersecurity system can be undone in seconds via a third-party partner with lax cyber defenses. Hackers take special delight in these attacks, which uncover vulnerabilities in the networks of small businesses, and are then leveraged as back-door entryways into Fortune 500 companies and similar big corporate game. The problem is so prevalent, that market researcher Forrester predicts that by the close of this year, 60% of all cybersecurity incidents will be initiated at third-party vendors. Moreover, by 2025, insurers and others will consider the sophistication of cybersecurity protocols maintained at the third-party firms they do business with so important that a majority will insist those businesses prove they’re engaging in IT security best practices, according to Gartner. Jeffrey Wheatman, senior vice president of Black Kite, said: “Insurers are consistently blindsided with risk events that form deep in their digital supply chains. Black Kite’s latest research is a proof point that action needs to be taken to assess third-party risk — and plan accordingly.” Attacks on the cloud: Scores of insurers and others with systems and data in the cloud saw a significant uptick in cloud-computing-related security breaches, according to the 2022 CrowdStrike Global Threat Report. All insurers should insist on closely studying the security protocols their cloud provider offers, according to Andre W. Ahern, CEO, Ahern & Associates — a business consulting firm. Plus, insurers want to be sure those protocols are in writing and certified annually, Ahern adds. You’ll also want to be sure you have documentation that your cloud provider is aware of all local, regional, national and international laws regarding the security and privacy of your data. You’ll also want to see the documentation and descriptions of the systems your provider has in place to comply with those laws, he says. Also critical: Be sure — and get a guarantee — that your data does not pass through questionable technology hardware such as routers and other tech made by Chinese company HUAWEI, Ahern said. AI-powered attacks: During the past few years, the cybersecurity industry has made great gains infusing every manner of artificial intelligence into the computer networks of its customers — significantly increasing the efficacy of its tech. Unfortunately, so have the crooks. Essentially, the same AI technology well-armed insurance companies use to monitor and analyze the latest in hackers’ tricks, techniques and software is the same AI technology hackers are using to assess the cyber-mettle of insurers. For the foreseeable future, it appears AI has simply raised the stakes in the cybersecurity war — leaving any insurer devoid of AI shielding at graver risk than a well-equipped competitor. Andrew Walls, an analyst at Gartner, explained: “Attackers are weaponizing AI just as fast as organizations augment their defenses with it. It’s not enough for cybersecurity technologies to evolve — strategy and leadership approaches must change, too.” Adds Frost & Sullivan’s Pavlak: “Wider AI adoption will incorporate self-healing endpoints and become more comprehensive during the next few years.” **Topics:** Public Awareness, Technology --- ### [Trump Organization continuing 'fraudulent' practices after lawsuit, says New York AG](https://insurancefraud.org/news_archives/trump-organization-continuing-fraudulent-practices-after-lawsuit-says-new-york-ag/) **Published:** September 29, 2026 **Author:** Diane Beauchamp **Content:** New York Attorney General Letitia James is seeking a preliminary injunction as part of her $250 million civil lawsuit against former President Donald Trump to stop what she says is his ongoing fraudulent conduct. On the same day last month that James filed the lawsuit accusing Trump, his three eldest children, and two corporate executives of “staggering” fraud that she claims “grossly inflated” Trump’s net worth, the Trump Organization quietly registered a new entity, Trump Organization II, according to a new court filing Thursday. Investigators suspect that Trump could move assets from his family real estate business to the new entity in an attempt to evade liability posed by the lawsuit, according to the attorney general’s motion for a preliminary injunction. “\[T\]he Trump Organization now appears to be taking steps to restructure its business to avoid existing responsibilities under New York law,” the filing said. Thursday’s filing also made clear James is concerned that Trump and the other defendants could be using the same alleged “fraud and misrepresentation” as they prepare Trump’s financial statements for the current year. For example, the filing claims that Trumps’ current valuation for his Mar-a-Lago estate still does not account for restrictions on the use of the property, and that Trump continues to treat $93 million held in a partnership with Vornado Realty Trust as his own cash. “Indeed, in many areas, the Trump Organization has continued using practices they knew to be improper or fraudulent,” the motion said. Trump’s attorney, Alina Habba, called the filing “nothing more than a thinly-veiled attempt to keep this case with Justice Engoron rather than have it transferred to the Commercial Division where it belongs.” “We have repeatedly provided assurance, in writing, that the Trump Organization has no intention of doing anything improper,” Habba said in a statement. “This is simply another stunt which Ms. James hopes will aid her failing political campaign.” James is also seeking the appointment of an independent monitor to oversee the Trump Organization’s submission of financial information to accountants, lenders and insurers, “to enjoin Defendants from transferring to non-party affiliates or otherwise disposing of assets without Court approval,” the filing said. “Our investigation uncovered the fact that Donald Trump and the Trump Organization engaged in significant fraud to inflate his personal net worth by billions of dollars to illegally enrich himself and cheat the system,” James said in a statement Thursday. “Since we filed this sweeping lawsuit last month, Donald Trump and the Trump Organization have continued those same fraudulent practices and taken measures to evade responsibility. Today, we are seeking an immediate stop to these actions because Mr. Trump should not get to play by different rules.” The Trump Organization did not immediately respond to James’ newest filing. Trump has denied wrongdoing and has called James’ investigation a politically motivated “witch hunt” by an attorney general he has called “racist.” James, who is black, rejected a settlement offer from the Trump Organization last month to resolve the matter, sources told ABC News. The lawsuit accused them of engaging in “numerous acts of fraud and misrepresentation in the preparation of Mr. Trump’s annual statements of financial condition” that overstated the values of nearly every major property in the Trump portfolio over at least a ten-year period. “These acts of fraud and misrepresentation grossly inflated Mr. Trump’s personal net worth as reported in the Statements by billions of dollars and conveyed false and misleading impressions to financial counterparties about how the Statements were prepared,” the lawsuit said. “Mr. Trump and the Trump Organization used these false and misleading Statements repeatedly and persistently to induce banks to lend money to the Trump Organization on more favorable terms than would otherwise have been available to the company, to satisfy continuing loan covenants, and to induce insurers to provide insurance coverage for higher limits and at lower premiums,” said the suit. In Thursday’s motion, James said that nearly a month after she filed her suit, the former president and his son Eric have refused to accept service of the lawsuit. She sought permission to serve them electronically. The motion also asked for a court conference to set a trial date for early October 2023. **Topics:** Financial Fraud, Judicial/courts --- ### [‘Oct 2’ date on insurance policy leads vehicle tribunal to discover forgery](https://insurancefraud.org/news_archives/oct-2-date-on-insurance-policy-leads-vehicle-tribunal-to-discover-forgery/) **Published:** September 29, 2026 **Author:** Diane Beauchamp **Content:** Police registered an FIR against a Gurugram-based transporter and other suspects on the direction of the Motor Vehicle Act Tribunal (MVAT) in the city after it found that a forged insurance policy was placed before it to pass on the compensation claim burden to the insurance firm in a seven-year-old accidental death case. According to the police, the policy was dated October 2 and it was the date that brought the fraud to the fore as no office work takes place on October 2, Gandhi Jayanti, a national holiday. On the directions of the court of additional district and sessions judge Phalit Sharma, the insurance firm manager submitted a complaint regarding the alleged forgery at the Shivaji Nagar police station on Monday, following which an FIR against the transporter and other suspects under sections 420 (cheating), 467 (forgery), 468 (forgery for purpose of cheating) and 471 (fraudulently or dishonestly using forged document) of the Indian Penal Code on Monday night, said police. As per the FIR, one of the trucks owned by the transporter ran over a man in Gurugram on the night of October 5, 2016 and an FIR was registered at the Sector 18 police station the next day. The truck was registered in Gurugram. The family of the deceased, Rakesh Kumar, moved the court to claim compensation after which the transporter submitted a vehicle insurance policy, issued from Dhanbad in Jharkhand, showing that it was insured from October 2, 2016 to October 1, 2017. A senior police officer, privy to the case, said the date on which the policy was issued, was also shown as October 2, 2016, which raised the tribunal’s suspicion as it’s a national holiday and all government and quasi government offices as well as private ones remain closed that day. “The manager also alleged in his FIR that his company office was closed on October 2, 2016, and thus no such policy was issued on that date. After inquiry, it was found that the policy actually was issued on October 18, 2016, following an inspection of the truck carried out a day before,” he said. The officer said the tribunal ordered a police inquiry on April 16 this year and its report mentioned that the actual policy was valid from October 18, 2016, to October 17, 2017. This was changed so that the accident date is covered and absolve the transporter of having to pay the compensation. Inspector Sunder Pal, station house officer of Shivaji Nagar police station, said police are investigating the case. “Further details will be know after the suspects are questioned,” he said. **Topics:** Auto fraud **Categories:** Arrest --- ### [Arson Attack on Turkish Restaurant Blamed on ‘Far Right’ Was Actually Done by Owner for Insurance Money](https://insurancefraud.org/news_archives/arson-attack-on-turkish-restaurant-blamed-on-far-right-was-actually-done-by-owner-for-insurance-money/) **Published:** September 29, 2026 **Author:** Diane Beauchamp **Content:** A German court convicted the owner of a Turkish restaurant Tuesday of ordering an arson attack that he blamed on far-right extremists in the eastern city of Chemnitz four years ago. The arson attack in October 2018 happened a few weeks after Chemnitz was shaken by anti-migrant protests following the killing of a German man for which a Syrian migrant was later convicted. The Chemnitz regional court ruled found the 50-year-old restaurant owner guilty of 15 counts of attempted murder and fraud. Judges said he had ordered the attack to obtain a large insurance payout, leaving open a window through which unknown accomplices were able to enter the restaurant. At the time of the attack, 15 people were sleeping in apartments above the restaurant. Nobody was seriously injured. German police initially said a xenophobic motive couldn´t be ruled out but that they were investigating “in all directions.” The court sentenced the defendant to eight years in prison, German news agency dpa reported. The defendant´s lawyers had sought his acquittal. The verdict can be appealed. **Topics:** Business - arson --- ### [FICO Survey: 42 Percent of South Africans Believe It Is OK to Exaggerate Insurance Claims](https://insurancefraud.org/news_archives/fico-survey-42-percent-of-south-africans-believe-it-is-ok-to-exaggerate-insurance-claims/) **Published:** September 18, 2026 **Author:** Diane Beauchamp **Content:** Many financial institutions consider their fraud teams to be a necessary overhead to cut fraud losses, but the latest consumer survey from global analytics leader FICO shows that a successful fraud protection function can drive sales and increase revenue. The survey also reveals consumer attitudes and preferences regarding fraud checks – and indicates that many will commit fraud themselves to get a loan or file an insurance claim. When asked to rank their considerations in selecting a financial account provider, 36 percent ranked good fraud prevention as their number one concern and 43 percent ranked it as the second most important consideration, making it by far the most important measure of the eight in the survey. This suggests that financial institutions that can effectively communicate a focus on fraud protection will have a competitive advantage. Ease of use in accessing their banking services was selected as the number one criterion for 31 percent of respondents. Sound environmental and green policies were only considered a top consideration for 1 percent, while 35 percent had ranked it last of 8 in the list of considerations. **First-party fraud is considered acceptable by many** When asked about their attitudes to actions that financial institutions consider fraud, many people think that behaviours such as exaggerating income on applications or inflating insurance claims are either OK in some circumstances, or normal behaviour. While most think that people should never take these fraudulent actions, it is worrying that as many as 42 percent find it acceptable in at least some circumstances “Many South Africans are experiencing a rise in the cost of living and might consider that they can ease their circumstances by falsifying information in applications for credit,” said Michelle Beetar, who heads FICO’s operations in Africa. “However, this misrepresentation is fraud. Financial institutions that can spot anomalies suggesting that information is being exaggerated or misstated can take positive action to protect themselves from losses which would occur when the customer cannot afford the repayments, and the customer can be prevented from going down a path they will end up regretting.” **When fraud protection methods don’t work well, they drive customers away** Customers must engage with fraud protection and security when they open a new account or when they use an existing account. An increased need to stop fraud and an industry drive to provide more security through the rollout of initiatives such as 3D Secure 2, means that people are seeing fraud checks more frequently and it is impacting their willingness to open and use some accounts. - 66 percent said that identity checks when they make an online purchase using their cards have increased over the past year. - 65 percent said that identity checks have increased when they log in to their bank accounts. People also said that Identity checks that were too difficult or time-consuming have stopped them from opening a range of different accounts. Once accounts are open, identity checks can still have an impact. Nearly one in four people surveyed (23 percent) said they have reduced or stopped use of their personal bank account because of identity checks, and 25 percent said the same about a credit card. “Each customer interaction has a different risk profile which is influenced by behavioral signals, the ability and willingness of customers to use various authentication methods, the value of the transaction and the financial institution’s own risk appetite,” said Beetar. “Financial services providers need to be able to take a flexible approach that doesn’t put too many barriers in the way of legitimate customers, but equally doesn’t lower fraud defences.” **More South Africans think they have been victims of identity theft than in 2020** 7.2 percent of South African survey respondents said that they know that their stolen identity has been used by a criminal to open a financial account. This is a significant increase from 4.6 percent in our 2020 survey. In percentage terms these figures may seem low, but when you equate it to number of victims, the scale of the problem becomes more alarming; 7.2 percent of the South African adult population is over 2.7 million people. An additional 6.9 percent think it is likely that their identity has been used to open an account fraudulently. Men (9.2 percent) are more likely than women (5.3 percent) to say their stolen identity has been used to open an account and those aged 65 and above (22.6 percent) are the most likely to say so. “With almost a quarter of South African respondents feeling that it’s possible or likely that they been the victims of identity theft, financial institutions have an important role to play in establishing trust,” Beetar said. “Those who can demonstrate good practices that prevent fraudsters and money-launderers from opening accounts could enhance their reputation.” **Biometrics take the lead in account security – but people still want choice** People expressed a strong preference to use a wide variety of account security methods. Biometric methods are popular security choices. 62 percent have a strong preference for using a fingerprint scan, 52 percent a face scan and 38 percent an iris scan. Despite biometrics becoming a popular choice in all countries surveyed, South Africa is among the leading proponents — for example, across all 14 countries surveyed in total 36 percent of people had a strong preference for a fingerprint scan, compared to 62 percent for South Africa. However, 40 percent of South Africans also had a strong preference for usernames and passwords, compared to just 23 percent for the rest of the world. When it comes to receiving one-time passcodes, 38 percent rate receiving it by SMS as excellent for security, compared to 45 percent who believe receiving an OTP through their banking app provides excellent security and 16 percent who rate WhatsApp as excellent for security. FICO surveyed 1,000 people each in 14 countries: South Africa, the USA, Canada, Brazil, Mexico, Colombia, Peru, Philippines, Malaysia, Thailand, Indonesia, South Africa, Germany, the UK and Sweden. **Topics:** Public Awareness --- ### [Woman Says EMS Charged Her $400 for a Blood Test They Said Was Free — "American Healthcare Is a Scam"](https://insurancefraud.org/news_archives/woman-says-ems-charged-her-400-for-a-blood-test-they-said-was-free-american-healthcare-is-a-scam/) **Published:** September 29, 2026 **Author:** Diane Beauchamp **Content:** TikToker Anne Lee ([@annxetime](https://www.tiktok.com/@annxetime)) went viral after calling the United States healthcare system a scam upon sharing her story of what happened after she fainted in public and someone called 9-1-1 on her behalf. She says Emergency Medical Services arrived on the scene and asked if she needed any help, which she promptly declined. Anne says she informed the EMS workers that she didn’t have insurance and was feeling fine. She didn’t want to get any of her vitals checked, but they repeatedly told her several times that it was probably best if she received an assessment, since they were already there and it would be in her best interest. Anne says she decline again, told them she felt fine and reiterated she didn’t have insurance. The EMS workers replied that it was fine and that she wouldn’t have to pay anything. She ultimately agreed and they performed a blood test on her, a procedure that she said took about “3 minutes.” Later, Anne was outraged to receive a $399 bill for the test the EMS workers administered. She ranted about the questionable ethics of charging her that much money for essentially sitting in the back of a truck for three minutes and getting her finger pricked for a blood sample. Anne said in the video, “American healthcare is a f—— joke. Like it’s actually a f—— scam. OK, so the other day I fainted in public and I was fine. I was literally f—— fine I got right back up, and I was like, ‘oops sorry about that.’ I was fine. But, you know, someone called 9-1-1.” The TikToker continued, “And they came over and then they were like hey, ‘Miss, um are you OK?’ And I was like, ‘yep, I’m fine.’ And they’re like, OK, well I think you should come out and like let us, you know.” Anne could see that they were attempting to administer care to her, but didn’t want to have to pay. “And I was like, ‘nope, I don’t have health insurance. I’m OK I don’t want to do this.’ And they’re like, no like, ‘but I really think you should let us run some tests’ and I was like, ‘nope I don’t have health insurance and I’m not comfortable with this. I don’t want to pay for this.'” “HE LIED,” she writes in a text overlay, and her narration continued. “It was literally like 3 minutes and all my vitals were good. I only said yes because they said I didn’t have to pay.” She continued to say in her TikTok, “And they’re like yeah no, no worries, we’re gonna take care of that.” Throughout the video, she holds a bill up to the screen that shows she was charged $399, presumably for her visit from EMS workers. “Tell me why they f—— send me this bill for me sitting down in the back of their fire truck and getting my finger pricked for like a tiny blood sample just to see my vitals. That’s literally all they f–king did. $400 for a prick?! Are you f—— kidding me?” Other TikTokers in the comments section shared medical horror stories of their own. Some offered tips to argue down the cost of the bill, such as asking for itemized charges for the services provided. Some users also claimed this was a “common” ploy enacted by EMS workers who respond to calls, and that Anne shouldn’t pay the bill. Despite [having the highest medical care costs](https://www.healthsystemtracker.org/chart-collection/health-spending-u-s-compare-countries-2/#:~:text=Health%20spending%20per%20person%20in,half%20that%20of%20the%20U.S.) in the world, the United States only ranks [11th when compared to other industrialized nations](https://www.citizen.org/article/dead-last-u-s-health-care-system-continues-to-rank-behind-other-industrialized-countries/) when it comes to system performance, i.e., “dead last.” **Topics:** Public Awareness --- ### [Medical Board files accusation against Bakersfield doctor facing medical fraud charges](https://insurancefraud.org/news_archives/medical-board-files-accusation-against-bakersfield-doctor-facing-medical-fraud-charges-2/) **Published:** September 29, 2026 **Author:** Diane Beauchamp **Content:** A Bakersfield doctor facing criminal medical fraud charges had an accusation filed against him by the California Medical Board claiming he mandated unnecessary laboratory tests for his patients without their consent and profited by charging insurers for those tests. Jason Helliwell, who was charged in September 2019, has pleaded not guilty to dozens of felony charges related to making false claims for health benefits and grand theft of property. The accusation filed by the Medical Board makes similar claims. Helliwell’s lawyer could not be reached for comment Monday. It was unclear whether Helliwell’s alleged victims in the Kern County district attorney’s case are the same people who filed a complaint with the medical board. Carlos Villatoro, a spokesman for the Medical Board, wrote in an email Monday privacy laws prohibit him from providing specific details. **Topics:** Healthcare Fraud **Categories:** Arrest --- ### [Guilty Verdict in Case Prosecuted by Medicaid Fraud Control Unit](https://insurancefraud.org/news_archives/guilty-verdict-in-case-prosecuted-by-medicaid-fraud-control-unit/) **Published:** September 29, 2026 **Author:** Diane Beauchamp **Content:** A jury found Gracious Weah guilty of Aggravated Assault causing permanent impairment and Reckless Endangerment, on September 23, in Barnes County. The evidence at trial showed that Weah, a certified nurse aide, performed an improper, one-person lift of a resident of the Sheyenne Care Center resulting in severe and painful injuries to the resident. The evidence also showed Weah failed to report the injury causing the resident to be undiagnosed and untreated for more than 12 hours. “Weah callously committed these horrible crimes against a vulnerable adult. I want to thank the Medicaid Fraud Control Unit for thoroughly investigating this crime and successfully pursuing justice. My thoughts are with the family of the victim, and I hope that holding Weah accountable provides them with some measure of healing,” Attorney General Drew Wrigley said. Weah is being held in custody until the date of her sentencing hearing on November 29, 2022. The sentencing hearing will be held in Valley City with the Honorable Jay Schmitz presiding. The case was investigated and prosecuted by the Medicaid Fraud Control Unit, a division of the North Dakota Attorney General’s Office, with assistance from the Valley City Police Department. **Topics:** Medicare/Medicaid **Categories:** Conviction --- ### [Boulder County Veterinarian Indicted for Fentanyl Fraud](https://insurancefraud.org/news_archives/boulder-county-veterinarian-indicted-for-fentanyl-fraud/) **Published:** September 29, 2026 **Author:** Diane Beauchamp **Content:** The United States Attorney’s Office for the District of Colorado announces Lindsay Oklesh, 37, of Boulder County has been indicted by a federal grand jury for fraudulently obtaining fentanyl, which is a controlled substance. According to the indictment, between March 10, 2020 and September 22, 2021, Oklesh, a doctor of veterinary medicine, utilized her Drug Enforcement Administration (DEA) registration number to purchase controlled substances from a distributor while misrepresenting that they were for the use of legitimate veterinary patients, rather than for her personal use. Oklesh made her initial appearance before Magistrate Judge S. Kato Crews on October 11, 2022. This case was investigated by the Drug Enforcement Administration. The prosecution is being handled by Assistant United States Attorney Alyssa Mance. The charges contained in the indictment are allegations and the defendant is presumed innocent unless and until proven guilty. Case Number: 22-cr-316 **Topics:** Drug Diversion **Categories:** Arrest --- ### [Addiction recovery industry rife with abuse, state investigators say](https://insurancefraud.org/news_archives/addiction-recovery-industry-rife-with-abuse-state-investigators-say/) **Published:** September 29, 2026 **Author:** Diane Beauchamp **Content:** While most new businesses take up to two years to become profitable, and a quarter fail their first year, Nicholas DeSimone bucked those trends, big-time. The Mullica Hill businessman made $15 million in three years after opening his first addiction recovery center, according to the New Jersey State Commission of Investigation. DeSimone’s success didn’t come from hard work or because his pocket of Gloucester County had more people struggling with addiction than anywhere else, investigators said. Instead, DeSimone took advantage of a largely unregulated system to make a fortune in the addiction recovery industry — and bent the law so much that commission officials have asked prosecutors to act on their findings, according to testimony during a public hearing Tuesday in Trenton. Like DeSimone, many recovery center operators exploit vulnerable people and trap them in addiction to ensure their hefty health insurance payments continue, investigators testified. Agents detailed illegal business practices such as double-billing, billing for services not provided, and falsifying urine tests to indicate a relapse, thereby extending patients’ stays. Many entice customers through free food, gifts, transportation, and living accommodations, while others outright accept or pay money for referrals of patients with generous private insurance coverage — an illegal practice known as “body brokering.” State legislators specifically [criminalized](https://www.njleg.state.nj.us/bill-search/2020/A2280) patient brokering last year, but commission investigators Tuesday said they were unaware of anyone charged under the law. Many operators then use their profits for personal gain. DeSimone and his wife, Michelle, skirted federal financial reporting requirements to dodge taxes and divert millions from their business — called Kingsway Recovery Center — to financial investments, credit card purchases, and cash purchases of cars and a home, said Laura Mercandetti, a forensic accountant with the commission. “Nicholas DeSimone’s main motivation was to make money from the insurance companies,” Mercandetti said. The commission subpoenaed DeSimone to testify Tuesday, but he failed to appear, prompting the commission’s counsel Lisa Cialino to say they would file a motion against him for contempt of court. DeSimone did not respond to the New Jersey Monitor’s request for comment after the hearing. Investigators referred the DeSimones for possible prosecution for money laundering, health care fraud, and income tax evasion, Mercandetti said. A spokesman for the Gloucester County Prosecutor’s Office said he didn’t have any information about what, if anything, they’re doing about DeSimone. ## A widespread problem The DeSimones may have been the commission’s chief target Tuesday, but investigators say they’re far from unique. An outpatient treatment center called The Sanctuary in Cherry Hill brought in $6 million in insurance payments over 18 months, Mercandetti said. “They spent it on food, clothing, car payments, personal vacations and entertainment, other home expenses, and ATM cash withdrawals,” she said. The center closed down when it couldn’t cover employee salaries or business expenses, she added. Even nonprofit treatment providers acted unscrupulously, accepting donations in exchange for referrals, investigators said. Recovery Advocates of America, a Hamilton-based nonprofit, accepted more than $600,000 from 2017 through 2020 from about 35 treatment centers, with the biggest payoffs coming from two Florida-based providers, said Eric Rennert, a commission special agent. Reached by phone after the hearing, Stacey Ross, Recovery Advocates’ executive director, referred questions to the nonprofit’s attorney, who did not respond to a request for comment. Commission chairwoman Tiffany Williams Brewer said investigators expect to release a report on their findings in the coming months and will recommend how policymakers can curb abuse in the industry. ## An entrenched problem, a growing industry The opioid epidemic may have fallen out of the daily headlines, but it continues its deadly rampage in New Jersey, Brewer said. More than 3,100 people died of drug overdoses last year, with another 2,237 so far this year, state [data](https://ocsme.nj.gov/Dashboard?_gl=1%2Av1u4ca%2A_ga%2AMzk5MjA0NTM2LjE2NjUwODY3MDA.%2A_ga_5PWJJG6642%2AMTY2NTUxNDE3Ni4xLjAuMTY2NTUxNDE3Ni4wLjAuMA..) shows. Another 75,000 people have been saved in New Jersey since 2017 with the overdose-reversing drug naloxone, the data shows. “Many more remain trapped in the cycle of addiction, desperate for help in breaking their dependence on pills, alcohol and other illegal substances,” Brewer said. “But all too often, addicted individuals and their families are victimized by the very system that’s supposed to help them recover and rebuild their lives.” The addiction recovery industry is a growing $42 billion business, Brewer said. When providers let their financial interests — instead of a recovering patient’s needs — dictate their treatment placement, patients don’t get the specialized care best suited to their needs, Brewer added. Nicole DiMaria lost her sister to addiction last year, saying she tried — and failed — to navigate a system whose lack of transparency ensures many never get the life-saving help they need. Georgine DiMaria represented New Jersey in the 2007 Miss America competition. She later became addicted to prescription medication and struggled with alcoholism, leaving an in-patient treatment program halfway through a planned monthlong stay partly because of confusion about insurance coverage and costs, her sister testified. She died at age 37 of addiction-related liver disease and organ failure in August 2021. Nicole DiMaria urged the commission to recommend changes that would require providers and insurers to reveal costs so families can make informed decisions about care. “I am a health care attorney, and I research this space for a living, and I found it so difficult to find information,” Nicole DiMaria said. **Topics:** Healthcare Fraud, Public Awareness --- ### [Central Valley Workers’ Comp Fraud Task Force uncovers $2.5 million in underreported payroll by Fresno business owners](https://insurancefraud.org/news_archives/central-valley-workers-comp-fraud-task-force-uncovers-2-5-million-in-underreported-payroll-by-fresno-business-owners/) **Published:** September 29, 2026 **Author:** Diane Beauchamp **Content:** Karamjit Nijjar, 57, his wife Rajinder Kaur Nijjar, 55, and their daughter Mandip Nijjar, 31, were arraigned today on four felony counts each for their involvement in a workers’ compensation insurance fraud scheme after allegedly underreporting over $2.5 million in employee payroll to illegally reduce insurance premiums. The investigation, led by the Fresno County District Attorney’s Office, began after the California Department of Insurance received a tip that an employee of a Fresno area trucking business owned by Karamjit Nijjar was denied workers’ compensation benefits. Throughout the course of the investigation, investigators with the Central Valley Workers’ Compensation Fraud Task Force identified an additional business related to Nijjar, Renteria Trucking. According to various business records, Karamjit and Rajinder Nijjar own and operate Renteria Trucking. Their daughter, Mandip Nijjar, is an employee. The task force investigation into Renteria Trucking revealed the company reported approximately $2,475,000 in employee payroll during their routine payroll audits; however, a forensic audit revealed Renteria Trucking actually had over $5 million in employee payroll for the same time period. The amount of unreported payroll identified totaled $2,577,035. The misrepresentations made by the Nijjars resulted in the reduction of workers’ compensation insurance premiums paid, a violation of Insurance Code 11880(a) for each policy period, which resulted in $352,913 in premium owed to the State Compensation Insurance Fund. The Central Valley Workers’ Compensation Fraud Task Force is an inter-agency anti-fraud partnership with members from the California Department of Insurance, the Fresno County District Attorney’s Office, the Tulare County District Attorney’s Office, the Kings County District Attorney’s Office, the Kern County District Attorney’s Office, the Merced County District Attorney’s Office, the Madera County District Attorney’s Office, the San Luis Obispo County District Attorney’s Office, the California Employment Development Department, and the California Franchise Tax Board. Karamjit Nijjar, his wife Rajinder Kaur Nijjar, and Mandip Nijjar pleaded not guilty to the charges and are expected back in court on November 15, 2022. The Fresno County District Attorney’s Office is prosecuting this case. **Topics:** Work comp - employer **Categories:** Arrest --- ### [London police crack down on travel insurance fraudsters](https://insurancefraud.org/news_archives/london-police-crack-down-on-travel-insurance-fraudsters/) **Published:** September 29, 2026 **Author:** Diane Beauchamp **Content:** The City of London Police’s Insurance Fraud Enforcement Department (IFED) has executed multiple warrants across the country as part of its offensive against travel insurance fraud, resulting in seven arrests. The operations came after IFED’s awareness campaign in early summer, which urged the public to check that they are properly insured before travelling abroad. The campaign also reminded the public that exploiting a travel insurance policy to make bogus claims is a criminal offence. IFED released a video containing examples of fraudulent claims that could lead to a criminal conviction, such as exaggerating the cost of a lost camera or claiming twice for a stolen item. “At the start of the summer holidays, we explained to the public what could count as a fraudulent travel insurance claim,” said Detective Chief Inspector Tom Hill, head of IFED. “Unfortunately, people continue to flout the law by submitting bogus claims with their travel insurer. During this enforcement period, we have seen the breadth of misfortunes that criminals will exploit for fraudulent gain – from an individual pretending to have food poisoning whilst on a Caribbean getaway, to an organised crime group with inside links to insurance companies.” Over the past five years, IFED has received 57 referrals for travel insurance fraud, with a total estimated value of £2,393,680.51, averaging £41,994 per case. During the COVID-19 pandemic, IFED received reports of individuals abusing travel restrictions by submitting claims for cancelled flights and non-existent holidays. With foreign travel resuming, IFED said it expects fraudsters will refocus by making claims for bogus incidents whilst on holiday. A recent IFED investigation saw a man from Liverpool jailed for making £75,000 worth of bogus travel insurance claims by impersonating people he knew. The fraudster made 15 claims with six different insurance companies for missed or cancelled travel, using excuses such as injury or disruption due to the COVID-19 pandemic. “Travel insurance is intended to be a reassuring safety net should the worst happen, not a means of personal financial gain,” Hill said. “We hope that this period of enforcement sends a clear message to fraudsters: this type of crime will not be tolerated, and we will bring criminals to justice for their actions.” **Topics:** Traveler's Insurance --- ### [Travel agent Lyne Barlow admits £1.6m holidays scam](https://insurancefraud.org/news_archives/travel-agent-lyne-barlow-admits-1-6m-holidays-scam/) **Published:** September 29, 2026 **Author:** Diane Beauchamp **Content:** A travel agent has pleaded guilty to a scam involving hundreds of customers, which could total £2.6m. Lyne Barlow, 39, previously of Stanley, County Durham, admitted stealing £500,000 from one person, 10 counts of fraud and a money laundering charge involving £1.6m. Durham Crown Court was told Barlow’s offending topped £2.6m, although her defence team disputes that figure. Judge James Adkin said she faces jail when she is sentenced on 12 December. Barlow defrauded family and friends of their savings to set up her travel agency before falsely selling holidays to customers, Durham Police said after the case. She lied that she was protected by the ATOL insurance scheme and was a member of the Association of British Travel Agents. Many of those people who handed over their money later discovered that Barlow had never paid for the holidays they booked with her. ‘Lives changed forever’ “Several hundred” people came forward to make complaints against her and Det Sgt Alan Meehan said it had been one of the biggest fraud cases the force had dealt with. “So many people have been affected by her actions, lives have been changed forever and some are still feeling the effects today,” he added. Police said the frauds related to loans, investments and holiday sales. The court heard that some of Barlow’s victims may wish to read statements during the sentencing hearing. Tony Davis, defending, said some of her clients received their holidays and suffered no loss. He asked the court to allow a psychiatric report to be prepared and referred to the fact Barlow told some people she has a terminal illness. Judge Adkin granted her bail ahead of the sentencing but told her she would be given “a long prison sentence”. Durham Police said Barlow’s travel business was no longer operational, and its social media page was taken down shortly after her arrest in September 2020. **Topics:** Commercial Fraud, Financial Fraud, Insider - agent, Traveler's Insurance, Unlicensed **Categories:** Conviction --- ### [Film Doctor Bakshi highlights medical scams](https://insurancefraud.org/news_archives/film-doctor-bakshi-highlights-medical-scams/) **Published:** September 29, 2026 **Author:** Diane Beauchamp **Content:** A character teaser of Saptaswa Basu’s film Doctor Bakshi dropped recently. The film, which highlights a set of medical scams, revolves around a charming doctor who takes up his own path of justice, a writer who is caught in a web of mystery and a criminal recently out of jail. “The character teaser depicts Subhashree as a writer (Mrinalini) who is out on a vacation and is exploring new ideas for her new novel. However, a series of mysterious incidents engulf her. The character teaser directly addresses the hook point in our storyline and gives the audience a feel that this film is made for a big-screen experience. This teaser has been edited (by Pabitra Jana) keeping the focus on the look and shade of Mrinalini Sen, the author. The first teaser had a bluish tone for Parambratada (Doctor Bakshi), the second teaser had a reddish palette for Bonny (Aditya) and in this one we have used green in subtle ways to characterise it and also to denote three primary colours (RGB) for three primary characters. There is a feel of illusion and trap towards the end of the teaser, which will make the audience wait for the trailer and finally the film,” said Saptaswa. **Topics:** Public Awareness --- ### [Detroit Health Department provides notice after data security incident](https://insurancefraud.org/news_archives/detroit-health-department-provides-notice-after-data-security-incident/) **Published:** September 29, 2026 **Author:** Diane Beauchamp **Content:** The Detroit Health Department (DHD) is notifying specific individuals about a recent security incident that involved the unauthorized release of confidential client information. On May 12, 2022, it was discovered that protected health information was compromised due to an unauthorized disclosure in the office of the Detroit Health Department. Upon the DHD being notified about this incident, they began to mitigate the threat of any continued breach and sought assistance from external security professionals. “To the best of our knowledge and belief, information was improperly disclosed to a third party which information contained names, address, dates of birth, contact information, gender, race, marital status, household size, and participation status in certain Detroit Health Department programs,” the department said. “This incident does not affect all Detroit Health Department clients.” Individuals who have been notified about this matter are being provided with best practices to protect their information, including but not limited to monitoring their credit information. The department is fully committed to maintaining the private and personal information in its possession and has taken many precautions to safeguard it. For those who have questions or need additional information regarding this incident, contact DHD officials at 833-242-6019. **Topics:** Public Awareness, Technology --- ### [Information Expected to Emerge Slowly in Hospital Chain Cyberattack](https://insurancefraud.org/news_archives/information-expected-to-emerge-slowly-in-hospital-chain-cyberattack/) **Published:** September 29, 2026 **Author:** Diane Beauchamp **Content:** Details of an apparent cyberattack on one of the largest health systems in the U.S. were slow to emerge as security experts on Oct. 7 warned that it often takes time to assess the full impact on patients and hospitals. Earlier in the week, CommonSpirit Health confirmed it experienced an “IT security issue” but it has yet to answer detailed questions about the incident, including how many of its 1,000 care sites that serve 20 million Americans may have been affected. The health system giant, which is the second largest nonprofit health system in America, has 140 hospitals in 21 states. “It actually takes a while to fully know the scope because you’re in the middle of trying to restore all your systems,” said Allan Liska, an analyst with the cybersecurity firm Recorded Future. “You’re trying to get patient care up and running. You’re trying to get your nurses and your doctors back to the systems they need.” Healthcare organizations are an appealing target for cyber attackers – particularly those who use malware to lock up a victim organization’s files and leverage the information for a payment. Ransomware has remained a persistent threat for the industry, which is among the 16 sectors the U.S. government classifies as critical infrastructure. “Ransomware actors know that’s going to cause a lot of disruption,” Liska said. Health care systems in 2021 saw an unusually high amount of attacks, with 285 publicly reported worldwide, Liska added. So far, Liska’s firm has tracked 155 this year with an average of 20 attacks happening a month. However, he estimated that only about 10% of ransomware attacks are publicized. Cybersecurity experts said years of work have built health care leaders’ trust in the FBI and other federal agencies focused on cyber crime. An FBI spokesperson declined to comment on whether they were investigating the CommonSpirit Health cyberattack. ![](https://ra.wellsmedia.com/www/delivery/lg.php?bannerid=0&campaignid=0&zoneid=162&loc=https%3A%2F%2Fwww.insurancejournal.com%2Fnews%2Fnational%2F2022%2F10%2F11%2F689129.htm&cb=91298b131c)John Riggi, the American Hospital Association’s national advisor for cybersecurity and risk, said he could not discuss CommonSpirit specifically. In general, though, he said it can take days, weeks or more to discover how an attacker gained access, determine what damage has been done and prevent further harm. Riggi, who spent nearly 30 years with the FBI, called any significant cyber attack on a hospital “a potential risk to patient safety” and said the U.S. government takes that seriously. Their goal, he said, is to identify the attacker and make their identity and methodology public. “They don’t want to show their hand, what they know about the bad guys,” he said. “You’re really processing a crime scene in real time.” But there are risks to victims of cyber attacks who fail to communicate their response plan and strategies for recovery, said Mike Hamilton, the chief information security officer with Critical Insights Cybersecurity in Washington state. The reaction of patients, staff and affiliated health care operations to the chain’s handling of the incident all could affect the company’s future survival, he said. “Here’s how close we are to resolution, here’s where we’re diverting, here are the other hospitals we’re partnering with,” Hamilton said. “They need to be sure they’re communicating … because so many people are being impacted by this.” **Topics:** Public Awareness, Technology --- ### [Healthcare billing fraud: 10 recent cases](https://insurancefraud.org/news_archives/healthcare-billing-fraud-10-recent-cases-6/) **Published:** September 29, 2026 **Author:** Diane Beauchamp **Content:** From an Ohio radiology company president getting sentenced to 15 years in prison, to an Indiana health system agreeing to settle claims that it submitted improper revenue codes to Medicaid, here are 10 healthcare billing fraud cases Becker’s has covered since Sept. 20. 1. Medical equipment company owner gets prison for healthcare fraud scheme Jamie McCoy, 42, was sentenced on Oct. 6 to 30 months in prison and ordered to pay $7.5 million after pleading guilty to his role in a billing fraud scheme. Mr. McCoy contracted with marketing firms who placed ads on television and online that offered orthotic braces at no cost. The firms sent patient information to a telemedicine physician who signed an order form for equipment without evaluating the patient. The patient information and medical equipment orders were sold to durable medical equipment companies owned or operated by Mr. McCoy. 2. Florida provider to pay $700K to settle Medicaid fraud allegations Jacksonville, Fla.-based Physicians Group Services agreed on Oct. 5 to pay $700,000 to resolve allegations that the provider submitted false claims to the state’s Medicaid program. The Justice Department alleged that Physicians Group Services billed Medicaid for quantitative drug testing that was medically unnecessary because the testing was not designed to meet the needs of each patient. 3. Former Kentucky lawmaker gets 2 years in prison for healthcare billing fraud Former Kentucky state representative Robert Goforth, 46, was sentenced to 25 months in prison Oct. 3 after admitting that a pharmacy he owned billed insurance programs, including Medicare and Medicaid, for prescriptions that customers didn’t pick up. The pharmacy then multiplied profits by putting those medications back on the shelf and selling them multiple times. 4. Radiology company president gets 15 years for $2M X-ray billing scheme Thomas O’Lear, 58, president of North Canton, Ohio-based Portable Radiology Services, was sentenced on Sept. 29 to 15 years in prison after being convicted of billing Medicare, Medicaid and two Medicaid-managed care organizations for X-ray services his company did not provide, covering up the scheme and committing aggravated identity theft. 5. California physician to pay $2.3M for illegal drug distribution Santa Ana, Calif.-based physician Mohammed El-Nachef, MD, pleaded guilty on Sept. 28 to defrauding California’s Medi-Cal system by prescribing medically unnecessary drugs to more than 1,000 patients. 6. Indiana system to pay $2.9M to settle Medicaid overbilling allegations Fort Wayne, Ind.-based Parkview Health System agreed on Sept. 27 to pay $2.9 million to settle allegations it overbilled Medicaid between January 2017 and March 2021. Improper revenue codes were submitted to Medicaid for certain blood-clotting tests performed on patients at several Parkview hospitals. 7. Former federally qualified health center CEO convicted of Medicaid fraud Victor Kirk, 73, former CEO of St. Gabriel (La.) Health Clinic, was convicted of a $1.8 million Medicaid fraud scheme on Sept. 26. St. Gabriel practitioners provided character development and other educational programs to entire classrooms of students during regular class periods. Mr. Kirk directed practitioners to falsely diagnose students with mental health disorders. From 2011 to 2015, Mr. Kirk fraudulently billed these programs to Medicaid as group psychotherapy. 8. Medical equipment company VP pleads guilty in $50M fraud scheme Kala Sloan, 28, vice president for a pair of North Carolina medical equipment companies, pleaded guilty Sept. 21 to falsifying physician orders for equipment as part of a $50 Medicare fraud scheme. 9. Former Missouri physician pleads guilty to role in Medicare, Medicaid fraud scheme Former Joplin, Mo., physician Oluwatobi Alabi Yerokun, MD, 36, pleaded guilty Sept. 21 to his involvement in a scheme in which he signed orders for products and tests for more than 2,000 Medicare and Medicaid patients he never met or examined. 10. Ohio physician accused of fraudulent medical billing Cleveland-based physician Timothy Sutton, MD, was accused of illegally billing Medicare for tests that aim to predict a patient’s likelihood of cancer, and prescribing braces to patients who didn’t need them, Cleveland.com reported Sept. 20. **Topics:** Judicial/courts, Medicare/Medicaid **Categories:** Conviction --- ### [Louisiana Woman Arrested for Insurance Fraud Following Fire Investigation](https://insurancefraud.org/news_archives/louisiana-woman-arrested-for-insurance-fraud-following-fire-investigation/) **Published:** September 29, 2026 **Author:** Diane Beauchamp **Content:** The Louisiana Department of Insurance announced that a Monroe woman has been arrested for fraudulently obtaining insurance benefits following a residential fire. Tashira S. Glover, 42, allegedly submitted a homeowners insurance claim on Jan. 13, 2026 for damage caused by a house fire in Ouachita Parish. In March the LDI received a referral of the claim and investigated the matter with the State Fire Marshal’s Office. The agencies determined the fire had occurred several months before the homeowners insurance policy took effect. Glover was taken into custody on July 21, 2026, and was booked into the Ouachita Parish Correctional Center on charges of Insurance Fraud (La. R.S. 22:1924) and Theft Over $5,000 (La. R.S. 14:67(B)(2). **Topics:** Homeowners - arson **Categories:** Arrest --- ### [Renfroe v. USAA, 24-13382 (11th Cir. 2026)](https://insurancefraud.org/news_archives/renfroe-v-usaa-24-13382-11th-cir-2026/) **Published:** September 29, 2026 **Author:** Diane Beauchamp **Content:** **Justia Opinion Summary** A father and daughter jointly owned a house in Alabama but had a contentious relationship, with both warning their insurer, USAA General Indemnity Co., that the other might intentionally set fire to the property. Despite these warnings, USAA issued a $500,000 policy covering both as insureds. The policy included an exclusion that denied coverage to all insureds if any one of them intentionally caused a loss, except in certain cases of domestic abuse. Shortly after the policy was issued, the house was destroyed by fire. The father, Martin D. Renfroe, filed a claim, but USAA denied coverage, suspecting arson by either Renfroe or his daughter. The United States District Court for the Northern District of Alabama considered Renfroe’s claims for breach of contract and bad faith. The court ruled that the innocent-insured exclusion was void as against Alabama public policy, allowing Renfroe’s breach of contract claim to proceed to trial, but granted summary judgment for USAA on the bad faith claim due to evidence suggesting Renfroe might have committed arson. At trial, the jury found in favor of Renfroe, awarding him damages, which the court later reduced. The United States Court of Appeals for the Eleventh Circuit reviewed the case. It held that Alabama law does not prohibit innocent-insured exclusions in insurance policies unless specifically barred by statute, and found no such bar here. The appellate court concluded the exclusion was enforceable, vacated the district court’s judgment on the breach of contract claim, and remanded for a new trial. The Eleventh Circuit affirmed the district court’s summary judgment for USAA on the bad faith claim, holding that USAA had at least an arguable basis for denying coverage due to evidence implicating Renfroe in arson. **Topics:** Homeowners - arson, Judicial/courts --- ### [Insurance Company Says Arson. Now What?](https://insurancefraud.org/news_archives/insurance-company-says-arson-now-what/) **Published:** September 29, 2026 **Author:** Diane Beauchamp **Content:** When an insurance company says a fire was caused by arson, the label often changes the entire posture of the case. A routine property loss can quickly become a coverage dispute, a fraud investigation, or litigation involving allegations about origin and cause, motive, opportunity, accelerants, witness credibility, and the quality of the scene examination. For counsel and property professionals, the immediate question is not whether the accusation is dramatic. It is whether the conclusion is scientifically supportable. That is where a disciplined fire investigation matters. In an insurance fire claim dispute, the difference between a defensible conclusion and a speculative one usually comes down to methodology: what was observed, what was documented, what was tested, what was excluded, and whether alternative hypotheses were actually considered. NFPA 921 remains the central reference point for that analysis because it frames fire investigation as a scientific process, not a search for confirming facts after a theory has already been chosen. The First Question Is Not “Who Did It?” When an insurer announces an arson theory, the first question should always be: what is the basis for the conclusion? In a scientifically sound investigation, origin and cause are developed through a process of hypothesis generation and testing. Investigators collect scene data, evaluate burn patterns, look for heat and ventilation effects, review electrical and mechanical systems, consider accidental ignition sources, assess fuel loads, and determine whether there is any reliable evidence of ignitable liquid use or incendiary behavior. That order matters. A conclusion that begins with motive and ends with selective support is not the same as a conclusion that begins with physical evidence and rules out other causes. Under NFPA 921, investigators are expected to consider all reasonably credible ignition scenarios. If the file reads like a narrative of suspicion rather than a methodical analysis, the opinion deserves close scrutiny. This is especially important because many fire scenes are more complex than they first appear. A structure that burns heavily may show low-level patterns, deep charring, or melted materials that can be misread by a non-specialist. Ventilation effects can create misleading burn geometry. Flashover can alter nearly every visible indicator of where ignition started. Debris from suppression activity, collapse, and overhaul can also distort the physical record. A reliable opinion has to account for those variables, not ignore them. What an Arson Theory Usually Relies On In practice, an insurer’s arson position often rests on a combination of scene observations and circumstantial facts. The physical side may include the claimed presence of multiple points of origin, suspected pour patterns, melted materials interpreted as indicators of accelerant use, unexplained fire progression, or laboratory results that allegedly show ignitable liquid residues. The non-physical side may include alleged financial stress, recent policy changes, occupancy issues, prior losses, inconsistent statements, surveillance gaps, or access concerns. Each category has limits. Multiple points of origin can be real, but they can also be inferred incorrectly when a fire has burned through connected compartments, when ventilation has changed the flow path, or when suppression and collapse have destroyed the earliest indicators. Pour patterns are not proof by themselves. Many post-flashover conditions can mimic liquid pour effects. Laboratory detection of ignitable liquids is useful, but the result must be interpreted in context. A positive sample from a debris pile does not automatically establish an intentional fire. It has to be linked to the scene, timing, collection method, and chain of custody. On the circumstantial side, motive is not an ignition source. Financial pressure may explain why an investigator suspects arson, but it does not prove it. Likewise, unusual behavior after a loss may appear suspicious to a claims team but can have multiple innocent explanations. A good expert does not dismiss circumstantial evidence. The expert places it in its proper evidentiary category and separates it from the science of origin and cause. Common Investigation Errors Insurance fire claim disputes often turn on errors that are visible only when the file is reviewed carefully. One common error is premature conclusion. An investigator may decide early that the fire was incendiary and then start evaluating evidence through that lens. Once that happens, confirmation bias can influence everything from witness interviews to scene photography to sample selection. NFPA 921 is designed to reduce exactly that risk. Another frequent problem is overreliance on burn pattern interpretation. Not every irregular pattern is evidence of accelerant use. Not every low burn is a pour pattern. Not every area of greatest damage is the area of origin. Investigators must account for ventilation, fuel distribution, room geometry, suppression activity, and fire dynamics before drawing conclusions from visual patterning. A third issue is incomplete documentation. If scene photographs do not show the entire fire area, if sketches are missing critical dimensions, if evidence logs are inconsistent, or if sample collection is not carefully documented, the reliability of the final opinion declines. In litigation, those gaps matter. An expert’s testimony is only as good as the underlying record. Laboratory interpretation can also be misused. A chromatogram or lab report is not self-explanatory. The analyst and the investigator must connect the testing to the scene context. Was the sample collected from a known liquid spill area, from a suppression water path, or from a debris field contaminated by unrelated hydrocarbons? Was packaging appropriate? Was the scene protected before sampling? Were control samples taken? These questions are not academic. They go directly to admissibility, weight, and credibility. Why Independent Review Changes the Case When a carrier asserts arson, an independent evaluation often becomes the most valuable step in the case. That review may include scene file analysis, origin-and-cause methodology review, examination of photographs and diagrams, interpretation of lab reports, witness statement comparison, and assessment of the insurer’s claim handling timeline. Independent review is not about reflexively rejecting the insurer’s position. It is about testing it. An experienced arson defense expert will ask whether the scene was preserved adequately, whether all ignition hypotheses were considered, whether the investigator’s reasoning followed the physical evidence, and whether the conclusions are consistent with fire science. The expert may also evaluate whether the insurer moved too quickly from suspicion to denial, or whether the claim file shows investigative steps that were skipped because the conclusion had already been decided. That distinction is especially important in litigation. A case can look strong on paper until the investigation is measured against the standards that govern modern fire analysis. If the insurer’s position depends on inferential leaps, selective readings of the scene, or unsupported assumptions about motive, those weaknesses may become central to the dispute. Litigation Implications for Counsel For plaintiff attorneys and policyholder counsel, the first issue is often whether the insurer’s arson allegation is being used to justify delay, deny coverage, or create leverage during settlement. Once the label is attached, the carrier may frame its position as a fraud defense, which can complicate discovery and slow claim resolution. That makes early expert review critical. Counsel needs to know whether the insurer’s theory rests on science or rhetoric before discovery windows close and memories fade. Defense attorneys and coverage counsel face a different but equally important task. They need to understand whether the insurer’s investigation was thorough enough to support the position being taken, and whether the file can survive cross-examination on methodology. A weak origin-and-cause opinion can create exposure far beyond the immediate claim amount. It can affect bad faith allegations, fee shifting arguments, and the credibility of future positions taken by the carrier. For property owners, the practical challenge is often confusion. A fire loss is already disruptive. When a claim shifts into arson territory, the owner may suddenly face document requests, sworn examinations, forensic examinations, and difficult questions about finances, access, and daily operations. In that environment, precision matters. The facts should be assembled calmly, chronology should be preserved, and all scene-related records should be maintained before assumptions harden into allegations. Public adjusters are often in the middle of this process. They may see early warning signs that the carrier is leaning toward an incendiary theory, or they may be asked to help document the loss after the insurer has already raised concerns. Their role is strengthened when the investigative record is organized, the timeline is clear, and the physical evidence is protected for expert review. What a Useful Expert Review Looks Like A meaningful review of an arson allegation is not limited to reading the denial letter. It usually includes several connected tasks. First, the expert reviews the scene documentation. That includes reports, photos, sketches, measurements, lab submissions, chain-of-custody records, suppression notes, and any available video or alarm data. The aim is to understand what was actually observed, not what was later inferred. Second, the expert evaluates the fire dynamics. Was the damage pattern consistent with the stated area of origin? Did flashover occur? Were there ventilation effects that could have changed the appearance of the room? Were there multiple rooms or levels involved? Was the structure compartmentalized in a way that could create misleading visual indicators? Third, the expert assesses ignition sources. Electrical systems, appliances, extension cords, heating equipment, stored materials, temporary work, and smoking materials are all part of the accidental-fire analysis. A defensible report should explain why these sources were accepted or excluded. Fourth, the expert looks at the alleged incendiary indicators. If accelerant use is claimed, the expert should evaluate the sample collection process, laboratory methodology, scene contamination risks, and whether the findings truly support intentional introduction of a fuel. If motive evidence is cited, the expert should note whether it is being used as a substitute for physical proof. Finally, the expert considers the litigation file as a whole. Statements, interviews, property records, prior losses, policy status, and claim correspondence all matter. The point is not to build a theory around suspicion. The point is to determine whether the insurer’s conclusion withstands disciplined review. The Role of NFPA 921 NFPA 921 is often cited in litigation because it reflects the accepted scientific framework for fire and explosion investigations. It does not guarantee a particular outcome, and it does not replace scene-specific judgment. What it does provide is a standard for method: develop hypotheses, test them against the physical evidence, eliminate those that are inconsistent with the data, and avoid conclusions that are not supported by reliable reasoning. That framework is useful in cross-examination and in expert reports because it shifts the conversation from opinion to process. If the insurer’s investigator did not follow a systematic method, or if the report leaps from suspicion to conclusion without a documented analytical path, NFPA 921 becomes highly relevant. For attorneys, this is where the science and the litigation strategy intersect. A strong expert is not simply someone who says the insurer is wrong. A strong expert is someone who can explain, in disciplined terms, why the investigative process failed to support the conclusion. That distinction is often decisive in mediation, motion practice, and trial. Why the File Should Be Reviewed Early The earlier an arson allegation is reviewed, the better the record can be preserved. Scene access may be lost, debris may be discarded, witnesses may become unavailable, and critical digital information may disappear. Early independent evaluation gives counsel a chance to identify weaknesses in the insurer’s theory before they become embedded in the case narrative. Early review can also reduce avoidable conflict. Some arson allegations are based on thin or incomplete records. Others are more substantial but still require careful testing. Either way, the parties benefit from a clear-eyed assessment of what the evidence actually shows. That is the kind of work that moves a case forward. In the end, “insurance company says arson” is not the conclusion. It is the beginning of the analysis. The real questions are whether the physical evidence supports the claim, whether the investigation followed accepted fire science, and whether the conclusion can withstand litigation scrutiny. For attorneys, adjusters, and property owners dealing with an insurance fire claim dispute, the most useful next step is not speculation. It is a careful, independent review of the fire investigation record. **Topics:** Homeowners - arson, Public Awareness --- ### [Arson Claim Denied? How One VA Homeowner Fought Back](https://insurancefraud.org/news_archives/arson-claim-denied-how-one-va-homeowner-fought-back/) **Published:** September 29, 2026 **Author:** Diane Beauchamp **Content:** ## When an Arson Claim Denied Label Gets Weaponized Against Innocent Homeowners An arson claim denied on the basis of alleged fraud can happen to homeowners who did absolutely nothing wrong. In the Virginia case we examine throughout this article, the insurer invoked its policy’s “concealment or fraud” clause — not because investigators found physical proof of intentional fire-setting, but largely because the homeowner was behind on mortgage payments and had recently increased their coverage. That financial circumstance alone became the insurer’s primary weapon, and it nearly worked. Key takeaways - An insurer invoking the ‘concealment or fraud’ clause to deny an arson claim must have credible, documented evidence — not just a financial motive theory. - A public adjuster can reopen a denied arson claim by systematically challenging the insurer’s investigation methodology and timeline. - An independent fire investigator’s origin-and-cause report often carries decisive weight when it contradicts the insurer’s hired expert. - Virginia policyholders have the right to request a complete copy of the claim file, which frequently reveals gaps or bias in the denial rationale. - Documenting your financial situation thoroughly before a loss — mortgage statements, tax returns, insurance payment history — can directly undercut an assumed motive argument. ### The Virginia Homeowner’s Situation at a Glance The homeowner, a longtime Virginia resident, experienced a devastating house fire that caused extensive structural and personal property damage. They filed promptly, cooperated with the insurer’s investigators, and submitted the documentation they were asked for. Weeks later, they received a denial letter. The insurer’s position rested on two pillars: - **Financial motive:** The homeowner had been experiencing financial hardship, which the insurer framed as a reason to commit arson for the insurance payout. - **Alleged misrepresentation:** The insurer claimed the homeowner had not been fully transparent about certain policy details during the application process, triggering the fraud and concealment exclusion. Neither accusation came with a criminal charge. No arrest was made. Yet the claim was denied in full. ### Why Insurers Lean on the Fraud Clause — Even Without Hard Evidence Insurance companies understand that the “concealment or fraud” clause is one of the most powerful tools available to them. When invoked, it can void an entire policy retroactively — meaning the insurer owes nothing, not even for losses that are clearly covered. For a homeowner already in financial distress, the cost and complexity of fighting back can feel insurmountable. Some simply walk away. That is precisely what makes this tactic so effective — and so troubling. Financial hardship is not evidence of arson. A mortgage in arrears does not make someone an arsonist. Yet the circumstantial framing can feel damning when it is laid out in a formal denial letter by an insurer’s legal team. ### How the Denial Was Successfully Challenged — The Short Answer The Virginia homeowner did not walk away. By retaining a [public adjuster and an independent fire investigator](https://forthepublicadjusters.com/blog/benefits-of-hiring-an-independent-claims-adjuster/), they were able to build a counter-case grounded in physical fire science, documentation, and policy law. The insurer’s circumstantial argument unraveled once objective evidence was placed against it. The sections below explain exactly how that process worked — and what Virginia and North Carolina homeowners in similar situations can do right now. ## What Does the ‘Concealment or Fraud’ Clause Actually Mean in a Fire Claim? ## Why Was This Arson Claim Denied — and Was the Insurer’s Case as Strong as It Seemed? The arson claim denied in this Virginia case rested almost entirely on circumstantial financial evidence — not physical proof of intentional fire-setting. The insurer pointed to the homeowner’s recent mortgage stress and a lapsed life insurance policy as signs of motive, but a closer look at the denial letter revealed that the carrier’s own fire investigation report contained critical gaps that undercut the whole conclusion. ### The Insurer’s Core Arguments When the denial letter arrived, it cited three main pillars the insurer believed justified withholding payment: - **Financial motive:** The homeowner had missed two mortgage payments in the months before the fire, which the carrier framed as evidence of a deliberate plan to collect insurance proceeds. - **Alleged opportunity:** The insurer noted the homeowner was the last known person at the property before the blaze started, though no witness placed them there at the time of ignition. - **Fire origin conclusions:** The carrier’s investigator classified the fire’s point of origin as “undetermined” but still characterized burn patterns as “consistent with” accelerant use — a phrase that sounds damning but carries far less legal weight than a definitive finding. ### What the Denial Letter Left Out When a public adjuster reviewed the file, several evidentiary gaps became apparent almost immediately. These weren’t minor technical quibbles — they went to the heart of whether the insurer had a defensible basis for denial at all. - **No laboratory confirmation of accelerant:** Despite the language about burn patterns, the investigator had not submitted samples to an accredited lab for chemical analysis. “Consistent with” accelerant is not the same as finding accelerant. - **Alternative ignition sources were not ruled out:** The home had aging electrical wiring and a natural gas line that ran near the area identified as the fire’s origin. Neither was documented as having been fully examined or eliminated. - **Financial stress reframed:** Missed mortgage payments can reflect hardship just as easily as motive. The insurer made no attempt to account for documented job loss the homeowner had experienced, which provided an alternative explanation for the financial picture. - **No arson conviction or criminal charge:** Insurers sometimes proceed as if a civil denial and a criminal finding are equivalent. In Virginia, an insurer bears its own burden of proof in a coverage dispute — the absence of a criminal case matters. ### Why This Pattern Is More Common Than Homeowners Realize Insurance companies are entitled to investigate suspicious fires thoroughly, and legitimate fraud does occur. But financial pressure alone is not proof of arson, and an “undetermined” origin finding is not a finding of intentional fire-setting. When a carrier conflates the two, the denial may look airtight in a letter while being genuinely vulnerable to challenge once a qualified expert examines the underlying investigation. ## How a Public Adjuster and Independent Fire Investigator Documented the Truth After an Arson Claim Denied When a homeowner’s arson claim is denied, the insurer’s origin-and-cause report is not the final word. A licensed public adjuster and a certified independent fire investigator can systematically re-examine the scene, challenge flawed methodology, and build a counter-narrative grounded in physical evidence — often uncovering critical details the insurance company’s team missed or ignored. ### Step 1: Securing and Documenting the Scene The public adjuster’s first move was to preserve what remained of the property before further deterioration or cleanup could destroy evidence. Working alongside a certified fire investigator credentialed through the National Association of Fire Investigators (NAFI) or the International Association of Arson Investigators (IAAI), they conducted a thorough walk-through, photographing burn patterns, char depth, structural damage, and the condition of windows, doors, and utility systems. ### Step 2: Re-Examining Origin and Cause Findings The insurer’s investigator had pointed to a specific room as the fire’s origin and suggested the burn pattern indicated an accelerant was used. The independent investigator applied NFPA 921 — the nationally recognized guide for fire and explosion investigations — and found significant problems with that conclusion: - The “V-pattern” burn the insurer cited as evidence of accelerant use was consistent with a known piece of furniture burning near a wall, a well-documented phenomenon in modern fire science. - Char depth measurements across the structure did not support the claimed origin point. - No laboratory analysis confirming accelerant residue had been performed by the insurer’s team — a serious procedural gap under NFPA 921 standards. ### Step 3: Exposing Timeline Inconsistencies The insurer’s denial letter leaned heavily on the homeowner’s timeline, suggesting it was implausible. The public adjuster gathered utility records, cell phone location data, neighbor statements, and the local fire department’s dispatch and arrival logs. When laid side by side, these records directly contradicted the insurer’s claimed timeline and corroborated the homeowner’s account of when they left the property. ### Step 4: Identifying Accidental Cause Evidence The independent investigator also examined the electrical panel, HVAC system, and appliances in the area where the fire most likely started. Evidence of electrical arcing and a malfunctioning component provided a credible accidental ignition source — one the insurer’s report had not ruled out through any documented testing or analysis. ### Why This Matters for Your Claim Insurers sometimes build an arson narrative on methodology that would not withstand scrutiny in a courtroom or before a Virginia or North Carolina insurance commissioner. A public adjuster coordinates the investigative process, manages documentation, and works with qualified experts so that when you dispute a denial, you have a concrete, evidence-based rebuttal — not just your word against theirs. ## What Court Cases Show That Insurers Can’t Deny an Arson Claim Without Solid Proof? Courts across Virginia, North Carolina, and the broader United States have consistently held that an insurance company cannot simply label a fire as arson and walk away from a claim. To successfully deny an arson claim, an insurer must meet a genuine burden of proof — typically demonstrating arson by clear and convincing evidence, and in many jurisdictions also proving the policyholder’s direct involvement. Without that, denials don’t hold up. ### The Burden of Proof Falls on the Insurer, Not You One of the most important legal principles protecting homeowners is that when an insurer raises arson as a defense to paying a claim, the burden of proving that defense belongs to the insurance company. This is not a small hurdle. Courts have repeatedly overturned denials where insurers relied on circumstantial evidence — things like financial stress, the absence of forced entry, or a fire that burned hot — without presenting a complete, cohesive case that eliminates accidental or natural causes. Virginia courts, following well-established common law, require that fraud and arson defenses be supported by more than suspicion or inference stacked on inference. The insurer must affirmatively establish: - That the fire was intentionally set (incendiary origin) - That the policyholder either set it or procured someone else to do so - That there was a clear motive, such as financial gain ### What Happens When Insurers Overreach In cases where insurers have invoked fraud or concealment clauses based on flimsy or one-sided investigations, policyholders who litigated their claims have won substantial judgments — not only recovering the policy value but sometimes additional damages for bad faith handling. Virginia’s bad faith statute and similar provisions in North Carolina create real consequences for insurers who deny claims without a reasonable basis for doing so. ### Why Independent Evidence Changes the Legal Landscape Courts pay close attention to whether a policyholder obtained their own independent fire investigation and documentation. When a homeowner can present a competing expert opinion — a certified fire investigator who examined the same evidence and reached a different conclusion — it often dismantles the insurer’s case entirely. Judges and juries are not required to accept an insurance company’s hired expert as the final word. If your arson claim was denied, the legal record strongly suggests that a well-documented challenge backed by independent expertise gives you meaningful leverage, both at the negotiation table and in court. You are not powerless simply because your insurer used the word “arson.” ## What Should You Do If Your Fire or Arson Claim Was Denied in VA or NC? If your fire or arson claim was denied in Virginia or North Carolina, act quickly and methodically: preserve all physical evidence, obtain your full claim file from the insurer, hire a licensed public adjuster and an independent fire investigator, and invoke your policy’s appraisal or suit provisions before any deadline passes. Taking these steps in the right order dramatically improves your chances of a successful appeal or legal challenge. ### Step 1: Preserve Evidence Immediately The single biggest mistake homeowners make after a denial is allowing the damaged property to be demolished, cleaned, or altered before an independent expert can examine it. Even if the insurer’s investigator has already completed their report, physical evidence can still matter during a reinvestigation or legal proceeding. - Photograph and video the fire scene from multiple angles before anything is moved. - Secure the property to prevent unauthorized access or further alteration. - Retain any physical debris, wiring, or appliance components that investigators may want to re-examine. - Keep copies of every document the insurer has sent you, including denial letters and investigation summaries. ### Step 2: Demand Your Complete Claim File Under Virginia and North Carolina insurance regulations, you have the right to request the claim file your insurer compiled. This file should include the adjuster’s notes, the fire investigator’s report, any photographs taken, and the specific policy provisions the insurer relied on to deny your claim. Reviewing this file often reveals weaknesses in the insurer’s reasoning or procedural errors they made during the claims process. - Submit your request in writing and keep a copy with a timestamp. - Note any deadlines stated in your denial letter — most policies impose a suit limitation period, often one to two years from the date of loss. ### Step 3: Hire a Licensed Public Adjuster and Independent Fire Investigator A licensed public adjuster works for you, not the insurance company, and can re-document your loss, challenge the insurer’s valuation, and manage communications on your behalf. Pair that with a credentialed, independent fire investigator — ideally one certified through the National Association of Fire Investigators or a similar recognized body — who can produce a competing origin-and-cause report if the insurer’s investigator reached unsupported conclusions. You can verify a public adjuster’s license in Virginia through the [Virginia State Corporation Commission Bureau of Insurance](https://www.scc.virginia.gov/pages/Licensing-and-Compliance) and in North Carolina through the [North Carolina Department of Insurance](https://www.ncdoi.gov/). ### Step 4: Invoke Your Policy’s Appraisal or Suit Provisions Most homeowner policies contain an appraisal clause that allows both parties to appoint their own appraiser when there is a disagreement over the amount of a loss. If the dispute goes beyond dollar amounts and involves coverage itself — as it typically does when an arson claim is denied — consulting an insurance coverage attorney about filing suit may be appropriate. Do not let the suit limitation period expire while waiting for the insurer to reconsider voluntarily. ### Realistic Timeline to Set - **Days 1–14:** Preserve evidence, submit your claim file request, and consult a public adjuster. - **Weeks 2–6:** Independent fire investigator completes their report; public adjuster prepares a formal rebuttal to the denial. - **Weeks 6–12:** Submit the rebuttal to the insurer and request a reconsideration decision in writing. - **Beyond 90 days:** If the insurer does not reverse the denial, evaluate the appraisal clause or consult legal counsel — well before any policy suit deadline. ## Arson Claim Denied vs. Successfully Challenged: Key Differences in Approach | Factor | Claim Stays Denied | Claim Successfully Challenged | |---|---|---| | Fire Investigation | Insurer relies solely on its own hired investigator | Policyholder retains independent certified fire investigator (CFEI) | | Financial Motive Argument | Insurer’s theory goes unchallenged and undocumented | Policyholder presents financial records disproving distress narrative | | Claim File Review | Policyholder never requests or reviews the claim file | Full claim file obtained and scrutinized for procedural errors | | Professional Advocacy | Policyholder navigates denial alone | Public adjuster coordinates documentation, rebuttal, and re-inspection | | Timeline of Response | Denial accepted at face value after initial letter | Formal dispute or appraisal demand filed within policy deadlines | ## Illustrative Case: Northern Virginia Homeowner Reverses Arson Denial Illustrative example In a composite scenario based on common patterns in disputed fire claims, a Northern Virginia homeowner’s total loss fire claim was denied after the insurer alleged financial motive, pointing to a recent job change and a refinanced mortgage as evidence of distress. The homeowner retained a public adjuster, who requested the full claim file and identified that the insurer’s fire investigator had not documented alternative ignition sources near the point of origin. An independent CFEI-credentialed investigator was then hired and produced a competing origin-and-cause report concluding the fire was consistent with an accidental electrical fault, not intentional ignition. Armed with the competing expert report, bank statements showing consistent mortgage payments, and a formal letter of representation, the public adjuster submitted a comprehensive rebuttal package to the insurer’s special investigations unit. Within several months, the insurer agreed to reconsider the claim and ultimately issued payment for the covered loss, illustrating how methodical documentation can shift the outcome of an arson claim denied on questionable grounds. ## Frequently asked questions ### What does it mean when an arson claim denied decision is based on the ‘concealment or fraud’ clause? Most homeowner insurance policies include a concealment or fraud clause that allows the insurer to void coverage entirely if they believe the policyholder misrepresented material facts or participated in causing the loss. When an insurer invokes this clause in a suspected arson case, they are essentially alleging that the homeowner either set the fire or concealed information relevant to the claim. This is a serious allegation, and the burden generally falls on the insurer to support it with credible evidence — typically by establishing opportunity, motive, and incendiary cause. A denial on these grounds does not mean the case is closed. ### How can a public adjuster help if my fire insurance claim is denied due to suspected arson? A licensed public adjuster works on behalf of the policyholder — not the insurance company — to evaluate the claim, review the insurer’s investigation, and document evidence that supports a legitimate loss. In arson-related denials, a public adjuster can identify gaps or inconsistencies in the insurer’s fire investigation report, help organize financial records that counter a motive argument, and prepare a detailed claim package for appraisal or reconsideration. They can also help coordinate an independent fire investigator to provide an alternative expert opinion on the fire’s origin and cause. ### What can an independent fire investigator find that an insurance company’s investigator might miss or interpret differently? Independent fire investigators are retained by the policyholder and approach the scene without a predetermined conclusion. They may identify alternative accidental or electrical causes that were overlooked, challenge the methodology used to classify burn patterns as incendiary, or find that evidence was misinterpreted due to post-fire conditions like firefighting water damage or structural collapse. Their findings can be submitted as part of a formal dispute, used in an appraisal process, or presented if the case proceeds to litigation. A second expert opinion carries significant weight, especially when the insurer’s own report contains ambiguous conclusions. ### What are the general steps a homeowner can take to dispute an arson-related claim denial? First, request a complete copy of the insurer’s claim file, including all investigation reports, recorded statements, and the specific policy language cited in the denial letter. Second, consult a public adjuster or policyholder attorney to assess the strength of the denial. Third, commission an independent fire investigation if the origin and cause findings are in dispute. Fourth, compile financial records, bank statements, and other documentation that counters any alleged motive. Finally, submit a formal written dispute or invoke your policy’s appraisal clause if a disagreement over the loss value is also involved. Many states also allow complaints to the state insurance commissioner if bad faith handling is suspected. **Topics:** Homeowners - arson, Public Adjuster, Public Awareness --- ### [Stanford Children's Hospital Hit with Multi-Million Dollar Healthcare Billing Fraud Lawsuit](https://insurancefraud.org/news_archives/stanford-childrens-hospital-hit-with-multi-million-dollar-healthcare-billing-fraud-lawsuit/) **Published:** September 29, 2026 **Author:** Diane Beauchamp **Content:** The Wonderful Company filed suit in California State Superior Court against Stanford for alleged multi-million dollar healthcare fraud at the Stanford Lucile Packard Children’s Hospital. The lawsuit is captioned The Wonderful Company vs. Stanford Children’s Hospital et. al. The suit alleges that Stanford and its affiliates are involved in “extortion” through demands from exorbitant and fraudulent medical bills. The complaint also alleges that Stanford and its affiliates habitually and egregiously upcoded and double billed for the medical care of a very young child. The suit seeks to hold Stanford accountable for its “unlawful, and unconscionable behavior” in connection with alleged frankly fraudulent medical charges submitted for the care of a young child. But the lawsuit seeks more than that- it also pleads relief from the court for “others who are similarly situated” pursuant to California statutes which allow the same. The complaint alleges that although Stanford had already billed and been paid for $1.3 million for services rendered at Stanford to just one child, Stanford Children’s Hospital suddenly demanded an additional $4,605,066.26 for the treatment of the same child. The suit states that Stanford as a tax advantaged “non-profit”, took further advantage of its financial privileges by charging “unlawful and duplicate charges” for this pediatric care which resulted in false and fictional charges for over $6 million in total. The allegations of unlawful unbundling and upcoding at Stanford’s Children’s Hospital, and in many cases double and triple billing for the same services are nearly identical to the allegations in the lawsuit filed on behalf of the Government against Stanford in Federal Court. The Federal court pleadings allege that “Stanford is not a prototypical “non-profit”. Stanford is very profit driven- indeed it prides itself on billing high and maximal at all costs. Despite its not-for-profit basis, Stanford consistently ranks as of the top five earning hospitals in the nation, earning $9.4 billion at relevant times in its hospital alone. Stanford more than doubled its Medicare annual revenues from 2012 to 2016, without a corresponding or explainable increase in Stanford’s bed count, staffing, or overhead. And Stanford’s disproportionate revenue escalation has only intensified from 2017 onward. Stanford achieves these astonishing profits because it extracts far greater gains from the Government, than conventionally operating hospitals. Medicare’s payment systems are relatively weak, and riddled with loopholes which can be circumvented by certain electronic medical record business algorithms—and Stanford knew this. Stanford further receives more federal stimulus money than any hospital system in California, production payments which are based on Stanford’s voluminous false claims. “ The Wonderful Company’s suit alleges that Stanford’s billing fraud is not just limited to Medicare patients, but egregiously extends to Stanford Lucile Packard Children’s Hospital. The State suit alleges that Stanford and its affiliates have engaged in a multi-year long commercial and private insurance fraud in excess of multi-millions of dollars, primarily against infants and children. And these lawsuits and healthcare billing fraud allegations both as to Stanford children and Medicare patients really make sense. According to a study published by the journal Health Affairs in 2016, Stanford Hospitals and Clinics in Palo Alto consistently ranks as one of the top 5 most profitable hospitals in the United States. That same years, the majority of U.S. hospitals lost money caring for patients. Multiple employment and wrongful termination lawsuits for whistleblowing employees against Stanford Hospital, University Healthcare Alliance, and Stanford University have been filed like Young vs. Stanford (RG17-877055) in the Alameda County Superior Court, Gaines vs. Stanford (3-16-02381) in California Federal Court, and others. The law not only has built-in protections for whistleblowers, which prohibits retaliation by employers, but 31 U.S.C. section 3279 also mandates a monetary award of a percentage of any recovery by the Government which results from a whistleblower’s insider information of fraud on the Government. There are very specific rules for how the “original source information” is brought to the Government’s attention, and these require typically a special lawsuit called a qui tam action filed by the whistleblower. If the information is however publicly disclosed, then that alone may disqualify the whistleblower from receiving an award. The Law Offices of Gloria Juarez represent the interests of whistleblowers on behalf in the United States vs. Stanford HealthCare. Ms. Juarez’s firm has a special interest in prosecuting false claims act cases on behalf of the Government- both State and Federal, and uncovering Stanford billing fraud. The Law Firm commented that it is really only through the ongoing dedication, and courageous whistleblowing and voluntary outreach from Stanford insiders like its former employees, billers, and coders that Stanford’s fraudulent healthcare scheme will be fully uncovered and finally brought to justice. **Topics:** Healthcare Fraud, Judicial/courts --- ### [OIG Special Fraud Alert: Seven Suspect Characteristics of Fraudulent Telemedicine Arrangements](https://insurancefraud.org/news_archives/oig-special-fraud-alert-seven-suspect-characteristics-of-fraudulent-telemedicine-arrangements/) **Published:** September 29, 2026 **Author:** Diane Beauchamp **Content:** It is no surprise that the use of telemedicine as a means of providing patients with access to medical care has increased significantly in recent years. Likewise, the number of telemedicine companies offering a broad range of health care items and services through physician and nonphysician practitioners has also increased significantly. On July 20, 2022, the United States Department of Health and Human Services Office of Inspector General (“OIG”) issued a Special Fraud Alert (“Alert”) warning physicians and other practitioners to exercise caution when entering into arrangements with telemedicine companies. The Alert is in response to dozens of OIG investigations of fraud schemes involving telemedicine and other companies that purported to provide telemedicine, telehealth, or telemarketing services. Although the fraud schemes vary in design and operation and involve a wide range of different individuals and types of entities, the Alert explains that one common element of the schemes is the way the telemedicine companies have used kickbacks to reward physicians and nonphysicians (collectively, “Practitioners”) to further the fraud schemes. Specifically, the telemedicine companies will generally arrange with Practitioners to order or prescribe medically unnecessary items and services for individuals who are solicited and recruited by telemedicine companies. Often, the Practitioners are paid to order or prescribe items or services (1) to patients with whom the Practitioners have limited, if any, interaction, and (2) without regard to medical necessity. To assist Practitioners, the Alert identifies a list of seven “suspect characteristics” related to Practitioner arrangements with telemedicine companies which could suggest an arrangement that presents a heightened risk of fraud and abuse, as follows: 1. The purported patients for whom the Practitioner orders or prescribes items or services were identified or recruited by the telemedicine company, telemarketing company, sales agent, recruiter, call center, health fair, and/or through internet, television, or social media advertising for free or low out-of-pocket cost items or services. 2. The Practitioner does not have sufficient contact with or information from the purported patient to meaningfully assess the medical necessity of the items or services ordered or prescribed. The Alert provides as an example a telemedicine company that requires the Practitioner to use audio-only technology to facilitate an engagement with purported patients, regardless of their preference, and does not provide the Practitioner with other telehealth modalities. The Practitioner may also receive from the telemedicine company purported “medical records” that reflect only cursory patient demographic information or a medical history that appears to be a template but does not provide sufficient clinical information to inform the Practitioner’s medical decision-making. 3. The telemedicine company compensates the Practitioner based on the volume of items or services ordered or prescribed, which may be characterized to the Practitioner as compensation based on the number of purported medical records that the Practitioner reviewed. 4. The telemedicine company only furnishes items and services to Federal health care program beneficiaries and does not accept insurance from any other payor. 5. The telemedicine company claims to only furnish items and services to individuals who are not Federal health care program beneficiaries but may in fact bill Federal health care programs. 6. The telemedicine company only furnishes one product or a single class of products (e.g., durable medical equipment, genetic testing, diabetic supplies, or various prescription creams), potentially restricting a Practitioner’s treating options to a predetermined course of treatment. 7. The telemedicine company does not expect Practitioners (or another Practitioner) to follow up with purported patients nor does it provide Practitioners with the information required to follow up with purported patients (e.g., the telemedicine company does not require Practitioners to discuss genetic testing results with each purported patient). The Alert clarifies that the above list is not exhaustive, and the presence or absence of any one of the suspect characteristics is not determinative of whether an arrangement would be grounds for legal sanctions, such as criminal, civil, or administrative liability (including possible disciplinary action against the Practitioner’s health professional license or registration). The Alert encourages Practitioners to use heightened scrutiny and exercise caution before entering into an arrangement with a telemedicine company. For this purpose, physicians who are considering entering into an arrangement with a telemedicine company should consult with legal counsel to review any written agreement with the telemedicine company and to ensure that the arrangement is legitimate and enables the physician to comply with applicable state and federal laws. For example, Michigan law prohibits a physician or other health professional from providing a telehealth service without directly or indirectly obtaining consent for treatment. Proof of such consent must be maintained in the patient’s up-to-date medical record that is retained in accordance with the Public Health Code’s medical record retention requirements. In addition, Physicians should ensure that they provide telemedicine services only to patients who are located in states in which the physician is licensed or authorized to provide telemedicine services. **Topics:** Healthcare Fraud, Public Awareness --- ### [CONSUMER ALERT: Attorney General’s consumer survey reveals that millions of Washingtonians may have been unintentionally enrolled in a subscription service](https://insurancefraud.org/news_archives/consumer-alert-attorney-generals-consumer-survey-reveals-that-millions-of-washingtonians-may-have-been-unintentionally-enrolled-in-a-subscription-service/) **Published:** September 29, 2026 **Author:** Diane Beauchamp **Content:** Attorney General Bob Ferguson [released the results of a consumer survey](https://agportal-s3bucket.s3.amazonaws.com/Hardwick%20Research%20Report%20Hidden%20Fees%207-30-22.pdf) revealing that 59% of Washingtonians may have been unintentionally enrolled in a subscription plan or service when they thought they made a one-time purchase, highlighting a problem that may be impacting millions of Washingtonians. The U.S. Census Bureau [estimates](https://www.census.gov/quickfacts/WA) that just over 6 million adults live in Washington state. Consequently, 59% represents 3.5 million Washingtonians. Respondents reported that pre-check boxes constitute a significant source of the problem. The survey also reveals that approximately 100,000 Washingtonians may have been unable to cancel the unwanted subscription because it was too difficult. The Attorney General’s Office recently commissioned the online survey of 1,207 adult Washington consumers. The survey is part of the Attorney General’s Honest Fees Initiative. Here are some of the highlights from the survey: - 59% of the 1,207 respondents noted that in the last four years they unintentionally enrolled in a subscription plan that automatically billed them when they thought they were making a one-time purchase. Of those: - A majority (51%) cited a pre-checked box as the reason they unintentionally enrolled. 37% did not remember if a pre-checked box was present. 12% reported that a pre-checked box was not present. - 63% reported that they unintentionally enrolled in a subscription more than once. - 2.75% reported that they did not cancel the subscription because it was “too difficult to cancel.” Extrapolated over the population, this represents 1.6% of adult residents, or approximately 100,000 Washingtonians who could not cancel an unwanted subscription - A significant majority of the respondents (70%) noted pre-checked boxes should be prohibited. - Washingtonians cited online retailers (29%) as the most common source of the problem, and Amazon was the company that received the most mentions by consumers. Attorney General Ferguson urges consumers to file a complaint with his office if they inadvertently signed up for a subscription while attempting to make a one-time purchase. The Attorney General’s Office responds to every consumer complaint. It fields approximately 24,000 complaints annually, and returns approximately $18 million per year to consumers through its informal complaint resolution process, which involves working with businesses to resolve consumer complaints pre-investigation or litigation. “The average consumer has to keep an eye out all the time. Merchandisers are constantly changing their tactics,” one respondent from southwest Washington noted after taking the survey. “This survey reveals that corporations are deceiving Washingtonians into paying for unwanted subscriptions – and consumers want this practice to end,” Ferguson said. “If you unintentionally signed up for a subscription service, contact my office so we can help.” “Before signing up for any new subscription, membership or trial offer, it’s important that consumers take the time to understand exactly what they are agreeing to,” said AARP State Director Marguerite Ro. “Reputable retailers will give you straightforward procedures for setting up, cancelling or changing your account settings. If those terms are difficult to find or understand, beware.” **Survey** Hardwick Research [conducted its online survey](https://agportal-s3bucket.s3.amazonaws.com/Hardwick%20Research%20Report%20Hidden%20Fees%207-30-22.pdf) from June 24 through July 7, and 1,207 adult Washington consumers answered the survey. The survey included some of the following demographics: - Respondents came from across the state, primarily from the Puget Sound area at 57% and 43% from other areas of Washington state. - Respondents split between 50% female and 48% male. - Respondents split among age groups: approximately one third were between the ages of 18-34, one third were 35-55 and one third were 55 or more years old. - The average respondent’s household income was $76,500. **Topics:** Public Awareness --- ### [As insurance covers at-home COVID tests, FTC warns program prone to scams](https://insurancefraud.org/news_archives/as-insurance-covers-at-home-covid-tests-ftc-warns-program-prone-to-scams/) **Published:** September 29, 2026 **Author:** Diane Beauchamp **Content:** Although funding for free COVID-19 tests has run out, the federal government says there is still a way to get kits without any out-of-pocket expenses. The Federal Trade Commission said that at-home COVID-19 tests are covered by insurance providers. The FTC said that those on employer, Medicare, or an Affordable Care Act marketplace plans are eligible for up to eight tests per month. “There are two ways to get your tests for free,” the FTC said. “Use a pharmacy or store that your health plan designates ‘in network’ where you’ll be charged $0 or get reimbursed by submitting a claim to your insurance plan. Check with your health insurance provider to find an in-network pharmacy or to know what receipts or other documentation you’ll need.” The FTC also noted that scammers target Medicare recipients with “fake offers” for free coronavirus tests. The FTC said these scammers are attempting to steal personal information to commit fraud and bill bogus charges to insurance companies. The FTC recommends obtaining tests from reputable companies and not giving out any personal information to anyone who calls out of nowhere. **Topics:** COVID-19, Public Awareness --- ### [Trial for former ISP trooper accused of arson pushed to 2023](https://insurancefraud.org/news_archives/trial-for-former-isp-trooper-accused-of-arson-pushed-to-2023/) **Published:** September 29, 2026 **Author:** Diane Beauchamp **Content:** The trial for a former ISP trooper accused of arson has been postponed to 2023. Troopers say Jeremy Galloway is accused of setting fires at his Tell City property in October of 2020. He was arrested in February of 2021 for arson and insurance fraud charges. A charge of cruelty to an animal was added when troopers say two dogs were killed in the fire. Jury selection in this case was scheduled to begin Monday but has now been postponed to April 10th, 2023. Galloway resigned after his arrest. **Topics:** Homeowners - arson **Categories:** Arrest --- ### [Des Moines Man Pleads Guilty to Insurance Fraud](https://insurancefraud.org/news_archives/des-moines-man-pleads-guilty-to-insurance-fraud/) **Published:** September 29, 2026 **Author:** Diane Beauchamp **Content:** Sang Nguyen, age 47, of Des Moines, pled guilty on October 4, 2022, to one count of Insurance Fraud – Application Submission (Class D Felony) following an investigation by the Iowa Insurance Division’s Fraud Bureau. The investigation began in June of 2022 after the Iowa Insurance Division’s Fraud Bureau received information indicating Nguyen had provided false information to an insurer when purchasing full coverage automobile insurance. The investigation determined that after Nguyen’s motorcycle was involved in a single vehicle collision and sustained over $3,000 in damage he contacted an insurer to purchase auto insurance coverage. During the purchase Nguyen provided false information about the existing damage to his motorcycle and was granted full coverage automotive insurance. Days later, Nguyen filed an insurance claim alleging that the pre-existing damage occurred after he obtained the insurance coverage. Nguyen’s intent was to receive insurance benefits to which he was not entitled. Nguyen was arrested on July 20, 2022. Following his guilty plea, Nguyen received a five year suspended prison sentence and was placed on supervised probation for two years. Nguyen was also ordered to pay a fine of $1,025. **Topics:** Auto - underwriting **Categories:** Conviction --- ### [Thieves feared to have slaughtered more than 100 stolen sheep - as criminals 'weaponise' cost of living crisis](https://insurancefraud.org/news_archives/thieves-feared-to-have-slaughtered-more-than-100-stolen-sheep-as-criminals-weaponise-cost-of-living-crisis/) **Published:** September 29, 2026 **Author:** Diane Beauchamp **Content:** When farmer Ed Lovejoy rounded up his sheep last month, he was left “stunned” and feeling “pretty sick”. A total of 116 ewes had vanished from his flock of 460, with the missing livestock worth about £17,000. Initially suspecting the animals may have escaped, Mr Lovejoy went searching near his farm in Woodchurch, Kent, but there was no trace of them. It wasn’t until a witness reported seeing someone on a quad bike pushing the sheep to the side of a field that the reality dawned on the 40-year-old farmer. Brazen thieves had staged a daring raid to steal the animals, which are now feared to have been slaughtered and their meat sold on the black market. It comes amid warnings that Britain is a facing a “potential crime crisis” linked to the soaring cost of living. Electricity thefts, shoplifting, insurance fraud and rural crime are reportedly on the increase as the cost of food and energy rises. Fraudsters are “weaponising” the situation with a series of scams, a charity says, and organised crime groups are said to be viewing the crisis as an opportunity to recruit. In the countryside, insurance company NFU Mutual has warned of an increase in rustling, with livestock worth £2.4m stolen last year, and animals with a value of £1.4m taken in the first eight months of 2022. Mr Lovejoy said the theft of his Romney sheep, a Kent breed, would have a “knock-on effect” on his business for two to three years. He suspects the animals were taken to a “dodgy abattoir” or killed and the meat sold by the criminals themselves. “There is years and years of breeding that goes into these sheep and you care for them all year round,” Mr Lovejoy told Sky News. “For someone to just take them and steal them, it makes you feel pretty sick. “I think they would have probably slaughtered them and put them into the food chain somehow.” Fears livestock thieves can’t be stopped Mr Lovejoy said he reported the theft to the police but the culprits have not been found. He is now concerned the criminals will return and try to attempt to steal more. “How do you secure 700 acres to stop people getting on it to steal sheep? I’m not sure it’s possible,” he said. “It is a worry that they’re going to take more. “If food becomes really expensive then there’s always a black market. “If the cost of living crisis gets worse, there’s a chance we’re going to see more and more livestock thefts.” Rise in violent crime predicted A criminologist says the UK faces a “potential crime crisis” linked to the cost of living, including an increase in violence on the streets. Dr Robert Hesketh, from Liverpool John Moores University, told Sky News: “As the cost of living crisis starts to peak, I think there will be an increase (in crime) – I think it’s a no-brainer. “In areas like mine – marginalised areas, areas of social exclusion – it’s going to shoot up, particularly with young people. “I heard on one occasion the family of a young person being told: ‘Look, we’ll pay your Sky bills, just let your lad do some deliveries for us’. “You’ll get people within organised crime groups monopolise on this, because they know people are going to need money. “Already there’s been an increase in electricity theft – it’s up 13% (in 2021-22 on the previous year). “In communities like mine, it only takes one to get away with it and there’s \[people\] saying: ‘Get on to this’.” ‘Police are going to have to prioritise’ Dr Hesketh said organised crime groups view the cost of living crisis as “an opportunity to get more manpower, more people involved in street crime and drug dealing, and those in charge keep their hands clean”. “With the organised crime groups around my area, it’s very territorial,” he added. “As people get desperate, and organised criminals get more greedy, then they’ll start overtaking other people’s turf…. obviously that becomes violent. “Violence is part and parcel of organised crime… that’s how they thrive. Without violence, they’re nothing.” Dr Hesketh said he believed the police “are going to have to prioritise”. “Resources are short as it is, they’re going to focus mainly on more serious violent acts, I think,” he added. Victims targeted ‘left, right and centre’ Victim Support said it had seen people targeted by scams around the government’s council tax rebate and an increase in people trying to take out “quick loans” through unregulated services. Lisa Mills, the charity’s senior fraud manager, told Sky News: “People are in this hot state – they’re anxious about the cost of living – so they are taking more risks than they would normally. “This scenario now is going to be weaponised by the fraudsters. We saw it with the pandemic. “When people are feeling anxious and uncertain, their ability to rationalise and think about things is going to be compromised. “What we have seen is people who are desperately in need of money are taking unnecessary risks by taking out loans online. “We know people are going to be targeted left, right and centre.” Ms Mills warned of a rise in “money muling” – when a criminal persuades someone to put “dirty” money into their account before the funds are then moved into another account. “It’s in effect money laundering – it’s washing dirty money,” she said. “We have seen instances where younger people are being promised free trainers if they accept money to then forward on. “Your guard is down in this time of crisis and people will just be at the end of their tether thinking ‘I need a quick fix now’, and this is being offered to me and it sounds great.” Ms Mills said that some unregulated loans may charge high interest rates or the loan may not even exist. She said: “As soon as they pay money, a website gets taken down, you’ve lost your money – so the loan didn’t exist in the first place. “It’s capturing people that way.” The National Police Chiefs’ Council (NPCC) has said forces have considered the impact of the cost of living crisis but denied reports it was preparing for a “tidal wave” of violent crime and public disorder. An NPCC spokesman said: “Our ongoing priority remains prevention, and we continually work with communities to gather intelligence around crime and disorder. “As a result, policing is able to regularly intervene early to prevent incidents or their escalation due to this community intelligence to keep the public safe.” **Topics:** Public Awareness --- ### [Mumbai: Wife ploys husband's death to claim Rs. 50 lakh insurance, booked](https://insurancefraud.org/news_archives/mumbai-wife-ploys-husbands-death-to-claim-rs-50-lakh-insurance-booked/) **Published:** September 29, 2026 **Author:** Diane Beauchamp **Content:** The Dindoshi Police have booked a husband and wife duo for cheating and forgery after she ploy’s husband’s death in order to claim the insurance worth Rs. 50 lakh. However her insurance claim for husband dropped dead when the insurance firm found out the truth during the verification. In January this year, Prakash Mane, 36 had taken an insurance policy with covering death benefits of Rs. 25 lakh along with additional accidental benefits of Rs. 25 lakh with his wife (name withheld) as his nominee, the police said. According to the police, Barely three months later his wife informed the insurance firm that her husband had died in a tragic accident on March 6 and claimed insurance 10 days later. To support her claims she attached copies of husband’s death certificate, inquest and spot panchanama, case details, autopsy report, a certificate given by the police along with copy of her and her brother- in-law’s statement to the police. The insurance firm’s claims department got in touch with the concerned departments to verify the claim documents those were attached by Mane’s wife. They had written a letter to the concerned departments along with the documents, however the got a reply back saying that the documents attached by the woman were bogus, the police said. The company officials recently filed a written complaint to the Dindoshi Police since their office is located in their jurisdiction, an official said. After going through the documents, the Dindoshi Police on Friday booked both the husband wife duo. They have been booked for criminal conspiracy (120-B) cheating (420), forgery (465), forgery for purpose of cheating (468), using as genuine a forged document (471) and punishment for attempting to commit offences (511) of the Indian Penal Code (IPC), he added. **Topics:** Life Insurance **Categories:** Arrest --- ### [Teen in Dongri Children’s Home shines in NEET exam](https://insurancefraud.org/news_archives/teen-in-dongri-childrens-home-shines-in-neet-exam/) **Published:** September 29, 2026 **Author:** Diane Beauchamp **Content:** 17-year-old’s bail plea has been twice rejected by Juvenile Justice Board;had tried to pull off an insurance fraud and was sent to the Dongri correctional home three days before his National Eligibility Entrance Test (NEET) in July, he has scored an impressive 540 marks out of 720 A teenaged boy, who tried to pull off an insurance fraud and was sent to the Dongri correctional home three days before his National Eligibility Entrance Test (NEET) in July, has scored an impressive 540 marks out of 720. He is, however, still lodged in the home and has been unable to get bail. Arun was detained by the Jogeshwari police on July 14 for blowing up a courier parcel with a homemade bomb in order to get insurance benefits. Police officials said the idea came to him when he saw a courier company’s ad which said that items damaged during the journey or handling would be reimbursed at the original cost plus 10 percent compensation. Convinced that he could pull off the fraud, Arun bought the material required to assemble a crude timer bomb. “The intention was to completely destroy the parcel and later declare it as a very expensive one so that he could claim commensurate insurance,” said a police officer. “On July 12, the teenager booked a courier service to Delhi for a parcel containing electronics parts, which he claimed were valued at ₹9.81 lakh. He initially made fake invoices worth ₹9,81,800 for two computer processors, mobile handsets and memory cards. Using the fake invoices, he bought insurance online,” said senior inspector Satish Tavare of Jogeshwari police station. The parcel was picked up by the courier agency and, as intended by Arun, exploded hours later at its warehouse in Jogeshwari. Agency staffers extinguished the fire in which, fortunately, no one was hurt. The courier agency, after carrying out a thorough inquiry, reported the incident to the Jogeshwari police the next day. During the spot panchnama, the police found leftovers of a cheap damaged mobile phone, a half-burnt circuit, some pencil cells and half-burnt firecrackers inside the parcel. It was then that they sensed something was amiss, and after getting details of the sender, despatched a team to Arun’s house in Santacruz. “When he was brought to the police station, he was shocked,” said API Javed Shaikh, the investigating officer of the case. “He did not expect that his crime would get out of hand thus.” During his interrogation, Arun revealed that he had done this because he wanted quick money to buy an iPhone and an expensive laptop. He was booked in a criminal case which, apart from including sections of the Indian Penal Code for a negligent act endangering human life, also attracted charges under the Explosive Substances Act. Later, he was sent to the Children’s Home in Dongri. Introverted kid Arun’s family, which hails from Uttar Pradesh, moved to Mumbai over 20 years ago. His father owns a farsan shop in the western suburbs, and Arun would spend most of his time there. His mother is a housewife. According to the police, the Class 12 student has been an introvert from childhood with few friends and very limited interaction with his parents. Although he was always interested in pursuing engineering, his father goaded him to think of a more lucrative career in medicine, and made him prepare for the NEET exam. Arun would often do experiments of one kind or another at home, and it was perhaps his success in those that gave him the confidence to pull off the courier insurance fraud. “He was smart enough to adopt an innovative method to make some quick money, but he was not a professional criminal and hence made some mistakes,” said API Shaikh. “He didn’t stop to think that if the ruse failed, the police would get him since he had booked the courier in his own name and personally handed over the parcel.” Arun has undergone several sessions of counselling in the Dongri home. The authority paid special attention to him before his NEET exam and provided him with the study material, teachers, facility for e-classes and counselling, and ensured that he remained motivated. “Arun is smart and did well in the exam. He would have done even better if this incident hadn’t taken place,” said an officer from the home. Struggle to get bail The Juvenile Justice Board (JJB), based on the evaluation of four psychiatrists and some other factors, has twice rejected the teenager’s bail plea. The psychiatrists, who were roped in for a proper evaluation of Arun’s potential and risk assessment, feel that he still shows signs of indulging in acts that could harm others – which is why the concerned authority believes he needs to spend more time in counselling till he is totally reformed. Primarily, a source revealed, Arun does not believe that what he did was a crime. “He kept telling his counsellors that he had no ‘criminal’ motive and only wanted some quick money, which too he does not want now,” he said. “In his mind he did not equate his fraud with crime.” **Topics:** Fraud General **Categories:** Arrest --- ### [Delhi: Two men die after falling from construction site](https://insurancefraud.org/news_archives/delhi-two-men-die-after-falling-from-construction-site/) **Published:** September 29, 2026 **Author:** Diane Beauchamp **Content:** As many as two people succumbed to their injuries after falling from height at under-construction Node building T-1 in Dwaraka. The two deceased have been identified as Vikash and Manoj. They were shifted to the Safdarjung Hospital and Vikash was declared brought dead by doctors of the hospital whereas, Manoj died during his treatment. Apart from the two deceased six other men have been injured and are under treatment at the hospital. The police informed that the work of scaffolding was under contractor Mintu Yadav at Node building T-1 arrival at L and T construction site. The police have registered an FIR in the matter and the investigation is on. Further probe into the matter is awaited. (ANI) **Topics:** Public Awareness, Workers Comp --- ### [‘Held captive, forced to commit cyber fraud’ – Over 100 Indians rescued from fake job scam in Myanmar, Cambodia](https://insurancefraud.org/news_archives/held-captive-forced-to-commit-cyber-fraud-over-100-indians-rescued-from-fake-job-scam-in-myanmar-cambodia/) **Published:** September 29, 2026 **Author:** Diane Beauchamp **Content:** Over 100 Indian workers were rescued from Myanmar, Laos and Cambodia after they were lured by agents for fake job opportunities in the information technology sector in Thailand, the Centre said on Friday. The Indian authorities have urged people to be alert and exercise caution about dubious job offers. Addressing media in New Delhi, External Affairs Ministry spokesperson Arindam Bagchi said some fraudulent IT companies appear to be engaged in digital scamming and forged cryptocurrencies and the Indian workers were held captive and forced to commit cyber fraud. “Nearly 50 workers have been brought back to India from Myanmar, while some others were still in Myanmar police custody for questioning because they illegally entered the country without visas,” he added. Bagchi further said that 80 other Indian workers have been rescued from Cambodia and Laos. Also Read \| Gyanvapi case: Varanasi court defers hearing on plea seeking carbon dating of ‘Shivling’ in Mosque premises An ANI report quoted Bagchi as saying that Indian embassies in Vientiane, Phnom Penh and Bangkok have been helping in repatriation of Indian nationals stuck in Laos and Cambodia in similar job rackets. The companies appear to be operating through agents in Dubai, Bangkok and some Indian cities and were recruiting Indian workers through social media advertisements for fake highly lucrative jobs in Thailand, the MEA spokesperson said, adding, “Many of the workers were taken illegally across the border into an area of Myanmar that is difficult to access because of the local security situation.” Global job scam Citizens of other countries in the region have suffered in similar scams. On Thursday, 21 Malaysians rescued from human traffickers in Cambodia and Laos returned home. Malaysian Foreign Minister Saifuddin Abdullah said the government has now rescued 273 people out of 401 reported missing in Cambodia, Laos, Myanmar and Thailand. Most have returned except for 60 still in immigration detention centres in those countries who are waiting to be processed, he said. A UN envoy has said the scam networks, which often have links to transnational organised crime, are set up in countries with weak law enforcement, attracting educated young workers with promises of high earnings. The workers are then subject to isolation and the threat of violence unless they succeed in cheating victims reached by phone into transferring payments into overseas bank accounts. **Topics:** Employment fraud --- ### [Five Mistakes That Cost Motorists Insurance Claims After Accidents](https://insurancefraud.org/news_archives/five-mistakes-that-cost-motorists-insurance-claims-after-accidents/) **Published:** September 29, 2026 **Author:** Diane Beauchamp **Content:** Motor insurance covers are meant to cushion motorists and road users from the ravaging effects of car accidents. On most occasions, insurance companies step in to pay for damages that are resulted from accidents. However, more often than not, some motorists fail to get the much-needed reprieve after accidents because of decisions made after an accident. Here are mistakes that could cost you your insurance claim after an accident. **1. Failing to make a police report** When making claims after an accident, insurance companies demand that motorists attach a police report. Police report not only confirms to the insurance companies that the accident occurred but also give details of the accident in terms of location and time. These reports are heavily relied on because they provide an authoritative account of the accident rather than word of mouth by the driver. This is the main reason why motorists are urged to involve the police after an accident. **2. Fleeing the accident scene** After an accident, fleeing the scene can cost your insurance claim because this makes it difficult to prove that an accident actually took place at a given location. That is the reason why motorists are urged not to move their vehicles after an accident to allow the police to document the nature of the accident. Secondly, fleeing the scene is often an admission of guilt that you actually cause an accident. Most people flee the scene in fear of involving the police in the case. **3. Falsefying details of the accident** Falsifying accident details amounts to insurance fraud. Motorists are always urged to give true accounts of events leading to the accident. **4. Making settlements with the other motorists** One common trend that has been witnessed over the years is that motorists often settle for roadside settlements with other motorists to cover for damages caused. This is often witnessed in cases where the motorists do not want to involve the police in the matter as they could be at fault. Another reason people settle for settlements is that they lack valid insurance coverage. Making a settlement at the scene is also disadvantageous because it makes it difficult to prove that an accident happened. After all, the other motorist always leaves the scene after making the settlement. In most cases, in the roadside settlement, motorists get a lower payment for damages than they could have gotten through the insurance. **5. Failing to notify the insurance company** Another reason why people lose out on insurance is if they fail to make their claims on time. This is the reason why motorists are often urged to notify their insurance of an accident once it happens. Delays in reporting also affect the motorist’s account of events, and making mistakes in recounting the accident can lead to errors in the claim. Once it is determined that there are errors in the claim, the insurer will often deny it as they also investigate the incident. The National Transport and Safety Authority (NTSA) indicates that [15,925 crashes were recorded](https://www.kenyans.co.ke/news/80064-police-begins-crackdown-motorists-seatbelts-among-7-compliance-areas) on Kenyan roads between January 1 and September 26. Most of the cases were linked to human errors. **Topics:** Public Awareness --- ### [Digital fraud attempts in Kenya drops by 27% in Q2](https://insurancefraud.org/news_archives/digital-fraud-attempts-in-kenya-drops-by-27-in-q2/) **Published:** September 29, 2026 **Author:** Diane Beauchamp **Content:** The rate of suspected digital fraud attempts from Kenya in Q2 decreased by 27% compared to the same period last year, while there was a 14% drop globally. This is according to TransUnion’s quarterly fraud analysis. The largest declines from Kenya-based transactions came from communities (which include online forums and dating) (-70%), telecommunications (-42%) and insurance (-20%). The industry that saw the biggest increase in suspected digital fraud attempts coming from Kenya was logistics, which increased 61%. The most common fraud type here is shipping fraud, where buyers spoof shipping addresses, or a seller receives payment for goods or services, but never ships the goods to the buyer. Other Kenyan industries with increases were gambling (36%) and retail (23%). The global insurance industry saw a year-on-year suspected digital fraud attempt rate of 159% in Q2 2022, while the global logistics sector increased by 13%. In contrast, TransUnion observed a -20% decrease in the rate of suspected digital fraud attempts in insurance worldwide for transactions originating from Kenya. The most common type of fraud reported to TransUnion by its insurance customers in Q2 2022 was first-party application fraud, which involves fraudulent applications containing intentionally inaccurate information with the intention of receiving certification, lower rates or better terms for a policy/contract. TransUnion’s data on fraud against businesses is based on intelligence from billions of transactions and more than 40,000 websites and apps contained in its flagship identity proofing, risk-based authentication and fraud analytics solution suite – TransUnion TruValidate™. **Topics:** Public Awareness, Technology --- ### [₹824cr GST fraud by 16 insurance companies detected](https://insurancefraud.org/news_archives/₹824cr-gst-fraud-by-16-insurance-companies-detected/) **Published:** September 29, 2026 **Author:** Diane Beauchamp **Content:** The GST authority has caught an alleged misappropriation of input tax credit worth ₹824 crore by 16 insurance companies who used their intermediaries to issue fake invoices, a statement issued by the Union finance ministry said on Friday. The Goods and Services Tax (GST) authority has caught an alleged misappropriation of input tax credit (ITC) worth ₹824 crore by 16 insurance companies who used their intermediaries to issue fake invoices, a statement issued by the Union finance ministry said on Friday. The statement did not disclose the names of the firms. “Investigations have revealed that input tax credit of ₹824 crore has been availed, out of which an amount of ₹217 crore has been paid voluntarily by these sixteen insurance companies so far,” the ministry said quoting the Directorate General of GST Intelligence (DGGI), Mumbai zonal unit. The investigation was initiated by the DGGI, Mumbai. The statement did not disclose the names of the firms. During investigations, the ministry statement said, it came to notice that these insurance companies have availed ITC based on invoices issued by several intermediaries for providing services such as advertising, marketing, and brand activation. But no such services were provided, it added. “Thus, in the absence of any underlying supply, the input tax credit availed by the said insurance companies is not permissible under the GST law,” the statement said, adding that further investigation is in progress. Explaining the modus operandi, the ministry said: “Several non-banking financial companies (NBFCs) engaged in micro-financing businesses are acting as corporate agents of the insurance companies and are cross-selling their single premium credit liked insurance policies in the course of their lending business. As per IRDA regulations, only a nominal commission is permitted to corporate agents. In order to circumvent these regulations, the insurance companies have resorted to obtaining invoices from intermediaries, in order to transfer commission (over and above the permissible limit) to NBFCs, for the supply of services of advertising, web marketing etc., whereas there has been no underlying supply of services. In turn, these intermediaries have received invoices from NBFCs for such supplies.” **Topics:** Financial Fraud, Insider Fraud, Regulatory actions --- ### [Motorists warned of elaborate car scam that's already fooled 3,000 drivers](https://insurancefraud.org/news_archives/motorists-warned-of-elaborate-car-scam-thats-already-fooled-3000-drivers/) **Published:** September 29, 2026 **Author:** Diane Beauchamp **Content:** Motorists are being warned of an elaborate scam that’s already fooled 3,000 drivers. With car prices rising, many scammers are out to try and con you to get your car or steal your details. There are tons of car-buying scams out there but one specific one is leading drivers to hand over thousands of pounds. And it has caught out many motorists. A [BBC investigation](https://www.bbc.co.uk/news/uk-63047193) recently revealed just how easy it is to fall for such scams, while exposing a fake car dealership website that defrauded people out of thousands of pounds with Pietro Pagliuca from West Yorkshire told the BBC how he transferred almost £4,000 to a legitimate-sounding company for a second-hand Nissan Qashqai. He even chatted with someone saying they were a sales director before parting with his cash – and he even saw what he thought was a company stamp on the invoice they sent him. But he was scammed. The scam involves people posing as a legitimate car dealership online and tricks people to hand over their money. The scammers also set up websites that look convincing but are completely fake. According to Action Fraud the number of people being conned is growing. Last year there were 3,000 reports of online fraud from UK drivers – a 21 per cent rise compared to 2019. **Topics:** Auto fraud, Public Awareness --- ### [Mumbai: Insurance firm staffers held for Rs 1.5-cr fraud](https://insurancefraud.org/news_archives/mumbai-insurance-firm-staffers-held-for-rs-1-5-cr-fraud/) **Published:** September 29, 2026 **Author:** Diane Beauchamp **Content:** Two employees of a well-known insurance company have been arrested on the charge of fraudulently settling several unclaimed and lapsed policies and siphoning off about Rs 1.5 crore. The accused worked at the Malad branch of the company. Sources at the Bangur Nagar police station said assistant manager, Dipesh Jadhav, 33, dealt with cases where policyholders had discontinued paying the premiums. As part of his job, he had access to the policy and bank details of the company’s customers from across the country. The police said Jadhav roped in his colleague Rohan Naidu, 32, to commit the fraud. Over the past few years, the duo settled about 50 policies where premiums had been paid for some time. While Jadhav got Rs 97 lakh transferred to his and his relatives’ accounts, Naidu made Rs 61 lakh. The duo’s undoing started after a customer from Indore visited a local branch saying he wanted to liquidate a policy for which he had paid a few premiums but discontinued later. But to his utter shock, the customer was informed by the staff that his policy had already been settled. He then filed a complaint with the insurance company which forwarded it to a third party—Gru Systems—that works with banks and insurance firms to investigate financial frauds. After a probe, its proprietor Gruswami Naikar discovered the embezzlement of Rs 1.58 crore allegedly by Jadhav and Naidu. On behalf of the company, Naikar lodged a complaint in July against the two employees, who were booked for fraud. Guided by DCP Vishal Thakur of Zone XI, senior inspector Pramod Tawde and inspector Dattatre Gund worked on the case and picked up Jadhav from his Borivli home on Wednesday. Naidu was taken into custody from Jogeshwari, where he lives, the same day. “We have found that the money was transferred to the close relatives and friends of the duo,” an official said. Rs 97L Money embezzled by accused Jadhav **Topics:** Insider - agent **Categories:** Arrest --- ### [FSRA initiates action against insurance agent](https://insurancefraud.org/news_archives/fsra-initiates-action-against-insurance-agent/) **Published:** September 29, 2026 **Author:** Diane Beauchamp **Content:** Ontario’s Financial Services Regulatory Authority (FSRA) has announced that it has initiated enforcement action against a life insurance agent for his purported misleading statements and fraud. The regulator alleges that Sudeep Sharma made false or misleading statements in soliciting or registering insurance. FSRA additionally alleges that Sharma knowingly procured his clients’ insurance payments. FSRA has proposed revoking the license of Sharma, as well as imposing three administrative penalties on the agent totalling $35,000. Sharma is licensed as a life, accident, and sickness insurance agent. At the time of his alleged fraud, he was an agent employed by RBC. RBC began investigating Sharma’s actions in May 2020 after receiving a complaint from a policyholder that a new insurance policy had been opened in her name without her knowledge or consent. As a result of the investigation, the insurer later filed a form on Sharma to the FSRA, and the insurer subsequently terminated Sharma’s employment for cause on September 16, 2020. In the Life Agent Reporting Form it submitted to the FSRA, RBC indicated that it had evidence that Sharma had engaged in forgery, improper paperwork, misrepresentation to the insurer, and lack of trustworthiness. The FSRA launched its own investigation after reviewing RBC’s evidence, interviewing Sharma and his clients. It found that Sharma was placing both current and former clients for additional life insurance policies without their knowledge and consent. For some clients, the agent placed them with disability insurance policies without explaining that by doing so, it would put existing universal life policies on hold – all while using the premiums his clients paid for universal life policies to pay for the disability insurance. It was also found by the FSRA that Sharma signed his clients up for new insurance policies while altering the premium payments of their existing insurance policies, without the knowledge or consent of his clients. He placed some of his clients’ existing universal life policies on a premium vacation, which allowed him to use the accumulated savings to pay for the premiums owed on the new policies he “sold” his clients without their knowledge. FSRA suggested that Sharma engaged in these activities for greater variable compensation. A release from the FSRA stated that Sharma may request a hearing before the Financial Service Tribunal. **Topics:** Insider Fraud, Life Insurance, Regulatory actions --- ### [Homeowner, check washing scams loom ahead of fall season, BBB warns](https://insurancefraud.org/news_archives/homeowner-check-washing-scams-loom-ahead-of-fall-season-bbb-warns/) **Published:** September 29, 2026 **Author:** Diane Beauchamp **Content:** Fall brings in new scams. The Better Business Bureau is urging homeowners to be alert of the most common scams during this time of year. Those scams include home improvement, furnace, roof and other seasonal scams. “The fall season is notorious for home improvement scams,” said Steve J. Bernas, president and CEO of the Better Business Bureau. “Fraudsters see this time as a prime opportunity to rip-off homeowners, and in some cases, steal thousands of dollars for unnecessary or shoddy work.” Typical home improvement scams include chimney and roof repairs, gutter cleaning, energy audits and more. The BBB is also warning of Medicare scams as open enrollment starts Oct. 15. The scammer will tell you that your Medicare will be discontinued if you didn’t reenroll. “Con artists claiming to be a ‘health care benefits advocate or a similar title’ will allege they can enroll you in a better program than what you currently have,” Bernas said. “(Scammers) will claim this new plan is cheaper, and you can keep all the same services. To get started, all you need to do is provide some personal information, such as your Medicare ID number. Of course, the call is a scam, and sharing personal information will open you up to identity theft.” Check washing is also a concern, according to the BBB. Scammers wash checks in a simple bath of household chemicals to erase the original name and dollar amount written on the check. The process leaves a blank space where the “Pay to” name and dollar amount used to be. A simple $25 birthday check can be converted into a $2,500 check. Experts estimate it’s an $815 million business and growing. “Even businesses are now being impacted,” Bernas said. “Anyone who writes and mails a check is at risk.” **Topics:** Public Awareness --- ### [Colorado man who murdered wife in 2015 and staged it to look like an accident killed her ON THE DAY another woman contacted her to reveal she'd gone on a date with him](https://insurancefraud.org/news_archives/colorado-man-who-murdered-wife-in-2015-and-staged-it-to-look-like-an-accident-killed-her-on-the-day-another-woman-contacted-her-to-reveal-shed-gone-on-a-date-with-him/) **Published:** September 29, 2026 **Author:** Diane Beauchamp **Content:** The woman who claims she unknowingly dated a Colorado man who staged his wife’s murder to look like an accident is now saying she spoke to the victim on the day of her death. In a brand new interview with ‘Dateline,’ Susan McBride says she approached Stacy Feldman, the Denver woman murdered by her husband, Robert Feldman, to let her know he had been cheating on her. The call, according to McBride, came just hours before Stacy was murdered. In a clip of the interview released exclusively to DailyMail.com, McBride tells ‘Dateline’ correspondent Keith Morrison about her conversation with the late Feldman.’ ‘I said, “My name’s Susan McBride. You don’t know me, but I met your husband on a dating site called Tinder. He told me you had been separated for quite some time. If you’re not separated, you should know that he’s cheating on you” ‘ McBride tells Morrison. The ‘Dateline’ correspondent has a visceral reaction to that news, responding, ‘oh boy.’ McBride continued, saying Stacy responded and confirmed she and Robert were not separated, causing Susan to offer extra support. ‘I wrote back, and I said, “I’m so sorry, Stacy. Here’s my number if you’d like to call me,”‘ she said in the interview. The two allegedly got on the phone and discussed the situation immediately. The woman said she met Robert on Tinder and that he claimed to be separated from Stacy. McBride said they connected immediately and there was a general sense of hurt and pain on both sides. ‘She was so sweet and kind. And she wasn’t angry. And she said, “I’m so sorry he did that to you.” ‘ Morrison then insinuated this may not have been Stacy’s first time dealing with Robert’s infidelity. ‘That sounds almost more like somebody who knows that’s happened before and this isn’t the first time she’s had to go through this,’ he asks. ‘Right. And she said, “I’m done with him,” ‘ McBride elaborated. McBride allegedly never spoke to Stacy or Bob ever again. Months later, the woman stumbled upon Stacy’s obituary. Her date of death? March 1, 2015. The same day she had struck up a conversation with the woman. ‘I got physically ill, physically ill. It was just, it was like something out of a movie.’ The episode of ‘Dateline’ covering the story will premiere on Friday at 9 p.m. eastern. Robert Feldman was convicted of killing Stacy after she confronted him about his affair. He strangled her and then attempted his wife’s death look like an accident. In April, Robert was found guilty of first degree murder and given the mandatory life sentence without parole. Robert, who shared two children with Stacy, was also found to have used his wife’s $750,000 life insurance payout to pay for his legal defense. It took investigators three years to charge the Denver man with his wife’s murder, as FOX 31 reported at the time it took them that long to find a medical expert willing to testify that Stacy died by strangulation, rather than a slip-and-fall accident in the shower. In court, Stacy’s mother, Dorothy Malman, urged the judge to issue justice for the death of her daughter. ‘If you really loved your children, you wouldn’t have killed their mother,’ Malman said. ‘You wouldn’t have taken their mother from them. The only person you love is yourself.’ Stacy’s older sister, Susan Malman Altman, echoed her mother’s sentiments and said that she had fought long and hard for the verdict and the sentencing. ‘My sister deserves to leave in peace,’ Altman said. ‘Instead of letting her go to be happy, he killed her.’ Stacy’s family had hired a private investigator after her death in order to identify enough evidence to bring charges against her husband. **Topics:** Life Insurance **Categories:** Conviction --- ### [How to avoid falling victim to scams](https://insurancefraud.org/news_archives/how-to-avoid-falling-victim-to-scams/) **Published:** September 29, 2026 **Author:** Diane Beauchamp **Content:** In the last month, there have been multiple reports of scams targeting different groups across New York and Pennsylvania. These types of scams cost Americans billions of dollars every year, says the Federal Trade Commission. Scams target groups like the elderly, students, teens, and even veterans. The FTC says that in 2021, it received almost six million reports of fraud, identity thefts, and complaints about businesses. In total, these cost Americans more than $5.8 billion, a more than 70% increase in losses compared to 2020.Scammers will often present you with a problem or a prize. In the ever-growing “Grandparent scams”, scammers target the elderly by claiming to be a relative that’s in an emergency. In the prize scenario, they may also claim that the victim has won the lottery or a free trip, such as the recent Disney theme park scam reported by the Elmira Police Department. The FTC and Better Business Bureau also say that the scammer will often pressure you to act quickly, keep it secret from family, and pay in a specific way. Multiple local law enforcement agencies have also reported a rise in gift card scams in the last year. The BBB, FTC, the Consumer Financial Protection Bureau, and local law enforcement have all provided tips on how to avoid these scams. The tips boil down to being aware of your online transactions, taking a breath and talking with someone you trust, and being cautious of deposits, offers, or emails that seem too good to be true or that you don’t remember making. With any scam in the Twin Tiers, Sheriff’s Offices and police departments remind residents not to give out personal information to someone they don’t know, don’t trust, or who they haven’t met face-to-face. They also say to check in with any family members who may be more susceptible to being taken advantage of. If you do think you’ve been scammed, you can report it to the FTC, BBB, or your county’s sheriff’s office. **Topics:** Public Awareness --- ### [DWF strengthens counter fraud team with six new hires](https://insurancefraud.org/news_archives/dwf-strengthens-counter-fraud-team-with-six-new-hires/) **Published:** September 29, 2026 **Author:** Diane Beauchamp **Content:** DWF, a global provider of integrated legal and business services, has announced that it has bolstered its counter insurance fraud capabilities with the hiring of a six-strong team. The entire team joins DWF from DAC Beachcroft, bringing with them significant counter fraud experience. Led by director Neville Sampson, other members of the team include senior associate Amy Goodwin, associate Cath Murdock, solicitor Rohini Kapoor and senior paralegal Fareen Akhtar. The final member of the team, Angela Tank, will join in early November. Sampson has over 15 years of experience in fraud defence litigation and has worked with various insurers to develop fraud defence strategies. The six will join DWF’s global counter fraud team in Birmingham, joining partners Miles Hepworth and Mike Henman. “Neville and his team have an excellent reputation for client service and putting clients first in delivering a great service with great results,” said DWF partner and global head of fraud Lorraine Carolan. “I am really looking forward to working with the team and our clients to continue to innovate our legal services in combatting fraud.” “I am delighted to welcome Neville and his team to DWF. Neville enjoys a market leading reputation and together with his team he will further strengthen our already class leading specialist fraud team operating across the UK and into Europe. This is a further sign of our commitment to the insurance and financial sector as well as to the growth of the wider DWF business,” added DWF global head of insurance Glyn Jones. Last month, DWF became a gold sponsor for the Insurance Cultural Awareness Network (iCAN) – the second organization to do so, after [Marsh](https://www.insurancebusinessmag.com/uk/companies/marsh/29798/). A volunteer-run network with more than 3,000 members, iCAN advocates multicultural inclusion across the insurance industry. **Topics:** Public Awareness --- ### [CommonSpirit Health Suffers IT Outages, EHR Downtime at Multiple Hospitals](https://insurancefraud.org/news_archives/commonspirit-health-suffers-it-outages-ehr-downtime-at-multiple-hospitals/) **Published:** September 29, 2026 **Author:** Diane Beauchamp **Content:** Multiple hospitals within the CommonSpirit Health system, one of the nation’s largest nonprofit healthcare systems, are reporting IT outages and EHR downtime. CommonSpirit Health [confirmed](https://www.commonspirit.org/news-and-perspectives/news/Statement-IT-Security-Issue) that it has been suffering IT outages as a result of an unspecified IT security incident that began on October 3. The incident is impacting multiple facilities within the health system, forcing some hospitals to take their EHR systems offline. The incident impacted CommmonSpirit itself, not its EHR vendor. CommonSpirit Health is one of the largest nonprofit healthcare systems in the US, with more than 1,000 care sites and 140 hospitals in 21 states. “Our facilities are following existing protocols for system outages and taking steps to minimize the disruption. We take our responsibility to ensure the security of our IT systems very seriously,” a brief notice on the health system’s website stated. “As a result of this issue, we have rescheduled some patient appointments. Patients will be contacted directly by their provider and/or care facility if their appointment is impacted.” At MercyOne Des Moines Medical Center, the incident forced certain systems offline as a “precautionary step,” the *Des Moines Register* [reported](https://www.desmoinesregister.com/story/news/health/2022/10/04/mercyone-online-systems-shut-down-cybersecurity-incident-des-moines-hospital/69538349007/). The hospital had to divert ambulances away from its emergency department for a short period of time on Monday. The incident is also causing appointment cancellations in some locations. The list of healthcare facilities impacted by the CommonSpirit incident continues to grow. [CHI Health](https://www.3newsnow.com/news/local-news/chi-health-dealing-with-it-security-issue-leaving-local-patients-unable-to-schedule-appointments) locations in Omaha confirmed that they were impacted by the security incident. **Topics:** Public Awareness, Technology --- ### [Pharmacy notifies police of phony prescription](https://insurancefraud.org/news_archives/pharmacy-notifies-police-of-phony-prescription/) **Published:** September 29, 2026 **Author:** Diane Beauchamp **Content:** A local pharmacy called the police after receiving a suspicious medication order from a person claiming to be a local nurse practitioner. Pharmacists at North Fulton Pharmacy on South Main Street grew suspicious after receiving a call from someone claiming to be a nurse practitioner at a local medical practice, attempting to fill a prescription for the narcotic, Suboxone. Pharmacists knew the practice never called in prescriptions by phone and were told that the prescription was fraudulent when they called to confirm with the practice. A doctor at the practice told police the prescription was filed with her valid DEA ID number and was placed under the name of a former patient, who had been discharged from the practice for providing fake urine samples. Police attempted to contact the suspect but were unsuccessful at the time of the report. **Topics:** Drug Diversion --- ### [LifeBridge Health data breach $9.5M class action settlement](https://insurancefraud.org/news_archives/lifebridge-health-data-breach-9-5m-class-action-settlement-2/) **Published:** September 29, 2026 **Author:** Diane Beauchamp **Content:** ## This settlement is closed! Please see what other class action settlements you might qualify to claim cash from in our [Open Settlements](https://topclassactions.com/category/lawsuit-settlements/open-lawsuit-settlements/) directory! LifeBridge Health (LBH) agreed to a nearly $9.5 million class action lawsuit settlement to resolve claims it failed to protect patient information in a data breach. The settlement benefits individuals whose personal information was accessed during the LifeBridge data breach announced in May 2018. [**LifeBridge Health**](https://www.lifebridgehealth.org/Main/Home.aspx) is a Baltimore-based health system that includes Sinai Hospital. In May 2018, LifeBridge [**disclosed**](https://healthitsecurity.com/news/lifebridge-health-sued-over-data-breach-of-530000-patients) it had been the victim of a data breach that affected 530,000 patients. Further investigation into the breach revealed it had been ongoing for 18 months after the initial breach in September 2016. This ongoing breach compromised patient names, dates of birth, Social Security numbers, health information and more. In June 2020, the health system announced yet another data breach impacting Sinai Hospital records. Affected patients took legal action against LifeBridge in a data breach class action lawsuit, arguing the health system failed to prevent, identify or mitigate the data breaches due to its subpar cybersecurity policies. “As a result of LifeBridge’s failure to implement and follow basic security protocols and procedures, Plaintiffs’ and Class Members’ Personal Information is now in the hands of thieves,” the data breach class action lawsuit claims. Plaintiffs in the case say they have been harmed by the breaches. In addition to facing the ongoing risk of identity theft and fraud, the plaintiffs allegedly experienced declined transactions, email account access problems, fraudulent accounts, fraudulent unemployment submissions and fraudulent applications for [**COVID-19**](https://topclassactions.com/category/coronavirus-covid-19/) disaster business loans. LifeBridge hasn’t admitted any wrongdoing but agreed to a class action settlement valued at $9.475 million. The settlement includes $800,000 in payments to class members, $775,000 in fees, and $7.9 million in additional security measures. Under the terms of the LBH settlement, class members can receive reimbursement for lost time and other ordinary and extraordinary losses resulting from the data breach. Each class member can claim up to three hours of lost time at a rate of $20 per hour. If they suffered extraordinary out-of-pocket expenses, class members can claim an additional two hours of lost time at the same rate. Class members can receive up to $250 for ordinary data-breach losses such as bank fees, communication charges, credit monitoring, credit freeze costs and other expenses. For extraordinary losses such as unreimbursed monetary losses, class members can receive up to $5,000. Under the terms of the LBH settlement, LifeBridge agreed to make cyber security improvements valued at $7.9 million. This includes encryption of sensitive data, tracking software for biomedical devices, network monitoring, regular maintenance, annual security training, enhanced account security, two-factor authentication and more. The deadline for exclusion and objection is Oct. 4, 2022. The final approval hearing for the LifeBridge Health data breach class action lawsuit settlement is scheduled for Oct. 26, 2022. In order to receive settlement benefits, class members must submit a valid claim form by Feb. 1, 2023. ###### Who’s Eligible Individuals whose personal information was accessed during the LifeBridge data breach announced in May 2018 ###### Potential Award **Varies** ###### Proof of Purchase Proof of purchase not applicable ###### Claim Form [CLICK HERE TO FILE A CLAIM »](https://www.lbhsettlement.com/submit-claim) **NOTE:** If you do not qualify for this settlement do NOT file a claim. Remember: you are submitting your claim *under penalty of perjury*. You are also harming other eligible Class Members by submitting a fraudulent claim. If you’re unsure if you qualify, please read the FAQ section of the Settlement Administrator’s website to ensure you meet all standards (Top Class Actions is not a Settlement Administrator). If you don’t qualify for this settlement, check out our database of other [**open class action settlements**](https://topclassactions.com/lawsuit-settlements/open-lawsuit-settlements/) you may be eligible for. ###### Claim Form Deadline 02/01/2023 ###### Case Name *Johnson, et al. v. LifeBridge Health Inc.,* Case No. 24-C-18-006801 in the Circuit Court for Baltimore City, Maryland ###### Final Hearing 10/26/2022 ###### Settlement Website **[IBHSettlement.com](https://www.lbhsettlement.com/)** ###### Claims Administrator LifeBridge Class Action Settlement c/o Settlement Administrator 1650 Arch Street, Suite 2210 Philadelphia, PA 19103 844-953-2333 ###### Class Counsel Nikoletta S Mendrinos MURPHY FALCON & MURPHY Barrett J Vahle STUEVE SIEGAL HANSON LLP John A Yanchunis MORGAN & MORGAN COMPLEX LITIGATION GROUP ###### Defense Counsel Paul G Karlsgodt Elizabeth A Scully Evan Mannering Michael J Baxter LIFEBRIDGE HEALTH INC **Topics:** Judicial/courts, Technology --- ### [St. Police Give 4 Tips To Avoid Insurance & Contractor Scams](https://insurancefraud.org/news_archives/st-police-give-4-tips-to-avoid-insurance-contractor-scams/) **Published:** September 29, 2026 **Author:** Diane Beauchamp **Content:** With so much damage left behind due to [Hurricane Ian](https://myq105.com/tag/hurricane-ian), scammers are ready to take their best shot at getting some cash out of your wallet. [St. Petersburg](https://myq105.com/tag/st-pete) police posted four tips to avoid getting taken for a ride by shady fake insurance companies or crooked contractors. **The call you SHOULDN’T take…** If you get a phone call you didn’t ask for from someone claming to be with your insurance company, don’t give out any information to “verify” your account. **The call you SHOULD make…** If you get one of those suspicious calls, hang up. Then call your insurance company to see if there was any legitimate reason for a call. Chances are it was a fraud. **Contractor claims…** If a contractor says they work directly with your insurance company, be skeptical. Do NOT give them your policy number, your coverage amounts or any other kind of personal information they can use. **To see if a contractor is legit…** Simply verify they are licensed and insured. Don’t take them at their word. Always do the research at myfloridalicense.com. There you can also file a complaint. Our friends to the south are still reeling from the direct hit by Hurricane Ian. Here are some of the scenes from the ground. Our station is part of the Beasley Media Group. We sent broadcast equipment to our affiliate stations in Fort Myers to help those without power and cell service to get updates on where to find food and help. If you’d like to offer your support, money is being raised for the American Red Cross relief efforts at [bbgi.com/donate](http://bbgi.com/donate). **Topics:** Public Awareness --- ### [Florida CFO Jimmy Patronis on navigating insurance after Hurricane Ian](https://insurancefraud.org/news_archives/florida-cfo-jimmy-patronis-on-navigating-insurance-after-hurricane-ian-2/) **Published:** September 29, 2026 **Author:** Diane Beauchamp **Content:** WINK News consumer reporter Andryanna Sheppard spoke with Florida CFO Jimmy Patronis about insurance issues that arise now that Hurricane Ian has passed. In Port Charlotte, an insurance village is set up so you can talk face-to-face with a claims expert and even start a claim at the Port Charlotte Town Center. All the national insurance companies and about 20 of our local FL insurance companies will be there to help you navigate insurance claims for damage to your home and other possessions. State Attorney Amira Fox has also activated its Hurricane Ian Response Team to help people who may become victims of insurance fraud. The State Attorney’s Office says if you believe you have fallen victim to insurance fraud or are the victim of an unlicensed contractor, you can call them at 1-239-533-1342. They ask that you leave a detailed message with your complaint as well as contact information so you can be reached for additional information and investigation support as needed. **Topics:** Public Awareness --- ### [Disability Income Compensation Insurances Market Is Booming Worldwide: The Guardian Life Insurance, Northwestern Mutual, Mutual of Omaha, Mass Mutual](https://insurancefraud.org/news_archives/disability-income-compensation-insurances-market-is-booming-worldwide-the-guardian-life-insurance-northwestern-mutual-mutual-of-omaha-mass-mutual/) **Published:** September 29, 2026 **Author:** Diane Beauchamp **Content:** Advance Market Analytics published a new research publication on “Disability Income Compensation Insurances Market Insights, to 2027” with 232 pages and enriched with self-explained Tables and charts in presentable format. In the Study you will find new evolving Trends, Drivers, Restraints, Opportunities generated by targeting market associated stakeholders. The growth of the Disability Income Compensation Insurances market was mainly driven by the increasing R&D spending across the world. Some of the key players profiled in the study are: Unum (United States), Assurity (United States), Northwestern Mutual (United States), Mutual of Omaha (United States), Mass Mutual (United States), Nationwide Mutual Insurance Company (United States), Prudential Financial (United States), The Guardian Life Insurance (United States), AIG (United States) and SBLI (United States). Scope of the Report of Disability Income Compensation Insurances Disability Income Compensation Insurances is a kind of health insurance product which is paid to a worker in case a worker be unable to continue to perform their job due to risk of disability or accident. Disability Income Compensation Insurances are provided on a monthly basis. It pay a portion of a salary so that the individual can maintain his / her standard of living and continue to pay their regular expenses until retirement age. Disability income Compensation insurance helps protect people from financial losses if an accident or illness renders them incapable of working and receiving regular income. The titled segments and sub-section of the market are illuminated below: by Type (Individual Disability Insurance, High-Limit Disability Insurance, Key-Person Disability Insurance), End Use (Government Institutions, Workers and Employees, Other), Coverage (Short-Term, Long-Term) Players and Region – Global Market Outlook to 2027 Market Trends: Technological Innovation and penetration in Insurance Services Opportunities: Continuous Growth in Fintech infrastructure Growth in Insurance and Financial Advising Firms Market Drivers: Increasing awareness among workers and employees related health and illness Increasing Awareness among Individuals About Bankruptcy and Other Financial Emergencies Have Any Questions Regarding Global Disability Income Compensation Insurances Market Report, Ask Our Experts@ [https://www.advancemarketanalytics.com/enquiry-before-buy/198125-global-disability-income-compensation-insurances-market#utm\_source=SBWireLal](https://www.advancemarketanalytics.com/enquiry-before-buy/198125-global-disability-income-compensation-insurances-market#utm_source=SBWireLal) Region Included are: North America, Europe, Asia Pacific, Oceania, South America, Middle East & Africa Country Level Break-Up: United States, Canada, Mexico, Brazil, Argentina, Colombia, Chile, South Africa, Nigeria, Tunisia, Morocco, Germany, United Kingdom (UK), the Netherlands, Spain, Italy, Belgium, Austria, Turkey, Russia, France, Poland, Israel, United Arab Emirates, Qatar, Saudi Arabia, China, Japan, Taiwan, South Korea, Singapore, India, Australia and New Zealand etc. Market Leaders and their expansionary development strategies On 20 July 2022, Assurity Life Insurance Company Released Income Protection Individual Disability Insurance, A Short-Term Disability Product Designed To Make Coverage Simple And Accessible For More People. Income Protection, Available Now, Fills A Need For Affordable Paycheck Protection Among A More Mobile Workforce. and On 27 October 2020, Mutual Of Omaha Has Introduced A New Disability Income Insurance Product Featuring A Fully Digital Experience And Additional Coverage Options For Customers Who Are Seeking To Protect Their Income If They Become Sick Or Injured And Are Unable To Work. Strategic Points Covered in Table of Content of Global Disability Income Compensation Insurances Market: Chapter 1: Introduction, market driving force product Objective of Study and Research Scope the Disability Income Compensation Insurances market Chapter 2: Exclusive Summary – the basic information of the Disability Income Compensation Insurances Market. Chapter 3: Displaying the Market Dynamics- Drivers, Trends and Challenges & Opportunities of the Disability Income Compensation Insurances Chapter 4: Presenting the Disability Income Compensation Insurances Market Factor Analysis, Porters Five Forces, Supply/Value Chain, PESTEL analysis, Market Entropy, Patent/Trademark Analysis. Chapter 5: Displaying the by Type, End User and Region/Country 2015-2020 Chapter 6: Evaluating the leading manufacturers of the Disability Income Compensation Insurances market which consists of its Competitive Landscape, Peer Group Analysis, BCG Matrix & Company Profile Chapter 7: To evaluate the market by segments, by countries and by Manufacturers/Company with revenue share and sales by key countries in these various regions (2021-2027) Chapter 8 & 9: Displaying the Appendix, Methodology and Data Source finally, Disability Income Compensation Insurances Market is a valuable source of guidance for individuals and companies. Read Detailed Index of full Research Study at @ [https://www.advancemarketanalytics.com/reports/198125-global-disability-income-compensation-insurances-market#utm\_source=SBWireLal](https://www.advancemarketanalytics.com/reports/198125-global-disability-income-compensation-insurances-market#utm_source=SBWireLal) Thanks for reading this article; you can also get individual chapter wise section or region wise report version like North America, Middle East, Africa, Europe or LATAM, Southeast Asia. **Topics:** Disability, Public Awareness --- ### [For Cybersecurity Awareness Month (and Halloween) – Some Scary Cyber Threat Stats](https://insurancefraud.org/news_archives/for-cybersecurity-awareness-month-and-halloween-some-scary-cyber-threat-stats-2/) **Published:** September 28, 2026 **Author:** Diane Beauchamp **Content:** A couple times a year I compile, analyze, and write about cybersecurity developments and statistics. As we begin the Cybersecurity Awareness month of October 2022, it is incumbent for all of us to be more wary than usual by the scary stats surrounding an increasingly sophisticated and lethal cyber threat landscape. A first case in point to the precariousness of cybersecurity is the ease of beaching by criminal hackers. Most hackers need 5 hours or less to break into enterprise environments Most hackers need 5 hours or less to break into enterprise environments \| CSO Online “ Around 40% of ethical hackers recently surveyed by the SANS Institute said they can break into most environments they test, if not all. Nearly 60% said they need five hours or less to break into a corporate environment once they identify a weakness. The SANS ethical hacking survey, done in partnership with security firm Bishop Fox, is the first of its kind and collected responses from over 300 ethical hackers working in different roles inside organizations, with different levels of experience and specializations in different areas of information security. The survey revealed that on average, hackers would need five hours for each step of an attack chain: reconnaissance, exploitation, privilege escalation and data exfiltration, with an end-to-end attack taking less than 24 hours.” Chuck’s Comments: Thankfully this statistic cites ethical hackers. Many are top notch and exceptionally good at what they do. Still, exploitation of weaknesses is relatively easy even if it takes more than five hours for less experienced hackers. This call attention to the urgency of cyber hygiene including strong passwords, multifactor authentication, having good anti-malware software, and patching regularly. Phishing remains the top threat in almost all cyber-threat statistics out there, especially driven more and more by mobile: Phishing Attacks Crushed Records Last Quarter, Driven by Mobile Phishing Attacks Crushed Records Last Quarter, Driven by Mobile (darkreading.com) “Shocking phishing numbers (more than 1 million in a single quarter) are being driven by vishing, smishing, and other lures that target mobile devices. Last quarter saw a record-shattering number of observed phishing attacks, fueled in large part by attempts to target users on their mobile devices. The latest Anti-Phishing Working Group (APWG) “Phishing Activity Trends Report” for the second quarter of 2022 found 1,097,811 observed phishing attacks, the most the group has ever measured in its history. “ The financial sector remained the top target for phishing lures (27.6%), along with other bombarded sectors, including webmail and software-as-a-service providers, social media sites, and cryptocurrency. “We’re seeing a huge increase in mobile phone-based fraud, with smishing and vishing collectively seeing a nearly 70% increase in volume as compared to Q1 totals,” Matthew Harris, senior product manager of fraud at Opsec said in reaction to the APWG findings. “We are still seeing fraud coming in via the typical OTT apps (WhatsApp, WeChat, Facebook Messenger, etc.), but the SMS-based fraud is really the kicker here.” Chuck’s Comments: Phishing is the tool of choice for many hackers. Phishing is commonly defined as a technique of hackers to exfiltrate your valuable data, or to spread malware. Anyone can be fooled by a targeted phish, especially when it appears to be coming as a personal email from someone higher up the work chain, or from a bank, organization, or a website you may frequent. Usually, the phishing malware comes via email attachments but can also be web-based. According to an analysis by Webroot, 46,000 new phishing sites are created every day and 1.385 million new, unique phishing sites are created each month. At a more granular level, the firm Wandera says that a new phishing site launches every 20 seconds. Two cybersecurity hygiene actions to improve your digital life in 2021 \| AT&T Cybersecurity (att.com) Phishes can be quite sophisticated nowadays. The tools are available on the Dark Web and the graphics used to mimic emails or texts from banks, companies, employers, and even friends are a far cry from the misspelled and cheesy phishing attempts from a decade ago. Moreover, they are automated and sent by the thousands with help of machine learning. I am frightful as deep fakes are on the horizon and they are a scary proposition in the wrong hands. Be alert and double check before you click! Most organizations had a cloud-related security incident in the past year Most organizations had a cloud-related security incident in the past year \| Cybersecurity Dive Security leaders consider the risk of cloud-based incidents higher than on-premises incidents, yet they expect to move more applications to the cloud. More than 80% of organizations have experienced a cloud-related security incident over the past 12-month period, according to research from Venafi. Almost half of those organizations reported at least four incidents over the same period. Companies are rapidly undergoing digital transformation to the cloud. Organizations in the study currently host 2 in 5 applications in the cloud, however that figure is expected to reach 3 in 5 over the next 18 months. Despite those rapid changes, more than half of all organizations said they consider the risk of security incidents higher in the cloud, compared with on-premises environments. Chuck’s Comments: Both the public sectors and private sectors are rapidly transitioning into a cloud and hybrid cloud world and computing is certainly moving closers to the edge. It is important to work closely with your cloud provider, know what data you need to protect and encrypt, and have an incident response plan in case you get breached .Clouds are not inherently risky, but companies need to recognize they have to evaluate provider policies and capabilities to protect their vital data. The use of the cloud and hybrid clouds enables implementation of dynamic policies, faster encryption, drives down costs, and provides more transparency for access control (reducing insider threats). When viewed from a security administrator perspective, optimized security in the cloud mitigates the risk of hackers getting key access to data. 64% of Businesses Suspect They’re Target of Nation State Attacks 64% Of Businesses Suspect They’re Targets Of Nation-State Attacks- Expert (informationsecuritybuzz.com) New findings from Venafi 64% of Businesses Suspect They’ve Been Targeted or Impacted by Nation-State Attacks. Among key findings: 82% believe geopolitics and cybersecurity are intrinsically linked 77% believe we’re in a perpetual state of cyberwar More than two-thirds (68%) have had more conversations with their board and senior management in response to the Russia/Ukraine conflict 63% doubt they’d ever know if their organization was hacked by a nation-state Chuck’s Comments: Critical Infrastructure has been increasingly targeted by nation states and evidenced by Colonial Pipeline and other high profile events. Protecting critical infrastructure Industrial Control Systems, Operational Technology, and IT systems from cybersecurity threats is a difficult endeavor. They all have unique operational frameworks, access points, and a variety of legacy systems and emerging technologies. As DHS CISA mission has recognized, protecting the critical infrastructure supply chain in IT and OT systems need to be a public and private sector priority. The Russian/Ukraine conflict has led to a “Shields Up” response from DHS CISA and stronger threat sharing between industry and government. Unfortunately, the energy sector and especially the Grid is still at great risk with a mix of OT/IT systems and infrastructure built decades back. Fortification of critical Infrastructure need to be a top priority. More on that OT cybersecurity topic of Industrial Control Systems: Industrial control systems face more cyber risks than IT, expert testifies Industrial control systems face more cyber risks than IT, expert testifies \| Cybersecurity Dive Most ICS technology was designed more than 20 years ago and built without cyber resilience, Idaho National Laboratory’s Vergle Gipson said. Operational technology systems in the U.S. are more vulnerable to malicious cyberattacks than information technology. Most industrial control systems currently in use were designed more than two decades ago, before there was a clear understanding of how to build cyber resilience into those systems, according to Gipson. While IT systems have been more actively managed, with firmware and patches frequently upgraded, OT systems are usually not upgraded or replaced until significant failures. 90% of companies affected by ransomware in 2022 An annual SpyCloud survey found that 90% of organizations were impacted by ransomware over the past twelve months, an alarming increase from last year’s 72.5%. Despite increased investment in cybersecurity, over the past year, the relentless tide of ransomware continued to disrupt operations and put organizations’ data at risk. Moreover, organizations were more likely than last year to be impacted more than once: 50% were hit at least twice, 20.3% were hit between 6 and 10 times and 7.4% were attacked more than 10 times. Chuck’s Comments: a statistic of 90% in ransomware attacks is more than alarming, it is spooky. Ransomware attacks are easy to initiate and criminal hackers can get paid in cryptocurrency and are difficult to find and prosecute. There are many anti-ransomware tool software tools available for companies to protect themselves. And for any company, backing up and isolating and encrypting sensitive data should be a part of their risk management strategy. Ransomware attacks surge in education sector Ransomware attacks surge in education sector \| Cybersecurity Dive Colleges and universities are particularly challenged as repercussions of ransomware hit them harder and longer than other organizations. The education sector got hit with even more ransomware attacks in 2021, impacting almost two-thirds of higher education organizations, Sophos concluded in a new survey. Ransomware attacks hit more than half of the lower-education organizations surveyed and almost two-thirds of higher education institutions. This marks a jump from the 44% of respondents combined across lower and higher education that reported ransomware attacks in 2020, but it’s consistent with an upward trend in ransomware attacks across all sectors. Chuck’s Comments: unfortunately, the education vertical is a cyber target like healthcare. Their systems are often made up of many networks and devices that can be targets of exploitation. This is a serious risk to high education, and in fact, one College (Lincoln College in Illinois) had to close after being victimized by a ransomware attack. Half of global firms supply chains compromised by ransomware Half of global firms supply chains compromised by ransomware \| Cyber Magazine Global cybersecurity company, Trend Micro, announced new research today that reveals global organizations are increasingly at risk of ransomware compromise via their extensive supply chains. · Trend Micro commissioned Sapio Research in May and June 2022 to poll 2,958 IT decision makers across 26 countries. The research revealed that 79% of global IT leaders believe their partners and customers are making their own organization a more attractive ransomware target. The challenge is particularly acute considering that potentially less well-secured SMBs make up a ‘significant’ portion of the supply chain for over half (52%) of these organizations. Chuck’s Comments: Supply chains that often are comprised of multiple vendors are a top target. Companies need to better authenticate, validate, and protect their supply chains. Supply chain cyber-attacks can be perpetrated from nation state adversaries, espionage operators, criminals, or hacktivists. Their goals are to breach contractors, systems, companies, and suppliers via the weakest links in the chain. This is often done through taking advantage of poor security practices of suppliers, embedding compromised (or counterfeit) hardware and software, or from insider threats within networks. The remedy to fixing supply chain vulnerabilities is heightening government and industry collaboration highlighted in the policy initiatives, such as NIST, and in task forces on supply chain security established by the Executive Branch. More precisely, it requires enacting a risk management process that identifies vulnerable systems (especially legacy) and gains visibility into all the elements of the supply chain. Please see my article in GovConWire on this topic: Chuck Brooks: Government Focused on Securing the Cyber Supply Chain – GovCon Wire Less Than Half of Large US Businesses Investing in Cybersecurity Despite Major Concern Despite the rise in threats to businesses, companies aren’t doing enough to protect themselves or their customers. Less Than Half of Large US Businesses Investing in Cybersecurity Despite Major Concern (tech.co) · With cyberattacks on the rise and the average cost of an attack in the millions, safeguarding against issues such as data breaches and ransomware should be a number one concern for businesses of all sizes — but especially large businesses. · While small businesses are the least likely to be protected, large businesses are the most targeted by attackers and, surprisingly, don’t fare much better. 83% of large businesses see security as a significant threat to their business growth. Yet only 43% of large businesses consider security a top three tech budget priority to invest in. Chuck’s Comments: there is an adage that you can lead a horse to water, but you cannot make them drink. This rings true for industry. What will it take to make them take cybersecurity as an existential threat to their business operations and reputations? Cybersecurity Statistics are good indicators where there are gaps and what the public and private sectors need to help remedy their situations. There is a lot of great advice out there to consider, especially in risk management. Below are a couple of my own articles on paths forward to consider. They are focused on the actions of proactive cybersecurity and public private cooperation. Why Proactive Cybersecurity Is a Must in Today’s Sophisticated Threat Environment Prevention and preparedness begin with discovering the knowns and unknowns in the code that is the backbone of the array of applications and operating networks. By Chuck Brooks Why Proactive Cybersecurity Is a Must in Today’s Sophisticated Threat Environment – HS Today In recent years, the cybersecurity focus and activities by both industry and government have been reactive to whatever is the latest threat or breach. As a result, mitigating the threats was difficult because, from the outset, cyber-defenders were always at least one step behind. The reactive mindset has been changing due to a series of wake-up calls that have included a major series of intrusions by sophisticated threat actors against many high-profile targets (including SolarWinds, Colonial Pipeline, OPM, Anthem, Yahoo, and many others) that exposed a flawed approach to defending data and operating with a passive preparedness. As our reliance on the interconnectivity of cyber devices, enterprises, and applications on the cyber landscape has grown, so have the cyber intrusions and threats from malware and hackers. The growing and sophisticated cyber threat actors include various criminal enterprises, loosely affiliated hackers, and adversarial nation-states. The firm Cybersecurity Ventures expects global cybercrime costs to grow by 15 percent per year over the next five years, reaching $10.5 trillion USD annually by 2025. Cybercrime To Cost the World $10.5 Trillion Annually By 2025 (cybersecurityventures.com) Also, a change in the cyber risk environment resulting from a transition to remote work coinciding with a heightened need for procurement of innovative technologies and services has created a new paradigm for cybersecurity. With the growing realization of just how important IT is to our business and as a result of the dramatic increase in breaches, there is a growing recognition that protection against them should be considered more than a business cost item and a necessity to ensure business continuity and reputation. Proactive cybersecurity has been a posture that has been adopted increasingly by industry and government. Proactive Cybersecurity = Risk Management Being proactive in the evolving digital ecosystem is not just about procuring technologies and hiring people. It also means adopting a cybersecurity framework that would include tactical measures, encryption, authentication, biometrics, analytics, and continuous testing, diagnostics, and mitigation, as they may apply to specific circumstances. Concisely, proactive cybersecurity means helping ensure business continuity. In a core sense, a successful cyber threat consequences strategy is really about risk mitigation and incident response to maintain business continuity. It is critical to be aware of the morphing threat landscape and plan contingencies for all potential scenarios. A risk management strategy requires stepping up assessing situational awareness, information sharing, and especially resilience planning. Foundational to a commitment to proactive cybersecurity is a cyber vulnerability risk assessment. That action item is a critical first step in cybersecurity best practices. A risk assessment can quickly identify and prioritize cyber vulnerabilities so that you can immediately deploy solutions to protect critical assets from malicious cyber actors while immediately improving overall operational cybersecurity. A comprehensive risk management approach should include cyber-hygiene best practices, education/training, use policies and permissions, configuring network access, testing of code, security controls, applications, device management, application controls, and regular network audits. Three strategies are most commonly being used today to bolster risk management in cybersecurity. They include Security by Design, Defense in Depth, and Zero Trust. Security by design monitors manages and maintains the security process. Defense in depth enables layers of redundant protective security measures to help deter data breaches. And zero trust focuses on protecting resources (assets, services, workflows, network accounts) through strict identity and access management enforced by authentication and proper authorization. Combining Three Pillars of Cybersecurity (forbes.com) The specifics of a security approach may vary according to circumstances, but the mesh that connects the elements are situational awareness combined with systematic abilities for critical communications in cases of emergency. These guidelines are represented in the U.S. government’s National Institute of Standards and Technology (NIST) mantra for industry and government: “Identify, Protect, Detect, Respond, Recover.” ![](https://insurancefraud.org/wp-content/uploads/image-20.png)**First Steps: Testing of Code & Applications** Testing software code is a critical function of information technology product validation. If the process of testing is not followed, the end-use product may be defective and potentially put a business or organization at risk. Detecting and fixing bugs in software development is a way to ensure the end quality of products. That assessment needs to begin with application security testing to identify vulnerabilities that can be exploited in code or misconfigurations, or the discovery of malware already existing in programs and applications. Prevention and preparedness begin with discovering the knowns and unknowns in the code that is the backbone of the array of applications and operating networks that will determine our digital future. New code, especially third-party software, needs to be thoroughly identified, assessed, and validated before it is installed on the network. Third-party advisory websites such as US-CERT and BugTraq are important to monitor for new known vulnerabilities for your cybersecurity team. While new code is a threat, many applications and programs may already be operating on legacy systems that include flaws and access points that can lead to breaches. Therefore, legacy code needs to be reviewed for patches along with any new code as part of a vulnerability assessment. Every application begins with software coding and standards are needed to optimize and discover vulnerabilities. This can be done by visibility scanning and penetration testing, which includes the verification/validation of the source code that can be exploited. The testing and validation testing process is all about finding issues before they get to production and contaminate networks and devices. What is known can be tangible, but a big challenge for software testing, assessment, and validation is being able to anticipate the unknown threats common with cybersecurity breaches. These unknowns may include finding hidden malware undetectable by sandboxes, signature-based, and other behavioral identification products. For most companies, software testing is used for quality assurance purposes that bring value to the users. Testing is a reputational enabler that helps ensure that quality products and any troubling issues are fixed before they are brought to the marketplace. The testing checks the alignment, user interface, and functionality of the products which translates to customer satisfaction. If you are planning to launch an application, it is necessary to check the compatibility and performance of the same in a wide array of operating systems and devices. Testing also is a budget-related issue because it is cost-effective. It allows for planning and saves money in the software development process where bugs and misconfigurations can be caught and fixed in the initial stages of the software development lifecycle. Security is another significant factor in the need for software testing. If security capabilities are built into the products in development, it builds trust for the users. Product security is a fundamental requirement for both industry and government, especially with the heightened sophistication of cyber threat actors. **The Need for Continuous Simulation Validation Testing** The sober reality is that cyber-breaches are not a static threat and criminal hackers are always evolving in tactics and capabilities. Cyber-criminals are now using stronger evasion techniques that can even stop running if it detects it is in a sandbox or other malware detection capabilities are detected. Software runs injection of code and manipulation of memory space as an exploit kit is injected in the target system. Often these criminals use stolen certificates that are sold underground or on the Dark Web to bypass anti-malware detection and get around machine learning code. Industry and government must do more to meet and contain cyber-threat challenges. Because of the sophisticated and growing attack surface being exploited by hackers, testing needs to go beyond traditional vulnerability scanners and manual penetration testing. It also needs to be automated to keep up with the pace of change in the evolving cyber landscape. Anticipating what criminal hackers might do in likely scenarios and practicing how to defend against it is a prudent measure to improve cybersecurity. That is what is done via continuous simulation validation testing. Continuous simulation validation testing helps fill that discovery and protection gap. Through simulations, results can be immediate, can be performed frequently, and do not rely on the skill level of the tester, which can be a weak point that leads to vulnerabilities. Continuous simulation validation testing combined with penetration testing is a good avenue to consider since new payloads and attacks show up in the wild every day. There are currently several vendors providing continuous security validation solutions with different approaches. According to one of those vendors, Cymulate, in 2021 top threats that impacted companies include LockBit, Conti and Dharma ransomware, HAFNIUM, TeamTNT, and APT29 with Log4j abuse. Cymulate’s simulation validation approach employs an Immediate Threat Intelligence module to enable companies to assess and optimize their Email Gateway, Web Gateway, and End Point security controls with out-of-the-box test scenarios that simulate potential new threats. [Cymulate research reveals unique threats in the wild rose by over 35% in 2021 – Cymulate](https://cymulate.com/news/cymulate-research-reveals-unique-threats-in-the-wild-rose-by-over-35-in-2021-2/) Simulated attacks are useful because they also enable security blue teams to assess and fine-tune their detect, alert, and response capabilities through integrations with existing security programs and systems including vulnerability management, EDRs, SIEM, SOAR and GRC systems. **Cyber-Resilience and Business Continuity** Cyber-resilience and business continuity after an intrusion is an area that must be continuously developed for optimizing response protocols, training of information security personnel, and deployment of automated detection and backup technologies. Cyber-resilience, business continuity, innovation, and collaboration between government and industry stakeholders is a proven model that makes good sense. Together, government and the private sector can identify products and align flexible product paths, evaluate technology gaps, and help design, evaluate, and simulate scalable architectures that will lead to more efficiencies, and fiscal accountability. Information sharing is also a key cog to the resilience and business continuity equation as it helps both industry and government keep abreast of the latest viruses, malware, phishing threats, ransomware, insider threats, and especially denial of service attacks. Information sharing also establishes working protocols for lessons learned and resilience that is critical for the success of commerce and the enforcement against cyber-crimes. DHS CISA has expanded its programs in information sharing with industry in the past couple of years, especially with companies involved in operating critical infrastructure. Cybersecurity at the leadership level requires effective communication with the board and management team. The CISO, CTO, CIO, and executive management must align strategies, collaborate, and regularly assess their information security programs, controls, and safety of networks. Reputation management is often needed if the breach interferes with a company’s operations. Remediation is important to continuity; no matter what, breaches will happen. To be most effective for resilience, industry and governments should have an incident response plan that includes mitigation, business continuity planning, and secure backup protocols in case networks and devices are compromised. Training and tabletop exercises can improve incident response plan implementation should an actual incident occur. The incorporation of best practices and the lessons learned from the various and many breaches over the past few years is certainly valuable data for establishing components of prevention, recovery, and continuity in a plan. Unfortunately, many businesses are still negligent in their preparation and analyses. A recent study by Wakefield Research found that a third of mid-sized organizations still do not have a cyber-incident response plan in place! [A third of mid-sized organizations don’t have a cyber-incident response plan (betanews.com)](https://betanews.com/2022/07/08/a-third-of-mid-sized-organizations-dont-have-a-cyber-incident-response-plan/) **The Challenge of Emerging Technologies** Emerging technologies are both tools for cyber-defenders and threat actors. The current cyber-threat landscape now includes artificial intelligence, machine intelligence, IoT, 5G, virtual and augmented realities, and quantum computing. Automation, combined with artificial and machine intelligence, is an emerging and future cybersecurity pathway. Artificial intelligence (AI) is really going to be a big catalyst for cybersecurity. It will enable real-time threat detection and real-time analysis. Companies will be able to monitor what is in their system, and who may be doing things that are anomalies. AI can also be used as a tool for nefarious purposes by criminal hackers to find vulnerabilities and automate phishing attacks, so not deploying or understanding the implications of such usage will undermine resiliency and continuity. AI and these other emerging technologies will all have a disruptive impact on security and operating models for the near future. Addressing new and more sophisticated threats will be fundamental to cyber-resilience and business continuity in the next decade. In today’s sophisticated threat environment, cybersecurity can no longer be viewed as an afterthought if businesses are going to survive and thrive. Being proactive rather than reactive makes sense for anyone operating in the digital landscape. There are a variety of established paths to follow in cyber risk management to fill gaps and bolster defenses. Complacency in the face of growing threats is not one of them. **Government and Industry Cooperation: More Important Than Ever for Cybersecurity Awareness** By [***Chuck Brooks***](https://www.uscybersecurity.net/writer/chuck-brooks/) [Government and Industry Cooperation: More Important Than Ever for Cybersecurity Awareness – United States Cybersecurity Magazine (uscybersecurity.net)](https://www.uscybersecurity.net/csmag/government-and-industry-cooperation-more-important-than-ever-for-cybersecurity-awareness/) With another National Cybersecurity Awareness Month upon us, few major things have changed from the past year in terms of threats. As the capabilities and connectivity of cyber devices have grown, so have the cyber intrusions from malware and hackers. The cyber- threat actor ecosystem has grown in both size and sophistication. They are also openly collaborating in sharing targets. And tools. The cyber threat actors include various criminal enterprises, loosely affiliated hackers, and adversarial nation states. **Information sharing on threats and risk is one of the most principal functions of government and industry collaboration.** Achieving a full awareness of nefarious actors who operate in the cyber realm and protecting against their capabilities is an arduous task. Clearly, industry cannot respond to growing cyber-threats alone, especially for small and medium businesses who lack the resources and expertise. Increased government and industry cooperation to meet those challenges is a viable course to help mitigate threats and challenges. It is a proven risk management model that makes good sense. In several areas. Information sharing on threats and risk is one of the most principal functions of government and industry collaboration. Sharing such information helps allow both government and industry to keep abreast of the latest viruses, malware, phishing threats, ransomware, and insider threats. Information sharing also establishes working protocols for lessons-learned and resilience that is critical for the success of commerce and the enforcement against cyber-crimes. Both Solar Winds and the Colonial pipeline breaches highlighted the government’s assistance in mitigating breaches and moving toward resilience. Government was directly collaborating with the companies to discover the extent of the breaches and options for amelioration. Remediation of breaches is important to continuity; no matter what, breaches will happen. The incorporation of best practices and the lessons learned from the various and many corporate breaches over the past few years is certainly valuable data for both industry and government in terms of prevention, recovery, and continuity. **GOVERNMENT TAKES PROACTIVE ROLE WITH INDUSTRY PARTNERSHIPS** The government and industry partnership are being well coordinated via the Cybersecurity and Infrastructure Protection Agency (CISA) of the Department of Homeland Security (DHS). Over the past few years, CISA has taken on a formal and increasingly larger role as the lead civilian agency in government working with industry, and state & local and tribal stakeholders on cybersecurity threats. The proposed 2023 DHS budget has appropriated more than $2.5 billion toward cybersecurity demonstrating the importance of the agency’s role in protecting the homeland in cyberspace, including in the aforementioned areas of information sharing and resilience. Most significant is that CISA under the leadership of Jen Esterly created the [Joint Cyber Defense Collaborative](https://www.cisa.gov/joint-cyber-defense-collaborative) (JCDC) last year to fundamentally transform how cyber risk is reduced through continuous operational collaboration between government and trusted industry partners. “The Cybersecurity and Infrastructure Security Agency established JCDC—the Joint Cyber Defense Collaborative—to unify cyber defenders from organizations worldwide. This diverse team proactively gathers, analyzes, and shares actionable cyber risk information to enable synchronized, holistic cybersecurity planning, cyber defense, and response.” The JCDC also is supported by other government agencies including the FBI, NSA, and U.S. Cyber Command to help drive down risk in partnership with industry. In recent years, DHS along with The National Institute of Standards (NIST), has made a growing effort to bring the private sector together with the government, especially to develop information sharing protocols in risk management. In a core sense, a successful cyber threat consequences strategy is really about risk mitigation and incident response. A risk management strategy requires stepping up assessing situational awareness, information sharing, and especially resilience planning. It is critical to be aware of the morphing threat landscape and plan contingencies for all potential scenarios. NIST has been extremely helpful to industry in those areas. The White House has also heighted government and industry cooperation in various areas including supply chain security, protecting critical infrastructure (most of which is owned by the private sector). In specific regard to critical infrastructure, the underlying goal of collaboration is to help protect against targeted cyber intrusions of the nation’s critical infrastructure, such as financial systems, chemical plants, water and electric utilities, hospitals, communication networks, commercial and critical manufacturing, pipelines, shipping, dams, bridges, highways, and buildings. White House and industry cooperation has been primarily aimed at identifying vulnerabilities, ensuring security, and integrating resilience in the public/private cyber ecosystem. The most recent activity by the White House was an executive order formulating a Zero trust strategy for government agencies. That “trust nothing connected” perspective is also being assimilated in industry. Congress has supported CISA’s expanded role and involvement with industry. Several bi-partisan bills have bolstered the agency’s integral role in cyber preparedness, response and resilience for both government and industry. **COOPERATIVE RESEARCH AND DEVELOPMENT** Research and development of potentially disruptive cybersecurity technologies is another benefit of government and industry cooperation. The change in the cyber risk environment coinciding with a heightened need for procurement of innovative technologies and services has created a new paradigm for a cybersecurity partnership between government and industry. Together, government and the private sector can identify products and align flexible product paths, evaluate technology gaps, and help design scalable architectures that will lead to more efficiencies, and fiscal accountability. Bridging R&D spending between the government and private sectors should also allow for a more directed and capable cybersecurity prototype pipeline to meet modern technology requirements. An enhanced and streamlined government and industry partnership should continue to be a priority for cybersecurity strategies in 2023, as threats can morph, especially with the emergence of technologies such as artificial intelligence, machine learning, 5G, and eventually quantum computing. The partnership needs to be both proactive and adaptive to change as the threat matrix may become increasingly lethal to economic and strategic stability if we remain unaware and unprepared for the potential consequences. **Topics:** Public Awareness, Technology --- ### [Attorney General Josh Stein Reaches $3.6 Million Medicaid Settlement with Radeas](https://insurancefraud.org/news_archives/attorney-general-josh-stein-reaches-3-6-million-medicaid-settlement-with-radeas/) **Published:** September 28, 2026 **Author:** Diane Beauchamp **Content:** Attorney General Josh Stein reached a $3,653,858 settlement with Radeas, LLC, a South Carolina clinical laboratory company headquartered in Wake Forest, North Carolina. The settlement resolves allegations that Radeas submitted false claims for some urine drug tests to the North Carolina Medicaid program. Funds from the settlement will go to reimburse the Medicaid program and to North Carolina schools. “Health care companies and labs must be responsible stewards of taxpayer dollars,” said Attorney General Josh Stein. “When they waste Medicaid resources, my office will hold them accountable.” Between Jan. 1, 2016, and Sept. 30, 2021, Radeas allegedly offered health care providers the option to order two types of urine drug tests at the same time. A presumptive drug test detects the general presence of a substance and a definitive drug test determines the precise amounts of a substance. Radeas then performed both tests on the same sample. However, performing both tests at the same time is not medically necessary, and definitive drug tests are generally performed at a later time after a presumptive drug test has been completed. Radeas allegedly conducted both tests simultaneously without supporting clinical documentation and in violation of Medicaid policy and was reimbursed for Medicaid funds that it was not entitled to. The civil claims resolved by settlement here are allegations only, and there has been no judicial determination or admission of liability. **About the Medicaid Investigations Division (MID)** The Attorney General’s MID investigates and prosecutes health care providers that defraud the Medicaid program, patient abuse of Medicaid recipients, patient abuse of any patient in facilities that receive Medicaid funding, and misappropriation of any patients’ private funds in nursing homes that receive Medicaid funding. To date, the MID has recovered more than $1 billion in restitution and penalties for North Carolina. To report Medicaid fraud or patient abuse in North Carolina, call the MID at 919-881-2320. The MID receives 75 percent of its funding from the U.S. Department of Health and Human Services under a grant award totaling $6,106,236 for Federal fiscal year (FY) 2022. The remaining 25 percent, totaling $2,035,412 for FY 2022, is funded by the State of North Carolina. **Topics:** Judicial/courts --- ### [Audit: Arizona healthcare system for low income not investigating fraud](https://insurancefraud.org/news_archives/audit-arizona-healthcare-system-for-low-income-not-investigating-fraud/) **Published:** September 28, 2026 **Author:** Diane Beauchamp **Content:** Arizona’s healthcare program for low income is not doing a good job of investigating potential incidents of fraud or abuse committed by providers or patients, the state Auditor General’s Office has concluded. The new report finds that the Arizona Health Care Cost Containment System has taken more than a year to initiate or complete preliminary investigation of more than half of potential fraud and abuse cases that were open in May when auditors looked at the agency’s records. And that, said Auditor General Lindsey Perry, comes at a cost. “Untimely fraud and abuse investigations could result in AHCCCS making unnecessary payments,” she wrote in the report. And Perry said there clearly are such cases. She pointed out that in the last fiscal year, AHCCCS reported that it either recovered or saved about $48.1 million in state and federal funds. But Perry said if the agency doesn’t investigate and resolve cases in a timely manner it “potentially continues to pay thousands of dollars each year to provide healthcare coverage for a member who may have obtained this coverage fraudulently.” But that’s not the only problem. “Untimely investigations could also delay efforts to recover fraudulent payments and make recovering improper payments more difficult,” the report states. “Finally, AHCCCS risks compromising its ability to gather evidence and follow leads that might become stale as cases age.” The problems, the report says, are not limited to patients. Perry said AHCCCS had not completed a preliminary investigation of 87% of potential provider fraud or abuse to the Attorney General’s Office within three months, the time frame established in an agreement between the two agencies. In fact, nearly 60% had been open for longer than a year. And she said AHCCCS has not reviewed the health plans, with which it contracts to provide direct services to patients, once every three years as required. Lindsey said that goes to the question of whether the agency is making “incentive” payments to providers for their performance without first determining that the providers actually are eligible. AHCCCS, formed in 1982, is the state’s Medicaid program. Unlike some Medicaid fee-for-service programs that operate in other states, AHCCCS makes regular payments to provider organizations who, in turn, provide direct care to “members.” About 2.4 million Arizonans receive care under one of several AHCCCS programs, about 38% who are children. Most of the estimated $21.4 billion cost is picked up by the federal government, with the $2.7 billion in state costs making it the largest item in the budget, AHCCCS, in a response to the audit, said part of the problem was related to the COVID outbreak. “Investigators were not able to conduct-in person visits to homes and schools as part of their investigations, which impacted their ability to verify the reported number of members living in the home and contributing to the household,” the report said, The agency said those visits resumed in January. That, however, still left the issues of staff turnover and an insufficient number of investigators. And while the agency said it is bringing new people on board, it said it can take a year to properly train them. Perry, however, said AHCCCS needs to do more. She said the agency needs to conduct a workload and cost analysis to evaluate whether its funding and staffing levels are sufficient for timely investigating fraud and abuse incidents. And if it is not, Lindsey said, AHCCCS should work with the legislature to provide more funds. The report found some incidents that auditors decided to single out for special mention. One goes back to August 2014 with allegations that another adult was living in and contributing financially to the household. More to the point, the allegation was that had this person’s income been included in the application, the household would not have been eligible for AHCCCS coverage. Perry said that AHCCCS, as allowed by its process, did not assign it for investigation until October 2018. But even then, she said, the agency did not complete its preliminary inquiry within the year as required under its policy. But here’s the thing: As of this past July, Perry said the case was still under investigation. AHCCCS said it was having difficulty in subpoenaing needed information from the member and the member’s employer because the member had moved and changed jobs multiple times since 2014. And, as of July, the individuals involved are still enrolled. “As a result, AHCCCS has continued, for nearly eight years, to pay hundreds of dollars each every month in capitation payments for members who may be ineligible for healthcare coverage,” Perry said. **Topics:** Public Awareness, Regulatory actions --- ### [Homeowners: Beware these common scams following a natural disaster](https://insurancefraud.org/news_archives/homeowners-beware-these-common-scams-following-a-natural-disaster/) **Published:** September 28, 2026 **Author:** Diane Beauchamp **Content:** [Hurricane Ian clobbered Florida](https://www.cbsnews.com/feature/hurricane-ian/), Georgia and the Carolinas, causing [billions of dollars in damages](https://www.cbsnews.com/news/hurricane-ian-tropical-storm-citrus-mining-tourism-economic-impact/) to businesses and homeowners. But the storm wasn’t the only threat to those in its path. Natural disasters like Ian commonly attract scammers, sometimes dubbed “storm chasers,” who pose as reputable contractors and trawl damaged communities in order to bilk unsuspecting homeowners out of their insurance payouts or other benefits, such as private donations or federal recovery funds.. But there are ways to spot fraudsters, experts told CBS MoneyWatch. It starts with simply being aware of the types of scams that often trail the destruction left by hurricanes, earthquakes, floods and other disasters. Here are three of the most common scams, along with tips from insurance professionals on how to avoid being taken for a ride. ## Phony contractors Phony contractors often appear a day or two after a major storm hit an area and set up shop in a strip mall or a recreational vehicle, said David Glawe, CEO of the National Insurance Crime Bureau. These fraudsters will contact homeowners and tell them that workers can begin repairs on their house immediately so only as they sign a contract with the company. The contract, however, re-assigns any forthcoming insurance payout to the fake company instead of its intended recipient, the homeowner. People impacted by a major storm are trying to get back on their feet as quickly as possible, and these faux contractors are like “vultures” who prey on people’s understandable desire to resume life as normal, Glawe said. “Vulnerable people will think they’re getting a quick solution, but they won’t be,” he told CBS MoneyWatch. If someone contacts you claiming to be a contractor, take down the person’s name and phone number, Glawe advised. Research the company online and make sure it’s licensed to work in your state or city. If the company has bad reviews from the Better Business Bureau or doesn’t have a registered license, it’s likely a scam. “If your Spidey sense is going off, reject them,” Glawe said. ## Roof wreckers Another common scam involves someone visiting your home after a severe storm and offering to check for damage on your roof. Once on your roof, the person pretends to spot or actually deliberately damages your property, sometimes using golf balls under their shoes to simulate puncture marks from hail. They then offer to help the homeowner submit a damage claim to the insurance provider. The fake roofers get paid by convincing the homeowner to file a claim with their insurance company and then sending the check to them. One red flag is if a person is going door to door offering roof work, using pushy sales tactics and demanding payment up front, said Logan McFaddin, a regional manager covering Florida for the American Property Casualty Insurance Association. “Never pay up front in full,” she said. “That’s not how legitimate contractors work. Payments are done in installments as the work is done.” McFaddin said the best strategy is to ask the person at your door for a list of references. A reputable company should be able to provide that information, she said. Experts also recommend getting price quotes from two or three licensed roofers before making any decisions, she said. ## Debris clearing no-shows For this scam, bad actors typically target the elderly or disabled. Someone pretending to represent a removal company will go door to door asking homeowners to sign a contract and make a down payment to have someone clear fallen tree branches, rubble and trash from their lawn. The person walks away with a signed contract and down payment money, but no one returns to do the work. The best way not to get ripped off is never to give anyone a down payment for future services and only offer payment after the work is done, Glawe said. “Once you pay that money to them, it’s out the door and you may not get it back,” he said. **Topics:** Contractor fraud, Public Awareness --- ### [HRS Senior Living: Medicare Fraud and Prevention Tips](https://insurancefraud.org/news_archives/hrs-senior-living-medicare-fraud-and-prevention-tips/) **Published:** September 28, 2026 **Author:** Diane Beauchamp **Content:** Senior citizens often receive phone calls from someone asking for sensitive information that could lead to the loss of thousands of dollars. Due to isolation, cognitive decline and fewer technical skills, some seniors are more vulnerable to fraud and scams and it’s happening now more than ever. If this has happened to you or a loved one, where do you turn for help? Your first call should be to the Senior Medicare Patrol. **Topics:** Elderly Fraud, Medicare/Medicaid, Public Awareness --- ### [BBB: Scammer could target your wallet or home in wake of Hurricane Ian](https://insurancefraud.org/news_archives/bbb-scammer-could-target-your-wallet-or-home-in-wake-of-hurricane-ian/) **Published:** September 28, 2026 **Author:** Diane Beauchamp **Content:** More [Ohio Task Force 1](https://abc6onyourside.com/news/local/osu-doctor-helps-in-florida-former-sanibel-island-city-manager-reacts-to-hurricane-ian-storm-surge-recover-phase) members mobilized Thursday to help in the [hurricane zone](https://abc6onyourside.com/news/nation-world/ian-nearing-hurricane-strength-again-headed-to-south-carolina-after-slamming-florida-tropical-storm-warning-wind-rain-extreme-weather-flooding-damage-tornado-twister-major-disaster-declaration-rapid-response-team), where they’ll focus on search-and-rescue, hazmat operations and medical aid. “For us to be able to go down there and provide that help, help them locate those people and solve any of those problems…that is why we do this,” One of the task force members said. Many who are staying in Ohio are looking for ways to help as well. “Scammers are really good at targeting current events. And unfortunately, scams centered around charitable giving is no exception, and hurricanes and natural disasters, it’s a great opportunity for them,” Judy Dollison with the Better Business Bureau of Central Ohio said. Dollison said it’s a good idea to do your research. > Look for organizations that are upfront and clear about their services that they’re going to be providing. A vague description could definitely be a red flag. And you may see requests for donations and social media feeds or texts or emails. Just like with any other phishing scam, the links can take you to look like websites, So don’t click that link she says. Plus, scammers may also try to hit, right at your front door, if remnants of [Hurricane Ian](https://abc6onyourside.com/news/nation-world/national-weather-service-warns-of-indirect-hurricane-fatalities-concerning-generators-florida-north-south-carolina-georgia-extreme-weather-rain-wind-storm-surge-flooding-power-outages-carbon-monoxide-levels-dizzy-ill-sick-fresh-air) impact Central Ohio. “We call them our storm chasers. And we see them with any large rain, or you know, flooding that happens or a tornado that passes. What we recommend as you get those door-to-door salesmen, and some are legitimate companies, and some aren’t. So do your research. Get referrals from friends or family, check bbb.org,” Dollison said. When it comes to scammers, she says they often use that sense of urgency, wanting you to act now and think later. Plus, don’t pay all upfront if you need house repairs for example. There are a lot of ways to double-check who you are doing business with, you can look up charities on the secretary of state’s [website](https://charitableregistration.ohioattorneygeneral.gov/charities/Research-Charities.aspx) and you can check online at [Give.org](https://www.give.org/) **Topics:** Public Awareness --- ### [Michigan Medicaid Fraud Control Unit: 2021 Review](https://insurancefraud.org/news_archives/michigan-medicaid-fraud-control-unit-2021-review/) **Published:** September 28, 2026 **Author:** Diane Beauchamp **Content:** WHY WE DID THIS STUDY OIG administers the Medicaid Fraud Control Unit (MFCU or Unit) grant awards, annually recertifies the Units, and oversees the Units’ performance in accordance with the requirements of the grant. As part of this oversight, OIG conducts periodic reviews of Units and prepares public reports based on these reviews. OIG conducted this review of the Michigan MFCU to examine three areas of concern that we identified during our ongoing administration and oversight activities of the Michigan MFCU: (1) the number of fraud referrals from the State Medicaid agency, (2) the Unit’s fiscal controls, and (3) the Unit’s staffing levels. As part of this review, we also examined the Unit’s performance and operations. HOW WE DID THIS STUDY OIG conducted the review of the Michigan MFCU in September 2021. Our review covered the 3-year period of FYs 2018-2020. We based the review on an analysis of data and information from 7 sources: (1) Unit documentation; (2) financial documentation; (3) structured interviews with key stakeholders; (4) structured interviews with Unit management and selected staff; (5) a random sample of 90 case files from the Unit’s 493 nonglobal case files that were open at any point during the review period; (6) a review of convictions submitted to OIG for program exclusion and adverse actions submitted to the National Practitioner Data Bank during the review period; and (7) an onsite review of Unit operations. WHAT WE FOUND We found that the Unit reported strong case outcomes for FYs 2018-2020, with over $47 million in combined criminal and civil recoveries. However, we identified several operational challenges that warrant further attention. We made nine findings for which we are making recommendations to improve the Unit’s adherence to the MFCU performance standards. We found that (1) the Unit received few fraud referrals from the State Medicaid agency, and despite the Unit taking steps to increase these referrals, they remained low; (2) the Department of Attorney General repeatedly submitted the MFCU’s financial reports late, lacked support for some MFCU expenditures, and lacked accounting procedures, raising concerns about the MFCU’s fiscal controls; (3) despite the Unit’s request for additional resources to increase its staffing levels, Unit staffing remained constant and did not align with the growing Medicaid expenditures; (4) although the Unit coordinated with Federal partners, it worked few joint cases with them, missing opportunities for sharing resources and training; (5) the Unit did not always report convictions or adverse actions to Federal partners within the appropriate timeframes; (6) 62 percent of the Unit’s case files lacked documentation of periodic supervisory reviews; (7) although the Unit maintained an annual training plan for its staff, Unit supervisors did not consistently track or verify that staff documented their training; (8) the Unit’s case management system made it difficult for Unit staff to retrieve case information and performance data; and (9) the Unit’s memorandum of understanding (MOU) with the State Medicaid agency did not reflect current practice or law. WHAT WE RECOMMEND To address the findings and further improve Unit operations, we recommend that the Unit (1) build upon its efforts to increase fraud referrals from the State Medicaid agency; (2) refund the Federal grant for unsupported expenditures and establish processes to ensure Unit involvement and oversight of fiscal controls and reporting; (3) assess the adequacy of existing staffing levels and, if appropriate, develop a plan to expand the size of the Unit; (4) seek opportunities, as appropriate, to investigate more joint cases with Federal partners; (5) develop and implement processes to ensure that all convictions and adverse actions are reported to Federal partners within the appropriate timeframes; (6) ensure that supervisory reviews of case files are documented in accordance with Unit policy; (7) ensure that Unit supervisors track and verify that all staff in professional disciplines document their training; (8) implement a new, comprehensive case management system that allows for efficient access to case documents and information; and (9) revise its MOU with the State Medicaid agency to reflect current practice and law. The Unit concurred with all nine recommendations. <https://oig.hhs.gov/documents/evaluation/3008/OEI-06-21-00270-Complete%20Report.pdf> **Topics:** Medicare/Medicaid, Public Awareness, Regulatory actions --- ### [Magellan Health settles data breach lawsuit for $1.43M](https://insurancefraud.org/news_archives/magellan-health-settles-data-breach-lawsuit-for-1-43m/) **Published:** September 28, 2026 **Author:** Diane Beauchamp **Content:** Magellan Health will pay $1.43 million to settle a lawsuit over a May 2019 phishing scheme that compromised the protected health information of 273,000 patients, [*Top Class Action*](https://topclassactions.com/lawsuit-settlements/privacy/data-breach/magellan-health-data-breach-1-43m-class-action-settlement/) reported Sept. 28. Magellan Health hasn’t admitted any wrongdoing, but agreed to the settlement resolving allegations that the company failed to properly notify patients of the breach, as well as allegations suggesting that Magellan could have prevented the data breach with reasonable cybersecurity measures. Under the settlement, affected patients from Magellan Health, as well as 44,000 affected patients from Tennessee’s Medicare program, TennCare, can receive up to $225 in ordinary out-of-pocket expenses including telephone charges, credit report costs, internet usage and up to two hours of lost time at a rate of $15 per hour. In addition, affected individuals may be able to collect ordinary expense reimbursement for credit monitoring and fraud-resolution services, as well as payments of $2,500 if they suffered extraordinary out-of-pocket expenses. **Topics:** Judicial/courts --- ### [California Doctor Prescribing Unneeded Drugs Guilty of Insurance Fraud](https://insurancefraud.org/news_archives/california-doctor-prescribing-unneeded-drugs-guilty-of-insurance-fraud/) **Published:** September 28, 2026 **Author:** Diane Beauchamp **Content:** A physician pleaded guilty to defrauding California’s Medi-Cal system by prescribing unnecessary drugs to more than 1,000 patients, prosecutors said. Dr. Mohammed El-Nachef entered pleas in Orange County to one count of insurance fraud and one count of aiding and abetting the unauthorized practice of medicine, according to a statement from the state attorney general’s office. He was ordered to pay $2.3 million in restitution and surrender his medical license. Prosecutors said that for two years beginning in 2014, El-Nachef prescribed unnecessary HIV medications, anti-psychotics and opioids to patients at clinics in Anaheim and Los Angeles. The patients were Medi-Cal recipients who were recruited with the promise of cash payments, and the recruiters then illegally sold the drugs, prosecutors said. El-Nachef was recruited to write the unnecessary prescriptions and was paid in cash, prosecutors said. “El-Nachef used his position as a physician to steal taxpayer money from our state programs and fuel illicit pharmaceutical sales on the streets of Southern California – all for personal gain,” Attorney General Rob Bonta said in the statement. “Abuses of power – whether big or small – will never be tolerated by the California Department of Justice.” **Topics:** Drug Diversion **Categories:** Conviction --- ### [New York Doctor Who Performed Unnecessary Back Surgeries Pleads Guilty To Participating In Trip-And-Fall Fraud Scheme](https://insurancefraud.org/news_archives/new-york-doctor-who-performed-unnecessary-back-surgeries-pleads-guilty-to-participating-in-trip-and-fall-fraud-scheme/) **Published:** September 28, 2026 **Author:** Diane Beauchamp **Content:** New York Litigation Funding Company Operator Who Financed Fraudulent Lawsuits In Furtherance of the Scheme Previously Pled Guilty Damian Williams, the United States Attorney for the Southern District of New York, announced that SADY RIBEIRO, a New York-licensed pain management doctor and surgeon, pled guilty today to one count of conspiracy to commit mail fraud and one count of conspiracy to commit wire fraud in connection with a scheme to obtain fraudulent insurance reimbursements and other compensation from fraudulent trip-and-fall accidents. RIBEIRO is the second defendant to plead guilty in the case. ADRIAN ALEXANDER, the owner of a litigation funding company who was also involved in the trip-and-fall fraud scheme, previously pled guilty to one count of conspiracy to commit wire fraud on August 30, 2022. ALEXANDER and RIBEIRO both pled guilty before U.S. District Judge Sidney H. Stein. U.S. Attorney Damian Williams said: “As alleged, Sady Ribeiro abused his professional license and position of trust by performing medically unnecessary surgeries to increase the value of fraudulent trip-and-fall lawsuits. In carrying out the scheme, Adrian Alexander, who funded many of the fraudulent lawsuits, Sady Ribeiro, and their co-conspirators preyed upon the most vulnerable members of society in order to enrich themselves. Ribeiro and Alexander now await sentencing for their reprehensible crimes.” According to the Indictment, the Superseding Informations filed against RIBEIRO and ALEXANDER, other documents filed in this case, and statements made in court: SADY RIBEIRO and ADRIAN ALEXANDER, among others, were involved in an extensive fraud scheme through which fraud scheme participants defrauded businesses and insurance companies by staging trip-and-fall accidents and filing fraudulent lawsuits arising from those staged trip-and-fall accidents. The fraud scheme participants recruited individuals (the “Patients”) to stage or falsely claim to have suffered trip-and-fall accidents at particular locations throughout the New York City area (the “Accident Sites”). In the course of the fraud scheme, scheme participants recruited more than 400 Patients. In the beginning, scheme participants would instruct Patients to claim they had tripped and fallen at a particular location, when in fact, the Patients had suffered no such accidents. Eventually, at the direction of the lawyers who filed fraudulent lawsuits on behalf of the Patients, scheme participants began to instruct Patients to stage trip-and-fall accidents, i.e., to go to a location and deliberately fall. Common Accident Sites used during the fraud scheme included cellar doors, cracks in concrete sidewalks, and purported “potholes.” After the staged trip-and-fall accidents, Patients were referred to specific attorneys who would file personal injury lawsuits (the “Fraudulent Lawsuits”) against the owners of the Accident Sites and/or insurance companies of the owners of the accident sites (the “Victims”). The Fraudulent Lawsuits did not disclose that the Patients had deliberately fallen at the accident sites or, in some cases, had not fallen at all. During the course of the fraud scheme, the defendants, together with others known and unknown, attempted to defraud the Victims of more than $31,000,000. The Patients were also instructed to receive ongoing chiropractic and medical treatment from certain chiropractors and doctors, including RIBEIRO. The fraud scheme participants advised the Patients that if they intended to continue with their lawsuits, they were required to undergo surgery. As an incentive to getting surgery, the recruited Patients were offered a payment of typically between $1,000 and $1,500 after they completed surgery (“Post-Surgery Payments”). Patients generally were told to undergo two surgeries. Doctors in the fraud scheme, including RIBEIRO, were expected to, and in fact did, conduct these surgeries regardless of the legitimate medical needs of the Patients. For example, RIBEIRO wrote an August 2015 email to ALEXANDER—the owner and operator of a litigation funding company that financed numerous Fraudulent Lawsuits—in which RIBEIRO described the services that he performed, stating, “I will play very honest ‘game’ with you . . . I see the patient and I generate a very good dictation that justifies the treatment-there is a cost for that and I hope a profit.” RIBEIRO performed back surgeries, among other medical procedures, on nearly 200 Patients. To maximize his patient base, RIBEIRO paid participants cash kickbacks in exchange for patient referrals. Members of the fraud scheme often recruited individuals who were extremely poor as Patients—individuals desperate enough to submit to surgeries in exchange for the small Post-Surgery Payments. For example, it was common for Patients to ask for food when they would appear for their intake meetings with the lawyers. Many of the Patients did not have sufficient clothing to keep them warm during the wintertime and had poor-quality shoes. Members of the fraud scheme also recruited Patients who were drug addicts. It was also common for scheme participants to recruit Patients from homeless shelters in New York City. The Patients’ legal and medical fees were usually paid for by litigation funding companies (the “Funding Companies”), including one Funding Company that, as noted above, was owned and operated by ALEXANDER. Funding Companies were used even if the Patient maintained medical coverage through an insurance company or a government-subsidized program. The Funding Companies also paid the fraud scheme organizers and participants referral fees, typically $1,000 to $2,500, for each Patient who signed a funding agreement. In exchange for funding Patients’ medical and legal costs, the Funding Companies charged the Patients high interest rates, sometimes up to 50% on medical loans and up to 100% on personal loans. The interest rates were so high that oftentimes the majority (if not all) of the proceeds that were awarded in the Fraudulent Lawsuits were paid to the Funding Companies, lawyers, doctors, and others, with the Patients receiving a much smaller percentage of the remaining recovery. --- RIBEIRO, 72, of New York, New York, pled guilty to one count of conspiracy to commit mail fraud, which carries a maximum sentence of five years in prison; and one count of conspiracy to commit wire fraud, which carries a maximum sentence of five years in prison. As part of his plea agreement, RIBEIRO agreed to forfeit $513,005 to the United States and to make restitution in the amount of $3,928,133. ALEXANDER, 77, of New York, New York, previously pled guilty to one count of conspiracy to commit wire fraud, which carries a maximum sentence of five years in prison. As part of his plea agreement, ALEXANDER agreed to forfeit $659,001 to the United States and to make restitution in the amount of $3,928,133. The maximum potential sentences in this case are prescribed by Congress and are provided here for informational purposes only, as any sentencing of the defendants will be determined by the judge. RIBEIRO is scheduled to be sentenced on January 5, 2023. ALEXANDER is scheduled to be sentenced on November 30, 2022. Both defendants will be sentenced by U.S. District Judge Sidney H. Stein. Mr. Williams praised the outstanding investigative work of the Federal Bureau of Investigation. Mr. Williams also thanked the National Insurance Crime Bureau for their assistance in the investigation. This case is being handled by the Office’s Complex Frauds and Cybercrime Unit. Assistant United States Attorneys Nicholas Chiuchiolo, Nicholas Folly, Danielle Kudla, and Alexandra Rothman are in charge of the prosecution. **Topics:** Commercial Fraud, Healthcare Fraud, Third party litigation funding **Categories:** Conviction --- ### [Missouri Health Executives Plead Guilty in Widespread Fraud](https://insurancefraud.org/news_archives/missouri-health-executives-plead-guilty-in-widespread-fraud/) **Published:** September 28, 2026 **Author:** Diane Beauchamp **Content:** Two former executives of a Missouri health nonprofit have pleaded guilty to their roles in a corruption scheme that ensnared several Arkansas elected officials and lobbyists, federal prosecutors said. Bontiea Bernedette Goss, 63, and her husband, Tommy Ray Goss, 66, pleaded guilty Wednesday in federal court to conspiracy charges arising from a multi-year federal investigation. The couple were executives at Preferred Family Healthcare Inc., a Springfield-based nonprofit that provided services such as substance abuse treatments and counseling to people in Missouri, Arkansas, Kansas, Oklahoma and Illinois. Federal prosecutors said in a news release the Gosses and other co-conspirators paid bribes and kickbacks to Arkansas lawmakers to obtain favorable legislation and other official actions that helped the nonprofit. As part of the plea agreement, the Gosses must forfeit up to $4.3 million as determined by the court at their sentencing. A sentencing date has not been set. Bontiea Goss pleaded guilty to conspiracy to pay bribes and kickbacks to elected public officials in Arkansas. Tom Goss pleaded guilty to being part of the conspiracy by embezzling funds from the nonprofit and paying bribes and kickbacks to Arkansas officials. He also pleaded guilty to preparing a false tax return. Earlier this year, Preferred Family Healthcare agreed to pay more than $8 million in forfeiture and restitution to the federal government and the state of Arkansas under a non-prosecution agreement, which acknowledges the criminal conduct of its former officers and employees. Other Preferred Family employees, Arkansas lobbyists and some Arkansas lawmakers, including former state Sen. Jeremy Hutchinson, nephew of Gov. Asa Hutchinson, have pleaded guilty for their roles in the scheme. **Topics:** Financial Fraud **Categories:** Conviction --- ### [Law firm adds former NYS special assistant AG for Medicaid fraud](https://insurancefraud.org/news_archives/law-firm-adds-former-nys-special-assistant-ag-for-medicaid-fraud/) **Published:** September 28, 2026 **Author:** Diane Beauchamp **Content:** A law firm with offices across the state has added a former New York State special assistant attorney general in Medicaid fraud. Glenn Jones, a healthcare litigator, has joined Harris Beach, which also has an office in New jersey and Connecticut. Jones works in the firm’s Long Island office in Uniondale. Jones brings decades of expertise complex regulatory proceedings and criminal and civil investigations in healthcare and other industries. He has defended individuals and organizations on issues involving the U.S. Department of Justice and the Department of Health and Human Services, New York Attorney General Office, New York State Department of Financial Services and other federal, state and local agencies. His areas of expertise include alleged violations of the Stark Act, the False Claims Act, the Anti-Kickback Statute, Foreign Corrupt Practices Act, the Health Insurance Portability and Accountability Act and other compliance regulations. “Glenn deepens the legal talent of Harris Beach in addressing difficult matters concerning government compliance and investigations, especially in healthcare,” Partner Terry Flynn, a former U.S. Attorney for the Western District of New York who leads the Harris Beach Government Compliance and Investigations Group, said in a statement. “Our attorneys have broad-based experience across federal, state and local jurisdictions, representing public and private sector companies and individuals,” Flynn added. “Like Glenn, many of our attorneys formerly held significant positions in government, addressing many of the same matters. We’re excited that Glenn chose Harris Beach for the next stage of his career.” Prior to joining Harris Beach, Jones served as partner and chair of the healthcare fraud and regulatory enforcement practice at a mid-sized law firm in New York City. He also worked for two firms in Washington, D.C. in business litigation, white-collar crime, government investigation/enforcement and healthcare practice groups, and operated his own practice. Jones spent eight years as a New York State special assistant attorney general for Medicaid fraud. During that time, he earned the Louis J. Lefkowitz Award, given by the New York State Attorney General for outstanding performance by an attorney in pursuit of the public good. Earlier in his career, he served as a trial attorney with the U.S. Commodity Futures Trading Commission, where he investigated and prosecuted fraud and other civil enforcement actions. Jones also spent time in the asset forfeiture and narcotics units in the New York County District Attorney’s office following his graduation from the Northwestern University School of Law. **Topics:** Public Awareness --- ### [Investigators from University of California San Francisco (UCSF) Have Reported New Data on Insurance (Legislating Medicare Fraud: the Politics of Self-regulation and the Creation of Professional Standards Review Organizations): Insurance](https://insurancefraud.org/news_archives/investigators-from-university-of-california-san-francisco-ucsf-have-reported-new-data-on-insurance-legislating-medicare-fraud-the-politics-of-self-regulation-and-the-creation-of-professional-stand/) **Published:** September 28, 2026 **Author:** Diane Beauchamp **Content:** By a News Reporter-Staff News Editor at Health Policy and Law Daily — Data detailed on Insurance have been presented. According to news reporting from San Francisco, California, by NewsRx journalists, research stated, “Not long after the 1966 enactment of Medicare and Medicaid, evidence emerged that unscrupulous physicians and health care organizations were gaming the system. Research over the past 50 years shows that around 10 percent of the federal government’s annual cost for these programs is attributed to fraudulent claims or abuses where hospitals and treatments have been overused for undue provider profit.” The news correspondents obtained a quote from the research from the University of California San Francisco (UCSF), “This article examines early congressional attention to this problem and describes lawmakers’ attempts to find legislative solutions to it. It historicizes the dilemma of balancing the ideological limits of government regulation with cultural assumptions about professional self-regulation, focusing on a major 1972 law, the Professional Standards Review Organization (PSRO) Act. The law launched a 10-year career for PSROs, physician-staffed peer-review boards designed to identify and sanction efforts to overcharge Medicare.” According to the news reporters, the research concluded: “The article contextualizes multiple actors’ concerns over cost containment and the crisis of faith in medical authority that persisted following failures to control professional malfeasance.” This research has been peer-reviewed. For more information on this research see: Legislating Medicare Fraud: the Politics of Self-regulation and the Creation of Professional Standards Review Organizations. *Journal of Policy History*, 2022;34(4):475-504. *Journal of Policy History* can be contacted at: Cambridge Univ Press, 32 Avenue Of The Americas, New York, NY 10013-2473, USA. (Cambridge University Press – [www.cambridge.org](http://www.cambridge.org/); Journal of Policy History – <http://journals.cambridge.org/action/displayJournal?jid=JPH>) Our news journalists report that additional information may be obtained by contacting Brian Dolan, University of California San Francisco (UCSF), Hist Hlth Sci, San Francisco, CA 94143, United States. The direct object identifier (DOI) for that additional information is: <https://doi.org/10.1017/s0898030622000173>. This DOI is a link to an online electronic document that is either free or for purchase, and can be your direct source for a journal article and its citation. **Topics:** Public Awareness --- ### [Snagged: These Americans Are Doing Hard Time for Social Security Fraud](https://insurancefraud.org/news_archives/snagged-these-americans-are-doing-hard-time-for-social-security-fraud/) **Published:** September 28, 2026 **Author:** Diane Beauchamp **Content:** Snagged: These Americans Are Doing Hard Time for Social Security Fraud A Maryland woman who worked for eight years as the office administrator for a Washington-based trade association was sentenced to four years in federal prison, for a series of charges that included wire fraud, social security fraud, tax evasion, and aggravated identity theft. According to the Social Security Administration’s (SSA) Office of the Inspector General, the crimes included “schemes to defraud her employer, fraudulently obtain disability insurance payments, and evade more than $225,000 in taxes, including by concealing income in connection with a bankruptcy petition,” to the tune of $1.4 million. The woman “spent more than $175,000 of the stolen funds at a local bingo hall, used more than $100,000 for retail, restaurant, and grocery expenditures, and withdrew more than $200,000 in cash,” the statement said, and applied for Social Security Disability Insurance (SSDI) payments despite working at the trade association. She was also accused of fraudulently declaring bankruptcy. In South Carolina, a sixty-one-year-old woman was sentenced to fifteen months in federal prison after pleading guilty to theft of government funds over $258,000. According to the Office of the Inspector General for SSA, the woman “unlawfully obtained Social Security Retirement Insurance Benefits (RIB) on behalf of her deceased grandmother,” failing to notify the government of her death between 2001 and 2020. SSA paid $22,840.10 in Medicare premiums for the deceased grandmother, and the woman was wrongly paid $22,875 as Supplemental Security Income (SSI) recipient, and she failed to report her husband’s Veterans Administration (VA) benefits. Also this month, a thirty-seven-year-old Massachusetts man was sentenced to twenty-five months in prison, for “misusing a Social Security number to fraudulently obtain a Massachusetts ID and driver’s license as well as MassHealth benefits,” the U.S. Attorney’s office for the District of Massachusetts announced September 28. The man had pleaded guilty to one count of false representation of a Social Security number and one count of aggravated identity theft back in May. He had used someone else’s name and Social Security number to apply to the Massachusetts Registry of Motor Vehicles on three occasions in 2016. And in Maine, a woman pled guilty to Social Security fraud and theft of public money. Between 2009 and 2020, the woman “concealed the presence of her husband in her household to maintain her eligibility to receive Supplemental Security Income (SSI) payments.” On multiple occasions, the woman falsely claimed that she and her husband had separated in 2008. The woman, according to the OIG, faces “five years in prison on the Social Security fraud charge and up to 10 years in prison on the theft of public money charge.” **Topics:** Social Security fraud **Categories:** Conviction --- ### [State Attorney warns of fraudulent contractors](https://insurancefraud.org/news_archives/state-attorney-warns-of-fraudulent-contractors/) **Published:** September 28, 2026 **Author:** Diane Beauchamp **Content:** 14th Circuit State Attorney Larry Basford said hundreds of Bay County residents lost hundreds of thousands of dollars to fraudulent contractors after Hurricane Michael. “We had unlicensed people coming into the area,” Basford said. “Whether that was general contractors, roofers, people making repairs and getting citizens to assign their benefits to them.” Basford said some cases are still ongoing. Fraud delayed the home repair process for many residents. Basford said much of the fraud was from unlicensed contractors asking people to assign their insurance settlements to them. “Some of the cases involve tens of thousands of dollars in restitution for our homeowners,” Basford said. Basford said some contractors performed shoddy or unnecessary repairs. Some never finished the work but took the money. He’s concerned there will be fraud in South Florida as they repair from Hurricane Ian. “Sometimes these unlicensed contractors would get a substantial deposit and then leave without making any of the repairs,” Basford said. “Or make substandard repairs that would not pass inspection.” Homeowners can avoid scam artists by using a list of licensed contractors. The Bay County Chamber of Commerce said people should use the Disaster Contractors Network. “If they’re not dealing with licensed contractors then they’re going to have problems later on resolving issues with their insurance company and getting the proper,” Basford said. **Topics:** Contractor fraud, Public Awareness --- ### [Out-of-state repair companies fined for alleged insurance scams following July hailstorm](https://insurancefraud.org/news_archives/out-of-state-repair-companies-fined-for-alleged-insurance-scams-following-july-hailstorm/) **Published:** September 28, 2026 **Author:** Diane Beauchamp **Content:** Montana’s insurance commissioner has fined four out-of-state vehicle repair companies for allegedly illegal activity after they attempted to service cars in the Bigfork area following July’s massive hailstorm. Commissioner Troy Downing said his office targeted the companies for illegally waiving or offering to waive insurance deductibles. He said Montana law prohibits this practice because, in many cases, the dent repair company overcharges insurance companies to recoup the loss of paying the deductible. That leads to higher premiums all around, he said. “One of the things that we have in law is that a repair place cannot charge a different amount for an insured customer than they can for an uninsured customer, and what this ends up being is it’s a different amount for an insured customer because they’re adding in the coverage of that premium,” Downing said. “One of the things that I just wanted to point out is … we’re all paying for insurance fraud.” The companies fined $1,000 include Hail Repair A1 LLC of Tucson, Arizona; Prestige Hail Damage Corporation of Royse City, Texas; SBM Ventures LLC of Castle Rock, Colorado; and National Dent Busters of South Boardman, Michigan. Downing said it’s common for contractors called “storm chasers” to go to areas that just experienced damaging weather. They go door-to-door trying to sell their repair service, and oftentimes, they take advantage of a bad situation to pressure consumers into signing with them, he said. Other pressures, such as the lack of available contractors due to Montana’s rapid growth, play a part, too. Downing said people already struggling often fall victim. “You’re looking at this damage and you have an obligation to mitigate the damage, and somebody is calling you up and saying, ‘Hey, sign this and we’ll have somebody there on Monday.’ That’s obviously enticing,” Downing said. “And a lot of times they’ll use these high-pressure sales techniques saying, ‘Well, if you don’t agree right now and if I don’t get a deposit right now, then you may be at the bottom of the list.’” He said it’s important for people to vet vendors. Consumers can also be liable for insurance fraud, especially if they know what they are doing is against the law. “We try to impress upon people that if somebody’s knocking on your door, or calling you trying to sell you a repair service, make sure that you do your homework,” Downing said. “Make sure that they’re licensed, make sure they are who they say they are, make sure that you can call them back from a website or a phone book or directory, so that you know who they are … For the most part, just make sure that they’re legitimate, that they’re licensed and a legitimate repair operation or contractor operation.” Montanans are urged to report all insurance fraud to the Office of the Commissioner of Securities and Insurance by calling 406-444-2040 or by going to CSIMT.gov. **Topics:** Contractor fraud, Regulatory actions --- ### [Cancer Testing, Diagnostics Lab Suffers Phishing Attack, 244K Impacted](https://insurancefraud.org/news_archives/cancer-testing-diagnostics-lab-suffers-phishing-attack-244k-impacted/) **Published:** September 28, 2026 **Author:** Diane Beauchamp **Content:** CSI Laboratories suffered a phishing attack on one employee email account that impacted 244,850 individuals. Cytometry Specialists, known as CSI Laboratories, disclosed a phishing attack that impacted 244,850 individuals. On July 8, CSI discovered that an employee email account had been compromised. After discovering the incident, CSI said it took steps to isolate the email account and investigate the attack. “We believe the access to a single employee mailbox occurred not to access patient information, but rather as part of an effort to commit financial fraud on other entities by redirecting CSI customer health care provider payments to an account posing as CSI using a fictitious email address,” CSI stated in a [notice](https://www.csilaboratories.com/) to patients. “The invoices were not directly billed to patients. Thus, we believe that the malicious actor was seeking to divert invoice payments.” On July 15, CSI determined that the unauthorized party managed to acquire certain files, including those containing patient information. The files were all related to invoices sent to CSI healthcare provider customers. Although the information differed by invoice, the files contained some combination of patient names, sample numbers, birth dates, and health insurance information. “At this time, we have no facts suggesting that any of the patient information has been used and, in most cases, it will be very difficult, if not impossible, for anyone to further use the patient information that was accessed,” CSI stated. “Accordingly, we do not believe that you need to take any steps at this time to protect your information.” ## CA Mental Health Clinic Experiences Breach Tessie Cleveland Community Services Corp., a mental health clinic based in California, disclosed a breach to 9,747 individuals. An unknown individual accessed information contained in some employee email accounts between June 17 and June 30. Tessie discovered the breach on June 30. “Based on our investigation, this incident was likely an attempt to commit business fraud against Tessie. We don’t believe the intent was to take a particular person’s information,” the organization [stated](https://www.tccsc.org/). “However, in an abundance of caution, we reviewed the contents of the email accounts and identified client information, including names, demographic information, health insurance identification numbers, limited information regarding care at Tessie, and in some instances, Social Security numbers.” Tessie Cleveland Community Services Corp. said it was working on further securing its email and network environment. ## Columbia River Mental Health Services Suffers Email Security Incident Vancouver, Washington-based Columbia River Mental Health Services (CRMHS) suffered a nearly year-long breach from May 2021 to April 2022, the organization [said](https://www.prnewswire.com/news-releases/columbia-river-mental-health-services-crmhs---notice-of-data-breach-301640493.html). CRMHS “determined that there was unauthorized access” to certain email accounts, but said it could not confirm whether information relating to specific individuals was actually accessed. The information in the email accounts included names, addresses, Social Security numbers, medical information, usernames and passwords, dates of birth, driver’s license numbers, and financial account information. CRMHS is mailing notification letters to impacted individuals. **Topics:** Public Awareness, Technology --- ### [Pinnacle hackers leak patient info, data on the web](https://insurancefraud.org/news_archives/pinnacle-hackers-leak-patient-info-data-on-the-web/) **Published:** September 28, 2026 **Author:** Diane Beauchamp **Content:** Pinnacle Midlands Health Network has confirmed a data leak following its report of an [IT breach](https://www.healthcareitnews.com/news/anz/hackers-strike-again-midland-health-services) on 28 September. In an update on 9 October, the network said malicious actors have uploaded to the internet information and data “related to past and present patients and customers” of the Pinnacle group in Waikato, Lakes, Taranaki and Tairāwhiti districts, including GP practices under Primary Health Care. Pinnacle CEO Justin Butcher said that “much of the information and data that was stolen last week has been made public.” “While Pinnacle does not hold GP notes and consultation records, we now have a much clearer understanding of the breadth of stolen data. This includes high-level data related to the use of hospital services, claiming information related to services that Pinnacle provides, and information sent to practices around immunisation and screening status of individual patients,” he explained. “This is extremely unfortunate, and we are gutted as this impacts our whānau also. Cyber incidents like this are a constant threat, and while they are the doing of malicious actors, we feel for everyone who may have been affected,” the network’s official added. Pinnacle said they are in contact with the police and the Office of the Privacy Commissioner. **THE LARGER CONTEXT** Two weeks ago, Pinnacle immediately took its IT system offline upon identifying a breach. In a statement, Te Whatu Ora, which is assisting in the investigations, maintained that the cyberattack is “no indication of a threat to Te Whatu Ora networks” as its system is separate from Pinnacle. Meanwhile, the network, which serves about 450,000 patients in 87 practices, has tapped IDCare for people specialist support to individuals who are believed to be at high risk due to the exposure of their information. **Topics:** Public Awareness, Technology --- ### [CA: Cardiac Imaging Associates notifying patients of data breach](https://insurancefraud.org/news_archives/ca-cardiac-imaging-associates-notifying-patients-of-data-breach/) **Published:** September 28, 2026 **Author:** Diane Beauchamp **Content:** Cardiac Imaging Associates (“CIA”) is notifying people of a breach that occurred earlier this year after an unauthorized actor could access files in an email account between approximately March 30, 2022, and April 6, 2022. CIA could not determine if the unauthorized actor viewed any particular email or attachment as a result of this activity. They report that the types of personal and/or medical information that may have been accessed or acquired included: names, dates of birth, Social Security numbers, driver’s license numbers, financial account information, payment card information, medical diagnosis, and condition information, medical laboratory results information, medication, and prescription information, and medical treatment information. CIA’s press release states that they are unaware of any actual or attempted misuse of the affected information due to this incident. Their press release does not mention any offer of credit monitoring or restoration services, and Cardiac Imaging Associates does not appear to have a website. Those seeking additional information will need to use the contact information provided in their [full press release:](https://www.prnewswire.com/news-releases/cardiac-imaging-associates-provides-notice-of-data-privacy-incident-301643844.html) > ***For More Information.*** Individuals seeking additional information regarding this incident can call CIA’s dedicated, toll-free number at (833) 708-2890, Monday through Friday 8 am – 10 pm CST, Saturday and Sunday 10 am – 7 pm CST (excluding major U.S. holidays). Please reference engagement number B071116. Individuals may also write to CIA directly at: 8581 Santa Monica Blvd., #471, Los Angeles, CA 90069. The press release source is listed as Positron Imaging Associates, Inc. but there does not seem to be any website for them, either. **Topics:** Public Awareness, Technology --- ### [How Scammers Are Using Technology With Medicare Fraud](https://insurancefraud.org/news_archives/how-scammers-are-using-technology-with-medicare-fraud/) **Published:** September 28, 2026 **Author:** Diane Beauchamp **Content:** According to the National Health Care Anti-Fraud Association, health care fraud costs the US [$68 billion every year](https://www.bcbsm.com/health-care-fraud/fraud-statistics.html). Fraudsters are always looking for ways to prey on citizens, using phone and technology scams to steal personal information. Medicare fraud and abuse usually target the elderly. With ever-advancing technology, scammers can lure them into sharing their Medicare numbers. Once they have Medicare numbers, they’re well on their way to full identity theft. In this post, we’re going to help you better understand these scams so you can prevent Medicare fraud from happening to you or your loved ones. The best prevention method is knowledge. The most common Medicare fraud cases involve enticing people with free offers or incentives. Offering medical equipment, such as braces, canes, or crutches, at no cost – and under the guise of professionalism – seems to affect the elderly the most. Once an offer is accepted, the scammer just has to get the victim’s Medicare number, and the job is done. They’re often extremely believable, and in some cases, the scammers may claim to be referred by the victim’s doctor. In order to avoid scams of this nature, be wary of anyone claiming to be giving out free medical equipment. A Medicare representative would never solicit you in this manner. This is one of the most obvious signs of scammers. **Bogus Prescriptions** Scammers will also work [in cahoots with health professionals](https://www.npr.org/sections/health-shots/2019/10/07/766517003/phone-scammers-and-teledoctors-charged-with-preying-on-seniors-in-fraud-case), having them contact people they’ve never met before. These immoral doctors will then perform a “medical consultation,” asking the victim a series of general questions, like “do you experience pain?” or “are you sleeping well?” Sometimes the doctor won’t even be present. Instead, a scammer will perform the consultation, then one or two doctors will write hundreds of fake prescriptions. Medicare numbers are then obtained. As the telemedicine industry grows, so does the prevalence of these types of scams. The simplest way to combat this fraud is to never accept a prescription from a doctor you’ve never met. This is not how telemedicine is designed to work. **How Technology Scams Work** There are a variety of tactics that technology scammers use to make themselves believable. Aside from phone calls and fake medical consultations, you see a lot of this done via email. You may receive an email that looks like it’s a Medicare email. These emails may ask you to update your financial records or say you’re entitled to a refund of some sort. These are phishing emails that are designed to look like official Medicare emails in order to get you to take a certain action. Again, Medicare will never email you unless you contact them first. Phishing is one of the most common scamming methods across every industry. They’re particularly dangerous for the elderly, who are less experienced with recognizing email scams. **Avoiding Medicare Fraud and Abuse** Now that you understand more about Medicare fraud and abuse, you’ll be in a much better position. There are bad actors in this world, and with advances in technology, they’ll always try new ways to get your money. Take note of what we’ve discussed here, and you’ll be able to avoid being taken advantage of. **Topics:** Healthcare Fraud, Medicare/Medicaid, Technology --- ### [West Virginia attorney general alerts public of hurricane relief scams](https://insurancefraud.org/news_archives/west-virginia-attorney-general-alerts-public-of-hurricane-relief-scams/) **Published:** September 28, 2026 **Author:** Diane Beauchamp **Content:** Fraud and scams can come in many shapes and sizes. There’s mail fraud, healthcare fraud and even charity and disaster fraud. West Virginia Attorney General Patrick Morrisey is warning residents in the Mountain State about a new scam popping up involving hurricane relief. “West Virginians are generous; we want to make sure they are protected and give to the right funds,” Morrisey said. West Virginia watched as Hurricane Ian affected millions of people. Now, residents may be impacted by efforts to donate and give back. “When something like that happens, obviously our thoughts and our prayers go out to the people affected. We want to make sure also that when people want to be generous and contribute to the folks who are really hurting, they are doing it the right way,” Morrisey said. “First, you want to make sure you’re donating to a bona fide charity registered with the Secretary of State. Second, call our office and find out if there are any scams associated with the particular charity, and third, you can do research to make sure that donations made to the charity are actually being used for the right purposes,” Morrisey said. While Florida works to rebuild and recover, officials remind you to monitor your personal information and donate wisely. “We live in the best state in the nation. It’s an amazing place. We just want people to be cautious when they are helping others so they are not getting ripped off,”Morrisey said. “We want you to be able to fulfill your intent and remain generous without the thieves coming in to block you.” The Federal Trade Commission Reports Consumers lost more than $5.8 billion to fraud in 2021. This is an increase of 70% from 2020, and the trend is continuing. “We see all of the above, we see phones, we see texts, we see emails, and folks are always trying to reach out on social media, and sometimes people try to push money in the wrong direction,” Morrisey said. To report charity or disaster fraud, you can contact the [Attorney General’s Consumer Protection Division](https://ago.wv.gov/consumerprotection/pages/default.aspx) or file a complaint online. **Topics:** Public Awareness --- ### [Baker & Hostetler helped client conceal 'blatant insurance fraud,' suit alleges](https://insurancefraud.org/news_archives/baker-hostetler-helped-client-conceal-blatant-insurance-fraud-suit-alleges-2/) **Published:** September 28, 2026 **Author:** Diane Beauchamp **Content:** A bankruptcy trustee has filed a lawsuit alleging that Baker & Hostetler helped a client commit “blatant insurance fraud” and cause several companies to wrongly pay more than $100 million in rebates to pharmacy benefit managers that managed patients’ insurance. The [Sept. 26 complaint](https://fingfx.thomsonreuters.com/gfx/legaldocs/lbvgnqlaapq/Yvette%20Austin%20Smith%20v%20Baker%20Hostetler%20-%20complaint.pdf) was filed by a trustee in the bankruptcy for the firm’s former client, Utah pharmacy company Alliance Health. [Law.com](https://www.law.com/texaslawyer/2022/10/03/bakerhostetler-accused-of-fraud-conspiracy-in-alliance-health-collapse), [Reuters](https://www.reuters.com/legal/legalindustry/bakerhostetler-partner-must-face-roche-lawsuit-amid-new-fraud-claims-against-law-2022-10-04) and [Law360](https://www.law360.com/articles/1535995/bakerhostetler-accused-of-fraud-in-100m-bankruptcy-suit) have coverage. The suit says Alliance Health was charging retail prices in its pharmacies for not-for-retail blood-glucose strips that were packaged as mail-order products for insured customers and purchased on the secondary market. Yet Alliance Health pharmacies were submitting insurance claims for the strips to insurers that covered retail strips, which were more expensive. The scheme caused makers of the test strips to pay more than $100 million in rebates on strips wrongfully designated as retail products and to lose a similar amount in sales of retail strips, the suit says. The rebates were paid for retail products but not the mail-order strips. Baker & Hostetler “had intimate knowledge of the questionable business practices” gained from performing legal services for Alliance Health and from a partner’s service on the company’s board of directors, according to the suit. “For more than two years,” the lawsuit says, “Baker helped a series of corporate executives carry out blatant insurance fraud. Baker had purported to offer its client expert counsel in health care law, but when attorneys at the firm learned that their client was engaged in fraudulent activity—a fraud that was highly profitable for the client—the attorneys shirked their ethical duties and instead used their legal skills and national reputation to facilitate the illegal activity.” According to the suit, Baker & Hostetler intentionally misled auditors and created “a labyrinth of corporate shell companies to hide the extent of, and thereby perpetuate, the fraud.” The firm also installed partner Lee Rosebush on Alliance Health’s board of directors “to cement the close relationship between Alliance and Baker,” the suit says. The suit alleges that Rosebush was informed of Alliance Health’s business model in a memorandum but counseled the company’s general counsel that it should continue the practice, according to Law.com’s coverage of the complaint. The trustee sued on behalf of Alliance Health’s three largest creditors, blood-glucose strip companies LifeScan Inc., the Roche Diagnostics Corp. and Roche Diabetes Care Inc. The suit alleges legal malpractice, aiding and abetting breach of fiduciary duty, negligent and fraudulent misrepresentation, and fraud. Rosebush, meanwhile, has to face a lawsuit filed by the Roche Diagnostics Corp. that alleges a fraud and racketeering scheme in connection with Alliance Health’s billing practices, Reuters reports. A federal judge in New Jersey on Friday [refused to toss](https://fingfx.thomsonreuters.com/gfx/legaldocs/gdvzyzkempw/Roche%20v%20Smith%20-%209-30-22%20ruling.pdf) the Roche case and a similar suit filed by LifeScan that does not name Rosebush as a defendant. The cases also target former Alliance Health employees and business partners. Rosebush and Baker & Hostetler did not immediately respond to an email seeking comment. **Topics:** Insider Fraud, Judicial/courts --- ### [NYT: Medicare Advantage rife with fraud](https://insurancefraud.org/news_archives/nyt-medicare-advantage-rife-with-fraud/) **Published:** September 28, 2026 **Author:** Diane Beauchamp **Content:** A [report](https://www.nytimes.com/2022/10/08/upshot/medicare-advantage-fraud-allegations.html) from *The New York Times* on Medicare Advantage says that most of the large insurers in the program have been accused of fraud. Insurers are accused of making patients appear sicker than they actually were to boost pay by looking for old illnesses in medical records and paying bonuses to doctors to add illnesses to patients they hadn’t seen in weeks. [Medicare Advantage](https://www.medicare.gov/sign-upchange-plans/types-of-medicare-health-plans/medicare-advantage-plans) is a private sector alternative to traditional Medicare and more than half of Medicare patients will be in the program by next year. According to the *Times* report, eight of the 10 largest [Medicare Advantage](https://www.medicaleconomics.com/view/how-to-improve-the-prior-authorization-process-for-medicare-advantage) insurers have submitted inflated bills. Four of the five largest players—UnitedHealth, Humana, Elevance, and Kaiser—face federal lawsuits alleging that efforts to overdiagnose their patients crossed the line into fraud. The fifth company, Aetna, told investors its practices were also being investigated by the Department of Justice. AHIP, the industry trade group for the insurance companies, said the accusations reflect missing documentation rather than fraud, and the *Times* reported that insurers dispute the federal allegations and were aiming to improve care by documenting more conditions to accurately reflect a patient’s health. *The Times* report also pointed out that [Medicare Advantage](https://www.medicaleconomics.com/view/price-not-a-good-indicator-of-medicare-advantage-plan-s-quality) plans typically earn twice as much gross profit than other types of insurance. According to *The Times*, the most common allegation is that the insurers did not correct potentially invalid diagnoses after becoming aware of them. At Anthem, for example, the Justice Department said “thousands” of inaccurate diagnoses were not deleted. According to the lawsuit, a finance executive calculated that eliminating the inaccurate diagnoses would reduce the company’s 2017 earnings from reviewing medical charts by $86 million, or 72 percent. The company said that the government is holding it to standards not grounded in statuatory and regulatory rules. **Topics:** Medicare/Medicaid, Public Awareness --- ### [Blood on Their Hands: Inside the staged car crash insurance scam which saw family pocket $6M as horror injuries & sick urine trick revealed](https://insurancefraud.org/news_archives/blood-on-their-hands-inside-the-staged-car-crash-insurance-scam-which-saw-family-pocket-6m-as-horror-injuries-sick-urine-trick-revealed/) **Published:** September 28, 2026 **Author:** Diane Beauchamp **Content:** A FAMILY of scammers pocketed $6million by staging car crashes using a sick urine trick and making themselves bloodied beforehand. William Oldham Mize, or Uncle Bill as he is known as, from Spokane Washington was the self-proclaimed mastermind behind his family’s life of crime. New York Magazine spoke with Ryan Park, Mize’s nephew, and Angela, his daughter, and reported on criminal court documents about the elaborate plots that they got sucked into. Mize, 61, would only work with people close to him as he thought including strangers would lead to too much uncertainty. For one of Mize’s insurance scams to work, the fake car crash had to look convincing and would lead to real injuries. He would usually place the fake victims in their cars, take his briefcase of tools and reach in through the windows so that the blood spatters looked real. He would cut people with razor blades and scuff up their wounds with sandpaper to make it look more believable, the outlet alleges. Mize would give his accomplices concussions by hitting them with a liquor bottle or a frying pan. Ryan said that Mize once made him chip his tooth with a pair of pliers, so he could later tell officials that he’d smashed it on a bottle during the crash. Then the battered actors would get into a car and Mize would get into another car and hit the actors at 40mph or 50mph, the outlet reported. Once he made impact, Mize would leave the car and hop into a getaway car, while another actor climbed into the driver’s seat to act as the at-fault driver. Angela recalled one crash, where she swapped with her father and entered the driver’s seat. She watched Mize crash her Sebring into a Mercedes. Mize escaped in another car, leaving Angela in the wreckage, among the smoke, chemicals, and road dust billowing from the crash. When the police showed up, Angela said: “How could I have done this?” and asked about the fake victims. To Angela’s surprise, the cops willingly believed the scam. It would happen at night with no cameras to catch them in their act before the cops would come. SICK URINE TRICK The “victims” would even spill a bottle of their own urine on themselves, so it looked like they blacked out. Once the paramedics took the actors to the hospital, they would repeat their made-up stories that Mize had them rehearse prior. They would tell hospital staff that they were covered by insurance, but didn’t have their member cards on them. Weeks later, the fake victims asked for an itemized bill and asked to pay at a cash-discount rate. Mize would then act as the victims’ representative under a fake name. He would negotiate a settlement with the at-fault insurance company, the outlet said. Sometimes, Mize would go as far as to fake the itemized bills to show even higher costs. Mize averaged six staged accidents a year and made more than $6million. Mize would pocket half the profits off of a scam and then once expenses like travel, celebrations, and even office supplies were calculated, Mize would give the rest of the actors their net profit. FAMILY OF CRIMINALS Other members of his family would join in on the scams that took place in Spokane and Las Vegas like his partner Sandi, his son Will V, and Ryan’s girlfriend Kimberly Boito. Ryan said “I was basically his minion” and that it was “like a cult.” Mize would find people when they were desperate for money, his family members said. “Business, I hated. Family, I loved,” Ryan said. “I couldn’t say goodbye to one side of it without saying goodbye to the other.” In 2018, the FBI raided Mize and Ryan’s houses. Twenty-two co-conspirators were charged for carrying out 33 staged car crashes since 2013. The scams go beyond five years, with the first one recorded in 2006 by the outlet, but since their is a five-year statue of limitations, the government couldn’t charge them of all of their crimes. Mize then went on the run and became a fugitive in 2019. Ryan, Kimmy, Angela, Sandi, and Ron Wells, Mize’s friend who was a part of the scheme, all took plea deals and everyone but Sandi, who is serving nearly six years, are already out of prison. **Topics:** Auto - staged **Categories:** Arrest --- ### [Is the cyber insurance industry on the brink of collapse?](https://insurancefraud.org/news_archives/is-the-cyber-insurance-industry-on-the-brink-of-collapse/) **Published:** September 28, 2026 **Author:** Diane Beauchamp **Content:** The cyber insurance industry, battered by a seemingly unending onslaught of claims, is reaching a breaking point. According to the FBI’s latest Internet Crime Report, cyber-related complaints have increased by more than 180% over the last 5 years, resulting in $18.7 billion in losses. Last year, some carriers ended up paying out more in claims than they received from premiums. As a result, the industry is now demanding that customers reduce their exposure or face steep price increases or quite possibly cancellations. In an effort to shore up the industry, some insurance providers are taking a more hands-on approach in an effort to reduce their client’s risk. At the forefront is an attempt to mitigate human error, the crux of the problem. According to a 2021 Data Breach Investigations Report from Verizon, accidental clicks or other mistakes make up 85% of successful hacks. This has led insurers in search of cybersecurity training programs that have been independently verified to actually change human behavior. No longer optional Survival of the cyber insurance industry is paramount. According to the National Cyber Security Alliance, 60% of small to medium businesses (SMBs) fold within six months of a cyberattack. The irony is that while SMBs cannot afford to go without cyber insurance, many soon won’t be able to afford the insurance itself. Business owners and CEOs are feeling the seriousness of the situation when their renewal letters arrive. Premiums – which increased by as much as 300% in 2021, according to a report by Risk Placement Services Inc. – are expected to escalate at an even more dramatic pace moving forward. At the same time, insurers are adding exclusions, limiting coverage, and some are even exiting the market entirely. “For some underwriters, the risk in offering cybersecurity coverage is simply too great at this point in time,” noted Mark Weir, who has spent over 30 years in the insurance industry and is now managing director of LCM Solutions, a Canadian consulting firm. “In spite of the fact that taking risks is their business, insurance is an industry that doesn’t like uncertainty.” In the early days of cyber insurance, the one thing guaranteed was hefty profits. Insurance companies were eager to get into the market because demand was high and the perceived risk was low. “Initially, companies were offering cyber insurance thinking they would never actually have a claim,” explains Jeremy Harris, CEO of Mindshare IT, a managed service provider offering both IT and cybersecurity services. “Now they find themselves in a sticky situation and are looking for solutions.” In the past, almost all incidents were covered regardless of fault. Today, if a company fails to properly train employees or demonstrates poor security hygiene and gets hacked, its claim may be denied and future access to coverage could also be in jeopardy. Dramatic rise in attacks The cyber insurance industry may have become a victim of its own success. As insurers began to offer more coverage, businesses may not have felt the need to be as vigilant in their defenses. Often, they would quickly pay ransomware assuming they would be reimbursed. As a result, cybercriminals may have become incentivized to target companies with cyber insurance policies in place. Now, with escalating attacks and shrinking coverage, insurers are trying to actuate companies to be more vigorous in reducing risk. Of note is the push for more stringent employee education on cybersecurity issues. Many experts feel training is crucial in order to slow down successful phishing breaches, which account for an overwhelming majority of attacks. Phishing, along with other forms, like vishing – over the phone, smishing – via text, and pharming – visiting fraudulent websites, often leads to the deployment of malicious software, like ransomware. A growing number of new regulations now require a number of industries to add ongoing education to their security programs, but some top executives question whether these generic training programs work as advertised. “Our view is training that does not impact risky behaviors is a waste of time and money for our clients,” says Kirsten Bay, CEO of Cysurance – a US-based cyber insurance company that writes policies to protect against privacy breaches, identity theft, system damage, and other cybercrimes. Bay says that Cysurance was looking for a training platform that took into account how different personality types perceive and respond to risks, such as an email with a link or attachment. The platform would then target those specific people with consistent, ongoing training materials that would evoke a change in one’s actions. “For us, the goal is to find proven ways to detect and prevent harm which then lowers the risk of both a security event for our clients and also a future claim,” explains Bay. “Our partnership with cyberconIQ accomplishes that.” Based in York, PA, cyberconIQ pioneered the merging of psychology and technology to measure and manage cybersecurity risk. The company’s assessment, training and education have been proven to reduce the risk of a successful attack by 45-90%. “I think what you’re seeing with the better security training companies out there is that they really focus on the individual’s personality and train them accordingly,” says Harris. “Those that have metrics proving a reduction in potential breaches are rising to the top.” Personalized behavioral training Some personalized training programs have demonstrated they greatly reduce the rate of phishing failures. For example, cyberconIQ has been verified to cut failures from a national average rate of 15% – 18%, to fewer than 2% after just 30 days. In their program, CyberconIQ uses a 40-question assessment, akin to a Myers-Briggs personality test, to assess the susceptibility of each employee. Then, by utilizing machine learning to develop a customized approach, they can correct key motivating factors that drive underlying online behavior and measurably lower their vulnerability to fraud. “What we look for is to develop a ‘culture of compliance,” remarked Weir. “However, what helps one person, may not be helpful to another. So, this idea of first evaluating the psychology of the individual and then educating that person based on their natural propensity is a game-changer. I think it is going to be what keeps the cyber insurance industry afloat.” By partnering with a cyber training company that provides verified proof of reducing claims, insurance companies can greatly minimize their risks and therefore reduce the costs of their coverages. “I give a lot of credit to those insurance companies who are smart enough to realize they have to help their clients mitigate risk,” concludes Harris. “It’s for the good of these small companies as well as the overall health of the cyber insurance industry.” **Topics:** Public Awareness --- ### [Iowa Medicaid fraud unit reports 37 convictions, calls for more use of False Claims Act](https://insurancefraud.org/news_archives/iowa-medicaid-fraud-unit-reports-37-convictions-calls-for-more-use-of-false-claims-act/) **Published:** September 28, 2026 **Author:** Diane Beauchamp **Content:** The head of Iowa’s Medicaid Fraud Control Unit said his team secured 37 fraud convictions during the previous fiscal year, but said more could be done. It also recovered $3.9 million from civil settlements, joint federal/state False Claims Act recoveries, and administrative repayments. The update came during the third meeting of the newly formed Iowa Medicaid Fraud Elimination Task Force. Jeremy Ingram, director of the Medicaid Fraud Control Unit, said Iowa’s nine-member unit is one of the smallest in the country, costing $1.3 million. ## Director calls for more collaboration Ingram said the state should be enforcing the Civil False Claims Act more to reduce Medicaid fraud. He said those cases could bring more money back to the state. “It is imperative that the Iowa Medicaid fraud control unit, Iowa Medicaid, and managed care organizations continue to collaborate to increase and enhance fraud referrals, streamline the flow of fraud tips to the Medicaid fraud control unit,” Ingram said. Ingram said more collaboration and funding is needed between his team, the attorney general’s office, and the Department of Inspections, Appeals, and Licensing on cases involving false claims. The False Claims Act allows citizens to sue healthcare providers on the state’s behalf for billing Medicaid for work they didn’t do. The Medicaid Fraud Control Unit uses those claims, with the help of the attorney general’s office, for its investigations. “Coordinating available DIAL and attorney general office resources to pursue violations of Iowa code chapter 685 may serve as a force multiplier to increase Medicaid fraud recoveries and assist in deterring healthcare fraud in Iowa,” Ingram said. Ingram did not have the number of false claims that have been filed when asked. ## Attorney general addresses need for task force Attorney General Brenna Bird was asked why the new task force is needed given that the current unit’s efforts resulted in 37 convictions out of about 700,000 Iowans who use Medicaid health insurance. “It’s important that we are not just reactive but we are proactive when it comes to fighting fraud, and so it is very important that we get those tips from people, and that those are investigated and followed up on. But we also need to be more proactive looking at where the fraud may be occurring, rather than waiting for some to discover it and report it,” Bird said. ## Former official says attorney general should be more aggressive Dean Lerner, a former state department head who attended the meeting, criticized the state for not using the Medicaid Fraud Control Unit more. He said it is the attorney general who should be more aggressive in enforcing the False Claims Act. “Those dollars that are spent on those nursing homes for medicaid residents, should be sought from the nursing homes and should be put back in the state coffers, and they are not being done. And that would be one area that should be a big focus,” Lerner said. “There are numerous opportunities to file those cases against nursing homes that are providing woefully inadequate care to people and killing people,” Lerner said. Lerner said the task force should take funds recovered from false claims investigations and put them back into the Medicaid program. ## Next steps The task force must present recommendations to Gov. Kim Reynolds next month. Bird says it’s up to both the governor and state legislators to implement those recommendations. Bird, a Republican, is running for reelection this November. Her Democratic opponent, Nate Willems, said in a statement that the state should be supporting and funding the Medicaid Fraud Control Unit that already exists, “not pretending a new taskforce and more bureaucracy is getting the job done.” **Topics:** Public Awareness, Regulatory actions --- ### [Texas Mental Health Clinic Owner Convicted in $26M Scheme to Defraud Military Health Benefits Program](https://insurancefraud.org/news_archives/texas-mental-health-clinic-owner-convicted-in-26m-scheme-to-defraud-military-health-benefits-program/) **Published:** September 28, 2026 **Author:** Diane Beauchamp **Content:** A federal jury in Fort Worth convicted a Texas licensed professional counselor yesterday for his role in a $26 million health care fraud, kickbacks, and money laundering scheme. “Yesterday’s verdict makes clear that those who try to defraud the United States will be met with swift and decisive justice,” said Assistant Attorney General Colin M. McDonald of the Department of Justice’s National Fraud Enforcement Division. “This defendant exploited a critical health care program serving active-duty servicemembers and their families, diverting taxpayer dollars to bankroll personal luxuries ranging from hotel stays to a casino-themed party and even a gold‑plated Tesla Cybertruck. Such conduct is an affront to the military community and the American public. The Department of Justice will continue to aggressively pursue anyone who abuses federal programs for personal gain.” “Kevin Curry shamelessly preyed on the trust of servicemembers, veterans, and their families, siphoning millions from TRICARE through lies and coercion, said U.S. Attorney Ryan Raybould. “He fabricated medical records, stole doctors’ identities and clogged the system with fraudulent claims, all while lining his pockets with kickback‑tainted money. This conviction sends an unmistakable message that those who manipulate our military community and defraud federal healthcare programs will face the full force of federal prosecution.” According to court documents and evidence presented at trial, Kevin D. Curry, 64, of Frisco, Texas, orchestrated a scheme to bill TRICARE for transcranial magnetic stimulation (TMS) therapy that was medically unnecessary or not provided. Curry, the owner and operator of two purported mental health clinics in Texas, Acuity TMS of Plano LLC and Acuity TMS of Fort Worth LLC, and one purported mental health clinic in Florida, Emerald Coast TMS of Fort Walton Beach LLC (collectively, Acuity), offered and paid over $5.5 million in kickbacks to convince active-duty servicemembers, veterans, and their family members to consent to TMS therapy they did not qualify for and, in many instances, did not receive. Curry, who falsely held himself out to be a medical doctor, used actual doctors’ credentials without their knowledge and consent to bill TRICARE as part of the scheme. In an effort to conceal his fraud, Curry directed employees to fabricate medical records that he submitted to TRICARE to justify his fraudulent billings. Acuity billed TRICARE over $26 million in false, fraudulent, and kickback-tainted TMS claims, based on which TRICARE paid approximately $17 million. Curry laundered some of the proceeds by spending his ill-gotten gains on hotels, a lavish casino-themed party, and a gold-plated Tesla Cybertruck worth over $100,000. The jury convicted Curry of three counts of health care fraud, three counts of offering and paying illegal health care kickbacks, and three counts of engaging in monetary transactions in criminal derived property. He is scheduled to be sentenced at a later date and faces a maximum penalty of 10 years in prison on each count. A federal district court judge will determine any sentence after considering the U.S. Sentencing Guidelines and other statutory factors. Assistant Attorney General Colin M. McDonald of the Justice Department’s Fraud Division; United States Attorney Ryan Raybould of the Northern District of Texas; Special Agent in Charge Chad Gosch of the Department of Department’s Defense Criminal Investigative Service (DCIS), Southwest Field Office; Special Agent in Charge R. Joseph Rothrock of the FBI Dallas Field Office; Chief William Marlowe of the Texas Attorney General’s Medicaid Fraud Control Unit (MFCU); and Special Agent in Charge Kris Raper of the Department of Veteran’s Affairs Office of Inspector General (VA-OIG), South Central Field Office, made the announcement. DCIS, FBI, MFCU, and VA-OIG investigated the case. Assistant U.S. Attorney Ethan Womble for the Northern District of Texas and Trial Attorneys Adam Tisdall and Yael Mash of the Fraud Division’s Health Care Fraud Section are prosecuting the case. On April 7, the Department of Justice announced the creation of the National Fraud Enforcement Division (Fraud Division). The Fraud Division is laser-focused on investigating and prosecuting those who commit fraud against the American people. The Department’s work to combat fraud supports President Trump’s Task Force to Eliminate Fraud, a whole-of-government effort chaired by Vice President J.D. Vance to eliminate fraud, waste, and abuse within Federal benefit programs. The Department of Justice’s Health Care Fraud Strike Force Program, currently comprised of nine strike forces operating in federal districts across the country, has charged more than 6,200 defendants who collectively billed federal health care programs and private insurers more than $45 billion since 2007. In addition, the Centers for Medicare & Medicaid Services, working in conjunction with the Office of the Inspector General for the Department of Health and Human Services, are taking steps to hold providers accountable for their involvement in health care fraud schemes. More information can be found at [www.justice.gov/criminal-fraud/health-care-fraud-unit](http://www.justice.gov/criminal-fraud/health-care-fraud-unit). **Topics:** Veterans Benefits Fraud **Categories:** Conviction --- ### [Insurers Split Over AI Coverage As Misinformation And Deepfakes Drive Most Reported Harms](https://insurancefraud.org/news_archives/insurers-split-over-ai-coverage-as-misinformation-and-deepfakes-drive-most-reported-harms/) **Published:** September 28, 2026 **Author:** Diane Beauchamp **Content:** Businesses are rapidly embedding artificial intelligence into customer service, hiring, fraud detection and autonomous systems, but insurance coverage for any resulting harms remains fragmented and inconsistent, according to RAND. The report, from RAND’s Institute for Civil Justice and Feinberg Center for Catastrophic Risk Management and Compensation, examined the AI Incident Database, a George Washington University database of AI lawsuits, enacted state laws and insurance filings submitted through the industry’s electronic rate and form filing system. Of 713 generative AI incidents tracked since ChatGPT’s November 2022 launch, 599, or 84%, involved misinformation or deepfakes, RAND found. An additional 47% of incidents fell into categories including hallucinations and factual errors (30%), harmful content (13%) and agentic or autonomous failures (12%), with some incidents spanning multiple categories. Litigation tells a different story. Of 249 U.S. generative AI lawsuits reviewed, 150, or 60%, centered on intellectual property or training-data disputes against AI developers rather than harms from model outputs, RAND found. Privacy and surveillance claims, fraud and deception cases, and product liability suits, including wrongful-death claims tied to companion chatbots, made up smaller but growing shares. Separately, most of the 189 enacted state AI laws RAND examined target harmful synthetic content: 33 states have passed 62 laws addressing nonconsensual intimate images and child sexual abuse material. ### Carriers Diverge On Exclusions, Coverage And Silence Insurers are not treating AI as a single peril or a stand-alone line, RAND found, because the same model can generate very different forms of loss depending on how it is trained, deployed and used. Some major carriers are moving to exclude AI losses broadly. Verisk/ISO developed exclusionary language in January 2026 for bodily injury, property damage and personal and advertising injury caused by generative AI, and its standardized forms appear in more than 80% of U.S. property and casualty policies, according to the report. Berkley revised its directors and officers, errors and omissions, and fiduciary liability policies to exclude claims tied to nearly any use, deployment or development of AI, including a company’s own statements about its AI capabilities, the report said. RAND said filing data show exclusion activity surging beginning in summer 2025, concentrated in commercial umbrella and commercial general liability policies. Other carriers are moving toward affirmative coverage. Munich RE, AXA XL and Coalition have expanded policies to address hallucinations, bias, privacy infringement and AI-enabled fraud, while new entrants including Testudo, Armilla and the Artificial Intelligence Underwriting Company offer stand-alone AI liability products, some with limits up to $50 million, according to RAND. Most carriers, however, are doing neither, leaving policies silent on whether AI-related losses are covered. RAND said this silence does not necessarily create ambiguity for policyholders in every case, but coverage still depends on policy language, the theory of liability and how exclusions and definitions not drafted with AI in mind ultimately apply. ### Accumulation Risk And A Widening Protection Gap RAND identified five mechanisms that could produce correlated, large-scale losses across insurers: - Universal attacks exploiting the same vulnerability across many AI systems. - Common dependency on shared models or infrastructure, including hyperscalers Amazon Web Services, Microsoft Azure and Google Cloud. - AI acting as a “force multiplier” for cyberattacks. - Legal or regulatory shocks that suddenly expose many firms to liability at once. - Subtle, prolonged degradation of model performance. RAND said the size of the AI protection gap, the difference between economic losses and insured losses, and the extent of insurer accumulation exposure are linked: broader affirmative coverage shrinks the protection gap but raises insurer exposure, while broader exclusions do the reverse. Silent coverage, the report said, obscures both metrics, making it difficult for policyholders, insurers and regulators to determine what is actually insured. RAND recommended that state insurance regulators and the National Association of Insurance Commissioners develop a standardized AI Coverage Notice, that industry stakeholders build a common taxonomy for tracking AI incidents and claims, and that insurers and reinsurers conduct and disclose AI accumulation scenario analysis. **Topics:** Public Awareness, Technology --- ### [Monterey Co.: Ex-Salinas Prison Officer Pleads No Contest To Workers Comp Fraud Charge](https://insurancefraud.org/news_archives/monterey-co-ex-salinas-prison-officer-pleads-no-contest-to-workers-comp-fraud-charge/) **Published:** September 28, 2026 **Author:** Diane Beauchamp **Content:** A former correctional officer at Salinas Valley State Prison pleaded no contest to felony insurance fraud after she was accused of falsely claiming a workplace injury and receiving more than $100,000 in insurance benefits, prosecutors said Wednesday. Lorena Hernandez Alvarado, 43, of King City, also pleaded guilty in two separate DUI cases. The insurance fraud case stemmed from a claim she made after an April 2021 incident at the prison, the Monterey County District Attorney’s Office said in a statement. Prosecutors allege Alvarado claimed she injured her shoulder, neck, back and knees while using a heavy shield to protect herself from liquid thrown by an inmate. The prison’s insurer, the State Compensation Insurance Fund, accepted the claim, and Alvarado received more than $100,000 in wage replacement and health care benefits. She never returned to work, the District Attorney’s Office said. An investigation by the California Department of Corrections’ Internal Affairs found that Alvarado never used a shield during the 2021 incident, prosecutors said. Investigators also alleged she had fabricated a separate workplace injury claim in 2019 involving a struggle with an inmate. That earlier claim was denied. Alvarado’s plea included an admission that the fraud caused more than $100,000 in losses. She will return to court Oct. 22 for sentencing, prosecutors said. **Topics:** Work comp - worker **Categories:** Conviction --- ### [Attorney General Alan Wilson announces nurse charged with stealing drugs from patients](https://insurancefraud.org/news_archives/attorney-general-alan-wilson-announces-nurse-charged-with-stealing-drugs-from-patients/) **Published:** September 28, 2026 **Author:** Diane Beauchamp **Content:** South Carolina Attorney General Alan Wilson announced that his office’s Vulnerable Adults and Medicaid Provider Fraud Unit (VAMPF), in coordination with the South Carolina Department of Public Health’s Bureau of Drug Control, has arrested Joanne Claus, 70, of Bishopville, S.C. Claus faces the following charges: Five (5) counts of Exploitation of a Vulnerable Adult {§ 43-35-85(D)} Five (5) counts of Obtaining Controlled Substance by Fraud {§ 44-53-0390} Claus was booked into the Kershaw County Detention Center on September 23, 2026. A joint investigation by VAMPF and the Bureau of Drug Control alleges that Claus, while employed as a Licensed Practical Nurse at Karesh Long Term Care and Rehab in Camden, S.C., used misrepresentation, fraud, forgery, deception, or subterfuge to obtain Hydrocodone/Acetaminophen, a Schedule II controlled substance, from five residents of the facility. The victims, all residents of the facility, were legally classified as vulnerable adults under South Carolina law. The alleged incidents occurred between April 11, 2026, and July 1, 2026. South Carolina Offenses and Penalties: Exploitation of a Vulnerable Adult – Felony, punishable by imprisonment for not more than 5 years, a fine of not more than $5,000, or both. Obtaining Controlled Substance by Fraud – Felony, punishable by imprisonment for not more than 5 years, a fine of up to $10,000, or both. This case will be prosecuted by the Attorney General’s Office. Pursuant to federal regulations, VAMPF has authority over Medicaid provider fraud; abuse and neglect of Medicaid beneficiaries in any setting; and the abuse, neglect, and exploitation of individuals residing in assisted living facilities or nursing homes. Attorney General Wilson stressed that all defendants are presumed innocent unless and until they are proven guilty in a court of law. **Topics:** Drug Diversion, Elderly Fraud, Medicare/Medicaid **Categories:** Arrest --- ### [Former Delaware insurance agent sentenced for theft of client funds, targeted vulnerable communities](https://insurancefraud.org/news_archives/former-delaware-insurance-agent-sentenced-for-theft-of-client-funds-targeted-vulnerable-communities/) **Published:** September 28, 2026 **Author:** Diane Beauchamp **Content:** The Delaware Department of Insurance announced that former Delaware insurance agent Zenaida Nieves-Cordero has been sentenced to three years in prison and will also have to pay over $600k in restitution. She pleaded guilty to three counts of felony theft involving the misappropriation of client funds. The Department says their investigation began after multiple reports of unexplained withdrawals and missing funds were received. DOI investigators started a detailed inquiry into business practices at Nieves-Cordero’s former agency, Apple Insurance Inc., and uncovered a pattern of unauthorized withdrawals from clients’ bank accounts. Her clients had entrusted Nieves-Cordero to withdraw funds solely for the purpose of paying insurance premiums, but evidence showed she diverted hundreds of thousands of dollars for her own personal use over several years. According to the DOI, the majority of Nieves-Cordero’s clients were Spanish-speaking residents of Kent and Sussex Counties. Department officials believe she deliberately targeted this vulnerable community, exploiting fears of talking to law enforcement and therefore making it less likely that victims would report her misconduct. The DOI adds that they acknowledge and commend those who overcame these fears and came forward anyway, allowing investigators and the Department of Justice to hold Nieves-Cordero accountable. Insurance Commissioner Trinidad Navarro asked for and was granted a Court of Chancery conservatorship over Apple Insurance Inc. and Nieves-Cordero’s business operations in order to ensure an orderly wind-down of the business. The DOI says after the conservatorship was approved, investigators found that Nieves-Cordero had already emptied the company’s known bank account and continued accessing funds through undisclosed accounts, which the DOI says demonstrates clear efforts to evade accountability. Commissioner Navarro highlighted the severity of Nieves-Cordero’s crimes. He said that in nearly a decade as Commissioner and more than 26 years of combined law enforcement experience, he had never seen a case involving theft of this magnitude by an insurance agent. Commissioner Navarro emphasized that Nieves-Cordero’s fiduciary responsibilities and her deliberate targeting of a community based on their heritage should be recognized as significant aggravating factors. “This was one of the most severe breaches of trust by an insurance agent that our Department has ever encountered,” said Commissioner Navarro. “Ms. Nieves-Cordero exploited her position and targeted a community that placed their confidence in her. I am grateful to the individuals who came forward despite their fears, allowing us to uncover the full scope of her actions and ensure she is held accountable. The Department remains steadfast in protecting Delaware consumers and upholding the integrity of our insurance marketplace.” In addition to her three-year prison term, Nieves-Cordero received additional levels of probation after her release. The Department says she was ordered to have no contact with victims and must pay $625,226.75 in restitution. **Topics:** Insider - agent **Categories:** Conviction --- ### [NICB & Honk partner to combat predatory towing and vehicle-related fraud](https://insurancefraud.org/news_archives/nicb-honk-partner-to-combat-predatory-towing-and-vehicle-related-fraud/) **Published:** September 28, 2026 **Author:** Diane Beauchamp **Content:** The National Insurance Crime Bureau (NICB) announced a new strategic partnership with Honk Technologies that will combine both organizations’ data and intelligence capabilities to combat fraud and abusive practices related to vehicle towing, impound, storage and salvage. Through this partnership, NICB and Honk said they will establish paths for sharing information and emerging fraud intelligence across NICB’s consortium of fraud-fighting partners as new issues and questionable activity emerges across the towing and vehicle services marketplace. NICB highlighted this collaboration expands on its approach by fostering cooperation between roadside assistance providers, insurance companies, and law enforcement agencies to identify and address insurance fraud and related criminal activity. NICB added that partnerships enable to convert information that might otherwise remain isolated into actionable insights that protect insurers, legitimate businesses and policyholders from the costly burden of fraud. “Fraud and questionable practices both on and off the road can create significant costs for consumers and insurers alike,” said Tim Slater, Chief Operating Officer of NICB. “By working closely with Honk and combining information from our respective networks, we can identify concerning activity sooner, provide the key information that helps solve cases and strengthen our protections against fraud and abuse in the vehicle services ecosystem.” Honk is a technology platform designed to modernize the way towing and roadside assistance are delivered nationwide. Working with leading insurance carriers, automotive companies, fleets and mobility providers, Honk can connect motorists with a nationwide network of service providers while capturing real-time data across the service lifecycle. That combination of technology, network scale and operational visibility gives Honk a unique perspective into trends and activity across the towing and roadside ecosystem. “Because of the volume of towing and roadside activity that moves through our platform, we have a unique view into what’s happening on the ground across the country,” Honk president Matt Bijur said. “Fraudulent and predatory practices hurt motorists and insurers, but they also hurt the reputation and livelihood of honest, hardworking service providers doing things the right way. “Our partnership with NICB gives us a way to turn what we’re seeing into actionable intelligence that can help root out bad actors and protect the broader towing and roadside ecosystem,” Bijur added. **Topics:** Public Awareness, Technology --- ### [Grassley Continues Fight Against Healthcare Fraud, Praises Latest White House Anti-Fraud Task Force Action](https://insurancefraud.org/news_archives/grassley-continues-fight-against-healthcare-fraud-praises-latest-white-house-anti-fraud-task-force-action/) **Published:** September 28, 2026 **Author:** Diane Beauchamp **Content:** Happy news in the fight against fraud – this week, the White House Task Force to Eliminate Fraud took steps to stop fraud and to prevent bad actors from gaming Obamacare. The administration is working to stop fraudulent and improper Obamacare enrollment. Now, just think, over 600,000 consumers attested to unauthorized enrollment or plan switching. This task force has the potential to save billions in taxpayer dollars. This action will ensure resources are only going to those who are eligible and have signed up or authorized their enrollment. Too often, taxpayers’ money is lost to fraud, waste and abuse. This not only wastes taxpayer dollars, but it also limits how effectively those dollars could be used to help the most vulnerable, those people that Medicaid and Obamacare were intended to serve. The administration’s action complement my work in the Senate and the work of Iowa’s Representatives Hinson, Miller-Meeks, Nunn and Feenstra in the House, accomplished when we passed the 2025 Working Families Tax Cuts law. The tax cuts law not only prevented the largest tax increase in American history, but it also established program integrity reform to stop fraud, waste and abuse, as well as preserve programs like Medicaid and Obamacare. In the past year, I’ve come to this floor highlighting how my own oversight, along with inspectors general audits and Government Accountability Office reports, have found taxpayer dollars being wasted on: deceased enroll\[ees\] and providers, enrollees participating in two different states’ Medicaid programs and who are dually enrolled in Medicaid and Obamacare, excess Obamacare subsidies not being paid back and consumers being fraudulently enrolled in Obamacare. The Working Families Tax Cuts Act put an end to much of this fraud, waste and abuse in the Medicaid and Obama\[care\] programs. To bolster these efforts, last month, I introduced a bill with the title: Health Care Fraud Prevention and \[Enforcement\] Act. This bill will improve and will invest in the Health Care Fraud and Abuse Control program. That program was created to combat fraud across federal health programs, but that program needs improvements. Federal health care spending is expected to exceed $24 trillion over the next decade. Through the Working Families Tax Cuts Act and by improving the Health Care Fraud and Abuse Control Program, we can crack down on bad actors stealing the taxpayers’ money and really protect resources for the most vulnerable Americans. **Topics:** Legislative, Public Awareness --- ### [Florida Doctor Sentenced for Making False Statements in Connection with Multi-Million-Dollar Health Care Fraud Scheme](https://insurancefraud.org/news_archives/florida-doctor-sentenced-for-making-false-statements-in-connection-with-multi-million-dollar-health-care-fraud-scheme/) **Published:** September 28, 2026 **Author:** Diane Beauchamp **Content:** A Florida-based doctor was sentenced on Sept. 22, 2026 in federal court in Boston for making false statements in connection with a multi-million-dollar health care fraud scheme involving medically unnecessary genetic testing and durable medical equipment (DME). Simon Grinshteyn, 52, was sentenced by U.S. District Court Judge Angel Kelley to four years of probation with six months in home confinement and 400 hours of community service. The defendant was also ordered to pay $3,160,809.43 in restitution. The government recommended a sentence of 18 months in prison followed by 18 months of supervised release. In March 2026, Grinshteyn pleaded guilty to one count of making false statements relating to health care matters. Grinshteyn was charged in January 2026. Between February 2020 and June 2020, Grinshteyn worked with a purported telemedicine company to sign medical documentation, including doctors’ orders, for medically unnecessary genetic testing and DME. The medical records and doctors’ orders Grinshteyn received and signed were pre-populated and made it appear that Grinshteyn was providing legitimate consultations to Medicare beneficiaries and had conducted examinations of the beneficiaries and/or would provide further medical care to them. Grinshteyn generally did not contact the beneficiaries himself and had no provider-patient relationship with the beneficiaries. DME suppliers and laboratories ultimately submitted claims to Medicare for these signed orders. As a result of Grinshteyn’s participation in this scheme, Medicare paid more than $3.1 million in claims for DME and genetic testing that were based on false documentation. United States Attorney Leah B. Foley; Robert Coviello, Special Agent in Charge, Health and Human Services-Office of Inspector General; Ted E. Docks, Special Agent in Charge, Federal Bureau of Investigations, Boston Division; Justin Page, Acting Inspector in Charge of the U.S. Postal Inspection Service’s Boston Division; Kelly Lawson, Regional Director, Boston Regional Office, Employee Benefits Security Administration, U.S. Department of Labor; and Christopher Silvestro, Special Agent in Charge of the Defense Criminal Investigative Service, Northeast Field Office made the announcement today. Assistant U.S. Attorneys Alexandra Brazier and Lindsey Ross of the Affirmative Civil Enforcement Unit prosecuted the case. **Topics:** Healthcare Fraud **Categories:** Conviction --- ### [AG Nessel Charges Dental Practice Manager for Alleged Medicaid Fraud Scheme](https://insurancefraud.org/news_archives/ag-nessel-charges-dental-practice-manager-for-alleged-medicaid-fraud-scheme/) **Published:** September 28, 2026 **Author:** Diane Beauchamp **Content:** Yesterday, Lina Abraham, 41, of Dearborn, was arraigned in the 54B District Court in East Lansing on 15 felony charges related to an alleged Medicaid fraud scheme, announced Michigan Attorney General Dana Nessel. Abraham was employed as an office manager at Dearborn Family Smiles, a Dearborn dental clinic, at the time of the alleged crimes. Abraham is charged with one count of Conducting a Criminal Enterprise, punishable by up to 20 years’ incarceration and/or a fine of up to $100,000, and 14 counts of Medicaid Fraud, each punishable by up to four years’ incarceration and/or a fine of up to $50,000. Abraham is alleged to have repeatedly billed the taxpayer-funded Medicaid program for dental crowns that were never provided to patients, under her employing clinic’s former name, Artistic Dentistry. It is not suspected that others associated with the dental clinic were involved in the alleged fraud scheme. “Medicaid provides access to health care for millions of Americans,” said Attorney General Nessel. “It is a vital resource for family health all across Michigan, and my office is specifically entrusted to defend the state and federal program from fraud. I’m grateful to our team of investigators and prosecutors for bringing this case, and for their efforts to protect our institutions.” Abraham was arraigned on September 23rd, and will next appear before the 54B District Court for a probable cause conference on October 2nd. This case was referred for investigation to the Michigan Department of Attorney General by Delta Dental. The Attorney General’s Health Care Fraud Division (HCFD) is handling this case for the Department. The HCFD is the federally certified Medicaid Fraud Control Unit for Michigan, and it receives 75% of its funding from the U.S. Department of Health and Human Services under a grant award totaling $5,517,524.00 for the fiscal year 2026. The remaining 25% percent, totaling $1,839,170.00, is funded by the State of Michigan. **Topics:** Medicare/Medicaid **Categories:** Arrest --- ### [Attorney general sues Durango doctor for alleged defrauding of Colorado Medicaid](https://insurancefraud.org/news_archives/attorney-general-sues-durango-doctor-for-alleged-defrauding-of-colorado-medicaid/) **Published:** September 28, 2026 **Author:** Diane Beauchamp **Content:** Colorado Attorney General Phil Weiser filed a lawsuit at the start of the month against Durango doctor Daniel Caplin for allegedly defrauding Colorado Medicaid out of hundreds of thousands of dollars. The lawsuit, filed Sept. 1 in Denver District Court, alleges Caplin knowingly submitted or caused Colorado Addiction Treatment Services, which he owned and operated, to submit fraudulent Medicaid claims after the clinic’s probationary controlled substance license expired. The state says Medicaid paid $374,240 on the claims. “We allege that Dr. Caplin knew his clinic had lost the license needed to provide these services and continued billing Medicaid anyway,” Weiser said in a Tuesday news release. “Providers who accept public funds have a responsibility to follow the law, and we will hold accountable those who defraud Colorado taxpayers.” Caplin declined to comment for this story. Colorado Addiction Treatment Services was a medical practice that provided medication-assisted treatment for substance use disorder, colloquially known as a “methadone clinic,” according to the lawsuit. The clinic frequently administered buprenorphine or buprenorphine compounds to aid opioid use relapse and manage withdrawal symptoms. This form of treatment requires providers to maintain a controlled substance license, and Colorado Medicaid is not supposed to pay billing claims for any such treatment done by a facility without one. According to the lawsuit, Caplin’s practice was found to be in violation of seven rules after a virtual visit conducted by the Colorado Behavioral Health Administration in March 2022. The violations included failures of data reporting, patient record keeping, absent discharge summaries and no documented pregnancy screenings for eligible women, among others. As a result, the treatment clinic was placed on a probationary controlled substance license that required renewal every 90 days and correction of any violations. However, Caplin never re-applied, and the addiction treatment clinic failed to submit a required plan of action to correct the violations and renew it’s license. The complaint alleges Caplin had direct notice that the clinic was no longer authorized to provide the treatment but continued prescribing medication for the next year. From June 2022 through November 2023, the treatment center submitted 703 claims totaling $270,664 for the administration of buprenorphine or buprenorphine compounds after its controlled substance license expired, the lawsuits claimed. Additionally, it submitted 1,001 claims totaling $103,575 for evaluation and management services related to substance-use disorder treatment during the period it was not licensed to provide medication-assisted treatment. Colorado Medicaid would not have paid the claims had it known CATS lacked the required license. Caplin dissolved the practice in 2023. The Attorney General’s Office is seeking damages, civil penalties, costs and attorney fees, and other relief allowed under the Colorado Medicaid False Claims Act, which says a person who knowingly submits false or fraudulent claims for reimbursement can be held liable for up to three times the damages sustained by the state, in addition to civil penalties **Topics:** Judicial/courts, Medicare/Medicaid --- ### [Long-term care pharmacy Remedi to pay $5.3M+ to settle allegations in assisted living prescription case](https://insurancefraud.org/news_archives/long-term-care-pharmacy-remedi-to-pay-5-3m-to-settle-allegations-in-assisted-living-prescription-case/) **Published:** September 28, 2026 **Author:** Diane Beauchamp **Content:** Towson, MD-based long-term care pharmacy Remedi SeniorCare Holding Corp. has agreed to pay more than $5.3 million to settle allegations that it violated the False Claims Act by billing the Medicare and Medicaid programs for prescription drugs for assisted living residents despite lacking valid prescriptions, the Department of Justice announced Thursday. The case began in December 2020, when former Remedi employees Maureen Gearhart and Laura Griffieth filed claims under the whistleblower provisions of the False Claims Act. Under those provisions, a private party can file an action on behalf of the federal government and receive a portion of any recovery. The federal government alleged that, from Jan. 1, 2015, through March 31, 2021, “Remedi submitted false claims to the Medicare and Medicaid programs for prescription drugs that lacked valid prescriptions and were dispensed to residents of assisted living facilities in various states.” Doing so, Acting Deputy Inspector General for Investigations Miranda L. Bennett of the US Department of Health and Human Services Office of Inspector General said in a statement, “puts residents of assisted living facilities at risk and undermines essential safeguards designed to protect patient health and federal healthcare programs.” Additional resolutions The government described the settlement amount of $5,389,780 as restitution and said that Remedi also will pay 4.5% interest. The first payment of approximately $1.19 million was due by Sept. 11, according to the 24-page consent judgment and settlement agreement, which several parties signed Sept. 9. A table included in the document indicates that payments are scheduled to be made through October 2030. The Justice Department said the settlement was based on Remedi’s ability to pay. The whistleblowers will receive 20% of each payment to the federal government. Separate agreements cover their expenses, attorneys’ fees and other costs. Individual retaliation claims filed by Gearhart under the False Claims Act and provisions of Ohio law also were resolved separately. Additionally, Remedi will pay $110,220 in restitution, plus 4.5% interest, to state Medicaid programs under other agreements. “The claims resolved by the settlement are allegations only, and there has been no determination of liability,” the Justice Department said. The case involved in the settlement announced Thursday is United States ex rel. Gearhart & Griffieth v. Remedi SeniorCare Holding Corp., et al. A request for comment by McKnight’s Senior Living to Remedi parent company Clarest Health had not been answered as of publication time. Clarest announced its acquisition of Remedi in January 2024. Another case involving assisted living News of the Remedi settlement came the same week as long-term care pharmacy Omnicare and its parent company, CVS Health, won approval of a bankruptcy plan that followed an almost $950 million judgment in a case over what a jury said was the fraudulent dispensing of drugs to residents of assisted living communities and other non-skilled nursing residential long-term care settings. The federal government had alleged that “for certain non-skilled nursing facilities, Omnicare improperly filled prescriptions beyond one year where a valid prescription did not exist and that these dispensing events violated the federal False Claims Act,” CVS said in a previous filing with the Securities and Exchange Commission. The government asserted that the long-term care pharmacy fraudulently billed federal healthcare programs for “hundreds of thousands” of “stale” or invalid prescriptions for residents in assisted living communities, group homes, independent living communities and other non-skilled residential long-term care facilities. CVS, in a previous statement to McKnight’s Senior Living, said that the lawsuit “​​centered on a highly technical prescription dispensing record keeping issue that was allowed by law in many states. “The dispensing practices referenced were limited to Omnicare, ended in 2018, were used by many others in the industry at the time, and were accepted by CMS,” the statement continued, referring to the Centers for Medicare & Medicaid Services. “There was no claim in this case that any patient paid for a medication they shouldn’t have or that any patient was harmed.” Omnicare filed for bankruptcy in September 2025, citing the need to “resolve issues” related to the civil litigation, which resulted in what the Justice Department previously called “one of the largest damages verdicts rendered by a jury in a False Claims Act case.” In July, Omnicare and CVS agreed to a $440 million settlement with the Justice Department to resolve its claims with the federal government. GenieRx Holding’s bid to acquire Omnicare from CVS is expected to close later this year. The federal government’s settlement with Remedi specifies that if Remedi or its assets are sold before the settlement amount and applicable interest have been paid in full, then the remaining balance must be paid in full at the time of sale. 2010 case Remedi SeniorCare paid almost $1.3 million to settle a separate False Claims Act case in 2010. In that case, the company was accused of submitting false claims to Medicare Part D, Medicaid, the Federal Employees Health Benefit Plan and TRICARE from January 2006 to December 2007 by billing for unused prescriptions that had been returned by assisted living communities without giving credits to the programs. Remedi denied the allegations, brought by a former employee in 2009. In addition to the monetary settlement, according to the Justice Department, Remedi at the time agreed to enter into a five-year integrity agreement with the US Department of Health and Human Services Office of the Inspector General. That agreement imposed compliance measures and ongoing monitoring to ensure the integrity of claims submitted by Remedi to federal and state healthcare programs. **Topics:** Drug Diversion, Judicial/courts, Medicare/Medicaid --- ### [Watch out for insurance fraud’s red flags](https://insurancefraud.org/news_archives/watch-out-for-insurance-frauds-red-flags/) **Published:** September 28, 2026 **Author:** Diane Beauchamp **Content:** Receiving a payout from an insurance company based on a lie is insurance fraud. Exaggerating the loss of an insurance claim to get more money from an insurance company is insurance fraud. Insurance fraud is a felony. Since ignorance of the law is not a defense, I thought it’d be a good idea to let you know some important things about insurance fraud. According to a 2022 study conducted for the Coalition Against Insurance Fraud, this crime costs Americans $308.6 billion annually. That’s about $3,800 a year for a family of four. Some estimates suggest that 20 cents of every premium dollar go to cover the cost of fraud. Here are a few things to remember about insurance fraud: - Don’t ignore red flags. If you’re suspicious about anything dealing with insurance, stop and call the Department of Insurance at 855-408-1212. We have consumer experts available to answer your questions weekdays from 8 a.m. to 5 p.m. You may also find us online at *[www.ncdoi.gov](http://www.ncdoi.gov/)*. - If you see or suspect fraud, report it. You may anonymously report fraud by calling our Criminal Investigations Division at 919-807-6840 or toll free from anywhere in North Carolina at 888-680-7684. You may also report it online at [www.ncdoi.gov/fraud-control](http://www.ncdoi.gov/fraud-control). We have 50 special agents investigating insurance fraud in North Carolina, along with a team of special prosecutors to assist local district attorneys with fraud cases. - Insurance fraud is a crime which leads to higher rates for all consumers. All businesses must take fraud into account when setting rates. For example, stores take shoplifting and other forms of theft into account when setting prices. The cost of fraud is passed along to consumers in the form of higher premiums. Insurance fraud is a form of theft. It comes in various shapes and sizes. While some insurance fraud acts are intended to defraud consumers, others are committed by consumers. Fake insurance companies or agents defraud consumers by taking money for premiums on bogus policies with no intention of paying claims. Here are some examples: - Scammers may offer fake policies at costs that are significantly lower than competitors’ prices. - Companies may sell non-insurance products marketed to look like insurance. For example, an agent working for a company may sell health discount plans, calling the plan “insurance” when it is an unregulated, non-insurance product. - A dishonest agent may collect a premium from a consumer without forwarding the payment to the company. The consumer believes premiums are paid, while the insurance company has no record of payment and cancels or does not renew the policy. Consumers can also commit fraud. Here are some examples of consumer-initiated insurance fraud: - A motorist may deliberately stage an automobile crash, claim injury and make an insurance claim. - A consumer may exaggerate a legitimate claim, hoping to obtain a larger settlement than he or she is entitled to receive. - A consumer may falsify documents or provide false information on a claim. - A motorist may have allowed an insurance policy to lapse and have a crash. After the crash, the consumer will get the policy reinstated and claim the crash occurred after the policy was reinstated. I hope these tips help you avoid becoming a victim of fraud. Together, we can work to fight insurance fraud and slow the increase in premiums. **Topics:** Coalition Against Insurance Fraud, Public Awareness --- ### [Charlotte man accused of using stolen identities, fake insurance to buy vehicles](https://insurancefraud.org/news_archives/charlotte-man-accused-of-using-stolen-identities-fake-insurance-to-buy-vehicles/) **Published:** September 28, 2026 **Author:** Diane Beauchamp **Content:** A Charlotte man is facing 14 felony charges after North Carolina investigators accused him of using stolen identities and fraudulent auto insurance policies in a scheme to purchase vehicles across multiple counties. North Carolina Insurance Commissioner Mike Causey announced the arrest of Joshua Alexander Willis, 35, of Charlotte. Willis is charged with insurance fraud, obtaining property by false pretenses, attempting to obtain property by false pretenses and identity theft. According to the North Carolina Department of Insurance’s Criminal Investigations Division, Willis added individuals to Progressive Premier Insurance automobile insurance policies without their knowledge to obtain proof of insurance for vehicle purchases made in those individuals’ names. Investigators said the scheme involved multiple victims and transactions spanning several counties. In Union County, Willis faces insurance fraud charges tied to an attempt to purchase a 2022 Dodge Challenger. Authorities said the warrant was served Aug. 28, and bond was set at $220,000 secured. In Gaston County, Willis is charged in connection with an attempt to purchase a 2026 Ford Mustang. The warrant was served Sept. 14, and bond was set at $75,000 secured. Investigators also filed eight felony charges in Mecklenburg County, alleging Willis attempted to purchase multiple vehicles from dealerships using false identities and fraudulent insurance policies. The warrant was served Sept. 15, and bond was set at $75,000 secured. The investigation remains ongoing. “Insurance fraud is not a victimless crime,” Causey said. “I’m fighting this aggressively to help hold down future rate increases.” North Carolina officials have expanded insurance fraud enforcement efforts in recent years. The Department of Insurance reported 380 fraud-related arrests and 199 convictions in 2025 while recovering $6.4 million in fraudulent expenditures. State officials said recoveries have exceeded $20 million so far in 2026. The department cites a study by the Coalition Against Insurance Fraud estimating insurance fraud costs Americans $308.6 billion annually. Officials have said those costs contribute to higher insurance premiums for consumers. **Topics:** Coalition Against Insurance Fraud, Insider - agent, Synthetic Identity Theft **Categories:** Arrest --- ### [West Virginia woman accused of killing her husband, setting fire to home in 2025](https://insurancefraud.org/news_archives/west-virginia-woman-accused-of-killing-her-husband-setting-fire-to-home-in-2025/) **Published:** September 28, 2026 **Author:** Diane Beauchamp **Content:** An Eastern Panhandle woman is accused of killing her husband and setting fire to their home following a nearly yearlong investigation by West Virginia State Police. Nicole Ellen Taylor, 55, of Harpers Ferry is charged with murder, arson and use or presentation of a firearm during the commission of a felony in connection with an incident on Sept. 30, 2025, on Blackberry Lane in Harpers Ferry, according to a news release from West Virginia State Police. Troopers said when they initially arrived on the scene of a house fire in 2025 they found Taylor who had escaped the residence with significant burn injuries. She was taken to a regional burn center for treatment. Two people – Taylor’s husband, Robert Hayne Taylor III, 56, and daughter, Cynthia Allison Taylor, 21 – were found dead inside the home. An investigation by the West Virginia State Fire Marshal’s Office found the fire to be an act of arson, the news release said. Examinations of the victims found that they were dead prior to the fire and that Robert Taylor III had suffered multiple gunshot wounds. Troopers said further investigation found that Nicole Taylor was connected to the shooting death of her husband and the subsequent fire at the residence. **Topics:** Homeowners - arson --- ### [New Jersey Civil Justice Institute Announces Support for the Stop Auto Fraud Act of 2026](https://insurancefraud.org/news_archives/new-jersey-civil-justice-institute-announces-support-for-the-stop-auto-fraud-act-of-2026/) **Published:** September 28, 2026 **Author:** Diane Beauchamp **Content:** A bipartisan group of lawmakers recently introduced the Stop Auto Fraud Act of 2026, legislation that would make it a federal crime to intentionally cause, stage or fabricate a motor vehicle accident as part of a fraudulent insurance claim. The bill — introduced by Congresswoman Laura Gillen (D-NY 4) alongside Reps. Josh Gottheimer (D-NJ 5), Troy Nehls (R-TX 22) and Vince Fong (R-CA 20) — targets coordinated fraud rings and would hold those involved in staged accident schemes accountable. The New Jersey Civil Justice Institute strongly supports the bill’s goal of ending auto insurance fraud, restoring fairness to the civil liability system, prosecuting those who game the system, and lowering costs for working families. Elissa Frank, President of the New Jersey Civil Justice Institute, said, “Criminal actors who deliberately cause car accidents and defraud our legal system must be held accountable for driving up the cost of living and putting innocent New Jersey drivers at risk. We applaud Congressman Gottheimer for championing the Stop Auto Fraud Act alongside a bipartisan group of lawmakers to make staging an accident a federal crime and ensure New Jersey drivers no longer pay the price for insurance fraud. Cracking down on this most egregious form of legal system abuse — and holding the full ecosystem of culprits responsible — is a critical step in protecting our institutions of justice, and making the Garden State a safer and more affordable place to live and do business.” In addition to NJCJI, the legislation is endorsed by the National Insurance Crime Bureau, American Trucking Associations, American Bus Association, Truck Renting and Leasing Association, American Property Casualty Insurance Association (APCIA), National Association of Mutual Insurance Companies (NAMIC), National Tank Truck Carriers Association, Truckload Carriers Association, Trucking Association of New York, Texas Trucking Association, Southwest Movers Association, United Motorcoach Association and Coalition Against Insurance Fraud. NJCJI is a nonpartisan, not-for-profit organization supported by many of New Jersey’s largest employers, business associations, and professional organizations. We work to promote a fair, efficient, and predictable civil justice system, which is essential for innovation, economic growth, and job creation. **Topics:** Legislation, Public Awareness --- ### [Synthetic IDs, ghost broking push insurers beyond one-time identity checks](https://insurancefraud.org/news_archives/synthetic-ids-ghost-broking-push-insurers-beyond-one-time-identity-checks/) **Published:** September 28, 2026 **Author:** Diane Beauchamp **Content:** Synthetic identities now account for about half of identity fraud recorded in National SIRA, according to [Synectics Solutions](https://www.biometricupdate.com/companies/synectics-solutions), as insurers confront growing reuse of stolen and fabricated identities across products and sectors. Its new Signals [report](https://www.synectics-solutions.com/hubfs/SYN0002%20Signals%20Full%20Report%20Digital.pdf) shows repeat offenders exploiting gaps in monitoring across financial services. Operated by Synectics since 1992, [National SIRA](https://www.synectics-solutions.com/what-we-do/national-sira) is the UK’s largest cross-sector consortium of confirmed, suspected, victim and clear risk intelligence. Synectics CEO Richard Wood said the report “examines and interprets those critical fraud patterns impacting financial services organisations.” Insurance fraud is becoming an identity-lifecycle problem. Criminals are not simply presenting a fake identity once; they are recycling compromised and synthetic identities across products, companies and sectors. That pattern is particularly visible in ghost broking, where criminals use stolen or fabricated identities to arrange fraudulent insurance policies. Victims whose identities were used in ghost-brokered policies rose 93 percent in 2025, while two-thirds of compromised identities linked to ghost broking were subsequently reused across the financial ecosystem. The Association of British Insurers and the Insurance Fraud Enforcement Department have campaigned to raise awareness of the problem. The report found 22 percent of fraudsters flagged by one firm had already been identified elsewhere. Motor finance fraud often carried linked intelligence from insurance. Investigations finished up to 75 percent faster when cross‑sector data was used. One case study tracked an offender across 13 months, 10 organizations and eight product types, with activity escalating toward higher-payout products such as business banking and loans. More than half of the activity involved business banking and motor insurance, with impersonation and synthetic identities the main methods. National SIRA now holds 350,000 synthetic ID signals, up 50 percent in two years. One in three synthetics is tied to repeat offending. Some products saw growth of 152 percent in a single year. Synectics says AI tools and siloed onboarding checks have lowered barriers to creating and reusing synthetics. Fraudsters are also failing on purpose, deliberately triggering fallback verification routes that rely on documents. AI‑generated papers then pass these checks. Synectics stresses lifecycle monitoring must match onboarding controls. Forty‑four percent of serious fraud showed early warning signals. Synectics argues that connected intelligence is vital to stop repeat offenders before identities are burned. ## The changing mechanics of identity fraud The technologies available to fraudsters are also making identity attacks easier to scale. [Unico](https://www.biometricupdate.com/companies/unico)’s latest [Identity Fraud Intelligence](https://www.unico.io/identity-fraud-intelligence-report) report, which examines identity fraud across sectors, found injection attacks accounted for 45.8 percent of detected attacks, physical presentation attacks 30.9 percent and combinations involving deepfakes 23.3 percent. Unico says the cost of carrying out sophisticated synthetic identity attacks has fallen by more than 100-fold as generative AI and readily available manipulation tools improve. Nine out of ten fraud professionals surveyed by the company now rank synthetic content among their leading threats. For insurers, that adds another dimension to the problem identified by Synectics. A customer who clears an identity check at onboarding may still present different risk later if an account is compromised, credentials are reused or fabricated documents are introduced through fallback verification processes. That puts more weight on monitoring identity signals throughout the policy and claims lifecycle rather than treating verification as a one-time event. ## South Korea looks to cross-industry response South Korea’s insurers have joined forces with the National Assembly, government agencies and research institutions to battle insurance crime. The National Assembly Research Forum on Preventing Insurance Crimes launched with a ceremony and seminar hosted by the General Insurance Association of Korea, which will act as secretariat. The forum brings together lawmakers, regulators, police and industry leaders to address emerging fraud threats, including schemes using generative AI and deepfakes. Its first meeting focused on measures to innovate the insurance fraud response system. Discussions focused on linking data between public and private insurers and building a joint response framework across agencies. Officials say the need for stronger cooperation has grown as fraudsters exploit new technologies to create synthetic identities and falsified documents, reports [Asia Insurance Review](https://www.asiainsurancereview.com/News/View-NewsLetter-Article/id/96953/Type/eDaily/South-Korea-General-insurers-will-work-with-the-country-s-National-Assembly-to-develop-insurance-fraud-response-system). The General Insurance Association of Korea will support ongoing research and policy development, backing efforts to expand information sharing and investigative collaboration while identifying legal and institutional reforms needed to counter evolving insurance fraud. For insurers, identity risk no longer ends at onboarding. It follows the customer through the policy and claims lifecycle, reinforcing a broader shift in financial services toward [continuous identity signals](https://www.biometricupdate.com/202608/financial-institutions-turn-identity-signals-into-continuous-trust) and tools that can [connect suspicious accounts, devices and other risk indicators](https://www.biometricupdate.com/202609/seon-adds-new-fraud-signals-to-find-links-between-suspicious-accounts). **Topics:** Public Awareness, Synthetic Identity Theft, Technology --- ### [Jamestown funeral home director indicted on 52 counts including abuse of corpse and fraud, TBI says](https://insurancefraud.org/news_archives/jamestown-funeral-home-director-indicted-on-52-counts-including-abuse-of-corpse-and-fraud-tbi-says/) **Published:** September 28, 2026 **Author:** Diane Beauchamp **Content:** A Fentress County grand jury has indicted the owner of a Jamestown funeral home after allegations of widespread fraud, financial exploitation and the mishandling of cremated remains, according to the Tennessee Bureau of Investigation. Chadrick “Chad” Mundy, 37, owner of Mundy Funeral Home, was arrested Wednesday afternoon following an investigation by TBI. Mundy is facing the following charges: 15 counts of theft of property over $2,500 12 counts of fraudulent insurance act 9 counts of financial exploitation of an elderly or vulnerable adult 5 counts of theft of property over $1,000 4 counts of abuse of a corpse 4 counts of theft of property under $1,000 2 counts of criminal simulation 1 count of worthless checks TBI said agents began investigating allegations against the funeral home in May at the request of 8th Judicial District Attorney General Jared Effler. According to state investigators, evidence showed Mundy filed numerous fraudulent insurance claims connected to burial policies, exploited elderly clients for personal gain and mishandled cremated remains. In August, the State Board of Funeral Directors and Embalmers temporarily suspended the licenses for both Mundy and the funeral home, declaring the business an immediate risk to the public’s health, safety and welfare. During that state hearing, investigators revealed that a financial audit exposed missing documentation and showed Mundy had filed fraudulent life insurance death claims for individuals who were still alive, including his own wife. Mundy was booked into the Fentress County Jail on an $80,000 bond. **Topics:** Elderly Fraud, Funeral Director Fraud **Categories:** Arrest --- ### [Duo who staged New York City car accidents sent to prison](https://insurancefraud.org/news_archives/duo-who-staged-new-york-city-car-accidents-sent-to-prison/) **Published:** September 28, 2026 **Author:** Diane Beauchamp **Content:** Two men accused of staging automobile crashes in New York City have received their prison sentences as new reforms proposed by Gov. Kathy Hochul are implemented. Those measures seek to lower the nation’s highest auto-insurance premiums and allow prosecutors to seek criminal penalties against any individual responsible for a staged accident instead of just the driver. Last month, Jaime Huiracocha and Victor Murillo, described as a ringleader and a co-conspirator, received their prison sentences from Queens County Supreme Court Justice Jerry Iannece. Huiracocha pleaded guilty to insurance fraud and conspiracy in May and will serve 1-3 years in jail. Murillo pleaded guilty to staging an accident, insurance fraud and conspiracy and will serve two years. Prosecutors said they staged car crashes on NYC highways in 2024, with Murillo acting as the driver. He would suddenly brake to create rear-end collisions and even went in reverse once when the trailing car braked in time, they said. Huiracocha, meanwhile, trailed Murillo on the road. Murillo would hop in his car after the wreck and flee the scene, and the passengers in Murillo’s car would exit and claim injuries, dashcam footage showed. Other alleged participants have also pleaded guilty and are expected to be sentenced soon. The scheme was intended to work the state’s no-fault insurance policy, which is paid by New York drivers and allows them and others to obtain benefits of up to $50,000 for injuries caused in accidents. The program invites staged accidents and inflated bills from medical-care providers for services that were unnecessary or never performed. A federal indictment against four men filed earlier this year alleged physicians and psychologists were among those to submit fraudulent claims in a separate scheme, and funding companies affiliated with a law firm provided a “veneer of legitimacy,” U.S. Attorney Jay Clayton said. Auto-insurance premiums in New York had risen to about an average of $4,000 annually, leading Hochul to address alleged schemes like that. Hochul has said insurers reported more than 38,000 incidents of suspected auto-insurance fraud in 2023, which helped tack an extra $300 onto everyone’s yearly premium. In civil court, Uber and FedEx have filed lawsuits against groups of people it says are staging accidents involving their fleets of vehicles. “The pick-up locations are residential side streets (usually one-way roads) in Nassau County, which allow the Fraud Ring to lure the unsuspecting… drivers using the Uber app toward a location where a hit-and-run collision will occur,” the Uber suit says. “The pre-determined locations for the staged collisions are often intersections with stop signs… (T)he Fraud Ring chooses these locations due to the low probability that they are monitored by video cameras.” The wrecks are usually side-swipes, Uber says, and the defendants then submit fraudulent claims of injury to Uber. Several health care companies are also named as defendants for allegedly verifying these fake injuries and submitting claims to insurance companies like Liberty Mutual, which is co-plaintiff in the suit. Florida’s 2023 tort reforms partly inspired Hochul’s reforms. An analysis by Florida’s Office of Insurance Regulation shows how its 2023 tort reform package has resulted in a 5.6% decrease in average auto insurance rates across the majority of its market. For example, in 2025, Florida’s largest carrier returned nearly $1 billion in excess profits to 2.7 million policyholders. Florida has seen its double-digit growth of auto insurance rates in 2023 turn into a 7.4 percent reduction in the average rates by 2025. **Topics:** Auto - staged **Categories:** Conviction --- ### [Kansas Man Sentenced to Probation for Insurance Fraud](https://insurancefraud.org/news_archives/kansas-man-sentenced-to-probation-for-insurance-fraud-2/) **Published:** September 28, 2026 **Author:** Diane Beauchamp **Content:** Kansas Insurance Commissioner Vicki Schmidt, announced a Johnson County man has been sentenced to 24 months of probation for insurance fraud. Dwayne Wright, aged 52, pleaded guilty on July 9, 2026, in Johnson County District Court to two felony counts of insurance fraud. Wright filed multiple fraudulent claims for damaged and stolen materials while at various worksites and forged receipts to validate his fraudulent claims for the materials. He was sentenced on September 14, 2026, to 24 months of probation and ordered to pay $1,449.31 in restitution. “Every time someone commits insurance fraud, it causes families and businesses across Kansas to pay more,” said Commissioner Vicki Schmidt. “The Department will continue to hold these individuals accountable.” This case was investigated by the Kansas Department of Insurance and prosecuted by the Kansas Attorney General’s Office. **Topics:** Contractor fraud **Categories:** Conviction --- ### [76-year-old man charged with insurance fraud over car repairs worth $7K](https://insurancefraud.org/news_archives/76-year-old-man-charged-with-insurance-fraud-over-car-repairs-worth-7k/) **Published:** September 28, 2026 **Author:** Diane Beauchamp **Content:** A St. George man has been charged with insurance fraud after he allegedly lied to the insurance company in an attempt to get car repairs worth more than $7,000 covered. Harold Carter, 76, was charged with insurance fraud of more than $5,000, a second-degree felony. According to the indictment brought by the Utah Attorney General’s Office, on July 10, Carter filed an insurance claim on his car, claiming that the vehicle sustained heavy front-end damage on June 26 at 11 a.m. The repair estimate was $7,319.10. During the claims process, the insurance company discovered that Charter made changes to his policy on June 3 from liability only to comprehensive and collision coverage, and the company found that a body shop made an estimate for the repair on May 27, before Carter said the accident happened. Insurance fraud investigators with the Utah Attorney General’s Office began looking into it, and they confirmed that the estimate from the body shop was timestamped before the date and time the accident was reported to the insurance company. They allege that Carter misrepresented the time and date of the accident in an attempt to have the insurance company pay for the damage. On Sept. 9, investigators spoke with Carter, who reportedly admitted that the accident happened on May 27, not June 26. He only had liability coverage at that time, and investigators say that Carter mentioned that he “panicked” and added comprehensive and collision insurance before making the report. He also allegedly admitted to trying to gain coverage. Carter has an initial court appearance scheduled for Oct. 29, and a summons was issued. **Topics:** Auto - padding/false claim **Categories:** Arrest --- ### [New judge assigned for Brent Swadley sentencing after state fraud conviction](https://insurancefraud.org/news_archives/new-judge-assigned-for-brent-swadley-sentencing-after-state-fraud-conviction/) **Published:** September 28, 2026 **Author:** Diane Beauchamp **Content:** A new judge will be in charge of sentencing an embattled restauranteur who is behind bars after being convicted of defrauding the State of Oklahoma. Brent Swadley was found guilty in May on six felony counts, including conspiracy to defraud the state. After the verdict, the judge denied Swadley bond. Nearly four months later, Swadley still has not been sentenced in the case. In July, Judge Susan Stallings also denied Swadley’s request to be released on an appeal bond. In response, Swadley’s defense team asked that Stallings recuse herself from the case, saying they did not believe she could be impartial. They claim that Stallings engaged in ex parte communications with jurors after the verdict, and that she relied on that communication to deny Swadley’s request for a bond. In their motion for recusal, the defense said Stallings’s “actions and statements” during the hearing “cast serious doubt on her ability to impartially preside over the remaining proceedings in this case.” On Friday, Judge Stallings agreed to move Swadley’s sentencing to Judge Truong’s courtroom. His sentencing is set to begin Oct. 21. **Topics:** Commercial Fraud **Categories:** Conviction --- ### [NC Insurance Agent Charged With Taking Out Life Policy on Elderly Without Consent](https://insurancefraud.org/news_archives/nc-insurance-agent-charged-with-taking-out-life-policy-on-elderly-without-consent/) **Published:** September 28, 2026 **Author:** Diane Beauchamp **Content:** A North Carolina insurance agent was charged this week with exploiting an elderly person by stealing identify information and taking out a life insurance policy without the woman’s knowledge. Tony Lee Gunter, 29, of Spruce Pine, also earned $257 in commission from Foresters Insurance Co. on the fraudulent policy, the North Carolina Department of Insurance and the arrest warrant indicated. “The defendant, (a) licensed North Carolina insurance agent, used the checking account information of (the victim) to purchase life insurance policy” without the victim’s consent, reads the arrest information in Yancey County court. The offense took place in January 2025, the court record indicates. The agent was released on $20,000 bond and is set to appear in court on Oct. 12. It’s not clear how the case came about, but state Insurance Commissioner Mike Causey credited NCDOI investigators with bringing the case to light. Court records in Yancey County show this is not the first brush with the law for Gunter. In August 2025, he pleaded guilt to a larceny charge. Two forgery charges were dropped and Gunter was sentenced to probation upon providing a sample of his DNA. Details of the crime were not included in the court file online. Gunter has held an active insurance producer license since March 2024, the National Association of Insurance Commissioners’ license page shows. He is appointed with two life insurance companies. Gunter could not immediately be reached for comment. **Topics:** Insider - agent, Life Insurance **Categories:** Arrest --- ### [Trump administration to remove 760,000 Affordable Care Act enrollees over fraud claims](https://insurancefraud.org/news_archives/trump-administration-to-remove-760000-affordable-care-act-enrollees-over-fraud-claims/) **Published:** September 28, 2026 **Author:** Diane Beauchamp **Content:** Vice President JD Vance and other Trump administration officials said Tuesday they plan to remove 760,000 Affordable Care Act enrollees from public healthcare exchanges, alleging that the individuals were fraudulently enrolled in the program, or simply do not exist. Vance said the discovery and canceled subsidy payments for hundreds of thousands of people from the exchanges, part of an administration-wide crackdown on fraud, would result in $2.2 billion in cost savings. “We’re actually making sure that the people receiving Obamacare subsidies are actually entitled to receive them,” said Vance, who leads a government task force to eliminate fraud. He was flanked by Dr. Mehmet Oz, the administrator for the Centers for Medicare and Medicaid Services, or CMS, and other administration officials. Vance said the cancellation of approximately 315,000 enrollments covering 760,000 people was done in part because the government was not checking whether people enrolled were eligible. Vance said another 419,000 enrollments will get additional verification to make sure they are eligible for the benefit. The Trump administration also announced a six-month suspension on new agents or brokers who sign up enrollees for healthcare coverage, who officials say commit a disproportionate amount of the fraud they uncovered. Roughly 19.2 million Americans are actively enrolled in ACA marketplace health plans as of early 2026, according to the Department of Health and Human Services website. The number of enrollees grew during the COVID-19 pandemic when enhanced subsidies became available through the American Rescue Plan Act and Inflation Reduction Act, both signed into law by former President Joe Biden. Tuesday’s announcement is the latest in an initiative by the Trump administration to address fraud around the country, including in federal healthcare programs, which officials say is needed to rein in runaway spending and protect taxpayers. Some healthcare policy experts are calling for more transparency on how the Trump administration decided to cut hundreds of thousands of enrollees — and question how many people may have been wrongly cut from the program. Cynthia Cox, a vice president and director of the ACA program at the healthcare research nonprofit KFF, said “I think there’s no question that somebody who was fraudulently enrolled should have their coverage canceled,” however, “I think the question is whether this was the appropriate process by which to identify fraudulent enrollees, and also whether all of them were indeed fraudulently enrolled.” Cox said the elimination of the people from ACA programs was done outside of the normal regulatory process. Ellen Montz, a former deputy administrator and director at the Center for Consumer Information and Insurance Oversight at CMS during the Biden administration said during her time in government, there was an ongoing effort to eliminate fraud from ACA programs. “There’s a lot of work to be done, and the Trump administration has done some good things that are targeting the actual fraudsters,” she said. Adding that Tuesday’s announcement lacked details on how the administration determined who to cut. ” I would imagine we’ll hear from some subset of consumers that ask: why did my enrollment get cancelled?” Montz said. At the press conference, Tuesday, Vance referred to some enrollments lacking social security numbers or immigration documentation. ### [As ACA enrollment drops, hopes for Congress to restore funding are fading](https://www.npr.org/2026/01/17/nx-s1-5680302/as-aca-enrollment-drops-hopes-for-congress-to-restore-funding-are-fading) The announcement comes as stubbornly high inflation and rising healthcare costs pressure the Trump administration to come up with a plan to bring down costs for Americans as affordability remains a central issue in the fall midterm elections. The price of ACA insurance has skyrocketed for many Americans during Trump’s second term, after Republicans opposed extending COVID-era subsidies that had helped offset the costs of health insurance for most enrollees during Biden’s term. Premiums doubled or tripled for many enrollees, prompting millions to downgrade their plans or exit the program entirely after the Republican-led Congress allowed the subsidies to expire this year. The Government Accountability Office suggests fraud risks in the advance premium tax credit do exist – however it’s unclear at what scale. The GAO conducted covert testing using fictitious ACA applicants enrolled in 2024 and 2025. A report released in December showed that the federal marketplace approved subsidized coverage for almost all of the GAO’s 24 fake enrollees. The White House referred The Associated Press to the Vice President’s team for additional comment on bigger plans to address healthcare affordability. The Vice President’s office and CMS did not respond to Associated Press requests for comment. The Wall Street Journal first reported the news of the Trump administration’s plan to remove ACA enrollees from public exchanges. Democratic lawmakers criticized the move to remove enrollees from ACA coverage. Richard E. Neal, a Massachusetts Democrat and ranking member of the Ways and Means Committee, said “Republicans have already created the worst healthcare crisis ever, but every decision by the Trump Administration is designed to keep making it worse.” “As if making coverage harder to access through skyrocketing premiums and more red tape wasn’t painful enough, they’re doubling down to take it away entirely,” Neal said. **Topics:** Public Awareness --- ### [Insurance Fraud Costs $45 Billion per Year, and Honest Policyholders Often Pick Up the Tab | Insurify](https://insurancefraud.org/news_archives/insurance-fraud-costs-45-billion-per-year-and-honest-policyholders-often-pick-up-the-tab-insurify-2/) **Published:** September 28, 2026 **Author:** Diane Beauchamp **Content:** Fraud, inaccurate information, and misrepresentation cost the U.S. personal auto and homeowners insurance markets an estimated $45.3 billion annually, according to an analysis released by insurance risk-assessment company Clearspeed. The analysis estimates the cost of inaccurate information and fraud at $31.6 billion annually for auto insurance and another $13.7 billion for homeowners insurance. And those losses don’t necessarily stay on insurers’ balance sheets. Instead, insurers can account for expected fraud and other losses when setting rates, passing on at least some of the expense to policyholders through premium increases. The National Insurance Crime Bureau (NICB), citing research from the Coalition Against Insurance Fraud, estimates that insurance fraud results in roughly $900 in additional annual premium expense per policyholder. The FBI has also estimated the impact at $400–$700 annually for the average U.S. family. “It’s embedded in loss costs, goes through the rate-making process, and ultimately ends up being a pretty important factor in what the premium levels are,” Rob Hoyt, a risk management and insurance professor at the University of Georgia, told P&C Specialist. $45.3 billion is an estimate, not a tally of documented losses Clearspeed calculated its estimated figures by assuming about 10% of policies involve fraud or misrepresentation and that insurers lose about 15% of premiums associated with those policies. For consumers already facing rapidly rising insurance costs, that could mean another hidden expense built into their premiums. So far this year, 27 states have seen their insurance rates increase, according to Insurify data. Drivers in seven states and Washington, D.C., pay more than $3,000 annually for full-coverage car insurance. Meanwhile, Insurify projects the average annual cost of home insurance in the U.S. will increase by 4% in 2026, reaching $3,057 by year-end. Fraud costs more than the fraudulent claim Insurers have spent decades building systems designed to catch false information and suspicious claims. These systems can include additional documentation, verification, investigations, and other procedures — costs that apply even when a customer is telling the truth. And those systems mean insurers now face not only the financial losses stemming from fraud and inaccurate information but the expense and customer inconvenience of trying to detect it. The results show up on more than just a policyholder’s bill. Legitimate policyholders can face additional questions when buying coverage, requests for documentation, longer claim investigations, and delays in receiving claim payments. Clearspeed contends insurers could reduce those costs by better distinguishing low-risk customers from cases that merit additional scrutiny. Home insurance may be particularly vulnerable Clearspeed’s research argues that homeowners insurance could be the first major personal insurance market where rising losses, affordability problems, and the costs of operating in a “low-trust” environment become unsustainable. That’s because fraud and inaccurate information are just additions to a much longer list of forces putting upward pressure on home insurance costs. Rising construction and repair expenses, severe weather, reinsurance costs, and insurers’ reassessment of catastrophe risk all play roles in pushing home insurance premiums higher. And the costs associated with all these perils are becoming increasingly visible to consumers via steep renewal increases, higher deductibles, non-renewals, and difficulty finding coverage. Can insurers trust customers without treating everyone like a suspect? Clearspeed’s report states insurers need to rethink the system because it subjects millions of legitimate customers to fraud-prevention measures designed to catch a relatively small number of bad actors. “It is no longer arguable. The U.S. insurance system has evolved into a low-trust system that cannot run indefinitely, as the costs of a few overwhelm the many,” study author Kim Garland said in a statement announcing the analysis. The challenge is finding a way to identify suspicious behavior without making insurance more difficult for everyone else — or creating new problems involving privacy, accuracy, or discrimination. For policyholders, the stakes are substantial. If insurers can reduce fraud and the cost of detecting it, consumers could theoretically benefit from lower expenses and faster claims processing. **Topics:** Fraud General, Public Awareness --- ### [Attorney General Raoul Obtains Prison Sentence In Medicaid Fraud Case Against Transportation Business Owner](https://insurancefraud.org/news_archives/attorney-general-raoul-obtains-prison-sentence-in-medicaid-fraud-case-against-transportation-business-owner/) **Published:** September 28, 2026 **Author:** Diane Beauchamp **Content:** Attorney General Kwame Raoul today announced the former owner of Clay Transportation was sentenced to four years in prison after pleading guilty to stealing nearly $180,000 from the state by fraudulently submitting Medicaid claims for transportation services he did not provide. Cook County Circuit Court Judge Thomas J. Byrne today sentenced Antonio Clay, 42, of Prospect Heights, Illinois, to four years in prison after he pleaded guilty to a Class 1 charge of vendor fraud in April. Clay has already paid $40,000 in restitution to the state’s Medicaid program. “Medicaid provides vital healthcare services, including transportation, to millions of Illinois families, seniors and individuals with disabilities,” Raoul said. “I will continue to work to hold individuals like Clay accountable if they exploit this critical program for their own financial gain.” The Attorney General’s office prosecuted this case based on a referral from the Illinois Department of Healthcare and Family Services Office of Inspector General (HFS-OIG). Raoul’s investigators determined that from January 2018 to May 2022, Clay submitted false Medicaid claims to HFS for transportation services to 18 recipients that he did not provide. As a result, Clay received $179,455. Raoul’s Medicaid Fraud Control Unit receives 75% of its funding from the U.S. Department of Health and Human Services under a grant award totaling $12,584,776 for the federal government’s 2026 fiscal year. The remaining 25%, totaling $4,194,923 for the federal government’s 2026 fiscal year, is funded by the state of Illinois. The case was prosecuted by Deputy Bureau Chief Melissa Guske for Raoul’s Medicaid Fraud Control Unit. **Topics:** Medicare/Medicaid **Categories:** Conviction --- ### [Another construction fraud case on the local court docket: Who can you trust?](https://insurancefraud.org/news_archives/another-construction-fraud-case-on-the-local-court-docket-who-can-you-trust/) **Published:** September 28, 2026 **Author:** Diane Beauchamp **Topics:** Contractor fraud **Categories:** Arrest --- ### ['Straight Up Fraud': Data Confirms Private Insurers Use Medicare Advantage to Steal Billions](https://insurancefraud.org/news_archives/straight-up-fraud-data-confirms-private-insurers-use-medicare-advantage-to-steal-billions/) **Published:** September 27, 2026 **Author:** Diane Beauchamp **Content:** Insurance giants are exploiting [Medicare](https://www.commondreams.org/tag/medicare) Advantage–a corporate-managed program that threatens to result in the complete [privatization](https://www.commondreams.org/tag/privatization) of traditional Medicare–to capture billions of dollars in extra profits, Saturday [reporting](https://www.nytimes.com/2022/10/08/upshot/medicare-advantage-fraud-allegations.html) by *The [New York Times](https://www.commondreams.org/tag/new-york-times)* confirmed. The newspaper’s analysis of dozens of lawsuits, inspector general reports, and watchdog investigations found that overbilling by [Medicare Advantage](https://www.commondreams.org/tag/medicare-advantage) (MA) providers is so pervasive it exceeds the budgets of entire federal agencies, prompting journalist Ryan Cooper to call the program “a straight up fraud scheme.” Nearly half of Medicare’s 60 million beneficiaries are now enrolled in MA plans managed by for-profit insurance companies, and it is expected that most of the nation’s seniors will be ensnared in the private-sector alternative to traditional Medicare by next year. Six weeks ago, Sen. [Ron Wyden](https://www.commondreams.org/tag/ron-wyden) (D-Ore.) launched an inquiry into “potentially deceptive” marketing tactics used by MA providers to “take advantage” of vulnerable individuals. As the table below shows, almost every major player in the industry has been accused of fraud by a whistleblower or the U.S. government. In addition, the vast majority are engaged in rampant upcoding, or exaggerating patients’ illnesses in order to reap more money from taxpayers–something they do while refusing to provide necessary care for tens of thousands each year. Larry Levitt, executive vice president for health policy at Kaiser Family Foundation (KFF), which has no connection with Kaiser Permanente, [wrote](https://twitter.com/larry_levitt/status/1578768720708542464) on [social media](https://www.commondreams.org/tag/social-media) that “the move to privatize Medicare” has “been very profitable, in part because insurers are good at making their patients seem sicker.” Journalist Natalie Shure concurred, [tweeting](https://twitter.com/nataliesurely/status/1578753466465648640): “Privatized Medicare plans cherry-pick healthier enrollees, fudge medical records to make them look as sick as possible, coax doctors into tacking on extra sham diagnoses to bill for, and pay themselves a profit on top of it. Medicare Advantage shouldn’t exist.” “For all its faults, Medicare is a (nearly) universal program for 65+, with overhead hovering around 2%–far lower than its private counterparts,” Shure added. “What inefficiencies did anyone think MA would be solving exactly\[?\]” she asked. According to the *Times*, MA was created by congressional [Republicans](https://www.commondreams.org/tag/republicans) “two decades ago to encourage health insurers to find innovative ways to provide better care at lower cost.” Matt Bruenig, founder of the People’s Policy Project, a left-wing think tank, argued that the notion that private insurers would “provide more benefit for less money” than traditional Medicare “while taking a profit” is insane on its face. “They innovate on other margins, namely by bending and breaking rules that determine how much money Medicare gives them, as such things are hard to detect,” said Bruenig, “and we are now stuck in an endless cat and mouse enforcement game with them.” As the *Times* reported: > The government pays Medicare Advantage insurers a set amount for each person who enrolls, with higher rates for sicker patients. And the insurers, among the largest and most prosperous American companies, have developed elaborate systems to make their patients appear as sick as possible, often without providing additional treatment, according to the lawsuits. > > As a result, a program devised to help lower health care spending has instead become substantially more costly than the traditional government program it was meant to improve. > > \[…\] > > The government now spends nearly as much on Medicare Advantage’s [29 million beneficiaries](https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/MCRAdvPartDEnrolData/Monthly-Contract-and-Enrollment-Summary-Report) as on the [Army and Navy](https://comptroller.defense.gov/Portals/45/Documents/defbudget/FY2022/FY22_Green_Book.pdf#page=123) combined. It’s enough money that even a small increase in the average patient’s bill adds up: The additional diagnoses led to $12 billion in overpayments in 2020, according to an [estimate](https://www.medpac.gov/wp-content/uploads/2022/03/Mar22_MedPAC_ReportToCongress_Ch12_SEC.pdf) from the group that advises Medicare on payment policies–enough to cover [hearing and vision care](https://www.cbo.gov/system/files/2019-12/hr3_complete.pdf) for every American over 65. > > Another estimate, from a former top government health official, suggested the overpayments in 2020 were double that, more than $25 billion. Citing a KFF study which [found](https://www.kff.org/report-section/financial-performance-of-medicare-advantage-individual-and-group-health-insurance-markets-issue-brief/) that companies typically rake in twice as much gross profit from MA plans as from other types of insurance, the *Times* pointed out that the growing privatization of Medicare is “strikingly lucrative.” MA plans “can limit patients’ choice of doctors, and sometimes require [jumping through more hoops](https://www.nytimes.com/2022/04/28/health/medicare-advantage-plans-report.html) before getting certain types of expensive care,” the newspaper noted. “But they often have lower premiums or perks like dental benefits–extras that draw beneficiaries to the programs. The more the plans are overpaid by Medicare, the more generous to customers they can afford to be.” “By exploiting and overbilling Medicare, these companies profit off the public. Think of how this money could have been better spent.” The MA program has grown in popularity, including in Democratic strongholds, over the course of four presidential administrations. Meanwhile, regulatory and legislative efforts to rein in abuses have failed to gain traction. Officials at the Centers for Medicare and [Medicaid](https://www.commondreams.org/tag/medicaid) Services (CMS), some of whom move between the agency and industry, have not been aggressive “even as the overpayments have been described in inspector general investigations, [academic research](https://scholar.harvard.edu/timothylayton/publications/upcoding-or-selection-evidence-medicare-squishy-risk-adjustment), Government Accountability Office [studies](https://www.gao.gov/assets/gao-22-106026.pdf), MedPAC [reports](https://www.medpac.gov/wp-content/uploads/2022/03/Mar22_MedPAC_ReportToCongress_Ch12_SEC.pdf), and [numerous](https://publicintegrity.org/health/why-medicare-advantage-costs-taxpayers-billions-more-than-it-should/) [news](https://www.nytimes.com/2017/05/15/business/dealbook/a-whistle-blower-tells-of-health-insurers-bilking-medicare.html) [articles](https://www.washingtonpost.com/business/2022/06/05/medicare-advantage-records-fraud/),” the *Times* reported. “Congress gave the agency the power to reduce the insurers’ rates in response to evidence of systematic overbilling, but CMS has never chosen to do so.” Ted Doolittle, who served as a senior official for CMS’ Center for Program Integrity from 2011 to 2014, said that “it was clear that there was some resistance coming from inside” the agency. “There was foot-dragging.” Almost 80% percent of U.S. House members, many of whom are bankrolled by the insurance industry, signed a [letter](https://bettermedicarealliance.org/wp-content/uploads/2022/01/final_2022_house_ma_letter_.pdf) earlier this year indicating their readiness “to protect the program from policies that would undermine” its stability. David Moore, co-founder of *Sludge*, an independent news outlet focused on the corrupting influence of corporate cash on politics, [observed](https://twitter.com/ppolitics/status/1579136735816347649) on social media that “members of the health subcommittee of the House Ways and Means Committee could speak publicly on whether they think oversight of the insurance industry has been adequate.” However, Moore pointed out, committee Chair Richard Neal (D-Mass.) “has received $3.1 million from the insurance industry, the most in the House.” As the *Times* noted, “Some critics say the lack of oversight has encouraged the industry to compete over who can most effectively game the system rather than who can provide the best care.” “Medicare Advantage overpayments are a political third rail,” Richard Gilfillan, a former hospital and insurance executive and a former top regulator at Medicare, told the newspaper. “The big [healthcare](https://www.commondreams.org/tag/healthcare) plans know it’s wrong, and they know how to fix it, but they’re making too much money to stop.” **Topics:** Medicare/Medicaid, Public Awareness --- ### [When a hurricane brings scammers knocking, ‘you are the best protection against fraud’](https://insurancefraud.org/news_archives/when-a-hurricane-brings-scammers-knocking-you-are-the-best-protection-against-fraud/) **Published:** September 27, 2026 **Author:** Diane Beauchamp **Content:** Hurricane Ian brought the deadliest destruction Florida has seen in years, and with it, likely billions of dollars in damages. Florida officials and property insurers are warning people left vulnerable after the storm to not become victims twice and fall prey to common scams. Following Ian, Attorney General Ashley Moody dispatched consumer protection investigators to newly-opened [Disaster Recovery Centers](https://www.floridadisaster.org/news-media/news/20221006-governor-ron-desantis-announces-the-opening-of-two-additional-disaster-recovery-centers/) in Southwest Florida. The centers are located in Shannon Staub Library in Sarasota County and Joseph P.D. Alessandro Office Complex and Lakes Regional Library in Lee County. Investigators will be there daily, distributing information about how to spot, avoid and report scams, and helping consumers file price gouging complaints. According to attorneys, there are several different kinds of scams to look out for if you are a survivor of Hurricane Ian. “If it doesn’t seem right, it’s probably not right,” said Kathy Grunewald, disaster coordinator attorney at Legal Services of North Florida. As an advocate for post-disaster victims, she said it’s a particularly fertile time for scammers looking to make money off people whose homes and livelihood have been damaged. Most people, she said, are just desperate to get back to normal and may sign a contract that will leave them worse off than before. “Don’t let someone pressure you into signing something,” Grunewald said. Michael Flynn, a professor of law at Nova Southeastern University’s Shepard Broad College of Law, said some populations are more at risk than others. The elderly he said, are a major target. “Minority communities will also be targeted,” Flynn said, “The immigrant population may not be so familiar with what goes on here.” One of the most common types of fraud Grunewald said, comes in the form of general contractors who flood into the area after a disaster. Many come from outside the state and may be unlicensed or working with sub-par materials. Flynn said to always ask a potential contractor to give you their licensure number, and [check](http://www.myfloridalicense.com/dbpr/) to see if it’s legit. An unwillingness to provide their license or a written estimate, and a request for payment up-front are all major red flags. “Make sure you are satisfied with the work, and that it complies with all state and local codes,” Flynn said, before you pay the full amount. Grunewald also warns against contracts that contain an AOB, or [Assignment of Benefits](https://myfloridacfo.com/docs-sf/insurance-consumer-advocate-libraries/ica-documents/aob-consumer-protection-tips-brochure.pdf?sfvrsn=690bdde6_4). That allows a contractor to communicate directly with the insurance company and file claims on your behalf. Though it may seem tempting, cutting yourself out of the process will result in you losing control over your claim and you may be left with unfinished or shoddy repairs. Citizens, the state’s not-for-profit property insurer, recommends you deal with your insurance directly first, before signing any contracts. The three Disaster Recovery Centers can help you meet with your insurance provider and begin the process. Flynn recommends getting at least three written estimates to compare and using a contractor that comes recommended from a friend or family member. Grunewald said to look for an established contractor in your area who will have local credibility. You can also check the [Better Business Bureau](https://www.bbb.org/) for ratings. But it’s ultimately up to the homeowner to do their due diligence. “You are the best protection against fraud,” Flynn said. Fraud is not limited to contractors. Grunewald said people may also come into the area posing as FEMA employees. They may even be wearing a false uniform. These scammers may try to get you to pay an “application fee” or hand over personal information. [FEMA warns](https://www.fema.gov/fact-sheet/beware-fraud-and-scam-artists-3) to never answer unsolicited phone calls or emails from someone claiming to be a FEMA agent. If you are approached by an agent, you may ask to see their badge. A FEMA agent will never ask for any money. They will ask for your personal information for your assistance application, so make sure you are dealing with a legitimate agent. Scammers may also take the guise of charities and go knocking on doors, claiming they can provide assistance if you give them your identifying information. Grunewald said there is no reason to ever hand over personal information to a legitimate humanitarian group. For those trying to help, avoid donating to fraudulent causes. The Attorney General recommends using a well-established charity or using [Charity Navigator](https://www.charitynavigator.org/). When donating to a crowdsourcing platform, research the donee and search to see if there are any duplicate campaigns on other crowdsourcing networks. Scammers may copy a legitimate campaign to attract donors. Both Flynn and Grunewald agree it is best to avoid getting involved with a scammer in the first place. But if you do become a victim, there are some avenues you can take. Grunewald said that every county in Florida has a not-for-profit legal services organization that should be able to help you if you are the victim of a scam. In addition, “you can file a complaint with the Attorney General’s office online,” Grunewald said, “and if someone has actually stolen money from you, you can go to your local police or sheriff’s office.” But Flynn and Grunewald said even if you are able to initiate a lawsuit against scammers, their transient nature can make them hard to serve with a lawsuit, and even harder to collect from if you win. Flynn said you may be able to use the [Florida Homeowners Construction Recovery Fund](http://www.myfloridalicense.com/dbpr/pro/cilb/documents/recov_form.pdf), which helps homeowners collect from an uncollectable contractor. Homeowners can only access the fund after a final judgement in civil court, an arbitration award or an order of restitution from the Florida Construction Industry Licensing Board. The compensation is limited to $25,000. **Topics:** Public Awareness --- ### [Homeowners May Be Victimized a Second Time Following Hurricane Ian](https://insurancefraud.org/news_archives/homeowners-may-be-victimized-a-second-time-following-hurricane-ian/) **Published:** September 27, 2026 **Author:** Diane Beauchamp **Content:** As Hurricane Ian leaves a path of destruction in its wake, the [National Insurance Crime Bureau](https://c212.net/c/link/?t=0&l=en&o=3668938-1&h=3585856962&u=https%3A%2F%2Fc212.net%2Fc%2Flink%2F%3Ft%3D0%26l%3Den%26o%3D3271966-1%26h%3D1991380551%26u%3Dhttp%253A%252F%252Fwww.nicb.org%252F%26a%3DNational%2BInsurance%2BCrime%2BBureau&a=National+Insurance+Crime+Bureau) (NICB), the insurance industry’s association dedicated to predicting, preventing, and prosecuting insurance crime, is warning disaster victims to stay vigilant against dishonest contractors and scammers. Hurricane Ian wreaked havoc across wide stretches of land, leaving untold numbers of homeowners to the daunting task of rebuilding their homes and lives. According to NICB analysis, fraud accounts for approximately 5-to-10 percent of all insurance claims filed. With that in mind, fraud-related claims could account for $3-6 billion of the total claims submitted following Hurricane Ian – a cost transferred to policyholders through their annual insurance premiums. “Recovering from a disaster is an intimating task, and homeowners should not be victimized twice,” said NICB President and CEO David Glawe. “Take time to vet legitimate contractors, get at least three bids, and never pay a contractor in full before the work is complete. Ensure that a dishonest contractor is not further complicating your already devastating situation.” “Consumers who have already been impacted by Hurricane Ian should not also have to deal with deceptive, unscrupulous tactics perpetrated by scammers,” said Florida’s Insurance Consumer Advocate Tasha Carter. “I encourage consumers to first contact their insurance company before contracting with any third party, a party that may not have their best interest in mind.” Before hiring a contractor, call your insurance company. There is no need to rush into an agreement with a contractor who solicits your repair work, especially if it was not requested. **NICB SUGGESTS YOU CONSIDER THESE TIPS BEFORE HIRING A CONTRACTOR:** - Get more than one estimate. - Get everything in writing. Cost, work to be done, time schedules, guarantees, payment schedules, and other expectations should be detailed and itemized. - Request references and do the research. - Ask to see the salesperson’s driver’s license and write down the license number and their vehicle’s license plate number. - Look out for out-of-state contractor licenses, as well as vehicle registrations, as these may also indicate possible fraudulent contractors. - Never sign a contract with blanks; terms you don’t agree with can be added later. - Never pay a contractor in full or sign a completion certificate until the work is finished. - Ensure reconstruction is up to current code. - Make sure you review and understand all documents sent to your insurance carrier. Signing an [Assignment of Benefits](https://c212.net/c/link/?t=0&l=en&o=3668938-1&h=868124094&u=https%3A%2F%2Fwww.myfloridacfo.com%2Fdocs-sf%2Finsurance-consumer-advocate-libraries%2Fica-documents%2Faob-consumer-protection-tips-brochure.pdf%3Fsfvrsn%3D690bdde6_4&a=Assignment+of+Benefits) agreement transfers your insurance rights to the contractor. Know what that means for you. - Never let a contractor pressure you into making a quick decision or hiring them. - Never let a contractor interpret the language of your insurance policy. - Never let a contractor discourage you from contacting your insurance company. Contact your insurance company first. - Remember, if you didn’t request it, reject it! Also, check out Insurance Consumer Advocate (ICA) Carter’s [Demolish Contractor Fraud: Steps to Avoid Falling Victim.](https://c212.net/c/link/?t=0&l=en&o=3668938-1&h=3583218199&u=https%3A%2F%2Fwww.myfloridacfo.com%2Fdivision%2Fica%2Fdemolish&a=Demolish+Contractor+Fraud%3A+Steps+to+Avoid+Falling+Victim.+) Furthermore, some deceitful contractors will state they are supported by the government. However, the Federal Emergency Management Agency does not endorse individual contractors or loan agencies. Always request official identification from those claiming to represent governmental agencies. Consumers should call FEMA for more specifics at (800) 621-FEMA. If you believe you have been a victim of fraud, call the NICB at 1-800-TEL-NICB. For additional information, visit NICB’s website, [www.NICB.org](https://c212.net/c/link/?t=0&l=en&o=3668938-1&h=4169060939&u=http%3A%2F%2Fwww.nicb.org%2F&a=www.NICB.org). **REPORT FRAUD:** Anyone with information concerning insurance fraud or vehicle theft can report it anonymously by calling toll-free 800.TEL.NICB (800.835.6422) or submitting a [form](https://c212.net/c/link/?t=0&l=en&o=3668938-1&h=2216907401&u=https%3A%2F%2Fwww.nicb.org%2Fabout-nicb%2Freport-fraud&a=form) on our website. **Topics:** Public Awareness --- ### [Doc who reaped $127M off sober-home drug tests pleads guilty to health care fraud](https://insurancefraud.org/news_archives/doc-who-reaped-127m-off-sober-home-drug-tests-pleads-guilty-to-health-care-fraud/) **Published:** September 27, 2026 **Author:** Diane Beauchamp **Content:** A Delray Beach doctor who pocketed more than $127 million by forcing people struggling with addiction to undergo bogus tests pleaded guilty on Tuesday to conspiracy to commit health care fraud. Dr. Michael Ligotti faces a maximum 20-year prison sentence for taking advantage of scores of vulnerable patients and billing their insurance companies for tests medical experts said were clearly unnecessary. Those who spent years trying to get authorities to take action against the 48-year-old owner of Whole Health Medical Center said they were heartened that Ligotti had finally been held accountable. But, they said, foot-dragging by the Florida Board of Medicine and other regulators caused many to suffer needlessly. Kenneth Bailynson case: West Palm sober home operator gets 6 years in prison in $31.3 million health fraud scheme Kenny Chatman case: Woman who ran sober homes headed to prison for role in Kenny Chatman’s million-dollar fraud scheme Federal fraud: Charge against Palm Beach Gardens lawyer alleges he stole $1.6 million in COVID relief loans “It’s horrifying that we allow this type of practice in Florida,” said Maureen Kielian, who heads up Southeast Recovery Advocates. She bristled at the notion that the only ones who were hurt were insurance companies, who paid thousands of bills Ligotti submitted from May 2011 until shortly before his arrest in July 2020. “Is it fraud really?” Kielian asked. “Is it that or is it that he abused his license, he abused people who were seeking help and caused deaths?” Miami lawyer Jose Quinon, who represents Ligotti, didn’t return an email for comment. Michael Ligotti’s operation far bigger than other drug-recovery kingpins Like all but a handful of those who have been prosecuted since the crackdown on South Florida’s illicit addiction industry began, Ligotti wasn’t accused of causing any deaths. He instead faced 13 charges, including health care fraud and money laundering. When he agreed to plead guilty to a single count of conspiracy to commit health care fraud, the other 12 charges were dropped. But even compared with others who have been prosecuted in the last decade, Ligotti’s operation stands out. The amount of money he raked in far outstrips the $31 million Kenneth Bailynson made in illicit profits by operating a West Palm Beach sober home and testing lab. It was far more than the $16 million notorious operator Kenny Chatman was forced to pay insurers in connection with his far-flung addiction treatment scam. Chatman, who lived near Boynton Beach, infamously forced women who came to him for help to work as prostitutes. According to federal prosecutors, Ligotti’s operation was massive. He billed insurers $746 million and was paid $127 million. He was able to amass such wealth by serving as medical director for more than 50 sober homes, substance-abuse treatment centers and clinical-testing laboratories in South Florida, prosecutors wrote in court papers. As medical director, Ligotti fueled the operation. Without his signature on orders, insurance companies wouldn’t pay for the tests. Realizing they needed his help for their illegal operations to thrive, other unscrupulous operators agreed to send their patients to Whole Health, prosecutors said. Kickbacks and bribes fueled the illegal quid pro quo arrangement, prosecutors said. Ultimately, however, those who benefited from Ligotti’s help turned against him, prosecutors said. Those who cooperated in the investigation weren’t identified by name. But one is believed to be Eric Snyder, owner of the former Real Life Recovery and Halfway There in Delray Beach, where Ligotti served as medical director. Sentenced to 10 years in prison in 2019 after pleading guilty to conspiracy to commit wire fraud, Snyder has been allowed to remain free so he can testify against others. Ligotti also served as medical director of Academy Health Solutions in Lake Park, court records show. Its former owners, Mimi, David and Levi Bieda, were also prosecuted on patient brokering charges in Palm Beach County Circuit Court. FBI: Michael Ligotti kept scam going after denying it to state regulators In court papers, FBI agents said Ligotti tried to hide his illegal activities. Worried he was under investigation in 2013, he wrote a letter to state regulators. “I was astonished and outraged to learn that my name and license may be currently used in an unauthorized fashion by entities involved in the treatment of patients/clients in recovery for drug and alcohol dependence,” he wrote. But, agents said, the letter was a sham. “In the nearly seven years since Ligotti drafted it, he continued to authorize addiction treatment centers and sober homes to order medically unnecessary urine drug tests through the laboratories,” they wrote in 2020. Ligotti also put his $5.1 million home and another $855,000 residence he owned on the market and unsuccessfully tried to declare bankruptcy to hide his assets, investigators said in court papers. In court papers, Ligotti said he put the house on the market because he got a job in Maine and planned to move. Ultimately, when he realized he was the target of the FBI investigation, he in 2020 shuttered Whole Health and put the building on Southeast Sixth Avenue up for sale, investigators said. By then, Southeast Recovery Advocates’ Kielian said, the human cost of Ligotti’s operation was enormous. She and grieving mothers who lost children who went to Ligotti for help wrote letters to the state Board of Medicine asking that it yank his license. Protests were held outside the clinic to emphasize the need to act. But, Kielian said, even though it’s been more than two years since his arrest, Ligotti’s medical license is still active, according to the state Department of Health’s online records. State health officials didn’t return an email for comment to explain why Ligotti hasn’t lost his medical license. Kielian said regulators told her that once the FBI gets involved, they let the criminal investigation proceed before acting. Kielian said she expects parents of Ligotti’s patients to testify against him when he is sentenced Dec. 13. “We will be there in force to support every parent who has the guts and courage to stand there and relive the most terrible moments of their lives,” she said. **Topics:** Healthcare Fraud **Categories:** Conviction --- ### [Red Springs Pharmacy Owner Pleads Guilty in Healthcare Fraud Scheme](https://insurancefraud.org/news_archives/red-springs-pharmacy-owner-pleads-guilty-in-healthcare-fraud-scheme/) **Published:** September 27, 2026 **Author:** Diane Beauchamp **Content:** James Craig Bell, 63, pleaded guilty today to conspiracy to defraud Medicare, North Carolina Medicaid, and private health insurers through his pharmacy in Red Springs that operated under the name Townsend’s Pharmacy. “This defendant lined his own pockets with money intended to provide vital prescription drugs for the poor and disadvantaged,” said U.S. Attorney Michael Easley. “We will continue to investigate and prosecute shady schemes like this.” “Submitting false and excessive claims to Medicare and Medicaid undermines the integrity of federal health care programs and wastes valuable taxpayer dollars,” said Tamala E. Miles, Special Agent in Charge with the U.S. Department of Health and Human Services, Office of the Inspector General (HHS-OIG). “HHS-OIG works tirelessly along with our law enforcement partners to hold accountable perpetrators of federal health care fraud.” “Medications are expensive enough without pharmacy owners defrauding Medicaid and ripping off taxpayers,” said Attorney General Josh Stein. “These resources are meant to help people get the care and prescriptions they need. I’m grateful for U.S. Attorney Easley and his office’s partnership with my Medicaid Investigations team to hold accountable health care providers who waste these resources.” According to the criminal information and evidence summarized in Court, beginning as early as 2006 through July 2017, Bell, acting through Townsend’s Pharmacy, billed Medicare, Medicaid, and various private health plans for prescription drugs that were never actually dispensed by the pharmacy. Bell conspired with his employee, Melisha West, 51, of Raleigh. West began independently running the pharmacy’s operations while Bell continued to knowingly profit from the fraudulent billing practices. West pleaded guilty to Healthcare Fraud in January 2022 for her role in the scheme and her sentencing hearing is set for the January 3, 2023 term of court. Bell had trained West and other employees on how to bill health care benefit plans for drugs that were not authorized or dispensed. Bell also trained employees to falsely reauthorize a previously existing prescription from a licensed medical professional, and, how to falsely bill health care benefit programs as though a drug had been dispensed. Bell pleaded guilty to Conspiracy to Commit Healthcare Fraud. He faces up to 10 years in prison and a potential fine. Sentencing before United States District Judge Louise W. Flanagan is scheduled to occur early next year. Michael Easley, U.S. Attorney for the Eastern District of North Carolina made the announcement after United States Magistrate Judge Robert Jones accepted the plea. The United States Department of Health and Human Services Office of the Inspector General and the North Carolina Medicaid Criminal Investigation Unit are investigating the case, and Assistant U.S. Attorneys William M. Gilmore and David G. Beraka are prosecuting the case. **Topics:** Drug Diversion, Medicare/Medicaid **Categories:** Conviction --- ### [Sheriff, District Attorney searching for motive in triple murder-suicide](https://insurancefraud.org/news_archives/sheriff-district-attorney-searching-for-motive-in-triple-murder-suicide/) **Published:** September 27, 2026 **Author:** Diane Beauchamp **Content:** Erie County’s sheriff and district attorney released new details on a triple murder-suicide that occurred Thursday in Clarence and Newstead. Erie County Sheriff John Garcia said Friday that deputies responded to a 911 call just after 10:30 a.m. on Oct.r 6. They were called to investigate three deaths — two women were found dead at two different homes in Clarence, and a man was killed at an outdoor shooting range in Newstead. Sheriff Garcia said Erik Bergum, 43, first shot his wife, Mary Beth Bergum, 37, before going to a second location and fatally shooting his mother, Nancy Bergum, 64. Garcia said Erik Bergum then went to the Ten X Shooting Range on Greenbush Road where he shot and killed his father, Mark Bergum, 64. Authorities say Erik Bergum then took his own life. Another person was at the range when the shooting happened and called 911. Erik and Mary Beth Bergum had four children. They were at school when the killings occurred. “I have two victim advocates from my office that are working with the school counselors from the Clarence School District and helping the children out,” Erie County District Attorney John Flynn said. “Right now the children are staying at a friend’s house, but as the sheriff mentioned, without a lot of family in there area here, my concern is what is going to happen to these four children now.” Flynn indicated the father knew his son was going to meet him at the range but didn’t have any idea his son had just committed two murders. Garcia said a note was recovered from Erik Bergum’s vehicle. He didn’t go into detail about what it contained but said the note outlined a timeline of the acts that were perpetrated. “Every time I received a call, it was just gut-wrenching. When the mother was found dead. When the wife was found dead. Thank God the kids were in school. Thank God the business partner is fine,” Garcia said. “It was just a very tragic family event.” Added Flynn: “We don’t know how far in advance it was planned. Based upon the note that we found, at a minimum it was potentially planned (Thursday) morning. But whether or not he thought about it for two weeks or a month, that we don’t know.” The district attorney said his team is still investigating a motive. None was given in the note. “This matter is still under investigation,” Flynn said. “We are trying to ascertain a motive. That’s your first question here. What’s the motive? Why? Why did this happen? We are still trying to figure that out. We are still trying to figure out why someone would kill his wife, mother, and father.” At a news conference Friday morning, Flynn was asked about any prior criminal history. Erik Bergum was convicted of misdemeanor insurance fraud in 2011 and was sentenced to probation, according to the district attorney. Garcia said Bergum had a pistol permit. He did not say what kind of weapon was used in the murders. He added that detectives are trying to determine if the same weapon was used to kill all three victims. Erik and Mary Beth’s four children don’t really have any family in Buffalo. Garcia says their grandfather is on the way from Maryland to Western New York. Counselors have also been sent out to their schools. One of the kids’ neighbors has set up a GoFundMe for them. You can donate here. Eastern Hills Wesleyan Church has also set up a fund for the children. “A number of the churches in the area have some connection to the family, and it just seemed like everybody was waiting for someone to take the lead because everybody wants to do something,” lead pastor Pat Jones said. “You look for hope in the midst of every tragedy and the only hope we have is that God out of the depth of all of this is going to try to bring comfort and hope to the kids eventually and to the rest of us as we try to understand it all.” To donate to the church fund for the Bergum kids, you can click here. You can also send a check to the church at: 8445 Greiner Rd, Williamsville, NY 14221. Just put “Bergum Fund” in the notes. **Topics:** Public Awareness --- ### [US hospital chain CommonSpirit Health says ‘IT security issue’ is disrupting services](https://insurancefraud.org/news_archives/us-hospital-chain-commonspirit-health-says-it-security-issue-is-disrupting-services/) **Published:** September 27, 2026 **Author:** Diane Beauchamp **Content:** CommonSpirit, the second-largest nonprofit hospital chain in the U.S., has confirmed a cybersecurity incident that is disrupting medical services across the country. In a [brief statement](https://www.commonspirit.org/news-and-perspectives/news/Statement-IT-Security-Issue), Chicago-based CommonSpirit said the “IT security issue” is impacting some of CommonSpirit’s facilities and some patient appointments have been rescheduled as a result. “CommonSpirit Health is managing an IT security issue that is impacting some of our facilities,” said the hospital giant, which operates more than 700 care sites and 142 hospitals in 21 states. “As a precautionary step, we have taken certain IT systems offline, which may include electronic health record and other systems.” “Our facilities are following existing protocols for system outages and taking steps to minimize the disruption. We take our responsibility to ensure the security of our IT systems very seriously. As a result of this issue, we have rescheduled some patient appointments. Patients will be contacted directly by their provider and/or care facility if their appointment is impacted.” CommonSpirit has yet to confirm the nature of the security incident, and it is unknown if patient information or health data was compromised. When reached, CommonSpirit spokesperson Chad Burns declined to comment beyond the organization’s statement. The extent of the disruption caused by the issue is emerging. CommonSpirit’s Nebraska-based subsidiary, CHI Health, [reported outages](https://www.3newsnow.com/news/local-news/chi-health-locations-in-omaha-dealing-with-it-security-incident) across its Omaha hospitals, and MercyOne Des Moines Medical Center has [shut down](https://eu.desmoinesregister.com/story/news/health/2022/10/04/mercyone-online-systems-shut-down-cybersecurity-incident-des-moines-hospital/69538349007/) some of its IT systems, including access to its electronic health records. In July, U.S. cybersecurity agency CISA, the FBI and the U.S. Treasury warned in [a joint statement](https://techcrunch.com/2022/07/06/fbi-north-korea-targeting-healthcare/) that North Korea-backed hackers were targeting healthcare and public health sector organizations across the U.S. with ransomware. The warning followed a spate of high-profile attacks on U.S. healthcare systems, including University Medical Center Southern Nevada, Eskenazi Health, and [Kaiser Permanente](https://techcrunch.com/2022/06/14/hacked-email-kaiser-permanente-breach/). According to Brett Callow, threat analyst at Emsisoft, at least 15 U.S. health systems operating 61 hospitals across the country have been impacted by ransomware so far in 2022. In at least 12 of these incidents, sensitive data, including personal health information (PHI), was compromised. **Topics:** Public Awareness, Technology --- ### [Inmate healthcare provider hit by data thieves, affecting 54K Ga. inmates](https://insurancefraud.org/news_archives/inmate-healthcare-provider-hit-by-data-thieves-affecting-54k-ga-inmates/) **Published:** September 27, 2026 **Author:** Diane Beauchamp **Content:** A Forsyth County company that provides healthcare for people inside correctional facilities nationwide was the target of a recent data breach, leaving tens of thousands of incarcerated people at risk of having their identities stolen. CorrectHealth reported the breach and notified the 54,000 affected inmates in late August, but the incident until now has largely avoided publicity. Inmates are among the more vulnerable people to data breaches and among the more tempting targets for cyber thieves. That’s because of the potential for criminals to obtain sensitive personal information and use it without detection as an incarcerated person might not be promptly alerted nor have access behind bars to tools with which to protect themselves. Of the affected inmates nationwide, it is unclear how many are from Georgia or who are incarcerated here. Georgia Attorney General Chris Carr’s office said last week it had not been notified by CorrectHealth of the breach. On Aug. 25, CorrectHealth said on its website it reported the data breach to the FBI and the [Maine Attorney General’s office](https://apps.web.maine.gov/online/aeviewer/ME/40/7b84f223-3af8-4c22-88c6-ae8d58659055.shtml). Under Maine state law, companies are required to disclose a data breach any time the vital information of a resident of the state is compromised. According to the state’s attorney general, three Maine residents were among the victims of the breach. While other Georgia companies such as financial technology and credit reporting giant Equifax have suffered larger data breaches over the past few years, experts said the CorrectHealth incident ranks as one of the more severe because of the information that was compromised and the victims’ incarcerated status. “If their mail hasn’t been properly routed to them… and it hasn’t been forwarded to the place where they’re incarcerated, that could increase the difficulty (of protecting themselves),” Jim Van Dyke, vice president of innovation for Sontiq, told The Atlanta Journal-Constitution. Sontiq, a [cybersecurity company](https://www.sontiq.com/) owned by TransUnion, ranks the severity of data breaches on a one to 10 scale, with 10 being the most serious. Van Dyke said the CorrectHealth breach is a seven, which ranks in the top 8% of data breaches his company analyzes. [CorrectHealth](https://www.correcthealth.org/), which operates in 37 facilities and treats more than 14,000 patients each year, did not respond to multiple requests for comment. The company does not list all of its locations on its website. CorrectHealth has provided services to several Georgia correctional facilities, including the Clayton County jail, the Chatham County jail and a nursing center in Milledgeville for parolees, according to reports in the AJC. The hacking incident went undetected for months, increasing the likelihood of financial consequences for the victims, experts say. On Nov. 10, CorrectHealth discovered an unauthorized user gained access to employee email accounts through a phishing scam, according to the [company’s breach notice](https://www.correcthealth.org/our-industry-copy/). After roughly half a year of investigating and review, CorrectHealth determined that names, addresses, Social Security numbers, driver’s license numbers, passport numbers, financial account information and medical information may have been leaked. “Although ( CorrectHealth) has not received any reports of related identity theft since the date of the incident, we are notifying you out of an abundance of caution and for purposes of full transparency,” the company said in the notice. A pair of trade publications first reported on the breach in August. Van Dyke said hackers who get their hands on this leaked information could establish new credit accounts, access the victims’ existing financial accounts or commit medical identity theft. The company said it is cooperating with the FBI “as part of a larger investigation into the threat group responsible.” Tony Thomas, a spokesman for the FBI’s Atlanta office said he can’t confirm or deny the existence of specific investigations, but he said the FBI has roughly 100 open investigations into ransomware attacks across the country. “All Georgia companies are at risk,” Thomas said in an email. “It is vital for Georgia businesses to come forward when crimes like ransomware strike their operations.” Georgia Watch, a [consumer advocacy organization](https://georgiawatch.org/about/), said inmates have the same rights as all Americans and should take steps to protect themselves after a data breach, namely freezing their credit. “As we become more connected through technology, there are more opportunities for data to slip through the cracks, putting consumers from all walks of life at risk,” Georgia Watch said in a statement. “These data breaches have shown us that we cannot always trust that the sensitive information we give to businesses is safe and protected.” **Topics:** Public Awareness, Technology --- ### [Who's using what in P&C insurance: October 17, 2022](https://insurancefraud.org/news_archives/whos-using-what-in-pc-insurance-october-17-2022/) **Published:** September 27, 2026 **Author:** Diane Beauchamp **Content:** [**Nationwide**](https://www.nationwide.com/) partnered with [**HomeZada**](https://www.homezada.com/) to make HomeZada’s digital home inventory technology available to Nationwide Private Client customers at no additional charge. Homeowners can upload photos, estimated values and important property and asset documents. They can securely access those records either online or through the HomeZada app – anywhere and anytime. For an upgrade fee, users will also be able to upload videos, create reports and access the platform’s other features. [**ClarionDoor**](https://clariondoor.com/) partnered with [**One80 Intermediaries**](https://www.one80intermediaries.com/) and their contract binding division at Access One80. One80, a wholesale brokerage, managing general agency and program manager, is now live on ClarionDoor’s comparative rating and quoting solution. ClarionDoor’s comparative rating and quoting solution revolutionizes MGA services with speed, efficiency and transparency. Established with the fastest growing excess and surplus lines carrier network, ClarionDoor’s solution helps MGAs and carriers expand distribution channels and create business opportunities. [**VEREINIGTE HAGEL**](https://vereinigte-hagel.net/de/) partnered with [**Sapiens International Corporation**](https://sapiens.com/) for deployment of its cloud-first P&C platform IDITSuite. VEREINIGTE HAGEL’s current, historically grown application landscape will be replaced by the Sapiens modular and complete system that enables continuous end-to-end processing from front-end portal to back-end billing. [**Capital Insurance Group**](https://www.ciginsurance.com/) selected [**Guidewire**](https://www.guidewire.com/)‘s InsuranceSuite to power core operations, simplify IT operations, and quickly adapt to changing market demands. CIG is a member of Auto-Owners Insurance Group and plans to first migrate InsuranceSuite for its commercial lines of business, beginning with ClaimCenter, then PolicyCenter and BillingCenter. Migration for its personal lines of business will follow afterwards. [**CoverTree**](https://www.covertree.com/) partnered with [**Socotra**](https://www.socotra.com/) to launch easy and affordable insurance for owners, renters and landlords of manufactured homes. With Socotra, CoverTree can now automate 92% of its applications with straight-through processing, enabling their customers to purchase a policy online in less than three minutes and save up to 40% in premiums. [**FBM Idaho**](https://www.idahofarmbureauinsurance.com/) selected InsuranceSuite on [**Guidewire**](https://www.guidewire.com/) Cloud to power core operations, simplify IT operations, quickly adapt to changing market demands and deliver more value to its agents and policyholders. A Guidewire self-managed customer since 2010, the company plans to migrate InsuranceSuite to Guidewire Cloud across the entire organization at the same time. **Topics:** Public Awareness, Technology --- ### [FEMA Approves $420 million to Help Floridians with Hurricane Ian Recovery](https://insurancefraud.org/news_archives/fema-approves-420-million-to-help-floridians-with-hurricane-ian-recovery/) **Published:** September 27, 2026 **Author:** Diane Beauchamp **Content:** FEMA is providing rental assistance, hotel stays, repair assistance, reimbursement for temporary lodging and other forms of support for Floridians affected by Hurricane Ian who can’t live in their homes. As of today, FEMA has provided $420 million in assistance to help survivors jumpstart their recovery. ### How FEMA is helping Floridians: - **FEMA has made individual assistance available to 26 counties in Florida.** Residents in Brevard, Charlotte, Collier, DeSoto, Flagler, Glades, Hardee, Hendry, Highlands, Hillsborough, Lake, Lee, Manatee, Monroe, Okeechobee, Orange, Osceola, Palm Beach, Pasco, Pinellas, Polk, Putnam, Sarasota, Seminole, St. Johns and Volusia counties are eligible to apply for Individual Assistance. - **FEMA is meeting survivors where they are to help jumpstart their recoveries.** Disaster Survivor Assistance specialists are going door-to-door in Florida neighborhoods to help individuals register for assistance. These teams have interacted with 26,500 individuals. - **Survivors can visit one of 14 Disaster Recovery Centers** operating in Charlotte, Collier, Hardee, Highlands, Lake, Lee (2 locations), Orange, Osceola, Polk, Sarasota, Seminole, St. Johns and Volusia counties. More centers are planned to open in the coming days. Interpretation services and translated materials are available at these centers to help survivors communicate in the language with which they feel most comfortable. Disaster Recovery Center locations are chosen for their accessibility, with the goal of reaching as many people as possible. As centers are added, real-time locations will be updated at [FloridaDisaster.org](https://www.floridadisaster.org/info/). - **FEMA will pay hotel and motel costs for eligible survivors.** FEMA and the state of Florida activated the Transitional Sheltering Assistance Program, which allows FEMA to make payments directly to participating hotels and motels in Alabama, Florida and Georgia that provide emergency shelter to survivors. As of today, the program is providing housing for **1,256** households with **3,233** members. - **Hundreds of FEMA inspectors** have performed over **73,000** home inspections for survivors who applied for federal disaster assistance. - **The U.S. Small Business Administration has approved $65.4 million** **in low-interest disaster loans** to homeowners, renters and business owners. Business Recovery Centers are located in Collier, DeSoto, Hillsborough, Lee and Seminole counties. - **As of Oct. 16, FEMA’s National Flood Insurance Program (NFIP) has received more than 39,000 flood insurance claims and paid more than $77 million to policyholders, including $56 million in advance payments.** - **NFIP policyholders may receive up to $1,000** to reimburse the purchase of supplies like sandbags, plastic sheeting and lumber. They may also receive up to $1,000 in storage expenses if they moved insured property. Policyholders should file a claim for flood loss avoidance reimbursement, regardless of whether it was successful in preventing flood damage. - **Disaster Unemployment Assistance is available to eligible survivors**. Floridians can file a claim for loss of income caused by Hurricane Ian by going to [Disaster Unemployment Assistance – FloridaJobs.org](http://floridajobs.org/Reemployment-Assistance-Service-Center/reemployment-assistance/claimants/disaster-unemployment-assistance) and selecting “Apply for Hurricane Ian DUA,” visiting a [local CareerSource Career Center](https://careersourceflorida.com/career-services/your-local-team/?utm_source=sfmc&utm_medium=email&utm_campaign=DUA%20Press%20Release%20Hurricane%20Ian%2010.1.22&utm_term=https%3A%2F%2Fcareersourceflorida.com%2Fyour-local-team%2F&utm_id=81666&sfmc_id=63357513), or calling **800-385-3920**. Customer service representatives are available Monday through Friday from 7:30 a.m. to 6:30 p.m. ET. - **Low-income Florida residents recovering from Hurricane Ian may be eligible for assistance from the Department of Agriculture’s Disaster Supplemental Nutrition Assistance Program (D-SNAP).** Survivors can find more information on Florida’s D-SNAP program by visiting the Florida Department of Children and Families’ [Hurricane Ian Response & Recovery](https://www.myflfamilies.com/hurricaneian/) website. - **Operation Blue Roof has installed 1,521 roofs.** This is a free service provided to homeowners and is currently operating in Charlotte, Collier, Desoto, Lee and Sarasota counties. Residents impacted by Hurricane Ian can sign up at [BlueRoof.us](https://www.usace.army.mil/Missions/Emergency-Operations/Blue-Roof-Information/) or call toll-free at 1-888-ROOF-BLU (1-888-766-3258) for more information. The call center will be open from 8 a.m. to 8 p.m. ET. - **National Flood Insurance Program Florida policyholders who had flood damage from the hurricane have a 90-day window to renew their policies.** The extension applies to policies with renewal dates beginning Aug. 25, through Oct. 23. Policyholders whose renewal date is in this range should contact their agent or insurance company. FEMA also extended the proof of loss requirement for flood insurance policyholders in Florida who experienced flood damage from Hurricane Ian from 60 to 365 days. For more information on how to file a flood insurance claim, visit [How to Start Your Flood Insurance Claim](https://www.floodsmart.gov/how-do-i-start-my-flood-claim). - **FEMA approved Critical Needs Assistance for disaster survivors with immediate or critical needs because they are displaced from their primary dwelling**. Immediate or critical needs are life-saving and life-sustaining items. This assistance is a one-time payment of **$700 per household**. - If you or a member of your household uses adaptive or accessibility items that were damaged by Hurricane Ian, you may be eligible for FEMA assistance for those items. For homeowners, items can include an exterior ramp, grab bars and a paved pathway to the home’s entrance from a vehicle. Awards do not count toward your Housing Assistance or Personal Property maximum awards. For more information for homeowners and renters, visit [Update to FEMA’s Individual Assistance Program and Policy Guide](https://www.fema.gov/sites/default/files/documents/fema_updated-iappg-version-1.1.pdf). **Topics:** Public Awareness --- ### [Longtime city contractors plead guilty to $1M insurance fraud scam](https://insurancefraud.org/news_archives/longtime-city-contractors-plead-guilty-to-1m-insurance-fraud-scam/) **Published:** September 27, 2026 **Author:** Diane Beauchamp **Content:** A pair of longtime New York City contractors, who are brothers, pleaded guilty Friday to evading more than $1 million in insurance premiums by misclassifying workers for financial gain, the Manhattan DA’s office announced. Nicholas Dragonetti, 49, and Vito Dragonetti, 53, each pleaded guilty to offering a false instrument for filing, and their companies, Dragonetti Brothers Landscaping and D.B. Demolition, pleaded guilty to insurance fraud between 2017 and 2019. Since 1998, the Long Island brothers have secured more than 100 city contracts for park landscaping and maintenance, as well as for sidewalk reconstruction and pedestrian crosswalk ramp construction, according to the DA’s office. These “higher-risk” jobs typically require workers to use heavy machinery to demolish and replace pavement and ramps, and accordingly, a higher workers’ compensation insurance classification. The duo bid on and won contracts for excavation, sidewalk reconstruction and pedestrian ramp replacement for residential blocks throughout the city, totaling millions of dollars, while falsely classifying 217 laborers, foremen and heavy-equipment operators as florists, office workers or sales representatives. “Workers doing dangerous work should be afforded every protection possible, yet these city contractors misclassified their employees for financial gain,” said Manhattan District Attorney Alvin Bragg. “As a result, they put their workers at risk, while also undermining the integrity of the public bidding process.” The district attorney’s office said that through this scheme, the two avoided paying more than $1.1 million in insurance premiums between 2017 and 2019 by intentionally misclassifying numerous employees on their applications to the New York State Insurance Fund for workers’ compensation insurance in order to avoid paying required premiums. In the same period, D.B. Demolition evaded more than $81,000 in insurance premiums by misclassifying a number of employees in NYSIF paperwork by claiming the individuals were office workers. Prosecutors said that simultaneously, the employees were listed as commercial drivers in paperwork filed with the New York City Business Integrity Commission, the organization in charge of regulating the city’s private carting industry. Both agreed to pay $1.2 million in restitution to the New York State Insurance Fund as part of their plea agreement, and they were barred from bidding on any future contracts with the New York City Department of Design and Construction and BIC for the next three years. The ban also includes any other companies where the brothers hold more than 10% ownership. Their plea agreement also stipulates further actions, such as the appointment of a managing director for the landscaping company and the placement of independent monitors in their companies for a three-year period. **Topics:** Work comp - employer **Categories:** Conviction --- ### [Healthcare Data Breach Impacts 13 Anesthesia Providers, 380K Individuals](https://insurancefraud.org/news_archives/healthcare-data-breach-impacts-13-anesthesia-providers-380k-individuals/) **Published:** September 27, 2026 **Author:** Diane Beauchamp **Content:** More than 380,000 individuals and 13 anesthesia provider practices were impacted by a healthcare data breach, the HHS Office for Civil Rights (OCR) data breach portal shows. Breach notifications have been scarce, but one [media notice](https://elpasoheraldpost.com/notice-of-data-security-incident-anesthesia-associates-of-el-paso-pa/) from Anesthesia Associates of El Paso, explained that the breach impacted the practice’s unnamed management company. “Information stored in the Management Company’s system could include some combination of patient names, addresses, health insurance policy number, Social Security numbers, payment information, and health information such as treatment and diagnosis,” the notice explained. The notice encouraged patients to monitor their credit reports and financial statements for suspicious activity and explained that additional security controls have since been implemented to protect patient information. The following anesthesia service providers have submitted breach notices to HHS OCR: > - Anesthesia Associates of El Paso: 43,168 individuals impacted > - Upstate Anesthesia Services PC: 9,065 individuals impacted > - Resource Anesthesiology Associates PC: 37,697 individuals impacted > - Resource Anesthesiology Associates of IL PC: 18,321 individuals impacted > - Resource Anesthesiology Associates of CA: 16,001 individuals impacted > - Providence WA Anesthesia Services: 98,643 individuals impacted > - Palm Springs Anesthesia Services: 58,513 individuals impacted > - Lynbrook Anesthesia Services: 3,800 individuals impacted > - Hazleton Anesthesia Services: 13,607 individuals impacted > - Fredericksburg Anesthesia Services: 7,069 individuals impacted > - Bronx Anesthesia Services: 17,802 individuals impacted > - Anesthesia Services of San Joaquin: 44,015 individuals impacted > - Anesthesia Associates of Maryland: 12,403 individuals impacted **Topics:** Public Awareness, Technology --- ### [United States Files Civil Fraud Lawsuit Against Cigna For Artificially Inflating Its Medicare Advantage Payments](https://insurancefraud.org/news_archives/united-states-files-civil-fraud-lawsuit-against-cigna-for-artificially-inflating-its-medicare-advantage-payments-2/) **Published:** September 27, 2026 **Author:** Diane Beauchamp **Content:** Damian Williams, the United States Attorney for the Southern District of New York, announced that the United States has filed a civil healthcare fraud lawsuit against CIGNA CORPORATION and its subsidiary Medicare Advantage Organizations (collectively, “CIGNA”). The lawsuit seeks damages and penalties under the False Claims Act for CIGNA’s submissions to the Government of false and invalid patient diagnosis codes to artificially inflate the payments CIGNA received for providing insurance coverage to its Medicare Advantage plan members. The Government is intervening in a lawsuit filed by a whistleblower, which was originally filed in the United States District Court for the Southern District of New York and later transferred to the Middle District of Tennessee. The Government’s complaint alleges that the reported diagnoses codes were based solely on forms completed by vendors retained and paid by CIGNA to conduct in-home assessments of plan members. The healthcare providers (typically nurse practitioners) who conducted these home visits did not perform or order the testing or imaging that would have been necessary to reliably diagnose the serious, complex conditions reported and were prohibited by CIGNA from providing any treatment during the home visit for the medical conditions they purportedly found. The diagnoses at issue were not supported by the information documented on the form completed by the vendor and were not reported to CIGNA by any other healthcare provider who saw the patient during the year in which the home visit occurred. Nevertheless, CIGNA submitted these diagnoses to the Government to claim increased payments and falsely certified on an annual basis that its diagnosis data submissions were “accurate, complete, and truthful.” U.S. Attorney Damian Williams said: “As alleged, CIGNA obtained tens of millions of dollars in Medicare funding by submitting to the Government false and invalid diagnoses for its Medicare Advantage plan members. CIGNA knew that, under the Medicare Advantage reimbursement system, it would be paid more if its plan members appeared to be sicker. This Office is dedicated to holding insurers accountable if they seek to manipulate the system and boost their profits by submitting false information to the Government.” Medicare Advantage, also known as the Medicare Part C program, provides health insurance coverage for tens of millions of Americans who opt out of traditional Medicare. Under Medicare Part C, Medicare Advantage Organizations (“MAOs”), typically operated by private insurers like CIGNA, provide coverage for Medicare beneficiaries. In return, MAOs receive capitated payments from the Centers for Medicare and Medicaid Services (“CMS”) based on demographic information and the diagnoses of each plan beneficiary. MAOs submit diagnosis data, typically passed along from beneficiaries’ healthcare providers, to CMS. CMS then uses that diagnosis data, in conjunction with demographic factors, to calculate a “risk score” for each beneficiary and, in turn, the amount of the monthly capitated payment that the MAO will receive for covering that beneficiary. The Medicare Advantage payment model is intended to pay MAOs more to provide healthcare for sicker enrollees (expected to incur higher healthcare costs) and less for healthier enrollees (expected to incur lower costs). The following allegations are based on the Complaint that was filed in federal court: CIGNA, through its subsidiaries and affiliates, owns and operates numerous MAOs that administer Medicare Advantage Plans. CIGNA contracted with several vendors to conduct home visits of Medicare Advantage plan members across the country as part of its broader so-called “360 comprehensive assessment” program. The home visits were typically conducted by nurse practitioners, and on occasion by other non-physician healthcare providers such as registered nurses and physician assistants (the “Vendor HCPs”). Based on the visit, the Vendor HCPs completed a CIGNA-created form (“360 form”) that included a check-the-box multi-page list of a wide range of medical conditions. CIGNA had its coding teams identify diagnosis codes that corresponded to the recorded medical conditions and then submitted those to CMS for risk adjustment payment purposes. CIGNA structured the 360 home visits for the primary purpose of capturing and recording lucrative diagnosis codes that would significantly increase the monthly capitated payments it received from CMS. The purpose of the visits was not to treat patients’ medical conditions, and CIGNA explicitly prohibited the Vendor HCPs from providing actual patient treatment or care. As CIGNA acknowledged in an internal document discussing the program, “\[t\]the primary goal of a 360 visit is administrative code capture and not chronic care or acute care management.” But this was not disclosed to CIGNA’s plan members when the home visit was scheduled or during the actual visit. When identifying plan members to receive home visits, CIGNA targeted individuals who were likely to yield the greatest risk score increases and thus the greatest increased payment. The Vendor HCPs spent limited time with the patients and did not conduct a comprehensive physical examination. When completing the assessments and recording the diagnoses, the Vendor HCPs relied largely on the patient’s own self-assessment and their responses to various basic screening questions. Vendor HCPs did not have access to the patient’s full medical history and typically did not obtain or review relevant records from the patient’s primary care physician in advance of the visit. CIGNA’s 360 home visit program regularly generated false and invalid diagnosis codes for certain serious, complex conditions that cannot be reliably diagnosed in a home setting and without extensive diagnostic testing or imaging. In tens of thousands of instances, CIGNA submitted diagnosis codes that represent serious, complex medical conditions that (a) were based only on the home visits conducted by the Vendor HCPs; (b) required specific testing or imaging to be reliably diagnosed, which was not performed; (c) were not supported by the information documented on the 360 form completed by the Vendor HCPs; and (d) were not reported by any other healthcare provider who saw the plan member during the year in which the home visit occurred (the “Invalid Diagnoses”). The Invalid Diagnoses included, but are not limited to, diagnoses for complex medical conditions such as chronic kidney disease, congestive heart failure, rheumatoid arthritis, and diabetes with renal complications. According to CIGNA’s own clinical guidelines, accurately diagnosing these conditions requires specialized testing. CIGNA exerted pressure on Vendor HCPs to record high-value diagnoses that significantly increased risk adjustment payments. CIGNA management identified at least twelve classes of generic chronic diagnoses that they thought were “often underdiagnosed” among its Plan members and, through trainings and seminars, encouraged the Vendor HCPs to make these diagnoses during the home visits. CIGNA also closely tracked the volume and nature of the diagnoses generated by each vendor’s home visits, as well as how the diagnoses affected risk-adjusted payments. CIGNA provided trainings to vendors to improve their “performance” when they failed to deliver the expected level of high-value diagnosis codes. Indeed, CIGNA tracked the return on investment of the 360 home visit program by comparing the costs of the in-home visits (i.e., payments to vendors) against the additional Part C payments generated by increased risk scores. For example, according to an internal report, CIGNA determined that, during the first nine months of 2014, one vendor’s 6,658 in-home visits resulted in more than an additional $14 million in Medicare payments, which dwarfed the approximately $2.13 million that CIGNA paid to the vendor. When specific providers were found to have captured fewer diagnoses than expected, CIGNA asked the vendor to prepare a “performance improvement plan” for the provider. The Invalid Diagnoses generated by the 360 home visits also did not conform with the International Classification of Diseases (“ICD”) Office Guidelines for Coding and Reporting (the “ICD Guidelines”), as required by applicable federal regulations. The Invalid Diagnoses did not affect patient care, treatment, or management during the home visit, as required under the ICD Guidelines, and thus were ineligible for risk adjustment. In addition, the Invalid Diagnoses were not supported by the minimal information recorded on the 360 forms, in violation of the ICD Guidelines’ medical record documentation requirement. In fact, in some cases, the 360 forms include clinical exam findings that contradict the supposed diagnosis. For example, one patient received a congestive heart failure diagnosis from a home visit even though the 360 form explicitly noted that physical exam results found her heart to be “regular” and “normal” and stated, “cardiac reviewed and unremarkable.” Through its 360 home visit program, CIGNA submitted diagnosis codes for tens of thousands of Invalid Diagnoses to CMS that constituted false claims for payment. Based on these unlawful false claims, CIGNA improperly received tens of millions of dollars in risk adjustment payments from CMS, in violation of both the False Claims Act and the common law. Mr. Williams thanked HHS-OIG and the U.S. Attorney’s Office for the Middle District of Tennessee for their assistance with this case. This case is being handled by the Office’s Civil Frauds Unit. Assistant U.S. Attorney Peter Aronoff is in charge of this case. **Topics:** Judicial/courts, Medicare/Medicaid --- ### [Louisiana Church Lady Preyed On Men And Poisoned Them With Arsenic](https://insurancefraud.org/news_archives/louisiana-church-lady-preyed-on-men-and-poisoned-them-with-arsenic/) **Published:** September 27, 2026 **Author:** Diane Beauchamp **Content:** From a distance, Lynette Bell appeared to simply be a devout church-going widow eager to take in and help men who were down-and-out. But a closer look revealed a darker reality, as seen on “Black Widow Murders,” airing Sundays at 7/6c on Oxygen. Lynette’s deadly web was exposed in May 1984. She and her daughter, Susan, had gone to the Pineville, Louisiana police station, so Lynette could report her live-in friend, Mountville Townley, 43, had died at her apartment after a night of drinking. A manual laborer known around town for hard living, Townley was a heavy drinker with cardiac issues. Lynette said he died of a heart attack. At her residence, investigators found Townley’s body in a scene that looked staged. Why was a whiskey bottle hidden behind a couch? The coroner’s report raised other red flags. It noted that Townley’s beard and hair were singed. Police learned that earlier that month, 64-year-old Lynette’s house had burned down, which is why she was living in the apartment. Fire officials had said that there were possible signs of arson at Lynette’s razed house. Was Townley involved in the residential blaze? Although he wouldn’t directly benefit from insurance payouts, Lynette would. Investigators considered this as they took a deep dive into her background to determine what had happened to Townley. Born in 1919, Lynette was an only child with a seemingly storybook upbringing. According to Lynette, however, her father was abusive and an alcoholic, as seen on “Black Widow Murders.” Forensic psychologist Helen Smith told producers that dynamic could have helped forge Lynette’s relationship patterns with men. Lynette married Arnold Guy in 1940 and had two children. Over time, their marriage began to sour. In 1948, Arnold decided to build a new house and Lynette fell in love with the contractor, Venson Bell. An affair ensued, along with a quickie divorce between Arnold and Lynette. Lynette married Bell in 1950. She gave her two children to her parents to raise, according to Diedre Guy, Lynette’s daughter-in-law. Meanwhile, Lynette and Venson had two daughters of their own, Debbie and Susan. In the early 1970s, Lynette hit a rough emotional patch. She lost her mother, husband, and father in quick succession. Her behavior changed, and she began frequenting bars. “It was like daylight and dark,” Diedre Guy told producers of the personality shift. She seemed to find love again, though. In November 1975, Lynette married William Johnson. Six months after they tied the knot, he collapsed in a bar where he was drinking and playing pool. Johnson’s cause of death was deemed a cardiac event. There was no investigation at the time because no one observed a pattern, according to Smith: “It was just an isolated incident.” Lynette subsequently shared her life and home with Ira Butter, a Navy veteran. They broke up in January 1977. Butter, whose family had a history of alcoholism, was found dead three months later. The death was attributed to alcohol poisoning, according to “Black Widow Murders.” In December 1977, Lynette wed again, this time to hard-partying local fisherman Tanzy Clifford Reeves, who had had various scrapes with the law. Around this period, rumors started to circulate that men Lynette married and dated kept dying because of poisoning, Cliff Strider, prosecutor for Rapides Parish, told producers. Some of those reports came from Reeves himself, who wondered if Lynette was poisoning his pea soup. But he never made a formal complaint. In November 1979, Reeves fell ill and died. Despite his concerns about poisoning, the cause of death was said to be congestive heart failure. Reeves was the fourth man in Lynette’s life to die in less than eight years. However, Venson Bell’s modest pension provided the only financial gain for her from these tragedies. In 1981, Lynette befriended an elderly couple from church, Earl and Blanche Campbell. Blanche began suffering from a mysterious illness and died of apparent natural causes. Rumors swirled that Earl and Lynette were a couple. Earl moved in with Lynette, and by September 1982 he was dead, the victim of a self-inflicted gunshot. His death was ruled a suicide. Lynette inherited his house, boat, truck, and other possessions. Ten years, six deaths, several of them mysterious. To detectives investigating the death of Mountville Townley, a pattern emerged. Lynette hitched herself to people with alcohol and chemical dependencies and then nurtured those needs to her advantage, said Strider. None of the six deaths were formally investigated. But Townley was found to have 30 times the normal arsenic level in his body. Traces of arsenic were found in the whiskey bottle that had been stashed behind a sofa. Why would Lynette want him dead? Greed, investigators concluded. There was a $10,000 insurance policy on her home, and Townley helped her burn it down. She poisoned him so he wouldn’t tell anyone, they theorized. Investigators had enough evidence to arrest Lynette. Before they did, Lynette’s daughter from her relationship with Venson Bell, Debbie, told them her mother had poisoned others as well with arsenic. Exhumations would be needed to confirm arsenic poisoning. On July 12, 1984, Pineville police opened the graves of Clifford Reeves, William Johnson, Ira Butter, Blanche and Earl Campbell, and Venson Bell. Most of the coffins were not well preserved. But medical examiners determined that Reeves died of arsenic poisoning. Earl Campbell also had lethal arsenic levels in his system. Results on the four other bodies were inconclusive. Police arrested Lynette Bell on August 21, 1984. She was charged with the second-degree murders of Townley and Reeves and attempted murder of Earl Campbell, the Associated Press reported. Although Campbell died by suicide, being poisoned may have led him to that, they argued. Each charge was tried separately. The court proceedings were finally set to start in September 1988, but Lynette entered a guilty plea. She was sentenced to 21 years, although she only served nine years in prison. She was released in 1998 on good behavior and failing health. She died not long after her release. **Topics:** Homeowners - arson, Life Insurance **Categories:** Conviction --- ### [Victims of fraud with mental health issues 'less likely get money back'](https://insurancefraud.org/news_archives/victims-of-fraud-with-mental-health-issues-less-likely-get-money-back/) **Published:** September 27, 2026 **Author:** Diane Beauchamp **Content:** Victims of fraud with mental health problems are less likely to get their money back and twice as likely to fall into debt due to scams, according to Which? The consumer group surveyed more than 1,000 fraud victims and found that six in 10 (58%) with a diagnosed mental health problem got all or some of their money back. This is compared to two thirds (68%) of victims with no mental health condition. One in three (31%) had to borrow money from friends or family, compared to one in five (18%) with no diagnosed mental health condition, and were twice as likely to borrow money from a bank (11% compared to only 5%). They were almost twice as likely to not have enough money for essentials (29%) and go into debt (26%) as a result of fraud compared to victims with no mental health conditions (15% and 12% respectively). One fraud victim told Which?: “It was horrific. I lost my job because of it, and a lot of other things in my personal life went downhill. It wasn’t a pleasant experience at all and I still feel like it impacts my trust in people.” Another said: “I feel stupid and ashamed to be scammed. It has affected how I see myself and has led to bouts of depression and anxiety.” A third victim said: “It was the first time I really trusted this misleading website and I was overwhelmed by self-criticism. Luckily my bank dealt with it very quickly and returned all the money taken out. It would be nice if there was a phone number to chat about this experience to get counselling to soothe my anxiety.” A fourth said: “It has destroyed my mental health completely as fraud happened to me three times in a year. I’m still paying for it mentally and financially.” Rocio Concha, Which? director of policy and advocacy, said: “Our survey shows fraud victims experiencing mental health problems are being failed, with devastating effects on their wellbeing and finances. “New rules to make reimbursement of bank transfer fraud mandatory can’t come soon enough. They must be backed with tough enforcement measures for any banks that flout them and fail to treat their customers fairly.” Under recent proposals from the Payment Systems Regulator (PSR), banks will be forced to reimburse anyone who loses more than £100 to bank transfer or payment fraud, apart from in exceptional circumstances. Which? said this should mean the vast majority of victims are fully reimbursed – putting an end to the “reimbursement lottery” they face. At present, many banks are signed up to a voluntary code to reimburse victims of bank transfer scams and some have their own reimbursement guarantees. **Watch: How to avoid Cyber Criminals** <https://finance.yahoo.com/news/victims-of-fraud-with-mental-health-issues-less-likely-get-money-back-230134298.html> **Topics:** Public Awareness --- ### [India 360: Government In Action Against Cyber Fraud, KYC Rules For Buying New Mobile Number To Get Stricter](https://insurancefraud.org/news_archives/india-360-government-in-action-against-cyber-fraud-kyc-rules-for-buying-new-mobile-number-to-get-stricter/) **Published:** September 27, 2026 **Author:** Diane Beauchamp **Content:** Now KYC rules for mobile connections will be more strict. Government will block fake sim cards. It will not be easy to get SIM from fake documents. The Digital Communication Commission approved the creation of a data analytics center. DAC will prevent fraud from mobile connections. DAC will be connected in the servers of all telecom companies. It will be easy to track SIM issued on fake document from Artificial Intelligence, Blockchain. Watch this special report on India 360. https://www.zeebiz.com/india/video-gallery-india-360-government-in-action-against-cyber-fraud-kyc-rules-for-buying-new-mobile-number-to-get-stricter-203835#goog_rewarded **Topics:** Public Awareness, Regulatory actions, Technology --- ### [How financial services businesses can avoid fraud](https://insurancefraud.org/news_archives/how-financial-services-businesses-can-avoid-fraud/) **Published:** September 27, 2026 **Author:** Diane Beauchamp **Content:** For as long as the financial services sector has existed, unscrupulous entities have found ways to exploit weak spots for personal gain. Fraud itself is nothing new, but as the financial system becomes increasingly decentralised, online criminals are becoming more sophisticated in the ways they breach security protocols. In this article, we’ll look at why financial fraud is on the rise and discuss how businesses in the financial sector can protect themselves with thorough due diligence tools, including an examination of their existing and potential clients’ credit history and criminal risk. Financial fraud is rising in 2022 Over the last decade or so, we have seen the proliferation of fintechs developing technologies aimed at fast-tracking, simplifying, and decentralising financial processes. These advances allow us to perform transactions that would have been unthinkable 20 years ago, like making instant transfers from one side of the world to the other or securing small personal loans outside of banking hours. Thanks to these technological advances, companies are able to automate processes, like the approval of a loan or cash transfer, that would previously have required a laborious paper-based credit check. This has allowed them to cut down on admin costs, increase efficiency, and reduce reliance on major financial institutions to act as intermediaries, but it has also opened them up to heightened financial risk. Studies have shown that fraud occurs in fintechs like neobanks at roughly double the rate of credit card companies. Rates of financial crime like fraud, blackmail, and extortion have been rising for a number of years; South Australia Police reported an increase in financial crime of 29 per cent between 2020 and 2021. How to protect your business from fraud There is no question that recent innovations have helped businesses boost efficiency and achieve growth. But protecting your finances doesn’t mean you need to forgo those benefits altogether; it just means that you need to be strategic about which transactions you automate and use only the best available systems. It is important to conduct due diligence before taking on a new client. The best way to protect your business when you extend credit is to start with a credit check. Yet not all credit checks are equal. Gain an advantage with CreditorWatch’s credit check processes, which combine and analyse data from a wide range of sources to produce valuable insights and predictions on every business in Australia. CreditorWatch has developed a unique suite of financial tools that use advanced AI automation to accurately calculate the credit risk posed by a potential debtor. RiskScore is the most predictive company credit score and rating system available in Australia. It uses more than 50 data points to generate a comprehensive credit report on any business, including credit and payment history and any high-risk indicators. ApplyEasy is our onboarding tool that simplifies the credit application process into a single online form. Businesses can streamline and customise their credit approval process, automating credit checks and trade reference changes, to increase efficiency and security. ApplyEasy verifies entity information immediately, ensuring you know exactly who you’re bringing on as a new client. CreditorWatch also offers ongoing credit monitoring and alerts for all the businesses in your portfolio. We will notify you in real-time of any adverse behaviour that could affect your debtor’s ability to meet their financial obligations. Meanwhile, our interactive trade payment program, DebtorLogic, analyses your Aged Trial Balance (ATB) to measure changes in payment behaviour over time and across markets, alerting you to adverse behaviour so you can take a proactive approach to debtor management. Finally, our offering includes features designed specifically to help businesses identify and prevent financial crimes. Our Know Your Customer (KYC) and Anti-Money Laundering (AML) features give anyone the power to conduct advanced screening of their trading partners. Our AML reports include politically exposed person (PEP) and sanction checks to identify involvement in bribery or corruption. They also include adverse media checks to reveal any negative news or coverage associated with the entity, and verification of identity (VOI) checks and document verification services (DVS) to avoid fraud. These procedures help to protect your business from illegal activity such as corruption, money laundering, tax evasion, theft and other financial crimes. CreditorWatch works with some of Australia’s top financial businesses. To better understand how we can help you safeguard your business against fraud and financial crime, get in touch with us for a free demo today. Credit management made easy – with CreditorWatch, everything about credit management is suddenly a lot easier. Do business better – CreditorWatch gives our customers the tools to do business better. Keeping you in good company – CreditorWatch will help your business ensure it’s in good company, only doing business with others who are safe to trade with and therefore avoiding bad debt. CreditorWatch is Australia’s top commercial credit reporting bureau with more than 55,000 customers, from sole traders through to ASX-listed companies. CreditorWatch and their innovative credit management solutions help businesses strengthen due diligence, mitigate risks and secure their cash flow. We provide exclusive credit risk insights, helping our customers make smarter decisions to protect themselves in this complex economy. At CreditorWatch, we go above and beyond with our data, products and service. Dedicated to our customers and our people, we empower them to grow and succeed. **Topics:** Financial Fraud, Public Awareness, Technology --- ### [Medicare fraud to be investigated, but $8 billion rorts claims 'way out of whack', Mark Butler says](https://insurancefraud.org/news_archives/medicare-fraud-to-be-investigated-but-8-billion-rorts-claims-way-out-of-whack-mark-butler-says/) **Published:** September 27, 2026 **Author:** Diane Beauchamp **Content:** ## Key Points - Claims of billions of dollars being rorted each year from the Medicare system are being taken seriously. - The health minister said an investigation would be carried out following media reports. Health Minister Mark Butler says claims of billions of dollars being rorted each year from the Medicare system are being taken seriously. Mr Butler said an investigation would be carried out following reports from the ABC and Nine newspapers that [up to $8 billion was being rorted from the system](https://www.sbs.com.au/news/article/unjustified-slur-doctors-take-aim-at-medicare-rorts-claims-as-government-investigates/6p6nw6o08). The media reports alleged some practitioners were ripping off Medicare and charging for services that weren’t delivered, with some doctors reportedly billing dead people and falsifying medical records. Mr Butler said while there was “fraud in the Medicare system”, the $8 billion figure cited in the media was higher than he expected. “It’s way out of whack with any other figure that’s ever been provided to government, including by the National Audit Office that only did a review of the program a couple of years ago, but I’m taking it seriously,” he told ABC Radio on Tuesday. “We want to make sure that we do everything we can as a government to ensure that every dollar is spent wisely.” Peak body the Australian Medical Association said the allegations of Medicare rorting were a slur on the profession. The association’s president Steve Robson said the vast majority of GPs did the right thing by their patients and indicated the $8 billion figure was “grossly inflated”. Mr Butler said he wanted to find out the truth behind the allegations of rorting. The investigation into the rorting, carried out by the federal health department, will include an analysis of the work of experts who examined Medicare claiming and compliance measures. “(The investigation) is a timely opportunity for us to have a thorough look at the way in which the audit and compliance system is working and ensuring … we’re getting the maximum value for money,” Mr Butler said. “Any single case of fraud or improper claiming, particularly right now given the state of crisis in general practices, is going to raise very serious levels of concern in the Australian population.” **Topics:** Medicare/Medicaid, Public Awareness --- ### [Doctors slam Medicare fraud allegations](https://insurancefraud.org/news_archives/doctors-slam-medicare-fraud-allegations/) **Published:** September 27, 2026 **Author:** Diane Beauchamp **Content:** The Australian Medical Association (AMA) said most doctors in Australia are ethical and will be “sickened” by a recent report claiming Medicare is rorted by up to $8 billion per year. A joint ABC and Nine investigation claimed that some medical practitioners charged for services that were never delivered by billing dead people and falsifying patient medical records to lift their incomes. Meanwhile, others made mistakes in claims. Medicare expert Dr. Margaret Faux estimated that the fraud cost taxpayers up to $8 billion a year. “These claims are an unjustified slur on the medical profession, with the vast majority of doctors doing the right thing by their patients and by Medicare rules,” Dr. Faux said in a statement, as reported by SBS News. The AMA further argued that it regularly meets with the Department of Health and “understands that there is no evidence of the widespread fraud suggested in today’s media.” “Doctors will be sickened by \[the\] reporting, which is an undeserved attack on the whole profession based very much on anecdotes and individual cases,” said AMA president Steve Robson, as reported by SBS News. Meanwhile, Health Minister Mark Butler asked the Department of Health to provide an analysis of Dr. Faux’s work and a “report on the department’s existing compliance, audit, and professional services review programs.” “All governments must apply strict compliance standards to any publicly funded system – including Medicare – to ensure that the small minority that do the wrong thing are picked up quickly and dealt with,” he said, as reported by SBS News. **Topics:** Medicare/Medicaid, Public Awareness --- ### [Free FOX10 Shred Event at the Spanish Fort Center, Saturday morning from 7 to 11](https://insurancefraud.org/news_archives/free-fox10-shred-event-at-the-spanish-fort-center-saturday-morning-from-7-to-11/) **Published:** September 27, 2026 **Author:** Diane Beauchamp **Content:** The shred event is free for everyone and will be in the parking lot near the [Bass Pro Shop in Spanish Fort](https://goo.gl/maps/PkvLheKGMptrEouR9) this Saturday morning from 7 a.m. to 11 a.m. For more information, click [here](https://www.facebook.com/events/1147766972838748/). MOBILE, Ala. ([WALA](https://www.fox10tv.com/)) -Identity theft is a serious problem across Alabama that can come in a lot of different ways. “They start opening up loans in their names, they start opening up bank accounts in their names,” said Better Business Bureau Vice President Monde Donaldson. “They also get access to their information so you can be recreated very quickly if you don’t watch out.” While it doesn’t take long to for identity theft to cause problems. Donaldson says it’s not so easy to undo the damage. “It’s not some damage that just goes away overnight,” said Donaldson. “When you’re a victim of identity theft it can last for years because it takes a long time to get everything straightened out on your accounts” Experts recommend shredding sensitive documents like old credit card receipts, medical bills and some others that you might not normally think about. “We’re still getting a lot of credit card offers in the mail so you don’t want to throw those out in your garbage can because that way someone can just take it out, fill out, change the address and have it sent to them,” added Donaldson. That’s why we’re partnering with Gilmore to give you an easy way to safely shred all of those old documents at once. “This is the most secure way to get rid of your old bank statements, your medical bills perhaps some health records that are no longer valuable,” said Donaldson. “So you get rid of that information at a shred event and you’re very secure.” **Topics:** Public Awareness --- ### [Blue Cross Blue Shield of Massachusetts Warns of Health Care Scams Targeting Members](https://insurancefraud.org/news_archives/blue-cross-blue-shield-of-massachusetts-warns-of-health-care-scams-targeting-members-2/) **Published:** September 27, 2026 **Author:** Diane Beauchamp **Content:** [Blue Cross Blue Shield of Massachusetts](https://c212.net/c/link/?t=0&l=en&o=3681434-1&h=4065231405&u=http%3A%2F%2Fwww.bluecrossma.org%2F&a=Blue+Cross+Blue+Shield+of+Massachusetts) (Blue Cross) is cautioning members to be vigilant, as scams offering free durable medical equipment (DME) and pharmacy products are on the rise. “While these types of scams have been around for years, the uptick in telemedicine usage during the COVID-19 pandemic is causing a resurgence in fraud,” said Jennifer Stewart, senior director for fraud investigation and prevention at Blue Cross Blue Shield of Massachusetts. Medicare beneficiaries and patients who’ve had a recent injury or surgery are often targeted by scammers. In many cases, the perpetrators solicit physicians to sign off on unnecessary orders or prescriptions, such as back braces or pain cream, which are then improperly billed to a patient’s health insurer. **Avoiding Fraud** Medical equipment and pharmacy products that are not properly prescribed to patients are potentially dangerous, said Stewart. In fact, some may not even be authorized by the FDA. “Members should treat their medical information like their credit card number and if they’re unsure, they should call their clinician to confirm if a service or product is necessary,” Stewart noted. She also recommends reviewing medical statements carefully to ensure accuracy and reporting any discrepancies. **For Clinicians and Health Plans** Clinicians should encourage patients to report any suspicious activity to [Medicare](https://c212.net/c/link/?t=0&l=en&o=3681434-1&h=697509515&u=https%3A%2F%2Fwww.medicare.gov%2Fbasics%2Freporting-medicare-fraud-and-abuse&a=Medicare), their health plan, and law enforcement, explained Stewart. “With any health care scam, everyone pays the price – whether you know it or not,” added Martin Flood, senior investigator for fraud investigation and prevention at Blue Cross. “In addition to the financial consequences, these scams have the potential to jeopardize patient health and result in long-term complications. It’s everyone’s job to be more vigilant.” **Monitoring for Fraud** Stewart emphasized that Blue Cross’ fraud departments work together to monitor claims for suspected fraud and alert government agencies if needed. “Once we start shutting down these claims and not paying them, these fraudulent organizations disappear quickly. However, they typically move on to new targets which proves that we all need to remain vigilant,” said Stewart. **Reporting Suspected Fraud** Blue Cross members who suspect, experience or witness health care fraud should report the information by calling the number on the back of their member identification card. Consumers who are not Blue Cross members can call the company’s fraud reporting hotline at 1-877-327-BLUE (2583). Federal employees and retirees can report potential health care fraud by calling 1-800-337-8440. **Topics:** Healthcare Fraud, Public Awareness --- ### [New York’s $4.5M Cybersecurity Settlement with EyeMed Bars Insurance Recovery](https://insurancefraud.org/news_archives/new-yorks-4-5m-cybersecurity-settlement-with-eyemed-bars-insurance-recovery/) **Published:** September 27, 2026 **Author:** Diane Beauchamp **Content:** Health insurance company EyeMed Vision Care LLC will pay a $4.5 million penalty to New York State for violations of the state’s cybersecurity regulation that officials said exposed hundreds of thousands of consumers’ personal health data, including data concerning minors. Under terms of the settlement with the Department of Financial Services, EyeMed cannot seek reimbursement or indemnification for the $4.5 million penalty from any insurance policy. DFS has included similar provisions in prior settlements. DFS Superintendent Adrienne A. Harris announced the [consent order](https://www.dfs.ny.gov/system/files/documents/2022/10/ea20221018_eyemed.pdf). She said that her department’s investigation revealed that in the summer of 2020 a bad actor gained access to a shared EyeMed email mailbox which contained over six years’ worth of consumer non-public information. The intrusion lasted from June 24, 2020, until July 1, 2020. The investigation was not able to determine how the unauthorized individual gained access to the mailbox, but EyeMed believes that it was likely a result of a successful phishing scheme. DFS said it found that EyeMed had failed to implement multi-factor authentication throughout its email environment. EyeMed further failed to limit user access privileges by allowing nine employees to share login credentials to its email mailbox and failed to implement sufficient data retention and disposal processes. At the time of the cyber event, EyeMed was in the process of rolling out multi-factor authentication for its email, but did not yet have it implemented for the mailbox. In addition, DFS discovered that EyeMed failed to conduct an adequate risk assessment, a requirement of the state’s cybersecurity regulation. While EyeMed engaged third-party vendors to conduct periodic risk management audits of IT, these assessments did not meet the standard required, DFS said. Upon learning of the threat, EyeMed immediately blocked the unauthorized access, launched an investigation, and retained outside breach counsel. EyeMed began to notify the affected individuals and file regulatory notices in September 2020. The DFS acknowledged EyeMed’s “commendable cooperation” throughout the investigation. ![](https://ra.wellsmedia.com/www/delivery/lg.php?bannerid=0&campaignid=0&zoneid=162&loc=https%3A%2F%2Fwww.insurancejournal.com%2Fnews%2Feast%2F2022%2F10%2F19%2F690860.htm&cb=f600e0fdce)As part of the settlement, EyeMed has agreed to undertake remedial measures to better secure its data. Among other things, EyeMed will conduct a comprehensive cybersecurity risk assessment and develop a detailed action plan describing how EyeMed will address the risks identified in that assessment. DFS said the provision barring insurance recovery has also been included in prior cybersecurity consent orders with firms including Carnival Cruises, Banner Life Insurance, Guarantr Inc. and Robinhood Crypto among others. DFS’s cybersecurity regulation became effective in March 2017. **Topics:** Judicial/courts, Technology --- ### [Fraud, DUI Investigations Get Funding Boost In Riverside County](https://insurancefraud.org/news_archives/fraud-dui-investigations-get-funding-boost-in-riverside-county/) **Published:** September 27, 2026 **Author:** Diane Beauchamp **Content:** The Board of Supervisors Tuesday authorized the Riverside County District Attorney’s Office to accept $5.3 million in criminal justice grants for prosecuting everything from impaired drivers to perpetrators of healthcare fraud. In a 5-0 vote without comment, the board gave District Attorney Mike Hestrin the green light to add the four California Department of Insurance grant awards and one California Office of Traffic Safety grant award to the office’s budget for the current fiscal year. The largest grant, totaling $3.25 million, was provided by the DOI specifically for cases stemming from workers’ compensation fraud. “It is my continuing intent that these funds be used effectively to pursue and investigate fraud across California,” Insurance Commissioner Ricardo Lara said in the award statement sent to the county. “It is important to focus these finite resources on combating fraud that continues to increase costs on the workers’ compensation system, including medical provider insurance fraud, employer premium fraud, insider fraud and claimant fraud.” The next highest sum received by the D.A. from the DOI — $904,390 — focused on auto insurance fraud. “Funding for this program is to be used by the District Attorney’s Office for the purpose of enhanced investigation and prosecution of automobile insurance fraud and economic car theft cases,” according to a statement posted to the board’s agenda. The state Office of Traffic Safety awarded $659,000 to support the D.A.’s Alcohol & Drug-Impaired Driver Prosecution Program. The grant award requires the D.A.’s office to permanently assign three prosecutors to handle misdemeanor impaired driving cases. “The prosecutors will share information with peers and law enforcement personnel throughout the county and across the state,” according to the OTS. “The D.A.’s office will accomplish these objectives as a means to prevent impaired driving and reduce drug-involved traffic fatalities and injuries.” The DOI furnished a $454,058 grant for disability and healthcare fraud prosecutions, and the agency’s smallest award — $61,522 — was for “life insurance and annuity consumer protection.” “The Department of Insurance … is dedicated to protecting consumers, the majority of whom are seniors, from abuse involving the sale of individual life and annuity products,” according to an agency letter attached to the grant. Nearly one-third of the D.A.’s fiscal year budget each year is comprised of grants, fees and other revenue streams independent of the county General Fund. **Topics:** Auto fraud, Insider Fraud, Public Awareness, Regulatory actions, Workers Comp --- ### [Catalytic Converter Law aims at curbing theft](https://insurancefraud.org/news_archives/catalytic-converter-law-aims-at-curbing-theft/) **Published:** September 27, 2026 **Author:** Diane Beauchamp **Content:** In an effort to try and stop criminals from stealing catalytic converters NY Governor Kathy Hochul is spending $20 million in technologies like surveillance cameras and license plate readers. “This will allow localities to purchase the technologies that they can do for this surveillance, and help law enforcement actually prosecute and stop the crimes from happening, so we’re going to double down on these efforts because this is a serious problem.” Joe Mastrangelo of Mastrangelo Truck Refinishers has been hit with catalytic converter theft ten times. “License plate readers…these guys are stealing them on bicycles.” He feels something has to be done since bail reform isn’t stopping crime. The Governor says this law will require business owners to keep track of catalytic converter sales. “We’re going to require vehicle dismantlers, which is a nice way of probably saying chop shops, and the scrap processors to keep information on anyone who sells them a converter. Let’s track who’s selling them. If a theft is reported, we’ll know where to get the information.” Hochul is spending another $3.7 million in motor vehicle theft and insurance fraud prevention, so those who take precautionary steps will see their insurance costs decrease. Taxpayers will continue to pay to reduce insurance costs, but is this law stopping catalytic converter theft? “The crime is a minor crime, and they figured maybe this will curb it by making it more difficulty to get rid of….I don’t know.” Joe Mastrangelo believes you can’t just give up. “A lot of people just say well no one’s going to anything because of bail reform. They’re going to get out anyway. You have to report it. You report a crime. It turns into a multiple crime. Then there’s a little more leverage.” The new legislation will go into effect January 1st. **Topics:** Legislation --- ### [United Kingdom Personal Insurance Claims Industry Report 2022 with Focus on Motor, Home, Travel, and Pet Insurance Markets - ResearchAndMarkets.com](https://insurancefraud.org/news_archives/united-kingdom-personal-insurance-claims-industry-report-2022-with-focus-on-motor-home-travel-and-pet-insurance-markets-researchandmarkets-com/) **Published:** September 27, 2026 **Author:** Diane Beauchamp **Content:** The [“United Kingdom (UK) Personal Insurance Claims Market by Private Motor Insurance, Household Insurance, Travel Insurance and Pet Insurance 2022”](https://www.researchandmarkets.com/reports/5661388/united-kingdom-uk-personal-insurance-claims?utm_source=BW&utm_medium=PressRelease&utm_code=cwpnpg&utm_campaign=1766019+-+United+Kingdom+Personal+Insurance+Claims+Industry+Report+2022+with+Focus+on+Motor%2c+Home%2c+Travel%2c+and+Pet+Insurance+Markets&utm_exec=chdo54prd) report has been added to **ResearchAndMarkets.com’s** offering. This report analyzes the claims landscape across motor, home, travel, and pet insurance. Claims fraud, the methods and channels used for claims, and claim satisfaction are all examined across the lines. The future of the claims landscape is also discussed. As the UK economy emerges from the COVID-19 pandemic, the primary challenge faced by insurers is a growing inflation rate. In August 2022, the UK inflation rate was at 10.1%. In line with growing inflation, gross claims incurred in 2022 across the four key personal lines all look set to grow compared to 2021. Repair, rebuild, and replacement costs are all growing, driven by supply-side pressures caused by both the pandemic and Brexit. **Scope** - Around 15% of motor, home, and travel insurance customers made a claim in 2021, with this figure rising to over 30% in the pet line. Of these claims, across all four lines over 80% were accepted. - Across all four key personal lines, consumers more commonly make a claim over the phone than through any other channel. This is both time-consuming and costly to insurers and claims handlers, who should encourage consumers to make use of simpler and faster digital channels. - Increased use of devices based upon the Internet of Things, enhanced digitalization across claims channels, and improved fraud detection methods will all act to help insurers reduce the impact of growing claims in the future. **Reasons to Buy** - Determine the extent of claims inflation across the four key personal lines and ways to react to these growing costs. - Understand how consumers derive satisfaction from the claims process and use these insights to create new solutions for customers. - See the role of technology in reducing the impact, frequency, and handling costs of claims. **Key Topics Covered:** - Executive summary - Background - Private Motor Insurance - Household Insurance - Travel Insurance - Pet Insurance - Appendix **Companies Mentioned** - Admiral - Aviva - Direct Line - LV= - Churchill - Marshmallow For more information about this report visit [https://www.researchandmarkets.com/r/a123z](https://www.researchandmarkets.com/reports/5661388/united-kingdom-uk-personal-insurance-claims?utm_source=BW&utm_medium=PressRelease&utm_code=cwpnpg&utm_campaign=1766019+-+United+Kingdom+Personal+Insurance+Claims+Industry+Report+2022+with+Focus+on+Motor%2c+Home%2c+Travel%2c+and+Pet+Insurance+Markets&utm_exec=chdo54prd) **Topics:** Public Awareness --- ### [Police ram ‘reckless’ motorcyclist after high-speed pursuit](https://insurancefraud.org/news_archives/police-ram-reckless-motorcyclist-after-high-speed-pursuit/) **Published:** September 27, 2026 **Author:** Diane Beauchamp **Content:** Police have released dramatic video footage of officers ramming a “reckless” motorcyclist following a high-speed pursuit. The dashcam footage shows the Hampshire police vehicle pursuing Owen Watson as he rode a black Honda 125cc moped at speeds of 60mph in a 30mph limit on The Avenue, Southampton, on April 23 2022. A force spokesman said: “The bike had fraudulent plates and Watson had no licence or insurance. “The motorcyclist refused to stop and tried to evade police by attempting to enter The Common, which was busy with pedestrians. “Officers made tactical contact to stop the bike, but Watson and the passenger ran from the scene. “Watson was arrested a short distance away and was also found in possession of cannabis.” The 23-year-old, of Taranto Road, pleaded guilty at Southampton Magistrates’ Court to driving without due care and attention, driving without a licence, failing to stop, using a fraudulent registration mark, possession of cannabis and driving uninsured. He was sentenced to a six-week prison term suspended for 12 months and fined £400 and ordered to pay £85 in costs and a £128 victim surcharge. He was also banned from driving for three months. Pc Paul Weston said: “The footage of this pursuit shows how reckless Watson’s actions were. It was a very busy time of day and there were lots of cars and pedestrians in the area. “Speed limits are there for a reason and it is extremely lucky there was nobody seriously injured or worse as a result of his speeding. “We are committed to apprehending all motorists who show complete disregard for the laws of the road and we hope this court result shows we will make sure these people are prosecuted.” **Topics:** Auto Rate Evasion **Categories:** Conviction --- ### [Insurance Regulator Wades Into Debate On “End-of-life Industry” After Nyaradzo Is Accused Of Fraud](https://insurancefraud.org/news_archives/insurance-regulator-wades-into-debate-on-end-of-life-industry-after-nyaradzo-is-accused-of-fraud/) **Published:** September 27, 2026 **Author:** Diane Beauchamp **Content:** The Insurance and Pensions Commission (IPEC, the statutory body regulating the insurance and pensions business in Zimbabwe, says it has taken note of the grievances that have been raised by the public regarding funeral assurance products’ design and pricing. IPEC said they were already talking with the industry on the need for changes to product design and broader industry reform. There has been debate on social media platforms in recent days about Nyaradzo Group’s funeral benefits, with some commentators accusing the end-of-life industry firm of fraud. Nyaradzo has been accused of ripping off its clients by revoking policies if the assured fails to pay subscriptions for three months when they will have been paying them consistently for three decades. In a statement seen by *Pindula News*, IPEC said it is seized with the concerns raised by the public and will update stakeholders on the outcome of its ongoing engagement with funeral assurers. Reads the statement: > The Insurance and Pensions Commission (IPEC) has taken note of ongoing discussions on social media, regarding funeral assurance products and pricing in Zimbabwe. > > IPEC acknowledges the concerns that have been raised by the public on the matter and wish to advise that prior to the current discussions on the matter, IPEC, in line with its mandate of protecting the interests of policyholders, was already in engagement with funeral assurers through their association Zimbabwe Association of Funeral Assurers (ZAFA) on these and other issues. > > These engagements, which also centre around product design and pricing, are expected to culminate in reforms that will ensure the vibrancy and sustainability of the sector and the protection of policyholder interests. > > IPEC will update stakeholders on the progress regarding this exercise. IPEC said policyholders with complaints against any of IPEC’s regulated entities, can raise their complaints with IPEC using the contact details below: HEAD OFFICE- 160 Rhodesville Ave, Greendale, Harare, Zimbabwe +263 (242) 443358/59/61 1443322 1444033 +263 772 154 281-4 COMPLAINTS HANDLING OFFICE HARARE-Kingstons House, Cnr Leopold Takawira/Kwame Nkrumah Avenue, Harare, Zimbabwe +263 (242) 749491/94 COMPLAINTS HANDLING OFFICE BULAWAYO- Office Number 18, Bulawayo Centre, Cnr Joshua Nkomo Street & 9th Ave, Bulawayo, Zimbabwe +263 (292) 261 822 **WhatsApp No:** +263772154281 **Email:** enquiry@ipec.co.zw **Website:** www.ipec.co.zw **Topics:** Life Insurance, Public Awareness, Regulatory actions --- ### [Korea's car accident insurance merry-go-round policies support recurring insurance fraud](https://insurancefraud.org/news_archives/koreas-car-accident-insurance-merry-go-round-policies-support-recurring-insurance-fraud/) **Published:** September 27, 2026 **Author:** Diane Beauchamp **Content:** About two decades ago, I had a car accident. I had gotten my driver’s license a few years before, but the license was just kept in a drawer as I wasn’t sure about my driving skills. Eventually, I decided that it was time I should start driving, and booked some hours of driving lessons with a tutor. During one lesson, another car crashed into the car I was driving at a crossroad. The insurance companies later decided that the other driver was 70 percent liable and I was 30 percent liable, but that didn’t matter much to me. I thought it was my fault since anyone driving on the road by oneself is supposed to be better than someone who is taking a driving class. The other driver ― a middle-aged lady ― as well as my driving tutor and I were all at a loss and didn’t know what to do. We just got out of the cars and looked at the damage. It was a quiet road with only a few, if any cars or passersby. Then out of the blue, an ambulance and wreckers arrived. I was wondering how they found out about the car accident since none of us had made a phone call, as far as I knew. The ambulance driver came to me and asked if I was okay. I said I was fine. The driver asked again if I was really okay. I said I was really okay. My right knee had hit below the steering wheel so it did hurt but I wanted to minimize the scale of the accident. Then the ambulance driver pulled me aside to have a more private conversation. “Look. It seems you were having a driving lesson and the tutor’s car has been damaged. Don’t you think there should be some compensation from the insurance?” Half convinced by the ambulance driver, and half due to the concern that I might have been hurt more seriously than I thought, I got in the ambulance, with my tutor as I remember. I don’t know where the other driver ― the middle-aged lady ― went. By that time, officials from insurance companies had arrived and were handling the details, so we could leave. We were transferred to a small hospital. I got some X-rays and the doctor checked me and asked for how long I wanted to be hospitalized. So it was me, not the doctor, who was to decide how many days of hospitalization I need. If I wanted to stay there for a month, I could, and the insurance company would pay all medical costs. I chose not to be hospitalized, though. I am not saying that people should refrain from hospitalization after being in a car accident. Even if you seem to be okay immediately after the accident there can be aftereffects that don’t appear until later so people are generally advised (by neighbors, friends, colleagues, or anyone they know) not to hurriedly sign and close the deal with the insurance companies. Still, the experience gave me a glimpse into how insurance money can be wasted. Drivers or passengers or pedestrians get hospitalized for longer than they need (in some cases perhaps even unnecessarily), and get compensation for the lost days of work, from the insurance companies involved. Doctors get paid by the insurer for the medical procedures, which can sometimes be excessive. The ambulance driver probably is paid by the doctor for having brought the “customer.” Things could be somewhat different since my experience was some 20 years ago, but it seems that the old problems related to insurance persist. The Financial Supervisory Service and the Ministry of Land, Infrastructure and Transport have been examining around 500 hospitals around the country since June, jointly with local governments and the General Insurance Association of Korea, to monitor patients hospitalized after traffic accidents. They are examining if the hospitalized patients were really staying there, as some hospitals, specializing in car accidents, are operating in such a manner that patients can freely come and go ― even sleeping off-site ― which could be construed as proof that they don’t need hospitalization at all. According to the Korea Insurance Research Institute, hundreds of billions of won in car insurance money is wasted through such fraudulent practices, as patients receive unnecessary or excessive treatment. The ratio is especially high among Oriental medicine hospitals where the fee for doctor’s practice is not set as strictly as in Western medicine hospitals. We all eventually have to pay for such fraudulent practices, as insurance premiums rise. **Topics:** Auto fraud, Public Awareness --- ### [Scollick v. Narula False Claims Act Case Update](https://insurancefraud.org/news_archives/scollick-v-narula-false-claims-act-case-update/) **Published:** September 27, 2026 **Author:** Diane Beauchamp **Content:** The July 2017 decision in *United States ex rel. Scollick v. Narula[**\[1\]**](https://www.insurancejournal.com/blogs/iat/2022/10/27/691230.htm#_ftn1)* (*Scollick),* determined that sureties and surety agents could be held liable under [the False Claims Act](https://blog.iatinsurancegroup.com/the-false-claims-act-what-contractors-and-businesses-need-to-know) (FCA) for bonding a fraudulent set aside contractor. The complaint alleged that a larger contractor set up a sham company, supposedly owned and operated by a service-disabled veteran, but actually controlled by the larger contractor to illegally bid on service-disabled veteran-owned small business (SDVOSB) contracts from the federal government. Although the 2017 *Scollick* opinion was decided at the pleading stage and therefore did not find any party liable, it was the first decision to hold that a surety could face potential FCA liability for bonding a fraudulent set aside contractor. Five years later, on July 29, 2022, all claims against the surety defendants in *Scollick v. Narula[**\[2\]**](https://www.insurancejournal.com/blogs/iat/2022/10/27/691230.htm#_ftn2)* were dismissed on summary judgment. In the 2022 *Scollick* opinion, the judge found no evidence that the surety defendants knew of the SDVOSB requirements or intended to deceive the government. Without such evidence, the whistleblower could not prove that the surety defendants knew or should have known that the bonded contractors’ statements to the government were false as required for FCA liability. The judge also found that the sureties and agent were not required to know the government regulations regarding disabled veteran or other set aside programs because sureties did not participate in them, rather the contractors did. Because of this, the surety defendants could rely upon the government’s certification that the bonded contractors met federal set aside program requirements. The question is: What does this mean for sureties? ### No “Free Pass” for Sureties that Bond Federal Set Aside Contractors The potential for FCA claims against sureties is now public knowledge and the issue will not go away any time soon. This recent decision in favor of the surety defendants is only the latest chapter in a series of ongoing developments. Here’s what you need to know. ### Is the *Scollick* decision final? No. Since the decision was made at the trial court level, it could be overturned on appeal after the case against the remaining defendants goes to trial. In fact, the whistleblower’s lawyers already noted that they plan on appealing the decision.[\[3\]](https://www.insurancejournal.com/blogs/iat/2022/10/27/691230.htm#_ftn3) ### Could sureties still be sued in similar cases? Yes. The judge’s decision does not absolve a surety that knows the contractor its bonding is defrauding the government. So, if the whistleblower had provided evidence that the sureties and the agent knew that the contractors were lying about their qualifications to bid on the subject projects, there would have been a different outcome. ### Does it matter who certifies a set aside contractor? Yes. In the *Scollick* case, the Veterans Administration certified that the contractor was a valid SDVOSB contractor, and the court found that the sureties could rely upon the government’s certification. The decision could have been different if a contractor self-certified that it was qualified to work on a federal set aside program. ### Is the decision binding on other courts? No. The *Scollick* decision is not a binding precedent on other federal courts, which means it doesn’t have to be followed by other courts. ### What can sureties and surety agents do to protect themselves from potential FCA liability for bonding a set aside contractor that turns out to be fraudulent? Despite the ruling in *Scollick* that sureties are not obligated to be familiar with the requirements of federal set aside programs, it is still recommended that sureties have enough knowledge regarding federal set aside requirements to be alert to “red flags” indicating that the account may not be a valid set aside contractor and avoid bonding such contractors. **Topics:** Contractor fraud, Judicial/courts --- ### [Elevance Health facing Medicare fraud suit, and 4 more updates](https://insurancefraud.org/news_archives/elevance-health-facing-medicare-fraud-suit-and-4-more-updates/) **Published:** September 27, 2026 **Author:** Diane Beauchamp **Content:** Here are five updates from Elevance Health, formerly Anthem, since Oct. 5. Elevance Health is facing a federal lawsuit alleging the payer received more than $100 million in overpayments from CMS after a judge declined to dismiss the suit. Elevance failed to show the lawsuit should be dismissed for lack of material, U.S. District Court Judge Andrew Carter said in a ruling in early October. Elevance Health is now the largest commercial health insurer in the nation by total membership. As of Sept. 30, total membership at Elevance was 47.3 million, an increase of 4.9 percent year over year. Elevance expanded its home-based nursing management company, myNEXUS, to Medicare Advantage members in 15 states. Deanna Strable, CFO of Principal Financial, will join Elevance Health’s Board of Directors. Elevance Health took in $1.6 billion in net income for the third quarter and raised its earnings outlook for the rest of the year, according to the company’s third quarter earnings report. **Topics:** Judicial/courts, Medicare/Medicaid --- ### [Fraud Week: Kickbacks for Home Healthcare Referrals](https://insurancefraud.org/news_archives/fraud-week-kickbacks-for-home-healthcare-referrals/) **Published:** September 27, 2026 **Author:** Diane Beauchamp **Content:** The U.S. Department of Justice (DOJ) announced on October 18 that Oklahoma-based Carter Healthcare LLC and its affiliates, plus two executives, agreed to pay a total of over $30 million to resolve two separate qui tam cases. [One lawsuit](https://www.justice.gov/usao-wdok/pr/oklahoma-city-home-health-company-and-two-former-corporate-officers-agree-pay-229) claimed that Carter paid remuneration to physicians in Oklahoma and Texas to induce referrals of Medicare and TRICARE home healthcare patients between 2013 and 2020, and [the second](https://www.justice.gov/opa/pr/carter-healthcare-affiliates-and-two-senior-managers-pay-7175-million-resolve-false-claims) alleged that Carter billed the Medicare program for medically unnecessary home healthcare services for patients in Florida between 2014 and 2016. Both lawsuits were brought under the False Claims Act, as submitting claims based on such wrongful conduct violates the FCA. The settlement in the Oklahoma case was $22,948,004 and the settlement in the Florida case was $7,175,000, of which the company’s President and Chief Operations Officer will pay a total of $250,000. The executives also agreed to be excluded from participating in Medicare, Medicaid, and all other federal healthcare programs for five years. Previously, DOJ [announced](https://www.justice.gov/opa/pr/home-health-care-company-owners-sentenced-67-million-health-care-fraud) on September 30 that home healthcare company owners Patricia Omorogbe and Felix Omorogbe were sentenced to two years and 18 months in prison, respectively, for participating in a $6.7 million fraud scheme. From 2009 to 2018, the Omorogbes paid bribes and kickbacks to patient marketers in exchange for referrals of Medicare beneficiaries to their three home health companies in Michigan and Indiana. Patricia Omorogbe was also ordered to pay $6,643,094 in restitution, and Felix Omorogbe was ordered to pay $1,592,362 in restitution. **Topics:** Judicial/courts, Medicare/Medicaid, Veterans Benefits Fraud **Categories:** Conviction --- ### [Federal Tally Reaches 5,000 Health Data Breaches Since 2009](https://insurancefraud.org/news_archives/federal-tally-reaches-5000-health-data-breaches-since-2009/) **Published:** September 27, 2026 **Author:** Diane Beauchamp **Content:** The federal tally of health data breaches reached a new milestone this week: The healthcare industry has reported more than 5,000 major data privacy and security incidents to the Department of Health and Human Services. The department’s Office of Civil Rights keeps a public online tally on its HIPAA breach “wall of shame,” which has been running since 2009. A Wednesday snapshot of the [website](https://ocrportal.hhs.gov/ocr/breach/breach_report.jsf) shows a total of 5,006 reported incidents, each affecting more than 500 individuals, with an overall total of nearly 369 million affected individuals. That’s more people affected by large health data breaches than the total U.S. population, which the Census Bureau on Jan. 1 tallied as 332.4 million. Likely many individuals have been caught up in more than one major health data breach. So far in 2022 alone, 562 major [data breaches](https://www.healthcareinfosecurity.com/breach-notification-c-327) affecting more than 39.2 million individuals have been posted to the tally. Companies reported hacking as the cause behind a large majority of those incidents. About 206 of the breaches so far this year involved business associates. Those breaches affected 18.7 million individuals – or about 48% of the total affected by major health data breaches in 2022. ### 10 Largest Health Data Breaches in 2022, So Far | Breached Entity | Individuals Affected | |---|---| | OneTouchPoint | 4.1 million | | Advocate Aurora Health | 3 million | | Shields Health Care Group | 2 million | | Professional Finance Co. | 1.9 million | | Baptist Medical Center | 1.6 million | | Novant Health | 1.4 million | | Broward Health | 1.35 million | | Texas Tech University Health Sciences Center | 1.3 million | | Practice Resources | 942,000 | | Partnership HealthPlan of California | 855,000 | Source: U.S. Department of Health and Human Services ### Bigger Picture Of the 5,006 known healthcare industry breaches, slightly less than half are hacking incidents – but their relatively low frequency belies their importance, since those breaches were responsible for nearly 83% of all people affected. Incidents involving business associates are less lopsided in the gap between frequency and effect. They amount to about 27% of total breaches and about 35% of all people affected. ### 10 Largest Health Data Breaches Since 2009 | Breached Entity | Individuals Affected | |---|---| | Anthem Inc. | 79 million | | Optum360 | 11.5 million | | Premera Blue Cross | 11 million | | Laboratory Corp. of America | 10.3 million | | Excellus Health Plan | 9.36 million | | Community Health Systems | 6.1 million | | Science Applications International Corp. | 4.9 million | | Community Health Systems | 4.5 million | | UCLA | 4.5 million | | 20/20 Eye Care Network | 4.1 million | Source: U.S. Department of Health and Human Services To date, the 2014 cyberattack on health plan [Anthem Inc.](http://www.healthcareinfosecurity.com/anthem-hit-by-massive-data-breach-a-7876), which was reported in February 2015 as a hacking incident affecting nearly 79 million individuals, remains the largest health data breach appearing on the tally. So far, none of the 10 largest [HIPAA](http://www.healthcareinfosecurity.com/hipaa-hitech-c-282) breaches appearing on the HHS website were reported in 2022. The 11th-largest breach posted to the federal tally was reported this year on July 27 by business associate [OneTouchPoint](https://www.healthcareinfosecurity.com/printing-vendors-breach-tally-soars-to-nearly-27-million-a-19933), a Wisconsin-based printing and mailing vendor. That hacking incident, which involved [ransomware](https://ransomware.databreachtoday.com/), was reported by the [business associate](https://www.healthcareinfosecurity.com/vendor-risk-management-c-434) as affecting more than 4.1 million individuals. It is the largest breach posted on the federal tally so far this year. ### Looking Ahead Health data breach trends – especially those involving hacking incidents, such as ransomware and data exfiltration attacks, and vendors – will likely expand, given the consolidation and duplication of electronic protected health information in the “extended outsourcing environment,” says Chris Gray, vice president of cybersecurity at security firm Deepwatch. “Perimeters have been shattered, and extended telehealth/reporting/intake services open up the attack surface,” he says. “The healthcare industry needs more security resources. If the number of defenders remains status quo, while the attack surface grows and more sophisticated ‘hacking tools’ become freely available, then we’d expect more breaches and impact.” Michael Hamilton, CISO of security firm Critical Insight and former CISO of the city of Seattle, offers a similar assessment. “I do not see these trends changing until the market economics change around records theft and monetization,” he says. **Topics:** Public Awareness, Technology --- ### [Michigan Medicine: Health information of more than 30K patients could be exposed after breach](https://insurancefraud.org/news_archives/michigan-medicine-health-information-of-more-than-30k-patients-could-be-exposed-after-breach/) **Published:** September 27, 2026 **Author:** Diane Beauchamp **Content:** Michigan Medicine has announced that a recent breach could have exposed private health information. The health system is working to notify approximately 33,850 patients whose information may have been compromised as the result of a cyber attack between Aug. 15-22 directed at employee emails. According to Michigan Medicine, employees were targeted by cyber attacker with a “phishing” scam. They were sent a link that prompted employees to enter their Michigan Medicine login information. “Four Michigan Medicine employees entered their login information and then inappropriately accepted multifactor authentication prompts which allowed the cyber attacker to access their Michigan Medicine e-mail accounts,” reads a release. The health system learned of the compromised accounts on Aug. 23 and immediately disabled them. Although officials said no evidence during an investigation that followed suggested the purpose of the attack was to obtain private health information, they said they could not rule out data theft. A review of all the compromised emails and attachments to determine if sensitive data was leaked was completed on Oct. 17. Patients affected by the incident will be notified by letters which were mailed between Oct. 19-26. Some emails and attachments included identifiable information of patients such as name, address, date of birth, medical record number, treatment and diagnostic information and in some cases health insurance information. Officials said the emails were “job-related communications for coordination and care of patients, and information related to a specific patient varied, depending on a particular email or attachment.” Since the incident, the health system updated its email system to feature additional technical safeguards to prevent a similar future attack. No financial information like credit card, debit card or bank account numbers were found in the emails. In one case, a patient’s Social Security Number was involved, and they received a separate notice, officials said. Michigan Medicine said it will continue employee training and education to recognize scam emails when they encounter them. The employees involved in the incident are subject to disciplinary action, according to the health system’s policies and procedures. They had previously undergone training for scam emails. “Patient privacy is extremely important to us, and we take this matter very seriously,” Michigan Medicine chief compliance officer Jeanne Strickland said in a statement. “Michigan Medicine took steps immediately to investigate this matter and is implementing additional safeguards to reduce risk to our patients and help prevent recurrence.” Patients who do not receive a letter and are concerned about the breach can call the toll-free Michigan Medicine Assistance Line at 1-833-814-1736. between 9 a.m.-9 p.m. Monday through Friday. **Topics:** Public Awareness, Technology --- ### [Healthcare’s email security problem is a compliance and forensics nightmare](https://insurancefraud.org/news_archives/healthcares-email-security-problem-is-a-compliance-and-forensics-nightmare/) **Published:** September 27, 2026 **Author:** Diane Beauchamp **Content:** Email hacks against the healthcare sector are common — and problematic from a compliance perspective in terms of reporting requirements. While the consensus is that email is merely a pivot point for other nefarious activities, the stat doesn’t hold as much water in highly regulated industries. Fortified Health Security CEO Dan L. Dodson explains that email is the No. 1 attack vector, mainly through phishing attacks because “the end user is obviously one of, if not the riskiest, point of entry to the organization.” SC Media examined the Office for Civil Rights breach reporting tool and found more than 122 email-related incidents affecting over 1.33 million patients have been reported to the Department of Health and Human Services in 2022, so far. The tallies range from 500 or 501 patients (typically filed as such to denote an ongoing investigation), to as many as 502,869. Although some of these breach tallies are notable, what’s more concerning is the length of time between detection and reporting it to the impacted patients and regulators. As seen with the [largest email hack reported this year](https://www.scworld.com/analysis/breach/a-single-email-account-hack-spurs-breach-notice-for-503k-christie-clinic-patients), Christie Business Holdings reported the hack of a single email hack in April this year. One of the largest multi-specialty group medical practices in Illinois, Christie Clinic’s notice resembles most email-related reports: Namely, the date of discovery is often not included, only when the investigation concluded. For the clinic, the forensics ended on Jan. 27, 2022, even though the monthlong hack occurred six months earlier, between July 14 and Aug. 19, 2021. Further, the notice was not sent for another three months after the investigation ended. Under The Health Insurance Portability and Accountability Act, covered entities and relevant business associates are required to report data breaches within 60 days of discovery — not at the end of an investigation. But Christie Clinic is not alone in its forensics and reporting challenges. To understand why email creates such a compliance headache for providers and how to improve data retention policies, SC Media spoke with Dodson, First Health Advisory Chief Security Officer Will Long, and Impact Advisors Principal Dan Golder. “Email is the unspoken repository of data that we probably shouldn’t be keeping,” said Golder. “We all do it.” Consider a personal email account, “it’s a file system for people.” The bad habit of leaving data in these accounts is also rife for legal pursuit or even enforcement actions by OCR, not to mention the ongoing trend of legal actions being taken against providers directly following breach reports. ## ‘Pivot point’ is moot when health data is involved In many of these instances, the hacker isn’t necessarily looking for the data contained in these accounts. Their goals are simple: target an individual, entity or government to look for unprotected or semi-protected data with a server hack or social engineering attack. “Most of the time, hacking is a crime of convenience,” said Golder. “They’re not really targeting specifically, they’re just looking for somebody that will type in their password.” There are also true social engineering attacks where they target specific individuals or companies, even with phone calls pretending to be tech support. Upon mention of the email trends, Golder also reviewed the OCR breach reporting tool, noting his shock at the size of these breaches. It’s “staggering” to think of how many people have been impacted. “The risk here is off the charts.” Threat actors target email accounts by exploiting or stealing weak credentials to gain a broader foothold onto the network. Many breach notices even include language that implies these email hacks were designed for fraud attempts or further activities unrelated to personal data. Most email-related breach notices also contain a major red flag: “However, the evidence could not conclusively determine what, if any, access to the data contained in the accounts was accessed.” Long explained that this is due to the sheer lack of visibility into actions made within the account due to the platforms used or overall settings. The actor may reset those passwords and dupe staff members to steal their passwords, then move on to other systems, which could lead to other compromises. The hacker may also phish other internal accounts to launch a ransomware attack, or another hack but have no interest in the data contained in those accounts. But the privacy team will immediately want to know what protected health information was in the email accounts accessed by the attacker. Long said, “the struggle is that most email systems don’t log which emails were opened or read.” In less or differently regulated industries that insight may not be needed. But when a covered entity loses control over any system or account with protected health information, the onus squares wholly on the entity to prove, or disprove, whether PHI was indeed party to unauthorized access. A similar reporting conundrum occurs when a device is stolen. If the device data is not encrypted, it’s presumed a HIPAA-reportable breach even if it appears the theft was meant to get ahold of the tech. Without evidence supporting that access didn’t occur, HIPAA requires the provider to file a breach report with the OCR. And that’s where providers find themselves in a world of trouble. ## The compliance nightmare of email forensics Without strong data retention policies, a given entity may have tens of thousands of emails within a single account. After an account hack, the privacy team will need to know what data is contained in the account, prompting the security team to extract data for the entire account and run it through a scanning engine to look for PHI and credit cards. It’s “a huge struggle because most privacy compliance and legal teams take the stance that ‘if they were in there, we have to assume that they saw it because we can’t prove they didn’t,’” said Long. In some cases, they’ll consider the amount of time the actor was in the account and what they were seeking, then do a risk assessment. As a result, teams “have to scour” these accounts. In particular, if it’s a doctor’s account that’s been accessed, the forensics can contain hundreds of spreadsheets with PHI all over the emails. Long explained that when the access lasts for days, weeks, or months, without a log of what was opened or not opened, “what can providers do?” “Most organizations have to default that the 10,000 PHI records represented in all these emails have to be reported as a breach,” he added. Even though email is not a database, a lot of PHI is shared via spreadsheets, PowerPoints, tables, and other means. After a hack, the files are extracted into a large folder that must be manually sifted through by the forensics team, including removing duplicate records and finding health information. “It’s a huge undertaking. There is no automated tool,” said Long. “One of the side effects that a lot of people don’t talk about is the reporting of it.” Security teams might not be worried about that element from a cyber perspective. “But this is a drop-everything-for-a-whole-bunch-of-people project.” The process to just get the data “normalized and into a spreadsheet of who you’re going to report to” is a huge effort. The teams must also consider the different data types like children, parents, or even whether a patient is deceased. “It’s unbelievable,” said Long. “I’ve seen compliance issues and people just pulling their hair out, when all of a sudden we’ve got hundreds of files and figuring out reporting requirements. That’s why they usually don’t make the deadline.” ## When “just archiving” the data is not an option Particularly when email is commonly used as an access point for ransomware attack and fraud attempts, providers should look to reduce both the attack surface and the amount of data left hanging around like low hanging fruit. Improving data retention policies is a strong solution for reducing these headaches, and Long has seen some providers move in that direction. But legal and compliance teams often take different stances on the best manner to go about this, as some departments want to keep everything no matter the risk. It’s not always as simple as deleting the old email, especially given the culture shift that would need to occur for entities to be comfortable with it. Golder typically recommends data archiving for older emails, so the information is kept — but safely stored offline. Even in Outlook, the data can be saved offline as a separate file and stored on a CD or a digital drive. If it’s stored separately, the information is still accessible to providers who may need to revisit past communications with patients or colleagues. Golder added the process is an easier task within a business account than it is for personal email, as many of those platforms make it difficult to archive data. Providers also need to be very careful about what they choose to keep in the accounts. The concern for Golder is that “there are a lot of email and email discussions that probably, at this stage of the game, shouldn’t be in email because it is discoverable.” Secondly, studies have found that phishing education and training drastically reduce the risk posed by the accounts. Entities should make cybersecurity a prime initiative within the organization because, as Golder puts it, “Despite our best efforts throughout the industry, we still have people that are not security aware enough.” “Hackers are always trying to stay one step ahead, so in many ways no matter what we do from a global perspective, it really does come down to the individual person being somewhat accountable,” said Golder. “Consistency matters in this space,” so Dodson recommended that it’s realistic for entities to train employees, at a minimum, on a quarterly basis. Some progressive organizations perform it monthly. Numerous technical options can reduce the risk as well, with some large health systems taking even larger steps by banning the use of personal email on the hospital network. Dodson takes it a step further and highly recommends leadership not to give email accounts to workforce members who don’t need it. In doing so, entities can reduce their attack surface. Better email filtering can also reduce the amount of nefarious emails entering a user’s inbox, he added. Golder added that a hardware security key can ensure that even if a password is stolen, the attacker can’t access the account without the physical key. The tool should be a business imperative for providers insistent that they’ll “continue to maintain email as a file system.” The hard key is ideal for stolen password situations, as well as the current threat of phone calls. Even when the password is handed out, it’s useless without a hardware key to provide the required two-factor authentication Using a multi-pronged approach, providers can simply work to reduce the amount of PHI sent and stored within email accounts. On the smaller side, PHI just shouldn’t be put into spreadsheets and sent via email, Long explained. For example, some providers send daily reports to every workforce member with patient connections on a daily basis inside of the email account, often more than 100 employees. That means the report with PHI is now within 100 email accounts. Instead, providers should be directed to that data via a secure link with two-factor authentication. By reducing the PHI shared within accounts, reducing the length of time data is stored, and improving training, these small reductions would drastically reduce the amount of unnecessary PHI within email accounts. But security leaders must work to convince the board of the need to take on another project, which can bolster compliance. An entity should weigh their options, but the choice appears to be: either reduce the amount of data stored in the account and how long, or spend months or up to a year with multiple employees down trying to identify the data, all while at the risk of failing HIPAA’s 60-day reporting requirement and possible enforcement actions. “It really comes down to cost-benefit,” said Golder. “Everything is a cost-benefit analysis. If the cost is too high, you don’t do it. If the benefit is great, then you will. And for security, most people feel the cost is too high: ‘I don’t want to bother with all that stuff…’ When they suddenly get the data breach, then they go, ‘Oh, that cost was pretty high. Maybe I need to do something.’” “It’s just human nature,” he added. “We’re not going to do it until it’s so painful that we feel we have to.” **Topics:** Public Awareness, Technology --- ### [Airman who plotted to kill spouse for insurance money appears in court](https://insurancefraud.org/news_archives/airman-who-plotted-to-kill-spouse-for-insurance-money-appears-in-court/) **Published:** September 27, 2026 **Author:** Diane Beauchamp **Content:** When Airman 1st Class Katelyn Day first met her husband five years ago, she probably did not expect to wind up in front of the military’s highest court years later with charges of trying to kill him. Yesterday, however, Day appeared before a judge after reportedly attempting to poison her estranged spouse with fentanyl and secure a $100,000 life insurance payout. Day, who was previously stationed at Barksdale Air Force Base in Louisiana, pleaded guilty to attempted wrongful possession of fentanyl as well as several other counts of attempted premeditation and attempted conspiracy to commit murder, according to court documents. She was initially sentenced on July 23, 2020 to a dishonorable discharge, confinement of 10 years and a reduction to the lowest enlisted Air Force rank, according to the documents. Her sentence was affirmed in January by the Air Force Court of Criminal Appeals before reaching the U.S. Court of Appeals for the Armed Forces yesterday. Day joined the service in April 2016 and met her husband, listed by his initials “TD” in court documents, the following year at an outpatient mental health treatment center in Shreveport, Louisiana. The couple quickly married in July 2017, and it would not be long before the relationship took a turn for the worse. Just two weeks after tying the knot, Day learned that TD had an “on-again, off-again relationship” with a woman identified in court records by the initials “JM,” with whom he had a child born later that month. In Dec. 2018, Day and TD had a child of their own, but the couple soon faced financial problems — in part, because TD’s sole source of income was a part time position that earned minimum wage. After trying marriage counseling, Day told TD in Feb. 2019 that she wanted to separate. TD was out the following month and Day filed for divorce in April. Since Day and TD shared a child under 18 years old, Louisiana state law required the couple to live apart for at least a year before a judge would grant them a divorce. A lack of consistent child support from TD, however, further complicated financial matters for the airman. By that fall, Day was finding emotional support from an unlikely source: JM, with whom TD had another child. Along with two other individuals, the pair would often converse in a Facebook group called “Hot Mess Express,” where they vented about TD. Things escalated, however, in private messages between Day and JM. “Have someone kill him … then we won’t have to deal anymore,” Day wrote. “I’ll give you half his life insurance.” That life insurance policy would have been nullified if Day and TD were granted their divorce. About a month later, Day reached out to a former boyfriend, named “SP” in the court documents, and asked for help. “Do you know a hit man or something …\[a\]nd yes I’m serious,” she said. When SP declined, Day turned to a coworker named “JJ” for assistance. Although he too declined — and had local police contact Day on Nov. 30 — the airman persisted. On Nov. 30, Day reached out to an old contact, named “TL” in proceedings, and devised a plan in which TL would charge Day $100 a month to teach her how to fatally poison her estranged husband. The duo’s scheme would not go as planned. On Dec. 15, the Air Force Office of Special Investigations began exploring the case with help from none other than JM, the former romantic rival-turned-friend-turned-confidential informant. Under direction from the AFOSI, JM messaged Day about the status of hiring a hitman. The two agreed to drug TD by putting “muscle relaxers and pain killers” into a drink. On Dec. 18, JM met Day at a Walmart and gave her a “clear baggy” with a white substance that AFOSI agents told her to say was fentanyl. Day bought the faux drugs from JM for $100, with the intention of executing the plan three days later. Day’s opportunity never came. That night, AFOSI agents arrived at Barksdale Air Force Base to search Day’s home, where they found the fake drugs stashed in her freezer along with a pair of rubber gloves. After initially denying the plot to murder her husband, Day eventually confessed. According to the Daily Beast, TD’s mother confirmed in January that her son Tyler Day is the TD referenced in the court records. In court yesterday, prosecutors asserted that the two “attempted conspiracy” charges Day faces are fair, though her defense team pushed back, arguing that the charges are too vague and diverge from federal law. “In short, this court should hold attempted conspiracy is not an offense under the \[uniform code of military justice\],” Air Force Maj. Matthew Blyth said during the court-martial hearing. Setting aside the two attempted conspiracy charges will reportedly not impact the actual sentence Day received in the lower court. The status of when a final decision will be reached is unclear at this time. **Topics:** Life Insurance **Categories:** Conviction --- ### [Federal grand jury indicts Mansfield doctor, LPN for prescription drug fraud](https://insurancefraud.org/news_archives/federal-grand-jury-indicts-mansfield-doctor-lpn-for-prescription-drug-fraud/) **Published:** September 27, 2026 **Author:** Diane Beauchamp **Content:** A longtime DeSoto Parish physician was indicted Wednesday on prescription drug fraud charges. The indictment accuses Dr. Jeffrey L. Evans, Jr., 65, of Mansfield, along with his nurse, Debra E. Craig, 66, of Converse, of illegally obtaining and distributing controlled substances, U.S. Attorney Brandon B. Brown said. Evans’ tenure as a licensed medical doctor with DeSoto Regional Health System ended in May just as a federal investigation was underway. Evans and Craig are not the first to be caught up in the investigation. Earlier this month, Debra Bossier, 48, also known as Debra Palmer, of Mansfield, a former medical assistant at the hospital, pleaded guilty to forging prescriptions to get pain pills. She’ll be sentenced on Feb. 10. Evans is also the elected coroner for DeSoto Parish. The DeSoto Parish Police Jury will hold a special meeting at 4:20 p.m. Thursday to accept Evans’ resignation and appoint a replacement. Evans’ indictment alleges that beginning on or about Jan. 2, 2014 and continuing until about March 9, he and Craig, who was assigned to work for Evans in his medical office, conspired together and with other persons to obtain hydrocodone and Adderall, both Schedule II controlled substances, by fraud. It is alleged in the indictment that Evans would write prescriptions for Schedule II controlled substances to an unnamed person identified as “Individual 1” and to Craig. The prescriptions included hydrocodone-acetaminophen tablets, hydrocodone-homatropine syrup, and Adderrall. According to the indictment, Individual 1 would fill the prescriptions at a Mansfield area pharmacy then provide the Adderrall to Evans, who would split the drugs containing hydrocodone with Individual 1. The indictment further alleges that Craig would fill the prescriptions at a Mansfield pharmacy using the name “Debbie Craig.” Evans would provide cash to Craig to pay the pharmacy for the drugs, and after filling the prescriptions Craig would in turn provide them to Evans. It is alleged in nine counts in the indictment that Evans obtained controlled substances by fraud from December 2017 through August 2018. In addition, Evans and Craig are both charged with five counts of obtaining controlled substances by fraud between September 2020 and March. Finally, the indictment alleges that Evans distributed controlled substances through prescriptions that were not issued for a legitimate medical purpose between February 2018 and August 2018. If convicted, Evans faces a sentence of up to 20 years in prison, 3 years of supervised release, and a fine of up to $250,000. If convicted, Craig faces a sentence of up to 4 years in prison, 3 years of supervised release, and a fine of up to $250,000. The case is being investigated by the U.S. Drug Enforcement Administration and is being prosecuted by Alexander C. Van Hook, special counsel to the U.S. attorney, and Assistant U.S. Attorney Michael Shannon. **Topics:** Drug Diversion **Categories:** Arrest --- ### [I-TEAM: 2 men accused of having fraudulent contracts with customers for more than $700K](https://insurancefraud.org/news_archives/i-team-2-men-accused-of-having-fraudulent-contracts-with-customers-for-more-than-700k/) **Published:** September 27, 2026 **Author:** Diane Beauchamp **Content:** Steven Ford, Lawrence Gilmore IV arrested on charges that include organized fraud, workers’ compensation insurance fraud Two Jacksonville men are accused of trying to scam more than $700,000 from homeowners and businesses, according to records obtained by the News4JAX I-TEAM. Steven Ford and Lawrence Gilmore IV were arrested late last week on charges that include organized fraud and workers’ compensation insurance fraud. Ford is also accused of passing himself off as a licensed contractor. As of Wednesday, Ford was still being held in the Duval County jail on $100,000 bond. Gilmore bonded out Friday night. According to an affidavit, the organized scheme to defraud people began in September of last year. The court document lists 14 victims, but the warrant says additional victims are still being discovered. News4JAX spoke with one of them — Elana Fields. She and her daughter bought a house last August where she would retire and her grandchildren would grow up. But it needed work, including a new driveway. “You can’t drive over it,” Fields. They also planned to add a suite to the home for Fields. “I still wanted my own space,” she said. In December, they signed a contract with Ford Contracting LLC for $78,173 for renovations upon the suggestion of a real estate agent who Fields knew. “I just assumed that, like I said, that LLC after his name, that he was licensed,” Fields said. Investigators said she paid $23,000, but that to this day, no permits were obtained, no work was done, and Ford has not responded to texts or phone calls. “I said well that guy is out and out lying to me so something is wrong here,” Fields said. According to investigators, Ford and Gilmore of Ford Contracting had fraudulent contracts with customers for more than $700,000. In the affidavit, the detective on the case writes that Ford would sometimes collect a 50% deposit but never get the building permits or start the work — like at Fields’ house. Other times, according to investigators, Ford and Gilmore would get building permits by using the forged signature of a local contractor who was licensed and then abandon the job in the early stages. No one answered when the I-TEAM tried to call Ford Contracting. We got a message saying, “The number you dialed is not a working number.” Florida records show Ford Contracting is registered to an address in the Holiday Hill area on the Southside. No one answered the door, and the office looked abandoned when the I-TEAM paid a visit Wednesday. Workers at nearby businesses said people had been living there until officers evicted them on Friday — the same day Ford was arrested. People like Fields are now out tens of thousands of dollars — or with home renovations left in disarray or not begun at all. “We’re going to have to find a contractor,” Fields said. “I will be sure to check the licenses and all that.” Investigators also said Ford and Gilmore violated Florida by did not obtaining workers’ compensation insurance coverage for a salaried employee and other non-exempt subcontractors, leading to one of the charges against them. Both Ford and Gilmore have court dates set for next month. **Topics:** Contractor fraud, Unlicensed, Work comp - employer --- ### [Government to crack down on NDIS provider fraud amid warning scheme will soon cost $50bn annually](https://insurancefraud.org/news_archives/government-to-crack-down-on-ndis-provider-fraud-amid-warning-scheme-will-soon-cost-50bn-annually/) **Published:** September 27, 2026 **Author:** Diane Beauchamp **Content:** The federal government is creating a “fraud fusion taskforce” to try to claw back nearly $300m from national disability insurance scheme providers, amid warnings the NDIS could cost more than $50bn annually within four years. The new body, which will replace the existing NDIS fraud taskforce, will target “fraud and serious non-compliance” with the help of law enforcement, regulatory and intelligence agencies. Tuesday’s budget earmarks $126m over four years to set up the new taskforce but predicts this will be eclipsed by the amount recovered from NDIS providers, estimated in the budget to total $291.5m. That means the measure should deliver $165m after the costs of the taskforce are taken into account. The budget papers show NDIS costs will increase by 14% a year over the next decade, driven by the growth in the number of participants and average support costs. The total cost of federal, state and territory funding for the NDIS is expected to increase from $35bn this year to $52bn in 2025-26. The government has ordered a review into the program’s design, operations and sustainability, raising the possibility of future sweeping changes. The treasurer, Jim Chalmers, said the review was needed “because the spending trajectory right now is putting incredible pressure on the budget”. In an interview with ABC TV on Tuesday night, Chalmers said the Labor government did not see the NDIS “as the source of savings for the sake of it”. Labor created the NDIS and wanted it to “endure and survive”, he said, but added that “every dollar needs to get value for money”. The minister for the NDIS and government services, [Bill Shorten](https://www.theguardian.com/australia-news/bill-shorten), said the government was acting on its promise “to get the NDIS back on track”. “Labor’s announcement of a cross-agency fraud fusion taskforce will help defend the scheme from crooks and help deliver our pledge to crack down on NDIS fraudsters,” he said. Shorten said the government had worked with states and territories to improve National Disability Insurance Agency administrative processes “to ensure that people with disability do not languish in hospital unnecessarily”. The budget funds an extra 380 permanent staff for the NDIA, and $6m for an alternative dispute resolution pilot aiming to help people with disability resolve complaints over NDIS decisions more quickly. The NDIS provider fraud crackdown is one of a [number of measures the Albanese government is pursuing](https://www.theguardian.com/australia-news/2022/oct/25/october-budget-2022-cuts-savings-infrastructure-rorts-waste-environment-explainer-federal-government-australia) to regain modest amounts of revenue as it leaves the expensive stage-three income tax cuts in place, for now at least. The government says its major measures to improve the budget bottom line will deliver more than $18bn over four years, with the biggest measure being $4.7bn from overhauling infrastructure spending. **Topics:** Disability, Public Awareness, Regulatory actions --- ### [Fraud victim loses claim dispute after failing to take precautions](https://insurancefraud.org/news_archives/fraud-victim-loses-claim-dispute-after-failing-to-take-precautions/) **Published:** September 27, 2026 **Author:** Diane Beauchamp **Content:** A small business that had $130,510 siphoned from its accounts by an employee will not be compensated for its losses after a dispute ruling determined that its insurer’s “segregation of duty” exclusion was correctly applied. The complainant lodged a claim on February 3 last year after it uncovered that a part-time accounts administrator, referred to as EK, misappropriated funds. The employee was subsequently fired from the business, and the matter was referred to the police. The claimant alleged that EK had been misappropriating funds from when she first began working at the business in September 2019 through thefts of cash, cheques and EFT payments. It said that EK utilised an authorisation token from another employee, referred to as AK, to access the funds and hid the transactions by debiting accruals in the accounting system. EK was found to have engaged in 56 fraudulent transactions amounting to $130,510 between April 2020 and February last year, with individual transfers ranging between $500 to $6000. Lloyd’s Australia declined to cover majority of the losses, saying that its management liability policy held exclusions for transactions exceeding $1000 that were sustained by a “failure to have a clear segregation of duties”. The policy stated that transactions above $1000 “must be counter signed or authorised by another authorised officer,” independent of the person handling the transfer. The insurer accepted 19 transactions below $1000, totalling $15,760, but said the amount fell below the $20,000 policy excess. It said it was not required to pay the remaining $114,750 because of the applied segregation of duties exclusion. Lloyd’s Australia told the Australian Financial Complaints Authority (AFCA) panel that there had been “no written proof” to show that employees were informed on the appropriate use of the security tokens. AK was found to have provided EK with his authorisation token and password, which the insurer said showed that “there was no formal segregation of duties, process or procedure in place within the company”. It contended that if the company had conducted “a simple review” of its accounts, it would have uncovered the fraud earlier. The complainant said there had only been one instance where AK had prompted EK to use his authorisation token, and “on all further occasions the token was fraudulently acquired from AK and used without his knowledge and will”. The business said it had two employees authorise all payments and that it acted according to the policy’s protocol. It said AK “would have no reason to question EK’s requests,” given that she had handled the company’s accounting. AFCA said that while the claimant “theoretically” established a segregation of duties process, its accounts transaction process showed that it was not practically enforced. “The panel is satisfied that by providing EK access to his token and password, AK effectively removed the segregation of duties process, that should have been in place and was required to be in place for policy coverage,” it said. It said the insurer was entitled to apply the exclusion for the appropriate funds and accepted that the insurer was not required to pay the covered funds because it was lower than the policy excess. The ruling also supported Lloyd’s Australia’s refusal to cover costs for an investigator hired by the insured who conducted an internal audit. The insurer said it had already hired an investigator and did not authorise the claimant’s appointment. It alleged that most of the investigator’s work did not cover the claimed event and therefore was not applicable. The panel said it was not satisfied that the accounting costs incurred by the complainant “assisted in the resolution of the claim”. **Topics:** Financial Fraud, Public Awareness, Regulatory actions --- ### [Medibank says hackers had access to ‘all personal data’ belonging to all customers](https://insurancefraud.org/news_archives/medibank-says-hackers-had-access-to-all-personal-data-belonging-to-all-customers/) **Published:** September 27, 2026 **Author:** Diane Beauchamp **Content:** Medibank, the Australian health insurance company which initially claimed to have [foiled a ransomware attack](https://therecord.media/shares-in-australias-medibank-drop-despite-foiling-ransomware-attack/) — saying that it had found “no evidence customer data has been removed from our network” — has now confirmed that criminals had access to all of the personal data of all of its customers. In a [statement on Wednesday](https://www.medibank.com.au/health-insurance/info/cyber-security/) the company announced that its cybercrime investigation has found the attackers had access to “significant amounts of health claims data” alongside the personal details it held about current and former customers. “We have evidence that the criminal has removed some of this data and it is now likely that the criminal has stolen further personal and health claims data” the company said. Medibank shares dropped 18% following the company’s announcement, wiping around AUS $1.7 billion ($1.1 billion USD) from the company’s market value. Trading in Medibank’s shares, which is publicly listed on the Australian Stock Exchange (ASX), was halted last week when the company announced it had [received an extortion demand](https://therecord.media/shares-in-australias-medibank-halt-trading-after-criminals-claim-theft-of-customer-data/) from criminals alongside evidence they had stolen some customer’s data. [Furious Medibank customers](https://www.theage.com.au/business/companies/medibank-confirms-that-every-customer-s-personal-data-was-accessed-in-hack-20221026-p5bsy7.html) have written to The Age newspaper and threatened to bring forward a class action lawsuit against the company for the breach. It quoted a Melbourne woman who said the risk of having the health data released publicly “poses a risk to potential employment” for instance if employers realized someone received mental health treatment and discriminated against them. Medibank, which was formerly government owned before being privatized as a not-for-profit in 2014, has around 3.7 million customers in Australia and [reported](https://www.medibank.com.au/content/dam/retail/about-assets/pdfs/investor-centre/results/FY21_Results_Media_Release.pdf) an annual group revenue of AUS $6.9 billion ($4.33 billion USD) in 2021. The company on Wednesday [warned the ASX](https://yourir.info/resources/229150fa807ea4f2/announcements/mpl.asx/3A605496/MPL_Medibank_cybercrime_business_and_FY23_outlook_update.pdf) that the incident was going to cost it at least AUS $25 million to address, even before considering customer compensation schemes, regulatory fines, and potential legal costs if it faces a class action. In its statement, the company said: “Our priority is to continue working to understand the specific data that has been taken for each of our customers so that we can contact them directly to let them know.” It said it had put together a support package for these customers, including financial support “for customers who are in a uniquely vulnerable position as a result of this crime. They will be supported on an individual basis.” Free identity monitoring services will also be provided to customers who had their primary ID compromised, and customers who have had to pay to get identity documents re-issued will be reimbursed for that cost. The company’s chief executive David Koczkar said: “Our investigation has now established that this criminal has accessed all our private health insurance customers’ personal data and significant amounts of their health claims data… I apologize unreservedly to our customers. This is a terrible crime – this is a crime designed to cause maximum harm to the most vulnerable members of our community.” **Topics:** Public Awareness, Technology --- ### [Public Service Announcement: Beware of Phone and Email Scammers Posing as Drug Enforcement Administration (DEA) and Federal Bureau of Investigation (FBI) Agents](https://insurancefraud.org/news_archives/public-service-announcement-beware-of-phone-and-email-scammers-posing-as-drug-enforcement-administration-dea-and-federal-bureau-of-investigation-fbi-agents/) **Published:** September 27, 2026 **Author:** Diane Beauchamp **Content:** Bassett Healthcare Network has become aware of a telephone and email scam that appears to be targeting medical practitioners. Community members are also urged to stay alert for suspicious phone or email messages from these criminals. While there may be variations, scammers are posing as Drug Enforcement Administration (DEA) and/or Federal Bureau of Investigation Agents (FBI) agents. Either through a phone call or an email, the scammer asks to speak with the victim concerning an ongoing investigation that “may impact their medical license.” They may even suggest that there is a warrant issued for the arrest of the practitioner or receiver of the call. The scammer then will attempt to engage the victim in a series of elaborate and sophisticated questions and processes to extract information and demand money. DEA and FBI personnel will never contact medical practitioners or members of the public by telephone or email to demand money or any other form of payment, nor to request any personal or sensitive information. The DEA has published a public warning about these suspicious calls. [Read more here](https://www.dea.gov/press-releases/2021/03/03/dea-warning-scammers-impersonating-dea-agents-0). **If you receive a call like this, hang up immediately. If you receive an email like this, do not respond. If you believe you have fallen victim to this scam, you should take steps to protect yourself right away, including, but not limited to:** - Contacting your local police department or Sherriff’s office to file a complaint. - File a complaint with the FBI website – at the Internet Complaint Center – by visiting [www.ic3.gov](https://www.ic3.gov/) – or call 202-324-3000. - Call the Federal Trade Commission at 877-FTC-HELP, 877-ID-THEFT, or [www.ftc.gov](https://www.ftc.gov/). - Change all passwords, especially for financial institutions, and begin using two-factor authentication methods. - Call your banks and financial institutions and activate a credit freeze. - If you subscribe to services from an identity protection service – like LifeLock, Identity Guard, or IDShield – call them. - Call your insurance company – some personal policies have protection. - Seek advice from your personal attorneys or accountants. **Topics:** Public Awareness --- ### [Why Managed Care Hasn’t Solved Medicaid Fraud](https://insurancefraud.org/news_archives/why-managed-care-hasnt-solved-medicaid-fraud/) **Published:** September 27, 2026 **Author:** Diane Beauchamp **Content:** A striking aspect of Medicaid fraud news is that it took so long for public officials to figure out that private companies have a profit motive. Also notable is that Managed Care Organizations (MCO) are not only lax in addressing fraud committed by participants (beneficiaries and providers); some are active practitioners of fraud. Since the implementation of the Affordable Care Act in 2012, the percentage of Medicaid spending going to MCOs has risen from 38% in 2012 to 70% in 2020. In the same time period, criminal fraud recoveries as a percentage of Medicaid spending has decreased by 74%. Legislators believed they were transferring risks, including fraud risk, onto the Managed Care Organization, or MCO. For this they were willing to pay a premium and the MCO would have a reason to address fraud head-on. This argument is badly flawed. In fact, the MCO and its customer, the Medicaid Agency, both have a vested interest in increasing spending. If MCO costs remain constant or fall, the States risk losing ‘free money from the Federal Treasury. Both States and MCOs benefit when adding fraud to the expense base- this means larger premiums and larger profits, and the State has a higher cost base for their next State budget and CMS appropriations request. There is no check and balance. The Medicaid funding formula is gasoline on this fire. The FMAP (the percentage of Medicaid paid with Federal Dollars) has increased from the designed 50% to a national average of 70%. For every dollar, a State allocates (often as a ‘provider tax’ on hospitals and physicians they are assured of getting back) the State receives $1.68 from non-resident taxpayers. Fraudulent claims, undetected, become a permanent part of the ‘claims expense’ in subsequent budgets. As further repellant, States must rebate their FMAP percentage of recoveries back to the Federal Treasury- 70 cents of every dollar. By design or by neglect, this encouraged MCOs and their State customers to take minimal action against fraud (see the percentage decline in the first paragraph) and keep the money in the state. In the Fiscal Year 2021, New York, the largest program in the country, recovered $483,000 in Medicaid criminal fraud in a program with a $74 Billion budget. This example can be extended to most States. Addressing fraud/managing costs constrains what the Medicaid agency can request from its legislature, and outside taxpayers, thereby limiting what the MCOs can charge. Both the State and the MCOs suffer financially from reducing fraud. There is no shifting of risk and no urgency to oversee the efforts to prevent, detect or deter fraud. Convinced they had transferred the fraud risk to the MCOs, States outsourced oversight and anti-fraud responsibilities to them. Only now are they starting to realize the flaws in that policy. Just recently authorities started to question the minimal number of fraud referrals from MCOs to law enforcement. While ‘in -network’ providers bring patients and patients bring premiums, as well as fraud padding the expense base, this will remain substandard. Fraud will not be pursued to the level it can and should be. The recent actions of Centene, the largest MCO, are also troubling. Centene settled fraud claims with 14 states for overcharging for pharmacy benefit services. This cannot be explained as a one-off case or aberration. Yet, after these settlements, Centene continues to service its Medicaid contracts and no executive has faced any liability from any State or Federal authority. Shockingly, Centene contributed $84,000 to Governor Brian Kemp’s reelection campaign one day after Kemp vetoed a bill that would increase legislative oversight of both the Department of Community Health, which runs the State Medicaid plans and the MCOs themselves. Similar contributions were made to Mississippi’s Governor, Lieutenant Governor, Speaker of the House and Commissioner of Insurance after Centene reached a $55 million settlement with that State. Mississippi also has the greatest leverage and greatest disincentive to address fraud; its FMAP of 77.86% means that the Magnolia State gets $3.52 of Federal money for each $1 the State ponies up. Further entanglements exist to explain why Managed Medicaid pays so little attention to fraud. In State bids, MCOs are graded on the breadth of their networks. From the need to show robust networks, MCOs are loath to boot a provider from a network. The MCOs are part of companies that sell Medicare Advantage, commercial plans, and State and local employee insurance. This further reduces the incentive to address provider fraud. A provider may be in multiple profitable networks. There have been recent cases where an MCO presented a network including providers that did not exist and/or were not part of the network. The providers are the drivers of premium income The belief that capitated Managed Medicaid would fight Medicaid fraud has proven to be misguided. Neither MCOs nor their State customers who are supposed to oversee MCOs, have the incentive to address fraud, waste and abuse. Doing so would merely increase the risk of budget tightening. And the ultimate majority payer, CMS, who represents the US taxpayer, has been all too silent about the blatant abuses and conflicts of interest. Can we expect State Legislatures or Congress to do better? Only when the programs crowded out by this uncontrolled spending threaten to withhold campaign funds from those who enable it. **Topics:** Medicare/Medicaid, Public Awareness --- ### [ Covered Members Only: Federal Court Accepts Yacht Club’s Wire Fraud Allegations](https://insurancefraud.org/news_archives/covered-members-only-federal-court-accepts-yacht-clubs-wire-fraud-allegations/) **Published:** September 26, 2026 **Author:** Diane Beauchamp **Content:** A federal court recently found that a policyholder adequately plead that a loss of hundreds of thousands of dollars through wire fraud is covered under a commercial crime policy. In Landings, Yacht, Golf, and Tennis Club v. Travelers Casualty and Surety Company of America Case No. 2:22-cv-00459, Landings Yacht, Golf, and Tennis Club (“Landings”) sued Travelers Casualty and Surety Company of America (“Travelers”) under a crime policy for denying coverage for: (1) about $6,885.79 in unauthorized withdrawals (“First Withdrawal”) from users purporting to be Landings and (2) $575,723.95 in withdrawals made by a third-party purporting to act on behalf of Landings (“Second Withdrawal”).\[1\] Travelers moved to dismiss Landings’ complaint, arguing that the alleged wire fraud was not covered under the policy because the fraudulent transfers did not meet the requirements necessary to trigger coverage under the crime policy. Travelers argued that the policy requires fraudulent wire transfer instructions be transmitted or issued by someone purporting to be the insured, and the complaint alleged the instructions were transmitted by someone purporting to act on behalf of the insured, not someone purporting to be the insured. The Court granted Travelers motion to dismiss in part and denied it in part. The Court found Landings’ allegations about the First Withdrawal sufficient to defeat Travelers’ motion to dismiss, but found the allegations about the Second Withdrawal insufficient because Landings had alleged that the fraudulent instructions for the Second Withdrawal were transmitted by someone acting on the insured’s behalf and the policy defined “insured” to mean Landings or a formal subsidiary, but not a separate entity acting on behalf of Landings. The Court, however, granted Landings leave to amend the allegations related to the Second Withdrawal. Ultimately, Landings filed an amended complaint, and the Court found the amendment sufficient to overcome Traveler’s motion to dismiss for the Second Withdrawal as well. Landings highlights the increasingly common threat companies are facing with wire transfer fraud. And while companies often turn to their insurance to recover their resulting loss, insurance companies are largely denying coverage for wire fraud transactions arguing that certain actions – whether it’s the insured’s employee or fraudulent instructions from a bad actor that may not exactly fit the policy requirements – break the causal chain between the bad actor’s use of the computer and the insured’s loss. See our previous blog posts here and here where courts have found coverage under crime policies for fraudulent wire transfers, and our blog post here where a court concluded that the fraudulent wire transfer was not covered. Understanding policy language is key to avoid the unpredictability associated with litigation. Although some policies have traditionally provided “silent cyber coverage,” coverage not primarily intended to cover cyber losses but which nonetheless applies to cyber-related losses based on broadly worded insuring agreements, insurers are introducing broad exclusions or restrictive language to curtail such coverage—making it all the more important for businesses to ensure that their insurance portfolio specifically targets cyber risks. Waiting until an incident occurs may be too late. Policyholders should act now, by reviewing their insurance policies with trusted coverage counsel, to ensure their coverage expectations are being met so they are protected and can maximize insurance recovery if a loss occurs. **Topics:** Financial Fraud, Judicial/courts --- ### [Phony Pumpkin Assault Claim Gets 3 Years For Insurance Fraud](https://insurancefraud.org/news_archives/phony-pumpkin-assault-claim-gets-3-years-for-insurance-fraud/) **Published:** September 26, 2026 **Author:** Diane Beauchamp **Content:** Insurance fraud is a crime that costs everyone. While some insurance fraud schemes are triumphs of the criminal mind, others have an element of slapstick. The following case of insurance fraud falls into the latter category. Thomas Lucey, 49, a former MBTA trolley operator, paid a friend to wear a Hollywood movie slasher costume and assault him on his midnight trolley run on the day before Halloween. Mr. Lucey’s objective was to claim post-traumatic stress from the assault and collect workers’ compensation from the MBTA and payments from his personal disability insurance policies with Unum. Mr. Lucey collected $30,000 in compensation and $36,000 from Unum before the police discovered the assault was a hoax A Suffolk County grand jury indicted Mr. Lucey for workers’ compensation fraud, insurance fraud, misleading a police investigation, and perjury. After his conviction, he appealed his three-year prison sentence to the Massachusetts Appeals Court. The following is the Appeals Court summary of Mr. Lucey’s off-the-wall plan to collect insurance benefits for an on-the-job injury. I have quoted the summary extensively because it lays out the prosecution’s case exemplifying the extremes to which some people will go to fraudulently collect insurance benefits. The work-related assault and the plastic pumpkin clue Mr. Lucey was a trolley driver on the Massachusetts Bay Transportation Authority (MBTA) Red Line. Just after midnight on October 30, 2016, Mr. Lucey was assaulted by a person in a “Michael Myers” costume carrying a plastic Halloween pumpkin at the Cedar Grove station \[a trolley station in the Dorchester section of Boston on the line that runs through the Cedar Grove Cemetery, the only cemetery in the world with a trolley line through it\]. The attacker got into a dispute with Mr. Lucey over the trolley fare and punched Mr. Lucey, pulled him off the trolley, and continued to beat him as he lay on the platform. The attacker left the plastic pumpkin behind. Two witnesses to the attack ran to a nearby home. An off-duty Boston police officer Steven McKunes answered their knock and used his radio to call for help. Multiple agencies responded, including the MBTA transit police, Boston police, and Boston Emergency Medical Services. The MBTA transit police found the plastic pumpkin the attacker had dropped and gave it to the Boston Police for a fingerprint check. Mr. Lucey suspiciously recalls how long he claimed to be unconscious Emergency medical technician (EMT) Daniel Sheehan arrived at the scene and found Mr. Lucey alert and awake on the ground. Mr. Lucey told Sheehan that he had been knocked unconscious for fifteen seconds. Sheehan noted that in his experience as an EMT, people do not usually recall the length of time that they were unconscious. Additionally, Mr. Lucey did not exhibit any physical signs that he had previously lost consciousness. Mr. Lucey was transported to Carney Hospital, where he was treated for minor physical injuries. On the day of the assault, Mr. Lucey files for workers’ compensation benefits On October 30, 2016, Mr. Lucey filed a claim for workers’ compensation benefits and began to receive benefits based on his inability to work because of post-traumatic stress caused by the assault. On December 1, 2016, Mr. Lucey filled out an “Industrial Accident Data Form” that he signed under the pains and penalties of perjury, in which he recounted details of the incident that he claimed left him injured. Mr. Lucey collects $30,000 in workers’ compensation benefits and $36,000 in disability policies benefits On January 23, 2017, Mr. Lucey’s workers’ compensation benefits were terminated after he failed to provide the required notes from his doctor. He appealed the termination, and his workers’ compensation benefits were restored. He continued to receive workers’ compensation benefits through 2018. In all, Mr. Lucey collected about $30,000 in workers’ compensation benefits from the MBTA. In late January 2017, Mr. Lucey made a claim on two disability insurance policies that he had purchased through the Unum Insurance Company. Again, claiming total disability because of post-traumatic stress relating to his being assaulted, he collected $7,203.15 from Unum policy 1307720 and $28,783.33 from Unum policy 3669703.” The plastic pumpkin tells the tale Over a year after the October 30, 2016, assault, the Boston police identified five latent fingerprints on the plastic pumpkin left at the scene as belonging to one, Kevin O’Leary, a friend and former MBTA coworker of Mr. Lucey. On November 28, 2017, the police went to O’Leary’s home to speak with him. O’Leary confessed that he carried out the assault. The next day, O’Leary went to the MBTA transit police headquarters and spoke in detail in a recorded interview about the planned attack. O’Leary testified at trial that Mr. Lucey met O’Leary at a Hooters restaurant in Saugus on October 26, 2016, and paid him $2,000 in cash to stage an attack on Mr. Lucey while he was at work driving a trolley for the MBTA. Police confirm O’Leary’s account of Mr. Lucey paying $2,000 for a phony beating Further police investigation revealed bank and telephone records corroborating O’Leary’s account. On October 25, 2016, the day before Mr. Lucey met O’Leary at Hooters, Mr. Lucey withdrew $3,000 from his bank account. The day after the Hooters meeting, October 27, 2016, Mr. Lucey deposited the remaining $1,000 in cash back into his own account. Also, on October 27, 2016, O’Leary deposited $1,900 in cash in his bank account. O’Leary’s cellular telephone records also revealed that O’Leary had been in communication with Mr. Lucey on the night of the incident before and after the attack. AAA records confirm O’Leary’s presence because he locked his car keys in his getaway car Also, records of the American Automobile Association (AAA) confirmed where O’Leary had parked in the early hours of October 30, 2016, and how long he had remained in the area after the alleged attack on Mr. Lucey. When O’Leary left the \[Cedar Grove\] station, he ran to his car, which was parked near Dorchester Park, and realized he had locked the keys inside. He removed his Michael Myers mask, put it underneath his car, and went into Dorchester Park, where he sat on a bench to take off his coveralls and gloves. Then he searched for a payphone along Dorchester Avenue, hid in a yard to avoid police presence, and eventually went to Carney Hospital, where he was allowed to use its phone to call AAA at 2:37 A.M. Jury trial, guilty verdicts, and three-year sentence to serve in state prison On February 21, 2018, a Suffolk County grand jury returned indictments against Mr. Lucey, charging him with worker’s compensation fraud, in violation of G.L. c. 152, § 14; two counts of insurance fraud, in violation of G.L. c. 266, § 111A; misleading a police investigation, in violation of G.L. c. 268, § 13B; and perjury, in violation of G.L. c. 268, § 1A On June 4, 2019, after a four-day jury trial, the jury found Mr. Lucey guilty of all charges. Considering the sentences in other insurance fraud cases that Agency Checklists has reported on, the presiding justice effectively threw the book at Mr. Lucey for his criminal machinations and sentenced him to: State prison for three years and a day. A fine of $5,000 for the worker’s compensation fraud, one count of insurance fraud, and misleading a police investigation. Three years of probation to begin, on the remaining counts of insurance fraud and perjury, after the prison sentences; and, As a special condition of probation, the judge ordered Mr. Lucey to pay “full restitution” to the MBTA and Unum Insurance Company Appeal and affirmance of conviction except for order for the Superior Court to revisit Mr. Lucey’s ability to pay restitution The Appeals Court denied all of Mr. Lucey’s grounds for appeal except a question on the procedure concerning the Superior Court’s order for “full restitution.” Mr. Lucey argued, and the Appeals Court agreed, that the Superior Court judge had erred by ordering him to make “full” restitution without holding an evidentiary hearing to determine the amount of restitution and to consider his ability to pay. The Appeals Court noted that the law required where restitution is ordered as a condition of probation, a judge “must consider a defendant’s ability to pay and may not impose a longer period of probation or extend the length of probation because of a defendant’s limited ability to pay restitution.” The Appeals Court’s conclusion Conclusion. For the reasons set forth above, the judgments of conviction and the order denying the motion for a new trial are affirmed. The order of restitution is vacated, and the matter is remanded for further proceedings consistent with this memorandum and order. Conclusion. For the reasons set forth above, the judgments of conviction and the order denying the motion for a new trial are affirmed. The order of restitution is vacated, and the matter is remanded for further proceedings consistent with this memorandum and order. So, ordered. **Topics:** Work comp - worker **Categories:** Conviction --- ### [Hospitals said they lost money on Medicare patients. Some made millions, a state report finds.](https://insurancefraud.org/news_archives/hospitals-said-they-lost-money-on-medicare-patients-some-made-millions-a-state-report-finds/) **Published:** September 26, 2026 **Author:** Diane Beauchamp **Content:** Atrium Health, the largest hospital system in North Carolina, has declared publicly that in 2019 it provided $640 million in services to Medicare patients that were never paid for, by far the largest “community benefit” it provided that year. Like other nonprofit hospitals around the nation, Atrium logs losses on the federal health insurance program for seniors and people with disabilities as a community benefit to satisfy legal requirements for federal, state, and local tax breaks. But for the same year that Atrium’s website says it recorded the $640 million loss on Medicare, the hospital system claimed $82 million in profits from Medicare and an additional $37.2 million in profits from Medicare Advantage in a federally required financial document, according to a [report released Oct. 25](https://www.shpnc.org/what-the-health/overcharged-nc-hospitals-profit-on-medicare) by the North Carolina state treasurer’s office. The lack of clarity about whether health systems like Atrium gain or lose money treating Medicare recipients reflects how loosely the federal government regulates the way hospitals calculate their community benefits. As a result, the analysis of North Carolina hospitals’ financial data concluded, what taxpayers get from local nonprofit hospitals in return for tax exemptions worth billions of dollars a year is unclear. “There is no transparency, no accountability, and no oversight,” said North Carolina State Treasurer Dale Folwell, a Republican who is critical of Atrium and other hospitals’ business practices. “With the hospital cartel, it is always profits over people.” Atrium did not make officials available for an interview. In a statement, spokesperson Dan Fogleman said the hospital system reported $85 million in services to Medicare patients that weren’t paid for in its most recent cost report to the Centers for Medicare & Medicaid Services. “And, as labor, equipment, supplies and inflation continue to drive health care costs higher, the gap between Medicare payments and costs incurred to deliver the quality care we provide has grown in the post-Covid inflationary environment,” Fogleman said. More than half of the hospitals in the United States are nonprofits or government-run. The federal government requires them to operate emergency rooms open to all patients regardless of their ability to pay, accept patients insured by Medicare, and use surplus funds to improve facilities and patient care to demonstrate they are giving back to the community. Even though their tax-exempt status is based on charitable acts, nonprofit hospital systems sat on more than $283 billion in assets from stocks, hedge funds, venture capital, and private equity and other investments in 2019, according to a 2021 [KHN analysis of IRS filings](https://khn.org/news/article/mission-and-money-clash-in-nonprofit-hospitals-venture-capital-ambitions/). The hospital systems used most of that to produce income and classified only $19 billion, or about 7% of their total investments, as principally devoted to their nonprofit missions, the analysis found. The new North Carolina report describes how hospitals’ self-reported Medicare profit margins differed from the financial picture they provided to the public through IRS records, annual reports, and community benefit documents. Although most hospitals have complained of significant Medicare losses, the analysis of data from more than 100 North Carolina hospitals found that most made profits on Medicare from 2015 to 2020. IRS audits are supposed to protect the public from fraud and abuse, but the system has major gaps, said health economists and federal watchdog groups. Federal law requires the IRS to review community benefit activities at least once every three years. Yet the agency did not “have a well-documented process to ensure that those activities are being reviewed,” said a [2020 report](https://www.gao.gov/products/gao-20-679) from the Government Accountability Office. In response to GAO recommendations, IRS leaders updated the system last year to help ensure the agency could identify cases in which hospitals were suspected of not meeting requirements. The IRS referred nearly 1,000 hospitals nationwide to its audit division for violations of the Affordable Care Act from 2015 to 2019, but the IRS could not identify if they were related to community benefits, the GAO said. The tax agency has no authority to determine what activities hospitals must perform to comply with the law, the GAO said. An analysis of IRS data found 30 hospitals that reported no spending on community benefits in 2016, “indicating potential noncompliance,” the report said. “Perhaps this is the result of the IRS being underfunded,” said [Vivian Ho](https://profiles.rice.edu/faculty/vivian-ho), a health economics professor at Rice University in Houston, who worked on the North Carolina report. “They don’t have the resources to reconsider what information they should seek.” It is critical that the government collects accurate information from hospitals because the data affects all patients, Ho said. Federal law forbids IRS employees from discussing tax information submitted to the agency by people or organizations, IRS spokesperson Anthony Burke said in response to questions about how effectively the government monitors hospitals. Hospitals have long used what they report as losses on Medicare to justify charging patients with private insurance higher prices. According to a study [released in 2021](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8383843/) by the Rand Corp., a nonprofit research organization, hospitals across the nation charge private insurers more than what they receive from Medicare for the same services. In the Affordable Care Act, federal lawmakers mandated that to maintain their tax-exempt status, nonprofit hospitals must conduct a community health needs assessment, maintain a written financial assistance policy, set billing and collections limits, and set a limit on charges. In written responses to KHN, the North Carolina Healthcare Association, which lobbies on behalf of hospitals, said hospitals provided $1.2 billion in charity care in 2020. It added that those community benefits can include a lot of different activities, such as covering the gap between how much a procedure costs and what a provider is reimbursed, volunteering by staff, and paying for medical outreach programs. “Providing care to vulnerable populations is part of their nonprofit mission,” the statement said. Atrium spends millions of dollars per year to provide care to people who need behavioral health care “but have no safety net — even from the state,” the association said. Fogleman, the Atrium spokesperson, said an advisory commission has consistently told Congress that Medicare payments do not cover the full costs of services at most hospitals, including Atrium’s. In North Carolina, large hospital systems received $1.8 billion in tax breaks in 2020, according to the state treasurer’s office. The same year, lobbyists for North Carolina hospitals reported collectively losing $3.1 billion on Medicare, according to the office’s report. Other data shows they made $87 million in profit. From 2015 to 2020, the report concludes, 35 hospitals posted profits from Medicare each year. Other hospitals listed in the report did not respond to requests for comment. The American Hospital Association contends that the federal government reimburses providers significantly less than it costs to care for Medicare recipients. Unlike private insurers, the federal government does not negotiate prices with hospitals. Medicare bases the amount it pays on hospitals’ locations, labor costs, and other factors. Melinda Hatton, the association’s general counsel, said in a statement that “underpayments” totaled more than $75 billion in 2020. “These data show that few, if any, hospitals break even much less make a profit on the basis of Medicare payments,” she said. But [Glenn Melnick](https://priceschool.usc.edu/people/glenn-melnick/), a health economics and finance professor at the University of Southern California who reviewed the North Carolina data, said no one is certain how nonprofit hospitals are calculating their numbers. “The nonprofit hospital systems are getting so big, we need greater transparency,” Melnick said. “Health care is amazingly expensive, and it will bankrupt us if we don’t get it under control.” Nonprofit hospitals receive significantly more in tax breaks than they spend on community investment or charity care, according to [a report](https://lownhospitalsindex.org/2022-fair-share-spending/) released this year by the Lown Institute, a think tank in Needham, Massachusetts. Using 2019 data from the IRS, researchers found that out of 275 hospital systems across the country, 227 spent less on community investments or charity care than they got in tax breaks. The deficit totaled more than $18 billion, the report said. [Leah Kane](https://charlottelegaladvocacy.org/our-team/leah-kane/) is a senior attorney for consumer protection at the Charlotte Center for Legal Advocacy, a nonprofit that provides civil legal assistance to people who cannot afford an attorney. She said her agency receives calls from people who were not offered charity care from hospitals. She said her group is worried that hospitals are offering charity care to uninsured patients but not to other people, like the underinsured, who don’t have the income to pay thousands of dollars for treatment not covered by their insurance plans. “People are angry and stressed out,” Kane said. “They don’t know what this \[debt\] will mean for their lives.” **Topics:** Medicare/Medicaid, Public Awareness --- ### [Expungement Motion Granted to Repeat Insurance Fraud Offender](https://insurancefraud.org/news_archives/expungement-motion-granted-to-repeat-insurance-fraud-offender/) **Published:** September 26, 2026 **Author:** Diane Beauchamp **Content:** Early this week in Ventura County Superior Court, Judge Patricia Murphy granted a request to dismiss felony charges of insurance fraud dating back to 1995, nearly 30 years ago. The accused was charged—in the last century—with felony perjury and several counts of insurance fraud, all to which she had pleaded guilty. Defense counsel initially pointed out the discrepancy within the restitution records of the accused. Attorney Catina Irvin explained the accused has contributed a substantial amount toward restitution and has otherwise completed all conditions as indicated in the probation report, with diligent payments over the course of four years. The accused has now paid off all but $40,000 for restitution. However, Judge Murphy confirmed the stated amount and, according to the court’s record, the accused still has an outstanding balance of $107,000 that needs to be paid. Before discussing more about the restitution amount, Deputy District Attorney Jillian Ewan commented the motion of expungement should not be granted even if the remaining restitution is only $40,000. Judge Murphy expressed hesitation, recalling the last time the same request was made and was denied due to the accused being charged with a subsequent insurance fraud after she was placed on probation. However, the judge took into account the fact that those charges were far back in 1995, and there has been “an absence of law enforcement contact” since then. Considering that denying the expungement motion would not increase the likelihood of the restitution being paid, the court granted the request to dismiss all charges and guilty pleas, and convert the restitution to civil judgment, with the amount actually owing to be determined later. **Topics:** Judicial/courts --- ### [NHS vendor Advanced won’t say if patient data was stolen during ransomware attack](https://insurancefraud.org/news_archives/nhs-vendor-advanced-wont-say-if-patient-data-was-stolen-during-ransomware-attack/) **Published:** September 26, 2026 **Author:** Diane Beauchamp **Content:** Advanced, an IT service provider for the U.K.’s National Health Service (NHS), has confirmed that attackers stole data from its systems during an August ransomware attack, but refuses to say if patient data was compromised. Advanced first confirmed the ransomware incident on August 4 following widespread disruption to NHS services across the U.K. The attack downed a number of the organization’s services, including its Adastra patient management system, which helps non-emergency call handlers dispatch ambulances and helps doctors access patient records, and Carenotes, which is used by mental health trusts for patient information. In an update dated October 12 and shared with TechCrunch on Thursday, Advanced said the malware used in the attack was LockBit 3.0, according to the company’s incident responders, named as Mandiant and Microsoft. LockBit 3.0 is a ransomware-as-a-service (RaaS) operation that hit Foxconn earlier this year. In its updated incident report, Advanced said that the attackers initially accessed its network on August 2 using “legitimate” third-party credentials to establish a remote desktop session to the company’s Staffplan Citrix server, used for powering its caregiver’s scheduling and rostering system. The report implies there was no multi-factor authentication in place that would block the use of stolen passwords. “The attacker moved laterally in Advanced’s Health and Care environment and escalated privileges, enabling them to conduct reconnaissance, and deploy encryption malware,” Advanced said in the update. Advanced said some data pertaining to 16 Staffplan and Caresys customers (referring to NHS trusts) was “copied and exfiltrated,” a technique known as double-extortion, where cybercriminals exfiltrate a company’s data before encrypting the victim’s systems. In the update, Advanced said there is “no evidence” to suggest that the data in question exists elsewhere outside our control and “the likelihood of harm to individuals is low.” When reached by TechCrunch, Advanced chief operating officer Simon Short declined to say if patient data is affected, or whether Advanced has the technical means, such as logs, to detect if data was exfiltrated. Lockbit 3.0’s dark web leak site did not list Advanced or NHS data at the time of writing. Short also declined to say if Advanced paid a ransom. “We are, however, monitoring the dark web as a belt and braces measure and will let you know immediately in the unlikely event that this position changes,” Advanced said in the update. Advanced said its security team disconnected the entire Health and Care environment to contain the threat and limit encryption, which downed a number of services across the NHS. The extended outage left some trusts unable to access clinical notes and others were forced to rely on pen and paper, BBC News reported in August. Advanced said its recovery from the incident is likely to be slow, citing an assurance process set by the NHS, NHS Digital and the U.K. National Cyber Security Center. “This is time-consuming and resource intensive and it continues to contribute to our recovery timeline,” Advanced said. “We are working diligently and bringing all resources to bear, including outside recovery specialists, to help us restore services to our customers as quickly as possible.” The healthcare industry remains a top priority for ransomware actors. Earlier this month, U.S. hospital giant CommonSpirit was hit by a cybersecurity incident that is disrupting medical services across the country — which it later confirmed was a ransomware attack. **Topics:** Public Awareness, Technology --- ### [UP Bar Council cancels licences of 30 lawyers in accident claim fraud](https://insurancefraud.org/news_archives/up-bar-council-cancels-licences-of-30-lawyers-in-accident-claim-fraud/) **Published:** September 26, 2026 **Author:** Diane Beauchamp **Content:** The Bar Council of Uttar Pradesh has decided to cancel the licences of 30 lawyers involved in the submission of fake claims under the Motor Accident Claims Tribunal. After the Supreme Court’s rap, the Bar Council of Uttar Pradesh has decided to terminate the licences of 30 lawyers involved in the submission of fake claims under the Motor Accident Claims Tribunal. The decision was taken based on the special investigation team (SIT) report by the police. Along with the lawyers, a few policemen were also involved in the fraud and an investigation has been carried out. Most of the cases were reported from Meerut, Bareilly and Shahjahanpur. The lawyers caused a loss of several crores to insurance companies by submitting fake claims under the Motor Accident Claims Tribunal and Workmen Compensation Act as per an October 7, 2015 order given by Allahabad high court. **Topics:** Regulatory actions --- ### [Murder accused tells court he helped feed body into woodchipper but didn’t kill Bruce Saunders](https://insurancefraud.org/news_archives/murder-accused-tells-court-he-helped-feed-body-into-woodchipper-but-didnt-kill-bruce-saunders/) **Published:** September 26, 2026 **Author:** Diane Beauchamp **Content:** Soon after connecting online, Gregory Lee Roser claims a woman he hardly knew asked him to kill a man he hadn’t met. Months later, Roser helped feed Bruce Saunders’ body into a woodchipper, a Brisbane court has heard. But Roser told a supreme court jury on Thursday he did not kill Saunders, instead pointing the finger at a “nasty, murderous” woman and a man with alleged Mafia connections. Roser, 63, and Sharon Graham, 61, have pleaded not guilty to murder after Saunders died while working on a property north of Brisbane in November 2017. The Crown alleges Graham asked Roser and another lover, Peter Koenig, to kill her ex-partner Saunders, 54, and make it look like an accident in a bid to claim his $750,000 life insurance. Footage has been shown to the jury of Saunders’ legs protruding from the chipper at the Goomboorian property near Gympie after clearing trees with Roser and Koenig. Roser agreed on Thursday that soon after meeting online in March 2017, Graham had asked him to murder Saunders. “Because he was pissing her off and he had plenty of money,” Roser told the court. First, she wanted Saunders to be killed at the Nambour home he shared with Graham, Roser said. He refused but wrote down instructions from Graham on how to get into the house and the dates to do it after she raised her voice. “I didn’t think she was serious at all,” Roser said. By July 2017, Roser said Graham gave him a gun “out of the blue” that was provided by Koenig. “I took it off her to quiet her down,” he said on Thursday. Graham allegedly first planned for Saunders to be shot on his way to or near his workplace by Roser, the court heard. Roser said he again refused but wrote down more notes, with Graham this time detailing Saunders’ work schedule. “Every time I said no to her she ended up chucking a big turn, screaming and yelling and all that,” he told the jury. Roser said he returned the gun but Koenig and Graham began pressuring him to kill Saunders. He alleged Koenig suggested suitable secluded spots for murder as the pair drove around but he ruled them out. Roser said the drive was one of the occasions Koenig claimed to have killed someone, laughing while telling him he had pushed someone into a meat grinder at an Adelaide abattoir. Graham had also told him Koenig had “dangerous criminal associates”, Roser said. “She said Peter had a Mafia connection and he knows people who can … get rid of you,” Roser told the court. By mid-October 2017, Roser said Graham shared her plan to kill Saunders while clearing a friend’s property, making it look like an accident, using the chipper. On the final day of work, Roser said he was under pressure, with Koenig telling him “we have to get rid of him” and Graham demanding he “hurry up and do the job” in abusive texts. Roser said he still refused and kept working as the sun set before he heard what sounded like a “couple of whip cracks or gunshots”, thinking it was a falling branch. He then saw Saunders slumped on the chipper, with Koenig telling him “well, it is done now” before agreeing to help feed the body into the machine, the court heard. “I thought if I didn’t do anything that he said to I would end up like Bruce,” Roser said. Saunders’ body went through the chipper in “one go”, Roser said. He said Koenig stopped the machine with Saunders’ legs sticking out, telling him “oh that should be enough”. Koenig pleaded guilty to being an accessory after the fact to murder in June 2022, the jury has been told previously. Graham has successfully applied for a separate trial. Roser’s trial before Justice Martin Burns continues. **Topics:** Life Insurance **Categories:** Arrest --- ### [New Orleans Woman Pleads Guilty To Identity Theft](https://insurancefraud.org/news_archives/new-orleans-woman-pleads-guilty-to-identity-theft/) **Published:** September 26, 2026 **Author:** Diane Beauchamp **Content:** U.S. Attorney Duane A. Evans announced today that RAYCHAEL DEPLAND, age 33, of New Orleans, plead guilty today to Identity Theft, in violation of Title 18, United States Code, Section 1028(a)(7). According to documents filed in federal court, DEPLAND, while working at University Medical Center in New Orleans as a patient access representative, sent personal information of UMC patients to Acia Gray who, along with others, used this information in a check cashing scheme at Wal-Mart stores, primarily in Texas. Gray and other members of this check cashing scheme were charged and convicted of Conspiracy to Commit Wire Fraud in violation of Title 18, United States Code, Sections 1343 and 1349 in the United States District Court for the Eastern District of Texas, and Gray received a sentence of fifty-seven (57) months imprisonment. DEPLAND faces a maximum penalty of five (5) years imprisonment, followed by up to three (3) years of supervised release, a fine up to $250,000.00, and a mandatory $100 special assessment fee. Sentencing in this matter is scheduled for March 2, 2023 before Chief United States District Judge Nannette Jolivette Brown. The U.S. Attorney’s Office would also like to acknowledge the assistance of the United States Department of Treasury, Inspector General for Tax Administration, in investigating this matter. The prosecution of this case is being handled by Assistant U.S. Attorney Brian M. Klebba, Chief of the Financial Crimes Unit. **Topics:** Financial Fraud, Insider Fraud, Synthetic Identity Theft **Categories:** Conviction --- ### [Viewpoint: Detecting Inflation-Driven Fraud in Insurance Claims](https://insurancefraud.org/news_archives/viewpoint-detecting-inflation-driven-fraud-in-insurance-claims/) **Published:** September 26, 2026 **Author:** Diane Beauchamp **Content:** Following the easing of Covid pandemic restrictions, we are now facing a fresh “cost of living crisis” created by rising inflation and soaring energy bills. *The Guardian* newspaper reported that petrol stations in the United Kingdom face up to 3,000 attempted fuel thefts a month as fuel prices soar. Additionally, there was a 39% increase of non-payment between January and May in 2022 based on the figures from Forecourt Eye, a company that collects payments on behalf of about 1,000 garages around the United Kingdom. The insurance market is also predicting an increase in fraudulent claims as the cost-of-living crisis deepens. For example, NFU Mutual, the UK’s leading rural insurer, has warned rising food prices will see livestock thefts increase. Furthermore, its rural crime claims pay-outs between January and March 2022 were more than 40% higher than the same period in 2021. As forensic accountants, we are directed to where a fraud has already been identified or where one has not, but it emerges during the normal claim review process. We also are asked to review unexplained physical losses which can often turn out to be innocent accounting errors. Inventory losses are common in property claims but with the increase in warehouse cover being written under Marine policies, we are increasingly being involved in claims in this class of business. Moreover, since the Basis of Valuation is often selling price, the stakes are often higher. This article focuses on mysterious disappearance of inventory, how to identify the difference between accounting error and physical theft, the accuracy of accounting records, and how to review the associated claims. ###### Lost Inventories Claim Due to Mysterious Disappearance After physical inventory counts are undertaken, it is not uncommon for policy holders to identify a shortfall between their accounting records and physical inventory/stock on hand and assume the difference is a physical theft. They then file an insurance claim on the basis of theft, missing goods, or mysterious disappearance. One of the key questions in these cases is whether the shortfall identified is a physical theft or an innocent accounting error. ###### Why is There a Shortfall of Inventory: Accounting Error or Physical Theft? Inventory totals per the accounting records and the physical inventories on hand should match as the accounting records should mirror what the policy holder has in their warehouse. Differences arise between these two data sources due to reasons such as timing differences, physical count errors, unregistered returns, damaged goods, and more. Once identified, the accounting records of the physical inventory record should be adjusted to reflect the actual physical inventories on hand. When these adjustments are not made, they will cause variances between the accounting record and the physical inventory which may appear to be a physical loss but, in reality, are an accumulation of innocent accounting errors. For example, there may be 1,000 items shown in the accounting records and only 900 items held at the warehouse. Therefore, it appears that 100 items are missing, and this could form the basis of a claim. However, if the accounting records have not been updated to account for 100 goods which in fact were sold or in transit but not recorded as such, there has not been a loss. It is just an accounting error. ###### What is the Acceptable Level of Variance – Accuracy of Accounting Records? An inventory variance rate is a measurement to show the accuracy of the accounting record compared to the physical inventory counted. It is calculated as follows: | The No. of units you count less the No. of units per the accounting system | X100 | |---|---| | The No. of units per the accounting system | In the previous example, the variance is 10%. | 900-1,000 | X100 | |---|---| | 1,000 | What is a normal level of variance will depend on the type of company and industry. Some experts view an inventory variance greater than 5% in the retail industry as significant and in need of investigation. It is also important that these variances are corrected properly at the end of accounting period so that the variances do not accumulate over time. For example, consider an alleged inventory theft claim where the policy holder had not conducted any physical inventory counts for more than five years. The policy holder subsequently undertook a physical count and found a 20% shortfall between the accounting records and physical count, and this formed the basis of the claim. The missing inventory volume is likely to include an element of accounting errors due to a lengthy period without checking for errors. Furthermore, a physical loss would have been prevented and detected sooner if the policy holder had conducted physical inventory counts at least annually and ideally more regularly. ###### Importance of Internal Controls Lack of proper internal controls usually leads to an increased risk of missing inventories and delayed detection. Based on the 2021 Global Fraud Survey conducted by the Association of Certified Fraud Examiners (“ACFE”), the most common factor underlying the occupational frauds was a lack of internal controls. However, before jumping to the conclusion of the missing inventories being due to theft, there could be several internal control issues contributing to the missing inventories that are not due to theft. For example, poor accounting procedure (i.e., accounting errors as discussed above), an employee training issue, inaccurate counting procedures, poor handling of returns, or timing issues with the recording of goods in transit. ###### Key information Required to Verify a Claim In most inventory loss reviews, we request the following information regarding the inventory control system to understand the normal controls and procedures in respect to the physical inventory. Below are examples of typically requested documents. If these are not available, we would ask for other material. - An explanation as to how regularly physical counts are undertaken and reconciled to the inventory control system. - A summary, including supporting documents, confirming the dates and results (i.e., physical quantities counted and inventory system totals) for the last three inventory counts including the most recent one attended by auditors. - Documents to support that the inventory control system had been updated for the variances identified during the most recent physical count prior to the incident. By reviewing the above, we can identify the normal level of inventory variances, whether these variances have been rectified, and whether a policy holder has good internal controls over its inventory. This helps us to determine whether the apparent stock loss is more likely to be an accounting error. In a time of a cost-of-living crisis, insurers are expecting an increase in fraudulent insurance claims, including marine stock throughput claims. Our role as forensic accountants is to validate the actual loss being sustained via careful analysis and detailed review of the supporting accounting records. But it is not uncommon for alleged disappearances to turn out to be an accumulation of accounting and procedural errors. **Topics:** Fraud General, Public Awareness --- ### [Iowa Insurance Division Reminds Customers Harmed by Andrew Joyce or Joyce Funeral Home to Complete Claims Process](https://insurancefraud.org/news_archives/iowa-insurance-division-reminds-customers-harmed-by-andrew-joyce-or-joyce-funeral-home-to-complete-claims-process/) **Published:** September 26, 2026 **Author:** Diane Beauchamp **Content:** The Iowa Insurance Division is reminding customers that may have been harmed by Andrew Joyce or Joyce Funeral Home in Emmetsburg to complete the claims process. The claims process began in September and all claims must be submitted on or before Monday, November 7, 2022. “Letters via postal mail have been sent to those known to have been harmed in this case, however, there may be more people still out there that have not yet come forward,” Iowa Insurance Commissioner Doug Ommen said. “I encourage any and all Iowans that believe they have been harmed to fill out a claim form either online or via mail for our office to review.” Customers harmed may submit a claim online or by sending the Iowa Insurance Division a completed paper claim form. Claims must be submitted on or before Monday, November 7, 2022. Submitting any supporting documentation with the claim form will help the Iowa Insurance Division evaluate and process the claim. Customers harmed may still make a claim even if they do not have all or any of the documentation for the claim. If you have any questions regarding the claims process, contact Connie Dykstra by email at <connie.dykstra@iid.iowa.gov> or by phone at 515-314-9380. **Topics:** Public Awareness --- ### [Owner of Toledo Area Medical Transportation Service Found Guilty of Healthcare Fraud](https://insurancefraud.org/news_archives/owner-of-toledo-area-medical-transportation-service-found-guilty-of-healthcare-fraud/) **Published:** September 26, 2026 **Author:** Diane Beauchamp **Content:** A federal jury on Monday, Oct. 24, 2022, convicted the founder and owner of Blue Line Express Taxi & Medical Transport, a Toledo-area ambulette transportation business, of three counts of healthcare fraud following a three-day trial before Judge Jeffrey J. Helmick in Toledo. According to court documents and evidence presented at trial, Abdul Haji Faqi, 46, of Toledo, was found guilty of participating in a scheme that knowingly submitted and received reimbursement payments from Medicaid for ineligible claims. Faqi’s co-defendants pleaded guilty and were sentenced earlier this year for their part in the scheme. Between 2009 and 2016, Faqi schemed with his co-defendants to transport and bill Medicaid for ambulette transportation services of Medicaid beneficiaries who did not require or use a wheelchair. Faqi and his co-defendants knew that Medicaid only provided ambulette reimbursement for recipients who did require the use of a wheelchair and were actually transported in a wheelchair. In addition, as part of the scheme to defraud, evidence presented during the trial showed that Faqi and his co-defendants billed Medicaid for wheelchair attendants without actually providing any attendants. Furthermore, evidence showed that Faqi and his co-defendants billed Medicaid for trips with multiple riders as separate individual trips, thereby inflating their Medicaid billing. Faqi and his co-defendants also failed to obtain, and falsified, ambulette Certification of Medical Necessity (CMN) documents from Medicaid recipients that they transported. Faqi and the others knew and understood that Medicaid required a CMN for each recipient transported. In total, court documents state that Faqi and his co-defendants received over $800,000 in reimbursements from Medicaid to which they were not entitled. Faqi is scheduled to be sentenced on Feb. 13, 2023. This case was investigated by the Health and Human Services Office of Inspector General (HHS OIG), the Ohio Attorney General’s Healthcare Fraud Section and the Toledo Resident Agency of the Cleveland FBI. This case is being prosecuted by Assistant United States Attorneys Jody L. King and Michael J. Freeman. **Topics:** Medicare/Medicaid **Categories:** Conviction --- ### [Attorney General James Announces Settlement in Medicaid Fraud Investigation of Central New York Doctor](https://insurancefraud.org/news_archives/attorney-general-james-announces-settlement-in-medicaid-fraud-investigation-of-central-new-york-doctor/) **Published:** September 26, 2026 **Author:** Diane Beauchamp **Content:** New York Attorney General Letitia James today announced that her office, in conjunction with the U.S. Attorney’s Office for the Northern District of New York, has [reached a settlement with Ahmad M. Mehdi, M.D. and Ahmad M. Mehdi, M.D., P.C](https://ag.ny.gov/sites/default/files/ahmad_m._medhi_signed_settlement_agreement.pdf). This settlement resolves an investigation involving Medicaid overpayments for “up-coded” medical services, as well as Medicaid payments for smoking cessation counseling that were not sufficiently documented. “Up-coding” is the improper practice of claiming reimbursement for enhanced and more lucrative procedures than were in fact performed. As part of a joint settlement, Mehdi has agreed to reimburse $260,000 to the state Medicaid program and to pay a penalty amount of $308,750. In the companion civil settlement agreement with the U.S. Attorney, Mehdi will pay $331,250 to the federal government to settle up-coding and smoking cessation claims, and certain claims arising under the Controlled Substances Act. “Every dollar scammed from Medicaid is a dollar not spent caring for New Yorkers with actual medical needs,” said **Attorney General James**. “I am proud of the work my team did, together with the U.S. Attorney’s Office for the Northern District of New York, in uncovering these false claims and securing these funds. Let this settlement be a clear message: We have zero tolerance for lying to Medicaid, and we will hold those who do accountable.” “The U.S. Attorney’s Office will continue to work with state and federal enforcement partners to maintain the integrity of public programs and safeguard federal healthcare dollars,” said **U.S. Attorney for the Northern District of New York Carla B. Freedman**. “This settlement should deter anyone thinking about abusing federal healthcare programs for their own benefit.” Dr. Mehdi is the principal owner of Ahmad M. Mehdi, M.D., P.C., a general medical practice with offices located in Groton and Tully, New York. Between January 1, 2012, through September 17, 2018, Dr. Mehdi engaged in up-coding of billings for medical services and billed for smoking cessation counseling services that were not sufficiently documented. He submitted, or caused to be submitted, those claims for payment to the Medicaid program and to various Medicaid Managed Care entities, and these government payors relied on those fraudulent claims to pay him. An audit and investigation conducted by the Office of the Attorney General’s (OAG) Medicaid Fraud Control Unit (MFCU) in conjunction with the U.S. Attorney’s Office for the Northern District of New York, uncovered the fraudulent claims. The OAG MFCU investigation was conducted by Senior Auditor-Investigator Carri Merry, under the supervision of Regional Chief Auditor Dejan Budimir, and Detective Patrick Lynch, under the supervision of Detective Supervisor Christopher Burns and Deputy Chief-Commanding Officer William Falk. The investigation and settlement were handled by MFCU’s Syracuse Regional Director Ralph D. Tortora, III. MFCU is led by Director Amy Held and Assistant Deputy Attorney General Paul J. Mahoney. MFCU is a part of the Division for Criminal Justice, which is led Chief Deputy Attorney General José Maldonado and overseen by First Deputy Attorney General Jennifer Levy. Attorney General James thanks the U.S. Attorney’s Office for the Northern District of New York for its collaboration in the investigation, litigation, and resolution of this matter. **Reporting Medicaid Provider Fraud:** MFCU defends the public by addressing Medicaid provider fraud and protecting nursing home residents from abuse and neglect. If you have information about Medicaid provider fraud or know about abuse or neglect of a nursing home resident, please [file a confidential complaint online](https://urldefense.com/v3/__https:/lnks.gd/l/eyJhbGciOiJIUzI1NiJ9.eyJidWxsZXRpbl9saW5rX2lkIjoxMDAsInVyaSI6ImJwMjpjbGljayIsImJ1bGxldGluX2lkIjoiMjAyMjA4MDEuNjE2MDE2ODEiLCJ1cmwiOiJodHRwczovL2FnLm55Lmdvdi9tZWRpY2FpZC1mcmF1ZC9jb250YWN0In0.oHimSQcYvqgbFTVcVu2gShlQZkE2AHSyOhRI_VlXONE/s/777987213/br/141882064160-l__;!!Ke5ujdWW74OM!9ccccvOysMSWUbItFiIMTdMGVYXWXL7V30oOMsGLCBxrJ3qkBypGVyn_cHPl0HI7yLgYD0f3Qu9_-dw6rv8xB81jvfkYiSbRMpNvbL8Y%24) or call the MFCU hotline at (800) 771-7755. If the situation is an emergency, please call 911. MFCU’s total funding for federal fiscal year (FY) 2023 is $65,717,936. Of that total, 75 percent, or $49,288,452, is awarded under a grant from the U .S. Department of Health and Human Services. The remaining 25 percent, totaling $16,429,484 for FY 2023, is funded by New York state. Through MFCU’s recoveries in law enforcement actions, it regularly returns more to the state than it receives in state funding. **Topics:** Judicial/courts, Medicare/Medicaid --- ### [U.S. Rep. Pocan: Pocan, Khanna introduce bill to strengthen Medicare, define alternative plans](https://insurancefraud.org/news_archives/u-s-rep-pocan-pocan-khanna-introduce-bill-to-strengthen-medicare-define-alternative-plans/) **Published:** September 26, 2026 **Author:** Diane Beauchamp **Content:** Ahead of the Medicare Open Enrollment period, **U.S. Representatives Mark Pocan (WI-02) and Ro Khanna (CA-17)** are introducing the “Save Medicare Act” to rename so-called “Medicare Advantage” plans, prohibit private insurers from using “Medicare” in plan titles or advertisements, and impose significant fines for any insurer that engages in this deceptive practice. “Only Medicare is Medicare. It is one of the most popular and important services the government provides,” **Rep. Pocan said.** “We should be working to expand this service to include coverage for dental, vision, and hearing care, as well as looking at ways to strengthen it rather than allowing these ‘Medicare Advantage’ programs to provide pale alternatives to what Medicare does. These non-Medicare plans run by private insurers undermine traditional Medicare. They often leave patients without the benefits they need while overcharging the federal government for corporate profit. This bill eliminates any confusion about what is – and what is not – Medicare, and ensures this essential program will continue to serve seniors and other Americans for years to come.” “‘Medicare Advantage’ is just private insurance that profits by denying coverage and the name is being used to trick seniors into enrolling. That’s not right,” **said Rep. Khanna.** “This bill will prevent these private insurers from labeling themselves as ‘Medicare’ and allow us to focus on strengthening and expanding real Medicare instead.” “So-called Medicare Advantage is neither Medicare nor an advantage,” **said Wendell Potter, President of the Center for Health and Democracy.** “It is simply another scheme by the insurance companies to line their pockets at the expense of consumers. I applaud Congressman Pocan and Congressman Khanna for introducing this vital legislation. The health care market is confusing for consumers and misleading branding like so-called Medicare Advantage just makes it worse.” “Medicare is a national treasure, delivering real value to millions of older adults and people with disabilities,” **Diane Archer, Senior Advisor at Social Security Works and President of Just Care USA said.** “Corporate insurance plans too often lean on Medicare’s good name to mislead people into signing up with them. Rep. Pocan and Rep. Khanna’s bill would put an end to this practice.” According to a recent [New York Times article](https://house.us20.list-manage.com/track/click?u=fc63ebf06e3a0b6ba10e8e383&id=bd40837300&e=435fc01d04), “8 of the 10 largest Medicare Advantage insurers – representing more than two-thirds of the market – have submitted inflated bills…and four of the five largest players – United Health, Humana, Elevance, and Kaiser – have faced federal lawsuits alleging that efforts to overdiagnose their customers crossed the line into fraud.” Additionally, according to the federal Medicare Payment Advisory Commission’s [2022 report to Congress](https://house.us20.list-manage.com/track/click?u=fc63ebf06e3a0b6ba10e8e383&id=97e3b5a251&e=435fc01d04), at least $12 billion in overpayments were made to Medicare Advantage plans in 2020 by the federal government. The “Save Medicare Act” will eliminate the confusion private insurers have relied upon for years to enroll unsuspecting seniors, and restore true Medicare as the primary health plan older Americans rely on. **Topics:** Legislative, Medicare/Medicaid --- ### [United States Files Civil Fraud Lawsuit Against Cigna For Artificially Inflating Its Medicare Advantage Payments](https://insurancefraud.org/news_archives/united-states-files-civil-fraud-lawsuit-against-cigna-for-artificially-inflating-its-medicare-advantage-payments/) **Published:** September 26, 2026 **Author:** Diane Beauchamp **Content:** Damian Williams, the United States Attorney for the Southern District of New York, announced that the United States has filed a civil healthcare fraud lawsuit against CIGNA CORPORATION and its subsidiary Medicare Advantage Organizations (collectively, “CIGNA”). The lawsuit seeks damages and penalties under the False Claims Act for CIGNA’s submissions to the Government of false and invalid patient diagnosis codes to artificially inflate the payments CIGNA received for providing insurance coverage to its Medicare Advantage plan members. The Government is intervening in a lawsuit filed by a whistleblower, which was originally filed in the United States District Court for the Southern District of New York and later transferred to the Middle District of Tennessee. The Government’s complaint alleges that the reported diagnoses codes were based solely on forms completed by vendors retained and paid by CIGNA to conduct in-home assessments of plan members. The healthcare providers (typically nurse practitioners) who conducted these home visits did not perform or order the testing or imaging that would have been necessary to reliably diagnose the serious, complex conditions reported and were prohibited by CIGNA from providing any treatment during the home visit for the medical conditions they purportedly found. The diagnoses at issue were not supported by the information documented on the form completed by the vendor and were not reported to CIGNA by any other healthcare provider who saw the patient during the year in which the home visit occurred. Nevertheless, CIGNA submitted these diagnoses to the Government to claim increased payments and falsely certified on an annual basis that its diagnosis data submissions were “accurate, complete, and truthful.” U.S. Attorney Damian Williams said: “As alleged, CIGNA obtained tens of millions of dollars in Medicare funding by submitting to the Government false and invalid diagnoses for its Medicare Advantage plan members. CIGNA knew that, under the Medicare Advantage reimbursement system, it would be paid more if its plan members appeared to be sicker. This Office is dedicated to holding insurers accountable if they seek to manipulate the system and boost their profits by submitting false information to the Government.” Medicare Advantage, also known as the Medicare Part C program, provides health insurance coverage for tens of millions of Americans who opt out of traditional Medicare. Under Medicare Part C, Medicare Advantage Organizations (“MAOs”), typically operated by private insurers like CIGNA, provide coverage for Medicare beneficiaries. In return, MAOs receive capitated payments from the Centers for Medicare and Medicaid Services (“CMS”) based on demographic information and the diagnoses of each plan beneficiary. MAOs submit diagnosis data, typically passed along from beneficiaries’ healthcare providers, to CMS. CMS then uses that diagnosis data, in conjunction with demographic factors, to calculate a “risk score” for each beneficiary and, in turn, the amount of the monthly capitated payment that the MAO will receive for covering that beneficiary. The Medicare Advantage payment model is intended to pay MAOs more to provide healthcare for sicker enrollees (expected to incur higher healthcare costs) and less for healthier enrollees (expected to incur lower costs). The following allegations are based on the Complaint that was filed in federal court: CIGNA, through its subsidiaries and affiliates, owns and operates numerous MAOs that administer Medicare Advantage Plans. CIGNA contracted with several vendors to conduct home visits of Medicare Advantage plan members across the country as part of its broader so-called “360 comprehensive assessment” program. The home visits were typically conducted by nurse practitioners, and on occasion by other non-physician healthcare providers such as registered nurses and physician assistants (the “Vendor HCPs”). Based on the visit, the Vendor HCPs completed a CIGNA-created form (“360 form”) that included a check-the-box multi-page list of a wide range of medical conditions. CIGNA had its coding teams identify diagnosis codes that corresponded to the recorded medical conditions and then submitted those to CMS for risk adjustment payment purposes. CIGNA structured the 360 home visits for the primary purpose of capturing and recording lucrative diagnosis codes that would significantly increase the monthly capitated payments it received from CMS. The purpose of the visits was not to treat patients’ medical conditions, and CIGNA explicitly prohibited the Vendor HCPs from providing actual patient treatment or care. As CIGNA acknowledged in an internal document discussing the program, “\[t\]the primary goal of a 360 visit is administrative code capture and not chronic care or acute care management.” But this was not disclosed to CIGNA’s plan members when the home visit was scheduled or during the actual visit. When identifying plan members to receive home visits, CIGNA targeted individuals who were likely to yield the greatest risk score increases and thus the greatest increased payment. The Vendor HCPs spent limited time with the patients and did not conduct a comprehensive physical examination. When completing the assessments and recording the diagnoses, the Vendor HCPs relied largely on the patient’s own self-assessment and their responses to various basic screening questions. Vendor HCPs did not have access to the patient’s full medical history and typically did not obtain or review relevant records from the patient’s primary care physician in advance of the visit. CIGNA’s 360 home visit program regularly generated false and invalid diagnosis codes for certain serious, complex conditions that cannot be reliably diagnosed in a home setting and without extensive diagnostic testing or imaging. In tens of thousands of instances, CIGNA submitted diagnosis codes that represent serious, complex medical conditions that (a) were based only on the home visits conducted by the Vendor HCPs; (b) required specific testing or imaging to be reliably diagnosed, which was not performed; (c) were not supported by the information documented on the 360 form completed by the Vendor HCPs; and (d) were not reported by any other healthcare provider who saw the plan member during the year in which the home visit occurred (the “Invalid Diagnoses”). The Invalid Diagnoses included, but are not limited to, diagnoses for complex medical conditions such as chronic kidney disease, congestive heart failure, rheumatoid arthritis, and diabetes with renal complications. According to CIGNA’s own clinical guidelines, accurately diagnosing these conditions requires specialized testing. CIGNA exerted pressure on Vendor HCPs to record high-value diagnoses that significantly increased risk adjustment payments. CIGNA management identified at least twelve classes of generic chronic diagnoses that they thought were “often underdiagnosed” among its Plan members and, through trainings and seminars, encouraged the Vendor HCPs to make these diagnoses during the home visits. CIGNA also closely tracked the volume and nature of the diagnoses generated by each vendor’s home visits, as well as how the diagnoses affected risk-adjusted payments. CIGNA provided trainings to vendors to improve their “performance” when they failed to deliver the expected level of high-value diagnosis codes. Indeed, CIGNA tracked the return on investment of the 360 home visit program by comparing the costs of the in-home visits (*i.e.*, payments to vendors) against the additional Part C payments generated by increased risk scores. For example, according to an internal report, CIGNA determined that, during the first nine months of 2014, one vendor’s 6,658 in-home visits resulted in more than an additional $14 million in Medicare payments, which dwarfed the approximately $2.13 million that CIGNA paid to the vendor. When specific providers were found to have captured fewer diagnoses than expected, CIGNA asked the vendor to prepare a “performance improvement plan” for the provider. The Invalid Diagnoses generated by the 360 home visits also did not conform with the International Classification of Diseases (“ICD”) Office Guidelines for Coding and Reporting (the “ICD Guidelines”), as required by applicable federal regulations. The Invalid Diagnoses did not affect patient care, treatment, or management during the home visit, as required under the ICD Guidelines, and thus were ineligible for risk adjustment. In addition, the Invalid Diagnoses were not supported by the minimal information recorded on the 360 forms, in violation of the ICD Guidelines’ medical record documentation requirement. In fact, in some cases, the 360 forms include clinical exam findings that contradict the supposed diagnosis. For example, one patient received a congestive heart failure diagnosis from a home visit even though the 360 form explicitly noted that physical exam results found her heart to be “regular” and “normal” and stated, “cardiac reviewed and unremarkable.” Through its 360 home visit program, CIGNA submitted diagnosis codes for tens of thousands of Invalid Diagnoses to CMS that constituted false claims for payment. Based on these unlawful false claims, CIGNA improperly received tens of millions of dollars in risk adjustment payments from CMS, in violation of both the False Claims Act and the common law. Mr. Williams thanked HHS-OIG and the U.S. Attorney’s Office for the Middle District of Tennessee for their assistance with this case. This case is being handled by the Office’s Civil Frauds Unit. Assistant U.S. Attorney Peter Aronoff is in charge of this case. **Topics:** Judicial/courts, Medicare/Medicaid --- ### [Man pleads guilty to insurance fraud over filing claim for camper he set ablaze](https://insurancefraud.org/news_archives/man-pleads-guilty-to-insurance-fraud-over-filing-claim-for-camper-he-set-ablaze/) **Published:** September 26, 2026 **Author:** Diane Beauchamp **Content:** A Minnesota man pleaded guilty in U.S. District Court on Tuesday to wire fraud after making fraudulent insurance claims for his camper, which he set on fire. U.S. Attorney Andrew Luger announced that Denis Molla, 30, filed false insurance claims regarding his camper. He attempted to convince law enforcement that his garage door was vandalized with “Biden 2020,” “BLM,” and an antifa symbol spray-painted on it. Molla told law enforcement on Sept. 23, 2020, that his camper had a Trump flag on it before it was set ablaze. He attempted to pin the damage on three men he saw outside his camper who he said targeted him because of their political differences. “Molla submitted multiple insurance claims seeking coverage for the damage to his garage, camper, vehicles, and residence caused by the fire,” a press release read. “In total, Molla submitted more than $300,000 in fraudulent insurance claims, and he received approximately $61,000 from his insurance company. Molla also received more than $17,000 from individual donors via GoFundMe.” Eventually, the FBI and the Brooklyn Center Police Department conducted an investigation that found Molla had committed the arson himself. Senior Judge David Doty heard Molla’s guilty plea to one count of wire fraud. The sentencing has yet to be scheduled. **Topics:** Homeowners - arson **Categories:** Conviction --- ### [AG Healey’s Medicaid Fraud Division Recovers More Than $71 Million in Federal Fiscal Year 2022](https://insurancefraud.org/news_archives/ag-healeys-medicaid-fraud-division-recovers-more-than-71-million-in-federal-fiscal-year-2022/) **Published:** September 26, 2026 **Author:** Diane Beauchamp **Content:** Attorney General Maura Healey announced today that her office’s Medicaid Fraud Division recovered more than $71 million during the most recent federal fiscal year, which ended on September 30. The Division recovered approximately $11 for every dollar appropriated by the federal government and the Massachusetts legislature for its work. The AG’s Medicaid Fraud Division investigates and prosecutes providers who defraud the state’s Medicaid program, MassHealth. The Division is also responsible for reviewing complaints of abuse, neglect, mistreatment, and financial exploitation of patients in long-term care facilities and MassHealth members in any health care setting. “I’m proud of the important work our Medicaid Fraud Division does to ensure the integrity of our MassHealth system on behalf of taxpayers and MassHealth members,” said **AG Healey**. “The tens of millions of dollars recovered by the Division during this fiscal year send a strong message that we are committed to ensuring that our MassHealth dollars are going to our most vulnerable residents and we take seriously attempts to defraud our important safety net health care system.” “Our administration has made program integrity a priority of the MassHealth program so that it can continue to successfully perform its primary purpose – providing crucial health care supports for Massachusetts’ most vulnerable,” said **Secretary of Health and Human Services Marylou Sudders**. “I am grateful for the Attorney General’s partnership in protecting the integrity of MassHealth’s billing system and ensuring the effective usage of taxpayer dollars.” During the most recent federal fiscal year, the Division secured 35 civil settlements with various entities, including outpatient mental health providers, home health agencies, substance abuse treatment facilities, adult day health centers, skilled nursing facilities, and dental practices. The overwhelming majority of the Division’s recoveries were returned to MassHealth. Funds were also returned to the Opioid Recovery and Remediation Fund – a fund established by the Legislature in 2020 with money from AG Healey’s opioid litigation and settlements, to mitigate the impacts of the opioid epidemic in Massachusetts; the Department of Public Health’s Long-Term Care Facility Quality Improvement Fund; former employees of MassHealth providers who were owed unpaid wages; and whistleblowers who brought lawsuits against providers alleging fraud. The Division brought criminal charges against 24 providers and individuals for defrauding MassHealth and two individuals for abuse, neglect, or financial exploitation of elders. The Division also secured criminal indictments against a variety of providers and individuals, including physicians, clinical laboratories, mental health providers, personal care attendants, and home health aides. **Combatting fraud** **in behavioral health services** Safeguarding high-quality mental and behavioral health services for MassHealth members remained a priority for the Division over the last fiscal year. In October 2021, in the largest-ever settlement of its kind, a private equity firm and former executives of South Bay Mental Health Center, Inc. (SBMHC) [agreed to pay $25 million](https://www.mass.gov/news/private-equity-firm-and-former-mental-health-center-executives-pay-25-million-over-alleged-false-claims-submitted-for-unlicensed-and-unsupervised-patient-care) for allegedly causing fraudulent claims to be submitted to MassHealth for mental health services provided to patients by unlicensed, unqualified, and improperly supervised staff at clinics across the state. This settlement was the largest publicly disclosed government health care fraud settlement in the nation involving private equity oversight of health care providers, as well as the largest amount a private equity company itself has agreed to pay to resolve fraud allegations involving health care portfolio companies. Similarly, in June 2022, Pathways of Massachusetts, a former Massachusetts outpatient behavioral health provider, and Molina Healthcare, Inc., its former corporate parent, [agreed to pay $4.6 million](https://www.mass.gov/news/outpatient-mental-health-company-will-pay-46-million-to-resolve-false-claims-allegations) to resolve allegations that Pathways and Molina caused fraudulent claims to be submitted to MassHealth for behavioral health care services provided to patients by unlicensed and improperly supervised staff members. In November 2021, the Division worked with the Insurance Fraud Bureau [to secure indictments](https://www.mass.gov/news/quincy-woman-arrested-arraigned-for-scheme-to-bill-public-and-private-insurance-for-behavioral-health-services-not-provided) against Nicole Kasimatis, the owner and operator of Fortitude Counseling and Recovery Center in Quincy, for billing MassHealth and private health insurers for substance use disorder and/or mental health services she did not perform either because she was incarcerated or out of the country; billing for services not rendered by licensed or supervised Fortitude employees; and billing for services under the name and number of providers who no longer worked for Fortitude and who did not provide the services. In July 2022, Kasimatis [pleaded guilty](https://www.mass.gov/news/quincy-woman-pleads-guilty-sentenced-to-prison-for-fraudulent-billing-scheme-for-behavioral-health-services-not-provided) and was sentenced to serve three to four years in state prison in connection with this scheme. **Protecting the physical and financial safety of elderly patients** The AG’s Medicaid Fraud Division continued to prioritize the physical and financial security of elderly patients during this federal fiscal year. In May 2022, the Division [announced settlements](https://www.mass.gov/news/ag-healey-secures-resolutions-with-five-nursing-homes-over-claims-of-patient-neglect-inadequate-care-of-residents) with five Massachusetts nursing homes resolving allegations of patient neglect, insufficient staff training, and inadequate care for vulnerable nursing home residents. These cases involved preventable harm and, in some situations, the deaths of nursing home residents, and returned more than $250,000 to the state, including more than half to the Massachusetts Department of Public Health (DPH) Long Term Care Facility Quality Improvement Fund. In June 2022, the Division [sued](https://www.mass.gov/news/ag-healey-sues-rowley-nursing-home-and-owner-over-infection-control-failures-during-covid-19-pandemic) a Rowley nursing home and its owner for infection control failures at the start of the COVID-19 pandemic, including failing to cohort, isolate or test residents who were suspected, symptomatic, or known to have tested positive for COVID-19. In September 2022, the Division [secured indictments](https://www.mass.gov/news/home-health-aide-charged-with-assault-and-battery-against-elderly-patient) against a home health aide who is allegedly shown on home surveillance video abusing her elderly patient, including shaking the patient from a recliner and aggressively dragging her into the bathroom, causing noticeable bruising on the patient’s left arm and side. In April 2022, the Division [announced indictments](https://www.mass.gov/news/worcester-nursing-assistant-indicted-and-arraigned-in-connection-with-theft-from-elderly-patients) against a Worcester nursing assistant in connection with his alleged unauthorized use of four nursing home residents’ debit cards and the theft of over $30,000 from their accounts. Additionally, the Division [sought and obtained](https://www.mass.gov/news/optometrist-charged-with-fraudulently-billing-masshealth-for-care-never-provided-to-nursing-home-residents) indictments against a Carlisle optometrist for allegedly falsely billing MassHealth during the COVID-19 pandemic for services that were not provided to nursing home residents. **Continuing to pursue fraud in home-based care** The Division continued its ongoing efforts to combat fraud among providers who deliver home-based services. After two trials in Middlesex Superior Court in [June](https://www.mass.gov/news/medford-man-found-guilty-sentenced-to-jail-for-defrauding-masshealth) and [September](https://www.mass.gov/news/lowell-man-found-guilty-sentenced-to-jail-for-defrauding-masshealth) 2022, two individuals were found guilty in connection with their roles in a scheme to falsely submit timesheets for personal care attendant services that were not actually rendered; the two individuals were sentenced to a one-year term and a two-year term, respectively, in the House of Correction. In February 2022, the Division [secured indictments against](https://www.mass.gov/news/four-individuals-indicted-in-connection-with-personal-care-attendant-fraud) four individuals who are accused of defrauding MassHealth by knowingly submitting false personal care attendant timesheets claiming they were providing services while they were working at other jobs. Since 2016, the AG’s Office has successfully prosecuted three home health agencies and their owners and settled civilly with 14 home health agencies, returning more than $50 million to MassHealth. That effort continued during this federal fiscal year. In March 2022, a Worcester home health company reached a $6.53 million settlement to [resolve longstanding litigation](https://www.mass.gov/news/home-health-agency-agrees-to-pay-653-million-to-masshealth-to-resolve-allegations-of-fraud) with the AG’s Office concerning its noncompliance with MassHealth regulations. The settlement also returned $375,000 to employees to whom the home health company owed unpaid wages. In May 2022, a Tewksbury home health agency and its owners [agreed](https://www.mass.gov/news/ag-healey-secures-550000-from-home-health-care-company-to-resolve-false-billing-allegations) to pay $550,000 to resolve allegations that the agency billed the state for services not appropriately authorized by a physician. In December 2021, a Chicopee-based home health agency and its owners [reached](https://www.mass.gov/news/ag-healey-secures-630000-from-home-health-care-company-to-resolve-false-billing-allegations) a $630,000 settlement to resolve allegations that the agency had not complied with MassHealth regulations. In November 2021, a Brockton-based home health company and its owners [agreed](https://www.mass.gov/news/ag-healey-secures-12-million-from-brockton-home-health-agency-that-falsely-billed-masshealth) to pay $1.2 million to resolve similar allegations. **Preventing the illegal prescribing and dispensing of opioids** The Division pursues providers engaged in the illegal prescribing of opioids. In May 2022, the former medical director at Lawrence Medical Center [was indicted](https://www.mass.gov/news/lawrence-based-doctor-charged-with-illegally-prescribing-drugs-to-substance-use-disorder-and-chronic-pain-patients) for prescribing controlled substances to his patients including amphetamines, benzodiazepines, and morphine sulfate, even when he knew from repeated urine drug screens that the patients were not taking the drugs. In June 2022, a Newton physician [agreed to pay $100,000](https://www.mass.gov/news/newton-physician-resolves-claims-of-illegally-prescribing-addictive-drugs-without-reviewing-patient-prescription-history) and to enter into an independent compliance monitoring program to resolve allegations that he prescribed controlled substances without first reviewing patient prescription histories to prevent drug diversion and misuse. And in September 2022, the Division [announced criminal charges](https://www.mass.gov/news/marshfield-pharmacy-and-owner-charged-with-false-billing-to-masshealth-and-insurers) against a Marshfield pharmacy and its owner for allegedly accepting cash payments from MassHealth recipients for prescriptions for controlled substances, in many cases charging cash in an amount over and above what MassHealth would have reimbursed the pharmacy. The AG’s Medicaid Fraud Division has maintained a national presence and leadership role within the [National Association of Medicaid Fraud Control Units](https://www.namfcu.net/) (NAMFCU). The Chief of the Division, Toby Unger, is currently serving as the President of NAMFCU. The Division is also a national leader in policy and training initiatives as well as in multistate false claims cases. Medicaid is a multi-billion-dollar joint state and federal program that provides health care coverage for the economically disadvantaged. The Division works cooperatively with MassHealth and other state and federal agencies to prosecute provider fraud in the Massachusetts Medicaid program. Many of the cases handled by the Division were referred by MassHealth, as well as state and federal agencies and law enforcement partners. The success of the Division is due to its dedicated team of investigators, attorneys, analysts, and administrative staff along with the leadership of the Division’s management team, including Chief Toby Unger; Deputy Chief Kevin Lownds; Managing Attorneys Jennifer Goldstein, Gregory Matthews, and Ian Marinoff; Senior Trial Counsel Elisha Willis; and Investigation Supervisors Joseph Shea, Dean Bates and Christopher Cecchini. The Medicaid Fraud Division receives 75 percent of its funding from the U.S. Department of Health and Human Services under a grant award. The remaining 25 percent is funded by the Commonwealth of Massachusetts. **Topics:** Judicial/courts, Public Awareness --- ### [Lawyer Is Latest to Plead Guilty in $31M Trip-and-Fall Insurance Fraud Scheme](https://insurancefraud.org/news_archives/lawyer-is-latest-to-plead-guilty-in-31m-trip-and-fall-insurance-fraud-scheme/) **Published:** September 26, 2026 **Author:** Diane Beauchamp **Content:** A New York lawyer pled guilty Monday in connection with a scheme to obtain millions of dollars in fraudulent insurance reimbursements and other compensation from fraudulent trip-and-fall accidents Damian Williams, the U.S. Attorney for the Southern District of New York, announced that Marc Elefant pled guilty to one count of conspiracy to commit wire fraud in connection the scheme. Elefant is the third defendant to plead guilty this year. Two other defendants — Adrian Alexander, the owner of a litigation funding company, and Sady Ribeiro, a pain management doctor and surgeon — pled guilty earlier this year. Alexander pled guilty to one count of conspiracy to commit wire fraud in August. Ribeiro pled guilty to one count of conspiracy to commit wire fraud and one count of conspiracy to commit mail fraud in September. All defendants pled guilty before U.S. District Judge Sidney H. Stein. Elefant faces a maximum sentence of five years in prison. As part of his plea agreement, Elefant will forfeit $955,281 to the U.S. and to make restitution in the amount of $1,486,000. Elefant is scheduled to be sentenced on January 25, 2023. According to the indictment, Elefant and others were involved in a scheme in which they defrauded businesses and insurance companies by arranging for staged trip-and-fall accidents throughout the New York City area and then filing fraudulent lawsuits. In the course of the fraud scheme, participants recruited more than 400 patients. The defendants, together with others known and unknown, attempted to defraud the victims of more than $31,000,000. The patients were encouraged and in some cases paid to receive ongoing chiropractic and medical treatment from certain chiropractors and doctors. Their legal and medical fees were usually paid for by litigation funding companies. As part of their plea agreements, Ribeiro agreed to forfeit $513,005 and to make restitution in the amount of $3,928,133 while Alexander agreed to forfeit $659,001 and to make restitution in the amount of $3,928,133, according to officials. Ribeiro is scheduled to be sentenced on January 5, 2023. Alexander is scheduled to be sentenced on November 30, 2022. Three other members of the scheme were [sentenced to prison](https://www.insurancejournal.com/news/east/2020/05/26/569839.htm) terms in 2020. **Topics:** Commercial Fraud, Healthcare Fraud **Categories:** Conviction --- ### [Former Judge David Bell pleads no contest to lesser charge in auto theft ring investigation](https://insurancefraud.org/news_archives/former-judge-david-bell-pleads-no-contest-to-lesser-charge-in-auto-theft-ring-investigation/) **Published:** September 26, 2026 **Author:** Diane Beauchamp **Content:** David Bell, the former Orleans Parish Juvenile Court judge accused of taking part in a large-scale auto theft ring that operated in the New Orleans area for more than seven years, pleaded no contest Monday to a reduced charge of misdemeanor possession of stolen property, according to Jefferson Parish court records. Judge E. Adrian Adams, of the 24th Judicial District Court in Gretna, deferred a six-month sentence in parish prison and ordered Bell to serve one year. Bell, 53, had been charged with racketeering and conspiracy to commit theft valued over $25,000. He was accused of co-owning a New Orleans scrapyard used to dispose of stolen vehicles. Bell was one of 17 men who have been indicted by the Jefferson Parish District Attorney’s Office in the scheme, which operated between 2009 and 2016. Authorities alleged the crew was responsible for about 32% of the auto thefts in Jefferson Parish during the height of the conspiracy, costing victims more than $2.5 million in losses. Bell has always maintained his innocence. Prosecutors on Monday dropped the conspiracy charge against him and amended the racketeering charge to possession of stolen property, said Bell’s attorney, John Venezia. “They did so because they recognized that they had a very weak case against Mr. Bell,” he said. The lower-tier members of the theft ring stole pickup trucks, sport utility vehicles, cars, vans, four-wheelers, tires, rims and other property from residences and businesses in Jefferson and Orleans parishes between May 2009 and February 2017, according to the Jefferson Parish Sheriff’s Office, which investigated with help from the New Orleans Police Department. Officials estimated the group made off with about 400 vehicles in 2014 and 2015 alone. The stolen vehicles were either sold or dismantled at chop shops where parts such as engines, catalytic converters and tailgates were resold. The crew sometimes switched out vehicle identification numbers on the stolen cars, which were then used to stage fake accidents for insurance fraud, authorities said. Investigators alleged Bell and Harry Sorrell, 55, co-owned H&H Scrap LLC, a New Orleans yard where stolen vehicles were scrapped and then sold for profit. The two were responsible for paying the crew for the auto thefts, according to court records. Most of the lower-tier members of the scheme pleaded guilty as charged and were ordered to serve between six and 20 years in prison, court records said. Sorrell was sentenced to 10 years after pleading guilty on June 30, 2016 to racketeering and conspiracy to commit theft, court records said. He detailed Bell’s alleged involvement in the scheme, including fraudulent insurance payouts for vehicles that Bell falsely claimed had been stolen, court records said. Bell had also been accused of using his “former capacity as an elected official” to hamper investigations into the ring, according to court records. Bell was elected to Section C of the Orleans Parish Juvenile Court in December 2004. He resigned in June 2010 after six courthouse employees accused him of sexual harassment. During Monday’s hearing, Bell entered an “Alford” or no-contest plea to the stolen property charge. Under an Alford plea, the defendant is adjudicated guilty but does not actually admit guilt. In addition to probation, Bell must pay a $500 fine and perform 50 hours of community service, court records said. Bell’s indictment included two co-defendants, Travis Brissette, 48, and Jimmy Chanzy, 40, who were also charged with racketeering and conspiracy to commit theft. Brisette, who faced an additional theft charge, was accused of stealing vehicles and teaching others how to do so, court records said. Chanzy allegedly helped with the insurance fraud associated with the scheme. Like Bell, both men pleaded no contest to a reduced charge of possession of stolen property while the other counts were dismissed, court records said. They received the same sentence as Bell. **Topics:** Auto fraud **Categories:** Conviction --- ### [Alaffia Health taps AI to detect errors in hospital bills](https://insurancefraud.org/news_archives/alaffia-health-taps-ai-to-detect-errors-in-hospital-bills/) **Published:** September 26, 2026 **Author:** Diane Beauchamp **Content:** The multidecade rise in healthcare costs isn’t expected to reverse course any time soon. In search of a fix, Adun Akanni and TJ Ademiluyi co-founded [Alaffia Health](https://www.alaffiahealth.com/) in 2020, one of the startups participating in the TechCrunch Disrupt Battlefield 200. The health tech company uses machine learning to try to identify fraud, waste and abuse in healthcare claims. “We leveraged key insights from our family’s medical billing company in founding Alaffia,” Ademiluyi told TechCrunch in an interview. “We determined that the majority of the waste in the system results from natural human error, lack of transparency in claims processing, and misaligned incentives between healthcare providers and payers. We founded Alaffia to tackle these issues using nascent machine learning and AI, built on top of deep healthcare domain expertise.” Alaffia sells services primarily to health insurance payers and enterprises that provide their employees health coverage. Using AI to extract and standardize data from hospital bills, including various medical billing procedure codes and dates of service, the platform aims to reduce payers’ spending by finding errors and overcharges within the bills sent by healthcare providers. The causes of medical billing errors are myriad but often arise from double billing, missing the payer submission deadline and a failure to capture patient information. Non-specific diagnostic codes are another common issue, leading to instances of upcoding and undercoding. Upcoding is when a coder reports a higher-level service than patients received or never had performed, while undercoding is when billing codes don’t capture the full scope of work performed by a physician. Medical expenses are expected to grow by an average of 5.1% from 2021 to 2030, reaching $6.8 trillion, [according](https://www.cms.gov/newsroom/press-releases/cms-office-actuary-releases-2021-2030-projections-national-health-expenditures#:~:text=The%20report%20finds%20that%20annual,annually%20over%20the%20same%20period.) to the Centers for Medicare and Medicaid Services — and a significant portion of those expenditures are derived from errors in health insurance claims. It’s [estimated](https://etactics.com/blog/medical-billing-error-statistics) that about 80% of claims in the U.S. contain at least one medical billing error and that as much as $300 billion is [lost](https://brighterion.com/5-insights-about-using-ai-to-detect-fraud-waste-and-abuse-in-healthcare-ahip-2021/) to provider fraud, waste and abuse each year. **Topics:** Public Awareness, Technology --- ### [Major Medical Societies to Support Texas Medical Association Federal Surprise Billing Lawsuit](https://insurancefraud.org/news_archives/major-medical-societies-to-support-texas-medical-association-federal-surprise-billing-lawsuit/) **Published:** September 26, 2026 **Author:** Diane Beauchamp **Content:** The American College of Emergency Physicians, American College of Radiology® (ACR®) and American Society of Anesthesiologists support the new Texas Medical Association (TMA) suit filed Oct. 12, stating that the [Surprise Billing Final Rule](https://www.dol.gov/agencies/ebsa/laws-and-regulations/laws/no-surprises-act) independent dispute resolution (IDR) process still fails to comply with No Surprises Act (NSA) statutory text. The new TMA suit is filed in the same Texas Federal Court that [ruled in favor of the TMA](https://affordablecareactlitigation.files.wordpress.com/2022/02/tma-summary-judgment-opinion-2-23.pdf) thus vacating parts of the IDR process published in the Surprise Billing *Interim* Final Rule issued last September. ACEP, ACR and ASA filed a joint amicus brief with the Texas court in support of TMA on October 19. Additionally, ACEP, ACR, and ASA will dismiss their joint lawsuit in the U.S. Court for the Northern District of Illinois challenging the interim final IDR rule because that rule is no longer in effect. ACEP, ACR, and ASA will monitor the TMA suit and stand ready to challenge the final rule in the Northern District of Illinois if necessary. The final rule, issued in August, skews the IDR process to favor the insurer-calculated Qualifying Payment Amount (QPA) over other factors Congress specifically directed IDR arbitrators to consider equally with the QPA. Insurers are using the new law to raise profits by initiating reductions in contracted fee schedules and narrowing medical networks, which denies patients their choice of providers and can delay diagnosis and treatment of illness and injury. - In possible violation of the NSA, insurers are [likely using lower *primary care provider* contract rates](https://www.acr.org/-/media/ACR/Files/Advocacy/2022-8-15-Avalere-QPA-Whitepaper_Final.pdf) (for specialty services those practices never offered nor performed) in calculating QPA. - Blue Cross Blue Shield of [North Carolina](https://www.acr.org/-/media/ACR/Files/Advocacy/20211105-BCBSNC-rate-reduction-notice_Redacted.pdf), Blue Cross Blue Shield [of Tennessee](https://www.acr.org/-/media/ACR/Files/Advocacy/BCBS-of-TN-Letter-to-Employers.pdf) and CIGNA of Tennessee are the first to cite the new law in demanding providers accept drastic cuts in payment for services provided or risk contract termination. Many practices, reeling from COVID-19’s economic impact, cannot withstand this insurer multi-edged profit grab and may be dropped from networks. These insurer restrictions impact all care (not just out-of-network care), including cancer screenings, [which plummeted ](https://www.iqvia.com/-/media/iqvia/pdfs/institute-reports/shifts-in-healthcare-demand-delivery-and-care-during-the-covid-19-era/iqvia-institute-reportcovid-19-impact-on-us-healthcare4292020.pdf?_=1598879241220)during the pandemic and may yet lead to [more cancer deaths.](https://science.sciencemag.org/content/368/6497/1290.abstract) **There is no evidence that insurers use profit margin increases, obtained at patient and provider expense, to lower beneficiary costs. In fact:** - [Medical imaging costs are down significantly ](https://www.neimanhpi.org/data_series/medicare-part-b-total-imaging-spending/#/graph/2006/2020/true)in recent years,[ including in 2020](https://www.ama-assn.org/system/files/2020-prp-covid-impact-medicare-physician-spending.pdf). Yet [insurance premiums continue to rise](https://www.kff.org/report-section/ehbs-2019-section-1-cost-of-health-insurance/) — along with insurance company revenue. - [Studies](https://www.asahq.org/madeforthismoment/wp-content/uploads/2022/04/MFTM-Research-Summary_2-18-22.pdf) have demonstrated that the anesthesiologist’s role in the care of surgical patients results in lower length of stay, fewer complications, and better overall outcomes. Unfortunately, the financial strain may result in lack of access to in-network anesthesiologists, practice reductions and closures. - Health insurers’ net incomes and profit margins [have grown every year ](https://content.naic.org/sites/default/files/inline-files/2020-Annual-Health-Insurance-Industry-Analysis-Report.pdf)since 2015, including [record profits in 2020](https://www.nytimes.com/2020/08/05/health/covid-insurance-profits.html), even as [their costs dropped. ](https://www.shrm.org/resourcesandtools/hr-topics/benefits/pages/health-plan-cost-increases-return-to-pre-pandemic-levels.aspx) The Texas case again solely impacts the IDR process to determine provider reimbursement for out-of-network care. The suit does not impact No Surprises Act patient protections, which ACEP, ACR and ASA continue to fully support, nor raise patient out-of-pocket costs. **About the American College of Emergency Physicians** The [American College of Emergency Physicians](https://www.acep.org/) (ACEP) is the national medical society representing emergency medicine. Through continuing education, research, public education, and advocacy, ACEP advances emergency care on behalf of its 40,000 emergency physician members, and the more than 150 million Americans they treat on an annual basis. For more information, visit [http://www.acep.org](http://www.acep.org/) and www.emergencyphysicians.org. **About the American College of Radiology** The [American College of Radiology](http://www.acr.org/) (ACR), founded in 1924, is a professional medical society dedicated to serving patients and society by empowering radiology professionals to advance the practice, science and professions of radiological care. **About the American Society of Anesthesiologists** Founded in 1905, the American Society of Anesthesiologists (ASA) is an educational, research and scientific society with more than 55,000 members organized to raise and maintain the standards of the medical practice of anesthesiology. ASA is committed to ensuring physician anesthesiologists evaluate and supervise the medical care of patients before, during and after surgery to provide the highest quality and safest care every patient deserves. **Topics:** Legislation --- ### [A Boisean ran for Congress. A Meridian man laundered money. Feds hunt ID COVID fraud](https://insurancefraud.org/news_archives/a-boisean-ran-for-congress-a-meridian-man-laundered-money-feds-hunt-id-covid-fraud/) **Published:** September 26, 2026 **Author:** Diane Beauchamp **Content:** Idaho’s top federal prosecutor has created a task force to combat fraud related to the COVID-19 pandemic. U.S. Attorney Josh Hurwit announced in a news release the creation of the District of Idaho’s COVID‑19 Fraud Task Force, made up of “a broad group of law enforcement agencies, with prosecutors who will work jointly to hold accountable criminals who unjustly enriched themselves at the expense of taxpayers by defrauding economic aid programs.” The task force will include representatives from the law enforcement and investigation arms of the Small Business Administration, Internal Revenue Service, U.S. Department of Treasury, FBI, Federal Deposit Insurance Corp., Social Security Administration, U.S. Department of Agriculture, U.S. Department of Health and Human Services, U.S. Postal Inspection Service and U.S. Secret Service. The task force will identify, investigate and prosecute fraud cases involving the abuse of programs that were created to help people and small businesses weather the COVID‑19 pandemic since 2020, such as the Paycheck Protection Program, Economic Injury Disaster Loans, Coronavirus Farm Assistance Program, Emergency Rental Assistance Program and enhanced unemployment payments. The task force is seeking tips from the public. Make a report to the COVID-19 Pandemic Fraud Hotline at [www.pandemicoversight.gov/contact/about-hotline](http://www.pandemicoversight.gov/contact/about-hotline) or directly to the U.S. Attorney’s Office at 208-334-1211. Investigators and prosecutors have identified and charged several Idahoans in connection with allegedly creating businesses or falsifying information to claim COVID-19 assistance. Among them are: Nicholas Jones, a 36-year-old Boise resident and small business owner who unsuccessfully opposed U.S. Rep. Russ Fulcher in the 2020 Republican primary. Jones was sentenced Oct. 19 to 30 months in federal prison and a $100,000 fine, for wire fraud and filing false campaign finance disclosures, the news release from Hurwit’s office said. Jones received $753,600 in PPP and Economic Injury Disaster Loan payments. Instead of using them for his business, the release said, he used “a significant portion” for personal expenses, such as car payments, life insurance, mortgage payments and to buy “a significant amount” of stocks and investments. Jones also spent the funds on political advertising for his congressional campaign, and to pay his restaurant’s employees for their work on his campaign, the release said. Douglas Wold, of Meridian, who was sentenced in December to 41 months in federal prison for wire fraud, mail fraud and money laundering related to a COVID-19 testing scheme. “Wold deposited the funds he received into a bank account he controlled and did not pay the health provider that actually conducted the testing,” the release said. Wold used $69,116 of the ill-gotten gains to buy a speedboat and trailer, the release said. Jeff C. Vogt, of Caldwell, who received $250,000 in CFAP funds by claiming he produced but couldn’t sell 22.5 million pounds of dry onions in the first few months of the pandemic. Vogt did not respond to a civil lawsuit; the court entered a default judgment for $761,665 against him. Lawrence Sikutwa, of Boise, was indicted this month on charges of bank fraud, aggravated identity theft and money laundering. Sikutwa allegedly filed fraudulent applications and obtained $337,976 in PPP loans from two banks, then used the money for personal and non-business related expenses, the release said. Three defendants from other states, who were indicted in July with bank fraud related to more than $2.4 million in PPP loans they received from a financial institution in Boise, the release said. **Topics:** COVID-19, Regulatory actions **Categories:** Arrest --- ### [Florida CFO Calls for Ban on Assignments of Benefits, Limits on Public Adjusters](https://insurancefraud.org/news_archives/florida-cfo-calls-for-ban-on-assignments-of-benefits-limits-on-public-adjusters/) **Published:** September 26, 2026 **Author:** Diane Beauchamp **Content:** In the wake of Hurricane Ian, Florida’s chief financial officer has taken a hard line on insurance claims litigation, calling for an outright ban on assignments-of-benefits agreements. At a press conference in Cape Coral, a city hit hard by the hurricane this month, and in a statement Wednesday, CFO Jimmy Patronis also urged Florida lawmakers to establish a statewide insurance fraud prosecutor and to disincentivize public adjusters after a storm. “We have bad public adjusters swarming impacted areas, soliciting, and trying to make a quick buck,” Patronis said. “Not only do individuals need more time to get out of a public adjuster contract during a state of emergency, we need to reduce the percentage a public adjuster is entitled to immediately following a storm, ensuring their motives are aligned with helping Floridians get back on their feet.” Patronis, whose Department of Financial Services regulates adjusters, did not say what he based the “bad adjusters” assertion on. But some Florida insurers have long complained about public adjusters working closely with contractors and promising homeowners free roofs after a windstorm, leading to exaggerated claims and litigation. The CFO also did not provide details on his proposed schedule of fees for adjusters. The call for an end to assignments of benefits, or AOBs, has already met with support from one insurance industry leader. “We commend the CFO for calling attention to ongoing abuse of assignment-of-benefits tools by shady vendors whose goal is profit above all else,” said Michael Carlson, president of the Personal Insurance Federation of Florida, which represents a number of insurance carriers. “Eliminating post-loss assignments that transfer consumer rights to vendors is a good idea. We also believe that addressing exorbitant public adjuster fees is another good idea and a means to reduce predatory behavior by these licensees.” Several Florida insurance executives in recent years have called for statutory changes that would allow insurance policies to bar AOB agreements, noting that thousands of lawsuits in recent years have resulted from disputed AOB claims. Data from CaseGlide, a litigation management software firm, shows that as much as 41% of litigated claims against Florida’s largest insurers resulted from assignees of benefits, usually from restoration contractors. In July, the AOB share of new litigations reached an 18-month high, the company said. That came despite 2019 Florida legislation that aimed to reduce AOB suits. A number of other states allow insurance policies to include non-assignment of benefits clauses. Carlson said that claims litigation is “the storm after the storm,” and that one-way attorney fees also need to be addressed to disincentivize unnecessary lawsuits. The Florida Association of Public Adjusters pushed back on Patronis’ agenda. “We are concerned that the recent release misrepresents the important role and work of licensed public adjusters,” FAPIA President Chris Cury said in a statement Thursday. Instead of bad actors in the hurricane zone in southwest Florida, “it appears there is a focus on lawful and licensed insurance professionals who are truly working to help policyholders in their time of need.” Cury noted that, following a declared emergency, adjuster fees already are limited to no more than 10% of any claim made in the first year after the loss. “Licensed public adjusters, who are regulated by the Department of Financial Services, adhere to strict standards and continue to serve in an essential capacity for the sake of policyholders,” Cury said. Insurance industry advocates have often blamed the adjusters for advertising heavily after storms and encouraging inflated claims. Insurance agents have reported that homeowners in the Hurricane Ian strike zone have fielded dozens of calls and door-knocks from public adjusters. But some adjusters and claimants’ attorneys have maintained that public adjusters help homeowners achieve a fair payout on claims, while insurance companies sometimes try to minimize the extent of damages. “The insurance company has adjusters trained to interpret policies and assess a loss but want to preclude an insured from retaining professionals to assist them in doing the same,” said West Palm Beach attorney Gina Clausen Lozier, who has represented policyholders in claims disputes. She pointed out that many insurance policies require insureds to submit statements within a short timeframe attesting to the amount of losses. Failure to submit can result in denial of the claim. If it’s overstated, insurers have been known to allege fraud. A public adjuster can help provide a timely estimate. Lozier agreed that Florida’s insurance market is facing a number of problems, but said that licensed adjusters are not to blame. “The public adjusting industry in Florida is highly regulated, despite ongoing insinuations that public adjusters are operating without legal or ethical restraints by ‘preying’ on insureds,” she said. Patronis did not call for another special session of the Florida Legislature to adopt his reform ideas, as some industry advocates have done, but referred to “this coming legislative session.” The 2023 regular session begins in March. Patronis also reiterated his call for a $3 million anti-fraud and public education campaign. “Policyholders need to understand what they are signing, and that litigation will only slow down their claims and could result in liens on their property,” Patronis said. **Topics:** Legislation --- ### [Florida man pleads guilty for his role in international health care fraud scheme](https://insurancefraud.org/news_archives/florida-man-pleads-guilty-for-his-role-in-international-health-care-fraud-scheme/) **Published:** September 26, 2026 **Author:** Diane Beauchamp **Content:** Nagaindra Srivastav has pleaded guilty to conspiracy and kickback charges for his role in selling fraudulent doctors’ orders to his co-conspirators, who used the orders to obtain at least $25 million in fraudulent payments from Medicare. “Srivastav and his co-conspirators targeted our most vulnerable citizens to line their pockets with taxpayer money,” said U.S. Attorney Ryan K. Buchanan. “Our office is committed to finding and prosecuting those who exploit telemedicine and use it as a platform for their criminal schemes.” “Healthcare fraud touches every corner of the United States. Srivastav’s actions cost taxpayers at least $25 million dollars,” said Keri Farley, Special Agent in Charge of FBI Atlanta. “His criminal conduct was driven by personal greed. This guilty plea will serve as a reminder to others that the FBI and its law enforcement partners will investigate and prosecute individuals illegally exploiting healthcare technology for their own riches.” “Health care fraud is not a victimless crime and those who defraud federal health care programs carelessly waste valuable taxpayer dollars and contribute to the rising cost of health care,” said Special Agent in Charge Tamala E. Miles, at the Department of Health and Human Services, Office of Inspector General (HHS-OIG). “Working closely with our law enforcement partners, HHS-OIG remains committed to investigating and holding accountable perpetrators of health care fraud.” According to U.S. Attorney Buchanan, the charges and other information presented in court: Srivastav was the owner of B2B Apps Solutions (“B2B”), a Florida-based company. Through B2B, Srivastav and his co-conspirators created and operated an internet-based platform that individuals and businesses in the health care industry used for the purchase and sale of physician orders for Durable Medical Equipment (“DME”), such as ankle, back, knee, or leg braces. Through B2B, Srivastav paid and received remuneration for the referral of federal health care business. To accomplish this, Srivastav created a website, RepsHub, in which DME companies and others uploaded potential DME-patient information, called “leads,” which were generally obtained through telemarketing campaigns targeting beneficiaries for whom DME products could be billed. In addition, and in conjunction with his selling of physician orders, Srivastav also offered and sold leads, which he obtained through call centers controlled by himself and his co-conspirators. Srivastav purchased the physicians’ orders that he sold to his customers from purported telemedicine companies based in the Philippines and Pakistan. These orders lacked medical necessity, and Srivastav was notified on numerous occasions that the purported authorizing physician had not actually spoken with the patient, signed the order, or prescribed the braces. Although Srivastav never personally submitted claims to Medicare or any other health care program, he is responsible for at least $25 million in federal health care program reimbursement. Sentencing for Nagaindra Srivastav, 58, of Tampa, Florida, is scheduled for January 19, 2023, at 10:30 a.m., before U.S. District Judge Steve C. Jones. This case is being investigated by the Department of Health and Human Services Office of Inspector General and the Federal Bureau of Investigation. Assistant U.S. Attorney David A. O’Neal is prosecuting the case. **Topics:** Medicare/Medicaid **Categories:** Conviction --- ### [Nurse pleads guilty in $4.4M health care fraud scheme](https://insurancefraud.org/news_archives/nurse-pleads-guilty-in-4-4m-health-care-fraud-scheme/) **Published:** September 26, 2026 **Author:** Diane Beauchamp **Content:** A registered nurse practitioner pleaded guilty to obtaining millions of dollars through a health care fraud scheme, the office of U.S. Attorney Zachary Cunha said Thursday. Alexander A. Istomin, 56, admitted he routinely submitted claims to insurance and Medicare providers for in-person appointments in Rhode Island, New York, and Florida that he never actually conducted, according to prosecutors. He also admitted to waiving copayments and using patient information to obtain prescriptions and distribute them elsewhere, prosecutors said. In addition, Istomin claimed that he maintained an office in East Greenwich that did not exist. Prosecutors said some of the fraudulent payments were mailed to that address. Istomin agreed to plead guilty to charges of health care fraud, mail fraud, aggravated identity theft, and causing the introduction of misbranded drugs into interstate commerce. He was ordered to forfeit the $4.37 million he obtained through the scheme and is scheduled to be sentenced on Jan. 26. **Topics:** Medicare/Medicaid **Categories:** Conviction --- ### [Federal lawsuit alleges heath care giant defrauded CMS of more than $100M](https://insurancefraud.org/news_archives/federal-lawsuit-alleges-heath-care-giant-defrauded-cms-of-more-than-100m/) **Published:** September 26, 2026 **Author:** Diane Beauchamp **Content:** Indianapolis-based health insurance giant Elevance Health, previously Anthem, Inc., will have to face a federal lawsuit alleging it pocketed at least tens of millions of dollars by submitting inaccurate claims to the U.S. Centers for Medicaid & Medicare Services. The original lawsuit, filed by the U.S. Department of Justice in March 2020, alleges the company did not check diagnosis codes it submitted for reimbursement between early 2014 and 2018 for its Medicare Advantage plans for senior citizens. These plans are run by private insurers like Elevance Health that contract with CMS. Around 28.7 million people — nearly half of all eligible Medicare beneficiaries — are covered under these plans. Earlier this week, a U.S. district judge in Manhattan ruled the company failed to prove that the lawsuit lacked materiality. Judge Andrew Carter said the financial costs to the government were “substantial” and not “merely administrative” — amounting to more than $100 million. In a statement to WFYI, Elevance Health said that it complied with federal regulations. “We are confident that our health plans and associates have complied with Medicare Advantage regulations, including those set forth by the Centers for Medicare & Medicaid Services,” the statement said. Elevance said the company operated in “good faith” and that CMS should update regulations if the agency wants to “change how it reimburses Medicare Advantage Plans for health services.” But the lawsuit alleges that when Elevance did a review of diagnosis codes it had submitted to CMS and found that some were not valid, the company did not “make any effort to verify or delete these codes.” In his decision letter dated Sept. 30, Judge Carter said the plaintiff alleges the company was aware of CMS’ requirements to submit diagnosis data. This story comes from a reporting collaboration that includes the Indianapolis Recorder and Side Effects Public Media, a public health news initiative based at WFYI. Contact Farah at <fyousry@wfyi.org>. Follow on Twitter: @Farah\_Yousrym. The post Federal lawsuit alleges heath care giant defrauded CMS of more than $100M appeared first on Indianapolis Recorder. **Topics:** Judicial/courts --- ### [Urbandale Woman Pleads Guilty to Insurance Fraud](https://insurancefraud.org/news_archives/urbandale-woman-pleads-guilty-to-insurance-fraud/) **Published:** September 26, 2026 **Author:** Diane Beauchamp **Content:** Devon Wilkins, age 30, of Urbandale, pled guilty on October 19, 2022, to one count of Presenting False Information (Class D Felony) following an investigation by the Iowa Insurance Division’s Fraud Bureau. The investigation began in June of 2022 after the Iowa Insurance Division’s Fraud Bureau received information indicating Wilkins had provided false information to an insurer when purchasing full coverage automobile insurance. The investigation determined that after Wilkins’ car was involved in a single-vehicle collision and sustained over $2,000 in damage she contacted an insurer to purchase auto insurance coverage. During the purchase, Wilkins provided false information about the existing damage to her vehicle and was granted full coverage of automotive insurance. Days later, Wilkins filed an insurance claim alleging that the pre-existing damage occurred after she obtained the insurance coverage. Wilkins’s intent was to receive insurance benefits to which she was not entitled. Wilkins was arrested on August 11, 2022. Following her guilty plea, her second original charge of Insurance Application Fraud (Class D Felony) was dismissed. Wilkins was also granted a Deferred Judgment and received a five-year suspended prison sentence, and was placed on supervised probation for a period of two years. Wilkins was also ordered to pay a fine of $1,025. **Topics:** Auto - underwriting **Categories:** Conviction --- ### [Bajaj Allianz Incurs Loss Worth Lakhs in Insurance Fraud: FIR](https://insurancefraud.org/news_archives/bajaj-allianz-incurs-loss-worth-lakhs-in-insurance-fraud-fir/) **Published:** September 26, 2026 **Author:** Diane Beauchamp **Content:** Insurance firm Bajaj Allianz has lodged an FIR with Hazratganj police alleging that owners of 21 commercial four and three-wheelers in the state have got their vehicles insured as two-wheelers in the last one month and paid less premiums. Insurance firm Bajaj Allianz has lodged an FIR with Hazratganj police alleging that owners of 21 commercial four and three-wheelers in the state have got their vehicles insured as two-wheelers in the last one month and paid less premiums. The company claimed it suffered huge loss amounting to lakhs due to the fraud, which was found during an audit. The firm suspects it to be handiwork of an all-India level gang that uses an online portal for getting vehicles insured. On behalf of the company, branch manager Ravi Shanker Tiwari of Shahnajaf Road in Hazratganj lodged a complaint with police in this connection. In his complaint, Tiwari said one Abhishek Pandey was appointed as an agent for Point of Sale at the company’s satellite office in Gonda on November 20. “In September 2021, the company came to know that Pandey had issued a two-wheeler liability policy to a commercial four-wheeler owner. This caused a loss to the company of premium meant for a four wheeler, GST loss to state and central governments and also to the customer as well,” Tiwari said. The fraudulent practice by Pandey surfaced following an internal inquiry. “We were shocked to know that Pandey sold 21 such policies to four-wheeler vehicles of different customers during his nearly one-year stint in the company,” Tiwari alleged. Hazratganj SHO Abhishek Mishra said based on a complaint, police registered a case of criminal breach of trust and forgery against Pandey and an investigation was underway. Bajaj Allianz Head Vikas Dave told TOI that the fraud is pan-India, in which 1.36 lakh four/three wheelers have been registered as two wheelers causing a loss of around Rs 110 crore to the company and Rs 20 crore to the government as GST. Dave further said as per records, 26,000 commercial four wheelers have been registered as two wheelers in UP within a year (October 2021-October 2022), causing loss of around Rs 20 crore. Highly responsive to unfolding developments. Reports on crime, and terrorism in UP and also probes by National Investigation Agency (NIA), Central Bureau of Investigation (CBI), Enforcement Directorate (ED), Economic Offences Wing (EOW) Narcotics Control Bureau (NCB) in Uttar Pradesh. **Topics:** Auto fraud, Public Awareness --- ### [‘Debate is about the scale of fraud’: Why Medicare needs a royal commission](https://insurancefraud.org/news_archives/debate-is-about-the-scale-of-fraud-why-medicare-needs-a-royal-commission/) **Published:** September 26, 2026 **Author:** Diane Beauchamp **Content:** The country’s powerful Health Services Union has demanded the federal government hold a royal commission into the health system after revelations that billions of dollars are being lost to Medicare in systematic fraud, errors and waste. HSU national president and NSW secretary Gerard Hayes, a former paramedic, said federal Health Minister Mark Butler’s move to conduct a departmental probe into Medicare didn’t go far enough. Hundreds of cases of Medicare abuse have flooded in after a [joint investigation](https://www.smh.com.au/politics/federal/medicare-is-haemorrhaging-the-rorts-and-waste-costing-taxpayers-billions-of-dollars-a-year-20221013-p5bpp9.html) into Medicare by *The Sydney Morning Herald, The Age* and ABC’s *7.30* was published last week. According to Medicare expert Dr Margaret Faux, who completed a PhD into claims and compliance last year, up to 30 per cent of Medicare funding – equivalent to $8 billion – is being wasted each year. That investigation prompted Butler to announce the inquiry, but there are growing calls for an independent review that isn’t influenced by vested interests and lobby groups. “What we really need is a full royal commission with powers to discover documents and compel witnesses,” Hayes writes [in an opinion piece](https://www.smh.com.au/national/medicare-doesn-t-need-a-check-up-it-needs-a-full-body-examination-20221021-p5brtz.html) in *The Sydney Morning Herald* and *The Age*. The scope should extend beyond GPs and Medicare to consider how and where the health budget is being spent, he said. Hayes said that a decade ago the HSU was one of the most corrupt unions but public exposure and a royal commission had been the best thing for it to embrace change. “Ultimately, the exposure was entirely healthy. The rorters were expunged, and the HSU is perpetually alert to how it uses resources,” he said. “Every time we spend a dollar we genuinely ask ourselves if members will benefit. As a result our union membership has almost doubled, our staff has tripled and our finances have transformed from a $23 million deficit to a $55 million surplus.” Hayes said the broader health system would benefit from the same discipline and rigour. “Instead of brittleness it needs honest self-appraisal.” Hayes said he was disturbed by the reaction to the story. “One of corruption’s more insidious aspects is the way it gets explained away and diminished,” he said. “The medico lobbies squealing about Adele Ferguson’s expose on Medicare rorts no doubt believe there is no problem because the practice is widespread and normalised,” he said regarding the reaction of some groups, including the Australian Medical Association, which dismissed the media investigation as an “unjustified slur on the medical profession”. Hayes said dead people were being billed and patient records falsified. “A cottage industry has emerged to help practitioners milk the system. No one even denies Medicare is being rorted. Indeed, the debate is now about the scale of fraud.” **Topics:** Medicare/Medicaid, Public Awareness --- ### [Are Vermonters more vulnerable to identity theft?](https://insurancefraud.org/news_archives/are-vermonters-more-vulnerable-to-identity-theft/) **Published:** September 26, 2026 **Author:** Diane Beauchamp **Topics:** Public Awareness, Synthetic Identity Theft, Technology --- ### [Advocate Aurora Health reports data breach that may have exposed personal data of 3 million patients](https://insurancefraud.org/news_archives/advocate-aurora-health-reports-data-breach-that-may-have-exposed-personal-data-of-3-million-patients/) **Published:** September 26, 2026 **Author:** Diane Beauchamp **Content:** Advocate Aurora Health, which operates hospitals in Libertyville, Barrington and throughout the Chicago area, reported a data breach that may have affected three million patients. The health system released a statement and said that pieces of code called pixels, which gather user information on some of the health system’s websites or applications, shared certain patient information to third-party vendors that provided the health system with the pixel technology. Tracking pixels or similar technologies were installed on patient portals available through MyChart and LiveWell websites and applications, as well as some of the system’s scheduling widgets. The shared information may have involved a patient’s IP address, first and last name, medical record number, insurance status, proximity to an Advocate location, provider information, communications through MyChart and information about appointments or procedures. “Based on our investigation, no social security number, financial account, credit card, or debit card information was involved in this incident,” the system said in the statement. The system said they review in aggregate the information gathered by tracking pixels so that they can “better understand patient needs and preferences to provide needed care to our patient population.” According to a list of breaches provided by the U.S. Department of Health and Human Services Office for Civil Rights, Advocate’s breach may have affected three million people. The health system has since disabled or removed the pixels from patient websites and applications and launched an investigation into the matter. The system is assuming that all of its patients with a MyChart account, including users of the LiveWell application or anyone that has used scheduling widgets, may have been affected. “Users may have been impacted differently based on their choice of browser; the configuration of their browsers; their blocking, clearing or use of cookies; whether they have Facebook or Google accounts; whether they were logged into Facebook or Google; and the specific actions taken on the platform by the user,” the system said. The system said patients can protect themselves from online tracking by blocking or deleting cookies or using browsers that support privacy protection, like incognito mode. “These pixels would be very unlikely to result in identity theft or any financial harm, and we have no evidence of misuse or incidents of fraud stemming from this incident.” “Nevertheless, we always encourage patients to regularly review their financial accounts and report any suspicious, unrecognized or inaccurate activity immediately.” **Topics:** Public Awareness, Technology --- ### [CFO Patronis wants Legislature to crack down on insurance fraud](https://insurancefraud.org/news_archives/cfo-patronis-wants-legislature-to-crack-down-on-insurance-fraud/) **Published:** September 26, 2026 **Author:** Diane Beauchamp **Content:** Florida Chief Financial Officer Jimmy Patronis said he will press the Legislature to do more to rein in property insurance fraud in the aftermath of Hurricane Ian. On a stop Wednesday in storm-ravaged Cape Coral, Patronis, who is running for re-election next month, said he wants the Legislature to crack down on “predatory” public adjusters, combat “Assignment of Benefits” abuse and establish a statewide prosecutor to specifically target property insurance fraud. He also wants $3 million to create an anti-fraud public education campaign. Patronis said he wants to curb adjusters’ “ability to take advantage of Floridians under financial duress.” He said “bad public adjusters \[are\] swarming \[storm\] impacted areas, soliciting, and trying to make a quick buck” in the aftermath of Hurricane Ian, one of the worst storms to strike Florida in history. Under state law, public adjuster fees are limited to 20%, but when the governor declares a state of emergency for a natural disaster, like Ian, the fees are limited to 10% of the insurance claim payment. Patronis also wants to eliminate the practice of “AOB” entirely, saying “bad actors use tools like AOBs to take advantage of Florida consumers in their most vulnerable moments, preying on our citizens for too long.” “Assignment of benefits,” or “AOB” has been a contentious issue for years in the Legislature. It is a practice in which homeowners sign over insurance claims to contractors, who then seek payments directly from insurance companies, often spawning a flood of lawsuits about claims and payments. Insurance companies blame the high cost of property insurance in Florida on abusive AOB practices. Patronis said his office has two “Anti-Fraud Homeowner Squads” following up on thousands of leads and tips on fraud since Hurricane Ian made landfall on Sept. 28, pummeling the state with a crushing storm surge, obliterating wind speeds and torrential rainfall, leaving a swath of devastation from the southwestern coast across the I-4 corridor. “In the wake of Hurricane Ian, we need to build on the efforts from the recent special \[legislative\] session and continue to reduce frivolous litigation, stop predatory public adjusters and tackle AOB abuse once and for all,” he said. Any legislation for Patronis’ proposals would need a lawmaker to sponsor them in the Legislature. In a statement released by Patronis’ office, incoming Senate President Kathleen Passidomo didn’t specifically endorse the legislative ideas but commended the CFO for “working hard to fight fraud and protect consumers.” Other Republican legislators, including House Majority Leader Michal Grant and state Sen. Joe Gruters, who is chair of the Republican Party of Florida, said they would support legislation to curb property insurance fraud. **Topics:** Legislative, Public Awareness --- ### [Sober homes will be a focus of federal Health Care Fraud task force](https://insurancefraud.org/news_archives/sober-homes-will-be-a-focus-of-federal-health-care-fraud-task-force/) **Published:** September 26, 2026 **Author:** Diane Beauchamp **Content:** United States Attorney Will Thompson announces Sober living residences will be a priority of the Health Care Fraud Task Force. Sober homes provide drug and alcohol-free living environments essential for promoting and sustaining long-term recovery from substance use disorder. However, the potential for fraud has increased with the rise in treatment recovery programs and facilities across the district. The United States Attorney’s Health Care Task Force brings together federal, state, and local law enforcement partners from several agencies to streamline intelligence sharing and prosecution of health care fraud impacting Medicare, Medicaid, and other health care programs. Over 50 law enforcement officers, public health officials, and others received the most recent information about fraud as it impacts healthcare costs and quality of care. Experts detail trends and developments in such areas as prescription opioid and health care investigations as well as substance use disorder. They warn that fraud can exploit every level of care for substance use disorder, from detox residential treatment facilities to outpatient programs. **Topics:** Public Awareness, Regulatory actions --- ### [Fraud Fighters warning about latest scams at West Des Moines seminar](https://insurancefraud.org/news_archives/fraud-fighters-warning-about-latest-scams-at-west-des-moines-seminar/) **Published:** September 26, 2026 **Author:** Diane Beauchamp **Content:** Whether it’s the latest scam or some old trick, scammers are always looking for their next victim. That’s why the Iowa Insurance Division’s Fraud Fighters are hosting a seminar Monday at the West Des Moines Public Library. The United Way of Central Iowa is helping organize Monday’s event, which begins at 10:30 a.m. and should last about an hour. The Fraud Fighters will give people tips on how to spot and fight potential scams. Mike Merritt, who’s one of the Fraud Fighters, said there are several cons people should be on the lookout for. They include investment scams, affinity scams, and Medicare scams. People should also watch out for computer fraud. “We have concerns with computers. A lot of times people will try to take advantage, particularly with the older people, what is happening with the computer industry. One of the main rules we talk about is don’t give out your passwords on the phone. We also talk about if you don’t know the caller, have the call go to voicemail so that you have a chance to sort of screen the calls,” he said. The presentation also covers how the Iowa Insurance Division and Iowa Attorney General’s Office have resources to help people who suspect they’ve been victimized. “What you’re going to hear is if you are a victim of one of these scams, various departments in the State of Iowa have resources to help you with the scam to hopefully recover some of your money if you’ve lost some money from the scam,” said Sally Merritt, a Fraud Fighter. **Topics:** Public Awareness --- ### [U.S. Attorney Announces Results Of Multi-Faceted Strategy To Combat Fraud Related To COVID-19](https://insurancefraud.org/news_archives/u-s-attorney-announces-results-of-multi-faceted-strategy-to-combat-fraud-related-to-covid-19/) **Published:** September 26, 2026 **Author:** Diane Beauchamp **Content:** United States Attorney Roger B. Handberg announces the results achieved by the Middle District of Florida’s efforts to combat fraud related to COVID-19 during fiscal year 2022, ending September 30, 2022. Those efforts have included complementary actions by the Criminal, Asset Recovery, and Civil Divisions, along with federal, state, and local law enforcement agencies. “The U.S. Attorney’s Office will continue to work with its law enforcement partners to protect the integrity of government programs established to provide relief for those impacted by the COVID-19 pandemic,” said U.S. Attorney Handberg. “Those who seek to exploit these programs and further harm victims should beware. We will prosecute them to the fullest extent of the law.” On the criminal-enforcement front, the United States Attorney’s Office and federal, state, and local law enforcement agencies joined together in March 2020 to form the Middle District of Florida COVID-19 Fraud Task Force to identify, investigate, and prosecute fraud related to the ongoing COVID-19 pandemic. Since its inception, the task force has prosecuted more than 40 defendants for fraud schemes designed to exploit federal programs created or expanded to address the COVID-19 pandemic, including the Paycheck Protection Program (“PPP”), Economic Injury Disaster Loans (“EIDL”), Unemployment Insurance (“UI”), the Main Street Lending Program (“MSLP”), and the Emergency Rental Assistance Program (“ERAP”). These cases and matters involve diverse schemes, from traditional healthcare fraud involving COVID-19 programs, to violent gangs using unemployment insurance fraud proceeds to operate their narcotics businesses. These defendants collectively sought to defraud the United States of over $43 million. Over thirty of those defendants have already been found guilty, while prosecution remains pending against nine defendants. (*See chart for criminal case details*.) For example, on September 15, 2022, Marqus Johnson (40, Tampa) pleaded guilty to a 9-count Information charging him with bank fraud and illegal monetary transactions. Johnson formed and operated two corporate entities—All American Health, LLC and Next Level Health & Transportation, LLC—that purportedly were engaged in health care-related transportation services. In April and June 2020 and January 2021, Johnson use false and fraudulent representations to apply for a total of seven SBA-backed loans (one PPP loan and six EIDL) and received loan funding in connection with three of the loan applications. Based on his false representations, Johnson fraudulently obtained $544,900, including a $375,000 PPP loan. In another matter, Julio Lugo (45, Davenport), a convicted felon on federal supervised release, conspired with others to steal nearly $6 million from the SBA’s PPP and EIDL programs and launder the proceeds of those stolen funds. Lugo pleaded guilty conspiracy to commit money laundering and was sentenced to more than nine years in federal prison on July 28, 2022. The court also imposed a forfeiture money judgment in the amount of $4.4 million and entered an order of restitution in the amount of $4.8 million. The Middle District of Florida has been at the forefront of addressing the complex issues that arise out of investigating and charging frauds relating to new government programs. The Fort Myers Division, for example, was the first office in the country to take a COVID-19 fraud case to trial in *United States v. Casey Crowther*. Crowther was found guilty and sentenced to more than three years in federal prison. The Orlando Division meanwhile handled the country’s first COVID-19 fraud-related extradition in *United States v.* *Don V. Cisternino*. Cisternino recently pleaded guilty to wire fraud, aggravated identity theft, and illegal monetary transactions related to his scheme to secure more than $7.2 million in emergency funds through a PPP loan. Further, the Asset Recovery Division and federal seizing agencies have completed the forfeiture of more than $14.3 million of EIDL, UI, and PPP funds that were fraudulently obtained, depriving the fraudsters of their ill-gotten gains and recovering the proceeds for the victims. More than $8.5 million in additional pandemic fraud proceeds have been seized and are pending civil or criminal forfeiture. The Attorney General has established the COVID-19 Fraud Enforcement Task Force to marshal the resources of the Department of Justice in partnership with agencies across government to enhance efforts to combat and prevent pandemic-related fraud. For more information on the department’s response to the pandemic, please visit https://www.justice.gov/coronavirus. Through the PPP, the federal government authorized over $600 billion in forgivable loans to small businesses for job retention and certain other expenses through the PPP. The EIDL program provides economic relief to small businesses that are currently experiencing a temporary loss of revenue. The MSLP provided support to small and medium-sized businesses and their employees across the United States during the COVID-19 pandemic. UI programs provided unemployment benefits to eligible workers who became unemployed through no fault of their own. The criminal cases charged by the Middle District of Florida COVID-19 Fraud Task Force have been investigated by the Federal Bureau of Investigation, United States Secret Service, Internal Revenue Service—Criminal Investigation, Department of Labor—Office of Inspector General, U.S. Postal Service, Federal Housing Finance Agency, Small Business Administration, Federal Deposit Insurance Corporation—Office of Inspector General, Homeland Security Investigations, Bureau of Alcohol, Tobacco, Firearms and Explosives, Special Inspector General for Pandemic Recovery, Federal Reserve Board – Office of Inspector General, Metropolitan Bureau of Investigation, the Tampa Police Department, the Orlando Police Department, the Manatee County Sheriff’s Office, the Hillsborough County Sheriff’s Office, the Sarasota County Sheriff’s Office, the Winter Park Police Department, the Osceola County Sheriff’s Office, the Seminole County Sheriff’s Office, and the Orange County Sheriff’s Office. The cases are being prosecuted by Assistant United States Attorneys throughout the Middle District of Florida. The Department of Justice needs the public’s assistance in remaining vigilant and reporting suspected fraudulent activity. To report suspected fraud, contact the National Center for Disaster Fraud (NCDF) at (866) 720-5721 or file an online complaint at: https://www.justice.gov/disaster-fraud/webform/ncdf-disaster-complaint-form. Complaints filed will be reviewed at the NCDF and referred to federal, state, local, or international law enforcement or regulatory agencies for investigation. **Topics:** COVID-19, Medicare/Medicaid, Regulatory actions **Categories:** Arrest --- ### [Bar owner indicted on arson and fraud charges in 2017 fire that damaged his downtown Waukesha building](https://insurancefraud.org/news_archives/bar-owner-indicted-on-arson-and-fraud-charges-in-2017-fire-that-damaged-his-downtown-waukesha-building/) **Published:** September 26, 2026 **Author:** Diane Beauchamp **Content:** Twice burned and now gone, a two-floor commercial building in downtown Waukesha became the focus of a federal investigation for a March 2017 fire. A grand jury indictment has alleged that incident involved arson, with the owner of the bar within the now-demolished building illicitly pocketing more than $161,000 in insurance claims paid in three subsequent checks. In the federal indictment filed Dec. 3 in U.S. District Court for Eastern Wisconsin, prosecutors suggested that basement fire at 854 Martin St. was intentionally set — though the only court document currently available doesn’t explain how the fire started or how bar owner Brian Whitton was involved in the blaze itself. Nor does it mention the second fire, in April 2019, that fire officials say started on the upper floor, badly damaging the roof and residential areas of the already-compromised two-floor building whose commercial space had remained vacant. Whitton is not accused in that fire, which ultimately led to the building’s demolition. According to the indictment, Whitton and an unamed business partner purchased the Martin Street property through a land contract prior to the 2017 fire. Whitton operated the Stage Off Main bar during that time. The property, business and related income was insured for up to $2 million by the United States Liability Insurance Co. In addition to the arson charge, the indictment also alleges four other criminal counts. Two of those counts allege Whitton defrauded the insurer between March 2017 and September 2018, when the final claim check was issued. Because the transactions and claims involved U.S. mail, he was also indicted for mail fraud. He also allegedly misled or lied to agents of the federal Bureau of Alcohol, Tobacco, Firearms and Explosives who investigated the March 25, 2017, fire, according to the indictment. Whitton’s attorney, Daniel Adams, declined to address details or clarifications of the indictment’s allegations, but said his client will ultimately prevail in court. “Mr. Whitton is innocent of all wrongdoing and looks forward to being vindicated,” Adams said in an email message. The building on the property, which, according to tax records, is now owned by Historic Prairieville LP, was demolished in November. It’s unclear if the property, located adjacent to the vacant Ace Hardware building, is part of Historic Prairieville’s redevelopment of the original Waukesha County Courthouse into apartments. **Topics:** Business - arson **Categories:** Arrest --- ### [Kochi medical insurance fraud case: Probe launched](https://insurancefraud.org/news_archives/kochi-medical-insurance-fraud-case-probe-launched/) **Published:** September 26, 2026 **Author:** Diane Beauchamp **Content:** The police have launched a detailed probe into a medical insurance fraud case in which an employee of a major private hospital in the city allegedly siphoned off lakhs of rupees after forging insurance records of patients. Based on the complaint lodged by the hospital, a case has been registered against four persons including a senior staff identified as Shiny P P, 47, of Ikkaranadu North who used to work in the insurance wing of the hospital. The police said the incident came to light after hospital authorities lodged a private complaint before a local court and secured a favourable verdict to conduct a detailed probe. The police said Shiny was working as a senior manager at the insurance department of the hospital and had allegedly committed fraud to the tune of Rs 15 lakh between December 1, 2011 and October 14, 2020. The accused forged documents and misappropriated the amount collected from the patients as advance payment for the insurance claim despite claiming the amount from the insurance company. Though she was supposed to transfer the advance amount as refund to the patients after claiming the amount, she failed to transfer the amount to the patients. The accused transferred the money she allegedly misappropriated by committing fraud in three tranches. Initially, she transferred Rs 5.24 lakh to her aunt’s account, then Rs 3.61 lakh was transferred to her son’s account and again Rs 6.39 lakh to another account. The police said the accused could access the list of patients with insurance coverage as it was her duty to prepare the list of patients eligible for insurance claim. **Topics:** Insider Fraud --- ### [Zego Partners With Synectics Solutions to Automate Fight Against Motor Insurance Fraud](https://insurancefraud.org/news_archives/zego-partners-with-synectics-solutions-to-automate-fight-against-motor-insurance-fraud/) **Published:** September 26, 2026 **Author:** Diane Beauchamp **Content:** Commercial motor insurer [Zego](https://www.zego.com/) is automating its fraud detection in response to significant recent growth. The company has recently featured in the FT 1000 list of Europe’s fastest-growing companies and the Deloitte UK Technology Fast 50. The partnership will enable Zego to rapidly screen all policies with [Synectics Solutions](https://www.synectics-solutions.com/)’ National SIRA – the UK’s largest syndicated database of cross-sector customer risk intelligence – to improve fraud detection rates and significantly reduce the amount of time spent on manual processing and investigations. Working with Synectics Solutions is part of Zego’s long term strategy to leverage analytics, AI and syndicated data to enhance customer journeys and to support the motor insurance industry’s fight against fraudulent activity. Zego combines advanced technology with multiple data sources to offer products ranging from flexible pay-as-you-go insurance for self-employed drivers & riders to annual policies for fleet managers. With hourly, 7-day, 30-day and annual policies available, Zego needs a flexible way to identify genuine customers from fraudulent ones. The partnership with Synectics Solutions will allow Zego to adopt different fraud screening strategies – in the future incorporating point of quote screening – depending on product type, changing fraud trends, and risk appetite. All of which will support informed critical decision making and customer service. Zego will share their proven fraud data with the 100 plus National SIRA members and gain access to some of the unique datasets such as integrated alerts from National Vehicle Crime Intelligence Service (NaVCIS), enhancing Zego’s commitment to customer support including its Risk Management Academy which supplies behavioural insight to help fleet managers and drivers cut insurance claims. **[Sten Saar](https://ffnews.com/people/sten-saar), CEO of Zego, said,** “We have always had a zero-tolerance policy to fraud and as we grow, we want to leverage every tool at our disposal to maintain this stance. Which is exactly why this partnership with Synectics Solutions is so important. “Using National SIRA to automate policy screening isn’t just a way for us to improve and streamline our own processes, it’s also a way for us to collaborate with the insurance industry as a whole – to share insights and help more of our customers minimise their risk. This is something we simply can’t get from other suppliers.” **[Murray Raw](https://ffnews.com/people/murray-raw), Head of Business Development at [Synectics](https://www.synectics-solutions.com/) added**: “Our partnership with Zego is a natural fit. This is a great opportunity to work with a likeminded company: one that sees the value in using data, is committed to fighting fraud, and wants to make insurance accessible to niche markets. We’re looking forward to growing our relationship further, while reducing fraud together.” **Topics:** Public Awareness, Technology --- ### [Whitehaven woman denies caravan fire fraud allegations](https://insurancefraud.org/news_archives/whitehaven-woman-denies-caravan-fire-fraud-allegations/) **Published:** September 26, 2026 **Author:** Diane Beauchamp **Content:** A [WHITEHAVEN](https://www.newsandstar.co.uk/sport/rugby-league/whitehaven-rl/) woman is facing a crown court trial over allegations that she torched her caravan as part of an insurance fraud. During a brief hearing at [Carlisle](https://www.newsandstar.co.uk/sport/football/carlisle-united/) Crown Court, Catherine Dockray McCreadie, 59, of Esk Avenue, Whitehaven, entered not guilty to the four allegations she faces. Those charges were outlined as: \* Arson while being reckless as to whether life was endangered on September 14, 2020, at Fitz Bridge, Lamplugh, when she allegedly destroyed a caravan by fire. \* Arson with intent to endanger life, also on September 14, 2020. \* Fraud by false representation: that on October 5, 2020, at Fitz Bridge, Lamplugh, she committed fraud in that she dishonestly made a false representation, claiming that the fire which destroyed her caravan was caused by another person, thereby intending to make a gain for herself – namely an insurance payment to cover replacing the caravan. And perverting the course of justice: that on October 9, 2020, at Richmond, North Yorkshire, she gave a false statement to the police who were investigating the fire at Inglenook Caravan Park, near Lamplugh. After legal discussions involving lawyers for both the prosecution and the defence, Judge Richard Archer adjourned the case and ruled that the trial will take place in the week of March 6. The case is expected to last four days. **Topics:** Homeowners - arson **Categories:** Arrest --- ### [Plymouth Woman Pleads Guilty in Federal Child Nutrition Fraud Scheme](https://insurancefraud.org/news_archives/plymouth-woman-pleads-guilty-in-federal-child-nutrition-fraud-scheme/) **Published:** September 26, 2026 **Author:** Diane Beauchamp **Content:** A Plymouth woman, whom prosecutors describe as “a serial fraudster,” has pleaded guilty to her role in trying to defraud the federal government out of more than $11 million. U.S. Attorney Andrew Luger announced the plea on Friday. Prosecutors accused Anab Awad, 52, of operating a scheme with others to take advantage of a federally-funded child nutrition program. Court documents show Awad operated a nonprofit called Multiple Community Services that was supposed serve meals to kids at several food distribution sites, including one in Osseo. However, court documents show Awad falsified invoices and meal count records, then later received funds that substantially exceeded the amount needed. Prosecutors say the scheme took advantage of oversight measures loosened during the pandemic. Awad admitted to participating in the scheme with others from September 20022 through January 2022. The scheme was among others that took place during the pandemic, including the Feeding Our Future fraud investigation, described by prosecutors as the largest pandemic-related fraud case in the nation. Court documents show the Minnesota Department of Education paid out about $9.7 million of the $11.2 million in funds that Awad fraudulently claimed. Court records also show Awad pleaded guilty in a separate Medicaid health care fraud scheme. In that case, prosecutors say Awad’s fraudulent claims caused nearly $100,000 in losses to the Minnesota Medicaid program. Awad conspired with mental health practitioners to sign billing forms for language interpretation services that were never provided, court documents showed. Prosecutors say Awad transitioned to the nutrition program scheme as she was awaiting trial for the Medicaid fraudulent billing practices case. **Topics:** Medicare/Medicaid **Categories:** Conviction --- ### [Aveanna Healthcare Data Breach Could Cost Firm More Than $1M](https://insurancefraud.org/news_archives/aveanna-healthcare-data-breach-could-cost-firm-more-than-1m/) **Published:** September 26, 2026 **Author:** Diane Beauchamp **Content:** A Georgia-based home healthcare and hospice provider will pay nearly $500,000 to the state of Massachusetts to end state litigation tied to a data breach affecting nearly 170,000 patients. The [settlement](https://ismg-cdn.nyc3.cdn.digitaloceanspaces.com/asset_files/external/aveanna-judgment.pdf) comes just weeks after Aveanna Healthcare [settled](https://ismg-cdn.nyc3.cdn.digitaloceanspaces.com/asset_files/external/gand-202277-orderoct192022.pdf) in federal district court a putative class action for up to $800,000 in cash payments and credit monitoring protections. Both court cases stem from a stream of 600 phishing attempts made during summer 2019 that grew more sophisticated over time. At one point, company employees received an email appearing to come from the company president asking for their participation in a survey. A [complaint](https://ismg-cdn.nyc3.cdn.digitaloceanspaces.com/asset_files/external/1-aveanna-complaint.pdf) from the Massachusetts attorney general says more than 50 employees succumbed to the two-month phishing onslaught. The [putative class action complaint](https://ismg-cdn.nyc3.cdn.digitaloceanspaces.com/asset_files/external/gand-202277-secondamendedcomplaint-aug202020.pdf) says phishers got away with patient data including Social Security numbers, payment details, identification numbers from passports and driver’s licenses, diagnoses information and treatment type (see: [*Data Breach Lawsuit Filed Against Pediatric Care Provider*](https://www.healthcareinfosecurity.com/data-breach-lawsuit-filed-against-pediatric-care-provider-a-14372)). Aveanna in February 2020 [reported](https://www.healthcareinfosecurity.com/health-data-breach-tally-spikes-in-recent-weeks-a-14031) the incident to the Department of Health and Human Services as affecting 166,077 individuals, patients and employees. Each of the settlements requires Aveanna to improve its cybersecurity. Both the Massachusetts and the proposed class action complaint accuse the company of not having instituted basic cybersecurity protections including multifactor authentication. “Companies have an obligation to put the right security measures and systems in place to prevent hackers from accessing sensitive information,” Massachusetts Attorney General Maura Healey [said](https://www.mass.gov/news/home-health-care-company-to-pay-425000-following-data-breach-impacting-thousands-of-massachusetts-residents) of her office’s $425,000 settlement with Aveanna. Her complaint charges that the company knew its cybersecurity was deficient, having just months before the phishing attacks developed a plan for cybersecurity improvements. A post-attack review by the company “acknowledged that its current cybersecurity posture was ‘lacking,'” the complaint also says. Besides noting the lack of multifactor authentication, it said the company’s network lacked a SIEM system. Under the finalized class action settlement, affected individuals are each eligible to receive reimbursement of up to $10,000 in expenses, including documented, unreimbursed out-of-pocket expenses resulting from the security incident, losses from [identity theft](http://www.databreachtoday.com/id-theft-c-31) and [fraud](http://www.healthcareinfosecurity.com/fraud-c-409), and up to $250 for time spent remedying issues relating to the breach. Aveanna also agreed to provide five years of identity theft and credit monitoring. The company did not immediately respond to Information Security Media Group’s request for comment on Healey’s enforcement action and the class action lawsuit settlement. **Topics:** Judicial/courts, Technology --- ### [St. Luke’s Health Reports Third Party Data Breach](https://insurancefraud.org/news_archives/st-lukes-health-reports-third-party-data-breach/) **Published:** September 26, 2026 **Author:** Diane Beauchamp **Content:** St. Luke’s Health has recently notified 16,906 patients that some of their protected health information has been exposed in a security incident at a vendor that provides consulting services. On November 5, 2021, the email accounts of two employees of Adelanto Healthcare Ventures (AHCV) were accessed by an unauthorized individual. An investigation was launched into the incident, which initially determined no patient information had been exposed; however, a subsequent review determined the information of certain St. Luke’s Health patients was present in the email accounts and could potentially have been accessed or acquired by the attackers. The exposed information included names, addresses, dates of birth, Social Security numbers, dates of service, medical record numbers, Medicaid numbers, and some limited clinical information, such as treatment and diagnosis codes. St. Luke’s Health was notified about the breach on September 1, 2022 St. Luke’s Health explained in its breach notification letters that no reports have been received that suggest there has been any misuse of patient data; however, as a precaution, AHCV is offering affected individuals complimentary identity theft and credit monitoring services. St. Luke’s Health is currently recovering from a ransomware attack on its parent company, CommonSpirit Health, that occurred more than a month ago. CommonSpirit Health is still facing disruption to business operations as a result of the attack but has now restored the MyChart patient portal and providers can now access their patients’ electronic medical records. ## Tift Regional Health System Investigating Cyberattack and Data Breach Tift Regional Health System (TRHS) in Tifton, GA, has recently announced that its systems have been compromised and that the attackers potentially accessed and obtained the protected health information of some of its patients. The unauthorized system access occurred on or around August 16, 2022. Prompt action was taken to secure its systems and an investigation was launched to determine the nature and scope of the attack. TRHS said files on its systems were not encrypted, and its electronic medical record system was not accessed; however, the forensic investigation was unable to rule out unauthorized access and theft of files that contained patient information. The files on the compromised part of the network contained Social Security numbers, patient identification numbers, driver’s license numbers, medical information, treatment information, diagnosis information, health insurance information, and dates of birth. TRHS said it is reviewing its existing policies and procedures regarding cybersecurity and additional safeguards are being evaluated to protect against this type of incident in the future. The breach has been reported to the HHS’ Office for Civil Rights as affecting 500 individuals. That number is often used as a placeholder until the full extent of the breach is known. ## Wenco Management Reports Breach of Health and Welfare Benefit Plan Member Data The protected health information of 20,526 employees of Wenco Management, LLC, has been exposed and potentially obtained by unauthorized individuals. Wenco Management operates the Wendy’s fast-food chain. Affected employees were members of its Health and Welfare Benefit Plan. Wenco Management identified the breach on August 21, 2022. After its systems were secured, a forensic investigation was launched to determine the nature and scope of the breach, which confirmed an unauthorized individual had accessed its network and potentially viewed and obtained employee records that included names, Social Security numbers, and plan selection information. The breach occurred on the same day it was identified and blocked. Affected individuals have been offered complimentary credit monitoring services. Wenco Management said it has taken steps to improve the security of its systems to prevent further data breaches in the future. **Topics:** Public Awareness, Technology --- ### [Cyber Frauds Dupe Retired BHEL Officer Of Rs 52 Lakh On Pretext Of Renewing Insurance Policy](https://insurancefraud.org/news_archives/cyber-frauds-dupe-retired-bhel-officer-of-rs-52-lakh-on-pretext-of-renewing-insurance-policy/) **Published:** September 26, 2026 **Author:** Diane Beauchamp **Content:** A retired officer of the Bharat Heavy Electricals Limited (BHEL) lost Rs 52 lakh over two years after he was conned by a gang who contacted him over phone calls and WhatsApp messages on pretext of renewing his lapsed life insurance policy. The police in Greater Noida on Tuesday arrested five members of the gang, including its mastermind, who were behind the fraud with the 75-year-old man. The police also claimed that the thugs have been involved in many more such con jobs since 2019 and have been cheating unsuspecting, gullible people after obtaining their contacts and policy details online through call centres. **Forged Stamps Of Ministry, RBI And Forged Letters** Greater Noida’s Deputy Commissioner of Police Abhishek Verma said the police also recovered fake stamps of the Union Finance Ministry and the Reserve Bank of India from the possession of the gang. The gang also sent forged letters in the name of the ministry and the RBI to the victim over WhatsApp in order to convince him into believing that they are genuine representatives. **How The Victim Was Trapped** According to police, Ashok Kumar Sharma had purchased an insurance policy six years ago but had to discontinue paying its premium due to his financial conditions which led the policy getting lapsed. However, two years ago, he started getting phone calls by people who identified themselves as representatives of insurance companies and the RBI to say that his insurance policy could be revived. They also told him that the fund in his insurance has increased to Rs 1.20 crore which he will be able to withdraw now. “One of the representatives kept a regular touch with Sharma and sent him forged documents over WhatsApp which had letters bearing seals of the Finance Ministry, the RBI, etc. However, Sharma was asked on multiple occasions to transfer funds on pretext of processing charges, etc. For over two years, the retired officer ended up transferring Rs 52 lakh in total to them in the hope of getting his insurance money,” the police said. **Data Leak And Fraud Tele-Callers** DCP Abhishek Verma said the gang has duped several other people in a similar manner and the amount of fraud runs into crores till date. “Deepak Kumar, the key person in the gang, has been active in duping people since 2019. Prior to this case, he had been conning people of smaller amounts only, but this time he had obtained complete insurance details of Sharma and went for a big fraud,” Verma told reporters. “The gang would obtain details of insurance policies of customers through its network. They knew when a person’s policy was on verge of lapsing or expiring. They would then pose as tele-callers from the insurance company and ask customers to pay some amount in some bank accounts to renew it,” he said. Among others arrested is Deepak’s wife Priyanka, who is also a police constable in Shamli district of Uttar Pradesh, according to the officer. **Legal Action Against Culprits** The five accused who have been arrested were produced in a local court in Greater Noida on Tuesday. They were sent to judicial custody for 14 days by the judge. The FIR has been lodged under sections 420 (cheating), 120B (party to criminal conspiracy), 467, 471 (both related to forgery) of the Indian Penal Code as well as under provisions of the Information Technology Act. **How To Avoid Such Traps** While there is no doubt that technological advancements have helped us a great deal, there is also no denying the fact that the threat of cyber crimes in our lives has also increased. Common activities and works like a renewal of life insurance or vehicle insurance, payment of electricity or water bills, search for jobs or business opportunities, etc are works where one needs to be extra careful if doing online. Experts suggest that lucrative offers like manifold financial benefits on investments, lotteries, cash-rich job opportunities by people who contact you over phone or email could possibly be a fraud attempt. The need for people is to stay careful in dealing with such situations, and cross-verifying the identity of people or organizations with whom they are interacting. Another factor to be kept in mind always is being careful in sharing information personal or financial information online or over telephone with strangers, or even known persons. Sensitisation towards data privacy is the need of the hour. **Topics:** Life Insurance **Categories:** Arrest --- ### [Australia blames Russians for health insurance data theft](https://insurancefraud.org/news_archives/australia-blames-russians-for-health-insurance-data-theft/) **Published:** September 26, 2026 **Author:** Diane Beauchamp **Content:** Moscow must he held to account for Russian cybercriminals accused of hacking Australia’s largest health insurer and [dumping customers’ personal medical records](https://apnews.com/article/abortion-technology-health-business-australia-2aa6f49fa33605ae98b06e8eb87fc04d) on the dark web, Australian officials said Friday. Australian Federal Police took the unusual step of attributing blame for the unsolved cybercrime that resulted in the personal data of 9.7 million current and former Medibank customers being stolen. A group of “loosely affiliated cybercriminals” operating like a business in Russia were likely responsible for the Medibank attack as well as other significant security breaches around the world, Australian Federal Police Commissioner Reece Kershaw said. “We believe we know which individuals are responsible, but I will not be naming them,” Kershaw told reporters. “What I will say is that we’ll be holding talks with Russian law enforcement about these individuals.” Prime Minister Anthony Albanese, who is a Medibank customer who had personal data stolen, said he had authorized police to reveal where the attack had come from. “We know where they’re coming from, we know who is responsible, and we say that they should be held to account,” Albanese said. “The nation where these attacks are coming from should also be held accountable for the disgusting attacks, and the release of information including very private and personal information,” Albanese added. An official from the Russian Embassy in Australia could not be immediately contacted for comment. The extortionists have been linked to high-profile Russian cybercrime gang REvil, short for Ransomware Evil and also known as Sodinokibi. The Russian Federal Security Service said in January REvil “ceased to exist” after several arrests were made at the insistence of the United States. An old REvil dark web site had started redirecting traffic to a new site that hosts the stolen Medibank data. Fergus Hanson, director of Australian Strategic Policy Institute think tank’s cyber policy center, said he was not surprised that the crime gang was based in Russia. A Medibank employee’s stolen username and password, which allowed the hackers to enter the company’s database, had been sold on a Russian dark web forum, Hanson said. Hanson doubted that culprits operating in Russia would be brought to justice. But Australia could use its offensive cyber capabilities against the gang in Russia and prosecute their affiliates, who police suspect are operating in other countries. “There’s potential to conduct operations against the group to disrupt their operations, but in terms of seeing them go to prison or appear before a court, I think that’s pretty unlikely,” Hanson told Australian Broadcasting Corp. Cybercriminals dumped personal medical records on the dark web for a third day on Friday, this time focusing on alcohol-related illnesses, as they pressure Medibank to pay a ransom. The criminals [began dumping customer records Wednesday](https://apnews.com/article/technology-health-business-australia-d13942ecf46d61b952d35a098fa73a80), including those involving treatments for HIV and drug addiction, which they described as a “naughty” list, after [Medibank ruled out paying a ransom](https://apnews.com/article/business-crime-australia-theft-cbf49791c7917d9498dbedfbe57c5336) for the return of the hacked data. The focus shifted to terminated pregnancies in Thursday’s dump and on Friday to conditions related to harmful levels of alcohol consumption, in a file the thieves labeled “boozy.” Medical treatment records of more than 700 customers had been published through Friday in what has been described as Australia’s most invasive cybercrime. Other personal details of many more customers have also been made public that could leave them vulnerable to identity theft or fraud, including phone numbers and email addresses. Confirming the third dump, Medibank CEO David Koczkar said his company was contacting exposed customers and offering support. He expected the daily dumps would continue. “The relentless nature of this tactic being used by the criminal is designed to cause distress and harm,” Koczkar said. “These are real people behind this data and the misuse of their data is deplorable and may discourage them from seeking medical care,” he added. The gang, which is becoming increasingly better known as BlogXX within cybersecurity circles, blamed Medibank’s failure to pay a $9.7 million ransom demand. “But we warned you. we always keep our word, if we wouldn’t receive a ransom – we should post this data, because nobody will believe us in the future,” they posted on Friday. Kershaw said Australian government policy did not condone paying ransoms to cybercriminals. “Any ransom payment, small or large, fuels the cybercrime business model, putting other Australians at risk,” Kershaw said. Australian authorities are hoping the data remains confined to the dark web and is not spread to a wider audience by social media or reported in detail by the news media. Albanese urged against anyone accessing the data. “We need to provide a disincentive for this sort of criminal, disgusting behavior that is reprehensible,” Albanese said. “It’s causing a great deal of distress in the community. The government acknowledges this and we’re doing all we can to limit the impact of this and to provide that support to people who are going through this distressing time,” Albanese added. **Topics:** Public Awareness, Technology --- ### [Meta Faces Legal Firestorm As Hospitals Cite Its Pixel Tool In Health Data Breaches](https://insurancefraud.org/news_archives/meta-faces-legal-firestorm-as-hospitals-cite-its-pixel-tool-in-health-data-breaches/) **Published:** September 26, 2026 **Author:** Diane Beauchamp **Content:** Two health systems have become the latest healthcare organizations to name a web tracking tool created by Meta (formerly Facebook) as responsible for their data breach. This comes as the social media giant faces a growing number of lawsuits alleging that the tool improperly collects and sells sensitive patient health information. Both of the recent incidents, which were announced in mid-October, involved a Meta tracking tool known as Meta Pixel. Meta Pixel is a snippet of JavaScript code that allows companies to track visitor activity on their website. It works by loading a small library of functions that companies can use whenever a site visitor takes an action. What makes the tool questionable is that in addition to tracking web activity, it sends some of the data it gathers to Meta. According to [research](https://themarkup.org/pixel-hunt/2022/06/16/facebook-is-receiving-sensitive-medical-information-from-hospital-websites) by *The Markup*, Meta Pixel is currently in wide use. To get a sense of how widespread use of the tool is within hospitals, the site tested websites for Newsweek’s top 100 hospitals in America. The researchers found that 33 of the sites had Meta Pixel in place, and that seven major health systems were using the tool within patient portals. However, Meta is facing a backlash related to the data Meta Pixel sends home, as well as how it uses the data. One hospital chain which blames Meta Pixel for a data breach is Advocate Aurora Health, which operates 26 hospitals across Wisconsin and Illinois. AAH just [informed](https://www.bleepingcomputer.com/news/security/health-system-data-breach-due-to-meta-pixel-hits-3-million-patients/) its patients that due to an incorrectly configured version of Pixel, the health system exposed personal data on 3 million patients. When patients used AAH portals available through MyChart and LiveWell – in addition to some of its scheduling widgets – the systems seem to have leaked PHI to Meta, especially if the users were logged into Facebook or Google accounts. Another health system [citing Meta Pixel](https://www.wakemed.org/about-us/news-and-media/wakemed-news-releases/wakemed-notifies-patients-of-potential-data-privacy-incident) for data exposure was three-hospital chain WakeMed Health and Hospitals, which placed Pixel on both its corporate website and its MyChart portal in March of 2018. The health system recently found that Pixel might have transmitted data entered in MyChart back to Facebook. WakeMed’s leaders reported that they weren’t sure whether sensitive patient data got sent to Facebook, but nonetheless disabled the tool in May 2022. Previously, in August of this year, hospital chain Novant Health [disclosed a data breach](https://www.bleepingcomputer.com/news/security/misconfigured-meta-pixel-exposed-healthcare-data-of-13m-patients/) affecting roughly 1.4 million individuals in which Meta Pixel collected sensitive patient information and sent the data home. Meanwhile, Meta has been hit with at least three separate class action suits contending that the Meta Pixel tool played a role in alleged illegal information gathering. According to reporting in *Fierce Healthcare,* a [class action was filed](https://www.fiercehealthcare.com/health-tech/report-third-top-hospitals-websites-collecting-patient-data-facebook) in June on behalf of an anonymous patient of Baltimore’s Medstar Health System contending that Meta has violated HIPAA by collecting patient status data, including IP addresses, doctor names and recent health-related activity. In August, Meta was hit with a second class action lawsuit citing UCSF Medical Center and Dignity Health as co-defendants. In the complaint, the patient said that Meta harvested sensitive medical information through UCSF and Dignity Health’s patient portals, then sold the data to pharmaceutical and other companies which fed her targeted advertising related to her medical conditions. Also in August, a patient filed a class action lawsuit against Northwestern Memorial Hospital, arguing that while the provider had disclosed the use of the data tracker in its terms and conditions, the waiver didn’t release Northwestern from state-level privacy protections. It also alleges that Meta had violated state and federal data protection laws by collecting and selling private medical information. The plaintiff is asking for punitive damages of $5 million or more for himself and others similarly situated. **Topics:** Judicial/courts, Technology --- ### [Salud Family Health Reports Data Breach Following Apparent Cyberattack](https://insurancefraud.org/news_archives/salud-family-health-reports-data-breach-following-apparent-cyberattack/) **Published:** September 26, 2026 **Author:** Diane Beauchamp **Content:** On November 4, 2022, Salud Family Health (“Salud”) reported a data breach with the Montana Attorney General’s Office after the company learned that an unauthorized party was able to access sensitive employee and patient information contained on its network. According to Salud, the breach resulted in the names, Social Security numbers, driver’s license numbers or state identification card numbers, financial account information, credit card numbers, passport numbers, medical treatment and diagnosis information, health insurance information, biometric data, and usernames and passwords being compromised. Recently, Salud sent “Notice of Security Incident” letters to all affected parties, informing them of the incident and what they can do to protect themselves from identity theft and other frauds. If you are among those who received a “Notice of Security Incident” letter from Salud Family Health, it means that your personal information was leaked as a result of the current breach. As we’ve discussed in previous [articles](https://www.myinjuryattorney.com/consumer-privacy-data-breach-lawyers/2022-data-breach-trends-and-statistics/), healthcare providers have been one of hackers’ favorite targets this year, in part because the information these organizations maintain is not only very valuable but also easy to use to commit a wide range of frauds. Victims of the breach may also be able to pursue a claim for compensation against the company in the event it negligently stored patient data leading up to the attack. ## The Details of the Salud Family Health Breach The available information regarding the Salud Family Health breach comes from the company’s filing with the Montana Attorney General as well as a notice posted on its website. According to these sources, on September 5, 2022, Salud detected unusual activity within its computer network. Concerned that the suspicious activity may be related to a cyberattack, the company secured its systems and began working with third-party data security specialists to investigate the incident and determine if any patient or employee information was compromised. The company’s investigation confirmed that an unauthorized party had gained access to the Salud Family Health network. Further, the investigation revealed that the affected portion of the network contained sensitive patient and employee information. Upon discovering that sensitive consumer data was made available to an unauthorized party, Salud Family Health began to review the affected files to determine what information was compromised and which consumers were impacted. While the breached information varies depending on the individual, it may include your name, Social Security number, driver’s license number or state identification card number, financial account information, credit card number, passport number, medical treatment and diagnosis information, health insurance information, biometric data, and username and password. On November 4, 2022, Salud Family Health sent out data breach letters to all individuals whose information was compromised as a result of the recent data security incident. Founded in 1970, Salud Family Health is a healthcare provider based in Fort Lupton, Colorado. The practice caters to the needs of the migrant, seasonal farmworker population living and working in and around Fort Lupton. Salud Family Health currently operates 13 clinics as well as a mobile unit in ten communities throughout northern and southeastern Colorado. In total, Salud serves more than 68,000 patients each year. Salud Family Health employs more than 715 people and generates approximately $28 million in annual revenue. **Topics:** Public Awareness, Technology --- ### [IOTW: Everything we know about the Medibank data leak](https://insurancefraud.org/news_archives/iotw-everything-we-know-about-the-medibank-data-leak/) **Published:** September 26, 2026 **Author:** Diane Beauchamp **Content:** The hacker responsible for a data breach of Australian health insurance provider Medibank which affected [9.7 million people](https://www.cshub.com/attacks/news/hacker-threatens-to-release-data-stolen-from-97m-medibank-customers) has released private medical information on the [dark web](https://www.cshub.com/attacks/news/hacker-releases-stolen-medibank-data-on-the-dark-web). The hacker posted a file labelled “abortions” to dark web hacking site BreachForums on November 10, 2022. It apparently contains information on procedures that policyholders have claimed on, including miscarriages, terminations and ectopic pregnancies. The hackers also released files containing customer data called “good-list” and “naughty-list” on November 9, 2022. The so-called “naughty-list” reportedly includes details on those who had sought medical treatment for HIV, drug addiction or alcohol abuse or for mental health issues like eating disorders. The hacker added to the November 10 data leak post, saying: “Society ask us about ransom, it’s a 10 millions (sic) usd. We can make discount 9.7m 1$=1 customer.” During question time in Australian parliament on November 10, Minister of Home Affairs Clare O’Neil hit back at the hackers, saying: “I want the scumbags behind this attack to know that the smartest and toughest people in this country are coming \[at\] you. “I want to say, particularly to the women whose private health information has been compromised overnight, as the minister for cyber-security but more importantly, as a woman, this should not have happened, and I know this is a really difficult time.” David Koczkar, CEO of Medibank, called the release of the data “disgraceful” and a “weaponization of people’s private information”. He also called those involved in the cyber-attack and data leak “deplorable”. In an attempt to protect those affected by the cyber security incident and the [subsequent data leaks](https://www.cshub.com/attacks/news/hacker-threatens-to-release-data-stolen-from-97m-medibank-customers), Medibank urged members of the public and the media to not “unnecessarily download sensitive personal data from the dark web” and to “refrain from contacting customers directly”. ## How did the breach happen? The initial cyber security incident occurred on October 13, 2022, when Medibank detected some “unusual activity” on its internal systems. After [dealing with the cyber-attack,](https://www.cshub.com/attacks/news/medibank-is-latest-australian-company-to-suffer-cyber-security-incident) Medibank said in a statement that there was “no evidence that customer data has been accessed” during the breach. Medibank was then contacted on October 17 by the [malicious party](https://www.cshub.com/attacks/news/iotw-medibank-confirms-200gb-of-customer-data-stolen), who aimed to “negotiate with the \[healthcare\] company regarding their alleged removal of customer data”. The malicious party attempted to weaponize Medibank’s customers’ private medical data to extort the medical insurer, saying that they would release the data of the“1k most \[prominent\] media persons” that include “\[those with the\] most \[social media\] followers, politicians, actors, bloggers, \[LGBTQ+\] activists \[and\] drug-addicted people” as well as people with “very interesting diagnoses”. It was confirmed on October 20 that the hacker’s claims were legitimate. Medibank, however, publicly refused to bend to the hacker’s demands and said it [would not pay a ransom](https://www.cshub.com/attacks/news/medibank-refuses-pay-ransom-after-97m-customers-details-stolen) over concerns it would “encourage the criminal to directly extort \[its\] customers”. The company also said that it had received council from cyber security experts who had said there was only a “limited chance” that paying the ransom would result in the return of the stolen data. In a tweet on November 10, journalist Jeremy Kirk suggested that the hack took place as a result of hackers gaining access to Medibank’s internal systems via compromized login credentials, a tactic that “may have involved VPN access”. According to Kirk, the hackers claim they used jump servers to access Amazon data warehouse Redshift. The hackers also claim that they had access to Medibank’s internal systems for a month before they were discovered. ## What data was stolen in the hack? On November 7, Medibank revealed the true extent of the [hack](https://www.cshub.com/attacks/news/iotw-capital-one-hacker-given-probation-following-cyber-attack). The malicious actor gained unauthorized access to and stole the data for 9.7 million past and present customers. The information included email addresses, phone numbers, addresses, Medicare numbers, names, dates of birth, passport numbers and visa details. It also encompassed the health claims data for 192,000 customers which contained private medical information including where customers were admitted for procedures, service provider names and locations and codes associated with diagnosis and procedures given. Medibank urged all those affected to “stay vigilant” against [cyber attacks](https://www.cshub.com/attacks/news/dropbox-suffers-data-breach-following-phishing-attack) that may be levelled against them because of the leak. ## A full timeline of the data breach - **13 October** – Medibank notices some unusual activity on its networks. The affected networks are shut down. - **14 October** – the affected networks are restarted. Medibank releases a statement saying that there is “no evidence” that any customer data was accessed during the breach. - **17 October** – Medibank releases an update on the cyber security incident, describing the ongoing investigation into the unusual activity and recognizing that while it was “consistent with the precursors to a ransomware event”, there was still no evidence customer data had been compromised. - **19 October** – Medibank are contacted directly by the hacker, who claims to have stolen 200GB worth of customer data. The hacker attempts to negotiate the release of the information. - **20 October** – Medibank confirms that the hacker’s claims are legitimate. The Australian Federal Police starts investigating the cyber-attack. - **7 November** – the scope of the data breach is revealed, with Medibank confirming that the data of 9.7 million past and present customers was stolen in the breach. Medibank makes a public statement refusing to pay any ransom to the hacker. - **8 November** – the hacker threatens to release files on the dark web and encourages Medibank shareholders to sell their shares. - **9 November** – the hacker releases the “good-list” and “naughty-list” customer data files on the dark web. The Australian Federal Police partners with Commonwealth agencies and the Five Eyes Law Enforcement partners to investigate the cyber crime. Operation Guardian, which was previously introduced to help the victims of the Optus data breach, is extended to those affected by the Medibank data breach. - **10 November** – the hacker releases the “abortions” customer data files on the dark web and demands US$10mn to stop releasing data. - **11 November** – The AFP, in collaboration with Interpol, linked the gang to a Russian hacking group **Topics:** Public Awareness, Technology --- ### [Lurie Children’s Hospital Resolves Healthcare Data Breach Lawsuit](https://insurancefraud.org/news_archives/lurie-childrens-hospital-resolves-healthcare-data-breach-lawsuit/) **Published:** September 26, 2026 **Author:** Diane Beauchamp **Content:** Lurie Children’s Hospital agreed to implement additional security measures to settle a healthcare data breach lawsuit. Chicago-based Lurie Children’s Hospital settled a data breach lawsuit outside of court relating to a security incident that began in 2018. The hospital agreed to implement additional security measures to protect patient health information. Unlike other healthcare data breach settlements, no monetary agreement was made, meaning impacted individuals are not eligible to receive any damages. In December 2019, Lurie Children’s sent a notice to patients informing them that an employee had improperly accessed patient data without a valid reason between September 2018 and September 2019. The hospital immediately terminated the employee’s access to patient information. In May 2020, Lurie Children’s notified patients that another employee had improperly accessed patient information “without a work-related reason” between November 2018 and February 2020. That employee’s access was also terminated following the discovery. The lawsuit, filed by “Jane Doe” on behalf of her child, alleged that Lurie Children’s breached its implied contract and its privacy practices and neglected to supervise its staff appropriately in order to protect sensitive health information. Lurie Children’s Hospital denied the allegations and noted that the “plaintiff fails to state a claim upon which relief can be granted including because Plaintiff fails to assert any basis that Lurie Children’s Hospital proximately caused any harm.” If the court approves the final settlement, Lurie Children’s Hospital will implement more robust security measures, including increased monitoring of employee medical record access via detailed audit logs and additional training on the importance of patient privacy. In addition, the hospital will apply “Break the Glass” protocols to “highly sensitive medical information for certain treatments.” “These security measures include monitoring of employees’ access of electronic medical records in audit logs, applying a special designation to highly sensitive medical information involving evaluations for sexual abuse or sexual assault, requiring additional confirmations of authorization and monitoring before employees can access this specially designated information, reviewing audit alerts at least twice a week, and requiring additional training on patient privacy and appropriate access for certified nursing assistants,” the settlement agreement continued. The Court will hold an approval hearing on January 25 to finalize the settlement. **Topics:** Judicial/courts --- ### [Don’t be a Medicare scheme victim](https://insurancefraud.org/news_archives/dont-be-a-medicare-scheme-victim/) **Published:** September 26, 2026 **Author:** Diane Beauchamp **Content:** We are currently in the middle of the Medicare open enrollment period and, unfortunately, this is a high time for older Americans to fall victim to an online scheme. Lucilia Prates-Ramos, Director of the Massachusetts Senior Medicare Patrol Program, is here with some helpful advice so that you stay protected. For more information visit [MASMP.org](http://masmp.org/) or call the Massachusetts Office of Elder Affairs at 800-243-4636. **Topics:** Public Awareness --- ### [KC Pediatrician Pleads Guilty to $300,000 Medicare Fraud](https://insurancefraud.org/news_archives/kc-pediatrician-pleads-guilty-to-300000-medicare-fraud/) **Published:** September 26, 2026 **Author:** Diane Beauchamp **Content:** A Kansas City-area pediatrician pleaded guilty in federal court today to his role in causing fraudulent Medicare claims to be submitted for more than 1,000 beneficiaries for medications and equipment they didn’t need, which was part of a larger nationwide scheme to defraud Medicare. “A physician abused his position of trust to cause fraudulent claims to be filed for more than 1,000 Medicare beneficiaries,” said U.S. Attorney Teresa Moore. “This theft of public funds was part of a larger nationwide scheme that includes prosecutions in other districts where additional perpetrators are being held accountable for their criminal actions.” “To help protect the federal health care system, doctors participating in the Medicare program are obligated to provide medically appropriate services and prescriptions to their patients and bill the program properly,” stated Special Agent in Charge Curt L. Muller with the U.S. Department of Health and Human Services Office of Inspector General. “Our agency and law enforcement partners are dedicated to identifying and pursuing providers who disregard these vital responsibilities in exchange for personal enrichment.” Frederick Scott Dattel, 57, of Leawood, Kansas, waived his right to a grand jury and pleaded guilty before U.S. District Judge Brian C. Wimes to a federal information that charges him with making a false statement related to a health care matter. Dattel, a licensed medical doctor with a specialty in pediatrics, owns and operates his own medical practice, Kansas City Pediatrics, L.L.C., in Kansas City, Mo. Between August 2017 and February 2018, Dattel worked as a physician for RediDoc, L.L.C., a commercial telemedicine company. RediDoc’s owners unlawfully profited by paying kickbacks and bribes to doctors so those doctors would sign high volumes of expensive prescriptions and durable medical equipment orders that were not medically necessary. National Health Care Fraud Conspiracy RediDoc owners Stephen Luke and David Laughlin have pleaded guilty in the District of New Jersey to conspiracy to commit health care fraud. In this scheme, marketers identified Medicare beneficiaries to target for expensive medications and durable medical equipment, and persuaded beneficiaries to try the medications and medical equipment – even when the beneficiary’s need for those items was not clear and was not discussed with the beneficiary’s doctor. The marketers then transmitted the beneficiaries’ medical information to RediDoc along with the proposed prescriptions or doctors’ orders for medical equipment that included pre-marked check-off boxes for particular drugs or equipment that would yield large reimbursements. The marketers paid reimbursement proceeds to RediDoc and its owners. These orders were then filled by providers and pharmacies around the country who received lucrative reimbursements from federal health care benefit programs, including Medicare. In many circumstances, the providers and pharmacies then returned a portion of the health insurance reimbursements as kickbacks to the telemedicine companies, who, in turn, paid the doctors who had prescribed or ordered the unnecessary medical equipment and compounds. RediDoc ensured doctors would sign a high volume of expensive beneficiary prescriptions or medical equipment orders by paying the doctors bribes and kickbacks. Dattel’s Guilty Plea By pleading guilty today, Dattel admitted that, while working as a physician for RediDoc, he unlawfully caused false and fraudulent Medicare claims to be submitted for prescriptions for durable medical equipment and compounds without examining or speaking to patients and without any physician-patient relationship. Between August 2017 and February 2018, while practicing telemedicine for RediDoc, Dattel reviewed 1,077 patient files. He issued orders or prescriptions for 1,075 beneficiaries for durable medical equipment, orthotics, and/or compounds. Dattel issued the orders and prescriptions without seeing, speaking to, or otherwise communicating or examining the beneficiaries, and without regard to whether the beneficiaries actually needed the durable medical equipment and compounds. These orders and prescriptions, as Dattel knew, were used to submit false and fraudulent claims to Medicare. Almost the entirety of Dattel’s completed, signed prescriptions and orders for durable medical equipment and compounds, as he knew, were not legitimately prescribed, not needed, and not used. As a result of Dattel’s RediDoc prescriptions and orders, between Aug. 28, 2017, and Feb. 26, 2018, Medicare was billed at least $312,392 for durable medical equipment and compounds, and paid at least $211,542 for these orders. Under the terms of today’s plea agreement, Dattel must pay restitution in the full amount of $211,542. During the same timeframe, RediDoc deposited a total of $22,270 in 13 payments into Dattel’s bank accounts. Under federal statutes, Dattel is subject to a sentence of up to five years in federal prison without parole. The maximum statutory sentence is prescribed by Congress and is provided here for informational purposes, as the sentencing of the defendant will be determined by the court based on the advisory sentencing guidelines and other statutory factors. A sentencing hearing will be scheduled after the completion of a presentence investigation by the United States Probation Office. This case is being prosecuted by Assistant U.S. Attorney Brent Venneman and Nicholas P. Heberle. It was investigated by Health and Human Services, Office of Inspector General, the FBI, and the U.S. Office of Personnel Management, Office of Inspector General. **Topics:** Medicare/Medicaid **Categories:** Conviction --- ### [Judge raises bond for man accused of trying to kill wife for $3M life-insurance policy](https://insurancefraud.org/news_archives/judge-raises-bond-for-man-accused-of-trying-to-kill-wife-for-3m-life-insurance-policy/) **Published:** September 25, 2026 **Author:** Diane Beauchamp **Content:** A Belmont man had his bond increased after he was accused of attempting to kill his wife after taking out a $3 million life insurance policy. A judge set David Warlick’s bond in September at $2 million. Warlick was hoping to get that reduced but the judge raised it to $3 million. Several of Warlick’s former employees came to court Tuesday to tell the judge he is a danger to the public. They brought letters detailing how they say he has threatened them over the years. Warlick owns a profitable car wash in Belmont. Police reported finding several guns, silencers and ammunition around his house, and had information that he planned to leave the country. In September, the district attorney told the judge someone will die if Warlick gets out of jail. There is a good chance that Warlick will stay in jail until the trial. **Topics:** Life Insurance **Categories:** Arrest --- ### [SAS scores a Celent Luminary trifecta in insurance fraud detection solutions](https://insurancefraud.org/news_archives/sas-scores-a-celent-luminary-trifecta-in-insurance-fraud-detection-solutions/) **Published:** September 25, 2026 **Author:** Diane Beauchamp **Content:** SAS is lauded an insurance fraud detection Luminary in Celent’s inaugural trio of SolutionScape reports evaluating anti-fraud solutions across insurance market segments. The research and advisory firm analyzed a total 13 vendors’ fraud detection offerings in three markets, evaluating each for its level of advanced technology and breadth of functionality. Notably, **SAS** **was the *only* vendor to earn Celent’s Luminary designation in all three** of its *Insurance Fraud-Detection Solutions, 2022 Edition* reports: - [Property and Casualty Insurance](https://c212.net/c/link/?t=0&l=en&o=3706640-1&h=1517996532&u=https%3A%2F%2Fwww.sas.com%2Fgms%2Fredirect.jsp%3Fdetail%3DGMS247277_342209&a=Property+and+Casualty+Insurance). - [Health Insurance](https://c212.net/c/link/?t=0&l=en&o=3706640-1&h=4203947295&u=https%3A%2F%2Fwww.sas.com%2Fgms%2Fredirect.jsp%3Fdetail%3DGMS247277_342230&a=Health+Insurance). - Life Insurance. “Insurers’ fraud tools have evolved from deploying scenarios to identify individual frauds to revealing fraud patterns based on historical fraud and detecting fraud in real time,” said Andrew Schwartz, Insurance Analyst at Celent. “Amid the industry’s accelerating digital transition, the tech prowess and vast applicability demonstrated in SAS’ anti-fraud offerings prove why SAS remains at the forefront of [insurance analytics](https://c212.net/c/link/?t=0&l=en&o=3706640-1&h=4023620048&u=https%3A%2F%2Fwww.sas.com%2Fen_us%2Findustry%2Finsurance.html&a=insurance+analytics) – and the only vendor to be named a Luminary in all three reports.” **Harnessing the power of diverse data sources, automated decision making and AI** Celent’s analyses highlighted major insurance industry trends, dominated by more virtual customer engagement in the wake of the COVID-19 pandemic. The anonymity of digital engagement only augments insurers’ fraud risks – and at a time when the Great Resignation has forced greater reliance fraud detection tools and technologies, as top talent becomes increasingly difficult to attract and retain. To keep pace with ever more sophisticated fraudsters, Celent recommends that insurers choose vendors strong in the following categories: technology; functional capabilities; vendor stability, knowledge and investment in the solution; and implementation and support capabilities and experience. SAS’ [insurance fraud solutions](https://c212.net/c/link/?t=0&l=en&o=3706640-1&h=1370308603&u=https%3A%2F%2Fwww.sas.com%2Fen_us%2Fsoftware%2Fdetection-investigation-for-insurance.html&a=insurance+fraud+solutions) on SAS® Viya® check all the boxes. SAS’ industry-tailored solutions deliver a single, end-to-end framework that uses layered defenses incorporating predictive modeling, text mining, network link analysis and more to better identify fraudulent activity before claims are paid. Industry-specific data models enable insurers to gather and consolidate internal and external data from varied sources, fueling a broad set of advanced analytic and AI techniques that automatically score claims at every stage of the process. Built-in case handling streamlines and facilitates investigations via a configurable workflow. “Insurance fraud in its various forms costs consumers and businesses $308.6 billion in the US alone, according to the latest figures from the Coalition Against Insurance Fraud,” said Stu Bradley, Senior Vice President of Fraud and Security Intelligence at SAS. “Our latest **[insurance fraud technology study](https://c212.net/c/link/?t=0&l=en&o=3706640-1&h=2266166872&u=https%3A%2F%2Fwww.sas.com%2Fgms%2Fredirect.jsp%3Fdetail%3DGMS247277_342212&a=insurance+fraud+technology+study)** with the Coalition found that insurers are diversifying their data sources to gain a more complete and accurate claims picture. As this trend continues, they’ll need robust data management and orchestration. SAS delivers these capabilities, combined with a powerful decisioning automation engine that helps uncover once-hidden patterns and enable real-time fraud detection.” **Beyond fraud detection** SAS’ holistic approach to insurance technology topples operational silos and boosts efficiency by integrating fraud detection, risk management, and customer experience decision making on open, cloud-native SAS Viya. To learn more, please check out Insurance Innovation Reporter’s [recent interview](https://c212.net/c/link/?t=0&l=en&o=3706640-1&h=1611080263&u=https%3A%2F%2Fiireporter.com%2Fanalytics-pioneer-sas-emphasizes-perennial-strengths-embraces-technological-openness%2F&a=recent+interview) with SAS Chief Technology Officer Bryan Harris. “SAS Viya is a platform designed to drive data and analytics innovation and navigate disruption,” said Harris in the interview. “It’s a way to unite and govern enterprise data and drive new and better decisions, whether it is for underwriting, mitigating enterprise risk, managing claims, detecting fraud or delivering a better customer experience.” **Topics:** Public Awareness, Technology --- ### [Georgia Ex-Insurance Chief Oxendine Denies Knowing of Fraud, Seeks Dismissal of Charges](https://insurancefraud.org/news_archives/georgia-ex-insurance-chief-oxendine-denies-knowing-of-fraud-seeks-dismissal-of-charges/) **Published:** September 25, 2026 **Author:** Diane Beauchamp **Content:** Former Georgia Insurance Commissioner John Oxendine denies knowingly being involved in any fraud scheme and has moved to have the criminal charges brought against him dismissed. A November 4 defense filing in federal court in Atlanta claims that the indictment against Oxendine does not allege any criminal knowledge or intent on his part. It further asserts that the claims are time-barred. Oxendine was indicted on charges of conspiracy to commit health care fraud and conspiracy to commit money laundering between 2015 and 2017 by a federal grand jury on May 17, 2022. He pleaded not guilty in an initial court appearance. Oxendine served as state insurance commissioner from 1995 to 2011, before the alleged conspiracy. In formally seeking dismissal of the charges, Atlanta attorneys Drew Findling and Marissa Goldberg argue that the healthcare fraud statute carries with it a “heightened burden of intent” that has not been met. According to the defense lawyers, the indictment fails to allege that Oxendine had any knowledge that the medical claims being submitted were false, and it fails to specifically allege how Oxendine’s presence at a meeting in Dallas led him to knowingly take part in a criminal conspiracy. “\[T\]he indictment vaguely outlines conduct which allegedly constitutes conspiracy to commit health care fraud – but entirely fails to allege any element of knowledge on the part of Mr. Oxendine. Rather, the indictment alleges acts, which otherwise are not violations of law, in hopes that the cumulative effect casts a shadow of culpability upon Mr. Oxendine,” his lawyers wrote. The defense further argues that the charges are beyond the five-year statute of limitations, which means some overt act must have occurred on or after May 17, 2017. The indictment lists one act during that time – a $42 check paid to Oxendine Insurance Services— but all other acts alleged in the indictment occurred outside of the five year limitations period. “While attempting to bootstrap the entire case onto this one check, the indictment fails to allege that the $42 check was actually a profit of the alleged healthcare fraud and that Mr. Oxendine knew it was a profit of such,” the defense claims. According to information presented to the court, Oxendine allegedly conspired with Dr. Jeffrey Gallups and others to submit fraudulent insurance claims for medically unnecessary testing. As part of the alleged scheme, a Texas lab company agreed to pay Oxendine and Gallups a kickback of 50% of the net profit. In total, the lab company submitted claims for more than $2,500,000 for lab tests ordered by Gallups’s practice, according to prosecutors, who claim that insurance companies paid more than $600,000 as a result of these claims. The lab company then allegedly paid $260,000 in kickbacks through Oxendine’s insurance services business. At the time of the indictment, Oxendine’s attorneys told Insurance Journal that their client was “targeted in this investigation because of his name and gravitas, but to be clear, he has not broken any laws and is innocent of this indictment.” Gallups previously pleaded guilty to health care fraud and was sentenced to 36 months in jail in June. Oxendine, who ran for governor in 2010 but lost the Republican primary, was investigated by the state ethics commission over his campaign finances in 2009 and settled the last of those cases this past May, The Atlanta Journal-Constitution reported. **Topics:** Healthcare Fraud **Categories:** Arrest --- ### [Doctor who fed drug abuse in Kentucky with illegal prescriptions sentenced to prison](https://insurancefraud.org/news_archives/doctor-who-fed-drug-abuse-in-kentucky-with-illegal-prescriptions-sentenced-to-prison/) **Published:** September 25, 2026 **Author:** Diane Beauchamp **Content:** A Tennessee doctor who illegally prescribed drugs that fed addiction in southeastern Kentucky has been sentenced to seven years in prison. James J. Maccarone pleaded guilty to conspiring to illegally distribute drugs. Maccarone operated Gateway Medical Associates P.C., a clinic in Clarksville, Tenn. People from the Knox County area in Kentucky, about four hours away from Clarksville, traveled to the clinic to get prescriptions for pain pills that were diverted to illegal sales, according to court records. **Topics:** Drug Diversion --- ### [Primer warns of a fake health insurance billing scam](https://insurancefraud.org/news_archives/primer-warns-of-a-fake-health-insurance-billing-scam/) **Published:** September 24, 2026 **Author:** Diane Beauchamp **Content:** Consumers should pay attention to document descriptions, which always contain elements that help establish the authenticity of the charges The Boleto coup has increased to advance Brazil’s health plans The Boleto coup has increased to advance Brazil’s health plans the **[Bank coupon](https://jovempan.com.br/tag/boleto)** It is the second most used form of payment in Brazil, after only the credit card. Many criminals take advantage of the situation to apply **[strikes](https://jovempan.com.br/tag/golpe)**. Fraud with fake bank slips has increased in the country. Scammers send customers fake bills, as if they were health insurance companies, for example, and consumers who are used to receiving bills by email end up falling for the scam. Think about it, the **Brazilian Association of Health Plans** (Abramge) launches a booklet with the main care that a patron needs to not fall into this type of fraud, notes the executive supervisor of the entity, Marcos Novaes: every month, they end up being the most used by these scammers, because we are already used to paying them, and then, eventually, they arrive through digital or physical means, and people make those payments almost naturally.” Pay, the money goes into the fraudster’s pocket. The advice is to pay attention to the characteristics of the ticket. A real document will always contain elements that help prove the authenticity of the fee, such as the name of the issuing company, the bank and institution code, the beneficiary account number, and the amount of the bill.” Actually check the recipient of the coupon , try to find out who is the sender who sent the receipt. And if you have any questions, big or small, call the operator. “To avoid a fraudulent bill, every connection makes sense,” Novaes says. Increased customer interest in any kind of irregularity in the ticket is important, but despite this, experts point out, healthcare companies are investing specifically in taking care of data protection, so that there are no leaks. Consumer law attorney Renata Abalim explains that in most cases, criminals are able to file false charges because they have access to leaked customer data. “When we talk about a criminal organization giving way to do this, they already have the health plan beneficiary data, they already know the age, they already know what the consumer is suffering from, including pre-existing diseases. The fraudster knows this by leaking information. I understand that The deadlock is back there. It’s up to the consumer to be the manager of their data. From the moment they give the information to the health worker, they have an obligation to take care of it, keep it and handle it. We have a law, the GDPR, that does that to us. Abalém also remembers That it is possible to protect yourself and act in the event that you are a victim of a scam.” Once a person realizes or receives a charge back for this open amount, he should contact the operator. And knowing that she was the victim of a coup, she should contact the police departments specializing in the consumer, Procon, she should put her mouth on the tropon “, the lawyer points out. **Topics:** Public Awareness --- ### [Not everyone registered as an insurance fraudster is guilty: NOS](https://insurancefraud.org/news_archives/not-everyone-registered-as-an-insurance-fraudster-is-guilty-nos/) **Published:** September 24, 2026 **Author:** Diane Beauchamp **Content:** Insurers are registering more people for fraud but a number of them have been unjustly accused, an analysis by broadcaster [NOS](https://nos.nl/artikel/2460997-verzekeraars-registreren-steeds-meer-mensen-als-fraudeur-niet-altijd-terecht) shows. NOS looked at the outcomes of a number of recent court cases against insurers by people who felt they had been unjustly accused of fraud, as well as figures from complaints institute Kifid. Some 18,200 people are currently included in the insurance fraud register. Every year some 5,000 names are added to the list where they remain for a maximum of eight years. Neither insurers nor financial services watchdog AFM keep a tally of cases where the insurers got it wrong. Inclusion in the list can have serious consequences, NOS said. Registered fraudsters can often be excluded from getting insurance, or have to pay thousands of euros extra in premiums. Lawyer Yusuf Ersoy said he had worked on ‘various’ cases where a car insurer and health insurer had been forced to withdraw the accusation of fraud because it had been based on insufficient evidence. The association of insurers VvV said in a reaction that unsubstantiated inclusion in the fraud list is ‘regrettable’ but that people are not put in the register without a thorough investigation. **Topics:** Insider Fraud, Regulatory actions --- ### [Berlin police target 40 car rental companies](https://insurancefraud.org/news_archives/berlin-police-target-40-car-rental-companies/) **Published:** September 24, 2026 **Author:** Diane Beauchamp **Content:** In Berlin, police are targeting several dozen car rental companies that have attracted attention with dubious practices and links to crime, said police chief Barbara Slowik on Monday in the Interior Committee of the House of Representatives. According to the statement, police have currently “detected 40 individuals and companies that explicitly show references to clan criminality.” Clan criminals “resort to these car rental companies.” Behind the companies, either criminal structures stand as operators – or criminals regularly use the vehicles of these companies, he said. “The supply of vehicles through dubious car rental companies is an essential component of criminal groups,” Slowik said. This is organized in a “multi-layered and confusing system,” he added. A prominent example: During the robbery of the Postbank in July 2022, the perpetrators used the car of a car rental company. A German-Polish man imprisoned for insurance fraud controlled the company from prison by cell phone; even fellow inmates knew that he is also said to have indirectly laundered the loot money of Arab clans with the car rental. The bank’s car was a rare model: the Audi RS6 Avant Performance has a 605-horsepower engine, accelerates from 0 to 100 km/h in just 3.7 seconds, according to the manufacturer, and can reach a top speed of 305 kilometers per hour. Only 20 cars of this model are registered in Berlin. Police chief Slowik said there were several business models among the dubious lenders. Private individuals even had various vehicles registered with them and would rent them out, but then, in the event of an incident, would not know who was in possession of the car at the time. Companies offered the same service as reputable rental companies, but did not comply with the requirements for the rental or did not demand the usual securities from customers – age for high-powered cars, driver’s license, complete documents and credit card. “These different business models all serve one purpose, which is to allow targeted criminals to use vehicles, commit crimes or use the vehicles as a means of committing a crime or escaping,” Slowik said. “Coke cabs are also served to a significant extent through this business model.” In addition, he said, high-priced cars from these companies also attract attention for so-called “profiling” driving, which is more about loud engines than speeding. These car rental companies are not a specific Berlin problem, he said, but a nationwide phenomenon. The companies deliberately work with “non-transparent rental contracts and chains of people”. This makes it difficult for law enforcement agencies to identify the drivers in individual cases. The police work closely with leasing companies, insurance companies and tax offices to combat this phenomenon. There are also regular interdepartmental checks and joint operations at the relevant car rental companies and car dealerships. Money laundering investigators are also involved. **Topics:** Auto fraud, Business - padding/faking, Financial Fraud --- ### [Impersonators posing as homeowners linked to 32 property fraud cases in Ontario and B.C.](https://insurancefraud.org/news_archives/impersonators-posing-as-homeowners-linked-to-32-property-fraud-cases-in-ontario-and-b-c/) **Published:** September 24, 2026 **Author:** Diane Beauchamp **Content:** Mortgage and title fraudsters who impersonate homeowners and tenants have targeted at least 32 properties in Ontario and British Columbia, investigators and official warnings suggest. ![](https://d21y75miwcfqoq.cloudfront.net/70c8fc80)Insurance investigator Brian King, president and CEO of King International Advisory Group, said his firm had received 30 such claims in Ontario. They include six instances of “total title fraud” in which con artists pose as homeowners to list properties for sale. In B.C., the Land Title and Survey Authority warned in 2021 that there had been two attempts of title fraud involving the impersonation of owners who lived abroad. King said such impersonators had to put in performances worthy of an “Emmy Award,” but they were not the only people involved in the scam. “What you got to understand is that the people that are doing this, it’s a group ? It takes several people to make this process work,” said King. He said his firm was handling six claims of total title fraud, with several coming forward after recent media coverage of the fraud technique. King’s investigations include the case of Toronto condo owner Moffy Yu, who discovered that her two-bedroom downtown property had been listed and sold last year for $970,000 by someone using her name. The property’s title now lists someone else as the owner, although a “caution” notice has been placed on the document by the director of land titles, indicating that it is disputed. Toronto Police confirmed they are investigating. King said total title fraud was once “very, very rare,” but now it “seems like every other file that’s coming in is a total title transfer.” The B.C. Land Title and Survey Authority said in a March 2021 notice that it was aware of two cases involving property managers being tricked into taking instructions from fraudsters impersonating owners who lived abroad. It said one of the frauds was successful. “Both properties were listed for sale by realtors who accepted a scanned copy of a forged passport to verify the identity of the supposed owner,” the notice said. King said title and mortgage fraud typically involve homes with low or no mortgages. After identifying such a home, the fraudsters research the homeowners to create fake identification in their name. He said “actors” are then paid $5,000 to $10,000 to put the property on the market and seek a “fairly quick” sale with an unsuspecting buyer. “They are not necessarily going for the most amount of money because they want to deal with this quickly. The quicker they get in and out, the better,” said King. He said a recent case his firm investigated involved a home valued at $2.2 million in Ontario. The true owners contracted a property management company to rent out their home after moving to England for work. But it was rented by fraudsters who moved in, impersonated the owners, and sold it for $1.7 million within two weeks. In another type of property fraud, impersonators pose as homeowners to obtain mortgages from private lenders, said King. Compared to total title fraud, King said mortgage fraud was much “easier and quicker.” But the potential payoff for total title fraud was much greater. “When they sell to an unsuspecting (buyer), they get not only the mortgage amount, they get the equity amount as well,” said King. He said total title fraud resulted in a legal “mess” that could take a year and a half for the courts to sort out. Daniela De Tommaso, president of First Canadian Title Company Limited, said the firm had seen a “definite rise” in title fraud. Although he could not say how many cases it had received, Tommaso said it was growing, although it involved “small numbers.” Tommaso said the sophistication of fraudsters was increasing. “We are seeing identity theft where you look at the ID, unless you are trained, you would never be able to tell that it has been falsified.” He said people with home title insurance who were targeted by fraudsters could hand the matter over to their insurance company to “step in and take over”, contacting the police, notifying all parties involved, and hiring lawyers to fix the problem. But in some cases, the homeowners would balk at the lengthy court proceedings and walk away from the property, taking a payout instead. Neesha Hothi, communications director of the Better Business Bureau of Mainland B.C., said title fraud shows the importance of protecting personal information “like gold.” “When you are getting rid of any bank documents, bills and etc. Make sure you are shredding those, you don’t want your bank account numbers, your social insurance and other personal information out there,” she said. Hothi said another measure is to request an alert on title activity on a property, such as someone attempting to place a mortgage on it. Yu, who now lives in China’s Hubei province, said she couldn’t sleep over the theft of her home as she worked with her insurance company and King to find a solution. “Hopefully, I can hear some good news this year,” said Yu. **Topics:** Public Awareness, Title Insurance --- ### [The growing need for cyber-fraud security](https://insurancefraud.org/news_archives/the-growing-need-for-cyber-fraud-security/) **Published:** September 24, 2026 **Author:** Diane Beauchamp **Content:** Valery Migirov, Founder of cyber-fraud protection company B24cyber, explains about the increasing risks and how they can be mitigated Now more than ever, technology is an integral part of our day to day lives. Every aspect of our day to day is becoming ever more digitized, creating an era of convenience that would have been impossible to imagine mere decades ago. Those advances do not come without their vulnerabilities though, as cyber-attacks are now a very real concern, with cyber-criminals constantly finding new ways to gain access to personal and financial data potentially giving them the ability to cause widespread damage and disruption. With the advent of deepfake technologies, criminals can now impersonate someone’s appearance, as well as their texting habits and their manner of speaking in order to commit fraud. Thankfully, just as antivirus software was created to counter the spread of computer viruses in the late 80s, new anti-fraud security technologies are now being developed to counter this new vector for cyber-attacks. B24Cyber’s outstanding team of software engineers specializing in machine learning, artificial intelligence and data science have developed real-time video recognition algorithms that can identify people’s faces in videos with the ability to distinguish them from Deepfakes using a combination of physical indicators as well as visual anomalies, such as inconsistencies in facial features. Furthermore, the software uses NLP (Natural language processing) AI to analyze text from messenger, text messages and email apps to recognize any specific person’s texting habits, as well as detecting and identifying speech patterns in real-time while you are using a video-messaging app, not only confirming caller identity, but even providing insight into the tone and intentions of the person on the other end of the call. It is even possible to distinguish the identity of a person using a specific computer or cell phone by minute factors such as the time between and strength of button presses, and even the miniscule differences in how a person’s hand might shake during the typing. If, for example, someone were to even use your code or password to attempt to breach your smart device, the device will immediately recognize that it is not you and deny access. While this kind of technology will eventually become easily accessible for anyone’s day-to-day usage, the most immediately practical use cases for this kind of cybersecurity and anti-fraud technology include financial institutions, such as banks and insurance providers, infrastructural institutions such as healthcare providers, and perhaps most pertinently, intelligence agencies. **Topics:** Public Awareness, Technology --- ### [Court finds murdered man’s life policy was valid, again](https://insurancefraud.org/news_archives/court-finds-murdered-mans-life-policy-was-valid-again/) **Published:** September 24, 2026 **Author:** Diane Beauchamp **Content:** An Ontario appeal court upheld a [lower court’s ruling](https://advisor.ca/news/industry-news/insurer-wrong-to-deny-payout-in-murder-case/) that an insurer was wrong to deny a $500,000 life insurance payout to the son of a murdered man on the basis that the man had lied about his criminal history on his insurance application. The Court of Appeal for Ontario rejected an appeal from Desjardins Financial Security Life Assurance Co. seeking to overturn a Superior Court of Justice decision from January 2022, which ruled that a life policy taken out by Dean Costanza in 2012 was valid, despite his failure to properly disclose a past criminal conviction. Costanza was found murdered outside his home in 2017. The company declined to pay out on his life insurance policy, stating that the client’s failure to disclose a 2009 conviction for assault constituted a material and fraudulent misrepresentation. The insurance application required him to disclose any convictions in the previous three years. However, the lower court found that the insurer failed to prove that Costanza lied on the application, taking the position that while he could have been sentenced within the three-year window, that didn’t mean the conviction fell within that time frame. The judge said the insurers’ evidence of a misrepresentation fell “woefully” short of adequate proof of fraud, and that it’s possible he made a mistake on the dates or was negligent in filling out the application. It also rejected the allegation that Costanza failed to disclose a criminal background that would have been material to the application for life insurance. On appeal, the insurer sought to introduce new evidence that Costanza’s assault conviction did occur within the three-year window before he applied for life insurance and that the insurance application contained a misrepresentation. The appeal court rejected the insurer’s bid to introduce new evidence to establish the date of Costanza’s conviction. “Although the fresh evidence could affect the issue of whether there was a material misrepresentation, it could not reasonably be expected to affect the result of the application, because it could not reasonably be expected to affect the application judge’s finding that the insurer had failed to establish the intent required for civil fraud,” Justice Jill Copeland wrote for the appeal court in its decision released on Thursday. The appeal court concluded that Superior Court judge Erika Chozik did not err in applying the standard of intent required to prove fraud. As a result, the appeal court rejected the insurers’ effort to introduce new evidence, and dismissed its appeal. **Topics:** Judicial/courts, Life Insurance --- ### [University of Colorado Hospital Authority Announces Third-Party Data Breach Following Incident at Diligent Corporation](https://insurancefraud.org/news_archives/university-of-colorado-hospital-authority-announces-third-party-data-breach-following-incident-at-diligent-corporation/) **Published:** September 24, 2026 **Author:** Diane Beauchamp **Content:** On January 17, 2023, the University of Colorado Hospital Authority (“UCHealth”) filed notice of a data breach with the U.S. Department of Health and Human Services Office for Civil Rights after learning about a cybersecurity incident at one of the organization’s vendors, Diligent Corporation. Based on a notice provided on the UCHealth website, the incident resulted in an unauthorized party gaining access to consumers’ names, Social Security numbers, financial account information, dates of birth, and protected health information. After confirming that consumer data was leaked, the University of Colorado Hospital Authority began sending out data breach notification letters to all individuals who were impacted by the recent data security incident. If you are among the 48,879 individuals who received a data breach letter from UCHealth, it means that your sensitive information was leaked in the recent Diligent Corp. data breach. As we’ve discussed in prior [posts](https://www.myinjuryattorney.com/consumer-privacy-data-breach-lawyers/healthcare-data-breaches/), cybercriminals routinely target healthcare providers and related companies in hopes of obtaining information they can use to commit identity theft and other frauds. Thus, as a result of the UCHealth / Diligent data breach, you are now at a significantly increased risk of being the target of identity theft or other frauds. ## What We Know So Far About the Diligent Corporation Breach The available information regarding the Diligent Corporation breach comes from the UCHealth filing with the U.S. Department of Health and Human Services Office for Civil Rights. UCHealth also posted a notice of the data breach on its website. According to these sources, Diligent Corp. is a software company that provides business operations tools for UCHealth. Recently, Diligent informed UCHealth that it had experienced a cybersecurity incident impacting its computer network that compromised certain information related to UCHealth patients. However, UCHealth’s systems, including its email and electronic medical record, were not impacted by this incident. Upon discovering that sensitive consumer data was made available to an unauthorized party, UCHealth began to review the affected files to determine what information was compromised and which consumers were impacted. While the breached information varies depending on the individual, it may include your name, Social Security number, financial account information, date of birth, and protected health information. On January 17, 2023, Diligent Corporation sent out data breach letters to all individuals whose information was compromised as a result of the recent data security incident. ## About the University of Colorado Hospital Authority University of Colorado Hospital Authority is a locally owned, private, not-for-profit healthcare organization based in Aurora, Colorado. UCHealth serves patients throughout Colorado, southern Wyoming and western Nebraska, providing a wide range of healthcare and healthcare-related services. UCHealth operates or is affiliated with over 600 offices. UCHealth employs more than 27,000 people and generates approximately $5.4 billion in annual revenue. **Topics:** Public Awareness, Technology --- ### [Healthcare overtakes finance as most breached industry - Kroll](https://insurancefraud.org/news_archives/healthcare-overtakes-finance-as-most-breached-industry-kroll/) **Published:** September 24, 2026 **Author:** Diane Beauchamp **Content:** Healthcare has overtaken finance as the most [breached](https://businessplus.ie/news/dpc-whatsapp-fine-e5-5m/) global industry, according to risk advisory **[Kroll](https://www.kroll.com/en)**, with 22% of breaches handled by the company in 2022 affecting healthcare businesses. The 22% figure is a 38% increase year-on-year from 2021, when the sector accounted for 16% of breaches. Finance dropped to second place with 19% of the cases in 2022, a 3% drop from 2021 where it accounted for 22% of breach cases. However, the number of incoming calls related to data breaches in healthcare and the number of consumers taking up identity protection was still less than in the finance industry. Overall, 49% of calls coming from consumers in 2022 following being notified of a breach were related to the finance industry, whereas only 32% were in the healthcare industry. Of all the monitoring taken up by consumers, 69% were involved in financial breaches, compared to only 20% in healthcare, and finance saw annual growth of 127% in the number of calls following a breach, compared to 19% in healthcare. ![](https://insurancefraud.org/wp-content/uploads/image-20-19.jpg)Finance also saw a 126% year-on-year increase in the amount of identity monitoring taken up, compared to a 66% increase for consumers in healthcare. “The healthcare industry was particularly vulnerable to data breaches in 2022. Still in recovery from the pandemic, it is hardly surprising that data management may have become less of a priority, potentially putting data at risk of exposure,” said **David White**, managing director in Kroll’s cyber risk practice. “The finance industry continued to report a substantial number of breaches, likely because of the regulatory obligations in the industry mandating disclosure.” White continued: “It is revealing that consumers seemed more concerned about their financial data than health data, based on the number of incoming calls from consumers and the amount of identity monitoring taken up following a breach. “This gives organisations—and their insurers—clues on how they should prepare for a breach, both in terms of costs and potential litigation. “Despite the proportion of breaches in the health care industry growing, it seems that the finance industry still has the most to worry about in terms of consumer reaction and the impact of a data breach.” **Topics:** Fraud General, Public Awareness --- ### [Cyberattacks on the Healthcare Sector](https://insurancefraud.org/news_archives/cyberattacks-on-the-healthcare-sector/) **Published:** September 24, 2026 **Author:** Diane Beauchamp **Content:** The healthcare sector is a common target for cybercriminals. In fact, according to Check Point Research (CPR), healthcare organizations experienced 1,426 attacks per week in 2022. This is a 60% increase over the previous year, and many of the largest attacks of the year targeted healthcare organizations. In many cases, cyberattacks against healthcare organizations carried a high cost for organizations, with the cost of a data breach growing by 42% over the past two years. According to the [Cost of a Data Breach Report](https://www.ibm.com/reports/data-breach), healthcare continues to have the highest data breach cost of any industry, averaging $10.10 million per incident. Ransomware is another common and pricy threat to healthcare organizations. In the third quarter of 2022, [1 out of every 42 healthcare organizations](https://blog.checkpoint.com/2022/10/26/third-quarter-of-2022-reveals-increase-in-cyberattacks/) was the victim of a ransomware attack. **Topics:** Public Awareness, Technology --- ### [Police: 2nd suspect in Hialeah insurance fraud scheme turns self in](https://insurancefraud.org/news_archives/police-2nd-suspect-in-hialeah-insurance-fraud-scheme-turns-self-in/) **Published:** September 24, 2026 **Author:** Diane Beauchamp **Content:** The second of four people accused in a Hialeah auto insurance fraud scheme has turned himself in to police, according to an arrest report. Yander Sanchez, 26, accused of being involved in at least one staged crash, surrendered to Hialeah police Wednesday afternoon with his attorney’s guidance, the report states. Police already arrested Marlon Aldecoa, 22, of northwest Miami-Dade on Monday. Two other suspects, Dalin De La Torre, 21, and Yalema Gonzalez, 47, remained at large at the time of Sanchez’s arrest, according to the arrest report. Like Aldecoa, Sanchez faced charges of organized scheme to defraud, staging an accident and filing fraudulent insurance claims. According to a police report, police were first made aware of the scheme on Sept. 22, when an insurance investigator shared his suspicions about a July 7 crash in Hialeah where Aldecoa claimed to be injured. Sanchez, Aldecoa’s passenger, also claimed to be injured, collecting more than $16,000 in medical claims in July and August, police said. The report states that Aldecoa had filed a claim for an identical crash on Sept. 30, 2021. An insurance investigator told officers that repair claims in the sum of $632.37 had been paid to Aldecoa. Police said during the July 7 “crash,” body camera footage showed purportedly-fresh rear bumper damage on Aldecoa’s car. But, according to police, footage from mobile license plate readers revealed that Aldecoa had been driving around the city with the same rear bumper damage since Sept. 30, 2021. Police said the four defrauded insurance companies to the tune of $53,000 during the scheme. According to police, Gonzalez has allegedly been involved in seven car crashes dating back to 2007, all of which involved insurance claims. At least one, in 2015, was determined to have been staged and an insurance company wouldn’t pay for a Feb. 2021 crash either. Police wrote that Aldecoa “partially admitted to not repairing his vehicle before (the July) accident and then claimed more damage was sustained.” This was “not true based on pictures and evidence gathered,” the report states. Police took Sanchez, who did not speak to officers, to the Turner Guilford Knight Correctional Center, where he was being held on a $25,000 bond. He bonded out Thursday morning. **Topics:** Auto - staged **Categories:** Arrest --- ### [Healthcare Remains Top Target in 2022 ITRC Breach Report](https://insurancefraud.org/news_archives/healthcare-remains-top-target-in-2022-itrc-breach-report/) **Published:** September 24, 2026 **Author:** Diane Beauchamp **Content:** At least 344 organizations in the healthcare industry suffered data breaches in 2022, according to a just-released report from the Identity Theft Research Center® (ITRC). This is the third year in a row that healthcare organizations led all industries in the number of data compromises. Healthcare organizations represented 19 percent of the 1,802 breaches reported in the 2022 ITRC report, with Financial Services (268), Manufacturing and Utilities (249), and Professional Services (224) following behind. In 2021, 15 percent of the breaches tracked by ITRC affected healthcare companies. Cyberattacks continued to be criminals’ weapons of choice, with 1,595 breaches in 2022, a slight decrease from 1,613 in 2021 with drops year-over-year in the number of breaches attributed to phishing, ransomware, and malware. Supply chain attacks outstripped malware attacks in 2022, with 115 instances affecting 1,743 organizations and at least 10 million people. Healthcare organizations were hit particularly hard by supply chain attacks as eight of the 12 supply chain breaches cited in the report affected [business associates](https://c212.net/c/link/?t=0&l=en&o=3765488-1&h=287219544&u=https%3A%2F%2Fcompliancy-group.com%2Fhipaa-business-associate%2F&a=business+associates) of healthcare organizations or health insurance companies. The breaches listed below reinforce the importance of having well-crafted [business associate agreements](https://c212.net/c/link/?t=0&l=en&o=3765488-1&h=917652819&u=https%3A%2F%2Fcompliancy-group.com%2Fbusiness-associate-agreements-just-template-get-best-baas%2F&a=business+associate+agreements) with vendors to limit liability and maintain [HIPAA compliance](https://c212.net/c/link/?t=0&l=en&o=3765488-1&h=1474202563&u=https%3A%2F%2Fcompliancy-group.com%2Fwhat-is-hipaa-compliance%2F&a=HIPAA+compliance). - Shields Health Care Group, Inc.: 56 Entities; 1,804,069 Victims - Eye Care Leaders: 37 Entities; 3,372,880 Victims - Practice Resources, LLC: 28 Entities; 942,138 Victims - MCG Health, LLC: 10 Entities; 793,283 Victims - Comstar, LLC: 2 Entities; 585,621 Victims - Adaptive Health Integrations: 1 Entity; 510,574 Victims - Connexin Software, Inc.: 1 Entity; 2,216,365 Victims “Breaches like the ones affecting the business associates listed above illustrate why HIPAA Compliance must be the foundation upon which you build your privacy and security strategy,” said [Marc Haskelson](mailto:marc@compliancygroup.com), the CEO of Compliancy Group, the leading provider of automated HIPAA compliance solutions for healthcare organizations. “It is impossible to prevent every data breach, especially when it happens outside of your organization, but HIPAA compliance can limit your liability and expose potential problems with suppliers through the due diligence that takes place while forging a business associate agreement. **Topics:** Public Awareness, Technology --- ### [Insurer Deemed to Waive Right to Rescind but Commingling Exclusion Bars Coverage for Claims Against “Innocent” Insureds](https://insurancefraud.org/news_archives/insurer-deemed-to-waive-right-to-rescind-but-commingling-exclusion-bars-coverage-for-claims-against-innocent-insureds/) **Published:** September 24, 2026 **Author:** Diane Beauchamp **Content:** Applying New Mexico law, the Tenth Circuit has held that an insurer that waits over a year to seek rescission after learning of the insured’s actual fraud has waived its right to do so. [*Evanston Ins. Co. v. Desert State Life Mgmt.*, 2022 WL 17998401 (10th Cir. Dec. 30, 2022)](https://www.executivesummaryblog.com/assets/htmldocuments/ES-Evanston.pdf). The court nonetheless reversed in favor of the insurer, holding that a commingling exclusion applied to bar coverage for an entire lawsuit despite additional negligence allegations against “innocent” insureds. The policyholder, a corporation acting as a trustee for disabled individuals, obtained a professional liability policy from the insurer. The CEO had submitted an application in 2016 stating that no one was “aware of any fact, circumstance, situation, incident or allegation of negligence or wrongdoing, which might afford grounds for any claim such as would fall under th\[e\] proposed insurance.” Also, the policy contained an exclusion for Claims “\[b\]ased upon or arising out of any conversion, misappropriation, commingling \[of\] or defalcation of funds or property.” Unbeknownst to the insurer, the policyholder’s CEO was engaged in an embezzlement scheme in which he intentionally misappropriated and commingled approximately $5 million of the policyholder’s disabled clients’ money. A regulatory investigation revealed the scheme in March 2017, and in November 2017, the CEO pled guilty to wire fraud and money laundering in connection with the scheme. Soon after, former clients of the insured brought a class action lawsuit against the policyholder, the CEO, his ex-wife, and one of the insured’s former directors, alleging breach of fiduciary duty and negligence. The insurer denied coverage under the policy and filed suit seeking rescission and a declaration that the policy did not cover the class action. Following a bench trial, the trial court held that the insurer did not timely rescind the policy because it waited over a year after learning of the alleged scheme to file suit seeking rescission and instead notified the policyholder that it was not planning to renew. The court also held that the policy covered the class action lawsuit for the policyholder corporation and the “innocent” director but not for the CEO and his wife, rejecting the insurer’s argument that the conversion/commingling exclusion applied to bar coverage for the entire suit. On appeal, the Tenth Circuit affirmed the district court’s determination that the insurer had not sought rescission in a timely manner, but it reversed on the coverage issue. The appellate court rejected the insureds’ argument that the commingling exclusion did not apply to bar coverage for the entire class action because the complaint contained additional causes of action against the policyholder and the “innocent” director for mismanagement of client accounts and failure to monitor the financial health of the insured company. The Tenth Circuit explained that the exclusion barred overage for the entire class action because “the origin of the damages ar\[ose\] out of \[the CEO’s\] commingling,” even though “the legal theory undergirding the class-action claims” was the “innocent” director’s negligence. **Topics:** Judicial/courts --- ### [Two Individuals Admit Participating In Health Care Fraud And Kickback Schemes](https://insurancefraud.org/news_archives/two-individuals-admit-participating-in-health-care-fraud-and-kickback-schemes/) **Published:** September 24, 2026 **Author:** Diane Beauchamp **Content:** An Indiana man and an Arizona man yesterday admitted their roles in a health care fraud conspiracy in which they received payment for doctors’ orders for durable medical equipment (DME), namely orthotic braces, and genetic test referrals, U.S. Attorney Philip R. Sellinger announced. Scott Wohrman, 50, of Florence, Arizona, pleaded guilty by videoconference before U.S. District Judge Kevin McNulty to an information charging him with one count of conspiracy to violate the Federal Anti-Kickback statute and one count of conspiracy to commit health care fraud. On Jan. 24, 2023, David Heneghan, 53, of Indianapolis, Indiana, pleaded guilty to conspiracy to violate the Federal Anti-Kickback statute and conspiracy to commit health care fraud. According to documents filed in this case and statements made in court: Heneghan and Wohrman operated American Health Screening (AHS), a company that purportedly provided marketing services to laboratories. From July 2020 through January 2021, Heneghan, Wohrman, and others agreed to engage in a scheme to provide DME orders and genetic testing referrals for Medicare beneficiaries in exchange for kickbacks of approximately $1,500 per patient or for each test that resulted in a reimbursement from Medicare. Heneghan and Wohrman entered into a sham contract and utilized fraudulent invoices to make it appear that AHS was being paid for legitimate services and to conceal their fraudulent kickback scheme. Heneghan and Wohrman received kickbacks of at least $547,310 for durable medical equipment and at least $18,319 for genetic testing. Heneghan and Wohrman’s scheme resulted in an actual loss to Medicare of at least $565,629. Heneghan and Wohrman previously pleaded guilty in the Northern District of Texas to an information charging them with conspiracy to defraud the Federal Anti-Kickback statute. The count of conspiracy to commit health care fraud carries a maximum potential punishment of 10 years in prison. The count of conspiracy to violate the Anti-Kickback Statute carries a maximum potential penalty of five years in prison. Both offenses are also punishable by a fine of $250,000 or twice the gross gain or loss from the offense. Sentencing for Heneghan and Wohrman is scheduled for September 6, 2023. U.S. Attorney Sellinger credited special agents of the FBI, under the direction of Special Agent in Charge James E. Dennehy in Newark; the U.S. Department of Health and Human Services, Office of Inspector General, under the direction of Acting Special Agent in Charge Naomi Gruchacz; the U.S. Department of Defense, Office of the Inspector General, Defense Criminal Investigative Service, Northeast Field Office, under the direction of Special Agent in Charge Patrick Hegarty; the U.S. Department of Veterans Affairs Office of Inspector General, Northeast Field Office under the direction of Special Agent in Charge Christopher Algieri with the investigation leading to the guilty pleas. The government is represented by Assistant U.S. Attorney Ray Mateo of the U.S. Attorney’s Office, Opioid Abuse Prevention and Enforcement Unit in Newark. **Topics:** Healthcare Fraud, Medicare/Medicaid **Categories:** Conviction --- ### [Cape Cod dentist pleads guilty to $1.2 million embezzlement fraud scheme](https://insurancefraud.org/news_archives/cape-cod-dentist-pleads-guilty-to-1-2-million-embezzlement-fraud-scheme/) **Published:** September 24, 2026 **Author:** Diane Beauchamp **Content:** A Boston man who worked as a dentist in Hyannis pleaded guilty to a $1.2 million embezzlement fraud scheme, according to the U.S. Attorney’s Office for the District of Massachusetts. Jack Massarsky, 65, embezzled the $1.2 million from his employer, and fraudulently obtained government benefits in his employer’s name, the office stated. He pleaded guilty to one count of mail fraud and one count of wire fraud before U.S. District Court Chief Judge F. Dennis Saylor IV. Massarsky was charged on Dec. 13, 2022, and his sentencing is scheduled for May 15, 2023. Massarsky worked as a dentist and bookkeeper for a general dentistry practice in Hyannis from 2015 until 2021. When he first began with the practice in 2015, Massarsky opened a “secret bank account” in the name of the practice, and was then able to intercept checks sent to the dentistry practice for insurance reimbursement. Massarsky would deposit those checks into the secret bank account, continuing to do so for over five years and embezzling a total of over $1.2 million. The office stated the dentist used the stolen cash for “personal and family expenses.” The office added that Massarsky also used his practice’s name to defraud the United States by applying for COVID relief funds from the Health Resources and Services Administration Provider Relief Fund (HRSA PRF) in the name of the practice in July 2020, and ended up depositing over $52,000 in relief funds into the secret bank account. The HRSA is part of the United States Department of Health and Human Services, and gives healthcare to those who are “geographically isolated or otherwise vulnerable,” the office said. The HRSA gave financial relief to qualifying healthcare providers during the pandemic, including some dentistry practices. A mail fraud and a wire fraud charge each can allow for a sentence of up to 20 years in prison, the office said, along with three years of supervised release, a $250,000 fine or twice the gross gain or loss — whichever is greater, and in this case, it would be double the $1.2 million — along with restitution and forfeiture. United States Attorney Rachael S. Rollins and Joseph R. Bonavolonta, Special Agent in Charge of the Federal Bureau of Investigation, Boston Division made the announcement of Massarsky’s guilty plea on Jan. 25. The office stated assistance in the investigation was provided by the United States Department of Health and Human Services Office of Inspector General. Assistant U.S. Attorney Christopher J. Markham of Rollins’ Securities, Financial & Cyber Fraud Unit were prosecuting the case, the office said. **Topics:** COVID-19, Financial Fraud, Insider Fraud **Categories:** Conviction --- ### [Clayton County Woman Sells Fraudulent Insurance Policy](https://insurancefraud.org/news_archives/clayton-county-woman-sells-fraudulent-insurance-policy/) **Published:** September 24, 2026 **Author:** Diane Beauchamp **Content:** Insurance and Safety Fire Commissioner John F. King announced today that Oluwatosin Oyediran, 21, of Ellenwood, has been charged with insurance fraud and theft by deception. Ms. Oyediran is wanted in connection with a Douglas County case. In November of 2021, Ms. Oyediran sold a fraudulent auto insurance policy to her victim, charging them over $1,500 via mobile transactions in the span of eight months. The victim discovered the policy was fake when attempting to make a claim following an accident. “Neither Ms. Oyediran nor her company, Dirt-Cheap Insurance, are licensed to sell insurance in the state of Georgia,” said Commissioner King. “In fact, our office investigated this fraudulent insurance company last year in connection with a Rockdale County case. In the future, we discourage Georgians from purchasing an insurance policy from Dirt-Cheap Insurance.” To avoid falling victim to these scams, consumers can use our online license lookup tool, or call us at 1-800-656-2298 to find out whether an insurance professional, agency, or company is licensed in Georgia. Warrants were taken out against Ms. Oyediran on January 17th in Douglas County. She is still wanted at this time. **Topics:** Insider - agent, Unlicensed **Categories:** Arrest --- ### [Smaller medical practices increasingly targeted for cyber attacks](https://insurancefraud.org/news_archives/smaller-medical-practices-increasingly-targeted-for-cyber-attacks/) **Published:** September 24, 2026 **Author:** Diane Beauchamp **Content:** Patient data is so valuable — and smaller providers are more vulnerable — that hackers are increasingly targeting physician groups. In the past, breaches were less of a concern for smaller medical practices; hackers seemed content to target large health systems. Unfortunately for those in charge of keeping patient information safe, that’s no longer the case. Patient data is so valuable — and smaller providers are more vulnerable — that hackers are increasingly targeting physician groups. A report1 from the cybersecurity firm Critical Insight found that the number of attacks on physician groups rose from 2% of healthcare attacks in the first half of 2021 to 12% in the first half of 2022. One reason for the increase is the number of attacks on EHR systems through business associates (BAs) and third-party vendors. The BA category accounts for 15% of all breaches, with 74 BA breaches reported to the Office for Civil Rights (OCR) in the first eight months of 2022. Of course, the ramifications for fines, remediation, bad publicity, increased cyber security insurance premiums and credibility loss are the same, regardless of whether hackers gained access to the practice’s system directly or through one of their third parties. There has also been an overall rise in ransomware breaches, in which attackers hold patient data hostage until a ransom is paid. The Verizon 2022 Data Breach Investigations Report2 found an almost 13% rise in ransomware, an increase as large as the last five years combined. Ransomware attacks are, of course, especially troubling for medical facilities, forcing them to cancel patient appointments and scramble to treat urgent needs while wondering when their systems will become available. Many small practices are particularly ill-equipped to deal with a cyberattack. They usually have a small IT staff or outsource that function, and the designated HIPAA security officer [may also be](https://www.hipaajournal.com/hipaa-security-officer/) the practice administrator and designated as the HIPAA privacy officer. IT security may be outsourced, which isn’t necessarily a bad thing, but an emerging cybersecurity situation isn’t the ideal time to test that relationship. ## **The good news** The U.S. Department of Health and Human Services (HHS) is aware of these issues and has been working to provide practices of all sizes with up-to-date cybersecurity information. The Cybersecurity Act of 2015 led to the creation of HHS’s CSA 405(d) program, which aims to help build cybersecurity resiliency across healthcare and public health. The [405(d) website,](https://405d.hhs.gov/) launched in 2021, contains a wealth of information, much of it written in layman’s terms. In addition to a section on why cybersecurity matters, there are: - Descriptions, real-world scenarios, and resources on the top five cyber threats - Health Industry Cybersecurity Practice’s (HICP) 10 best practices - Role-specific resources, including a guide for practitioners and one for small organizations - A bi-monthly newsletter with information on new and emerging cybersecurity threats - Webinars on topics like the Internet of Medical Things security and the legal implications of a cyberattack - Primers such as how to implement patching, cyber workforce development for small practices, how to prepare for/react to/recover from ransomware, and many more - Links to other resources, including the HHS Health Sector Cybersecurity Coordination Center, StopRansomware.gov from the Cybersecurity & Infrastructure Security Agency (CISA), and OCR Speaking of OCR, it has a Health Information Privacy section on its website that [contains](https://www.hhs.gov/hipaa/for-professionals/index.html) detailed information on the HIPAA Privacy Rule (with guidance), the Security Rule, the Breach Notification Rule (with information on breach reporting), the Patient Safety Rule, HIPAA enforcement, HIPAA and telehealth, and BAs (more on this below). There’s also an FAQ page and a section with free training materials and additional resources. ## **The other good news** Strong cyber hygiene is the best defense against cyberattacks — and it’s not all that complex. Hygiene-boosting tasks include patching as soon as patches become available, adopting multi-factor authentication, and conducting both an annual risk assessment and regular penetration tests (these often require help from an outside expert). Although these measures won’t deter the most determined hacker, that’s almost not the point. Hackers want a fast, easy way into your system. If your network doesn’t fill that bill, they’ll abandon their planned attack and move to an easier target. There are two caveats to this: humans and BAs. The 2022 Verizon report found that 80% of breaches involved humans in some way (e.g., social attacks, errors, and misuse). Education is the key to protecting against these types of attacks, which is good news in the sense that it can be done by an outside firm and doesn’t involve complex technology. [Phishing](https://terranovasecurity.com/what-is-spear-phishing/) attempts get more sophisticated all the time, so ongoing education is important for success. Some practices may want to go as far as hiring a company to send (fake) communications to their staff so they can refer those who click on the links for further education. When it comes to BAs, the first order of business is putting someone in charge of understanding [who is](https://www.hhs.gov/hipaa/for-professionals/privacy/guidance/business-associates/index.html) a BA, making sure all BAs have signed a [contract,](https://www.hhs.gov/hipaa/for-professionals/covered-entities/sample-business-associate-agreement-provisions/index.html) tracking renewals for those contracts, and staying up to date on BA-related regulations. The OCR website is a good resource for this part of the process. Next, it’s a good idea to seek assurance that each business associate is aligned with the organization in terms of the risk each BA could introduce to the organization. Associates with peripheral links to a covered entity may not need as stringent due diligence performed as would central BAs who are sharing large amounts of privileged information on a daily basis. Additionally, vendors can seek certifications from trusted organizations like EHNAC and HITRUST to prove their commitment to data safety and stakeholder trust. Certifications are considered the gold standard of assurance around security policies. It’s easy for small practices to become overwhelmed when evaluating cybersecurity risk and working on a strategic plan. A glance at the news shows that cybercrime is a serious issue for healthcare organizations of all sizes. However, with the right resources and a thoughtful plan that leverages the practice’s abilities and uses outside experts to fill in the gaps, lowering a practice’s cybersecurity risk is achievable. **Topics:** Public Awareness, Technology --- ### [Insulet reports data breach affecting 29,000 insulin pump users](https://insurancefraud.org/news_archives/insulet-reports-data-breach-affecting-29000-insulin-pump-users/) **Published:** September 24, 2026 **Author:** Diane Beauchamp **Content:** The data breach occurred when the company requested users acknowledge they had received a notice about a recall of the Omnipod DASH Insulin Management System. Mass.-based medical device company Insulet issued a notice of a data breach that may have compromised the protected health information of 29,000 users of its recently recalled Omnipod DASH Insulin Management System. In November, the FDA [posted a notice](https://www.fda.gov/medical-devices/medical-device-recalls/insulet-recalls-omnipod-dash-insulin-management-systems-personal-diabetes-manager-pdm-risk-battery?utm_medium=email&utm_source=govdelivery) about a [Class I recall](https://www.mobihealthnews.com/news/fda-identifies-insulet-omnipod-dash-battery-recall-class-i) of Insulet’s Omnipod DASH Insulin Management System Personal Diabetes Manager, following complaints about the battery, including swelling, fluid leaking and extreme overheating that may create a fire hazard. The company issued a voluntary device recall one month prior and notified users via an Urgent Medical Device Correction email. In December, Insulet sent a follow-up letter requesting users acknowledge they received a medical device correction letter with a link to a unique webpage that inadvertently exposed IP addresses and whether customers used the DASH system and PDM to website performance and marketing partners. According to a [copy](https://dojmt.gov/wp-content/uploads/Consumer-Notification-Letter-790.pdf) of the letter Insulet sent to customers regarding the data breach, the company said “configuration of web pages used for receipt verification exposed some limited personal information” about customers. Financial information, email addresses, passwords and social security numbers were not disclosed. “We notified customers that some protected health information (PHI) such as use of the Omnipod DASH product and use of a PDM, linked with an IP address, may have been exposed. IP addresses are considered personal identifiers; however, they are linked to the location or the network through which a user connects with the internet and are not necessarily unique to an individual,” a spokesperson for Insulet told *MobiHealthNews* via email. “lnsulet takes this event very seriously. After discovering the privacy incident on December 6, 2022, we disabled all tracking codes on the relevant acknowledgment web page that same day so that no further exposure of PHI could occur. Where possible, we are also requesting that our partners delete logs of the IP addresses and unique URLs so that they would not continue to have access to that information.” Insulet notified the U.S. Department of Health and Human Services of the data breach on Jan. 5, [according to the department’s database](https://ocrportal.hhs.gov/ocr/breach/breach_report.jsf). **THE LARGER TREND** The company launched its Omnipod 5 Automated Insulin Delivery System into the full U.S. market in early August after receiving [FDA 510(k) clearance just one year ago](https://www.mobihealthnews.com/news/insulet-scores-fda-greenlight-omnipod-5-insulin-delivery-system). In November, Insulet released its [2022 Q3 earnings](https://www.mobihealthnews.com/news/talkspace-reports-growing-loss-appoints-new-ceo-and-more-digital-health-earnings), noting the company beat its revenue expectations with $326.1 million, a 23.7% increase in constant currency compared to $275.6 million from last year. Following the DASH recall, the company said it would ship users an updated PDM upon availability, which it said would cost an estimated $35 million to $45 million. The FDA’s recall classification came just days after [the company issued a nationwide voluntary medical device “correction” for its Omnipod 5 controller](https://www.fda.gov/safety/recalls-market-withdrawals-safety-alerts/insulet-issues-nationwide-voluntary-medical-device-correction-omnipodr-5-controller) due to charging port and cable issues. The publicly-traded company received 24 reports that heat generated due to a poor connection between the cable and the port is causing the controller’s charging port or cable to melt or become discolored or deformed. The excess heat can lead to a fire or cause minor burns if a user touches that area of the controller. **Topics:** Public Awareness, Technology --- ### [One Brooklyn Health battling cyber attack that forced some critical services offline](https://insurancefraud.org/news_archives/one-brooklyn-health-battling-cyber-attack-that-forced-some-critical-services-offline/) **Published:** September 24, 2026 **Author:** Diane Beauchamp **Content:** A New York City hospital group has been battling a cyber attack that forced critical services to go offline. The New York Times reports One Brooklyn Health was hit by the attack in late November. Several major hospitals were affected, including Interfaith Medical Center, Brookdale Hospital and Kingsbrook Jewish Medical Center. Work stations used to access medical records, order prescriptions and fill in patient charts were shut down at one point, forcing doctors and nurses to use pen and paper. The FBI is investigating. **Topics:** Public Awareness, Technology --- ### [Nashua man indicted on Medicaid fraud charges](https://insurancefraud.org/news_archives/nashua-man-indicted-on-medicaid-fraud-charges/) **Published:** September 24, 2026 **Author:** Diane Beauchamp **Content:** A Merrimack County Grand Jury has indicted a Nashua man on charges of Medicaid fraud, prosecutors said Tuesday. Attorney General John M. Formella said in a news release Ronald Anderson, 46, of Nashua, has been indicted on charges of theft by deception and Medicaid fraud — false claims in connection with allegedly fraudulent claims for non-emergency medical transportation services. The indictments allege that between July 7, 2020 and Feb. 20, 2022, Anderson fraudulently requested trips through the Medicaid non-emergency medical transportation program related to medical visits that did not exist. Prosecutors claim Anderson acted with the intent to defraud New Hampshire Medicaid, receiving over $1,500 in Medicaid funds in connection with the alleged scheme. Anderson will be arraigned in the Merrimack County Superior Court on a date to be determined. The theft by deception charge carries a maximum penalty of 7 1/2 to 15 years in state prison and a $4,000 fine. The maximum penalty for the Medicaid fraud charge is 3 1/2 to 7 years in jail and a $4,000 fine. **Topics:** Medicare/Medicaid **Categories:** Arrest --- ### [Avoid getting ripped off by a bad contractor promising to fix damages from storm with these tips](https://insurancefraud.org/news_archives/avoid-getting-ripped-off-by-a-bad-contractor-promising-to-fix-damages-from-storm-with-these-tips/) **Published:** September 24, 2026 **Author:** Diane Beauchamp **Content:** We tracked a lot of storm damage across southeast Texas on Tuesday after heavy storms, wind gusts, and tornadoes blew through. So, if your home or business was damaged by the storm, be careful before signing with a contractor promising to fix things. If your home was damaged, you have to get things fixed, but you can avoid getting ripped off by a bad contractor. The state of Texas lists what they call [common scams on its website](https://www.texasattorneygeneral.gov/consumer-protection/home-real-estate-and-travel/how-avoid-home-improvement-scams). They include: - A contractor asking you to sign something agreeing to the work before giving you a written estimate of the repairs. - Do not sign a blank contract that can be filled in later with higher costs. - Do not hire a contractor who says he will waive your deductible of work into the bid. It is illegal for a contractor to waive a deductible or promise a rebate. - Do not give a contractor a large upfront payment or pay in full before the job is done. - It’s a good idea to work with companies you already know or ones recommended by family or neighbors. - Ask to see a contractor’s insurance information. - Be sure to get several estimates before choosing a contractor. Remember, the state does not issue licenses to roofers, but there is an independent licensing organization called the Roofing Contractors Association of Texas. They can help you find a contractor who will do what they promise. **Topics:** Contractor fraud, Public Awareness --- ### [Stockport Council implements anti-fraud measures to protect against false insurance claims](https://insurancefraud.org/news_archives/stockport-council-implements-anti-fraud-measures-to-protect-against-false-insurance-claims/) **Published:** September 24, 2026 **Author:** Diane Beauchamp **Content:** **Stockport Council has introduced anti-fraud measures in a move to protect taxpayers money from illegal insurance claims against the borough.** Since November 2017, the council has stopped £1.2 million of council funds being paid out on false insurance claims. Instead, this money has been used to support important frontline services. The council works closely with legal experts to identify fraudulent claims so that they can be stopped at the earliest point in the claims process. **Cllr Malcolm Allan, Cabinet Member of Finance and Resources at Stockport Council, said:** > “The council has insurance to cover when things go wrong and the vast majority of claims are made in good faith and are processed accordingly. Sadly, we are subject to scams and attempts at fraud like many individuals. Fraud is illegal and those who deliberately make false claims and try to cheat the system are taking valuable funds away from vital Council services, which in turn can see local communities and families suffer.” **Suzanne Milne, Local Government Partner and Head of Casualty Fraud at Weightmans LLP, who assist Stockport Council in identifying insurance fraud, said:** > “The pro-active fraud strategies we adopt with the council demonstrate the commitment of local authorities and the insurance market in protecting public funds. Together we detect, defend, and deter fraudulent claims. > > “It’s not acceptable to lie with the intention of obtaining financial compensation from a council who have to financially fund a significant proportion of claims. There needs to be an awareness of the consequences of this. > > “Dishonest claims for compensation are not victimless crimes, they are incredibly costly to the wider community when much needed public funds are needed elsewhere.” The anti-fraud strategy allows the council to quickly establish potentially fraudulent claims being brought against it, either due to exaggerating the value or circumstances of a claim, using forged evidence or entirely fabricating incidents or losses. **Topics:** Regulatory actions --- ### [LV=GI reports 60% year-on-year uptick in crash for cash linked personal injury claims](https://insurancefraud.org/news_archives/lvgi-reports-60-year-on-year-uptick-in-crash-for-cash-linked-personal-injury-claims/) **Published:** September 24, 2026 **Author:** Diane Beauchamp **Content:** The increase in these claims stem from roads into Scotland, where the UK’s whiplash reform regulation does not apply, says the insurer Personal injury claims in Scotland that are linked to crash for cash incidents increased by 60% between 2021 and 2022, according to LV= General Insurance (LV=GI). Crash for cash events refer to an induced incident where fraudsters target innocent motorists on the road to become the at fault driver in an insurance claim – this can happen by an individual deliberately slamming on their car brakes to ensure the vehicle behind crashes into them, for example. LV=GI believes the rise in crash for crash-related personal injury claims can be linked to the introduction of UK government’s [whiplash reform in May 2021](https://www.insurancetimes.co.uk/news/whiplash-reform-regulation-to-come-into-force-from-31-may/1436600.article) for England and Wales, which included the publication of a tariff table to determine compensation amounts for soft tissue or whiplash injuries. These amounts are lower than prior compensation brackets. The insurer added, however, that these new rules do not apply in Scotland. The M6 route into Scotland has, therefore, become a hotspot for crash for cash criminals. Matt Crabtree, head of fraud strategy at LV=GI, said that “insurance fraud is evolving all the time, with fraudsters continuing to find ways to target innocent motorists for their own financial gain”. He explained that this type of manipulated collision is not only an “extremely dangerous crime”, but it can also have “severe consequences \[for\] victims, including life changing injuries and fatalities”. LV=GI’s findings are based on the totality of its personal injury claims during the past year. ### **Claims ‘menace’** Despite the threat crash for cash scams pose, there is a lack of awareness among UK consumers. For example, according to a YouGov survey conducted on behalf of LV=GI between 19 and 25 August 2021, only 47% of residents in Scotland are familiar with crash for cash fraud. The survey sample included 171 adults in Scotland. Areas that fraudsters are targeting for crash for cash crimes that fork off the M6 include the A70, A74, A75, A76 and M74. These types of accidents have also been identified in the Greater Glasgow area. LV=GI added that it is aware of fraudsters having multiple accidents in the same vehicles but using different identities. One car, for example, was found to have caused a second accident just 12 days after its first attempt. Alastair Ross, head of public policy for Scotland, Wales and Northern Ireland at the ABI, said that “crash for cash criminals are a menace” and the amounts they fraudulently claim can be “huge and impact on the motor premiums paid by honest motorists”. LV=GI said it was “committed” to tackling the problem “at the source” alongside local police forces, as well as working to educate consumers. **Topics:** Auto fraud, Public Awareness --- ### [Reports of fake diplomas in healthcare doubled last year](https://insurancefraud.org/news_archives/reports-of-fake-diplomas-in-healthcare-doubled-last-year/) **Published:** September 24, 2026 **Author:** Diane Beauchamp **Content:** Last year, the Inspectorate for Health and Youth Care received 95 reports of healthcare workers working with a fake diplomas, double the number of the previous year. It also received 11 reports of employees who had falsified their certificate of good conduct (VOG), [RTL Nieuws](https://www.rtlnieuws.nl/onderzoek/artikel/5367007/diplomafraude-zorg-openbaar-ministerie-vervolging) reports. Everyone who works in the healthcare sector, and several other industries, require a VOG. It states that you don’t have a criminal record, among other things. On Thursday, eight former healthcare workers will appear in court on suspicion of providing care without the proper qualifications. The Public Prosecution Service (OM) believes they faked their diplomas and VOG. “These are serious cases because of possible health risks,” the OM told RTL Nieuws. According to the OM, one suspect used a fake diploma from ROC in Amsterdam and a falsified VOG to work with children for several healthcare institutions in the country. With the prosecution of these suspects, the Inspectorate hopes to send a strong signal to fraudsters and healthcare institutions. “False documents in healthcare pose a threat to the quality of care for vulnerable patients.” The Inspectorate also called on healthcare institutions to better check their employees’ documents. These checks are sometimes outsourced to intermediaries or employment agencies. But according to the Inspectorate, “ultimately, the employers themselves remain responsible for that screening.” Minister Conny Helder for Medical Care also called on employers to notify the Ministry and the police if they find an employee is using a falsified diploma. The authorities can’t prosecute these fraudsters if employers don’t file a report. The Inspectorate also wants health and youth care institutions to better use its register of people previously dismissed from healthcare institutions for serious dysfunction. “Last year, employers asked 10,854 times if their applicant had a note. Much less than the number of applications in the healthcare and youth services in a whole year,” the Inspectorate said. **Topics:** Unlicensed entities --- ### [Health data breach impact spikes](https://insurancefraud.org/news_archives/health-data-breach-impact-spikes/) **Published:** September 24, 2026 **Author:** Diane Beauchamp **Content:** Individual patient records impacted by data breaches totaled 28.5 million during the last six months of 2022, the highest on record, compared with 21.1 million in 2019, even though the number of breaches declined between the first and second halves of 2022, [HealthITSecurity](https://healthitsecurity.com/news/35-more-patients-impacted-by-healthcare-data-breaches-in-h2-2022) reports. Most [healthcare data breaches](https://www.scworld.com/news/ransomware/clop-ransomware-hack-of-fortra-goanywhere-mft-hits-1m-chs-patients) were due to hacking, followed by unauthorized data access, theft, loss, and improper data disposal practices, according to a report from Critical Insight. The findings also associated unauthorized data access with the highest number of record exposures per breach, with the increase attributed to three major breaches during the past year, which impacted 5.9 million patients. “Now is a good time for healthcare companies to make sure they are focusing on preparation, detection, and incident response. Companies seeking to improve their cybersecurity posture can do so by building capability internally, or by working with a partner who can provide expert cybersecurity staff and services,” said the report. **Topics:** Public Awareness, Technology --- ### [Advent Health Partners Agrees to $500K Healthcare Data Breach Settlement](https://insurancefraud.org/news_archives/advent-health-partners-agrees-to-500k-healthcare-data-breach-settlement/) **Published:** September 24, 2026 **Author:** Diane Beauchamp **Content:** Advent Health Partners has [agreed](https://adventhealthpartnerssettlement.com/) to pay a $500,000 settlement to resolve a class-action lawsuit stemming from a 2021 healthcare data breach that affected more than 60,000 patients. Advent Health Partners is a healthcare claims review vendor. In September 2021, it discovered suspicious activity within its email environment. Further investigation revealed that an unauthorized party accessed employee email accounts containing patient information, including names, Social Security numbers, driver’s license information, dates of birth, health insurance information, medical treatment information, and financial account information. The plaintiff alleged that Advent Health Partners failed to promptly notify impacted patients about the data breach, taking almost five months to do so, and provided no explanation for the significant delay between the initial discovery of the breach and the eventual notification. The notification delay allegedly violated [the HIPAA breach notification rule requiring organizations to notify patients of healthcare data breaches within 60 days](https://www.techtarget.com/healthtechsecurity/feature/Your-Responsibilities-Under-the-HIPAA-Breach-Notification-Rule). The subsequent lawsuit claimed the delay “resulted in Plaintiff and Class members suffering harm they otherwise could have avoided had a timely disclosure been made.” Besides the lack of timeliness of the notification, the plaintiff had additional concerns about the notice’s lack of detail. According to the class action complaint, “AHP’s notice of the Data Breach was not just untimely but woefully deficient, failing to provide basic details, including but not limited to, how unauthorized parties accessed its networks, whether the information was encrypted or otherwise protected, how it learned of the Data Breach, whether the breach occurred system-wide, whether servers storing information were accessed, and how many customers were affected by the Data Breach.” The lawsuit also alleged that the data breach occurred due to Advent Health Partners’ inadequate data security measures, violating several HIPPA and FTC guidelines. “Defendant disregarded the rights of Plaintiff and Class members by intentionally, willfully, recklessly, or negligently failing to take and implement adequate and reasonable measures to ensure that Plaintiff’s and Class members’ PII was safeguarded, failing to take available steps to prevent an unauthorized disclosure of data,” the lawsuit stated. While Advent Health Partners hasn’t admitted to any wrongdoing, it has agreed to resolve the class action lawsuit via a $500,000 settlement. Class members are eligible for up to $750 in reimbursement for expenses such as out-of-pocket losses, purchased theft insurance products, and lost time dealing with the breach at a rate of $18 per hour. Additionally, class members are eligible to receive three years of credit monitoring. Advent Health Partners has also agreed to implement data security enhancements to increase the protection of private information stored on its computer systems. Following a healthcare data breach, lawsuits have become increasingly frequent and often lead to large settlements. Since the start of 2023, [UMass Memorial Health Center](https://www.techtarget.com/healthtechsecurity/news/366594465/UMass-Memorial-Health-Center-Resolves-Healthcare-Data-Breach-Lawsuit-With-12M-Settlement), [GoodRx](https://www.techtarget.com/healthtechsecurity/news/366593881/GoodRx-Faces-Lawsuit-Over-Alleged-Improper-Health-Data-Sharing-Practices), [Katherine Shaw Bethea (KSB) Hospital](https://www.techtarget.com/healthtechsecurity/news/366594477/IL-Hospital-Reaches-380K-Settlement-to-Resolve-Lawsuit-Over-Healthcare-Data-Breach), [Logan Health](https://www.techtarget.com/healthtechsecurity/news/366594480/Logan-Health-Reaches-43M-Settlement-Following-Healthcare-Data-Breach-Lawsuit), and several others have been hit with large settlements as a result of a healthcare data breach. **Topics:** Public Awareness, Technology --- ### [Clop Ransomware Breaches 130 Organizations, Steals 1 Million CHS Healthcare Patients’ Records](https://insurancefraud.org/news_archives/clop-ransomware-breaches-130-organizations-steals-1-million-chs-healthcare-patients-records/) **Published:** September 24, 2026 **Author:** Diane Beauchamp **Content:** Clop ransomware gang claims to have stolen data from over 130 organizations, including 1 million CHS Healthcare patients. – Advertisement – The extortion gang [told](https://www.bleepingcomputer.com/news/security/clop-ransomware-claims-it-breached-130-orgs-using-goanywhere-zero-day/) *Bleeping Computer* it exploited a zero-day vulnerability in the GoAnywhere MFT secure file transfer tool to exfiltrate data for ten days. The high severity (CVSS v3 7.2) vulnerability [CVE-2023-0669](https://nvd.nist.gov/vuln/detail/CVE-2023-0669) affects unpatched Fortra (formerly HelpSystems) GoAnywhere MFT file transfer instances with internet-exposed administrative consoles. Shodan scans discovered over 1,000 GoAnywhere instances accessible over the internet. ## Clop ransomware gang exploits Fortra GoAnywhere zero-day vulnerability The remote code execution (RCE) vulnerability grants attackers shell access to vulnerable servers allowing them to execute arbitrary code without authentication. The Cybersecurity and Infrastructure Security Agency (CISA) has added the GoAnywhere zero-day flaw to the catalog of known exploited vulnerabilities. This requires federal agencies to patch the vulnerability within one month to prevent the exploitation of government networks. “GoAnywhere MFT contains a pre-authentication remote code-execution vulnerability in the License Response Servlet due to deserializing an attacker-controlled object,” CISA [wrote](https://www.cisa.gov/known-exploited-vulnerabilities-catalog). Meanwhile, Fortra published instructions on disabling the impacted servlet and later released security updates, urging customers to apply the fixes urgently. “We urgently advise all GoAnywhere MFT customers to apply this patch,” Fortra stressed. “Particularly for customers running an admin portal exposed to the internet, we consider this an urgent matter.” The company later disclosed that advanced persistent threat actors had compromised its servers and created rogue user accounts. Clop ransomware had told Bleeping Computer they could move laterally and deploy ransomware, although they decided against it. “Service continues to be restored on a customer-by-customer basis as mitigation is applied and verified within each environment,” Fortra wrote. The attack mirrors the December 2020 Accellion File Transfer Appliance (FTA) data breach that affected approximately 100 organizations. The [incident affected high-profile victims](https://www.cpomagazine.com/cyber-security/accellion-cyber-attacks-explode-as-criminals-exploit-multiple-fta-vulnerabilities/), including energy giant Shell, cybersecurity firm Qualys, Australian Securities and Investments Commission, Canadian aviation company Bombardier, Jones Day Law Firm, retail chain Kroger, Morgan Stanley, Singtel, Stanford University, and the University of California. Healthcare organizations Beaumont Health, Centene, Trinity Health, and Kroger Health also suffered the FTA data breach. The Clop ransomware incident forced Accellion to pay $8.1 million to settle a class action lawsuit accusing the company of failing to implement proper security measures and detect vulnerabilities. ## Fortra GoAnywhere MFT data breach exposes 1 million CHS Healthcare patients Community Health Systems (CHS), an American healthcare operator with nearly 80 hospitals in 16 states, confirmed that threat actors, likely Clop ransomware, had accessed CHS Healthcare patients’ data via Fortra GoAnywhere managed file transfer tool. “As a result of the security breach experienced by Fortra, protected health information and personal information of certain patients of the company’s affiliates were exposed by Fortra’s attacker,” CHS reported in an [8-K filing](https://www.sec.gov/Archives/edgar/data/1108109/000119312523035789/d422693d8k.htm) with the Securities and Exchange Commission. The healthcare provider began investigating the incident to determine if or which protected health information (PHI) and personally identifiable information (PII) was exposed. Although the probe was still in progress, the Franklin, Tennessee-based healthcare provider estimated that the Clop ransomware incident affected approximately 1 million patients. Subsequently, the healthcare service offered complimentary identity theft protection services to impacted CHS healthcare patients. According to its regulatory filing, CHS also anticipates additional costs beyond insurance coverage but does not believe the breach affected its information systems or would disrupt the delivery of patient care. This is the second large-scale data breach to impact CHS healthcare patients in almost a decade. Between April and June 2014, 4.5 million CHS healthcare patients were impacted by a larger data breach attributed to Chinese state-sponsored advanced persistent threat actors. Although the breach did not include protected patient health information, it exposed sensitive CHS Healthcare patients’ personal information, including names, addresses, dates of birth, Social Security Numbers (SSNs), and telephone numbers. In 2019, CHS agreed to pay $5 million to settle a [class action lawsuit](https://www.iowaattorneygeneral.gov/media/cms/CHS_Consent_Judgment_Signed_8A15D39286FC5.pdf) and implement security measures to prevent a similar incident. Commenting on CHS Healthcare patients’ data leak, Almog Apirion, CEO and Co-Founder of [Cyolo](https://cyolo.io/) said: “Healthcare organizations are unfortunately no stranger to cyberattacks and data breaches. Institutions like Community Health Systems (CHS) are an attractive target for threat actors due to their troves of personal information and their reliance on third parties both for cybersecurity and other aspects of their work.” According to Apirion, “it’s only a matter of time” before hackers exploit internet-exposed admin consoles. **Topics:** Public Awareness, Technology --- ### [Insurance scam costs Old Mutual US $90,000](https://insurancefraud.org/news_archives/insurance-scam-costs-old-mutual-us-90000/) **Published:** September 24, 2026 **Author:** Diane Beauchamp **Content:** An alleged insurance scam saw a man from Mutare yesterday in court for allegedly insuring an already damaged motor vehicle and staging a road traffic accident before claiming US$90 000 cash from the Old Mutual Insurance Company. Munyaradzi Ramhewa (31) appeared before Harare provincial magistrate Mr Dennis Mangosi charged with fraud and was remanded on $300 000 bail to March 30. Prosecutor Mr Pardon Dziva alleged that in May last year, Ramhewa approached Henrics Providence Donga and Llyod Makuzwa, who are already on remand, advising them that his VW Touareg with personalised registration number MUBARWE was involved in an accident. He said the vehicle was parked at his house in Mutare and he wanted it repaired. They decided to defraud Old Mutual Insurance Company to pay for the damage and Ramhewa went on to insure the motor vehicle through Reality Njabulo Chuma for US$90 000, although the SUV had already been involved in an accident. The court heard that on 14 August last year, Donga and Makuzwa went to Mutare where they met Ramhewa and staged the accident as if Ramhewa had crashed the car without involving anyone else. They then went to ZRP Mutare Traffic and reported the fake accident and the police attended the scene, with Road Angels Towing Company called to tow away the damaged vehicle. On September 20 last year, Ramhewa made a concocted claim through Chuma, an employee at Bright Insurance Brokers Private Limited, that the motor vehicle was severely damaged on the front, suspension, engine and gearbox. Acting upon the misrepresentation, Old Mutual went on to process the claim for US$90 000. The alleged fraud came to light when Old Mutual discovered that the photos sent by Ramhewa were different from the ones submitted by Road Angels who towed the vehicle from the scene. **Topics:** Auto - padding/false claim **Categories:** Arrest --- ### [A multi-million insurance fraud that preyed on disease, poverty, desperation](https://insurancefraud.org/news_archives/a-multi-million-insurance-fraud-that-preyed-on-disease-poverty-desperation/) **Published:** September 24, 2026 **Author:** Diane Beauchamp **Content:** Officially, Ajit Singh died in a road accident 8km from his village in Haryana’s Rohtak district at 7am on April 1, 2018. It’s what his wife, Satwanti, who claimed to be present on the spot, reported at the Hisar Sadar police station. His nephew, Sachin Dhull, explained the chain of events in his statement to the police: “My uncle, Ajit, and my aunt, Satwanti, had gone to the village Dabra to check out a buffalo for purchase. \[While they were out\] I was informed that a car hit my uncle causing an accident. Driving carelessly and at high speed, the driver of the \[Hyundai\] i-20 car (no: HR 31M 7380) hit my uncle from behind. He died due to the injuries from the accident. I have identified the dead body \[at Civil Hospital, Hisar\]…. I request the police to find the name and address of the driver and initiate legal action.” On April 2, a report on the front page of the newspaper Hisar Kesari laid out more details. “Ajit had climbed down from a bus and had barely taken a few steps when an unidentified vehicle hit him. Ajit dropped down unconscious. The driver fled the scene. Ajit was taken, with the help of people present on the spot, to the hospital where he was declared brought dead. The body has been handed over to his family after a post-mortem examination.” At 10.48am, the officer in-charge at Hisar Sadar station registered an FIR by Satwanti, and charged the unidentified driver under Sections 279 (rash driving) and 304-A (death by negligence) of the Indian Penal Code. Five people known to the deceased identified his body at the mortuary, including his wife, older brother, and nephew. “The body is lying on the stretcher. There is fresh blood on nose and mouth. The chest seems sunk on the right side,” read the panchnama or police’s record of observations. The post-mortem examination conducted at 12pm noted “clotted blood in both nostrils and mouth”, “blue-colour bruise of approximately 10 x 15 cm over right side of chest, multiple rib fractures, laceration of lung tissue” and “multiple abrasions over both foot, elbow, face and forehead”. Signed by the resident medical officer at Civil Hospital, Hisar, the post-mortem report put down the cause of death as “injury to vital organs…sufficient to cause death in ordinary course of life”. That settled the matter. Ajit’s wife and relatives went home. The police moved on. At least 150,000 people are killed in road accidents in India every year. Ajit happened to be just another one — an ordinary end to an ordinary life. Back home, his wife informally married his older brother, Naseeb, in a common turn of event in parts of rural Haryana. They expected no big changes to their life. Except one. Days before he was killed, Ajit had signed up for personal accident insurance policy with at least four companies, at an average premium of ₹5,000. An “accidental death” would entitle his nominee to at least ₹25 lakh from one. In July 2018, Satwanti sent a letter to the ‘claims’ department of Bajaj Allianz. “I am informing you with deep regret that my husband Ajit has died in a road accident. I have attached all documents related to his death. Please initiate the process of compensation.” CONCRETE DOUBT Sometime between 2017 and 2018, many insurance agencies operating in Haryana began to suspect a trend. During that period, Bharti AXA General Insurance received a stream of Personal Accidental Claims from Haryana. There was a strange commonality to them. “The nominee’s bank account was opened just one or two months prior to buying Bharti AXA General Insurance policies. The PAN (Permanent Account Number) card of nominees was also issued just a couple of months before. Interestingly, we found all the insured were farmers and they had never taken any personal accidental policies in past,” said Aman Bedi, associate vice-president, Fraud & Investigation Unit, Bharti AXA. This wasn’t all. “As per medical documents, we observed that all insured died due to head injuries and they were brought dead to the hospital. While scrutinising these cases, we also found three common mobile numbers,” Bedi said. Similar concerns were coming up at Bajaj Allianz. It was receiving “a lot” of cases from “Rohtak and Sonepat” of personal accidents in which the gap between buying of policy and pressing of claim was too close. It had also noticed in the police documents, the absence of eyewitnesses, photos of the accident spots, and injuries suffered by fellow passengers. Executives at Chola MS General Insurance had noticed that in four such claims received by the company in 2017-18 “the deceased were insured for ₹10 lakh each, neither for a higher value, nor for a lower value; the victims were farmers by profession but purchased online policies using credit/ debit cards; and the policies were bought one month prior to the deaths”. Mysteriously, in all the four cases, the victim was riding pillion on a motorbike whose driver lost balance because of the sudden emergence of an animal in front of the vehicle: buffalos in two cases, a bull in one, and an antelope in another. The insurance firms were also noticing that the road accidents killing their clients were being reported at the same police stations in Sonepat, Jhajjar, Hisar and Panipat.sometime in 2017, a private investigator (PI) in Haryana received “19 to 20” cases from “various insurance companies”. He reached out to the families, neighbours, doctors and police officers in each of these cases. No one was willing to talk, but he picked up some information. In 2018, he reported back to the insurance companies saying that he had “concrete doubt” that these deaths weren’t caused by road accidents. These farmers had died of cancer. On April 5, 2019, Bharti AXA filed a complaint with the director general of police in Panchkula, after a year of internal investigations, alleging that a gang of conmen had defrauded the company of crores of rupees. Several other insurance companies followed with similar complaints. The case was handed over to the Special Task Force (STF) of Haryana Police. On April 20, after two weeks of investigation, STF arrested the mastermind of the scam and his two close aides from Sonepat. Everything about the scam sounds strangely unreal. The Haryana-based gang allegedly identified terminal cancer patients from rural, low-income backgrounds, got them to insure themselves with multiple companies by hiding their condition, waited for them to die, and then put their dead bodies through “accidents”. The gang kept a part of the insured sum, between ₹8 and ₹20 lakh in each case, and distributed the rest among its partners in crime: family members, police officers, record keepers, doctors, insurance agents, and public prosecutors. At least 100 people have been accused of being complicit in the scam that allegedly carried on for two years, executed nearly a 100 cases, and cheated more than 25 insurance companies of over ₹100 crore, according to STF. HIT AND RUN In Bhagwatipur village, everyone remembers Ajit Singh, but few are willing to talk about the circumstances of his death. Except for Balwan Dhull, his longtime neighbour who treated him like a younger brother. “He was diagnosed with cancer two or three years before his death. His treatment was going on in PGIMS (Post Graduate Institute of Medical Science, Rohtak),” said Dhull between long drags on his hookah. He said he saw Singh shortly before the latter took his last breath. “At four in the morning, I went to see him. He was feeling uneasy. He asked me to place his cot out under the sky. When I went back at 6 am, he was lying dead. His wife was there.” Then, Dhull said, the “insurancewale” showed up. “They took away his body.unka accident dikha diya \[they showed his death as an accident\].” Dhull saw the dead body again after a few hours. “We were called to the mortuary to identify it. \[This time\] his body had injuries from head to chest.” Like most people close to Ajit Singh, Balwan Dhull knew what was going on. “Paise bana rahe the \[they were making money off it\].” Very little is known yet about the mastermind of the scam. Pawan Kumar Bhoria, 42, was born in Sevali village in Haryana’s Sonepat district. At the time of his arrest, he was living in a rented apartment in a housing society in Kundli on the Delhiharyana border with his wife and two children. After graduating from a Sonepat college and an unfinished course in law from Meerut University, he began to work for insurance agencies. Between 2005 and 2015, he worked in three insurance companies, starting as an agent and moving on to handling cases that went to MACT (motor accident claims tribunal). It was while working at Reliance General Insurance, where he spent eight years, that he got the idea for the scam. “It was a unique strategy, and no one had ever thought of turning deaths into accidents,” he explained to STF. Currently he and his seven-member gang — cousins, nephews, friends — are facing charges under section 201 (destruction of evidence), 205 (false personation for purpose of act or proceeding in suit or prosecution), 34 (common intention), 420 (fraud), 464 (making a false document), 465 (forgery), 468 (forgery for purpose of cheating), and 471 (using forged document) of the Indian Penal Code at Civil Lines police station in Sonepat. Bhoria began the scam in 2015 by contacting the computer operator of the cancer ward of the state’s largest public hospital and buying from him the details of patients going through the last stage of throat cancer. “The gang paid between ₹10,000 and ₹15,000 per file to the operator at PGIMS, Rohtak,” said director general of police Satheesh Balan. The computer operator at PGIMS was arrested on April 21. The institute has expressed “shock” at learning that “someone from PGIMS was also involved.” Dr Varun Arora, public relations officer at PGIMS, said the institute has launched an internal inquiry. “We treat more than a lakh patients per year, and their records are stored across different wards based on the category of ailment.” Armed with the names and addresses of the terminal patients, Bhoria and his gang went to their homes and proposed a lucrative deal. In most of the cases, it was middle-aged men who were about to die of cancer. Bhoria and his aides reminded the family of what they were set to lose with the death of the main working member of the family, and what they could gain if they played their part in the scheme. They wouldn’t have to do much, the gang told the families. Their bank accounts would be opened, the minimum amount put in, their PAN card applications would be submitted, insurance forms filled, even premiums provided for. STF’S investigations into the four cases brought up by Chola MS revealed that “all the insurance policies were purchased through the same IP address, even though the deceased belonged to different districts”. All the family had to do was to say as they were told and to sign, or mark their thumb impressions at the appropriate places. “In many cases, the family members turned down our offers. We used to target at least 50 patients a month out of which only 10 agreed to get insured,” Bhoria told STF. As part of this deal, the patient and their family also permitted Bhoria and his gang to seize control of the dead body and “kill” it in an accident. The most commonly enacted accident was a hit-and-run. “When the patient would die, they would take the body to a spot and crush it with a vehicle to pass it off as an accident,” said KK Rao, inspector general of police in the STF. On April 24, STF arrested Sumit Kumar, the son of a cancer victim who died in December 2018, for filing a false FIR for accidental death of his father. He had filed claims with various insurance companies aggregating to a sum of ₹1 crore. He received ₹2 lakh from the scamsters, according to STF. The police recovered the cash from his house in Ballah village in Karnal district. At times, it was the same car hitting “walking” or “bike-borne” persons in different districts and running away from the spot. “The death of Dharamvir Singh on 11.4.2019 who was from village Kansala and suffered from cancer was shown as being caused by an accident. The car that is supposed to have hit him (HR 11 LL 4100 I-20) belongs to Mohit \[accomplice of Pavan Bhoria\]. In an earlier claim \[received by Bharti AXA\], the accidental death of Sandeep from Uttam Vihar, Rohtak, on 25.11.18. also involved the same car,” noted the FIR. “The dead bodies were carried to the ‘dead house’ even before the police was informed.” The FIR also makes the crucial point that “the investigating officer in both the cases was the head constable Balbir Singh of Civil Lines station, Sonepat”. Occasionally, the terminal patients died a second time from “electrocution”. “This morning at 5.30am my husband Lilaram plugged in a heating rod to warm water for his bath. When I came back from the fields after feeding our cattle, he was lying face down on the bathroom floor. My relatives took his body to Civil Hospital in Jhajjar where he was declared brought dead. My husband died from electric current,” wrote Babli from Ahri village in Jhajjar district in her statement to the police on September 25, 2017. She repeated this account in her letter of claim to Bharti AXA, emphasising that “my husband had no previous illness” and “his death has left me in charge of our two children”. As attachments, she provided a joint statement by her neighbours and relatives confirming that “Lilaram’s death happened from electric current” and that he “had no previous illness”, a report from Civil Hospital, Jhajjar, noting his “abrasions and blisters”, and police inquest papers showing “death due to electrocution”. Lilaram had suffered from the last stage of throat cancer, according to a copy of his case file in Radiation Centre of PGIMS, Rohtak. While the computer operator had either sold or destroyed the original records, some copies remained in certain departments where the treatment was going on. They were found by the officers of STF when they went to the PGIMS for a raid. The 40-year-old farmer didn’t die of electric current. As KK Rao put it, “None of the eight patients whose investigation was conducted by the police had met with an accident or suffered external injuries.” THE MISSING MANDIBLE After the dead bodies of the cancer patients were given injuries through accidents, STF officers said the insurance conmen informed the police officers with whom they had already struck a deal. Bhoria had cultivated his contacts in Haryana Police through a head constable, Ashok Kumar, 30, at Kundli police station in Sonepat who happened to be an old friend of his. “In 2015, Bhoria contacted Ashok and discussed his plan and asked for help. Ashok used to contact the IOS (investigation offcers) and convince them to join hands with Bhoria,” said IGP Satheesh Balan of STF. Ashok Kumar was arrested on April 29. “They offered ₹1 lakh to each investigating police officer,” said Balan. Their role was to transfer the version of their death by accident to paper – from FIR to witness statements to record of observations submitted for post-mortem examination. The post-mortem examiners were paid too, said Balan, for mapping the police’s observations of the accident on to the medical assessment of the bodies. “They offered ₹1.75 lakh to the doctor who conducted the post-mortem examination,” he said. None of the doctors who conducted the postmortem examination in the eight cases brought up by Bharti AXA and investigated by STF used the C word. “There are external changes in the patients of throat cancer because they go through mandatory radiotherapy,” said Dr Niranjan Naik, cancer specialist at the Fortis Memorial Research Institute. “There is visible thickening and discolouration of the skin on their face and neck,” he said. The suspicion of throat cancer wasn’t signalled even in the case where a part of the jaw was missing in the dead body brought for postmortem examination at PGIMS, Rohtak. Ramshreshth Sahni, 38, of Ajmer Basti in Jind district died on July 4, 2017 in a road accident at 10.30 pm according to the FIR lodged at Hisar Sadar station. On June 9, 2017 the farm worker had bought a “premium personal guard policy” from Bajaj Allianz with an insured sum of ₹25 lakh. His body was taken to the PGIMS. “The \[post-mortem\] report said that ‘a skin defect of size 8 x 6 cm is present on the left Anterolateral aspect of Neck, a linear old healed scar is also visible, and a portion of the Jaw bone is missing at the left angle of Mandible’,” said Sanjiv Dwivedi, who heads the Investigation and Loss Mitigation at Bajaj Allianz. Suspicious, he and his team went to the PGIMS asking if the hospital has any previous treatment records for Sahni. “The hospital refused to share them with us.” Upon filing a Right To Information (RTI) application for procurement of the deceased’s health-related documents, “the hospital denied the request mentioning the confidentiality of the document,” he said. “When we approached the post-mortem department of the hospital with queries related to the missing mandible and the scar, the doctors refused to entertain us.” The police was no more forthcoming. “Our team visited the Rohtak police station multiple times to get details of the accident but no one provided any details. They told us it was a hit-and-run case by an unknown vehicle. There was no eyewitness in the case. The accident details were missing and a body part was also missing,” Dwivedi said. Dwivedi and his colleagues went to Sahni’s village to ask around. His landlord had a different story to tell. “Ramshreshth Sahni from Bihar was my tenant for 10 years. He died in July 2017 in the course of his treatment for cancer at PGIMS,” Rishipal wrote in a statement made to Bajaj Allianz. At the local Anganwadi centre, the team found in death records of village residents the “cause” for Ramshreshth Sahni’s demise: cancer. His wife, Renu Sahni, said she wasn’t aware that his death was shown as accidental. She said it was an insurance agent who had dealt with the documents. “We have arrested people who had major stakes, and others will be arrested soon. We are focusing on the doctors who are involved in multiple post-mortems and the policemen who were involved in more than one case,” said Haryana’s director general of police (DGP), Manoj Yadava. STF is currently looking into the suspected participation of 12 police officers and 10 government doctors in the scam. On April 21, STF arrested the computer operator at Civil Hospital, Sonepat, Pramod Kumar, for enabling the collusion between the conmen and the doctors who conducted the post-mortem examinations. On April 30, Ambuj Jain, a doctor at the same hospital who had conducted the postmortem examinations in some of the cases under investigation, moved a petition for anticipatory bail. Ashwani Kumar, principal medical officer, refuted all allegations concerning Civil Hospital, Sonepat. “The main culprits are the police and the family members. They should be arrested in this case, not the doctors. If an accident case is brought to the doctor for post-mortem examination, he will have to conduct it. A doctor’s job is to check the injuries causing death and submit the report based on the injuries found on the body,” he said, adding that if the police arrested a single doctor, all of them would go on a strike. However, STF officers said they have enough substance to frame charges against doctors who worked in collusion with the gang. “There are call records, witnesses and statements which prove them guilty,” said Balan. After receiving the complaint from Aman Bedi of Bharti AXA, STF began to tap phone calls between members of the gang. “The complainant had provided the mobile numbers of the suspects and we started intercepting three mobile numbers,” said KK Rao. The conversations noted in the FIR demonstrate the coordination between various players in the scam: ■ “In code word, Mohit is talking about a case in which someone’s throat is getting worse and his PAN card needs to be applied for.” ■ “Pawan is talking to Padam, saying that policy is done with PNB, Reliance, SBI and LIC. He says ICICI, HDFC and Birla are left to do.” ■ “They are talking about a police officer asking for an additional ₹20,000. They are saying they have settled the payment with the hospital.” Aware of the inquiries being made about them, Bhoria is also heard as telling one of his colleagues that “we will put in ₹2 crore and have the DSP transferred”. As investigations proceed, more people appear to be involved in the scam than what was originally suspected. “If any case gets stuck, they used to bribe the investigation agent of the private insurance company and ask him to submit a report in their favour. If any claim went to the court, they paid the public prosecutor,” said Balan. “If anyone has submitted the positive report for any such a fraud case, we will support the police and will demand stringent punishment,” said Dwivedi of Bajaj Allianz. “This is a big case, but we will make sure no one walks away,” said DGP Yadava. MINIMUM GAINS It was an ingenious scam, but also one that relied on the easy corruptibility of people in charge of the lives and deaths of poor and illiterate villagers. In fact, it began with bringing them on board. Not all conspiring families have ended up richer. Some of them claim not to know what they did was illegal. “My nephew did as he was told by Pawan, which was to call him up after the death of his father and to bring his body to Sonepat Civil Hospital where he had already managed to show it as an accidental death in collaboration with the doctor and the police,” said Mukesh Mann, a 43-year-old farmer in Ballah village. His nephew, a student at the local Industrial Training Institute, was arrested by STF for filing a false FIR about the death of his father. Sachin Dhull,26, nephew of Ajit Singh from Bhagwatipur and prime witness of his death by accident, says his uncle died of cancer. “The insurance agent had asked me to inform him after his death so we called him on April 1, 2018. They asked us to come to Civil Hospital, Hisar, as they had to get the post-mortem examination done for the insurance claim,” he said. Sachin said he signed the documents because he was told they were needed to complete the legal formalities to initiate the insurance claim. He didn’t read any of them before signing. He said it was the insurance agents who presented his uncle’s death as accident-related. “It’s wrong if they are saying that I was involved in any kind of fraud as I don’t even have any cheque book or ATM card of any account. The account was opened by them,” he said. Sachin said he is currently unemployed and struggling to get by. Ajit Singh’s wife, Satwanti, died in April. Balwan Dhull said she had been suffering from AIDS. Her account with YES bank in Rohtak has only ₹11, 357 —just a little more than the minimum amount deposited at the time of its opening. **Topics:** Insider - agent, Life Insurance **Categories:** Arrest --- ### [January 2023 Healthcare Data Breach Report](https://insurancefraud.org/news_archives/january-2023-healthcare-data-breach-report/) **Published:** September 24, 2026 **Author:** Diane Beauchamp **Content:** January is usually one of the quietest months of the year for healthcare data breaches and last month was no exception. In January, 40 data breaches of 500 or more records were reported to the HHS’ Office for Civil Rights, the same number as in December 2022. January’s total is well below the 53 data breaches reported in January 2022 and the 12-month average of 58 data breaches a month. [![](https://www.hipaajournal.com/wp-content/uploads/2023/02/jan-23-healthcare-data-breach-report-breaches-12-months.jpg)](https://www.hipaajournal.com/wp-content/uploads/2023/02/jan-23-healthcare-data-breach-report-breaches-12-months.jpg) For the second successive month, the number of breached records has fallen, with January seeing just 1,064,195 healthcare records exposed or impermissibly disclosed – The lowest monthly total since June 2020, and well below the 12-month average of 4,209,121 breached records a month. [![](https://www.hipaajournal.com/wp-content/uploads/2023/02/jan-23-healthcare-data-breach-report-records-12-months.jpg)](https://www.hipaajournal.com/wp-content/uploads/2023/02/jan-23-healthcare-data-breach-report-records-12-months.jpg) ## Largest Healthcare Data Breaches in January 2023 In January there were 13 data breaches involving 10,000 or more records, 8 of which involved hacked network servers and email accounts. The largest [HIPAA compliance](https://www.hipaajournal.com/hipaa-compliance-checklist/) data breach of the month affected Mindpath Health, where multiple employee email accounts were compromised. 5 unauthorized access/disclosure incidents were reported that impacted more than 10,000 individuals, three of which were due to the use of tracking technologies on websites. The tracking code collected individually identifiable information – including health information – of website users and transmitted that information to third parties such as Google and Meta, including the month’s second-largest breach at BayCare Clinic. Another notable unauthorized access incident occurred at the mobile pharmacy solution provider, mscripts. Its cloud storage environment had been misconfigured, exposing the data of customers of its pharmacy clients on the Internet for 6 years. | **HIPAA-Regulated Entity** | **State** | **Covered Entity Type** | **Individuals Affected** | **Cause of Breach** | |---|---|---|---|---| | Community Psychiatry Management, LLC (Mindpath Health) | NC | Healthcare Provider | 193,947 | Compromised email accounts | | BayCare Clinic, LLP | WI | Healthcare Provider | 134,000 | Impermissible disclosure of PHI due to website tracking technology | | DPP II, LLC (Home Care Providers of Texas) | TX | Healthcare Provider | 125,981 | Ransomware attack (data theft confirmed) | | Jefferson County Health Center (Jefferson County Health Department) | MO | Healthcare Provider | 115,940 | Hacked network server | | UCLA Health | CA | Healthcare Provider | 94,000 | Impermissible disclosure of PHI due to website tracking technology | | mscripts®, LLC | CA | Business Associate | 66,372 | PHI exposed due to misconfigured cloud storage | | Circles of Care, Inc. | FL | Healthcare Provider | 61,170 | Hacked network server | | Howard Memorial Hospital | AR | Healthcare Provider | 53,668 | Hacked network server | | Stroke Scan Inc | TX | Healthcare Provider | 50,000 | Hacking Incident – No public breach announcement | | University of Colorado Hospital Authority | CO | Healthcare Provider | 48,879 | Hacking incident at business associate (Diligent) | | Insulet Corporation | MA | Healthcare Provider | 29,000 | Impermissible disclosure of PHI due to website tracking technology | | City of Cleveland | OH | Health Plan | 15,206 | Unauthorized access/disclosure incident – No public breach announcement | | DotHouse Health Incorporated | MA | Healthcare Provider | 10,000 | Hacked network server | ## Causes of January 2023 Healthcare Data Breaches Just over half of the 40 data breaches reported in January were hacking/IT incidents, the majority of which involved hacked network servers. Ransomware attacks continue to be conducted, although the extent to which ransomware is used is unclear, as many HIPAA-regulated entities do not disclose the exact nature of their hacking incidents, and some entities have not made public announcements at all. Across the 23 hacking incidents, the records of 698,295 individuals were exposed or stolen. The average breach size was 30,61 records and the median breach size was 5,264 records. [![](https://www.hipaajournal.com/wp-content/uploads/2023/02/january-2023-healthcare-data-breach-report-causes.jpg)](https://www.hipaajournal.com/wp-content/uploads/2023/02/january-2023-healthcare-data-breach-report-causes.jpg) There was an increase in unauthorized access/disclosure incidents in January, with 15 incidents reported. The nature of 7 of the unauthorized access/disclosure incidents is unknown at this stage, as announcements have not been made by the affected entities. 5 of the 15 incidents were due to the use of tracking technologies on websites and web apps. Across the 15 unauthorized access/disclosure incidents, 362,629 records were impermissibly accessed or disclosed. The average breach size was 24,175 records and the median breach size was 3,780 records. There were two theft incidents reported, one involving stolen paper records and one involving a stolen portable electronic device. Across those two incidents, 3,271 records were stolen. No loss or improper disposal incidents were reported. [![](https://www.hipaajournal.com/wp-content/uploads/2023/02/jan-23-healthcare-data-breach-report-location-phi.jpg)](https://www.hipaajournal.com/wp-content/uploads/2023/02/jan-23-healthcare-data-breach-report-location-phi.jpg) ## Where Did the Data Breaches Occur? Healthcare providers were the worst affected HIPAA-covered entity with 31 reported data breaches and 5 data breaches were reported by health plans. While there were only 4 data breaches reported by business associates of HIPAA-covered entities, 14 data breaches had business associate involvement. 10 of those breaches were reported by the covered entity rather than the business associate. The chart below shows the breakdown of data breaches based on where they occurred, rather than which entity reported the breach. [![](https://www.hipaajournal.com/wp-content/uploads/2023/02/jan-23-healthcare-data-breach-report-breaches-entity.jpg)](https://www.hipaajournal.com/wp-content/uploads/2023/02/jan-23-healthcare-data-breach-report-breaches-entity.jpg) The chart below highlights the impact of data breaches at business associates. 23 data breaches occurred at health plans, involving almost 275,000 records. The 14 data breaches at business associates affected almost three times as many people. [![](https://www.hipaajournal.com/wp-content/uploads/2023/02/jan-23-healthcare-data-breach-report-records-entity.jpg)](https://www.hipaajournal.com/wp-content/uploads/2023/02/jan-23-healthcare-data-breach-report-records-entity.jpg) ## Geographical Spread of January Data Breaches California was the worst affected state with 7 breaches reported by HIPAA-regulated entities based in the state, followed by Texas with 6 reported breaches. January’s 40 data breaches were spread across 40 U.S. states. | **State** | **Breaches** | |---|---| | California | 7 | | Texas | 6 | | Georgia, Massachusetts, Missouri & Pennsylvania | 3 | | Florida, New York & North Carolina | 2 | | Alabama, Arkansas, Colorado, Illinois, Indiana, Minnesota, New Jersey, Ohio & Wisconsin | 1 | ## HIPAA Enforcement Activity in January 2023 The Office for Civil Rights announced one [settlement](https://www.hipaajournal.com/diagnostic-lab-settles-medical-record-access-case-for-16500/) in January to resolve potential violations of the HIPAA Right of Access. OCR investigated a complaint from a personal representative who had not been provided with a copy of her deceased father’s medical records within the allowed 30 days. It took 7 months for those records to be provided. Life Hope Labs agreed to pay a $16,500 financial penalty and adopt a corrective action plan that will ensure patients are provided with timely access to their medical records in the future. This was the 43rd penalty to be imposed under OCR’s HIPAA Right of Access enforcement initiative, which was launched in the fall of 2019. No HIPAA enforcement actions were announced by state attorneys general in January. **Topics:** Public Awareness, Technology --- ### [Hurt woman sentenced for Social Security fraud](https://insurancefraud.org/news_archives/hurt-woman-sentenced-for-social-security-fraud/) **Published:** September 24, 2026 **Author:** Diane Beauchamp **Content:** A Hurt woman, who stole more than $170,000 in Social Security Administration retirement funds to which she was not entitled, was sentenced in federal court just three months after her mother was sentenced on related charges. In November 2022, Christy Bowling, 38, pled guilty to concealment of bankruptcy assets and theft of government money. Last week, she was sentenced to two months in federal prison and one year of home detention. Bowling’s mother, Judith Cash, 58, of Shipman, pleaded guilty in May 2022 to one count of theft of public money and was sentenced to one year of home detention. According to court documents, in August 2020, Betty Gowen, who had been incarcerated since 2011 for the murder of her husband, contacted the Social Security Administration (SSA) to apply for Title II Retirement Insurance Benefits upon her release from prison. When SSA officials received Gowen’s application, it was revealed that her daughter, Judith Cash, and granddaughter, Christy Bowling, had already applied for and had been receiving Gowen’s SSA Retirement Benefits since 2010. Cash and Bowling had been using the funds through a shared bankcard. SSA determined that Cash and Bowling stole $172,952 and the court has ordered them to pay this amount back in restitution. United States Attorney Christopher R. Kavanaugh of the Western District of Virginia and Gail S. Ennis, Inspector General for the Social Security Administration, made the announcement. The Social Security Administration investigated the case. Assistant U.S. Attorney Charlene R. Day prosecuted the case. **Topics:** Social Security fraud **Categories:** Conviction --- ### [Car lease scam: how to spot fake leasing deals as criminals target drivers with bad credit](https://insurancefraud.org/news_archives/car-lease-scam-how-to-spot-fake-leasing-deals-as-criminals-target-drivers-with-bad-credit/) **Published:** September 24, 2026 **Author:** Diane Beauchamp **Content:** Criminal gangs are using the cost of living crisis to rip off unsuspecting [motorists](https://www.nationalworld.com/topic/motorists) looking for cheap leasing deals. Car lease specialists have warned that [scammers](https://www.nationalworld.com/topic/scammers) are using [social media platforms](https://www.nationalworld.com/topic/social-media) such as Instagram to target vulnerable motorists with too-good-to-be-true [finance](https://www.nationalworld.com/lifestyle/cars/car-finance-explained-from-pcp-to-hp-the-different-payment-options-and-what-the-jargon-means-3352192) deals which ultimately leave victims out of pocket. Fraudsters offer [brand new cars](https://www.nationalworld.com/topic/car-reviews) with lease deals and payment plans far below standard market rates and particularly target [drivers](https://www.nationalworld.com/topic/drivers) with little or poor credit history by offering deals without any credit checks. They trick drivers into providing bank details or making deposit payments for the non-existent vehicles, leaving victims worse off and without a car. Similar frauds have been used to [target drivers looking for cheap car insurance](https://www.nationalworld.com/lifestyle/cars/ghost-broking-car-insurance-scam-explained-how-to-spot-the-signs-of-3865495) as the cost of running a car has soared over recent years. These schemes see fake brokers or insurers take payment for fraudulent policies and target motorists who traditionally face higher premiums, such as newly qualified drivers. Keith Hawes, director of Nationwide Vehicle Contracts, commented: “When it comes to car leasing, most major brokers and automobile dealers are trustworthy, but like any type of business, it’s easy for customers to fall for genuine-looking scams. “If you’re suspicious about a business, then it’s always best to err on the side of caution. Scams are becoming increasingly sophisticated, so if something sounds too good to be true, it probably is, particularly if rates are hugely reduced compared to the rest of the market.” To help drivers avoid such scams, Keith’s team identified a suspected fraudulent operation online and has used it to [highlight the warning signs](https://www.nationwidevehiclecontracts.co.uk/blog/top-tips-to-help-protect-you-against-online-financial-scams), as well as what you can do to protect yourself. ## **How to spot an online leasing scam** Key giveaways include: - Too good to be true offer – any legitimate lender or broker will run credit check on potential customers, so the offer of leasing without the need for a credit check is a red flag - Limited contact details – the company doesn’t have a functioning websiteand the only contact details are a Whatsapp number - No search results – when searching for the business name online, there were no reviews as claimed on the account and the only search record was the Instagram account - The images of cars posted on the account were all taken from the internet and had appeared on multiple other sites in the past. Experts were able to check this by reverse image searching on Google - There was no record of the business name on the FCA and Companies House websites ## **How to avoid being a victim** One of the most obvious giveaways of a scam lease firm is a lack of official records. Reputable car leasing companies who deal with regulated customers must register with certain organisations, including the Financial Conduct Authority. Any legitimate firm should appear on the Financial Services Register, which holds details of every financial company registered and regulated by the FCA. You should be able to see their credentials by entering their name or postcode into the website. If a company offers financial services or associated products but not registered with the FCA, you should avoid using them. You can also confirm if a company is registered with the British Government by searching for a company’s details on the Companies House website. Whilst it is not a legal requirement to join a trade body site, you can often use sites like the British Vehicle Rental and Leasing Association (BVRLA) or the Finance and Leasing Association (FLA) to help verify a car leasing company. If you’re worried that contact from a company isn’t genuine, it’s worth running additional checks to avoid cold callers. Treat all unexpected calls, emails and text messages with caution. Don’t assume they’re genuine, even if the person seems to know some basic information about you. Always double-check the website URL and contact details of a firm to make sure they’re not a “clone firm” pretending to be a real firm and check for the SSL green padlock in your browser. Finally, verify the contact details on the FCA register to ensure you call the business’s genuine phone number. Finally, if you think you’ve been approached by an unauthorised or a clone firm (a firm you suspect isn’t legitimate) contact the FCA Consumer Helpline on 0800 111 6768 and report it to Action Fraud online or by calling 0300 123 2040. Keith adds: “Ultimately, you should feel 100% comfortable before entering into an agreement with a leasing provider. If something doesn’t feel right, trust your instinct and run additional checks. If you use an unauthorised firm, you won’t have access to the Financial Ombudsman Service or Financial Services Compensation Scheme (FSCS), so you’re unlikely to get your money back if things go wrong.” **Topics:** Auto fraud, Public Awareness --- ### [Woman in South Korea nabbed after staging road accidents, faking pregnancy to get sympathy](https://insurancefraud.org/news_archives/woman-in-south-korea-nabbed-after-staging-road-accidents-faking-pregnancy-to-get-sympathy/) **Published:** September 24, 2026 **Author:** Diane Beauchamp **Content:** Police in South Korea arrested a woman in her 30s suspected of deceiving drivers into believing she was hit as a pregnant pedestrian at least 103 times. The police in the Wansan district of Jeonju city, about 200km south of capital Seoul, said they were investigating traffic accident fraud cases involving a woman who was suspected to have received at least 27 million won (S$27,900) from drivers and insurance companies. She deliberately made contact with passing cars using her wrist or ankle, police said on Monday. The fake accidents had been occurring since October 2018 across South Korea, in locations across the cities of Jeonju, Gwangju and Busan. The police discovered the woman’s fraudulent activity while investigating a traffic accident in Jeonju last October. They discovered that the suspect pretended to be pregnant to gain the sympathy of her scam victims and mainly targeted drivers who were women. Victims of the scams also reported that the woman had suggested private settlements so they could avoid making police reports and more scrutiny. The woman was using the money she received as compensation from the drivers for her living and entertainment expenses, according to police. **Topics:** Auto - staged **Categories:** Arrest --- ### [Using AI and data analytics to fight insurance fraud](https://insurancefraud.org/news_archives/using-ai-and-data-analytics-to-fight-insurance-fraud/) **Published:** September 24, 2026 **Author:** Diane Beauchamp **Content:** IN 2021 in Singapore, 17 people were rounded up in a series of police operations to expose fraudulent and staged motor accidents. Five men were charged in April 2022 over their suspected involvement in motor insurance fraud. For some, the nefarious act is worth it: fraudsters can reportedly earn up to S$20,000 a month. The impact on the industry is vast. The General Insurance Association of Singapore (GIA) has found that some 20 per cent of all incurred motor claims in Singapore are fraudulent. In Malaysia, motor insurance fraud cases cost the industry an estimated 1 billion ringgit a year. One of the reasons road touting, or the business of inflating claims (which includes scouts, workshop operators who overcharge for repairs, and surveyors who endorse high repair fees), is so lucrative is that it has been difficult so far for insurers to detect fraud. However, the increasing digitalisation of the motor claims process and technological advances are changing that scenario. Artificial intelligence (AI) is being applied to the assessments process in various ways, from replacing the surveyor who visually scans photos or videos of the scene to assess claims to more conventionally interrogating vast amounts of motor insurance claims data to detect patterns and relationships that humans are not easily able to identify. For example, AI checks the veracity of a motor insurance claim by cross-referencing the information submitted on the claim, detecting inconsistencies or red flags like whether a specific type of vehicle is more frequently involved or if a particular repair shop is making a higher number than usual of claims. The AI filters motor insurance claims that require further investigation by flagging the claims that do not comply with pre-programmed approvals decision criteria. For instance, it can compare the date of the accident to the date of the claim, cross-referencing the policyholder’s location at the time of the accident. If a discrepancy is detected, the claim is flagged for further investigation. Some AI tools can outperform others simply due to the volume and quality of collected data. An aggregator for eClaims (a company that provides eClaims software to multiple insurers) would have a far bigger data pool that the AI can tap – the aggregator processes thousands of motor claims made daily. From their vast swaths of data, the AI can more easily cross-reference claims to identify patterns that potentially can lead to a fraud case. For instance, if a motor insurance claim is submitted for a vehicle that is reported stolen, the AI would easily identify the discrepancy from cross-referencing the claim against police reports. In automating their manual claims processes, insurers now have access to better, more accurate insights that are delivered in real time. That gives them time to effectively explore and prevent fraudulent claims, protecting the insurer and the industry from financial loss. Such technology is rebuilding trust between insurers and their customers, who are often the unwitting victims of road touting and claims insurance fraud. **Topics:** Public Awareness, Technology --- ### [North Korean hackers stole a record $2.7b of crypto last year](https://insurancefraud.org/news_archives/north-korean-hackers-stole-a-record-2-7b-of-crypto-last-year/) **Published:** September 24, 2026 **Author:** Diane Beauchamp **Content:** [Few forms](https://www.economist.com/asia/2023/02/22/north-korean-hackers-stole-a-record-17bn-of-crypto-last-year) [of celebration are as close to literally burning money as fireworks and missile tests.](https://www.economist.com/asia/2023/02/22/north-korean-hackers-stole-a-record-17bn-of-crypto-last-year) And for North Korea, a great fan of both, the more it burns the better. It launched more than 95 cruise and ballistic missiles in 2022, a new record. And it loves above all to splurge on the biggest, showiest rockets, like the intercontinental ballistic missile it fired eastwards into the sea on February 18th. Despite being unable to feed its people, North Korea has found innovative ways to fund its missiles programme, including by forging foreign currency, committing insurance fraud and making and selling arms and narcotics. A more novel revenue stream is stolen cryptocurrency. Last year its hackers pinched a record US$1.7 billion (NZ$2.7b) of the stuff, according to a report published this month by Chainalysis, a data firm based in New York. Some of North Korea’s hacking thefts were eye-wateringly big. Last March it ripped off a cross-chain bridge, a method for moving cryptocurrency from one coin’s blockchain to another, associated with the game Axie Infinity. At the time it was discovered, the stolen currency was worth more than $600m, making it the second-biggest crypto-theft ever. But as with all heists, the robbery is just the first step. To launder their loot North Korean hackers employ all sorts of tricks, including splitting up the money, moving it between different crypto-wallets, converting it into different coins and putting it through mixers–large digital pools where crypto owners can deposit funds to obscure their origins. Some of the stolen crypto was put to direct use. In 2022 two South Koreans, including an army captain, were arrested on suspicion of selling secrets to the North in return for bitcoin. But North Korean hackers mostly try to turn the loot into hard cash, either through a broker or more commonly through a centralised exchange. The fiat currency obtained is then used to purchase items through established procurement channels, run through front companies and North Korea’s embassies abroad. Most of the hacking-and-laundering operation is visible to expert eyes, however. “This isn’t happening in some shadowy corner of the world,” says David Carlisle of Elliptic, another blockchain-analysis company. “It’s happening in public on the blockchain.” This helps investigators trace funds and understand hacking methods–and they are getting better at doing both. America has blacklisted crypto-wallets associated with North Korean hackers. In May it targeted Blender.io, a mixer used in the Axie Infinity hack. In September American investigators recovered $30m of cryptocurrency stolen in that hack. Given a drop in the value of cryptocurrency after the heist, that represented about 10% of the total. On February 16th Norwegian authorities seized another $5.8m. But countries should adopt more stringent measures, argues Allison Owen of the Royal United Services Institute, a London-based think-tank. “Most hacks begin with relatively unsophisticated phishing attacks. Better regulation of the industry and cyber-hygiene could help prevent them.” The crypto industry is meanwhile getting better at policing itself. On February 14th two centralised exchanges, Binance and Huobi, froze $1.4m of cryptocurrency associated with a North Korean hack. The hackers are also adapting and improving. “It is a bit of a game of whack-a-mole,” says Carlisle. Even if North Korea’s hackers could actually lay their hands on only a fraction of the $1.7bn they stole, it would all be worthwhile, notes Dennis Desmond, a former American intelligence officer who now teaches at the University of the Sunshine Coast in Australia. “It’s all free cheese,” he says. Desmond foresees a continuing “arms race” in theft and counter-theft capability between the hackers and crypto-crimefighters. If the crimefighters could only get the upper hand, it might help to slow the actual arms race, illuminated by a blaze of ballistic missiles, taking place on the Korean peninsula. **Topics:** Public Awareness, Technology --- ### [South Plainfield health care provider ordered to repay $1 million in Medicaid overpayments](https://insurancefraud.org/news_archives/south-plainfield-health-care-provider-ordered-to-repay-1-million-in-medicaid-overpayments/) **Published:** September 24, 2026 **Author:** Diane Beauchamp **Content:** A South Plainfield man who works as a behavioral health provider has been ordered by the state to repay Medicaid more than $1 million for improperly billing the program. John Gore, a licensed drug and alcohol counselor at Clear Conscience Counseling on Park Avenue in South Plainfield, also allowed behavioral assistants to provide services to minors in one-on-one settings without conducting criminal background checks on the staffers, an audit by the Office of the State Comptroller (OSC) found. The audit determined that Gore improperly billed and received Medicaid payments of $1.1 million. The audit also found Gore failed to comply with state regulations in about a third of claims the State Comptroller’s office sampled. The OSC also found Gore billed for unsubstantiated services, maintained inaccurate and incomplete records and failed to ensure that his providers had current and valid drivers’ licenses before allowing them to provide services to Medicaid patients, according to a [news release from the agency](https://nj.gov/comptroller/news/2023/20230223.shtml). Other deficiencies discovered in the audit include Gore assigned cases to behavioral assistants without confirming they had the required professional licenses. The audit found that six did not. Gore also failed to ensure that behavioral assistants had the required training certifications and the audit discovered 24 did not, according to the agency. As a result of the audit’s findings, OSC has urged the New Jersey Division of Medicaid Assistance and Health Services (DMAHS), part of the Department of Human Services, to issue a rule requiring intensive in-community (IIC) providers to undergo fingerprint background checks before being allowed to treat children and young adults. IIC providers are now required to obtain criminal background checks of behavioral assistants, but there is no government oversight to enforce that requirement and no requirement for a fingerprint check, according to the OSC. “It’s standard practice for teachers, doctors, coaches, and many others who work with children to undergo fingerprint checks. Children who are in these Medicaid-funded community programs are entitled to the same protection,” Josh Lichtblau, director of OSC’s Medicaid Fraud Division, said in the release. In November 2021, the State Comptroller’s office notified DMAHS about flaws in the regulations and the risks they posed to children. Almost a year later, in September 2022, DMAHS told providers that they should contact the state’s Children’s System of Care to initiate fingerprint background checks, but it left the responsibility for compliance on the provider. DMAHS proposed a new rule in January that did not address the fingerprint requirement and state oversight. “Our findings are serious. When providers fail to ensure that employees have clean criminal backgrounds, they’re placing vulnerable children in potentially unsafe circumstances,” said Lichtblau. “The state should work quickly to close this gap in oversight.” **Topics:** Public Awareness, Regulatory actions --- ### [Florida man pleads guilty to $55M investment fraud scheme that affected over 10,000 people](https://insurancefraud.org/news_archives/florida-man-pleads-guilty-to-55m-investment-fraud-scheme-that-affected-over-10000-people/) **Published:** September 24, 2026 **Author:** Diane Beauchamp **Content:** A Florida man pleaded guilty on Thursday to orchestrating an investment fraud scheme. His crime allegedly defrauded more than 10,000 victims of over $55 million. According to court documents, Michael Glaspie, 72, of Palm City, marketed an investment opportunity under the name “CoinDeal” or “Coin Deal.” He claimed that CoinDeal would yield extremely high returns on the premise that one or more technology companies was about to be acquired by a wealthy buyers. Investigators said, to entice investors to put money into CoinDeal, Glaspie falsely promised that in the event the returns from CoinDeal failed to materialize, he would repay investors their money with seven percent annual interest over three years. However, investigators claim that Glaspie knew he had no means of making such repayments. According to the Department of Justice (DOJ), in order to support his false repayment promise, Glaspie deceptively claimed that he had an exclusive and lucrative contract with AT&T to distribute government funded phones, and that an app that he developed was being distributed by the Better Business Bureau and would yield over $400 million in revenue, when he had no such contract or distribution agreement. Investigators said that when the promised sale of CoinDeal did not close, Glaspie transmitted investor funds to Chandran after falsely representing to CoinDeal investors that he would not do so. Glaspie also falsely claimed that he never paid himself with CoinDeal investor funds, when in truth, he misappropriated nearly $2.5 million of victim investments for personal purposes, including trading cryptocurrency, paying his employees’ salaries, and buying a life insurance policy for a family member. Glaspie pleaded guilty to one count of wire fraud and is scheduled to be sentenced on June 16. He faces a maximum penalty of 20 years in prison. **Topics:** Financial Fraud **Categories:** Conviction --- ### [Los Angeles school district reveals ransomware gang leaked thousands of student health records online](https://insurancefraud.org/news_archives/los-angeles-school-district-reveals-ransomware-gang-leaked-thousands-of-student-health-records-online/) **Published:** September 24, 2026 **Author:** Diane Beauchamp **Content:** The [health records](https://www.foxbusiness.com/category/healthcare) of around 2,000 current and former Los Angeles students were published to the dark web after last year’s ransomware attack, the district revealed Wednesday. Jack Kelanic, the district’s senior IT administrator, said the district is still working to assess the ramifications of the widely-reported September 2022 [ransomware attack](https://www.foxnews.com/us/los-angeles-unified-school-district-targeted-ransomware-attack), which are only now being realized. “As \[LAUSD\] and its partners delve deeper into the reality of the data breach, the scope of the attack further actualizes and new discoveries have been revealed,” Kelanic said Wednesday. The administrator said 2,000 student assessment records have been confirmed as part of the attack – including 60 of whom are currently enrolled – as well as driver’s license and social security numbers and [COVID-19 test results](https://www.foxbusiness.com/category/coronavirus). Some of these records, he said, even go back several decades, creating “further time-consuming analysis.” “Los Angeles Unified takes student, family and employee privacy very seriously and has been implementing enhanced protections and procedures to ensure our data security,” Kelanic said. “As we continue to ascertain the accuracy and thoroughness of the data and follow protocols to conduct a comprehensive review, we have already notified some individuals and vendors who have been impacted by this attack and will continue notifying individuals as they are determined.” LAUSD Superintendent Albert Carvalho said the Russian ransomware gang Vice Society was responsible for the attack and had placed the material online. **Topics:** Public Awareness, Technology --- ### [WANTED: Toledo man accused of burning down his own mother’s house for insurance money](https://insurancefraud.org/news_archives/wanted-toledo-man-accused-of-burning-down-his-own-mothers-house-for-insurance-money/) **Published:** September 24, 2026 **Author:** Diane Beauchamp **Content:** Authorities are looking for a man suspected of burning down his own mother’s home in January. Toledo Police asked the public for help locating Christopher Knee who is wanted on charges of arson, insurance fraud and receiving stolen property. The fire occurred on the 3100 block of Radford on January 4. Neighbors informed police about suspicions they had about the people that lived in the home, and said there was a U-Haul truck parked outside that had just left that day. Anyone with info call OR text Crime Stoppers at 419-255-1111. You may be eligible for a cash reward up to $5,000. **Topics:** Homeowners - arson **Categories:** Arrest --- ### [Greensboro man accused of insurance fraud, falsely reporting auto theft](https://insurancefraud.org/news_archives/greensboro-man-accused-of-insurance-fraud-falsely-reporting-auto-theft/) **Published:** September 23, 2026 **Author:** Diane Beauchamp **Content:** North Carolina Insurance Commissioner Mike Causey today announced that Tyjuan Terrell Adams, 33, of 902 Hall St., Greensboro, was charged with insurance fraud and attempting to obtain property by false pretense, both felonies. Special agents with the Department of Insurance’s Criminal Investigations Division accuse Adams of falsely telling Integon Indemnity Corp. that his wife’s vehicle was stolen in an attempt to collect on a claim. According to the criminal summons, Adams wrecked the vehicle and left it at the scene of the accident before police arrived. The offenses occurred on Nov. 12, 2022. Adams was served with a criminal summons on Feb. 21. He is due in Guilford County District Court on March 20. Commissioner Causey encourages North Carolinians to help keep insurance premiums low by reporting suspicious fraud. “Insurance fraud is not a victimless crime,” Commissioner Causey said. “It hits all of us in the pocket through higher premiums.” **Topics:** Auto - padding/false claim **Categories:** Arrest --- ### [Biscoe woman accused of insurance fraud, attempting to obtain property by false pretense](https://insurancefraud.org/news_archives/biscoe-woman-accused-of-insurance-fraud-attempting-to-obtain-property-by-false-pretense/) **Published:** September 23, 2026 **Author:** Diane Beauchamp **Content:** North Carolina Insurance Commissioner Mike Causey today announced that Jackie Octavia Cozart, 31, of 504 Leach St., Biscoe, was charged with insurance fraud and attempting to obtain property by false pretense, both felonies. Special agents with the Department of Insurance’s Criminal Investigations Division accuse Cozart of falsely telling National General Insurance Co. that her vehicle was involved in a crash after she took out her insurance policy in an attempt to get the insurance company to pay for the vehicle damage. According to the criminal summons, the accident occurred on Jan. 23 the day before she took out the policy on Jan. 24. She told the insurance company that the vehicle was struck on Jan. 27. Cozart was served with a criminal summons on Feb. 21. She is due in Montgomery County District Court on March 7. “Insurance fraud hits consumers in the wallet,” Commissioner Causey said. “Approximately 20 cents of every insurance premium dollar go to covering the cost of fraud. I’m fighting this by aggressively pursuing and prosecuting insurance fraud in North Carolina.” **Topics:** Auto - underwriting **Categories:** Arrest --- ### [$40M Fraud: New Canaan Insurance Firm Owner Admits To Scam, Could Face Decades In Prison](https://insurancefraud.org/news_archives/40m-fraud-new-canaan-insurance-firm-owner-admits-to-scam-could-face-decades-in-prison/) **Published:** September 23, 2026 **Author:** Diane Beauchamp **Content:** In a New York federal court, Anthony Riccardi, of New Canaan, pleaded guilty to conspiracy to commit wire fraud and bank fraud on Tuesday, Feb. 21, according to the office of the United States Attorney for the Southern District of New York. Riccardi, the 50-percent co-owner and executive vice president of Employee Benefit Solutions LLC, a Connecticut insurance firm, was part of a widespread scheme to misappropriate and steal client healthcare funds and defraud lenders, as reported by Daily Voice. The 46-year-old is facing up to 30 years in prison, and also agreed to pay $14,870,653.36 in restitution and forfeit $2,000,000.00. According to the complaint and court filings: Riccardi and his co-conspirators began their scam by administering third-party healthcare claims for a car dealership chain. EBS, Riccardi’s insurance company, would create invoices for the car dealership brand, which would submit payments expecting the funds to be paid to healthcare providers. Almost $18 million of these funds, out of approximately $26 million paid by the car dealership company, were misappropriated by EBS. Most of this money was transferred into the company’s operating account and used for non-company expenses, including mortgage payments and boating, golf, and luxury car-related expenses. To perpetuate the plot, Riccardi and his co-conspirators would only pay healthcare claims from healthcare providers they thought were likely to complain, or those that were connected to the car dealership executives. The scam, which lasted from 2015 to 2019, also included falsely-inflated or fraudulent healthcare claims in the form of manually-created fake claims, including some submitted by a phony company under Riccardi’s name. EBS created falsified bank statements to keep the appearance that payments were being made to healthcare providers. Unmet financial obligations began to mount on the increasingly-fraught healthcare insurance company in mid-2017, prompting Riccardi and his co-conspirators to apply for millions of dollars in fraudulent bank loans and cash advances used in part, to pay financial obligations to the car dealership brand. To cover up the loan scheme, Riccardi and his co-conspirators fabricated invoices from a fake company that supposedly sold an upgraded billing software for their company. The scheme eventually folded, and Riccardi and his three co-conspirators were charged with fraud in July 2020. Two of his co-conspirators previously pleaded guilty. Patricia Riccardi, Riccardi’s wife, and co-defendant, previously pleaded guilty and is scheduled to be sentenced on Tuesday, June 20. Erin Verespy, Riccardi’s co-conspirator, previously pleaded guilty and was sentenced to 66 months in prison. Anthony Riccardi’s sentencing is scheduled on Thursday, July 20. **Topics:** Financial Fraud, Insider Fraud **Categories:** Conviction --- ### [Business rules alone are not enough to fight insurance fraud](https://insurancefraud.org/news_archives/business-rules-alone-are-not-enough-to-fight-insurance-fraud/) **Published:** September 23, 2026 **Author:** Diane Beauchamp **Content:** For as long as there has been insurance, there has been insurance fraud. And for as long as there has been [insurance fraud](https://www.propertycasualty360.com/instant-insights/insurance-fraud-detection-and-prevention/), insurance companies have tried to fight it. From what was once the domain of individuals with gut instincts arose technology solutions designed to help insurance professionals spot a greater number of suspicious claims with greater accuracy. These legacy approaches to technology aided fraud detection often centered on the use of business rules, which have long reigned as the first-line solution for insurers to support their fraud mitigation strategies. While rules engines can be a helpful tool, their effectiveness tends to diminish over time as fraudsters identify thresholds under which they can pass undetected. As such, the insurance industry has begun adopting [artificial intelligence (AI)](https://www.propertycasualty360.com/insurance-technology/artificial-intelligence/) to build on their use of business rules in an effort to mitigate more fraud, more effectively and more efficiently. But how did we get here? Let’s look at the evolution of technology use in the fight against insurance fraud. ## Rules-based fraud detection A business rule is part of a framework, constructed using what is formally known as a *rules engine*. It may state something along the lines of “IF \[situation occurs\], THEN \[perform action\].” For example, IF a certain insurer receives a claim for over $10,000, THEN it will automatically forward the claim to the special investigative unit (SIU) for review and/or investigation. This rule may not necessarily indicate that the claim is suspicious, but rather indicate that it is valuable enough to warrant at least a second look by professionals who are trained to spot fraudulent activities. As a system, business rules typically formalize and automate policies that were previously written on paper. The employee handbook for claims adjusters may also have a rule about claims over $10,000, for example, but business rules apply this policy in an immediate and uniform manner, without exception. Applying business rules to insurance claims has a lot of benefits — especially compared to the alternative, which is assigning claims manually based on an initial scan, made under time pressure, that may rely heavily on experience and intuition. Key benefits of business rules: - Faster than manual assignment; - Minimizes the potential for errors; - Avoids subjective reasoning; and - Reduces some training needs. In short, business rules help employees spend less time *deciding* what they should do, and more time *doing* what they should do — all while helping to make sure they’re doing the right thing. ## Exceptions diminish effectiveness The biggest problem with a rules-based approach to fraud detection is that it can easily be manipulated by those who want to take advantage of it. The simplest way, of course, is to identify the insurer’s thresholds and never file a fraudulent claim that exceeds it. But why stick to simple when you can be clever? Let’s take a closer look at our earlier “$10,000 Rule” deployed in the real world. We know that rules are most effective when they are applied evenly and without exception. Yet, exceptions will inevitably occur. In practice, applying more rigorous review to claims exceeding $10,000 is simply good business if most claims fall under this threshold. At the same time, this universal rule may not be applicable to a significant number of the policies the insurer writes. For example, an insurer that writes policies covering high-value vehicles or homes may find itself referencing a significant number of legitimate claims exceeding $10,000 to the SIU. This results in a significant workload increase for the SIU without mitigating any additional fraud. So, the business creates an exception to their business rule: “IF claim value exceeds $10,000, THEN claim referred for investigation, UNLESS claim associated with a high-value vehicle.” The rules structure weakens with every exception. Here’s how: - **Larger attacks surface:** Each exception to a business rule represents an area where bad actors can potentially submit fraudulent claims. In the example above, a fraudster could establish a policy covering a high-value vehicle then submit fraudulent claims without fear of exceeding the threshold triggering automatic investigation. - **More effort:** Business rules aren’t typically quickly self-configurable. Claims administrators need to work with the IT department to implement new rules. Depending on the IT workload, it can take a period of time for implementation. Fraud can continue unexamined in the interim. - **Less flexibility:** Insurance fraud isn’t static. If bad actors switch to a new form of fraud, the rules written to prevent it will no longer apply and false negatives will result. In some cases, adaptations to rules can also flag legitimate claims as false positives, driving up workloads for investigators and impacting the policyholder experience. As time goes on, the rules written to protect the organization become less clear, less efficient, and more vulnerable to exploitation. As important, updating rule sets to match evolving business requirements is most often costly and time consuming. ## AI solutions bolster business rules AI solutions aren’t necessarily a replacement for business rules. Instead, they build on existing foundations to provide the flexibility and efficiency that rules can lack on their own. Most AI solutions start with existing scenarios in which fraud has been identified and create new scenarios that catch evolving forms of fraud. The algorithms driving [AI-based fraud detection](https://www.propertycasualty360.com/2022/05/10/how-ai-uncovers-fraud-in-high-volume-low-value-claims/) can use a variety of data types to look at components of a claim individually, in combination, and most importantly in context to develop a more realistic understanding of what exactly happened and what the remedy should be. Fundamentally, AI helps insurers implement fraud detection strategies that are more accurate, easier to use, and provide more nuanced detection capabilities. For example, let’s return one last time to the “$10,000 Rule” we started with. Here, instead of forwarding the claim directly to the SIU, the business rule triggers review and analysis by AI. Here, the AI solution acts as an extra analytics layer for the business rule. The solution can examine the factors that comprise a claim — such as the age of the policy, the nature of the damage, and the claimants involved — to make a more accurate analysis on whether a claim is likely to be fraudulent. This helps investigators make more accurate, informed, and ultimately faster decisions on whether to pursue a claim. In the case of a high-value policy, the size of the claim becomes significantly less important and an indicator of probable fraud. The AI is now looking for a number of different things associated with the claim that will either mark it as likely legitimate or suspicious and in need of further investigation. That’s because the solution has been trained on billions of insurance claims previously, and it knows that high-value claims aren’t more likely to be fraudulent just because they’re larger. ## AI: Learning to spot fraud on its own Perhaps the biggest benefit of [using AI in the fight against fraud](https://www.propertycasualty360.com/2020/02/25/10-things-you-should-know-about-how-ai-fights-insurance-fraud/) is that unlike traditional business rules it has the capability to learn and evolve. Over the course of time the AI will discover fraud scenarios of its own. These scenarios are generated independently; no intervention is necessary to “tell” the AI that claims fitting certain characteristics are more likely to be fraudulent. Once these scenarios are identified, they can be implemented at the discretion of the insurer. In effect, the AI solution is creating its own dynamic rules to detect fraud schemes that not even the insurer is aware of. These are decisioning rules as they were meant to be — low touch, aware of nuance, and capable of evolving with changing circumstances. Business rules aren’t obsolete, but they need augmentation to remain relevant. That relevance comes with artificial intelligence. With AI solutions, insurers can create a significant improvement to business rules, but without the manual effort that business rule implementation usually requires. This results in a fraud detection workflow that is much more aligned to the goals of the insurer — and actually increases in effectiveness as time passes. **Topics:** Public Awareness --- ### [Des Moines Man Sentenced for Insurance Fraud Scheme](https://insurancefraud.org/news_archives/des-moines-man-sentenced-for-insurance-fraud-scheme/) **Published:** September 23, 2026 **Author:** Diane Beauchamp **Content:** Andrew Thomas Ellis, age 30, of Des Moines pled guilty on February 16, 2023, to one count Presenting False Information (Class D Felony) following an investigation by the Iowa Insurance Division’s Fraud Bureau. The charges against Ellis stemmed from an investigation which began in June 2022. According to criminal complaints filed by the Iowa Insurance Division’s Fraud Bureau, Ellis filed a false report to the Des Moines Police Department, claiming theft of personal property. Ellis then provided false statements to an insurer in connection with a personal property insurance claim in an attempt to receive loss claim benefits he would otherwise not be entitled to. Ellis was arrested on October 9, 2022 and booked into the Polk County Jail where he later posted bond. Following his guilty plea, Ellis received a five-year suspended prison sentence and placed on supervised probation for a period of two years. Ellis was also ordered to pay a fine of $1,025. Iowans with information about insurance fraud are encouraged to contact the Iowa Insurance Division’s Fraud Bureau at 515-654-6556. **Topics:** Homeowners Fraud, Synthetic Identity Theft **Categories:** Conviction --- ### [Tennessee health system reports RCM vendor data breach](https://insurancefraud.org/news_archives/tennessee-health-system-reports-rcm-vendor-data-breach/) **Published:** September 23, 2026 **Author:** Diane Beauchamp **Content:** Memphis, Tenn.-based Regional One Health is [notifying](https://www.regionalonehealth.org/blog/2023/02/14/reventics-experiences-data-security-incident/) patients that some of their confidential information may have been compromised in a data breach that affected its revenue cycle management vendor Reventics. On Dec. 15, Reventics learned that an unauthorized party accessed its servers and launched an investigation into the incident. The investigation determined that on Dec. 27, the unauthorized party had transferred files from its system, including files that contained patient information from Regional One, according to a Feb. 14 breach notification from Regional One. The files contained patient information such as names, patient addresses, dates of birth, Social Security numbers, medical record numbers, patient account numbers, financial information, driver’s license, and more. Reventics said it is mailing letters to potentially affected individuals, including Regional One Health. The RCM vendor [did not](https://reventics.com/) mention how many people were affected by the breach, but said it has contained the incident, as well as implemented new technical safeguards in order to prevent another incident. **Topics:** Public Awareness, Technology --- ### [Health systems affected by data breaches in the last 30 days](https://insurancefraud.org/news_archives/health-systems-affected-by-data-breaches-in-the-last-30-days/) **Published:** September 23, 2026 **Author:** Diane Beauchamp **Content:** From employee insider breaches to an anonymous call informing a health system of a data breach, here are the health systems that have been affected by a cybersecurity or data breach incident since Feb. 28: *Editor’s note: This article was updated on April 20 and will continue to be updated.* **April 20:** - An error led to some patient information from [John Muir Health Walnut Creek (Calif.) Medical](https://www.beckershospitalreview.com/cybersecurity/an-employee-of-a-california-hospital-accidentally-leaks-phi.html) to have been accessed by an unauthorized party. - Palo Alto, Calif.-based [Stanford Health Care](https://www.beckershospitalreview.com/cybersecurity/4-stanford-hospitals-affected-by-third-party-data-breach.html); Pleasanton, Calif.-based Stanford Health Care Tri-Valley, Palo Alto, Calif.-based Stanford Medicine Children’s Health, Castro Valley, Calif.-based Stanford Medicine Partners were affected by data breach at their behavioral and mental health service provider Brightline. - Boise, Idaho-based [St. Luke’s Health System](https://www.beckershospitalreview.com/cybersecurity/st-lukes-technical-error-compromises-15k-patients-data.html) notified 15,246 patients that some of their personal health information may have been compromised due to a technical error that caused letters to be mailed to incorrect addresses. - Knoxville, Tenn.-based [Tennova Healthcare](https://www.beckershospitalreview.com/cybersecurity/tennessee-health-system-affected-by-chs-third-party-breach.html) said it was affected by a third-party data breach that hit its parent company Franklin, Tenn.-based Community Health Systems. - Birmingham, Ala.-based [Grandview Medical Center](https://www.beckershospitalreview.com/cybersecurity/6-alabama-hospitals-affected-by-chs-third-party-breach.html); Huntsville, Ala.-based Crestwood Medical Center; Dothan, Ala.-based Flowers Hospital; Gadsden (Ala.) Regional Medical Center; Medical Center Enterprise (Ala.); and Foley, Ala.-based South Baldwin Regional Medical Center was affected by a third-party data breach that hit its parent company Franklin, Tenn.-based Community Health Systems. - Chicago-based [CommonSpirit Health](https://www.beckershospitalreview.com/cybersecurity/commonspirit-dozens-of-hospitals-across-13-states-affected-by-ransomware-attack.html) said many of its current and former Catholic Health Initiatives, Centura Health and MercyOne facilities were affected by last year’s ransomware attack on the health system. **March 20:** 1. A woman alleges that a contract employee from Martinez, Calif.-based [Contra Costa Regional Medical Center](https://www.beckershospitalreview.com/cybersecurity/patient-alleges-california-hospital-worker-posted-her-medical-records-to-facebook.html) gained access to her medical records and posted them to a Facebook account. 2. [UC San Diego Health](https://www.beckershospitalreview.com/cybersecurity/uc-san-diego-health-notifies-patients-of-vendor-breach.html)‘s technology vendor Solv Health transmitted patients’ confidential information to third-party service providers. 3. South Bend, Ind.-based [Beacon Health Syste](https://www.beckershospitalreview.com/cybersecurity/indiana-health-system-says-employee-inappropriately-accessed-patient-records.html)m notified 3,117 patients that some of their personal information may have been accessed by an unauthorized employee who viewed patient records outside the scope of their job duties. 4. Livonia, Mich.-based [Trinity Health](https://www.beckershospitalreview.com/cybersecurity/trinity-health-notifies-patients-of-data-breach.html) filed a data breach notice with the Massachusetts attorney general March 9 after it learned that some patient information was compromised as a result of unauthorized access. 5. Jamestown, N.Y.-based [The Chautauqua Center](https://www.beckershospitalreview.com/cybersecurity/new-york-medical-center-switches-ehr-vendors-after-third-party-data-breach.html) notified patients that some of their protected health information was compromised when its medical records provider WebPT experienced an unauthorized disclosure. 6. Richmond, Va.-based [Henrico Doctors’ Hospital](https://www.beckershospitalreview.com/cybersecurity/virginia-hospital-notifies-patients-of-data-breach.html) notified 990 patients that some of their protected health information was compromised in a data breach. 7. A cyberattack disrupted Warner Robins, Ga.-based [Houston Healthcare’s](https://www.beckershospitalreview.com/cybersecurity/georgia-health-systems-operations-disrupted-by-cyberattack.html) operations; the health system was able to remain open and care for patients using its backup processes and downtime procedures. 8. An anonymous individual called Norfolk, Va.-based [Sentara Healthcare](https://www.beckershospitalreview.com/cybersecurity/anonymous-call-informs-virginia-hospital-of-data-breach.html) to notify the hospital that a PDF copy of a Medicare remittance report for Sentara’s lab services was uploaded to an Adobe Acrobat website. **Topics:** Public Awareness, Technology --- ### [Why Digital Identity is About More Than Fighting Fraud](https://insurancefraud.org/news_archives/why-digital-identity-is-about-more-than-fighting-fraud/) **Published:** September 23, 2026 **Author:** Diane Beauchamp **Content:** Digital identity used to be something that people considered “just tick-the-boxes” technology. But as Steve Durney, vice president of strategy at Prove, told PYMNTS, forward-thinking companies can use digital identity as a way to differentiate themselves … and actually generate more revenue by improving the customer experience. There’s certainly room for many companies to improve how they verify and authenticate users. As it stands now, there are speed bumps in the mix as we conduct more of our daily commerce online. “The old joke,” he said, “is that secure and fast are not friends, and they’re not great dance partners. You wind up sacrificing one for the other.” Any time that users are attempting to get through a slew of online screens just to simply make a payment or to onboard themselves to set up a loyalty account, said Durney — well, those journeys come with a lot of friction. The enterprise-level challenge, he said, is to balance security and convenience in such a way that consumers complete those onboarding and verification activities … and businesses keep their top-line momentum intact. That’s no easy undertaking, as Durney observed. Here’s the quandary: Make it too easy to make transactions, and companies and consumers are exposed to the fraudsters. Make it too hard, and the shopping cart gets abandoned. The consumer, forced to pause, may disappear and never return. It’s more important than ever for security professionals to consider their tech investments and ID efforts, said Durney. In the current macro environment, the fraud threat is increasing. More people do shadier things when they’re stressed, said Durney, and that includes hacking. In addition, companies are finding it critical to do more with less, so streamlining business processes while improving top-line trajectory is an opportunity no firm should pass up. Regulations and compliance landscapes are shifting. “When the economy is challenged, it’s worthwhile for firms to be introspective about their own defenses and the strength of those defenses — and whether they’re in a position to fend off attacks,” he said. Amazon has set a high bar for eCommerce. Consumers are used to the experience where one click gets us through the transaction, through the payment … and to the goods being sent on their way to the homestead. That might be an aspiration for many companies — and getting there means rethinking how they think about verifying users. Through the past few years, Durney said, a number of providers (including Prove) have been making it easier for enterprises to identify who’s on the other side of the transaction. The pain points are eased a bit by connecting mobile phones with the desktop experience, or mobile phones exclusively with consumers’ identity that allows them to “get through” to the merchant without the latter’s having to “absorb” any incremental fraud. In fact, he said, advanced digital IDs can make onboarding 79% faster. In the identity space, he said, there are levels of verification. In some cases, he said, a company can make an “educated guess” as to whether they’re dealing with the right person, based on context and a variety of attributes. The next level of fraud prevention, he said, is “deterministic identity” tied to a driver’s licenses or tokens or devices themselves. “You’re absolutely certain that it’s them, as opposed to the educated guess — and this is what risk-based authentication is,” said Durney. For the companies that get it right, said Durney, the advantages accrue far beyond improved sales conversion ratios (which in turn give revenues a boost). “Identity may be, usually, tied to the fraud aspect,” he said, “but there are many other units within various businesses that can use identity to their advantage.” He offered the example of using IDs within marketing efforts to make sure a company is triangulating and collecting info on the same person. There’s value, too, in having the having the ability to cross-sell various products and services to a consumer once they are (digitally) onboarded — without having to ask them to re-verify themselves each time they apply for a loan or join a loyalty program. For the providers, if they make it a “low effort” endeavor for consumers to get what they want, it’s more than likely the individual’s going to want to come back for more. With a reduction in fraud and friction, he told PYMNTS, digital identification can help make sure “you can still maintain your customer experience, you can still maintain your customer throughput … and you’re not obstructing those individuals with unnecessary effort. That’s a significant win for everybody involved.” **Topics:** Public Awareness, Synthetic Identity Theft, Technology --- ### [Scam Missouri ‘cost-sharing’ ministry proves health care and religion are both ailing | Opinion](https://insurancefraud.org/news_archives/scam-missouri-cost-sharing-ministry-proves-health-care-and-religion-are-both-ailing-opinion/) **Published:** September 23, 2026 **Author:** Diane Beauchamp **Content:** The recent decision by federal law enforcement officials to shut down what they call a fraudulent, faith-based Missouri medical cost-sharing company reveals, again, a major failure of America’s health care system. Beyond that, it gives people one more reason to be wary of initiatives marketed as religious ministries with government oversight. The reputation of legitimate institutional religion gets enough self-inflicted wounds (sex abuse scandals, money-grubbing televangelists) without a private, highly questionable health care ministry adding to the list. The FBI and attorneys for the Department of Justice have shut down the St. Joseph-based Medical Cost Sharing Inc. Those authorities say the company marketed a well-planned fraud that drew in customers by seeking out “like-minded Christians.” **Topics:** Public Awareness --- ### [How can insurers protect against deepfake fraud?](https://insurancefraud.org/news_archives/how-can-insurers-protect-against-deepfake-fraud/) **Published:** September 23, 2026 **Author:** Diane Beauchamp **Content:** Deepfakes — phony images or videos that look like the real thing, but aren’t — [are everywhere](https://i-hls.com/archives/113657) these days. Some are perhaps [easy to spot](https://theconversation.com/celebrity-deepfakes-are-all-over-tiktok-heres-why-theyre-becoming-common-and-how-you-can-spot-them-187079) and, as a result, don’t really hurt anyone — but others, such as those used by [insurance fraudsters](https://www.propertycasualty360.com/2022/05/03/how-deepfakes-threaten-insurance-claims-automation/), can be used to swindle insurers into paying for phony claims, or even worse, fool a buyer into believing a substandard vehicle is safe, risking their lives. In order to avoid losses and weed out phony claims, insurers are going to need advanced fraud detection systems. Advanced communication technology, it turns out, is a double-edged sword for insurers. By providing customers with the opportunity to upload images and data, companies can save themselves — and customers — a great deal of time, effort, hassle and money. It’s a trend that flowered during the pandemic and continues to grow. For example, an uploaded claim that checks out could be paid off far more quickly and efficiently than a claim based on a manual inspection of a vehicle by a company agent. An AI-based analysis could quickly assess the legitimacy of the claim, ensuring that the customers get the money they are entitled to and protecting the insurer from overpaying for a claim. Uploaded, AI analysis-based claims are a boon to both customers and companies. However, the same system also provides opportunities for dedicated scammers to steal from insurers. Deepfake technology today has advanced to the point where, without advanced fraud detection systems, it’s extremely difficult to discern if an image is legitimate. In fact, [according to surveys](https://attestiv.com/over-80-percent-insurance-professionals-concerned/), more than 80% of insurance industry professionals are concerned that they could fall victim to deepfake frauds. Fortunately, there are some techniques insurers can use to avoid being ripped off; if fraudsters are using advanced technology to cheat insurers, then insurers have to use even stronger technology to avoid becoming victims. ## Making ‘fake’ look ‘real’ How would a deepfake insurance rip-off scam work? Presumably, it would require a degree of technological sophistication, with fraudsters perhaps using a play-for-pay service. The service would take images of their customer’s vehicle and use advanced [deepfake applications](https://www.facetuneapp.com/) to doctor them. The fraudster would then use it (as well as others) to file a claim, with the online service getting a flat fee or a percentage of the claim. An even easier — and cheaper — way to do this is to download an image of vehicle damage from one of the many [image databases](https://imgur.com/search/score?q=fender+damage) available today, and perhaps self-adjust the image using Photoshop. That kind of scam would probably work best for small payment claims; with the deepfake tech creating the kind of damage you might get in a fender-bender. It’s unlikely that a fraudster would use a basic technique like this to claim that their vehicle was totaled because that would require far more extensive faking than an individual would likely be willing to take a risk for. Such extensive fraud would more likely be carried out by an organized group, which would use not only deepfake tech to produce images — but would also create a phony ecosystem of attorneys, witnesses and other features to convince an insurer being asked to pay out tens of thousands of dollars in claims. Such gangs have been operating since [long before](https://www.dailymail.co.uk/news/article-2034993/Crash-cash-Gang-staged-120-fake-accidents-1m-insurance-scam.html) the deepfake era — and now with [advanced technology](https://www.hackread.com/new-scam-ai-generated-images-to-fake-law-firm/), the job of [changing images](https://www.advancedsciencenews.com/image-fraud-gets-a-boost-from-ai/) for profit gets even easier. ## Protecting against deepfake claims Many deepfakes are created using [adversarial neural networks](https://www.cvisionlab.com/cases/deepfake-gan/), where two machine learning (ML) algorithms are employed to ensure that the forgery looks authentic. These are extremely difficult to detect and analyze, and require matching “firepower” in the form of deep learning [neural networks](https://www.scirp.org/journal/paperinformation.aspx?paperid=109149). To protect themselves, insurers need to deploy big data analysis systems that can detect anomalies in images — indications that the image is not a “natural” one. These anomalies can range from the way [light is reflected](https://www.cnet.com/science/deepfakes-can-be-detected-by-analyzing-light-reflections-in-eyes-scientists-say/) off a vehicle to the relative position of [sunlight or artificial light](https://staff.ustc.edu.cn/~zhangwm/Paper/2022_26.pdf) to the [blood flow](https://www.intel.com/content/www/us/en/newsroom/news/intel-introduces-real-time-deepfake-detector.html#gs.o0rewb) in an individual’s face. Advanced big data systems can analyze millions of images to see if elements of an image [match another one](https://arxiv.org/abs/2207.09679) — from another accident that occurred far away. Another technique that has shown success is to utilize analysis systems that are based not on individual images, but on scans of a vehicle — utilizing numerous, sequential images, which makes it much harder for scammers to file claims based on fraudulent criteria. In addition, advanced systems using neural networks can even “unwind” the process used to create images, which are constructed by adversarial neural networks. Deep learning-based neural networks can analyze aspects of the image in order to determine if it has been manipulated in that manner. Clearly, advanced data, machine vision and AI-based analysis are necessary in order to combat the deepfake scourge. There are clear advantages for insurance companies to allow their customers to make claims online or via apps — but any goodwill and savings they accrue could be wiped out by savvy fraudsters who know how to use advanced technology to steal from firms. As online and app-based claims become more popular, insurers are going to need to prepare and defend themselves. **Topics:** Public Awareness, Synthetic Identity Theft, Technology --- ### [Logan Health agrees to $4.3M settlement after 2021 health data breach](https://insurancefraud.org/news_archives/logan-health-agrees-to-4-3m-settlement-after-2021-health-data-breach/) **Published:** September 23, 2026 **Author:** Diane Beauchamp **Content:** Logan Health Medical Center has reached a $4.3 million settlement with the 213,543 patients and employees whose personal and protected health information was likely accessed during a [Nov. 22, 2021, cyberattack](https://www.scworld.com/analysis/breach/logan-health-cyberattack-server-hack-leads-to-data-access-of-214k-people). This is the second breach-related lawsuit settled by the Montana provider in less than three years. Prior to [rebranding from Kalispell Regional Healthcare](https://www.logan.org/news/its-official--kalispell-regional-healthcare-is-now-logan-health/) in May 2021, the health system reported an undetected phishing attack in 2019 that led to a monthslong data compromise for 130,000 patients. The incident exposed Social Security numbers, birthdates, contact information, medical histories, insurance data, medical record numbers, insurance details, provider names, and other sensitive data. The hospital was sued by patients after that incident, leading to a $4.2 million settlement in December 2020. If the latest proposal is approved, [Logan Health will have paid $8.5 million](https://healthitsecurity.com/news/4.2m-settlement-proposed-in-kalispell-regional-breach-lawsuit) in breach settlements in less than three years. The latest settlement stems from [several lawsuits filed in April 2022](https://www.scworld.com/analysis/breach/alleging-security-failures-caused-data-breach-patients-sue-montanas-logan-health) and later merged into a class action suit. The breach victims claimed that a 2021 server hack and subsequent patient data compromise was caused by Logan Health’s failure to implement adequate security measures. During the incident, an attacker gained access to one of eight file servers and accessed both patient and employee health information. The exposed data varied by individual and including names, Social Security numbers, dates of birth, contact information, and email addresses. The lawsuit took aim at Logan Health’s previous security incident and lawsuit settlement, noting that the health system already “claimed to be taking ‘further steps to revise procedures that will minimize the risk of a similar event happening again.’” The breach victims further alleged that the 2021 incident was directly caused by the provider failing to adhere to representations expressed in the past breach notice. In particular, Logan Health was accused of failing to reasonably train employees and/or implement procedures or protocols that would have prevented the second security incident. “Particularly because Logan Health has demonstrated an inability to prevent a breach or stop it from continuing even after being detected, \[individuals\] have an undeniable interest in ensuring that their PII/PHI is secure, remains secure, and is not subject to further theft,” according to the lawsuit. As such, the filing asserted that the one-year of identity theft protection offered by the provider was “grossly inadequate.” The purported harm outlined in the lawsuit included references outlining the cost of medical identity theft recovery, which averages up to $19,000 and over 200 hours to resolve the issue. The suit did not, however, detail whether the breach victims had actually experienced these worst-case scenarios as a direct result of the 2021 breach. The proposed settlement appears to take these issues into account and requires Logan Health to share details into the actions it has already taken or its plans to strengthen the cybersecurity training and awareness programs, data policies, security measures, and data restrictions, as well as its monitoring and response capabilities. Individuals affected by the 2021 incident can also file claims to be reimbursed for up to $25,000 in out-of-pocket expenses directly tied to the breach and up to $125 for documented instances of time lost responding to the incident. The settlement also includes alternate cash payments and free credit monitoring for affected individuals. Logan Health also agreed to pay “attorneys’ fees not to exceed one-third” of the settlement and “reimbursement of litigation costs and expenses not to exceed $150,000,” according to the settlement proposal. The proposal is subject to final approval, which is scheduled for March 9. ## Current healthcare data breach lawsuit trends Logan Health joins an increasingly long list of provider organizations to be hit with a patient-led lawsuit after a reported security incident. Like Logan Health, the vast majority of these cases are settled to limit prolonged litigation. As [SC Media reported in May 2022](https://www.scworld.com/feature/breach/attorneys-line-up-to-take-on-healthcare-breach-lawsuits-amid-hopes-of-substantial-payouts), healthcare data breach litigation has been equated to modern-day ambulance chasing. In the days following an incident report, law firms will set up websites advertising “investigations” into reported incidents and seeking breach victims to join possible class-action suits. BakerHostetler confirms data breach lawsuits filed against hospitals in this fashion have rapidly grown in the last few years, [even after the Supreme Court](https://www.scworld.com/news/breach/kroger-reaches-5m-settlement-with-breach-victims-as-supreme-court-defines-actual-harm) ruled that victims must provide evidence of concrete harm to pursue a case. In many of these filings, that evidence is missing. The trend will likely continue into the coming year, with healthcare data breach lawsuits already stacking up. [CommonSpirit Health](https://www.scworld.com/analysis/ransomware/commonspirit-cyberattack-renews-patient-safety-concerns-amid-outages-care-delays) was just hit with another breach lawsuit after its massive outage and data exfiltration incident last year. The lawsuit joins four filings issued in just the last month against Maternal & Family Health Services, Shields Health Care Group, Retreat Behavioral Health, and [Connexin Software](https://www.scworld.com/analysis/breach/commonspirit-confirms-network-accessed-a-week-before-ransomware-attack) after their own security incidents and patient data compromises. **Topics:** Judicial/courts --- ### [Cost of living crisis is impacting insurance fraud – Carpenters Group](https://insurancefraud.org/news_archives/cost-of-living-crisis-is-impacting-insurance-fraud-carpenters-group/) **Published:** September 23, 2026 **Author:** Diane Beauchamp **Content:** Donna Scully, director of Carpenters Group, explains how high cost of living expenses in the UK is affecting opportunistic and application fraud in the insurance sector At our final Fraud Charter meeting of 2022 in December, we discussed the important issues that need to be on the anti-fraud agenda in 2023. The cost of living crisis was at the top of this list. It’s well reported that during an economic downturn, peoples’ behaviour can change due to the desperation of being unable to make ends meet. A worry in relation to insurance is that customers think this is something they can easily cut from their outgoings. Education is important here to highlight how vital insurance is, the protection it brings and how vulnerable customers can be without it. Another concern is people exaggerating or adding elements to claims for extra money. The type of person who might exaggerate claims could also change to include more middle class customers, who – before the crisis – were able to make ends meet better. With the cost of most things going up, including mortgage payments, the pool of people struggling is expanding all the time. Consumer lending and debt on credit cards went up 31% last year and is expected to peak at 38% in June 2023. Furthermore, credit card borrowing has soared to its highest level since 2004. With qualifying criteria for obtaining credit becoming harder, we’re seeing more application fraud too. New enquiries for a credit card were up 42% last year, compared to 2021. The cost of living is pushing people to find cheaper deals too, so ghost brokers are getting more traction. Prosecutions of ghost brokers are very low, under 0.5%, as the people targeted are often too embarrassed to seek police assistance. There’s a feeling that as the cost of living deepens this year, fraud will snowball. It’s never been more important for collectives like the Fraud Charter to continue, so that we can work together as an industry to share information and data – this will help ensure we are vigilant, spotting trends and stamping out fraud to protect genuine customers and offer competitive premiums when they are most needed. Things will get worse before they get better. **Topics:** Public Awareness --- ### [Warning on ‘Cestui Que Vie Trust’ car insurance scams](https://insurancefraud.org/news_archives/warning-on-cestui-que-vie-trust-car-insurance-scams/) **Published:** September 23, 2026 **Author:** Diane Beauchamp **Content:** We’re aware of fraudsters claiming to sell car insurance and advising users to claim the funds from a personal trust held by the government. They have called it a ‘cestui que vie trust’. Others are selling instructions on how to claim the funds. ## Cestui que vie trusts A cestui que vie trust does not exist and there’s no such trust held by the government. The phrase appears to be a combination of 2 genuine legal terms: - ‘cestui que trust’, which means someone entitled to money in a trust which has been set up for their benefit - ‘cestui qui vie’, which means a holder of a life interest in land which was settled on them before life interests were abolished in 1997, or the holder of a lifetime lease The term has been used from time to time by people claiming that it means they do not have to pay debts or comply with court orders, but there’s no reported example of this being successful in the UK. ## What this means A cestui que vie trust is a made-up term and does not exist. There’s no fund held by the government which you can claim against. This means that the car insurance is not backed by any funds and holders are driving without insurance. It’s illegal to drive a vehicle on a road or public place without [valid insurance](https://www.gov.uk/vehicle-insurance/driving-without-insurance). If you’re not correctly insured, you can be penalised. You could receive a fixed penalty, or be prosecuted in court, and the police might seize your car. ## Protecting yourself from scams We advise you to: - recognise the signs – always take a moment to stop and think before parting with money or your personal information - check [GOV.UK](https://www.gov.uk/) for information on how to avoid and report scams If you think you have been the victim of a scam and paid money, report it to [Action Fraud](https://www.actionfraud.police.uk/) or call 0300 123 2040 as soon as you can. **Topics:** Financial Fraud, Public Awareness --- ### [Martin’s Point Health Care Inc. to Pay $22,485,000 to Resolve False Claims Act Allegations](https://insurancefraud.org/news_archives/martins-point-health-care-inc-to-pay-22485000-to-resolve-false-claims-act-allegations/) **Published:** September 23, 2026 **Author:** Diane Beauchamp **Content:** Martin’s Point Health Care Inc. (Martin’s Point), headquartered in Portland, Maine, has agreed to pay $22,485,000 to resolve allegations that it violated the False Claims Act by submitting inaccurate diagnosis codes for its Medicare Advantage Plan enrollees in order to increase reimbursements from Medicare. Under Medicare Advantage, also known as the Medicare Part C program, Medicare beneficiaries have the option of enrolling in managed care insurance plans called Medicare Advantage Plans (MA Plans). MA Plans are paid a per-person amount to provide Medicare-covered benefits to beneficiaries who enroll in one of their plans. The Centers for Medicare and Medicaid Services (CMS), which oversees the Medicare program, adjusts the payments to MA Plans based on demographic information and the diagnoses of each plan beneficiary. The adjustments are commonly referred to as “risk scores.” In general, a beneficiary with diagnoses more expensive to treat will have a higher risk score, and CMS will make a larger risk-adjusted payment to the MA Plan for that beneficiary. Martin’s Point operates Medicare Advantage plans for beneficiaries living in Maine and New Hampshire. The United States alleged that, from 2016 to 2019, Martin’s Point engaged in chart reviews of their Medicare Advantage beneficiaries to identify additional diagnosis codes that had not been submitted to Medicare. Many of the additional codes submitted, however, were not properly supported by the patients’ medical records. The government alleged that Martin’s Point nevertheless submitted those diagnosis codes, which resulted in higher payments from CMS. “The government expects those who participate in Medicare Advantage to provide accurate information to ensure that proper payments are made for the care received by enrolled beneficiaries,” said Deputy Assistant Attorney General Michael D. Granston of the Justice Department’s Civil Division, Commercial Litigation Branch. “Today’s result sends a clear message to the Medicare Advantage community that the United States will take appropriate action against those who knowingly submit inflated claims for reimbursement.” “It is a privilege for health plans to provide services to Medicare beneficiaries, not a right. Medicare Advantage Plan sponsors that submit inaccurate claim information in order to justify inflated payments undermine the financial integrity of the program,” said Deputy Inspector General for Investigations Christian J. Schrank at the Department of Health and Human Services, Office of Inspector (HHS-OIG). “HHS-OIG remains committed to protecting taxpayer-funded health care programs, including Medicare Advantage.” The civil settlement includes the resolution of claims brought under the *qui tam* or whistleblower provisions of the False Claims Act by Alicia Wilbur, a former manager in Martin’s Point’s Risk Adjustment Operations group. Under those provisions, a private party can file an action on behalf of the United States and receive a portion of any recovery. The *qui tam* case is captioned *U.S. ex rel. Wilbur v. Martin’s Point Health Care Inc.*, No. 2:18-cv-00254 (DME). As part of today’s resolution, the whistleblower will receive approximately $3.8 million. The resolution obtained in this matter was the result of a coordinated effort between the Justice Department’s Civil Division, Commercial Litigation Branch, Fraud Section and the U.S. Attorney’s Office for the District of Maine, with assistance from HHS-OIG. The investigation and resolution of this matter illustrates the government’s emphasis on combating healthcare fraud. One of the most powerful tools in this effort is the False Claims Act. Tips and complaints from all sources about potential fraud, waste, abuse and mismanagement, can be reported to the Department of Health and Human Services at 800-HHS-TIPS (800-447-8477). The matter was handled by Trial Attorney J. Jennifer Koh of the Justice Department’s Civil Division and Assistant U.S. Attorneys John Osborn and James Concannon for the District of Maine with the assistance of the U.S. Attorney’s Office’s in-house auditor. **Topics:** Judicial/courts --- ### [Estranged husband fatally poisoned wife's food with fentanyl, later set fire to their travel trailer to collect insurance money: Police](https://insurancefraud.org/news_archives/estranged-husband-fatally-poisoned-wifes-food-with-fentanyl-later-set-fire-to-their-travel-trailer-to-collect-insurance-money-police/) **Published:** September 23, 2026 **Author:** Diane Beauchamp **Content:** It was Glennis Smith, 48, who called 911 and said his wife, Jennifer Smith-Floyd, 49, was unconscious and not breathing, say police. Investigators now claim that he murdered her. Cops in Elk Grove, California, received the call on Jan. 12, 2023, according to a press statement from Thursday. “The couple had been married for five years but had been living apart for several months prior to the incident,” police wrote. “Fire personnel and officers responded to their residence but where Smith had been predominately living and rendered medical aid; however, Smith-Floyd was pronounced deceased.” Investigators discovered fentanyl in her system; they claim Smith put it in her food on two occasions without her knowledge. The first poisoning allegedly happened on Jan. 11. “Early on in the initial investigation, officers learned that the victim had been transported to a local hospital the day before for what was described as an allergic reaction to some food that she consumed,” Sgt. Jason Jimenez with the Elk Grove Police Department said, according to KXTV. Months after Smith-Floyd died, Smith allegedly set fire to their travel trailer to claim it on insurance, Jimenez said. Hence, he is charged with both murder and insurance fraud. The trailer was being kept in storage at the time, according to police. Smith previously went to prison for spousal rape committed against a previous wife, according to CBS News. Smith-Floyd’s family called her a loving mother, daughter, sister, and friend, according to KXTV. She was a champion for women, building them up and providing them strength, they said. “Unfortunately, her life was ended due to her murder,” they said. “She didn’t deserve this. As a family, we are devastated by her loss. We miss her and our lives are forever changed.” Neighbors told the outlet Smith-Floyd is survived by two children. The locals also voiced shock at the murder allegation, saying Smith was a great neighbor and nice guy. **Topics:** Homeowners - arson **Categories:** Arrest --- ### [Three U.S. data breaches show varied healthcare exposure risks](https://insurancefraud.org/news_archives/three-u-s-data-breaches-show-varied-healthcare-exposure-risks/) **Published:** September 23, 2026 **Author:** Diane Beauchamp **Content:** Three recent data breaches from across the United States show that the risks of data breaches can come from multiple sources for healthcare providers. Employees, third-party vendor tools and cybercriminals all create data breach risks. ## EMPLOYEE RISKS The DCH Health System in Tuscaloosa, Alabama, notified its patients on January 19 of a data-privacy breach. While conducting a routine privacy audit, the health system discovered one of the hospital’s employees “accessed the electronic medical records” of a patient without an apparent business reason. After further investigation, the hospital discovered the employee had access and viewed additional patient electronic records between September 2021 and December 9, 2022, “without a legitimate business need related to the employee’s job duties.” The health system notified approximately 2,530 individuals that the employee may have accessed and viewed information including their name, address, date of birth, social security numbers, date of encounter, diagnoses, vital signs, medications, test results, and clinical/provider notes(LINK: https://www.dchsystem.com/news/2023/january/notice-to-our-patients-of-data-privacy-event/). The health system “immediately suspended the employee and terminated the employee’s access to all medical records and other information systems.” The individual’s employment was terminated one business day after initial discovery. The health system hired a “data breach recovery expert” and notified all affected patients as well as regulatory officials. Although it does not believe the information has been misused, the health system is providing free identity theft protection services, including credit monitoring, to all patients “whose insurance group and subscriber/policy numbers may have been involved.” ## THIRD PARTY ANALYTICS TOOLS UCLA Health announced on January 13, that it had “recently learned of an issue relating to the use of analytics tools on the UCLA Health website and mobile app.” Analytics tools on an appointment request form completed on the website or mobile app may have “captured and transmitted” information from the form to third-party service providers. UCLA Health notified nearly 94,000 individuals of the data breach(LINK: https://www.uclahealth.org/data-notice). UCLA Health has locations throughout southern California. UCLA Health began using the analytics tools from third-party service providers in April 2020. It disabled the tools when it learned of issues relating to the use of the analytics tools from healthcare providers in June 2022. It also engaged a third-party forensic firm to complete a “comprehensive analysis” of the use of the analytics tools on the website and mobile apps, evaluate what data the analytics tools collected and determine who the data belonged to. The information collected may have included first and last name, email address, mailing address, phone number and gender. UCLA Health states the analytics tools “never captured” Social Security numbers, financial account numbers or payment information. In December 2022, the U.S. Department of Health and Human Services Office for Civil Rights issued a bulletin highlighting the obligations of healthcare providers and business associates when using online tracking technologies on websites or mobile apps(LINK: http://go-ri.tr.com/vbOgCa). The office cautioned that the unauthorized collection or disclosure of protected health information could violate the Health Insurance Portability and Accountability Act (HIPAA). ## CYBERATTACKS AGAINST VENDORS UCHealth in Aurora, Colorado reported a third-party data breach that impacted nearly 49,000 individuals. UCHealth said that it was recently informed by Diligent Corporation, that the software company had experienced a security incident that may have included some of UCHealth’s patient, provider or employee data. Diligent provides hosted services to UCHealth and reported that its software was “accessed and attachments were downloaded including UCHealth files.” However, UCHealth’s systems, including its electronic health records, were not impacted by the incident. UCHealth does not believe the data taken from Diligent’s system “went beyond the cybercriminal or was misused in any way,” according to its notice(LINK: https://www.uchealth.org/today/software-vendor-shares-information-about-data-breach/). However, the data downloaded may have included name, address, date of birth, treatment information and, in limited cases, Social Security numbers or other financial information. The notice does not provide details about the cyberattack against Diligent. Health systems and hospitals have been subject to a wide range of cyberattacks, including ransomware attacks in recent years. The U.S. Department of Justice recently took down the Hive ransomware group that had targeted healthcare and financial entities in recent years. With the varied risks to health data, providers must make sure to engage in consistent and robust employee training as well as conducting due diligence on all third-party vendors to minimize the risk of data breaches. **Topics:** Public Awareness, Technology --- ### [The 5 online scams to watch out for in 2025](https://insurancefraud.org/news_archives/the-5-online-scams-to-watch-out-for-in-2025/) **Published:** September 23, 2026 **Author:** Diane Beauchamp **Content:** Americans lost $12.5 billion to fraud in 2024, including over $5.7 billion in investment scams alone, according to the Federal Trade Commission. Even as government agencies and nonprofits work to expose scams, criminals are becoming more sophisticated with their ruses — increasingly employing artificial intelligence to fool unsuspecting victims. In some cases, the goal is to get money quickly before the target realizes they’ve been duped. More often, however, the goal is to get personal information like Social Security numbers, birthdates, bank accounts and credit card numbers. Identity theft protection services and credit monitoring programs are a great line of defense. But being alert to the schemes fraudsters are employing is the best way to avoid falling prey to them. Protect yourself from identity theft 1. Toll fee scam The FBI is alerting the public about fraudulent text messages warning about unpaid tolls that must be paid or the recipient will face a $50 fine. The Internet Crime Complaint Center reports more than 60,000 people have been hit with this smishing attack. A combination of “SMS” and “phishing,” smishing sees fraudsters on both iPhones and Androids con unsuspecting victims into sharing personal information. 2. Jury duty scam Jury duty isn’t just your civic responsibility, it’s a legal obligation. But scammers have been calling and emailing victims, trying to convince them they’ve missed jury duty and need to pay fines. The scammer pretends to be a police officer or a U.S. Marshal threatening arrest unless payment is made immediately, often through gift cards, payment apps, cryptocurrency, or wire transfer like Western Union. They may also ask for your Social Security number or date of birth. According to the Federal Trade Commission, legitimate court officials would never ask for money or personal information over the phone. 3. Stimulus check scams If you didn’t file a tax return for 2021, you might still qualify for a Recovery Rebate Credit, a Covid-19 stimulus check worth $1,400. Scammers know this and are texting unsuspecting Americans telling them they’re eligible and asking them to click on a link to claim it. While the credit is real, the IRS would never text you a link about it. The link leads to a fake site designed to steal your Social Security number, credit card numbers and other personal information that can be used for identity theft. The IRS usually communicates with taxpayers through the mail. In the rare cases the agency calls or text, it will be in response to a query from you. If you’re legitimately eligible for the Recovery Rebate Credit, a check will automatically be sent to your mailing address or direct deposited into a bank account you have provided. If you receive the text, you should delete it immediately. You can also forward it to <phishing@irs.gov> and report it to the BBB Scam Tracker. 4. Cryptocurrency scams While it has grown in popularity, cryptocurrency is still a mystery to many Americans. That makes it a tempting target for fraudsters. According to the FBI, cryptocurrency investment fraud, or “pig butchering,” is the most common crypto scam to date in 2025. “Subjects target victims online and develop a friendship or relationship before introducing a fraudulent investment opportunity in cryptocurrency,” the agency said in a notice about Operation Level Up, its attempt to foil this crypto fraud. AARP reports that the fraudsters approach targets on messaging apps, social media, even dating apps, to build trust and form a close connection. They then share news about a crypto investment opportunity with minimal risk and big returns. The criminals will tout fake profit reports but when investors try to withdraw funds, they’re charged outrageous fees or the company vanishes before they can get their money. In 2023 alone, victims 60 and older registered nearly 17,000 complaints about crypto fraud and reported losses of $1.6 billion, according to the FBI. As of January 2025, the bureau has already notified 4,323 victims of cryptocurrency investment fraud totaling $285 million. Three-quarters were unaware they were being scammed, according to the bureau, and some were in the process of selling their home, liquidating their 401(K) plans or taking out a big loan to get in on the ground floor of this “opportunity.” If you are the victim of cryptocurrency investment fraud — or think someone has targeted you — file a report with the FBI’s Internet Crime Complaint Center. 5. Employment scams AI is aiding criminals in a variety of scams, including employment scams: According to the Identity Theft Resource Center, reports of job scams soared 118% in 2023. The criminals use legitimate sites like LinkedIn, posting fake job listings to get “new hires” to divulge Social Security numbers and bank accounts. In other cases, victims are told they must pay for training, certifications or other work-related expenses. According to AARP, the most common employment scams include: Fake job listings: Candidates are asked to pay a fee to complete their application Fake job offers: You may receive an unsolicited email asking for your Social Security Number or other personal information as part of the onboarding process. Fake interviews: You’re asked to share private information to be scheduled for an interview that never materializes Fake employment agencies: Victims are told they need to pay a screening fee to be considered. Fake work-from-home jobs: You’re asked to send money to pay for a laptop and other equipment. The best way to protect yourself If you’re contacted about a job opening is to visit the company website and confirm they are hiring for the advertised role. If you can, also try to confirm the recruiter is an employee. How to protect yourself from scams Scammers can be inventive and extremely persuasive. CNBC Select sat down with Michael Bruemmer, head of Global Data Breach Resolution at Experian, to learn how to protect yourself against them. Only click on links you trust “My rule of thumb is if somebody is going to send me something that they want me to click on, they need to call me and say ’Hey Mike, this is what I’m sending you. This is the link, it’s legit,” Bruemmers said. To spot phishing, check where the message is coming from: If it’s claiming to be from a reputable company but sent from a generic Gmail account or has a subtle misspelling (like “amaz0n” instead of “Amazon”), it’s probably a scam. Watch for bad grammar or emails threatening you or urging you to take action quickly. Always err on the side of caution when it comes to links and attachments. If you have doubts about whether or not an email or text is a phishing attempt, get in touch with the actual company that’s supposedly sent it using their official communication channels. Monitor your credit Many people only discover they’ve been scammed by looking at their credit report and seeing new accounts, debts or addresses. You can get a free credit report once a year from each bureau at AnnualCreditReport.com or more frequently by signing up for a credit monitoring service. IdentityForce® UltraSecure and UltraSecure+Credit offer three-bureau credit monitoring and track your information on various sites and services, including the dark web, court records and social media. Don’t respond to calls from unrecognized sources With scammers, sometimes all it takes is you picking up the phone and saying a few words for fraud to happen. Bruemmer says that he’s set up his phone so that all calls from numbers outside of his contact list go straight to voicemail. “Even \[when you’re\] saying hello and your name, someone can grab a voiceprint and use that as a second factor of authentication with a financial institution or to authorize a transaction,” he explains. Don’t use debit cards While popular, debit cards don’t offer the same consumer protections credit cards do and they are directly linked to your checking or savings account. That can make it harder to recoup stolen funds. For those reasons, Bruemmers recommends sticking to credit cards for most transactions. Why trust CNBC Select? At CNBC Select, our mission is to provide our readers with high-quality service journalism and comprehensive consumer advice so they can make informed decisions with their money. Every mortgage product review is based on rigorous reporting by our team of expert writers and editors with extensive knowledge of mortgage products. While CNBC Select earns a commission from affiliate partners on many offers and links, we create all our content without input from our commercial team or any outside third parties, and we pride ourselves on our journalistic standards and ethics. **Topics:** Public Awareness, Technology --- ### [New York State Police Department blotter](https://insurancefraud.org/news_archives/new-york-state-police-department-blotter/) **Published:** September 23, 2026 **Author:** Diane Beauchamp **Content:** New York State Police Department DWI: Patrick McMahon, 52, of Troy, was arrested at 5:08 pm on Jan. 25 in Saratoga Springs for driving while intoxicated, aggravated driving while intoxicated, and operating a motor vehicle with blood alcohol content .08 of 1%. DWI: Marcelo Torres, 30, of South Glens Falls, was arrested at 12:25 am on Jan. 26 in Saratoga Springs for driving while intoxicated and operating a motor vehicle with blood alcohol content .08 of 1%. Fraud: Tiffany Hunter, 27, of Moreau, was arrested at 3:50 pm on Jan. 26 in Wilton for fifth-degree insurance fraud. DWI: George Shaughnessy, 48, of Wilton, was arrested at 7:30 am on Jan. 26 in Wilton for driving while intoxicated and aggravated driving while intoxicated. DWI: Gina Dean, 35, of Stillwater, was arrested at 9:29 pm on Jan. 26 in Moreau for driving while intoxicated, aggravated driving while intoxicated, and operating a motor vehicle with blood alcohol content .08 of 1%. DWAI: Jamie Elder, 44, of Corinth, was arrested at 3:15 am on Jan. 26 in Saratoga Springs for first-degree operating a motor vehicle while impaired by drugs. DWI: Kathianne King, 64, of Ballston Spa, was arrested at 10 pm on Jan. 26 in Saratoga Springs for driving while intoxicated, second-degree obstruction of governmental administration, and fourth-degree criminal mischief. Larceny: Nicole Kope, 42, of Petersburg, was arrested at 10:05 am on Jan. 27 in Malta for third-degree grand larceny. Leandra’s Law: Jeremy Chapin, 43, of East Calais, VT, was arrested at 10:53 pm on Jan. 28 in Moreau for aggravated driving while intoxicated with a child passenger, first-degree operating a motor vehicle while impaired by drugs, endangering the welfare of a child, and seventh-degree criminal possession of a controlled substance. Larceny: Christopher Gibbons, 29, of Bennington, VT, was arrested at 10:41 pm on Jan. 28 in Halfmoon for petit larceny. DWI: Sheila Pizzitola, 55, of Selkirk, was arrested at 10:52 pm on Jan. 28 in Halfmoon for driving while intoxicated and operating a motor vehicle with blood alcohol content .08 of 1%. Larceny: Damon Garrison, 28, of Shelburne, VT, was arrested at 11:30 pm on Jan. 28 in Halfmoon for petit larceny, sixth-degree conspiracy, and seventh-degree criminal possession of a controlled substance. Criminal Possession: Melissa Slingerland, 35, of Essex Junction, VT, was arrested at 11:30 pm on Jan. 28 in Halfmoon for seventh-degree criminal possession of a controlled substance, petit larceny, and sixth-degree conspiracy. DWI: Brian Borgstede, 63, of South Glens Falls, was arrested at 11:52 am on Jan. 29 in South Glens Falls for driving while intoxicated and operating a motor vehicle with blood alcohol content .08 of 1%. Criminal Possession: Nicholas Vannorden, 34, of Ballston Spa, was arrested at 3:25 pm on Jan. 29 in Wilton for 2 counts of seventh-degree criminal possession of a controlled substance and petit larceny. Bail Jumping: Mark Woodard, 41, of Moreau, was arrested at 10:10 pm on Jan. Jan. 29 in Wilton for third-degree bail jumping. Larceny: Thomas Berry, 52, of Ballston Spa, was arrested at 9:30 pm on Jan. 30 in Colonie for fourth-degree grand larceny of property valued in excess of $1,000 and petit larceny. Criminal Mischief: Joseph Morgan, 30, of Gansevoort, was arrested at 5:10 pm on Jan. 30 in Wilton for third-degree criminal mischief and third-degree criminal trespassing. Larceny: Steven Gowie, 34, of Troy, was arrested at 12:30 pm on Jan. 30 in Halfmoon for petit larceny. Larceny: Makayla Johnson, 20, of Halfmoon, was arrested at 2:40 pm on Jan. 30 in Halfmoon for petit larceny. DWI: Christopher Haskell, 39, of Ballston Spa, was arrested at 9:49 pm on Jan. 31 in Malta for driving while intoxicated with 2 prior convictions within 10 years. Criminal Possession: Joel Burgess, 43, of Greenfield, was arrested at 3 am on Feb. 1 in Milton for seventh-degree criminal possession of a controlled substance, second-degree reckless endangerment, fourth-degree criminal mischief, second-degree obstruction of governmental administration, and resisting arrest. DWI: Thomas Resue, 64, of Ballston Lake, was arrested at 7:14 pm on Jan. 31 in Clifton Park for driving while intoxicated with a prior conviction within 10 years, aggravated driving while intoxicated with 1 prior conviction, and operating a motor vehicle with blood alcohol content .08 of 1%. **Topics:** Fraud General **Categories:** Arrest --- ### [Robocallers are preying on the elderly with fake Medicare calls. It's a no-brainer to stop it, but nobody has.](https://insurancefraud.org/news_archives/robocallers-are-preying-on-the-elderly-with-fake-medicare-calls-its-a-no-brainer-to-stop-it-but-nobody-has/) **Published:** September 23, 2026 **Author:** Diane Beauchamp **Content:** “Hello, this is Jennifer calling from the Medicare office,” began a scammer using Medicare’s phone number in one recording from a honeypot. “How are you?” “Do you have a Medicare health insurance card,” another asked before later adding, “What’s your card number?” Neither of these calls actually came from Medicare. In fact, they likely originated from scammers operating overseas — in January alone, an estimated more than 36 million Medicare robocalls were sent to US phone lines. The influx of these calls may seem relatively benign, but they’re a part of a larger scam to defraud taxpayers and the federal government. ## Defrauding the system Aaron Foss is the CEO and founder of Nomorobo, a premium service that screens users’ calls to prevent them from ever making contact with the phone scammer. In addition to screening others’ calls, the company has also amassed an arsenal of 350,000 “honeypot,” or decoy phone lines, built with the express purpose of sitting and waiting to receive spam calls. These honeypots comprise only a sliver of the total number of US phone numbers but provide valuable insights into how robocalling scams operate. Companies will call millions of phone lines in an attempt to engage with just a tiny handful of unsuspecting marks. While the response rates are “abysmal” and receive a “tenth of a percent response rate,” [Foss said in 2021](https://www.businessinsider.com/why-so-many-spam-robocalls-how-to-stop-them-2021-3), the schemes are cheap and work. Every day, the honeypot numbers get inundated with calls from scammers purporting to be from Medicare. Many of those calls spoof the services’ “1-800-MEDICARE” (1-800-633-4227) hotline in the phone’s caller ID. Call spoofing is a serious problem as it pertains to phone spam, as scammers are very easily able to change the apparent origin of their calls to add credibility to their grift. A spokesperson for the Centers for Medicare & Medicaid Services explained to Insider that the end goal for the scammers spoofing the 1-800-MEDICARE line is to pile up charges to Medicare and steal the victim’s identity. “Many seniors are targeted by scammers who want to steal their Medicare numbers to do things like rack up fake health care charges and commit identify theft,” the representative said. “These scams hurt seniors and other people eligible for Medicare, cost taxpayers money, and result in higher health care costs for everyone.” The representative further warned against ever sharing one’s Medicare number unless it’s with their “doctor, pharmacist, hospital, health insurer, or other trusted healthcare provider.” ## Stopping the spoofing [When caller ID was implemented](https://www.businessinsider.com/why-so-many-spam-robocalls-how-to-stop-them-2021-3), AT&T was the only phone company around. And as such, it implemented a system where a customer could put anything as their caller identification as they’d be able to verify who was who. But the government broke up AT&T and deregulated the telecom industry, ultimately crippling the effectiveness of caller ID by allowing scammers to easily game the system. The Federal Communications Commission attempted to combat the spoofed robocall problem by implementing STIR/SHAKEN protocols in 2021, which works to verify the caller ID of a user. Foss said that the implementation of STIR/SHAKEN protocols has led to a noticeable decline in the overall volume of robocalls. He explained, however, that scammers are still able to spoof numbers, and have just begun to go for “bigger” scams that have the opportunity to pull in high-dollar amounts, like Medicare or bank fraud. There is, however, another way to combat some of these scams. ## The DNO Registry was built to stop it, but isn’t used The Federal Communications Commission requires gateway providers to reference a “reasonable Do Not Originate” list, a registry of phone numbers that are never used for outbound calls, only inbound, like 911 or the IRS’ hotline. The providers, knowing these numbers are for inbound calls only, will then drop any call that has a caller ID of one of the numbers on the DNO registry. The easiest way to kneecap Medicare fraudsters would be to simply add the 1-800-MEDICARE line to the DNO registry. This would eliminate scammers from being able to spoof the official hotline. Swindlers will still have access to an abundance of other phone lines to use, but would no longer be able to claim they’re from Medicare by encouraging the target to check their caller ID. The biggest hurdle with this is that it appears the Centers for Medicare & Medicaid Services use the phone line for both inbound and outbound calls, according to one representative. “A customer service representative from 1-800-MEDICARE can call you if you’ve called and left a message or a representative said that someone would call you back,” the representative told Insider. Somos, a data registry manager, oversees the “RealNumber DNO database,” a comprehensive list of phone numbers that have been identified as never being used for outbound calls. It’s one of several DNO registries the FCC permits telecom companies to use to combat spam calls. Nelly Valentin, the director of marketing at Somos, told Insider “[responsible](https://www.unitedworldtelecom.com/learn/what-is-a-resporg/)” organizations that own and manage toll-free numbers (like the 1-800-MEDICARE line) “have the ability to identify these numbers in the RealNumber DNO database.” Valentin added that enterprises and brands “can also reach out to Somos to identify numbers that should not originate a call.” With this in mind, it’s unclear why the Centers for Medicare & Medicaid Services use the phone line for both outbound and inbound calls. Foss said the first step the group should take is to make their hotline “inbound only.” “Nobody should be able to make calls from there,” Foss said. “These criminal organizations have just had free roam of the phone network and that’s why we have this problem,” he added, “So we at least have to put some speed bumps. We at least have to make their job more difficult. DNOing 1-800-Medicare is very simple, very straightforward, and should be should have been done a while back.” **Topics:** Medicare/Medicaid, Public Awareness, Technology --- ### [Ocean Springs man indicted in healthcare fraud case involving businessman Ken Ritchey](https://insurancefraud.org/news_archives/ocean-springs-man-indicted-in-healthcare-fraud-case-involving-businessman-ken-ritchey/) **Published:** September 23, 2026 **Author:** Diane Beauchamp **Content:** James Wesley “Trey” Martin III is the latest person arrested on a federal charge as a result of an investigation into an alleged healthcare fraud scheme involving Ocean Spring businessman Kenneth Ritchey. The 30-year-old man from Ocean Springs pleaded not guilty Thursday during his arraignment on a federal charge of making false statements. Martin appeared in federal court in Gulfport with his attorney, Tristen Russell Armer. He faces up to 5 years in prison and up to $250,000 in fines if convicted. Judge Bradley Rath allowed Martin to remain free on a $25,000 unsecured bond. Martin is accused of committing the crime while working as a warehouse manager and permit holder for Gulf Coast Pharmaceuticals Plus, LLC. Ritchey controls and operates the Ocean-Springs-based business. According to the charging document, Martin created the fraudulent paperwork at Ritchey’s direction for Jada Gilbert, the pharmacist in charge at Blue Ribbon Pharmacy in Harris County, Texas. Gilbert called Martin to ask that he create the fraudulent paperwork after CVS Caremark decided to audit Gilbert’s pharmacy in 2019. In April, Gilbert pleaded guilty in federal court in Gulfport to a federal charge of conspiracy to commit healthcare fraud. As part of her plea, Gilbert admitted to conspiring with others to create fraudulent invoices and purchase logs for high-adjudication pharmaceutical products, namely specialized products to treat burns that she had never ordered or dispensed. Gilbert admitted she was trying to conceal her crime when she submitted the fraudulent paperwork to CVS benefit managers during the audit in an attempt to prevent a claw back of over $330,000 her pharmacy received from CVS through the benefits program. More on Ken Ritchey case Martin is the latest to face arrest over alleged crimes involving Ritchey and GCPP. Ritchey is awaiting trial on federal charges that include six counts of conspiracy to commit healthcare fraud and wire fraud, one count of making false statements, conspiracy to defraud the United States, and conspiracy to hoard designated scarce materials as a result of the same investigation. His arrest came after federal authorities raided his wholesale distribution business in Ocean Springs and seized various PPE gear and other items. He is accused of defrauding healthcare providers, such as Veterans Affairs hospitals, out of $18 million. The indictment against Ritchey says that the PPE gear he was selling was marked up as much as 300% over costs, and providers bought them out of fear of being unable to get the equipment during the national emergency due to the COVID-19 pandemic. To carry out the scheme, Ritchey allegedly directed his employees, including the head buyer for GCPP, Branden J. Reich, of Broward County, Florida, to buy the PPE gear and paid him and others, for example, 50 cents for each N-95 mask they acquire plus expenses. Reich, 36, worked at GCPP’s Fort Lauderdale branch. Reich has already pleaded guilty to a federal charge of conspiracy to commit healthcare fraud as part of the PPE price-gouging scheme involving PPE gear. He is only one of the 12 alleged co-conspirators involving the price-gouging scheme. Reich has been assisting federal authorities in their investigation. Assistant U.S. Attorney Jonathan Buckner and Sara Porter are prosecuting the case. **Topics:** COVID-19, Drug Diversion **Categories:** Arrest --- ### [In-home care provider investigated for $4M in Medicaid fraud](https://insurancefraud.org/news_archives/in-home-care-provider-investigated-for-4m-in-medicaid-fraud/) **Published:** September 23, 2026 **Author:** Diane Beauchamp **Content:** A St. Paul-based home health care company is being investigated by the Minnesota Attorney General’s Office for fraudulently overbilling the state’s Medicaid program, which is designed to support low-income residents and people with disabilities. State investigators took computers, financial reports, rental agreements, and other documents from Bridges MN on Thursday, according to court documents filed last week. Authorities say they have already tracked $4 million in fraudulent billing over five years, with the possibility of more instances of fraud expected, according to a search warrant. Bridges provides in-home care to more than 40 individuals across Minnesota, according to the warrant. Since 2016, the company has been reimbursed over $146 million for services provided to Medicaid recipients. The Minnesota Department of Human Services previously revoked Bridges MN’s license after finding instances of maltreatment and non-compliance. State records show that the company is appealing that decision and has continued to operate. DHS pieced together possible fraud after reviewing years of financial documents, daily care notes, and interviews with whistleblowers. The investigation comes after years of warnings from the agency, which told Bridges MN executives in 2019 the company was at risk of billing fraud if it provided services outside of the federally approved waiver plans. After two years of notices, “Bridges continued to bill for services… well after receiving the first notice of non-compliance,” investigators with the Attorney General’s Office said. No one from Bridges MN has been charged with a crime. In a statement to 5 INVESTIGATES, an attorney for Bridges MN said the company “denies any wrongdoing and believes that the allegations in the search warrant affidavit will prove to be incorrect,” adding: “While we proactively address these allegations, we will continue to focus our complete attention on the clients and caregivers who look to us for support.” Company executives are also facing accusations of billing for services on properties they own or have a financial stake in, which is illegal for “own-home” services in Minnesota. The state investigation found Bridges MN was billing for services even when some of its residents were sleeping, going to online school, or going to church. A case worker told the company in a January 2021 email: “it is fraudulent billing, and I can’t make that any different,” according to the warrant. Asked by investigators about the documented overbilling, co-owner, Chief Financial Officer and Vice President of Finance Scott Loe told DHS that his company “does not consistently review supporting documentation to determine how to bill.” Loe also told investigators it would be “a good question” for other staffers, the warrant states. Bridges MN is in the process of being sold to another company, Caregiver, which state officials said they believe will provide the same types of services. **Topics:** Public Awareness, Regulatory actions --- ### [PHI of Thousands of Patients Compromised in 4 Healthcare Data Breaches](https://insurancefraud.org/news_archives/phi-of-thousands-of-patients-compromised-in-4-healthcare-data-breaches/) **Published:** September 23, 2026 **Author:** Diane Beauchamp **Content:** A round-up of data breaches that have recently been reported to the HHS’ Office for Civil Rights and state Attorneys General. ## BayCare Clinic Announced Pixel-Related Data Breach The Wisconsin-based healthcare provider, BayCare Clinic, LLP, has recently announced that the protected health information of up to 134,000 of its patients has been impermissibly disclosed to unauthorized third parties as a result of the use of pixels by its partner, Advocate Aurora Health. Advocate Aurora Health previously disclosed a pixel-related data breach that resulted in the personal and protected health information of up to 3 million of its patients being disclosed to third parties such as Google and Meta. The impermissible disclosures occurred when users visited its website and patient portal while logged into either their Google or Facebook accounts. The types of information involved depended on users’ interactions on the MyChart and LiveWell websites and applications, which may have included the following types of [HIPAA](https://www.hipaajournal.com/hipaa-compliance-checklist/) data: IP address, dates, times, and/or locations of scheduled appointments, proximity to a practice location, provider information, type of appointment or procedure, whether the individual had insurance cover, communications between the patient and others through MyChart, which may have included first and last names and medical record numbers, and whether the user had a proxy MyChart account, in which case the first and last name of the proxy may have been disclosed. Advocate Aurora Health has removed the pixels and will subject all tracking technologies to more stringent checks in the future. Further information on the nature of the breach can be found [in this post](https://www.hipaajournal.com/advocate-aurora-health-website-tracking-code-impermissible-disclosure-3m-patients/). ## Rhode Island Department of Health Reports Internal Data Breach The Rhode Island Department of Health (RIDOH) has announced there has been an internal impermissible disclosure of patient information. The breach was discovered on October 21, 2022, with the investigation confirming patient information was impermissibly disclosed between July and October 2022. A hyperlink to a spreadsheet was included in emails sent to employees and the spreadsheet contained information about the individuals who were receiving food deliveries while in isolation or quarantine during the COVID-19 pandemic. The spreadsheet contained information such as names, addresses, phone numbers, household information, delivery information, and information about the specific food needs of those individuals. Access to the file was immediately restricted when the issue was detected, and a scan was conducted on email accounts to determine whether the emails had been shared. RIDOH said it is not aware of any misuse of the exposed information. Steps have since been taken to prevent further disclosures of this nature, including providing [additional training](https://www.hipaajournal.com/hipaa-training-requirements/) to employees on the handling of sensitive information. Approximately 8,800 individuals were affected. ## DCH Health System Discovers Insider Data Breach Tuscaloosa, AL-based DCH Health System, has recently announced that a former employee has accessed the medical records of patients without authorization. The unauthorized medical record access was discovered by DCH Health on December 9, 2022, during a routine privacy audit. The audit revealed the employee had viewed the medical records of a patient on December 5, 2022, when there was no legitimate work reason for doing so. During the subsequent investigation, DCH Health discovered this was not the first time that medical records had been accessed by the employee, as the privacy violations had been occurring since September 2021. During that time, the records of approximately 2,530 patients were impermissibly accessed. The types of information viewed included names, addresses, birth dates, Social Security numbers, dates of encounters, diagnoses, vital signs, medications, test results, and clinical/provider notes. DCH Health said the employee was immediately suspended when the first unauthorized access was discovered and was subsequently terminated over the privacy violations. Complimentary identity theft protection services have been offered to affected patients, although DCH Health said there are no indications that any patient information has been or will be misused. DCH Health said employees will continue to be provided with HIPAA and privacy training on appropriate access, and the incident will be used to improve privacy monitoring tools and processes. ## Patient Data Compromised in Rundle Eye Care Hacking Incident Drs. Keith and Herman Rundle have recently confirmed that the protected health information of certain Rundle Eye Care patients has been accessed and potentially obtained by unauthorized individuals. According to the breach notification letters, the attack occurred “recently” and involved patient names, birth dates, and treatment information. While data theft may have occurred, there are no indications that patient data have been or will be misused. As a precaution against the misuse of patient data, affected patients have been offered complimentary single bureau credit monitoring services for 12 months. Measures have also been taken to strengthen system security. While ransomware was not mentioned in the breach notice, the Everest Ransomware Group claimed responsibility for the attack and says 30 GB of data was stolen, including tax records, medical records, and prescription forms. The breach was reported to the HHS’ Office for Civil Rights as affecting 7,528 patients. **Topics:** Public Awareness, Technology --- ### [Hacking Accounted For Nearly 80% of Healthcare Data Breaches Last Year](https://insurancefraud.org/news_archives/hacking-accounted-for-nearly-80-of-healthcare-data-breaches-last-year/) **Published:** September 23, 2026 **Author:** Diane Beauchamp **Content:** In past years, unauthorized disclosures, loss, theft, and improper disposal accounted for more healthcare data breaches than malicious hacking. Nearly 80 percent of healthcare data breaches reported to the HHS Office for Civil Rights (OCR) in 2022 were attributed to hacking and IT incidents, Fortified Health Security [noted](https://www.accesswire.com/735523/Fortified-Health-Security-Releases-2023-Horizon-Report) in its “2023 Horizon Report,” signifying a 45 percent increase from just five years ago. What’s more, 70 percent of reported breaches (impacting more than 500 individuals each) affected healthcare providers, with business associates and health plans making up a much smaller portion of the total number of impacted entities. In total, 51.4 million healthcare records were breached in 2022, compared to 49.4 million in 2021. As previously reported, many of the [top ten largest healthcare data breaches](https://www.techtarget.com/healthtechsecurity/feature/This-Years-Largest-Healthcare-Data-Breaches) reported to HHS in 2022 stemmed from third-party vendors, underscoring the need for better third-party risk management. These trends are likely to continue into 2023 and beyond, Fortified Health Security suggested. “Healthcare organizations must get granular with cybersecurity precautions if they want to stem the tide of breaches,” the report continued. “Focusing on the basics — strong passwords, multi-factor authentication (MFA), vulnerability management, frequent patching, and managing human risk through continuous training of the entire workforce — will go a long way toward minimizing threats from the inside and outside.” The report offered five areas for healthcare security teams to prioritize in 2023. First, Fortified Health Security urged organizations to tackle emerging threats by knowing your IP range, managing password strength, and implementing endpoint detection and response solutions. Next, the report called attention to third-party risk management and stressed the importance of continuous monitoring and re-assessments. “Third-party risk management (TPRM) shouldn’t be a point-in-time response to a cyber insurance request or a mandate from the C-suite,” the report noted. “It should be a comprehensive and forward-looking program, integrated into the overall vendor evaluation process as a proactive engagement of identifying risk versus a reactive approach that happens after vendors are onboarded. In addition, Fortified Health Security encouraged healthcare organizations to implement and continuously monitor multi-factor authentication, leverage available subsidies and grants, and bolster their [security training and awareness programs](https://www.techtarget.com/healthtechsecurity/answer/How-Northwell-Health-Runs-Its-Cybersecurity-Training-and-Awareness-Program). The experts predicted an increase in cybersecurity funds for providers in 2023, along with an increase in cyber spending and an uptick in breaches to match. “Hospitals and health systems faced tremendous pressures, both internally and externally in 2022 — and not just from a cybersecurity perspective, but also in terms of profitability, expenses, and staffing,” Dan L. Dodson, CEO of Fortified Health Security said in an accompanying press release. “We cannot let our guard down, as we anticipate a rise in large-scale breaches this year. The effects of these hacking incidents and breaches on healthcare are detrimental, and to mitigate this, we expect to see an increased investment by stakeholders in new cybersecurity solutions that reduce risk and increase their security posture in 2023.” **Topics:** Public Awareness, Technology --- ### [Owners of Mobile Phlebotomy Company Plead Guilty to $ 7 Million Medicare Fraud](https://insurancefraud.org/news_archives/owners-of-mobile-phlebotomy-company-plead-guilty-to-7-million-medicare-fraud/) **Published:** September 23, 2026 **Author:** Diane Beauchamp **Content:** Gabriella Santibanez, 58, and her sister Lisa Hazard, 54, both of Temecula, California, pleaded guilty Friday to conspiring to commit over $7 million in health care fraud, U.S. Attorney Phillip A. Talbert announced. According to court documents, between Dec, 1, 2015, and Dec, 1, 2020, Santibanez and Hazard ran a mobile phlebotomy company, PhlebXpress Inc. that provided phlebotomy and other medical collection services at patients’ homes and long-term care facilities in Sacramento and elsewhere. Santibanez and Hazard agreed to bill Medicare for services provided that were not reimbursable by Medicare. Santibanez and Hazard also agreed to bill Medicare for overstated mileage that PhlebXpress phlebotomists traveled. On average, Santibanez and Hazard caused false billing to Medicare of over 140 miles for each patient seen by PhlebXpress. Santibanez and Hazard caused a loss to Medicare of at least $7.5 million based on false billing by PhlebXpress. In November 2020, due to “credible allegations of fraud” at PhlebXpress, Medicare instituted a payment suspension for PhlebXpress under which Medicare ceased paying PhlebXpress for the services it continued to bill Medicare. According to court documents, between July 1, 2021, and Dec. 31, 2021, Santibanez and Hazard agreed to circumvent the payment suspension by representing to Medicare that services provided to Medicare patients were done by another company, Phlebotomy Solutions, when they were in fact being provided by PhlebXpress through its contractors and employees from PhlebXpress’s offices. Through Phlebotomy Solutions, Santibanez and Hazard agreed to bill Medicare for a non-reimbursable service, misrepresenting that it was for another reimbursable service and overstating the mileage traveled by phlebotomists in order to receive additional money from Medicare. For example, in September 2021, Phlebotomy Solutions billed Medicare for 124.6 miles of travel by a phlebotomist when in fact the phlebotomist travelled 1.4 miles. Santibanez and Hazard caused a loss to Medicare of at least $50,000 based on false billing by Phlebotomy Solutions. This case is the product of an investigation by the Federal Bureau of Investigation and the U.S. Department of Health and Human Services Office of Inspector General. Assistant U.S. Attorney Lee Bickley is prosecuting the case. Santibanez and Hazard are scheduled to be sentenced by U.S. District Judge William B. Shubb on May 1, 2023. They each face a maximum penalty of 10 years in prison and $250,000 fine. The actual sentence, however, will be determined at the discretion of the court after consideration of any applicable statutory factors and the Federal Sentencing Guidelines, which take into account a number of variables. **Topics:** Medicare/Medicaid **Categories:** Conviction --- ### [23% of Consumers Admit to Committing 'Friendly Fraud' When Disputing Transactions](https://insurancefraud.org/news_archives/23-of-consumers-admit-to-committing-friendly-fraud-when-disputing-transactions/) **Published:** September 23, 2026 **Author:** Diane Beauchamp **Content:** ## What happened A whopping 23% of consumers admitted to disputing purchases as fraud, even though they received the item and were satisfied with the purchase, according to [Sift’s Q4 2022 Digital Trust & Safety Index](https://resources.sift.com/ebook/q4-2022-digital-trust-safety-index-the-rising-risk-of-online-disputes/). This is commonly known as friendly fraud or first-party fraud, because the cardholder is the one committing fraud. The average value of a chargeback was $192.53 in 2022. Merchant Fraud Journal expects that chargebacks will [cost merchants over $100 billion](https://www.newswire.com/news/merchant-fraud-journal-releases-chargebacks-consumer-survey-report-2022-21837006) in 2023. ## So what [Credit cards](https://www.fool.com/money/credit-cards/?luri=%2Fcredit-cards%2Farticles%2F23-of-consumers-admit-to-committing-friendly-fraud-when-disputing-transactions%2F&furi=%2Fcredit-cards%2Farticles%2F23-of-consumers-admit-to-committing-friendly-fraud-when-disputing-transactions%2F&fuuid=ad3a8473-8383-4126-b04f-3938052dff88&luuid=ad3a8473-8383-4126-b04f-3938052dff88<yp=txt) and debit cards offer a dispute process for cardholders to report issues with transactions. Legitimate reasons to file a dispute include: - **Unauthorized charges:** Someone used your credit card without your permission. - **Billing errors:** A merchant mistakenly charged you. For example, you canceled your gym membership, but it was charged anyway the next month. - **Problems with a purchase:** This covers orders that aren’t delivered, quality issues, and other purchase issues. Some consumers take advantage of these protections to get fraudulent refunds. “As the economy cools down from historic highs, consumers are looking to save money however they can, luring many to resort to first-party fraud,” said Sift Trust and Safety Architect Brittany Allen in a [press release announcing the survey results](https://www.globenewswire.com/news-release/2022/12/15/2574874/0/en/Report-Nearly-1-in-4-Consumers-Who-File-Chargebacks-Admit-to-Friendly-Fraud.html). Friendly fraud is a source of frustration for businesses, as they lose money when customers file chargebacks. It also affects shoppers, because merchants need to raise prices to account for fraudulent disputes. Visa has announced it will update its dispute program on April 15, 2023 to help merchants fight friendly fraud. While this is designed to limit fraud, it’s possible that changing the dispute process to help merchants could make it harder on consumers with legitimate card disputes. ## Now what The dispute process that credit cards and [debit cards](https://www.fool.com/money/banks/checking-accounts/what-is-debit-card/?luri=%2Fcredit-cards%2Farticles%2F23-of-consumers-admit-to-committing-friendly-fraud-when-disputing-transactions%2F&furi=%2Fcredit-cards%2Farticles%2F23-of-consumers-admit-to-committing-friendly-fraud-when-disputing-transactions%2F&fuuid=ad3a8473-8383-4126-b04f-3938052dff88&luuid=ad3a8473-8383-4126-b04f-3938052dff88<yp=txt) offer is a valuable protection for consumers. If you’re the victim of fraud, or there are problems with your purchase, you could get your money back. But it’s important to know when and how to [dispute a charge](https://www.fool.com/money/credit-cards/disputing-credit-card-charge/?luri=%2Fcredit-cards%2Farticles%2F23-of-consumers-admit-to-committing-friendly-fraud-when-disputing-transactions%2F&furi=%2Fcredit-cards%2Farticles%2F23-of-consumers-admit-to-committing-friendly-fraud-when-disputing-transactions%2F&fuuid=ad3a8473-8383-4126-b04f-3938052dff88&luuid=ad3a8473-8383-4126-b04f-3938052dff88<yp=txt). If you spot an unauthorized charge on your credit card, first double check to confirm that it’s fraud. Business names on a [credit card statement](https://www.fool.com/money/credit-cards/credit-card-statement-how-to-read/?luri=%2Fcredit-cards%2Farticles%2F23-of-consumers-admit-to-committing-friendly-fraud-when-disputing-transactions%2F&furi=%2Fcredit-cards%2Farticles%2F23-of-consumers-admit-to-committing-friendly-fraud-when-disputing-transactions%2F&fuuid=ad3a8473-8383-4126-b04f-3938052dff88&luuid=ad3a8473-8383-4126-b04f-3938052dff88<yp=txt) don’t always match store names. Sometimes legitimate purchases look like fraud for this reason. If you’re sure that it isn’t a purchase you made, that’s a valid reason to file a dispute. For billing errors and problems with a product, contact the merchant first to see if you can resolve the issue with them. Some consumers don’t realize this, but unless it’s fraud, you’re supposed to reach out to the merchant before disputing a transaction. If you and the merchant can’t come to an agreement, that’s when you can file a dispute and let your credit card company take the lead. **Topics:** Public Awareness --- ### [Two Sigma joins forces with NominoData to tackle insurance fraud](https://insurancefraud.org/news_archives/two-sigma-joins-forces-with-nominodata-to-tackle-insurance-fraud/) **Published:** September 23, 2026 **Author:** Diane Beauchamp **Content:** **[Two Sigma Insurance Quantified (TSIQ),](http://www.twosigmaiq.com./) an underwriting technology company for the commercial property and casualty industry, has partnered with [NominoData](http://www.nominodata.com/) to detect and reduce insurance fraud.** Two Sigma Insurance Quantified is an underwriting technology provider that arms commercial property and casualty insurance carriers and MGAs with the data and analytics they need to grow their business, improve underwriting profitability and be a preferred partner and employer NominoData is a solutions company formed to help clients with worldwide identity, compliance, and risk management issues associated with modern day commerce. Through this partnership, Two Sigma said NominoData’s OFACplus dataset will now be available to customers of TSIQ’s underwriting workbench solution, SubmissionIQ. By incorporating this data directly into their workflows, the two companies said firms will improve their ability to detect fraud and strengthen risk management earlier in the underwriting process. Jeff Tyler, head of product, data science, and engineering at Two Sigma Insurance Quantified, said, “At TSIQ, we are committed to making sure underwriters have the data where and when they need it to make more informed and consistent decisions. By integrating the OFACplus dataset with our SubmissionIQ platform, we’re further enhancing the underwriter’s experience and instilling confidence along the way. “NominoData’s innovation and commitment to empowering better risk management complements our mission of applying a more systematic underwriting process to promote safer practices.” Al Macdonald, chief executive officer of NominoData, added, “We are excited to make OFACplus available to TSIQ’s client base and look forward to working together to further simplify fraud detection. Our partnership enables enhanced transparency through greater and easier access to data, true tenants of data-driven digital transformation that both our companies value.” Last year, [TD Insurance (TDI) implemented FRISS’ AI-powered fraud risk scoring services](https://fintech.global/2022/01/27/td-insurance-boosts-insurance-fraud-protection-with-friss/) to combat the rising prevalence of insurance fraud in Canada. **Topics:** Public Awareness, Technology --- ### [Rochester insurance agency warns homeowners of mail scam](https://insurancefraud.org/news_archives/rochester-insurance-agency-warns-homeowners-of-mail-scam/) **Published:** September 23, 2026 **Author:** Diane Beauchamp **Content:** Insurance agency North Risk Partners sent out a warning for homeowners of a scam showing up in mailboxes. For the past few weeks, the company has gotten numerous calls from its clients regarding letters they have received in the mail stating their home warranty is expiring. According to North Risk Partners, the scam includes two letters to homeowners. The outside of the envelope leads people to think the warranty is somehow related to the homeowner’s insurance and bank. See photo below. ![](https://insurancefraud.org/wp-content/uploads/image-20-1024x707.png)Inside, there is a letter regarding a final notice for home warranty services. See photo below. ![](https://insurancefraud.org/wp-content/uploads/image-21-827x1024.png)Account managers say the scam is generally targeting elderly people. North Risk Partners recommends either ignoring the letter or reporting the scam to their local law enforcement agency. **Topics:** Public Awareness --- ### [Ransomware gang threatens to publish thousands of Australians’ health data](https://insurancefraud.org/news_archives/ransomware-gang-threatens-to-publish-thousands-of-australians-health-data/) **Published:** September 23, 2026 **Author:** Diane Beauchamp **Content:** A ransomware group with suspected links to the notorious [Russia-speaking REvil gang](https://techcrunch.com/2022/03/10/revil-hacker-kaseya-arrested/) has threatened to release the personal information of millions of Medibank customers after the Australian private health insurance giant pledged it would not pay the cybercriminals’ ransom demand. Medibank, Australia’s largest health insurance provider, first [disclosed](https://www.medibank.com.au/livebetter/newsroom/post/medibank-cyber-incident) a “cyber incident” on October 13, saying at the time that it detected unusual activity on its network and took immediate steps to contain the incident. Days later, the company said that customer data might have been exfiltrated. In [an update](https://www.medibank.com.au/livebetter/newsroom/post/medibank-cybercrime-update%207%20November?=november-7-update) posted this week, the Melbourne-based Medibank admitted that the attackers accessed roughly 9.7 million customers’ personal information, including names, birth dates, email addresses and passport numbers. The cybercriminals also accessed health claims data for almost 500,000 customers, including service provider names and locations, where customers received certain medical services, and codes associated with diagnosis and procedures administered. For 5,200 users of Medibank’s My Home Hospital app, the cybercriminals accessed some personal and health claims data and, for some, next of kin contact details. Medibank CEO David Koczkar said that while the health insurance giant believes that the attackers likely exfiltrated all of the data they were able to access, the organization would not pay the ransom demand. “Based on the extensive advice we have received from cybercrime experts, we believe there is only a limited chance paying a ransom would ensure the return of our customers’ data and prevent it from being published,” Koczkar said. The chief executive added that paying could even encourage the hackers to adopt a triple-extortion tactic by attempting to extort customers directly. Following Koczkar’s announcement, a ransomware gang believed to be a rebrand of the defunct REvil group threatened to leak the stolen Medibank data. The new dark web leak site, seen by TechCrunch, listed Medibank as one of its victims and said it planned to release the exfiltrated data publicly. The gang did not say how much data it exfiltrated from Medibank’s network, and did not share evidence of its claims. The links between the new leak site and REvil, which went dark after U.S. authorities pushed the operation offline in October after the gang targeted ransomware attacks against [Colonial Pipeline](https://techcrunch.com/tag/colonial-pipeline/), [JBS Foods](https://www.wsj.com/articles/jbs-paid-11-million-to-resolve-ransomware-attack-11623280781) and [U.S. technology firm Kaseya](https://techcrunch.com/2021/02/08/two-50m-ish-arr-companies-talk-growth-and-plans-for-the-coming-quarters/), remains unclear. Brett Callow, a ransomware expert and threat analyst at Emsisoft, said that the new operation uses a variant of REvil’s file-encrypting website and that REvil’s old website now redirects to the new leak site. Medibank described the gang’s threats as a “distressing development,” in a [second update](https://www.medibank.com.au/livebetter/newsroom/post/medibank-cybercrime-update8nov) published on Tuesday, and urged customers to be vigilant with all online communications and transactions. “We unreservedly apologise to our customers. We take seriously our responsibility to safeguard our customers and support them,” said Koczkar. “The weaponization of their private information is malicious, and it is an attack on the most vulnerable members of our community.” Medibank added that it is working with the Australian government, including the Australian Cyber Security Centre and the Australian Federal Police, in order to try and prevent the sharing and sale of customer data. News of the Medibank attack comes just weeks after Australia’s second largest telco [Optus was breached](https://techcrunch.com/2022/09/22/optus-australia-data-breach/). The Australian government [confirmed an upcoming legislative change](https://techcrunch.com/2022/10/24/australia-privacy-law-update/) that would see companies that fail to adequately protect people’s data face fines of $50 million or more. **Topics:** Public Awareness, Technology --- ### [Dylan Alcott lashes out at Australians rorting the NDIS out of millions that should be helping disabled kids take a shower or afford a wheelchair: 'They can go and get stuffed'](https://insurancefraud.org/news_archives/dylan-alcott-lashes-out-at-australians-rorting-the-ndis-out-of-millions-that-should-be-helping-disabled-kids-take-a-shower-or-afford-a-wheelchair-they-can-go-and-get-stuffed/) **Published:** September 23, 2026 **Author:** Diane Beauchamp **Content:** Wheelchair tennis champion [Dylan Alcott](https://www.dailymail.com/tvshowbiz/dylan-alcott/index.html) has lashed out at Australians stealing from kids who need care by rorting disability insurance. The 2022 Australian of the Year was launching The Field, a service matching disabled Australians to employers, alongside [Anthony Albanese](https://www.dailymail.com/news/anthony-albanese/index.html) at Parliament House. Mr Alcott was asked about fraud uncovered in the National Disability Insurance Scheme, which is being investigated by a $126.3 million taskforce. ‘They can go and get stuffed,’ he said, bluntly. ‘There are some dodgy people out there doing dodgy things, and the government has already commissioned the fusion fraud taskforce and that’s going to find people do the wrong thing. ‘If you are watching this and you are doing the wrong thing, you are literally taking away from a neurodiverse kid getting care. ‘You are taking away someone with a high level of disability having a shower. ‘You are not taking away us having fast cars and stuff like that. That is not what it’s about. So remind yourself, if you are doing that, hey, you know what? I’m not going to try and do that anymore.’ Mr Alcott said although problems with fraud existed, the NDIS was a ‘bloody awesome’ scheme that helped almost 550,000 Australians. ‘I’m starting by saying the NDIS is bloody awesome. We commissioned the NDIS report four months ago, the first half is about how good the NDIS is,’ he said. ‘We talked about early intervention before. One of the things we found out about in this report, for kids with early intervention on the NDIS before the age of six have double the amount of friends as kids without. ‘I had no friends when I was five, I’ve still got goosebumps saying that. I would have loved to have had the NDIS, did you know that? ‘We don’t talk about the economic growth of it being involved in things like that. First and foremost, it is awesome, and we need to hear more stories about the good things that are happening.’ Mr Alcott told reporters in Parliament House on Wednesday, alongside the prime minister and NDIS Minister Bill Shorten, that businesses needed help finding disabled staff. He said although Australia was in the middle of a worker shortage, there were 500,000 people with disabilities looking for work. ‘The number one question I hear from employers is, I want to hire a barista or a lawyer with a disability, where do I find them?’ he said. Mr Alcott agreed with Mr Albanese that politicians should take leadership in hiring disabled Australians, but shouldn’t have to disclose how many they had. ‘There are probably people with disability right here and you don’t know, because not all disabilities are physical,’ he said. ‘A lot of them are invisible, and it is not up to them to have to disclose to anybody about their disability. ‘They can be their selves, right? But we want to create cultures in this country where everybody feels like they can be their authentic self when they go to work, right?’ The federal Budget included a $126.3 million taskforce including federal police, the tax office and the Australian Criminal Intelligence Commission, expected to reap $291.5 million over four years. Some doctors have reportedly been billing dead people and falsifying patient medical records to lift their incomes, while others are making mistakes on claims. Other uncovered fraud included organised crime groups including the Hamzy gang in Sydney, were laundering million through the scheme. Australian Criminal Intelligence Commission chief Michael Phelan in August said intelligence found disabled Australians were being exploited by criminals. He said crime syndicates were extorting, threatening with violence or even involuntarily admitting people to psychiatric wards to steal their NDIS entitlements. Mr Phelan said the NDIS was more rorted than the Rudd-Gillard Government’s home insulation scheme, which was preyed on by dodgy operators. As 15 to 20 per cent of the annual budget of almost $30 billion may have been misused, he estimated. **Topics:** Disability, Public Awareness --- ### [IFED is working to eliminate ‘blight’ of ghost brokers](https://insurancefraud.org/news_archives/ifed-is-working-to-eliminate-blight-of-ghost-brokers/) **Published:** September 23, 2026 **Author:** Diane Beauchamp **Content:** Detective chief inspector Tom Hill, head of the City of London Police’s Insurance Fraud Enforcement Department, discusses how the unit has sought to tackle ghost broking Illegal insurance intermediaries – more commonly known as ghost brokers – continue to be a blight on the motor insurance industry. They are a risk to members of the public seeking a good value motor policy – especially in this challenging economic climate. By manipulating customer details with false information to lower premiums, or – in more serious cases – creating fraudulent documents in support of applications, the City of London Police’s Insurance Fraud Enforcement Department (IFED) continues to receive a large number of ghost broking-related crime reports from the insurance industry. In fact, over 30% of our current investigations involve an element associated with illegal insurance intermediaries. So, what is IFED doing to tackle this issue? ### **Eliminating online threats** Firstly, we are addressing the online threat. Operation Mirage is IFED’s online disruptions initiative, which was first established in March 2021. Working with the National Fraud Intelligence Bureau (NFIB), the Insurance Fraud Bureau (IFB), social media companies and internet hosting domains, Operation Mirage takes down websites and online profiles where there is a clear, unambiguous breach of the law, or breach of the terms and conditions agreed with the host platform. Following the launch of Operation Mirage, in July 2021, IFED led a two-week period of focused action against ghost brokers, removing 78 online entities used by fraudsters. This project was called Operation Ironclad. Working with our partners is crucial to tackling ghost broking in the future. ### **Enforcement** Ghost brokers can be challenging to prosecute. There are sometimes legitimate questions raised by prosecutors as to whether victims knowingly turned a blind eye to misrepresentation, as well as challenges for IFED to identify exactly who has committed the misrepresentation to the insurer. IFED is therefore working closely with specialist fraud prosecutors within the Crown Prosecution Service to discuss these issues and find a way forward. An example of this was the use of money laundering legislation to send ghost broker Marek Complak to prison for two and a half years in October 2021 or using the Financial Services and Markets Act 2000 to prosecute ghost brokers for acting as unauthorised insurance intermediaries. IFED has additionally adopted the practice of [serving hand delivered cease and desist notices](https://www.insurancetimes.co.uk/news-analysis/ifed-sees-success-combating-low-level-insurance-fraud-using-cease-and-desist-notices/1440690.article) to lower level insurance fraud offenders, including ghost brokers, from July 2021. This followed a trial period of this approach between September 2020 and July 2021. Using cease and desist notices has allowed us to take on more cases, diverted lower level fraudsters from the criminal justice system and can provide evidence of bad character in future prosecutions. In 2022, 30 notices were served to ghost brokers – working with the IFB to monitor these offenders, only 4.8% of them were found to have subsequently reoffended. These reoffenders were – and are – being dealt with robustly. ### **Public awareness** Raising awareness with the public is also key. IFED sits on the General Insurance Fraud Committee’s application fraud working group. Some excellent work was completed by this body in 2022 through a social media campaign run by the IFB, which was supported by funding and input from IFED. This initiative used paid-for advertising to target members of the public most at risk of falling victim to ghost brokers. The campaign, which ran for six weeks from October 2022, achieved some really impressive coverage, including an interview on *ITV News* with both myself and IFB director Ursula Jallow. Finally, we continue to speak about ghost broking to European and international colleagues to identify whether ghost broking is an issue in other countries and what their response is. In parts of Scandinavia, for example, it seems that national identity cards and centrally held address databases can restrict the impact that ghost brokers can have. This is an interesting finding, however any similar developments in the UK will face fierce debate before being considered. **Topics:** Public Awareness, Regulatory actions --- ### [Insurance fraud saw 11.2% uptick in 2022 – Allianz Commercial](https://insurancefraud.org/news_archives/insurance-fraud-saw-11-2-uptick-in-2022-allianz-commercial/) **Published:** September 23, 2026 **Author:** Diane Beauchamp **Content:** The insurer’s head of counter fraud says at ’each economic downturn, insurers usually see fraud escalate’ Insurance fraud saw an uptick of 11.2% in 2022 – equating to £7.1m – according to Allianz Commercial’s latest figures, published yesterday (11 January 2023). The insurer detected £70.7m worth of insurance fraud in 2022 – up from £63.6m in 2021. James Burge, head of counter fraud at Allianz Commercial, said: “At each economic downturn, insurers usually see fraud escalate. “In the midst of a cost of living crisis, we didn’t want our honest customers to bear any additional costs from fraudsters, which is why we were determined to detect and defeat fraud in order to protect them.” The cost of living crisis began in 2021 and reduced the available capital consumers had to spend or save after tax and inflation. According to a House of Commons briefing published on 20 December 2022, entitled the Rising Cost of Living in the UK, the annual rate of inflation reached 11.1% in October 2022 – representing a 41-year high – before dropping to 10.7% the following month. As noted in the briefing, this is underpinned by increased costs of consumer goods and food, supply chain bottlenecks, rising energy costs and the ongoing war between Russia and Ukraine. However, inflation is expected to fall later this year. Shift from traditional fraud In property and casualty lines, Allianz Commercial noted that it saw the greatest increase on fraud savings in comparison to the year before. The insurer believes that this might serve as evidence of a shift away from traditional motor fraud, such as crash for cash scams. However, the value of each case of property and casualty fraud increased to record levels, despite a decline in frequency during 2022. Meanwhile, application fraud – whereby a customer provides false information to acquire a policy – has grown. This, according to Allianz, suggests front-end controls are detecting lies and fabrications more effectively. In addition to this, machine learning has been helpful in picking up dishonest attempts for fraud at claims stage. **Topics:** Public Awareness --- ### [Millions of Aflac, Zurich insurance customers in Japan have data leaked after breach](https://insurancefraud.org/news_archives/millions-of-aflac-zurich-insurance-customers-in-japan-have-data-leaked-after-breach/) **Published:** September 23, 2026 **Author:** Diane Beauchamp **Content:** The Japanese customers of two large insurance companies have had their personal information leaked after the breach of a third-party service provider. Neither company would say if the two breaches were connected, and the attacked provider has not been named. But each company released statements this week warning their customers that their information was made public. Aflac director of communications Jon Sullivan said they recently became aware of a “data-related incident” involving Japanese customers. “The incident, caused by a vulnerability in a file transfer server, originated with a subcontractor of a third-party vendor that Aflac Japan uses for marketing purposes and affected approximately 1.3 million customers,” Sullivan said. “The data, which did not include personally identifiable information (PII), was posted on a dark website. This incident was confined to Aflac Japan and did not involve data related to U.S. operations or customers.” The company [released a statement in Japanese](https://docs.google.com/viewer?url=https%3A%2F%2Fwww.aflac.co.jp%2Fnews_pdf%2F2023011001.pdf) on Tuesday explaining that it plans to contact each customer individually to explain the support available to them. The breach was discovered on January 9. In the letter, they said they looked through the dark web post and confirmed that the data is from their company. The information included names, age, gender, insurance type, insurance number, premiums and more plan information. All of those affected – 1,323,468 people – had three different kinds of cancer insurance policies, according to the release, which provides a number to a call center with more information. Aflac noted that it removed the information that was stolen from the third-party server so it cannot be stolen again. A spokesperson for Zurich Insurance Group said it is also aware that Japanese customer data has been stolen and made public – similarly attributing it to a third-party service provider. They have contacted regulators and authorities while also beginning the process of notifying Japanese customers. “There is no indication that any customer data outside of Japan have been compromised, nor indication of any compromise of Zurich internal systems,” the spokesperson said. “Initially, it was falsely reported that 2.6 million customers were affected by the data breach. It has since been clarified that 757,463 ‘Super Automobile Insurance’ customers (a local motor insurance product) have been affected.” The information stolen includes names, policy numbers, customer IDs, emails, dates of birth and more vehicle information. Lior Yaari, CEO of Grip Security, said the incident was another example of the danger major companies face when entrusting personal customer information to third-parties that often have far more lax security policies. “Whether it’s a third-party, former employee, overly permissive grants, or dangling access on zombie accounts, the opportunity to exploit credentials and thereby gain access to sensitive information has never been more appealing, which is one of the reasons third parties and their credentials to access client systems remain top attacker targets,” Yaari said. Eureka Security CEO Liat Hayun said most companies are in an unenviable position because third-party vendors are often a necessary evil for companies of Aflac and Zurich’s size. “Who do you trust with your critical data assets? Your answer would be ‘no one,’ however, the reality is that organizations use third-party vendors to enable day-to-day operations,” Hayun explained. With that said, it is best to work with third-party vendors who have the same, if not better data security policies than your own organization to further accelerate day-to-day operations.” The breach announcement came just days after the head of the company [told Financial Times](https://www.ft.com/content/63ea94fa-c6fc-449f-b2b8-ea29cc83637d) that the scale and frequency of cyberattacks were making such incidents “uninsurable.” In October the company [settled](https://therecord.media/mondelez-and-zurich-reach-settlement-in-notpetya-cyberattack-insurance-suit/) a landmark multi-year legal battle over a food company’s $100 million claim regarding damage from the NotPetya cyberattack in 2017. **Topics:** Public Awareness, Technology --- ### [Odisha: South Point Private Hospital delisted for fraud](https://insurancefraud.org/news_archives/odisha-south-point-private-hospital-delisted-for-fraud/) **Published:** September 23, 2026 **Author:** Diane Beauchamp **Content:** The Odisha government on Friday de-empanelled Cuttack-based South Point Private Hospital for indulging in unethical practice and sending forged bills under the Biju Swasthya Kalyan Yojana (BSKY), the state’s flagship scheme in the health sector, to the state’s exchequer for reimbursement. The state government has asked the Cuttack district administration to shift the patients to appropriate BSKY-empanelled private hospitals or to government facilities for further continuance of uninterrupted treatment. “All the Swasthya Mitra deployed to the said hospital has been disengaged,” said a press release issued by the health department. Health secretary Shalini Pandit has asked the officials to further investigate the claims raised by the hospital earlier vis-a-vis claims scrutinized by Claim Panel Doctors of the State Health Assurance Society. “Intensive patient feedback is being collected through outbound calls to past patients at South Point Hospital in order to check past fraud if any,” said the release. Meanwhile, the state government has directed all the collectors and district magistrates to take stringent action, if any fraud is detected, over extending the benefits under the healthcare scheme to the people. BSKY beneficiaries are provided healthcare in empanelled private hospitals for an annual health coverage of Rs 5 lakh per family and an additional Rs 5 lakh for the women members of the family after the exhaustion of the initial limit. In 2022, the state government spent Rs 14,56.42 crore to provide treatment to patients under the BSKY. **Topics:** Public Awareness, Regulatory actions --- ### [Cyber Fraud Cases In India Are Substantially Low Compared To Other Countries](https://insurancefraud.org/news_archives/cyber-fraud-cases-in-india-are-substantially-low-compared-to-other-countries/) **Published:** September 23, 2026 **Author:** Diane Beauchamp **Content:** **Topics:** Public Awareness, Technology --- ### [54% of Young People in Ireland Have Been Tempted to Buy Fake Insurance Online](https://insurancefraud.org/news_archives/54-of-young-people-in-ireland-have-been-tempted-to-buy-fake-insurance-online/) **Published:** September 23, 2026 **Author:** Diane Beauchamp **Content:** A new survey\[i\] of insurance customers in the Republic of Ireland has highlighted the risks facing young people in the region who are being targeted by ghost brokers selling fake insurance policies. The study by LexisNexis® Risk Solutions, a leading data, advanced analytics and technology provider for insurance, found that: - 54% of 17–34-year-olds have been targeted and tempted by an advert for fake insurance on social media - More than 1 in 10 (16%) of the youngest people surveyed, aged 17-24, has bought insurance through one of these adverts - 71% of 17–34-year-olds are worried their identity could be compromised for insurance fraud such as ghost broking - 92% of 17–34-year-olds expect insurance providers to check they are who they say they are when applying for insurance - Only 24% of the people surveyed actually know what a ghost broker is In response to the growing problem of insurance application fraud and ghost broking\[ii\], LexisNexis Risk Solutions has launched [LexisNexis® Emailage® Rapid ](https://risk.lexisnexis.com/global/en/products/lexisnexis-emailage-rapid?trmid=INSMLT22.Cr_Mrk_Pro.TUPress.WSLN-828813) for the Irish insurance market. Emailage Rapid is a powerful fraud risk scoring solution based on the email address and other personal information provided during the personal lines insurance application process. As insurance fraud continues to cost insurance companies in Ireland an estimated 200 million annually\[iii\], Emailage Rapid provides immediate verification of the applicant’s digital identity and checks they are not linked to any fraudulent activity prior to policy inception. As well as helping to combat fraud, the solution may also help reduce the cost of cancellations to the insurance sector. Emailage Rapid is built from over 82 thousand fraud events and transactions shared daily\[iv\], to provide a real-time risk score\[v\] at the point of quote. The score indicates a genuine identity, whether the identity has previously been linked to fraud or whether it could be a fraudulent ID, which may have been created to either procure insurance with the intent of making a fraudulent claim or to sell insurance on as a ghost broker\[vi\]. It provides additional metadata points, such as whether the email address and domain even exist, when the email address was first seen, or whether the email address bears a close resemblance to the proposer’s name for the policy. An Garda Síochána (Ireland’s National Police and Security Service) lists the ‘Advance Fee Fraud of Ghost Broking and Car Insurance Fraud’ as one of the six most common types of fraud happening in Ireland today\[vii\]. Yet, research by LexisNexis Risk Solutions highlights that only 24% of people know about ghost brokers. As the number of internet users in Ireland continues to grow with a current 4.43 million internet users, projected to reach 4.73 million individuals by 2027\[viii\], so does the opportunity for online crime. Shane McCabe, insurance strategic account manager, LexisNexis Risk Solutions, Ireland, said: *“Ghost brokers typically advertise their services online, claiming to be able to secure prospective policyholders a cheap insurance policy. They often target the young, who are more likely to use social networking and instant messaging\[ix\]. As nearly one third (32%) of younger persons between 16 and 29 years of age either bought or renewed existing insurance policies online last year, we can see how vulnerable they might be to fraud\[x\]. It is critical that insurance providers can offer the seamless online experience that policyholders expect, while protecting themselves and their customers from fraudsters. Building on the success of Emailage Rapid in the UK, we are delighted to have launched LexisNexis [Emailage](https://risk.lexisnexis.com/products/lexisnexis-emailage) Rapid as our first motor insurance product for insurance providers in the Republic of Ireland.”* **Topics:** Public Awareness, Technology --- ### [Avoiding Canadian immigration scams and fraud](https://insurancefraud.org/news_archives/avoiding-canadian-immigration-scams-and-fraud/) **Published:** September 23, 2026 **Author:** Diane Beauchamp **Content:** Between November 14 to December 8, 2022, a span of just 24 days, CBC reported on three different alleged Canadian immigration scams. In Edmonton, a Concordia University student who moved to Canada from Iran this fall lost nearly $11,000 to [phone scammers](https://www.cbc.ca/news/canada/edmonton/edmonton-international-student-scammed-11k-1.6648287). In early December, reports surfaced that a Ghanaian man faced an alleged [social media employment scam](https://www.cbc.ca/news/canada/newfoundland-labrador/nl-immigration-job-offer-church-ghana-canada-1.6675663) that also asked for money related to a health insurance fee. Thankfully, he was vigilant and realized this was a scam before sending any money. Unfortunately, the “[dozens of victims](https://www.cbc.ca/news/canada/british-columbia/dozens-of-victims-allege-vancouver-consultant-scammed-them-with-fake-immigration-scheme-1.6676811)” who were allegedly each scammed out of “$5000 or more” by a Vancouver immigration consultant may not have been as lucky. It is alleged that the immigration consultant in this scam, who has now had a class action lawsuit filed against her, misrepresented herself as a lawyer and defrauded migrants “with promises of a path to permanent residence in Canada through a nonexistent program.” The above examples were all provided to outline the prevalence of Canadian immigration scams across the country. Accordingly, the following outlines three things to remember that will help recent Canadian immigrants and future hopefuls looking to work, study or immigrate to this country avoid the harsh consequences of falling victim to immigration fraud or an immigration scam. ### IRCC and the collection of fines/fees It is increasingly common for immigration scams, and scams in general, to be perpetrated over the phone. In fact, according to a poll conducted as part of a [January 2022 story](https://vancouver.citynews.ca/2022/01/23/canadias-scam-calls-polls/) from CityNews Vancouver, scam calls in Cantonese or Mandarin are up 20% since 2019. Adding to this is the fact that, according to the President of Vancouver-based research firm Research Co., 60% of cellphone users receive scam calls pretending to be part of a government agency. To this end, it is important for Canadian immigration hopefuls to understand that [Immigration, Refugees and Citizenship Canada](https://www.canadavisa.com/ircc.html) (IRCC) will [never call anyone or contact them](https://www.cic.gc.ca/english/helpcentre/answer.asp?qnum=1218&top=31) either online or in-person to collect fees or fines to avoid consequences such as deportation. IRCC notes that scammers will “often give a fake name and agent number to appear legitimate” but urges that these types of calls are always a scam. Do not be afraid to contact local police and/or report the incident if someone calls and threatens consequences for not paying money or providing personal information. ### IRCC’s official scam/fraud identification resources Immigrating to a new country is a journey that requires immigrants to find information that they can rely on. In the age of the internet, unreliable information is everywhere because just about anyone can start a website or a blog and claim to be an expert on a subject of their choosing. For that reason, official government resources are key to any immigrant’s journey to Canada. It is important to keep in mind that IRCC also offers [official government resources](https://www.canada.ca/en/immigration-refugees-citizenship/services/protect-fraud.html) (FAQs and tip sheets) to help recent Canadian immigrants and those looking to come to Canada in the future identify and avoid immigration-related fraud and scams. Whether someone is seeking information on a particular type of fraud/scam (telephone/internet scams, document fraud etc.) or looking to understand what to do if they fall victim to a scam/fraud, IRCC provides extensive online resources on all these subjects. These tools will help both recent immigrants to Canada and future Canadian immigration hopefuls stay aware and protect themselves from these situations. ### Verifying the legitimacy of Canadian immigration service providers When coming to a new country, immigrants often need help from other people. This help, depending on the choices made by the immigrant/immigration hopeful, may come from an online forum or an immigration advisor such as an immigration lawyer, representative or consultant. Still, similar to how anyone could present themselves as an online subject matter expert through a website, it is not difficult for scammers to pose as trustworthy and credible immigration advisors. To help both recent Canadian immigrants and future immigration hopefuls manage this, official Canadian [registries and directories](https://www.canada.ca/en/immigration-refugees-citizenship/services/immigration-citizenship-representative/choose/authorized.html) exist to verify the legitimacy of individuals who claim they are authorized to represent immigrants/provide immigration advice. For instance, all Canadian citizenship and immigration consultants must be a member of the College of Immigration and Citizenship Consultants. Likewise, Canadian immigration lawyers and notaries must be registered with a Canadian provincial or territorial law society and Ontario-based paralegals are required to become members of the Law Society of Ontario. IRCC notes that most provincial and territorial law societies provide online tools to verify if a particular individual registers as a member in good standing, and an individual’s “standing” is a worthwhile indicator of whether immigrants should use the services of that immigration lawyer. **Topics:** Public Awareness --- ### [University acts against eight employees over fraudulent benefits claims](https://insurancefraud.org/news_archives/university-acts-against-eight-employees-over-fraudulent-benefits-claims/) **Published:** September 23, 2026 **Author:** Diane Beauchamp **Content:** Following an investigation, a Toronto university has acted against eight of its employees for committing group benefits fraud. York University issued a statement saying that the school administration takes cases of false claims seriously, and that it has a process for addressing possible fraud. “The university thoroughly investigates suspected cases and works with the insurer in these matters to seek repayment of claims and refers suspected cases to police,” the university said, but details regarding what kind of specific actions were taken were not publicly disclosed. There is also no word if any more employees are being investigated by the university, or if criminal charges were laid against the eight. Sources told [CityNews](https://toronto.citynews.ca/2023/01/13/york-university-false-insurance-benefits-claims/) that the employees affected work in at least two departments – housing services and parking services. The anonymous sources also mentioned that in one of the cases, the fraud was related to a fake orthodontics claim, and that one of the employees is no longer with the school. CityNews reached out to employment lawyer Jon Pinkus for commentary on the development, explaining that it is usually the benefits provider that alerts the employer/plan sponsor of any irregularities or possible fraud. “They’re going to be undertaking an investigation, and that will notify the employer of some irregularities, some potential fraud. They’ll undertake an internal investigation and report to the employer,” the lawyer said. “And if it turns out that the employee or employees have been involved in this fraud, almost invariably those employees or employee is terminated.” According to the Canadian Life and Health Insurance Association (CLHIA), [both employers and insurers have lost millions of dollars each year](https://www.insurancebusinessmag.com/ca/news/breaking-news/clhia-launches-aipowered-solution-to-fight-benefits-fraud-325497.aspx) due to fraudulent group health benefits claims. **Topics:** Healthcare Fraud, Public Awareness --- ### [Attacks on 2 Specialty Care Providers Affect Nearly 600,000](https://insurancefraud.org/news_archives/attacks-on-2-specialty-care-providers-affect-nearly-600000/) **Published:** September 23, 2026 **Author:** Diane Beauchamp **Content:** Two specialty medical care firms – a Texas-based home healthcare agency and a Pennsylvania-based women’s and family health clinic – are reporting separate ransomware breaches that in total affect nearly 600,000 individuals. Dallas-based Home Care Providers of Texas reported its incident to the [Texas attorney general’s office](https://oagtx.force.com/datasecuritybreachreport/apex/DataSecurityReportsPage) on Jan. 13 as affecting about 124,000 residents of the Lone Star State. The company’s [breach notification statement](https://www.hcpoftexas.com/event.htm) indicates that an undisclosed number of North Carolina residents are also affected. Meanwhile, Wilkes-Barre, Pennsylvania-based nonprofit [Maternal and Family Health Services](https://www.bankinfosecurity.com/womens-health-clinic-suffers-breach-in-ransomware-attack-a-20878) reported a ransomware incident on Jan. 10 to the [Maine attorney general’s office](https://apps.web.maine.gov/online/aeviewer/ME/40/aa8282f5-0293-41fe-8074-d62e568e05ac.shtml) as affecting nearly 461,200 individuals, including 68 Maine residents. MFHS supports a network of health and nutrition centers in 17 Pennsylvania counties. The incidents follow a growing trend of ransomware criminals hitting a widening range of different types of healthcare providers and their vendors, including smaller and specialty entities. “Healthcare data is very lucrative right now and the criminals know that small to medium-sized companies tend to have less security than larger companies,” says Jerry Caponera, general manager of cyber risk at security firm ThreatConnect. Michael Hamilton, CISO of security firm Critical Insights, says that cybercriminals also appear to be picking potential healthcare victims more selectively. “The choice of targets is also criminal risk minimization at work. Organizations that do not provide acute care services are less likely to have patient outcomes that may include loss of life during a disruption event like ransomware,” he says. “This keeps the criminals at arm’s length of the ‘terrorist’ moniker, as has been applied by the Biden administration.” ### Home Health Care Incident HCPT says it became aware last June of its ransomware attack. “In addition, an unauthorized party removed a limited number of files from our systems,” the company says in its breach notification statement. The company alerted law enforcement and engaged a third-party cybersecurity firm. It completed a forensics investigation and a comprehensive review of all affected data on Nov. 15, determining that an unauthorized party had accessed HCPT systems between June 15 and June 29, 2022. Affected information includes individual names, addresses, birthdates, Social Security numbers, certain treatment or diagnosis information, and medication information. HCPT did not immediately respond to Information Security Media Group’s request for comment and additional details about its incident. ### Maternal and Family Health Services Breach MFHS says it started on Jan. 3 the work of notifying affected individuals – including current and former employees, patients and vendors – of its April 4, 2022 ransomware incident. The organization says an investigation into the incident determined that unauthorized access to MFHS systems occurred between Aug. 21, 2021 and April 4, 2022. Affected information includes names, addresses, birthdates, Social Security numbers, driver’s license numbers, financial information, usernames and passwords, medical information and health insurance information. MFHS says it does not have any evidence that any information has been misused as a result of the breach. The organization says it is offering individuals 12 months of complimentary credit and identity monitoring and is “strengthening” its security to prevent similar future incidents. MFHS did not immediately respond to ISMG’s request for additional details about its incident. ### Mounting Pressures Healthcare sector organizations across the board are facing a range of pressures that can ultimately affect their cybersecurity. “The challenges healthcare companies face are the squeeze on costs with rising inflation, decreasing payments from insurers, and increasing health care costs,” Caponera says. “IT – and by extension, cybersecurity – tends to get squeezed in that mix,” he says. Smaller healthcare sector organizations that are especially pinched for cybersecurity resources should “pull the lever that’s least expensive and moves the security needle the most: Create a policy of all personal use to be conducted on a personal device,” Hamilton says. “Those that don’t need external email should not get it, and social media and other sources of ‘bait’ should be blocked,” he says. **Topics:** Public Awareness, Technology --- ### [From vacuum recalls to insurance scams -- here are your latest consumer headlines](https://insurancefraud.org/news_archives/from-vacuum-recalls-to-insurance-scams-here-are-your-latest-consumer-headlines/) **Published:** September 23, 2026 **Author:** Diane Beauchamp **Content:** Help Me Hank warns Metro Detroiter about signing up for new credit cards and how an unemployment insurance scam is targeting you for your information. **Topics:** Fraud General, Public Awareness --- ### [Woman who allegedly conspired with lover to kill her husband in US to be extradited from S’pore](https://insurancefraud.org/news_archives/woman-who-allegedly-conspired-with-lover-to-kill-her-husband-in-us-to-be-extradited-from-spore/) **Published:** September 23, 2026 **Author:** Diane Beauchamp **Content:** A woman who was wanted in the U.S. for allegedly conspiring to murder her husband with her lover is pending to be extradited from Singapore. Fadaak Sahar Osama A, a Saudi Arabian national, was apprehended on Sep. 25, 2022, in Singapore. She was remanded pending the formal request for her extradition, according to the judgement released on Jan. 17, 2023. A Warrant of Apprehension for Fadaak was issued on Sep. 24, 2022, by a Magistrate, and a team of police officers from the Singapore Police Force arrested Fadaak at Park Royal Hotel on Beach Road the next day. After the arrest, the U.S. submitted a formal extradition request on Nov. 22, 2022. Fadaak is wanted in the U.S. for two charges, murder in the first degree and conspiracy to commit murder in the first degree, against Darwin Garcia Franco, her husband. Franco was stabbed at least 30 times to death on May. 31, 2019, in his residence, which he shared with Fadaak. On Nov. 22 2022, the U.S. submitted the formal extradition request. Fadaak was presented before the district court on Dec. 21, 2022, and evidence produced by the state supported the request for the surrender of Fadaak to the U.S. Conspired with her lover to murder her husband According to the judgement, Fadaak was accused of murder in the first degree and conspiracy to commit murder in the first degree. Fadaak conspired with her lover, Saif Al Obaidi, to murder Franco and cash in the victim’s life insurance policy. Between Jan. and May 2019, Fadaak and Saif developed a close personal relationship, and investigations revealed that the pair began a romantic relationship, said the judgement. On May 22, 2019, Fadaak looked for life insurance that would give her the maximum payout in the event of her husband’s death and insisted that she needed insurance on Franco’s life immediately. Fadaak submitted a claim for a policy with a US$250,000 life benefit on May 28, 2019. She listed her and the child she had with Franco as the beneficiaries in the event of Franco’s death. Fadaak enquired about a life insurance policy on Franco’s life despite her telling investigators that she was planning to leave Franco during an unrelated investigation with Child Protective Services. On May 31, 2019, Saif entered Franco’s residence and stabbed him 30 times, which caused his death. At that time, Fadaak and Franco had a woman and three children renting out the lower floor of their residence. The woman, Nelida Zuniga, heard the sounds of the attack and went to investigate. She witnessed Saif’s attack on Franco and tried to intervene. However, Saif turned to attack Zuniga and stabbed her 18 times. She ultimately escaped and survived the attack. When interviewed by investigators, Zuniga said Fadaak watched the whole attack and stood quietly by, making no effort to stop Saif from stabbing Franco. Fadaak called the police at 2:10 am after the attack and claimed someone had come into her residence, and an altercation ensued. However, when asked if Fadaak recognised the attacker, she omitted Saif’s presence at the scene and only said she saw her husband covered in blood and Zuniga. Multiple call logs were discovered that were not present on Fadaak’s phone when initially presented to investigators. This led the investigators to believe she had deleted her call logs with Saif before the police interview. It was later established several calls were placed to the insurance companies by Fadaak on May 30, 2019. Saif was arrested on May 31, 2019 at 8:00 am in the morning and was subsequently charged with the murder of Franco in the first-degree and attempted first-degree murder. Fadaak boarded a one-way flight to the United Arab Emirates with her child on Apr. 9, 2019. “Investigators believed that the evidence showed the conspiracy and murder was motivated in whole or in part, by financial gain and a romantic relationship between Fadaak and \[Saif\],” said the judgement. **Topics:** Life Insurance **Categories:** Arrest --- ### [Insurance con: Doctor cheated of Rs 45 lakh](https://insurancefraud.org/news_archives/insurance-con-doctor-cheated-of-rs-45-lakh/) **Published:** September 23, 2026 **Author:** Diane Beauchamp **Content:** A 61-year-old doctor running a nursing home in Behrampura was cheated of Rs 45 lakh by a woman who conned him into investing in multiple life insurance policies but did not deposit the money in the companies on his behalf. Dipesh Gangaram Dholakia, resident of Maninagar, who has been running Geeta Maternity Nursing Home for the last 15 years, filed a complaint at Kagdapith police station that in 2012-13, he was approached by one Hiral Rana who claimed to be an insurance agent. Putting trust in her, he bought 12 policies from companies like PNB Met Life, Reliance and Bharti AXA. Between 2012 and 2020 he regularly paid premiums worth Rs 45 lakh. Suspecting foul play when he did not get any intimation from companies on said maturity dates, he directly inquired with the insurance companies about the payments made on his behalf. He learnt that she had only paid Rs 29.5 lakh to PNB Met Life instead of Rs 36.5 lakh. Further, she had paid only Rs 2 lakh instead of Rs 12 lakh to Reliance. She didn’t pay a single penny to Bharti Axa despite collecting cheques worth Rs 28 lakh from the doctor. Since the pandemic was in full swing at the time, he did not file a complaint immediately in 2020. All his efforts to recover the money from Hiral also failed. **Topics:** Life Insurance, Public Awareness --- ### [Auto theft a huge problem in York, GTA](https://insurancefraud.org/news_archives/auto-theft-a-huge-problem-in-york-gta/) **Published:** September 23, 2026 **Author:** Diane Beauchamp **Content:** Auto theft is the number one crime in York Region. And a small but persistent group of officers is doing their best to combat the problem. York Regional Police officers informed King councillors recently about the issue, and the measures taken to mitigate the losses. Local thefts feed regional and international theft rings, according to Detective Scott Cresswell. More affluent areas like King Township mean more valuable targets for thieves. And there’s an “appetite” overseas for such high-end vehicles, Cresswell pointed out. There are several organized crime groups targetting York and the majority of vehicles are destined for overseas markets such as Africa, the Middle East, Eastern Europe and even South America. The detective said sought-after vehicles such as Range Rovers and Mercedes typically head to Lebanon, Turkey and Dubai. Police did repatriate more than 50 vehicles recently, discovered at a port in Malta. However, bringing them back to their owners here in Canada is an expensive process. Det. Cresswell noted automobile theft in much more than an insurance problem – “it’s an expensive social menace.” This costs Canadians roughly $1 billion annually, including $542 million for insurers to repair of replace stolen vehicles. Other related costs include policing, health care, court costs and correctional services. But “the sky isn’t falling,” he said, noting many police agencies work together to curb thefts. Joining the efforts of law enforcement are trucking associations, vehicle manufacturers, the Insurance Bureau of Canada and even local businesses. “We are working diligently and achieving a level of success,” Det. Cresswell said. There are many reasons why vehicles are stolen, including exportation, insurance fraud, dismantling for parts and for the commission of other crimes. Det. Cresswell said the groups are mainly made up of young males in the GTA and from Montreal, expressly for stealing cars. They are armed with the latest technology to break into vehicles and even reprogram new key fobs right on the spot. Push-button-start vehicles are the top victims. The most-stolen vehicles include Toyota and Lexus SUVs and trucks, Ford 150s, Dodge Rams, Jeep Cherokees and Range Rovers. “It’s very challenging for us,” he said, noting the trend is taking vehicles right from residents’ driveways. It only takes perhaps 30 seconds for the thieves to snatch a car. Investigators have identified an increasing trend where suspects place small tracking devices on high-end vehicles, so they can later locate and steal them. Brand name “air tags” are placed in out-of-sight areas when they are parked in public places. Thieves then track the vehicles to the victims’ residences. Thieves will then typically use tools like screwdrivers to enter the vehicles, ensuring not to set off the alarms. Once inside, a device used by mechanics to reprogram factory settings is connected to the onboard diagnostics port below the dashboard. They program the vehicle to accept a new key the thieves brought with them. Police note the thefts tend to occur between midnight and 4 a.m. every day of the week. Det. Cresswell said they’re trying to raise awareness and help citizens protect their assets. He pointed to some recent police projects that recovered vehicles and led to many arrests. The most recent, Project Touchdown, was a six-month investigation led by YRP and included Halton, Peel, Dirham and CBSA partners. It resulted in 215 vehicles being recovered and 51 people charged with literally hundreds of offences. Despite these wins, Cresswell noted the legal system’s tendency for “catch and release” of offenders isn’t helping matters. There are ways residents can protect their vehicles and be more vigilant. Det. Constable Al Henson urged residents not to leave their cars unattended while warming up. We should also put our valuables out of sight. People can also purchase kill switches, air tags and steering wheel locks. If residents don’t already have one, it’s recommended they buy a video surveillance system. Mayor Steve Pellegrini wants to set up public forums, to inform residents of the issue and ways to prevent further thefts. **Topics:** Auto fraud, Public Awareness --- ### [Private health data breach in Isle of Man to be dealt within 3 months, officials say](https://insurancefraud.org/news_archives/private-health-data-breach-in-isle-of-man-to-be-dealt-within-3-months-officials-say/) **Published:** September 23, 2026 **Author:** Diane Beauchamp **Content:** An organisation set up to focus on the delivery of health and social care on the Isle of Man has been given a three-month deadline to stop data breaches. Manx Care will be ordered to pay £170,000 if they fail to prevent breaches of people’s private data within the next three months. This warning comes after 1,870 people received an email attachment showing people’s confidential health information in 2021. Originally, the deadline for Manx Care to sort out the issue was December 31, 2022; however, it has now been changed to March 31, 2023, to give the health care provider more time to develop secure systems. Iain McDonald said: “The extension had been put in place because work to ensure the security of patient data being distributed internally had commenced. However, there was still significant work to be completed.” Manx Care was already struggling to handle confidential data before the distribution of the email in October 2021. In July 2022, the organisation was imposed with a financial penalty if they failed to comply with making its data systems more secure. “If Manx Care fails to comply with the notice by March 31, the fine would become immediately payable and limitations would be put on the health care provider’s use of internal emails to transmit personal data,” said Iain. Teresa Cope, Chief Executive for Manx Care, said: “A comprehensive action plan to address the issues had been submitted to the commissioner, including policy development, the changing of a global address list and putting in place a secure email system. “Work was also under way to increase the information governance staffing to ensure the notice could be complied with, and monthly updates on progress with the plan would continue to be provided to the commissioner’s office.” **Topics:** Judicial/courts, Technology --- ### [‘Must be stopped’: Fraud taskforce nabs NDIS firms charging for services not delivered](https://insurancefraud.org/news_archives/must-be-stopped-fraud-taskforce-nabs-ndis-firms-charging-for-services-not-delivered/) **Published:** September 23, 2026 **Author:** Diane Beauchamp **Content:** A new federal taskforce set up to catch fraudulent providers to the National Disability Insurance Scheme has exposed two Victorian companies who were charging taxpayers for services that were never delivered. The NDIS Quality and Safeguards Commission has issued a banning order against Millennium Disability Care Pty Ltd, which is based in Williams Landing in Melbourne’s west, permanently prohibiting it from providing services to people with a disability. The company’s director, Sarah Michael Leen Manyok Thiak, has also been issued with a banning order, and the firm’s registration has been revoked. A second Victorian company – Australian Home and Community Care, based in Kurunjang in Melbourne’s outer west – was also given a ban order after a separate investigation found it has charged the NDIS for services that were not delivered. After mounting evidence surfaced of fraudulent claims for payment to the NDIS, the Albanese government recently established the Fraud Fusion Taskforce, which works with the commission to investigate alleged wrongdoing by providers. It found the companies had submitted “falsified and inappropriate claims for payment to the NDIS for services not delivered”, which had a “serious adverse effect on NDIS participants’ mental and physical wellbeing”. NDIS and Government Services Minister Bill Shorten said the banning orders “send a strong message to any provider trying to take advantage of the NDIS and Australian taxpayers”. “For too long, criminals and rogue operators have been able to take advantage of a lack of communication between government agencies and a lack of coordination against fraud,” Shorten said. “Australians relying on government services and the NDIS are some of our most vulnerable, and any person or organisation taking advantage of their safety net must be stopped. “The Fraud Fusion Taskforce’s work is well underway and anyone ripping off people with disability and taxpayers should be prepared – you will be caught.” An investigation by The Age, The Sydney Morning Herald and 60 Minutes last year found members of Sydney’s notorious Hamzy crime network had infiltrated the NDIS. Australian Criminal Intelligence Commission chief Michael Phelan warned organised criminals involved in drug trafficking, violence and money laundering were exploiting systemic weaknesses in the NDIS to rort it on an unprecedented scale. Phelan estimated that as much as 15 to 20 per cent of the $30 billion it costs a year might be being misused. NDIS commissioner Tracy Mackey said her agency was taking “swift action” when NDIS providers and their personnel fail to meet their obligations. “The NDIS Commission continues to work closely with the NDIA and other government agencies to identify and address quality and safeguarding concerns, including those arising from engagement in fraudulent activity,” she said. “NDIS providers have very clear obligations and we will take action when providers do not meet those obligations.” **Topics:** Disability, Public Awareness, Regulatory actions --- ### [Fake Doctor Runs Phony Medical Spa Scheme, Part 1](https://insurancefraud.org/news_archives/fake-doctor-runs-phony-medical-spa-scheme-part-1/) **Published:** September 23, 2026 **Author:** Diane Beauchamp **Content:** Longtime friends Jill Alper and Holly Saunders are dazzled when they meet Beverly Hills plastic surgeon Dr. Dan, a man of many talents and interests. When Dr. Dan invites them to invest in his medical spa business, Jill dives in with a $10,000 offering. Holly, though, is beginning to think Dr. Dan may not be the man he claims. Will this scammer be any match for these friends when they team up with the FBI? The Perfect ScamSM is a project of the [AARP Fraud Watch Network](https://cms.aarp.org/content/aarpe/en/home/money/scams-fraud/about-fraud-watch-network.html), which equips consumers like you with the knowledge to give you power over scams. 00:00:01\] Bob: This week on The Perfect Scam. \[00:00:03\] Holly Saunders: They said, “Do you have a picture of this guy?” And so I pulled up this picture of Dr. Dan on my phone, and he’s sitting there in a white coat, but he’s got Dr. Dan embroidered on his coat. But it’s like the embroidery you would use on a towel or something. And Joe, being a surgeon, he looked at it and he said, “Uh, nope, nobody does that. That is absolutely a no. Don’t do anything with him.” (MUSIC SEGUE) \[00:00:39\] Bob: Welcome back to The Perfect Scam. I’m your host Bob Sullivan. Jill Alper and Holly Saunders had a great friendship. They were neighbors in South Carolina who bonded because they were both raising twins. So when the kids got older and opportunity presented itself, it seemed only natural for them to go into business together. But when they did, they never imagined they’d end up on the phone with a reporter from Western Massachusetts who’d been tracking the exploits of a serial con artist for more than two decades. And together, these three women decided it was high time to freeze this con man out of the crime business. Today, we begin a two-part series on a medical spa franchise opportunity that went south. But our story actually begins up north. \[00:01:33\] Stephanie Barry: My name is Stephanie Barry, and I am an investigative reporter in Springfield, Massachusetts. I work for The Republican and MassLive.com. \[00:01:43\] Bob: Is it fair to call you Western Massachusetts largest newspaper? \[00:01:45\] Stephanie Barry: Yes. \[00:01:46\] Bob: Okay. \[00:01:47\] Stephanie Barry: Yep. \[00:01:47\] Bob: So how, how long have you been there? \[00:01:49\] Stephanie Barry: So I have been at The Republican since 2003, and that’s when I first encountered Dana Dray McCann. \[00:01:58\] Bob: Dana Dray McCann. Stephanie was doing what all new reporters do when they first start out. She was shadowing a more experienced journalist, watching what was going on, trying to figure out when she’d get a byline and mostly, staying out of the way while watching Dana Dray McCann. \[00:02:16\] Stephanie Barry: I was a brand-new reporter. I was covering federal court, and he was being sentenced for many, many counts of fraud in Federal Court in Springfield. And so I was so new that I didn’t cover his trial. But I was sitting in as like a trainee listening to the sentencing uh, with an older, more experienced reporter. \[00:02:40\] Bob: There wasn’t supposed to be much drama that day. McCann was there just to be sentenced which normally would only take a few minutes. But he was given the chance to make a statement to the court and boy did he. \[00:02:53\] Stephanie Barry: So Dana McCann got up and spoke at length in front of a federal judge, who had, he was a Rhodes Scholar, this judge, and had a reputation of being very easy, you know, being very liberal in terms of his sentencings. So Dana McCann went off on this diatribe for probably nearly an hour, which is very long by these standards, talking about all of his talents and everything from being a writer, to a musician, to writing jingles for advertising agencies, to being a poet. \[00:03:33\] Bob: And, and this is your first, second, third, whatever day on the job? \[00:03:38\] Stephanie Barry: Just about. Just about, yeah. \[00:03:40\] Bob: (chuckling) What did you make of this? \[00:03:42\] Stephanie Barry: I, I, I thought, do all sentencings go this way? And I just remember listening to him with interest and kind of cringing inside because there was so much like braggadocio and backslapping and I, I found it almost embarrassing to watch, and I thought, who would ever buy this guy’s whatever he’s selling? But the fact of the matter was a lot of people have. \[00:04:11\] Bob: There was something special about McCann, Stephanie remembers. \[00:04:15\] Stephanie Barry: He was an average looking man. He was in orange prison garb, which is flattering to no one. I suppose that he was handsome enough, and I guess he was eloquent enough. His voice was kind of musical. I don’t mean he was singing the opera, but you know, he had a nice presentation. He just has a fair amount of charisma, and I think charisma gets you a long way. \[00:04:42\] Bob: It didn’t get him a long way with the judge, Michael Ponsor, however. He might have been known for being lenient from the bench, but not this time. \[00:04:52\] Stephanie Barry: And the just indulged him for a very long time and finally said, “I’m going to stop you right here. And I never, ever do this. But I am sentencing you to the maximum penalty that the law allows.” And that was 7 years in prison. So that was in 2003. \[00:05:14\] Bob: So McCann goes away for a long time. Seven years pass; Stephanie goes on to become an award-winning investigative reporter. McCann serves his time and ends up back in Judge Ponsor’s courtroom almost immediately. \[00:05:30\] Stephanie Barry: In 2010, I was sitting in federal court on another matter, I can’t recall what it was, but one of the US Marshalls scooched over to me on the court bench and whispered in my ear, “Do you remember Dana McCann?” And I said, “Vaguely. Vaguely I do, why?” He said, “Well, he’s on the lam and we have been tasked with finding him.” I said, “Really? Tell me about that.” So he had gotten out of prison, made his way to the Greater Boston area, hitched his wagon to a wealthy divorcee, so she had a lot of money, and they stayed in one of the swankiest hotels in Boston for a couple of months, stiffed the hotel for I think it was 30 something thousand dollars. And he stole $125,000 in her jewelry and took off. So she called the police, and then somehow the police in New York City, I believe he kinda tried to pull the same thing at a very fancy hotel in New York City that he was staying there, somehow convinced them that he could stay there. He had a line of credit, and then he stiffed them on the bill. So that hotel called New York City detectives and they started pursuing him. And so because he was still on probation, the, the US Marshalls got involved and they tracked him to Long Island. \[00:07:07\] Bob: So McCann is arrested and eventually lands back in that same Massachusetts court again, back before Judge Ponsor. And the judge put him away as long as he could, again, but his hands were a bit tied. \[00:07:22\] Stephanie Barry: The judge could only give him two years because his violations were actually probation violations, which only allows you to sentence, you know, kind of a minimal prison term. And then he acted like he was repentant, and the judge said, and I believe I quoted him in at least one or not more stories, “You are the most unrepentant, dangerous fraudster I have ever encountered.” So then he went away for another couple of years. \[00:07:50\] Bob: And in her story about that sentencing, Stephanie also used another quote from the judge who made quite an alarming prediction that day. \[00:08:00\] Bob: I have this, I’m dying to ask you about where this judge who seemed to have a very colorful career as well, “what on earth is going to happen to him, and what’s to become of the rest of us once he’s on the loose again?” \[00:08:12\] Stephanie Barry: Right. So that was prophetic, um, obviously. And I think Judge Ponsor, the judge, was really being sincere about that, because I think he felt, “I don’t know what’s going to stop this man. And God help us all if you bump into this guy in business or in romance.” And he was right. (MUSIC SEGUE) \[00:08:43\] Bob: Jill Alper is an art dealer who has traveled the world. She’s lived in Africa and New Zealand, but when it was time to start a family she landed in South Carolina, her happy place, she told me. But when she started that family, well it kind of happened all at once. She was pregnant with twins, and that’s how she meets Holly Saunders. \[00:09:05\] Jill Alper: Holly’s a little bit older than I, and every year we, we travel somewhere. We are really great friends. I used to live in Laurens, South Carolina, and she lived down the street from me. And I’ll never forget, I was pregnant with the twins and, and then she came into the driveway, and she said, “Hey, I’m your neighbor. I’m Holly Saunders. I have twins, and I’m going to be here for you.” I remember her saying like, it’s going to be okay. I know it, it seems like a big deal, you know, you’re pregnant, and she’s like, “I’m going to help you.” Her twins are, they’re in their probably 30s or 40s now. So anyways, we became friends 16 years ago. \[00:09:44\] Bob: Holly remembers the dawn of their friendship the same way. \[00:09:48\] Holly Saunders: I’m 69, and I don’t even know how old Jill is. But she’s, she’s younger, but we were neighbors, and so when she was pregnant with her twins, mine were, oh gosh, I guess 10 or something already. And so that kind of was our original bond together. I just remember telling her, you can do this. And it will get easier, but we’ve had a wonderful, wonderful friendship since those early days as being neighbors in Laurens. \[00:10:24\] Bob: As her kids start to get older, Jill begins to look around for business ideas in and out of the art dealer industry. \[00:10:32\] Jill Alper: So the, the art business has only been for like five years. Before that I was in banking. I had a durable medical equipment company, so I’ve, you know, I’ve done lots of different things, but then I got to a point where I wanted to do something creative, so I decided to start a company with a friend of mine, and we would take local art outside of South Carolina, and, and sell it in these beautiful homes in Atlanta, Charleston, and we’d have these big events and it was a lot of fun until COVID hit. I had just started the business. We were just starting to have these shows, maybe every, you know, six months; it wasn’t a, you know, something I was doing every day, but it was kind of a part-time and as a single mom it worked great for my schedule. So that’s kind of where I was at when I met him in 2019. \[00:11:22\] Bob: That’s where she meets him — Dr. Dan. Not at an art show, but at a theater performance. \[00:11:31\] Jill Alper: In Greenville, we have an amazing downtown, and lots of arts, culture, and we have a, a place that we have off Broadway shows, and I usually get tickets for the year, and I went to one of the, the shows, and I was really bored. For some reason, it just, I was just kind of falling asleep and I went with some friends. I’m like, “I gotta go. I was planning on…” well I was going to take my daughter to camp the next day, and then fly out to Spain two days later. So I, I walked out of the Broadway… off Broadway play, and I was going to call an Uber, and he, I was dressed, you know, when you go to a Broadway play or off Broadway you, you dress nice, and I was definitely dressed up and I’m, waiting. Beautiful night, just kind of waiting on my ride, and he walks up to me. He had, he had like a, a golf shirt with a horse emblem on the front of it, like something breeder, you know, something where he owned a horse farm or, you know, we just, we just started talking. Just very, “How are you doing?” “You look so,” you know, just, you know, complimentary and he, he said, we just started talking about life and um, and he’s just super interesting. And he said, “Would you like to go get a drink?” It was across the street, and I said, “No, you know, I’m not interested.” But we kept talking and you know, he, he said he was in town ’cause he had, he sells horses. We have a huge horse area in Tryon, North Carolina. He’s down here, you know, getting some dinner while he just dropped off all these horses, and showed me his card where he’s a plastic surgeon from Beverly Hills, and, and I mean he just started to just telling me about his life. I said, “I’m going to Spain.” He knew how to speak Spanish. I mean I was just very intrigued by this man. \[00:13:22\] Bob: As she waits for her Uber, it seems to take forever getting there. This man just keeps chatting away. Then he pulls out his phone to share pictures of his life in Beverly Hills. And he gives her the nugget of an idea, an opportunity. \[00:13:39\] Jill Alper: He showed me pictures of like him and Kate Moss. I mean he had, it was something to back everything he said. Because I, I usually have my guard up a little bit with men. I’m like, okay, what, you know, this is really interesting, but he just, he is smooth. No doubt about it. So that was our conversation and he said he’s going to open up some spas in Greenville and he, he had this whole, you know, there’s something called CoolSculpting that a lot of us know about and it’s, it’s pretty expensive, and they’re all over every city. I mean I feel like every doctor’s office, dermatologist, they’re all, they’re all doing it. And so when he was telling me about his fat freezing, you know, it’s a, a lot cheaper and the, you know, it just intrigued me, because what a great thing to, to be a part of with my schedule, with, you know, I could do my art, I could have, in my mind I’m thinking, ooh, I could have the spa here and have my own hours. It just, it made sense. I’m helping women. You know, just, it just all made sense. \[00:14:38\] Bob: The Uber finally arrives and Jill speeds away headed for her Spanish vacation with friend, Holly. But even in Europe, she can’t stop thinking about this business opportunity, and how it might really be the perfect fit for her. In fact, she texts with this man a little bit more while she’s away. Finally, she opens up to Holly about this chance meeting with Dr. Dan. Holly is very supportive right away. \[00:15:06\] Holly Saunders: She told me about this machine, this business possibility, this, or opportunity, and I said, “Jill, I think this is an answer to a prayer. I honestly think this is a great thing for you, particularly. Because you can pick up your children from carpool, you can do, you know, you can be a volunteer mom in their school. You can be a, a housewife, a mom, everything and have this business, and it’ll be yours.” And at some point I said to her, “And I’ll tell you, I like it, and I’m interested. And I would be very interested in having a partnership business with you. \[00:15:51\] Bob: So when the vacation is over, and the friends are back in South Carolina, Jill starts to do her due diligence. She learns more about how Dr. Dan got into the fat freezing business. He tells her to call a spa in New York to talk with one of his colleagues. She confirms a lot of what Dr. Dan had said. \[00:16:12\] Jill Alper: He was a, a baseball, a professional baseball player, or not professional, but you know, the way the leagues before, but he had a, he had pictures of him being a baseball player. He also said he had like a brain, he got hit by the ball or something, and that’s why he had a little bit of a shake. So his hands would shake a little bit and that’s why he could not be a plastic surgeon anymore. So he decided to go into the, the fat freezing business. I’m like, wow, I mean this guy is, this guy’s real. \[00:16:44\] Bob: So Jill decides it’s time for Dr. Dan to meet Holly and what better time than one of her art shows. But that night, it’s Dr. Dan who really steals the show. \[00:16:57\] Jill Alper: My company, we set up art, I think we, we were on the lake in Gainesville at this beautiful home. We usually connect with a nonprofit, so we give money, whatever we sell, we give a portion of it back, and we had a huge group of women come to the show. And he shows up in a suit, which I had never seen him in a suit, and he walks in, and he’s like, I want that piece, I want that piece, and I’m like, this is great. He’s going to buy art. And he sits down at the piano at this lady’s house, and he starts playing like he is on, he’s in New York on Broadway. I mean the whole, all the people are around him stunned. He is singing and I mean it was like a performance I had never seen in someone’s house. And I don’t, it’s just, out of nowhere. And I look at Holly, I’m like, oh my, I mean who is this guy? He, he just, he can dab in anything and, and he, I mean everyone was just blown away by this performance. \[00:17:58\] Bob: This accomplished piano player, doctor, entrepreneur who speaks multiple languages and wants to buy art? He seems heaven sent. Still, heaven is one thing, payment for art is another. \[00:18:13\] Jill Alper: So he’s done, but he picks out at least 5 or 6, 7 paintings, and I said, “You can’t take them until you pay me.” He was like, you know, “I need to get my CPA to send a check,” and, “Can I take some?” I’m like, “No, you cannot. With this business, you have to pay before you take.” \[00:18:30\] Bob: Still, Holly spends a lot of that night talking with Dr. Dan about his practice, his horses, his baseball career, and comes away impressed by everything except his car. \[00:18:43\] Holly Saunders: Now, I do remember one of the girls that’s one of Jill’s partners, we were standing outside, and we watched him leave, and he left in this ratty car. And he flies, I mean he just zooms. He takes off like a banshee. And so, anyway, I remember Courtney said, “Well, not liking his car” or something like that. And I said, “I know. It’s just not, not sharp at all.” \[00:19:15\] Bob: Soon after the art show, and that piano performance, Dr. Dan starts to get some paperwork to Jill which she shares with Holly and things start to seem very real. \[00:19:27\] Jill Alper: He had given me this huge manual, like 100 pages. It is every detail of this business. The grids of how to make money. What to say. How, the training of how using it, and with these places he told us, as long as there’s a doctor, you could open up these little spas. He would, he could have, you know, 10 of them and as long as there’s a, a medical person involved, then we’re good. And you know, I just, he, you know, everything just, was just this sounds good, wow, this is great. \[00:20:01\] Bob: Still the pair of new partners want confirmation about just what they’re getting into. So, they take a road trip to see the business in action. \[00:20:11\] Holly Saunders: So one hot, Sunday afternoon, we drove to right outside of Atlanta and go to like an office plaza park, and it was a nice looking one, not bad at all, like professional doctor’s plaza. And he wasn’t there, so we sat on the steps and waited a while, and I noticed all sorts of people were coming in the building next to us, and so anyway, he comes, zooms in in that ratty car, parks, tells us to stay seated, goes to the door, couldn’t get in the door. And he was like, “Ah, I don’t have the key” or “They’ve changed the locks,” or something like that. “Sit tight, I’ll be right back.” And he said, “I live real close to here.” So zooms out of there, he’s back in no time, and I thought, he didn’t go home. He hasn’t had time to go home. He literally gets out of the car with cat burglar tools. So anyway, he gets in the door… \[00:21:17\] Bob: Wait, he breaks in basically? \[00:21:20\] Holly Saunders: I’m not sure how he got in. ‘Cause I, he told us to stay seated which we did, we didn’t really stand behind him and look. But he got in there. \[00:21:30\] Bob: A bit confused, but nothing else seems wrong. So Holly and Jill proceed to see for themselves how fat freezing technology works. \[00:21:40\] Holly Saunders: It’s like going into a doctor’s office, or a spa office, like if you get a facial or something. It was nice — sort of. It didn’t look real super-duper, just somehow it just didn’t look that clean to me. It wasn’t filthy at all. But he had this business on Groupon. The girl that ran it, she walks in. She was very nice and very gentle type of a person. You know, she kind of took a back seat to him. I said, “So, is this working well? I mean are you getting a lot of customers?” She went, “Oh yes, yes, yeah.” And he’s doing the procedure on Jill. I think she was first, and then me, and telling us how to do the machine and telling us how to put this there and that there. And, and I thought, you know, that’s easy. I mean I; I can handle this. I know I can handle this. There’s just nothing complicated about it. \[00:22:47\] Bob: Nothing complicated about it. Perhaps the perfect side business. So they have lunch and talk about their good fortune. \[00:22:57\] Holly Saunders: And so Jill and I proceeded to go to eat pizza. And so talked about how much money we were going to make and laughed, and just had a good time. \[00:23:09\] Bob: Back in South Carolina, they start running the numbers. Dr. Dan can sell them a machine for $15,000, but there are plenty of other start-up costs too. They start looking for a storefront, start talking to landlords about leases. Dr. Dan wants to come and see how the setup might work. \[00:23:28\] Holly Saunders: Okay, so he says he’s coming to Greenville to talk to us about where to set up and just the real details of putting together a business. And so he comes to Jill’s home, and I was there. We go downtown, we knew a friend of ours had an office space available, and so we looked at the building and he said, “Let me just run around and look at the neighborhood and just see what I think about this neighborhood and blah, blah, blah, blah.” He took off, so we, we were looking in the building ourselves and talking about well this room could be for the lobby, and this could be where we put the machine, and this needs to be painted, and this, that, and the other. And so the rent was maybe, I don’t remember, 1200, 900, 1200? I don’t remember. Then you’d have to have pull in telephone, networking, all sorts of stuff. So I’m thinking to myself, whoa, here I am trying to set something up in downtown Greenville. This is a pretty expensive endeavor, monthly payment, that I really am not real sure I want to get into. So I’m having my doubts there. \[00:24:42\] Bob: While Holly is starting to get just a bit of cold feet when the numbers start turning into reality, Jill is full speed ahead. \[00:24:52\] Jill Alper: Anyway, he goes back to Greenville, and I start really going over the paperwork. I’m all in. So Holly and I were going to do this together, and then he really starts in my ear like, you need to do this on your own. And now I understand, ’cause he wanted to sell two or three machines. If Holly and I went in together for the spa, then it would have been one sale for him. You know, so he’s trying to get more money. So I told Holly, I’m like why don’t you do it in Laurens where she lived, and I’ll do it here, and she was kind of stunned, like what are you talking about? But he was so in my ear, I made that decision like, I need to do this on my own. \[00:25:35\] Bob: Just then, the opportunity starts to sound even sweeter to Jill. Dr. Dan has come by a discounted machine. \[00:25:43\] Jill Alper: He came to Greenville, and he said, “Listen, my, I have a friend who’s a chiropractor, and she, I literally talked to her on the phone, and she has a machine, and she says that her mom or someone’s sick and she needs to get rid of it. Do you want it? I’ll do it for $10,000 instead of $15,000.” And I was like, okay, okay, you know. So anyway, he came to Greenville, and he goes, “I need cash.” I said, “Okay.” At this point we are, you know, I’ve talked to him a ton, we’ve already gone through the training. I know the business. I mean he has shown me so many pictures of like the spas, people using it. I mean it’s just, it just was like, okay. \[00:26:31\] Bob: Dr. Dan wants payment right away, however. \[00:26:34\] Jill Alper: I gave him $4,000 in cash, and then once we got all the contract signed, I mean there was a full contract to even get this machine. And once I got all that information, and I talked to the chiropractor, I saw pictures of it, I saw serial numbers of it; it was already crated. I got pictures of that. You know, he sent pictures of the whole process. \[00:26:56\] Bob: You wired him the, the remaining $6,000, right? \[00:26:58\] Jill Alper: Right. \[00:26:59\] Bob: So all told, it’s less than two months from the day she had met Dr. Dan, to the day she sends him $10,000. She’s ready to sign a lease on that office space, but she hasn’t pulled the trigger yet. She decides to wait for the machine to get there. That turns out to be a good choice because she’s going to have to wait a long time. \[00:27:21\] Jill Alper: I said, “Alright, what’s the update?” And then he would text me back. “You know, there’s a storm in blah, blah, blah… and it’s on…” I mean, it was like, this is when I’m like, this is just so weird. And, you know, there was always something going but, you know, I would get updates. It’s kind of like here comes your puppy from across the country and here’s your updates of it. You know you’re, it’s an investment, and, and I was super excited. I’m, I’m studying, I’m learning all I can. But the, you know it, it just, there was one excuse after another and I’m just, it’s just not feeling good. \[00:27:59\] Bob: Meanwhile, Holly is keeping an eye out for the machine’s arrival. Despite her cold feet, she’s still thinking about investing in her own place. And during this time, she goes to visit one of her kids and tells the little party about this exciting opportunity. \[00:28:16\] Holly Saunders: My oldest and her husband, they also live in Greenville, and they said, “Come over for a drink tonight, Mom. Joe’s going to be here.” Joe is my daughter’s best friend from growing up. He is a Mohs surgeon in Charleston, and he was in town to fill in for someone’s practice for the week because the other doctor was on a trip or something. And I said, “Oh, okay. Great.” And so it’s a Thursday night, and I was telling them about this venture, and they all just laughed at me and said, “Look, you cra–, what is this? What in the world are you getting yourself into?” And I said, “No, I think it’s legit. I do. I mean wow, it’s a great opportunity.” They said, “Do you have a picture of this guy?” And I said, “Well, yeah, let me, here.” And so I pulled up this picture of Dr. Dan on my phone, and he’s sitting there in a white coat, but he’s got Dr. Dan embroidered on his coat. But it’s like the embroidery you would use on a towel or something. And Joe, being a surgeon, he looked at it and he said, “Uh, nope, nobody does that. I mean nobody does that. That is absolutely a no.” They said, “Don’t do anything with him. Don’t do anything with him, just hold off.” And I said, “All right, well I’m going to do a little more research on him.” And so I come home, house is quiet, everybody’s in bed. I go upstairs to my room. I googled, I put one more “n” on the “n” end of McCan, in other words, I looked up Dan, M-c-C-a-n-n. Boom. Up comes scammer, blah, blah, blah. His pictures. The history, the lawsuits or the whatevers, and I mean I just couldn’t believe it. I, I absolutely was stunned, and I thought that, there he is. That’s him. \[00:30:34\] Bob: Dan McCann, that’s him! What Holly finds that night is story after story, most of them written by Stephanie Barry up in Massachusetts chronicling the wild crimes of Dan McCann. \[00:30:48\] Holly Saunders: And so, I immediately texted, called Jill, I mean just called, texted, just sent her or forwarded her the thing about him online, I didn’t hear a thing. I was babysitting for a granddaughter, didn’t have a car, and I was texting and calling Jill; just stalking her on Friday. Nothing. She didn’t answer, she didn’t respond whatsoever. And so I was just furious to tell you the truth. And Lee, my Lilly’s twin, is in Laurens and she said, “Mom, do you want me to call the cops? Should I send them over there?” And I said, “No, the minute Lilly gets home I’m getting in that car and going to Jill’s.” And so I did. \[00:31:45\] Bob: And when she sees Jill, it’s not good. \[00:31:49\] Holly Saunders: I parked, I walked up to the front, her daughter Ellison comes to the door shaking her head like, “Uh-uh, no, no.” And I said, “Is your mother here?” And she went, “Yeah, but I don’t think she’s doing real well.” And I said, “Where is she?” And I mean I just burst into her room. And Jill’s in bed, just like a zombie, and I said, “What are you doing? What in the world? Why haven’t you answered my calls, my texts? I have been worried to death about you.” And she said, “I’ve been at the FBI all morning.” And I said, “Oh my gosh.” And then ding-dong, I’m not very intuitive sometimes, she said, “Holly, I sent him $10,000 two weeks ago or a week ago or whatever ago.” And I went, “Oh my gosh, okay.” So it all made sense then … sort of. \[00:32:55\] Bob: Yeah, yeah. \[00:32:56\] Holly Saunders: And um, I thought, okay. Well, you’ve saved me 15,000. I mean it’s really kind of tragic. Anyway, she was just a mess. She was embarrassed, she was physically sick, she just felt so stupid that she had allowed this to happen to her. And I said, “Jill, stop. Just don’t even go there.” \[00:33:21\] Bob: Instead, Holly has another place she wants to go; she wants to get revenge. \[00:33:28\] Holly Saunders: I said, “Jill, the only person who can take this man out of business is me. And I’m going to do that. I’m going to sign up for a machine.” \[00:33:46\] Bob: I’m going to sign up for a machine? Holly wants to buy another fat freezing device from a man she now believes is a scammer? What happens next? That’s next week on The Perfect Scam. (MUSIC SEGUE) \[00:34:13\] Bob: If you have been targeted by a scam or fraud, you are not alone. Call the AARP Fraud Watch Network Helpline at 877-908-3360. Their trained fraud specialists can provide you with free support and guidance on what to do next. Thank you to our team of scambusters; Associate Producer, Annalea Embree; Researcher, Sarah Binney; Executive Producer, Julie Getz; and our Audio Engineer and Sound Designer, Julio Gonzalez. Be sure to find us on Apple Podcasts, Spotify, or wherever you listen to podcasts. For AARP’s The Perfect Scam, I’m Bob Sullivan. *END OF TRANSCRIPT* **Topics:** Healthcare Fraud, Public Awareness --- ### [Impact of ransomware on healthcare: what’s confirmed and what’s just speculative?](https://insurancefraud.org/news_archives/impact-of-ransomware-on-healthcare-whats-confirmed-and-whats-just-speculative/) **Published:** September 23, 2026 **Author:** Diane Beauchamp **Content:** Sunday musings….. What impact do ransomware attacks have on delivering healthcare services to patients? Some claims have been made, but are the claims supported by any objective data, or are people just guessing what the impact has been or could be? In this week’s news, a hospital in Illinois announced it will be temporarily closing due to a combination of factors and events. [25News reports](https://www.25newsnow.com/2023/01/21/perus-only-hospital-temporarily-close-next-week/): > The letter says the hospital’s current provider of physicians terminated its contract and St. Margaret’s can’t find or financially support a new emergency room provider. > > In addition, the letter said there’s not enough staff to operate the hospital in Peru and St. Margaret Health’s other hospital a few miles away in Spring Valley. > > The letter blames COVID, a cyber-attack preventing timely billing, staffing shortages, and other rising costs. So how do we assess the impact of the ransomware attack in this type of case? It is undoubtedly challenging. Then, too, consider a report by Ponemon, who [surveyed](https://www.censinet.com/impact-of-ransomware-on-patient-safety-and-value-of-cybersecurity-benchmarking) 579 cybersecurity professionals. A key part of their findings is presented below: ![Findings from 2021 Ponemon survey concerning impact of ransomware attacks.](https://www.databreaches.net/wp-content/uploads/Ponemon_Findings.jpg)*From: The Impact of Ransomware on Healthcare During COVID-19 and Beyond.*According to their report, more than 1 in 3 respondents said ransomware resulted in increased complications from medical procedures, and more than 1 in 5 respondents responded that ransomware attacks adversely impacted patient mortality rates (respondents could identify more than one type of impact). But on what do the respondents base their reports? It is objectively easier to calculate the number of days routine testing or care may have been delayed in response to an attack. It is objectively easier to calculate the number of patients whose ambulances were diverted to other facilities, and how much time that potentially added to delay in care — although even then, when one remembers that ambulances are equipped and are providing care while the patient is in the ambulance, then is care even really delayed in many cases? But if you are going to claim that a ransomware attack led to increased mortality, then what happened as a result of the attack that was responsible? Was access to the patient’s medical history impacted? Was delivery of needed medications delayed due to the attack? How do you connect the dots between the attack and the increased mortality? Surveying professionals and asking them for their impressions differs from collecting objective data and analyzing it. Years ago, DataBreaches repeatedly criticized surveys that predicted a significant percentage of patients would leave their doctors or facilities (“churn”) if there had been a data breach involving their personal and health data. DataBreaches noted at the time that what people may SAY they will do and what they actually do are often significantly different — and that’s particularly true when a hospital may be the only one in an area, or there are no other specialists in reasonable distance. These days, because breaches are so common, you seldom hear about people leaving or changing doctors or hospitals because of a data breach. It happens, but nowhere near the rates surveys were claiming or predicting years ago. Similarly, a Ponemon study years ago about medical identity theft created certain impressions about its rate and occurrence unless you dug deeper into their methodology and discovered that a lot of what they coded as medical identity theft was patients knowingly sharing their health insurance information with family members or friends. When asked about that, Ponemon informed this blogger that they considered that medical identity theft because that is how law enforcement viewed it. And now here we are, again reading claims about the impact of crimes on healthcare. And again, DataBreaches is asking how these claims are being substantiated. Do ransomware attacks have an impact on patient care? There’s certainly the potential for harmful impact in many situations, but we shouldn’t be guessing or assuming. **Topics:** Public Awareness, Technology --- ### [Sheriff’s office warns about phone scam](https://insurancefraud.org/news_archives/sheriffs-office-warns-about-phone-scam/) **Published:** September 23, 2026 **Author:** Diane Beauchamp **Content:** In a Saturday [Facebook post](https://www.facebook.com/profile.php?id=100064673830291), the Henry County Sheriff’s Office has alerted the public about an attempted phone scam. Henry County residents have received phone calls from people claiming to be from the Henry County Sheriff’s Office, the post says: “These perpetrators are claiming a family member or friend have an arrest warrant and are requesting financial information.”“If you receive phone call likes this, please report the incident to your law enforcement agency in which you reside. This is a scam,” according to the post. The post says the Henry County Sheriff’s Office will not contact you and solicit financial information from you. These incidents are under investigation by the Henry County Investigation’s Division. **Topics:** Public Awareness --- ### [LIC Contractor Indicted After Defrauding State Of Over $7 Million: DA](https://insurancefraud.org/news_archives/lic-contractor-indicted-after-defrauding-state-of-over-7-million-da/) **Published:** September 23, 2026 **Author:** Diane Beauchamp **Content:** A Long Island City-based contractor and its owner were indicted after reporting a false workforce size to New York’s insurance carrier to save money on premiums, Manhattan District Attorney Alvin L. Bragg, Jr. announced. Oneteam Restoration and its owner Mario Rojas Jr. were indicted with insurance fraud and falsifying business records after filing false documents to the New York State Fund to save on workers’ compensation insurance premiums for two years since 2019, Bragg said. The company’s accountant, Steven Lyon, from Edgewater, New Jersey, was also indicted with the same charges after filing the false documents to the insurance carrier, prosecutors said. The contractor, which specialized in building façade repairs and waterproofing, and Rojas hired Lyon to prepare and file the company’s quarterly payroll reports, as well as serve as representative during mandatory annual audits, the district attorney said. Lyon used separate emails between Jan. 2019 to May 2021 to file payroll-related documents with the Department of Labor and NYSIF, Bragg said. He would send accurate records to the DOL, but reduced the size of Oneteam’s workforce in the files submitted to NYSIF. By understating the company’s workforce, the company paid less in workers’ compensation insurance premiums. Oneteam underreported its payroll to NYSIF by more than $16 million, and underpaid the carrier by more than $7 million, prosecutors said. **Topics:** Work comp - employer **Categories:** Arrest --- ### [New York StateWide Senior Action Council Announces Its First Medicare Fraud of the Month for the New Year](https://insurancefraud.org/news_archives/new-york-statewide-senior-action-council-announces-its-first-medicare-fraud-of-the-month-for-the-new-year/) **Published:** September 23, 2026 **Author:** Diane Beauchamp **Content:** New York StateWide Senior Action Council (StateWide), an organization dedicated to advocacy for the rights of seniors in New York State today announced its Medicare Fraud of the Month for January; **Medicare Card Fraud.** The StateWide Fraud of the Month is a component of the **Senior Medical Patrol**, the definitive resource for New York State’s senior citizens and caregivers to detect, prevent, and report healthcare fraud, errors, and abuse. StateWide is New York’s grantee/administrator for this Federal Program. “Senior citizens are not getting a new Medicare Card for the New Year or anytime,” explained Maria Alvarez, StateWide’s Executive Director. “Beware of scammers calling, emailing, and texting you trying to convince you to get a new Medicare Card. Never give out your Medicare number to anyone other than your doctor, health care provider, or other trusted representative. Never give out your Medicare number to anyone who contacts you through unsolicited calls, texts, or emails.” Alvarez continued, “Your Medicare number is extremely valuable to scammers. In the wrong hands, your Medicare number can be used to bill for services and products that you may not even receive to the benefit of Medicare scammers.” In the past, Medicare beneficiaries used their Social Security number as their Medicare number. In 2018, as a result of some changes instituted by the Center for Medicare & Medicaid Services (CMS) each Medicare beneficiary received a new card with a uniquely assigned combination of letters & numbers. This was done to help keep beneficiaries’ identity and Social Security numbers secure. However, fraudsters are still calling beneficiaries attempting to acquire their information. Their tactics include: - Medicare is issuing an updated or new card – a plastic one, metal one, one with a chip, or even a white and black COVID-19 card, and they need to verify your Medicare account number. - To receive a new Medicare card, you need to verify your identity. This is the scammer’s attempt to gain personal or financial information. - Scammers say Medicare cards are expiring, and a fine will be charged a fine if it is not renewed. No Medicare cards expire. The red, white, and blue paper card is the only card issued by Medicare. **The NYS Senior Medicare Patrol has a hotline for people who believe they have been a victim of any Medicare fraud. Call 800-333-4374. our visit nysenior.org.** Certified counselors are ready to help answer any questions regarding Medicare benefits and issues. It is estimated that Medicare fraud costs New York taxpayers over $5 billion dollars a year. To help combat this illicit industry StateWide earlier this year announced its **Fraud of the Month** program to highlight these scams being perpetrated on the State’s seniors. **Topics:** Medicare/Medicaid, Public Awareness --- ### [Objection denied in Ellwood City Medical Center fraud case](https://insurancefraud.org/news_archives/objection-denied-in-ellwood-city-medical-center-fraud-case/) **Published:** September 23, 2026 **Author:** Diane Beauchamp **Content:** An objection was overruled Thursday in the case of a reported Medicare fraud scheme out of the former Ellwood City Medical Center. Carol Fox, the Chapter 11 trustee of Americore Holdings — former owner of the ECMC — began a lawsuit case seeking to recover all fraudulent transfers from a reported laboratory program at the center. This involved illegally sending thousands of cancer genomic testing specimens to the ECMC to collect more than $25 million in fraudulent Medicare reimbursements. Fox is looking to recover $1,923,300 from Fulgent Genetics Inc., which objected to the mediation. Its attorney argued Fox did not state a claim against Fulgent upon which relief can be granted. The property of the former medical center was officially transferred Nov. 30 to Guardian Development Group LLC. While Pelorus was a lien holder on the property and made back tax agreements with the three taxing bodies, Guardian — not Pelorus — is the property owner. Plans for the use of the property will be disclosed in the future. **Topics:** Judicial/courts, Public Awareness --- ### [Healthcare Cyberattacks: 5 Factors For Staying Safe In 2023](https://insurancefraud.org/news_archives/healthcare-cyberattacks-5-factors-for-staying-safe-in-2023/) **Published:** September 23, 2026 **Author:** Diane Beauchamp **Content:** The healthcare industry plays a critical role in society. But the private nature of our health—and, therefore, our healthcare services—means these companies hold our most sensitive information. Unfortunately, gaining access to that information is extremely attractive to hackers and cybercriminals. Healthcare companies continue to be among the [most frequent targets of cyberattacks](https://www.redteamsecure.com/blog/the-top-6-industries-at-risk-for-cyber-attacks). And while huge, global healthcare companies might seem like the best targets for these attacks, the reality is that companies of every size have something worth stealing. In fact, [small- and mid-sized hospitals](https://www.fiercehealthcare.com/tech/himss21-roundup-zoom-launches-mobile-browser-for-telehealth-visits-samsung-unveils-tech-for) are the healthcare sector with the highest risk of experiencing a cyberattack. These trends have shown no signs of slowing down over the previous years, which is why it’s important for healthcare companies to put systems in place now to prepare for the coming year. We’ll dig into the five factors healthcare companies must consider to remain secure in 2023. 1\. Understanding the importance of awareness. 2\. Addressing legacy vulnerabilities. 3\. Maximizing the efforts of shrinking teams. 4\. Staying secure while prioritizing lean spending. 5\. Meeting the constant concerns of compliance. ## 1. Understanding The Importance Of Awareness We all know there are bad people on the internet who want to steal our information. But how do they do it? And how do our actions help or hurt their attempts to access our protected files? The IT department of healthcare companies must go beyond understanding these threats themselves—they must communicate these threats to everyone who interacts with their platform. Ransomware attacks are increasingly common in the healthcare industry. [A study on ransomware](https://assets.sophos.com/X24WTUEQ/at/s49k3zrbsj8x9hwbm9nkhzxh/sophos-state-of-ransomware-in-healthcare-2021-wp.pdf) found that almost a third of healthcare companies experienced this type of attack in 2020. The increased use of remote work was the main cause of this trend. Team members need to be aware of what devices they’re using to access healthcare systems. Phishing tactics through spoofed emails are another common source of cyberattacks, which can be mitigated through vigilance and heightened awareness by team members. ## 2. Addressing Legacy Vulnerabilities Digital transformations are becoming increasingly common in the healthcare industry. Older platforms and systems are being phased out in favor of updated software, streamlining processes and heightening security measures. According to the Healthcare Information and Management Systems Society (HIMSS), [80% of health systems plan to increase investments in their digital health over the next five years](https://acrobat.adobe.com/link/review?uri=urn:aaid:scds:US:bb7e6bd5-a697-3cce-bbc0-47bb7d07f883). And while this will yield great results in the future, it won’t do anything to protect healthcare systems in 2023. Even those that have started this process are likely still using older software as they transition to updated applications. Technical debt, outdated permissions and other potential liabilities lurk in these older systems. Healthcare companies need to scan legacy environments for vulnerabilities to address bugs or errors before they’re exploited by a cybercriminal. ## 3. Maximizing The Efforts Of Shrinking Teams The healthcare industry has seen a mass exodus of workers since 2020. Teams are being stretched thin at every level, which can lead to more mistakes and difficulty keeping up with demand. Support systems need to be in place to help the remaining team members accomplish their goals. Healthcare companies must source automated data security tools to cover this gap and address continued threats. Consistent oversight through automated tools like data backup and recovery or a policy manager ensures internal rules are being enforced and team members have the support they need to increase productivity. Equipping your team with automated tools expands its ability to find and rectify potentially dangerous errors. ## 4. Staying Secure While Prioritizing Lean Spending A major challenge of 2023 is going to be a continuation of what we’re already seeing. The economic slowdown evident throughout 2022 will continue into next year and exacerbate the challenges for IT and data security teams. ROI is always a major factor in sourcing data security tools, but it will be critical to streamlining operations while navigating difficult economic times. The portion of the healthcare industry’s IT budget dedicated to cybersecurity [is currently 6% or less](https://www.himss.org/resources/himss-healthcare-cybersecurity-survey), and even this could decrease if the economic situation continues its downward trajectory. That’s why IT teams need to stretch their cybersecurity budgets as far as they will go. We’ve mentioned the importance of automation, and this reinforces the criticality of reducing manual processes now. ## 5. Meeting The Constant Concerns Of Compliance Protecting personally identifiable information (PII) and protected health information (PHI) is a constant concern for healthcare companies. Even unintentional errors have the potential for incredibly negative consequences for any affected patients as well as team members, along with costly fines and penalties to the company itself. Healthcare companies need to prioritize collecting and storing documentation of security policies, assessments and any other activities that impact applicable data security regulations. 2023 will pose a series of unique challenges to the healthcare industry. Remaining secure is increasingly difficult but possible with concerted effort and vigilance. Cybercriminals are continuously adapting to the latest technology, thus continuing to advance with sophistication and causing cyberattacks to rise exponentially. It’s imperative for enterprises to allocate a special budget to invest in cybersecurity solutions in order to protect patient and customer data. By integrating automation, your team can save time and focus on providing valuable applications and updates to your customers. **Topics:** Public Awareness, Technology --- ### [CommonSpirit faces another lawsuit for data breach](https://insurancefraud.org/news_archives/commonspirit-faces-another-lawsuit-for-data-breach/) **Published:** September 23, 2026 **Author:** Diane Beauchamp **Content:** A class action lawsuit, [filed](https://www.classaction.org/media/koch-v-commonspirit-health.pdf) Jan. 13, accuses Chicago-based CommonSpirit Health of failing to protect patients’ personal information from a recent [ransomware attack](https://www.beckershospitalreview.com/cybersecurity/commonspirit-health-confirms-ransomware-attack.html) on the health system. According to the lawsuit, CommonSpirit Health “lost control” of patient data after its computer system was accessed by an unauthorized third party in a September that [caused](https://www.beckershospitalreview.com/cybersecurity/the-effect-of-common-spirit-s-it-issues-ehr-outages-and-rescheduled-appointments.html) widespread EHR outages and appointment cancellations As a result of the breach, 623,774 patients were notified that their information was compromised during the cyberattack. Patient information compromised in the attack included names, addresses, phone numbers, dates of birth and unique IDs used within CommonSpirit Health’s system. The lawsuit alleges that the data breach happened as result of CommonSpirit’s negligence and “abject failure” to take basic cybersecurity precautions to protect the patient identifiable information and protected health information stored within its network. This is the second lawsuit the health system has been hit with since the attack. On Dec. 29, Leeroy Perkins [filed](https://www.beckershospitalreview.com/cybersecurity/commonspirit-health-sued-over-ransomware-attack.html) a lawsuit in the U.S. District Court for the Northern District of Illinois against CommonSpirit for the ransomware attack. The complainant in that suit asked for class-action status as well as damages, restitution and other forms of equitable monetary relief, and declaratory and injunctive relief. **Topics:** Judicial/courts, Technology --- ### [Revealed – the 10 worst insurance fraud cases of all time](https://insurancefraud.org/news_archives/revealed-the-10-worst-insurance-fraud-cases-of-all-time-2/) **Published:** September 23, 2026 **Author:** Diane Beauchamp **Content:** From the silliest and downright bizarre to the most diabolical and tragic, the insurance industry has witnessed the lengths unscrupulous scammers would go to cash in on a claim. In this article, Insurance Business looks back at some of the worst cases of insurance fraud the world has ever seen and how these were unraveled. Here are the ones that made it to our top 10 list. ### **10. Nicholas Di Puma – “straight out of Three Stooges”** A cooking mishap that seemed straight out of a slapstick movie raised alarm bells for a Delaware home insurer after a local man claimed that a kitchen accident caused his home and convertible to go up in smoke. According to the [Daily Star](https://www.thedailystar.com/archives/man-pleads-guilty-to-fraud/article_516b29c5-bbf9-596d-b79d-247e6241b790.html), Nicholas Di Puma tried to put out a fire from a burning pan with a dishrag, but it also caught fire, so he took the pan and threw it out of his front door. Unfortunately, it landed on the backseat of his convertible setting it ablaze. A second pan also caught fire but as he was about to throw it out, he tripped over a box and the pan landed on his leather sofa, instantly igniting it. Authorities were not convinced by his explanation, with the presiding judge describing the events as “like the plot of a Three Stooges movie.” Di Puma pleaded guilty to second- and third-degree attempted insurance fraud. He was ordered to pay $37,997 in restitution and was sentenced to five years of probation. ### **9. Gerald Hardin – Choppy friendship** From comedy to horror. In May 2008, a South Carolina district court heard a case against Gerald Hardin, along with another person, who chopped off their friend’s hand to cash in on a $671,000 dismemberment claim. According to [FBI records](https://archives.fbi.gov/archives/columbia/press-releases/2012/cayce-man-arrested-in-insurance-fraud-case), the duo used a pole saw to cut off the hand of their accomplice, the mentally challenged Michael Weaver, who then submitted a claim against his home insurance policy, along with three accidental death and dismemberment policies. Weaver reportedly viewed Hardin as a father figure and agreed to have his hand sawed off so Hardin, a known drug user, could claim compensation for the accident on six different policies. Hardin was sentenced to five years in prison for the crime. That doesn’t seem like enough prison time… Head down to the comments section if you feel like it should have been more and let us know your thoughts. ### **8. John and Anne Darwin – the case of the Canoe Conman** One of the most infamous cases of life insurance frauds is that of [Brit](https://www.insurancebusinessmag.com/us/companies/brit/415486/) couple John and Anne Darwin, whose notoriety has inspired several documentaries. Drowning in debt, the couple realized that their obligations would be wiped out if John faked his own death. Anne helped her husband in doing so in 2002, when John reportedly disappeared in a canoeing accident. Anne cashed in on £680,000 worth of life [insurance claims](https://www.insurancebusinessmag.com/us/glossary/insurance-claims/559065/) and paid their debts. The couple then started a new life in Panama under a false identity. Eventually, the pair was caught because of a social media post. They were each sentenced to six years in prison. ### **7. Imad and Bahaad Dawara – Arson fail** Straight out of the [Coalition](https://www.insurancebusinessmag.com/us/companies/coalition/587387/) Against Insurance Fraud’s (CAIF) [Hall of Shame](https://insurancefraud.org/publications/insurance-fraud-hall-of-shame-2021/) list are brothers Iwad and Bahaa Dawara. The Philadelphia siblings attempted to save their fizzling hookah bar business by torching the place and cashing in on a $750,000 accidental fire coverage they took out just a few weeks before. The brothers, however, botched their insurance fraud attempt worse than they ran their hookah bar. Their act of arson ruined an old scenic neighborhood in Chestnut Street, shutting it down for months and causing several businesses to permanently close and dozens of workers to lose their jobs. The brothers were handed nine-year prison sentences and ordered to pay $22 million in restitution for the crime. All over a hookah bar that was supposed to go up in smoke, but instead went up in flames. ### **6. Andy House – Where’s the pelican?** In 2009, luxury car dealer Andy House drove his $1 million Bugatti Veyron into a swamp, hoping to collect a whopping $2.2 million in payout, in arguably among the least thought-out car insurance frauds of all time. House claimed that he lost control of his vehicle when he tried to avoid a pelican, causing him to swerve off the road and into a nearby swamp. The car sustained unfixable damages. The Bugatti Veyron is an extremely rare luxury car, with only 300 models manufactured in 2006. It is also among the most powerful, being able to accelerate up to 235mph. Unfortunately for House, a passenger in another vehicle – a fervent admirer of luxury cars – noticed the Bugatti and recorded the incident on his phone. This ruined House’s fraud attempt, as the video showed there were no pelicans when the claim occurred. ### **5. Harry Gordon – Dead man hiking** In 2000, Australian millionaire Harry Gordon tried to secure a AU$3.5 million payout from his life insurance policy by – bet you’re expecting this one – faking his own death. Aided by his wife, Sheila, and daughter, Josaphine, they cashed in on the claim. Harry used the proceeds to start a new life in New Zealand, where he met his second wife. The situation unraveled, however, after Harry and his new wife bumped into his brother, Michael, on a hiking trip in Tauranga. Things quickly escalated from there when Michael told Sheila about Harry’s new wife. Australian authorities later uncovered the fraud and Harry was arrested and sentenced to 15 months in jail after pleading guilty to conspiring to obtain money by deception, among other charges. He later went on to [write a book](https://au.newhollandpublishers.com/how-i-faked-my-own-death-and-did-not-get-away-with-it-9781760794071.html) aptly titled How I Faked My Own Death and Did Not Get Away with It. ### **4. Atul Shah and Mahaveer Kankariya – Snatch copycats** To save their floundering jewelry business, New York business partners Atul Shah and Mahaveer Kankariya laid out an elaborate plan to rob their own store. Disguised in Hasidic Jew costumes – copied from the opening scene of the Guy Ritchie film Snatch – the duo staged the fake heist in December 2008 and then filed a $7 million claim with their insurer, Lloyd’s of London. To cover their tracks, the men poured drain cleaner into security cameras, hoping to destroy any incriminating evidence. The scheme came apart, however, when law enforcement authorities were able to salvage footage, which showed both men entering their safe and removing jewelry a few hours before the supposed burglary. The pair was convicted of insurance fraud in the first degree, attempted grand larceny, and falsifying business records in [March 2011](https://www.cbsnews.com/newyork/news/diamond-dealers-sentenced-in-fake-nyc-heist/). ### **3. Jacques Roy – Medicare mayhem** In 2017, Texas physician Jacques Roy received a 35-year sentence and was ordered to pay $268 million for masterminding one of the biggest health insurance frauds of all time. According to an [FBI report](https://www.fbi.gov/news/stories/health-care-fraud), Roy and his accomplices scammed Medicare to the tune of $375 million by performing unnecessary home visits, ordering medical services for healthy patients, and submitting fraudulent claims between 2004 and 2011. Reports also suggest that the scheme generated hundreds of false claims daily before the deception was uncovered. ### **2. Eric Conn – American greed** Crippled and impoverished Kentucky residents trusted that local attorney Eric Conn would help them secure federal disability money. Instead, the small-town lawyer betrayed them in a massive $550 million Social Security fraud – the largest in history. In an unbelievable display of greed, Conn conned the Social Security Administration (SSA) into paying disability benefits to thousands of healthy people by making illegal payments to Social Security Administrative Law Judge David Daugherty, who essentially rubber-stamped the claims. When the scheme was uncovered, SSA suspended disability payments to about 1,700 recipients, which left those who truly needed the money in desperate straits. In 2017, Conn pleaded guilty to a two-count federal complaint of stealing from the government and paying illegal gratuities and was sentenced to 12 years in prison, according to a [CNBC report](https://www.cnbc.com/2018/03/29/how-a-country-lawyer-pulled-off-the-biggest-social-security-fraud-ever-and-why-it-could-happen-again.html). ### **1. Ali Elmezayen – Heartless murderer** This case topped the list of worst insurance frauds not because of the money involved but due to the sheer vileness of the act. In 2015, California resident Ali Elmezayen staged a freak car accident, which took the lives of his two autistic children and nearly drowned his wife. He cashed in on a $260,000 payout and used part of the money to buy real estate in his native Egypt and a boat. Authorities later began to piece together evidence to prove that what happened was indeed stone-cold murder, including his frequent confirmation with the insurers about the window for investigating fraud and recorded conversations with his wife after their sons’ deaths. Elmezayen was eventually sentenced to 212 years in prison for the murder of his children. ## **What is insurance fraud?** The [Insurance Information Institute](https://www.insurancebusinessmag.com/us/companies/insurance-information-institute/587360/) (Triple-I) defines [insurance fraud](https://www.iii.org/article/background-on-insurance-fraud) as a “deliberate deception perpetrated against or by an insurance company or an agent for the purpose of financial gain.” Such illegal acts may be committed by applicants, policyholders, third-party claimants, and even the insurance brokers and providers themselves. You can also find the [meaning behind the most common insurance terms](https://www.insurancebusinessmag.com/us/guides/55-insurance-terms-you-should-know-about-428387.aspx) in our handy guide. ## **Who commits insurance fraud?** According to the Triple-I, some of those who commit insurance fraud include: - Organized criminals who steal large sums through fraudulent business activities - Professionals and technicians who inflate service costs or charge for services not rendered - Ordinary people who want to cover their deductible or view filing a claim as an opportunity to make a little money Common acts of insurance fraud these people perpetrate include: - “Padding” or inflating claims - Misrepresenting facts on an insurance application - Submitting claims for injuries or damage that never occurred - Staging accidents Triple-I added that although the impact of insurance fraud can be felt across the industry, some sectors are more vulnerable than others. Among the industries most affected by fraud are healthcare, workers’ compensation, and auto insurance. ## **What are the most common types of insurance fraud?** Insurance fraud takes on different forms depending on the industry. Here are the most common types of fraud committed against various segments of the insurance sector, according to industry experts. ### **Auto insurance fraud** Premium leakage, or what the analytics firm [Verisk](https://www.insurancebusinessmag.com/us/companies/verisk/587345/) defines as the “omitted or misstated underwriting information that leads to inaccurate rates,” is among the most common and costliest acts of fraud in the car insurance sector. [Recent modelling](https://www.verisk.com/insurance/visualize/auto-insurance-premium-leakage-a-29b-problem-for-the-industry/) conducted by the company estimated that auto insurers lost at least $29 billion annually to what it called several “information failures and fraudulent practices.” These include: - Unrecognized drivers ($10.3 billion) - Underestimated mileage ($5.4 billion) - Violations and accidents ($3.4 billion) - False garaging to save on premiums ($2.9 billion) The financial impact of premium leakage, however, is not limited to insurance providers. Verisk’s analysis also showed that as much as 14% of all personal auto premiums can be attributed to the cost of covering premium leakage. Another practice that cost the auto insurance industry huge sums is padded claims. According to Triple-I, this usually happens in no-fault states, where “unscrupulous medical providers, attorneys, and others” pad expenses associated with legitimate claims. One example is billing an insurer for a medical procedure that was not performed. The institute also received reports of counterfeit airbags being used by unscrupulous auto body repair shops, which then obtain reimbursement from insurance companies for legitimate airbags. ### **Health insurance frauds** The FBI’s latest [financial crimes report](https://www.fbi.gov/investigate/white-collar-crime/health-care-fraud) revealed the most prevalent types of fraud that plague the healthcare insurance sector. These include: - Billing for services not rendered - Upcoding services and medical items wherein the provider submits a bill using a code that yields a higher payment than for the service or item that was actually rendered - Filing duplicate claims - Unbundling or billing in a fragmented fashion for tests or procedures that are required to be billed together at a reduced cost - Performing excessive and unnecessary services, while offering kickbacks Triple-I also cited the prevalence of health identity theft, where criminals steal a victim’s name, health insurance number, and other personal data to defraud insurance providers by making false claims. ### **Workers’ compensation insurance fraud** The most common acts of insurance fraud involving workers’ compensation, according to Triple-I, include the following: - Employers misrepresenting their payroll or the type of work carried out by their employees to save on premiums - Employers applying for coverage under different names to avoid paying claims or detection of their poor claims record - Employees who “over-utilize” medical care to keep receiving lost income benefits or seek compensation for a work-related injury that never occurred Here’s a recent workers’ insurance fraud we covered where a tradesperson failed to disclose the fact that he had recovered and [was working a new job](https://www.insurancebusinessmag.com/au/news/breaking-news/court-slams-tradesperson-for-workers-compensation-fraud-423106.aspx). That’s fraud every time. ### **Catastrophe-related property insurance fraud** Disasters often provide an opportunity for fraudsters to file claims that are “exaggerated or completely false,” the Triple-I notes. These include seeking payouts for an intentionally damaged property. Another example is contractor fraud, which involves using a person’s homeowners’ insurance to pay for unnecessary repairs. **Topics:** Public Awareness --- ### [Man Pleads Guilty To Committing Multi-Million-Dollar Fraud Against Medicare By Selling Bogus Orders For Medical Equipment](https://insurancefraud.org/news_archives/man-pleads-guilty-to-committing-multi-million-dollar-fraud-against-medicare-by-selling-bogus-orders-for-medical-equipment/) **Published:** September 23, 2026 **Author:** Diane Beauchamp **Content:** Damian Williams, the United States Attorney for the Southern District of New York, announced that MATTHEW TAYLOR WITKOWSKI pled guilty today to a one-count criminal Information charging him with conspiracy to commit health care fraud. WITKOWSKI is scheduled to be sentenced on April 20, 2023, before United States District Judge Denise Cote. U.S. Attorney Damian Williams said: “Medicare is a valuable, taxpayer-funded program designed to provide affordable health care to people over 65 or with disabilities, not to enrich those who would seek to benefit themselves through fraud. Today, Matthew Taylor Witkowski admitted to illegally selling orders for durable medical equipment, which were used to bilk Medicare out of millions of dollars.” According to the Information, statements made in court, and other publicly filed documents in this case: From at least August 2019 through the date of his arrest in July 2022, WITKOWSKI and a co-conspirator (“CC-1”) engaged in a scheme to defraud Medicare by illegally obtaining and selling fraudulent written orders for goods and services paid for by Medicare, including for durable medical equipment (“DME”). Using a call center that he owned and operated in the Dominican Republic, WITKOWSKI illegally generated and purchased fraudulent written orders for DME and then sold those fraudulent orders to pharmacies and DME suppliers, including in New York City. Those pharmacies and DME suppliers then used those fraudulent orders as the basis for more than $8 million in fraudulent claims to Medicare. Many of these fraudulent orders used names and personal health information of actual Medicare beneficiaries, without the beneficiaries’ authorization or prior knowledge. Many of these fraudulent orders also contained professional information of doctors and other health-care providers enrolled in the Medicare program, as well as the purported electronic signatures of these providers, which were falsified and created without the authorization or knowledge of these providers. During the course of the scheme, WITKOWSKI took more than $4 million in illegal kickbacks from DME suppliers, who made these payments to True Prospects Marketing, Inc., a company controlled by Witkowski and CC-1, and to Sales Drive Marketing LLC, a company owned and controlled by WITKOWSKI. --- WITKOWSKI, 37, an American citizen who has been residing in the Dominican Republic, and is currently on bail in Florida, pled guilty today to a single count of conspiracy to commit health care fraud. That charge carries a maximum sentence of 10 years in prison. The maximum potential sentence is prescribed by Congress and is provided here for informational purposes only, as any sentencing of the defendant will be determined by the sentencing judge. Mr. Williams praised the investigative work of the Office of the Inspector General of the U.S. Department of Health and Human Services. This case is being handled by the Office’s Complex Frauds and Cybercrime Unit. Assistant U.S. Attorney David Raymond Lewis is in charge of the prosecution. **Topics:** Medicare/Medicaid **Categories:** Conviction --- ### [Wife to pay $700,000 to settle federal claim against Rye health care fraudster](https://insurancefraud.org/news_archives/wife-to-pay-700000-to-settle-federal-claim-against-rye-health-care-fraudster/) **Published:** September 23, 2026 **Author:** Diane Beauchamp **Content:** Rye eye surgeon Ameet Goyal was a “broken and humbled” man before he was sentenced to prison last year for health care fraud, his attorneys told a federal judge, but he was prepared to endure “only because he is supported by loving family and friends.” Now his wife is backing him again by agreeing to pay $700,000 to the government to settle a forfeiture judgment. Goyal overbilled Medicare and private insurance plans by $3.6 million from 2010 to 2017, according to court records, at his ophthalmology practices in Rye, Mount Kisco, Wappingers Falls and Greenwich, Connecticut. Essentially, he submitted insurance claims for lucrative, complex surgeries when simpler operations or no surgeries had been performed. Goyal boasted to one of his colleagues that insurance companies were too stupid to catch him, according to the prosecutors”™ sentencing memorandum. But he got noticed, for instance, for submitting seven times more claims for a grafting procedure than all doctors in New York, New Jersey and Connecticut. He was accused of health care fraud and other charges in 2019 and pleaded guilty in 2021. U.S. District Judge Cathy Seibel ordered him to forfeit $3.6 million and last March sentenced him to 8 years in prison. He has paid nearly $1.8 million, according to a stipulation agreement approved by Judge Seibel on Jan. 19, leaving a balance of $1,809,146. But he still owned a house on Holly Drive in Rye with his wife, Alka Goyal. The 5 bedroom, 6.5 bath, 9,200-square-foot house is worth $1.6 million to nearly $2 million, according to estimates by the Zillow and Redfin online real estate marketplaces. The government agreed to accept $700,00 from Alka Goyal as representing the value of her husband”™s interest in the property, according to the stipulation agreement. The government also agreed to no longer seek forfeiture of the house, allow his interest to be transferred to his wife, and to treat the $700,000 payment as full satisfaction of all government claims against the property. The payment will bring the total of forfeited assets to $2,490,854, or 69% of the $3.6 million forfeiture order. Goyal, 59, is currently imprisoned at the U.S. Penitentiary at Canaan in northeast Pennsylvania. He is scheduled for release in February 2029. **Topics:** Healthcare Fraud, Judicial/courts **Categories:** Conviction --- ### [DePuy Synthes, Inc. Agrees to Pay $9.75 Million to Settle Allegations Concerning Kickbacks Paid to Massachusetts Orthopedic Surgeon](https://insurancefraud.org/news_archives/depuy-synthes-inc-agrees-to-pay-9-75-million-to-settle-allegations-concerning-kickbacks-paid-to-massachusetts-orthopedic-surgeon/) **Published:** September 23, 2026 **Author:** Diane Beauchamp **Content:** Medical device manufacturer DePuy Synthes, Inc. (DePuy), a subsidiary of Johnson & Johnson, has agreed to pay $9.75 million to resolve allegations it violated the False Claims Act by paying kickbacks to an orthopedic surgeon based in Massachusetts to induce his use of DePuy products. The settlement announced today resolves allegations that DePuy violated the Anti-Kickback Statute (AKS) and caused the submission of false or fraudulent claims to Medicare by paying the orthopedic surgeon kickbacks in the form of free spinal implants and tools for use in surgeries that the surgeon performed overseas to induce that surgeon to use DePuy products in surgeries performed in the United States. As part of the settlement, DePuy has admitted that from at least July 2013 through February 2018, DePuy, acting through certain former sales representatives, gave the Massachusetts surgeon thousands of dollars’ worth of free DePuy implants and instruments, including cages, rods, screws, plates, and surgical instrumentation, that the surgeon used to perform surgeries overseas for patients who were not federal health care beneficiaries. Of the $9.75 million to be paid by DePuy, approximately $7.23 million will be returned to the federal government, and approximately $2.52 million will be returned to Massachusetts, which jointly funded claims for surgeries involving DePuy devices that were submitted to the Massachusetts Medicaid program. The AKS prohibits offering, paying, soliciting, or receiving remuneration to induce referrals of items or services covered by Medicare and other federally funded programs. The statute is intended to ensure that medical providers’ judgments are not compromised by improper financial incentives and are instead based on the best interests of their patients. “Medical device manufacturers are prohibited from providing free items to induce a physician to use their devices,” said Principal Deputy Assistant Attorney General Brian M. Boynton, head of the Justice Department’s Civil Division. “When medical devices are used in surgical procedures, patients deserve to know that their device was chosen based on quality of care considerations and not on improper inducements from manufacturers.” “Today the United States resolves allegations that DePuy provided over $100,000 worth of free product to a surgeon in order to secure and reward that physician’s continued business,” said U.S. Attorney Rachael S. Rollins for the District of Massachusetts. “Unlawful kickbacks can severely distort medical judgment as well as the market for medical devices. The millions of patients that depend on our health care system deserve untainted medical decisions. This settlement reflects our commitment to stamping out illegal kickbacks.” “The American people, as both taxpayers and consumers, expect medical device manufacturers like DePuy to abide by relevant laws and regulations. When such health care companies provide illegal kickbacks in order to boost profits, their actions erode public confidence in the health care system, can compromise the patient-physician relationship, and waste government health program funding,” said Special Agent in Charge Phillip M. Coyne of the U.S. Department of Health and Human Services, Office of Inspector General (HHS-OIG). “In close cooperation with our law enforcement partners, we will continue to thoroughly investigate allegations of fraud to protect both federal health care programs and those served by them.” “Today’s settlement makes it crystal clear that it is illegal for medical device companies to provide physicians with free medical products to win business and boost their bottom line through illegal kickback schemes,” said Special Agent in Charge Joseph R. Bonavolonta of the FBI Boston Division. “Every year, health care fraud costs taxpayers billions of dollars. It is not a victimless crime and this unscrupulous scheme orchestrated by DePuy is just one example of how the FBI and our partners are working hard every day to protect both patients and taxpayers.” The lawsuit was originally filed under the qui tam or whistleblower provisions of the False Claims Act by Aleksej Gusakovs, who is a former sales representative for DePuy. Under those provisions, private parties, known as relators, can file an action on behalf of the United States and receive a portion of the recovery. The qui tam case is captioned United States et al. ex rel. John Doe v. Johnson & Johnson, et al., No. 17-cv-11502 (D. Mass.). As part of today’s resolution, Gusakovs will receive approximately $1.37 million. The settlement was a result of a coordinated effort between the Civil Division’s Commercial Litigation Branch (Fraud Section) and the U.S. Attorney’s Office for the District of Massachusetts. The HHS-OIG provided investigative support. The government’s pursuit of these matters illustrates the government’s emphasis on combating health care fraud. One of the most powerful tools in this effort is the False Claims Act. Tips and complaints from all sources about potential fraud, waste, abuse, and mismanagement can be reported to the Department of Health and Human Services, at 800‑HHS‑TIPS (800-447-8477). The matter was handled by Senior Trial Counsel Benjamin C. Wei of the Civil Division and Assistant U.S. Attorneys Jessica Weber and Andrew Caffrey for the District of Massachusetts. **Topics:** Judicial/courts, Public Awareness --- ### [Chiropractor in Missouri pleads guilty to $3.5 million dollar health care, disability fraud](https://insurancefraud.org/news_archives/chiropractor-in-missouri-pleads-guilty-to-3-5-million-dollar-health-care-disability-fraud/) **Published:** September 23, 2026 **Author:** Diane Beauchamp **Content:** A chiropractor from Missouri on Thursday admitted that he falsely claimed to have a medical license and exaggerated patients’ medical conditions so they would fraudulently receive more than $3.5 million in disability payments from the Social Security Administration and private disability benefit insurers. Thomas G. Hobbs, 65, from Jefferson County, pleaded guilty in front of U.S. District Judge Henry E. Autrey to a conspiracy charge and admitted conspiring to commit the crimes of health care fraud, making false statements, theft of government funds, and Social Security fraud. Hobbs, the co-owner of Power-Med Inc., a chiropractic clinic in Arnold, Missouri, admitted that he falsely claimed to have a medical license. Despite his lack of a medical license, between 2011 and 2019 he purchased and dispensed prescription medications, administered injections, and dispensed medications intravenously to patients. Hobbs admitted in his plea agreement that he knew he was not permitted to administer injections because the Missouri Board of Chiropractic Examiners placed him on probation for five years for fraudulently billing insurance companies for unlawfully administering injections. Beginning in 2011, Hobbs also fraudulently assisted patients in receiving disability benefit payments through the Social Security Administration’s Disability Trust Fund and through private disability benefit insurance providers. Hobbs charged patients between $2,000 and $8,600 to prepare disability forms and coach them to lie to the Social Security Administration and insurers about their ability to perform basic activities such as lifting, standing, walking, sitting, remembering, and taking care of their personal needs. Hobbs also used a fictitious medical license number to buttress patients’ disability claims so that his medical determinations would be given greater weight than those of medical experts evaluating the claims on behalf of the Social Security Administration and private disability benefit insurers. To further bolster his misrepresentations, Hobbs submitted false and fraudulent medical reports to give the appearance that he had a long history with the patients. Hobbs submitted or caused to be submitted false and fraudulent claims for reimbursement to health care benefit programs for services that were not provided medically unnecessary services, or services provided by unqualified persons to make it appear that the disabled patients had medical conditions. Those procedures included MRIs, CT scans, and cardiovascular studies. He also submitted numerous claims for office visits when he had not provided the required face-to-face evaluation and management services to the patients. Hobbs admitted the losses to the Social Security Administration and private insurers exceeded $3.5 million. Hobbs is scheduled to be sentenced on April 19. The conspiracy charge carries a maximum penalty of five years imprisonment for each count, a fine of $250,000, or both. Both sides have agreed to recommend a four-year prison term. Hobbs will also be ordered to repay the money. The cases were investigated by the Social Security Administration – Office of Inspector General and the Federal Bureau of Investigation. Assistant U.S. Attorneys Tracy Berry, Dorothy McMurtry Diane Klocke, and Gwendolyn Carroll are prosecuting the case. **Topics:** Disability, Drug Diversion, Social Security fraud, Unlicensed entities **Categories:** Conviction --- ### [HHS CIO Mathias says tree-based AI models helping to combat Medicare fraud](https://insurancefraud.org/news_archives/hhs-cio-mathias-says-tree-based-ai-models-helping-to-combat-medicare-fraud/) **Published:** September 23, 2026 **Author:** Diane Beauchamp **Content:** The [Department of Health and Human Services](https://fedscoop.com/tag/department-of-health-and-human-services-hhs/) has launched a pilot program to tackle Medicare [fraud](https://fedscoop.com/tag/fraud/) using tree-based [artificial intelligence](https://fedscoop.com/tag/artificial-intelligence-ai/) models and deep learning approaches, HHS Chief Information Officer Karl Mathias said Wednesday. The program has so far helped streamline fraud identification within the more than one million transactions processed each day by the [Centers for Medicare & Medicaid Services (CMS)](https://fedscoop.com/tag/centers-for-medicare-and-medicaid-services-cms/), according to the IT leader. “They’re using tree based models and deep learning approaches and then they go and look at the medicare administrative claims data,” said [Mathias](https://fedscoop.com/tag/karl-mathias/) during a AFCEA Bethesda Health IT event Wednesday. “It’s still in a pilot phase but they’ve seen some success with this and they intend to keep growing it.” The IT executive added that the AI systems being tested have an edge over current fraud detection systems because tree-based models allow faster identification of new types of criminal activity. “As medicare fraud criminals figure out what’s being spotted by law enforcement, they keep changing their techniques, then this AI system figures that out and drops obsolete models based on that,” said Mathias. Tree-based AI models use a decision tree to represent how different input variables can be used to predict a target value. Machine learning systems use tree-based models both for classification and regression problems. Mathias said that HHS has also started using new AI technology to speed up counterfeit drug detection at the Food and Drug Administration (FDA) by using computer vision AI to tell whether a drug is authentic or fake. The technology can do so within seconds by evaluating wavelengths, which mitigates the need for a human to carry out a physical inspection. Another branch of HHS, the [National Institutes of Health (NIH)](https://fedscoop.com/tag/national-institutes-of-health-nih/), has also begun using AI automation when it comes to [research grant](https://fedscoop.com/tag/research-grants/) proposal analysis and auditing. According to Mathias, the AI system has a 92% accuracy rate when it comes to accepting the appropriate grant proposals, thereby eliminating a key bottleneck for innovative research approval. The CIO added that the use of AI systems at NIH would ensure taxpayer dollars are used more efficiently. **Topics:** Public Awareness, Regulatory actions, Technology --- ### [Louisiana Police Arrest Public Adjuster Accused of Pocketing Clients’ Checks](https://insurancefraud.org/news_archives/louisiana-police-arrest-public-adjuster-accused-of-pocketing-clients-checks/) **Published:** September 23, 2026 **Author:** Diane Beauchamp **Content:** Louisiana State Police arrested a Texas public adjuster for allegedly pocketing $592,000 from settlement checks that were intended for seven former clients by forging the homeowners’ signatures. Andrew Joseph Mitchell, 43, voluntarily surrendered to state police at the St. Charles Parish jail on Thursday. He was still being held at the Nelson Coleman Correctional Center on Friday on two felony theft charges with bail set at $450,000. The Texas Department of Insurance has accused Mitchell of a similar scheme in his home state. “I am very pleased to see the prompt action by Louisiana insurance regulators in first revoking (Mitchell’s) license and now charging him with felony crimes,” stated insurance defense attorney Steven Badger, with the Zelle law firm in Dallas. “Hopefully we will soon see similar charges in Texas and Georgia where he has similar alleged victims.” Mitchell, who changed his name from Andrew Aga, is owner of Mitchell Adjusting International in Clear Lake Shores, Texas. He is accused by Texas officials of stealing from clients in Texas, Georgia, and Minnesota. Criminal charges have been filed only in Louisiana so far. The Louisiana Department of Insurance revoked Mitchell’s non-resident public adjuster’s license last August, and also a non-resident public adjuster license issued to his son, Kade Austen Mitchell. The department said the Mitchells misappropriated $267,441.43 from insurer payouts that were intended for homeowners. The Louisiana State Police said in a press release that it launched a criminal investigation after receiving a referral from the Insurance Department. The agency said that it found a total of seven victims of the scheme in St. Charles, St. John the Baptist, Orleans and Tangipahoa parishes. “The investigation revealed that during the aftermath of Hurricane Ida, Mitchell began soliciting victims of property damage throughout various parishes in Louisiana,” State Police said. “After obtaining a greater settlement, Mitchell deposited the funds and failed to provide the monies to the homeowner. In multiple situations, Mitchell forged the homeowner’s signature to obtain the funds.” State Police charged Mitchell with two counts of felony theft in St. Charles Parish. The agency said Mitchell will also be booked into jail in St. John the Baptist Parish on three counts of theft and three counts of forgery, in Orleans Parish on one theft and one felony count and in Tangipahoa Parish on one theft and one forgery count. “This case remains under investigation in Louisiana and our investigators are working with other agencies to determine if any fraud was committed outside of Louisiana,” State Police spokeswoman Katharine Stegall said in an email. The Texas Department of Insurance filed civil charges in the State Office of Administrative Hearings against Andrew Mitchell, accusing him of stealing $7.6 million from 14 clients. Mitchell allegedly cashed four insurer payout checks intended for the Friendship Missionary Baptist Church in Albany, Georgia that totaled more than $6 million. Investigators say Mitchell also took insurer checks totaling $322,531 that were intended for the St. Paul Lutheran Church in Minnesota, but returned the money minus his fee after the church filed a police complaint. “Hopefully by now they have referred these matters to local prosecuting attorneys,” Badger said. Presiding Administrative Law Judge Nicolette Robles issued a proposed ruling on Dec. 20 that states the Insurance Department had shown by a preponderance of evidence that Mitchell had committed “fraudulent and dishonest acts.” The proposed order says that the department may revoke Mitchell’s public adjusting license, collect administrative penalties for each violation and order Mitchell to pay restitution to his victims. The proposed order states that Mitchell defrauded insurers for $7,619,531 but paid back $1,022,968, leaving a restitution balance of $6,596,563. Mitchell also charged clients more than the maximum 10% fee allowed by Texas state law, the order says. He also charged fees greater than the maximum allowed under state law and conducted the business of insurance using corporate names that were not licensed, according to the order. “Respondent lacks the trustworthiness and moral character to conduct public adjuster business fairly and in good faith,” the proposed order states. **Topics:** Insider - agent **Categories:** Arrest --- ### [3 healthcare data vulnerabilities to be mindful of in 2023](https://insurancefraud.org/news_archives/3-healthcare-data-vulnerabilities-to-be-mindful-of-in-2023/) **Published:** September 23, 2026 **Author:** Diane Beauchamp **Content:** The growth of digitization in healthcare has led to better patient care and improved service delivery by healthcare providers. However, due to the abundance of personally identifiable information (PII), it has made the healthcare sector vulnerable to cyberattacks. According to the HIPAA Journal, there have been [4,419 healthcare data breaches](https://www.hipaajournal.com/healthcare-data-breach-statistics/#:~:text=Healthcare%20Data%20Breaches%20by%20Year,disclosure%20of%20314%2C063%2C186%20healthcare%20records.) between 2009 and 2021. This constitutes 314,063,186 healthcare records exposed. According to an IBM report, a data breach in the healthcare sector costs [$10.10 million per incident](https://www.ibm.com/reports/data-breach). Most of these breaches were third-party breaches, a shift from the common large healthcare system attacks. Facing this threat landscape, healthcare security leaders must be mindful of and mitigate a number of cybersecurity threats facing the sector. ### 1. Third-party breach The healthcare industry relies heavily on third-party vendors, like cloud web hosting and cloud-based software vendors. Third-party entities help healthcare organizations gain strategic advantages like cost saving and/or expertise they don’t have. As such, they pose a grave risk to these healthcare organizations because most of them don’t have proper cybersecurity plans or data breach protection. A typical healthcare organization has [an average of 1,320 vendors ](https://censinet.com/wp-content/uploads/2019/07/Ponemon-Censinet-Survey-Report-third-party-vendor-risk-management-research-economic-impact-v2-1.pdf)under contract. From a cybercriminal stand, it makes more sense to attack a third-party vendor. If the attack is successful, they gain access to the parent company’s data. It is in this nature that [55%](https://www.hipaajournal.com/55-of-healthcare-organizations-suffered-a-third-party-data-breach-in-the-past-year/) of healthcare organizations have suffered a third-party data breach in the last 12 months. Methods used by attackers include exploiting weak passwords and access controls to gain healthcare organizations’ network access. Also, a considerable number of healthcare organizations have insecure external-facing servers and databases that make it easy to hack and gain access to their valuable data. #### How to deal with a third-party breach In 2023 and beyond, healthcare organizations should have proper application security and network security to prevent a third-party breach from happening. Encryption is one strategy for protecting patient data. In case of a breach of patient data, the attacker cannot decrypt the data without access to the encryption keys. The encryption should be done at rest and in transit so that even if a hacker gets into the system, they cannot get away with the data. Training on handling personal health information will also be handy when curbing third-party breaches. Last, vet third-party vendors to ensure they have the proper security infrastructure to protect healthcare data from being vulnerable. ### 2. Cloud breaches [Seventy-three percent](https://www.netwrix.com/download/collaterals/Netwrix_Cloud_Data_Security_Report_2022.pdf) of healthcare organizations store sensitive data in the cloud. What’s more, 45% of this data is personal health information. Sixty-one percent of healthcare organizations surveyed by Netwrix had experienced an attack on their cloud infrastructure in the last 12 months, and phishing was the most common cloud breach. The biggest challenge in ensuring data security in the cloud was that 69% of their IT/security team are understaffed. 55% lack expertise in cloud security, and 33% lack the budget to implement a cloud security strategy. #### How to avoid cloud breaches Going forward, beyond securing the traditional on-premise IT infrastructure, healthcare organizations should invest in building a secure cloud infrastructure. Keep testing, monitoring and analyzing enterprise cloud infrastructure to catch on any vulnerabilities and seal loopholes in healthcare security. There are cloud management platforms that can monitor the cloud for your organization. While investing in the infrastructure, it is indispensable to have security policies in place for remote access, BYOD, password use, and data transfer and disposal. Continually, educate all staff on these cybersecurity guidelines. Lastly, have a disaster recovery plan in case of a cloud breach or attack. A remote data backup system will be paramount. ### 3. IoT attacks [Fifty-three percent](https://www.cynerio.com/landing-pages/the-state-of-healthcare-iot-device-security-2022) of Internet of Things (IoT) devices in a hospital are at risk of being attacked. The most vulnerable of these devices is the IV pump which accounts for 38% of a typical hospital IoT footprint. The second most vulnerable is the VOIP (Voice over Internet Protocol) which accounts for 50% of IoT devices in a hospital. The most common cybersecurity risk to these devices are insecure passwords. Most Internet of Medical Things (IoMT) and IoT devices use their default passwords, which hackers can get easily online from their manuals. The rest simply use weak passwords that are easy to hack. #### How to prevent IoT breaches It is vital to build more secure medical IoT devices. To secure IoT devices, a group of 104 tech stakeholders have come up with a global consensus on[ IoT security standards, specifications and guidelines](https://cybertechaccord.org/uploads/prod/2022/02/consumer-device-security-joint-statement_FINAL-2172022_PDF.pdf). The framework describes five tenets of IoT security, including: - End of universal default passwords - Implementing a vulnerability disclosure policy - Regular software updates - Securing communications - Ensuring that personal data is secure. Other solutions would be to use strong passwords for IoMT devices, as well as maintain an inventory of all IoMT technology and use it to conduct risk assessments. To protect healthcare organizations from cybersecurity vulnerabilities, it is crucial that security leaders understand them first, create a policy around them, and allocate a budget to handle them. With the above information, they will be able to do this and make headway in shielding their healthcare organizations from any data vulnerabilities. **Topics:** Public Awareness, Technology --- ### [Healthcare billing fraud: 13 recent cases](https://insurancefraud.org/news_archives/healthcare-billing-fraud-13-recent-cases/) **Published:** September 22, 2026 **Author:** Diane Beauchamp **Content:** From a Florida physician getting 20 years in prison for the “largest ever” case of its kind, to a New York gastroenterologist getting 30 months in prison for a Medicare fraud scheme, here are 13 healthcare billing fraud cases *Becker’s* has reported since Dec. 29. 1\. [Medical billing company settles false claims allegations](https://www.beckershospitalreview.com/legal-regulatory-issues/medical-billing-company-settles-false-claims-allegations.html) Birmingham, Ala.-based medical billing company Amvik has agreed to pay $153,300 to settle allegations that it submitted false claims to the Connecticut Medicaid program for applied behavior analysis services. 2\. [North Carolina lab owner convicted in $11M Medicaid fraud scheme](https://www.beckershospitalreview.com/legal-regulatory-issues/north-carolina-lab-owner-convicted-in-11m-medicaid-fraud-scheme.html) North Carolina lab owner Donald Booker was convicted for his role in a scheme to defraud the state’s Medicaid program with medically unnecessary urine tests. 3\. [Mississippi provider pays $1.8M to settle overbilling allegations](https://www.beckershospitalreview.com/legal-regulatory-issues/mississippi-provider-pays-1-8m-to-settle-overbilling-allegations.html) A Mississippi orthopedic clinic and its owner, Hanna “Johnny” Mitias, MD, agreed to pay $1.8 million to settle allegations he overbilled Medicare and Medicaid for viscosupplementation agents. 4\. [3 companies settle for $745K for misbranded migraine devices](https://www.beckershospitalreview.com/legal-regulatory-issues/3-companies-settle-for-745k-for-misbranded-migraine-devices.html) Medical device distributor Jet Medical and two related companies agreed to pay $745,000 for allegedly instructing, coaching and encouraging medical providers to submit improper billing codes to Medicare for services involving migraine headache devices not approved by the FDA. 5\. [Lab owner wanted for alleged Medicare cancer testing scam](https://www.beckershospitalreview.com/legal-regulatory-issues/lab-owner-wanted-for-alleged-medicare-cancer-testing-scam.html) Khalid Satary, the owner of several labs in Georgia, Oklahoma and Louisiana, is a wanted fugitive for alleged fraud involving unnecessary cancer genetic testing that resulted in billing Medicare for more than $547 million. After failing to appear at a Dec. 12 court date, Mr. Satary was declared a fugitive of justice and is believed to be in Dubai. 6\. [Georgia physician to pay $1.85M to settle false claim allegations](https://www.beckershospitalreview.com/legal-regulatory-issues/georgia-physician-to-pay-1-85m-to-settle-false-claim-allegations.html) Conyers, Ga., physician Aarti Pandya, MD, has agreed to pay $1.85 million to resolve allegations that she knowingly submitted false claims to Medicare, including for cataract surgeries and diagnostic tests that were not medically necessary, tests that were incomplete or of worthless value, and office visits that did not provide the level of service claimed. 7\. [Former Florida physician gets 20 years prison in ‘largest-ever’ case of its kind](https://www.beckershospitalreview.com/legal-regulatory-issues/florida-physician-gets-20-years-in-prison-loses-license-in-largest-case-of-its-kind-ever.html) Former Florida physician Michael Ligotti, DO, was sentenced to 20 years in prison and ordered to surrender his medical license after pleading guilty to an addiction fraud treatment scheme that accounted for more than $746 million in billings to federal and private insurers and about $127 million in reimbursements. 8\. [Texas lab owners charged in $107M Medicare fraud scheme](https://www.beckershospitalreview.com/legal-regulatory-issues/texas-lab-owners-charged-in-107m-medicare-fraud-scheme.html) The owners of the Lewisville, Texas-based Trinity Clinic are accused of allegedly acquiring thousands of Medicare beneficiaries DNA specimens and corresponding prescriptions that the laboratory used to fraudulently bill the Medicare and Medicare Advantage for genetic testing. The men allegedly concealed the kickbacks through sham contracts for marketing and other services. 9\. [South Carolina man sentenced to 7 years in prison for stealing providers’ identities, Medicaid fraud](https://www.beckershospitalreview.com/legal-regulatory-issues/south-carolina-man-sentenced-to-7-years-in-prison-for-stealing-providers-identities-medicaid-fraud.html) Jonathan Sumter, owner of PHC Supportive Services — a company that purported to provide behavioral healthcare to disabled, low-income individuals — was sentenced to more than seven years in federal prison for stealing the identities of providers and Medicaid recipients and billing South Carolina Medicaid for more than $1 million in false claims. 10\. [Arkansas cardiologist pays $900K to settle Medicare fraud allegations](https://www.beckershospitalreview.com/legal-regulatory-issues/arkansas-cardiologist-pays-900k-to-settle-medicare-fraud-allegations.html) Hot Springs, Ark.-based cardiologist Jeffrey Tauth, MD, agreed to pay more than $900,000 to settle allegations he submitted claims to Medicare for medically unnecessary placement of cardiac stents. 11\. [New York physician gets 30 months in prison for Medicare fraud](https://www.beckershospitalreview.com/legal-regulatory-issues/new-york-physician-gets-30-months-in-prison-for-medicare-fraud.html) New York gastroenterologist Morris Barnard, MD, was sentenced to 30 months in prison for billing Medicare more than $3 million for colonoscopies and other procedures that were not performed. 12\. [Cardiologist pays $931K to settle lab test kickback allegations](https://www.beckershospitalreview.com/legal-regulatory-issues/cardiologist-pays-931k-to-settle-lab-test-kickback-allegations.html) Kentucky cardiologist Dr. Kishor Vora paid $931,500 to settle allegations he took kickbacks from a testing lab. 13\. [Louisiana physician pleads guilty to Medicare fraud scheme](https://www.beckershospitalreview.com/legal-regulatory-issues/louisiana-physician-pleads-guilty-to-medicare-fraud-scheme.html) East Baton Rouge, La.-based physician Robert Dean, MD, pleaded guilty to his role in a $1.3 million Medicare fraud scheme in which he allegedly falsified medical orders for knee braces, claiming he examined and performed tests on patients he never met face to face. **Topics:** Healthcare Fraud, Judicial/courts --- ### [Seven Cybersecurity Best Practices to Protect your Business](https://insurancefraud.org/news_archives/seven-cybersecurity-best-practices-to-protect-your-business/) **Published:** September 22, 2026 **Author:** Diane Beauchamp **Content:** In a recent [Worcester Business Journal (WBJ) webinar](https://www.youtube.com/watch?v=N0xqUTJLE0s&feature=youtu.be) focused on cybersecurity for business executives and owners, Gregory Berks, SVP and Director of Operational Risk, Vendor Management, and Information Security shared his insights along with other local industry professionals on ways businesses can protect both their organization and customers. Regardless of a company’s budget, a core principle of sound cybersecurity is educating your staff and employees so they can react and plan accordingly. “Security professionals love to say that users are the weakest link in information technology (IT) security, however, a well-trained employee can be the best and last line of defense against a breach. Conversely, an employee that has received no training can be a huge risk to malware, ransomware, and data loss for your company,” said Greg. When getting started with cybersecurity guidelines for your organization, an IT policy is an essential guide for you and your staff. At the very top level, everyone should have an IT policy that will really be the framework for your IT Infrastructure and IT security practices. Developing an IT policy will add structure and define how you will manage your IT risk. Consider the following insights from Greg to create a sound IT policy for your business: **1. User training:** One of the most important elements of your IT policy is user training and having your employees understand the risks. Training your employees on keeping your company and corporate data confidential is critical, including how to identify phishing emails. Be sure to regularly test them with phishing simulations to make sure they are well prepared on the most active and current threats. **2.Patching/vulnerability scanning:** Key components of your IT policy should include things like patching frequencies, how you keep the systems up-to-date, and vulnerability scanning. How do you identify down level systems or systems that create a risk exposure? Do you have an anti-malware and anti-virus agent? Is there someone assigned to help you respond to an incident? What if you need to run a forensic investigation as a result of a ransomware attack; do you have a security firm on retainer? These are all important questions to be prepared for. **3. User access**: Review of user access to systems is another key element. Evaluate which employees have access to what and determine if they have access to more systems or functionalities than they need to do their job. While it may be easier to provide all users with the same system access regardless of job function, be sure to only provide users with access to what they absolutely need. **4. Restrict access to the internet and external email sources, if you can:** One example that comes to mind is of an employee receiving a fraudulent external email to transmit a wire that appears to come from the CEO or the CFO. Does that employee need to be able to receive email from external sources? Do they only primarily interact with internal employees? If so, why not limit their email correspondence to within the company and eliminate the phishing risk altogether? **5. Everyone should have web filtering**: This only allows access to business related internet sites, and blocks access to malicious or nefarious sites. Most employees have smartphones and mobile devices, so why do they need to access non-business related sites at work when they can just use their mobile device? In the current threat environment, employees should only be accessing sites on your company network that are business related. **6.Incident response procedures**: Your IT policy should also cover what you do in the event that you experience an incident such ransomware, a breach, or even an operational outage, and how you’ll recover. An important component of that is cyber insurance. **7. Cyber insurance**: It is recommended that everyone obtain cyber Insurance, but it is becoming more expensive, and many carriers are requiring fairly advanced and stringent IT security practices to be in place just to obtain coverage. What many companies don’t know is the carriers often will assist you with incident recovery, which includes breach coaches and crisis communications teams that can speed up your incident recovery time and minimize operational disruptions. It is critical that you incorporate your cyber insurance response into your incident response plans. **Once you’ve developed your IT policy, be sure to test its efficacy.** “I would encourage everyone to develop a testing program that assesses whether or not your IT and security controls are operating effectively,” said Greg. One of the best ways to do this is to have a third party audit firm conduct an annual assessment of your IT environment. Many times this is called an IT general controls audit, and it can be a very effective way to make sure your IT controls are operating effectively and they are being followed. It will also assist you in identifying areas that need improvement. **Topics:** Public Awareness, Technology --- ### [Morris County Prosecutor’s Office Detective Supervisor Received Recognition for Arson Investigation](https://insurancefraud.org/news_archives/morris-county-prosecutors-office-detective-supervisor-received-recognition-for-arson-investigation/) **Published:** September 22, 2026 **Author:** Diane Beauchamp **Content:** On January 12, Morris County Prosecutor Robert J. Carroll, First Assistant Prosecutor Maggie Calderwood, and Chief of Detectives Chris Kimker issued a commendation to Detective Supervisor Luis Goncalves. Det. Supervisor Goncalves is the recipient of the 2022 New Jersey Special Investigators Association (NJSIA) Investigation of the Year, an award initially presented on October 25, 2022, at the NJSIA Training Seminar and Conference. According to officials, the distinction stems from an arson investigation led by Det. Supervisor Goncalves in December 2019 of a residential fire in East Hanover. The investigation also involved fraud, specifically, the filing of false insurance claims involving five different insurance policies. The investigation ultimately resulted in the arrest, prosecution, and sentencing of Gilmar Tejada to seven years New Jersey State Prison, along with $304,764 in restitution. As part of the investigation, Tejada pled guilty to Disorderly Persons Offense for Hindering arising from the insurance fraud charges, which also uncovered the involvement of the defendant’s other family members. Prosecutor Carroll said, “Det. Supervisor Goncalves is commended for his commitment to duty, relentless investigative efforts, and skilled execution of this investigation. Had it not been for your efforts and involvement in this case, the arrest, prosecution, and conviction would not have been possible.” **Topics:** Homeowners - arson, Public Awareness --- ### [Auto insurance fraud: what to look out for in North Dakota](https://insurancefraud.org/news_archives/auto-insurance-fraud-what-to-look-out-for-in-north-dakota/) **Published:** September 22, 2026 **Author:** Diane Beauchamp **Content:** Most of us will be involved in a car crash at some point in our lives — and typically, they are accidental. But there is a type of fraud that can not only wreck your car but impact your insurance premiums. There are several scenarios to watch out for, but one of the most common is a staged crash, according to the North Dakota Insurance Department. Someone looking to cash in on an insurance payout may deliberately stop suddenly in front of you — forcing you to rear-end them. Then, they or their passengers may claim injury, even when the crash is minor. It’s also common for a con artist to signal you to proceed at an intersection, only to have them speed forward and hit you. They may say they never signaled you, or that you ran a stop sign. Both of these examples are crimes, and you should report them to the North Dakota Insurance Department. If you’re in a crash, insurance experts say you should contact police, take pictures of your car and theirs, write down their insurance information and avoid talking to people who suddenly appear on the scene claiming to be witnesses. **Topics:** Auto fraud, Public Awareness --- ### [Endicott Police Department warns of scammer using its phone number](https://insurancefraud.org/news_archives/endicott-police-department-warns-of-scammer-using-its-phone-number/) **Published:** September 22, 2026 **Author:** Diane Beauchamp **Content:** The Endicott Police Department is alerting residents of a phone using the department’s phone number. [The department said on Facebook](https://www.facebook.com/endicottpolice) that the scammers had the victim’s medical information and sought personal information to replace a Medicare card. After the victim hung up, the scammer called again and used the department’s phone number, which is 607-785-3341. The scammer said police became involved after the victim hung up the phone. Endicott Police ask anyone who thinks they received a fraudulent phone call, ask the caller for his name and rank, and then tell the expected scammer you will call them back. Then, call the agency they claimed to be calling from and ask for the person who called. The department said anyone who thinks they are being scammed should not give out their personal number over the phone. **Topics:** Public Awareness --- ### [Does Your Cyber Insurance Policy Cover a Ransomware Attack?](https://insurancefraud.org/news_archives/does-your-cyber-insurance-policy-cover-a-ransomware-attack/) **Published:** September 22, 2026 **Author:** Diane Beauchamp **Content:** Some policyholders mistakenly assume that all cyber insurance policies provide coverage for much the same type of losses. But unlike many other types of commercial insurance, cyber has not become standardized in the years since its inception. Instead, the cyber insurance market offers policyholders a menu of coverage options, from which the organization must purchase specific insuring agreements that match its risk profile. Cyber losses can result from cyber extortion (including the use of ransomware), theft, denial of service attacks, network disruption, and a host of other causes, and can lead to different types of losses, including ransom payments, business interruption, third-party liability due to unauthorized disclosure of confidential information, and regulatory defense and penalties – to name just a few. A given insurance policy may cover any combination of these losses, and some coverages may be optional. It is incumbent on the policyholder to know the risks it needs insured and work with its broker and coverage counsel to find the right policy. A decision last month by a federal court in Oregon highlights the risk of litigation when coverage is not clear. In *Yoshida Foods International, LLC v. Federal Insurance Company*, the policyholder suffered a ransomware attack demanding payment of $107,074.20 in cryptocurrency to recover encrypted data. Because Yoshida lacked access to cryptocurrency, one of its executives paid the ransom from his personal cryptocurrency account and was later reimbursed by the company. The policy did not explicitly provide coverage for extortion, ransomware, or encryption, but did cover a “direct loss” caused by “Computer Fraud,” which included unlawful taking of money resulting from unauthorized entry into a computer system. Federal refused to cover the ransomware payment, arguing among other things that the payment was not a “direct loss” insured by the computer fraud coverage grant because the company’s reimbursement to its executive was an indirect or consequential loss, and because the transfer of funds represented the company’s conscious decision instead of direct theft by the criminals. Over Federal’s objections, the district court found the policy language was broad enough to encompass the ransomware attack, obligating the insurer to indemnify Yoshida for its loss. The policyholder prevailed – but only after litigating the scope of the insurance policy that it purchased. The *Yoshida Foods* decision is not binding on other courts, and another jurisdiction could reach a different interpretation of similar policy language. But the coverage dispute might have been avoided if the policy included a specific coverage grant for extortion and ransomware. Amid the assortment of options in the cyber insurance market, policyholders are well advised to shop for policies that clearly identify the risks the organization intends to cover, while also paying attention to limits, definitions, conditions, and exclusions. **Topics:** Public Awareness, Technology --- ### [Bristol Twp. Woman Says She Was Scammed By Custom Furniture Company, Police Say There Are Other Victims](https://insurancefraud.org/news_archives/bristol-twp-woman-says-she-was-scammed-by-custom-furniture-company-police-say-there-are-other-victims/) **Published:** September 22, 2026 **Author:** Diane Beauchamp **Content:** Law enforcement across Bucks County are investigating a custom furniture company that allegedly scammed numerous customers via Facebook and other social media sites. The investigation, which is being led by the Bucks County Detectives and includes members of the Hilltown Township, Newtown Township, and Bedminster Township police departments, is targeting the Perkasie-based A&A Custom Furniture and it’s two owners — Austin and Amanda Smallacombe. Police said numerous victims have come forward stating they contacted the Smallacombe’s through Facebook and other social media networks to have them build custom furniture, however after paying large deposits, the Smallacombe’s never provided the finished furniture. According to the press release by Hilltown Township police, investigators believe there are additional victims that have yet to come forward. Police are asking anyone who may have been scammed by the Smallacombe’s to contact one of the following law enforcement officers: • Newtown Township Police – Detective Moffett, 215-579-1000 • Bedminster Township Police – Officer Pekach, 215-795-2972 • Hilltown Township Police – Detective Bell, 215-453-6000 Charges against the Smallacombe’s have not been filed at this time in connection with this investigation. Austin Smallacombe did not respond to a request for comment, and the Facebook page for A&A Custom Furniture has been taken down. A review of court records in Montgomery and Bucks counties shows multiple civil lawsuits against Austin Smallacombe, all of which he appears to have lost. Additionally, records show Austin Smallacombe pleaded guilty in June 2021 to felony counts of false statements to induce agreement for home improvement services, receiving advanced payment for services and failing to perform, theft by deception and theft by failing to make required dispersal of funds, along with multiple misdemeanor counts of insurance fraud. Sentencing notes indicate Smallacombe had to serve six months in county jail and six months of house arrest, followed by 10 years of probation. Smallacombe was also ordered to pay a total $45,537.58 in restitution and avoid further contact with the victims, which appears to have been completed in September 2022. Austin Smallacombe was also prohibited from operating his own contractor business as part of that sentence, court records show. In response to a request for comment, Hilltown Township Police said the investigation was launched in the middle of 2022 and has uncovered dozens of victims to date. Police confirmed to *North Penn Now* that charges have not yet been filed, however they added the charges are forthcoming. Stacy Ferguson, of Bristol Township, told *LevittownNow.com* she was happy the investigation has become public and justice might be served. Ferguson said she gave the Smallacombes a $1,200 deposit via Venmo as part of a $2,000 order for a custom wood dining room table and chairs in mid-2022. After being led on about the status of the set and without her deposit being returned when asked, she went to police and learned of the investigation, she said. “I would never take somebody’s money and not provide them with the service,” said Ferguson, who has run her own small business. “I was relieved and thought ‘finally we can get some type of justice,’” she said of the investigation becoming public. Ferguson said the custom furniture business came to her attention due to posts in Bucks County community pages on Facebook. She held off at first and had some doubts, but she decided to order a table once her existing set began to deteriorate. The local woman said she knew Amanda Smallacombe through a friend in Montgomery County and had even sold her cosmetics in the past. “I had heard good things,” Ferguson said of the Smallacombe’s business. However, once the deposit was paid and the product wasn’t delivered, Ferguson began to uncover reviews and comments online from unhappy customers, she said. Ferguson said there were excuses and the Smallacombes failed to return her $1,200 or even a photo of the table she order when they said it was nearly done in October 2022. Ferguson stated she has heard stories of people who the Smallacombes owe larger sums of money to and hopes a prosecution will lead to her getting her money back. “I should have followed my gut,” she said of her initial hesitations. **Topics:** Commercial Fraud, Public Awareness --- ### [Storm related insurance claims](https://insurancefraud.org/news_archives/storm-related-insurance-claims/) **Published:** September 22, 2026 **Author:** Diane Beauchamp **Content:** Storm related insurance claims are not always so straightforward, Jake Reiner reports. <https://www.cbsnews.com/losangeles/video/storm-related-insurance-claims> **Topics:** Public Awareness --- ### [Mayo Clinic Resolves Another Data Breach Lawsuit](https://insurancefraud.org/news_archives/mayo-clinic-resolves-another-data-breach-lawsuit/) **Published:** September 22, 2026 **Author:** Diane Beauchamp **Content:** The Mayo Clinic has apparently settled another lawsuit stemming from a data breach by a former Mayo Clinic employee. The lawsuit was filed in November 2020 by Olga Ryabchuk and sought class-action status on behalf of the more than 1600 [Mayo Clinic](https://krocnews.com/tags/mayo-clinic) patients who had their medical records improperly accessed. The case was officially dismissed by an [Olmsted County](https://krocnews.com/tags/olmsted-county) Judge on December 30th at the request of the parties involved. The terms of the apparent settlement have not been disclosed. When the data breach was disclosed by the Mayo Clinic in October 2020, it blamed former Mayo employee **[Ahmad Alsughhayer](https://krocnews.com/criminal-case-linked-to-mayo-clinic-data-breach-has-been-filed/)**, alleging he may have viewed information about the names of patients, demographic information, date of birth, medical record numbers, clinical notes, and images. The lawsuit claimed those images included nude photos taken for medical purposes. Alsughhayer now lives in Michigan and faces a gross misdemeanor charge of unauthorized computer access in connection with the data breach. He pleaded not guilty to the charge in August 2021 and demanded a jury trial, but there hasn’t been any activity in his criminal case since then. A [similar lawsuit filed against the Mayo Clinic was settled out of court](https://krocnews.com/lawsuit-over-2020-mayo-clinic-data-breach-resolved/) last August, but at least one other case is still pending. It was filed in Olmsted County Court in May 2021 and is currently scheduled for trial in September. **Topics:** Judicial/courts, Technology --- ### [NYC awards hundreds of millions to vendors with criminal pasts](https://insurancefraud.org/news_archives/nyc-awards-hundreds-of-millions-to-vendors-with-criminal-pasts/) **Published:** September 22, 2026 **Author:** Diane Beauchamp **Content:** City Comptroller Brad Lander — who has publicly vowed to [weed out bad actors](https://nypost.com/2023/01/12/crime-is-only-the-biggest-obvious-omission-in-adams-new-city-budget/) among city contractors — has a history of looking the other way at shady contractors with criminal pasts. The city’s top financial watchdog, [a socialist](https://medium.com/@bradlander/why-i-m-a-brooklyn-jewish-democratic-socialist-for-hillary-86efdbfa2aed#.yfe5436yc), is charged with monitoring city contracts, reviewing them for waste and fraud and — if there are red flags — sending them back to the issuing city agency for further review. Though Lander cannot stop a contract from proceeding, his office plays an [important role in oversight and in practice](https://nypost.com/2022/12/10/brad-lander-wants-to-outlaw-firing-workers-without-just-cause-even-though-he-did-it/) can gum up the approval process. In October 2022, Dragonetti Brothers Landscaping, a longtime city contractor, paid a $1.2 million fine after pleading guilty to insurance fraud, [according to a press release](https://www.manhattanda.org/longtime-city-contractor-pleads-guilty-to-1-million-insurance-fraud/) from Manhattan DA Alvin Bragg. The company had received hundreds of city contracts since the 1990s for projects including park landscaping, sidewalk reconstruction and pedestrian crosswalks. Reps for Dragonetti did not respond to request for comment The guilty plea barred Dragonetti from working with the city’s Department of Design and Construction and Business Integrity Commission for three years — though other agencies were free to keep working with them. Lander appears to have rubber-stamped no fewer than seven new contracts the firm won in October and November 2022, [according to the office’s own checkbook.com website](https://www.checkbooknyc.com/contract/all/transactions/contstatus/A/contcat/all/doctype/MMA1~MA1~CTA1~CT1~DO1~RCT1/vendornm_exact/dragonetti%20brothers%20land%20scaping%20nursery%20%26%20florist%20inc/regdate/2022-10-14~2023-01-05). The Parks Department contracts include $7.6 million to plant trees in Manhattan, $7.3 million for tree and stump removal in Queens, and $2.5 million for block pruning in Brooklyn. “I can tell you the \[comptroller’s\] job has gotten very politicized and the politicization of the job is starting to get in the way of how the job is being performed,” Michael Lambert, a [former deputy comptroller told The Post](https://www.bcnys.org/michael-lambert#:~:text=Michael%20is%20a%20former%20Deputy,the%2033rd%20NYS%20Assembly%20District.), calling the city’s work with shady vendors “a major dropping of the ball at the contract review process level.” In September 2022, a $130 million contract was awarded by the city Department of Design and Construction to LendLease US Construction LMB Inc. to build Brooklyn’s Shirley Chisholm Recreation Center. The 65,000-square-foot facility in East Flatbush will include a basketball court, indoor pool, indoor track, and gym. But in 2012, the same [company admitted](https://www.justice.gov/archive/usao/nye/pr/2012/2012apr24.html) to the US Department of Justice that they had defrauded public clients through systemic over-billing on projects — including many in New York. Two top executives later pled guilty, and the company ultimately ponied up $56 million in fines and restitution. “Through this deliberate scheme of billing clients for work not done, \[LendLease\] deceived their customers and stole taxpayer dollars,” then-US Attorney Loretta Lynch said. LendLease defended its current practices. “You’re referring to a case that concluded in 2012 when the company entered into a deferred prosecution agreement … and all charges dismissed in 2014, all of which meant we avoided a plea and/or prosecution,” a company rep said. “The company subsequently took appropriate remedial actions, including restitution payments to clients.” In 2019, the city [Department of Investigation launched a probe](https://www.wsj.com/articles/new-york-city-is-investigating-top-homeless-shelter-operator-11563471155?mod=article_inline) into Acacia Network, the largest provider of homeless shelters in the city, after the non-profit was busted for allegedly funneling $12 million into a for-profit subcontractor which was prinicpally owned by Acacia leaders. This did not prevent the city Department of Homeless Services from awarding the non-profit hundreds of millions worth of new contracts in 2022, including more than $140 million for a shelter in Queens and another $130 million for another in The Bronx. “Acacia Network is committed to providing high-quality, integrated services to thousands of vulnerable New Yorkers every year. These 2019 allegations in the media have constructed a narrative about the organization that simply isn’t true. We have welcomed the additional scrutiny and have complied with all information requests that have resulted from this. We continue to be in good standing with our City oversight agencies, and look forward to our continued work with our partners to fulfill our common missions,” a company spokesperson told The Post. Queens Democratic councilman Bob Holden said that these companies had “violated the public trust” and “should not be doing business with this city.” As custodian of city finances, he said the buck stopped with Lander. “Brad Lander is the gatekeeper. He is the person we have in there to investigate this and stop this and end this corruption. New York state is one of the most corrupt states in the union, and the city is a big part of that,” Holden said. “If he would do the job that he was hired to do, I don’t think we would have this problem and you wouldn’t be writing this story.” The shady contracts fly in the face of Lander’s public paeans for good government. The comptroller has long been a stickler for closing “corruption vulnerabilities in the city’s contracting process.” Team Lander pointed the finger at the city agencies issuing the contracts. “Councilmember Holden is intent on misunderstanding the basics of the City’s contracting process that gives City agencies the responsibility for selecting and vetting vendors while the Comptroller’s office is charged with final oversight over City agencies to ensure appropriate procurement rules were followed and that there is money in the budget to pay the contract,” said Lander spokesperson Chloe Chik. **Topics:** Public Awareness --- ### [Scammers trying to take advantage of people with damaged homes after tornadoes](https://insurancefraud.org/news_archives/scammers-trying-to-take-advantage-of-people-with-damaged-homes-after-tornadoes/) **Published:** September 22, 2026 **Author:** Diane Beauchamp **Content:** Two metro Atlanta counties are warning their residents about possible construction scammers in the area. Tornadoes hit Troup and Spalding counties on Thursday afternoon and left destruction in their wake for many neighbors. Now, some vulnerable homeowners could have to fend off scammers as well. Spalding County Sheriff Darryl Dix and Troup County sheriff’s deputies have issued warnings to be on the lookout for scammers. They say when talking to contractors about repairing destroyed homes, it is best not to take anyone at their word and do the proper research. Speaking with contractors who have done work for friends and family in the past can be a good way to know if someone is running a legit business. Anyone with questions on what their homeowners’ insurance covers should speak with the [Georgia Insurance Commission](https://oci.georgia.gov/). **Topics:** Contractor fraud, Public Awareness --- ### [Reporting gaps exposed for abuse allegations at Medicare/Medicaid certified hospices](https://insurancefraud.org/news_archives/reporting-gaps-exposed-for-abuse-allegations-at-medicare-medicaid-certified-hospices/) **Published:** September 22, 2026 **Author:** Diane Beauchamp **Content:** A new watchdog report is exposing reporting gaps for abuse and neglect allegations at Medicare and Medicaid certified hospices. [The report](https://www.gao.gov/assets/gao-23-105463.pdf) from the U.S. Government Accountability Office (GAO) points to two issues. First, it said these hospices are only required to report abuse or neglect allegations to the state if the alleged perpetrator is affiliated with the hospice, meaning it does not apply if the suspect is a caregiver or a family member. Secondly, the report said if the case does involve a person affiliated with the hospice, the hospices are only required to report it after the hospice completes an internal investigation, which can take up to five days. It points out this is different from nursing homes and hospitals, which are required to report all abuse or neglect allegations immediately and regardless of whether it is directly involved with a hospice staffer. “As a result of these gaps, hospice care providers’ reporting may be less complete or timely than that of nursing homes and hospitals providing extended care,” the report said. In response to the findings, the Department of Health and Human Services (HHS) pointed to the complexities in the process. “Abuse and neglect should never be tolerated,” HHS said in its response. But the Department goes on to say that state requirements determine reporting rules, saying: “additional reporting requirements may create confusion for both individuals required to report as well as the hospice programs and the state agencies and officials responsible for taking action and investigating allegations of abuse and neglect.” HHS did say it is reviewing its reporting guidance. **Topics:** Public Awareness, Regulatory actions --- ### [Hayward Sisters Hospital d/b/a St. Rose Hospital Announces Data Breach](https://insurancefraud.org/news_archives/hayward-sisters-hospital-d-b-a-st-rose-hospital-announces-data-breach/) **Published:** September 22, 2026 **Author:** Diane Beauchamp **Content:** On January 12, 2023, Hayward Sisters Hospital, which operates under the name St. Rose Hospital, filed notice of a data breach with the Attorney General of California after learning that an unauthorized party accessed and removed files containing sensitive patient information from its computer network. Based on the company’s official filing, the incident resulted in an unauthorized party gaining access to consumers’ names, Social Security numbers, dates of birth, e-mail addresses, and home addresses. After confirming that consumer data was leaked, St. Rose Hospital began sending out data breach notification letters to all individuals who were impacted by the recent data security incident. When you sought medical care at St. Rose Hospital, you didn’t think twice when providing hospital staff with your personal information. After all, healthcare workers need this information to provide you with the proper care. However, a hospital’s duty doesn’t end with treating the patient; it also needs to ensure that patient information stays safe. As we’ve discussed in previous [posts](https://www.myinjuryattorney.com/consumer-privacy-data-breach-lawyers/healthcare-data-breaches/), hackers have recently shown an increased interest in targeting healthcare providers due to the wealth of patient information these organizations have in their possession. It has therefore become critically important for hospitals to take heightened precautions to prevent these cyberattacks. In fact, healthcare providers that fail to securely store patient information that ends up leaked in a breach may be financially liable to patients through a data breach lawsuit. ## What We Know So Far About the St. Rose Hospital Breach The available information regarding the St. Rose Hospital breach comes from the company’s filing with the California Attorney General. According to this source, on about November 29, 2022, St. Rose Hospital detected suspicious activity within its computer network. In response, the hospital began working with third-party computer forensic specialists to investigate the incident and determine whether any patient or employee information was leaked as a result. The St. Rose Hospital investigation confirmed that an unauthorized party was able to access its computer network on November 18, 2022, during which they removed certain files. It was later determined that some of these files contained sensitive patient information. Upon discovering that sensitive consumer data was made available to an unauthorized party, St. Rose Hospital began to review the affected files to determine what information was compromised and which consumers were impacted. While the breached information varies depending on the individual, it may include your name, Social Security number, date of birth, e-mail address, and home address. On January 12, 2023, St. Rose Hospital sent out data breach letters to all individuals whose information was compromised as a result of the recent data security incident. **More Information About St. Rose Hospital** Founded in 1953, St. Rose Hospital is a community hospital in Hayward, California. St. Rose Hospital offers a range of healthcare services, including emergency care, diagnostic imaging, cardiology, orthopedics, rehabilitation, and surgery, and has a 17-bed Family Birthing Center. In total, St. Rose Hospital has 217 beds and delivers over 1,300 babies per year. St. Rose Hospital employs more than 522 people and generates approximately $100 million in annual revenue. **Topics:** Public Awareness, Technology --- ### [Community Health Network notifies patients of more data tracking](https://insurancefraud.org/news_archives/community-health-network-notifies-patients-of-more-data-tracking/) **Published:** September 22, 2026 **Author:** Diane Beauchamp **Content:** Community Health Network announced Saturday that it is notifying patients of a data breach involving one of its affiliates. According to [Community](https://www.ecommunity.com/), they have no indication that Social Security numbers, account numbers, or credit card information was collected or transmitted during the breach. Patients of Fishers Digestive Care may have had their data transmitted to website tracking technology vendors, such as Facebook (Meta) and Google, through Community’s MyChart patient portal. [Community announced a similar breach](https://www.wthr.com/article/news/health/community-health-network-notifying-patients-about-data-breach-personal-information-indiana/531-c87ba09d-b24b-48a0-b179-1c1935a026e3) regarding its own websites in November and found that Fishers Digestive Care was also impacted. Community uses tracking technologies or “cookies” and “pixels” on some of its websites to improve access to critical patient care services and manage key functions of patient-facing websites. Many other healthcare organizations commonly employ similar technologies throughout the United States. When Community learned about the tracking technology in MyChart, it immediately began working with its service providers to disable and/or remove certain technologies from its websites and applications and continued to investigate to better understand what information was collected and transmitted. Community determined that the type of information varied depending the user’s device and their activity within MyChart. Only certain data fields in MyChart transmitted information that was tracked, but the investigation was unable to determine the extent of each user’s interaction and what data was tracked. Information that *could* have been tracked may include computer IP address; dates, times, locations and types of medical appointments or procedures scheduled; information about a patient’s health care provider and communications through MyChart. Names and medical record numbers, insurance may have also been tracked. Community disabled and/or removed all third-party tracking technologies on MyChart. Community reported the breach to federal regulators and is contacting anyone potentially impacted by this incident to advise them of the steps they can take to [protect themselves from website tracking](https://www.ecommunity.com/notice-third-party-tracking-technology-data-breach.), which includes changing the privacy settings on their devices to block or delete cookies or by using browsers that support privacy-protecting operations, as well as adjusting privacy settings on any Facebook or Google accounts. Community is sending letters to all patients who have engaged with Fishers Digestive Care on or after January 1, 2020, which is the date Community began implementing third-party tracking technologies within MyChart. Information about the incident is available in the letters mailed to patients or by calling (866) 361-5593 between 9 a.m. and 7 p.m. ET, Monday through Friday. **Topics:** Public Awareness, Technology --- ### [U.S. Supreme Court to weigh key standard in whistleblower fraud cases](https://insurancefraud.org/news_archives/u-s-supreme-court-to-weigh-key-standard-in-whistleblower-fraud-cases/) **Published:** September 22, 2026 **Author:** Diane Beauchamp **Content:** The U.S. Supreme Court on Friday agreed to consider reviving two lawsuits accusing pharmacy operators of overbilling government health insurance programs for prescription drugs, a dispute that could have broad implications for whistleblowers and the government’s ability to go after fraud. The key question in both cases is whether companies can shield themselves from whistleblower fraud lawsuits by pointing to an “objectively reasonable” interpretation of the law that supports their conduct – regardless of whether they actually believed that interpretation in good faith at the time. That is what both Safeway Inc and SuperValu Inc, which was acquired by Rhode Island-based United Natural Foods Inc [(UNFI.N), opens new tab](https://www.reuters.com/companies/UNFI.N/) in 2018, argued in lawsuits filed by whistleblowers accusing them of defrauding Medicare and Medicaid. The Chicago-based 7th U.S. Circuit Court of Appeals agreed, granting judgment in favor of the companies. The whistleblowers appealed to the Supreme Court. “We are glad the court took up this important issue,” said Tejinder Singh, a lawyer who represents the whistleblowers in both cases. Safeway and United Natural Foods did not immediately respond to requests for comment. Both lawsuits claim that the pharmacy operators billed Medicare and Medicaid for prescription drugs based on artificially high sticker prices, while charging most customers paying for the drugs out of pocket much lower prices through discount programs. The whistleblowers said that federal law required pharmacies to bill Medicare and Medicaid based on “usual and customary” prices that they actually charge customers. They also said both companies knew they were defrauding the government and worked to conceal their pricing practices. The 7th Circuit agreed that the companies had overcharged the government. But it found they could not be held responsible for fraud because their billing practices were supported by an “objectively reasonable” interpretation of the law – even if they did not actually believe that interpretation and consciously intended to deceive the government. The U.S. Justice Department had urged the Supreme Court to take the case and reverse the 7th Circuit, saying the appellate court’s rulings frustrated the intention of a federal law called the False Claims Act that allows whistleblowers to sue for fraud on behalf of the government. **Topics:** Judicial/courts, Public Awareness --- ### [NYC Pair Cited For Prescription Fraud In Ocean County Drug Sting](https://insurancefraud.org/news_archives/nyc-pair-cited-for-prescription-fraud-in-ocean-county-drug-sting/) **Published:** September 22, 2026 **Author:** Diane Beauchamp **Content:** On Thursday, Jan. 12, the Brick Street Crimes Unit (SCU) acted on information they received from the Drug Enforcement Agency (DEA) regarding prescription fraud. According to the DEA, there is a small group traveling throughout NJ and beyond, targeting pharmacies for prescription fraud. Through investigative measures, Briar Mill Pharmacy was believed to be the next target, Brick police said. After speaking to the pharmacy directly, and with the help of the Ocean County Prosecutor’s Office, the SCU conducted surveillance on the pharmacy. During the investigation, the SCU arrested two suspects from New York City after they arrived and picked up multiple prescriptions. The vehicle which they were driving was subsequently seized pending a search warrant, along with an undisclosed amount of cash believed to be proceeds of criminal activity, police said. Alexis Inoa, 22, and Carlos Herrera, 21, were arrested and charged with three counts of possession with intent to distribute, four counts of obtaining prescriptions by fraud, possession of a controlled dangerous substance, and conspiracy, police said. **Topics:** Drug Diversion **Categories:** Arrest --- ### [East Wenatchee Insurance Agent Pleads Guilty to Defrauding Clients, Faces Three Years in Prison](https://insurancefraud.org/news_archives/east-wenatchee-insurance-agent-pleads-guilty-to-defrauding-clients-faces-three-years-in-prison/) **Published:** September 22, 2026 **Author:** Diane Beauchamp **Content:** A former insurance agent from East Wenatchee is facing up to three years in prison for defrauding his elderly clients. On Thursday, 55-year-old Gregory D. Lone pleaded guilty to five counts of first degree theft in Douglas County Superior Court. Back in 2020, Lone was arrested for defrauding five of his elderly clients through his company Paramount Financial Advisors between 2016 and 2019. The Washington State Department of Financial Institutions tipped off East Wenatchee Police of their investigation into Lone, who was funneling his clients’ money towards his own personal expenses. Douglas County prosecutors recommended Lone serve a three-year prison sentence, two years of probation unsupervised, and would be required to pay a restitution of $480,000. Lone’s sentencing hearing will be held at Douglas County Superior Court on Feb. 7, at 10 a.m. **Topics:** Insider - agent **Categories:** Conviction --- ### [December 2022 Healthcare Data Breach Report](https://insurancefraud.org/news_archives/december-2022-healthcare-data-breach-report/) **Published:** September 22, 2026 **Author:** Diane Beauchamp **Content:** The number of reported healthcare data breaches declined for the second successive month, with 40 data breaches of 500 or more healthcare records reported to the Department of Health and Human Services’ Office for Civil Rights (OCR) in December 2022 – The lowest monthly total of the year and 32% fewer data breaches than the average monthly for 2022. The year ended with 707 data breaches, which is a year-over-year reduction of 1.12% from the 715 reported in 2022. Only one other year has seen a fall in recorded data breaches (2015). [![](https://www.hipaajournal.com/wp-content/uploads/2023/01/healthcare-data-breaches-2023-dec-2022-br.jpg)](https://www.hipaajournal.com/wp-content/uploads/2023/01/healthcare-data-breaches-2023-dec-2022-br.jpg) The worst month of 2022 for breached records was followed by the best, with 2,174,592 healthcare records exposed or compromised in December, well below the 2022 average of 4,325,302 records per month and 68.5% fewer breached records than in November. While this is undoubtedly great news, even with this reduction, 2022 was one of the worst-ever years for healthcare data breaches with more than 51.9 million records exposed or impermissibly disclosed from January 1, 2022, to December 31, 2022. [![](https://www.hipaajournal.com/wp-content/uploads/2023/01/healthcare-records-breached-2023-dec-2022-br.jpg)](https://www.hipaajournal.com/wp-content/uploads/2023/01/healthcare-records-breached-2023-dec-2022-br.jpg) ## Largest Healthcare Data Breaches in December 2022 December saw 13 data breaches of 10,000 or more healthcare records reported to OCR. HIPAA Journal has been unable to obtain information on two of those breaches. Ransomware attacks continue to plague the healthcare industry, with 5 of the 13 largest breaches in December confirmed as involving ransomware, two of which involved the protected health information of more than 600,000 patients. Ransomware attacks on the healthcare industry more than doubled between 2016 and 2021 according to one [recent analysis](https://www.hipaajournal.com/study-identifies-healthcare-ransomware-attack-trends/), although it is becoming increasingly difficult to obtain reliable data on the extent to which ransomware is used in cyberattacks due to the lack of standardized reporting. While healthcare organizations of all sizes are being attacked, ransomware gangs tend to focus their efforts on larger healthcare organizations, according to a recent report by Delinea. | **Name of Covered Entity** | **State** | **Covered Entity Type** | **Individuals Affected** | **Cause of Breach** | |---|---|---|---|---| | CommonSpirit Health | IL | Business Associate | 623,774 | Ransomware attack with business associate involvement | | Metropolitan Area EMS Authority dba MedStar Mobile Healthcare | TX | Healthcare Provider | 612,000 | Ransomware attack | | Avem Health Partners | OK | Business Associate | 271,303 | Hacking Incident at a business associate | | Southwest Louisiana Health Care System, Inc. d/b/a Lake Charles Memorial Health System | LA | Healthcare Provider | 269,752 | Ransomware attack | | Fitzgibbon Hospital | MO | Healthcare Provider | 112,072 | Ransomware attack | | Monarch | NC | Healthcare Provider | 56,155 | Hacking Incident – No information released | | Ola Equipment LLC | HI | Business Associate | 39,000 | Hacking Incident – No information released | | The Elizabeth Hospice | CA | Healthcare Provider | 35,496 | An employee sent PHI to a personal email account | | Legacy Operating Company d/b/a Legacy Hospice | AL | Healthcare Provider | 21,202 | Compromised email accounts | | Employee Group Insurance Benefits Plan of Acuity Brands, Inc. | GA | Health Plan | 20,849 | Hacking incident (data theft confirmed) | | San Gorgonio Memorial Hospital | CA | Healthcare Provider | 16,846 | Hacking incident (data theft confirmed) | | Hawaiian Eye Center | HI | Healthcare Provider | 14,524 | Ransomware attack | | Foundcare, Inc. | FL | Healthcare Provider | 14,194 | Compromised email account | ## Causes of December 2022 Healthcare Data Breaches Hacking and other IT incidents continue to dominate the breach reports and typically involve many more records than other types of data breaches. In December, 28 incidents were classified as hacking/IT incidents – 70% of the month’s total breaches. 1,965,032 healthcare records were exposed or impermissibly disclosed in those incidents– 90.4% of the month’s breached records. The average breach size was 70,180 records and the median breach size was 4,152 records. 20 of the month’s breaches involved compromised network servers, with 12 incidents involving hacked email accounts. [![Causes of December 2022 Healthcare data breaches](https://www.hipaajournal.com/wp-content/uploads/2023/01/december-2022-healthcare-data-breach-report-causes.jpg)](https://www.hipaajournal.com/wp-content/uploads/2023/01/december-2022-healthcare-data-breach-report-causes.jpg) The risk of email-related data breaches can be greatly reduced by providing regular security awareness training to the workforce, as is required by the HIPAA Security Rule, and by implementing multi-factor authentication, with FIDO-based MFA providing the greatest level of protection. [HIPAA-regulated entities](https://www.hipaajournal.com/hipaa-compliance-checklist/) should also ensure that their password management practices are kept up to date. A [recent audit](https://www.hipaajournal.com/password-management-howlers-identified-at-u-s-department-of-interior/) of the Department of the Interior identified many password management failures, which are all too common in the healthcare industry. There were 10 unauthorized access/disclosure-related data breaches in December involving 168,386 records. The average breach size was 16,839 records and the median breach size was 1,739 records. There has been a decline in these types of data breaches in recent years as [HIPAA training](https://www.hipaajournal.com/hipaa-training-requirements/) and monitoring of medical record access have improved. There were two loss/theft incidents reported involving 41,174 records. Both of these incidents involved computers/other electronic devices and could have been prevented by encrypting the devices. [![December 2022 healthcare data breaches - location of breached PHI](https://www.hipaajournal.com/wp-content/uploads/2023/01/december-2022-healthcare-data-breach-report-location-phi.jpg)](https://www.hipaajournal.com/wp-content/uploads/2023/01/december-2022-healthcare-data-breach-report-location-phi.jpg) ## December Data Breaches by HIPAA Regulated Entity Healthcare providers were the worst affected type of HIPAA-regulated entity, with 24 breaches reported of 500 or more records. Business associates reported 11 data breaches and 5 data breaches were reported by 5 health plans. Two of the data breaches reported by healthcare providers had business associate involvement but were reported by the healthcare provider. The chart below shows the breakdown based on where the breach occurred. [![December 2022 healthcare data breaches - HIPAA-regulated entity type](https://www.hipaajournal.com/wp-content/uploads/2023/01/december-2022-healthcare-data-breach-report-regulated-entity.jpg)](https://www.hipaajournal.com/wp-content/uploads/2023/01/december-2022-healthcare-data-breach-report-regulated-entity.jpg) ## States Affected by December 2022 Data Breaches Healthcare data breaches were reported by HIPAA-regulated entities in 22 states. California was the worst affected with 4 reported breaches. | **State** | **Reported Data Breaches** | |---|---| | California | 4 | | Florida, New York, Texas & Washington | 3 | | Georgia, Hawaii, Illinois, Massachusetts, Missouri, South Dakota & Virginia | 2 | | Alabama, Connecticut, Louisiana, Maryland, North Carolina, Nebraska, Oklahoma, Rhode Island, Wisconsin & West Virginia | 1 | ## HIPAA Enforcement Activity in 2022 OCR closed the year with two financial penalties to resolve alleged HIPAA violations. [Health Specialists of Central Florida](https://www.hipaajournal.com/florida-primary-care-provider-fined-20000-for-hipaa-right-of-access-violation/)’s case stemmed from an investigation into a HIPAA Right of Access violation over the failure to provide a woman with a copy of her deceased father’s medical records. The records were provided, but there was a 5-month delay. Health Specialists of Central Florida settled the case and paid a $20,000 financial penalty. This was the 42nd financial penalty to be imposed under OCR’s HIPAA Right of Access enforcement, which was launched in 2019. [New Vision Dental](https://www.hipaajournal.com/ocr-fines-california-dental-practice-for-phi-disclosures-on-yelp/) in California was one of just two healthcare providers to settle a HIPAA violation case with OCR in 2022 that did not involve a HIPAA Right of Access violation. OCR investigated New Vision Dental in response to complaints that patient information was being impermissibly disclosed online in response to negative reviews on Yelp. OCR also identified a Notice of Privacy Practices failure. The case was settled for $23,000. Including these two penalties, OCR resolved 22 HIPAA violation cases with settlements and civil monetary penalties in 2022, more than any other year since OCR was given the authority to impose financial penalties for HIPAA violations. State Attorneys General also have the authority to impose financial penalties for HIPAA violations. In December, a joint investigation by Oregon and Utah resulted in a financial penalty for [Avalon Healthcare](https://www.hipaajournal.com/avalon-healthcare-settles-hipaa-case-with-oregon-and-utah-state-ags-and-pays-200000-penalty/) over a phishing attack. Avalon Healthcare was determined to be in violation of the HIPAA Security and Breach Notification Rules and state laws due to a lack of appropriate safeguards to protect against phishing attacks and an unreasonable delay in sending breach notification letters, which were issued 10 months after the breach was detected. The case was settled for $200,000. This was one of three enforcement actions by state attorneys general in 2022 to resolve HIPAA violations. **Topics:** Public Awareness, Technology --- ### [Who Is Brian Mann? Chiropractor Accused of Poisoning Wife With Lead Pills](https://insurancefraud.org/news_archives/who-is-brian-mann-chiropractor-accused-of-poisoning-wife-with-lead-pills/) **Published:** September 22, 2026 **Author:** Diane Beauchamp **Content:** An Alabama chiropractor accused of attempted murder has been released from jail in order to pay child support. Brian Mann was released last week Wednesday on a $500,000 bond so that he could pay alimony and child support. Judge Charles Elliot noted that there were strict conditions for Mann’s release and any small infractions would result in him being put behind bars again. Mann was initially arrested and charged with attempting to kill his wife, Hannah Pettey, with lead dietary supplements in September. Mann is accused of giving his wife the pills from late summer 2021 through to early 2022. Pettey’s lawyer, Jerry Knight, said Pettey claimed her husband had told her that the pills “would strengthen her immune system.” She was ultimately hospitalized and diagnosed with lead poisoning at the University of Alabama at Birmingham hospital in January 2022. After being discharged, Pettey filed for divorce. On May 19, Pettey amended her divorce complaint, according to a Hartselle Enquirer report, to say Mann “perpetrated acts of assault upon her person… by intentionally causing her to unwittingly ingest particles of lead.” When Mann was arrested in September, he was also accused of having multiple insurance policies against his wife. He was accused of holding a total of five life insurance policies that, upon his wife’s death, would tally up to benefits of $1.3 million. He was also accused of applying for two other insurance policies that were up to $1.5 million. Judge Elliot said that the case was at a crossroads because Mann was unable to pay his alimony and child support while in custody. He is believed to be $8,000 behind on those payments. The judge decided on the release as further lack of payments would punish his estranged wife and daughter. Upon his release, Mann must follow a series of rules and restrictions as well as avoid any illegality. He was initially released with similar rules in September, on the condition he provides his passport to authorities to prevent him from fleeing the country. After failing to do this, he was then put back into jail. The new conditions of Mann’s release say that he will wear a GPS monitor and will remain in his home from 6 p.m. and cannot leave before 8 a.m. He will also be required to spend every weekend in jail from 4 p.m. until Monday at 8 a.m. **Topics:** Life Insurance **Categories:** Arrest --- ### [Nursing Home Employee Wins $1.2 Million in Forced Resignation Case](https://insurancefraud.org/news_archives/nursing-home-employee-wins-1-2-million-in-forced-resignation-case/) **Published:** September 22, 2026 **Author:** Diane Beauchamp **Content:** A jury has awarded $1.2 million to a former nurse at a Palms nursing home who said she was forced to resign in 2019 because she could no longer tolerate working conditions after witnessing alleged irregularities in the handling of some Medicare patients. The Los Angeles Superior Court panel deliberated for less than a half- day Friday before finding in favor of plaintiff Malissa White in her constructive discharge suit brought against Overland Terrace Healthcare & Wellness Centre LP. Defense attorneys denied any liability on the part of the facility. White was hired to provide services at the Overland Avenue facility, also called Country Villa South Convalescent Center, in March 2018. Five months later, White was promoted to the position of minimum data set nurse, in which she was responsible for assessing the health needs of all residents on Medicare, according to the suit. In February 2019, White began witnessing alleged illegal activity at the facility, including the admission of Medicare patients using certification forms that were pre-signed by a doctor and otherwise blank, the suit states. “It was even more shocking that staff at Country Villa South joked about submitted fraudulent forms in group Whats App texts by saying that they obtained the physician’s pen so the fraudulent submissions could look more realistic,” the suit stated. White herself was asked to falsify records and encouraged to increase the level of acuity for some of the Medicare patients, all in an effort to collect improper fees from Medicare, the suit brought in October 2019 alleged. White complained internally about the issues, including to human resources, the suit stated. However, after her initial reports, her supervisor allegedly began to treat her differently and got angry at her for several insignificant matters. During a work-related class session, the boss, in reference to White’s Muslim husband, asked the plaintiff if he she wrapped up her head like other Muslim wives, the suit stated. Despite White’s internal reports and those to the state Department of Public Health, the Country Villa South staff continued to falsely admit patients and wanted the plaintiff to falsify documents, the suit stated. “Ms. White felt like she was in the middle of a Medicare fraud scheme and she couldn’t handle the stress,” the suit stated. “She was told on several occasions that this happens all the time.” The stress from her job environment caused her to miscarry what would have been her fourth child in April 2019 and she resigned a month later, according to the suit. **Topics:** Judicial/courts, Workers Comp --- ### [Sanford pastor netted $10K in kickbacks as part of Medicare fraud scheme, court docs show](https://insurancefraud.org/news_archives/sanford-pastor-netted-10k-in-kickbacks-as-part-of-medicare-fraud-scheme-court-docs-show/) **Published:** September 22, 2026 **Author:** Diane Beauchamp **Content:** A Sanford pastor will soon be sentenced on federal charges involving illegal Medicare reimbursements. Court documents state Pastor Daniel Owens netted more than $10,000 in kickbacks and bribes as part of a Medicare fraud scheme. Owens is a pastor at Life Springs Dream Center in Sanford. He is also the director of the Dream Center, an affiliate of the church that combats human trafficking, addiction and homelessness. In November 2022, Owens pleaded guilty to federal Medicare fraud charges. Owens is set to be sentenced federally on Jan. 23. The maximum penalty for the crime is 10 years in prison. On Thursday, Owens and Pastor Dale Sauls posted a 4-minute, six-second Facebook video to share their side of the story. “There has been some information that has surfaced about my twin brother pastor Daniel \[Owens\] that has been less than flattering, to say the least,” Sauls said of Owens in the video. In the video, Sauls said Owens can’t talk much about the charges. Court documents show between January 2020 and April 2020, Owens is accused of conspiring “to offer, pay, solicit and receive illegal heath care kickback payments in exchange for the referral of patients for cancer tests that were submitted to Medicare for reimbursement.” “We’ve known about that for two years,” Sauls said of Owens. “He’s walked. He’s cooperating with authorities. He’s admitted what he did. He didn’t know he was doing anything wrong.” Federal documents detail a scheme to recruit people to undergo unnecessary cancer screening tests. **Topics:** Medicare/Medicaid **Categories:** Conviction --- ### [Nurse 'laundered' cash from $1.5million COVID vaccine fraud to pay off her mortgage](https://insurancefraud.org/news_archives/nurse-laundered-cash-from-1-5million-covid-vaccine-fraud-to-pay-off-her-mortgage/) **Published:** September 22, 2026 **Author:** Diane Beauchamp **Content:** A Long Island nurse is accused of laundering $1.5million cash from selling fake COVID vaccine cards to pay off her mortgage. Nurse Julie DeVuono, 49 and employee Marissa Urraro, 44, are accused of selling fake vaccination cards ‘on one or more occasions’, undercover detectives have said. DeVuono’s NYPD officer husband is also said to be involved in the alleged scheme and was stripped of his badge last year. The nurse, who owns Wild Child Pediatrics Healthcare on Long Island, allegedly charged $220 for adults and $85 for children to enter fake information on the the New York State Immunization Information System. DeVuono would receive shipments of the vaccine to administer to patients for free but would opt to throw unused doses in the trash instead, the suit claims. Colleague Urarro would allegedly take patients into a room and ‘feigned’ by giving almost all of the vaccinations, but ‘occasionally gave actual COVID-19 vaccinations’. Police reportedly discovered $869,000 in cash at DeVuono’s home in Amityville, some of which was found in NYPD-issued helmet bags. DeVuono and Urraro have been charged with forgery and offering a false instrument for filing for fake vaccination cards. The two nurses have pleaded not guilty to the charges as they left Suffolk County Court on Friday. Both women were released without bail. The NYPD are now undergoing an internal investigation to look into the officer’s potential involvement. “It’s frightening beyond words,” local Erin Bevilacqua from Park Avenue Grill t old CBS New York. “I’m grateful it’s been put to an end. Break laws, give fake vaccines, it’s very disheartening.” “As nurses, these two individuals should understand the importance of legitimate vaccination cards as we all work together to protect public health,” Suffolk County Police Commissioner Rodney K. Harrison said in a statement. Suffolk County District Attorney Raymond Tierney also said: “I hope this sends a message to others who are considering gaming the system that they will get caught and that we will enforce the law to the fullest extent.” Urraro’s lawyer claims her client is ‘a respected license practical nurse’ who has faced ‘defects’ in the prosecutor’s investigations. “From our preliminary investigation, there are defects in the \[prosecutors’\] investigation and legal impediments to how the case came about,” lawyer Michael Alber claimed. **Topics:** COVID-19, Healthcare Fraud **Categories:** Arrest --- ### [Alabama Medical Billing Company Pays $153K to Resolve False Claims Allegations](https://insurancefraud.org/news_archives/alabama-medical-billing-company-pays-153k-to-resolve-false-claims-allegations/) **Published:** September 22, 2026 **Author:** Diane Beauchamp **Content:** Vanessa Roberts Avery, United States Attorney for the District of Connecticut, and Phillip Coyne, Special Agent in Charge for the U.S. Department of Health and Human Services, Office of the Inspector General, and Jean Pierre Njock, Acting Special Agent in Charge of the New Haven Division of the Federal Bureau of Investigation, today announced that AMVIK SOLUTIONS, LLC (“Amvik”) has entered into a civil settlement agreement with the federal government and has paid $153,300 to resolve allegations that it submitted false claims for payment to the Connecticut Medicaid program for applied behavior analysis (“ABA”) services. Amvik, based in Birmingham, Alabama, offers billing, claims, and collections services for healthcare providers. Amvik uses its proprietary WebABA software to perform these services for ABA providers throughout the United States. Helping Hands Academy, LLC (“Helping Hands”) was a Bridgeport-based ABA services provider that provided ABA services to children with autism. In 2018, Helping Hands retained Amvik to handle the billing and claims for those ABA services. The government alleges that when submitting claims for payment to Connecticut Medicaid on behalf of Helping Hands, Amvik falsely identified the incorrect Board Certified Behavior Analyst (“BCBA”) as the rendering provider on the claims. This caused Connecticut Medicaid to pay claims that it would not have otherwise paid. To resolve the allegations under the federal False Claims Act, Amvik has paid $153,300 to the federal government for conduct occurring between October 3, 2019, through October 1, 2020. This matter was investigated by the Office of the Inspector General for the Department of Health and Human Services, and the Federal Bureau of Investigation. This case was prosecuted by Assistant U.S. Attorney Sara Kaczmarek. People who suspect health care fraud are encouraged to report it by calling 1-800-HHS-TIPS or the Health Care Task Force at (203) 777-6311. **Topics:** Judicial/courts --- ### [Jacksonville father-son builders jailed for $5 million payroll tax scam with illegal workers](https://insurancefraud.org/news_archives/jacksonville-father-son-builders-jailed-for-5-million-payroll-tax-scam-with-illegal-workers/) **Published:** September 22, 2026 **Author:** Diane Beauchamp **Content:** Father-and-son owners of Jacksonville construction businesses are facing federal prison time for dodging about $5.6 million in payroll taxes their companies owed, largely for wages of immigrants working illegally. U.S. District Judge Marcia Morales Howard sentenced Raul Solis to 33 months behind bars and Raul Solis-Martinez to 21 months after the pair pled guilty to conspiring to defraud the Internal Revenue Service and employ immigrants who weren’t allowed to hold jobs. The men owned and operated Solis Brothers Company LLC and Duval Framing LLC, both companies that other businesses subcontracted for work on building projects. Plea agreements the men reached last year said they knew a lot of their employees couldn’t work legally in the United States. They made some payments in cash that was “off the books” and paid the rest in checks that understated workers’ real wages and led to less money being spent on Social Security and Medicare contributions that workers and employers both pay into through payroll taxes. About $22.2 million from the companies’ payroll went unreported to the IRS between 2014 and 2019, the U.S. Justice Department said in a release after the sentencing this week. “This father and son criminal team profited financially by perpetrating fraud against the United States and private industry, while taking advantage of the country’s workforce,” K. Jim Phillips, assistant special agent in charge of homeland security investigations at the Jacksonville office of Immigration and Customs Enforcement. The cash payments also helped the companies lower their premiums for worker’s compensation insurance and contracted payroll services that businesses pay for based on their payroll. “In this instance, greed drove the defendants to cheat their competitors and steal from both their employees and the American public,” Ronald A. Loecker, acting IRS special agent in charge of criminal investigations in the Tampa area, said in a statement. He said the sentencing “demonstrates that you can’t expect integrity and loyalty from an employer who would do anything for money.” Solis, 52, founded Solis Brothers in 2006 and had entrusted his son, now 33, to work on tasks including payroll since 2014, according to court records. The men had faced a potential maximum sentence of five years in prison. **Topics:** Work comp - employer **Categories:** Arrest --- ### [Lifetime airs movie about Portland romance novelist-turned convicted murderer Nancy Brophy](https://insurancefraud.org/news_archives/lifetime-airs-movie-about-portland-romance-novelist-turned-convicted-murderer-nancy-brophy/) **Published:** September 22, 2026 **Author:** Diane Beauchamp **Content:** The lurid story of a Portland romance novelist who murdered her husband in 2018 comes to the small screen this weekend on the Lifetime channel. The trial of 71-year-old Nancy Crampton Brophy was one of the most captivating Portland news stories of 2022. At the conclusion of the seven-week proceedings, a jury found Brophy guilty of second-degree murder. In June, she was sentenced to life in prison. Nancy Brophy was accused of shooting and killing her husband, 63-year-old chef Dan Brophy, inside the now-closed Oregon Culinary Institute at Southwest 17th Avenue and Jefferson Street on June 2, 2018. Dan Brophy was an instructor at the institute, and several of his students discovered his body when they arrived for classes that morning. The case gained national attention after Nancy Brophy’s arrest, when it was discovered that she had written an online essay titled “How to Murder Your Husband” years before the murder. The essay did not actually factor into the trial, however, as it was swiftly excluded from evidence. Instead, the trial hinged on Nancy Brophy’s activities immediately surrounding her husband’s death — her purchases of gun parts that were never accounted for, surveillance video placing her in the area of the Oregon Culinary Institute around the time of Dan’s murder, and initial statements she made to investigators that she’d been home all that morning. An insurance expert also testified that Dan Brophy’s life insurance policy was “inappropriately” high. Nancy Brophy’s replies to prosecutors’ suspicions about her activities often followed a familiar pattern: She was just doing research for her romance novels. Lifetime’s dramatization of the story, dubbed “How to Murder Your Husband: The Nancy Brophy Story” stars Cybill Shepherd as Nancy Brophy and Steve Guttenberg as Dan Brophy. “Based on a true story, Nancy Crampton-Brophy (Cybill Shepherd), seemed to have a knack for writing about murder,” Lifetime’s abstract reads. “The Portland-based romance-thriller novelist authored books about relationships that were tumultuous, while using seductive men on the covers to lure in her readers. Often, her books featured women protagonists who fantasized about killing their own husbands or fleeing their husbands and faking their own deaths. And then, in 2022 in a shocking turn of events, Brophy was convicted of killing her own husband.” The movie premieres Saturday, Jan. 14 on Lifetime at 7 p.m., 8 p.m. Central. It’s available to stream the following day. **Topics:** Life Insurance **Categories:** Conviction --- ### [72% of Private Practice Dentists Plan to Raise Fees This Year, Will Texas Do the Same for Medicaid Dentists With $32.7 Billion Extra in the Kitty?](https://insurancefraud.org/news_archives/72-of-private-practice-dentists-plan-to-raise-fees-this-year-will-texas-do-the-same-for-medicaid-dentists-with-32-7-billion-extra-in-the-kitty/) **Published:** September 22, 2026 **Author:** Diane Beauchamp **Content:** ![](https://insurancefraud.org/wp-content/uploads/image-20-17.jpg)The American Dental Association’s Health Policy Institute last month published the results of an ongoing survey it has been conducting since January 2022, quizzing some 3,000 participating private practice dentists each month to measure the impact of COVID-19 and other issues affecting the profession. The report includes breakdowns by “ownership status, DSO affiliation, practice size, geographic location, sex, age group, and race/ethnicity.” A PDF of the report is below. **Raising fees** The one remarkable statistic is that 72% of 1041 dentists across the country, representing a cross-section of private practice dentistry, responded that they are planning to raise their patient fees in 2023. Unfortunately, there are no survey results on why these dentists are raising their fees. But one can only conclude that the recent inflationary spiral which has hit dentistry hard plus the difficulties in staff recruitment are the reasons. **Bounty in the state budget** A few months ago, the Texas Comptroller of Public Accounts Glenn Hager estimated there would be a [budget windfall for Texas of some $27 billion](https://www.tdmr.org/will-medicaid-providers-benefit-from-texass-27-billion-budget-windfall/), thanks to high oil prices. It was announced this week that the [budget surplus is actually $32.7 billion](https://comptroller.texas.gov/about/media-center/news/20230109-texas-comptroller-glenn-hegar-releases-biennial-revenue-estimate-1672869909073). **Adverse effect on providers** As we have repeated in several stories, the [situation is desperate for Medicaid dentists](https://www.tdmr.org/inflation-and-low-fees-driving-medicaid-dental-providers-out-of-the-program/) who have to cope with the same costs as private practice dentists but get fees substantially less. The [Medicaid dental fee schedule](https://www.tdmr.org/time-to-review-medicaid-dental-fees-expenses-skyrocketing-while-fees-decrease-over-15-years/) has only gone down since 2007. The situation is becoming untenable for many who also have to put up with the [erroneous behavior of DMOs](https://www.tdmr.org/dentaquest-led-3-year-rule-outrages-medicaid-dentists/), [scrutiny of the OIG](https://www.tdmr.org/oig-update-quarterly-report-dental-fraud-highlighted/) and the [potential pitfalls and penalties of the Texas Medicaid Fraud Prevention Act](https://www.tdmr.org/house-committee-unanimously-approves-bill-to-fix-the-tmfpa/) and [whistleblowers such as Joshua Lafountain](https://www.tdmr.org/lafountain-settlement-continues-tmfpa-travesty-and-highlights-need-for-change/). We hope the legislature will look at raising Medicaid dental fees before the situation worsens. **Topics:** Public Awareness --- ### ['I had no choice': SJ couple billed more than $2,200 to take ambulance next door](https://insurancefraud.org/news_archives/i-had-no-choice-sj-couple-billed-more-than-2200-to-take-ambulance-next-door/) **Published:** September 22, 2026 **Author:** Diane Beauchamp **Content:** A San Jose couple says they were billed $2,255 after an emergency room visit led to an unnecessary ambulance ride – approximately 100 yards away. It was the shortest, yet most expensive ambulance bill Frank Chan and his wife hope to never see again. “I was shocked,” said Chan, staring at the bill in disbelief. “I know exactly how far the distance was.” In November, Chan’s wife, Amber drove herself to the emergency department at El Camino Health, an acute care hospital in Mountain View. Amber told the I-Team she was admitted and then transferred to the mental health inpatient clinic – which happened to be the building next door to the ER. “I wanted to walk, but was told an ambulance was required,” Amber said. “I had no choice.” The distance from the ER to the inpatient clinic was approximately 100 yards away. A short trip that turned out to be a pricey one. Weeks later Chan got a bill for $2,255 from Royal Ambulance, the company that provided her ride. Documents show their insurance paid $573.91, but it appeared the Chan’s were on the hook for the rest. “I was so shocked,” Chan said. “Was this really necessary?” The Chans told the I-Team they were stuck sorting this out for five days as both El Camino Health and Royal Ambulance pointed fingers at each other. According to Chan, a manager at Royal Ambulance told him on the phone: “Yes, this is your bill. You have to pay for it.” Then Chan said he called the ER desk at El Camino Health only to be transferred to a manager who didn’t call him back. Stephanie Sierra: “You called El Camino hospital how many times to sort this out over the past five days?” Frank Chan: “13 times.” The ABC7 News I-Team reached out to El Camino Health and Royal Ambulance, but both agencies were unavailable for an on-camera interview. In an email, El Camino Health told the I-Team: “If a patient arrives in our emergency room and it is determined they need care that is required in a building not connected to the hospital, professional medical transport is required to ensure patient safety. El Camino Health funds this service and the patient should never receive a bill. We have since been in contact with Royal Ambulance and they have rectified this matter.” The I-Team received this statement during the interview with Chan. Stephanie Sierra: “Did you get confirmation from El Camino Hospital that they will cover the rest of that payment?” Frank Chan: “No confirmation yet…even this morning they are still pointing me to Royal Ambulance.” Royal Ambulance told the I-Team, Chan’s insurance plan underpaid the claim. The company says they offered to help have the claim reprocessed to reduce expenses, but ultimately waived the unpaid portion as a courtesy-prior to any contact with ABC7. In the end, the bill sent to Chan was a mistake. But, by the time El Camino Health reported that to the I-Team, Chan said he still had no idea. “I was not made aware the bill was cleared until ABC7 contacted them,” he told the I-Team. “It should not take hours on the phone or the intervention of a news station to get a hospital to correct their billing,” said Carmen Balber, the executive director of Consumer Watchdog. Stephanie Sierra: “How often do you see cases like this where consumers get overcharged or get a bill that’s wrong?” Carmen Balber: “It happens all the time… patients are charged for procedures that never happen, patients are billed for doctors they never saw, patients are billed for charges that they legally are not required to pay.” As Balber explains, it takes looking at the bill and not just paying by reflex to find those discrepancies. If this happens to you, get a full accounting from the hospital and request that they itemize what each charge is for. State law requires hospitals to let patients know if they qualify for financial assistance. “But, all too frequently that’s a page and a form the patient misses when they’re in the middle of an emergent medical situation,” Balber said. “Then they end up with a huge bill on the back end.” Charged upfront — forced to ask questions later. This brings us back to Chan’s case. While his wife wasn’t eligible for financial assistance, they still ended up with a big bill. “I think it’s very unfair,” said Chan. “The process was frustrating.” But, thankfully one hour after Chan’s interview with the I-team, he said he finally got some answers. “It was from Royal Ambulance,” Chan said. “They said the bill has been cleared and I don’t owe them anything… thank you so much.” Another tip for consumers – hospitals may bill for what’s called ‘out-of-network’ charges which are often expensive, but can be challenged. Remember, always read the fineprint and don’t pay for a bill in question until the agency can explain the charge. **Topics:** Public Awareness --- ### [Health system to pay patients $4K each for data breach](https://insurancefraud.org/news_archives/health-system-to-pay-patients-4k-each-for-data-breach/) **Published:** September 22, 2026 **Author:** Diane Beauchamp **Content:** Gallup, N.M.-based Rehoboth McKinley Christian Health Care Services has agreed to pay victims of a 2021 [data breach](https://www.beckershospitalreview.com/cybersecurity/new-mexico-hospital-gives-details-of-january-ransomware-attack.html) up to $4,000 each, according to a recent federal court filing. In February 2021, the health system [discovered](https://www.beckershospitalreview.com/cybersecurity/new-mexico-hospital-s-computer-network-hacked.html) a cybersecurity incident where, in the weeks prior, hackers [stole](https://www.beckershospitalreview.com/cybersecurity/hackers-post-new-mexico-hospital-employees-info-online-after-ransomware-attack.html) the data of 191,009 individuals. The data included Social Security numbers, driver’s license numbers, and medical and financial information. The proposed class-action settlement, which a judge approved Jan. 9, offers up to $3,500 for “extraordinary losses” and reimbursement for out-of-pocket expenses and lost time up to $500, as well as two years of free credit monitoring services. Rehoboth McKinley Christian also agreed to cybersecurity improvements. A final approval hearing for the settlement is set for May 24. The news was first reported Jan. 10 by [*Bloomberg Law*](https://news.bloomberglaw.com/pharma-and-life-sciences/victims-of-hospital-data-breach-to-receive-up-to-4-000-each). **Topics:** Judicial/courts, Technology --- ### [Bay Bridge Administrators data breach hits more than 251K individuals](https://insurancefraud.org/news_archives/bay-bridge-administrators-data-breach-hits-more-than-251k-individuals/) **Published:** September 22, 2026 **Author:** Diane Beauchamp **Content:** Texas-based employee benefit plan administrator Bay Bridge Administrators had more than 251,000 individuals’ personal data compromised following a [data breach](https://www.scworld.com/brief/breach/draftkings-breach-impacts-almost-68k-customers) in September, reports [SecurityWeek](https://www.securityweek.com/251k-impacted-data-breach-insurance-firm-bay-bridge-administrators). BBA had its network disrupted by a cyberattack on Sept. 5, 2022, with subsequent investigation showing that unauthorized network access had been gained by attackers around Aug. 15 and that some data had been exfiltrated on Sept. 3. Both personally identifiable information including names, birthdates, addresses, Social Security numbers, driver’s license numbers, and ID numbers and protected health information were discovered to have been accessed by attackers, with BBA informing the Maine Attorney General’s Office regarding the impact of the breach on Dec. 29. “The personal and protected health information involved was shared with BBA either by the individual, the individual’s employer, and/or the individual’s insurance carrier(s), in connection with enrollment in an employment insurance benefit plan for calendar year 2022,” said BBA, which added that there has been no evidence suggesting any misuse of the compromised data. **Topics:** Public Awareness, Technology --- ### [3 recent self-disclosed fraud settlements involving hospitals](https://insurancefraud.org/news_archives/3-recent-self-disclosed-fraud-settlements-involving-hospitals/) **Published:** September 22, 2026 **Author:** Diane Beauchamp **Content:** Three hospitals or health systems agreed to settle self-reported fraud claims in November and December, according to the HHS Office of Inspector General. 1\. [Providence Saint John’s Health Center](https://oig.hhs.gov/fraud/enforcement/providence-saint-johns-health-center-and-saint-johns-physician-partners-agreed-to-pay-49-million-for-allegedly-violating-the-civil-monetary-penalties-law-by-submitting-claims-for-services-provided-for-in-clinical-research-studies/), based in Santa Monica, Calif., agreed to pay more than $4.9 million to settle allegations it submitted claims to Medicare, Medicaid and Tricare for items and services provided for in clinical research that should have been paid for by the research study sponsor or provided free to the research participant. 2\. [Kadlec Regional Medical Center](https://oig.hhs.gov/fraud/enforcement/kadlec-regional-medical-center-agreed-to-pay-143-million-for-allegedly-violating-the-civil-monetary-penalties-law-by-submitting-claims-for-services-that-did-not-meet-coverage-criteria/), based in Richland, Wash., agreed to pay more than $14.3 million to settle allegations it submitted claims to Medicare Part A for inpatient rehabilitation stays that did not meet Medicare coverage criteria. 3\. [Swedish Covenant Health](https://oig.hhs.gov/fraud/enforcement/swedish-hospital-agreed-to-pay-716000-for-allegedly-violating-the-civil-monetary-penalties-law-by-employing-an-excluded-individual/), based in Chicago, agreed to pay more than $716,000 to settle allegations it employed a person it knew or should have known was excluded from participating in federal healthcare programs. **Topics:** Judicial/courts, Technology --- ### [SEC Obtains Final Judgment Against Defendant Charged in $43 Million Tribal Bonds Scheme](https://insurancefraud.org/news_archives/sec-obtains-final-judgment-against-defendant-charged-in-43-million-tribal-bonds-scheme/) **Published:** September 22, 2026 **Author:** Diane Beauchamp **Content:** On January 10, 2023, the United States District Court for the Southern District of New York entered a final consent judgment against defendant Jason Sugarman, ordering him to pay over $10.2 million dollars in disgorgement, interest, and penalties. The judgment resolves the SEC’s charges against Sugarman for his role in a scheme to defraud ten pension funds out of $43 million in connection with the issuance of limited recourse Native American tribal bonds between 2014 and 2015. According to the SEC’s complaint(filed on June 27, 2019, and amended on November 2, 2022) Sugarman, and his partner Jason Galanis, acquired control of two investment advisers so that they and their associates could use the advisers’ clients’ funds to purchase Native American tribal bonds. While the bond sale proceeds were supposed to be invested in annuities to benefit the tribal corporation and repay the bondholders, the complaint alleged that Sugarman and his associates instead misappropriated the proceeds for their own benefit, including using proceeds of the initial round of bond sales to finance the acquisition of a foreign insurance company that was, in turn, used to acquire the second investment adviser used in the scheme. This action followed the SEC’s case against eight other participants in the scheme, *SEC v. Archer*, 16 Civ. 3505 (GHW) (OTW) (S.D.N.Y.), and the criminal indictments and convictions of seven of those defendants, including Galanis, in a parallel criminal case, *United States v. Galanis*, 16 Cr. 371 (RA) (S.D.N.Y.). Without admitting or denying the SEC’s allegations, Sugarman consented to entry of a final judgment permanently enjoining him from violations of the antifraud provisions of Section 17(a)(1) and (3) of the Securities Act of 1933, Section 10(b) the Securities Exchange Act of 1934 and Rule 10b-5(a) and (c) thereunder; ordering him to pay disgorgement in the amount of $7,157,232.19, plus prejudgment interest thereon in the amount of $1,317,703.82, and $1,789,308.05 in civil penalties; and barring him from serving as an officer or director of a public company for three years. The SEC’s investigation was conducted by Tejal D. Shah, Nancy A. Brown, Christopher Ferrante, and Adam S. Grace of the SEC’s New York Regional Office, under the supervision of Sanjay Wadhwa. The SEC’s litigation was led by Ms. Brown, Ms. Shah and Mariel Bronen, under the supervision of Sheldon L. Pollock, and with the assistance of Alistaire Bambach and Therese A. Scheuer. **Topics:** Judicial/courts, Regulatory actions --- ### [Texas Executes Former Cop Convicted Of Hiring Hitmen To Kill Wife Nearly 30 Years Ago](https://insurancefraud.org/news_archives/texas-executes-former-cop-convicted-of-hiring-hitmen-to-kill-wife-nearly-30-years-ago-2/) **Published:** September 22, 2026 **Author:** Diane Beauchamp **Content:** Aone-time police officer convicted of hiring two men to kill his estranged wife has died by execution. Robert Fratta, 65, died Tuesday at the Hunstville Penitentiary in Texas after receiving the lethal injection for the 1994 murder-by-hire of his estranged wife, Farah Fratta, 33, according to the Associated Press. When asked by state prison officials if he had any last words, the former suburban Houston-area police officer replied, “no.” In the galley was one of the Frattas’ now-adult children and Farah Fratta’s brother, neither of whom addressed the media following the convict’s execution, according to the Houston Chronicle. Robert Fratta’s death marked the state’s first execution in 2023, despite last-minute appeals for a stay of execution. Hours before Fratta’s passing, Judge Catherine Mauzy for the 419th District Court in Austin issued a temporary civil injunction, which briefly stopped the Texas Department of Criminal Justice from carrying out the execution, per the Houston Chronicle. Her ruling stated what Fratta and other death row inmates had maintained: that using expired drugs for lethal injection violated multiple pharmaceuticals regulations within the state, including The Texas Pharmacy Act, the Texas Controlled Substances Act and others. The practice of using expired drugs has been commonplace for years in Texas, with the Department of Criminal Justice regularly extending expiry dates for pentobarbital, the sole ingredient in the state’s lethal injection process, according to the Texas Tribune. Mauzy claimed the drug was “probably illegal to possess or administer because it is more likely than not expired” and that the Department of Criminal Justice hadn’t contradicted claims that the expired pentobarbital was capable of causing “torture, ill treatment or unnecessary pain,” which would have violated the defendant’s constitutional rights, according to the Tribune. Higher courts overturned Judge Mauzy’s injunction, and the U.S. Supreme Court allowed the execution to continue, according to the Chronicle. Fratta was convicted of hiring Joseph Prystash, who enlisted the help of Howard Guidry, to fatally shoot Farah Fratta at her home in Atascocita, a Houston suburb. The estranged couple was embroiled in a contentious divorce and custody battle when Farah was shot twice in the head in her garage. Evidence also showed that, just days after his estranged wife’s murder, Fratta tried to cash in on her life insurance policy, according to the Associated Press. He allegedly planned to pay the hitmen $1,000 and give them a Jeep in return for Farah’s murder. Court records stated that Fratta had previously asked several other people if they could help him find someone to kill Farah. “I’ll just kill her, and I’ll do my time and, when I get out, I’ll have my kids,” he told one friend, per court documents. Fratta was a public safety officer in Missouri City, Texas at the time of the murder and had long maintained his innocence, according to the Associated Press. He was initially sentenced to death in 1996. However, the conviction was vacated when a federal judge found Prystash and Guidry’s confessions shouldn’t have been introduced in the trial, according to the Associated Press. The federal judge who overturned his conviction referred Fratta as “egotistical, misogynistic and vile, with a callous desire to kill his wife” in his ruling. Fratta was retried, convicted and sentenced to death again in 2009. Prystash and Guidry were also sentenced to death for their roles in the slaying. Fratta had lost several appeals over the years, including arguments that newer ballistic testing could have excluded one gun from being the murder weapon — a bid that was rejected in 2018. The Frattas’ three children were raised by Farah’s father, Lex Baquer, who died in 2018, according to the Associated Press. Crime Stoppers Houston victim services director Andy Kahan and Harris County District Attorney Kim Ogg were among the spectators present for the execution, according to the Chronicle. Fratta was pronounced dead at 7:49 p.m., 24 minutes after the lethal dose was administered. “Bob was a coward in 1994 when he arranged the murder for hire of his estranged wife, and 28 years later, he still was a coward tonight,” Kahan commented after the execution. “He was offered an opportunity to at least extend an olive branch to his son, who he knew was watching this.” “He still could have said ‘I’m sorry,’” Kahan continued. Fratta’s execution was the second in the United States in 2023, following the lethal injection of Amber McLaughlin. **Topics:** Life Insurance **Categories:** Conviction --- ### [Business owner busted for intentional $100K boat-burning, sheriff’s office says](https://insurancefraud.org/news_archives/business-owner-busted-for-intentional-100k-boat-burning-sheriffs-office-says/) **Published:** September 22, 2026 **Author:** Diane Beauchamp **Content:** The Washington County Sheriff’s Office has arrested a Hurricane businessman for insurance arson after he allegedly burned a company boat and trailer. Key evidence in the case was using GPS tracking information for the rental truck allegedly used in the boat burning to place Joseph Brad Arave, 49, and the truck, at the scene, according to a sheriff’s press release. Arave’s business, Utah Epic Rentals, rents out vehicles. The boat-burning came Nov. 6, shortly after midnight, in a remote area of Warner Valley, south of Hurricane. A camper in the area who reported the fire recalled seeing a truck towing the boat an hour before the blaze, then seeing the truck heading in the opposite direction boat-less 15-20 minutes after he called 911. The boat, estimated at $100,00 in value and the trailer, deputies found were registered to Arave’s business. When contacted, he claimed he didn’t know the boat was missing and suggested it had been stolen, according to the sheriff’s press release on Arave’s arrest Thursday. Detectives found Arave had submitted a $100,000 insurance claim for the boat and trailer and had been stopped and cited for speeding in the rental truck the day after the fire by a Hurricane officer. When deputies arrested Arave, a substance identified as methamphetamine was found in his possession, according to the sheriff’s office, which subsequently learned Arave has an active warrant for alleged fraud out of California, from which he has fled. He was booked into the Purgatory Correctional Facility, Washington County’s jail, on charges of arson with intent to defraud an insurer, a second-degree felony, and misdemeanor counts of possession and providing false information to law enforcement. **Topics:** Business - arson **Categories:** Arrest --- ### [5 accused of staging car crash in Miami to defraud insurance companies](https://insurancefraud.org/news_archives/5-accused-of-staging-car-crash-in-miami-to-defraud-insurance-companies/) **Published:** September 22, 2026 **Author:** Diane Beauchamp **Content:** A group was facing charges on Thursday in Miami-Dade County after a state agency’s investigation found they had staged a car crash to defraud insurance companies out of about $58,000. Amauri Rodriguez, Orislaidy Montano, Vadira Sanchez, Ruberlandy Cruzata, and Lixelly Mayari were involved in the scheme, according to The Florida Department of Financial Services’s Division of Investigative and Forensic Services. The state agency’s bureau of insurance fraud investigated the Aug. 10 crash at the intersection of Southwest Fourth Street and 14 Avenue in Miami’s Little Havana after a police officer red-flagged it. Rodriguez was driving the 2011 silver Chevrolet Tahoe that collided with the 2012 blue Volkswagen Jetta that Cruzata was driving, according to the arrest reports. Surveillance video from a light pole camera showed the crash happened slowly, yet the damage reflected speeding, according to the arrest reports. National General and United Automobile were their insurance companies defrauded, according to investigators. Records show police officers arrested Rodriguez, Montano, Mayari, and Cruzata on Thursday. They were each facing charges of false fraudulent insurance claims, third-degree grand theft, and insurance fraud. **Topics:** Auto - staged **Categories:** Arrest --- ### [Home Health-Care Firms Must Pay $6 Million for Kickback Ploy (1)](https://insurancefraud.org/news_archives/home-health-care-firms-must-pay-6-million-for-kickback-ploy-1/) **Published:** September 22, 2026 **Author:** Diane Beauchamp **Content:** Anti-kickback statute violation established June 2021 Whistleblower gets maximum share under FCA Illinois home health-care companies must pay nearly $6 million for violating the False Claims Act by engaging in a kickback scheme whereby they paid a senior citizen support organization in return for information about potential Medicare-eligible clients to increase sales of services, according to a federal district court. Whistleblower Stop Illinois Health Care Fraud LLC accused Asif Sayeed, Management Principals, Vital Home & Healthcare Inc., and Physician Care Services SC of paying for information on clients Healthcare Consortium had evaluated for eligibility so defendants could then market Medicare reimbursed services to those clients. **Topics:** Judicial/courts --- ### [Bench warrant issued for Port Angeles man after he fails to appear in court](https://insurancefraud.org/news_archives/bench-warrant-issued-for-port-angeles-man-after-he-fails-to-appear-in-court/) **Published:** September 22, 2026 **Author:** Diane Beauchamp **Content:** Kacee Lee Garner, of Port Angeles, Wash., has been added to Insurance Commissioner Mike Kreidler’s Insurance Fraud Most Wanted list (insurance.wa.gov) after being charged with insurance fraud. If you have information that may lead to his arrest, please contact your local law enforcement agency or contact Kreidler’s Criminal Investigations Unit (CIU). Kacee Lee Garner was charged by Clallam County Prosecutor’s Office with attempted theft in the first degree and false claims or proof. He failed to appear at his arraignment and a bench warrant was issued for his arrest. Leading up to this charge, CIU’s investigation alleges that in December 2021, Garner was involved in single-vehicle auto collision. At the time of loss, Garner did not have any insurance coverage. An hour after the collision occurred, Garner purchased an insurance policy with Progressive. He later filed a claim for the damage to his 2006 GMC Sierra stating that the collision occurred a couple hours after he purchased his insurance policy. Progressive was able to confirm through cellular records that the collision occurred before Garner bought insurance. Progressive denied Garner’s claim for $6,374.91 and referred it over to CIU, as required by state law. CIU investigates insurance fraud and works with allied law enforcement agencies and state and local prosecutors on criminal cases. Insurance fraud costs the average family $400 to $700 per year in increased premiums. Insurance companies are required by law to report fraud to the commissioner. **Topics:** Auto - underwriting **Categories:** Arrest --- ### [Hampton Man Pleads Guilty to Fraud and Aggravated Identity Theft in Connection with Multiple Fraud Schemes](https://insurancefraud.org/news_archives/hampton-man-pleads-guilty-to-fraud-and-aggravated-identity-theft-in-connection-with-multiple-fraud-schemes/) **Published:** September 22, 2026 **Author:** Diane Beauchamp **Content:** Anthony Silva, 37, of Hampton, pleaded guilty in federal court to wire fraud, aggravated identity theft and mail fraud, United States Attorney Jane E. Young announced today. According to court documents and statements made in court, Silva orchestrated two different fraud schemes. First, in late 2021, he used stolen personal identifying information of victims, including their names, Social Security numbers, and dates of birth, to apply for 15 different credit cards from American Express. Silva sometimes also submitted fake driver’s licenses with the victims’ names and other personal identifying information, but with his own photograph. Silva used the credit cards to make personal purchases at retailers like Walmart, Victoria’s Secret, and Home Depot, and was recorded on store security footage making the purchases. Second, between April 2020 and May 2021, Silva submitted unemployment insurance applications to Vermont and Massachusetts using the identities of many individuals. He typically had the unemployment insurance payments mailed as checks to addresses he controlled or had access to. He then deposited the checks into one of 32 different trust accounts he opened at Citizens Bank, which were in the names of purported charitable causes. Silva will be required to pay restitution of $699,496.14 and forfeit the trust accounts he controlled at Citizens Bank. He is scheduled to be sentenced on February 13, 2023. The case was investigated by the U.S. Postal Inspection Service, Federal Bureau of Investigation, U.S. Department of Labor’s Office of the Inspector General, and Secret Service. It is being prosecuted by Special Assistant U.S. Attorney Alexander S. Chen and Assistant U.S. Attorney John Kennedy. **Topics:** Synthetic Identity Theft, Unemployment Insurance --- ### [Trump’s company appeals judge’s decision to appoint monitor](https://insurancefraud.org/news_archives/trumps-company-appeals-judges-decision-to-appoint-monitor/) **Published:** September 22, 2026 **Author:** Diane Beauchamp **Content:** Former President Donald Trump’s company is appealing a judge’s decision to appoint an independent monitor for its business dealings while it is being sued for fraud by New York’s attorney general. Lawyers for the Trump Organization filed paperwork Monday seeking to challenge Manhattan Judge Arthur Engoron’s decision, issued last Thursday, in a mid-level state appellate court. They are also seeking a stay to prevent Engoron’s ruling from taking effect while the appeal is pending. In court papers, the company’s lawyers argued that Engoron overstepped his bounds by requiring an outside watchdog to keep tabs on the Trump Organization for the duration of Attorney General Letitia James’ civil case. A message seeking comment was left with James’ office. **Topics:** Judicial/courts --- ### [Judge orders Trump to appoint independent monitor in New York attorney general’s $250M fraud case](https://insurancefraud.org/news_archives/judge-orders-trump-to-appoint-independent-monitor-in-new-york-attorney-generals-250m-fraud-case/) **Published:** September 22, 2026 **Author:** Diane Beauchamp **Content:** The Trump Organization was ordered by a New York judge to appoint an independent monitor, a win for the New York attorney general in her $250 million fraud lawsuit against former President Donald Trump, his companies and his officers. On Thursday, Justice Arthur F. Engoron of the New York County Supreme Court granted New York Attorney General Letitia James’ motion a preliminary injunction. [The order](https://ag.ny.gov/sites/default/files/ecf_-_decision_on_pi.pdf) aims “to ensure that defendants do not dissipate their assets or transfer them out of this jurisdiction.” It states that the Trump defendants’ “demonstrated propensity to engage in persistent fraud, failure to grant such an injunction could result in extreme prejudice to the people of New York.” The defendants are prohibited from selling noncash assets listed on Trump’s 2021 statement of financial condition “without first providing 14 days written notice” to the attorney general and the court. All the defendants—including Trump, the Trump Organization companies, Trump’s three adult children and longtime financial officers Allen Weisselberg and Jeffrey McConney—are impacted, as well as “all other persons or entities acting in concert with them,” according to the order. “This court will appoint an independent monitor, to be paid by defendants, for the purpose of ensuring compliance with this order,” Engoron wrote. “Today’s decision will ensure that Donald Trump and his companies cannot continue the extensive fraud that we uncovered and will require the appointment of an independent monitor to oversee compliance at the Trump Organization,” said James in a [Nov. 3 press release](https://ag.ny.gov/press-release/2022/court-rules-favor-attorney-general-james-and-orders-donald-trump-and-trump). During arguments prior to the written ruling, attorneys for Trump, the Trump Organization, Weisselberg and McConney stated that James was going too far and alleged that there was a lack of harm to the public, [Law360 reports](https://www.law360.com/articles/1546535). “There is zero public interest here, respectfully,” said Trump counsel Christopher Kise. “These corporate titans have unlimited resources.” The order follows [a motion last month](https://ag.ny.gov/sites/default/files/452564_2022_people_of_the_state_of_v_people_of_the_state_of_memorandum_of_law_i_38.pdf) for a preliminary injunction filed by the James’ office to stop Trump and his organization from engaging in the fraudulent and illegal business activity in New York by revoking their business certificates, banning them from corporate officer roles and halting acquisitions and loans for five years—as well as $250 million in alleged fraudulent gains. This is detailed in [the September 2022 pending suit](https://ag.ny.gov/sites/default/files/tto_complaint.pdf). **Topics:** Judicial/courts --- ### [Former Seal Beach insurance agent sentenced for theft from elderly consumer](https://insurancefraud.org/news_archives/former-seal-beach-insurance-agent-sentenced-for-theft-from-elderly-consumer/) **Published:** September 22, 2026 **Author:** Diane Beauchamp **Content:** Formerly licensed insurance agent Vincent Allen LaGrange, 66, of Seal Beach, was sentenced today in San Bernardino County Superior Court on one misdemeanor count of grand theft from an elder after an investigation by the Department of Insurance found he was acting as a licensed insurance agent to collect insurance premium payments from consumers, but pocketing the premium monies and leaving the consumers uninsured. LaGrange was sentenced to one year probation and has paid back full restitution to his victims. The Department of Insurance revoked LaGrange’s license and his entity license, operating as LaGrange and Associates Inc, and Empire-Valley Insurance Services, in May 2016 after proving that he had overcharged an elderly consumer by collecting earthquake coverage twice and misleading her about the billing. LaGrange even financed her premium with a separate finance company without her knowledge and attempted to re-apply for a new license six months later, but was denied. In 2019 following a consumer complaint, Department investigators learned that LaGrange was selling commercial liability policies under someone else’s insurance license number and collecting insurance premiums from consumers. LaGrange collected premium payments from two consumers in Lake Arrowhead, one of them being an elderly consumer, but failed to place the coverage and instead kept the money for himself. In order to cover up the theft, LaGrange issued the consumers certificates of insurance, which left them exposed to losses and in great financial risk. If any consumers have done business with LaGrange or his business and are concerned about their insurance coverage, please contact the Department at 714-712-7600. All consumers can check the license status of their agent or contact the Department of Insurance at 800-927-4357 if they suspect they are victims of insurance fraud. The San Bernardino County District Attorney’s Office prosecuted this case. **Topics:** Insider - agent **Categories:** Conviction --- ### [ND A.G. to expand Medicaid fraud unit](https://insurancefraud.org/news_archives/nd-a-g-to-expand-medicaid-fraud-unit/) **Published:** September 22, 2026 **Author:** Diane Beauchamp **Content:** Attorney General Drew Wrigley will ask the Legislature to expand his office’s Medicaid fraud unit. The unit’s six staff are made up of one attorney, two BCI agents, auditors, and support staff. The unit used to be 90% federally funded and 10% state funded, but now, it’s 75%-25%. And although there’s a higher share for the state now, Wrigley says increasing funding will be worth it. “That unit now is functioning so well: they’re bringing in great cases, we’ve had convictions in important cases. And also, financially, they more than pay for themselves by the fraud dollars that they’re bringing in the door,” said Wrigley. In addition to fraud cases, the unit also focuses on maltreatment in Medicaid-funded facilities. They have a budget of $1.2 million per biennium. **Topics:** Public Awareness, Regulatory actions --- ### [Husband Hires Hitman To Murder Wife For Insurance Money](https://insurancefraud.org/news_archives/husband-hires-hitman-to-murder-wife-for-insurance-money/) **Published:** September 22, 2026 **Author:** Diane Beauchamp **Content:** This was a ploy to get Devi on a bike so that she could be killed, police suggested. Chandra allegedly signaled the other accused that Devi had departed for the temple prior to the collision that killed her. In addition to Chandra, police have arrested Devi’s alleged killer, identified as Mukesh Singh Rathore, as well as two other conspirators, Rakesh Kumar and Sonu Singh. It was unclear what the charges are over Devi’s death. Rathore has already been paid Rs 5.50 lakh ($6,765) out of the promised Rs 10 lakh ($12,300) Chandra promised in their contract, according West deputy police commissioner Vandita Rana. In a similar [story](https://www.ibtimes.com/parents-admit-hiring-killers-murder-unemployed-alcoholic-son-3630997), a couple admitted to hiring a group of killers for around $10,000 to kill their 26-year-old abusive and unemployed son. **Topics:** Life Insurance **Categories:** Arrest --- ### [Arkansas health system suffers data breach; 85K patients impacted](https://insurancefraud.org/news_archives/arkansas-health-system-suffers-data-breach-85k-patients-impacted/) **Published:** September 22, 2026 **Author:** Diane Beauchamp **Content:** On Nov. 8, the health systems learned that an unauthorized party had removed one or more files from its systems on Oct. 30, according to a Nov. 11 breach notification from Mena. The files contained patient information such as names, dates of birth, Social Security numbers, financial account information, treatment information, medical provider names, lab results, prescription information and health insurance information. On Nov. 22, the health system notified the [84,814](https://ocrportal.hhs.gov/ocr/breach/breach_report.jsf) patients impacted by the breach but said it is not aware that any of the information removed from its systems was improperly used. **Topics:** Public Awareness, Technology --- ### [Atlanta healthcare employee pleads guilty to stealing patient info for $30 million unemployment scheme](https://insurancefraud.org/news_archives/atlanta-healthcare-employee-pleads-guilty-to-stealing-patient-info-for-30-million-unemployment-scheme/) **Published:** September 22, 2026 **Author:** Diane Beauchamp **Content:** The U.S. Department of Justice said seven Georgians have been indicted and one has pleaded guilty to defrauding the Georgia Department of Labor out of at least $30 million in stolen benefits. The seven defendants are accused of filing more than 5,000 fraudulent unemployment insurance claims with the Georgia DOL. The defendants include an Atlanta woman, Edith Nate Hicks, who prosecutors said stole personally identifiable information from patients as an employee of an Atlanta-area hospital network. She pleaded guilty to conspiracy to commit mail fraud on Nov. 15. Prosecutors said Hicks admitted to using patient databases to steal information and received money from Chime, Venmo and CashApp. Investigators said at least 1,600 people were affected. Hicks could be sentenced to up to 20 years in prison. Federal prosecutors said the funds were mean for assisting Georgians whose employment was affected by the COVID-19 pandemic. Federal prosecutors said the funds were mailed to addresses in Cordele and Vienna on prepaid debit cards. The list of defendants includes: Tyshion Nautese Hicks, 30, Vienna Shatara Hubbard, 34, Warner Robins Torella Wynn, 30, Cordele Macovian Doston, 29, Vienna Kenya Whitehead, 35, Cordele A’Darrion Alexander, 27, Warner Robins Membrish Brown, 27, Vienna Edith Nate Hicks, 45, Atlanta Tyshion Hicks, Hubbard, Wynn, Doston, Whitehead, Alexander, and Brown are each charged with conspiracy to commit mail fraud. Hicks and Doston face identity theft charges and Alexander was charged with money laundering. Defendants’ maximum possible sentences could range from 20 to 40 years, prosecutors said, depending on the charges. **Topics:** Unemployment Insurance **Categories:** Conviction --- ### [Scammers taking advantage of Medicare open enrollment season](https://insurancefraud.org/news_archives/scammers-taking-advantage-of-medicare-open-enrollment-season/) **Published:** September 22, 2026 **Author:** Diane Beauchamp **Content:** The deadline to [apply for Medicare](https://www.medicare.gov/plan-compare/#/?year=2023&lang=en) is December 7 and scammers are out in full force. The older population is a popular target for scams. [CNBC reports](https://www.cnbc.com/2022/11/09/how-to-avoid-getting-duped-by-medicare-scams-during-open-enrollment.html) that last year, older adults lost $121 million to imposters posing as government employees. During enrollment season, fraudsters try to con their targets by offering fake giveaways, medical supplies or inventing bogus charges to ship a “new” Medicare card. Telecom security expert Chris Drake says people need to be vigilant, defensive and never give out personal information to callers. “Medicare never phones you,” Drake said. “Social Security never phones you. The IRS never phones you. If you get this call, it’s a scam. And you just have to start understanding, sadly, that the world is full of people trying to prey on the unsuspecting.” Drake encourages victims to report scams to their local police department’s non-emergency line or the Federal Trade Commission website. **Topics:** Public Awareness --- ### [The 1988 Murder-For-Hire Of Elizabeth Sennett Sounds Straight Out Of A Movie](https://insurancefraud.org/news_archives/the-1988-murder-for-hire-of-elizabeth-sennett-sounds-straight-out-of-a-movie/) **Published:** September 22, 2026 **Author:** Diane Beauchamp **Content:** On November 17, 2022, as CNN reported, Alabama officials scrapped a planned execution of a condemned death row inmate at the last second after authorities were unable to find a vein for the lethal injection. It was the latest twist in a case that, in the decades since it began, has resulted in one absurd turn after another. The condemned man’s name is Kenneth Smith, and it’s nearing four decades since he committed the crime for which he would ultimately be given a death sentence. All the way back in the Reagan administration — 1988, to be specific — Smith was involved in a murder-for-hire scheme. However, absolutely nothing about the case, or its adjudication, has been anywhere close to straightforward, as evidenced by the fact that, even as officials were preparing to close the final chapter on it, it remains ongoing. The Murder Of Elizabeth Sennett “She fought it and she fought hard.” That’s what Ronnie May, at the time chief investigator with the Colbert County Sheriff’s Office, told AL.com in November 2022. He was referring to the day in 1988 when he came upon a murder scene. Moments earlier, a deputy had received a telephone call from a distraught man, screaming that his wife had been murdered. That man was Charles Sennett, a pastor at an area church, and the murder victim was his wife, Elizabeth. “All we knew was a pastor’s wife had been killed in what had been a home invasion,” May said of the scene. Even as he was initially investigating the scene, things didn’t look right, May would say. Specifically, he said it looked like it had been staged to look like a home invasion. Further still, when Charles realized that Elizabeth was still barely alive (she died at a hospital), May said he “almost fell” (per AL.com). Then, May started connecting some dots: Specifically, he remembered that when he investigated a crime a few weeks earlier, Charles was there and kept returning after repeatedly being told to leave. May later concluded that Charles was inspecting the crime scene to see what it looked like so that he could recreate it. Charles Sennett Commits Suicide Initially, Elizabeth Sennett’s murder scene looked like a run-of-the-mill home invasion. Some things — including a stereo and VCR — had been stolen, and glass had been shattered (per The Cinemaholic). Already the chief investigator, Ronnie May was beginning to have doubts that this was a simple home invasion gone wrong, and he began to wonder whether Charles Sennett might have had something to do with it (via AL.com). Police had already rounded up a suspect thanks to a CrimeStoppers tip (more on that in a moment) but still wanted to talk to Charles. There was plenty of circumstantial evidence pointing to Charles’ possible involvement — he was believed to have been unhappy in his marriage, and he had reportedly taken out a life insurance policy on Elizabeth. When brought in for questioning, Charles denied everything. And when someone in the interview room wondered aloud if Charles knew one of the suspects, he “went beet red,” according to May (via AL.com). Charles then left the police station, went straight to his sons to admit that he had had their mother murdered, and then returned to his pickup truck and shot himself. He did not survive. **Topics:** Life Insurance **Categories:** Conviction --- ### [AG Platkin Announces $1.4 Million in Funding to Enhance Prescription Monitoring Program](https://insurancefraud.org/news_archives/ag-platkin-announces-1-4-million-in-funding-to-enhance-prescription-monitoring-program/) **Published:** September 22, 2026 **Author:** Diane Beauchamp **Content:** Attorney General Matthew J. Platkin and Kelly E. Levy, Acting Director, Office of the New Jersey Coordinator for Addiction Response and Enforcement Strategies (NJCARES), today announced that the New Jersey Prescription Monitoring Program (“NJPMP”) was awarded $1.4 million in competitive federal funding from the FY22 Harold Rogers Prescription Drug Monitoring Program to enhance the State’s existing program that helps prescribers monitor patient use of opioid painkillers and other controlled drugs that can lead to addiction and fatal overdoses. This is in addition to the $972,426 in opioid settlement funds provided by Governor Murphy for the NJPMP. Those funds will be used to support the NJPMP’s Electronic Health Record (EHR) integration. EHR integration improves ease of access and increases utilization of the NJPMP so that healthcare providers can make the best data-informed treatment decisions for their patients. The NJPMP, within the Division of Consumer Affairs (the “Division”), is an electronic database that collects information from pharmacies on the dispensing of controlled dangerous substances, like opioids, to individual patients. The monitoring program allows healthcare professionals to see a patient’s prescription drug history with the aim of improving overall prescribing practices and reducing the risk of potential abuse or fraud by patients who obtain prescriptions from multiple providers. Since the NJPMP began operating in 2011, a total of 53,259 prescribers and 8,137 pharmacists have registered for access to the NJPMP, representing approximately 97 percent of eligible prescribers. To date, over 137 million controlled dangerous substance, human growth hormone and gabapentin prescriptions have been entered into the NJPMP from more than 3,300 New Jersey licensed pharmacies. The grant funds will further New Jersey’s efforts to prevent the abuse, misuse and diversion of controlled substances and will help prescribers make better clinical decisions. Specifically, the award will fund five critical enhancements designed to improve NJPMP information, reporting, quality, and integrity through the development and implementation of the following systems and modifications: - **Investigation Alerts Module.** With the Investigation Alerts Module, the NJPMP Administrator will be notified in near real-time when a patient of a prescriber who is under investigation has filled a prescription associated with that prescriber’s DEA registration number. - **NJPMP Reporting Exemption Module.** Currently, NJ-licensed pharmacies who are eligible to apply for NJPMP reporting exemptions must do so in paper form on an annual basis. The funding will upgrade the paper process to a streamlined electronic process. - **Public NJPMP Data Dashboard.** The interactive dashboard will hold over 137 million anonymized prescription records going back to 2011. Creating the dashboard will enhance public health initiatives, help develop targeted interventions and identify state trends, and enable data-driven policy. - **Interactive Reporting Module.** This module will allow the NJPMP to share enhanced data analytics and visual insights for state investigations by developing customized investigation-based reports about prescribers, pharmacies, and patients for use in state-initiated prescription-related investigations**.** The reporting module will create a secure, online portal for the Division’s drug diversion investigators to access interactive reports, and will aid in their investigations by automating the NJPMP data analysis process. - **NJPMP Programmatic Enhancements.** The NJPMP will implement platform modifications with its vendor to ensure that New Jersey healthcare practitioners are equipped with the most sophisticated prescription medication analytics program. “I am proud that the federal government has recognized the NJPMP’s innovative work with an award of over $1 million in competitive funds,” **said Attorney General Platkin.** “Combating the opioid crisis requires us to use every tool in the toolbox, and these grant dollars, together with funding already provided by the Murphy Administration to bolster our efforts, means that we will remain on the cutting edge of technological solutions to address this national public health crisis.” “The NJPMP is a highly effective tool in our fight against the opioid crisis. It helps ensure that prescribers and pharmacists have access to key signs of abuse and addiction,” **said Cari Fais, Acting Director of the Division of Consumer Affairs**. “These enhancements to the NJPMP will prevent opioids from falling into the wrong hands and will make the NJPMP an even stronger and more user-friendly tool for clinicians.” “Since the establishment of the NJPMP in 2011, the Department has been investing in enhancing the program to ensure prescribers and pharmacists have greater ability to prevent the abuse, misuse, and diversion of opioid drugs,” **said Kelly Levy, Acting Director of NJ CARES.** “This additional federal funding allocated for the NJPMP will undoubtedly continue our work towards strengthening the system by improving and advancing its data analytic capabilities.” **Topics:** Public Awareness, Regulatory actions --- ### [New York insurance regulators want to review health equity programs](https://insurancefraud.org/news_archives/new-york-insurance-regulators-want-to-review-health-equity-programs/) **Published:** September 22, 2026 **Author:** Diane Beauchamp **Content:** New York regulators are trying to get a better idea of how insurance companies are trying to reduce health disparities, especially in communities of color. The Department of Financial Services on Wednesday released a mandatory information request for insurance companies to show the work they’ve done on race, ethnicity and language data collection efforts as well as programs for health equity. “We must take every action we can to address the systemic health inequities in our society that have disproportionately impacted communities of color for far too long,” said Superintendent Adrienne Harris. “The insurance industry has the power and the responsibility to contribute to greater health equity. This RFI will allow DFS to establish a foundation from which to build thoughtful, data-driven policies moving forward and evaluate the full impact of existing programming across the entire industry to ensure better outcomes for all New Yorkers.” Harris pointed to studies that have shown a variety of measurements for health care quality such as access to providers, coverage from insurance, language barriers and satisfaction with care can have disproportionate outcomes based on race. The COVID-19 pandemic showed Black and Latino Americans were more likely to be hospitalized and die compared to white people — an inequity that was also seen in New York despite early efforts to counteract it. Health insurance companies have started programs that were meant to address the disparities. The request Harris is seeking is meant to review these programs and best practices as well as determine whether any further steps need to be taken in the insurance industry. **Topics:** Public Awareness, Regulatory actions --- ### [Ohio man found guilty in trial over family massacre of 8](https://insurancefraud.org/news_archives/ohio-man-found-guilty-in-trial-over-family-massacre-of-8/) **Published:** September 22, 2026 **Author:** Diane Beauchamp **Content:** An Ohio man accused of helping his family plan, carry out and cover up the killing of eight members of another family was found guilty of murder Wednesday. A jury convicted George Wagner IV on Wednesday afternoon on multiple counts of aggravated murder and other charges related to conspiracy and attempts to cover up evidence in the 2016 massacre of the Rhoden family. Wagner, who was not accused of shooting anyone, testified during the trial that he was unaware of his family’s deadly plans. Earlier in the trial, a judge decided Wagner would not face the death penalty upon a conviction as part of an agreement between the prosecution and two other members of Wagner’s family who agreed to testify truthfully against him. Prosecutors said Wagner and his family plotted to kill the Rhodens over a custody dispute involving Wagner’s brother Edward “Jake” Wagner and one of the victims, Hanna Rhoden, who shared a toddler daughter. In addition to Hanna Rhoden, 19, the victims were her parents, Christopher Rhoden Sr., 40, and Dana Rhoden, 37; her brothers: 20-year-old Clarence “Frankie” Rhoden and 16-year-old Christopher Jr.; Clarence Rhoden’s fiancée, Hannah Gilley, 20; Christopher Rhoden Sr.’s brother, Kenneth Rhoden, 44; and a cousin, Gary Rhoden, 38. After the verdict, members of the Rhoden family gathered outside the courthouse and wept, thanking the jury for giving them “a little bit of peace” years after their loved ones were killed. “It should have never happened,” family member Tony Rhoden said of the killings. Many members of the Rhoden family sat through the emotional trial, including its matriarch, Geneva Rhoden. Tony Rhoden said they have been able to get through the tragedy with “family support.” He called Geneva Rhoden “the rock” of the family and said, “She’s the one that got us this far.” Both Wagner brothers as well as their parents, Angela Wagner and George “Billy” Wagner III, were charged in the killings. George “Billy” Wagner III has pleaded not guilty. Angela Wagner pleaded guilty to a role in helping to plan the killings in exchange for a 30-year sentence. Jake Wagner last year confessed to shooting five of the Rhoden family victims and has been spared the death penalty as a result of his plea. ​​”These murders should never have happened,” special prosecutor Angela Canepa said during closing arguments. “We are here because eight innocent victims were slaughtered, most of them in their sleep, all of them unarmed.” Canepa said Wagner should be found guilty, even if he didn’t kill any of the Rhodens himself. “He doesn’t have to be the person that actually pulled the trigger,” she said. “You were complicit, because you knew what was going to happen, you knew what they were going to do, and you aided and abetted them,” she said of Wagner. During closing arguments, Wagner’s defense attorney told jurors that Wagner had no reason to participate in the killing of Hanna Rhoden and her family. Instead, he said, the blame lay with Wagner’s brother Jake and their mother, Angela. “Jake and Angela have destroyed this man’s life,” John Parker said of his client. “Why would he agree to kill Hanna and her family? You heard him testify, Hanna was like a little sister to him,” he said. “He wouldn’t kill anybody. He didn’t kill anybody, and he didn’t go along because it makes no sense,” Parker said. Earlier in the trial, George Wagner IV testified that he had no knowledge that his family planned to kill the Rhodens. While he detailed his family’s history of crimes, including burning their properties for insurance money, he said he would have tried to stop the killing plot had he known about it. “I never would have believed my family would be capable of doing something of this magnitude,” he testified. “Theft is one thing. Murder is an entirely different thing.” Wagner said if he had known about the plan, “one way or another, I would have never let it happen.” Both Jake Wagner and Angela Wagner testified against George Wagner IV at trial as part of plea agreements. Jake Wagner testified that he was increasingly concerned his child with Hanna Rhoden might suffer abuse and ultimately decided he “had no other choice than to kill Hanna,” according to NBC affiliate WLWT of Cincinnati. Jake Wagner opted to have his testimony confined to the courtroom, and not broadcast on audio or video, which the judge allowed. He also testified that George Wagner IV helped execute the plot and was supposed to kill Chris Rhoden Sr., the first member of the Rhoden family who was killed that night in April 2016, according to the station. Jake Wagner said his brother froze and did not fire, leading Jake to kill the man himself, according to WLWT. Angela Wagner also testified in court against her son, saying that he was willing to confess to the killings himself, but she was opposed, according to NBC affiliate WCMH of Columbus, Ohio. The prosecution asked Angela Wagner whether she regretted her actions, according to the station. She said yes and became visibly emotional, WCMH reported. “Because they’re my sons,” she said. “I should’ve protected them from that situation.” **Topics:** Homeowners - arson **Categories:** Conviction --- ### [Massachusetts Man Pleads Guilty in Physical Therapy Insurance Scam](https://insurancefraud.org/news_archives/massachusetts-man-pleads-guilty-in-physical-therapy-insurance-scam/) **Published:** September 22, 2026 **Author:** Diane Beauchamp **Content:** A Boston man pleaded guilty in federal court in connection with a scheme to defraud an insurance company for physical therapy services that were not provided to patients, according to prosecutors. Officials said Slava Pride pleaded guilty to one count of conspiracy to commit mail fraud. Other charges were dropped. Pride was indicted in February 2021 along with co-defendants Anna Barenboym, Gyulnara Bayryshova and Raya Bagardi. Pride was a physical therapy assistant at Brighton Physical Therapy (BPT), a clinic owned by Bayryshova. Both Barenboym and Bagardi were also employed at BPT. According to the court documents, from October 2018 through June 2020, Pride and his co-defendants at BPT conspired to gain insurance company reimbursements for physical therapy services that were not actually provided and/or were not medically necessary. Also, in some cases, they were allegedly provided by individuals not licensed to provide the services. Specifically, Pride and, allegedly, his co-defendants falsely billed for services purportedly rendered to patients injured in automobile accidents when the services were not actually provided. Prosecutors further allege that BPT paid patients for referrals, referred patients to attorneys to assist with patients’ insurance settlements, and accepted kickbacks from those attorneys in return. The government has claimed insurers paid more than $750,000 in false claims to BPT. Pride has reserved the right to dispute that amount as overstated at his sentencing hearing. Pride is the second defendant to plead guilty in the case. On March 17, 2022, according to the office of U.S. Attorney Rachael Rollins. Barenboym pleaded guilty to her role in the conspiracy and is scheduled to be sentenced on April 4, 2023. The details contained in the charging documents are allegations. Defendants are presumed innocent unless and until proven guilty beyond a reasonable doubt in a court of law. U.S. District Court Judge Richard G. Stearns scheduled sentencing for March 23, 2023 for Pride. The charge of conspiracy to commit mail fraud provides for a sentence of up to 20 years in prison, three years of supervised release and a fine of $250,000. The Federal Bureau of Investigation, Insurance Fraud Bureau of Massachusetts, Boston Police and Quincy Police made the announcement. Assistant U.S. Attorney Laura J. Kaplan of Rollins’ organized crime unit is prosecuting the case. **Topics:** Healthcare Fraud **Categories:** Conviction --- ### [Louisiana Woman Latest to Plead Guilty in Staged Auto Collision Scheme](https://insurancefraud.org/news_archives/louisiana-woman-latest-to-plead-guilty-in-staged-auto-collision-scheme/) **Published:** September 21, 2026 **Author:** Diane Beauchamp **Content:** United States Attorney Duane A. Evans announced that Florence Randle, age 70, of Gibson, Louisiana, pled guilty on November 29, 2022 to Count One (1) of her indictment, charging her with Conspiracy to Commit Mail Fraud in violation of Title 18, United States Code, Section 371. In exchange, the government agreed to dismiss four counts of Mail Fraud, a violation of Title 18, United States Code, Sections 1341 and 2. In pleading guilty to Count 1, the defendant faces a maximum penalty of five (5) years’ imprisonment; a term of supervised release of up to three (3) years; a fine up to $250,000.00, as well as a mandatory special assessment fee of $100.00. Today’s guilty plea brings the total number of defendants convicted in Operation Sideswipe to 43. According to court documents, Randle served as an intermediary who recruited and directed passengers to participate in staged automobile collisions with tractor-trailers on May 17, 2017 and June 6, 2017. The passengers in these collisions filed fraudulent lawsuits that falsely claimed that the tractor-trailers were at fault. Randle and her co-conspirators coordinated with others, including “slammer” Damian Labeaud and attorney Patrick Keating, to arrange the staged collisions. The Honorable Jane Triche Milazzo set sentencing in this matter for March 1, 2023. The U.S. Attorney’s Office would like to acknowledge the assistance of the Federal Bureau of Investigation, the Louisiana State Police, and the Metropolitan Crime Commission with this matter. The prosecution of this case is being handled by Assistant U.S. Attorney Maria M. Carboni; Brian M. Klebba, Chief of the Financial Crimes Unit; Assistant U.S. Attorney Edward Rivera; and Assistant U.S. Attorney Brandon S. Long. **Topics:** Auto - staged **Categories:** Conviction --- ### [How much? Auto insurance costs jump 8.4% this year — 52% for motorists with tickets. Tesla owners and those in Michigan, Florida, and Rhode Island are worst hit](https://insurancefraud.org/news_archives/how-much-auto-insurance-costs-jump-8-4-this-year-52-for-motorists-with-tickets-tesla-owners-and-those-in-michigan-florida-and-rhode-island-are-worst-hit/) **Published:** September 21, 2026 **Author:** Diane Beauchamp **Content:** Motor insurance premiums are climbing by 8.4 percent to reach an average of $1,780 this year — the biggest increase in six years, nudged up by rising costs of [replacement parts and repairs](https://www.dailymail.com/news/article-11512633/Accident-Ahead-Americas-worst-drivers-Utah-California-Iowa-study-shows.html), a study says. According to the report, motorists in [Michigan](https://www.dailymail.com/news/michigan/index.html), [Florida](https://www.dailymail.com/news/florida/index.html), and Rhode Island will pay well above-average costs, as will those with a record of driving violations and owners of Teslas and other fancy electric vehicles. Divya Sangameshwar, an insurance expert at ValuePenguin.com, the consumer spending site that [released its findings](https://www.valuepenguin.com/state-of-auto-insurance-2023) on Monday, said insurers had kept rates low for the past two year, but that 2023 was a different story. ‘This year’s auto insurance rate increase is the highest rate increase since 2017,’ said Sangameshwar. ![](https://insurancefraud.org/wp-content/uploads/image-20-16.jpg)![](https://insurancefraud.org/wp-content/uploads/image-21-6.jpg)The average American motorist will pay $1,780 this year, but those in some states will be hurt much more. Those in Michigan will fork out on average $4,788, well above the national average due to the state’s stringent minimum insurance requirements. Floridians will pay $2,856 and those in Rhode Island $2,748. Motorists across 45 states will see at least a 1 percent jump in premiums. The biggest hike will affect Illinois (17 percent), followed by Arizona (15.6 percent) and New Hampshire (13.6 percent). Those with records for traffic violations and accidents will see premiums grow by more than half, researchers say. Those with speeding tickets will see an average hike of $2,194, while those with DUIs will pay $3,281 extra. Folks driving crossover SUVs, such as Honda’s CR-V or Toyota’s RAV4, get among the best deals, as they are typically cheaper to repair and replace than other cars. Pickups and larger SUVs cost more. Still, owners of top-end electric cars are among the worst hit. Drivers of Porsche Taycans will pay on average $3,576 for the premiums this year, while those driving the Tesla Model Y will pay $3,110. ![](https://insurancefraud.org/wp-content/uploads/image-20-16.jpg)![](https://insurancefraud.org/wp-content/uploads/image-21-6.jpg)The study comes on the heels of research from Quotewizard, an insurance comparison website, which found that drivers in Utah are the worst in the nation and those in [Connecticut](https://www.dailymail.com/news/connecticut/index.html) are the safest [The group’s study of accidents](https://www.dailymail.com/news/article-11512633/Accident-Ahead-Americas-worst-drivers-Utah-California-Iowa-study-shows.html), speeding tickets, DUIs and citations from 10 million insurance quotes last month, found that Utah scored poorly in all categories of dangerous driving, including the number of crashes, drunk drivers on the roads and police tickets. Utah was followed by [California](https://www.dailymail.com/news/california/index.html), [Iowa](https://www.dailymail.com/news/iowa/index.html), Wisconsin, and Ohio as the five states with the country’s worst drivers. California, which ranked lowest in last year’s survey, still had ‘more DUIs over the last year than any other state’, [researchers said](https://quotewizard.com/news/the-best-and-worst-drivers-by-state). Connecticut’s drivers were singled out as the ‘best in the nation’ by a ‘wide margin’ by researchers, for having among the lowest rates of citations, DUIs, speeding tickets and pile ups in the nation. Michigan, West Virginia, Delaware, and Arkansas rounded out the top five safest motoring states in the country. Nationwide, researchers found that eastern states generally saw better drivers than western states, and that states with a high number of drunk drivers were also likely to see more crashes and speeding than elsewhere. ![](https://insurancefraud.org/wp-content/uploads/image-20-16.jpg)![](https://insurancefraud.org/wp-content/uploads/image-21-6.jpg) **Topics:** Public Awareness --- ### [South Africa Medical Aid Funding Industry Report 2022: State of the Industry, Key Trends, Key Issues, Notable Players, Corporate Actions, Regulations](https://insurancefraud.org/news_archives/south-africa-medical-aid-funding-industry-report-2022-state-of-the-industry-key-trends-key-issues-notable-players-corporate-actions-regulations/) **Published:** September 21, 2026 **Author:** Diane Beauchamp **Content:** The [“Medical Aid Funding in South Africa 2022”](https://www.researchandmarkets.com/reports/5684171/medical-aid-funding-in-south-africa-2022?utm_source=GNOM&utm_medium=PressRelease&utm_code=zv5mvt&utm_campaign=1805317+-+South+Africa+Medical+Aid+Funding+Industry+Report+2022%3a+State+of+the+Industry%2c+Key+Trends%2c+Key+Issues%2c+Notable+Players%2c+Corporate+Actions%2c+Regulations&utm_exec=chdo54prd) report has been added to **ResearchAndMarkets.com’s** offering. This report on medical aid funding in South Africa includes information on the effects of the pandemic and recovery, membership and claims trends and the development of the NHI. There are profiles of 30 companies including the major government scheme GEMS and major private sector players such as Discovery, Momentum and Bonitas. South Africa has a two-tiered, and highly unequal, healthcare system, with most of the population being state-funded. While only 14.86% of the population can afford private healthcare sector, the high costs are making it increasingly difficult for some people to continue. Government plans to implement National Health Insurance (NHI) to fund healthcare in the public and private sectors, with most of the funding coming from general taxes and contributions of people earning above a set amount. The process, which began in August 2011, has been slow, and the NHI Bill is still under consideration in the National Assembly. The private sector has raised concerns about its affordability, and the state’s ability to implement it effectively and competently. **Key Issues** Rising and unregulated healthcare costs, an ageing population and the increase in non-communicable lifestyle diseases are key challenges. Average annual consumer prices for medical services and pharmaceuticals continue to increase ahead of inflation and premiums are high, making membership unaffordable for most South Africans. Fraud, waste, and abuse is a key issue in the industry, impacting around 22% of all claims. Fraudulent activity and abuse includes doctors and medical personnel colluding with members, submission of false claims, over-servicing or over-charging. **Trends** There has been a decrease in the number of registered medical schemes over the past two decades, mainly due to consolidation. Medical scheme membership, however, has increased. Claims declined in 2020 but increased in 2021 as members scheduled delayed elective surgeries. Changes are taking place in terms of attracting young members and low cost cover, online consultations and predictive and preventative care. **Key Topics Covered:** **1. INTRODUCTION** **2. DESCRIPTION OF THE INDUSTRY** 2.1. Industry Value Chain 2.2. Geographic Position 2.3. Size of the Industry **3. LOCAL** 3.1. State of the Industry 3.2. Key Trends 3.3. Key Issues 3.4. Notable Players 3.5. Corporate Actions 3.6. Regulations 3.7. Enterprise Development and Social Development **4. AFRICA** **5. INTERNATIONAL** **6. INFLUENCING FACTORS** 6.1. COVID-19 6.2. Economic Environment 6.3. Input Costs 6.4. Fraud, Waste, and Abuse 6.5. Labour 6.6. Environmental Issues 6.7. Technology, R&D, Innovation 6.8. Government Interventions **7. COMPETITIVE ENVIRONMENT** 7.1. Competition 7.2. Ownership Structure of the Industry 7.3. Barriers to Entry **8. SWOT ANALYSIS** **9. OUTLOOK** **10. INDUSTRY ASSOCIATIONS** **11. REFERENCES** 11.1. Publications 11.2. Websites **COMPANY PROFILES** Notable Players - Major Open Medical Schemes - Major Restricted Medical Aids - Major Medical Fund Administrators Major Open Medical Schemes - Bestmed Medical Scheme - Bonitas Medical Fund - Discovery Health Medical Scheme - Fedhealth Medical Scheme - KeyHealth Medical Scheme - Medihelp Medical Scheme - Medshield Medical Scheme - Momentum Health - Sizwe Hosmed Medical Scheme Major Restricted Medical Aids - Anglo Medical Scheme - Bankmed Medical Scheme - Chartered Accountants Medical Aid Fund - Government Employees Medical Scheme - LA-Health Medical Scheme - Moto Health Care - Platinum Health Medical Scheme - Profmed Medical Scheme - SAMWU National Medical Scheme - Sasolmed Medical Scheme - South African Police Service Medical Scheme - Transmed Medical Fund Major Medical Fund Administrators - 3Sixty Health (Pty) Ltd - Agility Holdings (RF) (Pty) Ltd - Discovery Health (Pty) Ltd - Medscheme Holdings (Pty) Ltd - Metropolitan Health Corporate (Pty) Ltd - Momentum Health Solutions (Pty) Ltd - Momentum Thebe Ya Bophelo (Pty) Ltd - Professional Provident Society Healthcare Administrators (Pty) Ltd - Universal Healthcare Administrators (Pty) Ltd For more information about this report visit [https://www.researchandmarkets.com/r/el8io1](https://www.researchandmarkets.com/reports/5684171/medical-aid-funding-in-south-africa-2022?utm_source=GNOM&utm_medium=PressRelease&utm_code=zv5mvt&utm_campaign=1805317+-+South+Africa+Medical+Aid+Funding+Industry+Report+2022%3a+State+of+the+Industry%2c+Key+Trends%2c+Key+Issues%2c+Notable+Players%2c+Corporate+Actions%2c+Regulations&utm_exec=chdo54prd) **About ResearchAndMarkets.com** ResearchAndMarkets.com is the world’s leading source for international market research reports and market data. We provide you with the latest data on international and regional markets, key industries, the top companies, new products and the latest trends. **Topics:** Public Awareness --- ### [2021 hit-and-run turns out to be murder, four held](https://insurancefraud.org/news_archives/2021-hit-and-run-turns-out-to-be-murder-four-held/) **Published:** September 21, 2026 **Author:** Diane Beauchamp **Content:** A hit-and-run accident reported at Shadnagar in 2021 turned out to be a murder for claiming insurance, the police said, after arresting four persons, including a head constable, in the case. Among them was the man who had purchased the insurancy policy for the victim. According to the police, the main accused Boda Srikanth approached an insurance firm to claim money on the policy of the victim, Edla Bikshapathi. The firm contacted the police after finding that Srikanth was not related to the victim. The police said they gathered leads about the victim, based on technical evidence. “When we connected the dots and questioned the suspects, they admitted to having killed Bikshapathi to claim his life insurance and also a house registered on his name in Uppal,” Shamshabad DCP R. Jagadishwar Reddy said. He said that Srikanth was a repeat offender and was previously held by the Rachakonda police for duping a private bank of ₹1.3 crore by floating a fake firm, listing employees and obtaining credit cards for them. Srikanth, in October 2021, purchased a life insurance policy worth ₹50 lakh for Bikshapathi and house insurance, listing himself as the nominee for both, as the victim used to work for him and had no relatives. Upon facing a financial crisis, he teamed up with head constable Jatawath Motilal of CCS Balanagar, and two others, Banoth Sammanna and Chaganti Satish, to murder Bikshapathi. **Topics:** Auto - staged **Categories:** Arrest --- ### [Allianz Commercial reports detected fraud up 11.2%](https://insurancefraud.org/news_archives/allianz-commercial-reports-detected-fraud-up-11-2/) **Published:** September 21, 2026 **Author:** Diane Beauchamp **Content:** Allianz Commercial has revealed it detected £70.7m worth of insurance fraud in 2022, up 11.2% on the £63.6m uncovered the year before. The insurer noted that property and casualty saw the greatest increase in fraud savings against the prior year. Despite the number of fraud cases declining, it said the value of each case increased to record levels. Allianz Commercial added that this trend may indicate a move away from traditional types of motor fraud such as crash-for-cash scams, although these remain a major issue. **Topics:** Public Awareness --- ### [Psychiatrist who practiced for over 20 years accused of faking medical degree](https://insurancefraud.org/news_archives/psychiatrist-who-practiced-for-over-20-years-accused-of-faking-medical-degree/) **Published:** September 21, 2026 **Author:** Diane Beauchamp **Content:** A “bogus” psychiatrist spent two decades working for the UK’s National Health Service — earning more than $1 million — after forging her qualifications, a court heard. Zholia Alemi, described as a “most accomplished forger and fraudster,” is alleged to have fooled the General Medical Council (GMC) into granting her registration as a doctor and then worked for various health trusts across the UK. Manchester Crown Court heard how Iranian-born Alemi, believed to be 60, claims to have obtained her doctor’s qualification from the University of Auckland in 1992. However, it is alleged she never actually passed the six-year Bachelor of Medicine, Bachelor of Surgery (MBChB) course and failed her exams before coming to the UK three years later. Christopher Stables, a prosecutor, said, “In a nutshell, the prosecution case against this defendant is that, for a period of approximately 20 years, she held herself out and practiced as a doctor, a doctor of medicine, when, in truth, she had never passed or achieved the relevant university qualification and was not a properly qualified doctor at all.” “That identifies the issue which is at the heart of this case as you will hear.” All the charges against Alemi relate to the period from September 1995 to June 2017, after she had arrived in the UK from New Zealand. Stables said Alemi was a “fraud” who had secured entry onto the GMC register of medical practitioners by forging her qualifications and other documents. He explained, “She is, say the prosecution, a most accomplished forger and fraudster, but has no qualification that would allow her to be called, or in any way to be properly regarded as, a doctor.” Stables said Alemi used deception and fraud to obtain employment and a “conservative estimate” of the money she fraudulently obtained was the US equivalent of between $1.2 million and $1.5 million. He said the defendant’s case was that she was appropriately qualified and that documents demonstrating her qualifications were all genuine, and she was, therefore, entitled to the renumeration she received. Her motive was “irrelevant,” he told the jury, but she “may simply have wanted desperately to be a doctor” and, having failed her exams, forged her qualifications so “she could practice in a field that interested or stimulated her.” She may simply have “wanted the status of doctor,” he said, but it was “unlikely” the true position would be known, and “the fact remains” that the sums she obtained were the consequence of her dishonesty. The court heard how Alemi was allowed to join the GMC’s medical register by the Commonwealth Route — a legitimate route, closed off in 2003 — which could only be achieved if an applicant held a certain degree known as an MBChB. However, her application had included spelling and grammatical errors, with an alleged letter of verification for her degree from the university’s School of Medicine coming from a faculty “regitrar” instead of registrar. The court that the person alleged to have signed the letter had in fact left her post by that time. Stables said it was the prosecution’s case that the documents Alemi sent to the GMC were not genuine and were “forgeries” and were not issued by the University of Auckland. The court heard that Alemi had first enrolled at the university in 1988 for a Bachelor of Human Biology course which she gained, after failing some of her exams in 1992. Stables said this qualification did not make her a doctor, and Alemi was never awarded a degree of MBChB by the University of Auckland after failing her year 2 exams and “proceeding no further.” He said, “She never graduated as a doctor. And that is why she forged the degree certificate to send to the GMC with her application for registration.” “All of this” was confirmed by university records, he added. The court heard that police had raided one of her properties in Omagh, Northern Ireland, in 2019 and discovered a “forger’s kit.” Stables said an expert witness would give evidence that items found at the house in a briefcase, which included dry transfer letters purchased from the UK store W.H. Smith and blank degree documents, had been used to make Alemi’s fake university certificate. The court heard that Alemi became a member of the Royal College of Psychiatrists in 2003, passing part one of their exams after four attempts and part two after three attempts. However, her membership was terminated within days of her forgeries coming to light, Stables said. The GMC withdrew her license to practice as a doctor in November 2018. Alemi, of Burnley, Lancashire, denies 13 counts of fraud, three counts of obtaining a pecuniary advantage by deception, two counts of forgery and two counts of using a false instrument. The trial is expected to last several weeks. **Topics:** Healthcare Fraud, Unlicensed **Categories:** Arrest --- ### [Fraudulent claim lands Wishaw couple with criminal record, a fine, and thousands to pay in costs](https://insurancefraud.org/news_archives/fraudulent-claim-lands-wishaw-couple-with-criminal-record-a-fine-and-thousands-to-pay-in-costs/) **Published:** September 21, 2026 **Author:** Diane Beauchamp **Content:** A couple from Wishaw, North Lanarkshire, have been convicted of fraud and ordered to pay back thousands after attempting to claim that they sustained injuries so severe that they both struggled to walk and care for themselves as a result of a minor traffic collision. The husband and wife’s claim was further undermined when CCTV footage from the bus that scraped their vehicle at a junction, proved the husband was not even in the car at the time of the accident. Appearing at Hamilton Sheriff Court, both husband and wife, aged 58, were found to have conspired to commit fraud. Both were fined, ordered to pay thousands in legal costs and both have been left with a criminal record. A bus owned by First Bus scraped the couple’s car while it was stationary at a road junction in Wishaw near Glasgow. The driver, subsequently proven to be a much younger individual, supplied the bus driver with a much older man’s name and contact number. Afterwards, the couple claimed that the 7mph scrape across their rear bumper had ‘thrust and thrown’ them inside their vehicle, causing injuries to their backs and necks. They claimed that they struggled with housework, personal care, bending, dressing, climbing stairs and even walking. First Bus’s in-house claims team had immediate concerns due to the minor nature of the incident and launched an investigation. CCTV footage confirmed suspicions that the impact was no more than a scrape and therefore highly unlikely to cause any injuries. On further inspection it was also revealed that the male passenger pursuing compensation was not even in the vehicle. CCTV shows that the driver of the car was much younger, believed to be 37 years old, whilst the claimant was 58. It was noted that at the scene, the husband’s details were passed to the First Bus driver, indicating dishonest intent from the outset. As part of their investigation, First Bus’s in-house claims team and law firm Clyde & Co proceeded to instruct a medical expert to examine the husband. During this examination, the husband was confronted with evidence gained from the CCTV footage. In response, the husband admitted that the claim was fraudulent and that he had not been in the vehicle at the time of the collision. The claimants subsequently admitted their claim was fraudulent, however not content to leave it there, the Sheriff requested that the case be referred for further criminal action. Because of the blatant nature of the attempted fraud, First Bus reported the case to Police Scotland who, hugely supportive of investigating insurance fraud, recommended the case be bought before the Procurator Fiscal’s office. This led to a successful prosecution of not just the husband for his fraudulent claim, but also the wife, for supporting his fraudulent claim. Commenting on the case, Julie Randle, First Bus’s Fraud Prevention Officer, said: “Attempted frauds against our company will not be tolerated. This was a genuine accident resulting in minor vehicle damage. However, greed took precedence, resulting in no pay out, a criminal record and significant financial repercussions. “This case demonstrates the very real consequences of making a fraudulent claim and First Bus will take whatever steps necessary to defend itself against fraudulent claims.” Vikki Melville, a partner in Clyde & Co’s Glasgow office, said: “We are starting to see a notable increase of this type of fraudulent claim following accidents on the road. The fraudsters think they’ve found an easy way to make money. What they don’t take into account is the sophistication of our investigations and the amount of data we have on low-speed collisions. The consequence being that a fraudulent or exaggerated claim can be a fast track to a criminal record and even prison – as demonstrated by the approach taken in English courts in particular. Achieving results like this case whilst working closely with our clients demonstrates our clients ongoing commitment to win the fight against fraud.” Detective Superintendent David Ferry of Police Scotland said: “We take all forms of fraud seriously and any report we receive will be thoroughly investigated. Fraud, in any form, is a despicable crime and we know that fraudsters will try to exploit people and use any event to their own advantage. “We want to ensure that people and businesses are kept safe and informed. I would encourage any person or business who has or believes they have been the victim of fraud to report the matter as soon as it happens so that it can be investigated promptly. “We will continue to pursue those who set out to cause harm and misery to our communities to make Scotland a hostile environment for those who commit fraud.” **Topics:** Auto - padding/false claim **Categories:** Conviction --- ### [New York Department of Financial Services Announces a $1.9 Million Settlement With Insurance Agency For Violations of New York’s Cybersecurity Regulation](https://insurancefraud.org/news_archives/new-york-department-of-financial-services-announces-a-1-9-million-settlement-with-insurance-agency-for-violations-of-new-yorks-cybersecurity-regulation/) **Published:** September 21, 2026 **Author:** Diane Beauchamp **Content:** The New York Department of Financial Services (“NYDFS”) recently announced it has entered into a Consent Order with an insurance agency for alleged violations of New York’s Cybersecurity Regulation (the “NY Cybersecurity Regulation”). The NYDFS indicated that it had been investigating a Cybersecurity Event that was experienced by the Insurance Agency and that based on its investigation, the Department concluded that the Insurance Agency violated the following sections of the NY Cybersecurity Regulation: 1. The Insurance Agency did not have multi-factor authentication fully implemented for all users in the United States and did not have reasonably equivalent or more secure access controls approved in writing by the Insurance Agency’s Chief Information Security Officer(s) (“CISO”), in violation of 23 NYCRR § 500.12(b); 2. The Insurance Agency failed to maintain, for the required three years, audit trails designed to detect and respond to Cybersecurity Events, in violation of 23 NYCRR § 500.06(b); 3. The Insurance Agency improperly certified compliance with the Cybersecurity Regulation for the 2020 calendar year, in violation of 23 NYCRR § 500.17(b); and 4. The Insurance Agency did not file a certification of compliance with the Cybersecurity Regulation for the calendar years 2018 and 2019, in violation of 23 NYCRR § 500.17(b). 5. Under the Consent Order, the Insurance Agency agreed to: 6. Pay a $1.9 million penalty to the NYDFS. 7. Continue to strengthen its controls to protect its cybersecurity systems and consumers’ Non-Public Information (“NPI”) in accordance with the requirements of the NY Cybersecurity Regulation. 8. Cyber Maturity Assessment 9. 10. MFA Audit. Within 120 days of the effective date, hire a third-party auditor to conduct an audit of current MFA controls in the various environments utilized by the Insurance Agency and submit the results to the NYDFS. The Insurance Agency must remediate any issues identified within a reasonable timeframe agreed to by the Department. 11. Audit Trail Implementation and Audit. Within 120 days of the effective date, hire a third-party auditor to conduct an audit of the Insurance Agency’s audit trail record retention policy and develop a plan for becoming compliant with Part 500.06 requirements. Upon completion, a copy of the third-party audit will be provided to the NYDFS. 12. Information Security Dashboard. Within 180 days of the effective date, develop an information security reporting system that tracks all Information Security functions taking place at the Insurance Agency and that can be accessed by executives overseeing Information Security. Screenshots or samples of such system are to be made available to the NYDFS upon request. 13. The recent Consent Order continues a trend toward stepped up enforcement of the NY Cybersecurity Regulation.\[i\]\[ii\] 14. The NY Cybersecurity Regulation became effective in March 2017 and has served as a model to the states, as well as the National Association of Insurance Commissioner’s Insurance Data Security Model Law (“Model Security Law”), which applies to insurance companies, insurance agencies and agents, third party administrators, insurance adjusters and other entities licensed by state insurance departments. The Model Security Law requires insurance entities to establish and maintain a cybersecurity program designed to protect the confidentiality and integrity of their Information Systems, as well as any consumer non-public information. Additionally, the Model Security Law requires covered entities to (1) certify compliance with the Model Security Act annually, (2) have a written incident response plan, (3) develop and maintain a comprehensive written security program based on the entity’s risk assessment and (4) conduct risk management and risk assessment activities, including employee training and maintaining updates to network systems. Many states have adopted the Model Security Law and a number of state insurance departments have filing requirements applicable to licensed entities in their states. **Topics:** Judicial/courts --- ### [Scottish Government drafts rates avoidance legislation](https://insurancefraud.org/news_archives/scottish-government-drafts-rates-avoidance-legislation/) **Published:** September 21, 2026 **Author:** Diane Beauchamp **Content:** New draft legislation on non-domestic rates (NDR) has been tabled to tackle tax avoidance and promote the Deposit Return Scheme (DRS). Regulations laid before the Scottish Parliament will empower councils to crack down on tax-avoidance, such as the artificial use of insolvency, leasing arrangements or shell companies. They would also make owners of non-domestic properties liable for payment, rather than the property’s occupiers, and allow for liability for payment to be backdated if an offence is repeated within a five-year period. In a separate move, parts of properties solely used to house reverse vending machines, which refund users for recycling drinks containers, would be exempt from NDR. This is being introduced by the Scottish Government to help support businesses to get ready for the DRS implementation on 16 August. Further amendments to NDR, announced in the Scottish Budget 2023-24, will be published shortly as part of a package of regulations to provide more help for businesses through the current cost-of-living crisis. Public Finance Minister Tom Arthur said: “The Scottish Government is committed to a fair and transparent system of non-domestic rates which supports businesses and communities. “It is important that everyone pays their share and these regulations will help tackle those who seek to find loopholes to avoid payment. “We want to ensure that parts of properties used for reverse vending machines are not liable to pay rates. “Subject to the regulations passing in the Scottish Parliament, we will work to ensure Scotland’s non-domestic rates system remains progressive and in line with our net zero ambitions.” The Non-Domestic Rates (Miscellaneous Anti-Avoidance Measures) Regulations 2023 aim to deliver on a commitment in the Bute House Agreement to help local authorities tackle tax avoidance tactics, including when they make decisions on applying empty property relief and charity relief. The Non-Domestic Rating (Valuation of Sites of Reverse Vending Machines) Regulations 2023 should ensure the part of a non-domestic property used solely in the provision or use of a reverse vending machine, is not liable for rates. The latest budget announced the lowest poundage in the UK for the fifth year in a row and a package of reliefs worth an estimated £744m. Draft regulations are laid in order to be considered by Parliament before they are signed into law. These new regulations should come into force in Scotland on 1 April 2023. **Topics:** Legislation --- ### [Bigger than they knew: Diligent Corp. sends more notifications after discovering hacked data on the internet](https://insurancefraud.org/news_archives/bigger-than-they-knew-diligent-corp-sends-more-notifications-after-discovering-hacked-data-on-the-internet/) **Published:** September 21, 2026 **Author:** Diane Beauchamp **Content:** Diligent Corp is a software as a service company, headquartered in New York. In June, 2022, they disclosed an incident that occurred in May. According to their disclosure at the time, on or around May 21, 2022, an unauthorized actor accessed a network supporting Steele Compliance (a firm acquired by Diligent in February 2021). Diligent discovered the breach on May 23 and contained the event by May 24. In a [report](https://apps.web.maine.gov/online/aeviewer/ME/40/6244db97-8496-4386-befd-06e98f6d37b1.shtml) submitted to the Maine Attorney General’s Office in June, they reported that 1184 people were affected and offered credit monitoring services for 24 months. The information accessed without authorization included name, email address, mailing address, or Social Security number. ### When you discover the scope is bigger than you knew But if Diligent notified everyone affected in June 2022, why didn’t the University of Colorado Hospital Authority issue any notice until [January 17](https://www.uchealth.org/notifications/software-vendor-shares-information-about-data-breach/) of this year to 48,879 patients reportedly affected by the incident? In a notice on their website, UCHealth writes, “Some of UCHealth’s patient, provider or employee data may have been included in this incident.” The explanation for the delay is that Diligent discovered more entities had been affected than they had originally determined, and they discovered it the hard way. On February 2, Diligent submitted a notification to state attorneys general similar in content to the June 2022 notice but with a preface added that states, “We recently learned that additional individuals’ personal information was involved.” The updated notification explains: > Diligent recently learned the precise scope of the unauthorized third party’s access, when the third party posted a set of files that it had acquired on an external site. That access appears to have included access to personal data we did not initially believe was accessed, including some data regarding you. We are informing you so that you may take precautionary measures. Although UCHealth has reported the incident to HHS, there is no report directly to HHS from Diligent that provides any other numbers of patients who might have been affected. This post may be updated as more information becomes available. **Topics:** Public Awareness, Technology --- ### [Heads up: Highmark Health will be notifying 300,000 patients of a phishing incident. Watch for your mail this month.](https://insurancefraud.org/news_archives/heads-up-highmark-health-will-be-notifying-300000-patients-of-a-phishing-incident-watch-for-your-mail-this-month/) **Published:** September 21, 2026 **Author:** Diane Beauchamp **Content:** Highmark Health defines itself as a “national, blended health organization” that includes the Highmark Health Plan (a Blue Cross Blue Shield insurer); a regional hospital and physician network; and companies that offer dental solutions, reinsurance solutions, population health management, and technology solutions. Letters have not gone out yet and will not be going out in the mail until February 13, but Highmark Health will be notifying 300,000 patients of a data security breach that occurred on December 13, 2022, after an employee clicked on a link that they should not have clicked on. The breach was discovered on December 15, 2022. According to Highmark’s notification letter, seen by DataBreaches, the emails in the employee’s compromised email account may have included various protected health information elements: name, social security number, and enrollment information such as the individual’s group name, identification number, claims or treatment information such as claim numbers, dates of service, procedures, and prescription information. as well as in some cases, financial information, address, phone number, and email address. Not all individuals had all elements and there are two forms of the letter going out: one to those whose social security number was involved, and one to those who did not have their social security number involved. In either case, those being notified will read, “While, at this time, we have no evidence that your information was misused, our risk assessment on this incident concluded that notice to you is appropriate. To help protect your identity, we are offering complimentary access to Experian IdentityWorksSM for 24 months at no cost to you.”**1** The notification letters, copies of which were provided to the Maine Attorney General’s Office, do not explain why the employee had so many emails in their account that 300,000 people have to be notified. In response to the incident, Justine Patrick, Chief Privacy and Data Ethics Officer for Highmark Health writes: > Consistent with corporate policies and procedures, Highmark has taken internal actions to safeguard your protected health information. The mailbox was immediately shut down, network blocking was implemented, passwords were reset, and the enterprise will continue to enhance email security controls. Additional training and education has been provided to employees in regard to the Cyber Security Incident to make them aware and help prevent future Cyber/Phishing attempts in the future. **Topics:** Public Awareness, Technology --- ### [4 health systems facing lawsuits for data breaches](https://insurancefraud.org/news_archives/4-health-systems-facing-lawsuits-for-data-breaches-2/) **Published:** September 21, 2026 **Author:** Diane Beauchamp **Content:** Here are lawsuits involving four health systems as reported by *Becker’s* since March 28. **April 14:** 1. A lawsuit claims that Greensburg, Pa.-based [Excela Health](https://www.beckershospitalreview.com/cybersecurity/lawsuit-alleges-excela-health-shared-patient-data-with-facebook-google.html) improperly disclosed patients’ protected health information to Facebook and Google. 2. A lawsuit alleges that Clearfield County, Pa.-based [Mount Nittany Health](https://www.beckershospitalreview.com/cybersecurity/lawsuit-accuses-pennsylvania-hospital-of-secretly-sharing-data-with-google-facebook.html) used pixels on its website that sent some patients’ protected health information to Facebook and Google. 3. A lawsuit filed April 3 alleges that Dallas-based [Steward Health Care System’s](https://www.beckershospitalreview.com/cybersecurity/massachusetts-health-system-sued-for-allegedly-sharing-patient-data-with-google.html) website used a Meta pixel tracking tool that sent some patient information to Meta and Google. 4. An anonymous patient from [Orlando Health](https://www.beckershospitalreview.com/cybersecurity/orlando-health-faces-lawsuit-alleging-it-shared-patient-data-with-facebook.html) filed a lawsuit March 16 alleging that the health system’s website used pixel tracking technology that sent some patient information to Facebook. **March 21:** - [Mena (Ark.) Regional Health System and Nashville, Ark.-based Howard Memorial Hospital](https://www.beckershospitalreview.com/cybersecurity/arkansas-hospitals-hit-with-eight-lawsuits-over-cyberattacks.html) are being sued for data breaches that affected 84,814 people in late 2021 and 53,668 patients in late 2022. - San Bernardino, Calif.-based [Regal Medical Group](https://www.beckershospitalreview.com/cybersecurity/11-lawsuits-filed-against-california-medical-group-over-ransomware-attack-that-affected-3-million-patients.html) is facing 11 lawsuits for a December ransomware attack that compromised the protected health information of 3.3 million patients. - A [Lehigh Valley Health Network](https://www.beckershospitalreview.com/cybersecurity/woman-sues-lehigh-valley-health-network-after-russian-ransomware-gang-posted-her-photos-online.html) patient whose nude photos were posted to the dark web by a Russian ransomware gang sued the Allentown, Pa.-based health system. - A lawsuit alleges that [Lubbock (Texas) Heart & Surgical Hospital](https://www.beckershospitalreview.com/cybersecurity/texas-surgical-hospital-facing-lawsuit-for-july-data-breach.html) had inadequate cybersecurity practices in place when a July data breach compromised the protected health information of 23,379 current and former patients. - Freehold, N.J.-based [CentraState Medical Center](https://www.beckershospitalreview.com/cybersecurity/six-lawsuits-filed-against-new-jersey-hospital.html) has been hit with five more class-action lawsuits over a December cyberattack that affected nearly 618,000 patients, bringing the total to six. **Topics:** Judicial/courts --- ### [Banner Health reaches $1.25 million settlement over data breach](https://insurancefraud.org/news_archives/banner-health-reaches-1-25-million-settlement-over-data-breach/) **Published:** September 21, 2026 **Author:** Diane Beauchamp **Content:** On Thursday, the U.S. Department of Health and Human Services announced a $1.25 million settlement with Banner Health over a data breach. In 2016, the agency’s Office of Civil Rights launched an investigation into the hacking incident, which exposed the health information of nearly 3 million people. The settlement was linked to violations of HIPAA regulations. Banner Health was accused of failing to analyze threats to digital information and failing to protect against cyber attacks. Information breached ranged from patient names to Social Security numbers. Banner will need to follow a corrective action plan under the observation of the Office of Civil Rights. Melanie Fontes Rainer, the office’s director, stressed the importance of protecting people’s health information from cybersecurity attacks. **Topics:** Judicial/courts --- ### [Maryland Nurse Pleads Guilty to Health Care Fraud Conspiracy for Role in $14 Million D.C. Medicaid Scheme](https://insurancefraud.org/news_archives/maryland-nurse-pleads-guilty-to-health-care-fraud-conspiracy-for-role-in-14-million-d-c-medicaid-scheme/) **Published:** September 21, 2026 **Author:** Diane Beauchamp **Content:** Vera Nyiawung, 34, a registered nurse from Bowie, Maryland, pleaded guilty today in connection with a $14 million health care fraud scheme that billed D.C. Medicaid for mental health services that were never provided or were grossly inflated, announced U.S. Attorney Jeanine Ferris Pirro. “Padding call lengths, recycling notes, and billing Medicaid for care that never happened isn’t healthcare—it’s organized theft,” said U.S. Attorney Pirro. “Vera Nyiawung was trusted to oversee care for vulnerable youth but instead used her position to validate fake records and facilitate a multi-million-dollar fraud scheme. My office will relentlessly prosecute those who exploit public healthcare programs for personal gain.” Nyiawung pleaded guilty today before U.S. District Judge Emmet G. Sullivan to one count of conspiracy to commit health care fraud. Nyiawung faces up to 10 years in prison a $250,000 fine and restitution. According to court documents, Nyiawung was employed as a nurse at a D.C. Medicaid provider authorized to deliver mental health rehabilitative services to youth and adolescents, beginning in January 2023. In addition to her nursing duties, Nyiawung performed Community Support Worker (CSW) duties, supervised other staff, and reviewed encounter notes for approval. Nyiawung conspired with company employees and other community support workers to siphon millions from D.C. Medicaid through thousands of fraudulent claims for reimbursement. Company employees directed Nyiawung and other workers to bill the maximum allowable time per consumer regardless of medical necessity or actual service. To execute the scheme, workers, like Nyiawung, billed a full hour for telephonic encounters even if the calls only lasted a few minutes. Workers were trained to evade false claims detection by randomly selecting times a few minutes below the 60-minute maximum call length. Workers were directed to bill three hours, and later one hour, for diagnostic assessments regardless of how much time was spent with the consumer. Community support workers were told to recycle information from a single telehealth session to generate multiple fabricated encounter notes. This resulted in bills to D.C. Medicaid for several days of services that were based on only one actual conversation with the consumer. Investigators determined that Nyiawung’s participation in the conspiracy resulted in a loss to Medicaid of over $550,000. Joining in the announcement was Matthew Wilcoxson, Interim Inspector General for the District of Columbia. This case was investigated by the FBI Washington Field Office, the D.C. Office of the Inspector General’s Medicaid Fraud Control Unit, and the Department of Health and Human Services Office of Inspector General. The District Department of Health Care Finance’s Division of Program Integrity referred this matter and provided assistance during the investigation. The matter was prosecuted by Assistant U.S. Attorney Jason Facci of the Fraud, Public Corruption, and Civil Rights Section. On April 7, the Department of Justice announced the creation of the National Fraud Enforcement Division (“Fraud Division”). The Fraud Division is laser-focused on investigating and prosecuting those who commit fraud against the American people. The Department’s work to combat fraud supports President Trump’s Task Force to Eliminate Fraud, a whole-of-government effort chaired by Vice President J.D. Vance to eliminate fraud, waste, and abuse within Federal benefit programs. The Department of Justice’s Health Care Fraud Strike Force Program, currently comprised of nine strike forces operating in federal districts across the country, has charged more than 6,200 defendants who collectively billed federal health care programs and private insurers more than $45 billion since 2007. In addition, the Centers for Medicare & Medicaid Services, working in conjunction with the Office of the Inspector General for the Department of Health and Human Services, are taking steps to hold providers accountable for their involvement in health care fraud schemes. More information can be found at [www.justice.gov/criminal-fraud/health-care-fraud-unit](http://www.justice.gov/criminal-fraud/health-care-fraud-unit). **Topics:** Medicare/Medicaid **Categories:** Conviction --- ### [Atlanta lab executives accused in $13.7M Medicare scheme](https://insurancefraud.org/news_archives/atlanta-lab-executives-accused-in-13-7m-medicare-scheme/) **Published:** September 21, 2026 **Author:** Diane Beauchamp **Content:** The federal government is suing two former executives of an Atlanta clinical laboratory, accusing them of using church events and senior living communities to generate millions of dollars in improper Medicare payments. What we know: The False Claims Act lawsuit names Jay Johnson, the former CEO and chief operating officer of Capstone Diagnostics, and Austin Whiles, the company’s former chief sales officer and vice president of business development. Several related businesses are also named. Prosecutors allege the defendants caused Medicare to pay approximately $13.7 million for genetic and respiratory pathogen tests that were not medically necessary between 2019 and 2021. Testing at churches and religious events The backstory: The first alleged scheme involved church health fairs and religious conferences. According to the complaint, Johnson and Whiles arranged for people attending the events to be swabbed for large genetic testing panels that had not been requested by their doctors. Prosecutors allege Johnson directed Capstone employees to use doctors’ names, signatures and standing orders without permission to make the tests appear properly ordered and medically necessary. The complaint also alleges kickbacks were paid to conference organizers and independent marketers who generated testing business for Capstone. Extra tests added to COVID-19 screenings The second alleged scheme involved COVID-19 testing at senior living communities. Prosecutors said Capstone added broad respiratory pathogen panels to the COVID-19 tests requested by the facilities, increasing the amount Medicare paid. The lawsuit alleges the company improperly relied on community-wide standing orders, copied doctors’ signatures, used standardized diagnosis codes and allowed sales employees to enter medical orders instead of treating providers. Federal officials said laboratory testing should be based on a patient’s medical needs, not the amount of money a company can collect. Millions allegedly routed to others Johnson allegedly transferred millions of dollars from the schemes to his now-former wife, Sarah Haslock, according to the complaint. Whiles is accused of secretly routing about $4.75 million in volume-based sales commissions from independent marketers to himself. The federal government previously reached a $14.3 million settlement with Capstone and its owner, Andrew Maloney. Capstone’s billing company, VitalAxis Inc., separately agreed to pay $300,479. Whistleblower filed original lawsuit Dig deeper: Former Capstone laboratory manager Jesse Allen initially filed the case under the False Claims Act’s whistleblower provisions. Those rules allow private citizens to sue on behalf of the government and receive part of any money recovered. The federal government intervened in the lawsuit Sept. 4. Johnson also faces pending criminal charges stemming from the alleged scheme. A federal grand jury indicted him in December 2025 on charges including health care fraud, wire fraud and conspiracy to pay and receive kickbacks. The civil allegations and criminal charges have not been proven in court. What they’re saying: Federal prosecutors condemned the alleged million-dollar scheme during a review of the civil complaint. “I would say it was pretty brazen,” said Assistant U.S. Attorney Neeli Ben-David. “They took advantage of the government and they took advantage of the taxpayers.” Ben-David noted that the executives used event access to gather swabs from attendees as a basis for fraudulent billing. “They would meet with the organizers ahead of time,” Ben-David said. “They would say, ‘Look, if you give us access to your attendees, we’ll share our proceeds with you after the fact.'” According to federal prosecutors, the scheme continued despite clear legal boundaries. “There’s a lot of evidence that they knew that their scheme was illegal but went forward anyway,” Ben-David added. “They were eager to bring in the amount of money this type of scheme would bring in.” Attempts to reach attorneys for Johnson and Haslock were not immediately successful. A phone call to Whiles was disconnected by an individual who stated he was unavailable. **Topics:** Judicial/courts --- ### [Insurance Fraud Costs $45 Billion per Year, and Honest Policyholders Often Pick Up the Tab | Insurify](https://insurancefraud.org/news_archives/insurance-fraud-costs-45-billion-per-year-and-honest-policyholders-often-pick-up-the-tab-insurify/) **Published:** September 21, 2026 **Author:** Diane Beauchamp **Content:** Fraud, inaccurate information, and misrepresentation cost the U.S. personal auto and homeowners insurance markets an estimated $45.3 billion annually, according to an analysis released by insurance risk-assessment company Clearspeed. The analysis estimates the cost of inaccurate information and fraud at $31.6 billion annually for auto insurance and another $13.7 billion for homeowners insurance. And those losses don’t necessarily stay on insurers’ balance sheets. Instead, insurers can account for expected fraud and other losses when setting rates, passing on at least some of the expense to policyholders through premium increases. The National Insurance Crime Bureau (NICB), citing research from the Coalition Against Insurance Fraud, estimates that insurance fraud results in roughly $900 in additional annual premium expense per policyholder. The FBI has also estimated the impact at $400–$700 annually for the average U.S. family. “It’s embedded in loss costs, goes through the rate-making process, and ultimately ends up being a pretty important factor in what the premium levels are,” Rob Hoyt, a risk management and insurance professor at the University of Georgia, told P&C Specialist. ## $45.3 billion is an estimate, not a tally of documented losses Clearspeed calculated its estimated figures by assuming about 10% of policies involve fraud or misrepresentation and that insurers lose about 15% of premiums associated with those policies. For consumers already facing rapidly rising insurance costs, that could mean another hidden expense built into their premiums. So far this year, 27 states have seen their insurance rates increase, according to Insurify data. Drivers in seven states and Washington, D.C., [**pay more than $3,000 annually**](https://insurify.com/car-insurance/report/) for full-coverage car insurance. Meanwhile, Insurify projects the average annual cost of home insurance in the U.S. [**will increase by 4%**](https://insurify.com/homeowners-insurance/report/home-insurance-price-projections/) in 2026, reaching $3,057 by year-end. ## Fraud costs more than the fraudulent claim Insurers have spent decades building systems designed to catch false information and suspicious claims. These systems can include additional documentation, verification, investigations, and other procedures — costs that apply even when a customer is telling the truth. And those systems mean insurers now face not only the financial losses stemming from fraud and inaccurate information but the expense and customer inconvenience of trying to detect it. The results show up on more than just a policyholder’s bill. Legitimate policyholders can face additional questions when buying coverage, requests for documentation, longer claim investigations, and delays in receiving claim payments. Clearspeed contends insurers could reduce those costs by better distinguishing low-risk customers from cases that merit additional scrutiny. ## Home insurance may be particularly vulnerable Clearspeed’s research argues that homeowners insurance could be the first major personal insurance market where rising losses, affordability problems, and the costs of operating in a “low-trust” environment become unsustainable. That’s because fraud and inaccurate information are just additions to a much longer list of forces putting upward pressure on home insurance costs. Rising construction and repair expenses, severe weather, reinsurance costs, and insurers’ reassessment of catastrophe risk all play roles in pushing home insurance premiums higher. And the costs associated with all these perils are becoming increasingly visible to consumers via steep renewal increases, higher deductibles, non-renewals, and difficulty finding coverage. ## Can insurers trust customers without treating everyone like a suspect? Clearspeed’s report states insurers need to rethink the system because it subjects millions of legitimate customers to fraud-prevention measures designed to catch a relatively small number of bad actors. “It is no longer arguable. The U.S. insurance system has evolved into a low-trust system that cannot run indefinitely, as the costs of a few overwhelm the many,” study author Kim Garland said in a statement announcing the analysis. The challenge is finding a way to identify suspicious behavior without making insurance more difficult for everyone else — or creating new problems involving privacy, accuracy, or discrimination. For policyholders, the stakes are substantial. If insurers can reduce fraud and the cost of detecting it, consumers could theoretically benefit from lower expenses and faster claims processing. **Topics:** Public Awareness --- ### [Four North Texas Boarding-Home Operators Face Indictments in Separate Elder-Fraud Cases](https://insurancefraud.org/news_archives/four-north-texas-boarding-home-operators-face-indictments-in-separate-elder-fraud-cases/) **Published:** September 21, 2026 **Author:** Diane Beauchamp **Content:** Four North Texas boarding-home operators are facing federal charges in two separate cases involving alleged financial exploitation of vulnerable residents. The indictments, returned Aug. 26, concern the alleged sale of a 79-year-old woman’s Garland home and the alleged diversion of Social Security benefits connected to a resident who later died, according to [Dallas Express](https://dallasexpress.com/metroplex/four-north-texas-boarding-home-operators-indicted-in-elder-fraud-schemes/). The defendants are Donella Locke, Suekya Whitney, Shakoya Crenshaw and Krystle Locke. The allegations involve people who prosecutors say were entrusted with access to residents’ property, identities or benefits. An indictment is an accusation, and the defendants are presumed innocent unless prosecutors prove the charges in court. ### What prosecutors allege In the Garland case, Donella Locke, Whitney and Crenshaw are charged with conspiracy and four counts of making false statements to a financial institution. The indictment alleges that the three obtained power of attorney over a woman identified as W.S. and arranged for her longtime home to be sold to Whitney and Crenshaw. The transaction generated more than $156,000, and prosecutors allege that funds moved through several accounts before $147,000 was transferred to Donella Locke, according to the [Dallas Express account](https://dallasexpress.com/metroplex/four-north-texas-boarding-home-operators-indicted-in-elder-fraud-schemes/). The second indictment names Krystle Locke in four counts of theft of government money and one count of aggravated identity theft. Prosecutors allege that S.T. gave Locke durable power of attorney in December 2022, after which Locke applied for Social Security Disability Insurance and Supplemental Security Income for S.T. and directed the payments into her own account. The indictment further alleges that more than $50,000 in benefits was taken and that deposits totaling more than $44,000 were recorded in October 2024, around the time of S.T.’s death, as reported by [Dallas Express](https://dallasexpress.com/metroplex/four-north-texas-boarding-home-operators-indicted-in-elder-fraud-schemes/). ### Why the allegations fall within elder-exploitation safeguards The alleged conduct corresponds to examples of exploitation identified by the [Texas Department of Family and Protective Services](https://www.dfps.texas.gov/adult_protection/), which says exploitation can include using an elderly or disabled person’s resources for personal or monetary benefit, including taking Social Security or SSI checks or property. That definition provides general protective-services context; it does not establish that the allegations against these defendants are true. Texas Adult Protective Services investigates reports of abuse, neglect and financial exploitation involving people who are 65 or older or have disabilities, according to the agency’s [data book](https://www.dfps.texas.gov/About_DFPS/Data_Book/Adult_Protective_Services/). Its work can include people living in community settings such as unlicensed adult foster homes and unlicensed board-and-care homes, the agency says in its [investigations and services guidance](https://www.dfps.texas.gov/Adult_Protection/Investigations_and_Services.asp). The Social Security Administration’s Office of Inspector General separately lists representative-payee misuse and deceased-payee fraud among the disability-insurance fraud categories it investigates, while cautioning that the general categories do not determine whether a particular alleged scheme occurred. In Texas, boarding-home oversight can also vary by locality: a [presentation on the Texas regulatory model](https://www.nmlegis.gov/handouts/LHHS%20070616%20Item%203%20Eliot%20Shapleigh,%20former%20State%20Senator,%20The%20Texas%20Model%20of%20Boarding%20Home%20Regulation.pdf) says House Bill 216 gave local governments the option to regulate boarding homes subject to certain requirements. ### What remains unresolved The indictments establish the charges, not guilt. The supplied records and published reporting do not identify defense attorneys, detention decisions or plea entries. They also do not, by themselves, show how the homes were licensed or regulated locally, whether other residents were affected, or whether the alleged transactions resulted in any recovery of property or benefits. If convicted, the three defendants in the home-sale case face up to five years on the conspiracy charge and up to 30 years on each false-statement count, according to [Dallas Express](https://dallasexpress.com/metroplex/four-north-texas-boarding-home-operators-indicted-in-elder-fraud-schemes/). Krystle Locke faces up to 10 years on each theft count, while the aggravated-identity-theft charge carries a mandatory consecutive two-year sentence. Those are statutory maximums, not predictions of the sentences that would follow a conviction. **Topics:** Elderly Fraud **Categories:** Arrest --- ### [New murder trial set for men accused of killing federal witness in 'Highway Robbery' case](https://insurancefraud.org/news_archives/new-murder-trial-set-for-men-accused-of-killing-federal-witness-in-highway-robbery-case/) **Published:** September 21, 2026 **Author:** Diane Beauchamp **Content:** A federal judge has scheduled a new murder trial for former New Orleans attorney Sean Alfortish and Leon “Chunky” Parker, who are accused of killing a federal witness involved in a sprawling staged-crash insurance fraud investigation. Court documents show Chief U.S. District Judge Wendy Vitter has scheduled the new trial for June 7, 2027. Both sides must submit their proposed schedule by mid-October, with a final pretrial hearing set for May 2027. The new trial comes after a federal jury deadlocked earlier this month on all five murder-related charges against the men. After more than 30 hours of deliberations over five days, jurors were unable to reach unanimous verdicts, and Vitter declared a mistrial. The charges stem from the 2020 killing of Cornelius Garrison III, a participant in the staged-crash scheme who was cooperating with the FBI’s investigation. Garrison was shot and killed in September 2020 outside his mother’s home in New Orleans’ Gentilly neighborhood. Prosecutors allege Alfortish arranged for Parker to kill Garrison after learning that he was working with federal investigators. The case is part of Operation Sideswipe, a federal investigation into staged collisions in which so-called “slammers” intentionally crashed vehicles into 18-wheelers and other commercial vehicles to pursue fraudulent insurance claims and lawsuits. The murder case is separate from fraud-related convictions involving both defendants. Ryan Harris has pleaded guilty to aiding and abetting Garrison’s murder and faces up to 35 years in prison. As part of a plea deal, Harris testified that he and Parker planned the murder together, even driving by Garrison’s home the night before to check for surveillance cameras. Defense attorneys challenged Harris’ credibility during the trial, pointing to lies he acknowledged telling FBI agents and inconsistencies in his testimony about the killing. Alfortish was convicted in August of conspiracy to commit mail and wire fraud, two counts of mail fraud, obstruction of justice and witness tampering. He was acquitted of another obstruction charge and a count of subornation of perjury. Prosecutors say he faces up to 90 years in prison on those convictions. Parker previously pleaded guilty to conspiracy and two counts of mail fraud related to the staged-crash scheme. He faces up to 60 years in prison based on those convictions. **Topics:** Auto - staged **Categories:** Arrest --- ### [Maryland Long Term Care Pharmacy Pays $5.3M to Settle Allegations of Billing for Drugs Without Valid Prescriptions](https://insurancefraud.org/news_archives/maryland-long-term-care-pharmacy-pays-5-3m-to-settle-allegations-of-billing-for-drugs-without-valid-prescriptions/) **Published:** September 21, 2026 **Author:** Diane Beauchamp **Content:** Remedi SeniorCare Holding Corporation (Remedi), headquartered in Towson, Maryland, has [agreed](https://www.justice.gov/opa/media/1461646/dl) to pay over $5.3 million to the United States to resolve allegations that it violated the False Claims Act (FCA) by billing the Medicare and Medicaid programs for prescription drugs despite lacking valid prescriptions. The settlement is based on Remedi’s ability to pay and will be paid over time. The United States alleged that, from Jan. 1, 2015 through March 31, 2021, Remedi submitted false claims to the Medicare and Medicaid programs for prescription drugs that lacked valid prescriptions and were dispensed to residents of assisted living facilities in various states. “When pharmacies dispense drugs without valid prescriptions, they undermine both patient safety and the integrity of vital federal healthcare programs,” said Assistant Attorney General Brett A. Shumate of the Justice Department’s Civil Division. “Today’s resolution demonstrates the Department’s commitment to protecting vulnerable populations and holding accountable pharmacies that fail to comply with their obligations under the False Claims Act.” “Billing Medicare and Medicaid for prescription drugs without a valid prescription is unlawful and can present serious risks,” said U.S. Attorney Dominick S. Gerace II for the Southern District of Ohio. “As evidenced by this settlement, my Office will enforce the FCA to hold responsible those who improperly bill federal programs.” “Billing Medicare and Medicaid for drugs dispensed without valid prescriptions puts residents of assisted living facilities at risk and undermines essential safeguards designed to protect patient health and federal health care programs,” said Acting Deputy Inspector General for Investigations Miranda L. Bennett of the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG). “HHS OIG, working closely with our law enforcement partners, will continue to hold accountable those who disregard requirements meant to ensure the safety of patients and the integrity of taxpayer funded programs.” The settlement includes the resolution of claims brought under the *qui tam* or whistleblower provisions of the False Claims Act by Maureen Gearhart and Laura Griffieth, former employees of Remedi. Under those provisions, a private party can file an action on behalf of the United States and receive a portion of any recovery. The *qui tam* case is captioned *United States ex rel. Gearhart & Griffieth v. Remedi SeniorCare Holding Corp., et al.*, No. 1:20cv970 (S.D. Ohio). The settlement provides for the whistleblowers to receive a share of the settlement payments made over time. The resolution obtained in this matter was the result of a coordinated effort between the Justice Department’s Civil Division, Commercial Litigation Branch, Fraud Section, and the U.S. Attorney’s Office for the Southern District of Ohio, with assistance from HHS-OIG and the Attorney General’s Office for the State of Ohio. The matter was handled by Fraud Section Senior Litigation Counsel Laurie A. Oberembt of the Justice Department’s Civil Division and Assistant U.S. Attorney Brandi Stewart for the Southern District of Ohio. The investigation and resolution of this matter illustrate the government’s emphasis on combating healthcare fraud. One of the most powerful tools in this effort is the False Claims Act. Tips and complaints from all sources about potential fraud, waste, abuse, and mismanagement, can be reported to the Department of Health and Human Services at 800-HHS-TIPS (800-447-8477). This year the Administration launched the Task Force to Eliminate Fraud and the National Fraud Enforcement Division to enhance the Administration’s war on fraud, waste, and abuse in federal programs. When unscrupulous actors exploit these programs for their own financial gain, they defraud the government, harm the people these programs are designed to aid and protect, and undermine American businesses that play by the rules. The Civil Division’s FCA enforcement plays a critical role in combatting such fraudulent schemes, recovering billions of dollars for the American taxpayers, and holding wrongdoers accountable. FCA matters will continue to be on the forefront of the battle against fraud, and the Civil Division’s FCA work will support and advance the mission of the Task Force to Eliminate Fraud and the National Fraud Enforcement Division. **Topics:** Judicial/courts --- ### [Texas man who operated 'ghost broker' scheme sentenced to probation, deportation](https://insurancefraud.org/news_archives/texas-man-who-operated-ghost-broker-scheme-sentenced-to-probation-deportation/) **Published:** September 21, 2026 **Author:** Diane Beauchamp **Content:** A Texas man accused of running a “ghost broker” scheme in Utah was sentenced to probation and deportation. Carlos David Garcia Gonzalez, 38, of Liberty Hills, Texas, was charged in June in 3rd District Court with insurance fraud, communications fraud and two counts of engaging in a pattern of unlawful activity, second-degree felonies; and identity fraud and forgery, third-degree felonies. Garcia pleaded guilty on Aug. 22 to the insurance fraud charge and one count of a pattern of unlawful activity, second-degree felonies. The other four charges were dismissed as part of the plea agreement. “I did operate a large-scale ghost broker scheme whereby I procured auto policies out of Salt Lake County by submitting fraudulent data online to three insurance companies. This intentional misrepresentation resulted in approximately $832,000 restitution from premium avoidance,” Garcia said in his plea statement. Investigators say Garcia acted as a licensed insurance agent and obtained more than 1,100 auto policies from three different insurance companies. He used digital payment platforms and telecommunications to defraud the victims, “receiving approximately $84,470 in payments for faulty or non-existent auto insurance policies,” the charges said. “Garcia used the names, birth dates and insurance policy numbers of individuals to make unauthorized policy changes over the phone with insurance companies,” charging documents state. The fraudulent activity included “forging a name, fabricating a non-existent spouse and providing an incorrect driver’s license number of another.” One insurance company “identified over 1,000 phone calls made by Carlos Garcia where he misrepresented himself as various policyholders to modify driver and payment data,” the charges state. Investigators confronted Garcia at his home in Texas, and he “admitted to acting as a ‘ghost broker,’ to lower premiums for non-English-speaking clients, and receiving ‘tips’ or fees via Zelle,” according to the charges. But despite a cease-and-desist order from an insurance company following the visit by investigators, “Garcia’s phone number has continued to be used to make automated payments on fraudulent policies.” “The Utah Department of Insurance executed a ‘Buy Bust’ operation. An undercover investigator contacted Garcia via WhatsApp. Garcia requested a $100 Venmo fee, then provided the quote after receiving payment,” charging documents continued. One insurance company’s analysis of the “‘Buy Bust’ digital footprint” linked Garcia’s phone and email to “415 sold policies and 126 quotes between October 2025 and January 2026 alone,” while a second analysis “showed an additional 527 quotes and 194 policies sold between the previous buy bust and current date process,” the charges state. On Aug. 24, Garcia was sentenced to one to 15 years in prison for both charges, but the terms were suspended. He was then sentenced to 364 days in jail, but prosecutors agreed to stay the sentence and issue a $100,000 warrant within 60 days after the sentencing, according to court documents. “Defendant agrees (that) should he re-enter the country illegally after deportation, he will automatically serve the 364 days in jail without credit for time served and without the need for further proceedings,” the plea agreement states. As part of his plea deal, he will serve three years on probation and two of his bank accounts were seized to pay restitution. Garcia was released to the custody of Immigration and Customs Enforcement, according to court records. **Topics:** Insider - agent, Synthetic Identity Theft, Unlicensed --- ### [Federal watchdog accuses Humana, UnitedHealthcare Medicare Advantage plans of upcoding](https://insurancefraud.org/news_archives/federal-watchdog-accuses-humana-unitedhealthcare-medicare-advantage-plans-of-upcoding/) **Published:** September 21, 2026 **Author:** Diane Beauchamp **Content:** ### Dive Brief: - Plans operated by the two largest Medicare Advantage insurers jointly overcharged the government almost $180 million in 2020 and 2021 by exaggerating the health needs of their members, according to new audits from a federal watchdog that could intensify concerns about insurers gaming the privatized Medicare program. - [HumanaChoice](https://oig.hhs.gov/reports/all/2026/medicare-advantage-compliance-audit-of-specific-diagnosis-codes-that-humanachoice-contract-h5216-submitted-to-cms/) and [UnitedHealthcare of Wisconsin](https://oig.hhs.gov/reports/all/2026/medicare-advantage-compliance-audit-of-specific-diagnosis-codes-that-unitedhealthcare-of-wisconsin-inc-contract-h5253-submitted-to-cms/) frequently submitted diagnosis codes to Medicare that weren’t backed up by medical documentation, generating an extra $131 million and $47 million in reimbursement, respectively, over the two years, according to the HHS Office of the Inspector General. - The HHS OIG suggested that the insurers refund the estimated overpayments to the CMS and beef up compliance procedures to make sure they’re not submitting unsupported codes. Humana and UnitedHealthcare both said the audit methdology was flawed and that they don’t plan to return the funds. ### Dive Insight: In MA, the federal government pays private insurers a per member, per month fee for managing the health of Medicare seniors. That payment is adjusted up or down depending on the health needs of a particular member, so that insurers are paid more for seniors who are expected to require more medical care and therefore more expensive to cover. The purpose of this system is to level the playing field and keep plans from cherrypicking healthier members. But it also creates a significant incentive for insurers to exaggerate health needs of their members to receive higher reimbursement, a practice known as upcoding. CMS determines MA enrollees’ health statuses by collecting diagnosis codes from MA insurers. Certain diagnoses are at a higher risk of upcoding, which is why the HHS OIG set out on a series of investigations to see whether high-risk diagnosis codes for conditions like acute stroke, heart attack, embolism and sepsis were being misused. The watchdog’s latest audits published Tuesday zeroed in on plans operated by the two largest MA insurers in the U.S.: UnitedHealthcare and Humana, which collectively cover almost 15 million seniors in the privatized Medicare program. The HHS OIG focused on 11 groups of high-risk diagnosis codes for the 2020 and 2021 payment years. Researchers stratified the plans’ members who had one or more of these high-risk conditions into a metric called “enrollee-years,” to parse out data for specific conditions in each time period. Of the 220 enrollee-years the HHS OIG sampled for HumanaChoice, 178 weren’t supported by medical records, the HHS OIG found. That equates to almost $670,000 in overpayments, or about $130.9 million when extrapolated to HumanaChoice’s entire contract. For UnitedHealthcare of Wisconsin, medical documentation didn’t support diagnoses for 183 of the 250 sampled enrollee-years, according to the HHS OIG’s report. That generated roughly $722,000 in overpayments, causing the enforcement agency to estimate the plan received at least $46.9 million in improper reimbursement for 2020 and 2021. Types of improper coding varied, but generally boiled down to the plans recording a more severe version of a member’s actual medical condition, or including codes for diseases that a member used to have but had since recovered from, according to the report. #### The lion’s share of HumanaChoice’s and UnitedHealthcare of Wisconsin’s high-risk diagnoses weren’t supported by members’ medical records Both Humana and UnitedHealthcare said they disagreed with the audits’ conclusions, in part because the methodology was skewed toward finding overpayments. The insurers told the HHS OIG they have no obligation to return the funds or perform additional reviews of their coding practices. “Humana takes its compliance responsibilities seriously and remains committed to working with CMS and policymakers to find ways to preserve affordable coverage and effective healthcare services for older Americans,” a spokesperson for the Kentucky-based insurer said. “We strongly disagreed with the OIG’s methodology and findings, and that we have repeatedly shared our concerns about the methodology with CMS. As the OIG acknowledges, its findings and recommendations do not represent final determinations.” “While we welcome government reviews of our Medicare Advantage program, we disagree with the current approach to validating data,” a UnitedHealthcare spokesperson said. “The flawed methodology in this report from the Office of the Inspector General is further evidence that modernization is needed, and we remain committed to working with both CMS and the OIG to improve the program and their audit processes.” It’s not the first time the MA giants have found themselves in the spotlight over improper coding. [UnitedHealthcare in particular has faced censure](https://www.healthcaredive.com/news/unitedhealth-grassley-medicare-advantage-investigation/809377/) for its coding practices, with a Senate investigation earlier this year finding the company employs an army of coders to review medical records, incentivizes external providers to assess for certain conditions and takes other steps to aggressively capture diagnoses and maximize members’ risk scores. Smaller insurers have also faced scrutiny. This spring, the HHS OIG audited [Blue Cross and Blue Shield of Alabama](https://oig.hhs.gov/reports/all/2026/medicare-advantage-compliance-audit-of-specific-diagnosis-codes-that-blue-cross-and-blue-shield-of-alabama-contract-h0104-submitted-to-cms/), [Gateway Health Plan](https://oig.hhs.gov/reports/all/2026/medicare-advantage-compliance-audit-of-specific-diagnosis-codes-that-gateway-health-plan-inc-contract-h5932-submitted-to-cms/) and [Priority Health](https://oig.hhs.gov/reports/all/2026/medicare-advantage-compliance-audit-of-specific-diagnosis-codes-that-priority-health-contract-h2320-submitted-to-cms/) and found the three insurers’ improper submissions of high-risk diagnoses drummed up $7 million, $4.3 million and $4.4 million in overpayments in 2018 and 2019. The CMS has taken some steps to crack down on upcoding, finalizing a [policy meant to stop MA plans from getting paid for diagnoses](https://www.healthcaredive.com/news/cms-finalizes-higher-medicare-advantage-rates-2027/816633/) that aren’t tied to an actual medical encounter in April. **Topics:** Judicial/courts --- ### [Arizona Addiction Treatment Clinic Owner Sentenced to 14 Years in Prison for Leadership Role in $69M Medicaid Fraud Scheme](https://insurancefraud.org/news_archives/arizona-addiction-treatment-clinic-owner-sentenced-to-14-years-in-prison-for-leadership-role-in-69m-medicaid-fraud-scheme/) **Published:** September 21, 2026 **Author:** Diane Beauchamp **Content:** A Phoenix woman was sentenced to 14 years in prison in connection with her role in fraudulently billing Arizona’s Medicaid agency more than $69 million in less than one year for addiction treatment therapy. Many of the patients the defendant used to fuel her scheme were Native Americans covered by Arizona Medicaid under a specific program that reimbursed at higher rates than other Medicaid programs. In addition to the prison sentence, the defendant was ordered to pay almost $55 million in restitution, and to forfeit almost $9.5 million in fraud proceeds seized from seven bank accounts she controlled and almost $7 million in real estate properties. “The Fraud Division is determined to hold accountable individuals who exploit the Medicaid system and Native American health care programs,” said Assistant Attorney General Colin M. McDonald of the Justice Department’s National Fraud Enforcement Division. “This sentence sends a clear message — if you take advantage of vulnerable populations to steal from the American taxpayer, you will pay the price.” “Ms. Anagho’s scheme manipulated a program that was intended to help Native Americans in Arizona,” said U.S. Attorney Timothy Courchaine for the District of Arizona. “The fourteen-year sentence that she received is a sign of how serious and damaging health care fraud is to our society, and how important it is that we stop individuals who undermine the value of these programs.” “The FBI will investigate and hold those who target, defraud, and exploit our healthcare programs accountable,” said Special Agent in Charge Rebecca Day of the FBI Phoenix Field Office “We will continue to work with our partners to stop imposters like Ms. Anagho in their tracks and bring them to justice.” “Medicaid funds exist to support some of our nation’s most vulnerable individuals. Exploiting this program for personal gain steals taxpayer dollars and undermines a critical safety net relied on by millions,” said Acting Deputy Inspector General for Investigations Miranda L. Bennett of the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG). “HHS-OIG and our law enforcement partners will continue to pursue those who defraud Medicaid and ensure they are held fully accountable.” According to court documents, Rita Ntusa Anagho, 54, of San Tan Valley, Arizona, owned and operated Tusa Integrated Clinic, LLC (Tusa), an addiction treatment center that fraudulently billed the Arizona Health Care Cost Containment System (AHCCCS) over $69 million from approximately May 2022 through March 2023. AHCCCS paid Tusa approximately $54.9 million based on these false and fraudulent claims. Anagho, a licensed nurse practitioner, coordinated and carried out this massive health care fraud scheme by exploiting vulnerable substance abuse treatment patients. Anagho enrolled patients whose health care coverage was provided by the AHCCCS in her fraudulent clinic, Tusa. Indeed, Anagho and her co-conspirators deliberately targeted AHCCCS patients who were covered under the American Indian Health Care Program (AIHP) fee-for-service plan available to Native Americans. Anagho and her co-conspirators often deliberately sought such patients because the AIHP provided higher reimbursement rates than other AHCCCS health care plans. Anagho orchestrated this scheme to defraud AHCCCS by submitting false claims for purported addiction treatment services that were either not provided at all or not provided as billed. In addition, Anagho and her co-conspirators paid illegal kickbacks to owners of numerous area sober homes for patients who were referred to her clinic. Anagho and others falsified the treatment notes and records related to the purported addiction treatment services to conceal the scheme. Anagho then laundered the proceeds of her fraud and obstructed the investigation of her crimes by instructing her former employees to create fake medical records when Tusa received a subpoena for documents. In May 2025, Anagho pleaded guilty to conspiracy to commit wire fraud and health care fraud. FBI and HHS-OIG investigated the case. Assistant Deputy Chief James V. Hayes and Trial Attorney Sarah Edwards of the Fraud Division’s Health Care Fraud Section and Assistant U.S. Attorney Matthew Williams for the District of Arizona prosecuted the case. Assistant U.S. Attorney Joseph F. Bozdech for the District of Arizona assisted with forfeiture matters. On April 7, the Department of Justice announced the creation of the National Fraud Enforcement Division (Fraud Division). The Fraud Division is laser-focused on investigating and prosecuting those who commit fraud against the American people. The Department’s work to combat fraud supports President Trump’s Task Force to Eliminate Fraud, a whole-of-government effort chaired by Vice President J.D. Vance to eliminate fraud, waste, and abuse within Federal benefit programs. The Department of Justice’s Health Care Fraud Strike Force Program, currently comprised of nine strike forces operating in federal districts across the country, has charged more than 6,200 defendants who collectively billed federal health care programs and private insurers more than $45 billion since 2007. In addition, the Centers for Medicare & Medicaid Services, working in conjunction with the Office of the Inspector General for the Department of Health and Human Services, are taking steps to hold providers accountable for their involvement in health care fraud schemes. More information can be found at [www.justice.gov/criminal-fraud/health-care-fraud-unit](http://www.justice.gov/criminal-fraud/health-care-fraud-unit). **Topics:** Medicare/Medicaid **Categories:** Conviction --- ### [DOJ Sues Former Georgia Lab Execs for Defrauding Medicare by Targeting Faith-Based Communities and Seniors](https://insurancefraud.org/news_archives/doj-sues-former-georgia-lab-execs-for-defrauding-medicare-by-targeting-faith-based-communities-and-seniors/) **Published:** September 21, 2026 **Author:** Diane Beauchamp **Content:** The United States has filed a complaint under the False Claims Act against Jay Johnson, the former Chief Operating Officer and Chief Executive Officer of the Atlanta-based clinical laboratory Capstone Diagnostics, LLC (“Capstone”); Austin Whiles, Capstone’s former Chief Sales Officer and Vice President of Business Development; and associated entities. The complaint alleges that the defendants caused Medicare to pay approximately $13.7 million for genetic and respiratory pathogen panel testing that was not medically necessary. Johnson also faces criminal health care and wire fraud charges arising from the scheme, which allegedly exploited church health fairs, religious conferences, and senior living communities to generate testing volume, including by paying kickbacks to conference organizers and independent marketers. “Johnson and Whiles allegedly took advantage of individuals at religious events and senior living facilities to line their pockets and drain millions of dollars from the Medicare trust fund,” said U.S. Attorney Theodore S. Hertzberg. “This lawsuit reflects our commitment to recovering unlawfully diverted public money from anyone who defrauds the government and taxpayers.” “Today’s complaint reflects the Justice Department’s steadfast commitment to combating fraud in federal health care programs,” said Brett A. Shumate, Assistant Attorney General of the Civil Division. “Laboratory testing must be driven by patient needs, not financial incentives. We will continue to use the False Claims Act to hold accountable those who exploit Medicare for personal gain.” “The conduct alleged in this complaint reflects a blatant disregard for patient welfare and an abuse of trust,” said Acting Deputy Inspector General for Investigations Miranda L. Bennett of the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG). “HHS-OIG remains committed to working with our federal partners to safeguard Medicare and ensure that those who exploit the program and the vulnerable communities it serves are held accountable.” “Laboratory companies have a responsibility to perform the specific testing requested by physicians,” said Marlo Graham, Special Agent in Charge of FBI Atlanta. “Schemes like this raise healthcare costs for everyone. The FBI is committed to safeguarding the integrity of our federal health care programs.” According to U.S. Attorney Hertzberg, the complaint, and other information presented in court: Between 2019 and 2021, Johnson and Whiles allegedly engaged in two schemes to defraud Medicare. First, Johnson and Whiles allegedly targeted church-sponsored health fairs and religious conferences to perform and claim reimbursement for massive amounts of genetic testing not requested by physicians. Johnson allegedly directed Capstone personnel to swab attendees at mass events and then, without permission, used physicians’ names, signatures, standing orders, and other paperwork to make the testing appear properly ordered and medically necessary. Second, Johnson and Whiles allegedly added medically unnecessary respiratory pathogen panels to COVID-19 tests sought by senior living communities, which inflated the Medicare reimbursements paid to Capstone. They allegedly did so by improperly using community- and chain-wide standing orders, copying physician signatures, standardizing diagnosis codes, having sales personnel enter orders rather than treating providers, and paying unlawful remuneration in violation of the Anti-Kickback Statute. In total, the defendants allegedly caused Medicare to pay approximately $13.7 million for laboratory tests generated through the two schemes from 2019 through 2021. Johnson allegedly transferred millions of dollars derived from the schemes to his now-former wife, Sarah Haslock, and Whiles secretly routed to himself approximately $4.75 million in volume-based commissions from independent marketers. Relatedly, the United States reached settlements with [Capstone and its owner, Andrew Maloney, for $14.3 million](https://www.justice.gov/archives/opa/pr/georgia-laboratory-owner-pleads-guilty-felony-charge-and-pays-143-million-resolve-liability) and with [Capstone’s billing company, VitalAxis, Inc. for $300,479](https://www.justice.gov/archives/opa/pr/lab-billing-company-settles-false-claims-act-allegations-relating-unnecessary-respiratory) to resolve their potential civil liability under the False Claims Act. On September 4, 2026, the United States intervened in a lawsuit filed in the U.S. District Court for the Northern District of Georgia under the *qui tam* or whistleblower provisions of the False Claims Act, *United States ex rel. Allen v. Capstone Diagnostics, LLC, et al.*, Civil Action No. 1:19-CV-5598-SEG. Under the False Claims Act, private citizens may bring suit for false claims on behalf of the United States and share in any recovery obtained by the government. Jesse Allen, the former laboratory manager for Capstone, is the whistleblower who filed the initial lawsuit. On December 10, 2025, a federal grand jury indicted Johnson for conspiracy to commit health care and wire fraud, health care fraud, wire fraud, conspiracy to receive and pay kickbacks, and payment of kickbacks in connection with a federal health care program. Those charges are currently pending. Assistant U.S. Attorney Neeli Ben-David and Associate Deputy Attorney General Paul Perkins, Fraud Section Trial Attorney Asha Natarajan, and Healthcare Fraud Investigative Analyst Alena Evans of the Justice Department’s Civil Division are handling the civil False Claims Act matter, with substantial assistance from the United States Department of Health and Human Services, Office of Inspector General and the Federal Bureau of Investigation. Assistant U.S. Attorney Angela Adams and Special Assistant U.S. Attorney Jim Mooney are handling the criminal matter. One of the most powerful tools in the effort to combat healthcare fraud is the False Claims Act. Tips and complaints from all sources about potential fraud, waste, abuse, and mismanagement, can be reported to HHS at 800-HHS-TIPS (800-447-8477). This year, the Trump Administration launched the Task Force to Eliminate Fraud and the National Fraud Enforcement Division to enhance the Administration’s war on fraud, waste, and abuse in federal programs. When unscrupulous actors exploit these programs for their own financial gain, they defraud the government, harm the people these programs are designed to aid and protect, and undermine American businesses that play by the rules. The Civil Division’s False Claims Act enforcement plays a critical role in combatting such fraudulent schemes, recovering billions of dollars for the American taxpayers, and holding wrongdoers accountable. False Claims Act matters will continue to be on the forefront of the battle against fraud, and the Civil Division’s False Claims work will support and advance the mission of the Task Force to Eliminate Fraud and the National Fraud Enforcement Division. **Topics:** Judicial/courts --- ### [Tower Hill faces malicious prosecution suit after fraud case collapses](https://insurancefraud.org/news_archives/tower-hill-faces-malicious-prosecution-suit-after-fraud-case-collapses/) **Published:** September 21, 2026 **Author:** Diane Beauchamp **Content:** A Florida roofing contractor has filed a federal lawsuit accusing Tower Hill Insurance of engineering a criminal fraud prosecution that ran for more than two years – then collapsed one week before trial. The complaint was filed September 15, 2026, in the US District Court for the Southern District of Florida. It names Tower Hill Insurance Group, Tower Hill Prime Insurance Company, the law firm Zinober, Diana & Monteverde, and four individuals. The core claim is malicious prosecution, meaning the contractor says he was put through a baseless criminal case on purpose. The suit brings that claim under both federal civil rights law and Florida common law, and adds conspiracy on top. It starts with a roof. After Hurricane Irma, the Rookery Pointe Homeowners Association in Lee County assigned its insurance claim rights to the contractor’s company. That company submitted an estimate of approximately $414,000 for roofing and related work to Tower Hill. A subcontractor’s permit application put the roofing portion at about $233,000. Tower Hill’s special investigations unit reported the claim to the Florida Department of Financial Services as suspected fraud in 2021, according to the complaint. DFS looked into it. The head attorney of the Economic Crimes Unit at the Lee County State Attorney’s Office found there was “no criminal violation” – just a pricing dispute suited to civil court. DFS closed the investigation. That should have been the end of it. But the complaint alleges Tower Hill and its co-defendants did not let it go. A fresh DFS investigation into the same Rookery Pointe claim was opened in 2023, according to the filing. The complaint states that a DFS lieutenant apparently submitted the fraud tip, listing a Rookery Pointe homeowner as the complainant. That homeowner later testified he “never initiated an investigation with DFS” and the department “was not authorized to use his name at all.” The detective assigned to the 2023 case, the filing alleges, was not told about the 2021 finding of no probable cause. And the pricing gap at the heart of the new investigation was actually smaller than the one prosecutors had already reviewed and dismissed two years earlier. Then there are the hidden estimates. The complaint alleges the defendants had estimates that backed the contractor’s pricing – and buried them. An appraiser’s estimate and one from AAP Claims were both higher than the contractor’s company’s figure, according to the filing. A third, from Catastrophe Response Unit, was described as “in line” with it. All three, the complaint alleges, were “concealed and conveniently omitted” from the criminal investigation. The contractor was arrested in November 2023. The charges: insurance fraud and grand theft, both first-degree felonies that the complaint says carried a combined potential sentence of up to 60 years in prison. The filing reproduces a DFS press release from December 4, 2023, in which the then-CFO of DFS announced the arrest in strongly condemnatory language. The case fell apart during discovery, according to the complaint. Witnesses gave “conflicting testimony or recanted prior statements altogether.” The DFS detective who led the 2023 investigation allegedly testified there was no evidence the contractor had personally “drafted, prepared, or provided any specific estimate” to Tower Hill. Tower Hill’s own SIU director allegedly testified under oath that he had “no idea” whether the contractor had ever prepared an estimate submitted to the carrier. Asked whether the contractor had “taken money from Tower Hill that he was otherwise not entitled to,” the answer was blunt: “Not to my knowledge, no.” Evidence went missing, too. The complaint alleges a CD containing the complete 2021 investigative file – spreadsheets, presentations, the disposition memo – was “later lost or destroyed by DFS.” About one week before trial, the State of Florida formally abandoned the prosecution. Public statements attributed the dismissal to “a lack of evidence.” The contractor alleges the two-plus years of criminal proceedings destroyed his company. Vendors and referral sources walked away. The complaint seeks compensatory damages, punitive damages, lost profits, and attorneys’ fees. One defendant is not yet in the case. The plaintiffs sent a pre-suit notice to DFS under Florida law, which requires a six-month waiting period before a state agency can be sued. That clock runs out in January 2027. For SIU teams and claims professionals, the case is a pointed reminder that a fraud referral does not end at the referral – if a prosecution built on it collapses, the insurer that fed it may find itself on the other side of a courtroom. The allegations in the complaint have not been tested in court, and no court has made any findings on the merits. **Topics:** Judicial/courts --- ### [Southern Tier Arson Case Named Among New York’s Worst Insurance Fraud Schemes Of 2026](https://insurancefraud.org/news_archives/southern-tier-arson-case-named-among-new-yorks-worst-insurance-fraud-schemes-of-2026/) **Published:** September 21, 2026 **Author:** Diane Beauchamp **Content:** A Tioga County arson case has landed on a statewide list most local business owners would never want to make. The New York Alliance Against Insurance Fraud (NYAAIF) just released its 2026 “Filthy Five,” a mid-year rundown of the five most outrageous alleged insurance fraud schemes uncovered across the state so far this year, and one of them happened right here in the Southern Tier. Tioga County Arson Ring Highlights Fraud Concerns In The Southern Tier Investigators allege a man from Nichols orchestrated multiple suspicious structure fires in and around Berkshire as part of an insurance-fraud scheme, before becoming the subject of a multi-state manhunt. NYAAIF describes the case as a reminder of how organized and dangerous arson-for-profit schemes can become once they escalate beyond a single property. As with all pending cases, the individual involved is presumed innocent unless proven guilty in a court of law. A separate case out of Franklin County in the North Country made the list as well, where authorities allege a man intentionally set fire to his own building before attempting to collect insurance proceeds. NYAAIF says traditional arson-for-insurance schemes like that one continue to show up across New York even as fraud tactics elsewhere grow more sophisticated. Watchdog Group Names New York’s Filthy Five Fraud Cases For 2026 The other three cases on this year’s list involve alleged healthcare fraud rather than fire. In Queens, two Flushing men are accused of running a decade-long, $120 million Medicaid and Medicare scheme through two social adult-daycare centers and a pharmacy, allegedly bribing elderly beneficiaries with cash and gift cards to enroll in unnecessary services. On Long Island, prosecutors allege two transportation-company operators billed Medicaid more than $35 million by manipulating mileage and routing patients on needlessly long trips to treatment centers. And in Brooklyn and Manhattan, investigators allege an optical business billed Medicaid millions of dollars for eye surgeries that never happened, despite primarily selling eyeglasses. NYAAIF Board Chairman Kevin O’Connor said insurance fraud is not a victimless crime, pointing to staged crashes, fake medical bills and fraudulent claims as drivers of higher costs for everyone else. Assemblyman David Weprin echoed that sentiment, calling the Queens case in particular a reminder of why continued investigation and prevention efforts matter statewide. Insurance Fraud Costs New Yorkers More Than $920 A Year NYAAIF estimates insurance fraud costs every person in New York more than $920 annually, factoring in higher premiums, the diversion of public resources and higher prices on everyday goods and services. The organization is encouraging anyone with information about suspected fraud to report it at fraudny.com or by calling 844-FRAUDNY. For Southern Tier residents, the Tioga County case is a local reminder that fraud schemes are not just a big-city problem. They can start with a single suspicious fire in a small town and end up on a statewide watch list before the year is even halfway over. **Topics:** Public Awareness --- ### [Murder by Wholesale: The Remarkable Career of Dr. Henry Meyer](https://insurancefraud.org/news_archives/murder-by-wholesale-the-remarkable-career-of-dr-henry-meyer/) **Published:** September 19, 2026 **Author:** Diane Beauchamp **Content:** It is a curious thing how some monsters, like Jack the Ripper or H.H. Holmes, linger in human memory to the point where they become dark legends, while equally prolific evildoers have a brief moment of fame, only to be quickly forgotten. An outstanding example of the latter breed was Dr. Henry C.W. Meyer, aka Hugo Wehler, aka William Reuter, aka Schaffer, aka Oswald, aka Stoffen. In 1893, the good doctor and his colorful career of insurance fraud and murder made newspaper headlines across America, but today, it is doubtful that even most true crime writers know his name. It is known that Meyer graduated from Chicago’s Homeopathic Medical College in 1878, but other than that little is known about his early years, aside from the fact that he married a Miss Kirehoff in 1877. Meyer first caught the legal system’s eye in 1880, when he was working as an agent for Chicago’s Germania life insurance company. He used his job to issue fraudulent policies, and collect the premiums. When his little scheme was discovered, he fled to Denver, where he was arrested and brought back for trial. Oddly, he was acquitted, even though one of the men who allowed the use of his name in one of the bogus policies testified for the prosecution. In 1881, a patient of his named Henry Geldemann suddenly died of undetermined causes. Meyer’s wife soon died as well, after which the doctor immediately married Geldemann’s widow Ida (gaining both their dead spouses’ sizable life insurance policies in the bargain.) The police began to take an interest in the proceedings. Despite their suspicions, it was decided that there was not enough evidence for murder charges, and the doctor was set at liberty. After his release, Meyer faced a dilemma: He now also wanted liberty from his new wife, but he wished to stay married to all that sweet insurance money. Like many a spouse in a similar situation, he decided there was nothing for it but to recall those words, “Till death do you part.” Meyer hired an old boyfriend of Ida’s, Peter Bretz, to murder her. However, even though the doctor helpfully provided him with vials of poison to do the deed, Bretz got cold feet and went to the police. Meyer was tried on charges of conspiracy, but—proving the law often works in mysterious ways—he was acquitted. I have no idea what he told Ida about the matter, but the couple remained together for several more years, until his son from his first marriage suddenly died. Again, the police looked into this latest Meyer-related death, and again found insufficient reason to prosecute. Meyer—who truly seemed to have the devil’s own luck—ran off with an actress, which finally inspired Ida to file for divorce. Some months after that, Meyer returned to Ida and suggested they get back together. Clearly, he just couldn’t get that insurance money out of his heart. Mrs. Meyer, who must have been either the most obtuse or the most masochistic of women, agreed. Predictably enough, the reunion did not last long. Meyer entered into an affair with a pretty young woman named Mary Dressen…and Ida’s health suddenly and dramatically declined. Ida, at long last getting a clue, cut off Meyer’s allowance and threw him out of the house. As soon as she broke up with her husband, her condition rapidly improved. Meyer shrugged, took up a new career forging checks, and married Dressen. He soon forged the name of his new father-in-law to a hefty life insurance policy…and the normally robust old man suddenly became very ill… Fortunately, this forgery was detected by the authorities, and Meyer was arrested. With his son-in-law behind bars, the ailing Mr. Dressen immediately began to recover. Meyer was tried for forgery, but acquitted. While awaiting his day in court, he made the most of his leisure time by brooding upon the subject dearest to his heart: Wholesale insurance fraud. He enlisted two fellow inmates, minor criminals named Gustave Baum (who was currently going by the name of “Ludwig Brandt,”) and Carl Mueller, in a plan that he assured them was both foolproof and lucrative. Meyer’s formula was this: Brandt would enter into a marriage with a woman who’d be in on the game. Then, he’d take out a large insurance policy on his own life. After a decent interval, Meyer would dose him with a liquid of the doctor’s own invention that would make Brandt appear to be dead. Meyer would bring in outside doctors to confirm the “death,” after which he would administer an antidote, forge a death certificate, and find a corpse to take Brandt’s place in the grave. Then, all the conspirators would collect the insurance money and live happily ever after. As long as there has been life insurance, there have been many ambitious souls who have tried the “get someone to pretend to die in order to cash in” scheme. Almost inevitably, the ringleaders of these schemes begin to think how much easier and safer the project would be if they could arrange a *genuine* death… After all the plotters were released, they went right to work. Meyer announced that he knew of the perfect woman to “marry” Brandt. He introduced Mary Meyer to his confederates, not mentioning, of course, that she was already his own wife. After she and Brandt went through a marriage ceremony, the groom took out a number of life insurance policies which totaled $8500. It had been understood that the marriage would be in name only, but Brandt was quite taken with his attractive bride, and tried to persuade her to consummate their irregular union. It is said that Dr. Meyer’s annoyance with this led to what happened next, but it seems certain that he planned from the start that Brandt would not get out of this marriage alive. The doctor dosed the new “husband” not with some fictitious “secret potion,” but a mixture of antimony and arsenic which killed him on March 30, 1892. The new “widow” was able to collect most of the policies, but several insurance agents correctly sensed something was up and sicced the detectives on the Meyer gang. Brandt’s body was exhumed, and when it was discovered he had been poisoned, the police went in full pursuit of Meyer. The doctor and his surviving cohorts had fled, but after a well-publicized search, they were finally tracked down in Toledo, Ohio, where they were discovered to be in the middle of yet another scam. Meyer, deciding that the simplest methods were after all the best, had arranged for Mueller to marry a young servant girl, Mary Neiss. The plan was that she would take out insurance policies on her life, after which Meyer would poison her. Unfortunately for Meyer, romance once again complicated his schemes. Mueller decided that he preferred his bride to the money, confessed all to her, and the pair escaped to Chicago. Meyer, not one to give up easily, somehow acquired the corpse of a young woman, and was trying to pass it off as that of Neiss when the law finally caught up to him. Mueller was the star witness for the prosecution at Meyer’s December 1893 trial for Brandt’s murder. The court proceedings, already of the most sensational character, were enlivened even further when near the close of the trial, one of the jurors suffered a psychotic breakdown while sitting in the jury box and had to be committed to a mental hospital. It was noted that Meyer was grinning as the man was led away. The jury was dismissed, and Meyer was re-tried. Everyone following his trials fully expected to see the good doctor fry, particularly since it was widely believed Brandt had been only one of Meyer’s many victims. (Detectives solemnly informed the press that they believed Meyer had murdered at least half a dozen other people in the course of his various insurance frauds.) However, the jury delivered a verdict of only second degree murder. While there were eleven votes for the ultimate penalty, one juror stubbornly insisted on voting for manslaughter. Rather than have a mistrial, the jurors settled on the lesser verdict as a compromise. (As the “New York Times” commented afterwards, “with all the good luck Meyer has had in his troubles he never had such a stroke as when the jury found him guilty of murder in the second degree.”) There was talk about charging Mary Meyer with grand larceny for her role in the insurance frauds, but I have found no evidence she was actually tried. Considering the odd turns justice took throughout this story, I would not be at all surprised if she was given her liberty. Meyer spent the rest of his days in Sing Sing, where he was described as a mild-mannered man with an “almost visible aura of sanctity.” **Topics:** Public Awareness --- ### [Insurance fraud charges against Trump's bookkeeper 'seem pretty clean': former prosecutor](https://insurancefraud.org/news_archives/insurance-fraud-charges-against-trumps-bookkeeper-seem-pretty-clean-former-prosecutor/) **Published:** September 19, 2026 **Author:** Diane Beauchamp **Content:** The Trump Organization’s bookkeeper, Allen Weisselberg, is currently in New York City’s Rikers Island jail for five months after sharing responsibility for the company’s 17 guilty convictions involving tax fraud. According to former prosecutor Harry Litman, however, that might not be the end of the charges he’s facing. For a “75-year-old man … Rikers is an especially hellish prison,” Litman said. “You wonder how much more pressure he could take.” “The snippet that has him on the hook for insurance fraud seems pretty clean to me,” he said, citing recent reporting from The New York Times this week. “It has him telling the Zurich insurance company to re-insure Trump that they had done an independent appraisal on the holdings of the company and they hadn’t. And if he wrote that and attested to it, that’s pretty flat-out insurance fraud. That carries a couple of years. He’s 75 and in a really bad spot, so if that’s their strategy, I think it’s promising.” The details come from the information collected in the investigation by New York Attorney General Letitia James. **Topics:** Financial Fraud **Categories:** Conviction --- ### [As cargo theft continues to rise, experts advise on prevention and spotting fraud](https://insurancefraud.org/news_archives/as-cargo-theft-continues-to-rise-experts-advise-on-prevention-and-spotting-fraud/) **Published:** September 19, 2026 **Author:** Diane Beauchamp **Content:** The latest data shows 2022 was a peak in a long trend of increased cargo theft. Thefts using fraudulent identities, in particular, are on the rise, as are thefts in eastern states. Plus, the most-targeted cargo shifts with the economic tides. Shippers and carriers should be vigilant as new data shows 2022 saw an increase in cargo theft from the year prior, and experts indicated it’s a trend that shows no signs of slowing. Theft prevention and recovery network [CargoNet has reported](https://www.cargonet.com/news-and-events/cargonet-in-the-media/2022-theft-trends/) that almost 1,800 theft claims were made by its members last year—an increase of 15% from 2021, which saw fewer than 1,300 incidents reported. “You’re coming out of 2022 with severe momentum,” said Scott Cornell, transportation lead and [crime and theft specialist at Travelers](https://www.travelers.com/resources/business-industries/transportation/special-investigations-group-marks-15-years), adding that the data has been heading in this direction for several quarters. “The amount of stuff that’s going on right now, it’s just fast,” he said. “Very intense, very frequent.” ![](https://insurancefraud.org/wp-content/uploads/image-20-13.jpg)The most-targeted locations have changed, as well. Truck stops were the highest-risk areas in 2021, followed by warehouses and distribution centers. In 2022, warehouses and distribution centers took the top spot, with parking lots coming in second. Danny Ramon, intelligence and response manager at supply chain risk management company [Overhaul](https://over-haul.com/), noted an increase in high-value pilferages when cargo is stolen from a trailer, as opposed to the trailer itself being stolen. Ramon said that pilferage used to usually be “maybe 10% \[of cargo from\] a 53-ft. trailer. Now we’re seeing upwards of 90-plus percent.” ### What are cargo thieves stealing, and where? There also has been a rise in “strategic theft,” Ramon said, which is when thieves use fraudulent or stolen carrier or driver identities to book and then steal loads. Strategic theft has historically been most prominent in Southern California, Ramon said, but the trend has begun to creep eastward. “One of the things that we are starting to see, and I predict is going to be a long-term trend, is the shift of strategic and fraudulent thefts,” Ramon said, “moving to the East Coast and more eastern states. We’ve seen it start already in Indiana and Illinois, as well as Georgia and a couple of other East Coast port cities.” This increase in strategic theft eastward follows an increase in shipping container traffic to eastern states, Ramon said, as cargo theft follows cargo density. Another factor making those areas a riper target is that, because they don’t traditionally see as much strategic theft, many shippers and brokers out east do not vet their carriers as thoroughly, making it easier to fraudulently obtain loads, he said. Due to the increase in strategic theft, Ramon and Cornell underscored the importance of shippers and brokers preventing theft through thorough vetting. Additionally, carriers can assess risk themselves by checking their freight and the lane in which they will be hauling it against the data. “The numbers are extremely important, but pay attention to more of the trends—in the commodities, the locations,” said Keith Lewis, CargoNet’s VP of operations, who also worked in law enforcement for 24 years. Carriers must focus on their loads that travel through the most high-risk areas with the cargo that is most likely to be targeted. ”The golden rule for cargo theft is that they’re going to steal what they know they can sell,” Cornell said. Thieves steal to supply what is in demand as the economy fluctuates. In a stronger economy, luxury items, such as electronics and computers, are stolen more often. Essentials such as food are stolen more often during economic hardship. In 2022, household goods were the most commonly stolen item, a trend that began in the pandemic when everybody was at home, working or building home offices and gyms. Electronics—always lucrative—were the second-most popular targets, especially during chip shortages. Food and beverage weren’t far behind, according to CargoNet data. ### How motor carriers, brokers, and shippers can protect their cargo If drivers must travel through a high-risk area with high-risk cargo, they should plan their route as not to stop in those dangerous zones, said CargoNet’s Lewis. If they are operating in a high-risk area, they should allot time to be fueled, rested, and fed before picking up the load, so they can haul that freight out of the area without stopping. During the vetting process, having a photo of the truck with a record of its DOT number and VIN is invaluable to law enforcement. Overhaul’s Danny Ramon has seen cases where a driver doesn’t match the photo in the CDL he presents and even times where the DOT number on a truck is printed on a sheet of paper and attached to the side. Cases such as these, which would be obvious after even the most cursory investigation, can still result in theft if the company’s culture does not emphasize a vetting process, allowing thieves to successfully defraud shippers. A more subtle indication of a fraudulent pickup would be an operator using a day cab for what is supposed to be a long haul. “We’ve seen people showing up at an origin in California for a load booked to go all the way to Florida in a day cab which does not have a back seat, let alone a bed or a bunk,” Ramon said. “And nobody’s asking questions like, ‘Are you really driving that three days all the way to Florida?’” Cornell of Travelers suggests, for those who offer to take high-value loads, looking up carriers on [FMCSA’s website](https://www.fmcsa.dot.gov/registration/fmcsa-forms). He cited the example of a too-good-to-be-true offer of a carrier claiming it has so much capacity that it can send nine trucks to haul the load at a low rate, but that carrier has only two power units listed on its FMCSA page. Cornell also recommended getting the phone number of drivers who pick up high-value loads. While it’s not possible to get the cell number of every driver, which further heightens the importance of vetting carriers before freight is taken, high-target commodities traveling through high-target areas should dictate open communication with the driver. “If they say, ‘No, we’re not going to let you call the driver,’” Cornell added, “is that because they have a legitimate company policy in place? And then, OK, maybe you can work something else out with them. Or is it because you’re getting a feeling in your gut that they don’t want you to have contact information?” Cornell said locks, despite their apparent simplicity compared to higher-tech solutions such as telematics monitoring, are “underrated,” citing landing gear locks for trailers, kingpin locks for fifth wheels, and air-cuff locks for brakes as options. “Cargo thieves do not want to spend 20 minutes grinding through a lock,” Cornell said. “They want something they can be able to take quickly and be off-site quickly,” he said. Cornell added that parking in a well-lit location that isn’t isolated would further reduce the likelihood of thieves attempting to break a lock. (At truck stops—the most-targeted location in 2021—drivers should be aware that the only cameras are pointed toward the pumps, not the lots, Lewis said.) In addition to tracking trailers, fleets can also hide covert tracking devices within high-value cargo itself in case thieves move the freight from one trailer to another. Regardless of what technologies a fleet uses, carriers, brokers, and shippers should always be prepared for the possibility of theft, staying informed on the latest trends and ensuring their entire organizations are aware of risks. “The best weapon that you have for recovering is a network. Both a network of people who are doing the compliance monitoring,” Ramon said, “as well as, when it comes down to the recovery team, having a network of industry professionals.” **Topics:** Commercial Fraud, Public Awareness --- ### [Florida man reportedly used missing father’s identity for Social Security benefits](https://insurancefraud.org/news_archives/florida-man-reportedly-used-missing-fathers-identity-for-social-security-benefits/) **Published:** September 19, 2026 **Author:** Diane Beauchamp **Content:** A Florida man has been sentenced to federal prison for using his missing father’s identity to collect Social Security benefits, the U.S. Attorney’s Office for the Middle District of Florida (USAO) has announced. Robert Butzlaff, 57, of Volusia County, has been sentenced to five years and 10 months in federal prison for fraudulent use of an unauthorized access device and aggravated identity theft, the USAO said. As part of his sentence, the court also ordered Butzlaff to pay restitution in the amount of $57,296, and entered an order of forfeiture in the amount of $57,296, the proceeds of the access device fraud. A federal jury found Butzlaff guilty on September 21, 2022. According to evidence presented at trial, Social Security beneficiary M.B. was reported missing in October 2014 and has never been located. M.B.’s disappearance was not reported to the Social Security Administration (SSA), and SSA reportedly continued to make benefit payments on his behalf. M.B.’s SSA benefits were reportedly being deposited into an account held jointly with his son, Butzlaff, at the time of his disappearance. Following M.B.’s disappearance, Butzlaff is said to have opened a new bank account using M.B.’s personally identifiable information and redirected M.B.’s SSA benefits to the new account. The new account was solely in M.B.’s name. According to evidence presented at trial, Butzlaff obtained and used two debit cards issued in the name of M.B. to withdraw the funds that were being deposited by SSA into the new account. Butzlaff used the SSA funds intended for M.B. for his own personal expenses. “This sentence of 70 months’ imprisonment holds Mr. Butlzaff accountable for intentionally misusing Social Security benefits, intended for his father, for his own personal gain,” said Gail S. Ennis, Inspector General for the Social Security Administration Office of the Inspector General. “This is a federal crime, and we will continue to pursue perpetrators of Social Security fraud.” This case was investigated by the Social Security Administration, Office of the Inspector General, and the Ormond Beach Police Department. It is being prosecuted by Special Assistant United States Attorney Suzanne Huyler. **Topics:** Social Security fraud, Synthetic Identity Theft **Categories:** Conviction --- ### [Birmingham medical practice informs patients of security breach](https://insurancefraud.org/news_archives/birmingham-medical-practice-informs-patients-of-security-breach/) **Published:** September 19, 2026 **Author:** Diane Beauchamp **Content:** A Birmingham-based medical practice is informing patients of a data breach that could have compromised personal information. Cardiovascular Associates (CVA), a physician practice with multiple locations in and around Birmingham, discovered on December 5 that systems within CVA’s network may have been subject to unauthorized activity. After an investigation, it was determined that a third party had gained access to personal information and removed a copy of some data between November 28 and December 5. CVA said that some of the personal information involved may include one or more of the following: - Demographic information to identify and contact the patient, such as full name, date of birth, and address - Social security number - Health insurance information, such as name of insurer/government payor and member ID, policy and/or group number - Medical and treatment information, such as medical record number, dates of service, provider and facility names, other visit, procedure and diagnosis information, and possibly assessments, tests and imaging - Billing and claims information, such as account and/or claim status, billing and diagnostic codes, and payor information - Passport and driver’s license number - Credit and debit card information - Financial account information CVA said that for a limited number of people, the information may have also included username and password information. The practice did note that “not all data elements were involved for all individuals.” > CVA takes the security of personal information seriously. As soon as the incident was discovered, a forensic investigation was launched, and steps were taken to mitigate and remediate the incident and to help prevent further unauthorized activity. In response to this incident, security and monitoring capabilities are being enhanced and systems are being hardened as appropriate to minimize the risk of any similar incident in the future.Cardiovascular Associates CVA said they are offering complimentary credit monitoring and identity restoration services to those whose sensitive information may have been involved. They advise for patients to carefully review credit reports and statements from healthcare providers and financial institutions to ensure valid account activity. CVA has set up a dedicated assistance line for anyone seeking more information about the incident. Anyone with questions over the next 90 days can call 1 (833) 753-3802 between 8 a.m. and 8 p.m., Monday through Friday. More information is available at <https://response.idx.us/cvainformation/>. **Topics:** Public Awareness, Technology --- ### [Texas Executes Former Cop Convicted Of Hiring Hitmen To Kill Wife Nearly 30 Years Ago](https://insurancefraud.org/news_archives/texas-executes-former-cop-convicted-of-hiring-hitmen-to-kill-wife-nearly-30-years-ago/) **Published:** September 19, 2026 **Author:** Diane Beauchamp **Content:** A one-time police officer convicted of hiring two men to kill his estranged wife has died by execution. Robert Fratta, 65, died Tuesday at the Hunstville Penitentiary in Texas after receiving the lethal injection for the 1994 murder-by-hire of his estranged wife, Farah Fratta, 33, according to the Associated Press. When asked by state prison officials if he had any last words, the former suburban Houston-area police officer replied, “no.” In the galley was one of the Frattas’ now-adult children and Farah Fratta’s brother, neither of whom addressed the media following the convict’s execution, according to the Houston Chronicle. Robert Fratta’s death marked the state’s first execution in 2023, despite last-minute appeals for a stay of execution. Hours before Fratta’s passing, Judge Catherine Mauzy for the 419th District Court in Austin issued a temporary civil injunction, which briefly stopped the Texas Department of Criminal Justice from carrying out the execution, per the Houston Chronicle. Her ruling stated what Fratta and other death row inmates had maintained: that using expired drugs for lethal injection violated multiple pharmaceuticals regulations within the state, including The Texas Pharmacy Act, the Texas Controlled Substances Act and others. The practice of using expired drugs has been commonplace for years in Texas, with the Department of Criminal Justice regularly extending expiry dates for pentobarbital, the sole ingredient in the state’s lethal injection process, according to the Texas Tribune. Mauzy claimed the drug was “probably illegal to possess or administer because it is more likely than not expired” and that the Department of Criminal Justice hadn’t contradicted claims that the expired pentobarbital was capable of causing “torture, ill treatment or unnecessary pain,” which would have violated the defendant’s constitutional rights, according to the Tribune. Higher courts overturned Judge Mauzy’s injunction, and the U.S. Supreme Court allowed the execution to continue, according to the Chronicle. Fratta was convicted of hiring Joseph Prystash, who enlisted the help of Howard Guidry, to fatally shoot Farah Fratta at her home in Atascocita, a Houston suburb. The estranged couple was embroiled in a contentious divorce and custody battle when Farah was shot twice in the head in her garage. Evidence also showed that, just days after his estranged wife’s murder, Fratta tried to cash in on her life insurance policy, according to the Associated Press. He allegedly planned to pay the hitmen $1,000 and give them a Jeep in return for Farah’s murder. Court records stated that Fratta had previously asked several other people if they could help him find someone to kill Farah. “I’ll just kill her, and I’ll do my time and, when I get out, I’ll have my kids,” he told one friend, per court documents. Fratta was a public safety officer in Missouri City, Texas at the time of the murder and had long maintained his innocence, according to the Associated Press. He was initially sentenced to death in 1996. However, the conviction was vacated when a federal judge found Prystash and Guidry’s confessions shouldn’t have been introduced in the trial, according to the Associated Press. The federal judge who overturned his conviction referred Fratta as “egotistical, misogynistic and vile, with a callous desire to kill his wife” in his ruling. Fratta was retried, convicted and sentenced to death again in 2009. Prystash and Guidry were also sentenced to death for their roles in the slaying. Fratta had lost several appeals over the years, including arguments that newer ballistic testing could have excluded one gun from being the murder weapon — a bid that was rejected in 2018. The Frattas’ three children were raised by Farah’s father, Lex Baquer, who died in 2018, according to the Associated Press. Crime Stoppers Houston victim services director Andy Kahan and Harris County District Attorney Kim Ogg were among the spectators present for the execution, according to the Chronicle. Fratta was pronounced dead at 7:49 p.m., 24 minutes after the lethal dose was administered. “Bob was a coward in 1994 when he arranged the murder for hire of his estranged wife, and 28 years later, he still was a coward tonight,” Kahan commented after the execution. “He was offered an opportunity to at least extend an olive branch to his son, who he knew was watching this.” “He still could have said ‘I’m sorry,’” Kahan continued. Fratta’s execution was the second in the United States in 2023, following the lethal injection of Amber McLaughlin. **Topics:** Life Insurance **Categories:** Conviction --- ### [70% of Financial Institutions Lost Over $500K to Fraud in 2022: Weekly Stat](https://insurancefraud.org/news_archives/70-of-financial-institutions-lost-over-500k-to-fraud-in-2022-weekly-stat/) **Published:** September 19, 2026 **Author:** Diane Beauchamp **Content:** With a challenging economy and an already overflowing to-do list of preparation for the new year, CFOs must be mindful of technological threats to their businesses. Consequences of limited or misguided approaches towards cybersecurity can be lethal to an organization. According to the recent [State of Fraud Benchmark Report](https://www.alloy.com/state-of-fraud-benchmark-report) from Alloy, six and seven-figure-costing data breaches are becoming more common among financial institutions of all sizes. “Fraud is the highest it’s ever been,” said Tommy Nicholas, CEO and co-founder of Alloy. “Rapid digitization and an influx of cash from pandemic relief scams have created the perfect conditions for fraudsters to thrive.” Ninety-one percent of the report’s respondents said fraud rates have increased at their organization year-over-year. The report, which surveyed 251 people working in fraud-related roles at financial institutions, also found that 71% of respondents increased spending on fraud mitigation. #### What Types of Fraud Occur Most Often? The nexus of where security breaches occur is the first step in identifying where a company needs improvement post-infiltration. According to findings, 62% of breaches were labeled as first-party fraud, meaning an individual misrepresents their own identity, financial situation, or intention to repay a financial institution. For the other roughly two-thirds of case degrees, second-party fraud was nearly identical to third-party fraud in terms of response rate. Second-party fraud is when a perpetrator convinces another person to use their identity or personal information, and was responsible for 39% of fraud cases. Third-party fraud, or financial crimes that are committed while using someone else’s (stolen) identity, was responsible for 38% of crimes. “Regardless of sector or size, financial institutions must do more to keep their customers’ assets safe from fraud, but without compromising on the customer experience,” Nicholas said. Among these different fraud types, the sectors of financial industries varied. Online or pure-play lending institutions led the way in both first and second-degree fraud (75% and 58% respectively), and community banks and credit unions fell victim to the most third-degree fraud, with more than half (56%) of the fraud using someone else’s already stolen identity. #### **Rising Fraud, Rising Costs** While nearly 70% of respondents said their company fell victim to at least $500K in fraud in 2022, allocations towards cybersecurity should no longer be viewed as insurance, but as required costs to deter a larger, much more costly potential situation. Out of the group that had $500K of fraud or more, nearly a third (34%) of that group (24% of total respondents) fell victim to breaches that resulted in seven-figure losses. Few data breaches (3% of total respondents) occurred at costs of eight figures or more. > Regardless of sector or size, financial institutions must do more to keep their customers’ assets safe from fraud, but without compromising on the customer experience. — Tommy Nicholas, CEO of Alloy #### Total Loss Recovery is Unlikely Despite over half of respondents saying they were able to obtain some of the funds back from their breaches, few receive all that was lost. Only 5% of total respondents were able to fully recover from their breaches, with a fifth (20%) of all victims recovering more than three-quarters of all their fraud losses. ### Total Recovery is More Likely Than Total Loss A majority of organizations were able to recover more than half of their losses during a cybersecurity incident. No respondents reported a total loss. **51% to 75% of losses**(41%) **All losses recovered**(5%) **1% to 25% of losses**(9%) **76% to 99% of losses**(20%) **26% to 50% of losses**(25%) The size of an organization was a large determining factor in the amount of loss that was able to be recovered after a breach. According to findings, 74% of enterprise organizations were more likely to recover fraud losses, compared to 64% of mid-market organizations and 55% of growth companies. #### In-House Solutions via Tech A major portion (95%) of respondents told surveyors their organizations could manage their fraud issues in-house. With this, the choice to push for automation was the most common choice (46%) by respondents as a way to implement in-house cybersecurity measures. Things like an absence of individual fraud teams (41%) and an inability to adapt to new types of threats (39%) were also top choices on how organizations can combat fraud first-hand. **Topics:** Public Awareness, Technology --- ### [Hackers stole data of 460,000 individuals in MFHS ransomware attack](https://insurancefraud.org/news_archives/hackers-stole-data-of-460000-individuals-in-mfhs-ransomware-attack/) **Published:** September 19, 2026 **Author:** Diane Beauchamp **Content:** Pennsylvania-based nonprofit health provider Maternal & Family Health Services has confirmed cybercriminals accessed the sensitive data of close to half a million people. MFHS revealed [last week](https://techcrunch.com/2023/01/05/maternal-family-health-services-ransomware/) that it had been hit by ransomware that exposed the personal data of current and former patients, employees and vendors. The healthcare giant said it was made aware of the incident on April 4, 2022 but admitted that may have been initially compromised as far back as August 21, 2021. When asked by TechCrunch at the time, MFHS declined to confirm how many individuals were affected. However, [a notification from the Maine attorney general’s office](https://apps.web.maine.gov/online/aeviewer/ME/40/aa8282f5-0293-41fe-8074-d62e568e05ac.shtml/?=01/11/2022) this week reported that a total of 461,070 people, including 68 Maine residents, are affected by the breach. In a letter sent to affected residents on January 10 — more than nine months after the organization was first alerted to the ransomware incident — MFHS said that attackers accessed sensitive data, including names, addresses, date of birth, driver license numbers, Social Security numbers, usernames and passwords, health insurance and medical information, and financial information. The attackers also took credit and debit card numbers, the notification said. It remains unclear who was behind the ransomware attack, if MFHS paid a ransom demand and why the nonprofit didn’t disclose the incident sooner. MFHS didn’t immediately respond to TechCrunch’s questions on Wednesday, and it doesn’t appear that any major ransomware group has yet claimed responsibility for the incident. **Topics:** Public Awareness, Technology --- ### [Former insurance agent pleads guilty to defrauding victims in Dayton, Cincinnati area](https://insurancefraud.org/news_archives/former-insurance-agent-pleads-guilty-to-defrauding-victims-in-dayton-cincinnati-area/) **Published:** September 19, 2026 **Author:** Diane Beauchamp **Content:** A former insurance agent pleaded guilty Tuesday in U.S. District Court to receiving more than $100,000 in fraudulent commissions for unauthorized policies involving victims across the Dayton and Cincinnati area. Seneca Birchmore, 45, of Cincinnati, admitted to committing aggravated identity theft, a federal crime punishable by a mandatory two-year prison sentence Birchmore lost his license as an insurance agent in 2019 for writing unwanted insurance policies in order to collect commissions. Birchmore stole the identities of two other insurance agents to write life insurance policies and had those commissions deposited into his own bank accounts, a release from the office of U.S. Attorney Kenneth Parker of the Southern District of Ohio stated. Local law enforcement departments received complaints that money was being automatically withdrawn from bank accounts for unauthorized insurance policies. Many of the victims are senior citizens, and most reside in Dayton, Englewood, Middletown and Cincinnati, the release stated. The commissions for the fraudulent insurance policies under Birchmore’s name totaled more than $8,000. The commissions for policies created under the stolen identities of other agents totaled more than $93,000. As part of his plea, Birchmore agreed to pay the following restitution: — Americo Financial Life and Annuity Insurance Company: $34,820.37 — Columbian Life Insurance Company: $16,604.01 — Transamerica Life Insurance Company: $4,671 — Mutual of Omaha: $2,104.65 — Great Western Insurance Company: $16,303.17 — Aetna Health and Life Insurance Company: $8,826.84 — American General Life Insurance Company: $158.82 — Guarantee Trust Life Insurance Company: $17,906.07 — U.S. Small Business Administration: $41,665 In a separate scheme, Birchmore fraudulently obtained two COVID Paycheck Protection Program loans totaling more than $40,000. Birchmore claimed on both loan applications that he owned a business in his name and stated his gross income for 2019 was more than $13 million. However, no such business exists, the release stated. A sentencing date for Birchmore has not been scheduled. **Topics:** COVID-19, Insider - agent, Life Insurance, Unlicensed **Categories:** Conviction --- ### [Examining post-pandemic telehealth fraud risks](https://insurancefraud.org/news_archives/examining-post-pandemic-telehealth-fraud-risks/) **Published:** September 19, 2026 **Author:** Diane Beauchamp **Content:** Telemedicine services and telemedicine fraud schemes both surged during the global pandemic. The U.S. Department of Justice (DOJ) remains committed to combating telemedicine fraud as not only a pre-pandemic focus area, but as part of its ongoing initiative to prosecute fraud in connection with COVID-19 and various pandemic relief programs. During the public health emergency (PHE), Congress [enacted telehealth waiver rules](https://www.cms.gov/files/document/summary-covid-19-emergency-declaration-waivers.pdf), relaxing Medicare coverage requirements and expanding the population eligible to receive telehealth services. Regulatory efforts to increase telehealth services also included the U.S. Food and Drug Administration’s exercise of enforcement discretion over various telehealth devices. In addition, the U.S. Centers for Medicare & Medicaid Services (CMS) and many states deliberately relaxed licensure requirements to encourage greater use of telehealth in the federal health care programs, which enabled doctors to render telehealth services across state lines with minimal delays. Telehealth flexibilities and e-prescribing waivers that enabled providers to care for patients during the pandemic greatly expanded access to care. CMS increased the types of services that beneficiaries could receive via telehealth from 118 to 264 services. Telehealth practitioners can include occupational therapists, physical therapists, speech pathologists, and audiologists. There is currently no in-person requirement in the first six months of mental health services. As the pandemic stretched on, Congress passed the Consolidated Appropriations Act, 2022, which extended telehealth leniencies for 151 days after the expiration of the PHE. While the PHE expires on Jan. 11, 2023, the government stated that it will provide notice 60 days before the PHE ends. Because notice has not yet been given, many expect the president will soon extend the PHE (yet again) until April 2023. In any event, in July the House passed Advancing Telehealth Beyond COVID-19 Act of 2021, which will extend Medicare coverage of telehealth services until Dec. 31, 2024. And last month President Biden signed the $1.7 trillion spending bill, which prolonged telehealth pandemic-era flexibilities enacted as part of the Coronavirus Aid, Relief, and Economic Security (CARES) Act until Dec. 31, 2024. For the time being, at least, Medicare providers can continue to provide telehealth at home. But regardless of the temporary waivers of restrictions and relaxed enforcement of certain telehealth provisions, telehealth remains a key area of potential False Claims Act (FCA) liability, particularly in the post-COVID-19 era. On July 20, 2022, DOJ [announced](https://www.justice.gov/opa/pr/justice-department-charges-dozens-12-billion-health-care-fraud) a nationwide coordinated law enforcement action to combat telemedicine, laboratory, and durable medical equipment (DME) fraud. DOJ charged 36 defendants in 13 federal districts across the United States with more than $1.2 billion in alleged fraudulent telemedicine, genetic testing, and DME schemes, including criminal charges against a telemedicine company executive. That same day, the U.S. Department of Health and Human Services Office of the Inspector General (HHS-OIG) issued a [Special Fraud Alert](https://oig.hhs.gov/documents/root/1045/sfa-telefraud.pdf) to warn practitioners about potentially suspect arrangements with purported telemedicine companies that could implicate Anti-kickback Statute (AKS) violations. Since that time, DOJ has held numerous doctors accountable for their roles in telemedicine fraud schemes. In September 2022, HHS-OIG published a [report](https://oig.hhs.gov/oei/reports/OEI-02-20-00720.pdf) after analyzing data from the first year of the pandemic and identifying 1,714 high-risk providers with fraudulent billing for telehealth services to the tune of $127.7 million in Medicare fee-for-service payments. While for many the takeaway of the OIG report was that Medicare telehealth fraud was overall proportionally rare, the OIG set a high threshold and identified these “high risk” providers to reduce fraudulent billing practices. With this aim, HHS-OIG recommended that CMS reduce the risk of fraud, waste, and abuse in telehealth by: - Strengthening oversight of telehealth services - Educating providers on appropriate billing for telehealth services - Improving the transparency of “incident to” services when clinical staff primarily deliver the telehealth service - Identifying telehealth companies that bill Medicare - Following up on the high-risk providers identified in the [report](https://oig.hhs.gov/oei/reports/OEI-02-20-00720.pdf). Explicitly concurring the last recommendation, CMS will be following up with the identified high-risk providers. On Nov. 1, 2022, CMS released its final [2023 Medicare Physician Fee Schedule](https://public-inspection.federalregister.gov/2022-23873.pdf), which makes changes to reimbursements that will kick in 151 days after the PHE expires. For example, Medicare will no longer reimburse for audio-only evaluation and management services, save for mental health services, reverting to the pre-pandemic bundled and not separately reimbursable status. Reimbursement for telehealth provided by physical therapists, occupational therapists, speech language pathologies, and audiologists will no longer be allowed. The government’s continued focus on COVID-19 fraud enforcement also means providers that received federal relief money will be scrutinized for health care *and* Paycheck Protection Program (PPP) fraud. For example, in April 2022, DOJ [announced](https://www.justice.gov/opa/pr/physician-partners-america-pay-245-million-settle-allegations-unnecessary-testing-improper) a settlement resolving four separate *qui tam* actions of claims that a medical provider network company billed for unnecessary telehealth visits and instructed physicians to order certain medical tests without assessing for medical necessity. The U.S. also alleged that the company submitted false statements in a PPP loan application, by representing that the company was not engaged in unlawful activity. Notably, the filing of all four *qui tam* actions predated the creation of the PPP program under the CARES Act. So, while the whistleblowers originally alleged telemedicine fraud, the government also investigated the company’s false statements made to the U.S. Small Business Administration to secure millions in loans. ### Providers should be aware of FCA and AKS legal risks There are several ways that providers can guard against becoming involved in conduct that may be considered fraudulent or violative of the FCA or AKS. Telehealth arrangements commonly involve coordination and potential referrals among multiple parties and by their nature present a degree of inherent risk. Seeking federal reimbursement for telehealth services may subject a provider to FCA if done in violation of legal restrictions. For example, before the pandemic, telehealth providers generally could not assess patients by telephone and instead used real-time audio-visual communication at specific qualifying sites. Currently, Medicare covers audio-only telehealth under temporary waivers that will remain for 151 days after the PHE ends. But audio-only billing can still present red flag for fraud. Billing primarily for audio-only telehealth services can be an indication that providers are cold calling beneficiaries to increase billings for DME and other services. After they disclosed conduct to HHS-OIG pursuant to their corporate integrity agreement, one medical system entered into a [settlement agreement](https://oig.hhs.gov/fraud/enforcement/sanford-health-sanford-clinic-and-sanford-medical-center-agreed-to-pay-25000-for-allegedly-violating-the-civil-monetary-penalties-law-by-submitting-claims-for-telemedicine-services-that-did-not-meet-applicable-requirements/) in which OIG alleged that they submitted claims to federal health care programs for telemedicine services provided by a physician that did not involve interactive two-way video and audio as required. Other requirements were also allegedly not met: Telemedicine appointments were scheduled for times when the physician was out of the country and without access to the telemedicine platform. In addition, the submitted claims purported to be for multiple family members when the physician had only spoken to one person. Telehealth arrangements are also susceptible to AKS violations. For example, a telehealth company may refer potential payments or provide equipment or space to a provider to facilitate the provision of telehealth services while the provider may, even if not required to, refer patients back to the telehealth company. Depending on how this arrangement is structured, it could either implicate the AKS or fall under one of the AKS’ safe harbors. Other potentials for remuneration or inducements under the AKS reach beyond payments and include advertising for, or referrals to, telehealth companies; opportunities to earn telehealth per-visit fees and other reimbursement; referrals to specialists or labs; patient pricing arrangements and other situations that may be seen as arranging for furnishment of health care items or services. HHS-OIG’s advisory opinions continue to warn of inducements for referrals. A lab owner was recently [convicted](https://www.justice.gov/opa/pr/lab-owner-convicted-463-million-genetic-testing-scheme-defraud-medicare) of numerous counts of health care fraud and illegal kickbacks for paying bribes to patient brokers to obtain signed doctors’ orders authorizing $187 million of medically unnecessary genetic tests from telemedicine companies. Telehealth situations should be evaluated for investigation risks including patient steering, intrusion on independent clinical decision-making, likelihood of increasing inappropriate utilization or costs, and analyses of a company’s return on investments. ### Risk mitigation: Several safe harbors and good practices may permit appropriate relationships The safe harbor for [leases for space or equipment](https://www.law.cornell.edu/cfr/text/42/1001.952) may permit certain arrangements under which one party provides telemedicine equipment or space to the second party that provides telehealth services to patients. Likewise, the safe harbor for [personal services and management contracts](https://www.law.cornell.edu/cfr/text/42/1001.952) may permit certain arrangements under which physicians receive money from an entity, and use equipment provided by the entity, to provide telehealth services to the entity’s customers. According to HHS-OIG, such arrangements may be permissible even where physicians refer patients back to the entity, as long as such referrals are not required under the terms of the contract. Finally, arrangements that [promote access to care](https://www.govinfo.gov/app/details/FR-2016-12-07/2016-28297) and pose a low risk of harm to patients and federal health care programs may be permitted if they “improve a particular beneficiary’s ability to obtain” care by providing tools or resources necessary to remove “socioeconomic, educational, geographic, mobility, or other barriers” to care, pursuant to 81 Fed. Reg. at 88,392-94. With COVID-19 not yet in the rearview mirror, [demand](https://mhealthintelligence.com/news/majority-of-americans-value-the-convenience-associated-with-telehealth) for virtual visits is [firmly cemented](https://www.trillianthealth.com/insights/the-compass/post-pandemic-telehealth-supply-exceeds-consumer-demand) in the health care market. Reversion back to reimbursement models for services that only support in-person care seems unlikely. The inevitable end of the PHE poses questions about what will happen to telehealth benefits. Given extensive support for making changes that have launched telehealth and provided the opportunity to serve more patients, it is possible that Congress could permanently extend many pandemic telehealth waiver rules. Even with the implementation of additional guardrails and oversight to maintain telehealth program integrity, enforcement of telehealth fraud will likely remain a government priority for the foreseeable future. **Topics:** COVID-19, Public Awareness, Technology --- ### [Mnsure Warns of Insurance Scams](https://insurancefraud.org/news_archives/mnsure-warns-of-insurance-scams/) **Published:** September 19, 2026 **Author:** Diane Beauchamp **Content:** MNsure, Minnesota’s health insurance marketplace, is warning residents of new scams during this year’s open enrollment period through January 15th. Officials ask residents to beware of the “red flags” that might mean they’re being scammed. Watch out for any unsolicited calls, especially if they require payment immediately. MNsure does not cold call customers or ask for a social security number, credit card number, or bank accounts. Make sure that you’re on a legitimate website, and not a fake site built to gather your personal information. Take advantage of free, anonymous, tools that allow you to compare different plans and coverage areas. MNsure has a cost estimator tool that does not require personal information, like a phone number, which may lead to unwanted calls. Finally, make sure you’re buying comprehensive coverage, instead of reduced coverage for cheaper prices. Check that all plans contain essential health benefits and consumer protections to make sure you don’t have surprise bills if you need medical services. MNsure will have certified brokers standing by through the open enrollment period. **Topics:** Public Awareness --- ### [Indian American doctor pays $1,850,000 for healthcare fraud](https://insurancefraud.org/news_archives/indian-american-doctor-pays-1850000-for-healthcare-fraud/) **Published:** September 19, 2026 **Author:** Diane Beauchamp **Content:** ***Aarti Pandya allegedly performed and billed for unnecessary cataract surgeries and diagnostic tests*** An Indian American doctor has agreed to pay about $1,850,000 to resolve allegations that she billed the government for cataract surgeries and diagnostic tests that were not medically necessary for six years. Aarti D Pandya and her Pandya Practice Group based in Conyers, near Atlanta, Georgia allegedly violated the False Claims Act by also billing for incomplete or worthless tests and office visits that did not provide the level of service claimed. This settlement resolves allegations that between 2011 and 2016, Pandya knowingly submitted false claims to federal healthcare programs for medically unnecessary cataract extraction surgeries and YAG laser capsulotomies, according to a press release from the US Attorney’s Office for the Northern District of Georgia. Prosecution alleged that Pandya performed these procedures on patients that did not qualify for the procedure under accepted standards of medical practice and, in some cases, caused injury to her patients. Prosecution also alleged that Pandya falsely diagnosed patients with glaucoma to justify unnecessary diagnostic testing and treatment that was billed to Medicare. Many of the diagnostic tests that Pandya ordered were not properly performed, were performed on a broken machine, or were not interpreted in the medical record, as required by Medicare, it alleged. This settlement resolves allegations in a lawsuit filed by Laura Dildine, a former Pandya Practice Group employee, under the qui tam, or whistleblower, provisions of the False Claims Act (FCA), the release said. After the government intervened in the lawsuit in 2018, the Department of Health and Human Services (HHS) imposed a payment suspension on the Pandya Practice Group that precluded it from receiving any reimbursement from Medicare for Part B claims. The payment suspension was imposed in Oct 2019. Pandya and the Pandya Practice Group unsuccessfully challenged the payment suspension in district court. As part of the settlement of the government’s claims in this case, the Pandya Practice Group agreed to forfeit the suspension amount to the government. The payment suspension will also be lifted as part of the settlement, the release said. To protect federal health care programs and beneficiaries going forward, Pandya and the Pandya Practice Group have entered into a detailed, multi-year Integrity Agreement and Conditional Exclusion Release (IA) with the Office of Inspector General (OIG) that is more robust than OIG’s standard agreement. The IA includes training and reporting requirements and enhanced material breach provisions. The IA also requires that Pandya and the Pandya Practice Group hire an Independent Review Organization to conduct annual claims reviews to determine whether the items and services furnished were medically necessary and appropriately documented, and whether the claims were correctly coded, submitted, and reimbursed. OIG did not release its permissive exclusion authority and will provide such a release only after Pandya and the Pandya Practice Group have satisfied their obligations under the IA, the release said. **Topics:** Judicial/courts --- ### [3 physician fraud cases in 2023](https://insurancefraud.org/news_archives/3-physician-fraud-cases-in-2023/) **Published:** September 19, 2026 **Author:** Diane Beauchamp **Content:** Here are three physician fraud cases so far this year: 1. Great Neck, N.Y.-based gastroenterologist Morris Barnard, MD, was sentenced to 30 months in prison and must pay $1.4 million for a Medicare billing fraud scheme. In March, Dr. Barnard pleaded guilty to submitting more than $3 million in bills to Medicare for gastroenterological procedures that he never performed. 2. Kishor Vora, MD, owner of Owensboro (Ky.) Heart and Vascular and Owensboro Medical Practice, paid $931,500 to settle a Medicare fraud case with the U.S. Justice Department for referring patients for genetic testing in exchange for an estimated $335,700 in kickbacks. 3. Jeffrey Tauth, MD, a cardiologist at Hot Springs (Ark.) National Park Medical Center and National Park Cardiology Services, has agreed to pay $900,000 to resolve claims alleging he violated the False Claims Act. Between September 2013 and August 2019, Dr. Tauth allegedly submitted claims to Medicare. **Topics:** Medicare/Medicaid **Categories:** Conviction --- ### [False Claims Act Settlements For Medical Device Fraud](https://insurancefraud.org/news_archives/false-claims-act-settlements-for-medical-device-fraud/) **Published:** September 19, 2026 **Author:** Diane Beauchamp **Content:** The [Department of Justice](https://www.justice.gov/) recently announced two settlements of cases alleging medical device fraud. [One case](https://www.justice.gov/usao-ma/pr/massachusetts-iv-pump-manufacturer-agrees-pay-nearly-500000-resolve-allegations-it#:~:text=The%20settlement%20resolves%20allegations%20that%20Zyno%20knowingly%20distributed,of%20chemotherapy%20and%20other%20medications%20to%20Medicare%20beneficiaries.) involved a Massachusetts manufacturer (Zyno Medical) that distributed defective intravenous (IV) administration kits. [The other](https://www.justice.gov/opa/pr/jet-medical-and-related-companies-agree-pay-more-700000-resolve-medical-device-allegations) involved a Pennsylvania company (Jet Medical) that distributed migraine treatment devices that were not FDA-approved. ## Zyno Medical Two whistleblowers sued Zyno Medical, LLC (Zyno) for knowingly distributing defective IV kits. Providers used these kits to deliver chemotherapy and other medications to Medicare patients. The defect caused leaks during the infusion of these medications. Zyno admitted knowing of the defect as early as November 2015. However, it did not issue a recall for the kits until late July 2016. Instead, it continued to sell them. Under the [settlement](https://www.whistleblowerllc.com/wp-content/uploads/2023/01/zyno_-_settlement_agreement_0.pdf), Zyno agreed to pay $493,140, and the government awarded the whistleblowers 20% of that amount. In [announcing](https://www.justice.gov/opa/pr/medical-device-company-zyno-medical-llc-agrees-pay-nearly-500000-resolve-false-claims-act) the settlement, DOJ emphasized that “Medicare patients who need chemotherapy or other medication administered intravenously should not have to worry about whether the devices used for their treatment will deliver the intended dosage.” Further, Principal Deputy Assistant Attorney General Brian M. Boynton, who heads DOJ’s Civil Division, warned medical device manufacturers: > We will pursue appropriate relief when health care providers, including medical device manufacturers, knowingly put the safety and welfare of federal healthcare program beneficiaries at risk. ## Jet Medical The settlement involving Jet Medical (Jet) included both [criminal and civil penalties](https://www.justice.gov/opa/pr/jet-medical-and-related-companies-agree-pay-more-700000-resolve-medical-device-allegations). Jet distributed a device called the Allevio SPG Nerve Block Catheter (Allevio). Jet claimed that Allevio was effective in treating migraines by administering nerve blocks into the skull. However, it never sought approval from the FDA for this use. In addition, Jet never properly studied whether Allevio was safe and effective for treating migraines. Whistleblowers alleged that Jet and two related companies caused false claims by persuading providers to submit claims for Allevio. They contended that, because the FDA had not approved or authorized Allevio for treating headaches, the nerve-blocking device was not covered by Medicare. DOJ settled their civil False Claims Act case for $545,000. In addition, Jet agreed to a deferred prosecution and criminal penalties of $200,000. As part of the settlements, Jet admitted to distributing “misbranded” (not FDA-approved) devices. In connection with this settlement announcement, Principal Deputy Assistant Attorney General Boynton emphasized: > The FDA approval and clearance process serves an important role in ensuring that devices used to treat patients are safe, effective, and medically appropriate. We will not permit companies to circumvent that process and put profits over patient safety. ## Medical Device Fraud Continues to be an Enforcement Priority for DOJ These settlements demonstrate the continuing commitment by DOJ, the FDA, and other federal agencies to use the False Claims Act to combat device manufacturers and distributors who put patients at risk and cost taxpayers money. We’ve [previously written](https://www.whistleblowerllc.com/what-we-do/healthcare-fraud/medical-device-and-equipment-fraud/) about many of the ways in which device manufacturers can violate the False Claims Act. About a year ago, one of our whistleblower cases involving medical devices settled for [$16 million](https://www.whistleblowerllc.com/arthrex-false-claims-act-settlement/). That case alleged that Arthex, the device manufacturer, paid kickbacks to orthopedists to get them to order or recommend its surgical products. Other successes include a case against [heart monitoring companies](https://www.whistleblowerllc.com/success/medi-lynx-ami-spectocor-and-bogdan-13-4-million/) that overbilled for remote cardiac monitoring, which settled for $13.4 million. **Topics:** Judicial/courts, Public Awareness --- ### [Why Insurance Fraud Succeeds](https://insurancefraud.org/news_archives/why-insurance-fraud-succeeds/) **Published:** September 19, 2026 **Author:** Diane Beauchamp **Content:** It is Time For Insurers to be Proactive Against Fraud here has been much hand wringing and wailing over the malfeasance of the corporate officers and directors of FTX Crypto Exchange, Enron, WorldCom and others. No one, however, has gone to the root causes of the situation. It should be a foremost duty of the insurance industry to do whatever it can to defeat insurance fraud and work to compel prosecutors, police officers, fraud division of fraud bureau investigators, SIU investigators, and claims handlers to work to deter or defeat insurance fraud. It is not that some corporate executives, suddenly turned to the dark side and became evil. It is not that police and prosecutors have turned to the dark side. It is, I submit, because they were all trained by the Department of Justice and local prosecutors to believe that there was almost no penalty for their crimes. White-collar crime, especially insurance fraud, has been ignored for the last three decades as a serious crime. A crime unpunished emboldens others who might never consider a life of crime to pursue wealth the easy way. Prosecution of what the Coalition Against Insurance Fraud contends is a $308 billion annual insurance fraud take, the massive crime perpetrated against insurers and government “insurance” programs like Medicare are miniscule, to the point of non-existence. Fraud is rampant and almost universally unpunished. Every year more than $100 billion is stolen from Medicare and Medicaid programs across the country while private property and casualty insurers lose a similar loss closer to $200 billion every year to insurance criminals. Even with the recent push against Medicare and Medicaid fraud by the U.S. Department of Justice, it is still so easy, with so little chance of being caught, to commit insurance fraud. Schools were formed to teach gang members to commit insurance fraud so that they can move out of the dangerous field of armed robbery where, if not killed by the convenience store operator, the robber will surely be hunted down and prosecuted. In my 55 year career trying to defeat or deter insurance fraud I have been told by a prosecutor that the robbery of a convenience store, with a gun, where no one is hurt and $300 is stolen is more important than a $2,000,000 fraud against an insurer perpetrated by the stroke of a pen in the hands of an insurance criminal. The prosecutor refused to prosecute the insurance criminal and the insurer was compelled to defend the lawsuit filed by the fraud without any assistance from the criminal justice system. It appears to me: 1. that the police and prosecutors ignore the person who commits a white-collar crime. 2. Insurers, as victims of crime, are disfavored. 3. Some police officers, prosecutors and judges believe that an insurance company cannot be a victim of a crime. Unlike all other crime victims insurers are required by statute to fund local police agencies and prosecutors, conduct the entire investigation, and present the case to the prosecutor on pain of losing the right to do business. The prosecutor will then review the materials and usually refuse to prosecute for lack of sufficient evidence. Police agencies – except for insurer paid for Insurance Fraud Bureaus – ignore insurance fraud and many other white-collar crimes. CALIFORNIA SIU REGULATIONS The full set of the Regulations are available at [https://insurancefraud.us1.list-manag…](https://www.youtube.com/redirect?event=video_description&redir_token=QUZZTVljRUdacVdvYlY4YWlpeUo0ZWZzcUUyZXxBTl9pYzRkS2phVmxpcDNRell6YWVsWTdWaGxMRmwyWWVTdENhU3pMMkRmRk5TQ2dxZ2VZXzRaSzBKVkY4S2ZpRGpEOThETTRzM1lKNDhETnZBUThuYWxEUFIwUkJuZVc2X3Jn&q=https%3A%2F%2Finsurancefraud.us1.list-manage.com%2Ftrack%2Fclick%3Fu%3Da440c5b647697de580a2fd586%26id%3D193011d9cb%26e%3D5e34ee91b1&v=KrAF0lGbwlU) The California SIU Regulations were approved in their final form effective October 1, 2020. The SIU Regulations attempt to micromanage the work of insurance company efforts against insurance fraud and were enacted following a model act of the National Association of Insurance Commissioners (NAIC). In addition to the special assessments enacted to fund the fight against fraud, the California Department of Insurance audits insurers regularly to be sure that each insurer works hard to investigate and seek prosecution of the crime of insurance fraud in accordance with the California SIU Regulations. Simultaneously, the same Department of Insurance punishes insurers for not paying claims rapidly or for not treating insureds or claimants fairly, many of whom are experienced insurance cheats who use the Department’s consumer unit to brow-beat insurers into paying fraudulent claims. Similar businesses in the financial sector, who are also regular victims of fraud and other crimes, are not taxed or compelled to investigate crimes committed against them. **Topics:** Public Awareness --- ### [Niles doctor accused of trading drugs for sex favors](https://insurancefraud.org/news_archives/niles-doctor-accused-of-trading-drugs-for-sex-favors/) **Published:** September 19, 2026 **Author:** Diane Beauchamp **Content:** A Niles doctor is accused of arranging a scheme that exchanged prescription drugs for sexual favors, according to a bill of information filed Monday in U.S. Northern Ohio District Court. Jeffrey Sutton of Sutton Internal and Physical Medicine Clinic faces 32 counts of dispensing controlled substances and 20 counts of health care fraud. Court documents allege the activity happened between January 2015 and January 2022. Seven patients are alleged to have been victimized by Sutton. Of the seven, three are said to have engaged in sex with Sutton in exchange for drugs during office visits, the court document states. The bill of information alleges Sutton enriched himself by attracting and maintaining patients that seek prescriptions for medically unnecessary controlled substances. The government also factored into Sutton’s alleged scheme obtaining reimbursement for office visits from health care benefits programs. During these visits, Sutton is said to have issued prescriptions for medically controlled substances patients did not need. The filing states Sutton would prescribe high levels of opioids combined with benzodiazepines, issued outside a professional practice. These fraudulent prescriptions then were billed to the health care benefit program, the document states. Around March 2019, the filing states a patient was admitted to a local hospital for an “altered mental state” and was diagnosed with substance abuse and addiction. When the patient returned around April 2019, Sutton is alleged by the government to have stopped the treatment for addiction and started the patient back on high-dosage opioids. **Topics:** Drug Diversion **Categories:** Arrest --- ### [Portland lawyer used money stolen from clients for lavish trips to nudist resort, African safaris: DOJ](https://insurancefraud.org/news_archives/portland-lawyer-used-money-stolen-from-clients-for-lavish-trips-to-nudist-resort-african-safaris-doj/) **Published:** September 19, 2026 **Author:** Diane Beauchamp **Content:** A former Portland, Oregon, lawyer defrauded injured clients out of millions of dollars in insurance payments – then spent some of the cash on lavish trips to a nudist resort, an African safari and other destinations, federal prosecutors said. Lori E. Deveny, 57, was sentenced this week to more than eight years in prison in an insurance scheme in which she stole more than $3.8 million from at least 135 clients between 2011 and 2019 and then used the money to “bankroll a lavish lifestyle,” the U.S. Department of Justice said in a press release. “It’s hard to overstate the extraordinary impact Ms. Deveny’s crimes had on the many innocent and vulnerable victims who trusted her,” Ethan Knight, chief of the Economic Crimes Unit for the U.S. Attorney’s Office, said in a statement. “As a former attorney, she had a special responsibility to her clients and to the public, but she repeatedly abused this trust and prioritized her own needs. This is a just sentence for serious crimes.” Deveny would steal clients’ identities and then forge insurance checks and deposit the funds into her personal bank account, court documents show. She would then deceive her clients by telling them the compensation for their various injuries would eventually show up in their bank accounts, according to court records. “The cruelest thing of all is knowingly providing false hope,” said Special Agent in Charge Bret Kressin, IRS Criminal Investigation, Seattle Field Office. “Having already suffered losses, Ms. Deveny’s clients deserved an attorney who represented their best interests. What they got instead was someone who inflicted more loss.” Deveny received what she never provided her clients: “a picture of reality that those who choose to defraud will face the consequences of their actions,” Kressin added. The DOJ noted in its press release that, “many of Deveny’s victims were particularly vulnerable to her criminal behavior after sustaining serious brain and bodily injuries and never received the insurance payouts they were owed.” Deveny spent $150,000 on foreign and domestic airline tickets, $173,000 on African safari and big game hunting trips, and $60,000 on trips to a luxury nudist resort in Palm Springs, California, according to the DOJ. She spent $35,000 on taxidermy expenses, ostensibly stemming from her big game hunting trips, $195,000 on her mortgage, a whopping $220,000 in cigars, and a combined $91,000 on a Cadillac and recreational vehicle expenses. She also spent $58,000 on pet boarding and veterinary costs, according to the DOJ. Deveny pleaded guilty in June 2022 to one count each of mail, wire and bank fraud. She also pleaded guilty to money laundering, filing a false tax return, and two counts of aggravated identity theft. She was ordered on Monday to pay more than $4.5 million in restitution to her victims. “While serving as an attorney, Ms. Deveny brazenly stole money that should have gone to pay for health care for her clients for serious injuries and ailment,” said Kieran L. Ramsey, special agent in charge of the FBI Portland Field Office. “Instead, that money funded things like big game hunting trips to Africa and home remodeling,” Ramsey said in a statement. “She took advantage of people who were physically and emotionally hurting by forging insurance checks, stealing the funds and lying to her clients about the payouts.” **Topics:** Insider Fraud **Categories:** Conviction --- ### [Hive claims stealing Consulate Health data; provider reports vendor incident](https://insurancefraud.org/news_archives/hive-claims-stealing-consulate-health-data-provider-reports-vendor-incident/) **Published:** September 19, 2026 **Author:** Diane Beauchamp **Content:** The Hive ransomware threat group claims to have stolen 550 GB of data from Consulate Health Care. The actors’ dark web posting appeared around the same time [a notice was posted](https://consulatehc.com/security-incident-notice/) on the Consulate website that warned patients of potential access to their data. Consulate Health owns 140 nursing homes across the country and also provides other senior care services. A STAT report from August shows the company has been dealing with financial issues in recent years, including [filing for bankruptcy at six of its care](https://www.statnews.com/2022/08/05/consulate-health-care-litigation-tangled-corporate-structure-bankruptcy/) sites. The size of the organization may have widespread data impacts, but the number of patients has not yet been listed on the Department of Health and Human Services breach reporting tool. Consulate Health has also not confirmed whether the vendor incident is tied to the Hive posting. Currently, they’ve determined that one of Consulate’s vendors experienced a “security incident” in early December. Threat actors targeted portions of the network, prompting incident response plans and an investigation to determine the scope. The analysis confirm the threat actors may have accessed records containing personal information. The investigation into the incident is ongoing, but Consulate Health issued its notice in an effort of transparency. The provider intends to notify patients as soon as they’ve determined whether their information was contained in the files accessed by the actors. For now, patients are being urged to “remain vigilant” and monitor for unauthorized activity. Consulate Health is “in regular touch with our vendor, and we are closely monitoring the investigation, as they work to finalize the investigation as soon as possible.” according to the notice. ## Disruptions continue at CentraState HealthCare after cyberattack CentraState is continuing to face network issues after falling victim to an apparent cyberattack, first launched during the morning hours of Dec. 30. An update posted last week shows four departments are still facing care disruptions after the attack. No walk-ins are being accommodated at its outpatient radiology. Instead patients are being sent to a care partner site. Only one lab appears to be holding routine appointments and walk-ins, and patients are being asked to call ahead for appointments at other labs. [As previously reported](https://www.scworld.com/analysis/ransomware/nj-hospital-centrastate-diverting-patients-after-cyberattack-it-shutdown), the hospital’s CEO confirmed the provider organization was dealing with technical issues stemming from an IT security issue, which prompted care diversion processes and other appointment delays and cancellations. The impacted sites are operating under electronic health record downtime procedures with paper processes, which has allowed for patient care to continue without any adverse effects. Patients are still being urged to contact 911 for emergencies, as it continues to respond to the security issues and service impacts. However, officials say their “high standards of patient care remain in place, and our emergency department continues to function at near full capability with some limited exceptions.” ## After ransomware attack on MedStar Mobile, 612K notified of data breach The data of 612,000 patients was potentially compromised after a ransomware attack on MedStar Mobile Healthcare in October. MedStar Mobile is an ambulance service provider for 15 cities in Tarrant County, Texas. Deployed on Oct. 20, 2022, network system issues prompted an investigation that discovered a threat actor accessed a restricted location in the network. A number of patient files were stored in the impacted system, but MedStar Mobile was unable to confirm whether those files were actually accessed by the attacker. The compromised data involved patients who received care from the ambulance service provider, and for many, only non-financial billing information was impacted. For a smaller number of individuals, names, dates of birth, contact details, treatment information, and other identifiers were exposed. MedStar Mobile explained its previously implemented security measures enabled prompt action against the attack and also reduced the proliferation of the attack. With support from a third-party firm, the provider is working to bolster its systems and data security. ## 271K Avem Health patients informed of May data breach Approximately 271,000 Avem Health Partners patients are learning that a “data security incident” at a data storage vendor, 365 Data Centers, possibly compromised their protected health information. Avem is an administrative and technology service provider. It’s unclear when Avem was notified of the incident, but 365 Data Center confirmed that data stored on their servers was likely subjected to access by a threat actor during an incident in mid-May. As [HHS recently reminded providers](https://www.scworld.com/analysis/security-awareness/hipaa-requires-timely-response-for-security-incidents-says-alert-to-health-sector), data breaches are to be reported without undue delay and within 60 days of discovery. The delay was possibly tied to a review of the files stored on the impacted servers, as per its breach notice. The review found that the compromised information included names, dates of birth, Social Security numbers, driver’s licenses, health insurance details, diagnoses, and treatment information. Patients whose driver’s licenses or SSNs were compromised are being offered credit monitoring and identity theft protection services. The incident did not directly affect Avem systems. Avem is currently examining its vendor relationships and the security measures of their connected partners. ## Fitzgibbon Hospital informing patients of June 2022 breach A network hack on June 6, 2022, at Fitzgibbon Hospital in Missouri led to the possible access or acquisition of protected health information for 112,072 patients. But patients weren’t notified of the incident and data impacts until January 2023. The notice appears to attribute the delay to only discovering the possible data compromise on Dec. 1. It remains to be seen how the delay will be viewed by HHS. An investigation was launched in June with support from a third-party cybersecurity team, which is ongoing. The response team has confirmed personal and health data were accessed and stolen “in connection with the incident.” The stolen data varied by individual and could include SSNs, driver’s licenses, financial account numbers, health insurance details, and/or medical information. Not all Fitzgibbon Hospital patients were impacted by the network hack. Patients with compromised SSNs will receive free credit monitoring services. ## Patients learning of Maternal & Family Health April 2022 data breach Maternal & Family Health Services (MFHS) recently began notifying an undisclosed number of patients that their data was accessed during a ransomware attack in April 2022, becoming the third provider to fail to timely report a PHI incident this month. Upon discovering the attack on April 4, MFHS engaged a third-party forensic incident response firm for support with securing their systems and to conduct a forensics investigation. The team found that while the incident was discovered in April, the attackers had access to the system for eight months — beginning in August 2021. The forensics confirmed patient data was accessed during the incident, including contact details, dates of birth, SSNs, driver’s licenses, financial account/payment card information, usernames and passwords, medical data, and/or health insurance information. **Topics:** Public Awareness, Technology --- ### [Scammers Targeting Health Insurance Buyers](https://insurancefraud.org/news_archives/scammers-targeting-health-insurance-buyers/) **Published:** September 19, 2026 **Author:** Diane Beauchamp **Content:** With the end of open enrollment for Minnesota’s healthcare exchange less than a week away, officials say scams are rampant. When someone uses Google to search for MNsure, the first results are paid ads designed to look like the official site. Instead, they are dummy pages that will collect information from unsuspecting people, including your age, financial data, and Social Security number. Pay close attention to the URL when you are redirected to a site. Make sure it reads MNSure.org. Another tip to avoid being defrauded is to be leery of unsolicited phone calls. MNsure brokers do not cold call potential customers and they never demand immediate payment to enroll someone into the program. The exchange allows you to browse options and get a free cost estimate anonymously without providing a telephone number. If you use another service that could result in you ending up on a contact list. Lastly, officials say you should buy comprehensive protection, guaranteed in every MNsure plan, but not when you use a private company. **Topics:** Public Awareness --- ### [Reality-TV Villain Meets Desperate Homeowners: Three States Are Suing Over Alleged Fast-Cash Scam](https://insurancefraud.org/news_archives/reality-tv-villain-meets-desperate-homeowners-three-states-are-suing-over-alleged-fast-cash-scam/) **Published:** September 19, 2026 **Author:** Diane Beauchamp **Content:** MV Realty has an offer for cash-strapped homeowners: Forget payday loans, which frequently start borrowers down the road to financial ruin, and instead take cash in the neighborhood of $1,000 from MV and never have to pay it back. The catch: For 40 years, the homeowners are required to use MV Realty as their real estate broker when they decide to sell. The contract says it’s enforceable even if the homeowner dies. There’s one escape hatch. If they want to get out of the deal, the owner or their family would have to cough up cash equal to 6% of the home’s sales price or market value — as determined by MV. That means that on a $1,000 payment, based on MV’s own estimates, they would have to pay MV roughly $10,000. **Topics:** Judicial/courts --- ### [St. Charles Patients Targeted By Fraudsters](https://insurancefraud.org/news_archives/st-charles-patients-targeted-by-fraudsters/) **Published:** September 19, 2026 **Author:** Diane Beauchamp **Content:** A nationwide scam is now using the St. Charles Health System name to dupe victims into turning over their personal information. SCHS Chief Information Security Officer Ron Buchanan says local patients have reported getting an unsolicited call from someone claiming to be from St. Charles or Medicare, offering free or low-cost medical equipment, “Oftentimes they’ll put a sense of urgency behind it also. You know, ‘you need to act now because money is going to run out with Medicare,’ something along those lines.” The scammers may offer things like knee braces, back braces, a wheelchair or walker. Buchanan tells KBND News, “Ultimately, what the goal is, they’ll try to get the person to give up their Medicare number and/or their Social Security Number.” Buchanan says Medicare, St. Charles and real equipment manufacturers won’t call you unsolicited, “Part of the definition of ‘durable medical equipment’ to be subsidized or covered by Medicare, is that it’s got to be medically prescribed. So, you have someone coming over the phone and saying, ‘hey, I’ve got this great offer for a free or a reduced price device.’ But, at the end of the day, that person isn’t the one who has prescribed it.” He adds, “This is Medicare fraud. So it’s targeting, oftentimes, seniors.” If you get a call from someone offering healthcare products without a prescription, hang up and check with your doctor. “Protect your Social Security Number; protect your Medicare number. Don’t give it out to anybody unless it’s your doctor or insurance company.” Buchanan also suggests checking your insurance or Medicare statements frequently to make sure you haven’t been billed for equipment you don’t need or didn’t order. And, if you do fall victim, call the Medicare fraud line. **Topics:** Public Awareness --- ### [Looking back at a year of P&C insurance fraud in the Big Apple](https://insurancefraud.org/news_archives/looking-back-at-a-year-of-pc-insurance-fraud-in-the-big-apple/) **Published:** September 19, 2026 **Author:** Diane Beauchamp **Content:** The Coalition Against Insurance Fraud estimates that insurance fraud steals at least $308.6 billion every year from American consumers. Insurance fraud leading to criminal prosecutions and civil cases will no doubt continue this year and for years to come. The prosecutions and convictions, however, often lag years behind the commission of the frauds and in most cases touch only upon the proverbial “tip of the iceberg.” Lawyers, accountants, other professionals, business people and consumers who are not directly involved in discovering, challenging and litigating insurance fraud matters likely would be shocked to learn about the breadth and prevalence of these schemes. By the same token, one might think that the number and range of insurance fraud-related indictments, convictions and sentencings in just the Southern District of New York alone over the past year would be enough to warn potential fraudsters to think twice before acting. Yet if history is any guide, we can expect the volume and range of fraud schemes to continue to multiply, along with a steady stream of eye-opening fraud charges being filed throughout the next year in New York and across the country. This column surveys a variety of Southern District of New York cases from the past 12 months, highlighting the key features of these demonstrated (or alleged) insurance frauds. No-fault insurance No-fault insurance fraud continues to be a major problem for insurance carriers and, because of the cost and the impact on premiums, for policyholders. Consider the case brought last January that U.S. Attorney Damian Williams referred to as a “$100 million automobile insurance fraud scheme” and one of the “largest no-fault insurance frauds in history.” According to the charges, the defendants illegally owned and controlled more than a dozen medical professional corporations — including medical, acupuncture, and chiropractic practices — by paying licensed medical professionals to use their licenses to incorporate the professional corporations. The defendants allegedly bribed 911 operators, hospital employees and others for confidential motor vehicle accident victim information. With this information, they then allegedly endangered victims by subjecting them to unnecessary and often painful medical procedures, in order to fraudulently overbill insurance companies. Then, in early April in a different case, Jelani Wray was sentenced to 84 months in prison by U.S. District Judge Paul G. Gardephe. Prosecutors asserted that Wray was a senior leader of a no-fault insurance fraud conspiracy spanning New York and New Jersey from at least in or about 2013 through in or about 2019 in which he and his co-conspirators bribed 911 operators, medical personnel and police officers for the confidential information of tens of thousands of motor vehicle accident victims. Using this information, prosecutors said, Wray and others contacted victims, lied to them, and steered them to clinics and to lawyers they handpicked. These clinics and lawyers then paid Wray and his associates kickbacks for these referrals, which they distributed to co-conspirators as payments and bribes, according to the government. Licensed professionals One can only speculate as to what would make a licensed professional risk his or her license, as well as prison time, by participating in egregious insurance fraud schemes. Yet it happens more often than one might expect. Consider the case of Dr. Sady Ribeiro, a New York-licensed pain management doctor and surgeon, who pleaded guilty in late September, before U.S. District Judge Sidney H. Stein, to one count of conspiracy to commit mail fraud and one count of conspiracy to commit wire fraud. As prosecutors explained, Ribeiro and others defrauded insurance companies and businesses by staging trip-and-fall accidents and then filing fraudulent lawsuits arising from those staged trip-and-fall accidents. Prosecutors asserted that the participants in the fraud recruited more than 400 individuals (patients) to stage or falsely claim to have suffered trip-and-fall accidents at particular locations throughout the New York City area. As alleged, in the beginning, the participants in the fraud would instruct patients to claim they had tripped and fallen at a particular location, when in fact, the patients had suffered no such accidents. Prosecutors alleged that, eventually, at the direction of the lawyers who filed fraudulent lawsuits on behalf of the patients, patients began to be instructed to stage trip-and-fall accidents, i.e., to go to a location and deliberately fall. Common accident sites used during the fraud scheme included cellar doors, cracks in concrete sidewalks, and purported “potholes,” according to the authorities. According to the authorities, during the course of the fraud, the defendants and others attempted to defraud insurers or property owners of more than $31 million. The government asserted that patients also were instructed to receive ongoing chiropractic and medical treatment from certain chiropractors and doctors, including Ribeiro. The participants in the fraud allegedly advised patients that if they intended to continue with their lawsuits, they had to undergo surgery. As an incentive to get surgery, the recruited patients were offered a payment of typically between $1,000 and $1,500 after they completed surgery, the government said. As alleged, patients generally were told to undergo two surgeries. The government asserted that doctors participating in the fraud, including Ribeiro, “were expected to, and in fact did, conduct these surgeries regardless of the legitimate medical needs of the patients.” According to the charges, Ribeiro performed back surgeries, among other medical procedures, on nearly 200 patients—and, to maximize his patient base, he paid participants cash kickbacks in exchange for patient referrals. The Coalition Against Insurance Fraud estimates that insurance fraud steals at least $308.6 billion every year from American consumers. Insurance frauds leading to criminal prosecutions and civil cases will no doubt continue this year and for years to come. The prosecutions and convictions, however, often lag years behind the commission of the frauds and in most cases touch only upon the proverbial “tip of the iceberg.” Insurance carriers’ fraud departments and federal, state, and local authorities will need to keep a keen focus on fighting fraud and evolving schemes to limit the damage to insurers, policyholders, businesses, and consumers alike. **Topics:** Coalition Against Insurance Fraud, Homeowners Fraud, Public Awareness --- ### [Don’t Copy New York’s Medicaid Home Care Disaster](https://insurancefraud.org/news_archives/dont-copy-new-yorks-medicaid-home-care-disaster/) **Published:** September 19, 2026 **Author:** Diane Beauchamp **Content:** The state invites fraud by spending nearly as much on home aides as the other 49 states put together. As America ages, states are investing in home-based care for the elderly and disabled in hopes of keeping people out of nursing facilities—and maybe saving money in the bargain. Before going too far, they should study how that approach has—and hasn’t—worked in New York. New York’s Medicaid program spends far more than any other on the nonmedical form of home care known as personal care or personal assistance, which covers services such as bathing, dressing, feeding and housekeeping for people who can’t manage those tasks on their own. According to a federal [analysis](https://www.medicaid.gov/medicaid/long-term-services-supports/reports-evaluations/index.html) of 2019 Medicaid spending, the Empire State’s annual personal-care outlays of $12 billion were the largest in the nation, and nearly as much as the other 49 states combined. Its per capita expenditures were eight times the U.S. average. That extraordinary spending has produced an extraordinarily large workforce. The number of home health aides employed in New York soared to 480,000 in 2021 from 250,000 in 2011, accounting for almost two-thirds of the state’s net job growth during that period. Their ranks now outnumber both retail clerks and fast-food counter workers. Home health employment is especially heavy in New York City, which has 236 aides for every 1,000 residents 65 or older, quadruple the national rate. For the U.S. as a whole to match that level, it would need to add nine million aides—roughly the population of New Jersey. **Topics:** Medicare/Medicaid, Public Awareness --- ### [Doctors Prescribing to Their Patients Did Not Create the US Opioid Crisis](https://insurancefraud.org/news_archives/doctors-prescribing-to-their-patients-did-not-create-the-us-opioid-crisis/) **Published:** September 19, 2026 **Author:** Diane Beauchamp **Content:** The 2016 and 2022 CDC opioid prescribing guidelines were based on the assertion that doctor over-prescribing to patients has been a major cause of opioid use disorder and overdose-related deaths. Published data from the CDC and other sources reveals that this assertion was incorrect – and the CDC knew it was incorrect when it published its guidelines. “Everybody knows” that America is undergoing a public health crisis in addiction and death involving opioids. Many media sources — and even some medical doctors who should know better — have attributed the causes of this crisis to “over-prescription” of opioids by clinicians to their patients. However, this explanation for our public health crisis is factually wrong. Data published by authoritative sources including the US Centers for Disease Control and Prevention ***prove*** that it is wrong. Opioid prescribing grew steadily from 1980 to 2011. Figure 1 shows numbers of prescriptions recorded for two high-volume prescription drugs over this period. ![](https://insurancefraud.org/wp-content/uploads/image-20-1024x537.png)Part of this growth can be attributed to a few doctors and pharmacists who operated pill mills, often serving walk-in clients who shammed pain-related illness in order to obtain opioids for resale in street markets. During this period, opioid overdose-related deaths also grew, with a very different trend curve: ![](https://insurancefraud.org/wp-content/uploads/image-21-893x1024.png)Also cited by Chuck Dinerstein in “The Overdose Epidemic in Three Pictures” *American Council on Science and Health,* September 20, 2018 <https://www.acsh.org/news/2018/09/20/overdose-epidemic-3-pictures-13424> Figure 2 shows the composite curve of mortalities from all accidental drug poisoning involving Heroin, Methadone, synthetic opioids other than Methadone, Cocaine, Methamphetamine, unspecified narcotics, unspecified drugs generally, and prescription opioids. Contributions to mortality from these “sub-epidemics” vary sharply over time and between US States. Even near the height of the pill mill sub-epidemic in 2008, deaths from prescription opioids ranked sixth – lower than unspecified narcotics, unspecified drugs generally, Methamphetamine, Methadone, and Heroin. The contribution of prescriptions made by clinicians to legitimate patients throughout the period 1999 to 2019 were literally so small that they got lost in the noise of street drugs and uncertainties in the attribution of deaths by medical examiners and coroners across the US. It must also be remembered that drugs dispensed by pill mills were *still* “prescription” drugs. Even when abused for non-medical purposes, such drugs are still of known doses and were significantly safer than illegal street drugs of unknown composition. Thus there is substantial reason to believe that dominant public narratives blaming the opioid crisis on doctors “over-prescribing” to their patients – or even doctors operating pill mills – are substantially unsupported by the available data. Working independently of Hawre, et al, the author has also analyzed opioid mortality statistics, arriving at closely similar conclusions. See Richard A Lawhern, Ph.D. “One Opioid Epidemic or Many?” *American Council on Science and Health,* May 14, 2018. <https://www.acsh.org/news/2018/05/14/one-opioid-crisis-or-many-12956> Four events during 2010-2012 had major impacts on legitimate prescribing, without substantially altering the exponential rise in overdose mortality. 1. US FDA-mandated reformulation of Oxycodone into abuse-resistant form in 2010 caused prescription rates for this drug to immediately drop, even as deaths from street Heroin tripled in three years. However, overall deaths from prescription drugs remained level. 2. Six US States created state-administered Prescription Drug Monitoring Programs (PDMPs). Volumes of opioids prescribed by pill mills became more visible to law enforcement. “Patients” who doctor-shopped with multiple medical providers also became more visible. 3. US Drug Enforcement Administration belatedly began prosecuting operators of pill mills. Unfortunately, DEA also mounted a witch hunt against many conscientious clinicians whose only crime was taking on patients who had lost their pain doctors due to the actions of the DEA itself. 4. Starting in 2012, increasing numbers of overdose deaths involved illegally imported Fentanyl and its analogs. By 2019, the fraction of opioid poisoning deaths attributable to Fentanyl rose to at least 80%. From 2010 to 2019, responding to both the crackdown on pill mills and the overshadowing effects of law enforcement prosecution of doctors who prescribed opioids to legitimate patients, the total volume of opioid prescriptions dropped by 60%. Deaths in which a prescription opioid was one factor remained steady at around 15,000 per year. However, total overdose-related deaths continued to climb exponentially. In an independent reanalysis of drug poisoning deaths and hospital admissions for treatment of opioid toxicity, Larry Aubry and B. Thomas Carr concluded in 2022 that despite US CDC assertions to the contrary, there has been no cause-and-effect relationship between rates of prescribing versus either rates of hospitalization or rates of opioid-related overdose mortality, since at least as far back as 2010. As noted above, there is also reason to doubt that prescribing by doctors contributed significantly even at the height of pill mill operations between 2001 and 2010. ![](https://insurancefraud.org/wp-content/uploads/image-20-1024x782.png)**Conclusion:** It is apparent from widely published data that America’s opioid “crisis” is multi-factorial and highly dynamic. However, as concluded by multiple investigators – and as known for years by both the US CDC and DEA – “Today’s nonmedical opioid users are not yesterday’s patients.” \[Source: Jeffrey A. Singer, Jacob Z Sullum, and Michael E Schatman, “Today’s nonmedical opioid users are not yesterday’s patients; implications of data indicating stable rates of nonmedical use and pain reliever use disorder” *Journal of Pain Research* 2019, 12, 617-620, <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6369835/> \] It is thus glaringly obvious that the emphasis of November 2022 CDC opioid prescribing guidelines on risks of opioid addiction and mortality among patients managed by clinicians is vastly over-hyped, scientifically unsupported and ethically inappropriate. The open question is how to correct course. The author offers the following insights. 1. The current misdirected regulatory climate for pain clinicians has driven thousands of doctors and treatment centers out of practice, deserting millions of patients to agony. To correct this state of affairs, clinicians need a balanced and scientifically based practice standard within which they can be assured that they will not be sanctioned, denied clinical privileges, or arbitrarily prosecuted for mythical “over-prescribing”. 2. Pain treatment by clinicians must be individualized to patient needs and sensitive to the wide variability of genetically mediated patient drug metabolism and side effects. 3\. Opioid therapy is not the automatic first choice for all patients. But it is indispensable and mostly safe for many who are in moderate to severe pain, who do not respond to other therapies, or for whom such therapies are contra-indicated. 4\. The central practice standard should be “When opioids appear to be needed, start at low doses and titrate to desired analgesic effect while monitoring and managing for disabling side effects. Treat for co-morbid depression and anxiety. Refer for indications of preexisting opioid misuse. If a satisfactory balance is not attained, transition the patient to other opioid medications and ancillary therapies.” 5\. Deeply revised guidelines are needed but cannot be attempted by CDC or AHRQ — both of which have both demonstrated a record of profound anti-opioid bias, bad faith and incompetence. US National Academies of Medicine likewise have not demonstrated competence in such a project. 6\. Political interference in the evidence-based treatment of pain must cease. Balanced treatment guidelines must instead be written in a publicly transparent process by clinicians who have hands-on experience in the community and/or hospital practice of pain management. Multiple medical specialties and practice environments must be represented. Patients and their advocates must also be represented in this process as voting members of any publication approval group. The process might resemble the HHS Inter-Agency Task Force on Best Practices in Pain Management, with participants nominated by the American Medical Association, American Academy of Family Physicians, and other medical professional associations **Topics:** Drug Diversion, Public Awareness, Regulatory actions --- ### [Rocky Hill Woman Charged in Scheme to Defraud Medicaid](https://insurancefraud.org/news_archives/rocky-hill-woman-charged-in-scheme-to-defraud-medicaid/) **Published:** September 19, 2026 **Author:** Diane Beauchamp **Content:** A Rocky Hill woman who worked as a personal care assistant to her mother was arrested today and charged with billing Medicaid for personal care services while she was working elsewhere. Deborah V. Swain, age 52, was arrested by Inspectors from the Medicaid Fraud Control Unit in the Office of the Chief State’s Attorney. She was charged with one count each of Health Insurance Fraud and Larceny in the First Degree By Defrauding a Public Community. According to the arrest warrant affidavit, Swain was hired in December of 2020 to provide personal care services for her mother. At the same time, Swain was employed as a licensed practical nurse for a short-term rehabilitation and skilled nursing care facility. A total of 188.5 hours for personal care services were submitted and paid to the accused while she was working elsewhere at the rehabilitation facility. The false claims, which occurred from January 17, 2021 to November 7, 2021, totaled $3,063.12. Swain was employed under the Personal Care Assistance Waiver (PCA) program, which is a federal and state funded Medicaid program administered by the Department of Social Services that provides funds to allow people with disabilities to hire assistants for daily care, thus enabling the individuals to remain at home instead of being placed in a health care facility. Swain was released on a $20,000.00 non-surety bond and is scheduled to appear in Hartford Superior Court, G.A. No. 14, on December 6, 2022. The charges are merely accusations and she is presumed innocent until and unless proven guilty. Health Insurance Fraud is an unclassified felony punishable by up to 5 years in prison. Larceny in the First Degree by Defrauding a Public Community is a class B felony punishable by up to 20 years in prison. The case will be prosecuted by the Medicaid Fraud Control Unit. The Unit is grateful for the assistance it received in this investigation from the state’s Department of Social Services’ Office of Quality Assurance and the Rocky Hill Police Department. **Topics:** Medicare/Medicaid **Categories:** Arrest --- ### [State Medicaid Fraud Office Expansion To Include CHIP Fraud Investigations](https://insurancefraud.org/news_archives/state-medicaid-fraud-office-expansion-to-include-chip-fraud-investigations/) **Published:** September 19, 2026 **Author:** Diane Beauchamp **Content:** The Attorney General’s Medicaid Fraud Control Unit is expanding to include investigations of Children’s Health Insurance Program (CHIP) fraud across the state. CHIP offers health insurance to children whose families earn too much money for Medicaid. Attorney General Patrick Morrisey said this expansion puts West Virginia’s fraud unit more in line with the majority of states and that investigating claims of CHIP fraud will save taxpayers more money. “I just view that if you have the ability to save an extra dollar more with really not much effort, why wouldn’t you do that for the taxpayers and for the beneficiaries of the program?” Morrisey said. The expansion was announced during a Tuesday press conference scheduled by Morrisey, who touted the successes of the fraud control unit under his office over the past three years. During that time the unit was expanded from 12 individuals to 21 with the average amount of civil recoveries from fraud per year climbing 268 percent. Investigations of Medicaid fraud were previously housed under the West Virginia Department of Health and Human Resources before being placed under the jurisdiction of the Attorney General’s office in 2019. **Topics:** Public Awareness, Regulatory actions --- ### [Suburban OB-GYN pleads guilty to Medicaid fraud](https://insurancefraud.org/news_archives/suburban-ob-gyn-pleads-guilty-to-medicaid-fraud/) **Published:** September 19, 2026 **Author:** Diane Beauchamp **Content:** A suburban OB-GYN alleged to have fraudulently charged Illinois’ Medicaid program pleaded guilty Tuesday in Cook County Circuit Court, Attorney General Kwame Raoul’s office said. Dr. Monique Brotman, 52, of River Forest, billed Medicaid $58,747.57 for ultrasounds and other procedures that were not provided, alleged the attorney general’s office, which prosecuted the case. The alleged false charges occurred between December 2008 and February 2015, Raoul’s office wrote in a news release. “Thousands of Illinois residents rely on Medicaid for their health care. Defrauding the people of Illinois by misusing needed Medicaid resources will not be tolerated,” Raoul wrote. The OB-GYN was ordered to pay full restitution upfront and will be excluded from the Medicaid and Medicare programs for at least five years. She was also sentenced to five days of community service, the news release said. Brotman told the Tribune she’s operated a private practice in the western suburbs since 2008, part of a decadeslong career. “And I would like to do so again,” Brotman said. She has been told that her medical license will be automatically suspended for the term of her five-year probation, a temporary stoppage of her practice that she called “heartbreaking.” “Things are not what they seem,” Brotman said, adding that she had doubts about some of the alleged fraudulent charges but decided to plead guilty to avoid facing potential jail time. “I think that it was very heavy-handed, and I don’t think that the punishment mirrors the offense,” she said. “This is something that occurred almost a decade ago in a very dark time in my life, and that should be taken into account.” Brotman’s office hasn’t accepted Medicare or Medicaid since the investigation into her office began in 2015, she said. She said she believes the pause should have been counted as time served. The attorney general’s statement credited the Illinois State Police for investigating the fraud allegations and said Assistant Attorney General Rob Sparano handled the case. **Topics:** Medicare/Medicaid **Categories:** Conviction --- ### [Two Owners of New Jersey Pharmaceutical Marketing Company Admit Role in $38 Million Compounding Fraud Scheme](https://insurancefraud.org/news_archives/two-owners-of-new-jersey-pharmaceutical-marketing-company-admit-role-in-38-million-compounding-fraud-scheme/) **Published:** September 19, 2026 **Author:** Diane Beauchamp **Content:** Two owners of a New Jersey pharmaceutical marketing company admitted their roles in a $38 million compounded medication health care fraud scheme, U.S. Attorney Philip R. Sellinger announced. Samantha Zaretzky, 42, of Wayne, New Jersey, and Lee Nichols, 43, of Fair Haven, New Jersey, pleaded guilty by videoconference before U.S. District Judge John Michael Vazquez to separate informations charging each with one count of conspiracy to commit health care fraud. According to documents filed in this case and statements made in court: Through their company, Synergy Medical LLC, Zaretzky and Nichols exploited the manner in which health insurance plans processed, screened, and paid for customized drugs known as “compounded medications,” causing tens of millions of dollars of losses to several health insurance plans over two years. Zaretzky and Nichols pocketed millions of dollars through this compounding fraud scheme. Compounded medications are specialty medications mixed by a pharmacist to meet the specific medical needs of an individual patient. Although compounded drugs are not approved by the Food and Drug Administration (FDA), they are properly prescribed when a medical professional determines that an FDA-approved medication does not meet the health needs of a particular patient. From April 2014 to June 2016, Zaretzky and Nichols used Synergy as a platform through which they could market prescription-based compounded medications without regard to whether a health insurance beneficiary actually needed such a medication or whether an FDA-approved medication would have been appropriate and sufficient. Zaretzky and Nichols and their conspirators determined which combination of compounded ingredients was most financially lucrative. Through their sales representatives, they recruited health insurance beneficiaries who were willing to obtain these expensive, but medically unnecessary, compounded medications before a medical professional had evaluated the beneficiaries’ unique and individualized need for the medications. After convincing the beneficiaries to obtain a pre-formulated compounded medication, in many cases, Zaretzky, Nichols, and their sales representatives steered beneficiaries to a medical professional with whom the beneficiaries had no prior doctor-patient relationship, such as a telemedicine company. Although the beneficiaries did not have a prior relationship with the telemedicine doctors, Zaretzky and Nichols paid that company for consulting with the beneficiaries. On at least one occasion, Zaretzky and Nichols paid an advanced practice nurse, whose license was inactive, to write prescriptions in exchange for cash. Once those medical professionals issued the prescriptions, Zaretzky and Nichols ensured that the prescriptions were steered to compounding pharmacies that paid them a kickback. The health care fraud conspiracy charge carries a statutory maximum prison sentence of 10 years and a fine of $250,000 or twice the gross gain or loss from the scheme, whichever is greatest. Sentencing is scheduled for April 23, 2023. U.S. Attorney Sellinger credited special agents and an analyst of the FBI, under the direction of Special Agent in Charge James E. Dennehy in Newark, and Defense Criminal Investigative Service, under the direction of Special Agent in Charge Patrick J. Hegarty, with the investigation leading to today’s guilty pleas. The government is represented by Assistant U.S. Attorney George L. Brandley of the Health Care Fraud Unit in Newark. **Topics:** Drug Diversion, Healthcare Fraud **Categories:** Conviction --- ### [Maryland Man Pleads Guilty to Defrauding Medicaid of More than $700,000 in Scheme Involving Personal Care Services](https://insurancefraud.org/news_archives/maryland-man-pleads-guilty-to-defrauding-medicaid-of-more-than-700000-in-scheme-involving-personal-care-services/) **Published:** September 19, 2026 **Author:** Diane Beauchamp **Content:** Joseph Tamjong, 51, of Lanham, Maryland, pleaded guilty today to defrauding the D.C. Medicaid program out of $733,405. ``` The announcement was made by U.S. Attorney Matthew M. Graves, Wayne A. Jacobs, Special Agent in Charge of the FBI Washington Field Office’s Criminal Division, Maureen R. Dixon, Special Agent in Charge of the U.S. Department of Health and Human Services’ Office of Inspector General for the region that includes Washington, D.C., and Daniel W. Lucas, Inspector General for the District of Columbia. Tamjong pleaded guilty in the U.S. District Court for the District of Columbia to health care fraud, which carries a statutory maximum penalty of 10 years in prison. Under federal sentencing guidelines, Tamjong faces a likely recommended sentence of between 27 and 33 months in prison. He has agreed to pay $733,405 in restitution and $396,155 in a forfeiture money judgment. The Honorable Christopher R. Cooper, who accepted Tamjong’s guilty plea, scheduled sentencing for March 7, 2023. In court documents, Tamjong admitted that between December 2014 and February 2022, he was employed as a Personal Care Aide and/or a Participant-Directed Worker to provide personal care aide services to residents of the District of Columbia who needed assistance performing activities of daily living, such as getting in and out of bed, bathing, dressing, and eating. Tamjong admitted that he submitted false timesheets that claimed he provided these personal care services when in fact he did not. As part of his scheme, he even caused Medicaid to be billed for approximately 3,400 hours of services that he purportedly provided when he actually was traveling internationally. On 156 separate occasions, he also caused Medicaid to be billed for 24 hours of services that he allegedly provided in one day. The FBI, the Department of Health and Human Services’ Office of Inspector General, the District of Columbia’s Office of the Inspector General’s Medicaid Fraud Control Unit, and the U.S. Attorney’s Office are committed to investigating and prosecuting individuals who defraud the D.C. Medicaid program. Tamjong is the twelfth former personal care aide since August 2018 to plead guilty to defrauding Medicaid in the U.S. District Court for the District of Columbia. Six of those aides were sentenced to 13 months in prison; a seventh and eighth were sentenced respectively to 15 months and 10 months. The government urges the public to provide tips and assistance to stop health care fraud. If you have information about individuals committing health care fraud, please call the Department of Health and Human Services’ Office of Inspector General hotline at (800) HHS‑TIPS [(800) 447-8477] or the D.C. Office of the Inspector General at (800) 724-TIPS [(800) 274-8477]. This case is being prosecuted by Assistant U.S. Attorney Kondi Kleinman with assistance from Paralegal Specialist Michon Tart. ``` **Topics:** Medicare/Medicaid **Categories:** Conviction --- ### [Healthcare data breaches have doubled in 3 years: 5 things to know](https://insurancefraud.org/news_archives/healthcare-data-breaches-have-doubled-in-3-years-5-things-to-know/) **Published:** September 19, 2026 **Author:** Diane Beauchamp **Content:** In the last three years, the volume and frequency of healthcare data breaches have nearly doubled, from 368 in 2018 to 715 in 2021, *[BankInfoSecurity](https://www.bankinfosecurity.com/healthcare-data-breaches-doubled-in-3-years-heres-why-a-20516)* reported Nov. 23. Five things to know about the increase in healthcare data breaches: 1. According to federal statistics, the number of individuals affected by the more than 5,000 major health data breaches since 2009 exceeds the total U.S. population. This indicates that some people likely have been the victims of more than one incident. 2. As of Nov. 10, the Department of Health and Human Services’ website has reported 595 breaches in 2022, affecting more than 40 million individuals. 3. These attacks are not only compromising data from patients but are resulting in significant IT system disruptions that interfere with patient care. 4. Data breaches are also increasingly costing health systems a lot of money. According to the report, San Diego-based Scripps Health incurred $112 million in costs in the first month after a May 2021 ransomware attack. 5. In addition to cost, the number of lawsuits against health systems for data breaches are also increasing. According to the report, Los Angeles-based UCLA Health paid $7.5 million to settle a consolidated class action lawsuit in 2019 for a data breach. **Topics:** Public Awareness, Technology --- ### [Cyberattacks are targeting smaller healthcare companies and specialty clinics. But why?](https://insurancefraud.org/news_archives/cyberattacks-are-targeting-smaller-healthcare-companies-and-specialty-clinics-but-why/) **Published:** September 19, 2026 **Author:** Diane Beauchamp **Content:** The healthcare industry has been a favored target for cybercriminals for many years. In the first half of 2022 alone, [324 attacks](https://www.cybersecuritydive.com/news/hospital-cyberattacks-small-hospitals/630570/) against healthcare organizations have been reported. Attackers have primarily focused on large hospitals in years past, but there has been a sudden switch to smaller healthcare companies and specialty clinics. There seems to be a clear trend in attacks against the healthcare industry, and that trend includes targeting smaller healthcare companies and clinics. ## Healthcare Cyberattacks in Numbers The healthcare industry is a prime target for cyberattacks, with hundreds of network and data breaches recorded in 2022 already. Some of the statistics and trends regarding cyberattacks on healthcare companies include: - During a peak period of healthcare-related cyberattacks, the industry was subjected to [393 breaches](https://www.helpnetsecurity.com/2022/08/29/data-breach-healthcare-organizations/) in the second half of 2020. - In the first half of 2022, the sector recorded 324 data breaches, affecting over twenty million people. - Smaller organizations are now seeing the brunt of cybercriminal activity. Most attacks have been targeted toward healthcare providers (73% of attacks), business associates/data handlers (15%), and health plan organizations (12%). - Electronic Health Record (EHR) attacks accounted for 8% of breaches in the first half of 2022, increasing from 0% in the first half of 2020. - Network server vulnerabilities remain the primary target, with 57% of attacks targeting them. However, this represents a decrease of 10% when compared to the first half of 2021. ## Examples of Recent Cyberattacks on Small Healthcare Businesses Recently, cybercriminals targeted Eye Care Leaders, which provide EHR and Practice Management systems for eye care businesses. This breach resulted in [over two million patient records](https://healthitsecurity.com/news/8-more-orgs-added-to-eye-care-leaders-emr-data-breach-tally) being exposed. Other high-profile attacks involved Practice Resources (revenue cycle management vendors), OneTouchPoint (printing services), and Professional Financial Company (an accounts receivable firm.) These three attacks together resulted in the data of [almost four million individuals](https://www.hhmglobal.com/knowledge-bank/news/cyberattacks-center-smaller-hospital-and-speciality-clinics) being illegally accessed. ## Why Do Cybercriminals Target the Healthcare Sector? Here are eight main reasons cybercriminals target the health sector: 1. **Patient details are valuable** – Confidential patient data can be worth a lot of money to cybercriminals who can easily sell it so it can be used for fraudulent activity. 2. **The attack surface is large** – The number of vulnerable entry points for attackers in healthcare organizations is plentiful. This is due to a [large number of connected devices](https://www.tripwire.com/state-of-security/medical-imaging-equipment-better-cybersecurity), such as X-Ray machines and monitoring equipment that lack the necessary security. 3. **Remote staff** – Many staff members within the healthcare sector need to access data remotely as they mostly work outside the office. This gives malicious actors more opportunities to gain access to a network. 4. **Processes are rarely updated** – As health professionals are extremely busy, processes are rarely changed to avoid disruption. This can result in security holes whenever new technology or applications are added to a network. 5. **A lack of security training** – Healthcare organizations rarely educate staff members about online security risks, and many employees lack the necessary training to avoid their credentials from being compromised. 6. **Healthcare information needs to be shared easily** – Staff members need to obtain patient information quickly and easily so care can be administered urgently if required. This means that healthcare data can be shared numerous times a day, and it has very little protection. 7. **Smaller organizations invest little in online security** – Many smaller organizations within the sector work on a tight budget, and online security is [one area of the business](https://www.tripwire.com/state-of-security/healthcare-providers-need-to-increase-budgets-for-cybersecurity) that receives minimal funding. 8. **Outdated technology** – A hesitancy to update IT systems due to the fear of disruption means that many healthcare networks are made up of outdated devices and software. Any software that is no longer supported presents a golden opportunity for cybercriminals. ## What Types of Cyberattacks Are Most Common? Many cyberattacks involve ransomware, or unauthorized access to IT networks. However, new scams are also being developed that target specific medical workers. One such scam involves attackers impersonating law enforcement agents and government officials. By impersonating officials, the attacker hopes to acquire personally identifiable information (PII). This can be achieved by [spoofing real names](https://www.investopedia.com/terms/s/spoofing.asp), phone numbers, and credentials to inform the victim that they have been subpoenaed to provide a witness statement in court. The victim is then ordered to pay a fine, with scare tactics used to ensure it is paid quickly. Common scare tactics include issuing threats that a person’s medical license may be revoked or convincing them that they could be arrested. If successful, the attacker can gain personal security information and financial details over the phone, which could then be used to attempt access on a secured network. Although not exactly a cyberattack, chargeback frauds contribute greatly to the losses healthcare businesses have incurred in recent years. With [more than 80%](https://www.waveapps.com/blog/red-flags-how-to-spot-fraud-and-protect-your-small-business-against-chargebacks) of all chargebacks being fraudulent, healthcare companies must invest in high-tech solutions, such as identity authentication tools, to rectify chargeback scams. ## The Shift From Large Hospitals to Smaller Healthcare Companies It is clear that the healthcare industry is a lucrative market for cybercriminals, but why the obvious retargeting of attacks toward smaller healthcare organizations? This is mainly because smaller businesses do not have the necessary cybersecurity to protect themselves, whereas larger organizations commit significant resources to protect their networks. Many of these organizations [work under tight financial constraints](https://www.tripwire.com/state-of-security/state-of-cybersecurity-improved-but-hardly-flawless), meaning they are unable to designate enough resources for their online security requirements, despite holding valuable information on their systems. If you manage a small healthcare company and don’t think you’re adequately protected, look for IT solutions that [come with crucial features](https://www.atlantic.net/hipaa-compliant-hosting/it-solutions-for-healthcare-how-to-choose/) such as HIPAA-compliant devices, networks, and servers; point-of-care devices; and Telehealth or remote healthcare support. Although data breaches in the healthcare sector have displayed a decline over the last 12 months, the concern is that there is a clear trend of widely-used, systemic technology that is being targeted. Experts within the cybercrime industry expect this trend to continue for the remainder of 2022. ## Conclusion Cyberattacks on the healthcare industry have declined in recent years. However, a clear trend has developed where smaller healthcare businesses and specialty clinics are now the most common victims. This is because many smaller organizations lack the necessary cybersecurity to [identify vulnerabilities](https://www.tripwire.com/state-of-security/vulnerability-management-best-practice) and protect against modern attacks. Until this issue is resolved, this trend will likely continue, putting millions of individuals’ data at risk. **Topics:** Public Awareness, Technology --- ### [The No Surprises Act is Full of Surprises](https://insurancefraud.org/news_archives/the-no-surprises-act-is-full-of-surprises/) **Published:** September 19, 2026 **Author:** Diane Beauchamp **Content:** The No Surprises Act (NSA) was meant to relieve the financial burden from consumers and help prevent unexpected, and sometimes massive, healthcare bills – a goal that providers, payors and the industry at large can get behind. But a [recent survey](https://assets.morningconsult.com/wp-uploads/2022/07/07104933/2206148_crosstabs_MC_HEALTH_SURPRISE_BILLING_Adults_v1_SH.pdf) from Morning Consult found that one in five patients will still receive a surprise bill. Couple this with the scope of changes and many surprises the NSA contains for payors, and providers – and it seems this bill will take some time to live up to its name. On July 1, 2021, the [Centers for Medicare and Medicaid](https://www.cms.gov/nosurprises/policies-and-resources/overview-of-rules-fact-sheets) (CMS) issued its “Interim Final Rule on Requirements Related to Surprise Billing; Part I,” aka the No Surprises Act implementing regulations. The NSA prevents patients with individual or employment-based health plans from receiving surprise bills for three types of healthcare services: – Emergency care – Non-emergency care from out-of-network providers at in-network facilities – Air ambulance services from out-of-network providers Here are some real-life examples of how the NSA protects patients: A patient seeks care at an in-network emergency room, yet the ER doctor is out-of-network. Thanks to the NSA, patients are no longer required to pay more for that out-of-network care than they would have paid if the doctor were in network. The same applies to an out-of-network pathologist who was involved in planned surgery performed at an in-network hospital. The pathologist cannot send that patient a “balance bill” – it’s up to the payor and the provider to work out any payment dispute. On September 30, 2021 the second [Interim Final Rule](https://www.cms.gov/nosurprises/policies-and-resources/overview-of-rules-fact-sheets) implementing the NSA established an independent dispute resolution (IDR) process to help providers and payors agree on out-of-network payments in dispute. The process gave precedent to a new benchmark called the Qualifying Payment Amount (QPA). After a string of lawsuits by provider groups, the first two decisions went the way of the providers, and a [Final Rule](https://www.dol.gov/sites/dolgov/files/EBSA/about-ebsa/our-activities/resource-center/faqs/ebsa1210-ac00-and-1210ab99-idr-process-final-rule-dol816-final.pdf), just released on August 19, 2022, settled the issue by calling for a number of factors – including the QPA — to be considered by arbiters when choosing between final offers submitted for IDR. **Patients: Not all bills are “surprise bills”** The NSA does *not* apply to every possible healthcare bill that a patient may receive – a surprise to some patients. When a patient chooses to go to an out-of-network physician for a scheduled appointment, or to an out-of-network hospital for a scheduled procedure, they are deliberately seeking care outside their network. Therefore, they’re subject to higher co-pays or co-insurance, and also may receive a “balance bill” for the difference between the provider or facility’s charges and the amount covered by the health plan. Many patients aren’t aware of this additional potential bill. The NSA attempts to address these surprises by requiring advanced estimates and signed consent for certain out-of-network care. However, rules finalizing these processes are not yet defined in the form of an Interim or Final Rule. Patients and their healthcare providers must also understand the NSA applies *when their health plan begins*. So if a plan doesn’t take effect until September 1st, a consumer is not covered by the new rule until September 1st. Further, it’s important to note the implementation of the NSA is still a work in progress. While patients should not receive a surprise bill as defined by the NSA, it’s possible they will as many kinks are still being worked out on both sides. Here’s the good news – patients no longer have to figure it out on their own. They should contact their payor, who is now responsible for settling the claim with the provider. **Payors and providers: More surprises than you expected** The NSA outlines three reimbursement scenarios between payors and providers: 1\. The provider bills the payor and the payor pays the bill. 2\. If either party disagrees with the amount reimbursed, they have 30 business days to negotiate a final amount. 3\. If they can’t agree, either party can initiate IDR, where a certified IDR entity selects one of their reimbursement proposals. Sounds simple, right? Unfortunately, it’s complicated for a number of reasons. First, there’s the federal NSA versus state laws. Insured health plans are regulated by states, and only 22 have surprise bill laws recognized as “specified state laws.” States often define surprise bills differently and/or offer fewer protections than the NSA. *So the NSA covers self-insured plans nationally, as well as insured plans in states that don’t have any — or as many — protections as the federal law.* Are you still with me? Wrapping the NSA around state laws was a surprise for payors, who now may need to determine claim by claim which adjudication rules and process to follow. And providers don’t generally know whether a patient’s plan is insured or self-insured, let alone the applicable state rules. The NSA also introduced another surprise, the QPA I mentioned earlier. In the absence of specified state laws, the patient’s cost share must be based on the QPA, which reflects the plan’s median contracted rates. By basing the patient’s cost share on QPA, the patient is held harmless from any additional payment the health plan makes through negotiation or arbitration. But most claim adjudication systems calculate plan and patient cost sharing using the amount the plan allows for the claim, and were not prepared to support this process of determining cost sharing based on a different amount. They’re catching up, but in the meantime many health plans have had no choice but to reimburse the QPA amount even if they don’t view it as the best reimbursement for the plan and patient. And finally, IDR is an entirely new function that requires certification, training, and support of IDR entities, and creation of a federal IDR portal to facilitate the process. To say the process is challenging is an understatement. It has very tight timelines, complicated eligibility rules, two different fees (one of which is credited back to the “winning” party), and requirements for what the IDR entity must consider in selecting between the two offers – which had been in limbo until the Final Rule was published on August 19th. Furthermore, the portal has been slow to develop, launching on April 15th with limited functionality. While CMS has been working diligently to enhance the portal, this only adds to the confusion all parties – including the IDR entities – have about the process. In fact, CMS reports that between April 15th and August 11th from more than 46,000 disputes initiated through the process, a payment determination was made in about 1,200 cases. Some 21,000 cases were challenged for their eligibility for IDR, of which about 7,000 so far have been ruled ineligible. Similar questions of eligibility plague the open negotiation process that precedes IDR. **Upgraded tech, better data analysis can ease the transition** Payors have been negotiating and reimbursing medical claims – and sometimes even arbitrating them — for years, and have the processes in place to do so. But the specific and sometimes nuanced changes the NSA introduces are significant, and while systems and processes don’t need to be completely replaced, it will take time to get them exactly right. It also will take time for payors and providers to find the new equilibrium that minimizes either party’s administrative costs, and that will likely call for further system and process changes. The big questions: Do payors and providers have the right data to understand the best payment to make and accept? From the beginning, the payor and the provider must put forth reasonable efforts and informed arguments to support the amounts they’re billing and offering to pay. To do that well, they need a great deal of data as well as the analytical tools to help them understand the data and the impact of decisions. It’s not unlike a chess match, with either player considering their opponent’s next likely move. The smartest moves to successfully incorporate the tenets of the NSA will be based on an abundance of data and sophisticated predictive and prescriptive analysis. **More surprises to come?** As you read this, it remains to be seen how the dust will settle on the Final Rule and clarifications on earlier rules that also were released. For example, while providers may be mollified by the Final Rule’s alignment with court rulings, health plans that do not use networks may object to the clarified requirement to base patient cost sharing on the network-based QPA. We’re also awaiting proposed rules impacting good faith estimates, consent requirements and advanced Explanations of Benefits – all of which will lead to system and process changes. Despite all of this, we can be grateful that the industry is on a path to putting billing surprises behind us. However, from my perspective, payors and providers should continue to expect the unexpected before all is said and done with the No Surprises Act. **Topics:** Legislation --- ### [40 million Americans' health data is stolen or exposed each year. See if your provider has been breached.](https://insurancefraud.org/news_archives/40-million-americans-health-data-is-stolen-or-exposed-each-year-see-if-your-provider-has-been-breached/) **Published:** September 19, 2026 **Author:** Diane Beauchamp **Content:** More than 40 million Americans’ medical records have been stolen or exposed so far this year because of security vulnerabilities in electronic health care systems, a USA TODAY analysis of Health and Human Services data found. And the problem is steadily worsening. From 2010 to 2014, the first five years that data was collected, close to 50 million people had their medical data stolen or exposed. In the following five years, that number quadrupled. And health privacy breaches have continued to grow on the heels of the COVID-19 pandemic. Federal law strictly prohibits medical institutions — hospitals, insurance companies and outpatient clinics — from sharing patient information, and requires that companies take steps to shield sensitive data from prying eyes. How do health care data breaches happen? More vulnerabilities have emerged as health care providers shift their records online and fail to protect legacy systems. Hacking accounts for about half of all security breaches, while about one-third are caused by employee errors, such as lost computers or accidental disclosures, our analysis shows. Bad actors often use private health information to target victims with scams that exploit their medical conditions. Criminals can also create fraudulent insurance claims to traffic drugs and buy or sell faulty medical devices. Has your health care provider experienced a data breach? Health care providers are required by law to report to Health and Human Services any security breaches that expose patient information. Using those records, USA TODAY built a searchable database of health care data breaches going back to 2009. Reporters analyzed 13 years of data and researched security vulnerabilities at health care companies across the nation. Our database updates daily. **Topics:** Public Awareness, Technology --- ### [Medical Doctor To Pay $86,506.30 To Resolve Civil Liability For Alleged Violations Of The False Claims Act](https://insurancefraud.org/news_archives/medical-doctor-to-pay-86506-30-to-resolve-civil-liability-for-alleged-violations-of-the-false-claims-act/) **Published:** September 19, 2026 **Author:** Diane Beauchamp **Content:** The United States Attorney’s Office for the Middle District of Pennsylvania announced that Dr. Musaddiq Nazeeri, of Lebanon, Pennsylvania, has agreed to pay the United States $86,506.30 to resolve civil liability for alleged violations of the False Claims Act. According to the United States Attorney Gerard M. Karam, between February 10, 2021 and January 21, 2022, Dr. Nazeeri billed Medicare for certain services that were not supported by the medical record. During the above timeframe, Dr. Nazeeri submitted Evaluation & Management (E&M) claims when the only service rendered was the administration of the COVID-19 vaccine. It is those type claims that were not supported by the medical record. Dr. Nazeeri cooperated with the investigation. “The U.S. Attorney’s Office is dedicated to combatting fraud and abuse impacting taxpayer-funded programs,” said United States Attorney Karam. “We use every tool at our disposal to do so, and this resolution reflects that commitment.” “Investigating violations of the False Claims Act is a top priority,” said Maureen R. Dixon, Special Agent in Charge for the Office of the Inspector General, U.S. Department of Health and Human Services. “We will continue to work with the U.S. Attorney’s Office to ensure the integrity of the Medicare program.” This Settlement Agreement is neither an admission of liability by Dr. Nazeeri nor a concession by the United States that its claims are not well founded. This matter was investigated by the U.S. Department of Health and Human Services Office of Inspector General. The investigation was handled by Assistant United States Attorney, Tamara Haken, and the Affirmative Civil Enforcement (ACE) Unit within the U.S. Attorney’s Office. \# # # **Topics:** Judicial/courts, Medicare/Medicaid --- ### [Former school counselor stripped of certificates after drug-fraud conviction](https://insurancefraud.org/news_archives/former-school-counselor-stripped-of-certificates-after-drug-fraud-conviction/) **Published:** September 19, 2026 **Author:** Diane Beauchamp **Content:** A guidance counselor imprisoned for his role in a prescription-drug fraud won’t be returning to work at any school in New Jersey, authorities say. A regulatory board has ordered revocation of two certificates held by 44-year-old Michael Pilate, a former Williamstown resident. The State Board of Examiners cited Pilate’s participation in a scheme to submit fraudulent claims for costly medications paid for by a benefits plan for public employees in New Jersey. Pilate recruited for public employees who received kickbacks for making fraudulent applications for compounded medications, according to the U.S. Attorney’s Office for New Jersey. Pilate received an 18-month prison term in December 2021 after pleading guilty to conspiring to commit healthcare fraud. The former Pleasantville school employee also was ordered to forfeit almost $393,000 in criminal proceeds and pay restitution of $3.49 million. Pilate held certificates as a school counselor, issued in August 2004, and as a director of school counseling services, issued in July 2012. The board, which ordered the revocation at its Oct. 28 meeting said Pilate had engaged in unbecoming conduct. It noted an educator’s position a role model for students ‘requires a degree of self-restraint and controlled behavior rarely requisite to other types of employment.” **Topics:** Drug Diversion **Categories:** Conviction --- ### [Attorney General James Sues Orleans County Nursing Home for Years of Fraud and Resident Neglect](https://insurancefraud.org/news_archives/attorney-general-james-sues-orleans-county-nursing-home-for-years-of-fraud-and-resident-neglect/) **Published:** September 19, 2026 **Author:** Diane Beauchamp **Content:** New York Attorney General Letitia James today filed a [lawsuit against Comprehensive at Orleans LLC doing business as The Villages of Orleans Health and Rehabilitation Center (The Villages)](https://ag.ny.gov/sites/default/files/orleans_nh_petition.pdf), a nursing home in Albion, New York, for years of financial fraud that resulted in significant resident neglect and harm. Following an extensive investigation conducted by the Office of the Attorney General (OAG), the lawsuit — filed against the owners, operators, and related companies (owners) — demonstrates how the owners took advantage of the state’s Medicaid program to increase their personal profits, rather than use those funds for the intended purposes of staffing and patient care. “Every individual deserves to live out their golden years in comfort and with dignity,” said **Attorney General James**. “Yet the abject failure of The Villages and its owners to uphold their duty under the law caused residents to suffer inhumane treatment, neglect, and harm. Instead of investing in staffing and resources, the owners allegedly disregarded laws designed to protect residents. I will continue to monitor nursing homes and residential care facilities statewide to ensure the safety of our most vulnerable communities. I encourage anyone who has witnessed alarming conditions, resident neglect, or abuse at a nursing home to contact my office.” Under New York law, owners of nursing homes have a “special obligation” to provide a high level of care and quality of life for residents, and to ensure the facility is sufficiently staffed so as to provide that care. The Villages’ owners failed in their duty to residents by engaging in a scheme to divert funds away from the facility to increase their own personal profit, drastically cutting staffing at The Villages to do so. With this lawsuit, OAG seeks to compel the owners to return all funds fraudulently received, to appoint a receiver and financial monitor to stop the self-dealing and a healthcare monitor to improve care, and to require The Villages to stop admitting new patients until further notice. The owners wove a complicated web of fraud, using their ownership stakes in multiple companies to turn The Villages into a profit machine. The named respondents in the complaint are The Villages of Orleans LLC; Telegraph Realty LLC (Telegraph), which owns the real property where The Villages is; CHMS Group LLC (CHMS), which provides administrative services to The Villages; and ML Kids Holdings LLC (ML Kids), which received over $1.5 million in cash transfers from Telegraph. Also named are individual owners, including the sole official owner of The Villages, his three sons-in law, his daughter-in-law; three undisclosed owners of The Villages; and the owners of Telegraph Realty LLC. Together, these individuals are referred to as the “owners.” **Financial Scheme** In January 2014, the owners formed Telegraph for the sole purpose of buying the real property on which The Villages sits, which they did a year later in January 2015. The Villages has since paid “rent” to Telegraph. CHMS was formed in January 2015, and The Villages has since paid CHMS for administrative services, including accounting, insurance billing, and payroll. From 2015 through 2021, The Villages received $86.4 million in funding, including millions in taxpayer dollars from Medicare and Medicaid, intended to provide quality healthcare to vulnerable residents. Instead, the owners cut staffing to increase their personal profits. By making payments to Telegraph and CHMS, and by making other transfers to themselves directly and indirectly, the owners were able to divert $18.6 million — more than 20% of The Villages’ operating budget. When the Villages was owned by Orleans County, the facility’s nursing home rating from the Centers for Medicare & Medicaid Services (CMS) was three out of five stars. In April 2015, just four months after the owners purchased The Villages, CMS decreased the rating to one star, the lowest possible rating. **Devastating Consequences** The OAG asserts in the suit filed today that The Villages’ reprehensible history of insufficient staffing and low quality of care is directly traceable to the owners’ financial scheme. Residents were subject to repeated abuse and neglect as the most basic functions of care were abandoned. Residents were forced to sit in their own urine and feces for hours; suffered malnourishment and dehydration; developed sepsis, gangrene, and other infections due to gaping bed sores and inadequate wound care; endured medical toxicity and unexplained doping; and sustained falls and other physical injuries. Some of these abuses, including other unmonitored or undocumented circumstances, resulted in hospitalization and even death. The lawsuit’s allegations include: - A woman was admitted to The Villages in January 2021 with a Stage II bed sore which was not treated for more than two weeks. Six months later, in June 2021, she suffered from two Stage III bed sores and an external wound care consultant ordered a new treatment, which The Villages did not implement until a week later. By July, both wounds had advanced to the point of being “unstageable.” A friend of the woman told OAG she received more than 1,000 texts asking for help with basic necessities like using the restroom or getting food and water. One text reported she had been “lying in a dirty diaper for hours,” and another lamented, “I just need a glass of water.” The Villages gave the resident psychotropic medications for severe anxiety, though there was no such diagnosis in her medical records. She was found unresponsive on July 13 and sent to the hospital, where she died. - A woman admitted to The Villages in January 2020 for rehabilitation of a broken leg soon began refusing her food and medication and spoke of wanting to die. An external psychological consult determined she was at high-risk for self-harm, and ordered staff check on her every 30 minutes. The Villages failed to monitor the woman, and she was found dead in early February 2020, less than a month after she was admitted. Her death was not reported to the New York State Department of Health (DOH) as required by law. - A man was admitted to The Villages in November 2020 to rehabilitate after a leg amputation, so he could gain enough strength to use his prosthetic and live independently. During his three months at The Villages, he had only a handful of physical therapy sessions, during which he was often left to sit without exercise or assistance. Due to his amputation, he required help with cleaning and caring for himself, but staff frequently failed to change his diaper in a timely manner, leaving him to often spend hours sitting in his own urine. He now resides in a different facility and is making great progress. **COVID-19 Pandemic** Residents’ low quality of life and unacceptable level of care further worsened with the onset of the COVID-19 pandemic as The Villages’ already stretched thin staff was forced to work even longer hours. Notably, management at The Villages tried to keep positive COVID-19 cases secret, and either delayed or entirely neglected to enforce proper protocols for quarantining infected residents. The owners forced staff to report to work even when they were sick, provided little to no personal protective equipment, failed to implement infection or isolation protocols, and did not report positive COVID-19 cases, resulting in unnecessary and preventable deaths. A Licensed Practical Nurse (LPN) at The Villages disclosed that the facility had its first COVID-19 case on March 30, 2020. Though the individual’s chart noted he’d had a fever for three days before he tested positive, nothing was done to prevent further spread of the virus. The Villages was so short staffed that employees were caring for residents who were both positive and negative for COVID-19 without following any quarantine protocols. As the pandemic progressed, COVID-19 positive employees, forced to report to work despite being sick, mixed with COVID-19 negative residents, and all residents intermingled regardless of infection status. Employees were told that if their temperature check indicated they had a fever, they were to go outside for an hour and come back to take their temperature again. Rather than hire enough medical staff qualified to deliver the level of care that nursing homes are required to provide, the owners instead expected Certified Nursing Assistants to perform work they were not licensed to handle. Staff and other witnesses reported times when The Villages was dangerously understaffed, such as an overnight shift where just four employees were on hand to care for all residents in the 120-bed facility. Despite this, the owners prioritized increasing resident admissions at The Villages in order to drive up revenue — even when the facility was providing substantially fewer hours of nursing care per resident than the state’s safety average, adding to the dangerous environment. **Remedies** The OAG found that the owners engaged in repeated and persistent fraud and illegality in operating The Villages, including a systemic, intentional pattern of understaffing. These actions stripped residents of their dignity and caused physical and emotional harm, while enabling the owners to reap enormous profits. In her lawsuit filed today, Attorney General James seeks to: - Remove David Gast, Sam Halper, and Ephram Lahasky from their ownership and managerial roles at The Villages; - Prohibit The Villages from admitting any new residents unless and until staffing levels meet appropriate standards; - Require The Villages to engage and pay for a receiver and a financial monitor to oversee the facility’s financial operations; - Require The Villages to engage and pay for a healthcare monitor to oversee the facility’s healthcare operations and ensure residents’ outcomes improve; - Direct each respondent to fully disgorge any and all funds wrongfully received as part of the scheme; and - Order all respondents with the exception of The Villages to reimburse New York state and the United States for the cost of the investigation. **Respondents** The named respondents in the complaint are Bernard Fuchs, supposed sole official owner of The Villages, his son and daughter-in-law Gerald and Tova Fuchs, and his sons-in-law Joel Edelstein and Israel Freund; David Gast, undisclosed owner of The Villages; Sam Halper, undisclosed owner of The Villages; Ephram Lahasky, undisclosed owner of The Villages; Benjamin Landa and his son-in-law Joshua Farkovits; and Teresa Lichtschein and her daughter-in-law Debbie Korngut. Together, these individuals are referred to as the “owners.” Also named are Villages of Orleans LLC, which is controlled by Gast; Telegraph Realty LLC (Telegraph), which owns the real property where The Villages is; CHMS Group LLC (CHMS), which provides administrative services to The Villages; and ML Kids Holdings LLC (ML Kids), which received over $1.5 million in cash transfers from Telegraph and is controlled by Ephram Lahasky. Though all official paperwork associated with The Villages represents the facility is owned entirely by Bernard Fuchs, OAG’s investigation revealed he had a very limited role. In reality, David Gast, Ephram Lahasky, and Sam Halper owned, managed, and controlled The Villages. Attorney General James has been investigating nursing homes throughout New York state based on concerns of patient neglect and other conduct that may have jeopardized the health and safety of residents and employees, both before and during the COVID-19 pandemic. In January 2021, Attorney General James [released a report](https://ag.ny.gov/press-release/2021/attorney-general-james-releases-report-nursing-homes-response-covid-19) revealing that many nursing homes were ill-equipped and ill-prepared to deal with this crisis because of poor staffing levels and a lack of compliance with infection control protocols. Today’s lawsuit is a direct result of those investigations, some of which are still ongoing. Attorney General James encourages anyone with information or concerns about alarming nursing home conditions, resident abuse, or neglect to [file confidential complaints online](https://ag.ny.gov/nursinghomes) or call the MFCU hotline at (833) 249-8499. The investigation was conducted by a multi-disciplinary team from the Medicaid Fraud Control Unit, including Assistant Attorneys General Maura O’Donnell, Soo-Young Chang, Kathryn Heim Harris, Jared W. Goldman, and Thomas Schlief; Medical Analyst Jennifer Cronkhite, RN; Detective Supervisor James Zablonski and Detective Jaimie Krzyskoski, supervised by Deputy Chief William Falk; Principal Auditor-Investigator Milan Shah and Regional Chief Auditors Mary Henry and Dejan Budimir; and Research Analyst Brandon Andrews; the investigative teams were supervised by Assistant Attorneys General Alee N. Scott and Thomas O’Hanlon; MFCU is led by Director Amy Held and Assistant Deputy Attorney General Paul J. Mahoney. MFCU is a part of the Division for Criminal Justice, which is led by Chief Deputy Attorney General José Maldonado and overseen by First Deputy Attorney General Jennifer Levy. Attorney General James thanks the New York State Department of Health and Human Services Commissioner Mary T. Bassett; the United States Department of Health and Human Services, Office of the Inspector General (Special Agent Kirin Hage); and the Orleans County Sheriff’s Department for their assistance in this investigation. MFCU’s total funding for federal fiscal year (FY) 2023 is $65,717,936. Of that total, 75 percent, or $49,288,452, is awarded under a grant from the U.S. Department of Health and Human Services. The remaining 25 percent, totaling $16,429,484 for FY 2023, is funded by New York state. Through MFCU’s recoveries in law enforcement actions, it regularly returns more to the state than it receives in state funding. **Topics:** Judicial/courts, Medicare/Medicaid --- ### [25 Investigates: Botched Insurance Job](https://insurancefraud.org/news_archives/25-investigates-botched-insurance-job/) **Published:** September 19, 2026 **Author:** Diane Beauchamp **Content:** When Lidiya Romanchuk picked up her car from a Malden auto body shop, she immediately noticed something odd. Her aluminum grill had been replaced with a black one and it did not match the trim on her 2017 Audi A6. Then, she noticed something else. One of her four matching Pirelli tires had been replaced with a different brand. Lidiya said all her tires appeared in great condition when she brought the car in. Romanchuk is a Ukrainian born women’s fashion designer. During an interview at her Revere home, she told 25 Investigates reporter Ted Daniel, “I work very hard to have my car and I polish my tires every week. I can spot my front tire is not my tire.'” Her grill and tire weren’t the only problems. It all started in August, when Romanchuk rear ended a car while driving in Boston. A video she took shows minor damage to her grill and a dent in the bumper from the fender bender. A friend recommended Auto Body Squad based on the shop’s location. She reported the crash to her insurance company, Progressive, and agreed to pay her $750 deductible. Progressive, initially estimated it would cost $1,454.66 to fix the car but Auto Body Squad of Malden reported finding more damage and the cost of the repairs jumped to $6,863.64. Auto Body Squad said the front headlights needed to be replaced at a cost of more than $3000. Romanchuk had her car inspected by a Progressive claims adjustor at the dealer she bought it from after it left Auto Body Squad. In a video she recorded, the adjustor is seen pointing out items Progressive paid for that Auto Body Squad never replaced including the headlights. He is heard saying, “Right there is two thousand dollars in insurance fraud that I just proved.” An email Progressive sent the body shop reads, “there are clearly several high dollar parts which were paid for by Progressive to be replaced. This did not happen. Additionally, the wrong grille was replaced on the front of her car and one of her Pirelli tires was inexplicably swapped out with a Continental.” Fabio Gomes owns Auto Body Squad. He told 25 Investigates Romanchuk asked that her car be finished early for a trip and they were not able to complete all the work. When 25 Investigates asked to see the headlights Progressive paid for, Gomes said he had returned them to the dealer. “They cannot say that’s fraud because the car was incomplete. You know, okay, that is my point. That’s where I’m coming from,” Gomes said. “I stand behind my work. I’ll do whatever it takes. Like I said, it’s not the money,” Auto Body Squad’s manager Brian Harris explained. Harris said a black grill is associated with the car’s vehicle identification number but an Audi tech who also accessed the VIN disputes that. As for the tire, Harris said one of the Pirelli’s was leaking and he did Romanchuk a, “favor” by replacing it at no charge. 25 Investigates asked the shop to provide texts or any documentation to show Romanchuk they were still working on the car. None has been provided. Emails reviewed by 25 Investigates show Progressive is trying to help Romanchuk resolve the problem but we found the insurance company is not required to by law. The reason: Auto Body Squad of Malden is not on Progressive’s list of recommended or approved repair shops. Anthony DiPaolo, Executive Director Insurance Fraud Bureau of Massachusetts said auto insurance companies do not have to intervene on behalf of customers if the shop is not in the insurer’s network. “If you’re using what the insurance company is recommending, then if there’s a problem with the repair going on, then the insurance company would step in and act on your behalf. It takes the weight off the consumer,” DiPaolo said. DiPaolo said most body shops play by rules but he cautions insurance fraud can come in many different forms including jacked up prices, unnecessary repairs, use of inferior parts and enhanced damage. Romanchuk has filed a complaint with the Office of the Massachusetts Attorney General. The Office confirmed they are investigating her complaint and one other unrelated one involving Auto Body Squad. A spokesperson was unable to comment further because the investigations are still active. 25 Investigates found 147 complaints filed with the Attorney General since 2018 that mention, “auto body” or “collision repair”. The AG logs more automobile related complaints than any other category. Auto Body Squad’s manager Brain Harris told 25 Investigates he would refund Romanchuk the money for the work that was not completed. Romanchuk is still waiting for a check. “I am sweet personality and happy and bubbly but I’m Ukrainian and unstoppable lady. That’s it. You’ve done me wrong for no reason I chose you for my baby, my car and you’ve done me wrong,” she said. **Topics:** Contractor fraud, Public Awareness --- ### [EyeMed Vision Care to Pay $4.5M to NY Over Healthcare Data Breach](https://insurancefraud.org/news_archives/eyemed-vision-care-to-pay-4-5m-to-ny-over-healthcare-data-breach/) **Published:** September 19, 2026 **Author:** Diane Beauchamp **Content:** As a result of an investigation into a 2020 healthcare data breach, vision insurer EyeMed Vision Care will pay a $4.5 million penalty to New York State for violating the Department of Financial Services (DFS) Cybersecurity Regulation, the department [announced](https://www.dfs.ny.gov/reports_and_publications/press_releases/pr202210181). EyeMed suffered a data breach in June 2020 stemming from a phishing attack that impacted 2.1 million individuals. Over the course of a week, a bad actor was able to access a shared EyeMed email inbox containing consumer information, including Social Security numbers and medical treatment information that dated back six years. The company [previously reached a settlement agreement](https://www.techtarget.com/healthtechsecurity/news/366594323/NY-Fines-EyeMed-600K-in-Wake-of-Healthcare-Data-Breach-Impacting-21M) with the New York Attorney General’s Office for $600,000 to resolve allegations relating to the breach. The settlement also required EyeMed to conduct regular penetration testing, encrypt sensitive consumer information, and implement updated security protocols. The DFS investigation reached similar conclusions surrounding the company’s alleged security failures and noted that EyeMed had violated its Cybersecurity Regulation by failing to implement multifactor authentication (MFA) throughout its email environment, which was required by the regulation. “Moreover, EyeMed failed to limit user access privileges by allowing nine employees to share login credentials to the affected email mailbox and failed to implement sufficient data retention and disposal processes, resulting in over six years’ worth of consumer data being accessible through the affected email mailbox,” the announcement noted. “Had these controls been in place, the July 1, 2020 cybersecurity event could have been prevented or been limited in scope.” Additionally, the DFS investigation revealed that EyeMed had failed to conduct an adequate risk assessment. In addition to the $4.5 million penalty, EyeMed agreed to conduct a comprehensive cyber risk assessment and develop an action plan for addressing the risks uncovered during the assessment. “It is critically important that consumers’ non-public information is kept safe from potential criminal activity, and DFS’s first-in-the-nation cybersecurity regulation requires New York-regulated entities to take that responsibility seriously,” said Adrienne A. Harris, superintendent of financial services. “This settlement demonstrates DFS’s ongoing commitment to protecting consumers while ensuring the safety and soundness of financial institutions from cyber threats.” **Topics:** Judicial/courts, Regulatory actions, Technology --- ### [Empress EMS 2022 Data Breach Affects Over 318K Customers, Class Action Claims](https://insurancefraud.org/news_archives/empress-ems-2022-data-breach-affects-over-318k-customers-class-action-claims/) **Published:** September 19, 2026 **Author:** Diane Beauchamp **Content:** New York ambulance service Empress EMS has been hit with a proposed class action claiming that its failure to properly secure approximately 318,558 customers’ private information resulted in a data breach between May and July 2022. The 46-page case alleges that a “[notorious ransomware hacking group](https://www.trendmicro.com/vinfo/us/security/news/ransomware-spotlight/ransomware-spotlight-hive)” was able to infiltrate Empress EMS’s network on May 26, 2022, and download files from the system on July 13, 2022, because the company failed to implement reasonable cybersecurity measures. The complaint argues that due to Empress EMS’s negligence, the sensitive data of nearly a third of a million customers, including their names, dates of service, Social Security numbers and insurance information, was compromised. According to the suit, Empress EMS did not detect the data breach until July 14, 2022, after the hackers had “unfettered access” to its electronic records for nearly two months. Empress EMS waited another two months before [notifying](https://www.hipaajournal.com/empress-ambulance-service-settles-class-action-lawsuit-for-1-05-million/) affected individuals of the ransomware attack, the complaint relays. The case argues that Empress EMS’s delayed notice was “inadequate” given it underplayed the gravity of the attack and the lifelong risk of identity theft and fraud that data breach victims now face. The suit says there is a “strong probability” that the hacked data will be bought and sold on the black market, requiring victims to pay out-of-pocket expenses for protective measures once the one year of identity monitoring services provided by the defendant has concluded. Additionally, the notice fails to disclose how the data breach occurred and if Empress EMS has regained control of its network, the filing asserts. Per the complaint, Empress EMS “knew or should have known” that cybercriminals would target its network in light of recent attacks on high-profile healthcare providers and warnings issued by the FBI and [U.S. Secret Service](https://www.secretservice.gov/sites/default/files/reports/2020-12/Preparing%20for%20a%20Cyber%20Incident%20-%20An%20Introductory%20Guide%20v%201.1.pdf). The case alleges Empress EMS nonetheless “intentionally, willfully, recklessly, or at the very least negligently” failed to take the available steps to prevent a data breach. Per the suit, Empress EMS not only failed to comply with the [minimum industry standards](https://www.cybersaint.io/ultimate-nist-cybersecurity-framework-adoption-guide) for cybersecurity and the Federal Trade Commission’s [cybersecurity guidelines for businesses](https://www.ftc.gov/business-guidance/resources/protecting-personal-information-guide-business), but overlooked the safeguards for patient health information required under [the Health Insurance Portability and Accountability Act (HIPAA)](https://www.cdc.gov/phlp/php/resources/health-insurance-portability-and-accountability-act-of-1996-hipaa.html). The lawsuit looks to represent anyone in the United States whose personally identifiable information or protected health information was accessed, acquired, used or disclosed as a result of the data breach Empress EMS revealed on September 9, 2022. **Topics:** Judicial/courts, Technology --- ### [Florida CFO Patronis warning hurricane victims about unlicensed and unscrupulous contractors](https://insurancefraud.org/news_archives/florida-cfo-patronis-warning-hurricane-victims-about-unlicensed-and-unscrupulous-contractors/) **Published:** September 19, 2026 **Author:** Diane Beauchamp **Content:** We all know we’re supposed to read every document before we sign it, and Florida’s Chief Financial Officer Jimmy Patronis warns that unlicensed or unscrupulous contractors are trying to get you into a contract with them. You could unintentionally be signing away the money from your insurance company without knowing it. Patronis says more than 40 officers are specifically going around to educate Ian victims on fraud and arresting anyone posing as a licensed contractor. He wants to remind everyone not to sign anything from anyone knocking at your door claiming to be a contractor or roofer. You could be signing something called an assignment of benefits or AOB. This is like giving that contractor power of attorney over your insurance policy. If you sign, you are letting them take charge of your policy and make all the decisions for you, which means they get the insurance money. “This person who you have just met at your doorstep now has been given a blank check that typically would have been written to you, but now it’s going to be written to them because you signed your benefits to them,” said Patronis. If you think you may have signed an AOB, you may be able to get out of it. In some cases, you have 30 days to terminate that contract. You can also end a contract you might have with a public adjuster. You only have ten days to do that. Patronis also proposes legislation to curb fraudulent public adjusters from taking advantage of people after a storm. **Topics:** Contractor fraud, Public Awareness --- ### [Iowa man pleads guilty to killing wife after taking out loans without his wife's knowledge](https://insurancefraud.org/news_archives/iowa-man-pleads-guilty-to-killing-wife-after-taking-out-loans-without-his-wifes-knowledge/) **Published:** September 19, 2026 **Author:** Diane Beauchamp **Content:** A 70-year-old man recently pleaded guilty to stabbing his 65-year-old wife to death in 2019 after lying about their finances. On April 5, 2019, at approximately 7 a.m., Roy Browning called Iowa City police and said his wife, JoEllen Browning, was unresponsive in their home, the Iowa City Press-Citizen reports. She had reportedly been stabbed in the front and back of her torso, as well as on her hand. The victim’s death was ruled a homicide, according to the Iowa City Press-Citizen. Roy Browning’s DNA was reportedly discovered on fingernail clippings from the victim. On the day of JoEllen Browning’s fatal stabbing, she and her husband were scheduled to meet with a financial institution, KCCI-TV reports. In April, JoEllen reportedly emailed her husband about bank account discrepancies, and she asked him to talk to someone from their bank. According to the Iowa City Press-Citizen, the banker they were going to meet with was going to tell the Brownings that money was withdrawn from a joint account, and Roy had taken out high-interest loans without JoEllen’s knowledge. JoEllen reportedly had a retirement and life insurance policy worth more than $2 million. Roy initially pleaded not guilty in November 2019, but on Wednesday, Oct. 12, he entered a guilty plea to one charge of second-degree murder, the Iowa City Press-Citizen reports. Roy reportedly faces a maximum 50-year sentence. His sentencing is scheduled for Dec. 2, and he remains held in the Johnson County Jail on $5 million bail, records show. Prior to her death, JoEllen worked as an administrator with the University of Iowa health system, according to the Iowa City Press-Citizen. **Topics:** Life Insurance **Categories:** Conviction --- ### [A1 crash in Hertfordshire caused by gang of crooks as part of £50,000 'crash for cash' plot](https://insurancefraud.org/news_archives/a1-crash-in-hertfordshire-caused-by-gang-of-crooks-as-part-of-50000-crash-for-cash-plot/) **Published:** September 19, 2026 **Author:** Diane Beauchamp **Content:** A gang of crooks deliberately caused a crash on a busy road that saw an innocent driver plough into the back of another car at around 50mph. The accident was part of a nearly £50,000 ‘crash for cash’ scam that saw four fraudsters make false insurance claims over the smash. The unsuspecting driver caught up in the scam was left injured after the premediated crash on the A1 in Hertfordshire on May 22, 2016. Zahid Hairan, 31, from Edgware, north London, was jailed for 15 months after being found guilty by a jury at a trial in his absence after he fled the country to avoid prosecution. His trial follows on from the sentencing of his three accomplices last September. To carry out the plot, Hairan drove a bright green BMW 320I, while his accomplice, Miatullah Marufkhail, 30, who was sentenced to 20 months in prison in 2021, drove a silver BMW 118D just ahead of him. When a slip road merged with the A-road, Marufkhail slowed down and Hairan slammed the brakes in front of an unsuspecting Peugeot 2008, causing the car to collide into the back of Hairan’s car at around 50mph. The crash shattered the windscreen of the Peugeot and the innocent driver suffered injuries to his hand and forearm. Video of the smash showed the fraudster’s vehicle suddenly break as a line of traffic moved on a slip road towards the main carriageway. The victim’s Peugeot 2008 could then be seen hitting the back of the scammer’s car, forcing other vehicles to evade the stationary cars. Around an hour after the collision, the police stopped Marufkhail in the silver BMW on the same A-road. After the crash, multiple personal injury claims, such as whiplash, were made against the Peugeot driver’s insurer by Hairan, Kudrat Azizi, 35, who was jailed for nine months, and Ghulem Haider, 34, who was sentenced to 12 months in prison. The group also claimed they received medical treatment the day after the accident and that they did not take time off work as a result. A £6,930 claim for the cost of a hire car to replace the green BMW was also made with their insurers. These claims were already suspicious as the innocent driver only saw two people in the car at the time of the crash and the claims from the men were almost identical, police said. Damning CCTV footage and inconsistencies in the accounts of the men raised alarm bells with the insurer, who referred the case to the City of London Police’s Insurance Fraud Enforcement Department (IFED) for investigation. Medical reports were found that stated that Haider had been unable to work for four weeks due to the injuries, while Azizi had taken four months off from work. Haider and Marufkhail were later arrested and interviewed. Marufkhail denied his involvement and said that he was not driving the silver BMW at the time of the collision. Haider claimed he did not remember the exact events which led to the crash as he was on his phone, but did confirm Azizi was not a passenger in the green BMW and that Marufkhail was driving the silver BMW ahead. Azizi was also questioned and admitted to knowing the other suspects. He also insisted that he had no knowledge of the crash and that he had not attended a medical examination for the personal injury claim. Detective Constable Haywood, from the City of London Police’s Insurance Fraud Enforcement Department (IFED), said on Wednesday, October 26: “Once again, ‘crash for cash’ drivers have shown that they have no qualms in endangering the lives of innocent road users. Cases like this demonstrate the pure greed of calculated insurance fraudsters and the measures they will take to gain financially. “The fact that the decoy vehicle was stopped by police on the exact same road just an hour after the first collision begs the question: were the group planning to cause another crash in the same way? Thankfully they did not, and now all four fraudsters have been brought to justice for this deceitful and dangerous scheme.” Neil Jones, intelligence and investigations manager at the Insurance Fraud Bureau, said: “These calculating ‘crash for cash’ fraudsters fuelled by their selfish greed, clearly had no care for the pain and distress they caused their victim to suffer. “I’m pleased that this gang has been brought to justice and that innocent road users in Hertfordshire are protected from the harm they posed. ‘Crash for cash’ fraud will never be tolerated, and we are working closely with IFED and the insurance industry to put a stop to these appalling car crash scams.” **Topics:** Auto - staged **Categories:** Conviction --- ### [NDIC Urge Students To Embrace Saving, Wary Of Fraud](https://insurancefraud.org/news_archives/ndic-urge-students-to-embrace-saving-wary-of-fraud/) **Published:** September 19, 2026 **Author:** Diane Beauchamp **Content:** The Nigeria Deposit Insurance Corporation (NDIC), has advised students to embrace financial savings and develop financial discipline at all times. They are also urged to be wary of financial fraud that mostly occur through online banking, Point-of-Service operators and others, due to greed and eagerness to obtain cheap proceeds. Umar Kaoje-Bello, the NDIC zonal controller in Sokoto, who gave the advice at this year’s World Saving Day commemorative lecture at A.A Raji Special School, Sokoto, remarked that, NDIC had been mentoring secondary school students on the benefits of efficient savings and money management. According to him, “the aim was to encourage financial prudence and management as well as encourage savings habits among students. It was also to accelerate investment growth in the nation’s economy through financial literacy, budgeting and saving culture. “Similarly, the exercise provided opportunity to educate youths on commercial and microfinance banks’ activities and dangers of keeping money in unsecure environment.” On her part, Nusra Wali, of the Corporation Communication and Public Affairs Department said, In spite of the difficulty in earning money, some people are still reckless with it due to the lack of budgeting. She explained to the pupils that, the primary objective of the deposit insurance system in the country was to protect the interest of small depositors, promote public confidence and ensure financial system stability. Wali thereafter, took the students on question and answers session after a video show on financial management, NDIC functions and educational activities. The School principal, Alhaji Aliyu Mudi-Sifawa, in his vote of thank assured the corporation that, the students will take advantage of lessons from the lecture and change their attitude to saving money. **Topics:** Public Awareness --- ### [Man 'murdered victim then posed as him to get Viagra prescription'](https://insurancefraud.org/news_archives/man-murdered-victim-then-posed-as-him-to-get-viagra-prescription/) **Published:** September 19, 2026 **Author:** Diane Beauchamp **Content:** A suspect is accused of murdering a man and trying to set fire to his body – before posing as him to get Viagra. David Barnes allegedly killed Ean Coutts, 60, on September 3, 2019. Prosecutors list a number of locations the murder may have happened – Kinglassie and Lochgelly, both Fife, or elsewhere in Scotland. Ean – also known as Ian – is said to have been attacked by “means unknown”. Barnes, 32, faces a separate charge of attempting to defeat the ends of justice. It is said he removed the body of Ean inside a wheelie bin from a property in Kinglassie before dumping the remains at an abandoned industrial unit in Glenrothes, Fife. Barnes is accused of then attempting to burn the corpse in a bid to avoid detection for the alleged crime. Among the 36 charges Barnes faces there are a series of fraud allegations in connection with Ean. It is said on October 24, 2019, he pretended to staff at a medical centre in Cardenden, Fife that he was Ean. He allegedly applied for a “repeat prescription” of Viagra and nicotine patches before getting them. The indictment earlier states Barnes stole a Nationwide bank card in Ean’s name days before the alleged killing. There a number of places listed he is accused of using the card including at a McDonalds in Glenrothes on September 6, 2019 for £15.50 of “goods”. It is also said to have allowed him to withdraw a total of £5,610. Among the other places he allegedly committed fraud was to make a £1.18 purchase at a Poundstretchers discount shop, to buy tickets for an “entertainment show” at Rothes Hall in Glenrothes and at a leisure centre in Dunfermline, Fife. Barnes also allegedly applied for a credit card in Ean’s name stating he was a £56,000-a-year self-employed forklift driver. The final charge claims Barnes contacted the Department of Work and Pensions on February 10, 2020 again claiming to be Ean. He said is to have stated he was now living in a caravan in England, had no access to the internet and no longer needed benefits. Prosecutors claim this was to “induce” the DWP that Ean was still alive. Ean’s remains were discovered at Whitehill Industrial Estate, Glenrothes in September 2020, but it was only later that he was identified. The case against Barnes called for a hearing at the High Court in Glasgow. His legal team pled not guilty on his behalf and a trial was fixed for November 2023. **Topics:** Drug Diversion, Healthcare Fraud, Synthetic Identity Theft **Categories:** Arrest --- ### [Health insurers suspect widespread Covid test fraud](https://insurancefraud.org/news_archives/health-insurers-suspect-widespread-covid-test-fraud/) **Published:** September 19, 2026 **Author:** Diane Beauchamp **Content:** Swiss healthcare insurers estimate that some CHF20 million ($20.02 million) could have been gleaned to date by scams involving fake bills for Covid tests. Swiss public television RTS [reportedExternal link](https://www.rts.ch/info/suisse/13510494-soupcons-de-fraude-massive-sur-la-facturation-de-tests-covid.html) Wednesday on numerous cases of people who noticed that their health insurance invoices included Covid tests that they had never done. “We estimate that 1% of all Covid tests have not been correctly invoiced, that fraud has presumably taken place, and that certain tests were counted twice or three times, or didn’t take place at all,” Matthias Müller of Santésuisse – the umbrella group for Swiss health insurers – told SRF public television earlier this month. The role of different actors in the fraud is not yet clear, RTS public television said on Wednesday. But one practice assumed to have been used is “factoring”, whereby a fraudster works in tandem with a testing centre and a certified doctor to send batches of fake bills to insurance providers, who then reimburse them. The cost of Covid tests in Switzerland, while a bone of [contention](https://www.swissinfo.ch/eng/politics/government-confirms-end-of-free-covid-testing/46994550) at some points during the pandemic, was largely taken over by public authorities, except in certain cases like asymptomatic people or those doing a test to travel abroad. ## Investigating further Various health insurers have been encouraging clients to flag any suspicious invoices. “These costs are a burden on the federal authorities and thus on taxpayers,” said the SWICA health insurer. Officials at the Federal Office of Public Health (FOPH) are currently investigating the affair, and will decide soon whether or not to launch legal proceedings, RTS writes. Since the start of the pandemic in 2020, over 23 million tests – PCR and antigen – have been carried out in Switzerland, according to FOPH data. **Topics:** COVID-19, Healthcare Fraud --- ### [Senate bill seeks online database on deaths to counter fraud ](https://insurancefraud.org/news_archives/senate-bill-seeks-online-database-on-deaths-to-counter-fraud/) **Published:** September 19, 2026 **Author:** Diane Beauchamp **Content:** A SENATOR has filed a bill seeking to establish an online death verification system to halt the fraudulent use of a deceased individual’s identity. “On many occasions, it has been proven in the many investigations conducted by the Senate that the names of the deceased are being used in fraudulent payment claims, election fraud and various types of fraud,” Senator Jose “Jinggoy” E. Estrada said in Filipino in a statement on Wednesday. “It is time to solve this matter.” Under the proposed Online Death Verification System Act, a centralized electronic database will be set up using information from local civil registry offices. The system will be managed by the Philippine Statistics Authority. Mr. Estrada said criminals and syndicates often exploit the lack of immediate access to death data in carrying out fraudulent activities and corrupt practices. He cited an incident in 2019 where multibillion-peso bogus claims were paid by the Philippine Health Insurance Corp. to dialysis centers. “Those funds that were intended for the poor and in actual need of medical assistance ended up in the hands of owners of private dialysis centers,” he said. The senator said the system can also be used to remove those who are deceased from the official list of registered voters. The bill also provides penalties of up to P4 million and imprisonment for violations. **Topics:** Legislative, Public Awareness --- ### [Understanding the nuances of the No Surprises Act good faith estimates](https://insurancefraud.org/news_archives/understanding-the-nuances-of-the-no-surprises-act-good-faith-estimates/) **Published:** September 19, 2026 **Author:** Diane Beauchamp **Content:** Passed in 2020 and effective Jan. 1, 2022, the No Surprises Act contains provisions that protect people from surprise medical billing and out-of-network emergency care costs not reimbursed by insurance. The law requires that providers and facilities send eligible uninsured or self-pay patients a [good faith estimate](https://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/Guidance-Good-Faith-Estimate-Patient-Provider-Dispute-Resolution-Process-for-Providers-Facilities-CMS-9908-IFC.pdf) (GFE). The GFE should detail as best as possible the charges patients can expect for scheduled visits, tests, supplies, drugs or other services based on the expected course of treatment. - No Surprises Act GFE requirements, eligibility and timing. - Information to include in the GFE. - Posting the good faith estimate notice. - Mitigating risks with workflow adjustments. - Scenarios to watch for. - Does your good faith estimate have what it needs? No Surprises Act good faith estimate requirements, eligibility and timing As with [other elements of the No Surprises Act](https://www.mossadams.com/articles/2021/07/5-tips-navigate-no-surprises-act), the scope of the GFE requirement is expansive. Many providers may be subject to it without realizing it. **Who’s required to provide good faith estimates?** GFE rules apply to health care providers and facilities, including physicians, air ambulance services, hospitals, outpatient clinics, labs, imaging centers and much more. The GFE can also apply to ancillary providers, such as dentists, chiropractors, cosmetic plastic surgeons, acupuncturists, behavioral health specialists, and physical, occupational and speech therapists. **Who is and isn’t eligible for good faith estimates?** Uninsured patients should be informed regarding their eligibility to receive GFEs orally or in writing, as well as individuals who otherwise have insurance but choose instead to self-pay. Health care providers aren’t required to provide a GFE to those covered by Medicare, Medicaid, Indian Health Services, Veterans Affairs Health Care and Tricare. **When is a good faith estimate required?** Providers should send GFEs when a patient has a primary item or service that’s scheduled for a date outside the current period of care — admission through discharge for hospitalizations and day of care for outpatient visits. Qualifying items and services can include: - Encounters. - Procedures. - Medical tests. - Supplies. - Prescription drugs. - Durable medical equipment. - Facility fees. Self-pay or uninsured patients may also request a GFE when shopping for an item or service, such as when they want to compare imaging prices from one center to another. **How soon should the good faith estimate be sent?** The No Surprises Act stipulates that GFEs are sent according to a strict schedule: ![](https://insurancefraud.org/wp-content/uploads/image-20-1024x440.png) - If the appointment or service is scheduled three to nine business days in advance, send the GFE within one business day after the date of scheduling. - If the appointment or service is scheduled at least 10 business days in advance, send the GFE within three business days after the date of scheduling. - If a GFE is requested for a nonscheduled appointment or service, send the GFE within three business days after the date of request. **Date of scheduling or request versus date of appointment** Remember that the date of scheduling is the day that the future item or service gets booked into the appointment calendar, and the date of request is the date that patients ask a question — any question — related to payment. GFE timelines apply to either the date of scheduling or the date of request, not the scheduled date of service. The clock starts at the point of scheduling, and deadlines work forward from there. This may mean that GFEs are sent weeks or months before a surgery, for example. If a patient is uninsured or chooses to self-pay at the time of scheduling or request for GFE but is later expected to become insured, a GFE is still required. **Information to include in the good faith estimate** GFEs contain itemized details about the primary item or service as well as the expected charges for anticipated services in the care plan or the individual’s expected course of treatment. GFEs must be delivered in written form, either on paper or electronically, and must follow a verbal notice. Be specific. While GFEs aren’t perfect, the name “good faith” implies just that: They are an honest effort and should meaningfully account for foreseeable changes, not just generically estimate or bundle prices. **What should a good faith estimate include?** The Department of Health and Human Services (HHS) has provided a [GFE template](https://www.cms.gov/files/document/good-faith-estimate-example.pdf) that can be helpful, but its use isn’t required. If you choose to create your own GFE, be sure to include the following: - Patient’s name and date of birth. - Clear and easy-to-understand description of the primary item or service with the scheduled date of the primary item or service, if applicable. - Itemized list of items or services as part of the treatment, grouped by each convening and co-provider or facility, to be provided during a defined period of care. - Diagnosis, expected service codes and expected charges associated with each listed item or service provided during a defined period of care. - Name, national provider identifier (NPI), and tax identification number (TIN) of providers involved in the treatment. - Specific disclaimers noted in the HHS example. A provider can issue a GFE for recurring primary items or services if the GFE clearly and understandably describes the expected scope of the recurring primary items or services — timeframes, frequency and total number — and doesn’t exceed 12 months. **What are expected charges?** The expected charge is the amount providers would charge cash payers, or the rate otherwise reserved for uninsured or self-pay patients — inclusive of discounts or adjustments. **Posting the good faith estimate notice** Much like the Health Insurance Portability and Accountability Act (HIPAA) Notice of Privacy Practices, all providers should post the required No Surprises Act GFE notice for uninsured and self-pay patients on their websites and in-person locations. HHS has developed a model notice in its [downloadable resource package](https://www.cms.gov/regulations-and-guidancelegislationpaperworkreductionactof1995pra-listing/cms-10791) for providers’ use. At the same time, providers should post the separate required notice about surprise billing for out-of-network services. HHS has also developed a [model notice](https://www.cms.gov/files/document/model-disclosure-notice-patient-protections-against-surprise-billing-providers-facilities-health.pdf) for this one. The first installment of our [NO SURPRISES ACT Implementation Guide](https://www.mossadams.com/articles/2021/12/no-surprises-act-protections-for-patients) further addresses those requirements. **Mitigating risks with workflow adjustments** As with any law of this scope, organizations should consider workflow adjustments as they prepare for GFE requirements. Adjustments can help mitigate certain risks, such as sending the GFE too late. **Timing** The American Hospital Association (AHA) estimates that [it takes 10 to 15 minutes to make a single GFE](https://www.aha.org/lettercomment/2022-03-04-aha-comments-cms-re-agency-information-collection-re-requirements-related). Estimates should go out no later than three days after scheduling, depending on the date of appointment. With this fast turnaround, the AHA has noted that facilities need to make operational and workflow changes to comply with the requirement — not just to send GFEs out, but also to monitor compliance systemwide. **How to mitigate** Process, process, process. Providers should establish a clear and repeatable procedure detailing how GFEs will get completed and sent on time, preferably codifying it into formal policy. They should also designate a team with oversight to generate GFEs, send them out and receive requests. One potential problem is a lack of controls over which personnel can make appointments when they don’t have the responsibility to generate GFEs. This means communication between the scheduler and the team authorized to generate GFEs is key. As the AHA notes, automated systems may help expedite some tasks. However, because GFEs are quite customized, complete automation may not be possible. **Internal controls** Given the manual or semi-manual nature of GFE generation, variations will be inevitable if internal controls aren’t in place to standardize GFE workflows. **How to mitigate** Establish internal controls and policies around generating the GFE and monitoring compliance. Use reporting and alerting tools at the point of scheduling to alert the scheduler or other staff that a GFE is required, as well as a form to generate the GFE. Developing tools that assist in preparing for routine services can facilitate workflows while mitigating variation. **Staff training** As workflows adjust, training gaps can further drive variation and noncompliance risk. **How to mitigate** Ensure that trainings and tools get equally distributed across the workforce and cover various areas, from generating the GFE to communicating about it to patients. In addition, make training more dynamic. It should adapt with workflow modifications and regulation changes. **Estimate ranges and complexity** While specificity is the gold standard, a range of costs may sometimes be acceptable for the GFE. As the Centers for Medicare and Medicaid Services (CMS) have indicated, an organization should try to capture all charges. Some providers, such as psychiatrists, may not know how much care planning new patients will need. If you provide a range, try not to make it too big of a range which could pose a compliance risk. **How to mitigate** Create a policy detailing how to approach ranges, such as identifying factors that could result in the lower or higher ends of the range. For example, a psychiatrist might recommend between 10 and 25 sessions at 50 minutes each within a given year, listing a charge at a given rate per session and what that is expected to total at the end of the year. In highly complex cases communicate with the patient. Understanding their preferences for an item or service — such as whether they want stainless steel or porcelain crowns for dental work, for example — may help narrow the scope of any applicable ranges. **Co-provider and co-facility collaborations (for 2023)** A single GFE should account for the mix of in-house providers, consultations and follow-up care required for a given course of treatment. After all, the intent is to give patients the full picture of costs for a particular health care event. However, comprehensive care often involves other providers and facilities. This may mean that the facility or provider who schedules the item or service — known as the convening provider — will have to collaborate with co-providers and co-facilities to determine what should go into the GFE. While this specific rule doesn’t take effect until Jan. 1, 2023, it’s a good idea to plan for it now. **How to mitigate** Collaborate with co-providers and co-facilities now to prepare for how the group will comply with the phase two regulations in January 2023. Have discussions to get familiar with the components that contribute to an accurate GFE. Consider implementing and testing before the due date. Establishing rules of the road prior to the due date to ensure turnaround times, staff training and controls may be helpful. **Scenarios to watch for** As with other aspects of the No Surprises Act, the rules around GFEs are nuanced. The below scenarios emphasize just how far the law’s scope extends. **What if there is no expected charge?** GFEs will still be required. There are no minimum qualifying payment amounts. Expected charges of the GFE include estimates of no financial responsibility — such as when the provider anticipates a $0 price. **What if you’re a dentist, physical therapist, chiropractor, etc.?** The No Surprises Act affects providers licensed to provide scheduled health care services. If you schedule an item or service for a self-paying or uninsured patient — or if you’re asked to provide an estimate from a self-pay or uninsured person shopping for services — you’re required to send a GFE. **What if a patient loses insurance coverage after scheduling the service?** At the time of scheduling, always ask whether the individual is uninsured. If they are insured during scheduling but then lose coverage within three business days before the appointment, there is no requirement in the No Surprises Act to provide a GFE or reschedule the appointment. But CMS does suggest that providers or facilities ask patients to report when their insurance information changes so that a new GFE can be issued if they become eligible before the appointment. **What if you don’t know whether the patient is self-pay or uninsured?** Providers are responsible for knowing the patient’s insurance status. Consider implementing changes to intake forms or scheduling scripts to confirm if patients are insured. If covered, ask directly whether they intend to self-pay for services. **What if the good faith estimate’s scope or provider changes?** If the provider or care plan changes, providers must send a new GFE within one business day before the scheduled item or service is rendered. The new provider must uphold the original GFE if the provider changes less than one business day before the scheduled item or service. **Does your good faith estimate have what it needs?** Organizations should assess GFE workflow changes, processes, policies and internal controls when designing an internal audit to ensure they comply with [No Surprises Act GFE guidance](https://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/Guidance-Good-Faith-Estimate-Patient-Provider-Dispute-Resolution-Process-for-Providers-Facilities-CMS-9908-IFC.pdf). Refer to this list of things to look for: - Has a policy and procedure been developed and implemented? - What workflow changes have been made in scheduling and patient contact areas, such as the front desk? - Is there a process for developing and provisioning GFEs? - Is there a process to ensure data quality among GFEs? - How will the GFE be tracked and monitored to flag needed updates or patient communications? - What’s the plan to keep trainings updated and ongoing? - Are internal controls and monitoring in place to ensure compliance with the No Surprises Act? **Topics:** Legislation, Public Awareness --- ### [Private Medicare Plans Misled Customers Into Signing Up, Senate Report Says](https://insurancefraud.org/news_archives/private-medicare-plans-misled-customers-into-signing-up-senate-report-says/) **Published:** September 19, 2026 **Author:** Diane Beauchamp **Content:** Companies selling private Medicare plans to older adults have posed as the Internal Revenue Service and other government agencies, misled customers about the size of their networks and preyed on vulnerable people with dementia and cognitive impairment, according to a new investigation of deceptive marketing practices in the industry released Thursday by Democrats on the Senate Finance Committee. Many individuals say they were enrolled in plans without realizing it. The report catalogs complaints from 14 states, and a multitude of marketing materials generated by the insurers and the companies they hire to help sell the private plans. The plans are part of a program called Medicare Advantage that now enrolls nearly half of all Medicare beneficiaries. The committee says people both in traditional Medicare and those already in a private plan have been inappropriately switched. “It is unacceptable for this magnitude of fraudsters and scam artists to be running amok in Medicare, and I will be working closely with C.M.S. to ensure this dramatic increase in marketing complaints is addressed,” said Ron Wyden, a Democratic senator from Oregon and the committee’s chairman, referring to the Centers for Medicare and Medicaid Services, the agency that oversees Medicare. “Medicare Advantage offers valuable plan options and extra benefits to many seniors but it is critical to stop any tactics or actors that harm seniors or undermine their confidence in the program.” Medicare Advantage has become a highly lucrative market for health insurers. But many of the insurers selling such plans have been accused of overstating how sick their customers are, according to a New York Times review last month that found four of the five largest insurers have faced federal lawsuits accusing them of fraud. **Topics:** Public Awareness, Regulatory actions --- ### [The worst-case scenario: A dead client, an advisor accused of murder and fraud, and an industry that didn’t see it coming](https://insurancefraud.org/news_archives/the-worst-case-scenario-a-dead-client-an-advisor-accused-of-murder-and-fraud-and-an-industry-that-didnt-see-it-coming/) **Published:** September 19, 2026 **Author:** Diane Beauchamp **Content:** Advisor Keith Todd Ashley allegedly told his client, James Seegan, he needed a blood sample for life insurance purposes. Seegan had a $2-million policy and weeks earlier, Ashley had changed the beneficiary of the policy from Seegan’s wife to a trust controlled by Ashley, according to investigators. On the appointed date, Feb. 19, Ashley allegedly stopped by the client’s suburban Dallas home for the sample. Hours later, Seegan’s wife came home to find her husband dead. Seegan, who was right-handed and who didn’t own any firearms, was holding a handgun in his left hand, according to authorities. Investigators say the request for a blood sample was a “ruse.” Police have arrested Ashley, who now faces charges for both murder and running a years-long multi-million dollar Ponzi scheme. Seegan is one of at least nine clients allegedly defrauded by Ashley for a combined $1.9 million, according to police in Carrollton, Texas. Besides the alleged murder and complex nine-month investigation, the case displays the troubling extent of the risk of financial advisor fraud in wealth management, industry experts say. For nearly seven years until Seegan’s death, Ashley allegedly carried out the scheme undetected by his former brokerage, Ann Arbor, Michigan-based Parkland Securities, and regulators such as FINRA that have been trying to crack down on bad actors. Yet, more than two months after his arrest, while Ashley was behind bars in jail awaiting trial, he still had not been barred from the industry. To assess the tragic lessons of the case for firms, regulators and financial professionals, Financial Planning sent some two dozen inquiries to every party mentioned in Ashley’s charging documents, law enforcement authorities at all levels, and other experts. Ashley’s lawyers and Parkland Securities — which terminated Ashley two weeks prior to his arrest — declined to comment on the allegations. Two experienced securities attorneys who examined the court documents but aren’t working on the case, Christine Lazaro and Thomas Lewis, raised issues they say might have blown open the alleged scheme. Neither could recall another advisor fraud case that involved a murder. There appear to be “lots of red flags” in Ashley’s written communications with clients and outside business entities registered under his name, according to Lazaro, the director of the Securities Arbitration Clinic at the St. John’s University School of Law. “We see this happen a lot of times when the broker is working in something like a storefront office where there isn’t really good close supervision of the broker,” Lazaro says. “The idea that firms still aren’t catching text messages and private emails is a little crazy.” A dismissed forgery charge from 1991 listed on FINRA BrokerCheck should have prompted Parkland to place Ashley under heightened supervision, says Lewis, a Stevens & Lee attorney who represents wealth management firms in securities litigation. Bank transactions allegedly moving money out of his clients’ accounts and into his own also could have set off alarms, he says. “At the end of the day, is there anything that can be done to avert this type of behavior from a really bad scheming individual?” Lewis says. “That’s not an amateur putting that together. The question we have to ask ourselves is, ‘Where were the regulators during this time period and did the regulators potentially miss something that happened before this episode?’” Ashley’s trial and client arbitration claims could shed light on these and other unanswered questions, such as the frequency of Parkland’s home-office compliance audits and branch manager inspections. Suspicious activity reports filed by banks and FINRA investigations — like one Lazaro says was likely triggered by Ashley’s Oct. 27 termination — are confidential. FINRA and the SEC declined to comment on the case, as did local and federal prosecutors and the FBI. A grand jury in the Eastern District of Texas [indicted](https://www.justice.gov/usao-edtx/pr/north-texas-financial-advisor-who-alleged-have-pocketed) Ashley Nov. 12 on six counts of wire fraud; a grand jury in Dallas County indicted him for murder Dec. 8. He’s incarcerated in Bowie County under a federal district judge’s Nov. 23 order. Citing an “actively ongoing” case that is “still in its early stages,” Ashley’s attorneys, James Whalen and Ryne Sandel, said in an emailed statement that it would be inappropriate to comment. They called Ashley “a long-time community member and small-business owner with no criminal record” and noted he’s presumed innocent until proven guilty. **Topics:** Insider Fraud **Categories:** Arrest --- ### [Medical Doctor Plus Eight Others Indicted for Drug Trafficking and Money Laundering](https://insurancefraud.org/news_archives/medical-doctor-plus-eight-others-indicted-for-drug-trafficking-and-money-laundering/) **Published:** September 19, 2026 **Author:** Diane Beauchamp **Content:** On September 28, 2022, a grand jury in Phoenix, Arizona returned a 34-count indictment against nine individuals, including: - Yvette Porras-Ochoa, 40, of Wittmann, Arizona - Ricardo Ochoa, 41, of Mesa, Arizona - Kourtney Moore, 40, of Akron, Ohio - George Martinez-Aviles, M.D., 55, of Peoria, Arizona - Vanessa Quijada, 36, of Phoenix, Arizona - Josefina Thomas, 57, of Glendale, Arizona - Angel Borunda, 26, of Odessa, Texas - Ibis Efren Miranda Hernandez, 43, of Peoria, Arizona - Kristel Pimentel, 37, of Buckeye, Arizona A 2021 investigation revealed that Martinez-Aviles, M.D., Porras-Ochoa, Ochoa, Moore, Quijada, Thomas, and Pimentel, each conspired to distribute oxycodone knowingly and intentionally, and to distribute promethazine-codeine outside the scope of professional practice and not for a legitimate medical purpose. Furthermore, Porras-Ochoa, Moore, Ochoa, and Borunda each face additional charges for conspiring to distribute cocaine for profit. Lastly, Moore also faces additional charges for possession with intent to distribute fentanyl. Six of the defendants were also charged with related money-laundering offenses. Over the course of this investigation, law enforcement officers seized cocaine, marijuana, oxycodone, promethazine-codeine, and counterfeit oxycodone pills containing fentanyl. An indictment is simply a method by which a person is charged with criminal activity and raises no inference of guilt. An individual is presumed innocent until evidence is presented to a jury that establishes guilt beyond a reasonable doubt. This case is part of an Organized Crime Drug Enforcement Task Forces (OCDETF) operation. OCDETF identifies, disrupts, and dismantles the highest-level criminal organizations that threaten the United States using a prosecutor-led, intelligence-driven, multi-agency approach. Additional information about the OCDETF Program can be found at <https://www.justice.gov/OCDETF>. The Drug Enforcement Administration led the investigation with significant contributions from Homeland Security Investigations, the United States Postal Inspection Service, the United States Marshals Service, the Phoenix Police Department, the Surprise Police Department, the Peoria Police Department, the Glendale Police Department, and the Goodyear Police Department. The United States Attorney’s Office, District of Arizona, Phoenix, is handling the prosecution. **Topics:** Drug Diversion, Financial Fraud **Categories:** Arrest --- ### [New York Attorney General Secures $523 Million from Top Opioid Manufacturer Teva, Bringing Total Funds for New Yorkers to More Than $2 Billion](https://insurancefraud.org/news_archives/new-york-attorney-general-secures-523-million-from-top-opioid-manufacturer-teva-bringing-total-funds-for-new-yorkers-to-more-than-2-billion/) **Published:** September 19, 2026 **Author:** Diane Beauchamp **Content:** New York Attorney General Letitia James today marked a monumental milestone in her fight against the opioid crisis in New York state and announced that her office has [secured up to $523 million](https://ag.ny.gov/sites/default/files/final_ny_teva_agreement_-_execution_version90.pdf) from Teva Pharmaceuticals, Ltd., its American subsidiary Teva Pharmaceuticals USA, and its affiliates (Teva) for their role in fueling the opioid crisis. The $523 million settlement is the largest reached with an individual opioid defendant by Attorney General James and raises the total amount secured from opioid manufacturers and distributors to more than $2 billion to combat the opioid crisis. The settlement resolves Attorney General James’ claims against Teva, the final remaining defendant not currently in bankruptcy and concludes the Attorney General’s litigation against opioid manufacturers and distributors. “Teva knowingly and intentionally misled New Yorkers and the American people about the deadly dangers of opioids, and last year, a jury found them responsible for the devastation and destruction they have caused,” **said Attorney General James**. “You cannot put a price on lives lost, addiction suffered, and families torn apart, but with the more than $2 billion we have now delivered to New Yorkers, we can continue to rebuild and recover. I made a promise to put an end to the havoc wreaked by opioid manufacturers in New York and across the nation and to hold them accountable for the consequences. This is a landmark day in our battle against the opioid crisis, and I am proud to be able to deliver critical funding and resources to the communities Teva and other companies ravaged with their rampant misconduct.” “We are holding Teva Pharmaceuticals accountable for its role in the opioid crisis and the irreparable harm it has done to New Yorkers, their families, and their communities,” **said Governor Kathy Hochul**. “This company misrepresented its products for decades, flooding the market with dangerous prescription drugs and endangering countless lives. New York has no tolerance for fraud — particularly on matters as serious as opioids — and I thank Attorney General James and the Department of Financial Services for bringing us to this resolution.” “The false information that Teva and other opioids manufacturers propagated about the safety of their drugs inflicted tremendous damage on the lives of countless people, while also abusing the health insurance system,” **said Superintendent of Financial Services Adrienne A. Harris**. “No monetary penalty can undo the immeasurable harm the opioid crisis has dealt to families across the country, but DFS is proud to have played a role in bringing about this resolution, holding opioid manufacturers and distributors accountable for their actions.” Attorney General James secured $523 million for New York state from two separate settlement agreements with Teva. Teva will pay up to $4.247 billion nationwide to settle opioid claims as part of the Teva Global Settlement. New York’s share of that amount is $210,548,226.20. After achieving a [historic liability verdict following a seven-month jury trial against Teva in 2021](https://ag.ny.gov/press-release/2021/attorney-general-james-victorious-new-yorks-opioid-trial), today’s Teva New York Agreement resolves the remedies phase for a total of $313,343,793.95. Combined, New York will receive $523,892,020.15 from Teva. The settlement would additionally resolve lawsuits against Teva by Nassau and Suffolk counties if the county legislatures approve it. In the meantime, Attorney General James plans to make a motion removing Teva from her opioid litigation, concluding New York’s opioid trial. The funds secured by Attorney General James will be paid out over a period of 18 years. The agreement also commits Teva to critical injunctive relief that includes: - A ban on high-dose opioids (greater than 40mg) and prescription savings programs; - Prohibitions on marketing opioids and funding third parties that promote opioids; - Restrictions on political lobbying; - Monitoring and reporting of off-label use of transmucosal immediate release fentanyl (TIRF) products; and - Disclosure of Teva opioid product clinical data. In addition, Attorney General James secured important injunctive relief from Teva’s distributor Anda, Inc. This includes: - Ensuring the independence of Anda sales personnel who sell controlled substances from incentive-based compensation and retaliation; - Mandatory training of new Controlled Substance Monitoring Program (CSMP) employees on CSMP and injunctive relief obligations. Employees will also be required to have annual training and testing of CSMP knowledge; - Periodic review of systems and procedures that evaluate customer data for diversion of controlled substances; and - Unannounced customer site visits verifying compliance with anti-diversion obligations. New York is a leading member of the national negotiations with Teva. Teva’s payments to New York from the Global Settlement will be paid over 13 years. While the implementation of the Global Settlement is contingent on sufficient state support, the New York agreement and Teva’s obligations to New York under the Global Settlement will remain in effect, even if the Global Settlement is not implemented. Today’s settlement also resolves administrative charges brought by the New York Department of Financial Services (DFS) against Teva for decades-long insurance fraud. In August 2020, DFS charged Teva with making fraudulent misrepresentations about the safety and efficacy of its opioid drugs, thereby causing significant numbers of unnecessary prescriptions to be written in New York, a large portion of which were then paid by commercial health insurers under DFS’s jurisdiction. DFS alleged that each such fraudulent prescription violated New York Insurance Law § 403 and New York Financial Services Law § 408. While these administrative charges were pending, Teva and other opioid manufacturers filed suit against DFS in New York Supreme Court, challenging DFS’s jurisdiction to conduct its investigation and bring these charges. That suit was rejected by the court in June of this year. In 2019, Attorney General James [filed the nation’s most extensive lawsuit against opioid distributors and manufacturers, including Teva, for their role in the opioid epidemic](https://ag.ny.gov/press-release/2019/attorney-general-james-files-nations-most-comprehensive-suit-against-opioid). In addition to Teva and its affiliates, the manufacturers named in the complaint included Purdue Pharma and its affiliates, as well as members of the Sackler Family (owners of Purdue) and trusts they control; Janssen Pharmaceuticals and its affiliates (including its parent company Johnson & Johnson); Mallinckrodt LLC and its affiliates; and Endo Health Solutions and its affiliates. The distributors named in the complaint were McKesson Corporation, Cardinal Health Inc., Amerisource Bergen Drug Corporation, and Rochester Drug Cooperative Inc. - Late last year, [Attorney General James won the trial against Teva Pharmaceuticals USA after a jury found the company and its affiliates liable for violating New Yorkers’ rights](https://ag.ny.gov/press-release/2021/attorney-general-james-victorious-new-yorks-opioid-trial). - In June 2022, [Attorney General James secured up to $58.5 million from Mallinckrodt for fueling the opioid crisis in New York](https://ag.ny.gov/press-release/2022/attorney-general-james-secures-585-million-top-opioid-manufacturer-mallinckrodt). - In December 2021, [Attorney General James reached a $200 million agreement with Allergan](https://ag.ny.gov/press-release/2021/attorney-general-james-delivers-200-million-help-new-york-combat-opioid-crisis). - In September 2021, [Attorney General James secured $50 million from Endo for New York state and Nassau and Suffolk counties to combat the opioid crisis and removed the opioid manufacturer from New York’s ongoing opioid trial](https://ag.ny.gov/press-release/2021/attorney-general-james-secures-50-million-opioid-abatement-drug-manufacturer-endo). - In July 2021, [Attorney General James secured](https://ag.ny.gov/press-release/2021/attorney-general-james-reaches-11-billion-agreement-big-three-distributors-treat) [a settlement with McKesson, Cardinal Health, and Amerisource Bergen that will deliver $1 billion to New York state to combat the opioid epidemic](https://ag.ny.gov/press-release/2021/attorney-general-james-reaches-11-billion-agreement-big-three-distributors-treat). - In June 2021, [Attorney General James announced a settlement that will deliver $230 to New York and end Johnson & Johnson’s sale of opioids nationwide](https://ag.ny.gov/press-release/2021/attorney-general-james-reaches-230-million-settlement-treatment-and-prevention). In 2021, Attorney General James championed legislation to create an opioid settlement fund to ensure these monetary settlements are invested in helping New Yorkers impacted by the opioid crisis. The bill, now codified as New York Mental Hygiene Law 25.18, passed unanimously through the state legislature, and requires the more than $2 billion secured in opioid settlements by Attorney General James to be used for abatement, treatment, and prevention efforts in communities devastated by this epidemic. Settlement discussions were led by Senior Advisor and Special Counsel M. Umair Khan and overseen by First Deputy Attorney General Jennifer Levy. The trial that led to this agreement was led by Senior Enforcement Counsel John Oleske and Special Counsel Monica Hanna, as well as Assistant Attorneys General Carol Hunt, Diane Johnston, Leo O’Toole, Jeremy Pfetsch, Noah Popp, Michael Reisman, and Lois Saldana; Project Attorneys Wil Handley, Stephanie Torre, and Eve Woodin; Paralegal Ketty Dautruche; Legal Assistant David Payne; Director of Research and Analytics Jonathan Werberg; Data Scientist Gautam Sisodia; Senior Data Analyst Akram Hasanov; Data Analyst Anushua Choudhury; Information Technology Specialists Hewson Chen and Paige Podolny; E-Discovery Document Review Specialist Kristin Petrella; Civil Recoveries Section Chief Martin Mooney; former Counsel for Opioids and Impact Litigation David Nachman; and former Assistant Attorney General Conor Duffy. **Topics:** Drug Diversion, Judicial/courts --- ### [Late boyfriend accused of Oakland murder-for-hire sang at victim's memorial](https://insurancefraud.org/news_archives/late-boyfriend-accused-of-oakland-murder-for-hire-sang-at-victims-memorial/) **Published:** September 19, 2026 **Author:** Diane Beauchamp **Content:** Nelson Chia is seen on YouTube video singing at the memorial for his girlfriend Lili Xu, the Oakland dentist who was shot and killed back in August in the city’s Little Saigon neighborhood. For months, he appeared at least outwardly to be the grieving boyfriend, heartbroken over his loss. But last week, he was arrested by Oakland police, accused of plotting a murder-for-hire so that he could take control of Xu’s financial assets and live off of her estate for the rest of her life. Hours after being taken into custody, he hanged himself at Santa Rita Jail in Dublin, according to the Alameda County sheriff’s office. “He always seemed like a pretty nice guy, pretty stand-up guy. It’s hard to believe,” said Ed Gonzalves, 74, of Hayward, who met Chia when they were in the second grade. Boyfriend accused of killing Oakland dentist takes own life in jail “I’m shocked at this scenario, you know of hiring somebody, just that kind of life, and I’m saddened by his suicide,” Gonzalves said. Authorities say Xu’s estate was worth up to $14 million dollars, including trusts, property and life-insurance policies and that Chia, a retired investment advisor, took control of many of her accounts after she died. Oakland police say Chia agreed to pay Hasheem Bason, 33, a “significant amount of money for murdering Xu.” Investigators say they obtained “communications” between Chia and Bason beginning in July, a month before the slaying, and continuing afterward. Bason has now been charged with murder with special circumstances of financial gain and lying in wait. He appeared in court Tuesday but did not enter a plea. He’s being held without bail. Surveillance video shows a white Lexus parked a short distance away before it pulls up alongside the couple’s Mercedes outside a spa at East 11th Street and 5th Avenue. Police say Bason got out of the Lexus, ignored Chia and went around the Mercedes to shoot and kill Xu. Cindy Zheng, who knew the couple, says she was immediately suspicious of Chia. “There are a lot of things that we couldn’t understand why he was doing that? The conclusion is that me might have a huge financial interest,” Zheng said. Video posted to YouTube video shows Bason participating in an “Occupy the Farm” protest in Albany in 2013. “You can’t help but to fall in line with it, you know? Like we’re going to do a community garden for free,” Bason says on the video. Bason also says, “We gotta think about the generation after that you know. We’re kind of still fighting an uphill battle for next generation.” Oakland police said Chia stood to immediately get $1 million after Xu was killed. **Topics:** Life Insurance **Categories:** Arrest --- ### [Stop frauds under garb of vehicle insurance claims: UP DGP](https://insurancefraud.org/news_archives/stop-frauds-under-garb-of-vehicle-insurance-claims-up-dgp/) **Published:** September 19, 2026 **Author:** Diane Beauchamp **Content:** In a bid to stop incidents of fraud under the pretext of claiming vehicle insurance after alleged road mishaps, Uttar Pradesh DGP Devesh Singh Chauhan has issued a circular with directions to strictly follow the rules while lodging FIRs. The instructions have been issued while citing orders of the Supreme Court. The development comes in the wake of cases involving fraudulent practices. A case is often lodged against an unidentified vehicle after mishaps and the gangs involved in frauds used to contact the family of victims under the pretext of helping them. The accused would mention the registration number of any random vehicle to claim insurance from the concerned company. To prevent more such frauds, an insurance company approached the Supreme Court. On the orders of the Supreme Court, officials are making efforts to stop such frauds by improving police action in connection with registering cases of mishaps. As per instructions issued by the DGP, police will prepare a report after every road mishap. The primary report itself will ascertain how and when the mishap took place. Police will complete further investigations within three months and will provide a full report to the insurance company and the person claiming the insurance. Notably, an FIR in cases involving road mishaps may also be registered online using the UPCOP App. The facility was introduced to maintain transparency. Anyone can take details and even download a copy of FIRs through the app. **Topics:** Auto fraud, Public Awareness --- ### [Insurance Fraud Bureau and Shift Technology launch AI counter-fraud solution for UK insurers](https://insurancefraud.org/news_archives/insurance-fraud-bureau-and-shift-technology-launch-ai-counter-fraud-solution-for-uk-insurers/) **Published:** September 19, 2026 **Author:** Diane Beauchamp **Content:** ## IFB Exploration will use artificial intelligence to enable the insurance industry to detect suspicious activity and organised fraud as it emerges The Insurance Fraud Bureau (IFB) and Shift Technology have announced that IFB Exploration is live. IFB Exploration is an artificial intelligence (AI) counter-fraud solution designed for UK insurers and will utilise AI to allow the collective insurance industry to identify any suspicious activity and organised fraud as it happens. It provides advanced network detection capabilities across motor, property, and liability lines of business. IFB members can remotely access the industry’s transactional data set, focusing on at-risk entities and networks that potentially link to organised fraud and gain contextual insights as they emerge. It is anticipated that counter-fraud teams can reduce the amount of time and money spent on manually searching for patterns in fraudulent activity. Ursula Jallow, Director at the IFB, said: “There has never been a greater need for the industry to collaborate and keep pace with the evolving tactics of fraudsters, and IFB Exploration marks that step change. This solution was built by leading counter-fraud teams from across the industry. It is designed to adapt and evolve to threats in real-time and it really will enable the industry to be stronger in their tactics to prevent and detect fraud.” [Shift Technology recently formed a strategic partnership with Sapiens International, a provider of software solutions to the insurance industry.](https://www.itij.com/latest/news/shift-technology-provide-ai-fraud-alerts-sapiens) **Topics:** Public Awareness, Technology --- ### [Nurse at Missouri hospital pleads guilty to fraudulently obtaining fentanyl for personal use](https://insurancefraud.org/news_archives/nurse-at-missouri-hospital-pleads-guilty-to-fraudulently-obtaining-fentanyl-for-personal-use/) **Published:** September 19, 2026 **Author:** Diane Beauchamp **Content:** A nurse at a Missouri hospital pleaded guilty to a federal felony and admitted fraudulently obtaining fentanyl for her own personal use. Lindsay J. Maupin, 31, of Cape Girardeau, pleaded guilty in front of U.S. District Judge Stephen R. Clark to one felony count of obtaining a controlled substance by fraud. Maupin, a registered nurse, admitted that from Jan. 18, 2020, to Feb. 2, 2020, while working at Mercy Hospital South in St. Louis County, she fraudulently obtained fentanyl from a Pyxis machine for her own use on multiple occasions. Maupin is scheduled to be sentenced on Feb. 2. The charge is punishable by up to four years in prison. This case was investigated by the Drug Enforcement Administration. **Topics:** Drug Diversion **Categories:** Conviction --- ### [NYS Inspector General and Navy SEAL to Speak at NYACT Conference for Law Enforcement and Insurance Professionals](https://insurancefraud.org/news_archives/nys-inspector-general-and-navy-seal-to-speak-at-nyact-conference-for-law-enforcement-and-insurance-professionals/) **Published:** September 19, 2026 **Author:** Diane Beauchamp **Content:** State Inspector General and lifelong New Yorker [Lucy Lang](https://stats.nwe.io/x/html?final=aHR0cHM6Ly9lbi53aWtpcGVkaWEub3JnL3dpa2kvTHVjeV9MYW5n&sig=RrbEXQKbtZAcHN7z2y9w6T_hjaBD5jL1oXY1xIXLKx8-WaOqSGkxJQDUsayjwkjGxJnoqqE1FiYRBU7akk4WaA&hit%2Csum=WyIzcGswanoiLCIzcGswazAiLCIzcGswazEiXQ), and [Kevin Holland](https://stats.nwe.io/x/html?final=aHR0cHM6Ly93d3cudW5pdGVkdGFsZW50LmNvbS9zcGVha2VyL2tldmluLWhvbGxhbmQv&sig=0Au9WnN1qfMVZiOJFG4mDZPo0N2wzElqJ3iQviheNMfQa9_9kg8PcYC4yZ-g6LnHsMZzOsZaIiElphSvAZJhAA&hit%2Csum=WyIzcGswazIiLCIzcGswazMiLCIzcGswazEiXQ), Master Sergeant, Former Navy SEAL Team 6 and Delta Force, will be featured speakers at [The New York Anti Car Theft and Fraud Association](https://stats.nwe.io/x/html?final=aHR0cHM6Ly93d3cubnlhY3Qub3JnLw&sig=o9H5KakWCddsEq9nfl13lJH1s0kM_MHIF2GNJ0EgiShPNzhAoGDXupXFHOxKRZ50wAf0fAEPZ3_ZMN30-xefsA&hit%2Csum=WyIzcGswazQiLCIzcGswazUiLCIzcGswazEiXQ) (NYACT) 2022 Annual Education Conference on Nov. 9, 2022, at the [Heritage Club at Bethpage State Park](https://stats.nwe.io/x/html?final=aHR0cHM6Ly93d3cubGVzc2luZ3MuY29tL2NvcnBvcmF0ZS93ZWRkaW5ncy92ZW51ZS9oZXJpdGFnZS1jbHViLWF0LWJldGhwYWdl&sig=iFHqytP7m2aXpXVJ_iSoDPqgx-kh2kqqfwALpJrOEcpBFMHZVY1grOr0FXcEoZQr2UNYrsHo4QSyWWy8GG-OLQ&hit%2Csum=WyIzcGswazYiLCIzcGswazciLCIzcGswazEiXQ). In addition to serving as New York’s Inspector General, Ms. Lang serves as the Vice Chair of the American Bar Association Criminal Justice Section, a member of the Council on Criminal Justice, and a Term Member of the Council on Foreign Relations. Prior to her appointment, [Ms. Lang served as Director of the Institute for Innovation in Prosecution (IIP),](https://stats.nwe.io/x/html?final=aHR0cHM6Ly9lbi53aWtpcGVkaWEub3JnL3dpa2kvTHVjeV9MYW5n&sig=RrbEXQKbtZAcHN7z2y9w6T_hjaBD5jL1oXY1xIXLKx8-WaOqSGkxJQDUsayjwkjGxJnoqqE1FiYRBU7akk4WaA&hit%2Csum=WyIzcGswanoiLCIzcGswazgiLCIzcGswazEiXQ) and as Assistant District Attorney in Manhattan, where she investigated and prosecuted violent crimes including homicides, gun violence, and domestic abuse. Ms. Lang brings her longstanding commitment to justice to bear in the Office’s investigations into corruption, waste, fraud, abuse, and misconduct in state government as well as deep experience designing and implementing practices that promote institutional integrity, transparency, and accountability. Kevin Holland, Master Sergeant, Former [Navy SEAL](https://stats.nwe.io/x/html?final=aHR0cHM6Ly93d3cubmF2eS5jb20vc2VhbHM&sig=wAmjLfH66YgzCmPLu0XQTIKtP9KdCiMYYQvvsfjGaHJT9HvtHwuVT69vRpdS637wcTJUJpOwZbnOmhVDalz8kw&hit%2Csum=WyIzcGswazkiLCIzcGswa2EiLCIzcGswazEiXQ) Team 6 and [Delta Force](https://stats.nwe.io/x/html?final=aHR0cHM6Ly93d3cubWlsaXRhcnkuY29tL3NwZWNpYWwtb3BlcmF0aW9ucy9kZWx0YS1mb3JjZS5odG1s&sig=K-93iyRkyeEqf86mO5eylgORJpTrHv-IJIoF7ynhYUikg1FdJdn5gY8oFdh4x3gxUhFXN7pCOsym9SvVEUpEBg&hit%2Csum=WyIzcGswa2IiLCIzcGswa2MiLCIzcGswazEiXQ), is the only publicly known operative to have served in both units over his noteworthy 20-year military career. Holland entered the Navy in 1988, volunteering for Basic Underwater Demolition/SEAL training. He first deployed in 1990, and during his deployment, Desert Storm began and during that time was awarded the Navy Achievement Medal and sent to Sniper School. He separated from the Navy in 1995, but after 9/11, Holland re-enlisted. He was assigned to the US Army Special Operations Command, completed the Special Forces Qualification Course, earning his Special Forces Tab and Green Beret. He deployed 20 times to the Middle East, conducting over 2000 combat missions. He was wounded in 2004 when an IED exploded behind his vehicle, and in March 2011, while on a mission in the Middle East, Holland was hit multiple times by a foreign fighter. Holland has received more than 30 awards, including seven Bronze Stars along with two Purple Hearts. Other informational sessions will include: Michael Mulcahy, Vanguard Direct, presents the *Digital Transformation of NYS’s Motor Vehicle Dealer Oversight Program.* [David M. Masur, Ph.D., ABPP](https://stats.nwe.io/x/html?final=aHR0cHM6Ly93d3cuZWluc3RlaW5tZWQuZWR1L2ZhY3VsdHkvMjc0MC9kYXZpZC1tYXN1ci8&sig=l9RcC6XRZnZZH_7C_VDYs6YBLRX37zAp_rfvNQbmWY-U8mhQMhVS43Z1u6kcgHGM-hwsVPznSU_hGpJJVQWtqA&hit%2Csum=WyIzcGswa2QiLCIzcGswa2UiLCIzcGswazEiXQ) will introduce *Basic Concepts of Billing Practices in Psychology,* and [Thomas Burke, Detective Bureau/Auto Crime, NYPD](https://stats.nwe.io/x/html?final=aHR0cHM6Ly93d3cubGlua2VkaW4uY29tL2luL3Rob21hcy1idXJrZS0zMDU5YjQ2&sig=j0UFqMhDLcKzKFUh3tMkvll2ysktpq5onHF89JZa0GqMHFKIncicl1PRRGefpGIbj_VCM3QeyJ2kox0qbzddqA&hit%2Csum=WyIzcGswa2YiLCIzcGswa2ciLCIzcGswazEiXQ), will present *Photo Identification of Motor Vehicles*. [The New York Anti Car Theft and Fraud Association](https://stats.nwe.io/x/html?final=aHR0cHM6Ly93d3cubnlhY3Qub3JnLw&sig=o9H5KakWCddsEq9nfl13lJH1s0kM_MHIF2GNJ0EgiShPNzhAoGDXupXFHOxKRZ50wAf0fAEPZ3_ZMN30-xefsA&hit%2Csum=WyIzcGswazQiLCIzcGswa2giLCIzcGswazEiXQ) (NYACT) is New York’s association founded to provide training for insurance and law enforcement personnel to combat vehicle crime and insurance fraud. Visit [nyact.org](https://stats.nwe.io/x/html?final=aHR0cDovL255YWN0Lm9yZw&sig=JAd5BIgd6Jx8La1mDYwKOBkHZ7YD1HcvCTivmrbNzN8ae_eYyWxZ9rrFt3Xmy7ZBGuNtfvxH3qaCQmNFghdmDw&hit%2Csum=WyIzcGswa2kiLCIzcGswa2oiLCIzcGswazEiXQ) for articles and from the conference or email the NYACT Office at [office@nyact.org](https://stats.nwe.io/x/html?final=aHR0cDovL255YWN0Lm9yZw&sig=JAd5BIgd6Jx8La1mDYwKOBkHZ7YD1HcvCTivmrbNzN8ae_eYyWxZ9rrFt3Xmy7ZBGuNtfvxH3qaCQmNFghdmDw&hit%2Csum=WyIzcGswa2kiLCIzcGswa2siLCIzcGswazEiXQ). **Topics:** Public Awareness --- ### [Former Spokane County worker pleads guilty to theft of $1.38M in public funds](https://insurancefraud.org/news_archives/former-spokane-county-worker-pleads-guilty-to-theft-of-1-38m-in-public-funds/) **Published:** September 19, 2026 **Author:** Diane Beauchamp **Content:** Attorney General Bob Ferguson announced today that former Spokane County worker Rhonda Sue Ackerman has pleaded guilty to one count of first-degree theft. Ackerman was employed as a liability claims technician and stole $1.38 million over the course of a decade from Spokane County by filing fake claims. Ackerman filed fake claims on behalf of 45 different claimants and requested claim payments from her office. She then directed the claimants, many of whom were relatives or friends of her son, to cash the checks and deliver the bulk of the funds back to Ackerman. According to the state’s charging documents, Ackerman spent the money on frequent gambling, new cars and lavish gifts. The Attorney General’s Office recommends that the court sentence Ackerman to one year and one day of prison, restitution of $1.38 million and the mandatory $500 victim penalty assessment. A judge will determine the sentence at a sentencing hearing on Jan. 4. “My prosecutors and I are committed to holding those who engage in public corruption accountable,” Ferguson said. “These prosecutions protect taxpayers and preserve the public trust.” Case background Ackerman was arraigned in October of 2021 for the theft charge. Her fraud scheme was discovered when the County Auditor’s Office found an uncashed check for $8,963.45. The check prompted an internal investigation and a follow-up investigation by the Washington State Auditor, as well as criminal investigations by the Spokane Police Department and Attorney General’s Office. The Internal Revenue Service also conducted a criminal investigation. Ackerman developed a check-cashing operation to finance her gambling habit. Ackerman conducted this fraud between 2007 and 2016, when she was an employee in Spokane County’s Department of Risk Management. Investigators found that she filed fake claims against Spokane County on behalf of people she knew, and directed them to cash the checks and return most of the money to her. The 45 “claimants” included relatives, family friends, and friends of her then 18-year-old son. Ms. Ackerman gave each “claimant” $100 to $200 for each check cashed. She gave her son $100 to $300 per check for accompanying his friends to the bank. Investigators found that Ms. Ackerman used the trust and access she had as a liability claims technician and as a parent to run the fraud scheme. The Attorney General’s Office prosecuted the case after receiving and accepting a referral from the Spokane County Prosecutor’s Office. Under state law and the Washington State Constitution, the Attorney General’s Office cannot investigate or prosecute a criminal violation without receiving and accepting a referral. The Attorney General’s Office often handles cases for county prosecutors when they have a conflict, including when a county employee is alleged to have committed a crime. Consequently, the Attorney General’s Office specializes in handling cases involving public corruption or other malfeasance by public employees. Without accepting a referral, the Attorney General’s Office has no jurisdiction over criminal matters. The Spokane County Prosecutor’s Office referred the matter to the Attorney General’s Office to avoid conflict of interest, since the suspect and most witnesses in the case were current or former county employees, and the funds were taken from the county. Assistant Attorney General Barbara Serrano is handling the case for the state. **Topics:** Insider Fraud **Categories:** Conviction --- ### [Federal Court Permanently Bars Utah Physician from Issuing Opioid and Controlled Substance Prescriptions](https://insurancefraud.org/news_archives/federal-court-permanently-bars-utah-physician-from-issuing-opioid-and-controlled-substance-prescriptions/) **Published:** September 19, 2026 **Author:** Diane Beauchamp **Content:** A federal judge entered a consent order that permanently bars a Utah physician from issuing prescriptions for opioids and other controlled substances. The consent order resolves allegations made by the United States against Dr. Sean Ponce, a medical doctor licensed in Utah. In a complaint filed in U.S. District Court for the District of Utah, the government alleged that Dr. Ponce unlawfully issued controlled substance prescriptions in violation of the Controlled Substances Act. The complaint alleged that Dr. Ponce catered to customer requests for opioids and other controlled substances, at times using text messages to arrange the exchange of prescriptions for cash. The complaint further alleged that Dr. Ponce used virtual office space in Cottonwood Heights, Utah, to meet with cash-paying customers to maintain the guise of a medical practice despite the routine lack of legitimate examinations, medical findings supporting the prescriptions or bona-fide doctor-patient relationships. “Doctors who facilitate the illegal diversion of opioids and other controlled substances harm the public and violate the law,” said Principal Deputy Assistant Attorney General Brian M. Boynton, head of the Justice Department’s Civil Division. “The Department of Justice will continue working with its partners to stop medical professionals who seek to profit from the opioid addiction epidemic.” “In the District of Utah, we will enforce the provisions of the Controlled Substances Act,” said U.S. Attorney Trina A. Higgins for the District of Utah. “This includes violations of the Act committed by doctors and healthcare professionals who unlawfully distribute controlled substances under the guise of legitimate medical practice.” “We entrust healthcare professionals to act in the community’s best interest,” said Special Agent in Charge Brian Besser of the DEA Rocky Mountain Division. “With that trust, the DEA expects practitioners to prescribe controlled substances in accordance with the laws and regulations set forth by legislation. When public trust is broken and healthcare providers seek to benefit from those that are at risk, they will most certainly be held accountable. I commend our Salt Lake City agents and our partners at the U.S. Attorney’s Office for the District of Utah and the Civil Division’s Consumer Protection Branch for judiciously building this case and seeing it through.” The consent order, entered by U.S. District Judge David Barlow, requires Dr. Ponce to pay a $65,000 civil penalty. The order also permanently prohibits Dr. Ponce from administering, dispensing or distributing controlled substances and from managing or supervising other medical providers who work with or prescribe opioids or controlled substances. The order prohibits Dr. Ponce from owning a business or medical practice where opioids or controlled substances are handled. The government was represented by Assistant U.S. Attorney Joel Ferre for the District of Utah and Trial Attorneys Yolanda D. McCray Jones and Scott B. Dahlquist of the Civil Division’s Consumer Protection Branch. The DEA’s Tactical Diversion Squad in the Salt Lake City District Office provided substantial investigative support. **Topics:** Judicial/courts --- ### [Everyone is talking about the NDIS – we spoke to participants and asked them how to fix it](https://insurancefraud.org/news_archives/everyone-is-talking-about-the-ndis-we-spoke-to-participants-and-asked-them-how-to-fix-it/) **Published:** September 19, 2026 **Author:** Diane Beauchamp **Content:** Last week’s budget revealed the rapidly escalating [costs of the National Disability Insurance Scheme](https://www.afr.com/politics/ndis-costs-growing-too-quickly-shorten-20221031-p5budp) (NDIS) and rekindled fears among people with disability about its sustainability. The Albanese government is unequivocal in its support for the NDIS, but has also [warned](https://www.abc.net.au/news/2022-10-26/federal-budget-ndis-funding-albanese-chalmers-review/101578300) more needs to be done to bring down costs. As part of this effort, it has brought forward an [independent review of the NDIS](https://www.ndisreview.gov.au/) to be co-chaired by former senior public servant Lisa Paul and former chair of the National Disability Insurance Agency (NDIA) Bruce Bonyhady. It will hand down findings and recommendations by October 2023. The next year will be crucial for setting out the future path of the NDIS and participants in the scheme. Our new survey shows Australians with disability are keen to see real change. The Summer Foundation – supported by People with Disability Australia – recently conducted a national survey of NDIS participants. We asked people with disability or their families what works well with the scheme and what needs to be changed. The 477 survey respondents included those with a wide range of disabilities, ages and locations around Australia. Previous research [drew on in-depth interviews](https://theconversation.com/what-the-ndis-needs-to-do-to-rebuild-trust-in-the-words-of-the-people-who-use-it-185880) and found that despite gratitude for the NDIS, participants have lost trust and confidence in the NDIA, which administers the scheme. The new survey provides hundreds of examples of how the NDIS has enabled a wide range of participants to achieve important and transformative outcomes. The survey also provides rich data that illustrates the stress and unpredictability of navigating the NDIS. There are insights into how the scheme could be much more efficient and simpler for users to navigate. As one told us: The concept of NDIS is great. The implementation and delivery needs to be improved. Jumping through hoops Survey responses indicate the range of issues participants want addressed. Participants take issue with the reports and assessments they are asked to obtain as part of funding plan reviews. The NDIA asks participants to submit evidence from health professionals about their disability and needs. But participants believe NDIA staff often do not read, understand or factor in this evidence. This feels like a waste of time, effort and money. The recommendations of long-term experts involved with a person \[shouldn’t be\] second-guessed or discarded by an inexperienced and unfamiliar NDIA officer (no matter their good intentions). Not everyone can be an advocate Participants report NDIA staff lack expertise and experience in disability issues. This puts a burden on the participant or their family to educate the agency. Those with the skills, knowledge, time and ability to self-advocate may eventually succeed in getting a suitable funding plan, but others with less capacity give up. Participants say NDIA staff should receive more training, or have their expertise better matched to who they are working with; hiring more people with disability experience was also suggested. Here are some of things participants shared: Planners, interviewers \[should\] know and understand the disabilities they are writing about fully – no one understands deaf. They keep trying to ring me – ughhh I am deaf. I am very grateful for the NDIS and what it does. Although it is working well for me personally, I am appalled at how complex, time-consuming and sophisticated I had to be to get what I have. The funding has been difficult to continue to fight for each year, having to prove lifelong disability that will never improve. However the funds received and the flexibility of using the funds has been so important. Wanting better Participants say the NDIA lacks the fundamental elements of contemporary customer service, let alone an agency designed to engage with people who may have severe cognitive and communication limitations. Participants’ frustration with the NDIS stems in part from knowing how well the scheme can work, and that it does work well for some people some of the time. The current design of the NDIS is unnecessarily [bureaucratic](https://www.smh.com.au/national/bureaucratic-nightmare-ndis-putting-lives-at-risk-say-advocacy-groups-20220423-p5afkz.html) in a way that [demonstrates a lack of trust](https://www.scribd.com/document/127196426/Designing-NDIS#download&from_embed) in the competency of participants to make decisions about their lives. Participants described many ways in which the NDIS allows them to participate socially and economically and make the most of life despite their disability. When it does work, it’s the people who listen, the people who treat people with disability as humans, not as a burden. The people who recognise they are handling a person’s life, rather than managing an account. My NDIS supports allow me to work for the first time in full-time ongoing employment in the open employment market. Prior to the NDIS supports that I receive, this would not have been possible. Our daughter volunteers at three local organisations with the help of support workers. She is supported to go shopping for herself. She attends a centre-based program for socialising and fun. She is receiving regular overnight support to help increase her independence from us, her parents. Getting to work Many NDIS participants have untapped potential to work and make other valuable contributions to society. A new [NDIS 2.0](https://ministers.dss.gov.au/media-releases/9436) needs to see the agency working in partnership with people with disability to enable economic and social participation and deliver real jobs for people with disability. Better connecting NDIS participants to job opportunities and reforming disability employment services may be part of the solution to increasing work participation. The government’s [pilot scheme announced this week](https://www.theguardian.com/australia-news/2022/nov/02/labor-to-launch-trial-to-help-ndis-participants-who-want-to-work) has this focus. However, our survey suggests many participants cannot even begin to explore employment because their basic daily supports and housing are not secure in today’s NDIS. Redesigning the NDIA to be an efficient and cost-effective administrator that consistently delivers great outcomes for NDIS participants will be a major challenge. Giving a voice to a broad range of participants and their families – who have a wealth of expert knowledge on what works well and what needs to be changed – is crucial to transforming the scheme. The NDIS review is a once-in-a-generation opportunity to get the scheme right, stem the current waste of public resources, and transform the lives of half a million Australians. **Topics:** Disability, Public Awareness, Regulatory actions --- ### [New cyber attack targets school students for data breach](https://insurancefraud.org/news_archives/new-cyber-attack-targets-school-students-for-data-breach/) **Published:** September 19, 2026 **Author:** Diane Beauchamp **Content:** Thousands of school families could be caught up in a terrifying cyber attack on a tech group used by state government departments. PNORS Technology Group, an enterprise used by the Department of Education and Training in Victoria, has been the latest victim of hackers. *The Age* reported on Sunday morning that data from a Victorian school entrance health questionnaire was among the information accessed and stolen during a breach. The questionnaire included very personal information about students, including developmental and behavioural issues, family alcohol or drug problems, and demographics. The questionnaire was received by the families of all students who’ve started in Victorian primary schools. PNORS chief executive Paul Gallo told *The Sunday Age* the extent of the breach is currently being investigated, but cybersecurity experts believed the hack was limited to encrypted systems. “However, overnight the criminals behind the cyberattack released to the company in a private communication a sample of what is believed to be stolen data,” Mr Gallo said. “When we were informed about the cyberattack, we immediately shut down and isolated all our internal systems and took further measures to secure our network and data, along with pausing all data processing.” Another source told *The Age* it is currently still unclear exactly which data has been stolen. PNORS reportedly detected the breach on Thursday after it impacted two of its businesses, Datatime and Netway. “The company immediately activated an incident response which included notifying affected clients, engaging external cybersecurity experts to assist in dealing with the issue,” Mr Gallo told *The Age*. A spokesperson from the Department of Premier and Cabinet told NCA NewsWire the Victorian Government was aware of the cyber incident, and protecting Victorian data was their highest priority. “We are continuing to provide support to PNORS Technology Group to determine the extent of the information breach and to prevent further incidents,” the spokesperson said. “The Victorian Government’s Cyber Incident Response Service have been notified and are taking appropriate action. “If it is determined that Victorian Government data has been exposed as a result of this breach, departments will notify impacted individuals and provide advice on steps they can take to minimise any risk.” Kilvington Grammar School in Melbourne has notified families of students of the data breach, and warned some personal information had already been published. “Kilvington Grammar confirms it has experienced a data incident involving unauthorised access to some of its online systems,” they revealed in a statement. They said the school’s primary database had not been accessed, but some third party information had been released. “The team has undertaken a forensic investigation to establish the nature of this data and we have notified and provided support to affected parties.” **Topics:** Public Awareness, Technology --- ### [4 health systems facing lawsuits for data breaches](https://insurancefraud.org/news_archives/4-health-systems-facing-lawsuits-for-data-breaches/) **Published:** September 19, 2026 **Author:** Diane Beauchamp **Content:** - [Mon Health](https://www.beckershospitalreview.com/cybersecurity/lawsuit-claims-mon-health-didn-t-protect-patients-from-data-breach.html) (Morgantown, W.Va.) is being sued over a December 2021 data breach that had compromised the health and personal data of at least 492,861 people. The lawsuit alleges that the health system failed to protect patient data and failed to notify patients of the breach in a timely manner. - [Advocate Aurora Health](https://www.beckershospitalreview.com/cybersecurity/patient-sues-advocate-aurora-health-in-federal-court-over-pixel-data-breach.html) (dually headquartered in Downers Grove, Ill., and Milwaukee), alongside Facebook parent company Meta, is facing a lawsuit over their use of “pixel” technology that may have ensnared protected health information. The health system installed the pixel tracker to monitor patient behavior, but the tracker may have sent more than 3 million patients’ information to the social media company. The suit alleges that because of this, Meta and Advocate violated privacy laws. - [WakeMed](https://www.beckershospitalreview.com/cybersecurity/wakemed-sued-for-allegedly-sending-patient-data-to-facebook.html) (Raleigh, N.C.) is facing a patient-led lawsuit for installing a pixel tracking tool from Facebook on its website and patient portal that allegedly led to patient data being sent to the social media company. The lawsuit alleged that for at least four years, WakeMed had the tracking tool, Meta Pixel, installed on its website and patient portal, which allowed it to capture and transmit certain information entered by patients. Patient information such as names, contact details, computer IP addresses, emergency contact information, check-in information, Social Security numbers and financial information were allegedly collected by the tool without the consent of patients. - [OakBend Medical Center](https://www.beckershospitalreview.com/legal-regulatory-issues/oakbend-medical-center-faces-lawsuit-for-ransomware-attack-that-breached-1m-patient-records.html) (Richmond, Texas) is facing a class action lawsuit over a September ransomware attack and data breach that exposed the personal information of more than 1 million patients. The plaintiffs allege that the hospital failed to take adequate measures to protect the personal information of patients, as well as failed to adequately notify patients of the breach and provide details about what information was exposed. **Topics:** Judicial/courts, Technology --- ### [Aveanna Healthcare Reaches $425K Settlement After Healthcare Data Breach](https://insurancefraud.org/news_archives/aveanna-healthcare-reaches-425k-settlement-after-healthcare-data-breach/) **Published:** September 19, 2026 **Author:** Diane Beauchamp **Content:** Aveanna Healthcare reached a proprosed settlement to resolve a healthcare data breach lawsuit stemming from a 2019 string of phishing attacks that impacted hundreds of thousands of Massachusetts residents, Attorney General Maura Healey [announced](https://www.mass.gov/news/home-health-care-company-to-pay-425000-following-data-breach-impacting-thousands-of-massachusetts-residents). The Massachusetts Attorney General’s office alleged that the Georgia-based home healthcare provider failed to sufficiently safeguard patient data, leading to protected health information (PHI) exposure for more than 4,000 patients and employees. Currently, Aveanna Healthcare operates in 33 states, with Massachusetts offices located in Brockton, Plymouth, Shrewsbury, Springfield, Waltham, West Springfield, and Worcester. According to the Attorney General’s office, Aveanna employees began receiving fraudulent “phishing” emails in July 2019, which exploited users into handing over credentials, money, and sensitive information to an unauthorized party. The information involved in the incident included social security numbers, driver’s license numbers, financial account numbers, and health information such as diagnoses, medications, and treatment records. Aveanna Healthcare notified impacted individuals of the breach in [February 2020 after discovering in August 2019 that certain accounts were hacked](https://www.techtarget.com/healthtechsecurity/news/366595804/Accounting-Firm-Ransomware-Hack-Affects-Community-Care-Patient-Data). In one instance, the threat actors sent a phishing email to employees disguised as the Aveanna Healthcare president. Over the course of several weeks, over 600 phishing emails were sent to employees by August 2019. Responses to these emails led to authorized access to parts of Aveanna Healthcare’s network. Additionally, the threat attempted to access the human resources system and modify individual employees’ direct deposit information. In response to the incident, Aveanna Healthcare said it offered impacted Massachusetts residents two years of free credit monitoring. The initial complaint stated that the Georgia-based home health provider “was aware that its cybersecurity required improvement but had not implemented new changes to improve it by the time the phishing attacks occurred.” Specifically, the attorney general alleged that Aveanna Healthcare did not implement tools or employee training to prevent phishing attacks, and “Aveanna’s security program failed to meet the minimum required safeguards to protect personal information under the Massachusetts Data Security Regulations.” Additionally, the complaint accused Aveanna of HIPAA noncompliance as the company failed to meet standards for protecting PHI. “Companies have an obligation to put the right security measures and systems in place to prevent hackers from accessing sensitive information,” AG Healey said in a press release. “As a result of this resolution, Aveanna will ensure compliance with our strong data security laws and the take steps necessary to protect its employees and the private data of Massachusetts residents moving forward.” The home health provider has denied all wrongdoing and agreed to a settlement. Under the terms of the consent judgment, Aveanna decided to pay the monetary settlement of $425,000 and implement a comprehensive information security program. In particular, the security program must include phishing protection technology and multi-factor authentication. Aveanna would also be required to “train its employees on data security, keep them up to date on security threats, and do an annual independent assessment of its compliance with the consent judgment and the Massachusetts Data Security Regulations for a period of four years.” This data breach also led to a [class-action lawsuit of more than 100 patients impacted by a month-long data breach](https://www.techtarget.com/healthtechsecurity/news/366595683/Aveanna-Healthcare-Faces-Lawsuit-Over-Monthlong-Data-Breach). As noted in the lawsuit, Aveanna waited well beyond the HIPAA-required 60-day notification rule to begin sending notices to potential victims. The lawsuit also argues that Aveanna Healthcare inadequately safeguarded patient data and carelessly maintained private information. The lawsuit sought out a financial remedy for out-of-pocket costs related to purchasing credit monitoring services, freezes, and reports, along with other protective measures against identity theft. **Topics:** Judicial/courts, Technology --- ### [New York City psychiatrist Pamela Buchbinder masterminded hit on her ex-lover, judge says](https://insurancefraud.org/news_archives/new-york-city-psychiatrist-pamela-buchbinder-masterminded-hit-on-her-ex-lover-judge-says/) **Published:** September 19, 2026 **Author:** Diane Beauchamp **Content:** On Oct. 11, 2022, Manhattan psychiatrist Pamela Buchbinder was sentenced to 11 years in prison after admitting her guilt in connection with one of the most bizarre crime stories in New York City history — the brutal and nearly fatal 2012 attack on her ex-lover and the father of her child, Dr. Michael Weiss. According to authorities, the assault on Weiss in his Manhattan office was the climax of an epic “War of the Roses” battle between two extremely well-educated and respected psychiatrists. “48 Hours” correspondent Peter Van Sant exclusively reports in The Psychiatrist and The Selfie.” What made the crime even more astonishing, according to Van Sant, was the fact that the alleged “hit man” turned out to be Buchbinder’s troubled young cousin, Jacob Nolan, who claimed that Buchbinder had manipulated him into carrying out the murder for her. Back in 2012, Buchbinder and Weiss were going through a bitter custody battle over their son, Calder, then 4 years old, and fighting over visitation. Yet, despite their arguing, it turned out Weiss took out a $1.5 million life insurance policy for his son, and gave his mother, Buchbinder, control in the event of Weiss’s death, starting on Nov. 9, 2012. By then, authorities said, Buchbinder allegedly had taken her bipolar cousin under her wing, seemingly to help him deal with his mental health and drug and alcohol issues. But instead of healing Nolan, the son of a wealthy real estate investor, authorities claimed Buchbinder slowly brainwashed and weaponized him into carrying out the hit. Buchbinder accompanied Nolan to a local Home Depot on Nov. 11, 2012, where they purchased a sledgehammer, according to authorities. And the following day, Nolan took the sledgehammer and a knife Weiss had given Buchbinder as a gift, and used a map Buchbinder drew of Weiss’s office to surprise him. But the assault did not kill Weiss. Instead, the two ended up fighting in the office, with both of them left bloodied, and badly hurt. According to prosecutors, while they waited for paramedics to arrive to take them to the hospital, Nolan snapped a selfie, which he sent to Buchbinder to show her what happened to him. Nolan’s defense attorney, Steven Brounstein, later said that Nolan was “putty” in Buchbinder’s hand. And at Nolan’s trial in 2016, Brounstein acknowledged Nolan committed the assault, but he argued that Buchbinder took advantage of Nolan’s fragile and submissive mental health, and therefore was not fully responsible for his actions. Prosecutors, however, disagreed, insisting that being bipolar did not mean that Nolan did not understand what he was doing, or had been turned into a “babbling idiot who had no control over his facilities.” In the end, a Manhattan jury took less than an hour to convict Nolan, then 23, and he was sentenced to more than nine years in prison. But his conviction did not end speculation that his older psychiatrist cousin was also responsible for the brutal assault. In 2017, prosecutors eventually charged Buchbinder in connection with the attack, and she then spent five years on Rikers Island as her lawyers wrangled over the case and the courts were shut down due to the pandemic. Meanwhile, her high-powered lawyers, Ronald Fishetti, Eric Franz and Monica Nejathaim, claimed Buchbinder was not only innocent, but there were legitimate explanations about her relationship with Nolan, and the evidence against her. But last September, Buchbinder — looking rail-thin and gaunt — surprised the court by announcing she had reached a deal with prosecutors, and she pleaded guilty to lesser charges in exchange for 11 years in prison. A month later, however, when she showed up for her routine sentencing, Buchbinder stunned the court again – this time saying she wanted to withdraw her plea. She claimed that on the day she pleaded guilty, she was exposed to mace on Rikers Island, did not take her medication, and inadvertently got a contact high when someone was smoking drugs on her bus ride to court. Judge Thomas Farber, however, rejected her argument, and continued the sentencing, with Weiss then reading a victim’s impact statement in which he laid out how the attack left him with PTSD, and a fear that Buchbinder’s hatred for him will continue even after she is released from prison. Then, Manhattan Assistant District Attorney Joel Seidemann took to the podium. “I think it’s necessary to make the record straight,” Seidemann began. “The defendant tried to have Dr. Michael Weiss murdered … she hated his guts.” “She sought to destroy him because of their failed relationship,” he continued. “She stood to control $1.5 million in life insurance on his life in the name of his son.” Buchbinder responded succinctly. “If there was one true statement Mr. Seidemann said, I missed it,” she said. Finally, Farber sentenced Buchbinder to 11 years and issued an order of protection, but not before he had his say. “There can be no doubt that if you plot to bash somebody’s head in with a sledgehammer that the intent is to cause his death,” the judge said. Outside court after Buchbinder was led away in handcuffs, her attorneys said that with time off for good behavior, Buchbinder will be free in 2027 to start her life over, and try to re-establish her relationship with her son. **Topics:** Life Insurance **Categories:** Conviction --- ### [Despite plenty of investigators and potential cases, Hawaii lags in Medicaid fraud and abuse prosecution](https://insurancefraud.org/news_archives/despite-plenty-of-investigators-and-potential-cases-hawaii-lags-in-medicaid-fraud-and-abuse-prosecution/) **Published:** September 19, 2026 **Author:** Diane Beauchamp **Content:** Hawaii has a huge population of people on Medicaid and thousands of health professionals, nursing home and care home operators taking care of them. **Topics:** Public Awareness --- ### [Want a puppy for Christmas? Know these warning signs of the puppy scam](https://insurancefraud.org/news_archives/want-a-puppy-for-christmas-know-these-warning-signs-of-the-puppy-scam/) **Published:** September 19, 2026 **Author:** Diane Beauchamp **Content:** If your holiday plans include welcoming a new furry friend, one woman learned the hard way you can’t trust every adorable puppy ad you see. Bridget Huddleston wanted a new puppy for the holidays. “I’m looking for a small lapdog puppy,” she said. She found a blonde Yorkshire Terrier in a Facebook group, offered at a great price. “It was $200,” she said. Huddleston fell in love. She showed us videos and images the seller had sent to her. All she had to do was buy a Visa gift card, and send the numbers to the out-of-state seller. As soon as she did that, the seller said the puppy was on its way. “They sent me pictures during transit,” she said. “They even gave me updates along the way.” But when she got to the airport, there was no dog. No airport baggage staffers knew anything about a puppy in a crate. Heartbroken woman waits hours at airport for no-show puppy https://assets.scrippsdigital.com/cms/video/player.html?video=https://content.uplynk.com/ad9d5adca66c48f59b21c8526e9b7c0b.m3u8&mp4=https://cf.cdn.uplynk.com/ausw/slices/ad9/45bf940c346f431c9be273b8942ab6eb/ad9d5adca66c48f59b21c8526e9b7c0b/ad9d5adca66c48f59b21c8526e9b7c0b\_e.mp4&autoplay=false&purl=/money/consumer/dont-waste-your-money/want-a-puppy-for-christmas-know-these-warning-signs-of-the-puppy-scam&ads.iu=/6088/ssp.wfts/money/consumer/dont-waste-your-money/want-a-puppy-for-christmas-know-these-warning-signs-of-the-puppy-scam&ads.proxy=1&poster=https://cf.cdn.uplynk.com/ausw/slices/ad9/45bf940c346f431c9be273b8942ab6eb/ad9d5adca66c48f59b21c8526e9b7c0b/poster\_86e077cc041e4cedb3030008dd755f76.jpg&title=Want%20a%20puppy%20for%20Christmas%3F%20Know%20these%20warning%20signs%20of%20the%20puppy%20scam&kw=Christmas%20puppy%2Cchristmas%2Cdog%20for%20christmas%2Cpuppy%20scam%2Cscam%20alert&contplay=\*recent&mute=0&tags=Dont%20Waste%20Your%20Money%2CNational%20News%2CConsumer%2CMoney%2CHomepage%20Showcase%2CNewsletter%20Showcase§ion=Don%27t%20Waste%20Your%20Money&cust\_params=temp%3D%26weather%3D&host=tampabay28.com&s=wfts&env=production If your holiday plans include welcoming a new furry friend, one woman learned the hard way you can’t trust every adorable puppy ad you see. Bridget Huddleston wanted a new puppy for the holidays. “I’m looking for a small lapdog puppy,” she said. ![Want a puppy for Christmas? Know these warning signs of the puppy scam](https://ewscripps.brightspotcdn.com/dims4/default/3864a92/2147483647/strip/false/crop/1280x714+0+3/resize/95x53!/quality/90/?url=https%3A%2F%2Fcf.cdn.uplynk.com%2Fausw%2Fslices%2Fad9%2F45bf940c346f431c9be273b8942ab6eb%2Fad9d5adca66c48f59b21c8526e9b7c0b%2Fposter_86e077cc041e4cedb3030008dd755f76.jpg)![Want a puppy for Christmas? Know these warning signs of the puppy scam](https://ewscripps.brightspotcdn.com/dims4/default/7ba33d6/2147483647/strip/false/crop/128x71+0+0/resize/95x53!/quality/90/?url=https%3A%2F%2Fcf.cdn.uplynk.com%2Fausw%2Fslices%2F41f%2F63c1dd2550f243de8acbe752dd0ab1bb%2F41f7a623c71a403f9ac915344d4e3c00%2F00000014.jpg)[![](https://ewscripps.brightspotcdn.com/dims4/default/ff20f65/2147483647/strip/true/crop/719x719+341+0/resize/300x300!/quality/90/?url=http%3A%2F%2Fewscripps-brightspot.s3.amazonaws.com%2F06%2F1e%2F29e0e8ec43b7aa9eb4f0d2086407%2Fjohn-materese-web1280.png)](https://www.tampabay28.com/john-matarese)By:[John Matarese](https://www.tampabay28.com/john-matarese) Posted 6:00 AM, Nov 07, 2022 and last updated8:03 AM, Nov 07, 2022 If your holiday plans include welcoming a new furry friend, one woman learned the hard way you can’t trust every adorable puppy ad you see. Bridget Huddleston wanted a new puppy for the holidays. “I’m looking for a small lapdog puppy,” she said. She found a blonde Yorkshire Terrier in a Facebook group, offered at a great price. “It was $200,” she said. Huddleston fell in love. She showed us videos and images the seller had sent to her. All she had to do was buy a Visa gift card, and send the numbers to the out-of-state seller. As soon as she did that, the seller said the puppy was on its way. “They sent me pictures during transit,” she said. “They even gave me updates along the way.” But when she got to the airport, there was no dog. No airport baggage staffers knew anything about a puppy in a crate. https://a98d11677c1e026be04c945a71b2f336.safeframe.googlesyndication.com/safeframe/1-0-45/html/container.html “I was at the 3A pillar where they told me to wait, ” she said. “I sat there for hours!” The seller and her money were gone. **Why it is so easy to be scammed** Puppy scams flourish during the holiday season, because so many people want a new dog for the new year. And many local breeders won’t have a new litter of puppies until next spring, so hopeful buyers scout Craigslist, Facebook groups, and other sites for puppies for sale. But the Better Business Bureau says buying a puppy online is among the riskiest purchases you can make, because it says as many as 80 percent of sponsored pet ads are fake. And of those targeted in 2020, the BBB says 70 percent lost money. Brandi Munden with the American Kennel Club says scammers are everywhere on social media in November and December, because “they know that people are trying to get a puppy underneath the tree.” **How to protect yourself** The BBB says when choosing a dog… - Meet the seller in person, or at least do a video chat: tell them to hold the puppy up to the camera in a Zoom call. If they won’t do it, there probably is no puppy for sale. - Do a price comparison, and be suspicious if the price is much lower than breeder quotes. - Watch out for copycat or stock photos: you can do a Google reverse search on the image, and see if that puppy has popped up on other websites. - Another red flag is a seller demanding extra money for shipping and handling at the last minute. “They do not need a nanny for handling, they do not need a temperature-controlled crate,” she said. The easiest way to avoid pet scams is to check out a local animal shelter where you can see a cat or dog in person. Bridget Huddleston is out $200, but says the hardest part is the loss of a puppy she fell for. “If I can help the next person to know and prepare themselves, then at least something will come of this, ” she said. That way you don’t waste your money. **Topics:** Public Awareness --- ### [York clinic warns of scammer posing as employee](https://insurancefraud.org/news_archives/york-clinic-warns-of-scammer-posing-as-employee/) **Published:** September 19, 2026 **Author:** Diane Beauchamp **Content:** York residents are reporting a new scam via phone. York Medical Clinic said someone is spoofing its phone number and pretending to be an employee named Kendall Mauer. If you receive a phone call purportedly from the clinic asking for any personal information, like your Social Security number or bank information, hang up and call the clinic. **Topics:** Public Awareness --- ### [Tips to Protect Your Health Data This Holiday Season](https://insurancefraud.org/news_archives/tips-to-protect-your-health-data-this-holiday-season/) **Published:** September 19, 2026 **Author:** Diane Beauchamp **Content:** Wearables like FitBit, smart watches, smart or connected health monitoring devices and their associated apps are popular holiday gifts that collect and store your health data. Despite stringent privacy laws intended to safeguard your personal health information (PHI), data breaches are on the rise and can lead to everything from medical identity theft to billing fraud to blackmail. The Health Insurance Portability and Accountability Act (HIPAA) [doesn’t cover everything](https://www.globenewswire.com/Tracker?data=1o-oV5GyZRqW08TEa9pxpaX9jcSAtZbb7Q6yjmwpvvdUypnPsAJp3KV30pd_ACH5MRt_edFJUAPbdZKcukPo0CQfbj8myJ3UyqRGySn6ZgOUnyAipLByKR8jxr19oAuUm26bgAw8Nb-hMcggmecW3cIChUlsntjAgBdMfWTtGM0ZsRoYiQMpTWYbtTa47IhP). A 2021 investigation by [Consumer Reports](https://www.globenewswire.com/Tracker?data=kI8FHWwJ8CTzEq9Whso7PZuCLYFx0Ldmv9Qki-NEedDu6Gc5Kjs5PQLuQFIOUNLu4aSoa0RysnzKS0rxlkYVl5Ez3JT93zX9uUWS6JLZzX2D0gijPyJuc73Km_lERLyCVJn6O17J4fl-ZthEF_uDX1cHmFn_zVyWMUXlsE87CMDK_SfgxkAbb7y6muhpQz0T) found that privacy policies for a number of companies behind health apps left open questions about their privacy practices, and recent [research](https://www.globenewswire.com/Tracker?data=vG_y5ncLlpzai701jqcbO-oK7GCoFDA8ncZ7feObwnchet1RAMwHmDBo__HzyTrFxcQKktRVnbiM_m2Em6dqToxh_tdCtBm99VP01Iw5WwN3616S4z2XvXG66tHgbCGm) indicates end users do not have full awareness of what their consent entails. **This holiday season, as part of their** ***Better Health is in Your Hands*TM** **campaign, the American Health Information Management Association (AHIMA) Foundation, shares tips and a** **[new animated video](https://www.globenewswire.com/Tracker?data=eCx5ccvXt94KA365aYB6qH9gJZXSyKMOQ5m4-rSi5YA7HlrAvP1TwoU9jZ6lWYeKIu74t78e5DqSUtA3NWLm0E2DnyopsOrQ76eSOq4mEd3d6gZVYt432AP4rnPJNgBH)** **that walks consumers through the steps to protect the privacy and security of health information on their personal cell phone or tablet.** “Your personal health data may include individually identifying information, such as your name, address, age, social security number, and location, as well as the places you travel, what doctors you visit and for what medical treatments or services, any diagnoses or conditions, current health status, and more,” said Anisa Tootla, AHIMA Foundation Executive Director. “And if you are setting up a new device for yourself or helping a loved one or are getting rid of an old one, there are ways to reduce privacy and security risks associated with your health information.” 1. **Turn off the location services on your personal cell phone or tablet.** This increases the privacy of information about your activities, your location, and the places you travel. 2. **Avoid giving any app permission to access your device’s location data, other than those apps where the location is absolutely necessary** (e.g., navigation and traffic apps). 3. **Use adequate security to send or receive health information over public Wi-Fi networks.** Open Wi-Fi networks at airports and other public locations can be an easy way for unauthorized users to intercept your information. Also be aware of any Bluetooth connections that you establish, like that rental car you authorized to use your phone. 4. **Delete all stored health information before discarding or reusing the mobile device**. When you use software tools that thoroughly delete (or wipe) data stored on a mobile device before discarding or reusing the device, you can protect and secure health information from unauthorized access. 5. **Avoid downloading unnecessary or random apps, especially those that are “free.”** In general, a free app is likely to include a lot of advertising and is therefore more likely to share your personal information with advertisers than a paid app. **Topics:** Public Awareness --- ### [Gadsden man pleads guilty to health care fraud conspiracy](https://insurancefraud.org/news_archives/gadsden-man-pleads-guilty-to-health-care-fraud-conspiracy/) **Published:** September 19, 2026 **Author:** Diane Beauchamp **Content:** A Gadsden man was one of two people who pleaded guilty on Thursday in related cases involving multi-million-dollar health fraud conspiracies, according to a news release from the U.S. Attorney’s Office for Alabama’s Northern District. James Ewing Ray, 51, pleaded guilty to one count of conspiracy to commit health care fraud before Chief United District Court Judge L. Scott Coogler in Tuscaloosa. Ray is the owner of Integrity Medical LLC, which markets health care items and services to medical providers. According to his plea agreement, Ray between 2012 and 2018 conspired with others to pay and receive kickbacks to issue medically unnecessary prescriptions and other goods and services Those charges then were billed to Medicare and other health insurers. They included electro-diagnostic testing provided by QBR, or Diagnostic Referral Community, based in Huntsville. Ray in return, according to the release, received per-patient payments from QBR for inducing medical providers to order tests from it. QBR’s owner, John Hornbuckle, 52, of Huntsville, pleaded guilty before Coogler to one count of conspiracy to commit health care fraud and another count of conspiracy to receive kickbacks. Hornbuckle in his plea agreement admitted that QBR billed insurers millions of dollars for electro-diagnostic testing performed by its technicians, whether needed medically or not. QBR paid medical providers a per-patient fee for ordering tests that were reimbursed by Medicare and other government health care programs. Those payments were disguised as hourly payments for the providers’ and their staffs’ time. In related legal action earlier this year, an Attalla man pleaded guilty to health care fraud conspiracy prior to a trial in which his co-defendants, two Lewisburg, Tennessee, providers, were convicted on health care fraud and kickback charges. Brian Bowman, 41, in his plea agreement admitted to marketing QBR’s electro-diagnostic testing to medical providers in return for a fee for each test ordered, collecting nearly $1 million. Bowman’s co-defendants, Dr, Mark Murphy and his wife, both 65, were convicted after a multi-week trial. The Murphys owned and operated North Alabama Pain Services, which operated in Decatur and Madison until closing in 2017. Evidence presented at trial showed they took more than $1 million in kickbacks. Bowman and the Murphys are awaiting sentencing; sentencing remains to be scheduled for Ray and Hornbuckle. The maximum penalty for kickback conspiracy is five years in prison. The maximum penalty for health care fraud conspiracy is 10 years in prison. The guilty pleas by Ray and Hornbuckle were announced by Prim Escalona, U.S. Attorney for the Northern District; Felix Rivera-Esparra, Federal Bureau of Investigation Acting Special Agent in Charge; and Tamala Miles, Special Agent in Charge of the Department of Health and Human Services’ Office of Inspector General. The FBI and HHS-OIG investigated the case; it was prosecuted by Assistant U.S. Attorneys J.B. Ward and Don Long. **Topics:** Healthcare Fraud **Categories:** Conviction --- ### [NYAG James Secures $523 Million From Opioid Manufacturer Teva to Settle Claims from](https://insurancefraud.org/news_archives/nyag-james-secures-523-million-from-opioid-manufacturer-teva-to-settle-claims-from/) **Published:** September 19, 2026 **Author:** Diane Beauchamp **Content:** New York Attorney General Letitia James today marked a monumental milestone in her fight against the opioid crisis in New York state and announced that her office has [secured up to $523 million](https://lnks.gd/l/eyJhbGciOiJIUzI1NiJ9.eyJidWxsZXRpbl9saW5rX2lkIjoxMDAsInVyaSI6ImJwMjpjbGljayIsImJ1bGxldGluX2lkIjoiMjAyMjExMDMuNjYwOTk5ODEiLCJ1cmwiOiJodHRwczovL2FnLm55Lmdvdi9zaXRlcy9kZWZhdWx0L2ZpbGVzL2ZpbmFsX255X3RldmFfYWdyZWVtZW50Xy1fZXhlY3V0aW9uX3ZlcnNpb245MC5wZGYifQ.6NJwFzywWMdcGs16MIuXewOJFUqEUIA2_ONZCcH9iTE/s/1480974249/br/147312738073-l) from Teva Pharmaceuticals, Ltd., its American subsidiary Teva Pharmaceuticals USA, and its affiliates (Teva) for their role in fueling the opioid crisis. The $523 million settlement is the largest reached with an individual opioid defendant by Attorney General James and raises the total amount secured from opioid manufacturers and distributors to more than $2 billion to combat the opioid crisis. The settlement resolves Attorney General James’ claims against Teva, the final remaining defendant not currently in bankruptcy and concludes the Attorney General’s litigation against opioid manufacturers and distributors. “Teva knowingly and intentionally misled New Yorkers and the American people about the deadly dangers of opioids, and last year, a jury found them responsible for the devastation and destruction they have caused,” said **Attorney General James**. “You cannot put a price on lives lost, addiction suffered, and families torn apart, but with the more than $2 billion we have now delivered to New Yorkers, we can continue to rebuild and recover. I made a promise to put an end to the havoc wreaked by opioid manufacturers in New York and across the nation and to hold them accountable for the consequences. This is a landmark day in our battle against the opioid crisis, and I am proud to be able to deliver critical funding and resources to the communities Teva and other companies ravaged with their rampant misconduct.” “We are holding Teva Pharmaceuticals accountable for its role in the opioid crisis and the irreparable harm it has done to New Yorkers, their families, and their communities,” said **Governor Kathy Hochul**. “This company misrepresented its products for decades, flooding the market with dangerous prescription drugs and endangering countless lives. New York has no tolerance for fraud — particularly on matters as serious as opioids — and I thank Attorney General James and the Department of Financial Services for bringing us to this resolution.” Attorney General James secured $523 million for New York state from two separate settlement agreements with Teva. Teva will pay up to $4.247 billion nationwide to settle opioid claims as part of the Teva Global Settlement. New York’s share of that amount is $210,548,226.20. After achieving a [historic liability verdict following a seven-month jury trial against Teva in 2021](https://lnks.gd/l/eyJhbGciOiJIUzI1NiJ9.eyJidWxsZXRpbl9saW5rX2lkIjoxMDEsInVyaSI6ImJwMjpjbGljayIsImJ1bGxldGluX2lkIjoiMjAyMjExMDMuNjYwOTk5ODEiLCJ1cmwiOiJodHRwczovL2FnLm55Lmdvdi9wcmVzcy1yZWxlYXNlLzIwMjEvYXR0b3JuZXktZ2VuZXJhbC1qYW1lcy12aWN0b3Jpb3VzLW5ldy15b3Jrcy1vcGlvaWQtdHJpYWwifQ.xUn3uFsB3W0JouYaQdV_kEcJasRPryoQ6MhTFOa3bjo/s/1480974249/br/147312738073-l), today’s Teva New York Agreement resolves the remedies phase for a total of $313,343,793.95. Combined, New York will receive $523,892,020.15 from Teva. The settlement would additionally resolve lawsuits against Teva by Nassau and Suffolk counties if the county legislatures approve it. In the meantime, Attorney General James plans to make a motion removing Teva from her opioid litigation, concluding New York’s opioid trial. The funds secured by Attorney General James will be paid out over a period of 18 years. The agreement also commits Teva to critical injunctive relief that includes: - A ban on high-dose opioids (greater than 40mg) and prescription savings programs; - Prohibitions on marketing opioids and funding third parties that promote opioids; - Restrictions on political lobbying; - Monitoring and reporting of off-label use of transmucosal immediate release fentanyl (TIRF) products; and - Disclosure of Teva opioid product clinical data. In addition, Attorney General James secured important injunctive relief from Teva’s distributor Anda, Inc. This includes: - Ensuring the independence of Anda sales personnel who sell controlled substances from incentive-based compensation and retaliation; - Mandatory training of new Controlled Substance Monitoring Program (CSMP) employees on CSMP and injunctive relief obligations. Employees will also be required to have annual training and testing of CSMP knowledge; - Periodic review of systems and procedures that evaluate customer data for diversion of controlled substances; and - Unannounced customer site visits verifying compliance with anti-diversion obligations. New York is a leading member of the national negotiations with Teva. Teva’s payments to New York from the Global Settlement will be paid over 13 years. While the implementation of the Global Settlement is contingent on sufficient state support, the New York agreement and Teva’s obligations to New York under the Global Settlement will remain in effect, even if the Global Settlement is not implemented. Today’s settlement also resolves administrative charges brought by the New York Department of Financial Services (DFS) against Teva for decades-long insurance fraud. In August 2020, DFS charged Teva with making fraudulent misrepresentations about the safety and efficacy of its opioid drugs, thereby causing significant numbers of unnecessary prescriptions to be written in New York, a large portion of which were then paid by commercial health insurers under DFS’s jurisdiction. DFS alleged that each such fraudulent prescription violated New York Insurance Law § 403 and New York Financial Services Law § 408. While these administrative charges were pending, Teva and other opioid manufacturers filed suit against DFS in New York Supreme Court, challenging DFS’s jurisdiction to conduct its investigation and bring these charges. That suit was rejected by the court in June of this year. In 2019, Attorney General James [filed the nation’s most extensive lawsuit against opioid distributors and manufacturers, including Teva, for their role in the opioid epidemic](https://lnks.gd/l/eyJhbGciOiJIUzI1NiJ9.eyJidWxsZXRpbl9saW5rX2lkIjoxMDIsInVyaSI6ImJwMjpjbGljayIsImJ1bGxldGluX2lkIjoiMjAyMjExMDMuNjYwOTk5ODEiLCJ1cmwiOiJodHRwczovL2FnLm55Lmdvdi9wcmVzcy1yZWxlYXNlLzIwMTkvYXR0b3JuZXktZ2VuZXJhbC1qYW1lcy1maWxlcy1uYXRpb25zLW1vc3QtY29tcHJlaGVuc2l2ZS1zdWl0LWFnYWluc3Qtb3Bpb2lkIn0.MVhDp59eeMNzgrCx_7oq58HsRvqC8W2djPsTLbwrSps/s/1480974249/br/147312738073-l). In addition to Teva and its affiliates, the manufacturers named in the complaint included Purdue Pharma and its affiliates, as well as members of the Sackler Family (owners of Purdue) and trusts they control; Janssen Pharmaceuticals and its affiliates (including its parent company Johnson & Johnson); Mallinckrodt LLC and its affiliates; and Endo Health Solutions and its affiliates. The distributors named in the complaint were McKesson Corporation, Cardinal Health Inc., Amerisource Bergen Drug Corporation, and Rochester Drug Cooperative Inc. Late last year, [Attorney General James won the trial against Teva Pharmaceuticals USA after a jury found the company and its affiliates liable for violating New Yorkers’ rights](https://lnks.gd/l/eyJhbGciOiJIUzI1NiJ9.eyJidWxsZXRpbl9saW5rX2lkIjoxMDMsInVyaSI6ImJwMjpjbGljayIsImJ1bGxldGluX2lkIjoiMjAyMjExMDMuNjYwOTk5ODEiLCJ1cmwiOiJodHRwczovL2FnLm55Lmdvdi9wcmVzcy1yZWxlYXNlLzIwMjEvYXR0b3JuZXktZ2VuZXJhbC1qYW1lcy12aWN0b3Jpb3VzLW5ldy15b3Jrcy1vcGlvaWQtdHJpYWwifQ.9wZcHCLeowq3_gyvamfF-VZ6UEk7vAfwYJdbJL08klw/s/1480974249/br/147312738073-l). **Topics:** Drug Diversion, Judicial/courts --- ### [State probing NYC pediatrician for alleged vaccine record fraud — again](https://insurancefraud.org/news_archives/state-probing-nyc-pediatrician-for-alleged-vaccine-record-fraud-again/) **Published:** September 19, 2026 **Author:** Diane Beauchamp **Content:** An Upper West Side pediatrician disciplined in 2007 in an unprecedented case of faking vaccine records has been hit with another state probe for allegedly doing it again, The Post has learned. A parent said he reported Dr. Mark Nesselson to the state Office for Professional Medical Conduct after seeing a falsified vaccination for his child allegedly prepared by the doctor. The father said his daughter had not been seen by the pediatrician on the day recorded for one of the vaccines in 2021, which was on an official form provided by Nesselson. The doctor also gave the family a form for insurance reimbursement that indicated an office visit had taken place that day for the shot when it had not, the dad said. The purported phony record included the MMR, polio vaccine and other standard shots for toddlers. It was allegedly created by Nesselson for the child’s mother, presumably to be used for school admissions, according to a copy of the parent’s complaint to the state. Proof of vaccination is mandated for day care or attending school in New York. The father said his family doled out about $4,300 to Nesselson over two and a half years, although some of that did cover legitimate office visits with the pediatrician. The OPMC acknowledged the parent’s complaint in March 2022, according to a copy of a letter seen by The Post. The dad said he was later interviewed by investigators. “It’s important that doctors act like doctors,” the furious dad said. In 2007, a state disciplinary board placed Nesselson on probation for three years after he admitted to faking vaccination forms. He was fined $10,000 and allowed to treat patients under a monitor. The state investigated him again in 2011, looking at whether he was complying with the terms of the previous order, records show. At that time, he signed an agreement saying he would adhere to the probation for 36 months, records show. Nesselson did not return a request for comment. The state Department of Health said it could not comment on investigations. DOH “takes instances of potential medical misconduct seriously and acts appropriately to protect the health and safety of patients,” a spokesman said. **Topics:** Healthcare Fraud --- ### [EXCLUSIVE: 'I always knew he was a liar': Ex-girlfriend of Manhattan doctor embroiled in $100M fraud scheme - who mysteriously vanished in a midnight boating accident - reveals he 'used to steal thousands from his own grandmother'](https://insurancefraud.org/news_archives/exclusive-i-always-knew-he-was-a-liar-ex-girlfriend-of-manhattan-doctor-embroiled-in-100m-fraud-scheme-who-mysteriously-vanished-in-a-midnight-boating-accident-reveals-he-used-to-steal-th/) **Published:** September 19, 2026 **Author:** Diane Beauchamp **Content:** A Manhattan doctor who vanished in a mysterious midnight boating accident has been branded a ‘liar’ who set up fraudulent finance scheme from the time he was in university by an ex-girlfriend. Marvin Moy, 51, is one of several doctors arrested in January for his suspected involvement in the $100m health insurance fraud, in which they pressured car accident victims to seek medical treatment at their facilities. The father-of-one was reported missing in the early hours of October 13 after heading out with a friend for a fishing trip on his boat the Sure Shot – a week before he was due in court. Previously friends have said they were shocked by his apparent death, and hope that he is ‘shipwrecked on a small rock’ after he vanished without a trace from the boat. But a former girlfriend told DailyMail.com that she was ‘not surprised at all’ to hear about the allegations Moy faced – claiming that he had previously stolen thousands of dollars from his grandmother. Moy, who attended NYU, pretended to his family that he was attending classes in order to get into medical school but was actually out boating. The avid fisherman requested a refund from the exclusive school within days of his grandparents paying his tuition and used the funds to purchase items from his boat. Moy, a physician and rehabilitation doctor who practiced out of Hempstead, New York, was on the boat with a passenger who was recovered by the Coast Guard. Rescuers reported coming across an oil slick and debris at the scene of the accident roughly 25 miles off the coast of Fire Island. Moy, meanwhile, was nowhere to be found, with searches taking place for more than 30 hours and covering 4,830 nautical miles to try to find the missing man. The former partner, who wished to remain anonymous, told DailyMail.com: ‘When I found out that he was working as a doctor who took payments, I thought there would be something in it for him. ‘I joked to him that I thought he wanted to be a cancer doctor because of what happened to his mother, rather than stealing money from patients, but I always knew he was a liar, so I’m not surprised. ‘He always liked boats, when we were together, he had a tiny motorboat and worked at a boating retail store. ‘He used to steal items, usually a Garmin GPS device, and give it to friends to return it to other stores to get store credit or a refund and then he would spend the money himself on boating equipment. ‘I was aware of it, and he told me that he thought it was funny. I just didn’t know that people really did things like that. ‘There was a summer of college that we lived together, his grandparents owned the building that the family lived in, and they paid for everything he wanted. ‘They paid thousands for him to go to classes to help him get into medical school, but he requested a refund after he enrolled and dropped out. ‘He only got part of the money back, but he would pretend to go to school every day, so his family didn’t find out. ‘I know that he used the money for boating and fishing things. At the time he also owed me money, he would ask me to pay on credit and say that he would pay me back. ‘But he would only give it back when i threatened to tell his grandmother, who spoke little English, that he was stealing from her.’ The couple broke up shortly after graduating, but kept in contact over the years, with Moy telling his ex that he was ‘unhappy’ in his marriage – adding that his family had ‘found’ him someone. Moy is also accused of lying to other women through college, telling them that he was a medical student before he even enrolled in his course. His former partner added: ‘He lied to this other girl that he was already in medical school. He thought it was funny and would put a backpack on and say he was going to class. ‘Marvin has been doing these things for years, so I’m not surprised by any of these accusations. ‘His family were very wealthy, they paid for everything, and his grandparents were very well connected with ambassadors. ‘He is very shady, has always been obsessed with boating, but it is very strange to go out at midnight on a fishing trip. ‘The fact that his family have access to money, and he may well have had access to people who could have helped him escape from the boat. ‘It is something out of a TV show, but you don’t know exactly who he knows internationally – he could well have afforded to have someone on a boat waiting for him. ‘He has always been very smart, working different angles, and had no problem lying to people so I was not shocked to hear about his court case or him vanishing. ‘There is no way of knowing, but he could easily have had the cash hidden to access the things you would need to vanish.’ Moy was one of several doctors arrested in January for his suspected involvement in two fraudulent schemes operated by gangsters Alexander ‘Little Alex’ Gulkarov and Bradley Pierre. The criminal enterprises connected car accident victims with doctors such as Moy who would perform unneeded medical procedures. This would then allow the gangs to overbill insurance companies and make off with $100million in profits over 13 years. Moy’s role in the scam saw him ‘conduct unnecessary and painful electrodiagnostic testing’ on a slew of car accident patients who did not need to undergo the procedure, the indictment alleged. The doctor was supposed to attend a court hearing on October 19 – less than a week after he disappeared without trace on the open water. At the hearing, Moy’s attorney told the judge that a legal representative from the Coast Guard said the doctor cannot be considered dead until the investigation into his disappearance ends. They said: ‘The representative indicated that he would keep us apprised of any developments and that, ultimately, a report would be issued and that we would be provided such a report.’ Moy, who divorced from his wife two years ago, had battled pancreatic cancer and was diabetic according to friends. A Coast Guard spokesman said: ‘The incident was reported just after midnight on the morning of October 13 of an alleged collision involving Mr. Moy and one other person with a large vessel. ‘The other person was recovered while Marvin remained missing. We conducted boat and helicopter searches for over 30 hours covering 4,830 nautical miles, finding only the Emergency Position Indicating Radio Beacon that he was allegedly holding when he was last seen. ‘The search was then suspended on October 14 pending any further info and Coast Guard Sector Long Island Sound is currently conducting an investigation into the incident. ‘The incident took place roughly 25 nautical miles South of Fire Island, New York. Although the active search has been suspended, Coast Guard units will continue to monitor the area for significant sightings and additional information.’ Moy was charged with healthcare fraud conspiracy and money laundering conspiracy, and was facing a maximum potential prison sentence of 30 years for his role in Pierre’s scheme. In January, US Attorney Damian Williams described the operation as ‘one of the largest insurance frauds in history’ and outlined the methods used by the conspirators to make their fortune. He said: ‘The defendants charged are alleged to have collectively perpetrated one of the largest no-fault insurance frauds in history. ‘In carrying out their massive scheme, among other methods, they allegedly bribed 911 operators, hospital employees, and others for confidential motor vehicle accident victim information. ‘With this information, they then endangered victims by subjecting them to unnecessary and often painful medical procedures, in order to fraudulently overbill insurance companies.’ **Topics:** Auto - padding/false claim, Healthcare Fraud **Categories:** Arrest --- ### [Wales' 22 most wanted in connection with crimes ranged from arson to fraud](https://insurancefraud.org/news_archives/wales-22-most-wanted-in-connection-with-crimes-ranged-from-arson-to-fraud/) **Published:** September 19, 2026 **Author:** Diane Beauchamp **Content:** There are numerous active arrest warrants in Wales right now. Police want to track down several people who they believe may have information about crimes ranging from arson to fraud. North Wales Police and South Wales Police regularly share appeals for people who are wanted in relation to alleged crimes via social media, in the hope that someone will come forward with information to help their investigations. Listed below are the people who have been subject to a police appeal in October 2022. If you have seen any of the following people, or know of their whereabouts, you are asked to call police on 101 and quote the relevant reference number beneath the picture. Alternatively you can call Crimestoppers anonymously on 0800 555111. In some instances you may be eligible to claim a reward. However, it is important to note that this is not a comprehensive list as the police do not hare all active appeals online. This list, reported by Wales Online, focuses on the appeals from last month, to ensure that the information is accurate and up to date. Sam Stopforth from Rhyl is wanted for several offences. Simon Evans, 34, has links to the Holywell area is wanted on warrant for a burglary offence. Sightings or information about his whereabouts can be made via the website <https://orlo.uk/tQdj1> or by calling 101. Keri John Phillips, 53, is wanted by police due to an ongoing investigation into the breach of a restraining order. Karlie Tuft, 32, is wanted for failing to appear in court. Police say she also goes by the alias Shanice Przyborowski. Thomas Dilwyn Thomas is wanted in connection with an alleged fraud. He has links to Swansea and Cardiff. Paul Harris, also known as Paul Bohm, 25, from Cinderford, is wanted by Gwent Police in connection with an investigation into drug-trafficking offences. He has links to the Chepstow and Magor areas and also Gloucester. Lewis Holton, 22, from Blackwood, is wanted for breaching his licence conditions. Liam Martin, 35, from Fairwater, Cardiff, is wanted for assault. Altaib Ahmad Altagani, 32, from Newport, has been recalled to prison. Damien Hawkins, 43, from Cardiff, is wanted in connection with an assault. Aaron Preece, 27, from Blackwood is wanted on recall to prison. John Kelly, 29, from Llanrumney, Cardiff, is wanted on recall to prison. Jameal Demournay, 34, from Butetown, Cardiff, is wanted on suspicion of breaching a restraining order. Muhamer Halili, 35, is wanted in connection with a number of alleged offences including assault, stalking, and harassment in the Grangetown area of Cardiff. Leon Wells, 40, from Abertysswg, is wanted for breaching his licence conditions. Craig Larkin, 43, from Wildmill, Bridgend, is wanted for assault. Simon Edwards, 25, from Merthyr Tydfil, is wanted for assault and malicious communications. Leon Jones, 37, who is from Maesteg and has links to Aberdare, is wanted for assault. Phillip Underhill, 33, from Bridgend, is wanted for breaching his restraining order. Matthew Samuel, 31, from Swansea is wanted for harassment. Osama Bakali: The 26-year-old from Mount Pleasant in Swansea is wanted on suspicion of breaching a court order. Shane Chamley, 54, from Swansea, is wanted in connection with an alleged assault. **Topics:** Public Awareness --- ### [TDCI Joins Movement to Shine a Spotlight on Fraud](https://insurancefraud.org/news_archives/tdci-joins-movement-to-shine-a-spotlight-on-fraud/) **Published:** September 19, 2026 **Author:** Diane Beauchamp **Content:** Fraud costs organizations worldwide an estimated 5 percent of their annual revenues, according to a study conducted by the Association of Certified Fraud Examiners (ACFE). [*Occupational Fraud 2022: A Report to the Nations*](https://legacy.acfe.com/report-to-the-nations/2022/) analyzed 2,110 occupational fraud cases that caused a total loss of more than $3.6 billion. The seriousness of the global fraud problem is why the **Securities Division** of the **Tennessee Department of Commerce & Insurance (TDCI)** announced that it will be participating in International Fraud Awareness Week, Nov. 13-19, 2022, as an official supporter to promote anti-fraud awareness and education. The movement, known commonly as Fraud Week, champions the need to proactively fight fraud and help safeguard business and investments from the growing fraud problem. The Securities Division joins hundreds of organizations who have partnered with the ACFE, the world’s largest anti-fraud organization and premier provider of anti-fraud training and education, for the yearly Fraud Week campaign. During Fraud Week, official supporters will engage in various activities, including hosting fraud awareness training for employees and/or the community; conducting employee surveys to assess levels of fraud awareness within their organization; posting articles on company websites and in newsletters; and teaming up with local media to highlight the problem of fraud. “The Securities Division is dedicated to equipping Tennesseans with the knowledge and resources needed to not only spot fraudulent schemes but avoid them altogether,” said TDCI Assistant Commissioner Elizabeth Bowling. “Our teams are serious about helping Tennesseans protect their personal information and hard-earned financial assets.” ACFE president and CEO Bruce Dorris, J.D., CFE, CPA, said that the support of organizations around the world helps make Fraud Week an effective tool in raising anti-fraud awareness. “Fraud is an issue that unfortunately affects people from all walks of life around the world and it takes many forms,” said Dorris. “Whether it’s a trusted employee stealing from a small business, or organized rings of fraudsters targeting seniors in our community, most people know someone who’s been victimized by fraud. That’s why it’s so important for organizations to join in this fight together in order to raise awareness during this week. It is a serious problem that requires a proactive approach toward preventing it and educating people is the first step.” For more information about increasing awareness and reducing the risk of fraud during International Fraud Awareness Week, visit [FraudWeek.com](http://www.fraudweek.com/). **Topics:** Public Awareness --- ### [National Disability Insurance Agency warned its old tactics for fighting fraud insufficient amid scheme's massive growth](https://insurancefraud.org/news_archives/national-disability-insurance-agency-warned-its-old-tactics-for-fighting-fraud-insufficient-amid-schemes-massive-growth/) **Published:** September 19, 2026 **Author:** Diane Beauchamp **Content:** A review led by Australia’s former top cop told the National Disability Insurance Agency its methods for fighting fraud were “no longer sufficient” as the scheme’s massive growth left it increasingly exposed to organised crime, dodgy providers and unscrupulous families. ACM, publisher of this newspaper, can reveal the agency last year ordered an independent review of its intelligence and investigations functions after senior executives questioned if it was able to manage the “growing fraud risk” surrounding the scheme. Fraud has emerged as an issue in the NDIS, the nation’s most senior intelligence official [estimating up to 20 per cent of funds](https://www.smh.com.au/national/the-scumbag-scale-how-organised-crime-has-infiltrated-the-ndis-20220811-p5b95s.html) were being misused. The scheme is forecast to cost almost $34 billion this financial year and grow to $50.3 billion in 2025-26, making it one of the biggest pressures on the federal budget. NDIS Minister Bill Shorten believes cracking down on fraud is among the keys to slowing the scheme’s surging costs, with last month’s budget committing $126.3 million toward a new cross-agency taskforce to address fraud and serious non-compliance. Mr Shorten told *The Canberra Times* the Coalition had been “asleep at the wheel” on scheme fraud, but declined to put a figure on the percentage of funds he believed was being rorted. The agency last year paid Deloitte almost $300,000 to conduct the review, which was led by former AFP commissioner and firm partner Andrew Colvin. The report was handed to the agency on March 10, in the dying days of the Morrison government. *The Canberra Times* is revealing details of the review as it launches “We need to talk about the NDIS”, a new series examining the future of the nation’s disability safety net. This masthead has obtained a heavily redacted copy of the report under freedom of information laws. The review acknowledged the agency had made significant investments to help detect and respond to fraud since its inception in 2013, highlighting the work of a dedicated fraud taskforce and a new compliance response team. However, it found methods used in the past were no longer “sufficient” as the scheme rapidly grew and the “intensity of opportunistic fraud and serious organised criminal activity” became more pervasive”. “With the estimated growth of participant costs forecasted to increase to $59.3 billion in 2029-30, the NDIS is increasingly exposed to the growing risk of highly sophisticated, complex serious and organised crime, criminal and opportunistic fraud perpetrated by providers, plan managers, partners in the community, participants, and unscrupulous family members,” it said. **Topics:** Disability, Public Awareness, Regulatory actions --- ### [BREAKING: Medibank Hacker releases more private medical details – less than 3 days after AFP announce “we know who you are”](https://insurancefraud.org/news_archives/breaking-medibank-hacker-releases-more-private-medical-details-less-than-3-days-after-afp-announce-we-know-who-you-are/) **Published:** September 19, 2026 **Author:** Diane Beauchamp **Content:** The person purporting to be the Medibank hacker went silent on Friday and over the weekend after the AFP publicly announced that they believed them to be in Russia and that “we know who you are” – this morning, they have uploaded the details of 500 more Australians onto the Dark Web. Over the weekend it seemed the AFP had had some luck in scaring the likely Medibank hacker and pushing them deeper into the underworld. This morning though, EFTM can reveal a new message from the hacker has been posted onto the Dark Web: This claim seems to suggest the hackers still feel there is some chance of a “meaningful” resolution, though it seems highly unlikely after both the AFP announcement, and Minister Clare O’Neill’s statement that a new taskforce had been setup to “hack the hackers” Today’s data leak contains the names, personal contact details and private medical information of 500 more Australians. EFTM chooses not to outline the name of the file, or the conditions being suggested, but again the Hacker has chosen a “theme” to the diagnosis we can only assume to spread fear in the community. Unfortunately for the hackers, there is no fear. Australian’s are upset that this happened, angry at the level of cyber security protections in place, but confident that none of this personal information will ever be published. The only Risk to Australians are scams and scammers who use the information to exploit people individually, and we urge anyone who receives a scam related to their private health information to follow Medibank’s advice and report it: *Be alert for any phishing scams via phone, post or email. We will not contact you about passwords or sensitive information, so any suspicious emails or SMS should be reported to <scaminvestigations@medibank.com.au>. We’ve also prepared some advice and resources on[ staying safe online](https://www.medibank.com.au/health-insurance/info/cyber-security/staying-safe-online/). If someone contacts you online, by phone or by SMS threatening to release your data unless payment is made, please report this through [ReportCyber](https://www.cyber.gov.au/acsc/report).* Every bit of information we are able to share with authorities will help track them down. **UPDATE: Medibank has released a statement from it’s CEO** *“We will continue to support all people who have been impacted by this crime through our Cyber Response Support Program. This includes mental health and wellbeing support, identity protection and financial hardship measures,”* Medibank CEO David Koczkar said. *“If customers are concerned, they should reach out for support from our cybercrime hotline, our mental health support line, Beyond Blue, Lifeline or their GP.* *“Anyone who downloads this data from the dark web, which is more complicated than searching for information in a public internet forum and attempts to profit from it is committing a crime.* *“The Australian Federal Police have said law enforcement will take swift action against anyone attempting to benefit, exploit or commit criminal offenses using stolen Medibank customer data. We continue to work closely with the Australian Federal Police who are focused, as part of Operation Guardian, on preventing the criminal misuse of this data.* *“I unreservedly apologise to our customers.* *“Our focus remains resolutely on doing everything we can to make sure our customers are supported during this difficult time.* *“These are real people behind this data and the misuse of their data is deplorable and may discourage them from seeking medical care.* *“We remain committed to fully and transparently communicating with customers and we will continue to contact customers whose data has been released on the dark web,”* he said*.* **Topics:** Public Awareness, Technology --- ### [BBB warns against scammers taking advantage of open enrollment for Medicare, ACA](https://insurancefraud.org/news_archives/bbb-warns-against-scammers-taking-advantage-of-open-enrollment-for-medicare-aca/) **Published:** September 18, 2026 **Author:** Diane Beauchamp **Content:** Enrollment for Medicare or Affordable Care Act (ACA) coverage is back open and the Wisconsin Better Business Bureau (BBB) has noticed an uptick in scammers who see the time as a way to trick people into giving them money and information. The BBB warns that it’s tracking service has already been notified of numerous callers claiming to be Medicare representatives. One victim said that there was an automated voice messaging system that led him to a man who claimed to be working for Medicare. These callers claim they can give better deals on coverage for a better price, the BBB said. The scammers then say you only have to give some of your personal information such as a Medicare ID number. The BBB explains these calls are scams and that sharing information will lead to identity theft. Common signs that a call might be a scam is if someone calls out of the blue. BBB said[Healthcare.gov](https://linkprotect.cudasvc.com/url?a=https%3a%2f%2fu7061146.ct.sendgrid.net%2fls%2fclick%3fupn%3d4tNED-2FM8iDZJQyQ53jATUULHSbDilys4GGsgftjv-2FXVVAe2yYHYAkecfgHQR8-2BwJzLYgmaZy8RiWzokZ02GLFg-3D-3DuzQD_UhPZkopTI9XxQT7tooyXT1bQYZ9Vf-2Fz1V-2FmorG-2FbBqv3Fu4WMu74SL6qvTiTog2aT1NJyueRMX-2FWIWKyvrd6wR1u7kSU-2FgDP8vIUartj5bzbyivwj1WFqj-2Bz3oc53-2FAz-2BsBO28gULUDTOwj5jS3tmRniws56-2FNwmHJdI4XD1-2B9pY13jY-2FmMmOeYnm5nvFWRCpLL7Y2QC5T3sn54xFWKZc0eRr5O-2B7LQIEnqHE-2FOHAK1-2BfLWze9WUdaSYO5AXdjU5U2b0Xmk0aPBWFFYV8lgg7E9u5bsigxspTLUJe3Lb4ERljaLjZtromnPzqoznIjlYiUpcLDZy8qvAXMdpmC6Xz9FYtuok9qoP9EpkTHr8APs-3D&c=E,1,EqTzJAWiwa-0YGvVjYfBdKX045b5ZPXp-ze0MTpqmfpn342rM4PV2KzYT7jZsSxg7thWLYTDAk5spbDvfoFGTHby2q9y6KOMvYgEdpwgH9253HUUv5GZwg,,&typo=1) and [Medicare](https://linkprotect.cudasvc.com/url?a=https%3a%2f%2fu7061146.ct.sendgrid.net%2fls%2fclick%3fupn%3d4tNED-2FM8iDZJQyQ53jATUULHSbDilys4GGsgftjv-2FXVVAe2yYHYAkecfgHQR8-2BwJ4sciT3oJtQeOtK0-2FTEONNw-3D-3Djx4c_UhPZkopTI9XxQT7tooyXT1bQYZ9Vf-2Fz1V-2FmorG-2FbBqv3Fu4WMu74SL6qvTiTog2aT1NJyueRMX-2FWIWKyvrd6wR1u7kSU-2FgDP8vIUartj5bzbyivwj1WFqj-2Bz3oc53-2FAz-2BsBO28gULUDTOwj5jS3tmRniws56-2FNwmHJdI4XD1-2B9pY13jY-2FmMmOeYnm5nvFWRCpLL7Y2QC5T3sn54xFWKZc5tYfybwRER9sBXsv3O1avmyPvvM-2FQ2YMLGQN97uk16B6vuoKRvQ3wZEeSRiodslI2KvVvvbRajD3TJTdEYU1u0sk6Nu-2F2mW-2BsFc3SraIyGVxo8bq7Gqu3xR9IBFyLWYvgGRlL6L9OXKc8Kzs0XHJmY-3D&c=E,1,sC4O7zp5oE1cx-nM_8S2E_fLI6yO01r-N4AwixPUWBfNPDwbn0I77hTHg9L-ZQUsbnQGazK6nqpdvXVdU9BYNtxuc8omLI6pzgGiHAWduPWwSIzdpg,,&typo=1) can give legitimate help to those who need it, but they will never charge for their assistance. Another sign is someone trying to offer free gifts or other special deals alongside their assistance. Brokers are not allowed to ask about an applicants physical health, and the BBB said to never trust expensive sign up gifts for personal information. Those who are unsure if their call is legitimate can contact 1-800-MEDICARE to report it. Similarly, if scammers call offering ACA coverage, go to go to [HealthCare.gov](https://linkprotect.cudasvc.com/url?a=https%3a%2f%2fu7061146.ct.sendgrid.net%2fls%2fclick%3fupn%3d4tNED-2FM8iDZJQyQ53jATUULHSbDilys4GGsgftjv-2FXVVAe2yYHYAkecfgHQR8-2BwJvxaABOIVq6WhOFzLuDERtw-3D-3D_WQO_UhPZkopTI9XxQT7tooyXT1bQYZ9Vf-2Fz1V-2FmorG-2FbBqv3Fu4WMu74SL6qvTiTog2aT1NJyueRMX-2FWIWKyvrd6wR1u7kSU-2FgDP8vIUartj5bzbyivwj1WFqj-2Bz3oc53-2FAz-2BsBO28gULUDTOwj5jS3tmRniws56-2FNwmHJdI4XD1-2B9pY13jY-2FmMmOeYnm5nvFWRCpLL7Y2QC5T3sn54xFWKZcyaCaq5VxPFumaAlz6A9Yw0HN0Fdsg4izACjF-2FmB2zo2pLufPgmtcx7NxA-2BagB74h1U5wHUi0G3HYPTxzIAeUWya7S2QM-2BIJrJobdvBwh1WswlkmETVXGNh-2Bks-2BbS3uv0PIZT1n4-2F8K5SccFyWYnKgI-3D&c=E,1,693LqFU_08_7vEv3Cm6d4pXMDPxyVjZ-3wEhiSe5iNfHAjJ1gD5W3rL_lA3sep1f-tqA0sBIoECmQNbYM0SGAY0yIcohOnWUZRioyDK0ApjhBJV3pKVdt3ne&typo=1) or call the Health Insurance Marketplace call center at 800-318-2596. **Topics:** Public Awareness --- ### [Aspiring Rapper Hired Hit On His Mom To Collect On Insurance Policy In Act Of 'Pure Greed'](https://insurancefraud.org/news_archives/aspiring-rapper-hired-hit-on-his-mom-to-collect-on-insurance-policy-in-act-of-pure-greed/) **Published:** September 18, 2026 **Author:** Diane Beauchamp **Content:** Who killed a hair salon owner in her own home? Was it her boyfriend who was sleeping at the residence, or someone else? In the early morning hours of September 2, 2012, Chicago homicide detectives responded to a 911 call. Yolanda Holmes, 45, a single mom who owned a hair salon, was found shot and stabbed to death in her apartment. She was killed as she slept alongside her on-off boyfriend, Curtis Wyatt. Detectives found a broken handgun on the bedroom floor and a paring knife missing from a kitchen block. Blood spatter on walls and signs of a struggle indicated “somebody was fighting for their life,” John Korolis, a Chicago PD homicide detective, told “Sleeping with Death,” airing Sundays at 7/6c on Oxygen. The fact that Yolanda had been shot and stabbed indicated “overkill,” said Michele Wood, a fellow Chicago PD homicide detective, adding that the killer “was set on making sure she didn’t survive.” Just before 6 a.m. Yolanda’s son, Qaw’mane Wilson, an aspiring rapper, came to the building to see his mother. He broke down in tears when he was told that she’d been killed. Wyatt, who called 911, was found to be bleeding from lacerations to his head and face and was treated by paramedics. While speaking with police, he told them he had recently reconnected with Yolanda. He said he was initially awakened by a phone ringing and Yolanda speaking to someone. Then, he heard the gunshots. He tried tackling the man, which was how he got his injuries, but the man escaped. He raised suspicion, though, when he told investigators that he had cleaned up the scene. “Why was Chris left alive?” said Korolis. “Something just didn’t add up.” Evidence technicians scoured the damaged home for items to test for DNA. No prints were found on the gun. “Everything was covered in blood,” said Wood. “So we also had to figure out whose blood it was.” Police canvassed the building but no residents heard the gunshots. Wood also interviewed Qaw’mane, who said he was unaware that his mother had rekindled her relationship with Wayatt. Qaw’mane indicted to the detective that he believed Wyatt was behind the murder, Wood told producers. Yolanda’s sister told investigators that Wyatt had had some violent altercations with Yolanda in the past. Investigators examined the apartment building’s surveillance footage. They saw that at 4:32 a.m., a man approached the main entrance, punched in a code, and entered the building. He wore a hoodie and was carrying clothes on a hanger and detergent bottle. At 4:46 a.m. he exited the building. He was wearing a different hoodie. As he left, he passed by another man who was identified as a resident. Detectives questioned him and found no link to the crime. Detectives turned their focus back to Wyatt, who agreed to take a polygraph test. The results indicated that he was being deceptive but investigators made no arrest at this point, as they had no evidence he was connected to the murder. So, they focused on the surveillance footage and noticed that the man entering the building was wearing headphones. One of the items of evidence in Yolanda’s apartment was a broken headphone cord. Investigators tested the headphone found at the crime scene. The DNA on it was not a match for any samples in the nationwide database. Blood evidence in the apartment showed that Yolanda’s blood was confined to the bedroom, while blood elsewhere belonged to Wyatt. That lessened the odds that the struggle in the home was between Yolanda and Wyatt. Weeks passed, and no new leads turned up. Detectives worked every possible angle, including Yolanda’s husband who was serving a life sentence for a double homicide. Police considered Yolanda’s murder as possible payback, but this line of investigation got no traction. A year went by until phone records provided a possible clue. Investigators realized that Yolanda had two phones. “We saw that on one of the phone lines there was a lot of activity before the murder, during the murder, and after the murder,” said Korolis. Then the activity stopped. Detectives tried to contact Qaw’mane for information on who she might have been calling, but they couldn’t reach him. They soon realized that the phone number that Qaw’mane provided to detectives was actually the second phone number registered to Yolanda. Thirteen months into the murder investigation detectives now knew that Qaw’mane was talking on Yolanda’s second cell phone at the same time she was killed. They determined that the person he was talking with was Eugene Spencer. Detectives issued an investigative alert for both him and for Qaw’mane. On December 23, 2013, detectives tracked down Qaw’mane, who said that he’d been trying to get in touch with them. “That was a little odd,” said Korolis. “Qaw’mane related that the phone number that we were discussing was actually his phone number under his mom’s account.” Qaw’mane admitted that he knew Spencer from the neighborhood and identified the man entering Yolanda’s building the night of the murder as Spencer. Qaw’mane then told detectives that when Spencer went to his mom’s building it was just supposed to be a robbery. Spencer was rounded up and brought in for questioning. Asked if he’d ever been in Yolanda’s apartment, Spencer said, “I went inside and some guy tried to kill me,” according to Wood. Detectives realized that no one knew Wyatt would be there. Spencer admitted that he shot and stabbed Yolanda, and revealed Qaw’mane had given him the access code to the entrance. “Qaw’mane had spoken to his mother about 40 minutes earlier and told her that he was coming over,” said Korolis. “So Yolanda was expecting her son to be at the front door. The real mastermind was Qaw’mane Wilson.” Investigators determined that in addition to supplying Spencer with the gun, he had given him clothes and detergent to make it look like he lived in the building. They also learned that Qaw’mane’s former girlfriend, Loriana Johnson, drove Spencer to Yolanda’s apartment building. When the murder was happening, Qaw’mane was on the phone with Spencer, according to Wood. “Qaw’mane tells him, ‘Make sure that bitch is dead,” she told producers. That explains why he stabbed Yolanda after shooting her in the head. He had offered Spencer $4,200 to kill his mother. Afterward, he gave him $70, according to Korolis. “Qaw’mane’s motive for having his mother murdered was pure greed,” said investigative journalist Steph Watts. Out of work and with a stalled career as a rapper, he wanted her life insurance policy, her business, and her car. After her death, Qaw’mane withdrew nearly $70,000 from his murdered mother’s accounts and spent the money on flashy clothes and cars, nbcchicago.com reported. On December 24, 2013, Qaw’mane Wilson was arrested for his mother’s murder. In January 2020, he was convicted of first degree murder and sentenced to 99 years in prison. Eugene Spencer was convicted of first degree murder and sentenced to 100 years in prison, the Chicago-Sun Times reported. Loriana Johnson pleaded guilty to robbery and served seven years in prison before being released on parole. **Topics:** Life Insurance **Categories:** Conviction --- ### [How a Detroit firefighter’s death might have sent an innocent man to prison](https://insurancefraud.org/news_archives/how-a-detroit-firefighters-death-might-have-sent-an-innocent-man-to-prison/) **Published:** September 18, 2026 **Author:** Diane Beauchamp **Content:** In the redemptive setting of Ypsilanti’s Second Baptist Church a well-dressed woman with a pleasant smile greets a man just released from prison. On this sunny September afternoon Ronnell Johnson is free after 14 years, following what the Washtenaw County prosecutor determined to be a wrongful robbery conviction. The woman co-hosting Johnson’s reception through the Ambassadors Group, a nonprofit support initiative, is Maxine Willis, who hopes the next homecoming will answer a prayer. Her son, Mario Willis, is serving year 12 of a 30-year minimum sentence for the 2008 blaze that killed firefighter Walter Harris. “The reason that you see all this here,” she later says, near basement shelves of court files, “is that it’s heart-wrenching to have a child in prison. But I didn’t just want to be a mother who said, ‘My child didn’t do this.’ I wanted to show it through evidence and facts.” Convicted in what prosecutors framed as an arson-for-insurance money scheme at 7418 East Kirby St. in Detroit, Mario Willis and his advocates await a judge’s decision, following a motion that could win his freedom. The filing includes disturbing claims of coercion and suppressed evidence while Willis was painted as villain in a crime widely regarded as one of Detroit’s worst of the decade. “I’ve been looking forward to having the opportunity to tell my story and have this false narrative changed,” he says from Saginaw Correctional Facility during a telephone call with Metro Times. Among numerous, sometimes complex, issues that Willis says snowballed into his imprisonment are: False testimony: Darian Ivan Dove, the central figure in Willis’s conviction, alleges detectives Scott Shea and Lance Sullivan refused to accept that the fire which killed Harris was accidental; Dove, who is serving a 17-year minimum sentence, ultimately testified that Willis paid him $20 to set the fire, then Dove tried to recant the story. Misleading statements: Rance Dixon, then a Detroit Fire Department investigator, allegedly misidentified the location of gasoline detected at 7418 East Kirby, testifying that its placement proved the blaze was deliberately set. Insurance coverage: Evidence jurors were presented, but Willis’s current attorney believes they misunderstood, shows that 7418 East Kirby wasn’t even insured in a way that would let Willis profit from its destruction. Withheld evidence: Jurors never saw video-recorded footage in which Willis and his future wife explain their whereabouts on the night of the fire. “That ‘innocent until proven guilty?’ That’s not true,” says Willis, 41. “You have to prove your innocence. The law doesn’t say it, but in actuality you do.” His insider’s understanding of the criminal justice system is nothing he or his family would have predicted. Coming from a stable, two-parent, Christian home, perhaps no one thought a future including prison less imaginable than Mario Lamont Willis. While a student at St. Martin DePorres High School he played trumpet in the band and competed on the squad of DePorres’s football team champions. A 1997 Detroit News profile of the teenager in the special “On Detroit” section, with the headline “Doin’ the Right Thing,” describes how Willis performed for younger children as part of his mother’s drug awareness group. Then six-foot-three and 256 pounds, Willis was known to don a costume, transforming into Zack the Lion, to help Maxine Willis deliver positive messages to her audience. Graduating from DePorres in 1999, he won a football scholarship to play lineman at Eastern Michigan University, but a car accident that left Willis susceptible to concussions forced a change of plans. Still, being what he calls “a glass-half-full kinda guy,” he bounced back. “My father had always owned property. Both of my parents are entrepreneurs, so I enrolled back at Davenport University as a marketing major,” says Willis. Equipped with Davenport’s instruction and support from his family, he began learning the real estate game. One mentor and asset was his godfather, the late Detroit business trailblazer and former NFL pro, Brady Keys. Known for operating successful Burger King and Kentucky Fried Chicken franchises in the 1980s and 1990s, Keys had also inspired and backed “K.E.Y.S. Kids” (an acronym for “Kids Enjoy YourSelves”), the drug prevention program with a TV show Maxine Willis produced for WHPR-TV in Highland Park. Before long, Keys had groomed his ambitious, young godson to take over a struggling shop in Detroit. “He allowed me to manage it for a year and he was so impressed that I was able to bring the numbers back, he allowed me the opportunity to acquire the business,” Willis proudly recalls. Located on West McNichols, Ramsey & Ramsey beauty shop became Mario’s Hair Salon, named for a large, bald man who didn’t need its services. Good Samaritans Progress continued as Willis bought his first residential property, a three-unit apartment building. He focused on Detroit real estate, he says, having been taught by his parents, “I need to live in my city, I need to own in my city.” He eventually bought about a half-dozen more homes, including 7418 East Kirby. Along with a sense of personal fulfillment, Willis’s contributions toward renewing the community’s landscape earned him a 2005 resolution from Detroit City Council. Meanwhile, a struggling outsider to the family had come to the attention of Marvin Willis, Mario’s dad. Marvin, a former entertainer with the Detroit Emeralds and co-writer of the 1970s R&B classic “Float On,” oversaw K.E.Y.S. Kids Plaza, the studio and building that also housed Mario’s Hair Salon. Marvin had hired Darian Dove, who was then in his late-30s, to do odd jobs and repairs, but when work became scarce he referred Dove to Mario. “This is kind of what we do. We help people out,” Mario Willis says. Dove, who declined a request to be interviewed by Metro Times, had substance abuse issues and a criminal record that included felonies, adds Willis. But his work was solid, so Willis took him on, even giving him a place to stay. Preferring the nickname “Gino,” Dove was embraced by the Willis clan. As he proved himself a reliable handyman, Dove made an agreement with Mario to trade the equivalent of monthly rent for part of his salary, so Dove and a girlfriend moved into one of Willis’s houses. Willis’s wife, then his high school sweetheart, has fond early memories of Dove and Valorie Ann Williams, to whom she occasionally gave clothing. “Honestly, I liked them. They had grown to be like family in a lot of ways,” says Megan Willis. “I’m very protective of Mario, so I try and keep an eye on people who are around him.” She says Dove occasionally grumbled that other maintenance workers who’d been hired were affecting his pay, but she saw no signs of disloyalty. Now and then came word of tools disappearing from properties where “Gino” had worked, yet his relationships with the Willis family remained intact. In 2007 there was a small fire at 7418 East Kirby, but the cause was undetermined after investigators identified nothing suspicious. By then Willis had sold the house to Megan, so he hired Dove to help repair the damage. They discussed the possibility of Dove becoming a tenant there when it was livable again. It would take a tragedy, a homicide investigation, and three years for Willis to learn that Dove began accessing the house without anyone’s permission. A tale of two dates The facts of what happened at 7418 East Kirby Saturday, Nov. 15, 2008 would be debated for years, but one thing Willis and Dove both claim their night involved was enjoying a woman’s company. Willis and Megan, who married in 2009, made regular practice of scheduling quality time together, so it was dinner and a movie for them. Dove’s encounter was much more complicated, mainly because his date for the night wasn’t the lady with whom he lived. He’d run into a woman who has been identified only as Felisha and went with her to East Kirby hours before Walter Harris would die at the scene. What Dove apparently imagined to be a harmless bit of trespassing at Megan’s property ended in a 911 call. He’d later say he caused the blaze while trying to keep Felisha warm when a flammable concoction spilled from its container. On Sunday morning the fire department called Megan, telling her about the incident during which the roof of the building reportedly collapsed with Harris inside. Today she still maintains she and Willis had slept together through the night. Although she owned the East Kirby house, Willis helped address investigators’ questions, given his familiarity with its history of break-ins and the previous year’s fire. “You have the death of a first responder, so I’m giving them everything they think they need,” he recalls. While the community mourned Harris, who was regarded as one of the Detroit Fire Department’s finest and most well-liked, weeks and months passed. Dove attended Willis family gatherings and performed regular work tasks, never mentioning any firsthand knowledge of what occurred at 7418 East Kirby. But by the next year he found himself on the radar of Detroit Police. In a five-page, handwritten account Dove points fingers directly at Detroit Police Detectives Lance Sullivan and Scott Shea, the homicide investigators who interviewed him and Willis on multiple, separate occasions, stating: “…the date was, first time, June 9, 2009, I, Mr. Dove, was arrested … now they want to put words in my mouth … they are telling me that I can spend the rest of my life in prison.” The letter further describes a call placed while Dove was in police custody, alleging that Sullivan urged him “to get Mr. Mario to say something on the phone to get him in jail.” But “that did not work at all, so they got mad and put me back in the cell,” Dove writes. A recording of the conversation Dove describes was never played for the jury during Willis’s eight-day trial in April 2010. “It wasn’t making sense to me,” Willis says, remembering the call. “He went from talking about traffic tickets to talking about this fire.” Seemingly puzzled by Dove’s questions like, “What if somebody saw me that morning?” Willis answers, “I don’t even know what you talking about, dog.’” (The term “dog” is slang for “man.”) Later in the call, Dove says, “I need to know what the hell to say.” “The truth, shit. Hell,” Willis replies. “What you mean, ‘what to say?’ Nothing. You said that like you trying to make something up.” Not much later Willis says he finally learned Dove was connected to the fire. What he still didn’t know is that Dove had been rehearsing what Willis calls an outright lie, one Dove would repeat before a judge, fearing a conviction for Harris’s death would seal his own death in prison, due to habitual offenses. In a conversation with Sullivan, secretly recorded after Dove’s release from jail, Dove’s tone is resentful as he says Willis did nothing for Dove’s girlfriend while he was in custody. “That fits the whole pattern,” Detective Sullivan says. “The whole ‘I’m above you,’ ‘I don’t care about you … I’m a so-called business man. I own all these houses.’” In less than a year, Willis would listen from a defendant’s table at Frank Murphy Hall of Justice as the government depicted him in a similar way. Forces and factors Assistant Wayne County Prosecutor Robert Stevens told jurors Dove was “an ordinary minion who thrives and survives based on what (Willis) provides him for work.” “He’s a nothin’. He’s a handyman,” Stevens declared, adding, “…his boss, a coward who sends this person out to take the hit.” Having accepted a plea deal to reduce his sentence, Dove no longer insisted the fire was a tragic accident; he mounted the witness stand, saying Willis wanted the house burned to collect insurance money. In return for his cooperation Dove was handed a second-degree murder conviction, but Willis’s appellate lawyer Craig Daly says he likely would be serving no prison time, had he maintained his original story of the accident. “That’s a weak manslaughter, negligence case. I think they would have had a hell of a time trying to prosecute him,” says Daly. Dove’s recorded 911 call, during which the mysterious Felisha’s voice is reportedly heard in the background, and Dove’s claim to Sullivan of having tried to smother the fire himself, suggest lack of intent, says Daly, not to mention lack of foresight that Harris would die. “That’s a tough, tough case,” Daly adds. Willis, too, remains puzzled that jurors weren’t more doubtful about a conspiracy after hearing Dove’s 911 call. “If you want something burned to get money, you want the most damage possible,” he says. “You’re not dialing 911 for help.” But there were more issues for Willis to overcome: Lt. Rance Dixon, Detroit Fire Department’s investigator, testified that flames started along the house’s walls, consistent with a deliberate attempt to burn the structure vertically for maximum destruction in minimum time. In fact, samples Dixon took were tested by Michigan State Police forensic experts, showing that only charred floor boards tested positive for gasoline — supporting Dove’s explanation that an accelerant could have spilled when the container was kicked. “I think what happened is that he had a theory,” Daly says of Dixon, “and he changed the facts to fit his theory.” Dixon could not be reached for comment, despite a Metro Times interview request to the Detroit Fire Department. If not somehow unpersuasive, perhaps more confusing to jurors was a discussion of the insurance coverage at 7418 East Kirby. “In this case, the homeowner’s policy had lapsed, so the mortgage company put on it what they call a ‘forced-placed’ insurance policy,” adds Daly. A 2018 letter requested by Willis for his appeal and exoneration efforts states that proceeds from the policy “would have been issued to the mortgage company.” Referring to statements made during trial, Kenneth M. Korotkin, insurance counselor with the Southfield-based Korotkin Insurance Group, adds, “There were numerous references made that Mario Willis had pure financial reasons to obtain proceeds or profit from a fire at E. Kirby on Nov. 15, 2008. Mario Willis, again, would not have been entitled to any of the insurance proceeds.” (Neither Korotkin, nor his insurance agency, had associations with 7418 East Kirby.) Korotkin’s letter also stresses that Willis no longer owned the house since he’d sold it to Megan, who “would also not have received any direct benefit,” because forced-placed coverage solely protects “the mortgage company for the amount owed to them.” “Unless you’re talking about it like we are, in context, calmly, the jury hears about it and it sounds bad, doesn’t it?” Daly admits. “Forced insurance.” He adds, “Megan took a loss on this of tens of thousands of dollars, because they weren’t going to get any insurance money.” Willis says he and Megan learned only when it was reported by TV news that the house they’d still planned to restore was demolished by the city three weeks after the fire. There had been no opportunity to hire an adjuster and the permit to raze the building wasn’t issued until two days after it was leveled, Willis says. Almost a year before his trial, a property he owned on the other side of town was damaged after police kicked in its door, shocking tenants who lived there. They’d come to the wrong address, expecting to arrest Willis, who was licensed to carry the pistol he says was near him at his actual home with Megan in Farmington Hills. “It would have been Breonna Taylor before Breonna Taylor,” he says, comparing the breach to a Louisville, Kentucky, case that drew nationwide attention. Taylor died in 2020 after she was stricken by police, who said they fired shots in response to her boyfriend Kenneth Walker. Walker admitted shooting out of fear for his and Taylor’s lives when he thought the cops were criminal intruders. “I thank God I wasn’t there,” Willis says, “because if I had been home with Megan and they had the right address, they would have killed me.” He voluntarily turned himself in to police after learning of their mistake. A lonesome Dove The rental property incident left Willis shaken, but also suspicious. Shea and Sullivan had come to the house when Willis still lived there, interacting with him peacefully, despite knowledge of his CCW permit. The detectives knocked, saying they had a warrant to take his vehicle as part of their investigation, Willis recalls. When he asked to grab his briefcase from the Ford Excursion, they agreed, but frisked him first to be sure his pistol wasn’t within reach. He later wondered: Had the cops who swarmed the house hoped he’d shoot at them out of fear when they kicked in the rental home’s door? The black Ford Excursion he drove became another point of dispute at Willis’s trial. He recalls an interview when detectives showed him a DVD case, saying they had footage of his SUV from the night of the fire. “No, you don’t,” Willis answered. They had images not only from the same date, but placing his truck near 7418 East Kirby, the cops told him. “No, you don’t,” Willis repeated. In his revised version of the events, Dove told police he and Willis drove to a gas station at Mt. Elliott and Gratiot, parking as they watched 7418 East Kirby burn. Prosecutors called a police expert to testify about images of the Excursion captured at a fueling location. Despite lacking a date or time stamp, what Willis calls “maybe about 30 seconds of fuzzy video” was shown to the jury, suggesting Willis’s vehicle might, indeed, have been where Dove placed it. Even the police witness acknowledged the footage was a re-creation, but Judge Michael Callahan allowed the video, despite defense objections. “This is cheating!” says Bill Proctor, the former WXYZ Channel 7 reporter and a private investigator hired by Willis’s family. After filling key roles in freeing 11 wrongfully convicted men from prison, Proctor says the level of malfeasance by police, fire, and court officials in Willis’s case is particularly striking. “The government gets to do that,” he adds. “They have all the authority and all of the influence. They come in the door pounding their chest and saying, ‘I’m right!’ even when they know they’re wrong.” Deciding the prosecution was indeed correct, jurors convicted Willis. Having played star witness a month earlier, Dove, who Maxine Willis describes as “a character,” appears to have felt isolated when several weeks after beginning his sentence he sent her a letter and makeshift Mother’s Day card. Signed “Gino” and “D. Dove,” the letter’s content suggests levels of comfort and entitlement that seem to contrast the reality that he helped send Maxine’s youngest son to prison. “Hi, mama,” he writes in the missive dated May 1, 2010. “This is your stepson. Well I have been alright in here, but I miss y’all … And I wish that I can finish helping Pops with the building, because that was fun. Maybe when I come home I hope that I will still have a job.” Adding, “mama, I am so, so sorry,” Dove ruminates, wishing he could “start over with” his life and asking God to help him “get through this and come back home with my family that took me in.” Receiving no response from Maxine, five weeks later, Dove penned a compelling attempt to recant his testimony against Mario Willis. The letter, which finds Dove often referring to himself in third person, reads in part: “I remember that morning about 2:30 a.m. or 3:20 a.m. on Nov. 15, 2008. That I did talk with Felisha, because we was old friends at that time, because I met her at a friend’s house, and we was talking about having fun and we had some beers & weed, but I did not smoke weed. So we \[decided\] to go over to East Kirby Street … and then she said she had to use the bathroom … So we went in and took the beer & weed in the house, and it was a little cold in the house … but then, after that, we was playing around … and she, Felisha, said, ‘Is it any heat in the house to break the chill?’ … And it was some gas in the house because I had found some wood and a big piece of metal, and I poured a little gas on the metal … and I started a little fire to keep Dove & Felisha warm, but I forgot to move the plastic gas can … and we was kissing, and before I knew what was going to happen — please, please — I was not trying to put the house on fire.” Dove details feeling “scared to death” while Felisha was in tears, attempting to smother the fire with clothing items and eventually finding a nearby pay phone to dial 911. Attempts by Willis’s defense team and investigators to locate Felisha, whose voice is reportedly heard describing firefighters arriving in the distance, all failed. “But let’s get this right,” Dove’s letter continues. “…I don’t know why the people are saying that Mr. Dove did this fire on East Kirby for $20. And for a fireman to get killed, I would never do something like that in my life, because Mario is my boss and he let Mr. Dove stay in one of his houses. And Mario did not \[hire\] Mr. Dove to burn down the house, because that was gonna be my house with my girlfriend.” Dove describes having bumped his head while trying to contain the blaze, and learning that “by the morning \[they\] were short a fireman” after Harris’s death. He vents frustration at the media’s portrayal of the accident — “like Mr. Dove is a killer and Mr. Mario is the mastermind of the situation.” Adding, “mama, I am so, so sorry,” Dove ruminates, wishing he could “start over with” his life and asking God to help him “get through this and come back home with my family that took me in.” Receiving no response from Maxine, five weeks later, Dove penned a compelling attempt to recant his testimony against Mario Willis. The letter, which finds Dove often referring to himself in third person, reads in part: “I remember that morning about 2:30 a.m. or 3:20 a.m. on Nov. 15, 2008. That I did talk with Felisha, because we was old friends at that time, because I met her at a friend’s house, and we was talking about having fun and we had some beers & weed, but I did not smoke weed. So we \[decided\] to go over to East Kirby Street … and then she said she had to use the bathroom … So we went in and took the beer & weed in the house, and it was a little cold in the house … but then, after that, we was playing around … and she, Felisha, said, ‘Is it any heat in the house to break the chill?’ … And it was some gas in the house because I had found some wood and a big piece of metal, and I poured a little gas on the metal … and I started a little fire to keep Dove & Felisha warm, but I forgot to move the plastic gas can … and we was kissing, and before I knew what was going to happen — please, please — I was not trying to put the house on fire.” Dove details feeling “scared to death” while Felisha was in tears, attempting to smother the fire with clothing items and eventually finding a nearby pay phone to dial 911. Attempts by Willis’s defense team and investigators to locate Felisha, whose voice is reportedly heard describing firefighters arriving in the distance, all failed. “But let’s get this right,” Dove’s letter continues. “…I don’t know why the people are saying that Mr. Dove did this fire on East Kirby for $20. And for a fireman to get killed, I would never do something like that in my life, because Mario is my boss and he let Mr. Dove stay in one of his houses. And Mario did not \[hire\] Mr. Dove to burn down the house, because that was gonna be my house with my girlfriend.” Dove describes having bumped his head while trying to contain the blaze, and learning that “by the morning \[they\] were short a fireman” after Harris’s death. He vents frustration at the media’s portrayal of the accident — “like Mr. Dove is a killer and Mr. Mario is the mastermind of the situation.” Dove’s letter concludes with regret that Harris lost his life, reiterating Willis’s innocence: “And I promise that Mr. Willis … was not around when I was over on East Kirby Street … Mr. Willis did not know nothing about this situation at all. I had keys to the house, and I did not want to go and pay for a \[motel\] room” to entertain Felisha. Painstakingly detailed and often emotional, Dove’s account ultimately failed as a formal recantation of damning testimony against his one-time benefactor. The Michigan Court of Appeals rejected the lengthy “truth statement,” as Dove titled it. “The recanting statements are particularly suspect,” wrote the appeals judges, “because, assuming that Dove actually made the statements, he apparently waited until after he learned the full extent of his sentence and made statements that tended to reduce his own culpability by characterizing the fire as accidental.” But just a few paragraphs earlier in the written decision the panel acknowledges the recantation as “consistent with Dove’s original claims in June 2009” — nearly a full year before Dove was ever sentenced. Daly wanted to recall Dove to the witness stand and cross-examine him about the statement, but the Court of Appeals denied the effort, refusing Willis’s request for a new trial. Daly says he understands doubts about Dove, given changes in his story. At one point before sentencing, Dove even flip-flopped into alleging that Willis joined him inside the East Kirby house, impatient because he wasn’t seeing flames: “I stated to him that I could not do it. That’s when he snatched the lighter from me, stating, ‘Your dumb ass can’t do anything right!’ and set the house on fire. We both ran out of the house.” But Daly points out that Dove gave recantation a second try in a sworn affidavit dated March 26, 2014, insisting, “Mario Willis had nothing to do with the fire.” “During their interrogations,” Dove’s statement reads, “the police insisted that I was paid by Mario to set the fire and they told me I could be forgiven for the fire if Mario paid me to set it. They made the idea seem very appealing and they pushed very hard for me to adopt their story.” Daly says Dove’s affidavit subjects him, once again, to a cross-examination if Willis is granted the motion for relief and evidentiary hearing being filed this month. The statement actually boosts Dove’s credibility, he adds. “I would say that no one would go to court and say that they lied under oath, knowing that could put him in prison for the rest of his life,” Daly says. “Darian Dove is eligible to be released soon. Why would he risk it? If he gets on the stand and says he lied, the deal he accepted is off.” ‘Damn! You caught a body or something?’ About six weeks after Dove’s affidavit an additional sworn statement from Valorie Ann Williams was given in support of Willis’s innocence. “In November of 2008 I was paying very close attention to Dove’s comings and goings from our home because I knew he was cheating on me,” the affidavit reads. “I slept very little and very lightly during that time, and made sure I was always awake when Dove left and returned.” Williams is certain Willis never retrieved Dove after midnight the date of the fire, as Dove told authorities Willis had, because “Willis never came to our house for any reason after 10 p.m.” “I always knew when Mario came by in the big truck, because it would vibrate the windows because of the engine size,” her statement reads. But detectives never interviewed Williams, who concludes: “If they had, I would have told them the truth.” Back in 2010 a former carpenter and one-time FEMA housing inspector named Walter Collier awaited his own interview about an encounter with Dove. While at Wayne County Jail a year earlier, on charges of which he was eventually cleared, Collier heard the familiar description of the East Kirby blaze as accidental. Dove “told me he was with a woman when this happened; he also told me that Mario Willis had given his name to the police and he was going to get back at him for doing that,” reads Collier’s affidavit. Still unaware Dove had been there Nov. 15, 2008, Willis says he told investigators about Dove only when they asked for names of those who had access to the dwelling. Daly says his client’s transparency further demonstrates innocence because it defies logic for a criminal to identify his co-conspirator. “You are not going to do that with an arson for profit,” Daily adds, “especially not with someone like Darian Dove.” When Collier unexpectedly found himself in a courtroom “bullpen” with Willis while awaiting the verdict in his own case, he shared Dove’s story and was asked to call Willis’s then-attorney Wright Blake. “After I was found not guilty and released I called Mr. Blake and left my name and number,” Collier states. Later missing the returned call from Blake, he says he tried reaching the lawyer again, leaving his name and number, but was never contacted to testify in Willis’s defense. A man identified as Nikemo Burton crossed paths with Dove, who he knew as “June Bug,” in lockup a few months later, according to Burton’s unsworn, handwritten statement. “I asked him how much time he was in for. He told me ‘20 years,’” reads the paragraph printed on Michigan Department of Corrections Prisoner Stationery. “I said, ‘Damn! You caught a body or something?’ He went on to tell me … he was over off Kirby and Townsend at a house with one of his girls. They was getting high and made a mistake and started a fire. He said they called 911 and left, but the next day he heard a firefighter died and the rest is history. And that \[was\] why he was here and with so much time.” Like Williams and Collier, Burton remains unknown to 12 jurors who’d been chosen to vote for Mario Willis’s guilt or innocence. Commissioning an alibi Another figure who would remain unknown to jurors has become much more familiar to the public in 2022. Chuck Simms, then a lieutenant and arson investigator for the Detroit Fire Department, was recently promoted from interim commissioner to the commissioner post. Simms, whose name appeared on both the prosecution and defense witness lists, was ultimately never called to testify, but has revealed himself as a potential asset in Willis’s exoneration efforts. Simms intercepted Willis on June 10, 2009 after Willis says he was tricked into visiting the police precinct, although he’d willingly answered questions about the fire. Megan Willis was being held on traffic-related charges, he was told. “It was a complete lie,” he says. “I never paid $260. She never had any warrants. I don’t know why they felt the need to concoct a story.” In fact, he says, Megan had been questioned about the fire and what she and Mario did during the hours leading to it: “date night,” dinner and a movie, she’s recorded saying before telling detectives they slept at home until the next day. Megan had already left the precinct when Willis arrived with cash in hand, so he cut short the ensuing conversation with detectives after their questions became “accusatory,” he says. Heading out the door, he was greeted by then-Lt. Simms. “Hey, Mario, don’t leave,” Willis recalls Simms saying. Although eager to get back to an aluminum-siding job at one of his properties, Willis agreed to talk, but asked that they first step into an empty interrogation room. Simms had interviewed Willis on Nov. 19, 2008, four days after the fire, but Willis only remembered his face. At one point during their video-recorded talk at the precinct he asks the lieutenant’s name, to which Simms replies, “Chuck,” though he doesn’t appear in the camera’s view. Excerpts from actual interviews conducted with Willis and Megan by Simms, Detective Shea, and Detective Sullivan are posted at justiceformariowillis.com, the website launched by supporters in 2020. “You remember what you told me, right?” Simms asks Willis. “…I remember you told me y’all went out that night. Y’all went out to dinner or something.” Simms’s memory is significant, says Willis, because, despite Willis’s and Megan’s repeated, matching accounts to police and fire officers of how they spent the night of Harris’s death, Detective Shea testified at trial that Willis never gave an alibi. Shea took the stand, saying he “reviewed the entire file.” When reached by phone, Shea, no longer a DPD officer, declined to comment about the investigation. Sullivan could not be reached, despite two interview requests through Detroit Police Media Relations. Simms did not respond to several telephone and email requests to be interviewed by Metro Times. Like Willis, it’s likely the commissioner was clueless that his confirmation of the alibi was being recorded. Also apparently clueless were police who’d continued recording in the same interrogation room where Megan sat more than an hour earlier. Willis had inadvertently chosen an empty cubicle that preserved both his and Megan’s words. But the discovery wouldn’t be made until three months after Willis was convicted. His dad Marvin owned and operated a video production company. Late nights, Maxine Willis lay in bed while her husband reviewed footage of the investigation that took their son away from them. “I would just hear him saying, ‘Shut up, Mario! You talking too much! Get up and get outta there!’” Maxine recalls — she, too, wishing Willis hadn’t spoken without a lawyer. One evening, Marvin dozed off while watching the interview detectives conducted with his daughter-in-law, Megan. But he woke up to a familiar voice none of them knew was also contained on the tape: Mario’s. Albeit too late to keep him out of prison, his answers to Simms’s questions proved Mario had shared his whereabouts on Nov. 15, 2008. Yet, having failed to convince jurors he was in bed with Megan, Willis was stuck. The prosecution had mocked the notion of his transparency, despite knowing Willis filed a required alibi notice with the court, meeting the deadline, says appellate lawyer Daly. “The thing that’s stunning is that nobody jumped up (to object) and the judge never said, ‘Wait a minute. That’s not a proper argument,’” Daly says. But Megan says someone had indeed jumped while she was on the stand testifying in Willis’s defense, only she insists Assistant Prosecutor Stevens leaped for the wrong reason. “I remember very clearly the man jumping up and down and asking, if Mario and I were together, why I didn’t tell anybody,” Megan says. Without Shea affirming the fact that she had, and with none of the video evidence that clearly proves it, even Judge Callahan took Willis to the woodshed, lecturing him about trying to deceive the court with Megan’s testimony. Megan says she took particular offense at the idea she was manipulated, given her partnership with the man she’s known since they were teenagers. Callahan issued Willis, who was 28 and had no criminal record, a whopping 40 to 60 years in prison, improperly exceeding sentencing guidelines. Willis has been re-sentenced four times, each with media fanfare and members of the Detroit Fire Department making their presence felt at Frank Murphy Hall of Justice downtown. In 43 years practicing law, Daly says he’s never seen displays like those Detroit Fire personnel have coordinated at Willis’s appearances, such as filling the courtroom and parking a ladder rig in front of Frank Murphy. Both Willis and Megan say various personnel observing proceedings often did whatever they could to rattle nerves. “Because I was on bond, I was walking into the courtroom everyday with my wife, my family, and my supporters, and there was definitely an intimidation factor,” Willis recalls. Sneers and curses were directed his way, even with his mother beside him, he says, causing the ex-lineman to wonder, “What if they try to do something to me?” Similarly, Megan says firefighters would do things like “follow you onto the elevator” or populate stairs leading to the courthouse entrance, but she kept her “head held high.” “I was representing Mario and I didn’t want them to know they were getting to us.” Later she’d slip away by herself: “I would go into the bathroom and cry,” she says. “I know that bathroom very well.” A major moment when she didn’t cry was at the trial’s conclusion, her body reacting too quickly for tears to form. Hearing that the jury reached its verdict, Megan left her job, but she arrived at Frank Murphy after the Willis family had already left the courtroom. “I can see it like it was yesterday,” she says. “The elevator doors opened and I saw their faces. They didn’t say anything and I knew it was ‘guilty.’ I passed out.” Fire wall Asked if her son had truly achieved the mini-Dan Gilbert, real-estate-magnate status jurors were led to believe he had, Maxine Willis lets out a laugh. “No! Just doing OK,” she says, “had five or six properties that my sister helped him invest in.” Through decades of work, which included producing a puppet show for Nancy Reagan during Reagan’s “Just Say No” anti-drug campaign, Maxine has collaborated with the same agencies that helped convict her son. “I’ve been around these groups and I’ve seen them do great things,” she says, “but to have them come to trial and distort, and line up fire trucks and carry signs that said, ‘Mario Willis, murderer…’ I hate to say it, because my momma told me you don’t call people liars — but they lied.” Pooling resources with relatives including Megan’s parents, and occasionally organizing fundraisers, Maxine estimates they’ve spent “probably $300,000” in legal fees since 2010. There have been other costs, too: The 10,000-square-foot K.E.Y.S. Kids Plaza, former home of Mario’s Hair Salon, mysteriously went up in flames. Battle-scarred and feeling unsafe, in 2014 Maxine and Marvin Willis left their west-side Detroit home of 36 years. Like countless numbers of Detroiters, in the wake of Harris’s death Maxine heard positive things about him. “My son is also a good man. Two good men were lost,” she says. Attempts by Metro Times to interview or gain reporting assistance from no fewer than six Detroit Fire Department executive-level or staff members were all unsuccessful. Additionally, a Sept. 7, 2022 Freedom of Information Act request for fire investigation records related to 7418 East Kirby remains unanswered, in violation of Michigan statute. Proctor, the private investigator, says firefighter culture is comparable with, if not more rigid than, the so-called “blue curtain” attributed to police. “Think about it this way,” adds Proctor. “Firemen literally live with one another where they’re in the beds, they’re showering, they’re in space together as much as they are with their own family.” Desire to gain accolades from a high-profile case like Harris’s death might also have fueled action and inaction by fire and police officers, says Proctor: “There are people whose ambition drives them to do things in uniform and behind ‘blue curtains,’ and that kind of crap, but a lot of the bad acts that we see have to do with the idea of guys on a treadmill, under pressure to close cases.” With a record of zero “tickets,” meaning citations for breaking prison rules, Willis has channeled his energy into daily exercise, helping to host church services, and supporting a youth diversion program at Saginaw Correctional in the years he has served. He’s hopeful his court case is reopened, if not through the motion for relief, through Wayne County’s Conviction Integrity Unit (CIU), which received the case in spring 2021. Maria Miller, spokesperson for the Wayne County Prosecutor’s Office, which oversees CIU, says Willis’s file is “in the initial review stage.” “I tell people, ‘Don’t listen to me,’” Willis adds. “Look at the facts and the evidence.” **Topics:** Homeowners - arson, Public Awareness --- ### [Americore trustee seeking restitution for Medicare fraud scheme](https://insurancefraud.org/news_archives/americore-trustee-seeking-restitution-for-medicare-fraud-scheme/) **Published:** September 18, 2026 **Author:** Diane Beauchamp **Content:** The Chapter 11 trustee of Americore Holdings, the prior owner of the former Ellwood City Medical Center, is looking to recover money from the fraudulent laboratory program at the hospital. In a court document, Carol Fox said with the assistance of her special counsel, she has been investigating the reported fraudulent laboratory program in which thousands of cancer genomic (CGx) testing specimens were illegally sent to the ECMC in order to collect more than $25 million in fraudulent Medicare reimbursements. Fox said she is currently filing adversary proceedings, or a lawsuit case, against those involved, seeking to recover all fraudulent transfers. In the court document, Fox is asking the bankruptcy court to authorize these proceedings, allowing her to get a mediator, and set a mediation deadline, in order to have the parties involved pay the restitution owed. In turn, if approved, the court would allow any potential defendants 14 days, from when a complaint is served and filed, to object to the mediation proceedings from Fox, in which a court hearing on the objection will be set as soon as possible. A hearing on the procedures motion will take place at 9 a.m. Thursday, at the U.S. Bankruptcy Court for the Eastern District of Kentucky, which is where the Americore bankruptcy case is ongoing. Daniel Hurt, 58, of Fort Lauderdale, Fla., pleaded guilty to charges including conspiracy to commit health care fraud, pay and receive unlawful kickbacks, and commit money laundering, and was ordered to pay more more than $97 million in restitution and forfeit more than $30 million in assets. This was based on multiple reported medical fraud schemes, including the one through the ECMC. **Topics:** Healthcare Fraud, Judicial/courts, Medicare/Medicaid **Categories:** Conviction --- ### [Son of Met-Con founder gets community service, restitution for insurance fraud conviction](https://insurancefraud.org/news_archives/son-of-met-con-founder-gets-community-service-restitution-for-insurance-fraud-conviction/) **Published:** September 18, 2026 **Author:** Diane Beauchamp **Content:** The son of the late founder of Met-Con pleaded guilty last week to insurance fraud. But the charge will be dismissed and Scott Michael McDonough, 53, of Faribault, won’t serve any jail time if he pays restitution, does community service and complies with other probation requirements. McDonough entered an Alford plea, meaning he did not admit guilt but acknowledged he likely would have been convicted if the case went to trial. McDonough was charged with felony counts of insurance fraud and theft by swindle in June 2021 in Rice County District Court. The charges claimed McDonough forged a signature and illegally cashed out a life insurance property owned by Faribault-based Met-Con. Father Tom McDonough took out a $500,000 life insurance policy on Scott McDonough in 2003, and MetCon made monthly payments, the charges said. Scott McDonough worked for the company at one time, but was ousted from the company in 2019, shortly after his father’s death. When Scott McDonough received a bill for the over $7,000 annual premium, he reportedly forged a name to transfer ownership of the policy to himself. He then collected a nearly $125,000 payout on the policy. Scott McDonough told an investigator with the Minnesota Commerce Fraud Bureau he believed he owned the policy. He said his father had told him he could cash out the insurance policy someday. McDonough initially pleaded guilty to the fraud charge in May, withdrew the plea in July, then pleaded guilty again last week. He was sentenced by Judge Karie Anderson to complete 40 hours community service and two years of probation. He also must pay restitution, the amount of which is still being determined. Probation conditions include he continue attending therapy and he stay away from MetCon and its new owners. Jail time will be waived if McDonough is completing those terms. **Topics:** Life Insurance **Categories:** Conviction --- ### [Florida Birth-Related Neurological Injury Compensation Plan and Association to Pay $51 Million to Resolve False Claims Act Allegations](https://insurancefraud.org/news_archives/florida-birth-related-neurological-injury-compensation-plan-and-association-to-pay-51-million-to-resolve-false-claims-act-allegations/) **Published:** September 18, 2026 **Author:** Diane Beauchamp **Content:** The Florida Birth-Related Neurological Injury Compensation Plan and its administrator, the Florida Birth-Related Neurological Injury Compensation Association (collectively, “NICA”), have agreed to pay $51 million to resolve allegations that they violated the False Claims Act by causing NICA participants to submit their healthcare claims to Medicaid rather than NICA, in violation of Medicaid’s status as the payer of last resort under federal law. The civil settlement resolves a lawsuit filed and pursued by Veronica N. Arven and the estate of Theodore Arven III against NICA under the *qui tam* or whistleblower provisions of the False Claims Act, which permit a private party (known as a relator) to file a lawsuit on behalf of the United States and receive a portion of any recovery. Although the United States did not intervene in this case, it continued to investigate the whistleblowers’ allegations, provided substantial assistance to the whistleblowers in defending against a motion to dismiss, and negotiated the settlement announced today. The Arvens will receive $12,750,000 as their share of the recovery in this case. “Health care plans may not shift the payment of claims to federally funded programs like Medicaid,” said Principal Deputy Assistant Attorney General Brian M. Boynton, head of the Justice Department’s Civil Division. “Today’s settlement demonstrates our continuing commitment to ensuring that federal health care dollars are spent appropriately.” “The Medicaid program provides a safety net for our most vulnerable populations that do not have access to traditional healthcare coverage,” said U.S. Attorney Juan Antonio Gonzalez for the Southern District of Florida. “My office is dedicated to protecting critical government healthcare programs, like Medicaid, that serve the elderly and disabled. The misuse of Medicaid funds will not be tolerated.” “When Medicaid is improperly billed for services that should be covered by other funding sources, the integrity of this safety net program is undermined,” said Special Agent in Charge Omar Pérez Aybar of the Department of Health and Human Services, Office of Inspector General (HHS-OIG). “HHS-OIG will continue to investigate such schemes to protect federal health care programs and those served by them.” The Florida Legislature established NICA in 1988 as an alternative to the traditional tort system. NICA was intended to provide compensation, on a no-fault basis, for the medical, rehabilitative and custodial care of children who suffered certain categories of birth-related neurological injuries. Under Florida law, once a child is admitted into NICA’s program, NICA is responsible for the payment of medical and other expenses incurred because of a birth-related neurological injury. Medicaid is a joint federal-state healthcare program that provides coverage and benefits to low-income and disabled individuals. Under federal law, Medicaid is generally the payer of last resort. The *qui tam* case is captioned *United States ex rel. Arven v. The Florida Birth-Related Neurological Injury Compensation Ass’n, et al.*, Case No. 19-cv-61053-WPD (S.D. Fla.). This case was handled by the U.S. Attorney’s Office for the Southern District of Florida, with assistance from the Civil Division’s Commercial Litigation Branch and the U.S. Department of Health and Human Services Office of Inspector General. The investigation and resolution of this matter illustrates the government’s emphasis on combating healthcare fraud. One of the most powerful tools in this effort is the False Claims Act. Tips and complaints from all sources about potential fraud, waste, abuse and mismanagement, can be reported to the Department of Health and Human Services at 800-HHS-TIPS (800-447-8477). The matter was investigated by Assistant U.S. Attorney Rosaline Chan for the Southern District of Florida and Fraud Section Attorney Seth Greene. **Topics:** Judicial/courts, Public Awareness --- ### [Prices are rising – and so is insurance fraud](https://insurancefraud.org/news_archives/prices-are-rising-and-so-is-insurance-fraud/) **Published:** September 18, 2026 **Author:** Diane Beauchamp **Content:** The cost-of-living crisis has led families across the country to examine where they can cut expenditure. Insurance, whether it be for a car, pet or home, is among life’s necessities – but fraudulent claims and organised insurance crime are becoming increasingly prevalent, encompassing everything from bad-faith claims to scams. More people in the UK are being exposed to fraud, a trend that accelerated during the Covid-19 pandemic. According to a recent survey by the credit agency TransUnion, 73 per cent of respondents said they had been targeted by scammers in the previous three months, as the cost of living rises. Meanwhile, UK insurer Aviva uncovered more than 11,000 instances of claims fraud last year, worth £122m. Instances of “ghost broking”, where fraudsters masquerade as insurance intermediaries and purchase insurance policies for victims using falsified information (only to then quickly cancel the contract, leaving people uninsured) is likely to increase as people search for cheaper deals. This appears to be a common practice in car insurance in particular: Aviva reported ghost broking accounted for 15 per cent of the 20,000-plus motor policy applications in which it identified fraud in 2021. Comprising 60 per cent of all fraudulent claims, motor-related insurance continues to be the preferred area for scammers to operate in, according to Aviva’s data. The UK’s Financial Conduct Authority (FCA) has warned that financial crime will become “even more prolific” as living costs increase. In September, Sarah Pritchard, the FCA’s executive director, warned of the “complex and ever-evolving enemy” scammers had become. “They will adapt to exploit new weaknesses in the financial system,” said Pritchard, “and they will constantly vary their tactics when targeting the vulnerable for fraud.” **Topics:** Public Awareness --- ### [How Reducing Confusion Can Ease Medical Billing Stress for Employees](https://insurancefraud.org/news_archives/how-reducing-confusion-can-ease-medical-billing-stress-for-employees/) **Published:** September 18, 2026 **Author:** Diane Beauchamp **Content:** Employees and employers agree that health care is a crucial benefit. Yet it’s the issue that causes the most stress, confusion and dissatisfaction among patients, employers and providers alike. Employees get endless bills, statements and notices, but the information rarely adds up. They don’t know what they owe and to whom. Nor do they understand what’s been covered by health insurance and what hasn’t. But this distress gives employers (and their plan providers) an opportunity to bring clarity and relief to their employees and their families by simplifying their Explanation of Benefits (EOBs) statements, answering their questions, and showing them how to navigate their plans. Employers and plan sponsors can play a much more significant role in helping employees get the right amount of care at the right time, and show them how to avoid costly mistakes. By reducing confusion and providing a patient-friendly path for those who need it, employees can be better informed and more in control of their medical expenses. **How Billing Became a Broken System** The financial burden of health care payments has tilted significantly toward consumers, who now find themselves buried in a blizzard of EOBs and “what you owe” statements. It’s partly due to more employers offering higher-deductible health plans as a way to share cost increases with employees, resulting in higher out-of-pocket costs. Employees on employer-sponsored plans also now have to deal with multiple invoices from different providers for deductibles and other payments. In fact, according to data from Health Payment Systems (HPS), the average U.S. family can expect to receive approximately 125 pieces of mail each year related to health care billing. The fragmented nature of health care payments, combined with a lack of coordination between employer plans and providers, has added to employee confusion around what they owe. Case in point: A recent study by [Bend Financial](https://www.bendhsa.com/newsroom/more-than-half-of-americans-confused-by-health-insurance-including-hsas) found that 56% of Americans admitted to feeling “completely lost” when it came to understanding how their health insurance worked. Nearly half (47%) were confused about which procedures were covered and which services were considered out of network. “And all this confusion has real-world consequences on health care consumers. On average, respondents with current health care coverage estimated that they waste $111 per month on confusion over their health insurance plan,” the Bend report said. **The High Stakes** This confusion has negatively affected patients’ care. For example, the Bend study found that nearly 60% of consumers have put off scheduling an appointment with their caregivers, and 53% have put off getting a prescription filled due to uncertainty. As plan participants delay making necessary and preventive appointments, as well as not taking their medications, it inevitably leads to more expensive, emergent needs for care. **How Employers and Plan Sponsors Can Help** Employers and plan sponsors can address the problem with a number of strategies. Employers can offer access to advocates within the plans, for example, that offer telephone hotlines that employees can call to answer health care benefit questions. Enhanced employee assistance programs (EAPs) can help employees avoid being billed for care by helping them resolve personal concerns before they turn into major health issues. Most importantly, employers can leverage new technology platforms that create a simpler, friendly patient-centric EOB and billing experiences for employees. Today, insurers cram EOBs with every detail – from service codes to provider charges, allowed charges, owed amounts and remark codes – because of fears of being non-compliant with HIPAA, COBRA and host of other regulations, or face costly fines and penalties. Adding all the necessary compliance information to EOBs is the path of least resistance for plans, but much of this information isn’t relevant, is repetitive and drives employees further into confusion. They believe they can mitigate their regulatory risk by including every piece of information. But at the expense of making EOBs incomprehensible. The fact is EOBs do not have to contain every claim detail in order to be compliant. These new platforms simplify healthcare billing automatically stripping away unnecessary details and data, while delivering a single consolidated statement that eliminates confusion. Employees receive a single, simplified “super EOB” rather than multiple bills from multiple providers for each medical treatment. Some of these platforms also help employees deal with billing stress by giving the option to pay over time, regardless of their credit histories. All employees can be issued credit for all allowed charges up to their out-of-pocket max, regardless of their credit standing. The technology guarantees prompt full payment to healthcare providers in exchange for giving employees these more manageable repayment plans. Not only does a single, consolidated EOB increase employee satisfaction rates, it improves access to care by alleviating the burden of up-front, in-full payments and rigid collection processes from providers. They also shift the financial relationship away from providers and indiscriminate debt collection agencies by taking inefficiencies out of the system and streamline the payments process for all. As soon as a claim is adjudicated, the solution sends participating providers 100% of the in-network allowed amount. Employees get a single monthly summary of all their care regardless where they went to get it, and the typical blizzard of confusing paperwork goes away. The new solutions also benefit employers. They can automatically take care of enrolling all employees on behalf of the employer, even if some employees have less-favorable credit histories, for instance. All employees can be issued credit for all allowed charges up to their out-of-pocket max, regardless of their credit standing. Some solutions can also reduce the burden of health care costs for employees, increasing overall satisfaction with employer benefits. The key is for employers to find a platform that offers all employee charges up to their out-of-pocket limits as opposed to those that only provide limited credit for a portion of their expenses. **Final Thoughts** Creating a good patient experience through better, patient-centric billing is a critical way to improve By reducing confusion and providing a payment path for consumers who need it, patients can be better informed, more in control of their medical expenses and, most importantly, re–engaged. **Topics:** Public Awareness --- ### [Latest Healthcare Data Breaches Have Varying Impacts on Health Data](https://insurancefraud.org/news_archives/latest-healthcare-data-breaches-have-varying-impacts-on-health-data/) **Published:** September 18, 2026 **Author:** Diane Beauchamp **Content:** The latest string of healthcare data breach notifications includes breaches at a New York police union, a California post-acute care facility, and a Colorado FQHC. California-based Legacy Post Acute Care notified patients of a data breach that occurred between January 19 and March 3 2022. In September, Legacy Post Acute Care first discovered that an unauthorized party had accessed several employee email accounts during the two-month period. The email accounts contained patient names, Social Security numbers, treatment information, health insurance information, financial information, prescription information, and patient account and medical record numbers. Legacy Post Acute Care said it was not aware of any identity fraud or misuse of information relating to the incident. “We are committed to maintaining the privacy of personal information in its possession and has taken many precautions to safeguard it,” the notice stated. “We continually evaluate and modify our practices and internal controls to enhance the security and privacy of personal information.” ## NY Police Detectives’ Endowment Association Breach Impacts 21K The Administrative Fund of the Detectives’ Endowment Association, Inc., Police Department City of New York (NYCDEA) disclosed a breach to HHS and submitted a notice to the Maine Attorney General’s Office detailing a 2021 breach that involved protected health information (PHI). More than 21,000 individuals were impacted by the breach. “Upon discovering the suspicious activity, the NYCDEA moved as quickly as we reasonably could,” the notice explained. “However, it took us considerable time to determine what information was impacted and who was potentially affected.” According to the notice, NYCDEA detected suspicious activity within its email environment in December 2021. Despite discovering the incident last year, the investigation into the impacts of the breach did not conclude until October 3, 2022. The information involved in the incident varied by individual, but may have included names, addresses, financial account numbers, medical history, health insurance information, usernames and passwords, dates of birth, and driver’s license numbers. NYCDEA said it did not have evidence that any information had been misused. The association offered impacted individuals 12 months of credit monitoring and identity theft protection services. ## Colorado FQHC Discloses Breach Colorado-based Salud Family Health, a Federal Qualified Health Center (FQHC), disclosed a healthcare data breach that it discovered in September. Further investigation revealed that Salud suffered unauthorized access on September 5 and that “certain data may have been accessed or taken.” “Salud’s investigation determined that some employee and patient personal and protected health information was potentially subject to unauthorized access,” the notice stated. Salud said it immediately took additional steps to protect sensitive information and confirm the security of its systems. “While Salud had policies and procedures in place at the time of incident regarding security of information, Salud is reviewing and enhancing those policies and procedures to further protect against similar incidents moving forward,” the notice continued. **Topics:** Public Awareness, Technology --- ### [Accused SC Attorney Murdaugh’s Involvement Looms Over Fraud Trial of his Banker](https://insurancefraud.org/news_archives/accused-sc-attorney-murdaughs-involvement-looms-over-fraud-trial-of-his-banker/) **Published:** September 18, 2026 **Author:** Diane Beauchamp **Content:** A banker accused of helping disbarred attorney Alex Murdaugh take money from the legal settlements of clients is the first person to stand trial in the sprawling rural South Carolina legal drama that has captivated true-crime audiences. Former Palmetto State Bank CEO Russell Laffitte faces wire fraud and bank fraud charges in federal court. And even though no one has connected Laffitte to the murder charges against Murdaugh in the deaths of Murdaugh’s wife and son, that case immediately popped up as Laffitte’s trial started this week. According to news outlets, an employee at Murdaugh’s law firm testified about the firm’s links with Laffitte’s bank and said she confronted Murdaugh about missing fees from one of his cases on June 7, 2021. Murdaugh’s wife and son were shot to death that night. Neither prosecutors in Laffitte’s, nor the investigators in the killings have mentioned whether they see a link between the events. Meanwhile, Murdaugh is playing a key role in Laffitte’s defense. So far, cross-examination by his attorneys has focused on how Murdaugh manipulated people and lied. The defense said Laffitte was only following Murdaugh’s instructions and didn’t willfully participate in the fraud, which prosecutors need to prove to get a conviction. Defense lawyers wanted to call Murdaugh as a witness, but Murdaugh’s attorneys said he would invoke his Fifth Amendment right to avoid self-incrimination since he could face charges. The judge has said he would only allow Murdaugh to take the stand if he had something substantial to say. Prosecutors said Laffitte knew what he was doing when he effectively worked as Murdaugh’s personal banker and eventually became the court-appointed custodian for the settlement money for several of his underage clients. Laffitte loaned Murdaugh and himself money from those settlements, diverting that money from personal injury or death cases. The trial is expected to last into next week in federal court in Charleston. Murdaugh was disbarred and Laffitte was fired last year. Murdaugh’s murder trial in the deaths of his wife Maggie, 52, and their 22-year-old son, Paul, is expected to begin in January. Murdaugh has repeatedly said he did not kill them. Murdaugh is not charged in the ongoing federal bank fraud case, but he faces dozens of other charges in state court, including allegations that he helped run a money laundering and drug ring. He has also been accused of stealing more than $8 million in settlements he obtained in wrongful death and injury cases. Both Murdaugh and Laffitte are from tiny Hampton County. Murdaugh’s family law firm dominated the legal community and his father, grandfather and great-grandfather were the area’s elected prosecutors for 87 years straight. Laffitte’s family built Palmetto State Bank, earning a sterling reputation that led to honors like being named banker of the year by the Independent Banks of South Carolina in 2019. And, as in many small towns, their families intertwined. The law firm employee who confronted Murdaugh about the missing money the day his wife and son died was Jeanne Seckinger, Laffitte’s sister-in-law. **Topics:** Financial Fraud, Insider Fraud **Categories:** Arrest --- ### [Navigating insurance claims: Patience is in our best interest](https://insurancefraud.org/news_archives/navigating-insurance-claims-patience-is-in-our-best-interest/) **Published:** September 18, 2026 **Author:** Diane Beauchamp **Content:** When you file a claim with your insurance company, being patient to receive an expected settlement check can be difficult. Like most who have been in this industry for any length of time, I have had the misfortune of enduring my share of insurance claims. Seldom have I gone through an insurance claim when a settlement was reached and paid as quickly as I had wished for. That slow, agonizing claims process always left me frustrated. However, since becoming an insurance agent and witnessing claims investigations, I have a new appreciation for that slow pace. Before you completely dismiss me, let me share what I have learned. It is quite possible, in fact probable, you will come to the same conclusion I have. In 2001, I was involved in a terrible accident. A car hit me on the passenger side of my 1994 W900 Kenworth, then spun in front of me and I “T-boned” the car broadside. The car spun again, now facing me on my driver’s side, and hit my driver’s side fuel tank, launching the car into the median. It came to rest under a bridge at the I-5, California 60 and I-10 junction in Los Angeles. One witness stopped and immediately checked on the driver of the other car (thankfully, his injuries were very minor), then came to check on me. He remained at the scene and insisted on providing a statement to the investigating police officer. The witness informed the officer that the car literally ran right into the side of my truck as if they had hit my truck deliberately. The damage to my truck was significant, but not to the point that I was unable to repair it myself. I took a week off work and replaced the bumper and one wheel; repaired both fuel tanks, fenders, etc.; and got back to work. The claim seemed to be taking forever, and I wanted to be reimbursed for my loss (repair expenses), especially when the witness indicated that this was a deliberate act by the driver of the car. After several months went by, I finally received a notice from my insurance company that the investigation of the claim was complete and that my policy would not pay for any medical or property damage to the other driver or the car he was driving. The adjuster’s investigation discovered several things. 1. The owner of the car was not the driver. 2. The car was not insured. 3. Several payments to the lien holder of the car were past due. The adjuster concluded that this was a case of insurance fraud. I did not want a claim on my policy (even for uninsured motorist), so I did not accept a claim settlement check for reimbursement of my repair costs. Had the insurance company not fully investigated the claim, with or without the eyewitness, and simply settled the claim quickly because that big, bad, ugly truck darn near ran over that poor, innocent little car, both I and the insurance company would have been victims of insurance fraud. It could have cost the insurance company an untold amount, up to $1 million (my policy’s limit of liability), and dramatically increased my premiums for years to come — or put me out of business altogether. In my case, it *would* have put me out of business, because I was already a [high-risk independent owner-operator paying near top dollar for my insurance.](https://www.overdriveonline.com/overdrive-extra/article/15288488/how-do-insurers-calculate-our-trucking-insurance-premium-rates) Recently, one of my insurance customers was involved in an accident. They were hit from behind by another truck. The company who owned that other truck filed a claim against my customer’s policy. They believed that my customer was at fault. Again, after many months (six or more, I believe) the insurance company’s adjuster completed the investigation. The adjuster denied the claim of the owner of the other truck who hit our customer from behind. In my customer’s case, had the insurance company paid and settled the claim with the owner of the other truck, the insurance company would have been accepting financial responsibility and paid out thousands of dollars for an accident the customer was not liable (at fault) for. In both of these very real examples the insurance company is doing exactly what we need them to do: making 100% certain that they and their insureds (us customers) are not being victimized by someone trying to either defraud the insurance company or having us accept financial liability for an accident we were not at fault for. What is most surprising to truck owners is a slow claims process for a single vehicle accident. In these instances, we still want the insurance company to fully investigate the claim before settling. Why? For the exact same reasons as the previous two examples! If insurance companies don’t investigate each and every claim thoroughly before paying a settlement, could you just imagine how many cases would be fraud!? In turn, that would result in premiums so high that none of us could afford to buy insurance. I have learned to think of our insurance system as something like our judicial system. It ain’t a perfect system, but it’s the best we have. **Topics:** Auto fraud, Public Awareness --- ### [Bakersfield doctor’s preliminary hearing postponed, charges dismissed against 2 others](https://insurancefraud.org/news_archives/bakersfield-doctors-preliminary-hearing-postponed-charges-dismissed-against-2-others/) **Published:** September 18, 2026 **Author:** Diane Beauchamp **Content:** A hearing to determine whether there is sufficient evidence to order a Bakersfield doctor to stand trial for alleged insurance fraud schemes has been postponed to mid-February. Dr. Jason Helliwell is now scheduled for a preliminary hearing Feb. 14. It had been scheduled Monday morning. Helliwell and two others were charged in 2019 with multiple counts of grand theft and making false claims for health benefits. The co-defendants, Brandon Williams, a lab representative, and Tambra Head, Helliwell’s biller at the time of the alleged crimes, recently had charges dismissed. Head’s charges were dismissed last week on the condition she testify truthfully if called in the case against Helliwell, Assistant District Attorney Joseph Kinzel said. The dismissal of Williams’ charges did not include that stipulation. “The dismissals help focus the case and the evidence to be presented on the charges specific to Helliwell,” Kinzel said. One alleged scheme involved an in-house allergy testing machine where Helliwell allegedly ordered “frequent, and likely unnecessary, allergy tests on patients that had no complaint of allergy symptoms,” according to a court document. Another plan involved an arrangement Helliwell made with a toxicology lab to send patients for unnecessary lab testing, the court filing says. The test consisted of a urinalysis to detect lead and mercury, but also included a comprehensive drug panel for illegal drugs. Patients weren’t aware of the drug panel when they went in for testing, according to the filing. Their insurance companies were billed $1,000 by the lab. A former employee said Helliwell received $20 to $25 from a lab representative for each patient who got tested, the document says. Another former employee reported the lab provided and paid for an additional personal medical assistant for Helliwell. **Topics:** Healthcare Fraud **Categories:** Arrest --- ### [Kansas City pediatrician pleads guilty to $300,000 Medicare fraud](https://insurancefraud.org/news_archives/kansas-city-pediatrician-pleads-guilty-to-300000-medicare-fraud/) **Published:** September 18, 2026 **Author:** Diane Beauchamp **Content:** A Kansas City-area pediatrician pleaded guilty in federal court today to his role in causing fraudulent Medicare claims to be submitted for more than 1,000 beneficiaries for medications and equipment they didn’t need, which was part of a larger nationwide scheme to defraud Medicare. “A physician abused his position of trust to cause fraudulent claims to be filed for more than 1,000 Medicare beneficiaries,” said U.S. Attorney Teresa Moore. “This theft of public funds was part of a larger nationwide scheme that includes prosecutions in other districts where additional perpetrators are being held accountable for their criminal actions.” “To help protect the federal health care system, doctors participating in the Medicare program are obligated to provide medically appropriate services and prescriptions to their patients and bill the program properly,” stated Special Agent in Charge Curt L. Muller with the U.S. Department of Health and Human Services Office of Inspector General. “Our agency and law enforcement partners are dedicated to identifying and pursuing providers who disregard these vital responsibilities in exchange for personal enrichment.” Frederick Scott Dattel, 57, of Leawood, Kansas, waived his right to a grand jury and pleaded guilty before U.S. District Judge Brian C. Wimes to a federal information that charges him with making a false statement related to a health care matter. Dattel, a licensed medical doctor with a specialty in pediatrics, owns and operates his own medical practice, Kansas City Pediatrics, L.L.C., in Kansas City, Mo. Between August 2017 and February 2018, Dattel worked as a physician for RediDoc, L.L.C., a commercial telemedicine company. RediDoc’s owners unlawfully profited by paying kickbacks and bribes to doctors so those doctors would sign high volumes of expensive prescriptions and durable medical equipment orders that were not medically necessary. National Health Care Fraud Conspiracy RediDoc owners Stephen Luke and David Laughlin have pleaded guilty in the District of New Jersey to conspiracy to commit health care fraud. In this scheme, marketers identified Medicare beneficiaries to target for expensive medications and durable medical equipment, and persuaded beneficiaries to try the medications and medical equipment — even when the beneficiary’s need for those items was not clear and was not discussed with the beneficiary’s doctor. The marketers then transmitted the beneficiaries’ medical information to RediDoc along with the proposed prescriptions or doctors’ orders for medical equipment that included pre-marked check-off boxes for particular drugs or equipment that would yield large reimbursements. The marketers paid reimbursement proceeds to RediDoc and its owners. These orders were then filled by providers and pharmacies around the country who received lucrative reimbursements from federal health care benefit programs, including Medicare. In many circumstances, the providers and pharmacies then returned a portion of the health insurance reimbursements as kickbacks to the telemedicine companies, who, in turn, paid the doctors who had prescribed or ordered the unnecessary medical equipment and compounds. RediDoc ensured doctors would sign a high volume of expensive beneficiary prescriptions or medical equipment orders by paying the doctors bribes and kickbacks. Dattel’s Guilty Plea By pleading guilty today, Dattel admitted that, while working as a physician for RediDoc, he unlawfully caused false and fraudulent Medicare claims to be submitted for prescriptions for durable medical equipment and compounds without examining or speaking to patients and without any physician-patient relationship. Between August 2017 and February 2018, while practicing telemedicine for RediDoc, Dattel reviewed 1,077 patient files. He issued orders or prescriptions for 1,075 beneficiaries for durable medical equipment, orthotics, and/or compounds. Dattel issued the orders and prescriptions without seeing, speaking to, or otherwise communicating or examining the beneficiaries, and without regard to whether the beneficiaries actually needed the durable medical equipment and compounds. These orders and prescriptions, as Dattel knew, were used to submit false and fraudulent claims to Medicare. Almost the entirety of Dattel’s completed, signed prescriptions and orders for durable medical equipment and compounds, as he knew, were not legitimately prescribed, not needed, and not used. As a result of Dattel’s RediDoc prescriptions and orders, between Aug. 28, 2017, and Feb. 26, 2018, Medicare was billed at least $312,392 for durable medical equipment and compounds, and paid at least $211,542 for these orders. Under the terms of today’s plea agreement, Dattel must pay restitution in the full amount of $211,542. During the same timeframe, RediDoc deposited a total of $22,270 in 13 payments into Dattel’s bank accounts. Under federal statutes, Dattel is subject to a sentence of up to five years in federal prison without parole. The maximum statutory sentence is prescribed by Congress and is provided here for informational purposes, as the sentencing of the defendant will be determined by the court based on the advisory sentencing guidelines and other statutory factors. A sentencing hearing will be scheduled after the completion of a presentence investigation by the United States Probation Office. This case is being prosecuted by Assistant U.S. Attorney Brent Venneman and Nicholas P. Heberle. It was investigated by Health and Human Services, Office of Inspector General, the FBI, and the U.S. Office of Personnel Management, Office of Inspector General. **Topics:** Medicare/Medicaid **Categories:** Conviction --- ### [New reports further highlight the need for Insurance Fraud Taskforce successor body](https://insurancefraud.org/news_archives/new-reports-further-highlight-the-need-for-insurance-fraud-taskforce-successor-body/) **Published:** September 18, 2026 **Author:** Diane Beauchamp **Content:** This week, reports published by both the House of Lords and the National Audit Office (NAO) highlight the scale and continuing threat of fraud in the UK. The number of fraud cases has been steadily increasing over recent years, with the Covid-19 pandemic leading to a particularly worrying increase in digital fraud. Data from Ofcom shows that over 45 million people were targeted by scam calls and texts in the summer of 2021 alone. The NAO’s report: ‘[Progress on Combatting Fraud](https://www.nao.org.uk/wp-content/uploads/2022/11/progress-combatting-fraud.pdf)‘ contains further data giving a more up-to-date picture. Fraudulent behaviour was the single largest category of crime in England and Wales in the year ending June 2022, making up 41 per cent of all crime against individuals, compared with 30 per cent in the year ending March 2017. The NAO’s estimates also showed thats there were over 3.8 million attempted incidents of fraud against individuals in England and Wales in the year ending June 2022, equivalent to 6.5 per cent of all those over 16. Although the financial cost this has on businesses is not yet known, the Home Office estimates that the cost of fraud to individuals stands at over £4.5 billion annually. The report concludes that fraud is often overlooked by law enforcement, industry and government, most notably the Home Office. The final publication from the Fraud Act 2006 Committee has also been released. ‘[Fighting Fraud: Break the Chain](https://publications.parliament.uk/pa/ld5803/ldselect/ldfraudact/87/8702.htm)‘ makes a number of recommendations to the government to ensure fraud is given proper attention. It has two months to respond to the report before the recommendations are discussed and debated further in parliament. Among other recommendations, the committee push for a new cabinet-level subcommittee to tackle fraud, chaired by the Security Minister along with a government-led consumer awareness campaign in partnership with industry to raise awareness about digital fraud. While ACSO supports the recommendations in both reports, the need for an Insurance Fraud Taskforce (IFT) successor body remains. The IFT’s January 2016 report made 26 recommendations to the insurance industry and wider stakeholders, with an update report published in 2017 identifying action taken in light of these recommendations. Five years on, there is still no sign of a successor body. The industry needs to grasp the nettle and form one now, with or without government support. **Topics:** Public Awareness, Regulatory actions --- ### [Insurance companies spot 13,000 fraudulent claims, more companies are cheating](https://insurancefraud.org/news_archives/insurance-companies-spot-13000-fraudulent-claims-more-companies-are-cheating/) **Published:** September 18, 2026 **Author:** Diane Beauchamp **Content:** Insurance companies prevented some 13,000 attempts to make fraudulent claims last year, which is in line with 2020, but more companies tried to fiddle their insurance. The Dutch insurers association [Verbond van Verzekeraars](https://www.verzekeraars.nl/publicaties/actueel/aanpak-verzekeringsfraude-voorkomt-85-miljoen-euro-aan-onterechte-claims-in-2021) said attempts to defraud members of over €85 million were foiled during the year. In total, 1,198 companies attempting to commit fraud were spotted, a rise of 13% on 2020. ‘We are paying an increasing amount of attention to business fraud,’ the association’s director Richard Weurding said. The number of companies now included on a special ‘watch list’ accessible to all insurance companies has more than doubled, he said. The most popular form of fraud involved car insurance, which accounted for 54% of fraudulent claims and were often based on exaggerating the damage. Property insurance accounted for 26% of claims and personal liability cases 12.5%. **Topics:** Public Awareness --- ### [45% of Indian firms report cybercrime frauds, rank second after customer frauds: study](https://insurancefraud.org/news_archives/45-of-indian-firms-report-cybercrime-frauds-rank-second-after-customer-frauds-study/) **Published:** September 18, 2026 **Author:** Diane Beauchamp **Content:** The shift to remote working because of the Covid-19 pandemic has opened up businesses to a new set of risks, with customer fraud (e.g. fraud involving mortgages, credit cards, claims, and cheques) being on top of the list, reported by 47% of companies, according to the PwC’s Global Economic Crime and Fraud Survey 2022: India Insights, The top frauds in India also changed significantly in the last… “With organisational perimeters becoming more vulnerable over the past two years, it is imperative for businesses to not just continually focus on policies, training, and internal controls but also prioritise investing in sophisticated technologies to manage and mitigate the evolving nature of frauds,” said Puneet Garkhel, partner and leader, forensics services, PwC India. Garkhel added that it is increasingly becoming important for organisations to understand the end-to-end life cycle of customer-facing products and strike a balance between user experience and fraud controls. “Over time, formidable actors become better at exploiting cracks,” he said. Among the organisations that encountered fraud in the last two years, 12% experienced ESG reporting fraud, 9% experienced anti-embargo fraud, and 19% experienced supply chain fraud. 67% of companies that experienced fraud reported that the most disruptive incident came via an external attack or collusion between external and internal sources. The new types of fraud experienced by companies include misconduct risk (67%), legal risk (16%), cybercrime (31%), insider trading (19%), and platform risk (38%). The survey also found that larger enterprises were hit harder, with 60% of companies with revenues over $1 billion experiencing fraud compared with 37% of firms with revenues under $100 million. Misconduct was the biggest challenge faced by organisations as bad actors began collaborating and taking advantage of pandemic-related uncertainties and volatilities. Amongst organisations that reported fraud, conduct risk (or risks associated with individuals within the firm, vendors, agents, and customers) was the biggest threat at 90%. **Topics:** Public Awareness, Technology --- ### [Kofax targets insurers, Aviva adopts claims fraud solution](https://insurancefraud.org/news_archives/kofax-targets-insurers-aviva-adopts-claims-fraud-solution/) **Published:** September 18, 2026 **Author:** Diane Beauchamp **Content:** Tech expert Kofax says its solutions are being rapidly adopted in the Asia Pacific region to transform processes and drive efficiency. California-based Kofax, founded in 1985, says its intelligent automation solutions transform content-intensive workflows. Its specialties include Robotic Process Automation (RPA), Intelligent Document Processing (IDP), and Optical Character Recognition (OCR) UK insurer Aviva has integrated Kofax TotalAgility within its casualty claims fraud processes, leading to higher detection rates and better protection. Singapore-based GM Solutions and Sales Asia Pacific Matthew Thomson, who took the role last month, says longtail claims need greater IA adoption as it’s a lengthy process with a large paper trail. “Digital transformation in the insurance and financial sectors can generate efficiencies, reduce errors and create faster turnarounds … while helping businesses and people to make better and more informed decisions,” he said. “It improves the swiftness of each task while ensuring that it is safe, secure and trusted – especially with protecting your data and money. “We are seeing a rapid adoption of Kofax’s Cloud solutions across the region.” Aviva uncovered 12,000 instances of insurance claims fraud in a year and the insurer’s UK-based Automation Customer and Engagement Lead Dave Warnes says Kofax is now a key partner after success in its casualty claims for the processing of inbound bodily injury claims. Kofax is helping Aviva with inbound post and email, and fraud OCR, and a number of other use cases, with Kofax TotalAgility integrated within its fraud processes. “We are looking at using automation and technologies across Aviva to understand the power of the data,” Mr Warnes said. “By driving the automated process, it helps us to really hone in and target suspected cases.” Engineer reports previously had to be manually retrieved by Aviva’s fraud analysis experts and “picked through”. Now, the files are uploaded and Kofax TotalAgility retrieves the imagery, and breaks the documents down into text, which is sent to frontline teams with appropriate indicators for them to start working on. Aviva plans to use OCR and Natural Language Processing (NLP) more and more, to “free frontline colleagues from laborious and repetitive tasks around analysis,” and spend more time working directly with customers, he says. “Kofax will be a key partner in that journey and automation.” **Topics:** Public Awareness, Technology --- ### [Health insurer’s breach should rejig any short-term memory loss](https://insurancefraud.org/news_archives/health-insurers-breach-should-rejig-any-short-term-memory-loss/) **Published:** September 18, 2026 **Author:** Diane Beauchamp **Content:** Anyone who thinks the scourge of ransomware has cooled off should think again. After years as the primary culprit behind rapid hardening in the cyber insurance market, there have been some reports that ransomware attacks have decreased in both frequency and severity in the last six months. People are using words like ‘stabilizing,’ ‘maturing,’ and ‘optimism’ in relation to the cyber insurance market – and whether they’re apt terms to describe the current state of the sector or not, I strongly believe this is no time for the industry to relax. In fact, I’m not sure the cyber insurance industry will ever be able to relax (consider that if you’re seeking a low-stress desk job). The good guys (you, the insurers) are always seemingly one step behind the threat actors. New attack vectors are emerging all the time, and so far, it’s proven impossible to keep up. So, even if the above stats are true and there was a slight decrease in ransomware activity in the early months of 2022, there will always be a new type of attack keeping business leaders, risk managers, and cyber insurers up at night – not to forget ransomware constantly bubbling under the surface. Turn your attention to Australia, where the country’s largest private health insurer – Medibank Private Ltd., which covers approximately one-sixth of Australians – is struggling with a crippling cyberattack. This wasn’t a ransomware attack (although a ransom was demanded); it was a data breach in which hackers exposed hackers exposed the private information of around 9.7 million current and former Medibank customers and some of their authorized representatives. Medibank first announced it had detected “unusual activity” on its internal systems on October 13, but it dealt with the cyberattack and initially reported “no evidence that customer data had been accessed” during the breach. The narrative changed on October 17, when a malicious party – now believed to be a rebrand of the defunct Russian ransomware group REvil – threatened to leak Medibank customers’ private medical data unless the insurer paid a ransom. On November 7, the private health insurer said it will not pay a ransom – a decision endorsed by Australian Home Affairs Minister Clare O’Neil – but by November 10, the hackers had released private medical information on the dark web, including a file labelled “abortions” and a “naughty-list” file reportedly including details of people who had sought medical treatment for HIV, drug addition, alcohol abuse, or for mental health issues. What a catastrophe. And the toughest part is, Medibank did everything seemingly by the book. Since its initial breach report on October 13, the health insurance giant has shared regular updates on the situation (including when new private medical data is leaked), the status of its investigation, and it has provided hotlines, assistance, and critical response tools for victims. Medibank’s decision not to pay a ransom was endorsed by the Australian government, but despite the Australian Minister of Home Affairs Clare O’Neil warning the “scumbags behind this attack” that “the smartest and toughest people in this country are coming \[at\] you” during question time in Australian parliament on November 10, the hackers keep leaking more data. They’re laughing at us. The Medibank data breach is a very significant and complex event, which (at the time of writing) is still unfolding. No doubt, when it has finally reached its conclusion, this mega breach will provide learning opportunities for insurers, brokers, and business leaders worldwide. For now, I hope that it rejigs people’s memories. Even if your country or your market has been lucky enough to experience a plateau or a decline in cyber insurance losses through 2022, or a drop in the frequency and/or severity of ransomware attacks, others, like Australia, have not been as fortunate. There will always be someone, somewhere, on the receiving end of criminal cyber activity. It’s the nature of the risk, and we are all exposed. I cannot fully embrace the optimism I’ve heard of in the cyber insurance marketplace when the next business-ending or state-stalling attack is likely right around the corner. **Topics:** Public Awareness, Technology --- ### [Yet ANOTHER hospital chain is struck by cyberattack: Half a million patient records in Texas 'are leaked' - weeks after massive multi-state healthcare IT breach led to cancer delays and ambulance diversions](https://insurancefraud.org/news_archives/yet-another-hospital-chain-is-struck-by-cyberattack-half-a-million-patient-records-in-texas-are-leaked-weeks-after-massive-multi-state-healthcare-it-breach-led-to-cancer-delays-and-ambulance-di/) **Published:** September 18, 2026 **Author:** Diane Beauchamp **Content:** Another hospital system has gone down in a ransomware attack with half a million patient records accessed — just weeks after [one of the biggest healthcare hacks in US history](https://www.dailymail.com/health/article-11404337/20MILLION-Americans-21-states-risk-faulty-healthcare-cyberattack.html). Texas-based OakBend Medical Center said names, dates of birth, addresses, email addresses and social security numbers had all been accessed in the cyberattack last Thursday. The nonprofit hospital chain company operates three hospitals as well as emergency centers, imaging centers and physical therapy clinics hospital in the greater Houston area. The medical system [reported](https://ocrportal.hhs.gov/ocr/breach/breach_report.jsf) the data breach to the Department of Health and Human Services (HHS) on October 28, stating that around 500,000 individuals had been affected. Daixin Team — a ransomware and data extortion group — has claimed responsibility for the attack. The group is financially motivated and emerged in June this year. Its previous victim is Fitzgibbon Hospital in Missouri, where the team claim to have stolen 40GB of sensitive data containing employee and patient records. The group is actively targeting the healthcare sector, a [joint alert](https://www.cisa.gov/uscert/ncas/alerts/aa22-294a) from the FBI, Cybersecurity and Infrastructure Security Agency, and Department of Health and Human Services released last month said. It comes after CommonSpirit Health – a hospital system that spans 21 states and has 20million patients on its register – fell victim to a similar ransomware attack. CommonSpirit admitted ‘some’ of its systems are still down after a ransomware attack in early October. The incident led to a three-year-old Iowa being being overdosed on pain meds, and delays to critical scans and surgery. Unlike OakBend Medical Center, CommonSpirit is still refusing to say who did the hack, if patient data was accessed, and if so, how many records were obtained. In an [update](https://www.oakbendmedcenter.org/wp-content/uploads/2022/11/11-10-22-PDF-Website-Breach-Notice-Revised.pdf) to patients, OakBend said it believed a ‘limited amount of data’ was actually lifted from the IT system, and that the hackers did not remove patient’s entire medical records. But it said that the hackers were able to access and remove employee data and reports that contained ‘personal and medical information’ of current and former patients. A sample of data shown to [DataBreaches.net](https://www.databreaches.net/oakbend-medical-center-hit-by-ransomware-daixin-team-claims-responsibility/) is said to contain BMIs, heights, weights, last admission date and medical record number. OakBend said: ‘While we know that the cybercriminals had sufficient access to OakBend’s systems to encrypt our data, our investigation indicates that a limited amount of data was actually transferred out of the OakBend computing environment. ‘For example, we do not believe that the cybercriminals were able to remove the entire medical record of OakBend’s patients.’ It added: ‘It does appear, however, that the cybercriminals were able to access and/or remove certain employee data sets and certain reports that included the personal and medical information related to our current and former patients, employees, and related individuals. ‘In some instances, this information may have included the name, contact information (such as street and email address), social security number, and date of birth for the impacted individuals.’ It said it has contacted the individuals it believes have been affected, and will be offering them ‘certain identity theft protection services’ for a ‘limited period of time’. However, ransomware group Daixin Team [claimed responsibility](https://twitter.com/BrettCallow/status/1569698738339463174?s=20&t=n13P9x9xNkm02N0JQFvYVw) for the OakBend attack, and claimed to have stolen over a million patient records. It said it obtained patient account numbers and medical and treatment information which could be used for things such as ‘opening new financial accounts, taking out loans… filing fraudulent tax returns… and giving false information to police during an arrest’. [HIPAA Journal](https://www.hipaajournal.com/oakbend-medical-center-suffers-ransomware-attack/) reported: ‘Some of the stolen data has been uploaded to the \[Daixin Team’s\] data leak site.’ The ominous notice from the cybercrime group claimed two further data leaks are planned, followed by a ‘full leak’, all of which ‘will be soon’. The hospital system said it had reported the attack to ‘law enforcement’ and was cooperating with the FBI. It said it had put in place extra security measures to deter future attacks. Cybercriminals demanded a ransom of tens of millions of dollars from the hospital, an OakBend spokesman confirmed to [Information Security Media Group](https://www.healthcareinfosecurity.com/texas-hospital-says-ransomware-breach-affected-500000-a-20454) in September. OakBend Medical Center did not respond to a request for DailyMail.com to reveal how many patients it serves, whether or not the ransom had been paid, and to confirm how many records had been accessed. The nonprofit hospital is also being [sued](https://www.classaction.org/media/higgs-et-al-v-oakbend-medical-center.pdf) by two patients affected by the attack. Ryan Higgs and Alissa Wojnar took legal action on October 28 in response to the theft of their protected health information. Filed by Texas-based attorney Joe Kendall, the lawsuit said the hospital system handled patients’ confidential information ‘in a reckless manner’ and ‘failed to properly monitor the computer network’. Mr Higgs and Ms Wojnar are alleging ‘negligence, breach of implied contract, negligence per se, breach of fiduciary duty, intrusion upon seclusion/invasion of privacy and unjust enrichment’. The lawsuit seeks compensatory charges, financial reimbursement and injunctive relief ensuring OakBend ups its security defenses. OakBend first learned of the attack on September 1, and instantly took all IT systems offline. In an [initial notice](https://www.databreaches.net/oakbend-medical-center-hit-by-ransomware-daixin-team-claims-responsibility/) about the attack, OakBend claimed: ‘At no time was patient safety ever in jeopardy.’ On September 9, it announced it was bringing clinical systems back online, and said on September 22 that almost all clinical systems were functional. Meanwhile, Chicago-based hospital system CommonSpirit is still struggling six weeks after a ransomware attack. It has admitted that some of its IT systems are still not running, and that the ‘majority’ of providers now have access to electronic health records. Most but not all patients can get into the patient portal to see their medical histories. CommonSpirit said it was trying to restore appointment scheduling programs, but patients should get in touch with providers directly to book an appointment. Security experts told the DailyMail.com that twenty million Americans were at risk of ‘dangerous’ healthcare after the cyberattack at one of the country’s biggest hospital chains last month. **Topics:** Public Awareness, Technology --- ### [Work Health Solutions Reports Data Breach Following Unauthorized Access to Employee Email Account](https://insurancefraud.org/news_archives/work-health-solutions-reports-data-breach-following-unauthorized-access-to-employee-email-account/) **Published:** September 18, 2026 **Author:** Diane Beauchamp **Content:** On November 9, 2022, Work Health Solutions reported a data breach with the Attorney General of California after an unauthorized party was able to access an employee’s email account that contained sensitive information related to certain individuals. According to WHS, the breach resulted in the full names, Social Security numbers, driver’s license numbers, health insurance information, and medical information being compromised. Recently, WHS sent out data breach letters to all affected parties, informing them of the incident and what they can do to protect themselves from identity theft and other frauds. Given the nature of Work Health Solutions’ business, there is a good chance that many of those who were impacted by the recent data breach had no idea that the company existed, let alone possessed their personal information. However, as we’ve discussed in previous [posts](https://www.myinjuryattorney.com/consumer-privacy-data-breach-lawyers/why-do-data-breaches-happen/), this type of data breach—which appears to be a third-party data breach—is quite common. In fact, a recent study found that approximately 60 percent of all data breaches involve hackers targeting a third party. ## What We Know About the Recent Work Health Solutions Data Breach The available information regarding the Work Health Solutions breach comes from the company’s filing with the California Attorney General’s Data Security Breaches web page as well as notice posted on the WHS website. According to these sources, Work health Solutions recently learned that an unauthorized party had access to a single employee’s email account. While the company did not elaborate on how it came to this realization, in response to its discovery, WHS launched an internal investigation with the assistance of third-party data security experts. The company’s investigation confirmed that an unauthorized party gained access to the employee’s email account on February 16, 2022. The period of unauthorized access lasted until March 24, 2022. Through its investigation, Work Health Solutions was also able to determine that some of the files accessible through the compromised email account contained sensitive information belonging to certain individuals. Upon discovering that sensitive consumer data was made available to an unauthorized party, Work Health Solutions began to review the affected files to determine what information was compromised and which consumers were impacted. While the breached information varies depending on the individual, it may include your full name, Social Security number, driver’s license number, health insurance information, and medical information. On November 9, 2022, Work Health Solutions sent out data breach letters to all individuals whose information was compromised as a result of the recent data security incident. ## More Information About Work Health Solutions Work Health Solutions is a medical services company based in San Jose, California. The company provides occupational health programs for large-scale employers designed to fit their unique needs. Work Health Solutions also provides onsite medical surveillance testing and occupational medical exams and offers wellness clinics, primary care, preventative programs and occupational health services. Work Health Solutions employs more than 100 people and generates between $5 and $25 million in annual revenue. **Topics:** Judicial/courts, Public Awareness, Workers Comp --- ### [Houston Business to Pay $300K For Workers’ Comp Insurance Fraud](https://insurancefraud.org/news_archives/houston-business-to-pay-300k-for-workers-comp-insurance-fraud/) **Published:** September 18, 2026 **Author:** Diane Beauchamp **Content:** The Texas Department of Insurance Division of Workers’ Compensation (DWC) announced that a Travis County district court judge convicted Sehgal & Sons Enterprises (Ultra Business Services Inc.) of first-degree felony in a scheme to defraud Texas Mutual Insurance Company (Texas Mutual). The court found that from August 2011 through December 2014, the company, owned by Kunal Puri of Stafford, Texas concealed payroll by having two separate payroll accounts with the Texas Workforce Commission, while reporting only the smaller payroll account to Texas Mutual. “Concealing payroll is a scheme companies use to get lower workers’ compensation insurance rates and that’s fraud,” says DWC’s Deputy Commissioner of Compliance and Investigations, Debra Knight. “We worked closely with the Texas Workforce Commission on this investigation and discovered new ways to track fraud like this in the future, so we’re pleased with the outcome.” DWC said its prosecution and Fraud Units also worked closely with the affected insurance carriers, Texas Mutual, Service Lloyds, and Travelers. **Topics:** Judicial/courts, Work comp - employer --- ### [Blue Cross Blue Shield recognizes, brings awareness of healthcare fraud](https://insurancefraud.org/news_archives/blue-cross-blue-shield-recognizes-brings-awareness-of-healthcare-fraud/) **Published:** September 18, 2026 **Author:** Diane Beauchamp **Content:** [Blue Cross Blue Shield of Kansas](https://www.bcbsks.com/) wants to bring awareness to the community about health care fraud. Nov. 13 to Nov. 19 is [International Fraud Awareness week](https://www.fraudweek.com/), and BCBSKS has decided to raise awareness for fraud to hopefully reduce the impact it inflicts on Kansans. According to the [National Health Care Anit-Fraud Association](https://www.nhcaa.org/) (NHCAA), healthcare fraud costs the United States approximately $68 to $260 billion annually. To combat fraud and protect Kansans, BCBSKS decided to start the special investigation unit (SIU) in 1984, suggested by John C. McCabe, the president of the Blue Cross and Blue Shield Association. The unit looks at claims and attempts to resolve wrongful activity being used for healthcare dollars and to investigates, detects, and corrects fraud. “Our staff are diligent to further their education through webinars, use of government and law enforcement websites, and local and national conferences. These educational opportunities enable staff to keep abreast of ongoing trends and examine recent case studies.” said Tina Zimmerman, manager, Blue Cross Blue Shield of Kansas special investigations and analytics. “The SIU works closely with other departments within the organization as well as contracted providers and members to combat fraud, waste and abuse.” **Topics:** Public Awareness, Technology --- ### [Insurance enrollment period attracts scammers](https://insurancefraud.org/news_archives/insurance-enrollment-period-attracts-scammers/) **Published:** September 18, 2026 **Author:** Diane Beauchamp **Content:** If you’re on Medicare, the annual enrollment period runs now through December 7. But use caution when choosing your coverage for 2023. Fraudulent activity targeting beneficiaries is an increasing problem, especially this time of year. **Topics:** Public Awareness --- ### [Knoxville-based TeamHealth sued by insurer for “fraudulent conduct”](https://insurancefraud.org/news_archives/knoxville-based-teamhealth-sued-by-insurer-for-fraudulent-conduct/) **Published:** September 18, 2026 **Author:** Diane Beauchamp **Content:** An insurer for a Tennessee firm embroiled in a medical overbilling scandal is refusing to pay the tab for what it calls “fraudulent conduct,” court records show. Ironshore Specialty Insurance Company has filed suit in U.S. District Court against Knoxville emergency medical outsourcing firm TeamHealth. The insurer says in the litigation that TeamHealth wants the company to pony up money to cover a $42 million settlement of overbilling claims in Texas. “The (Texas settlement) arises from and is based upon fraudulent conduct by TeamHealth in submitting false claims to federal healthcare programs in order to receive payments for services that were not provided and/or medically unnecessary,” Ironshore’s lawsuit stated. “The policy does not cover loss in connection with a claim made against an insured alleging, arising out of (or) based upon or attributable to any wrongful act committed with the knowledge that it was a wrongful act.” TeamHealth pioneered the outsourcing of hospital emergency medical care and is now one of the nation’s largest emergency medicine providers in the country. The Knoxville-based firm in recent years has been repeatedly accused in courtrooms across the country of scheming to turn emergency rooms into corporate profit centers through “cartel-like” behavior, including price fixing, legal intimidation and fraud. In the past two years, TeamHealth has ponied up millions of dollars to settle claims of overbilling emergency room patients, shortchanging doctors and cheating government-subsidized insurance firms but has repeatedly denied any wrongdoing. “TeamHealth is a physician-founded and physician-led network of more than 16,000 frontline clinicians treating patients in emergency rooms, hospitals, and clinics across the country,” the firm said [in a statement](https://tennesseelookout.com/2022/05/09/tennessee-health-billing-firm-accused-in-court-of-cartel-like-behavior/) to the Tennessee Lookout in connection with the overbilling scandal previously reported by the news organization. “The business model that TeamHealth uses to contract with clinicians through separate but affiliated professional entities is widely used by hospitals and other healthcare providers. “No court or administrative body has ever found that TeamHealth’s relationship with an affiliated medical practice violates a corporate practice of medicine law,” the statement read. **Insurer: No notice of settlement given** TeamHealth employees in Texas sounded the alarm on the firm’s alleged overbilling practices in a 2016 federal whistleblower lawsuit, laying bare for the first time TeamHealth’s hidden role in billing and suing patients and accusing the firm of ordering coders to inflate pricing for emergency room medical care for a decade. That litigation led a slew of private and government-subsidized insurers to audit their own books, hiring coders to gather patient records from across the nation and examine them for overbilling, court records show. Those insurers then began filing their own litigation, alleging TeamHealth inflated bills by as much as 75 percent nationwide. In June 2021, TeamHealth entered a $42 million settlement agreement in the Texas whistleblower case. The firm then turned to its own insurers, including Ironshore, to help pay that tab. But Ironshore alleges in its litigation against TeamHealth that the firm did not notify the insurer that the Knoxville firm intended to settle the Texas litigation and never gave Ironshore a chance to investigate. “The (Texas plaintiffs) claimed that TeamHealth used two fraudulent schemes … to systematically submit false claims to the Centers for Medicare and Medicaid services for reimbursement for services performed by healthcare providers at TeamHealth emergency rooms,” the Ironshore lawsuit stated. “Further, the (Texas plaintiffs) averred that TeamHealth intentionally carried out these schemes to unlawfully obtain grossly overpaid reimbursement amounts,” the lawsuit continued. “Ironshore contends that TeamHealth did not comply with the notice provisions in the policies and never requested Ironshore’s consent for defense costs or to enter into any settlement with the United States and (Texas whistleblowers).” Ironshore is asking a federal judge to declare “that coverage under the Ironshore excess policy is not available to TeamHealth for its defense and settlement of” the Texas whistleblower litigation. TeamHealth has not yet filed a response to Ironshore’s lawsuit. **Topics:** Judicial/courts, Public Awareness --- ### [SAS and ACFE reveal Fraud Awareness Week insights](https://insurancefraud.org/news_archives/sas-and-acfe-reveal-fraud-awareness-week-insights/) **Published:** September 18, 2026 **Author:** Diane Beauchamp **Content:** The Association of Certified Fraud Examiners (ACFE) has estimated that occupational fraud costs businesses around the world more than USD$4.7 trillion annually. A new report has found that as well as individuals, companies of all sizes lose billions more to external bad actors annually. There was found to be a significant array of consumer fraud threats circulating, from account takeovers to identity theft and phishing schemes. As part of International Fraud Awareness Week, SAS has teamed up with the ACFE for a campaign that looks to help individuals and organisations around the globe to proactively minimise frauds adverse impacts by promoting anti-fraud awareness and education. “Curbing the ceaseless torrent of fraud that erodes tax coffers and company balance sheets starts with building awareness,” says ACFE President and CEO Bruce Dorris. “In complement, anti-fraud professionals must be equipped with the technology and know-how necessary to detect and prevent increasingly vexing schemes. On all these fronts, SAS is a steadfast ally and partner throughout Fraud Week and all year long.” Stu Bradley of SAS says the company’s joint study with the ACFE gives insight into how organisations are feeling about fraud and how tools like data analytics can be used to prevent it. “Our latest anti-fraud technology study with the ACFE revealed that 97% or more of fraud examiners consider analytics an indispensable tool in increasing the amount of fraud prevented and boosting the timeliness, efficiency and accuracy of their fraud detection programs,” he says. “While that’s an impressive proof point, there is likely no greater testament to the immense value of analytics in fighting fraud than the innovations and successes of our many customers. According to conservative industry estimates, at least 10% of all insurance claims contain some fraud. Rampant fraud costs insurers an estimated USD$120 billion annually in the US alone, driving consumer insurance premiums steadily upward. Banks are being hit hard, but some use cases are proving that putting the right processes in place can promote positive outcomes. Australian customer-owned financial institution Greater Bank recently announced that it would employ a powerful, cloud-based fraud detection/prevention and AML solution from SAS to better safeguard its 270,000-plus customers. The solution will transform Greater Banks’ cybercrime toolkit into a world-class offering hosted on the SAS preferred cloud platform, Microsoft Azure. Implementation will see Greater Banks’ disparate IT systems transformed to meet organisational and regulatory fraud and AML requirements. It will also significantly streamline and reduce manual processes, enhancing the user experience for employees and customers. “In our quest to become a more agile, nimbler organisation, SAS is helping us to simplify our IT operations by eliminating the need to manage our own on-premises infrastructure,” says Greg Nyman, Group General Counsel and Company Secretary at Greater Bank. “Not only does this align with our own cloud journey and strategy, but it will enable us to invest more time into creating a safe, secure and reliable environment for our customers that ultimately allows us to focus on growth, building upon a really solid base of established trust.” **Topics:** Public Awareness --- ### [Initiative launches to ‘fix the cracks’ in auto glass claims](https://insurancefraud.org/news_archives/initiative-launches-to-fix-the-cracks-in-auto-glass-claims/) **Published:** September 18, 2026 **Author:** Diane Beauchamp **Content:** The initiative says questionable claims are driving up auto insurance premiums. A new initiative launched by insurance and tort reform groups is taking aim at assignment of benefits agreements for windshield repairs. Assignment of benefits, or AOB, is a legal process that allows policyholders to sign over their insurance benefits to a third party in exchange for a quick repair. Companies on the other end of AOB agreements often sue insurance companies to collect fees. Insurers say those lawsuits are often for inflated claims. Insurers say that AOBs, coupled with the one-way attorney fees statute requiring insurance companies to pay the cost of litigation if they lose, are driving up auto insurance premiums. The new initiative, “**[Fix the Cracks](https://fixthecracksfl.com/)**,” is a partnership between the National Insurance Crime Bureau (NICB), the Florida Justice Reform Institute (FJRI), and the Personal Insurance Federation of Florida (PIFF). According to a news release, the initiative “is working to protect consumers from predatory auto glass claims and litigation, ensure passenger safety and draw attention to the need for legislative changes.” Fix the Cracks said most policyholders aren’t aware they are signing over their rights as policyholders or that repair companies and trial lawyers are using rights gained under an AOB agreement to sue insurance companies. The group said many policyholders who sign AOB agreements are lured with promises of incentives. In past Legislative Sessions, lawmakers have tried to curb auto glass claims by limiting incentives, such as cash or gift cards. The provision was **[included](https://floridapolitics.com/archives/403818-no-fault-repeal-rolls-through-second-senate-committee/)** in a 2021 bill that would have ended the state’s no-fault auto insurance system. Though that bill cleared the Legislature it was ultimately **[vetoed](https://floridapolitics.com/archives/438546-gov-desantis-faces-pressure-on-no-fault-repeal/)** by Gov. **Ron DeSantis**. State data shows auto glass claim lawsuits are on the rise, with 28,156 such lawsuits filed last year. By comparison, there were 591 auto glass claim lawsuits filed in 2011. Overall, there were nearly a half million auto glass claims filed in Florida last year, more than in any other state. There were fewer than 400,000 claims filed in Arizona, the No. 2 state. Additionally, Fix the Cracks said Florida and Arizona account for nearly three-quarters of “questionable” auto glass claims nationwide. “It is a crime to file a fraudulent insurance claim in Florida, such as auto glass repairs or windshield replacements where no damage existed,” said **Eric De Campos**, Government Affairs Director for the National Insurance Crime Bureau. “This is occurring often in Florida as consumers are being solicited and offered incentives to file false or fraudulently inflated auto glass insurance claims. NICB supports the Fix the Cracks initiative in warning the public of these scams that take advantage of Florida consumers.” Data compiled by FJRI shows most auto glass claims are filed by about a dozen law firms operating in just a handful of Florida counties. However, their customers hail from all corners of the state. “Vendors use these assignments to seize the policyholder’s special one-way attorney fee right under statute and file expensive lawsuits based on inflated claims,” said **William Large, president of the Florida Justice Reform Institute**. “Many of these lawsuits happen without the policyholder’s knowledge or informed consent.” Fix the Cracks partners say they will continue to add and share resources to bring attention to the problem and advocate for reforms. “The Florida Legislature passed AOB property insurance reform in 2019, but auto glass claims abuse was left out,” said **Michael Carlson**, president and CEO of PIFF**.** “The AOB auto glass loophole, supported by the one-way attorney fee law, is the latest machine for some to profit at the expense of auto insurance consumers.” **Topics:** Legislation, Public Awareness --- ### [Former Central Vermont pharmacist gets probation for third drug theft](https://insurancefraud.org/news_archives/former-central-vermont-pharmacist-gets-probation-for-third-drug-theft/) **Published:** September 18, 2026 **Author:** Diane Beauchamp **Content:** A former Central Vermont pharmacy manager has been sentenced in U.S. District Court to serve three years on federal probation after he was caught stealing drugs for a third time, court records show. Brian Thomas Badgley, 37, of Waterbury, had his state pharmacy license suspended by the Vermont Pharmacy Board after the latest diversion of opioids was detected at the CVS drug store in Berlin in September 2021, court and disciplinary records show. Badgley had been caught earlier stealing drugs from a pharmacy in Texas in 2015 and from the Northwestern Medical Center in St. Albans in 2016, the U.S. Attorney’s Office said in court papers. Those two prior instances resulted in the State of Vermont’s Board of Pharmacy placing strict conditions for three years on Badgley’s license to practice pharmacy. Badgley’s license was fully reinstated in 2020, and then suspended on September 24, 2021 when the Board learned of new allegations of tampering and obtaining controlled substances by fraud at his latest job at the CVS on U.S. 302 in Berlin, records show. Berlin Police helped bring state charges last fall: two felony counts of prescription fraud and single counts of embezzlement, petty larceny and reckless endangerment, records show. Federal authorities expressed interest in January in filing two felony charges based on Badgley’s criminal record and the state planned to drop its case. Details about the pharmacy theft in Texas and any possible penalty were not disclosed in federal court papers. Court records show that Vermont Superior Court Judge Robert Mello imposed an 18-month deferred sentence on Badgley for an unlawful trespass charge as part of the St. Albans hospital case and that drug and larceny charges were dropped in the plea bargain in Franklin County. The deferred sentence allowed the Vermont criminal conviction to be wiped off his record and Badgley was permitted to get his pharmacy license back. In the latest case, the federal sentencing guidelines, which are advisory, suggested a penalty between zero and six months in prison for Badgley making false entries into the pharmacy ordering system in order to steal drugs, court records show. However, both the prosecution and defense agreed to a sentence of 3 years on probation, according to the signed plea agreement filed in July. The maximum possible penalty was up to 4 years in prison, followed by up to 1 year on supervised release and up to a $250,000 fine. Federal Judge Christina Reiss agreed with no prison time and placed Badgley on probation for three years with strict conditions. She also assessed him $439 in restitution and court costs during the sentencing this month. The defense and prosecution have said they believe Badgley’s career in pharmacy work has now ended permanently. “This is not the first time he has abused a position of trust to steal opiates. Defendant Badgley stole hydromorphone tablets from a pharmacy he worked at in Texas in 2015 … and forced his entry into a cabinet in an operating room at a Vermont hospital to steal hydromorphone tablets in 2016,” Assistant U.S. Attorney Jonathan Ophardt wrote in court papers. The St. Albans theft happened one day after Badgley was fired by the hospital, but he returned at night to commit the theft, according to St. Albans Police Officer Randy Dame in court papers at the time. Badgley had moved on to working in property management last year and formed his own home remodeling business, B-Square Builders on Randall Street in Waterbury, in August, records show. Berlin Police Officer Daniel Withrow reported he received a report Sept. 2, 2021 about a Berlin CVS employee stealing medication. The state pharmacy board said a complaint had been filed that Badgley appeared to be impaired while administering a COVID vaccine on Sept. 1, 2021. Badgley denied being impaired, records show. Berlin Police reported Badgley admitted to stealing the liquid form of hydromorphone and would later dilute the remaining drug container to hide the theft, court records show. Withrow told the court that this caused sanitation concerns with the remaining liquid narcotic. Police also said that the remaining diluted drug also could also be problematic because it would not work as an unopened dose. A patient might have to receive more of the diluted narcotic than usual, and then could potentially overdose if they were to later receive undiluted narcotic, according to court records. In charging papers in the disciplinary case, the Pharmacy Board said that by diluting the drug, Badgley put lives in jeopardy. Badgley initially pleaded not guilty in federal court to diverting hydromorphone hydrochloride tablets and solution between March and September last year by using fraud, forgery and deception. The indictment said Badgley made false electronic entries into the pharmacy ordering system so hydromorphone hydrochloride tablets and solution were delivered to his store. Badgley also denied a second federal count that he entered false pill counts into the pharmacy inventory system to obscure his thefts. The charge said he also used Benadryl and/or distilled water to try to avoid detection when he removed the hydromorphone hydrochloride solution from bottles. During one of his federal court hearings last year, Badgley said he had been treated for narcotic addiction in 2016. According to Berlin Police Officer Withrow in court records, Badgley reported he initially became addicted after serving in the U.S. Marine Corps and undergoing major shoulder surgery. **Topics:** Drug Diversion **Categories:** Conviction --- ### [Revealed – how many people are targeted by insurance fraud](https://insurancefraud.org/news_archives/revealed-how-many-people-are-targeted-by-insurance-fraud/) **Published:** September 18, 2026 **Author:** Diane Beauchamp **Content:** It’s no surprise that insurance fraud saw significant growth during the height of the pandemic, but the latest survey from credit agency TransUnion has revealed that the trend hasn’t gone away since. In fact, the figures have got worse. The cost-of-living crisis is forcing people to cut expenditure and search for more affordable deals, prompting a rise in people susceptible to cheap but fraudulent insurance. this is highlighting the fact that you need to [educate your clients on the basics of insurance claims](https://www.insurancebusinessmag.com/us/guides/insurance-claims-how-to-process-to-file-and-how-long-it-will-take-428385.aspx) so that they do not get caught in a scam From bad-faith claims to fraud schemes, 73% of respondents said they had been targeted by scams in the past three months. At the end of August, [Aviva](https://www.insurancebusinessmag.com/uk/companies/aviva/29727/) UK reported a 13% increase to more than 11,000 instances of fraudulent claims in 2021. Translated to daily figures, the collective number is equivalent to 30 fake claims daily, with each claim worth a whopping £336,246. According to Aviva, 60% of all fraudulent claims are made on motor-related insurance, and 15% of the 20,000 motor policy applications are from “ghost broking” alone. This practice has become a common occurrence in the sector, with scammers masking as insurance intermediaries to purchase insurance policies for victims using false information and cancelling them immediately after. Other sectors painted a similar picture: fraudulent [home insurance](https://www.insurancebusinessmag.com/uk/glossary/home-insurance/563138/) claims went up by 45%, property claims by 20%, credit hire and repair claims by 13% and public liability claims by 12%. The UK’s [Financial Conduct Authority](https://www.insurancebusinessmag.com/uk/companies/financial-conduct-authority/559010/) (FCA) has warned that financial crime will become “even more prolific” as living costs increase. “They will adapt to exploit new weaknesses in the financial system,” FCA executive director Sarah Pritchard said in September. “They will constantly vary their tactics when targeting the vulnerable for fraud.” **Topics:** Public Awareness --- ### [Are you at risk of being hacked?](https://insurancefraud.org/news_archives/are-you-at-risk-of-being-hacked/) **Published:** September 18, 2026 **Author:** Diane Beauchamp **Content:** According to findings made by The Insurance Octopus, cyber crime currently costs the UK economy £1 trillion a year. Small to medium-sized businesses are reportedly the most at risk, with data from the Manchester-based insurance company revealing that over 65,000 attempted breaches per day impact businesses of this size. [![](https://staging.hrnews.co.uk/wp-content/uploads/2024/08/cybersecurity.jpg)](https://staging.hrnews.co.uk/wp-content/uploads/2024/08/cybersecurity.jpg)One small business is successfully breached every 19 seconds in the UK due to a lack of IT security infrastructure or trained IT professionals who are able to identify, react and neutralise potential threats. Large organised crime groups target smaller businesses that have fewer cyber security measures in place, utilising the access breach to spread to larger businesses within their supply chain. Small to medium-sized businesses find it difficult to afford robust enough cyber security technology, which is typically expensive, research conducted by The Insurance Octopus finds. In 2021, over a third (39%) of UK SMEs reported a cyber breach. Businesses across the UK also faced solvency issues, with 1 in 5 SMEs sharing that they had to pay associated costs as a result of a cyber attack. For National Security Day, The Insurance Octopus has created an interactive quiz, styled in a coder design, to put common knowledge surrounding cyber security to the test. The goal is to educate business owners on the importance of cyber security and help them to better protect themselves against hacking attempts and malware attacks. > **Christopher Ashton, Cyber Security Expert at The Insurance Octopus, gives advice to victims of scams, fraud or cyber breaches:** *‘Hackers are getting smarter with technology and detecting suspicious activity can sometimes go completely unnoticed. It’s important to have the right tools in place to protect your personal, business and financial information. Investing in cyber protection tools like antivirus software and cyber insurance will help give you the extra protection you need to keep your business out of danger.* > *‘If you’ve fallen victim to a scam, we recommend you contact Action for Fraud. You can report fraud or cyber crime to Action for Fraud any time of the day or night using its online fraud reporting tool. You can also report and get advice about fraud or cyber crime by calling 0300 123 2040.’* **Topics:** Public Awareness, Regulatory actions --- ### [Gateway Ambulatory Surgery Center Reports Leaked Patient Data Following Phishing Attack](https://insurancefraud.org/news_archives/gateway-ambulatory-surgery-center-reports-leaked-patient-data-following-phishing-attack/) **Published:** September 18, 2026 **Author:** Diane Beauchamp **Content:** On October 31, 2022, Gateway Ambulatory Surgery Center reported a data breach with the U.S. Department of Health and Human Services Office for Civil Rights after the company confirmed that patient data was leaked after a successful email phishing attack. According to Gateway, the breach resulted in the following patient information being compromised: names, Social Security numbers, driver’s license numbers, health benefit enrollment information, health insurance information, medical history, patient account numbers, and dates of service. Recently, Gateway sent out data breach letters to all affected parties, informing them of the incident and what they can do to protect themselves from identity theft and other frauds. If you were ever a patient of Gateway Ambulatory Surgery Center, your information may have been among that which was leaked in the recent data breach. If so, there is no telling who has access to your Social Security and other sensitive data. As we’ve discussed in prior posts, hackers have been relentless in targeting healthcare providers in 2022 in an effort to obtain patients’ Social Security numbers and protected health information. Once hackers have your information, they can either sell it on the dark web or use it to perpetrate a wide range of frauds, including healthcare identity theft. Patients affected by the gateway Surgery Center data breach may consider discussing their rights with a data breach lawyer, including the possibility of bringing a civil lawsuit in pursuit of monetary damages. What We Know About the Gateway Surgery Center Data Breach The available information regarding the Gateway Surgery Center breach comes from the U.S. Department of Health and Human Services Office for Civil Rights data breach portal, as well as a notice posted on the company’s website. According to these sources, on April 6, 2022, Gateway Surgical Center learned that it had been the target of what appeared to be a cyberattack that affected two employee email accounts. In response, the company launched an investigation, promptly confirming the unauthorized access. Once Gateway confirmed it was the victim of a cyberattack, management secured all computer systems, reset passwords, and then began working with a third-party data security firm to assist with the company’s investigation. This investigation revealed that the unauthorized party or parties first gained access to two employee email accounts on February 14, 2022, and that they continued to have access until May 10, 2022—almost a month after Gateway learned of the incident. The Gateway investigation also revealed that information belonging to certain patients was accessible through the compromised email accounts. Upon discovering that sensitive consumer data was made available to an unauthorized party, Gateway Surgery Center began to review the affected files to determine what information was compromised and which consumers were impacted. While the breached information varies depending on the individual, it may include your name, Social Security number, driver’s license number, health benefit enrollment information, health insurance information, medical history, patient account number, and dates of service. It was not until September 1, 2022 that Gateway determined the source of the breach was an email phishing attack. On October 31, 2022, Gateway Surgery Center sent out data breach letters to all individuals whose information was compromised as a result of the recent data security incident. More Information About Gateway Ambulatory Surgery Center Gateway Ambulatory Surgery Center is an outpatient surgery center located in Concord, North Carolina. The practice performs a range of outpatient surgeries, including those related to podiatry, gynecology, orthopedics, urology, pain management, cataracts and more. Gateway has a staff of more than 60 physicians. Gateway Surgery Center employs more than 71 people and generates between $5 and $25 million in annual revenue. **Topics:** Public Awareness, Technology --- ### [5 Predictive Models Revolutionizing Workers’ Comp and Helping Claims Managers Focus on the Human Element of Claims](https://insurancefraud.org/news_archives/5-predictive-models-revolutionizing-workers-comp-and-helping-claims-managers-focus-on-the-human-element-of-claims/) **Published:** September 18, 2026 **Author:** Diane Beauchamp **Content:** Predictive claims models have been transforming the ways workers’ compensation professionals do their jobs for a number of years now. Models can help detect which injured workers are likely to struggle with recovery, allowing claims managers to focus on helping them stay on track. They can also spot fraud and potential compensability issues. “Analytics and modeling augments the expertise of the claims professionals and allows them to focus on areas where they can have the greatest impact,” said Dave Dwortz, president and CEO, Helmsman Management, Liberty Mutual Insurance’s wholly-owned third party administration unit. As models continue to become more sophisticated over the coming years, they’ll play an even bigger role in the claims profession. These tools bring an additional benefit: attracting and retaining claims talent. In today’s intensely competitive labor market, many third-party administrators are investing in data analytics and predictive modeling tools to help streamline workflows and help case managers focus on helping injured workers heal. “There’s been a ton of innovation in predictive analytics and it’s having a significant impact on the claims profession. The models themselves are making quantum leaps in terms of the data that’s being leveraged to drive the models and the techniques employed to analyze all that data,” Dwortz said. “This allows the claims professional to intercede at the most impactful time on these claims.” Here’s a look at some of the predictive modeling tools claims professionals are relying on and how they’re evolving to become more sophisticated while harnessing the human element of claims management. ### **5 Predictive Models Workers’ Comp Professionals Are Relying On** Dwortz outlined five major types of predictive models that have helped workers’ comp professionals identify potential claims obstacles and intervene, driving better outcomes for injured workers during the process. **1) Early Severity:** The first model he detailed was the early severity model. This type of predictive model helps flag claims that have the potential to become high-risk and cost organizations more than $100,000. It has systems in place to flag at-risk workers’ comp cases at 30, 60, 90 and 180 days, so it can help claims professionals at any point during the process. “These models empower our claims people to produce better outcomes and better experiences by helping us identify potentially concerning claims early on in the workers’ compensation process,” Dwortz said. He’s found that this type of model can double the identification of high-risk claims. **2) Dual Strategy:** This model identifies claims with a lower likelihood of return to work, so claims professionals can think broadly about a variety of strategies for resolution. Dual-strategy models help identify those cases so that injured workers can make a full recovery. In one case, Dwortz saw the use of this type of model reduce claims reserves by $20,000. “Not all claims are going to follow a traditional path to return-to-work, and this model identifies some claims with characteristics that suggest they need a different path and brings our people in earlier to look and start thinking about other potential ways to find a resolution,” Dwortz said. **3) Compensability:** These models help identify claims early in the process that may not qualify for workers’ compensation benefits. This helps workers’ compensation professionals save time and resources and reduces confusion for people who are injured, and who can then use their group health benefits to cover any costs. “It allows our people to take another look and make sure that a good decision is being made early on in the claim process,” Dwortz said. **4) Fraud:** This year, the Coalition Against Insurance Fraud reported that workers’ compensation fraud costs the industry $32 billion per year. “Unnecessary expenses like fraud add to the costs for everyone,” Dwortz said. Models that detect potential instances of fraud are attempting to reduce these costs, with great success. Dwortz explained that predictive models are 20% better than the random sampling methods previously used to identify instances of fraud. **5) Subrogation:** Subrogation occurs when an insurance company requests reimbursement from an at-fault third party for an already paid, covered claim. So if an injured worker is, for instance, injured on the job due to a negligent third party, a TPA or carrier may pursue subrogation. Subrogation models help identify opportunities to recoup some of the costs of already-paid claims. “Our new models have increased our annual recoveries by 300% without increasing any cycle time or the expense involved,” Dwortz said. ### **Structured Versus Unstructured Data Models: How Predictive Models Continue to Improve** In addition to working with a number of different models to identify potential claims obstacles, workers’ compensation professionals are finding new ways to utilize data and analytics to improve existing models and build new ones. Right now, claims models rely primarily on two different types of data: structured and unstructured. Structured data is that which can be organized using a standardized format. “It’s data that fits nicely and neatly into a particular field,” Dwortz said. If you enter an injured worker’s age, gender or even their type of injury into a form, you’re using structured data. Unstructured data, on the other hand, “includes the original sources of information like imagery, claim notes, emails, calls, billing records — all of the unstructured things that fall into a claims file,” Dwortz explained. Things like notes about potential biopsychosocial factors an injured worker may be dealing with or notes about specific comorbidities fall into the unstructured data camp. Investments in new technologies and artificial intelligence are helping workers’ comp professionals incorporate more unstructured data into their models, gleaning key insights about a variety of factors that influence claims outcomes. “Studies have shown that, by 2025, unstructured data is expected to comprise 85% of the available claims data,” Dwortz said. “The newer models and the models that we’ve invested in developing are tapping into the unstructured data, which is far and away the fastest-growing source of information.” ### **Using Predictive Models to Attract and Retain Claims Staff** Organizations across the workers’ compensation industry are finding that investments in predictive models and data analytics are key to attracting and retaining claims talent in this highly competitive labor market. Even before the term “[Great Resignation](https://riskandinsurance.com/employees-leaving-in-droves-the-great-resignation-warrants-a-serious-look-at-your-benefits-package/)” became part of everyday parlance, the workers’ compensation field — like much of the commercial insurance sector — was struggling to attract new claims professionals. Estimates from 2019 indicated that the insurance industry as a whole would need to fill [400,000 positions by 2020](https://riskandinsurance.com/improved-benefits-is-just-one-way-workers-comp-can-bridge-its-horrendous-talent-gap/). Now, that crisis has been exacerbated by new staffing challenges brought on by the pandemic, and it appears it may continue even as inflationary pressures and the potential for a recession put strain on the economy. A July survey from McKinsey found that [40% of employees](https://www.mckinsey.com/capabilities/people-and-organizational-performance/our-insights/the-great-attrition-is-making-hiring-harder-are-you-searching-the-right-talent-pools) were thinking about leaving their jobs within three to six months — a figure nearly identical to statistics from 2021. “In terms of the labor market today, people are oftentimes the most prized asset,” Dwortz said. In today’s hyper-competitive labor market, younger, more technologically savvy workers are considering a company’s ability to harness the power of data analytics to make work more efficient and to drive performance insights. “We’ve found providing claims professionals with the best possible tools has a direct impact on overall job satisfaction and engagement,” Dwortz said. “Continuously improving and refining our predictive models has become an important part of our talent strategy.” These models free up claims professionals to focus on helping injured workers — something that’s particularly appealing to millennial and Gen Z workers who repeatedly state their desires for [jobs where they can make an impact and help others](https://time.com/6176169/what-young-workers-want-in-jobs/). “By putting more holistic information in their hands earlier in the process, it allows claims professionals to spend the time where they can have the most impact. It also allows them to focus more on the human aspects of a claim,” Dwortz said. “There’s always another person on the other end of this who’s vulnerable, who’s injured, and the models really help our people gather what can be gathered, provide the insights, point us to areas that may cause concern and focus more on the person at the other end of the phone who needs our help.” **Topics:** Coalition Against Insurance Fraud, Public Awareness, Technology --- ### [Psychiatrist in Missouri pleads guilty to conspiracy linked to healthcare fraud](https://insurancefraud.org/news_archives/psychiatrist-in-missouri-pleads-guilty-to-conspiracy-linked-to-healthcare-fraud/) **Published:** September 18, 2026 **Author:** Diane Beauchamp **Content:** A psychiatrist from Missouri on Tuesday pleaded guilty in front of U.S. District Judge Sarah E. Pitlyk to a felony conspiracy charge and admitted that Medicare, Medicaid, and other insurers lost more than $3.8 million based on fraudulent reimbursement claims submitted by clinical laboratories that he owned. Dr. Franco Sicuro, 67, of Chesterfield, has also agreed to forfeit $3.1 million from various sources. Sicuro ran, owned, and served as the medical director of or was associated with healthcare businesses including Millennium Psychiatric Associates LLC (MPA), Advanced Geriatric Management (AGM), Centrec Care, Sleep Consultants of St. Louis LLC, Midwest Toxicology Group, Genotec Dx and Benemed Diagnostics LLC. In 2014, AGM was certified under the Clinical Laboratory Improvement Amendments (CLIA) and was then allowed to perform quantitative lab testing. That same year, Sicuro and Carlos Himpler opened another lab, Genotec, that was in the same building as AGM but would bill insurance companies as a separate, “out-of-network” lab. To obtain CLIA certification for Genotec, Himpler and AGM staff falsely stated that AGM and Genotec operated as separate labs, although AGM and Genotec shared one part-time employee, the same medical director, and the same testing equipment, Sicuro’s plea agreement says. Without the CLIA certification, Genotec could not perform any clinical lab testing. Sicuro also admitted in his plea that he chose to remain “deliberately ignorant” of the fact that his financial interest in Genotec was concealed from private health care insurers, Medicare, and Medicaid. As a result, the insurers did not know that Sicuro and employees of AGM were referring patients for urine tests to a lab in which Sicuro had a financial interest. Sicuro also admitted that he and other health care providers at AGM, MPA, Sleep Consultants, and Rest Easy of St. Louis LLC, a company run by Himpler, ordered clinical lab tests, including urine toxicology tests, that AGM and Genotec then sent to outside “reference” laboratories for more sophisticated testing that would show the quantities of drugs instead of simply detecting their presence, as AGM’s lab equipment did. AGM or Genotec paid the reference labs about $125 for a test and then billed insurers significantly more but did not disclose to the insurers that neither AGM nor Genotec had performed the tests. Medicare, Medicaid, and many private insurers would not have paid the “pass-through billing” claims had they known about it, Sicuro’s plea says. In 2015, Sicuro and Himpler incorporated Midwest, which they held out as a clinical testing lab although it did not have the equipment, staff, or supplies necessary to perform tests. Further Midwest was not certified by CLIA or authorized to perform tests of human specimens. Sicuro admitted that he and Himpler knew Midwest was a lab in name only but caused Midwest to bill for clinical lab tests. Sicuro further admitted that he either knew or was willfully blind to the fact that Himpler used Genotec’s CLIA certification number on reimbursement claims submitted by Midwest, deceiving health insurers into believing that Midwest performed the tests. Genotec and Midwest also frequently “split-billed;” each submitted a claim for the testing of the same specimen obtained from the same person on the same day of service. Sicuro is scheduled to be sentenced on February 8. He faces a penalty of up to five years in prison and will be ordered to repay the money. “Providers engaging in fraudulent schemes not only compromise the integrity of essential federal health care programs but also waste valuable taxpayer dollars,” said Special Agent in Charge Curt L. Muller with the Department of Health and Human Services, Office of Inspector General (HHS-OIG). “Alongside fellow law enforcement agencies, HHS-OIG holds accountable bad actors who exploit these programs for personal gain.” The case is pending against Himpler, 51, of the Baton Rouge, Louisiana area. He has pleaded not guilty to charges of conspiracy, healthcare fraud, and money laundering. The case was investigated by the FBI, the U.S. Department of Health and Human Services Office of Inspector General, and the IRS. Assistant U.S. Attorneys Dorothy McMurtry, Amy Sestric, and Kyle Bateman are prosecuting the case. **Topics:** Healthcare Fraud, Medicare/Medicaid **Categories:** Conviction --- ### [Target 11 investigation into data breach leads to new state law](https://insurancefraud.org/news_archives/target-11-investigation-into-data-breach-leads-to-new-state-law/) **Published:** September 18, 2026 **Author:** Diane Beauchamp **Content:** An exclusive Target 11 investigation into a massive data breach last year has led to a new state law meant to protect every citizen of the Commonwealth. Target 11 Investigator Rick Earle broke the story of that data breach last April and now because of his reporting, state lawmakers passed legislation requiring timely notification of data breaches. The governor recently signed the legislation into law. “We would not be here today having this conversation without the reporting of you and your team at WPXI,” said state Sen. Kristin Phillips-Hill, a Republican from York, Pennsylvania. Target 11 first reported more than a year ago that the personal and health information of 100,000 Pennsylvanians had been compromised. The information included names, addresses and personal health information about residents, including children. Target 11 tracked down several people in western Pennsylvania who were on the list. They were surprised that their information was in the public domain. “I’m very angry that I have like, this information is just out there. I’m also very disturbed because who else has access to this information?” said Zari Price, whom we spoke with in Washington County. The spreadsheets obtained by Target 11 included the personal information about residents across the state who had tested positive for COVID-19. They also included personal information and health data for people who had been in contact with a positive case. The state initially told Target 11 it wasn’t a big deal, and that it had been dealt with, but when Target 11 showed them multiple spreadsheets with the information, a spokesman for the state Health Department admitted it was an issue. Target 11 reached out to lawmakers, who were unaware of the massive data breach. “And Rick, it was you who brought this to our attention — not the Department of Health or the Commonwealth of Pennsylvania. It was your reporting. I can only imagine how I would have felt if my child’s personal information was found online. So and then to have to hear about it through a story on TV as opposed to directly from the state. I believe it was a complete failure,” said Phillips-Hill. After our exclusive report, the state terminated its $30 million contract with Insight Global. The Atlanta, Georgia-based company accused employees of failing to secure the data. It led to legislative hearings, a class-action lawsuit against the company and a brand-new law. That law requires state, county and municipal agencies, and public schools that experience a data breach to notify all those impacted within seven days. It also requires notification to the Pennsylvania attorney general within three days. “I mean this is exactly what government should be doing: working together for the common good of every resident of the Commonwealth of Pennsylvania. And look Rick, we love your reporting but a data breach in state government should result in state government notifying its victims,” said Phillips-Hill. **Topics:** Legislation, Public Awareness, Technology --- ### [Telltale Bullets, Exhumations, Staged Murders: Most Shocking ‘Accident, Suicide Or Murder’ Reveals](https://insurancefraud.org/news_archives/telltale-bullets-exhumations-staged-murders-most-shocking-accident-suicide-or-murder-reveals/) **Published:** September 18, 2026 **Author:** Diane Beauchamp **Content:** Investigations into deaths are dynamic and not always straightforward. Conclusions made early on in an inquiry can be reversed as new evidence turns up and witnesses come forward. [“Accident, Suicide or Murder,”](https://www.oxygen.com/accident-suicide-or-murder) which returns **Saturday, November 26 at 8/7c** on **Oxygen**, is all about covering cases with dramatic twists and turns. Some stories seem like accidents but end up being the result of deadly intentions, and vice versa. Before Season 4 of the series returns with new cases, here are five of the most unforgettable outcomes from the first three seasons. **Man fakes his murder so family gets insurance payout** [William Young](https://www.oxygen.com/accident-suicide-or-murder/crime-news/william-youngs-nashville-car-bomb-death-was-suicide), a 43-year-old family man who worked in the computer field, was killed in July 2004 when his car exploded in a parking lot near a Nashville resort. The entire property was swept for more explosive devices. None were found, and investigators eventually ruled out terrorism. Had he been murdered or did he kill himself? Investigators found no indication from the physical evidence and Young’s autopsy that he had been forced into the car before it exploded. They did find his wedding ring at home. They also turned up searches for bombs on his computer. Detectives learned that Young had been fired from his job and kept that a secret from his wife and friends for two years. He was deeply in debt. In a letter to his wife, he expressed his love for her and their son and mentioned his life insurance policy. He had bought the $1 million policy on July 15 and was notified that it was in effect four days later. He died on July 20. They eventually determined that Young, who was under severe stress, died by suicide. He tried to mask it as a murder so his family could collect his life insurance benefit. **Pastor killed his wife, not an accidental fire** On December 26, 1997, 28-year-old Dawn Hacheney was found dead in her bed at her home not far from Seattle, Washington. It initially appeared that her life had been snuffed out in a fire while her husband, [Nick Hacheney](https://www.oxygen.com/accident-suicide-or-murder/crime-time/accident-or-murder-pastors-wife-found-dead-in-bed-after-fire), a local pastor, was out hunting. But the fact that Nick bounced back quickly from his wife’s tragic death and had multiple love interests, some reaching back to before Dawn’s death, raised investigators’ suspicions. It was also determined that the fire was believed to have been caused by a space heater and the result of arson. Plus, toxicology reports showed that Dawn, who had no smoke in her lungs, was dead when the fire began. Nick Hacheney was sentenced to life in prison in 2003. Due to a technicality, his sentence was overturned in 2007. He was re-sentenced in 2008 to 26 years in prison. **Telltale bullet reveals a woman didn’t shoot herself** On October 31, 2014, [Tim Noble](https://www.oxygen.com/accident-suicide-or-murder/crime-news/tim-noble-murdered-fiancee-debbie-holden-staged-suicide) called 911 dispatch in Jacksonville, North Carolina to report that he had come home from work and discovered his fiancée, 58-year-old Debbie Holden, dead from a gunshot wound to the head. Police arrived and found a .38 caliber revolver at her side. The bullet, which had clearly exited her body, could not be found. Noble told authorities that Debbie suffered from chronic pain, but even so her death shocked him. Her death was ruled a suicide. Ten days later, Noble, who was found to be involved with another woman, arrived at a local hospital seeking treatment for a bullet in his left thigh. He said it ended up there when someone had thrown ammo into a campfire. An X-ray of the bullet, which was located in a spot in Noble’s thigh precluding surgery, matched the type of projectile that killed Holden. He was arrested for her murder, and trial, prosecutors drove home the point that Holden had no gunpowder residue on her the day she died. Noble was sentenced to life without the possibility of parole. **Staging a murder as a mishap with help from TV** On December 19, 2001, a 911 call made shortly before midnight reported that 84-year-old [Marina Calabro](https://www.oxygen.com/accident-suicide-or-murder/crime-news/anthony-calabro-plots-murder-of-marina-calabro-for-money-with) had fallen down stairs to her death at her home in Quincy, Massachusetts. Had she slipped and tumbled while taking out the trash? Marina’s body had been found by Anthony Calabro, her 19-year-old great-nephew, who lived in the house and stood to inherit much of her estate. He and a friend, Thomas Lally, 21, had returned to the home after being out all day and then discovered Marina, they said. The possibility of a woman in her mid-80s accidentally falling to her death was not hard to accept. But the young men’s stories — identical enough to sound rehearsed — raised red flags. So did an autopsy that showed Marina died by blunt force trauma, which shifted the investigation. Detectives figured out that Anthony Calabro planned the murder, and Lally carried it out. Jason Weir, another slacker pal, helped stage the body using information learned from watching TV. All three young men were sentenced to time behind bars. **Exhumation shows woman died by her own hand, not her husband’s** In September 1995, when 76-year-old [Josephine Galbraith](https://www.oxygen.com/accident-suicide-or-murder/crime-news/josephine-galbraith-death-family-prove-suicide-not-murder) was found dead in her bed in Palo Alto California, she was still bleeding from cuts to her wrists and elbows. A sash was wrapped around her throat. A razor and a knife were found near her body. Nelson Galbraith, her husband, said he had slept through the event. The scene made investigators question how she could have killed herself in this fashion. The fact that Josephine faced serious health issues, including Parkinson’s disease, added credence to the idea that she might kill herself, though. Police listed the manner of death in their report as a possible suicide, while the coroner investigator’s preliminary ruling was that Josephine had died from self-asphyxiation. Palo Alto police announced that they were investigating the case as a homicide, and that Nelson was considered a suspect Nelson’s case went to trial in August 1998, and prosecutors argued it was physically impossible for Josephine to have killed herself. The defense, meanwhile, argued that Nelson’s own health issues prevented him from being able to tie the knots. Nelson was found not guilty. A year later Nelson sued the state and his wife’s body was exhumed. A second autopsy confirmed the death as a suicide. **Topics:** Public Awareness --- ### [Alabama calls off execution after difficulties inserting IV](https://insurancefraud.org/news_archives/alabama-calls-off-execution-after-difficulties-inserting-iv/) **Published:** September 18, 2026 **Author:** Diane Beauchamp **Content:** Alabama’s execution of a man convicted in the 1988 murder-for-hire slaying of a preacher’s wife was called off Thursday just before the midnight deadline because state officials couldn’t find a suitable vein to inject the lethal drugs. Alabama Department of Corrections Commissioner John Hamm said prison staff tried for about an hour to get the two required intravenous lines connected to Kenneth Eugene Smith, 57. Hamm said they established one line but were unsuccessful with a second line after trying several locations on Smith’s body. Officials then tried a central line, which involves a catheter placed into a large vein. “We were not able to have time to complete that, so we called off the execution,” Hamm said. It is the second execution since September the state has canceled because of difficulties with establishing an IV line with a deadline looming. The U.S. Supreme Court cleared the way for Smith’s execution when at about 10:20 p.m. it lifted a stay issued earlier in the evening by the 11th U.S Circuit Court of Appeals. But the state decided about an hour later that the lethal injection would not happen that evening. The postponement came after Smith’s final appeals focused on problems with intravenous lines at Alabama’s last two scheduled lethal injections. Because the death warrant expired at midnight, the state must go back to court to seek a new execution date. Smith was returned to his regular cell on death row, a prison spokesperson said. Prosecutors said Smith was one of two men who were each paid $1,000 to kill Elizabeth Sennett on behalf of her husband, who was deeply in debt and wanted to collect on insurance. The slaying, and the revelations over who was behind it, rocked the small north Alabama community Alabama Gov. Kay Ivey blamed Smith’s last-minute appeals for the execution not going forward as scheduled. “Kenneth Eugene Smith chose $1,000 over the life of Elizabeth Dorlene Sennett, and he was guilty, no question about it. Some three decades ago, a promise was made to Elizabeth’s family that justice would be served through a lawfully imposed death sentence,” Ivey said. “Although that justice could not be carried out tonight because of last minute legal attempts to delay or cancel the execution, attempting it was the right thing to do.” The U.S. Supreme Court cleared the way for Smith’s execution when at about 10:20 p.m. it lifted a stay issued earlier in the evening by the 11th U.S Circuit Court of Appeals. But the state decided about an hour later that the lethal injection would not happen that evening. The postponement came after Smith’s final appeals focused on problems with intravenous lines at Alabama’s last two scheduled lethal injections. Because the death warrant expired at midnight, the state must go back to court to seek a new execution date. Smith was returned to his regular cell on death row, a prison spokesperson said. Prosecutors said Smith was one of two men who were each paid $1,000 to kill Elizabeth Sennett on behalf of her husband, who was deeply in debt and wanted to collect on insurance. The slaying, and the revelations over who was behind it, rocked the small north Alabama community Alabama Gov. Kay Ivey blamed Smith’s last-minute appeals for the execution not going forward as scheduled. “Kenneth Eugene Smith chose $1,000 over the life of Elizabeth Dorlene Sennett, and he was guilty, no question about it. Some three decades ago, a promise was made to Elizabeth’s family that justice would be served through a lawfully imposed death sentence,” Ivey said. “Although that justice could not be carried out tonight because of last minute legal attempts to delay or cancel the execution, attempting it was the right thing to do.” John Forrest Parker, the other man convicted in the slaying, was executed in 2010. “I’m sorry. I don’t ever expect you to forgive me. I really am sorry,” Parker said to the victim’s sons before he was put to death. According to appellate court documents, Smith told police in a statement that it was “agreed for John and I to do the murder” and that he took items from the house to make it look like a burglary. Smith’s defense at trial said he participated in the attack but he did not intend to kill her, according to court documents. In the hours before the execution was scheduled to be carried out, the prison system said Smith visited with his attorney and family members, including his wife. He ate cheese curls and drank water, but declined the prison breakfast offered to him. Smith was initially convicted in 1989, and a jury voted 10-2 to recommend a death sentence, which a judge imposed. His conviction was overturned on appeal in 1992. He was retried and convicted again in 1996. The jury recommended a life sentence by a vote of 11-1, but a judge overrode the recommendation and sentenced Smith to death. In 2017, Alabama became the last state to abolish the practice of letting judges override a jury’s sentencing recommendation in death penalty cases, but the change was not retroactive and therefore did not affect death row prisoners like Smith. The Equal Justice Initiative, an Alabama-based nonprofit that advocates for inmates, said Smith stands to become the first state prisoner sentenced by judicial override to be executed since the practice was abolished. The U.S. Supreme Court on Wednesday denied Smith’s request to review the constitutionality of his death sentence on those grounds. **Topics:** Judicial/courts **Categories:** Conviction --- ### [Jury finds former PlayBig Therapy co-owner not guilty in Medicaid fraud trial](https://insurancefraud.org/news_archives/jury-finds-former-playbig-therapy-co-owner-not-guilty-in-medicaid-fraud-trial/) **Published:** September 18, 2026 **Author:** Diane Beauchamp **Content:** A former owner of a Tallahassee facility that helps children with development delays was acquitted on Medicaid fraud charges in a case that took numerous legal turns over the past few years. Rachel Scharlepp, a former owner of PlayBig Therapy, was found not guilty Nov. 3 at the conclusion of a four-day trial in Leon Circuit Court. Jurors deliberated for only about half an hour before returning their verdict. “This would prove her absolute innocence,” said Tom Findley, one of her attorneys. “She’s a devoted health care expert on children’s mental health issues, and it’s great that she’s going to be able to continue to provide those services that are beneficial to the community.” Scharlepp was arrested in 2017 on charges of racketeering and Medicaid fraud after an investigation by the Florida Attorney General’s Office. State investigators alleged she hired employees who weren’t qualified to provide targeted case management and that children who received services weren’t eligible to get them. In 2018, then-Leon Circuit Judge Martin Fitzpatrick, now a federal magistrate judge, dismissed all charges against Scharlepp. However, the government appealed, and in 2020, the 1st District Court of Appeal reversed his decision and remanded the case for trial. The investigation into PlayBig, which uses play therapy to help children with autism and other issues, came to light in 2016, when the state temporarily suspended its Medicaid reimbursements amid the investigation. At the time, PlayBig, located on West Shannon Lakes Drive, was forced to turn away tearful parents whose children were on Medicaid. **Topics:** Judicial/courts, Medicare/Medicaid **Categories:** Arrest --- ### [Alleged Lili Xu murder-for-hire gunman Hasheem Bason pleads not guilty](https://insurancefraud.org/news_archives/alleged-lili-xu-murder-for-hire-gunman-hasheem-bason-pleads-not-guilty/) **Published:** September 18, 2026 **Author:** Diane Beauchamp **Content:** Hasheem Bason, a Stockton man who allegedly was hired to slay Oakland dentist Lili Xu, has pleaded not guilty to a laundry list of charges including three that could led to imprisonment for life without parole. Xu was killed in a brazen daylight Oakland Saigon neighborhood shooting as she exited her car on August 21st. The slaying triggered a wave of outrage from neighborhood residents and Oakland police increased patrols in the area. The murder was captured on surveillance video. In the warrant, investigators gave a chilling description of what happened. Nelson Chia, Xu’s partner, was driving the vehicle when it pulled up to park in the 1000 block of 5th Ave. “The surveillance footage showed a white Lexus sedan parked on the side of the street several minutes before the murder,” investigators said. “Xu and Chia arrive in Xu’s vehicle driven by Chia and park on the curb. Moments later the white Lexus sedan pulled away from its parked spot less than a block behind and pulled up next to Xu’s parked vehicle.” “The front passenger of the Lexus exited, walked around the rear of Xu’s vehicle touching the trunk area with his hand, and confronted her as she exited the front right passenger seat of her car. A struggle ensued, the suspect shot Xu, and fled back to the front right passenger seat of the Lexus as it sped away. Chia observed the entire incident.” Xu was transported to the hospital and died from her gunshot wounds. As the investigation unfolded, Chia was identified as a suspect. Xu had $12-$14 million worth of property and assets from life insurance policies, trusts, LLCs, real property and accounts. With her death, Chia took control of the estate. Investigators identified the license plate number of the Lexus used by the gunman from the surveillance video. The Lexus was then tracked to a dealership in Stockton and investigators learned that Bason was in possession of the vehicle at the time of the murder. “Cell phone records uncovered communications between Nelson Chia and Hasheem Bason starting in July of 2022 to present,” investigators said in the warrant. “Further communications after the murder between Chia and Bason demonstrate that Chia conspired with Bason to murder Xu for financial gain.” Both men were taken into custody, but within hours, Chia had committed suicide in his cell at Santa Rita jail. Bason was identified as the suspected shooter from DNA off a bullet cartridge and from the trunk of Xu’s car. He allegedly held onto the murder weapon, and it was seized during a raid on his Stockton home. He is charged among other crimes with the special circumstances of killing for financial gain, slaying while lying in wait and use of a firearm. Any of the three carry with them a death sentence or life without parole. **Topics:** Life Insurance **Categories:** Arrest --- ### [Protecting yourself from cyber fraud](https://insurancefraud.org/news_archives/protecting-yourself-from-cyber-fraud/) **Published:** September 18, 2026 **Author:** Diane Beauchamp **Content:** While the rise in internet usage is good news, one cannot ignore that there is an ugly side to it as well, which is frauds and cyber crimes. A look at the data shows that the number of cases registered for cyber crimes have been consistently on the rise and more than doubled in the last five years. While the rise in internet usage is good news, one cannot ignore that there is an ugly side to it as well, which is frauds and cyber crimes. According to NCRB data, in 2021, India registered 50,242 cases of cyber crimes, amounting to a loss of a whopping Rs 167.03 crore. Of the cases registered, 4,823 cases were of online banking fraud, 4,071 were identity theft cases, 2,028 OTP fraud cases and 1,176 belonged to cyber stalkings alone. A look at the data shows that the number of cases registered for cyber crimes have been consistently on the rise and more than doubled in the last five years. In 2017, there were just 21,796 cases registered. While guidelines are being issued from time to time by country’s central bank-RBI to practice safe online activities and banking and adoption of various mea-sures like deploying password managers, deleting saved passwords on primary devices, any cyber-attack can result in a huge financial loss for companies and individuals and that is where having a cyber insurance become all the more important. ![](https://insurancefraud.org/wp-content/uploads/image-20-9.jpg)**WHAT IS CYBER INSURANCE** A cyber-insurance is a kind of insurance that provides coverage against financial losses caused by many hazards of the digital age, including malware attacks, phishing, identity theft, social media breaches, email spoofing, etc. “With the widespread digitisation and internet penetration, threats of cyber-attacks are on the rise. A comprehensive cyber insurance policy can protect individuals against cyber risks,” says Subramanyam Brahmajosyula, Head – Underwriting & Reinsurance, SBI General Insurance. **WHO OFFERS IT** One can take coverage against cyber attacks by the likes of both public and private insurers- HDFC Ergo, Tata AIG, ICICI Lombard, SBI Insurance and New India Assurance. HDFC Cyber sachet policy offers a comprehensive range of cover, providing 360-degree protection to its customers against the uncer-tainty of the cyber world. Similarly, SBI general insurance has CyberVault Edge policy and Cyber Defence Policy. The coverage starts from upwards of Rs 10,000. The premium depends on the coverage chosen. **CUSTOMISATION** The good news is the policies offered by the insurance players can be bundled up by a customer as per his/her require-ment. They can pick, choose and make their own plan. For instance, if someone wants coverage only against online shop-ping, online sales and Identity theft from HDFC Ergo, he has to shell out Rs 1,251 for a sum assured of Rs 1 lakh. For a Rs 10 lakh coverage, this goes up to Rs 2,677. Sanjay Kaw, President, Commercial Business, HDFC ERGO General Insurance tells Entrepreneur India, “In retail cyber, one can customize their preferred cyber insurance plan. There are options available where one can select covers as per their needs and requirements. In ad-dition, there is also an option to extend the cover to their family.” **LOW AWARENESS ABOUT INSURANCE PRODUCTS** Despite cybercrime being identified by the World Economic Forum as “one of the most significant threats confronting countries in the next five years, there is still not enough awareness on cyber networkinsurance products. “The trend slightly changed post-pandemic when more and more people had to adopt online mode in their personal and professional lives. Also, in order to make it more relevant to the present market scenario, insurers have also adjusted the underwriting and pricing of these products. But the basic characteristics of cyber insurance make it difficult for insurers to draft and price policies that cover a wide range of risks. Many insurers are attempting to market stand-alone cyber insurance to aug-ment, if not replace, coverage included in traditional ordinary policies, which were most likely not designed to protect against today’s fast-changing cyber risk scenario.” adds Kaw. As per Data Security Council of India (DSCI), the cyber insurance market is expected to grow globally at a CAGR of 27% from INR 29,400 crore in 2017 to INR 1.59 lakh crore in 2024. **HEALTHCARE THE MOST VULNERABLE SECTOR** Not only banks, financial institutions, but many startups, from Software as a Service (SaaS), fintech, insuretech to life science enterprises, have sensitive customer data that must be secured.. “Amongst industries the most vulner-able one is healthcare as it often con-tains some of the most sensitive data that hackers could obtain, and ill and elderly people are much easier targets for online scams and thefts. However, there is an increase in exposure and claims from other industries like hospital-ity, manufacturing, IT, etc,” says Kaw. Concurs Brahmajosyula “With most of the corporates /sectors leaning towards digitisation, almost all sectors are prone to cyber risks. Hence, eventually the cyber insurance products will be relevant for all sectors.” **FACTORS TO CONSIDER** It is important to review the coverage, limit of liability, deductible and waiting time to assess cybersecurity rules and strategy,” says Kaw. However, for compa-nies, factors to consider include the kind of information the organisation gathers or handles, current methods of data storage and backup, and if the company places a high value on confidentiality. **Topics:** Public Awareness, Technology --- ### [The rise of shallowfakes](https://insurancefraud.org/news_archives/the-rise-of-shallowfakes/) **Published:** September 18, 2026 **Author:** Diane Beauchamp **Content:** A‘shallowfake’ is a form of disinformation produced to validate a non-truth. In the insurance fraud world, examples include digitally altering the details on a driving licence or editing a legitimate invoice to inflate costs. Any form of disclosure evidence has the potential to be a shallowfake, but the crucial differentiator between a shallowfake and any other false document is the manipulation of genuine, pre-existing media. We are becoming more familiar with the term shallowfake, as well as the better-known ‘deepfake’, as we learn more about fake news and the processes that sit behind the way false information is produced. Both refer to deception through the manipulation of media but while deepfakes involve the use of advanced artificial intelligence (AI) software, shallowfakes can be created with basic image editing software. Increased coverage of fake news has generated new ideas and opportunities for fraudsters to exploit. On the flip side, this has taught us all to scrutinise what we are told and shown. It seems these two opposing factors have resulted in an increase in the prevalence of shallowfakes being identified across the industry. Types of shallowfake Shallowfakes can be video, document or image based. A fraudster might use one to obtain insurance cover or to benefit financially from a fraudulent claim, transaction or acquisition of property. It might be a one-off attempt by one individual to defraud, or a more sophisticated fraud perpetrated repeatedly by networks of organised criminals. Shallowfakes usually fall into one of two categories: Proof of identity/address – such as photo ID documents like driving licences or passports and national insurance cards, utility bills or bank statements, which are used as evidence to prove who a person is. Supporting evidence – such as invoices, contracts and agreements, expert reports, accident damage and injury photos, which would be produced as evidence to support a claim or transaction. Technology is already being used to help identify shallowfakes, either through basic metadata validation or pixilation variance analysis. Unfortunately, the technology is less effective at spotting shallowfakes than the more complex deepfakes. This is due to the distinct coding patterns created by AI. Furthermore, even the most advanced detection software is easily bypassed through simple file formatting changes such as resaving an image as a PDF or printing a hard copy version and taking a photo of it. Human intuition and visual assessment remain the most important guardian against shallowfakes but it is their basis in reality that makes them hard to identify, especially by employees who have large volumes of disclosure to process and who are under pressure to make quick decisions on liability positions and settlement offers. How to spot it The true clues often lie in the finer details. One example is an individual who presented a bank statement to prove a transaction. The overall statement balance did not add up from that transaction onwards, despite it calculating perfectly beforehand. Another example is a scanned colour copy of an individual’s driving licence, complete with a licence number containing one too many digits and an unusual format. Common issues noted within shallowfakes are: Font changes and misalignments, inconsistent backgrounds and light sources, colour variations and ‘blemishes’. Hints of the original media still existing underneath. Signs of warping within paper creases or backgrounds of images. Miscalculated financial transactions/totals. Context – do the contents fit with everything else known? However, often the alterations are too subtle to be visually obvious. Equally, such inconsistencies could be the result of poor but legitimate reformatting. Fully investigating suspected shallowfakes involves a comparison against what ‘genuine’ looks like, cross-checking against other evidence and, where appropriate, contacting the source and requesting confirmation that the document and details provided match those held on official record. New tools The digital age is developing rapidly. We are seeing the evolution of new image creation tools, such as Open AI DALL-E and Google Brain’s Imagen, which use AI technology to generate realistic images using strings of words. Despite their legitimate purposes and no confirmation of such tools being used to validate fraudulent insurance claims to date, the potential impact they could have is clear – from the creation of false ID documents through to fabricated accident scenes and images of damaged vehicles or property. Insurers currently rely on human instinct, attention to detail, awareness and knowledge to check the validity of what is being processed. But now might be the right time to reassess internal system processes for disclosure validation across both policy and claims teams. Implementing enhanced authentication processes, such as video identification tools, document QR codes or the requirement to provide original images and audit trails tracking back to the source, will undoubtedly enhance an insurer’s protection against this threat. However, this must be balanced against the impact such implementations would undoubtedly have on claim lifecycles and the customer journey. When reviewing disclosure evidence for now, we must apply the same logic we use when we scrutinise the legitimacy of online media appearing to show a celebrity or politician in compromising scenarios, or when we consider the accuracy of social media ‘news’. **Topics:** Public Awareness, Technology --- ### [Man reports fake break-in but forgets police on Spain’s Costa del Sol had visited him that night](https://insurancefraud.org/news_archives/man-reports-fake-break-in-but-forgets-police-on-spains-costa-del-sol-had-visited-him-that-night/) **Published:** September 18, 2026 **Author:** Diane Beauchamp **Content:** A FUENGIROLA man who claimed thieves broke into his home and stole a €450 watch later admitted to police it was a home insurance fraud. The 51-year-old man reported the theft of the watch eight days after the alleged break-in, saying his front door had been forced open. The plot soon unravelled when police investigated the crime and realised that that same night a patrol car had called at his home. A neighbour had raised the alarm after he saw the door ajar. National Police surmised that he was too drunk to remember that fact. The local police had even asked him if he was the owner of the home on that night of October 20. He responded he was but had forgotten the keys, which was why he had to break into his own home. The man then lost his watch at a local festival and must have had the brainwave he could blame it on the break-in. He marched to the police station and reported the stolen watch. With that police ‘denuncia’ he headed off to his insurance company to get financial restitution. But following the investigation, National Police found out about the fraud attempt and arrested the accused. Under questioning, he admitted he had made up the break-in story to get the cash back from his home insurance premium. Police revealed that the man had committed similar crimes in the past. **Topics:** Homeowners - fake **Categories:** Arrest --- ### [One honest worker exposes massive insurance fraud in South Africa](https://insurancefraud.org/news_archives/one-honest-worker-exposes-massive-insurance-fraud-in-south-africa/) **Published:** September 18, 2026 **Author:** Diane Beauchamp **Content:** A PRASA investigation has uncovered a multi-million rand scam involving bogus insurance claims. The scam was uncovered because of the honesty of one of PRASA’s lowest-paid people. Zethembiso Dladla came forward after an additional R67,000 was deposited into her account. The payment was supposedly for an insurance claim in which Dladla was injured while using a train. But as she told PRASA, she hadn’t used the train, wasn’t injured and had never put in a claim. In its most recent annual report, for 2021/2022, the Passenger Rail Agency of South Africa (PRASA) reported a “flood of fictitious personal liability claims” and says that an investigation regarding these complaints is underway. GroundUp has seen a leaked PRASA investigation report into fraudulent claims worth at least R9-million, processed by the insurance department at PRASA. This report to PRASA executives, the Hawks and the Auditor-General from September last year uncovered a fraud ring operating out of the commuter rail agency’s insurance office. An honest person breaks the scam On 28 May, PRASA paid R67,000 into Zethembiso Dladla’s bank account. This was considerably more than the R1,500 she received in her last salary payment. Dladla, from Durban, worked for the Peoples’ Responsibility to Protect (PR2P) programme, PRASA’s quasi-volunteer initiative launched by Transport Minister Fikile Mbalula and PRASA chairperson Leonard Ramatlakane in March 2021. PR2P recruited local community members — “volunteers” — to guard rail infrastructure near to where they live. In return, they would receive training and a “stipend” of R3,000 per month, according to the PR2P implementation plan approved by Ramatlakane on 4 January 2021. Dladla reported the R67,000-deposit to her line manager, Thandeka Mnyandu, saying it was an error. The next day, Dladla received a call from Sidudzo Mayaba, who said that PRASA had given her this money by mistake, and asked her to come with him to Gateway Mall. In her 8 June 2021 affidavit, Dladla said that she had known Mayaba for two years through her boyfriend and knew he worked for PRASA in some or other capacity. There, they transferred R55,000 to an account with the reference “Monde”. She was told that she could spend R5,000 of what remained, and she transferred R2,000 to her boyfriend. Dladla did not feel comfortable with what had happened and approached a Durban PRASA security detail with her story. Soon after, investigators began uncovering a multi-million rand scam run from within PRASA’s insurance division. The payment came from PRASA’s Insurance department, and was registered as compensation for an injury that Dladla had supposedly sustained at Isipingo train station in January 2019. But Dladla had never suffered any injury. She told the investigators that she’d never used the train. The investigators discovered that the claim reference number attached to the payout, which appeared to come from the KwaZulu-Natal claims system, did not exist on that province’s system. Mandatory pieces of documentation were also missing: Dladla’s medical records, the claims form itself, and the APS (application payment schedule), which needs to be signed by the official requesting the payment and approved by another official. Even though required documents were missing, three members of the finance department signed off on the claim. Dladla was not the first to be used in this scam. But she was the first to speak out. An eight-year scam PRASA’s investigators discovered that Sidudzo Mayaba, the man who had called Dladla, took her to the bank and instructed her on what to do with the money, was the former brother-in-law to Sihle Mayaba, who handled claims in PRASA’s insurance division. The investigators dug into Sihle Mayaba, and were approached by a whistleblower. The whistleblower told them that they had been a runner for Sihle Mayaba. They collected ID numbers and bank statements, mostly from unemployed people, and handed them over to her “for processing”. These people would receive money from bogus claims manufactured by Mayaba. Like Dladla, they would then transfer most of the money into another account. Most often this would be the account of Zodwa Khanyeza, a relative of Sihle Mayaba. Sometimes they would withdraw cash, which was then given to Mayaba. The whistleblower told the investigators that the scam had been running since 2014. A deep rot in the insurance department The investigators then proceeded to analyse the claims made in Gauteng and KwaZulu-Natal for the first half of 2021. In Gauteng, they discovered that in a single month, Sihle Mayaba had submitted APSes for seven claims worth a total of R495,000 that did not exist in the Gauteng claims management system. Mayaba’s superior, Tilly Nkosi, senior manager in the insurance division, had signed off on these claims. The investigators discovered more irregular payments. They discovered 39 claims worth over R3-million that had fraudulent reference numbers. The system adds claim numbers sequentially, from “00001” up. The investigators found that these claims had numbers well over the current number. They also discovered 44 claims worth over R5-million that had an invalid number of digits — three instead of five. The investigators concluded that these claims were processed based on fraudulently generated claim numbers. A member of the finance department also processed one claim three times, worth a total of R131,000. In KwaZulu-Natal, 15 irregular payments worth R952,000 were found. Twelve of these payments did not appear in the provincial claims management system. There was a duplicate payment, and two had claims that did not match the accidents and medical records. In total, in the first half of 2021 alone, the investigators found fraudulently-processed claims worth over R9-million. Administrative failure PRASA’s insurance claims system was ripe to exploit. The investigators found that the department’s rules were circumvented easily — a claim could be processed without the required documents, and even then, those documents were easily modified or forged. The people that should have been reviewing documents before authorising payments did not do their jobs. Claims weren’t checked against medical records. Payments were authorised without all the required signatories. The controls that should have kept fraudsters at bay were not present. The investigators single out the supervisory failures of Nkosi, and Tokolle Mahlake, the general manager of the insurance division. The investigators recommend disciplinary action against Sihle Mayaba and Sidudzo Mayaba, and Nkosi and Mahlake as managers in the insurance division, and a finance manager, Thabiso Phori, for processing duplicate claims and signing off on Dladla’s fraudulent claim. They also instructed PRASA to open a criminal case, launch a full investigation into fraud in the insurance department, and recover the stolen money. The honesty of one person, in the lowest-paid role at PRASA, may have saved the beleaguered rail agency millions of rands. Requests for comment GroundUp approached PRASA’s spokesperson Andiswa Makanda with a number of questions, and a request to forward our inquiries on to the people implicated in this fraud – in particular Sihle Mayaba, Sduduzo Mayaba, Tilly Nkosi, Thabiso Phori, and Tokolle Mahlake. While our questions and requests were noted, and we offered a day’s extension, we have not yet received a response at the time of publication. We asked if disciplinary steps had been taken against these officials, and if so, what the sanctions were, and if any of these people were still working at PRASA. We asked if a criminal case had been registered, and if so, what was the status of the investigation. We asked if a full internal investigation into the fraud had been completed, and what the total value of the fraud was that the investigation had discovered. And we asked if PRASA had addressed the weaknesses in their administrative system that allowed the fraud to be perpetrated. UPDATE ON 2022-11-18 14:51 — After publication PRASA’s Andiswa Makanda sent the following response: “PRASA Management and the Board are rebuilding the organisation into a credible institution to ensure that it is able to deliver on its legal mandate. “To this effect, several investigations into misconduct, maladministration, corruption, and fraudulent activities have been instituted to address lapses that enabled systematic corruption within the organisation and to ensure consequence management for those who have been found guilty. “Disciplinary processes of those suspended pending various investigations are at various stages. “Details of the outcomes of the various investigations in the business will be shared at an appropriate time. “We are also working with the Hawks and Special Investigating Unit in finalising their investigations on other matters.” **Topics:** Public Awareness, Regulatory actions --- ### [Farrer Park Hospital fined S$58,000 over data breach affecting medical information of 2,000 people](https://insurancefraud.org/news_archives/farrer-park-hospital-fined-s58000-over-data-breach-affecting-medical-information-of-2000-people/) **Published:** September 18, 2026 **Author:** Diane Beauchamp **Content:** Farrer Park Hospital has been fined S$58,000 over a data breach that led to the confidential medical information of almost 2,000 people being automatically forwarded to a third party. In a judgment dated Sep 15 and released on Friday (Nov 18), the Personal Data Protection Commission (PDPC) gave more details about the breach and its decision to impose the financial penalty on the private hospital. The leak happened over a span of almost two years — between March 8, 2018 and Oct 25, 2019. The hospital notified the commission about the breach in July 2020 after receiving a complaint in October 2019. Among the 3,539 past, present or prospective patients whose personal data was leaked, 1,923 people had their medical information disclosed as well. Farrer Park Hospital claimed that none of the data was misused, but the PDPC did not accept this as a factor in reducing the penalty. ## WHAT HAPPENED A total of 9,271 emails had been automatically forwarded from two Farrer Park Hospital employees’ Microsoft Office 365 work email accounts to a third party’s email address. These employees worked in the marketing department, which processed requests for the hospital’s medical services via email. They could log into their email via a web browser. The requests contained personal data pertinent to prospective patients’ medical treatments, including their names, genders, National Registration Identity Card numbers, passport details, contact numbers and medical information. The medical information included health condition(s), diagnosis, medical history and medical reports such as X-rays. When the first instance of data breach happened in March 2018, the hospital had not implemented multi-factor authentication, which required staff to key in a one-time password sent to their registered mobile number when accessing their work email accounts from a new device. On Oct 24, 2019, the hospital’s IT help desk received a complaint that one of the marketing employees’ email accounts could not send outgoing emails. While checking on the complaint, the help desk discovered that Office 365 had automatically imposed restrictions on the email accounts as part of a security feature due to unauthorised access. Further investigations confirmed that the email accounts had been configured to automatically forward all incoming emails to the third party, which was not identified in Friday’s judgment. #### Related: The PDPC found that the hospital failed to implement reasonable security arrangements to protect the leaked personal data from the risk of unauthorised access and disclosure. Farrer Park Hospital should have put in place stronger measures to manage its marketing department’s work email accounts because it received and processed sensitive personal data of a large volume daily, the commission added. Such measures can include enhanced access controls for the department’s web-mail access, a separate web portal for the department to collect sensitive medical information, and processes to regularly move such information from the email accounts to a more secure system. While the PDPC noted that the automatic forwarding of emails in Microsoft Office 365 is a known security risk, it gave the hospital the benefit of the doubt that a lack of guidelines, standards and benchmarks may have affected its assessment of the risks. “However, there must be no doubt that failure to make reasonable assessment of the risks from email auto-forwarding within an organisation is breach of the Protection Obligation that would, in future cases, be met with the appropriate enforcement action,” the commission added. In deciding what financial penalty to impose, the PDPC considered some mitigating factors. After the breach came to light, the hospital took immediate remedial actions and fully cooperated during investigations. It also had various security measures in place before the data was leaked, and conducted data protection and cybersecurity training for its employees. The remedial actions it took were: - Disabling the auto-forwarding feature for end-users - Increasing the frequency of internal cybersecurity training and exercises - Implementing additional technical email and network security measures - Refreshing and upgrading its existing network security measures The hospital, in seeking a smaller penalty, said that it appointed a private forensic expert who had monitored the Internet and dark web from February to April 2020 and did not find any unauthorised disclosure of the personal data involved. The hospital also did not receive any complaints from the affected individuals. However, the PDPC said the lack of evidence of further exploitation, use or disclosure did not merit a reduction of the penalty. In response to CNA’s queries, Dr Timothy Low, chief executive officer of Farrer Park Hospital, said it immediately addressed the data breach in 2019 and informed all affected patients. Dr Low added: “The privacy, safety and wellbeing of our patients continue to be our utmost priority and we are committed to protecting their personal data at Farrer Park Hospital. “We have since strengthened our IT security measures and increased the frequency of cybersecurity training and exercises internally. “Please be assured that there was no impact on our hospital operations. We take this incident very seriously and deeply regret the inconvenience caused to the affected patients.” On Oct 1 this year, the maximum amount that a company can be fined for a data breach was increased to either 10 per cent of its annual turnover in Singapore or S$1 million, whichever is higher. Previously, organisations that violate the Personal Data Protection Act would face a financial penalty of up to S$1 million. **Topics:** Public Awareness, Regulatory actions, Technology --- ### [Digitalization will not reduce fraud in PhilHealth](https://insurancefraud.org/news_archives/digitalization-will-not-reduce-fraud-in-philhealth/) **Published:** September 18, 2026 **Author:** Diane Beauchamp **Content:** The Inquirer’s editorial of Nov. 11 reported that an Aboitiz Group-led consortium had submitted a P1-billion unsolicited proposal to digitize the claims process of the corruption-plagued Philippine Health Insurance Corp. (PhilHealth). Aboitiz InfraCapital President Cosette Canilao said digitalizing PhilHealth’s claims process is a crucial step in addressing the problem of corruption and incompetence in the state health insurance company. The *Inquirer*’s editorial of Nov. 11 reported that an Aboitiz Group-led consortium had submitted a P1-billion unsolicited proposal to digitize the claims process of the corruption-plagued Philippine Health Insurance Corp. (PhilHealth). Aboitiz InfraCapital President Cosette Canilao said digitalizing PhilHealth’s claims process is a crucial step in addressing the problem of corruption and incompetence in the state health insurance company. In 2006 an eye doctor in Iloilo filed claims amounting to P16 million in professional fees for 2,071 operations. In 2014, a Malalag, Davao del Sur infirmary with only an 18-bed capacity received P18 million for claims, and almost P10 million in just the first semester of 2015. There is the case of a patient in a hospital in Region 1. The patient, as well as both her parents, had cancer. The family was reimbursed P1.7 million. However, an investigation found out the family was non-existent. The Commission on Audit found out that PhilHealth paid P20.3 million in hospital expenses of 961 dead patients. Digitalizing PhilHealth’s claims process will not solve the problem of corruption in the state insurance company. It will just speed up the payment of fraudulent claims. In the insurance business there is what is called moral hazard. It is the tendency of the insurance policy holder to increase the probability of the occurrence of a loss or damage because the compensation is greater than the loss. For example, the owner of an insured vacant and rubdown building may increase the risk of the building burning down because he will gain from the insurance compensation. In health insurance moral hazard is multiplied threefold as the professional and the healthcare facility may be parties to the fraud. An example is the insured patient with a common cold asking a physician to recommend his hospital confinement. Doctors with slow or poor practices would be inclined to recommend confinement of individuals with feigned illness, and private hospitals with low bed occupancy rate would just be too ready to admit them. As PhilHealth pays on the basis of a package, the doctor and the hospital would bill PhilHealth for pneumonia instead of just for a common cold. PhilHealth reimburses hospitals P6,600 and doctors P1,980 for pneumonia, and P2,800 and P840 for common cold. Digitalization will not recognize the falseness of the claim of pneumonia, it will only speed up its processing and its payment. Moral hazard takes on greater magnitude when medically indigent people — those who cannot afford even the most basic healthcare service — are insured. According to the Department of Health, there are 38 million Filipinos who are medically indigent. Faked hospital confinement means free meals and a real bed for the indigent enrollee and revenue for the healthcare providers. When I was with a health insurance company, we received claims for whole families. We looked into the reason for this unusual sets of claims filed by a hospital in the province. Our inquiry revealed that when the children visited their father, a field employee of a geothermal company, in the hospital, they noticed he was served three good meals every day, slept on a comfortable bed in an air-conditioned room, amenities better than those in their own home. The children, who were also insured as dependents of the employee, found reasons, mostly mild ailments, to be confined as well, even for just a couple of days. As the children blabbed about their juvenile scam to the children of their father’s co-workers, the other children pulled off the same scheme. Some doctors, even those practicing in prestigious hospitals, can be unethical, if not greedy. In 2014, fraudulent claims filed by doctors and hospitals, both private and public, including the major medical centers in Metro Manila, against PhilHealth were estimated at P4 billion. But the greater fault with regard to the payment of fraudulent claims lies with PhilHealth. According to PhilHealth Vice-President Oscar Abad, Jr. there are 94.9 million Filipinos registered with the insurance company as of 2020. They include employees and their dependents, self-earning people, retirees and senior citizens, and indigents. The health insurance company I was with many years ago had 35,000 enrollees, 90% of whom were employees, the rest their dependents. An average of 6% of the insured filed claims during a one-year period, or an average of 2,100 claims were filed every year. Spread over 250 working days, the office received 8.4 claims each working day. There were three claims processors (they are called adjusters in the insurance industry), each one a registered nurse with at least one year experience as a nurse in a tertiary (Level 3) hospital. They could ask a licensed doctor retained by the company as consultant when some data in the claim did not seem right. Payment was made three days after the submission of all supporting documents — medical history, hospital charges, and professional fees. While the percent of claimants among PhilHealth enrollees may be significantly higher due to the inclusion of retirees, senior citizens, and indigents, for purposes of illustration we will use 6% as the rate of claimants per year among PhilHealth enrollees. With 94.9 million enrollees, the number of claimants each year could be 5.7 million. Spread over 250 working days, that is 22,776 claims filed each day. Claims are submitted to 17 regional claims processing centers. If the 22,776 claims were divided equally among 17 centers, each center could receive 1,340 claims a day. Each regional office needs a platoon of claims processors. A medical claims processor determines if the claim is valid or eligible for compensation. To do this, she verifies that a claim for pneumonia is really for pneumonia and not for a common cold. She determines this by looking at the results of the laboratory and diagnostic tests conducted and the medicine administered and reconcile them with the diagnosis. That reconciliation requires human intelligence. The processor must have strong analytical skills. She generally holds a bachelor’s degree in some medical field. Along with this, she has high level of healthcare experience. A registered nurse with at least one year experience in a tertiary hospital would be ideal. Department of Health Officer-in-Charge Maria Rosario Vergeire said last September that the country’s healthcare system lacks 106,000 nurses and also faces a shortage of professionals in the healthcare fields. It is highly probable that the PhilHealth processors lack the knowledge and experience required of a medical claims processor. While the PhilHealth processors are struggling to cope with the thousands of claims unloaded on their desks every day, the hospitals, strapped for cash, are putting tremendous pressure through a sympathetic press on PhilHealth to pay up the billions of pesos overdue them for past claims. When the situation reaches that point, both sides — the hospital administrators and the PhilHealth officials are forced to compromise. That is when agreements are forged outside of boardrooms. PhilHealth officials could have offered to pay for claims even if they had not been sufficiently or properly processed in exchange for some consideration. Hospital administrators badly in need of cash to fund the operations of their facility agree. Those agreements are not digitalized. Those side and private agreements account for the payment of thousands of fraudulent claims. Oscar P. Lagman, Jr. was country manager for the Philippine operations of a multinational health insurance company in the 1980s. As a consultant in 1988, he set up the health insurance line of the local partner of a London-based non-life insurance company. In 1999, he set up the health insurance line of the Philippine operations of yet another London-based insurance company. He was program director of the Executive Development Program the De La Salle Graduate School of Business conducted in 2007 for 50 officers of PhilHealth. **Topics:** Public Awareness, Technology --- ### [Madhya Pradesh man gets father killed for insurance money](https://insurancefraud.org/news_archives/madhya-pradesh-man-gets-father-killed-for-insurance-money/) **Published:** September 18, 2026 **Author:** Diane Beauchamp **Content:** In a shocking incident, in Madhya Pradesh’s Barwani district, a man hired contract killers to murder his own father. He did this to get his father’s insurance money, police said on Saturday. The man had gone to a police station saying his 52-year-old father died after being hit by a vehicle. The police examined the CCTV footage of the area and concluded that he was murdered. The man has been arrested. On the day of the crime, the man informed the contract killers that his father had left for the morning walk. The police later arrested one Karan Shinde from Pune who told them the victim’s son had promised to pay Rs 2.5 lakh for the murder of the man. The man later confessed that he hired the killers to get Rs 10 lakh as the insurance sum. The police have also arrested two others for the crime. **Topics:** Life Insurance **Categories:** Arrest --- ### [Cedric Stephens | Making sense of the greedy pastor and life insurance](https://insurancefraud.org/news_archives/cedric-stephens-making-sense-of-the-greedy-pastor-and-life-insurance/) **Published:** September 18, 2026 **Author:** Diane Beauchamp **Content:** Last Sunday Gleaner’s article about the ‘second coming’ of Kevin Smith – the late leader of Montego Bay’s Pathways International Kingdom Restoration Ministries – created a shroud around the short piece about the expected life insurance payout following the killing of a church member. More column inches were devoted to the late pastor’s unlikely resurrection than to the losers in the plot, – the victim’s family members. Their losses will be in blood and money. On the other hand, the late pastor’s family seems likely to get the funds. He was named as the policy beneficiary. None of this made sense to me. My plan to use these articles as content for today’s column grew stronger after I read David Geddes’ letter to the editor. It was last Wednesday Gleaner’s letter of the day. He was replying to another reader’s question: What is the use of insurance? Mr Geddes is the director of stakeholder engagement, communication and international relations of the Financial Services Commission (FSC), which regulates non-bank financial institutions, including life and non-life insurance companies, and intermediaries. Mr Geddes did not explain the motivation for his response. It is unclear whether criticisms were levelled at the insurance industry and its products, the FSC, or all three. The substance of the response suggests that the regulatory body bore the brunt of the implied criticism about the utility of insurance. As I read Mr Geddes’s letter for the umpteenth time, I wondered why members of the $410-billion industry, its lobby, the Insurance Association of Jamaica, or their respective public relations agencies ignored a reasonable consumer question and allowed Mr Geddes to beat them to the punch. Information about how the Taneka Gardner life insurance claim was handled influences public perceptions about insurance, insurers, their products, and the FSC. The Observer’s November 2 article, ‘Rich and Wily’, reflects the beliefs of some persons about insurance, insurance products, and the FSC. The following parts are germane to this discussion: - Countless claims settlement delays and non-payment of claims led to the conclusion that the FSC does not regularly audit the claims process of local companies even though it investigates some consumer complaints. - The requested information from the FSC about insurers’ claims settlement ratios, average settlement times, and other settlement data. Two officials there said that such information was not kept by the FSC. It would be better to seek that data from the insurers or the Insurance Association of Jamaica. (The 2020 IAJ annual statistical report does not include this data.) - Insurance regulators in foreign jurisdictions keep settlement data information (and use it to inform minimum regulatory standards, develop standards, and make decisions about best practices). - The Taneka Gardner claim was a prime example of the dysfunctions in the local claims process. Her throat was slashed in 2021. Following her killing, relatives complained of being left in the dark for over a year regarding the details of her life insurance policy, from which they are anticipating a pay-out. - Other examples were cited to support the argument about excessive settlement delays. None of the newspaper’s FSC informants or Mr Geddes referred to the existence of the regulator’s February 2019 insurance market conduct guidelines. They establish minimum rules on how claims should be managed and claimants are to be treated. Even though the regulator has kept a database of policyholder complaints since its inception 21 years ago, it still has no clue, for example, about how much time insurers are, on average, taking to pay motor claims. The Financial Services Commission Act 2001 mandates the FSC, under Section 6(1), to promote stability and public confidence in the operations of the financial institutions that it regulates; public understanding of the prescribed institutions; and the modernisation of the financial services with a view to the adoption and maintenance of international standards of competence, efficiency, and competitiveness. The collection, analysis, and monitoring of claims settlement data are consistent with the FSC’s mandate. Ben Kingree’s and Louise Tanner’s 1994 article in the Tort & Insurance Law Journal, ‘Life insurance as a Motive for Murder’ – [www.jstor.org/stable/25762461](http://www.jstor.org/stable/25762461) – provided an explanation as to why the pastor’s family will not profit from Ms Gardner’s death: Life insurance policies procured with the intent to murder the insured are void ab initio (from the beginning) if procured with the intent to kill the insured. The lack of insurable interest has been a common basis for voiding insurance policies. One has an insurable interest in his or her own life and may name anyone as a beneficiary. An individual who obtains insurance on another’s life must have insurable interest if the insurance is for his/her benefit. Otherwise, the insurance is considered void, speculative, or a wagering contract and is against public policy. The presence of insurable interest must be predicated on the continued interest in the life of the insured based on ‘blood or affinity’ or a reasonable expectation of sustaining loss from the insured’s death. I do not have any details about the process in which the pastor was named as the beneficiary under Ms Gardner’s policy. Also, I am unsure whether the change in beneficiary complied with the provisions of the Insurance Act of 2001. The absence of this information plus the fact that I am not an attorney precludes me from offering an opinion about whether Ms Gardner’s family should be paid the insurance proceeds. Final words: I still do not understand why Guardian Life treated this matter of public interest as though it were a state secret. Was Kevin Smith the only rogue pastor preying on citizens? Ironically, the all-knowing ‘runkus’ clergyman did not know that the United Kingdom Parliament passed the Life Insurance Act of 1774. The law requires policyholders (and by extension beneficiaries) to have an insurable interest in the life insured. As for questions about the ‘second coming’ of the late Mr Smith, the answer is above my pay grade! **Topics:** Life Insurance, Public Awareness --- ### [Sisters in Law: What can I do if my data was leaked in the Medibank hack?](https://insurancefraud.org/news_archives/sisters-in-law-what-can-i-do-if-my-data-was-leaked-in-the-medibank-hack-2/) **Published:** September 18, 2026 **Author:** Diane Beauchamp **Content:** Welcome to Sisters In Law, news.com.au’s weekly column solving all of your legal problems. This week, our resident lawyers and real-life sisters Alison and Jillian Barrett from Maurice Blackburn advise about what you can do if your sensitive data is leaked on the dark web. Question: I have private healthcare with Medibank and I was a victim of the recent cyberattack on their stored data. In the past, I’ve had an abortion and I believe I’m one of the people who had their health data – including information about having an abortion – on the dark web. I’m not ashamed of having had an abortion but at the same time this is my private health information and I’m horrified that it’s out there for people to see. I feel violated and angry that this was able to happen. What next? These companies need to be held accountable. What can I do? – Anon, WA Answer: We are sorry to hear you are one of the millions of Medibank customers who have had their personal data stolen. You have every right to be concerned about the ramifications of this serious data breach. The Medibank data breach didn’t just involve sensitive health care information being accessed, it also involved customers’ names, dates of birth, phone numbers, email addresses and some Medicare and passport numbers. Some of this stolen data has already started to be posted on the dark web by a ransomware group which means the potential consequences for individuals affected could be significant. You should not search for any information or data that may have been released on the dark web. Instead, contact Medibank directly for information about what data may have been compromised. The stolen personal information could be used to create new accounts in your name, including credit cards, loans, and social media profiles. You need to be highly alert to any signs that your data could be being used, for example, unexplained charges from bank accounts, or emails from unknown companies. It would be prudent to change all your online account passwords. You can also contact the main credit reporting bodies and ask that they place a temporary ban on your information being accessed in a credit report, which will prevent fraudulent loan applications from being processed. The Scamwatch website provides additional recommendations for protecting personal information following data breaches. If you end up being a victim of identity fraud you can report this to the police. You should also contact the relevant company where your personal data was used and ask that the account be cancelled. If you are the victim of unauthorised bank transactions or loans, report this to your financial institution so they can investigate. It is likely they will reimburse you the lost funds. Report any unusual activity to Report Cyber and ensure all your devices and accounts have the latest security updates, including multi-factor authentication. IDCARE is a support centre that provides free assistance to victims of identity theft, such as helping to repair any damage caused to your reputation or credit history. The burning question on everyone’s lips is whether companies like Medibank can be punished for these kinds of data breaches. Companies that hold sensitive personal information are required to have safeguards in place to protect the information from unauthorised access. There has been significant debate over many years about Australia’s privacy laws, and the Commonwealth Government has acknowledged that we need to better regulate how companies collect and manage our personal data. The government has proposed changes that include increasing penalties for serious and repeated privacy breaches from $2.2 million to $50 million dollars or more. The Attorney-General’s department is also completing a review of the Privacy Act and it is expected that further recommendations for changes in the law will result. Whether or not Medibank (and other companies who have been hacked) will be found liable under the Privacy Act will depend on whether the breach was ‘serious’ or ‘repeated’, and whether they have taken ‘reasonable steps’ to protect the personal information. This will involve a lengthy and complicated investigation into the cybersecurity systems they had in place, how their system was hacked and whether they could have prevented the attack. It is not just Medibank’s conduct before the data breach that will be under scrutiny. They also have obligations to ensure they report any breach in a timely manner, and they take reasonable steps after the breach to protect the personal information, such as patching up system issues. In addition to any financial penalties on the company, affected customers like you could be successful in claiming money from Medibank for any financial losses caused by the breach. For example, you may be able to claim the cost of things like seeing a counsellor to help manage the stress associated with the breach, or the installation of security cameras in your home to make you feel safer. If you are unable to resolve your complaint with Medibank directly, you may wish to lodge a complaint with the Office of the Australian Information Commissioner. This legal information is general in nature and should not be regarded as specific legal advice or relied upon. Persons requiring particular legal advice should consult a solicitor. **Topics:** Public Awareness, Technology --- ### [Court remands Medical Doctor for N8.5m fraud](https://insurancefraud.org/news_archives/court-remands-medical-doctor-for-n8-5m-fraud/) **Published:** September 18, 2026 **Author:** Diane Beauchamp **Content:** Justice P. Ayua of the Federal High Court sitting in Port Harcourt, Rivers State has remand a Medical Doctor, Okeogene Rawlings Godwin in the Port Harcourt Correctional Service for obtaining money by false pretence contrary Section 1 (1) (a) and punishable under section 1 (3) of the Advance Fee Fraud and Other Fraud Related offences Act. He was remanded after pleading “not guilty” to a five count charge preferred against him and his Company, Rhurrs Limited, upon being arraigned by the Economic and Financial Crimes Commission EFCC, Port Harcourt Zonal Command on Monday November 21, 2022. One of the Count Charge reads: “That you Dr. Okeogene Rawlings Godwin and Rhurrs Limited on or about 30th of July, 2019 at Port Harcourt, within the jurisdiction of this honourable court, with intent to defraud did obtained the sum of Eight Million, Five Hundred Thousand Naira (N8,500,000.00), from Dr. Igwe Etomchi Chimdi and 13 others on the premise that you will pay them 35% for 35 days returns on the investment, a pretext you knew to be false and thereby committed an offence contrary to section 1 (1) (a) and punishable under section 1 (3) of the Advance Fee Fraud and other Fraud Related offences Act”. Another count reads: “That you Dr. Okeogene Rawlings Godwin and Rhurrs Limited on or about the 30th July, 2019 at Port Harcourt, within the jurisdiction of this honourable court, not being a public company, invited the public to deposit money with you for 20% interest as return on investment and thereby committed an offence contrary to section 67 (1) of the Banks and other Financial institution Act, 2020 and punishable under section 67 (2) of the same Act.” They however pleaded “not guilty” to the charges preferred against them by the EFCC. In view of their pleas, prosecution counsel, E. K. Ebipade, asked the court to fix a date for commencement of trial and urged the court to remand Dr. Godwin in the Correctional Service. Counsel to the defendant, M. J. Otokwala informed the court of his application for the bail of the defendant. “The bail application was filled this morning, in view of the circumstances, I pray the court for a short adjournment to enable me serve the prosecution properly”, he said. Justice Ayua ordered that the defendant be remanded in the Correctional Service and adjourned the matter to November 24, 2022 for hearing of bail application and continuation of trial. Trouble started with Godwin when the Commission received a petition against him and his company, Rhurrs Synergy Investment Limited, sometime in July 2019, for allegedly obtaining the sum of Eight Million, Five Hundred Thousand Naira (N8,500,000.00) from his victims under the pretext of investing in medical equipment, promising them 20% to 35% interest as return on investment. It was revealed that Godwin collected the sum of Eight Million, Five Hundred Thousand Naira (N8,500.000.00) from the investors but converted it to his personal use. **Topics:** Financial Fraud **Categories:** Arrest --- ### [Fake profiles used in insurance scam that netted Taranaki man $27k](https://insurancefraud.org/news_archives/fake-profiles-used-in-insurance-scam-that-netted-taranaki-man-27k/) **Published:** September 18, 2026 **Author:** Diane Beauchamp **Content:** A New Plymouth man authorised to sell insurance used elaborately detailed yet fake profiles to fraudulently obtain more than $27,000 in commissions. Heino Albert Jansen Van Rensburg owns and operates Accelerate Services Limited (ASL), which the New Zealand Companies Office describes as a financial service. In November 2018, Partners Life Limited (PLL), which sells health and life insurance through a network of independent advisors, entered into a business agreement with ASL. This authorised Jansen Van Rensburg to sell its insurance policies, in return for a commission. An online portal was available for the defendant to use to submit applications when required. The police summary of facts outlined how between May 5-7 last year, Jansen Van Rensburg lodged two fake applications. The first was filed on May 5, under the name “Clifford Miller”. Included in the application was “extensive personal information including date of birth, medical history, and employment information” of the fictitious client. The application set up an insurance policy for Miller, for which ASL was paid a commission of $12,685.84. PLL’s regular auditing picked up “several irregularities” with ASL’s clients, which led to a full review, looking for potential fraud, the summary of facts said. The investigation found all the details given regarding Clifford Miller had been falsified. It also found the bank account used to pay two of the monthly premiums connected to the policy came from a bank account which belonged to Jansen Van Rensburg. The second fraud detected related to a May 7 application the defendant made, using the names “Patal Singh and Preet Sekhon”. Based on fake details, an insurance policy was created for the duo, which netted Jansen Van Rensburg a $14,543.46 fee. When police spoke to the defendant, he admitted the offending and said he did it to avoid becoming homeless “in a time of crisis”. On Thursday, the 40-year-old appeared in the New Plymouth District Court, and pleaded guilty to a representative charge of obtains by deception. The charge carries a maximum imprisonment period of seven years. Judge Gregory Hikaka remanded Jansen Van Rensburg on bail to reappear for sentencing on February 17. The case was also referred to restorative justice. **Topics:** Insider Fraud, Life Insurance **Categories:** Arrest --- ### [NIC Collaborates with EOCO to Fight Insurance Fraud](https://insurancefraud.org/news_archives/nic-collaborates-with-eoco-to-fight-insurance-fraud/) **Published:** September 18, 2026 **Author:** Diane Beauchamp **Content:** The National Insurance Commission (NIC) from 22nd – 24th November, 2022, organised a training programme on Insurance Fraud for eighty-six (86) officers of the Economic and Organised Crime Office. Speaking at the Opening ceremony, the Deputy Commissioner of the NIC, Mr. Michael Kofi Andoh noted that knowledge in Insurance Fraud has become very necessary because of emerging crime trends in the area. He mentioned Claims Fraud, Operation of illegal insurance companies and siphoning as some of the challenges that the insurance industry has to deal with. He added that Insurance fraud affects the financial sector through loss of funds and worsens the economic situation of individuals and consequently, the country. Madam Jacqueline Aba Opoku, Deputy Executive Director for Intelligence and Monitoring, EOCO, mentioned that insurance is one avenue that people use to generate money to fund other criminal activities. “This is why EOCO is collaborating with the NIC to equip officers with the requisite knowledge to detect and apprehend fraudsters who engage in insurance fraud” She reiterated the fact that when crimes go unpunished, criminals became emboldened to continue their trade and enjoy the proceeds of the crime. It is therefore important that participants take the training seriously in order to gain the ability to be ahead of the criminals and also to be able to investigate and prosecute such crimes. In a brief closing ceremony on 24th November, 2022, Executive Director, COP Maame Yaa Tiwaah Addo-Danquah, said she was very grateful to the NIC for collaborating with EOCO to make the training a reality. She again said investigating insurance fraud requires officers to be open minded, not assume anything and always look out for red flags. Participants were privileged to be exposed to Fraud Scenarios in the Insurance Sector (worldwide), NIC Corporate Governance Guidelines, the Regulatory Framework for Prevention of Insurance Fraud, Risk Management Systems and Processes, the Role of Internal Operating Procedures, Intelligence and Investigation Tools and Techniques in Insurance Fraud and the Anti- Fraud Policy among others. **Topics:** Public Awareness, Regulatory actions --- ### [Gambler Steals $280K From Victims in Austria Through Insurance Scams](https://insurancefraud.org/news_archives/gambler-steals-280k-from-victims-in-austria-through-insurance-scams/) **Published:** September 18, 2026 **Author:** Diane Beauchamp **Content:** A minor report to the Police Inspectorate in Saalfelden, Austria, has uncovered a major scam. A 45-year-old from Burgenland reportedly cheated Hungarian workers out of hundreds of thousands of dollars in order to feed his gambling and cryptocurrency purchasing habits. In January of this year, a 24-year-old Hungarian seasonal worker reported to the police station because he thought he was the victim of a fraudster. The police determined that he was correct, and that he was far from the only victim. A subsequent investigation tracked down a 45-year-old unidentified man from Burgenland, Austria. By the time the police unraveled the mystery, they realized he had been able to siphon money from a number of victims. Phone Fraud For Fun The scammer looked for his victims on social media. Since he spoke Hungarian, most of his targets were Hungarian nationals who had worked in Austria and were now abroad again. Apparently, he was able to capture the first and last names of the victims and their dates of birth, focusing on those people who had “public” in the user profile in their social media profiles, such as Facebook. With that information, and with intimate knowledge of the Austrian tax system, he was able to redirect payments the individuals should have received. He paid different people €500 (US$521) to allow him access to their bank accounts. This way, he could split the transfers between accounts and avoid detection. Through the scam, the man was able to steal from at least 224 people between March 2020 and April 2022. From what investigators gathered, he took around €280,000 (US$291,844). It also caused a headache for Vienna-based A-Trust, a digital security solutions company. It offers ID protection services for consumers, which the thief exploited. The company helped bring the scammer down after police figured out what 16 people out of money between 2005 and 2022. Initially, these victims were friends whom he scammed through various bogus financial emergencies. He asked for money, falsely promising to repay the debt. When that well dried up, he sought out victims whom he promised profitable investments in cryptocurrencies. He even convinced some to take out loans to make the investments. These scams caused the victims a total loss of at least €220,000 (US$229,306). Police arrested and later released the man, but are charging him with fraud, money laundering, theft, and other crimes. Those who offered their bank accounts to him will face charges of money laundering. Online Scams Not Disappearing Almost since the arrival of the mainstream internet some 25 years ago, there have been online scams. Despite an increase in security measures and better technology, they are still rampant, as consumers continue to fall for the old tricks. Most recently, UK police have had to launch a campaign to inform as many as 200,000 people that they might have fallen for a banking scam. The BBC reports that the fraudsters called their victims claiming to be bank representatives, informing the “client” that his or her account suffered a breach. The thieves then asked for certain personal details and security information associated with the account. The targets handed over the information freely. One client reportedly lost £3 million (US$3.6 million) through the scam. Most people reportedly lost a couple of thousand dollars each. By now, consumers should know that no bank is going to call a customer and ask for someone’s banking details. However, some have apparently ignored the message. The good news with the UK banking scam is that police have already arrested more than 120 people who organized and led the fraud. Consumers aren’t the only ones who fall victim to digital scams. Even some of the biggest, most sophisticated companies in the world fail to properly protect their platforms. Gaming operator DraftKings is a perfect example, as it is now, once again, dealing with a public relations nightmare after a number of customers lost their holdings. **Topics:** Financial Fraud, Synthetic Identity Theft, Technology **Categories:** Arrest --- ### [Wright & Filippis Files Notice of Data Breach Affecting More than 877k Individuals](https://insurancefraud.org/news_archives/wright-filippis-files-notice-of-data-breach-affecting-more-than-877k-individuals/) **Published:** September 18, 2026 **Author:** Diane Beauchamp **Content:** On November 18, 2022, Wright & Filippis reported a data breach with the U.S. Department of Health and Human Services Office for Civil Rights as well as the California Attorney General after the company learned it had been the target of a ransomware attack. According to Wright & Filippis, the breach resulted in the names, dates of birth, patient numbers, Social Security numbers, financial account numbers, and health insurance information being compromised. Recently, Wright & Filippis sent out data breach letters to all affected parties, informing them of the incident and what they can do to protect themselves from identity theft and other frauds. Those who receive a “Notice of Data Breach” letter from Wright & Filippis have reason to be concerned, as data breach victims are at a much higher chance of falling victim to identity theft and other frauds. However, as we’ve discussed in previous [posts](https://www.myinjuryattorney.com/consumer-privacy-data-breach-lawyers/what-to-do-if-you-are-a-victim-of-a-data-breach/), there are steps you can take to reduce these risks. Further, if evidence emerges that Wright & Filippis was negligent in how it stored your data, you may be able to pursue a data breach lawsuit against the company. ## What We Know About the Wright & Filippis Data Breach The available information regarding the Wright & Filippis breach comes from the company’s filing with the Attorney General of California. While the company also provided notice to the Department of Health and Human Services Office for Civil Rights, the information posted on the HHS-OCR Data Breach Portal is limited. According to the data breach letter filed with the California AG, Wright & Filippis recently learned that it was the target of a cyberattack. The company discovered the attack shortly after it was conducted and thereafter enlisted the help of third-party experts to assist with the company’s investigation. The Wright & Filippis investigation confirmed that an unauthorized party was able to access—and potentially remove—files containing sensitive consumer information stored on its computer network. Upon discovering that sensitive consumer data was made available to an unauthorized party, Wright & Filippis began to review the affected files to determine what information was compromised and which consumers were impacted. While the breached information varies depending on the individual, it may include your name, date of birth, patient number, Social Security number, financial account numbers, and health insurance information On November 18, 2022, Wright & Filippis sent out data breach letters to all individuals whose information was compromised as a result of the recent data security incident. ## More Information About Wright & Filippis Founded in 1944, Wright & Filippis is a manufacturing company based in Rochester Hills, Michigan. The company specializes in the design and manufacture of prosthetics, orthotics, and accessibility solutions. Wright & Filippis operates approximately 18 retail stores throughout Michigan. Wright & Filippis employs more than 290 people and generates approximately $31 million in annual revenue. **Topics:** Public Awareness, Technology --- ### [Community Health Network data breach compromises medical info](https://insurancefraud.org/news_archives/community-health-network-data-breach-compromises-medical-info/) **Published:** September 18, 2026 **Author:** Diane Beauchamp **Content:** ## Community Health Network data breach overview: - **Who:** Community Health Network has disclosed that more of its patients’ information may have been collected and transmitted by third-party tracking technologies than it had intended. - **Why:** Community says the potentially problematic third-party tracking technologies were installed on its MyChart patient portal and appointment scheduling sites. - **Where:** Community Health Network has locations in central Indiana. --- Community Health Network has revealed it discovered third-party tracking technologies were installed on its website, including its MyChart patient portal and appointment scheduling sites. The tracking technologies were found to allow for a “broader scope of information to be collected and transmitted to each corresponding third-party tracking technology vendor” than Community had “ever intended,” [**according to Community**](https://www.ecommunity.com/notice-third-party-tracking-technology-data-breach). Community said it “immediately” began working with its service providers to disable and/or remove the technologies as it continued to investigate what they were collecting and transmitting. Information that could have been transmitted to third-party tracking technology vendors includes computer IP addresses, scheduled appointment information and information about an individual’s health care provider, among other things, according to Community. Community Health Network said has no indication any of its patients’ Social Security numbers, financial account numbers or debit or credit card information was compromised during the data breach. ## Community has disabled, removed all third-party tracking technologies on its patient-facing websites, applications The non-profit health system said it has disabled and/or removed all of the third-party tracking technologies on its patient-facing websites and applications as it continues to “evaluate how to further mitigate the risk of unauthorized disclosures of patient information in the future.” “We have also improved our evaluation and management processes for all website technologies moving forward,” Community said. Community said out of “an abundance of caution,” it has contacted any patients who have engaged with either its provider or an affiliated entity since April 6, 2017, the date it says it began implementing third-party tracking technologies. Patients who may have been affected by the data breach are being instructed to monitor their credit reports for unauthorized activity, place fraud alerts, and, if necessary, place a security freeze on their credit reports. A number of companies have agreed to settlements this year to resolve claims revolving around [**their handling of data breaches**](https://topclassactions.com/lawsuit-settlements/lawsuit-news/companies-agree-to-settlements-with-consumers-in-data-breach-class-actions/), including T-Mobile, LifeBridge Health and ClearBalance, among others. **Topics:** Judicial/courts, Public Awareness, Technology --- ### [Healthcare Data Breach At PA Rehab Center Impacts 130K](https://insurancefraud.org/news_archives/healthcare-data-breach-at-pa-rehab-center-impacts-130k/) **Published:** September 18, 2026 **Author:** Diane Beauchamp **Content:** Pennsylvania-based Gateway Rehabilitation Center [notified](https://www.prnewswire.com/news-releases/gateway-rehab-provides-notification-o) 130,000 individuals of a data breach that it discovered in June 2022. The nonprofit provides drug and alcohol rehabilitation services to individuals throughout greater Pittsburgh. On June 13, Gateway Rehab discovered an “incident disrupting access to certain systems” and immediately took steps to secure its systems. Further investigation revealed that the names, birth dates, Social Security numbers, medical information, health insurance information, and financial account information of current and former patients were potentially compromised. Despite HIPAA’s 60-day notification requirement, Gateway Rehab notified individuals of the breach on November 18. “Gateway Rehab takes the security of its patient information very seriously and has taken steps to help prevent a similar event from occurring in the future. ## Employee Improperly Viewed EHRs at University Medical Center of Southern Nevada University Medical Center (UMC) of Southern Nevada [notified](https://umcsn.com/getmedia/de46df72-9a28-45f7-8a9b-8a7bcafd2b8f/111122_Notification-of-Disclosure-Web.pdf) 1,861 individuals of a breach that occurred when a workforce member accessed EHR information without an appropriate reason for doing so. The incident came to light during a review conducted in September. UMC discovered that the employee had accessed patient records between May 19, 2021 and September 22, 2022. The data accessed potentially included demographic information, clinical information, and insurance information. “UMC has no evidence that any of the information involved was misused and does not believe the access was an attempt to compromise identities or to seek commercial gain,” the notice to patients stated. UMC stated that the employee is no longer employed by UMC, and the medical center has implemented additional policies to prevent future incidents, including training and education. ## Yakima Neighborhood Health Services Notifies 2.6K of Breach Washington-based Yakima Neighborhood Health Services (YNHS) notified 2,689 individuals of a data security incident. “On October 4, 2022, a file containing certain individuals’ personal and protected information was inadvertently distributed to one individual,” YNHS [explained](https://www.prnewswire.com/news-releases/yakima-neighborhood-health-services-notice-of-data-security-incident-301677645.html). “Upon learning of this accidental disclosure, YNHS took steps to ensure the recipient deleted the file from their possession.” The file contained names, birth dates, medical treatment locations, and medical record numbers. YNHS said it has no evidence that any information involved in the incident has been misused. “YNHS has taken steps in response to this incident and has made alterations to its cyber environment to help prevent similar incidents from occurring in the future,” the notice concluded. **Topics:** Public Awareness, Technology --- ### [Healthcare Data Breaches Doubled in 3 Years: Here's Why](https://insurancefraud.org/news_archives/healthcare-data-breaches-doubled-in-3-years-heres-why/) **Published:** September 18, 2026 **Author:** Diane Beauchamp **Content:** Federal statistics show that the number of individuals affected by the more than 5,000 major health data breaches since 2009 exceeds the total U.S. population, indicating that some people likely have been the unfortunate victims of more than one incident. And the situation seems to be growing worse. In fact, in just the last three years, the volume and frequency of breaches have nearly doubled, from 368 in 2018 to 715 in 2021. And the nation is on track for more than 700 major health data security incidents this year. As of Nov. 10, the Department of Health and Human Services’ “wall of shame” website that tracks health data breaches affecting 500 or more individuals shows 595 breaches posted so far in 2022, affecting more than 40 million individuals. > “Every industry and every subindustry in healthcare is seeing an increase in attacks. This isn’t going away.” > – Taylor Lehman, Google Cloud Hacking incidents top the list as the most common type of health data breach to be reported to regulators in recent years, and phishing scams, ransomware attacks and data extortion attempts affect tens of millions of individuals every year. “Every industry and every subindustry in healthcare is seeing an increase in attacks,” says Taylor Lehman, director of the Office of the CISO for Google Cloud. “We’re seeing increased attacks on medical devices. We’re seeing increasing attacks on life sciences organizations. We’re seeing it for a variety of reasons. This isn’t going away.” ![](https://insurancefraud.org/wp-content/uploads/image-20-1024x576.png)### Potentially Deadly Impact on Patient Care Many of these incidents don’t just compromise the privacy and security of individuals’ protected health information. Some result in significant IT system disruptions that interfere with patient care, potentially posing serious safety concerns. Just ask Kelley Parsi, an Iowa mother whose 3-year-old son Jay in October was inadvertently administered a megadose of medication during an unexpected visit to MercyOne Medical Center in Des Moines after the boy began experiencing complications following a recent tonsillectomy. When Parsi initially took the boy to the hospital, she was unaware that the medical center was one of several CommonSpirit Health facilities dealing with a ransomware attack that had forced electronic health records, e-prescribing and related IT systems to be taken offline. CommonSpirit Health, the nation’s fourth-largest provider, which manages 142 facilities across the country, sold MercyOne in September but still shares digital infrastructure with the hospital. Parsi says that with the hospital’s systems offline, hospital staff completed Jay’s medication orders manually. “Because the computer system was down … it was handwritten and they misread it,” she says, resulting in Jay receiving five times more medication than what was prescribed – and twice the amount that should have been prescribed based on his age and size. Upon discovering the error, the hospital kept the child under observation and flooded him with IV fluids before releasing him. Thankfully, he is fully recovered, Parsi says, but during her stay, hospital personnel had no access to her son’s medical records – instead relying on sticky notes. On three occasions, they offered to administer ibuprofen, which was against her doctor’s orders, and they struggled with converting his weight from pounds to kilograms, she says. “They’re working in the dark,” Parsi says. “I can’t even imagine how they were trying to navigate it.” Unfortunately, [CommonSpirit](https://www.healthcareinfosecurity.com/commonspirit-systems-still-offline-one-month-post-attack-a-20357%22) facilities affected by the ransomware incident still hadn’t fully recovered more than a month after the attack. CommonSpirit in a Nov. 9 statement posted on its website says it is continuing to manage response to the cyberattack still affecting some of its facilities. “Our teams continue to work diligently to bring systems online and restore full functionality as quickly and safely as possible, including electronic health records,” the statement says. Providers in the majority of markets now have access to the EHR across the CommonSpirit Health system, including hospitals and clinics, the statement says. In addition, most patients can again review their medical histories through the patient portal. “We are working to restore appointment scheduling capabilities to the portal in cases where that feature exists.” ### Growing Costs of Healthcare Breaches Besides the safety risks ransomware attacks can pose to patients, the incidents also hit healthcare entities where it can hurt most – their pocketbooks. For instance, last year, San Diego-based Scripps Health incurred $112 million in costs in the first month after a May 2021 ransomware attack – including nearly $92 million in lost revenue related to redirecting emergency room visits and postponing elective surgeries. The hospital paid another $21 million in incident response and recovery costs. On top of that, Scripps Health was hit with at least four class-action lawsuits within the first few weeks of the attack related to the compromise of personal information for nearly 150,000 patients. These lawsuits can result in millions of dollars in settlement costs and legal fees. And ransomware incidents are not the only reason healthcare entities are taking a financial hit. Georgia-based home healthcare and hospice provider Aveanna Healthcare is paying a total of nearly $1 million to settle a regulatory enforcement action and separate class action lawsuit against the company in the wake of a 2019 phishing incident that affected nearly 170,000 patients. That amount includes the $500,000 Aveanna this month paid to the commonwealth of Massachusetts to end state litigation tied to the data breach, along with agreeing to shell out $800,000 in cash payments and credit monitoring costs to class members of a federal lawsuit involving the same incident. ### Class Action Lawsuits on the Rise But the costs can run much higher for some healthcare entities that experience larger breaches. In one high-profile case, a 2015 breach at UCLA Health that affected 4.5 million patients, the university paid a $7.5 million to settle a consolidated class action lawsuit in 2019. The university agreed to set up a $2 million fund to pay patients for damages related to the release of information and to pay for credit monitoring for two years. The UCLA settlement was one of the first to require the organization’s IT department to invest in new security controls. “We wanted to make sure that they were doing some things over and above what they were already doing, based on the internal reporting we saw about what was going on there,” says attorney Jeff Westerman of Westerman Law, which represented plaintiffs in that case. Not only healthcare provider and hospitals getting slapped for breaches. The Massachusetts consent order against Aveanna in the company’s breach comes weeks after New York financial regulators struck vision health insurance giant EyeMed Vision Care with a $4.5 million fine to settle an investigation into a 2020 data breach incident affecting 2.1 million individuals nationwide, including nearly 99,000 New Yorkers (see: [*NY State Smacks EyeMed Vision with Another Breach Fine*](https://www.healthcareinfosecurity.com/ny-state-smacks-eyemed-vision-another-breach-fine-a-20326)). That fine was the second by the state against EyeMed. In January, the New York attorney general announced a $600,000 settlement with EyeMed for the same data security incident. The largest HIPAA enforcement fine so far by HHS’ Office for Civil Rights was $16 million in a settlement against health plan Anthem for a 2014 hacking incident affecting nearly 79 million individuals. More enforcement actions by state and federal agencies in the wake of health [data breaches](https://www.healthcareinfosecurity.com/breach-notification-c-327) such as the Aveanna and EyeMed incidents are highly likely to trend upward, says regulatory attorney Rachel Rose, who was not involved in either of those cases. That’s because regulators are paying increased attention to critical infrastructure, consumer rights and the more aggressive types of [ransomware](https://ransomware.databreachtoday.com/) and other cyberattacks, she says. Those regulatory actions in turn can fuel more civil litigation in breach cases, she says. “Plaintiff’s counsel can always use the existence of a government investigation or settlement as leverage to substantiate the likelihood of a material cybersecurity event,” she says. “From the defense standpoint, the timing of settlements, as well as utilizing any proactive compliance measures, is critical.” ### Focusing on Patient Safety Dave Summitt, vice president of cybersecurity at Florida Cancer Specialist And Research Institute, says security teams need to consider the safety of patients – not just the security of servers and the potential costs and downtime related to an attack. “It’s what’s going to happen to patient care if that server goes down,” Summit says. “That has to be first and foremost for any security team.” > “It’s a very, very scary thing.” > – Kelley Parsi, mother, Des Moines Parsi, who experienced the impact of ransomware firsthand with her son Jay, says the effect on patients is terrifying. “I’m confused as to why people are targeting hospitals and potentially trying to accidentally or maybe even intentionally kill people because of these medication errors – or just any error,” Parsi says. “It’s a very, very scary thing.” **Topics:** Public Awareness, Technology --- ### [Kaiser Permanente employee allegedly breaches EHR](https://insurancefraud.org/news_archives/kaiser-permanente-employee-allegedly-breaches-ehr/) **Published:** September 18, 2026 **Author:** Diane Beauchamp **Content:** Kaiser Foundation Health Plan of the Mid-Atlantic States has reported that it discovered unauthorized access to its electronic health record system that may have disclosed patient information for more than 8,500 individuals. “On September 21, 2022, Kaiser Permanente determined that one of its employees inappropriately accessed portions of medical records for patients in the Mid-Atlantic region without a reasonable basis. “An investigation determined that the former employee’s access was outside the scope of their permissible job functions,” according to the announcement the healthcare provider posted to its website. While no social security numbers or financial information were involved in this incident, there is no evidence that the accessed information – patient demographics and medical information, including photos – were shared or used to commit fraud, the company said in the statement. After an internal investigation, the employee is no longer working for the company. In addition to reporting unauthorized access to federal agencies, the company says it is reviewing policies governing access to patient medical records and has sent letters to affected patients. Earlier this year, the Health Sector Cybersecurity Coordination Center published a [threat briefing on the potential cybersecurity risks of EHRs](https://www.healthcareitnews.com/news/hhs-cyber-arm-warns-ehr-vulnerabilities) ranging from phishing attacks, malware and overlooked gaps in encryption to cloud threats and employees. “Healthcare leaders should understand where operational vulnerabilities exist in their organization, from marketing all the way down to critical health records,” said the U.S. Department of Health and Human Services’ cyber agency. **Topics:** Public Awareness, Technology --- ### [San Juan Regional Medical Center data breach class action settlement](https://insurancefraud.org/news_archives/san-juan-regional-medical-center-data-breach-class-action-settlement/) **Published:** September 18, 2026 **Author:** Diane Beauchamp **Content:** San Juan Regional Medical Center (SJRMC) has agreed to settle claims that certain personal information was exposed in a data breach identified Sept. 8, 2020. Class members include all individuals whose personal identifying information or health information was compromised in the Sept. 8, 2020, cyberattack. A subclass has been established, consisting of individuals who received a notice from San Juan Regional Medical Center that their personal information was exposed. Patients filed a class action lawsuit against San Juan Regional Medical Center asserting the healthcare provider did not do enough to protect patients’ data from exposure in the event of a data breach. San Juan Medical Center does not admit to any wrongdoing in response to these claims, but the healthcare provider has agreed to settle with plaintiffs in the interest of avoiding the costs and risks of continued litigation. The following patient information was potentially exposed in the breach: - Drivers license number - Passport number - Social Security number - Financial account number - Health information - Name - Date of birth - Other information All class members are eligible to receive two years of free identity theft and credit-monitoring services. In addition to these benefits, all members of the subclass are eligible to receive compensation for losses related to the cyberattack, totaling $2,500 in compensation. Covered losses include the following: - Compensation for out-of-pocket expenses caused by the cyberattack - Compensation for fees for credit reports, credit monitoring, or other identity-theft insurance product purchased after the subclass member received notice of the cyberattack through Oct. 13, 2022 - Compensation for demonstrated monetary losses related to the cyberattack, such as attorneys’ and accountants’ fees, and fees for credit-repair services - Compensation for lost time related to the cyberattack, compensated at a rate of $17.50 per hour, if at least one hour was spent dealing with the effects of the cyberattack Class members who wish to object to or exclude themselves from the San Juan Regional Medical Center class action lawsuit settlement must do so by Jan. 9, 2022. To receive class action settlement benefits from the SJRMC data breach, class members must file valid claims by Feb. 8, 2023. ###### Who’s Eligible Class members include all individuals whose personal identifying information or health information was compromised in the Sept. 8, 2020, cyberattack. A subclass has been established, consisting of individuals who received a notice from San Juan Regional Medical Center that their personal information was exposed. ###### Potential Award **$2,500 plus credit monitoring** ###### Proof of Purchase Subclass members must submit documentation of their expenses. The required documentation varies by type of expense, but examples include receipts, phone bills or account statements reflecting purchases made for credit-monitoring services. Self-prepared documents, such as handwritten receipts, will not be accepted. ###### Claim Form [CLICK HERE TO FILE A CLAIM »](https://hendersondatabreachsettlement.com/submit-claim) **NOTE:** If you do not qualify for this settlement do NOT file a claim. Remember: you are submitting your claim *under penalty of perjury*. You are also harming other eligible Class Members by submitting a fraudulent claim. If you’re unsure if you qualify, please read the FAQ section of the Settlement Administrator’s website to ensure you meet all standards (Top Class Actions is not a Settlement Administrator). If you don’t qualify for this settlement, check out our database of other [**open class action settlements**](https://topclassactions.com/lawsuit-settlements/open-lawsuit-settlements/) you may be eligible for. ###### Claim Form Deadline 02/08/2023 ###### Case Name *Henderson, et al. v. San Juan Regional Medical Center*, Case No. D-111-CV-2021-01043, in the 11th Judicial District, County of San Juan, New Mexico ###### Final Hearing 02/22/2023 ###### Settlement Website **[HendersonDataBreachSettlement.com](https://hendersondatabreachsettlement.com/)** ###### Claims Administrator SJRMC Claims Administrator 1650 Arch Street, Suite 2210 Philadelphia, PA 19103 info@HendersonDataBreachSettlement.com 855-778-8861 ###### Class Counsel David K Lietz MILBERG COLEMAN BRYSON PHILLIPS GROSSMAN PLLC ###### Defense Counsel Christopher G Dean MCDONALD HOPKINS LLC **Topics:** Judicial/courts, Public Awareness --- ### [Congress Calls For Federal Investigation Into HCA on Fraud Allegations](https://insurancefraud.org/news_archives/congress-calls-for-federal-investigation-into-hca-on-fraud-allegations/) **Published:** September 18, 2026 **Author:** Diane Beauchamp **Content:** The federal government [may launch an investigation](https://www.axios.com/2022/09/16/congress-federal-probe-hca-hospital-chain) into HCA, the largest for-profit healthcare company in the United States on [allegations of fraud. ](https://pascrell.house.gov/uploadedfiles/2022.09.13_bp_to_hca.pdf) HCA is one of the largest for-profit healthcare chains in the United States, with more than 180 hospitals. They also own health clinics for wound care, behavioral health, and surgery centers all over the U.S. Their recent profits are around $7 billion annually (according to their [2021 metrics](https://s23.q4cdn.com/949900249/files/doc_financials/2021/q4/PR_HCA-Healthcare-Reports-4Q-2021-Results.pdf)). Recently, the House oversight committee asked [for a federal probe](https://pascrell.house.gov/uploadedfiles/2022.09.13_bp_to_hca.pdf) or investigation into HCA for allegations of widespread fraud, specifically regarding their emergency department admissions. [Allegations](https://pascrell.house.gov/uploadedfiles/2022.09.13_bp_to_hca.pdf) include, - Admitting patients who didn’t need emergency care - Having corporate admission targets - Understaffing - Preventable patient deaths ## **Medicare Fraud Allegations** In a [letter from Bill Pascrell](https://pascrell.house.gov/uploadedfiles/2022.09.13_bp_to_hca.pdf), the chair of the oversight committee, he claimed that HCA had accrued $1.8 billion in excess revenue from Medicare from the unnecessary admissions to the E.D. He goes on to mention that “HCA’s average staffing levels trail the national average by 30 percent.” The letter was sent to HCA Healthcare CEO Samuel Hazen requesting documents to explain the numbers by providing supporting material. The overcrowding with unnecessary admissions and short staffing ratios leads to risk for subpar patient care that has led to “preventable patient death and infection control breakdowns,” Pascrell further explained in his letter. In another [letter, Pascrell wrote to the U.S. Department of Health and Human Services](https://pascrell.house.gov/uploadedfiles/2022.09.13_bp_to_hhs_re_hca.pdf) explaining the need for further investigation. One of the HCA hospitals is currently at risk of being terminated from the Medicare program, and complaints from workers in HCA facilities have prompted the investigation of fraud. The letter further explains that the complaints from HCA workers included retaliation threats if admission goals are not met and that the emergency care is handled by a private emergency practice called EmCare to provide emergency physician staffing. Pascrell also points out [current peer-reviewed research](https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3964725) involving an HCA facility and other for-profit hospitals, supporting that Medicare patients are more often admitted to emergency departments at for-profit hospitals than in non-for-profit hospitals. ## **Former Settlements** This isn’t the first time HCA Healthcare has been accused of fraudulent activities. HCA has the record of the [largest healthcare fraud case](https://www.justice.gov/archive/opa/pr/2003/June/03_civ_386.htm) ever taken by the Justice Department. So far, the government has recovered $1.7 billion from HCA Healthcare. “Health care providers and professionals hold a public trust, and when that trust is violated by fraud and abuse of program funds, and by the payment of kickbacks to the physicians on whom patients and the programs rely for uncompromised medical judgment, health care for all Americans suffers,” Robert D. McCallum, Jr., Assistant Attorney General for the Civil Division [said](https://www.justice.gov/archive/opa/pr/2003/June/03_civ_386.htm).” This settlement brings to a close the largest multi-agency investigation of a health care provider that the United States government has ever undertaken and demonstrates the Department of Justice’s ongoing resolve and commitment to pursue all types of fraud on American taxpayers, and health care program beneficiaries. HCA has pleaded guilty and paid fines for several fraudulent activities in the past, including: - Kickbacks to physicians for patient referrals - Unlawful billing and claims to military healthcare programs, Medicare, Medicaid, and Tricare - Fraudulent filing and abuse of program funds - Kickbacks for costs with contractor manufacturers and non-covered medications - Transferring patients for the claim of excess costs - Inflating and false reporting of Medicare costs - Shifting employee salary to increase reimbursement of federal healthcare programs - Shifting home office costs to hospitals costs ## **HCA Response** **On 11/28/2022, HCA provided the following statement for Nurse.org:** *“The letter from Congressman Bill Pascrell repeats claims made by SEIU and its affiliates (CTW and SOC) over the past few years about emergency department admissions rates. We categorically reject any allegation that physicians admit patients to our hospitals on the basis of anything other than their independent medical judgment and their patients’ individual conditions and medical needs. There are no HCA Healthcare policies, processes or practices that require physicians to admit patients to our hospitals.* *The allegations made by the SEIU to the Congressman are based upon an invented and false premise and a lazy and manipulative argument. The SEIU has engineered a metric (the “standard” or “average” rate for emergency department admissions) that exists for no other purpose than the public criticism of HCA Healthcare. It appears that the SEIU used publicly available Medicare claims data and simple math to divide the number of ED admissions by the number of ED visits and arbitrarily deemed the resulting number to be a valid metric or benchmark.* *That metric is, however, not recognized by healthcare providers, experts or academics, and the failure of any hospital, including those operated by HCA Healthcare, to meet that metric is utterly meaningless. Credible and knowledgeable healthcare experts understand that many variables, including community demographics, hospital services, patient needs and acuity, and other related factors need to be considered in any analysis of hospital emergency departments.* *That said, even assuming, without agreeing, that the SEIU metric is meaningful, HCA Healthcare hospitals are in line with some of the best in the nation. Using the SEIU’s own methodology for example, of the top 20 US News’ Best Hospitals in 2021, the highest emergency department admission rate was 61% and the lowest was 28%. Comparatively, HCA Healthcare’s national average is on the lower end of that range at 37%.* *It seems the information the SEIU presented to Subcommittee Chairman Pascrell was incomplete and intentionally misleading.”* [Response from Phil Billington](https://www.sec.gov/Archives/edgar/data/860730/000119312521107058/d16776ddefa14a.htm), Senior vice president of HCA Healthcare, responded back to the allegations through email, “We found nothing to suggest that E.R. or medical-staff physicians admit patients to our hospitals based upon anything other than their independent medical judgment. None of our contractual arrangements with physicians incentivize them to admit patients to our hospitals.” [Read the full response here.](https://www.sec.gov/Archives/edgar/data/860730/000119312521107058/d16776ddefa14a.htm) Billington further explains in his email that Quality Improvement Organizations (QIOs) such as the Centers for Medicare & Medicaid Services (CMS) perform their regular reviews on facilities, including HCA facilities, and “reviewed thousands of such admissions to our hospitals, and substantially all were found to be appropriate.“ He continues to point out that HCA has been recognized by Ethisphere as one of the world’s most ethical companies for the 11th time. Phil Billington made a [statement to Business Journals](https://www.bizjournals.com/nashville/news/2022/09/19/congress-requests-federal-investigation-into-hca.html) that “There are no HCA Healthcare policies, processes or practices that require physicians to admit patients to our hospitals.” He goes on to say that the allegations are “based upon an invented and false premise and a lazy and manipulative argument.” **Topics:** Public Awareness, Regulatory actions --- ### [NY Pharmacy Owners Plead Guilty to Money Laundering During COVID-19](https://insurancefraud.org/news_archives/ny-pharmacy-owners-plead-guilty-to-money-laundering-during-covid-19/) **Published:** September 18, 2026 **Author:** Diane Beauchamp **Content:** The U.S. Department of Justice (DOJ) announced on November 16 that two pharmacy owners from Forest Hills, New York have pleaded guilty to conspiracy to commit money laundering through submission of fraudulent claims to Medicare during the COVID-19 pandemic. The co-conspirators owned over a dozen pharmacies in the New York area, through which they submitted fraudulent claims for expensive cancer medications (Targretin Gel 1% and Panretin Gel 0.1%) that were never prescribed by a physician or dispensed to patients. DOJ found that the co-conspirators were exploiting “emergency override” billing codes that were established in response to the COVID-19 emergency. Through this fraudulent scheme, the co-conspirators collected over $18 million from Medicare reimbursements, which they attempted to conceal through several shell companies, including sham companies that were designed to look like legitimate pharmacy wholesalers. The money was sent from the company bank accounts directly to the co-conspirators or their relatives or designees, or it was sent to companies in China and then distributed to individuals in Uzbekistan and collected by the co-conspirators in cash. The co-conspirators are scheduled for sentencing in May 2023 and face a maximum penalty of 20 years in prison. **Topics:** COVID-19, Drug Diversion **Categories:** Conviction --- ### [Seffner Man Pleads Guilty To Aggravated Identity Theft](https://insurancefraud.org/news_archives/seffner-man-pleads-guilty-to-aggravated-identity-theft/) **Published:** September 18, 2026 **Author:** Diane Beauchamp **Content:** United States Attorney Roger B. Handberg announces that Raul Gonzalez (63, Seffner) has pleaded guilty to one count of aggravated identity theft. Gonzalez faces a mandatory sentence of two years in federal prison. According to the plea agreement, Gonzalez applied for a United States passport on January 31, 2019. He used the identity of his deceased twin brother, Miguel Angel Gonzalez Rodriguez, in his passport application. Gonzalez also presented a driver license in his brother’s name and a baptism certificate bearing his deceased brother’s name and identity. United States Department of State investigators became aware of the possibility of fraud in this application and began an investigation. Their investigation revealed that Miguel Gonzalez was born on the same date as Raul Gonzalez but that Miguel had died a few days later due to dehydration and gastroenteritis. Further investigation revealed that this same “Miguel Gonzalez,” with the same date of birth and other similar identifiers, had applied over different points in time for Social Security, SNAP, and Medicaid/Medicare benefits. This purported “Miguel Gonzalez” then obtained over $145,000 from those various federal benefits programs using that false identity. As part of his plea agreement with the United States, the defendant has agreed to pay restitution to those agencies for those losses. This case was investigated by the U.S. Department of State Diplomatic Security Service, with assistance from the U.S. Department of Agriculture – Office of Inspector General, the U.S. Health and Human Services – Office of Inspector General, Social Security – Office of Inspector General, and further assistance from the Florida Highway Patrol and the Florida Department of Highway Safety and Motor Vehicles. It is being prosecuted by Assistant United States Attorney Jay L. Hoffer. **Topics:** Social Security fraud, Synthetic Identity Theft **Categories:** Conviction --- ### [Ambulance Company Settles Allegations of Billing Medicare for Unnecessary, Non-Emergency Ambulance Transportation](https://insurancefraud.org/news_archives/ambulance-company-settles-allegations-of-billing-medicare-for-unnecessary-non-emergency-ambulance-transportation/) **Published:** September 18, 2026 **Author:** Diane Beauchamp **Content:** HealthOne Critical Care Transport Service, Inc. d/b/a MedicOne Medical Response (“MedicOne”) of Marion, Illinois, has agreed to pay $302,124.37 in a civil settlement agreement resolving allegations the company improperly billed Medicare for scheduled, non- emergency ambulance transportation. The government alleges MedicOne’s former location in Mount Vernon, Illinois, routinely billed Medicare for non-emergency ambulance transports to regularly scheduled dialysis treatments when the services did not meet Medicare requirements. MedicOne typically picked up patients at their residences or nursing homes and transported the patients to and from dialysis treatment three times per week, sometimes for years. The government alleges many of MedicOne’s non-emergency ambulance transports did not meet Medicare requirements for coverage because the services were not medically necessary, particularly when the patients safely rode in other forms of transportation – such as personal vehicles, medical transport cars, and wheelchair vans – to medical appointments and social outings. The Medicare program paid MedicOne hundreds of dollars per round-trip ambulance transport taking patients to dialysis treatments. To resolve the allegations, MedicOne will pay the United States $302,124.37 for claims submitted to Medicare between April 2016 and January 2020. “Billing for unnecessary ambulance transports wastes taxpayer dollars and drains critical funds from the Medicare program,” said U.S. Attorney Rachelle Aud Crowe. “Our office is committed to protecting the integrity of federal health care programs.” “Health care providers that bill Medicare for medically unnecessary services improperly divert funds needed to care for beneficiaries while increasing the financial burden on taxpayers,” stated Special Agent in Charge Curt L. Muller of the Department of Health and Human Services Office of Inspector General (HHS-OIG). “Along with our law enforcement partners, we will continue to investigate health care schemes to protect the integrity of federal health care programs.” “Public health insurance programs, such as Medicare, can incur significant financial loss when their programs are exploited. Those losses cost the government and ultimately impact every American – contributing to the rising cost of health care for everyone,” said Federal Bureau of Investigation (FBI) Springfield Special Agent in Charge David Nanz. “This settlement is a result of the FBI’s commitment to work with our federal and state partners to ensure that federally funded health care programs are not abused by providers.” This matter was investigated by HHS-OIG, the FBI, and the Illinois tate Police Medicaid Fraud Control Unit in response to a hotline complaint submitted to HHS-OIG. Assistant U.S. Attorney Laura Barke prosecuted the case. Anyone who suspects health care fraud, waste, or abuse is encouraged to report it by calling 1-800- HHS-TIPS or visiting https://oig.hhs.gov/fraud/report-fraud/. The claims resolved by the settlement are allegations only, and there has been no determination of liability. **Topics:** Judicial/courts, Medicare/Medicaid, Public Awareness --- ### [Open Enrollment scams abundant during Medicare/Medicaid open enrollment](https://insurancefraud.org/news_archives/open-enrollment-scams-abundant-during-medicare-medicaid-open-enrollment/) **Published:** September 18, 2026 **Author:** Diane Beauchamp **Content:** As millions of Americans go through open enrollment for [Medicare](https://www.medicare.gov/) and [Medicaid](https://www.medicaid.gov/) experts warn of a popular form of imposter fraud where scammers scheme to steal critical health information. Kathy Stokes, who runs the [Fraud Watch Network](https://www.aarp.org/money/scams-fraud/) for [AARP](https://www.aarp.org/), said con artists use fake caller ID names and numbers to impersonate Medicare or popular healthcare organizations in order to steal your information and sell it on the dark web to the highest bidder. “Specifically with Medicare, it’s basically trying to get a Medicare beneficiary to believe something that’s not true—in order to convince them to give their Medicare number to you,” Stokes said. “We really have to focus on not engaging to begin with because they’re that good. Once we engage, it could be game over!” The AARP shared testimonies from people who contacted their fraud hotline. Complaints included scammers offering fake gifts and posing as Medicare agents. In separate instances victims turned over social security numbers and credit info to fraudulent callers. Hilary Donnell works for [Aura](https://www.aura.com/), a digital safety company. She’s heard from victims of medical identity theft who have lost more than $13,000 dollars in fake medical bills. Donnell says in some of the worst cases this scam can also affect a victim’s health. “Medical identity theft can result in the victim losing access to their health benefits, facing delays in getting critical care or even getting a misdiagnosis or the wrong treatment plan because of a medical history that was created by a scammer and that isn’t real for that victim,” Donnell explained. “These scams can affect anybody and they can take a variety of different forms. Hackers are becoming more and more sophisticated in an effort to convince you to fall victim to this scam.” Before you give out your health care information, experts like Donnell said think about what you’re doing and don’t be afraid to hang up the phone. If you have been contacted by a suspicious person, the [Center for Medicare and Medicaid Services](https://www.cms.gov/) says you can report any concerns about potential fraud by calling 1-800-633-4227. **Topics:** Medicare/Medicaid, Public Awareness --- ### [Advocacy groups urge US Congress to pass Improving Digital Identity Act](https://insurancefraud.org/news_archives/advocacy-groups-urge-us-congress-to-pass-improving-digital-identity-act/) **Published:** September 18, 2026 **Author:** Diane Beauchamp **Content:** The [Better Identity Coalition](https://www.biometricupdate.com/tag/better-identity-coalition) has joined with the Identity Theft Resource Center and eight other organizations to call on U.S. Congress to include the Improving Digital Identity Act of 2022 in its year-end spending bill. The letter to Congressional leaders on both sides of the was reprinted in [a Tweet](https://twitter.com/MakeIDbetter/status/1594773137979281423) from the Coalition. Other groups signing the call for federal action on digital ID include the U.S. Chamber of Commerce Technology Engagement Center and advocates for cybersecurity, healthcare, and financial services. The Digital Identity Act of 2022 has [advanced through committees](https://www.biometricupdate.com/202209/us-creeps-towards-digital-id-legislation-as-election-looms) in both the House of Representatives and Senate, but has yet to be brought to a vote. The letter highlights the 293 million people affected by data breaches in 2021, and a 333 percent increase in losses from identity fraud since 2017. Identity theft has impacted almost half of Americans, they say, and the proliferation of [unemployment insurance fraud](https://www.biometricupdate.com/202202/downwind-of-irs-decision-to-back-off-biometric-authentication-more-change) estimated by the Department of Labor. Signatories note the FTC’s estimate that identity theft for public benefits fraud increased by 3,000 percent from 2019 to 2020, and that FinCEN has identified the abuse of personally identifiable information and other components of digital identity is a key enabler of fraud and cybercrime in the U.S. Synthetic identity fraud now costs $20 billion a year, the Federal Reserve says. “The lack of an easy, secure, reliable way for entities to verify identities of people they are dealing with online creates friction in commerce, leads to increased fraud and theft, degrades privacy and hinders the availability of many services online,” the signatories write. Digital identity infrastructure could add 4 percent to America’s GDP by 2030, they argue, and NIST says it could save a single agency more than $300 million each year. “By prioritizing digital identity infrastructure, we will prevent costly cybercrime, help ensure Americans never become identity theft victims, give businesses and consumers new confidence, and foster growth and innovation across the economy,” the letter concludes. Many of the same groups wrote to President Joe Biden earlier this year to urge him to [put digital identity infrastructure in place](https://www.biometricupdate.com/202204/biden-urged-to-consider-federal-digital-identity-framework) through an executive order. **Topics:** Legislation, Public Awareness, Technology --- ### [House members urge changes to No Surprises Act final rule](https://insurancefraud.org/news_archives/house-members-urge-changes-to-no-surprises-act-final-rule/) **Published:** September 18, 2026 **Author:** Diane Beauchamp **Content:** Leaders of the House Ways and Means Committee have [sent a letter](https://aha.org/system/files/media/file/2022/11/key-house-committee-express-serious-concerns-regarding-latest-efforts-to-implement-the-bipartisan-no-surprises-act-letter-11-21-22.pdf) to several federal agencies saying the final rule implementing the No Surprises Act favors insurers and should be changed to reflect provider concerns. The law, which bans surprise medical bills, sees payers and providers entering into a third-party arbitration process to settle disputes regarding out-of-network charges. The final rules specify that certified independent dispute resolution (IDR) entities should select the offer that best represents the value of the item or service under dispute after considering the Qualified Payment Amount (QPA) and all permissible information submitted by the parties. The lawmakers argue the rule favors insurers in the IDR process. “Although the qualifying payment amount is an important factor, the statute lists the QPA as one of many factors an IDR entity must consider without giving preference or outsized weight to any one factor,” they wrote. Citing a prior federal district court decision findings flaws in the implementation of IDR requirements, the House members said that while the final rule makes some limited progress by no longer designating a “rebuttable presumption” towards the QPA as did the interim final rule, the new instruction to IDR entities largely would have the same effect. “In the new final rule, the Departments created a new ‘double counting’ test that has no basis in the statutory text, directing IDR entities to ‘consider whether the additional information is already accounted for in the QPA,'” lawmakers wrote. “Further, the rule states that the IDR entities ‘should not give weight to information related to a factor if the certified IDR entity determines the information was already accounted for in the calculation of the QPA.'” They maintained this perpetuates the flaws of the interim final rules and skews the determination of the IDR process toward the QPA. The final rule, they said, precludes IDR entities from giving weight to factors like patient acuity and the complexity of furnishing the item or service at issue – unless providers meet the “heightened burden” of disproving double-counting within the QPA. **WHAT’S THE IMPACT?** The market share of the entities in question, lawmakers said, may be a significant factor that should inform the IDR entity’s decision, but it may also be a variable in the calculation of the QPA and could fail the “double counting” test. “Disregarding this factor because of the ‘double counting’ test goes against the law’s intent for IDR entities to correct monopolistic pricing by either party,” House members wrote. They also expressed their concerns regarding what they perceive as the slow implementation of the Advanced Explanation of Benefits (AEOB) provision included in the No Surprises Act. The law instructed the departments to finalize rulemaking to implement the AEOB by plan years beginning on or after January 1, 2022. Despite this mandate, the departments only recently issued a request for information regarding the AEOB’s implementation on September 16, 2022 – a full eight months after the provision should have been in effect. “We are concerned that now, implementation will be delayed further into 2024 at the earliest,” they said. “Patients deserve access to the unprecedented and revolutionary transparency the No Surprises Act provided.” **THE LARGER TREND** In September, the [American Hospital Association](https://www.healthcarefinancenews.com/directory/american-hospital-association) and [American Medical Association](https://www.healthcarefinancenews.com/directory/american-medical-association) [moved to dismiss their challenge](https://www.healthcarefinancenews.com/news/aha-and-ama-withdraw-lawsuit-over-enactment-no-surprises-act) to the federal government’s September 2021 interim final rule governing the No Surprises Act’s independent dispute resolution process. However, the groups said they intended to “make our voices heard in the courts very soon” about continued problems with both the interim and final rules. The final rule continues to favor insurers and does not line up with what Congress intended when it passed the law, the groups said. The [lawsuit](https://www.aha.org/system/files/media/file/2021/12/AMA-v-HHS-As-Filed-Complaint.pdf) filed in December 2021 did not seek to prevent the No Surprises Act core patient protections from moving forward. It sought to force the administration to alter regulations over dispute negotiations between provider and payer. The groups said the lawsuit became moot when the administration released a [revised final rule](https://www.healthcarefinancenews.com/news/hhs-and-federal-departments-issue-final-rules-clarify-no-surprises-act-dispute-resolution) on the independent dispute resolution process this August. On December 27, 2020, the Consolidated Appropriations Act, which includes the No Surprises Act, was enacted to give protections against surprise billing by limiting out-of-network cost-sharing and by prohibiting balance-billing. Most patients get a surprise bill for unknowingly seeing an out-of-network provider, such as in the emergency room or from a clinical lab. The No Surprises Act protects patients by taking them out of the middle of disputes over out-of-network payment rates between providers and payers. In October, the AHA and American Medical Association filed a friend-of-the-court brief in support of a Texas Medical Association lawsuit claiming the revised independent dispute resolution process for determining payment for out-of-network services under the No Surprises Act skews the arbitration results in commercial insurers’ favor in ways that violate the compromise Congress reached in the Act. **Topics:** Legislation, Public Awareness --- ### [Insurance agent, attorneys indicted in multimillion-dollar scam](https://insurancefraud.org/news_archives/insurance-agent-attorneys-indicted-in-multimillion-dollar-scam/) **Published:** September 18, 2026 **Author:** Diane Beauchamp **Content:** A North Carolina insurance agent and two St. Louis tax attorneys have been indicted on charges related to a $200 million insurance scam and the operation of a fraudulent tax shelter that caused a tax loss to the IRS of tens of millions of dollars. David Shane Simmons, a North Carolina insurance broker, and attorneys Michael Elliott Kohn and Catherine Elizabeth Chollet have been charged with conspiring to defraud the United States and helping clients file false tax returns, according to the Department of Justice. The DOJ alleged that the three conspired to defraud the United States by promoting, marketing and selling to clients a tax scam known as the Gain Elimination Plan (GEP). Simmons, Kohn and Chollet allegedly designed the GEP to conceal clients’ income from the IRS by fraudulently inflating business expenses through phony royalties and management fees. These fictitious fees were paid – on paper – to a limited partnership largely owned by a charitable organization, the DOJ said. In reality, Kohn and Chollet allegedly fabricated the royalties and fees. The indictment also alleges that Kohn and Simmons collaborated in a scheme to bilk an insurance company by providing false information on insurance applications on behalf of their clients. The phony information allegedly included fictitious representations about the clients’ financials and the purpose of the insurance policies. In total, the insurance company issued more than $200 million in insurance policies based on false information, the DOJ said. Simmons allegedly earned large commissions on these policies, many of which he split with Kohn and Chollet. Simmons also allegedly filed false tax returns by underreporting his business income and inflating his expenses. If convicted, Simmons, Kohn and Chollet each face a maximum of five years in prison for conspiring to defraud the United States and three years for each of multiple counts of aiding and assisting in the preparation of false tax returns. Simmons and Kohn also each face up to 20 years for wire fraud, and Simmons faces an additional three years for several counts of filing false personal tax returns. **Topics:** Financial Fraud **Categories:** Arrest --- ### [Fraud Doesn’t Pay in New York: November 2022 Update](https://insurancefraud.org/news_archives/fraud-doesnt-pay-in-new-york-november-2022-update/) **Published:** September 18, 2026 **Author:** Diane Beauchamp **Content:** ## Another Overview of Recent Decisions, Demonstrating the Board’s Continuing Attitude Toward 114-a. ## Key Takeaways - WCL 114-a provides the board with the authority to disqualify a claimant from receipt of lost time benefits**,** “\[i\]f for the purpose of obtaining compensation pursuant to section fifteen of this chapter, or for the purpose of influencing any determination regarding any such payment, a claimant knowingly makes a false statement or representation as to a material fact.” Section 15 is specific to lost wage replacement. - It is important to note medical benefits remain open, but should be questioned in the litigation process. - While surveillance is key, communication among all parties is crucial to obtaining a strong mandatory and discretionary finding. As a part of our Quarterly Practice Group Update, we are pleased to produce our fifth installment highlighting examples of our continued success in the area of fraud litigation. This publication began as a one-time update; however, due to the consistent success of our dedicated attorneys we are pleased to be able to continue to relay our successes. The board has consistently broken down the severity of the violation into essentially two categories: mandatory and discretionary. The mandatory penalty correlates to the number of weeks, equivalent to what we are able to *definitively* prove. This typically runs from the first date of surveillance, or the first date we can prove an inconsistent statement, through to the date of the judge’s decision. The longer the period and scope of the evidence, the longer the mandatory period. The discretionary period is based on a standard of “egregiousness.” While there is no specific formula, this can be proven by contrasting the degree to which the claimant either misrepresented their condition, the absence of mitigating factors in the claimant’s favor, or the extent they have gone to perpetuate the misrepresentation. #### **WCB G2508681 “Social Media Shut Down”** Established claim for the right buttock, PTSD and Major Depressive Disorder. The claimant missed three different IMEs due to fear of leaving the house, COVID, people, etc. His own tele-health medical reports repeat the same inability to leave his room. Social Media showed him flying to Florida for his birthday, celebrating the release of his new “single” in Time Square, as well as posts concerning his career as an independent filmmaker, and his time in the gym. One of these posts coincided specifically with the date of a missed IME. The WCLJ found a full mandatory and discretionary ban due to the extent and contrast between the medical reports, indicating a homebound individual vs. the reality the claimant demonstrated in his own social media page. #### **WCB G2474597** **“Rain on, Denial.” — Update** Established claim for the neck, right shoulder and jaw. The claimant tried to include the low back and right knee. The severity of his symptoms kept him at 100-percent disability. The carrier obtained an IME to address expansion and obtained surveillance. The claimant denied any prior condition to his back, as well as attended the IME wearing a brace, and stated he could not do most ADLs. His doctor noted that the claimant demonstrated marked limitations in ROM. Surveillance showed the claimant far more capable than he demonstrated to the IME, including navigating stairs, driving, and running to catch a flyaway umbrella. In addition, we received additional records that showed the claimant did have significant prior issues and treatment for his low back only a few years before this incident. The judge found the claimant’s testimony “disingenuous, hostile and not credible,” and issued a full mandatory and discretionary ban. A unanimous board panel increased the duration of the mandatory penalty and left the discretionary ban in place. #### **WCB G3021502 “Family Ties”** Established claim for a facial contusion, amended to include the back, neck, bilateral knees and right ankle. The claimant’s treating doctor had her at 100-percent disability and additionally noted she was not working and could not work in any capacity, and reported pain in all activities of daily living. Investigators spoke to the claimant and her daughter during a routine claims check wherein her daughter confirmed she is babysitting during this time. The claimant was questioned at a following hearing and admitted after a few attempts to babysit for her brother’s child, eight hours per day, and, additionally, was being paid. She quit work in November 2021 when her family no longer needed help. The law judge found no 114-a as childcare cannot be fraud. We appealed and noted the case law the judge relied upon was not similar and had to do with Reduced Earnings entitlement. The board panel rescinded all awards to date as a mandatory penalty and found the claimant’s present lack of employment unrelated to her injury. #### **WCB G2831541 “2nd Time’s the Charm”** This case was established due to procedural error, wherein video contradicting the injury was not admitted to evidence, and upheld on appeal. However, we worked with the carrier to introduce the video as evidence of 114-a. The claimant in the original trial denied prior injuries and embellished his work injury. The video showed that the claimant greatly exaggerated his mechanism of injury and the claimant showed no overt signs of disability. That, coupled with medical records, proved the claimant was in a prior MVA, with overlapping injury sites. The law judge maintained the establishment of the case, but implemented a full mandatory and discretionary ban. The claimant has appealed, but we anticipate no modification to the finding. #### **WCB G2517119 “Just a little Patience”** Established claim for the left foot/ankle, neck and back from a May 2019 injury. Per the medical reports, the claimant was reliant on a cane and a back brace. Video surveillance was filed, showing the claimant doing a lot of walking without his cane, caring for his dogs, taking care of his cars, and getting in and out of his car with no apparent difficulty. In depositions, the claimant’s treating doctor reduced his opinion from 100-percent disability to “mild to moderate.” The claimant argued his video is not consistent with a partial disability and tried to change the narrative and preclude the video on the basis that administrative staff, which did not testify, burned the DVDs. The law judge admitted the video, but otherwise found no violation of 114-a as there was no evidence of work of heavy physical activity. We appealed. The board panel, thankfully, using the correct provisions of 114-a coupled with the claimant’s evasive nature during testimony, implemented the mandatory findings of 114-a, as well as a full discretionary ban. #### **NY WCB G2656436 “Pain in the Neck.”** Established neck and back claim from June 2020. The claimant denied any prior related injuries, however, disclosed prior unrelated injuries. She denied prior injuries to her doctors and the IME doctors. The carrier ran an ISO showing a 2010 MVA. We requested a HIPAA and obtained over 300 pages of records, which included letters from the claimant concerning the significance of her neck injury from the MVA. Those records indicated another neck injury in the summer of 2010 during which multiple diagnostic studies were done. During testimony, she attempted to argue the records were wrong and she had a head injury, not neck. The judge nullified all awards back to the inception of the claim. We have appealed for a discretionary ban. #### **WCB G1319024 “Oh, my back. Can’t keep track.”** This is an established claim for the back from a November 2016 accident. The claimant underwent two lumbar fusions in this file, one in March 2019 and a second one in May 2021. The record immediately prior to the second surgery indicates a subsequent MVA. We made multiple attempts to secure a HIPAA release and the claimant’s records. The claimant denied his back was involved in the accident. The records indicated the claimant told his doctors who treated him for the MVA that prior to the November 2020 accident, his back was “doing well” and only since the accident has he experienced an onset of pain. His symptoms were listed to be 80-percent worse. He then was treated by a different doctor, requesting the second fusion surgery under his WCL claim. The judge found a full mandatory and lifetime penalty as well as apportioned 35-percent of medical treatment as unrelated. The claimant has appealed but we do not anticipate a change in the outcome. #### **WCB G1748955 “Hot off the Presses”** This is a 2021 neck and back claim. We disputed lost-time benefits as employment had been terminated for unrelated reasons between the claim onset and asserted disability period. The claimant testified at a hearing that he did not work anywhere after the accident. He testified he tried to return for a shift for the employer of record but could not, and he is looking but has not worked any place else. Surveillance was initiated as well as a business search showing the claimant operating his own publication business, including receipt of a PPP loan. The business search, social media and video surveillance all showed the claimant physically running his own business, including driving a van with his name and logo on the vehicle and going into this business office. In addition to the business aspect, the claimant could be seen in the video moving fluidly and free from any assistive devices, contrary to his medical reports. During his IME, he marked the box “No” when asked if he returned to work or volunteered in any capacity since the injury. Despite being on notice for 114-a, claimant denied presently operating the business or being able to drive or even leave his property. The law judge found 114-a, and rescinded all awards made to date in the claim. An additional discretionary penalty equal to the same value was added. We are planning an appeal for a full discretionary ban. Yet again, these findings were made possible through coordinated efforts with our clients and with investigators and the collaborative, team-oriented attitude of our attorneys. As we stated before, while surveillance is key, communication among all parties is crucial to obtaining a strong mandatory and discretionary finding. We would recommend to any of our clients who feel a claim is not progressing, or have any indication of suspicious activity, to coordinate with our team. We continue to congratulate all of our clients and our attorneys for their hard work and dedication, and look forward to future successes and future publications. **Topics:** Judicial/courts, Public Awareness --- ### [Breach of Contract by Insurer as Insurance Fraud](https://insurancefraud.org/news_archives/breach-of-contract-by-insurer-as-insurance-fraud/) **Published:** September 18, 2026 **Author:** Diane Beauchamp **Content:** ## Abstract Insurance was intended to be a risk management tool, but in practice, it has become a means of exacerbating the risks borne by insured because reality is not as beautiful as imagined. This study wants to ascertain whether or not many breaches of the contract were committed by the insurer. The object of this research uses 42 insurance cases in the form of court decisions by content analysis approach. Data show that there are 34 cases or 80,95% of the total 42 insurance cases are breach of contract committed by insurance companies. In these cases the insurer “refusing to pay the claim request from the insured.” The insurer constantly argues that the insured’s claim was rejected to enforce the insurance law. However, the results of the examination by the Panel of Judges generally place the insured or his heirs as the winning party. **Topics:** Judicial/courts, Public Awareness --- ### [Supreme Court Declines To Hear Case Against Home Health Certificate Of Need Laws](https://insurancefraud.org/news_archives/supreme-court-declines-to-hear-case-against-home-health-certificate-of-need-laws/) **Published:** September 18, 2026 **Author:** Diane Beauchamp **Content:** A home health care company hoping to operate in Louisville, Kentucky has hit a road block in its fight against Certificate of Need (CON) laws. CON laws vary by state. Some have home health CON barriers, while others do not. That results in some states having far more home health agencies than others. Because Kentucky has CON laws in home health care, Dipendra Tiwari and Kishor Sapkota – two Nepalese immigrants – were met with resistance when they tried to open up an agency specifically tailored to the Nepali speaking people of Jefferson County and Louisville. Due to language barriers, Tiwari and Sapkota believed that there was a need for home health care services in the community, and were hoping to [keep more Nepali-speaking people out of nursing homes](https://www.whas11.com/article/news/investigations/focus/duo-wants-abolish-kentucky-home-healthcare-law/417-0f6c83d2-1382-425c-ae08-6ceed883a2b6) by offering up these services. The agency was to be dubbed Grace Home Care. After a request for a CON was denied by the state of Kentucky, Tiwari and Sapkota filed a lawsuit. The lawsuit was dismissed, however, and eventually, [they requested for the U.S. Supreme Court to review their case](https://news.bloomberglaw.com/us-law-week/kentucky-health-providers-seek-supreme-court-review-of-need-law?context=article-related). They failed to convince the court, however. “In these cases, the challengers often mischaracterize what CON laws do, what they represent and how they actually function,” Matt Wolfe, a shareholder at the law firm Baker Donelson, told HHCN in an email. “Each state’s CON law operates a little differently, but every CON law allows for and encourages public input, involves various stakeholders – including businesses, providers, and patients – and is flexible to adapt its approach to the changing needs of the communities it covers.” CON laws have undergone much legal scrutiny in the past, something that Wolfe does not think will stop just because of this case in Kentucky. Home Health Care News has reported on [the pros and cons of certificate of need laws in the past](https://homehealthcarenews.com/2022/01/hhcn-report-the-pros-and-cons-of-certificate-of-need-regulations-in-home-health-care/). While some believe that CON laws uphold quality in home health services, others argue that it hurts access and also deters competition. In Tiwari and Sapkota’s case specifically, they were trying – in part – to argue CON laws are unconstitutional. “There is a coordinated and well-funded campaign by ‘free market’ special interest groups to continue to bring these types of legal challenges to the constitutionality of CON laws in federal and state courts,” he said. And while the cases against CON laws often make intellectual sense, Wolfe does not believe that the evidence has created a good case against them. “CON laws play an important role in ensuring access to quality, affordable care,” he said. “The reality is that health care is not provided in a free market. Repealing or substantially limiting CON laws would do nothing to address access issues. In fact, in states that have repealed CON laws, we have seen a proliferation of providers with no appreciable improvement in access. Instead, home health agencies experience small and unsustainable patient censuses.” **Topics:** Judicial/courts, Public Awareness --- ### [Trump Might Be Back in Hot Water With Manhattan DA’s Office](https://insurancefraud.org/news_archives/trump-might-be-back-in-hot-water-with-manhattan-das-office/) **Published:** September 18, 2026 **Author:** Diane Beauchamp **Content:** In April, [Donald Trump](https://nymag.com/intelligencer/2022/11/trump-2024-announcement-totally-sad.html) received a rare bit of good legal news when a six-month grand jury called by the [Manhattan district attorney](https://nymag.com/intelligencer/article/manhattan-da-alvin-bragg-memo-trump.html) to determine if there was alleged business fraud at the [Trump Organization](https://nymag.com/intelligencer/2022/09/letitia-james-trump-fraud-lawsuit-indicts-justice-department.html) [expired](https://www.washingtonpost.com/national-security/2022/04/29/trump-grand-jury-over/) without any charges filed. At the time, Manhattan DA [Alvin Bragg](https://nymag.com/intelligencer/2022/04/alvin-bragg-insists-his-criminal-probe-of-trump-isnt-over.html) vowed that the criminal probe wasn’t over, saying that prosecutors were “investigating thoroughly and following the facts without fear or favor.” Seven months later, it appears as if his office is back on the trail. According to the [New York *Times*](https://www.nytimes.com/2022/11/21/nyregion/trump-bragg-stormy-daniels.html), prosecutors are now returning to one of the original legal crises of the Trump administration: the hush payments from ex-Trump fixer Michael Cohen to porn star [Stormy Daniels](https://nymag.com/intelligencer/2018/05/every-contradictory-thing-trump-said-about-stormy-daniels.html) to keep quiet about their alleged affair. After Feds raided Cohen’s office in 2018, the Manhattan district attorney’s office began investigating the payments before moving on to focus on alleged business misconduct — the practices thoroughly described in New [York attorney general Letitia James’s civil suit](https://nymag.com/intelligencer/2022/09/letitia-james-trump-fraud-lawsuit-indicts-justice-department.html) accusing the Trump Organization of fraud. Prosecutors with the Manhattan DA’s office have previously looked at the $130,000 payment to Daniels, which would violate laws against falsifying business records, to the point that they’ve [reportedly](https://www.nytimes.com/2022/11/21/nyregion/trump-bragg-stormy-daniels.html) been calling it the “zombie theory.” But now they hope to try a different strategy with the aid of the Trump Organization’s former CFO Allen Weisselberg. Of course, that would require Weisselberg to cooperate. Charged last year by the district attorney’s office for his role in the Trump Organization’s scheme to artificially deflate property values to avoid paying higher taxes, he has refused to flip. In August, he [pleaded](https://nymag.com/intelligencer/2022/08/allen-weisselberg-flips-on-trump-organization.html) guilty to 15 felony charges, including grand larceny, tax fraud, and falsifying business records. The DA’s office is now reportedly hoping to levy a new round of insurance-fraud charges on Weisselberg in an attempt to make him cooperate in the hush-money inquiry. Considering that Weisselberg has dealt coolly with the pressure and accepted a five-month prison sentence rather than provide information on his former boss, the new plan to make him flip may be a long shot. (Perhaps the DA’s office thinks a few months behind bars will influence his decision.) But even if the reported ploy to make Weisselberg cooperate doesn’t pan out, Trump is still facing several more investigations that could bog down his 2024 run — the [civil lawsuit](https://nymag.com/intelligencer/2022/09/letitia-james-trump-fraud-lawsuit-indicts-justice-department.html) filed by the New York attorney general, the [inquiry](https://nymag.com/intelligencer/2022/07/trumps-biggest-legal-danger-comes-from-georgia.html) from the Atlanta-area district attorney into his efforts to overturn the 2020 results, the [investigation](https://nymag.com/intelligencer/article/donald-trump-says-the-fbi-raided-his-home-at-mar-a-lago.html) into classified documents held at Mar-a-Lago, and the [investigation](https://nymag.com/intelligencer/2022/11/what-we-know-about-trump-probe-special-counsel-jack-smith.html) into Trump’s effort to stop the election certification on January 6. **Topics:** Judicial/courts, Public Awareness --- ### [Cyber insurance, a booming business as data breaches become more common](https://insurancefraud.org/news_archives/cyber-insurance-a-booming-business-as-data-breaches-become-more-common/) **Published:** September 18, 2026 **Author:** Diane Beauchamp **Content:** # **Introduction** As the world increasingly moves online, businesses are faced with new risks from [cyberattacks](https://www.forbes.com/sites/chuckbrooks/2022/11/23/a-boiling-cauldron-cybersecurity-trends-threats-and-predictions-for-2023/?sh=56a01a01143d). These attacks can be devastating, costing a business tens of thousands of dollars in recovery costs. That’s where cyber insurance comes in. Cyber insurance is a type of insurance that covers businesses in the event of a data breach or other cyberattack. It can help cover the cost of recovery, including data restoration, legal fees, and more. While it’s not required, it’s becoming more and more common for businesses to carry [cyber insurance](https://market.us/report/cyber-insurance-market/). Cyber insurance can be used to assist an organization in the event of a cyber-related security incident or similar events. Cyber insurance covers businesses against cyber-related threats like data breaches, malicious hackers, distributed denial-of-service, malware, and ransomware. It also provides financial protection for sensitive customer data, such as health records, social security numbers, account numbers, and credit card numbers. There are many challenges to managing digital security, privacy, and digitalization in the context of growing digitalization in businesses and economies. A rapid increase in cyber crimes, threats, hacking, and data breaches has made managing online and internet risks a priority for businesses. This is why cyber insurance is so important to help recover costs, regain core operations, and stabilize a company. Cyber insurance helps companies protect themselves from unauthorized access to networks and sensitive information. It is increasingly being used in small and medium-sized organizations (SMEs). Increased awareness about cyber risks to business interruption (BI), as well as the growing number of data security laws in different end users, such as banking, healthcare, and others, are key factors that have fueled the market for cyber insurance. Insurance plays an integral role in helping businesses and consumers manage cyber risks. Policyholders also have financial protection against attacks that can’t be prevented completely. Cybercrime is on the rise and data breaches continue to increase around the world. The Checkpoint report shows that there has been a 93% increase in ransomware attacks over the past year, with 6 out of 10 companies being affected. Increased use of data privacy laws, such as the Health Insurance Portability and Account Act (HIPAA) and EU General Data Protection Regulations (GDPR), can help to facilitate this demand. The rise in digitization has seen a dramatic increase in cyberattacks. This was more evident during the COVID-19 epidemic. The adoption of cybersecurity insurance will be driven by complex governance requirements and regulations regarding data security. Cyber insurance industry growth can be hindered by rising premium costs and charges for data recovery, negotiation with hackers, and other fees. Insurance companies are raising premiums, and this is hindering insurance policies’ continuation. American International Group Inc. is increasing its premium rates by 30% and reducing the coverage limit. This means that small and medium businesses will be more difficult to insure. The adoption of cybersecurity insurance is slowing down due to the rising cost. Organizations are more concerned with increasing cyber security than they are paying for the insurance premium. **How much does cyber insurance cost?**The cost of cyber insurance depends on the size and type of business, as well as the amount of coverage required. For small businesses, cyber insurance can start at around $500 per year. For larger businesses, the cost can be much higher, up to millions of dollars per year. Cyber insurance is becoming increasingly important for businesses of all sizes as the number of cyber attacks continues to rise. **These are some industry developments:** Microsoft released Defender in May 2022 as a security solution for SMEs and to reduce cyber risk, and the solution includes Endpoint Detection and Response, (EDR). Prevalent launched Connector Marketplace in October 2021. The marketplace has improved capabilities and includes new ESG- and regulatory findings that provide an integrated view of enterprise risk management. Finally, in September 2021, Zurich Insurance Group collaborated with BOXX Insurance, a Toronto-based insur-tech firm. By collaborating with BOXX the company hopes to enhance its customer-focused cyber protection solution for its customers as well as its partners. **Conclusion** In recent years, the number of cyber insurance claims has increased dramatically. This is due to the growing number of cyber-attacks and the increasing cost of damages. Despite this, many businesses still do not have cyber insurance. Cyber insurance is a type of insurance that covers losses caused by cyber-attacks. It can cover losses such as data breaches, ransomware attacks, and phishing scams. Cyber insurance can also cover the cost of legal fees and repairs. **Topics:** Public Awareness, Technology --- ### [Staged accident schemes and fraud among reason for FL having the most expensive auto insurance rates in the US](https://insurancefraud.org/news_archives/staged-accident-schemes-and-fraud-among-reason-for-fl-having-the-most-expensive-auto-insurance-rates-in-the-us/) **Published:** September 18, 2026 **Author:** Diane Beauchamp **Content:** Florida lawmakers are scheduled to return to Tallahassee soon for another special session to deal with the state’s property insurance crisis. But it’s not just homes and condos where Floridians pay high insurance costs, but automobiles as well. In fact, Florida’s auto insurance rates are among the [top in the nation](https://www.insure.com/car-insurance/car-insurance-rates.html#:~:text=Florida%20is%20the%20most%20expensive,an%20Insure.com%202022%20analysis.). An analysis from [insure.com](http://insure.com/) ranks Florida as the [most expensive state](https://www.insure.com/car-insurance/car-insurance-rates.html) in the nation for auto insurance, with the average premium at $2,560 a year, or $213 a month. That’s a 23% increase in rates from 2021. Ohio was listed as the lowest, with average insurance premiums of just $1,023 annually, [insure.com](https://www.insure.com/) reported. The average nationwide for full coverage car insurance is $1,682 in 2022. Another study, Bankrate’s True Cost of Auto Insurance Report in 2022, showed that the average annual full coverage car insurance premium for a Floridian is $2,762, the second highest rate in the country and trailing only Louisiana, at $2,864. Florida’s average is nearly $1,000 above the average annual premium in the United States of $1,771. Why are the numbers so high? There are myriad reasons, some indigenous to Florida and some attributable to national trends that have affected the industry overall coming out of the pandemic. A majority of state lawmakers believed that they had addressed the issue to some extent in 2021, when they passed a bill ([SB 54)](https://www.flsenate.gov/Session/Bill/2021/54/?Tab=VoteHistory) that would have repealed the state’s “no fault” insurance law that requires that motorists carry $10,000 in personal-injury protection (PIP) coverage to help pay their medical costs after accidents. It would have replaced PIP with mandatory bodily injury (BI) coverage of at least $25,000 per person and $50,000 per occurrence and required insurers to offer medical payments coverage (though policy holders could opt out of that coverage). Gov. DeSantis [vetoed the bill](https://www.flgov.com/wp-content/uploads/2021/06/SB-54-Transmittal-Letter.pdf) however, saying that the measure did “not adequately address the current issues facing Florida drivers” and could have unintended consequences that would be bad for consumers and the car insurance market. It would have raised car insurance rates, [according to a report](https://www.floir.com/siteDocuments/FloridaOIRPIPRepealImpactFinalReport06142021.pdf) commissioned by the Office of Insurance Regulation that was published right before that veto. The study from Pinnacle Actuarial Resources determined that if “no fault” was repealed, motorists would have seen their insurance premiums increase by 13%, or approximately $202 per vehicle annually. And the liability premium would go up nearly 20% for motorists who purchased medical payment coverage with a $10,000 limit. Insurance companies were happy that DeSantis vetoed the bill, though they do acknowledge that PIP reform is needed. “PIP is riddled with fraud. It is a problem,” says Michael Carlson, President and CEO of the Personal Insurance Federation of Florida (PIFF). “We have state law enforcement constantly working to root it out, to prosecute those folks who commit it.” That fraud plays itself by in several ways, Carlson says, such as a “whole cottage industry of phony medical providers” that send fraudulent medical bills to auto insurance companies. “They’ll charge soft-tissue treatments of various kinds…they’ll charge it until they hit $10,000 and then suddenly that patient is fine, and they won’t charge anymore.” There are also incidents with motorists staging accidents, and Tampa and Miami are known as being among the top cities in the country where such fraud is prevalent. In July, CFO Jimmy Patronis [announced the arrest of Angela Ippolito Duncan](https://www.myfloridacfo.com/sitePages/newsroom/pressRelease.aspx?ID=6220), owner of the Ybor Medical Center, for allegedly planning and participating in staged car accidents to submit more than $970,000 in fake accident automobile insurance claims. According to a press release from the CFO’s office, the investigation revealed that Duncan recruited an undercover detective to participate in an intentional motor vehicle traffic crash, provided the passengers for the vehicles, and directed all the participants for treatment at the Ybor Medical Center. “Scam artists are working every day to drive up your insurance rates to line their own pockets,” [Patronis said after the arrest was made](https://www.insurancejournal.com/news/southeast/2022/10/20/691119.htm). Another factor in driving up rates that hasn’t been addressed by state lawmakers is glass replacement fraud, which observers say has gone unchecked for years. This is where contractors literally will go after motorists in parking lots, gas stations or knock on their front doors to inform that they can have their windshields replaced for no cost if they have comprehensive insurance coverage, which about 90% of Florida drivers have, according to Mark Friedlander with the Insurance Information Institute. What motorists don’t realize, however, is that once they sign the paperwork with those contractors to get their windshield replaced, they have “assigned” a law firm to handle the issue with their insurance company. That assignment of benefits (AOB) with auto glass has led to an explosion of lawsuits filed in Florida over the past decade by more than 4,000%, according to a consortium of organizations calling themselves “[Fix the Cracks](https://fixthecracksfl.com/)” who want the state to address the issue. “This is an area of law where these cases were virtually nonexistent 10 years ago, and now they’ve perforated into the thousands, and the only explanation is that there was either a massive meteorite shower that went over the state of Florida, or the incentive for attorney’s fees are driving this and the loophole that was allowed to be created for auto glass claims is still in existence,” says William Large, the president of the Florida Justice Reform Institute. The Bankrate report also states that Florida drivers spend the second highest proportion of their money on car insurance at 4.42% of their income, trailing only Louisiana (5.26%). And of all the metro areas in the nation analyzed, Miami and Tampa drivers spend the highest percentage of their annual income on their car insurance coverage, at 5.58% and 4.49%, respectively. The average American motorist spends 2.57% of their annual income on auto insurance. Another factor in Florida’s auto insurance rates being among the highest in the nation are our frequent storms and flooding, and the fact that we have a lot of auto accidents. And keep in mind that Florida has a very high percentage of seniors 65 and older, according to U.S. Census data. [There were 3,737 fatalities from car crashes last year](https://www.flhsmv.gov/traffic-crash-reports/crash-dashboard/), making Florida the third most dangerous state to drive in the country, according to the [National Highway Traffic Safety Administration.](https://crashstats.nhtsa.dot.gov/Api/Public/ViewPublication/813283) There were more than 400,000 automobile crashes in Florida in 2021, resulting in more than 252,000 injuries from those crashes. Also, one [out of every 5 driver](http://insurance-research.org/sites/default/files/downloads/UM%20NR%20032221.pdf)s (20.4 percent) in the state is uninsured, the sixth highest rate in the nation. While the issues in Florida contribute to our higher-than-average premiums, national and global issues play a part as well, such as inflation and the breakdown in the supply chain that has raised rates everywhere. “You had inflation affecting new vehicles, the cost of used vehicles, the availability of spare parts and the cost of labor. So all of that means when an insurance company has to make you right after a crash, they have a bigger payout. And if they have a bigger payout, now they have to recover that somewhere,” says Michael Giusti, a senior reporter and analyst for [insurancequotes.com](https://www.insurancequotes.com/). Whether the Legislature is poised to take up any of these issues next year isn’t certain, but observers note that after the governor vetoed the PIP bill in 2021, the appetite for auto insurance reform in Tallahassee has chilled considerably. So will the Legislature attempt auto insurance reform in 2023? “I don’t think so,” Large says. “I think that the advocates who are moving for a bill to go from PIP to BI probably got a very clear message from Gov. DeSantis vis a vis his veto, and I don’t think they’re going to try to bring up a bill up in 2023.” But the future isn’t all bad news for Floridians hoping to save on their auto insurance bills. Unlike property insurers, who are dissolving and abandoning Florida at an alarming rate, the auto insurance industry remains robust in Florida, with more than 50 companies writing policies for motorists. “If you look at all the insurance products around the country, auto insurance is the most competitive,” says Friedlander. “Rates vary significantly between companies. And we always recommend (that you) shop your coverage if your rates are going up, because you can get multiple quotes and different discount programs that will help you.” Here’s a list of car insurance rates by states and Washington, D.C. in 2022, from an analysis by [insure.com](https://www.insure.com/): State 2022 Full Coverage (year) Difference from National Average ($1,682 in 2022) in % Florida $2,560 52% Louisiana $2,546 51% Delaware $2,137 27% Michigan $2,133 27% California $2,115 26% Kentucky $2,105 25% Missouri $2,104 25% Nevada $2,023 20% New York $2,020 20% Nebraska $2,018 20% Colorado $1,940 15% New Jersey $1,901 13% South Carolina $1,894 13% Texas $1,875 11% Washington, D.C. $1,858 10% Rhode Island $1,845 10% Oklahoma $1,797 7% Connecticut $1,750 4% Wyoming $1,736 3% Montana $1,692 1% Georgia $1,647 -2% Maryland $1,640 -2% Arizona $1,617 -4% West Virginia $1,610 -4% Mississippi $1,606 -5% Arkansas $1,597 -5% Kansas $1,594 -5% South Dakota $1,581 -6% Illinois $1,578 -6% Alabama $1,542 -8% Massachusetts $1,538 -9% New Mexico $1,505 -11% Wisconsin $1,499 -11% Minnesota $1,493 -11% Utah $1,469 -13% Pennsylvania $1,445 -14% North Dakota $1,419 -16% Tennessee $1,373 -18% Washington $1,371 -18% North Carolina $1,368 -19% Alaska $1,359 -19% Iowa $1,321 -21% Virginia $1,321 -21% New Hampshire $1,307 -22% Hawaii $1,306 -22% Indiana $1,256 -25% Oregon $1,244 -26% Vermont $1,158 -31% Idaho $1,121 -33% Maine $1,116 -34% Ohio $1,023 -39% **Topics:** Auto fraud, Legislative, Public Awareness --- ### [State AGs Urge Apple to Improve Privacy and Security Controls for Reproductive Healthcare Data](https://insurancefraud.org/news_archives/state-ags-urge-apple-to-improve-privacy-and-security-controls-for-reproductive-healthcare-data/) **Published:** September 18, 2026 **Author:** Diane Beauchamp **Content:** A group of 10 state Attorney Generals recently [wrote](https://www.nj.gov/oag/newsreleases22/2022-1121_Apple-final-signature-blocks.pdf) to Apple CEO, Tim Cook, urging the company to implement stronger privacy and security controls for applications available through the Apple App Store that track, collect, store, or transmit reproductive health data. The letter was written by Matthew Platkin, Attorney General of New Jersey, and was signed by the attorneys general of California, Connecticut, Illinois, Massachusetts, North Carolina, Oregon, Vermont, Washington, and Washington, D.C. The decision of the Supreme Court in *Dobbs v. Jackson Women’s Health Organization* removed the Federal right to an abortion and gave individual states the power to regulate abortions and several states have already introduced bans or severe restrictions on abortions. The state AGs are concerned that the health information collected through health apps “can be weaponized against consumers by law enforcement, private entities, or individuals.” AG Platkin cited a study conducted by the Mozilla Foundation of the most popular reproductive health apps to assess the security of health apps and how the apps collect, use, share, and retain user data. The privacy policies of many of the apps were opaque, especially regarding disclosures to law enforcement, and 18 of the 25 most popular apps – including period trackers, pregnancy/fertility apps, and health and fitness apps – either failed to abide by proper privacy and security practices or obfuscated the scope of the data collected by the apps. Many of the apps also failed to meet minimum standards for security, such as encrypting data, providing automatic security updates, having a clear and easily accessible privacy policy, and did not require strong passwords to be set. A majority of the apps also prompted users to input data that was outside the scope of the health services offered by the apps. The AGs say the privacy and security gaps associated with health apps available through the App Store threaten the privacy and safety of App Store customers, and that runs directly counter to Apple’s publicly expressed commitment to protect user data. Apple maintains that strong privacy controls are built into the Apple Health app, such as 2-factor authentication and all health data is encrypted until an Apple iPhone is unlocked by using a passcode, Touch ID, or Face ID. Health data is also encrypted at rest and in transit when it is synched to iCloud, and the latest version of iOS and watchOS have default 2FA and passcode-restricted access, which means Apple is unable to view users’ health data. Apple also maintains that there are already fine-grained controls for third-party health apps that use the HealthKit framework, which let users specify what information can be read by the apps, and users of third-party apps must either grant or deny permission for each app to read and write data to the HealthKit store. The state AGs claim Apple has not done enough to protect user privacy and have urged the company to go further. They have called for Apple to require third-party app developers to delete non-essential user data, such as location history, search history, and other related information of consumers who may be seeking access to reproductive healthcare. They urge Apple to display clear and conspicuous notices advising iPhone users that there is the potential for reproductive healthcare data to be disclosed to third parties, and to require all third-party app developers only to disclose reproductive healthcare data if they are issued with a valid subpoena, search warrant, or court order. Third-party apps that collect, user, store, or transmit reproductive health data, or that synch with user health data on Apple devices, should be required to match or exceed the privacy and security standards of Apple. If any health app does not meet these standards, Apple should remove the apps from the App Store, and should conduct periodic audits of apps to ensure compliance with these standards. “\[The\] provision of an app or service should not come at the cost of consumers losing control of their health data. To that end, Apple should pursue these measures to protect consumers’ reproductive health privacy. These steps will ensure that Apple stays true to its commitment “to provide a safe experience for users,” wrote AG Platkin. **Topics:** Public Awareness, Technology --- ### [Prescription fraud galore](https://insurancefraud.org/news_archives/prescription-fraud-galore/) **Published:** September 18, 2026 **Author:** Diane Beauchamp **Content:** **As many people continue to show up to dispensaries with forged signatures for drugs, fake prescriptions remain a concern for health professionals.** In fact, the Pharmaceutical Society of Jamaica said that pharmacists see fraudulent prescriptions daily, and described the situation as troubling. “It is always a topical issue and concern for us as pharmacists. Each day you see them and they keep increasing,” Immediate Past Secretary of the Pharmaceutical Society of Jamaica Kevar Bennett told the **Jamaica Observer**. And he said that where there is prescription fraud, the drugs being sought after are usually anti-depressants, high-inducing drugs, addictive drugs, sleep aids such as Xanax, and pain medication such as Panadeine, Panadeine F and morphine. “Experience and training as a pharmacist would have given you some amount of knowledge about the prescription, and especially if you’re working in a particular area for some time, you would have been familiar with the different doctors in your area, because we have seen their prescriptions over and over. So, we know what their prescriptions look like, how they sign their prescriptions, and how they write their prescriptions,” he continued. Bennett said pharmacies are vigilant and look out for spelling errors or misspelling of drug names, incorrect dosing, labels and packaging that is not in relation to a registered pharmacy. Special attention is also paid towards prescriptions that have unusual directions, and other information that seem unusual on the prescription, Bennett added, noting that oftentimes, pharmacists know which medications are in high demand that patients want to get illegally. “Sometimes, for our regular patients, we look at their history to see what is the pattern of dispensing and spot if there are any red flags. However, if the patient is new to us, we look at the prescription more carefully than if it is a regular customer. If something appears to be very strange to us, we will often call the office of the doctor who wrote the prescription to verify. And, if we can’t verify because we are not able to reach the office or doctor, we do not fill the prescription until we can verify it.” Attorney-at-law Kemar Setal warns people who present fake prescriptions that such a practice is fraudulent. “The prescription must be from a doctor’s office or hospital which would have the name and logo. Plus a doctor’s signature has to be on it and name. It is fraud. It is uttering a forged document,” he told the **Sunday Observer**. Bennett said that when people are caught with these fake prescriptions, their reasoning remain the same, with no admission of guilt. “They say it was written by their doctor, they say they are leaving the country so the doctor gave them excess supply, they say they ran out of the medications and couldn’t afford to go and see a doctor so they ask a friend or someone with limited medical knowledge to write it for them, or they say they lost their medication or shared it with someone or a relative so their supply ran out,” he related. The Pharmacy Act states that every prescription for a drug shall include the date, name, age and address of the person for whom the prescription is issued. In addition, there must also be the name, the generic name, and the quantity of the substance to be supplied; adequate directions for the use of the substance prescribed; the usual signature of the prescriber and his name in legible print form, along with the address, telephone number and registration number of the prescriber. “The issue that we have to deal with as pharmacists is that the doctors do not write their names legibly on the prescription, and sometimes there is no stamp to verify. What is usually presented to us on a prescription is a signature that we can’t even make out at times. We would then have to call the doctor for verification which impeded the process for a longer time to fill a prescription,” Bennett explained. “When a prescriber does not follow the law as outlined in the Pharmacy Act of 1975, it gives leverage to illegitimate persons to compromise a prescription or forge a doctor’s signature and make up a prescription and present it to you as the pharmacist. Oftentimes they just practise how the doctor writes and in some cases, it is hard to decipher the real from the fake one. And if you’re not careful and have some amount of experience, you will be caught in dispensing these medications to the persons.” President of the Jamaica Medical Doctors Association Dr Mindi FitzHenley told the **Sunday Observer** that prescription fraud is a major concern in the medical fraternity, and for that, she said doctors are forced to always be on guard. “Normally, how it would go is the doctors keep the prescriptions on hand and sign it or stamp it and give it to the patients, especially those doctors who are in the Government service. We really do try to protect it as much as possible. We do try and safeguard and tell all of our doctors to ensure they keep these things on hand.” Fitz Henley noted, however, that there are many instances in which people will visit health centres or hospitals with ill intentions to get their hands on prescriptions. “You can imagine in the middle of an emergency; the last thing you’re thinking is ‘oh, let me try and protect my prescription pad and my stamp.’ The first thing you’re doing, is running to the patient. It’s the same thing with cellphones, and persons have unfortunately taken doctors and other health-care workers wallets, money, when we are rushing to help others. That has been at hospitals as well as health centres,” she related. “It is a huge issue for us when this happens, because when your own information is used on fake prescriptions, your signature and your name, you have to report this to the Medical Council of Jamaica, and you have to get a whole new medical identification number. And of course, nobody wants their name to be associated with fake prescriptions,” Fitz Henley added. She told the **Sunday Observer** that there haven’t been many reports in recent time. “I know that some time ago, they actually took a surgeon’s entire prescription pad and was using it to get pain medication. Luckily, it was caught pretty quickly by the pharmacy, so they called the doctor and alerted them. The person was going islandwide with the prescriptions to try and make it harder to catch.” Fitz Henley stressed that these issues underscore the need for good relationships within the medical fraternity. “…So that when they see things, they can alert you, or check and see if it was really you. I work very closely with the pharmacists in my general zone, but even at private practices where a lot of my patients may frequent, they would call me and say, ‘Hey, this doesn’t look like your signature’ or ‘this doesn’t look like your handwriting.’ Again, we rely on that teamwork approach in the health-care system.” Meanwhile, Bennett has praised “insurance companies such as Sagicor”, which have put a system in place to minimise the occurrences of prescription fraud. “They have mandated that the doctor’s name and registration number must be legibly present and imputed in the system for a prescription to be accepted under their insurance scheme and for claim.” The National Heath Fund (NHF), Medcus Health and Canopy have applied similar systems. “When these companies come in to audit the pharmacies, any anomaly identified will be subjected for verification and if it cannot be validated, an audited report will subsequently follow and the reasons why the claim was not honoured,” Bennett said. **Topics:** Drug Diversion, Public Awareness --- ### [My Turn: Medicare open enrollment — Don’t get scammed](https://insurancefraud.org/news_archives/my-turn-medicare-open-enrollment-dont-get-scammed/) **Published:** September 18, 2026 **Author:** Diane Beauchamp **Content:** The open enrollment period for Medicare coverage is now through December 7, and it is ripe for scammers trying to get your personal information, which they then use to file fraudulent claims or steal identities. Scams come in all forms – phone calls, emails, flyers, and knocks on the door. Here’s how people can avoid getting scammed while they consider their Medicare Advantage options and year-round. Keep your info private Some of the most common scams are phone calls asking for personal information such as your Medicare number, social security number, address, and other demographic information. This information can be used to steal identities. Medicare will never call you uninvited to request personal or private information. Just hang up. Another common scam involves phone calls offering free medical equipment or genetic tests. Callers will ask for your Medicare number or other personal information so they can falsely submit a claim to Medicare. That is fraud. Again, just hang up the phone. If someone comes to your door and says they are from Medicare, do not believe them. **Medicare will never send anyone to your home**. Other common scams ■Offers of an *arthritis kit* to address back pain or other inflammation are fake. There is no such Medicare-approved kit. *COVID-19-related scams* have popped up since the pandemic began. Offers of free test kits in exchange for financial or Medicare information, unapproved testing sites, and offers to purchase COVID-19 vaccination cards are some tricks fraudsters are trying. Ensure you get any COVID-19 test kits and vaccines from a trusted health care provider or via the government’s [free test kit program](https://special.usps.com/testkits) via the Postal Service. *Prescription drug plan scammers* offer a year’s worth of prescription drugs for a low price and ask for banking information to make an automatic withdrawal of the cost. *Free medical evaluations and testing* can be nefarious. If they ask for your insurance numbers, social security number, or any other such information, walk away. ■Calls or emails asking for info to *replace, activate, or upgrade your Medicare card* are fake. Scammers will ask for personal information. Hang up or hit delete on that email. You can find more information on Medicare and the scams that target Medicare-eligible people at [Senior Medicare Patrol online](https://www.smpresource.org/Default.aspx) or at 1-877-808-2468. You can also call 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048. If you think you’ve been the target of a scam, contact 1-800-MEDICARE. You can also report suspected scams at the Federal Trade Commission’s web site at [ReportFraud.ftc.gov](https://reportfraud.ftc.gov/). [SHINE](https://www.mass.gov/health-insurance-counseling) Massachusetts’ free Medicare advice service. Online or call 1-800-243-4636. [Medicare.gov](https://www.medicare.gov/) **Topics:** Public Awareness --- ### [Ca: Riverside Health Care reports privacy breach was due to inappropriate access of EMR by a staff member](https://insurancefraud.org/news_archives/ca-riverside-health-care-reports-privacy-breach-was-due-to-inappropriate-access-of-emr-by-a-staff-member/) **Published:** September 18, 2026 **Author:** Diane Beauchamp **Content:** Riverside Health Care recently concluded an investigation into a privacy breach that was the result of a staff member inappropriately accessing patient electronic medical records. The inappropriately accessed personal health information was not disclosed or otherwise used by the staff member. Steps were immediately taken to prevent further inappropriate access to personal health information. A report has been submitted to the Information and Privacy Commissioner of Ontario. Patients whose personal health information was inappropriately accessed are being notified. Riverside Health Care takes its obligations and responsibilities as a health information custodian very seriously, including its responsibility to prevent any inappropriate access, use and / or disclosure of personal health information. Riverside Health Care continues to focus on our policies, procedures and practices, and on working with our regional partners, to protect our patients’ privacy. **Topics:** Public Awareness, Technology --- ### [UK insurers face crackdown for undervaluing cars in damage claims](https://insurancefraud.org/news_archives/uk-insurers-face-crackdown-for-undervaluing-cars-in-damage-claims/) **Published:** September 18, 2026 **Author:** Diane Beauchamp **Content:** BRITAIN’S financial watchdog warned insurers against undervaluing cars and other items when customers submit damage claims, and said it would take unspecified action against firms that break its rules. The Financial Conduct Authority (FCA) said on Friday (Dec 2) that it had evidence that some consumers whose cars were written off after an accident were offered sums lower than their vehicles’ fair market values. Offering a price lower than fair market value is not allowed under the FCA rules. Increasing business expenses pressure insurers to control the cost of claims, and one way they do so is by offering cash to settle instead of paying for vehicle repairs. In the FCA’s view, this move may not be in the best interest of customers. Sheldon Mills, executive director for consumers and competition at the FCA, said: “Insurance firms should offer settlements at the fair market value. This is especially important now, as people struggling with the cost of living will be hit in the pocket at precisely the time they can ill-afford it.” The Association of British Insurers (ABI), an industry body, said that insurers have processes in place to determine the fair market value for all written-off cars. It said: “We’ll discuss this with our members to understand how processes are kept under review, including the information provided to customers to (help them) understand the different settlement options available to them.” The ABI added that second-hand car prices are prone to fluctuations, and that impacts settlement options. Separately, insurance firms are also grappling with a rise in auto insurance application fraud. Earlier this week, insurer Aviva said it had seen a 16 per cent rise in such instances of fraud this year until October, compared with the same period last year. Applicants falsified information such as their ages, how long they had held their drivers’ licences, the number of penalty points they had, and their occupations, said Aviva. It warned motorists to think twice about lying to their insurers in an attempt to save a few pounds during the ongoing cost-of-living crisis. **Topics:** Public Awareness, Regulatory actions --- ### [Man jailed for murder of mother after searching for life insurance pay-outs](https://insurancefraud.org/news_archives/man-jailed-for-murder-of-mother-after-searching-for-life-insurance-pay-outs/) **Published:** September 18, 2026 **Author:** Diane Beauchamp **Content:** A man who murdered his own mother in a fire after carrying out internet searches for life insurance pay-outs has been jailed for life with a minimum term of 27 years. Andrew Wilding, 42, set fire to the flat he shared with his bedbound mother Elsie Pinder in Southend, Essex, on July 3, last year. Wilding had been the sole carer for his 66-year-old mother who had suffered a stroke. Ms Pinder died in the fire, as Wilding went to a nearby McDonald’s restaurant to buy a drink. Neighbours raised the alarm and had to evacuate the building. Wilding told police he had left a battery on charge in the hallway while he went to McDonald’s, and was initially treated as a witness. But during their investigation, officers found that in the lead-up to the fire the defendant had searched online for ‘fires’, ‘arsons’, ‘murders’ and ‘batteries involved in fires’. There were also searches around inheritance pay-outs and the life expectancy of a person with a stroke. A final search carried out on June 30, was for ‘suspected arson what to look for battery’. Jurors at Basildon Crown Court found Wilding guilty of murder following a trial, Essex Police said. He was also found guilty of arson with intent to endanger life, due to him being aware there were occupants in the flat above, the force said. Detective chief inspector Stuart Truss, who led the police investigation, said that Wilding’s “greed led to him setting a fire in the home he shared with his mother”. “He knew, there was no chance she would be able to get out of the building alive,” he said. “She had suffered a stroke and was bedbound and he was her sole carer. “Elsie, despite her health issues, was described as being full of laughter and energy. “Wilding took away from her the chance for her to enjoy her later years. “Even more than that, he also knew there were neighbours in the building in which he and his mother lived. “He undoubtedly put their lives at risk with his actions.” On Friday, Wilding was sentenced at Basildon Crown Court to a life sentence and must serve 27 years before he can be considered for release, Essex Police said. Mr Truss said afterwards: “Wilding believed he had concocted a believable story which would ensure he could continue on with his life without being punished. “Even through his trial as the evidence was laid out, he maintained his innocence and that Elsie’s death was a tragic accident. “Thankfully, we saw through his lies and so has the jury and today he has been handed a sentence which truly reflects his actions on July 2021.” **Topics:** Homeowners - arson, Life Insurance **Categories:** Conviction --- ### [Edmonton man charged with arson in Wetaskiwin Memorial Arts Centre fire](https://insurancefraud.org/news_archives/edmonton-man-charged-with-arson-in-wetaskiwin-memorial-arts-centre-fire/) **Published:** September 18, 2026 **Author:** Diane Beauchamp **Content:** An Edmonton man has been charged with arson in a fire that destroyed the Memorial Arts Centre in Wetaskiwin, Alta. The 42-year-old was arrested and released on an appearance notice and attended court in Wetaskiwin on Tuesday. He has been charged with committing arson for fraudulent purposes, with intent to defraud insurance. He is due back at court on Oct. 13. Wetaskiwin RCMP responded to a fire at the arts centre at around 8:20 p.m. on June 6. The Memorial Arts Centre was nearly 80 years old, built in 1947. **Topics:** Business - arson **Categories:** Arrest --- ### [Smarter corporate investigations Part 1: Insurance fraud investigation in the AI era](https://insurancefraud.org/news_archives/smarter-corporate-investigations-part-1-insurance-fraud-investigation-in-the-ai-era/) **Published:** September 18, 2026 **Author:** Diane Beauchamp **Content:** Insurance fraud has become increasingly sophisticated, making it harder for Special Investigation Units (SIUs) to identify connections between claims, individuals and organized fraud networks. Fraud schemes frequently span multiple claims, providers, businesses and jurisdictions, creating patterns that can be difficult to uncover through traditional investigative methods. At the same time, investigators are under pressure to manage growing caseloads while maintaining investigative rigor and thorough documentation. ## Why fraud investigations are becoming more complex Insurance fraud investigations have evolved into intricate challenges that test the limits of traditional investigative methods. While accessing individual pieces of information remains straightforward, the real difficulty lies in rapidly connecting disparate data points to reveal the complete picture. What appears to be separate, unrelated activity may actually be part of a wider fraud network operating across multiple claims and jurisdictions. AI-powered investigation tools are becoming essential for meeting speed requirements while maintaining investigative accuracy. The network effect compounds these challenges exponentially. Today’s fraud rarely involves isolated incidents, requiring investigators to understand the full web of relationships: shared addresses, connected phone numbers, common business affiliations, and historical interactions. Traditional investigation methods—running individual searches and manually connecting dots—simply can’t keep pace with sophisticated operations that exploit investigative bottlenecks. ## How AI helps investigators understand unknown connections Modern fraud investigations often require investigators to connect seemingly unrelated pieces of information. For example, two claims may contain different phone numbers, yet both could be linked to the same individual, business, or fraud network. AI-powered investigation workflows help investigators explore these connections more efficiently, validating information, identifying patterns, and surfacing relationships that might otherwise be missed. ### The network effect Modern insurance fraud rarely involves isolated incidents. Successful investigations require understanding the full network of relationships: shared addresses, connected phone numbers, common business affiliations, and historical interactions. AI-powered tools excel at mapping these relationships and presenting them in formats that investigators can quickly understand and act upon. When the system identifies potential connections, it automatically suggests next steps: run a person report on a connected individual, investigate adverse media for a related business, or analyze geographical patterns across claims. This guided approach ensures investigators don’t miss critical leads while maintaining the efficiency needed for high-volume caseloads. ### Defensible documentation In insurance investigations, documentation isn’t just important—it’s legally essential. AI-powered investigation tools provide complete audit trails with source citations for every finding. Investigators can download comprehensive reports that include their prompts, the AI’s analysis, and all supporting documentation. This approach transforms case documentation from a time-intensive manual process into an automated output that meets legal standards while freeing investigators to focus on analysis and decision-making. ## Strategic implications Organizations implementing AI-powered investigation capabilities report significant improvements in case closure rates, fraud detection accuracy, and investigator productivity. More importantly, they’re building sustainable advantages in an increasingly complex fraud environment. The technology enables SIU teams to shift from reactive claim processing to proactive pattern recognition. Instead of investigating individual claims in isolation, they can identify fraud networks before schemes fully develop, potentially preventing significant losses. **The competitive advantage:** Insurance organizations that embrace AI-powered investigation tools today will be better equipped to detect sophisticated fraud schemes, reduce investigation costs, and maintain the investigative rigor that protects both their business and their customers. Access to these tools is limited to authorized, vetted professionals. **Topics:** Public Awareness, Technology --- ### [zHealth, Inc. Data Breach: Edelson Lechtzin LLP Launches Investigation Into Exposure of Medical and Health Insurance Information](https://insurancefraud.org/news_archives/zhealth-inc-data-breach-edelson-lechtzin-llp-launches-investigation-into-exposure-of-medical-and-health-insurance-information/) **Published:** September 18, 2026 **Author:** Diane Beauchamp **Content:** Edelson Lechtzin LLP, a national class action law firm, is investigating data privacy claims arising from the zHealth, Inc. data breach. zHealth began notifying affected individuals on September 11, 2026, and reported the incident to state regulators, including the Texas Attorney General’s Office on September 15, 2026. **Key Facts at a Glance** - **Company:** zHealth, Inc. — a San Francisco-based healthcare technology company providing cloud-based practice management and electronic health record (EHR) software. - **When access occurred:** Between January 20 and January 21, 2026. - **When discovered:** On or about June 15, 2026. - **Data review completed:** September 3, 2026. - **Information exposed:** Names, medical information, and health insurance information (varies by individual). - **People affected:** Approximately 118,563. - **Individuals notified:** Beginning September 11, 2026. - **Regulators notified:** California and Texas Attorney General offices; the Oregon Attorney General was informed the breach affected 118,563 individuals. **What Happened** zHealth determined that an unauthorized third party accessed its network between January 20 and January 21, 2026. The company became aware on or about June 15, 2026, that certain information may have been copied, launched a forensic investigation, and completed its review of the affected data on September 3, 2026. zHealth then began notifying affected individuals on September 11, 2026. **What Information Was Exposed** The exposed data varies by individual and may include names, medical information, and health insurance information. Because medical and insurance records carry long-term risks of identity theft, insurance fraud, and misuse of protected health information, affected individuals should remain vigilant. **zHealth’s Response** zHealth has offered affected individuals single-bureau credit monitoring, credit report, and credit score services for 12 months and says it has reviewed and enhanced its data privacy and security policies. **Your Legal Options** Edelson Lechtzin LLP is investigating a potential class action to pursue legal remedies on behalf of individuals whose sensitive personal data may have been compromised in the zHealth breach. The firm will evaluate your rights and potential claims at no cost. **Recommended Protective Steps** - Preserve any breach notification letter and enroll in the credit monitoring offered by zHealth. - Review account statements, credit reports, and Explanation of Benefits notices for unfamiliar activity. - Consider placing a fraud alert or credit freeze, and stay alert for phishing attempts referencing the breach. **Topics:** Judicial/courts, Public Awareness, Technology --- ### [Former FL Coalition Against Domestic Violence CEO sentenced to probation in fraud case](https://insurancefraud.org/news_archives/former-fl-coalition-against-domestic-violence-ceo-sentenced-to-probation-in-fraud-case/) **Published:** September 18, 2026 **Author:** Diane Beauchamp **Content:** The former CEO of Florida’s Coalition Against Domestic Violence was sentenced to 10 years probation on Monday, according to court documents. Tiffany Carr faced three felony charges after a Florida Department of Law Enforcement investigation found she and the coalition’s former CFO, Patricia Duarte, allegedly awarded themselves excessive paid leave and bonuses with money meant for domestic violence shelters across the state. The two were arrested on fraud, grand theft and official misconduct charges in September 2023. Carr entered a no-contest plea in January to fraud and official misconduct charges. Court records show the grand theft charge would be dropped after Duarte stood trial. The plea agreement said she would have to testify against Duarte and could avoid a possible 35-year prison sentence for her testimony. Carr was sentenced to 10 years probation and must pay $100,000 in restitution to the state and $155,264.89 to FDLE for the investigative costs, according to court documents. Her sentence also prohibits her from being employed by or in leadership positions with any nonprofits organizations. FDLE previously stated that Carr received $3.4 million and Duarte received $291,000. Duarte entered a no-contest plea in April, weeks before she was set to stand trial on fraud and grand theft charges and was sentenced to eight year’s probation. She will also have to complete 350 hours of community service. Duarte is also barred from being employed or in leadership positions with any nonprofit organizations. A separate civil suit against Carr and Duarte was settled in August 2021. **Topics:** Financial Fraud **Categories:** Conviction --- ### [Alleged fabricated $6,200 repair invoice leads to arrest of local food truck owner](https://insurancefraud.org/news_archives/alleged-fabricated-6200-repair-invoice-leads-to-arrest-of-local-food-truck-owner/) **Published:** September 18, 2026 **Author:** Diane Beauchamp **Content:** A food truck owner has been arrested for alleged insurance fraud, according to an arrest report from the Department of Financial Services. DFS says that Marcel Laboris Hicks, who is the owner of a food truck called Meathead BBQ, was arrested earlier this week for several insurance fraud offenses stemming from reported traffic accident damage that his food truck was involved in back in Sept. 2025. According to the affidavit, after the accident, United Automobile Insurance Group asked Hicks for repair estimates and photographs to support the claim. Hicks allegedly submitted a $6,200 invoice from Build A Food Truck Miami, which was later determined to be fabricated by investigators. Additionally, DFS says that Hicks’ estimated number of 1005 belonged to a different person’s claim from back in 2023, not matching the numbering system for 2025 when Hicks put in the claim. The insurance company also confirmed to investigators that they never received an estimate, nor a repair deposit from Hicks. Following a lengthy investigation, investigators concluded that Hicks had knowingly submitted the false claims, and he was arrested and charged with false and fraudulent insurance claim, uttering a forged instrument, and organized scheme to defraud. **Topics:** Auto - padding/false claim **Categories:** Arrest --- ### [Federal Legislation Targets Auto Insurance Fraud With Steep Penalties](https://insurancefraud.org/news_archives/federal-legislation-targets-auto-insurance-fraud-with-steep-penalties/) **Published:** September 18, 2026 **Author:** Diane Beauchamp **Content:** Earlier this month, federal legislation was introduced to make motor vehicle collision fraud a federal crime, according to a joint press release by Congresswoman Laura Gillen (D-NY-04) alongside U.S Representatives Troy Nehls (R-TX-22), Josh Gottheimer (D-NJ-05) and Vince Fong (R-CA-20). The bipartisan bill, Stop Auto Fraud Act of 2026, targets deliberately staged accidents intended to defraud insurance companies, imposing stiff penalties, including possible jail time, for violations. “Long Islanders pay some of the highest car insurance rates in the country and ‘crash for cash’ schemes on our roads are driving rates even higher,” said Rep. Gillen. “When fraudsters stage car wrecks to scam their way to huge payouts, they’re putting lives at risk and forcing responsible drivers to bear the costs. I’m proud to lead this bipartisan bill to hold these criminals accountable, make our roads safer and lower sky-high car insurance costs.” ![](https://ra.wellsmedia.com/www/delivery/lg.php?bannerid=0&campaignid=0&zoneid=173&loc=https%3A%2F%2Fwww.carriermanagement.com%2Fnews%2F2026%2F09%2F16%2F291993.htm&referer=https%3A%2F%2Fwww.google.com%2F&cb=3a68e60716)Penalties range from up to ten years to life in prison if the staged accident results in bodily injury or death to an innocent party. Fines collected would be placed into the Highway Trust Fund, which provides resources to improve roads and make them safer. Insurance carriers reported 38,270 incidents of suspected motor vehicle insurance fraud to the New York State Department of Financial Services in 2023 alone, a 58% increase from 2020. The National Insurance Crime Bureau applauded the measure. “Staged vehicle accidents are not harmless property crimes. These are violent offenses that put innocent drivers and pedestrians at risk of injury or worse—all so that fraudsters and their facilitators can cash in. As NICB data and frontline investigations demonstrate, staged accident fraud is on the rise, costly—up to $300 a year in increased premiums—and increasingly organized. And it demands an organized, effective response,” said Kyle McCollum, vice president, National Insurance Crime Bureau. Long a target of fraudulent auto insurance claims, the commercial trucking industry also welcomed the legislation. “On highways across the country, brazen criminals are intentionally colliding with other motorists in an attempt to score a big payday, and commercial trucks are a top target. Their selfish actions put the lives of innocent Americans at risk and contribute to soaring insurance premiums that raise costs for all consumers,” said Alex Rosen, SVP of Legislative Affairs, American Trucking Associations. “We need stronger penalties to deter those who perpetrate these schemes, which is why ATA strongly supports the Stop Auto Fraud Act. The legislation is endorsed by the National Insurance Crime Bureau, American Trucking Associations, American Bus Association, Truck Renting and Leasing Association, American Property Casualty Insurance Association (APCIA), National Association of Mutual Insurance Companies (NAMIC), National Tank Truck Carriers Association, Truckload Carriers Association, Trucking Association of New York, Texas Trucking Association, Southwest Movers Association, United Motorcoach Association and Coalition Against Insurance Fraud. **Topics:** Coalition Against Insurance Fraud, Legislation, Public Awareness --- ### [Vermont AG announces settlement in Medicaid fraud case](https://insurancefraud.org/news_archives/vermont-ag-announces-settlement-in-medicaid-fraud-case/) **Published:** September 18, 2026 **Author:** Diane Beauchamp **Content:** The Vermont Attorney General’s Office has reached a settlement with a health care services agency over Medicaid fraud allegations. An investigation by the Attorney General’s Medicaid Fraud and Residential Abuse Unit determined that, over a three-year period, Health Care & Rehabilitation Services of Southeastern Vermont, based in Springfield, Vermont, improperly kept Medicaid funds that were not used for their original budgeted purpose. In some cases, they also retained Medicaid funds for clients who had ended their services. Any unused funds should have been returned to the state to be reallocated. Health Care & Rehabilitation Services of Southeastern Vermont has agreed to pay $391,816 to the state and undertake specific compliance measures going forward. **Topics:** Judicial/courts, Public Awareness --- ### [AARP Applauds U.S. House for Passage of Bills to Fight Fraud, Protect Scam Victims, and Keep AM Radios in Cars](https://insurancefraud.org/news_archives/aarp-applauds-u-s-house-for-passage-of-bills-to-fight-fraud-protect-scam-victims-and-keep-am-radios-in-cars/) **Published:** September 17, 2026 **Author:** Diane Beauchamp **Content:** AARP applauds the U.S. House of Representatives for passing three bipartisan bills on Tuesday that address real challenges Americans face every day, including grappling with a rising flood of fraud and scams and accessing critical news and emergency information. In a session late Tuesday evening, the House voted to pass the **GUARD Act**, which would provide federal resources to state and local law enforcement to investigate and crack down on scams, the **Tax Relief for Fraud Victims Act**, which would restore a federal tax deduction to ensure that scam victims aren’t forced to pay taxes on money stolen from them, and the **AM Radio for Every Vehicle Act,** which would require AM radios to remain standard in vehicles so people can access emergency alerts and news. AARP has spent years advocating for all three bills alongside bipartisan coalitions of members, partners, experts and advocates, and is thankful to the House for their leadership in working to address the real concerns facing Americans across the country. The next step is the U.S. Senate, where AARP urges lawmakers to follow the House’s lead and advance all three bills without delay. **AARP Senior Vice President, Government Affairs Bill Sweeney** issued the following comments on each bill: **On the GUARD Act**: “In a moment where Americans, especially older adults, are losing billions of dollars in hard-earned savings to scammers, the GUARD Act is exactly the kind of bipartisan action we need to crack down on criminals and ensure justice for victims.” **On the Tax Relief for Fraud Victims Act**: “For too many Americans, after a criminal steals their life savings, they find they owe tens of thousands of dollars to the IRS in tax bills on money that was stolen from them. This legislation would help victims rebuild their financial security and dignity.” **On the AM Radio for Every Vehicle Act**: “We thank the House for their leadership in advancing the AM Radio for Every Vehicle Act, and urge the Senate to follow suit. Particularly in rural areas where wireless and broadband connections are limited or nonexistent, AM Radio is critical. AM radio not only helps people stay connected through news and targeted programming but also serves as a vital public safety tool to alert people ahead of any natural disaster.” **Topics:** Legislation, Public Awareness --- ### [Middle District Of Louisiana Joins DOJ Fraud Division, SBA, And SBA OIG In Surge Takedown Exceeding $245 Million In Covid-Era Loan Fraud  ](https://insurancefraud.org/news_archives/middle-district-of-louisiana-joins-doj-fraud-division-sba-and-sba-oig-in-surge-takedown-exceeding-245-million-in-covid-era-loan-fraud/) **Published:** September 17, 2026 **Author:** Diane Beauchamp **Content:** The Middle District of Louisiana announced multiple charges and guilty pleas as part of a nationwide enforcement action led by the Justice Department’s National Fraud Enforcement Division, the Small Business Administration (SBA), and the SBA Office of Inspector General (SBA OIG) targeting fraud on the SBA’s Paycheck Protection Program (PPP). From June 12 to September 1, federal prosecutors across the country facilitated enforcement actions spanning over 160 criminal defendants, including approximately 80 newly charged defendants, reaching approximately $245 million dollars in intended loss to American taxpayers. U.S. Attorney Kurt Wall stated, “Millions of taxpayer dollars have been wrongfully obtained through fraudulent Paycheck Protection Program (PPP) loans. Our office is committed to finding those who have scammed the system, and we will prosecute them to the fullest extent possible.” In the Middle District of Louisiana, seventeen (17) defendants have been prosecuted as part of this takedown for PPP-related fraud involving approximately $5 million in alleged intended or actual losses. Charges Announced Jovan Renee Darbonne: Jovan Renee Darbonne, age 47, of Baton Rouge, Louisiana, was charged on August 31, 2026, in a Bill of Information with one count of making false statements to a financial institution and has indicated her intent to waive indictment and plead guilty. According to the charging document, Darbonne allegedly submitted fictitious 2020 IRS Form 941s on behalf of LA Educational Fund, LLC to a bank in support of a Paycheck Protection Program loan application, despite knowing the forms were fraudulent and had never been filed with the IRS. Assistant United States Attorney Stephen Vick is prosecuting the case. Brelle Ford and Rydell Banks, Jr.: Brelle Ford, age 34, of Geismar, Louisiana, and Rydell Banks, Jr., age 28, of Geismar, Louisiana, were indicted on August 26, 2026, on charges arising from an alleged multi-year scheme to fraudulently obtain federal emergency relief funds through the Paycheck Protection Program, the Economic Injury Disaster Loan program, and FEMA disaster assistance. According to the indictment, Ford and Banks allegedly conspired to submit false applications and supporting documents for pandemic and Hurricane Ida relief, including fraudulent PPP and EIDL applications in the names of multiple businesses, fictitious leases and receipts, and FEMA claims falsely asserting property damage. The indictment further alleges that the defendants used interstate wires to obtain FEMA deposits and made false statements to federally insured financial institutions in connection with second‑draw PPP loan applications. Ford is charged with conspiracy to commit wire fraud, two counts of wire fraud, and making a false statement to a bank, while Banks is charged with conspiracy to commit wire fraud, one count of wire fraud, and making a false statement to a bank. Assistant United States Attorney Elizabeth E. White is prosecuting the case. Michelle Jackson and Ryachenelle L. Morris: Michelle W. Jackson, age 52, of Denham Springs, Louisiana, and Ryachanelle L. Morris, age 29, of Vacherie, Louisiana, were indicted on August 12, 2026, for their alleged roles in a scheme to fraudulently obtain COVID‑19 pandemic relief and unemployment insurance benefits. According to the indictment, Jackson and Morris purportedly conspired with others to submit false PPP, EIDL, and unemployment applications using fabricated tax records, falsified payroll information, and misrepresentations about employment history and business operations, enabling them to gain or attempt to gain control of more than $289,000 in federal relief funds. Jackson is charged with conspiracy to commit wire fraud and three counts of wire fraud, and Morris is charged with conspiracy to commit wire fraud. The indictment further alleges that Jackson used interstate wires to deposit PPP funds into bank accounts she controlled and that both defendants used the fraudulently obtained funds for personal expenses, including food, shopping, travel, and vehicle rentals. Assistant United States Attorney John B. Casey is prosecuting the case. Cedrick Kelly: Cedrick Kelly, age 45, of Denham Springs, Louisiana, was indicted on August 12, 2026, on one count of wire fraud for allegedly obtaining a $20,833 Paycheck Protection Program loan through a fraudulent application submitted in April 2021. According to the indictment, Kelly purportedly falsely overstated his business income and provided a fictitious 2019 Schedule C tax form to support his claim, despite knowing the information was untrue. Based on these misrepresentations, an SBA‑approved lender wired the PPP loan proceeds to Kelly’s bank account in the Middle District of Louisiana, funds that he was not entitled to receive. Assistant United States Attorney Ellison C. Travis, who also serves as District Fraud Counsel, is prosecuting the case. Elton R. Kelly: Elton R. Kelly, age 46, of Baton Rouge, Louisiana, was indicted on August 12, 2026, on one count of wire fraud for allegedly submitting a fraudulent Paycheck Protection Program loan application in May 2021. According to the indictment, Kelly purportedly overstated his business income, misrepresented his criminal history, and submitted a fictitious 2019 Schedule C tax form falsely claiming more than $99,000 in gross receipts. Based on these misrepresentations, an SBA‑approved lender wired $20,732 in PPP funds to Kelly’s bank account in the Middle District of Louisiana, money he was not entitled to receive. Assistant United States Attorney Ellison C. Travis, who also serves as District Fraud Counsel, is prosecuting the case. Chris Plant, Jr.: On June 17, 2026, Chris Plant, Jr., age 39, of White Castle, Louisiana, a local preacher, was indicted for wire fraud and for making a false statement to a bank. As set forth in the indictment, Plant allegedly devised a scheme to defraud a financial institution by filing false and fraudulent applications for PPP funds. In furtherance of the scheme, Plant allegedly submitted fraudulent and misleading documents, including fictitious 2019 and 2020 Schedule C tax forms, which falsely represented Plant’s gross receipts, expenses, and net profits for applicant businesses. Based on Plant’s purportedly false representations and fraudulent supporting materials, the financial institution approved and funded four PPP loans for a total amount of $77,081. Assistant United States Attorney Elizabeth E. White is prosecuting the case. Marvin Richardson: Marvin Richardson, age 29, of Baton Rouge, Louisiana, was indicted on August 20, 2026, on two counts of wire fraud for allegedly obtaining more than $28,000 in fraudulent pandemic‑relief funds through the Small Business Administration’s Economic Injury Disaster Loan (EIDL) and Paycheck Protection Program (PPP). According to the indictment, Richardson submitted multiple false applications between July 2020 and May 2021, falsely overstating business revenues, employee counts, and income, and providing fabricated tax documents to support his claims. Based on these misrepresentations, Richardson received an $8,000 EIDL advance and a $20,832 PPP loan, which were transmitted to his bank account in the Middle District of Louisiana. Assistant United States Attorney Ellison C. Travis, who also serves as the District Fraud Counsel, is prosecuting the case. Guilty Pleas and Sentences Announced Keerria Anderson: On August 6, 2026, U.S. District Judge Brian A. Jackson sentenced Keerria Anderson, age 33, of Baton Rouge, Louisiana, to two years of supervised release after Anderson pled guilty to wire fraud. Anderson worked for the U.S. Postal Service between March 2016 and at least October 2022. Between July 2020 and at least October 2021, Anderson devised a scheme to defraud the United States, through the SBA and two financial institutions, by submitting applications for an EIDL and two PPP loans that contained false representations and documentation regarding her purported businesses and gross revenues and income. As part of her sentence, Judge Jackson also ordered Anderson to pay $50,962.00 as restitution to the SBA. Assistant United States Attorney Jessica M. Thornhill prosecuted the case. Lashae M. Bell and Johntrell Jamar White: On July 9 and July 28, 2026, U.S. District Judge Brian A. Jackson sentenced Lashae M. Bell, age 33, of Gonzales, Louisiana, and Johntrell Jamar White, age 32, of Simmesport, Louisiana, to 30 months and 27 months in federal prison, respectively, after each pled guilty to conspiracy to commit wire fraud for their roles in a scheme to defraud multiple COVID‑19 pandemic relief programs. Bell and White submitted fraudulent unemployment insurance applications in their own names and in the names of others to numerous state workforce agencies and to Puerto Rico, and Bell also obtained Paycheck Protection Program funds through false statements. Judge Jackson ordered Bell to pay $851,241 in restitution and imposed a forfeiture money judgment of $164,891. The court also ordered White to pay $830,409 in restitution with a forfeiture money judgment of $135,300. According to their plea agreements, the defendants’ fraudulent claims caused state workforce agencies and the SBA to disburse hundreds of thousands of dollars in federal pandemic relief funds to which they were not entitled. Assistant United States Attorney Elizabeth E. White prosecuted the case. Daysha Blount: Daysha Renee Blount, age 34, of Gonzales, Louisiana, pled guilty on August 13, 2026, to one count of wire fraud for fraudulently obtaining more than $83,000 in Paycheck Protection Program loan proceeds. According to court documents, Blount submitted four PPP loan applications in 2021—three in her own name and one on behalf of a company—using fabricated tax forms and altered bank records to falsely claim significant business income. She later submitted forgiveness applications containing additional false statements, resulting in all four loans being forgiven. Blount is scheduled to be sentenced on November 10, 2026, by U.S. District Judge Brian A. Jackson. Assistant United States Attorney Stephen Vick is prosecuting the case. Makyro Ferguson, Maletica Ferguson, and Vanshion Byrd: Maletica V. Ferguson, age 49; Vanshion J. Byrd, age 51; and Makyro V. Ferguson, age 26, all of Baton Rouge, Louisiana, pled guilty to one count each of conspiracy to commit wire fraud following their February 11, 2026 indictment for participating in a scheme to fraudulently obtain pandemic-related relief funds through the Paycheck Protection Program, the Economic Injury Disaster Loan Program, and unemployment insurance programs. According to court documents, the defendants and their co‑conspirators submitted numerous false applications supported by fabricated tax forms, altered bank records, and other fraudulent information, causing the disbursement of significant federal relief funds to which they were not entitled. Maletica Ferguson and Vanshion Byrd entered their guilty pleas on July 7, 2026, and Makyro Ferguson pled guilty on July 21, 2026. All three defendants are scheduled to be sentenced by U.S. District Judge Brian A. Jackson on December 3, 2026. Assistant United States Attorney John B. Casey is prosecuting the case. Lonell Taylor: Lonell Taylor, 32, of Baton Rouge, Louisiana, was sentenced on June 30, 2026, by U.S. District Judge Brian A. Jackson to five months in federal prison and ordered to pay $126,985.16 in restitution after pleading guilty to wire fraud and fraud to obtain federal employees’ compensation. According to her plea agreement, Taylor was an employee of the U.S. Postal Service who falsely claimed for years that she had no outside income while receiving workers’ compensation benefits, despite actively operating two businesses and earning income. Taylor also devised a scheme to obtain pandemic-related Paycheck Protection Program funds by submitting multiple fraudulent loan applications supported by fabricated tax documents, ultimately receiving more than $40,000 in SBA-backed PPP loans that she used for personal expenses. Assistant United States Attorney Jessica M. Thornhill prosecuted the case. U.S. Attorney Wall praised the Small Business Administration, Office of Inspector General; the Federal Bureau of Investigation; the U.S. Department of Homeland Security, Office of Inspector General; the U.S. Department of Labor, Office of Inspector General; the Export-Import Bank of the United States, Office of Inspector General; the U.S. Secret Service; and the U.S. Postal Service, Office of Inspector General, for their investigations in these matters. On April 7, the Department of Justice announced the creation of the National Fraud Enforcement Division (“Fraud Division”). The Fraud Division is laser-focused on investigating and prosecuting those who commit fraud against the American people. The Department’s work to combat fraud supports President Trump’s Task Force to Eliminate Fraud, a whole-of-government effort chaired by Vice President J.D. Vance to eliminate fraud, waste, and abuse within Federal benefit programs. **Topics:** Business - padding/faking, COVID-19, Unemployment Insurance **Categories:** Conviction --- ### [Farm manager pleads guilty in Oakes Farms fraud case](https://insurancefraud.org/news_archives/farm-manager-pleads-guilty-in-oakes-farms-fraud-case/) **Published:** September 17, 2026 **Author:** Diane Beauchamp **Content:** An Immokalee farm manager who oversaw a farm for Francis “Alfie” Oakes III became the 10th defendant to plead guilty to federal fraud charges, agreeing to cooperate and testify against all coconspirators. Mark Frisbie, 60, of Punta Gorda, signed a plea agreement admitting he made a false statement in a federal crop-insurance claim and agreed to pay restitution to the Federal Crop Insurance Corporation. For other frauds he participated in, he agreed to reimburse the U.S. Farm Service Agency for the Coronavirus Food Assistance Program and the U.S. Emergency Relief Program. Due to his cooperation, Frisbie won’t face the maximum 30 years in federal prison; a $1 million fine or twice the gross gain of the offense, whichever is greater; up to five years of supervised release; and a mandatory $100 assessment. Other coconspirators include Oakes Farms’ former acting CEO and president, its vice president, general manager, warehouse manager and two Immokalee harvesters. Others defrauded include the U.S. Department of Defense Fresh Program and the Defense Logistics Agency. The plea agreement, made public Sept. 15, was negotiated by Chief Assistant U.S. Attorney Jesus Casas, Assistant U.S. attorneys Chelsey Hanson and Simon Eth, Frisbie and his defense attorneys, Simon A. Gaugush of Tampa and Tino M. Lisella of West Palm Beach. Frisbie and attorneys signed the agreement Sept. 8. “For over 15 years, Mark Frisbie ran a legitimate farming operation in Southwest Florida, growing food to feed American families,” Gaugush said Sept. 15. “This charge does not change that fact. He is a family man and a respected member of his community. Mark has accepted responsibility for the conduct related to this charge, is cooperating fully with the government, and looks forward to closing this chapter of his life.” Oakes has not been charged. Neither he nor his civil attorney, Steven Bracci, has responded to requests for comment. Oakes has sued his former acting CEO and president, Steven Veneziano, alleging he masterminded a scheme to steal from his stores and farms; that case is pending, as is Veneziano’s sentencing. The prosecutions began after federal agents raided Oakes’ North Naples home and Immokalee packing plant in November 2024, when they hauled out boxes of documents and other evidence. Plea agreements don’t identify Oakes by name but refer to him as Coconspirator 1 or Farm Enterprise 1, a group of associated business entities involved in the farming, packing, shipping, retail market, food service and seafood distribution industries. The entities match Oakes’ Food & Thought, Seed to Table, Captain Jerry’s Seafood and his farms. Coconspirators have admitted proceeds “mostly benefited Coconspirator 1,” who used them to pay his farming expenses, debt and other business expenses or to purchase assets. Records say Frisbie, an agricultural chemical salesman, managed a farm “in or around Immokalee” under an agreement with Coconspirator 1, who funded the farm and marketed all crops. They shared profits and losses, with 60% going to Oakes and 40% to Frisbie. The plea agreement says that on or about Feb. 5, 2020, Frisbie signed a crop-year fall 2020 federal crop-insurance claim for the partnership’s bell peppers. The claim and payout were based on invoices he provided that detailed all bell pepper production and sales records. The invoices he provided to his crop-insurance adjuster — which Frisbie received from Coconspirator 2 — showed the partnership grew 16,417 cartons of bell peppers and sold them for $107,280.50. “In reality, Frisbie’s partnership had much more bell pepper production and sales than he reported — and Frisbie knew as much,” the agreement says, adding that he knowingly signed and submitted a false crop-insurance claim so the partnership could receive fraudulent crop-insurance proceeds. Frisbie knew the claim was false, the agreement says, because he received a “Grower Summary” from Coconspirator 2 that showed crop production and sales from Oct. 15, 2019, to Nov. 30, 2019, for crop-year fall 2020, detailing $379,661.67 in bell pepper sales — “more than three times the total fall bell-pepper sales that Frisbie certified for crop-insurance purposes.” “Frisbie not only received this Grower Summary before he falsely signed and certified a crop-insurance claim (in February 2020), contradicting it — he also reviewed it and responded,” the plea agreement says, showing a smiley face and “Nice.” Later in the season, on Jan. 6, 2020, Frisbie received another “Grower Summary” from Coconspirator 2 showing bell pepper crop production and sales from Oct. 14, 2019, to Jan. 6, 2020, that represented crop-year fall bell peppers, “more fulsomely capturing the season’s sales.” It showed nearly 10 times the total bell pepper sales Frisbie had certified for crop insurance. “Frisbie not only received this Grower Summary a month before he falsely signed and certified a crop insurance claim directly contradicting it — he also reviewed it and responded,” the plea agreement says, showing Frisbie’s note: “Nice average, considering some of the cheap chilis. Thanks for all the hard work, brother!” Based on the fraudulent claims, the FCIC paid $1,795,523 in insurance indemnities, when it would have paid only $134,585 if it had been provided with accurate crop and sales figures — a $1.66 million overpayment. Frisbie also signed and certified a false crop-insurance claim for tomatoes in crop-year fall 2021, reporting just $34,602.75 in tomatoes when records showed more than $177,390.07 in actual sales, “concealing more than 80%.” Based on the claim, the FCIC paid $87,470, when the partnership should have received no indemnity. The plea agreement says the overpayment was “shared with Coconspirator 1 and/or used to pay the partnership’s farm expenses,” which he was responsible for himself. “While Frisbie generally understood that Coconspirators 1 and 2 were hiding crop production with respect to other fields on which they were farming certain insured crops, Frisbie did not know or reasonably foresee the extent of insured crops/acres that Coconspirators 1 and 2 were farming — and did not know or reasonably foresee the extent of crop production that they were hiding on those acres,” the plea agreement says. The agreement says Frisbie was involved in other fraudulent government-benefits applications, including applications he submitted on behalf of his farm, Frisbie Farms LLC, for the Coronavirus Food Assistance Program and Emergency Relief Program. He admitted submitting fraudulent CFAP-1 and CFAP-2 applications covering two time periods and knowingly submitting a false and fraudulent Emergency Relief Program Phase 2 application. The proceeds were shared with Coconspirator 1 and/or used to pay the partnership’s farm expenses, which Coconspirator 1 was obligated to pay himself. Frisbie admits he wasn’t entitled to any ERP Phase 2 proceeds and was entitled to “significantly reduced” CFAP-1 and CFAP-2 payments. A plea hearing has been set for Sept. 29 in U.S. District Court in Fort Myers before U.S. Magistrate Judge Nicholas P. Mizell. So far, three defendants have been sentenced, and sentencing hearings have repeatedly been delayed as more defendants have been arrested. **Topics:** Crop insurance **Categories:** Conviction --- ### [Better Business Bureau scam alert: Beware of life insurance impostors targeting older adults](https://insurancefraud.org/news_archives/better-business-bureau-scam-alert-beware-of-life-insurance-impostors-targeting-older-adults/) **Published:** September 17, 2026 **Author:** Diane Beauchamp **Content:** The BBB is warning consumers to be cautious of unexpected calls from people claiming to represent a life insurance company. Recent reports involve callers telling older adults that they have signed up for a life insurance policy, then attempting to collect personal or financial information or initiate payments. How the scam works You receive an unexpected phone call from someone claiming to be a life insurance agent or representative. The caller may say you recently signed up for a policy or already have an account with the company. The caller may ask you to confirm personal information, provide banking or payment information or answer questions about your existing insurance coverage. In some cases, the caller may attempt to set up payments for a policy you do not remember purchasing. The call may seem convincing if the caller already knows your name or other basic information. However, scammers can use publicly available information to make their calls appear legitimate. An Ohio consumer reported to the BBB Scam Tracker that their sister was cold-called and enrolled in a life insurance policy she did not remember purchasing. The consumer noticed payments being withdrawn from her bank account and eventually stopped the payments through the bank. Another Ohio consumer reported receiving a call from someone claiming to be a life insurance agent who demanded information about their policy. After the consumer refused, they contacted the insurance company directly and learned the caller was not affiliated with the company. How to avoid voice search scams Be cautious of unexpected calls. If someone contacts you about a policy you do not remember purchasing, do not provide information until you can verify the claim.Check your bank statements. Look for unfamiliar withdrawals or recurring payments. If you notice an unauthorized payment, contact your bank or credit card company as soon as possible to dispute the charge. You should also report the scam to your state’s consumer protection office and the Federal Trade Commission at [ReportFraud.ftc.gov](http://reportfraud.ftc.gov/).Contact the company directly. Look up the insurance company’s official contact information independently and call to verify whether the policy or representative is legitimate.Do not confirm personal information. Never provide your Social Security number, banking information, credit card number or other sensitive information to an unsolicited caller.Research before purchasing insurance. Compare insurance companies, check that they are licensed and review their reputation before purchasing a policy. Carefully review the insurance contract and make sure you understand the premiums and terms. **Topics:** Elderly Fraud, Life Insurance, Public Awareness --- ### [Cross-National Comparison of Long-Term Care Fraud Oversight and Investigation Practices](https://insurancefraud.org/news_archives/cross-national-comparison-of-long-term-care-fraud-oversight-and-investigation-practices/) **Published:** September 17, 2026 **Author:** Diane Beauchamp **Content:** As long-term care (LTC) services and public coverage expand, concerns about improper billing and fraudulent claims have also grown. These practices can divert public resources and place vulnerable beneficiaries at risk across LTC systems. In response, countries have developed approaches to identifying suspicious activities, investigating potential fraud, recovering improper payments, and imposing administrative, civil, or criminal consequences, reflecting the structure of their LTC systems and the types of misconduct they encounter. Although these systems differ across countries, cross-national comparison can reveal reciprocal policy and practice lessons regarding case triage, evidence development, interorganizational coordination, payment recovery, and enforcement. This study compares LTC fraud oversight and investigation practices in the United States, Japan, and South Korea to identify transferable lessons for developing effective and sustainable fraud-control systems that preserve continuity of care for residents. **Speaker:** Hyunkyung “Yulia” Yun, PhD, MS, MSW, is an Assistant Professor at the Herbert Wertheim School of Public Health and Human Longevity Science, UC San Diego. She earned her PhD in Health Services Research, specializing in health economics, at the Brown University School of Public Health. Her research evaluates health policies and care delivery systems affecting older adults, focusing on long-term care, managed care, and quality of care, using causal inference methods with claims, assessment, and EMR data. Previously, she worked at South Korea’s National Health Insurance Service as a fraud investigator and researcher supporting the country’s long-term care insurance system. **Topics:** Long-Term Care Insurance, Public Awareness --- ### [Norwalk man pleads guilty to years-long prize insurance business scam](https://insurancefraud.org/news_archives/norwalk-man-pleads-guilty-to-years-long-prize-insurance-business-scam/) **Published:** September 17, 2026 **Author:** Diane Beauchamp **Content:** A Norwalk man pleaded guilty in federal court Tuesday to an offense related to the operation of a fraudulent prize insurance business, the United States Attorney for the District of Connecticut said. According to evidence and testimony, 69-year-old Kevin Kolenda operated Hole-in-Won LLC, Compliance HIW LLC, Hole-in-Won Worldwide, and Hole-in-Won.com (Hole-in-Won). Together, the businesses provided prize insurance to customers who offered promotions or prizes at events such as fishing contests or golf tournaments. An investigation discovered that Kolenda had defrauded dozens of individuals and organizations, often charitable or civic groups, out of hundreds of thousands of dollars over several years. Victims would complete an insurance contract and pay a premium, with Kolenda and Hole-in-One promising to pay out the claim for the cost of the insured prize if it was won. If nobody won the prize, Kolenda and Hole-in-One would keep the premium. If someone did win the insured prize, he used various fraudulent techniques to avoid paying the claim. In one instance, Kolenda used aliases to hide his involvement, directed victims to a non-existent claims department, made excuses as to why the claim was not being paid, and threatened legal action and reputational harm if victims continued to seek payment of the claim. Ultimately, Kolenda would simply stop responding to correspondence from victims and refused to pay out the cost of the insured prizes. The victim or their partners often paid for the cost of the insured prizes themselves in order to avoid reputational harm and potential legal action. Kolenda and his entities were not licensed to sell insurance products, and in many states, insurance departments issued cease and desist orders in an effort to stop his illegal sales, warnings that Kolenda ignored. Kolenda and his businesses were instructed to stop selling prize insurance coverage in a dozen states, including Connecticut. In 2011, Kolenda was convicted of first-degree larceny and third-degree attempt to commit criminal larceny, was ordered to pay restitution and serve three years of probation in Connecticut. Between 2013-2016, he was also convicted on various insurance-related charges in Montana and Washington. Kolenda was arrested on April 5, 2024. While released on bond, he violated the conditions of his release by, among other things, continuing to sell prize insurance without an appropriate license, and his bond was revoked. He has been detained since March 6, 2026. Kolenda pleaded guilty to one count of wire fraud, which carries a maximum sentence of 20 years in prison. His sentencing is scheduled for Dec. 15. **Topics:** Insider Fraud, Unlicensed entities **Categories:** Conviction --- ### [Repeat Felon Arrested and Charged in $4.75M Medicare Fraud Scheme](https://insurancefraud.org/news_archives/repeat-felon-arrested-and-charged-in-4-75m-medicare-fraud-scheme/) **Published:** September 17, 2026 **Author:** Diane Beauchamp **Content:** A federal grand jury in the Eastern District of Michigan returned an indictment charging Emory Matthews, 62, of Farmington Hills, Michigan, with conspiring to bill Medicare for psychotherapy services that were never provided to patients of an adult day care center owned by his wife. He was arrested yesterday. According to court documents and evidence presented in court, Emory Matthews was a managing employee and administrator of New Beginnings Adult Center Inc. (New Beginnings), an adult day care center in Detroit. Matthews was previously convicted of soliciting and receiving illegal health care kickbacks and bribes stemming from his earlier operation of the adult day care center. As a result of that conviction, he was excluded from billing Medicare. As alleged in the indictment, Matthews and his wife, Yolanda Matthews: Submitted false and fraudulent claims for individual and group psychotherapy services that were not provided; Billed Medicare for services purportedly provided to beneficiaries at New Beginnings when in fact those beneficiaries were hospitalized at the time and could not have received the services; Billed Medicare for services purportedly provided to beneficiaries at New Beginnings when those beneficiaries were deceased; Used the names of former employees on false claims submitted to Medicare; and Fraudulently concealed Matthews’ exclusion from Medicare by failing to disclose his role as a managing employee of New Beginnings as required by the rules. From January 2020 through June 2025, Matthews allegedly participated in submitting over $4.75 million in false and fraudulent claims to Medicare. Yolanda Matthews pleaded guilty to one count of Conspiracy to Commit Health Care Fraud on July 27. Emory Matthews is charged with conspiracy to commit health care fraud and three counts of health care fraud. If convicted, he faces a maximum penalty of 10 years in prison on each count. Assistant Attorney General Colin M. McDonald of the Justice Department’s National Fraud Enforcement Division; Special Agent in Charge Jennifer Runyan of the FBI Detroit Field Office; and Special Agent in Charge Thomas Ethridge of the Department of Health and Human Services Office of Inspector General (HHS-OIG) made the announcement. The FBI Detroit Field Office and HHS-OIG investigated the case. Trial Attorney Jeffrey A. Crapko of the Fraud Division’s Health Care Fraud Section is prosecuting the case. On April 7, the Department of Justice announced the creation of the Fraud Division. The Fraud Division is laser-focused on investigating and prosecuting those who commit fraud against the American people. The Department’s work to combat fraud supports President Trump’s Task Force to Eliminate Fraud, a whole-of-government effort chaired by Vice President J.D. Vance to eliminate fraud, waste, and abuse within Federal benefit programs. The Department of Justice’s Health Care Fraud Strike Force Program, currently comprised of nine strike forces operating in federal districts across the country, has charged more than 6,200 defendants who collectively billed federal health care programs and private insurers more than $45 billion since 2007. In addition, the Centers for Medicare & Medicaid Services, working in conjunction with the Office of the Inspector General for the Department of Health and Human Services, are taking steps to hold providers accountable for their involvement in health care fraud schemes. More information can be found at [www.justice.gov/criminal-fraud/health-care-fraud-unit](http://www.justice.gov/criminal-fraud/health-care-fraud-unit). **Topics:** Medicare/Medicaid **Categories:** Arrest --- ### [Semmes man arrested, accused of arson and insurance fraud after cabin fire](https://insurancefraud.org/news_archives/semmes-man-arrested-accused-of-arson-and-insurance-fraud-after-cabin-fire/) **Published:** September 17, 2026 **Author:** Diane Beauchamp **Content:** A Semmes man is facing arson and insurance fraud charges after a cabin fire in Coffeeville. According to a Facebook Post from the Alabama State Fire Marshal’s Office, Thomas Norman II was arrested and booked on Sunday, Sept. 13, by Border Patrol Agents in New Orleans. Officials said he was connected to a hunting cabin fire back on Aug. 21 in Coffeeville. Norman will be extradited to Alabama, where he will be charged with first-degree insurance fraud and second-degree arson. **Topics:** Homeowners - arson **Categories:** Arrest --- ### [The Synthetic Claims Crisis: How Generative AI Is Reshaping Insurance Fraud and Visual Verification](https://insurancefraud.org/news_archives/the-synthetic-claims-crisis-how-generative-ai-is-reshaping-insurance-fraud-and-visual-verification/) **Published:** September 17, 2026 **Author:** Diane Beauchamp **Content:** The Emergence of Deepfake Insurance Claims The insurance sector is currently undergoing a structural transformation driven by the rapid evolution of artificial intelligence. While automated underwriting and digital claims processing have streamlined operations, they have simultaneously exposed carriers to an entirely new category of risk. Generative artificial intelligence, diffusion models, and sophisticated image editing suites now allow bad actors to produce hyper-realistic visual evidence in seconds. From fabricating entirely non-existent motor vehicle collisions to subtly amplifying existing property damage, digital fraud has transitioned from crude editing tricks to sophisticated synthetic manipulation. Insurance adjusters who once relied on visual inspection can no longer evaluate claims photos by sight alone, as modern synthetic images easily deceive human perception. This shift poses a major challenge to First Notice of Loss workflows. Historically, fraudulent claims relied on staged incidents, falsified paper receipts, or stolen images sourced from public internet searches. Today, generative models allow claimants to render unique, high-resolution photographs showing crumpled fenders, cracked windshields, flooded basements, or charred personal items that have no prior digital footprint. Because these assets are synthetically rendered rather than copied, standard reverse-image lookups are entirely ineffective. Consequently, insurers face rising loss ratios and mounting operational friction as manual investigation queues become overwhelmed by increasingly convincing deepfake media. The Mechanics of Pixel-Level Forensics and Verification To protect digital claims channels without delaying settlements for honest policyholders, insurance carriers are forced to upgrade their technological defenses. Traditional metadata checks—such as inspecting EXIF data for timestamps or device models—are easily bypassed or stripped by standard social media platforms and messaging apps. Modern fraud defense relies heavily on advanced ai image detection engines designed to analyze visual assets at the structural level. Rather than relying on surface metadata, these specialized algorithms scan underlying pixel distributions, lighting vector consistency, edge artifacts, and sensor noise patterns to identify synthetic origin or localized digital tampering. The technical challenge of synthetic media detection lies in distinguishing natural camera noise from artificial generation artifacts. Every physical camera sensor leaves a unique hardware fingerprint on a captured photo, known as photo-response non-uniformity. Generative AI architectures, by contrast, leave distinct algorithmic footprints, such as unnatural pixel blending, mathematical pattern repetition, or spatial frequency anomalies. Advanced detection engines ingest incoming claim media in real time, computing a forensic confidence score in milliseconds. Clean uploads are routed straight through automated settlement pipelines, while flagged assets generate explainable heatmaps that pinpoint the exact regions of an image that exhibit synthetic manipulation or localized pixel editing. Evaluating Risk Profiles Across Domestic and Travel Insurance Synthetic image fraud spans virtually every sector of the insurance market, but its impact is particularly visible in high-frequency, low-touch claims categories. In property and casualty lines, bad actors frequently submit modified photos to claim reimbursement for non-existent damage or inflate repair estimates. Similarly, in personal line insurance, travel coverage has emerged as a frequent target for synthetic fraud schemes. Claimants filing for lost luggage, canceled trips, or stolen high-value personal electronics can now quickly generate convincing receipts, police reports, and damaged item photos directly from mobile devices while abroad. This vulnerability highlights the need for policyholders to maintain comprehensive coverage while carriers implement robust verification systems. Norwegian consumers seeking reliable financial protection, for instance, carefully compare market options to find the beste reiseforsikring available for international trips. Reliable coverage guarantees peace of mind against genuine medical emergencies, delayed transport, and stolen baggage. However, as travel claims processing becomes increasingly digitized to accommodate tourists worldwide, insurance providers must balancing frictionless service with robust fraud prevention, ensuring that legitimate travelers receive rapid support while fraudulent synthetic submissions are caught before payout. Integrating Automated Detection into Enterprise Workflows Deploying forensic AI into an insurance enterprise requires careful workflow integration. Inserting manual forensic reviews into every claim would create administrative bottlenecks and frustrate honest customers expecting instant payouts. To maintain efficiency, insurers embed automated image verification engines directly into their digital intake infrastructure. When a policyholder submits damage photos via a mobile app or web portal, the media is automatically scanned before reaching an adjuster. The system evaluates the image against known generative models, flags suspicious pixel arrangements, and verifies contextual consistency. If an image triggers a high risk score, the system automatically escalates the file to Special Investigation Units alongside a detailed forensic breakdown. Investigators receive visual diagnostic reports showing heatmaps of altered regions, probability scores of specific generative architectures, and contextual flags such as inconsistent shadow angles or mismatched ambient lighting. This explainable intelligence empowers claims handlers to make confident, evidence-backed decisions, protecting the carrier’s capital while upholding rigorous legal and regulatory compliance standards. Cryptographic Source Verification and the Future of Claims Integrity Looking ahead, the defense against synthetic image fraud will evolve from retroactive detection to preventative authentication. While pixel-level forensic engines remain the primary defense for incoming unauthenticated media, the industry is increasingly adopting cryptographic source-verification protocols. Through camera-level digital signatures and tamper-proof ledger logging, insurance apps can capture photos directly from policyholder devices while embedding immutable hardware signatures, precise geolocation coordinates, and verified atomic timestamps into the image file. By combining cryptographic source verification with automated deepfake analysis, insurance organizations can construct a layered security architecture. Honest policyholders benefit from immediate claims processing and seamless customer service, while bad actors attempting to exploit generative AI tools encounter an automated defense matrix. As generative models become increasingly accessible and realistic, maintaining rigorous visual verification standards will serve as the cornerstone of trust, security, and operational resilience across the global insurance ecosystem. **Topics:** Public Awareness, Synthetic Identity Theft, Technology --- ### [What If Employer’s Secret Identity Causes Workers’ Comp Claim to Be Filed Late?](https://insurancefraud.org/news_archives/what-if-employers-secret-identity-causes-workers-comp-claim-to-be-filed-late/) **Published:** September 17, 2026 **Author:** Diane Beauchamp **Content:** A late-filed workers’ compensation claim can be considered valid where the lateness is due to the identity of the claimant’s employer being concealed from her. The Virginia Workers’ Compensation Commission (VWCC) has upheld a deputy commissioner’s ruling that found an employee should not be denied benefits for filing her injury claim against the correct entity after the state’s two-year statute of limitations had expired. The claimant had no way of knowing that her employer was by law the federal grant-making agency AmeriCorps and not the school program where she was an assistant or the city that paid her. The 78-year old claimant participated in the Foster Grandparents Program, assisting students and teachers in the Hampton, Virginia school system. On May 1, 2023, she suffered a fall and sustained injuries. She filed three times for her workers’ compensation benefits; two claims were filed within the two-year limitation period. On the first, she named Peninsula Foster Grandparents as her employer; on the second, she listed Hampton Public Schools. Then, 27 months after her injury on August 18, 2025, her counsel moved to add AmeriCorps as the employer, a motion granted then appealed by AmeriCorps to the full commission. There was no dispute that AmeriCorps is the employer. AmeriCorps is a federal program that provides grants to state and local governments to help them meet community needs. The Virginia workers’ compensation act provides that an “employee” includes “AmeriCorps members who receive stipends in return for volunteering in local, state and nonprofit agencies in the Commonwealth.” However, the claimant initially filed her claim against the employer as it was identified to her at the time she applied. She was never informed about the existence of AmeriCorps during any of her years of service, and even her supervisor and the school human resource department were unaware of the fact that AmeriCorps was the employer for the foster program. She was not supervised by AmeriCorps. All payments she received, whether stipends or reimbursements, were from the city of Hampton. The 1099 IRS form she received was from the city as well. The commission explained that in order to prove estoppel and avoid the statutory time limit, the claimant needed to establish either fraud or concealment by the employer, or an act reasonably calculated to induce the employee to refrain from preserving her claim. The commission also noted that the doctrine of imposition empowers the commission, in appropriate cases, to render decisions based on justice shown by the total circumstances, even though no fraud, mistake, or concealment has been shown. Imposition requires a threshold showing of unfairness. At the same time, employers are also barred from relying upon the expiration of the statute of limitations. The deputy commissioner ruled that given that AmeriCorps must be presumed aware of the definition of an employee in the law, that it took no steps to inform workers within its purview of the employment relationship created by statute, and that the claimant correctly identified the employment unit for which AmeriCorps offered funding for stipends, the principles of estoppel prevent AmeriCorps from asserting that the provisions of Virginia law bar the woman’s claim. The deputy wrote: “An employee, such as the claimant, who was provided no information that her employer should be considered different from the entity that was routinely identified to her and that she routinely identified as her employer, should not be prejudiced. At the same time, an employer should not be allowed to evade its responsibilities under the act by omitting to take steps to ensure the clarity of the employment relationship established.” ![](https://ra.wellsmedia.com/www/delivery/lg.php?bannerid=0&campaignid=0&zoneid=162&loc=https%3A%2F%2Fwww.insurancejournal.com%2Fnews%2Feast%2F2026%2F09%2F14%2F884961.htm&referer=https%3A%2F%2Fwww.google.com%2F&cb=4201e47019)The full VWCC agreed, finding that “the claimant’s failure to identify her employer was due to concealment.” AmeriCorps argued that the claimant’s ignorance of the law was no excuse and that the claimant failed to identify any statute or rule requiring AmeriCorps to advise her of its statutory employer status. But the VWCC said those defenses mischaracterized the problem The VWCC said the clamant did not suffer from ignorance of the law. Rather, she was deprived of knowledge of a fact critical to her ability to file a timely claim, namely, the identity of her employer. “Knowledge of the Virginia law relating to the relationship between AmeriCorps and the Commonwealth of Virginia would have rendered her no less ignorant that those provisions applied to her, as she was never informed that she was an AmeriCorps employee,” the commission explained. The VWCC found that the doctrines of estoppel and imposition applied and affirmed the decision of the deputy to allow the claim. “In every conceivable regard, the claimant was deprived of any reasonable opportunity to discover the existence of the organization and that she was its employee. The deficiency was not ignorance of law, but ignorance of a fact necessary for the claimant to exercise rights granted to her under the law,” the VWCC concluded. **Topics:** Public Awareness, Regulatory actions, Workers Comp --- ### [Md. woman allegedly torches home](https://insurancefraud.org/news_archives/md-woman-allegedly-torches-home/) **Published:** December 19, 2020 **Author:** Coalition Against Insurance Fraud **Content:** A woman is charged with deliberately setting her house on fire for a fraudulent insurance claim. According to the Maryland State Fire Marshal’s Office, the fire last June in Federalsburg destroyed the home and cause about $215,000 damages. 45-year-old Caitlin Hudson was quickly identified as a suspect. She was indicted on several charges by a Caroline County Grand Jury. The fire marshal’s office says Hudson was arrested Monday in Selbyville without incident, and was extradited to Caroline County. The charges against her include arson, malicious burning, malicious burning with intent to defraud, false statements to insurance and reckless endangerment. If convicted, Hudson could face up to 60 years imprisonment and / or $75,000 in fines. **Topics:** Homeowners - arson **Categories:** Arrest --- ### [2 Bali Expats Busted on Interpol Warrants](https://insurancefraud.org/news_archives/2-bali-expats-busted-on-interpol-warrants/) **Published:** September 16, 2026 **Author:** Diane Beauchamp **Content:** Detik.com reports that two foreign nationals, Cyril Stiak (48) and Stefan Durina (39), sought by Interpol under an international “Red Notice,” have been taken into custody in Bali by the Indonesian Police. Cyril Stiak is a citizen of the Czech Republic, while Stefan Durina is Slovakian. Before their arrest, both men were sought by the Czech National Central Bureau (NCB) in 2019 in connection with criminal charges of embezzlement and tax evasion. Indonesian immigration records show the two men first entered Indonesia via Bali’s Ngurah Rai Airport in 2019. Stefan Durina first set foot in Indonesia in 2019 and most recently arrived on 20 March 2020. Records show Stefan During has traveled back and forth to Indonesia on eight occasions. While in Bali, the two men established businesses in Bali. Cyril Stiak managed a villa on Karma Beach, South Kuta. Meanwhile, Stefan Durina rented a villa that was used as a marketing office. The head of the International Relations Division of the Indonesian Police, Inspector General Krishna Murti, confirmed on Wednesday, 30 November 2022, that the men had been sought since 2019 by INTERPOL as high-profile fugitives under Red Notices. Indonesian Police arrested Cyril Stark at his rented residence in South Kute on Wednesday, 30 November. Stefan Durina was taken into custody a day later at Vila River in Canggu, North Kuta. Information provided by NCB in Prague stated Cyril Stiak embezzled 25,000 Czech Koronas (CZK) from a company listed as Majordomos Gastro SRO on 02 June 2008. Czech Police say the Stiak was involved in 18 separate acts of embezzlement, resulting in losses of CZK 529,890 from Majordomos Gastro and a further CZK 104,000 from a Czech company City Café SRO. Cyril Stiak is also accused of insurance fraud in 2008-2009 and tax evasion. According to Inspector General Krishna, Stefan Durina is accused of fraud and tax evasion committed between August 2014 and 28 January 2018. Police allege Durina’s modus operandi was to conceal and fail to pay applicable taxes on a network of transactions by companies he controlled by purchasing electronic equipment across Europe. The cumulative losses to the State resulting from the two men’s actions exceeded an amount estimated equivalent to Rp. 67 billion. **Topics:** Business - padding/faking, Insider Fraud **Categories:** Arrest --- ### [Bike owner overturns insurer's 'false theft' claim denial](https://insurancefraud.org/news_archives/bike-owner-overturns-insurers-false-theft-claim-denial/) **Published:** September 16, 2026 **Author:** Diane Beauchamp **Content:** The owner of a stolen motorcycle who had his claim denied will be reimbursed for his losses after an Australian Financial Complaints Authority (AFCA) determination refuted allegations from his insurer that the claim had been false. The complainant lodged a theft claim to IAG on June 9 last year after realising his bike was missing from his garage. The man told the insurer that he had been trying to sell the bike for months and held a meeting with prospective buyers a week before the incident. He claimed he observed the vehicle stored securely in the garage below his apartment block on June 6 and that it had not been used between the meeting and the theft. Following a report from its factual investigator, referred to as Q, IAG informed the owner that it had denied the claim, saying that it “was not satisfied that a theft of the bike had taken place”. The insurer alleged that the claimant had not acted in good faith as per section 13 of the Insurance Contracts Act 1984 (Cth), and that it was entitled to rely reduce its liability for the claim to nil. AFCA noted that while the insurer did not specifically allege that the policyholder made a fraudulent claim, its contention was “analogous to fraud or dishonesty” and held “serious ramifications for the complainant”. IAG argued that the man had a financial motive to make a false claim, noting that he had been unemployed for some time, relied on government payments during covid lockdowns, and was in debt. Q’s report pointed out the insured had reduced the price to sell the vehicle from around $10,500 to about $8000 because he could not find a buyer and noted that he signed up for the comprehensive motor vehicle policy only a few days before the claimed event. AFCA challenged the insurer’s allegations, saying that the complainant previously insured the vehicle with IAG until March 2021, but could no longer meet premium payments. It said that given his financial situation, it was understandable that the man would undersell the vehicle to increase the chance of a buyer. “I accept that the complainant was not in a strong financial position and that some of the matters raised by the insurer could suggest a motive to make a false claim,” the ombudsman said. “However, I am not satisfied that the insurer has comfortably proven the complainant was motivated to in essence commit a crime for purpose of making an insurance claim.” The insurer said that the insured had a direct opportunity to be involved in the theft because he had access to the area where the vehicle was stored and its keys. The claimant said the garage had multiple entries from which thieves could have entered, including a side door, which the police suspected had been where the bike was taken through. The ruling accepted that the complainant could have committed the theft but said that IAG had “not presented any cogent evidence” to prove that he did. Q’s report called into question the man’s explanation that he moved out of the apartment due to the threat that the thieves may return, noting that he had already called removalists before the incident. The owner said that the possible return of the thieves had been a reason for his decision but also referred to previous concerns surrounding a nearby arson attack and the presence of drug addicts in the area as other factors for why he called the removalists. AFCA noted that the police held no suspicions that the insured may have committed the theft and said his previous insurance history did not suggest any concerns surrounding his character. The ruling required IAG to cover the claim and pay the complainant $10,700 plus interest from November 1 last year until the settled date. It also mandated that the insurer compensate the claimant $2700 for its “poor claims handling” and unproven allegations that caused stress and inconvenience. AFCA said IAG had “selectively referred to information to suit its narrative” and “reached a conclusion that the complainant was involved in the theft/acted fraudulently despite the police having no concerns at all about him or the legitimacy of the theft”. **Topics:** Judicial/courts --- ### [Medibank hackers reportedly release all data on dark web](https://insurancefraud.org/news_archives/medibank-hackers-reportedly-release-all-data-on-dark-web/) **Published:** September 16, 2026 **Author:** Diane Beauchamp **Content:** Hackers who breached Medibank’s systems have dumped another batch of data on the dark web, along with claims the files contain all of the data they took in a heist that impacted 9.7 million customers. The Australian insurance group confirms six zipped files of data have been released, while government officials reiterate the overdue need to overhaul the country’s cyber strategy. Medibank on Thursday said it was analysing the data, which was released overnight on the dark web, but added that the files appeared to comprise customer [information compromised in the breach](https://www.zdnet.com/article/medibank-wont-pay-ransom-as-more-stolen-data-shows-up-on-dark-web/). First [announced in October](https://www.medibank.com.au/livebetter/newsroom/post/medibank-cyber-incident-update), the security incident affected 9.7 million current and former customers as well as some of their authorised representatives. Amongst those impacted were 1.8 million international customers. Before the latest data dump, hackers involved in the theft had released the files in batches along with demands for ransom. Medibank had said it [would not pay any ransom](https://www.zdnet.com/article/medibank-wont-pay-ransom-as-more-stolen-data-shows-up-on-dark-web/). In its statement Thursday, the insurance company said there was no indication financial or banking details had been compromised and the stolen data alone was insufficient to facilitate identity or financial fraud. It further noted that the raw data, so far, had been determined to be incomplete and difficult to understand. This remained so for the latest six zipped files, which were released in a folder tagged “full”, Medibank said, adding that the health data released was not matched up with customer and contact details. Australia’s Attorney-General Mark Dreyfus said the government was aware of the latest data dump and confirmed “agencies” were looking into it. A review of the country’s Privacy Act also was slated to be completed by year-end, Dreyfus said when asked about how legislation should be further updated, following the recent [increase in penalties for data breaches](https://www.zdnet.com/article/australia-seeks-stiffer-penalty-for-data-breaches-amidst-spate-of-security-incidents/). Speaking in an [interview with ABC Radio Melbourne](https://ministers.ag.gov.au/media-centre/transcripts/abc-radio-melbourne-ali-moore-01-12-2022), he said: “This is a really outdated piece of legislation. We need to have a wholesale reform of it.” Dreyfus added that he would be working on a “complete revision” of the Privacy Act next year. Until then, he noted that the significant increase in financial penalties should serve as an incentive for local organisations that stored personal information of Australian residents to ensure they took better care of the data and adopted better security measures. The government last month passed a legislation to [push up maximum financial penalties](https://www.zdnet.com/article/australia-seeks-stiffer-penalty-for-data-breaches-amidst-spate-of-security-incidents/) for serious or repeated data breaches to AU$50 million ($32.34 million), from its previous AU$2.22 million, or three times the value of any benefit obtained through the data misuse, or 30% of the company’s adjusted turnover in the relevant period, whichever is greater. **Topics:** Public Awareness, Technology --- ### [Florence woman pleads guilty to fraud, exploiting assisted living residents](https://insurancefraud.org/news_archives/florence-woman-pleads-guilty-to-fraud-exploiting-assisted-living-residents/) **Published:** September 16, 2026 **Author:** Diane Beauchamp **Content:** A Florence woman will serve 10 years of probation after pleading guilty to multiple counts of exploitation of vulnerable adults and breach of trust. The South Carolina Attorney General Alan Wilson says on Dec. 5, 57-year-old Regan Simone Carter, pleaded guilty to two counts of exploitation of a vulnerable adult and two counts of breach of trust with fraudulent intent, the value of $10,000 or more. Carter was sentenced to five years in prison, suspended to five years of probation for the exploitation charges, and seven years in prison, suspended to five years of probation for the breach of trust charges. Carter has also been ordered to pay restitution in the amount of $30,000. An SC Medicaid Fraud Control Unit investigation showed between Sept. 1, 2018, and Nov. 30, 2021, Carter, as a power of attorney for the two victims, willfully made, with fraudulent intent, unlawful and improper use of the victims’ assets. Both victims at the time resided at Elmcroft Assisted Living in Florence, which referred this matter to the Attorney General for investigation. As per federal regulations, the SCMFCU has the authority to oversee Medicaid provider fraud; abuse and neglect of Medicaid beneficiaries in any setting; and the abuse, neglect, and exploitation of individuals residing in assisted living facilities or nursing homes. **Topics:** Elderly Fraud, Financial Fraud, Insider Fraud **Categories:** Conviction --- ### [Don't fall for health insurance scams in NM](https://insurancefraud.org/news_archives/dont-fall-for-health-insurance-scams-in-nm-2/) **Published:** September 16, 2026 **Author:** Diane Beauchamp **Content:** Open enrollment for New Mexico’s health insurance marketplace, beWellnm, is underway and runs through Jan. 15, 2023. During this time, New Mexicans can enroll in a quality, affordable health plan that, per the Affordable Care Act (ACA), is guaranteed to cover a full list of benefits, caps out-of-pocket costs, and has an established network of providers. This year, plans through beWellnm are even more affordable thanks to additional discounts at the federal and state level, putting coverage in reach for more New Mexicans. During open enrollment, predatory companies will also scam hundreds of New Mexicans into junk insurance, leaving them uncovered and at risk of debt. These companies make their profit by impersonating government websites like [healthcare.gov](http://healthcare.gov/) or [beWellnm.com](http://bewellnm.com/), convincing consumers that they are selling legitimate ACA plans, or falsely claiming that their plans provide full coverage at a better price. Unfortunately, this is not an uncommon scenario. Having heard about open enrollment, a New Mexican might open their web browser and type in “affordable health insurance New Mexico.” The first three results are ads for non-government sites claiming to sell quality coverage at low prices. They click on the first link, enter their address and contact information, and receive a call from an agent claiming to be authorized to help them choose a plan. The individual picks a plan, provides credit card information over the phone for $40 a month, and receives an insurance card in the mail. A month later, this person is in an emergency situation for which costly care is immediately necessary. The receptionist comes into the room once the patient is stable with the bad news that their supposed insurance is worthless, and that they will need to pay out of pocket for any care received that day. Not only are they now dealing with the fallout of a medical emergency, but also an astronomical medical bill and no recourse for making a claim. Health coverage should be considered a necessity. The unfortunate reality is that anyone could end up in a situation where quality coverage is the difference between a manageable cost-sharing payment and life-altering medical debt. Shopping through beWellNM online ([bewellnm.com](http://bewellnm.com/)) or over the phone (1-833-862-3935), or through a certified broker or enrollment counselor is the only way to ensure you are purchasing a plan that will actually provide that security. While shopping for coverage, be wary of unsolicited phone calls, paid advertisements, and any entities other than beWellnm claiming to sell coverage in New Mexico. Always ask for documentation on the plan you’re selecting – know its benefits, network and full cost before purchasing. You may want to check directly with your doctor and pharmacy beforehand to make sure they accept that insurance. If you receive any assistance, make sure to request the person’s name and license number; if they won’t provide it, end your communication immediately. And if you’ve been scammed into paying for a junk insurance plan, report the incident to the Office of the Superintendent of Insurance by visiting [http://www.osi.state.nm.us](http://www.osi.state.nm.us/) or calling 855-427-5674. Legal action can be taken against these predatory companies, and your experience will help another New Mexican family avoid falling into a trap. Don’t waste your money or fall for a scam – only shop through beWellnm this open enrollment. **Topics:** Public Awareness --- ### [Baron & Budd Obtains $23.8 Million Settlement in Whistleblower Lawsuit Against Essilor](https://insurancefraud.org/news_archives/baron-budd-obtains-23-8-million-settlement-in-whistleblower-lawsuit-against-essilor/) **Published:** September 16, 2026 **Author:** Diane Beauchamp **Content:** Today, the nationally recognized law firm of [Baron & Budd](https://cts.businesswire.com/ct/CT?id=smartlink&url=https%3A%2F%2Fwww.becomeawhistleblower.com%2F&esheet=53004184&newsitemid=20221205005772&lan=en-US&anchor=Baron+%26amp%3B+Budd&index=1&md5=7e2b6a2e557891e86904d508f9e2c11b) announced a [settlement of $23.8 million](https://cts.businesswire.com/ct/CT?id=smartlink&url=https%3A%2F%2Fwww.becomeawhistleblower.com%2Fwp-content%2Fuploads%2FEssilor-CDI-Settlement-Agreement-All-Signatures.pdf&esheet=53004184&newsitemid=20221205005772&lan=en-US&anchor=settlement+of+%2423.8+million&index=2&md5=8793a1c3a7e2dcb97d2549b8eff9b622) in a whistleblower lawsuit filed against eye glass lens manufacturer, Essilor Laboratories of America, for violations of the California Insurance Frauds Prevention Act. The lawsuit alleged the company paid hundreds of millions of dollars in kickbacks and other incentives to eye care providers (ECPs) in exchange for selling its expensive lens products. This follows a [$22 million](https://cts.businesswire.com/ct/CT?id=smartlink&url=https%3A%2F%2Fwww.becomeawhistleblower.com%2Fnews%2Fbaron-budd-announces-22-million-settlement-in-lawsuit-against-the-worlds-largest-eye-glass-lens-manufacturer%2F&esheet=53004184&newsitemid=20221205005772&lan=en-US&anchor=%2422+million&index=3&md5=0d941bb65f81e34075b9a01a1265ca4c) False Claims Act settlement against Essilor in August 2022 in which Baron & Budd also represented the whistleblower client. The lawsuit also alleged that the company “engaged in a far-reaching scheme including the offer and/or payment of both ‘classic’ kickbacks – vast amounts of cash, trips, and lavish entertainment – as well as free and/or reduced-cost professional services including marketing support and business consulting. Essilor offered and/or provided these kickbacks to eyecare professionals for the purpose of buying loyalty and rewarding those who switched to Essilor products and optical laboratory services.” According to the suit, Essilor executed this scheme nationwide, including in the state of California, where it targeted and defrauded eyecare insurance companies and their insureds. These bribes caused the policyholders to pay more out-of-pocket costs for premium Essilor products and drove up the cost of benefits paid for by California insureds and their eyecare insurers. The [California Insurance Frauds Prevention Act](https://cts.businesswire.com/ct/CT?id=smartlink&url=https%3A%2F%2Fwww.becomeawhistleblower.com%2Fhealthcare-fraud%2Fprivate-insurance-fraud%2F&esheet=53004184&newsitemid=20221205005772&lan=en-US&anchor=California+Insurance+Frauds+Prevention+Act&index=4&md5=16ec8969006d31d8627f0948e66f3941) (“IFPA”) was implemented to combat abusive practices aimed at defrauding private insurers and their insureds. Similar to the federal False Claims Act, California’s IFPA allows private citizens to file a lawsuit against those who commit insurance fraud and share in a portion of the recovery. The whistleblower in this case was a former Essilor employee with inside information about the kickback scheme. “Whistleblowers, like our client, are crucial in the process of identifying and prosecuting companies like Essilor that perpetuate schemes that defraud insured individuals,” said Baron & Budd Shareholder [Scott Simmer](https://cts.businesswire.com/ct/CT?id=smartlink&url=https%3A%2F%2Fwww.becomeawhistleblower.com%2Fattorneys%2Fscott-simmer%2F&esheet=53004184&newsitemid=20221205005772&lan=en-US&anchor=Scott+Simmer&index=5&md5=92e6ba8f1db9c51857b9243e11053dbf). “These schemes result in billions of dollars of added healthcare costs for people across the nation because of corporate greed. We are pleased that Essilor was held accountable for these blatant violations of IFPA.” Ricardo Lara, California Insurance Commissioner, intervened and prosecuted the case in a public/private partnership along with Baron & Budd and other private firms. With more than 30 years of experience in Qui Tam cases, the attorneys on Baron & Budd’s whistleblower representation team have represented numerous clients in government fraud cases returning over $6.0 billion to federal and state agencies, with whistleblower recovery shares as high as 49%. **Topics:** Judicial/courts, Public Awareness --- ### [Lawsuit accuses Roseland Community Hospital, fired doctor of fraudulent billing related to COVID testing](https://insurancefraud.org/news_archives/lawsuit-accuses-roseland-community-hospital-fired-doctor-of-fraudulent-billing-related-to-covid-testing/) **Published:** September 16, 2026 **Author:** Diane Beauchamp **Content:** A lawsuit has issued serious claims of fraud against Roseland Community Hospital in the city’s Far South Side – centered around COVID-19 testing. As CBS 2’s Jermont Terry reported Friday night, a whistleblower accuses the hospital of running up insurance bills, and raking in millions. For more than a year, federal investigators kept documents in this case sealed – until Friday. A fired doctor whose sole job was to oversee COVID testing, along with a Roseland hospital executive, are accused of deliberately defrauding taxpayers and insurance companies for profit. During the height of the COVID-19 pandemic, health facilities scrambled to meet the demand for testing. On the Far South Side at the time, we saw people standing in long lines at Roseland Community Hospital. Now, two years later, the whistleblower claims the hospital “billed for services related to COVID-19 testing that were never provided.” The newly-unsealed complaint was filed by Elio Montenegro, who is an “employee of Roseland where he works as the Senior Director of Development.” The whistleblower worked directly with hospital leaders back then, and still does today. The 25-page complaint accuses a now-fired employee – “Dr. Terrill Applewhite, an independent contractor, who worked as Medical Director overseeing the hospital’s COVID-19 response.” The suit says Applewhite and his company, along with the hospital, “knowingly and intentionally submitted false claims for payment.” Instead of testing only for COVID, the federal suit says insurance companies and the government were “billed for a “full panel” of blood tests” – resulting in unnecessary charges and bills. How much are we talking? According to the complaint, the doctor and the hospital “billed for approximately 20,000 to 25,000 patients visits,” resulting in “between $2.8 and $3.6 million in fraudulent billing.” The whistleblower said when he informed the hospital, the doctor was fired. Btu the suit claims, The suit says Applewhite and his company, along with the hospital, “knowingly and intentionally submitted false claims for payment.” Instead of testing only for COVID, the federal suit says insurance companies and the government were “billed for a “full panel” of blood tests” – resulting in unnecessary charges and bills. How much are we talking? According to the complaint, the doctor and the hospital “billed for approximately 20,000 to 25,000 patients visits,” resulting in “between $2.8 and $3.6 million in fraudulent billing.” The whistleblower said when he informed the hospital, the doctor was fired. Btu the suit claims, The suit says Applewhite and his company, along with the hospital, “knowingly and intentionally submitted false claims for payment.” Instead of testing only for COVID, the federal suit says insurance companies and the government were “billed for a “full panel” of blood tests” – resulting in unnecessary charges and bills. How much are we talking? According to the complaint, the doctor and the hospital “billed for approximately 20,000 to 25,000 patients visits,” resulting in “between $2.8 and $3.6 million in fraudulent billing.” The whistleblower said when he informed the hospital, the doctor was fired. Btu the suit claims, “Roseland never disclosed these false billings to any government agency or private insurer.” And when the whistleblower brough the concerns directly to hospital executives, the suit claims hospital leaders said, “it was so Roseland could earn more profits.” But an attorney for Roseland Community Hospital issued a statement denying that the hospital or its chief executive officer, Tim Egan, were involved in anything improper: > “Mr. Egan and Roseland Hospital share the Relator’s concern with improper third-party billing and services. Unbeknownst to Mr. Montenegro, for more than a year, Mr. Egan has been sharing information on a confidential basis with federal investigators into Dr. Applewhite. Mr. Egan completely denies any insinuation by Mr. Montenegro that he or Roseland Hospital were involved in any improper behavior.” The whistleblower did not want to talk directly to us about the lawsuit. But Roseland Community Hospital insisted they hid nothing from federal investigators. **Topics:** COVID-19, Judicial/courts, Public Awareness --- ### [Home repair fraud prevention nonprofit is coming to Florida to help disaster victims avoid shady contractors](https://insurancefraud.org/news_archives/home-repair-fraud-prevention-nonprofit-is-coming-to-florida-to-help-disaster-victims-avoid-shady-contractors/) **Published:** September 16, 2026 **Author:** Diane Beauchamp **Content:** Hurricane Ian left extensive damage in Florida, a gold mine for contractor fraud and scams. A nonprofit is coming to the area to help protect disaster victims from becoming victims twice. The National Alliance Against Home Repair Fraud (NAAHRF) will hold its SmartPower workshop Protecting Yourself from Home Repair Fraud and Scams at the following locations: **Monday, Dec. 5, 4 p.m. – 6 p.m.** South Co. Regional Library – 21100 Three Oaks Parkway in Estero Tuesday, Dec. 6, 2 p.m. – 4 p.m. Cape Coral Library – 921 S.W. 39th Terrace in Cape Coral Tuesday, Dec. 6, 5:30 p.m. – 7:30 p.m. **East Co. Regional Library – 881 Gunnery Road N in Lehigh Acres** The seminars are free and open to the public. Speakers at the event include local law enforcement, local building & zoning officials, consumer protection attorneys, insurance experts, and more. “Disaster/storm victims are especially vulnerable to contractor scams,” says Phae Moore, Executive Director of NAAHRF. “After a disaster hits, scam artists take advantage of stressed-out homeowners, making them victims, twice.” Moore is also the author of “Don’t Even Think About Ripping Me Off! (Amazon), a step-by-step instructional guidebook for homeowners on how to find, hire, work with and pay contractors. NAAHRF also has a free app, HOME REPAIR HELPER, which can be downloaded from the Apple Store. “For me, it’s personal because my grandmother was ripped off by a contractor. I remember the pain in her face. It will stay with me always. That’s why I started the organization. I don’t want it to happen to anyone else.” Topics of discussion will include how to find contractors, how to vet them, determining your budget, the building permitting process, insurance issues you may not know about, what should and should not be in your contract, dealing with unexpected repairs and change orders, how to set up payment schedules to avoid being ripped off, lien releases, and a whole lot more. “There are excellent and honest contractors out there, but you still need to educate yourself on the process. I cannot stress that enough,” says Moore. “It’s so frustrating to get calls from homeowners who have already been scammed. It breaks my heart because by then, it’s too late.” **Topics:** Public Awareness --- ### [New York Attorney General’s Office Fall Round-Up](https://insurancefraud.org/news_archives/new-york-attorney-generals-office-fall-round-up/) **Published:** September 16, 2026 **Author:** Diane Beauchamp **Content:** The New York Attorney General’s Office (the “NYAG” or the “Office”) continues to serve as a leader for other state attorneys general, having a profound impact on corporations, nonprofits, and individuals in New York and beyond. This round-up summarizes the major cases and initiatives pursued by New York State’s 67th Attorney General, Letitia James, and her team since August 2021. AG James was just re-elected to another four-year term beginning January 2023. The NYAG’s priorities include a mix of local and national issues, including data privacy, cybersecurity, and data breaches; employee rights; investor protection; environmental and animal protection; protecting consumers, including homeowners, taxpayers, and seniors; and cracking down on Medicare fraud. There is certainly overlap in the NYAG’s priorities and those of federal regulators, and, like attorneys general around the country, increasingly the NYAG investigates and brings high-profile actions alongside federal regulators—including in cases where she may not have jurisdiction. One new trend is that AG James is issuing reports that provide information about the NYAG’s investigative findings. Although these reports are not “legal proceedings” and often do not have any legal significance, the reports can have important public relations and reputational impact, and potentially spawn other regulatory investigations. Recently, for example, the Office has issued reports on the Nursing Home Response to the COVID-19 Pandemic, fake comments submitted in response to an FTC rulemaking on net neutrality, the sexual harassment allegations against Governor Andrew Cuomo, and the mass shooting in Buffalo, NY. In terms of litigation, in recent years, the Office has made headlines for bringing large-scale suits in healthcare, including e-cigarette use among youth, the opioid crisis, and access to health care. That said, the Office initiates litigation in very few cases, resolving most through settlements. Like many AGs offices around the country, the Office is focused on enforcement against what it calls “Big Tech,” based on various legal theories, and in the past year has initiated several high-profile investigations into technology companies and other businesses. AG James continues to advocate for legislation in various key areas, including health care and the environment. The Office’s biggest headline-grabber this year has been the September 2022 lawsuit against Donald Trump, the Trump Organization, senior management, and other entities. The case alleges that the Trump defendants engaged in years of financial fraud by falsely inflating Trump’s worth by billions of dollars in order to induce banks to lend money to the Trump Organization on more favorable terms, satisfy continuing loan covenants, induce insurers to provide insurance coverage for higher limits and at lower premiums, and gain tax benefits.[\[1\]](https://www.gibsondunn.com/new-york-attorney-generals-office-fall-round-up-november-2022/#_edn1) On November 4, AG James won a motion that granted a preliminary injunction freezing certain assets, appointed an independent monitor to oversee the submission of financial information to certain third parties, and scheduled a preliminary conference for November 22 to set an expedited trial schedule.[\[2\]](https://www.gibsondunn.com/new-york-attorney-generals-office-fall-round-up-november-2022/#_edn2) In this Round-Up, we discuss in further detail numerous of AG James’s key cases and initiatives over the past year, including her support for antitrust legislation and efforts to enforce antitrust laws; her continued focus on data privacy rights of New Yorkers as reliance on consumer technology has increased as a result of the COVID-19 pandemic; her new efforts to in investor protection; her ongoing focus on health care, including abortion access; and her attention on the environment and labor and employment rights of New Yorkers. **I. Antitrust and Competition** AG James has continued to support efforts seeking to strengthen and modernize the antitrust laws. In September 2021, AG James co-led a bipartisan coalition of 32 state attorneys general in calling on Congress to fund state antitrust efforts in response to changing technology.[\[3\]](https://www.gibsondunn.com/new-york-attorney-generals-office-fall-round-up-november-2022/#_edn3) In New York specifically, AG James has continued to be a proponent of enacting the 21st Century Antitrust Act, a bill that its supporters claim would update New York’s antitrust laws to address the modern economy.[\[4\]](https://www.gibsondunn.com/new-york-attorney-generals-office-fall-round-up-november-2022/#_edn4) The bill passed the New York State Senate on May 25, 2022 but did not pass the Assembly.[\[5\]](https://www.gibsondunn.com/new-york-attorney-generals-office-fall-round-up-november-2022/#_edn5) The law seeks to expand antitrust liability under New York’s Donnelly Act to, among other things, make it unlawful for a company to “abuse” a “dominant position” in a relevant market—a standard that is adopted from European law.[\[6\]](https://www.gibsondunn.com/new-york-attorney-generals-office-fall-round-up-november-2022/#_edn6) The bill has been criticized as excessively vague and potentially harmful to the New York economy. AG James has also continued to aggressively investigate and pursue litigation against technology and pharmaceutical companies for alleged antitrust violations.[\[7\]](https://www.gibsondunn.com/new-york-attorney-generals-office-fall-round-up-november-2022/#_edn7) In January 2022, a coalition of 48 attorneys general (led by AG James) appealed the D.C. federal district court’s dismissal of their claims against a tech giant for allegedly anticompetitive acquisitions.[\[8\]](https://www.gibsondunn.com/new-york-attorney-generals-office-fall-round-up-november-2022/#_edn8) Also in January 2022, the Southern District of New York ruled in favor of New York, the FTC, and six other states in finding that Martin Shkreli engaged in illegal and anticompetitive practices while serving as the CEO of a pharmaceutical company. Shkreli was banned from the pharmaceuticals industry for life and was ordered to pay nearly $65 million.[\[9\]](https://www.gibsondunn.com/new-york-attorney-generals-office-fall-round-up-november-2022/#_edn9) AG James also launched antitrust investigations into and reached agreements with other businesses. For example, in November 2021, the Office reached an agreement with two large supermarket chains to divest stores located in New York in connection with the companies’ proposed merger because it would have allegedly eliminated direct competition between local supermarkets.[\[10\]](https://www.gibsondunn.com/new-york-attorney-generals-office-fall-round-up-november-2022/#_edn10) And on July 28, 2022, AG James announced a lawsuit against a national pharmacy for alleged antitrust violations that allegedly impacted hospitals and clinics that provide care for underserved communities across New York State, by purportedly restricting their ability to take advantage of certain federal subsidies.[\[11\]](https://www.gibsondunn.com/new-york-attorney-generals-office-fall-round-up-november-2022/#_edn11) **II. Data Privacy, Cybersecurity, and Data Breaches** AG James continued to be active in the data privacy and cybersecurity realms over the past year, announcing several investigations arising from alleged data breaches, focusing on the importance of corporations keeping their customers’ personal data safe. In fact, according to a list identifying the number of complaints AG James’s Office received in 2021, which AG James published in March of this year, the Office received the greatest number of complaints for “Internet-Related” issues, including “data privacy and security” and “data breaches.”[\[12\]](https://www.gibsondunn.com/new-york-attorney-generals-office-fall-round-up-november-2022/#_edn12) Notable investigations and settlements, specifically arising from data breaches, include the following: - In January 2022, the Office reached a $600,000 agreement with a vision care provider, arising from an alleged 2020 data breach compromising the personal information of approximately 2.1 million consumers nationwide, including 98,632 New York State residents.[\[13\]](https://www.gibsondunn.com/new-york-attorney-generals-office-fall-round-up-november-2022/#_edn13) AG James’s investigation was brought pursuant to the Stop Hacks and Improve Electronic Data Security Act (the “SHIELD” Act), New York’s cybersecurity statute which, effective March 2020, expanded the State’s data breach notification law and imposed cybersecurity requirements on companies that collect or maintain “private information” of New York residents.[\[14\]](https://www.gibsondunn.com/new-york-attorney-generals-office-fall-round-up-november-2022/#_edn14) In addition to the monetary payment, the company agreed to maintain a comprehensive information security program, regularly report any security risks to its leadership, maintain reasonable account management and authentication systems, encrypt sensitive consumer information, maintain appropriate logging and monitoring of network activity, and permanently delete consumers’ personal information when there is no reasonable business or legal purpose to maintain it.[\[15\]](https://www.gibsondunn.com/new-york-attorney-generals-office-fall-round-up-november-2022/#_edn15) - In June 2022, the Office, along with 45 other attorneys general, reached a $1.25 million settlement with a cruise line, arising from an alleged 2019 data breach that compromised the personal information of 180,000 employees and customers nationwide, including 6,575 New Yorkers.[\[16\]](https://www.gibsondunn.com/new-york-attorney-generals-office-fall-round-up-november-2022/#_edn16) Under the agreement, the cruise line will strengthen its email security and breach response practices, including by implementing and maintaining a breach response and notification plan; requiring email security training for employees; instituting multi-factored authentication for remote email addresses; requiring strong, complex passwords, password rotation, and secure password storage; maintaining enhanced behavior analytics tools to log and monitor potential security events; and undergoing an independent information security assessment.[\[17\]](https://www.gibsondunn.com/new-york-attorney-generals-office-fall-round-up-november-2022/#_edn17) - In June 2022, the Office reached a $400,000 settlement with a grocery store chain based on allegations that the company exposed the personal information of more than three million consumers, including more than 830,000 New Yorkers, due to allegedly unsafe cloud storage practices.[\[18\]](https://www.gibsondunn.com/new-york-attorney-generals-office-fall-round-up-november-2022/#_edn18) The NYAG alleged that compromised data included usernames and passwords, customers’ names, email addresses, mailing addresses, and data derived from driver’s license numbers.[\[19\]](https://www.gibsondunn.com/new-york-attorney-generals-office-fall-round-up-november-2022/#_edn19) Under the terms of the settlement, aside from paying $400,000 in penalties, the grocery store will overhaul its security and data management policies, particularly those related to cloud assets.[\[20\]](https://www.gibsondunn.com/new-york-attorney-generals-office-fall-round-up-november-2022/#_edn20) AG James has also launched several consumer protection investigations into various social media companies in connection with in allegedly harmful activity or prolonged social media engagement by young adult users.[\[21\]](https://www.gibsondunn.com/new-york-attorney-generals-office-fall-round-up-november-2022/#_edn21) Additionally, on January 5, 2022, AG James released a Business Guide for Credential Stuffing Attacks after an investigation into “credential stuffing”—repeated, automated attempts to access online accounts using usernames and passwords stolen from online services—revealed that over 1.1 million online accounts had allegedly been compromised in cyberattacks at 17 well-known online retailers, restaurant chains, and food delivery services.[\[22\]](https://www.gibsondunn.com/new-york-attorney-generals-office-fall-round-up-november-2022/#_edn22) According to press reports, this “credential stuffing” allegedly compromised customer accounts at each of the companies.[\[23\]](https://www.gibsondunn.com/new-york-attorney-generals-office-fall-round-up-november-2022/#_edn23) The Office urged the companies to investigate and protect impacted users, and every company complied.[\[24\]](https://www.gibsondunn.com/new-york-attorney-generals-office-fall-round-up-november-2022/#_edn24) Given evolving technology and the increase in cyber-attacks against businesses and consumers, we expect data privacy and cybersecurity to remain a high priority for the Office in the next year. **III. Cryptocurrency and Consumer/Investor Protection** We also expect that AG James will continue to scrutinize actors, investments, and exchanges in the cryptocurrency space, and generally in the consumer financial and investor protection areas. AG James’s efforts this past year demonstrate continued scrutiny of allegedly misleading statements and practices, including by debt collection agencies and student loan servicing agencies, as well as scrutiny of general consumer financing practices by non-bank retailers and money transmitters. AG James’s focus on cryptocurrency investment has included an August 1, 2022 “investor alert” that urged “any New Yorker deceived or affected by the cryptocurrency crash to contact her office.”[\[25\]](https://www.gibsondunn.com/new-york-attorney-generals-office-fall-round-up-november-2022/#_edn25) The alert also “encourage\[d\] workers in the cryptocurrency industry who may have witnessed misconduct or fraud to file a whistleblower complaint.”[\[26\]](https://www.gibsondunn.com/new-york-attorney-generals-office-fall-round-up-november-2022/#_edn26) The alert, which is only AG James’s most recent action in the space, came after the cryptocurrency market, in general, lost significant value this summer. Prior to this most recent notice, in March 2022, AG James issued a “taxpayer notice,” reminding cryptocurrency investors and their tax advisors “to make sure that they accurately declare and pay taxes on their virtual investments” to avoid any violations of tax law.[\[27\]](https://www.gibsondunn.com/new-york-attorney-generals-office-fall-round-up-november-2022/#_edn27) AG James has also focused on cryptocurrency exchanges. On October 18, 2021, AG James sent cease and desist letters to two unnamed cryptocurrency platforms and directed three other unnamed platforms to provide information about their activities and products.[\[28\]](https://www.gibsondunn.com/new-york-attorney-generals-office-fall-round-up-november-2022/#_edn28) According to redacted cease and desist letters made publicly available by the NYAG, the two unnamed exchanges are allegedly “unlawfully selling or offering to sell . . . securit\[ies\] . . . without having registered as required” under New York’s Martin Act, which requires these exchanges to be registered with the Office as brokers, dealers, or salespersons, unless otherwise exempted.[\[29\]](https://www.gibsondunn.com/new-york-attorney-generals-office-fall-round-up-november-2022/#_edn29) The letters also came only weeks after AG James won a $3 million judgment against a cryptocurrency trading platform in New York County State Supreme Court.[\[30\]](https://www.gibsondunn.com/new-york-attorney-generals-office-fall-round-up-november-2022/#_edn30) On September 26, 2022, AG James joined the securities regulators of seven other states in suing related cryptocurrency companies in New York County State Supreme Court for allegedly failing to register with the state as securities and commodities brokers or dealers and for allegedly misrepresenting their registration status to investors.[\[31\]](https://www.gibsondunn.com/new-york-attorney-generals-office-fall-round-up-november-2022/#_edn31) The defendants have not yet responded to the NYAG’s complaint. Moreover, on September 13, 2021, AG James settled alleged claims without admission against two related media companies in connection with allegations that they unlawfully sold stock and cryptocurrency without registering them in New York State.[\[32\]](https://www.gibsondunn.com/new-york-attorney-generals-office-fall-round-up-november-2022/#_edn32) In addition to offering and selling stock beginning in April 2020, the two companies allegedly raised more than $30 million from pre-sales of two digital instruments promoted as cryptocurrencies.[\[33\]](https://www.gibsondunn.com/new-york-attorney-generals-office-fall-round-up-november-2022/#_edn33) Pursuant to the agreement, the companies will get credit toward the $479.9 million settlement for payments to the Securities and Exchange Commission (“SEC”) in connection with a related SEC investigation.[\[34\]](https://www.gibsondunn.com/new-york-attorney-generals-office-fall-round-up-november-2022/#_edn34) AG James has also been active in the consumer financial protection space, particularly with respect to debt collectors and student debt services. Most recently, on August 16, 2022, AG James applauded the U.S. Department of Education for discharging the federal student loan debt of over 4,000 New Yorkers who attended certain for-profit colleges between 2005 and 2016.[\[35\]](https://www.gibsondunn.com/new-york-attorney-generals-office-fall-round-up-november-2022/#_edn35) Earlier this year, AG James also encouraged students who attended other institutions that allegedly inflated their job placement statistics to apply for federal loan discharges, and led a coalition of eight attorneys general in asking President Biden to fully cancel federal student debt writ large.[\[36\]](https://www.gibsondunn.com/new-york-attorney-generals-office-fall-round-up-november-2022/#_edn36) In August 2022, President Biden announced that the Department of Education will cancel $10,000 of student debt for borrowers who meet identified income requirements.[\[37\]](https://www.gibsondunn.com/new-york-attorney-generals-office-fall-round-up-november-2022/#_edn37) The Eighth Circuit Court of Appeals issued an administrative stay pausing the program on October 21.[\[38\]](https://www.gibsondunn.com/new-york-attorney-generals-office-fall-round-up-november-2022/#_edn38) AG James also secured two agreements earlier this year with federal loan servicers. In the first, one of the country’s largest student loan servicers agreed to cancel $1.85 billion in private student loan debt nationwide, and to pay $95 million in restitution to students and $142.5 million to states.[\[39\]](https://www.gibsondunn.com/new-york-attorney-generals-office-fall-round-up-november-2022/#_edn39) The agreement followed an investigation by 39 attorneys general, including AG James, into whether the servicer allegedly improperly caused students to enter into forbearance plans that were ultimately detrimental to borrowers.[\[40\]](https://www.gibsondunn.com/new-york-attorney-generals-office-fall-round-up-november-2022/#_edn40) In the second, the student loan servicer agreed to automatically review the accounts of approximately 10,000 New Yorkers and credit accounts as appropriate, in order to settle a 2019 lawsuit alleging the servicer mismanaged student debt.[\[41\]](https://www.gibsondunn.com/new-york-attorney-generals-office-fall-round-up-november-2022/#_edn41) In addition to student loan servicing, AG James has also devoted attention to practices of debt collection agencies. This year, AG James has settled claims with two debt collection businesses, enjoining these business from acting as debt collectors in the future.[\[42\]](https://www.gibsondunn.com/new-york-attorney-generals-office-fall-round-up-november-2022/#_edn42) AG James also issued a consumer alert in December aimed at educating consumers about their rights and warning of improper debt collection tactics.[\[43\]](https://www.gibsondunn.com/new-york-attorney-generals-office-fall-round-up-november-2022/#_edn43) Aside from settling recent cases, AG James has also initiated litigations to enforce consumer protection laws in the financial services area. For example, in April 2022, AG James and the Consumer Financial Protection Bureau filed a lawsuit against a large money transfer provider, alleging the provider violated consumer protection laws, including by failing to timely transfer funds or refund consumers for delayed transfers.[\[44\]](https://www.gibsondunn.com/new-york-attorney-generals-office-fall-round-up-november-2022/#_edn44) In August, the money transfer provider filed a motion to transfer the action from the United States District Court for the Southern District of New York to the Northern District of Texas and to dismiss the complaint.[\[45\]](https://www.gibsondunn.com/new-york-attorney-generals-office-fall-round-up-november-2022/#_edn45) Moreover, in February 2022, state regulators, including AG James, along with the SEC and the U.S. Commodity Futures Trading Commission, brought a lawsuit alleging that a precious metals company and its owner unlawfully solicited nearly $68 million for precious metals and misrepresented fees charged to investors.[\[46\]](https://www.gibsondunn.com/new-york-attorney-generals-office-fall-round-up-november-2022/#_edn46) These litigations are still pending. **IV. Health Care** AG James has continued to focus on inadequately managed properties that threaten tenant and worker safety, health products that endanger children and babies, the opioid epidemic, the COVID-19 pandemic, and reproductive health. AG James has sought to protect the public from inadequately managed properties that threaten tenant health. For example, in September 2021, AG James and the New York City Department of Investigation indicted four Certified Asbestos Investigators on 19 counts, including felony charges, for allegedly filing false asbestos inspection reports.[\[47\]](https://www.gibsondunn.com/new-york-attorney-generals-office-fall-round-up-november-2022/#_edn47) And in June 2022, AG James agreed to resolve an October 2021 lawsuit against a landlord in Syracuse for allegedly failing to protect children from lead paint.[\[48\]](https://www.gibsondunn.com/new-york-attorney-generals-office-fall-round-up-november-2022/#_edn48) This success comes in the wake of a multi-state call on the Environmental Protection Agency (“EPA”)—which AG James led—to strengthen protections against lead poisoning for children living in low-income communities and communities of color.[\[49\]](https://www.gibsondunn.com/new-york-attorney-generals-office-fall-round-up-november-2022/#_edn49) That same month, AG James reached an agreement with a wireless network operator to help prevent the spread of Legionnaires’ disease, which can be spread by poorly monitored building cooling towers.[\[50\]](https://www.gibsondunn.com/new-york-attorney-generals-office-fall-round-up-november-2022/#_edn50) AG James has taken other steps involving children’s health. In October 2021, AG James led a coalition of 23 attorneys general to petition the Food and Drug Administration to accelerate the removal of heavy metals from baby food.[\[51\]](https://www.gibsondunn.com/new-york-attorney-generals-office-fall-round-up-november-2022/#_edn51) She also issued an alert to protect children from deceptive cannabis products sold in snack packaging, warning New Yorkers to “remain vigilant” against such products.[\[52\]](https://www.gibsondunn.com/new-york-attorney-generals-office-fall-round-up-november-2022/#_edn52) AG James has devoted significant attention to the opioid epidemic. In March 2019, AG James filed an extensive lawsuit aiming to hold various manufacturers and distributors accountable for the epidemic.[\[53\]](https://www.gibsondunn.com/new-york-attorney-generals-office-fall-round-up-november-2022/#_edn53) AG James entered three notable settlements in the suit in the last year, with one manufacturer for $523 million and another for $200 million (most of which are earmarked for opioid abatement) and with a pharmaceutical company for $58.5 million. She also sought to bring a previously dismissed pharmaceutical company back into the lawsuit, moving to vacate their dismissal for allegedly making “significant and intentional misrepresentations” to her Office regarding the extent of its role in its subsidiary’s opioids business.[\[54\]](https://www.gibsondunn.com/new-york-attorney-generals-office-fall-round-up-november-2022/#_edn54) AG James has also urged the CDC to adopt stronger opioid prescription guidelines,[\[55\]](https://www.gibsondunn.com/new-york-attorney-generals-office-fall-round-up-november-2022/#_edn55) and in recent months has distributed over $100 million from settlements with opioid manufacturers and distributors to communities across the State impacted by the epidemic.[\[56\]](https://www.gibsondunn.com/new-york-attorney-generals-office-fall-round-up-november-2022/#_edn56) AG James has also begun to distribute $256 million earmarked for New York City to combat the crisis—the first round of payments from the $1.5 billion that AG James has secured for the State from settlements with opioid manufacturers and distributors.[\[57\]](https://www.gibsondunn.com/new-york-attorney-generals-office-fall-round-up-november-2022/#_edn57) AG James has also continued to prioritize public health in light of the COVID-19 pandemic. For example, AG James issued a warning letter to a diagnostics company for allegedly misrepresenting its turnaround times for COVID-19 test results, and she launched an investigation into a clinic over reports that it allegedly wrongfully billed New Yorkers for COVID-19 tests.[\[58\]](https://www.gibsondunn.com/new-york-attorney-generals-office-fall-round-up-november-2022/#_edn58) AG James has helped consumers recover over $400,000 who paid for expedited COVID-19 tests but received results later than promised.[\[59\]](https://www.gibsondunn.com/new-york-attorney-generals-office-fall-round-up-november-2022/#_edn59) Finally, after a draft Supreme Court opinion in *Dobbs v. Jackson Health Women’s Health Organization* was leaked to the press in May 2022, AG James quickly mobilized around women’s reproductive health issues. AG James and Assembly Member Jessica González-Rojas announced a bill to establish a state program to provide financial resources to abortion providers, which is currently in committee, and offered guidance to protect the privacy of individuals seeking abortions.[\[60\]](https://www.gibsondunn.com/new-york-attorney-generals-office-fall-round-up-november-2022/#_edn60) Following the publication of the Supreme Court’s decision in *Dobbs*, AG James vowed to keep New York a “safe haven” for those seeking an abortion.[\[61\]](https://www.gibsondunn.com/new-york-attorney-generals-office-fall-round-up-november-2022/#_edn61) **V. Environmental Protection** AG James’s Office continued its environmental activism over the past year, leading other state attorneys general in urging federal agencies to take more aggressive stances on environmental issues, particularly climate change. The majority of AG James’s actions directed at federal regulations came in the form of letters to various federal actors urging progressive rules and regulations concerning climate and pollution-related topics. For example, on September 14, 2021, AG James, along with 20 state attorneys general, asked Congress to respond to the climate crisis and support environmental justice by funding programs in budget reconciliation legislation.[\[62\]](https://www.gibsondunn.com/new-york-attorney-generals-office-fall-round-up-november-2022/#_edn62) In December 2021, AG James and 15 other Democratic state attorneys general also filed comments in support of the Pipeline and Hazardous Materials Safety Administration’s proposal to suspend a Trump-era rule allowing liquefied natural gas to be shipped in rail tank cars, arguing, in part, that the environmental assessment of the rule “did not adequately consider upstream and downstream effects on greenhouse gas emissions.”[\[63\]](https://www.gibsondunn.com/new-york-attorney-generals-office-fall-round-up-november-2022/#_edn63) On June 30, 2022, in response to the Supreme Court ruling in *West Virginia v. EPA*, which ruled that the EPA lacked authority to restructure the electric power industry, AG James issued a statement saying that her Office “will continue to be a champion for our environment, our future, and the health of New Yorkers” and “will work to end our nation’s reliance on fossil-fuel power plants that pollute our environment, and move towards clean, renewable, and affordable electricity.”[\[64\]](https://www.gibsondunn.com/new-york-attorney-generals-office-fall-round-up-november-2022/#_edn64) Most recently, on September 20, 2022, AG James announced an agreement with the U.S. Department of Energy (“DOE”) committing DOE to a new timetable for updating energy efficiency standards for 20 categories of common consumer products and commercial equipment, ranging from residential furnaces to laundry machines to electric motors.[\[65\]](https://www.gibsondunn.com/new-york-attorney-generals-office-fall-round-up-november-2022/#_edn65) This agreement resolved a complaint against the DOE filed by the NYAG and a coalition of 17 states in 2020 alleging that the DOE failed to comply with certain deadlines for updating energy efficiency standards set by the Energy Policy and Conservation Act of 1975.[\[66\]](https://www.gibsondunn.com/new-york-attorney-generals-office-fall-round-up-november-2022/#_edn66) In addition to regulatory advocacy, AG James also filed lawsuits related to environmental protection. On April 28, 2022, AG James and California Attorney General Rob Bonta led a multistate coalition in suing the United States Postal Service for allegedly failing to consider the environmental impact of its new fleet of mail trucks.[\[67\]](https://www.gibsondunn.com/new-york-attorney-generals-office-fall-round-up-november-2022/#_edn67) The lawsuit is currently pending before the Judicial Panel on Multidistrict Litigation, and oral argument the motion to transfer for coordinated pretrial proceedings was denied on October 7, 2022.[\[68\]](https://www.gibsondunn.com/new-york-attorney-generals-office-fall-round-up-november-2022/#_edn68) On March 31, 2022, the offices of AG James and Department of Environmental Conservation Commissioner Basil Seggos announced the indictment of a Kentucky-based freight shipping and trucking company and its Vice President for allegedly dumping hazardous materials in Chenango County and creating fake scale tickets to conceal the alleged disposal.[\[69\]](https://www.gibsondunn.com/new-york-attorney-generals-office-fall-round-up-november-2022/#_edn69) **VI. Labor and Employment** This year, as labor organizing efforts generally have picked up around the state, AG James turned to support local unions. In August 2021, AG James announced that she, along with 16 other attorneys general, asked the U.S. Senate to pass the Protecting the Right to Organize Act of 2021 (“PRO Act”).[\[70\]](https://www.gibsondunn.com/new-york-attorney-generals-office-fall-round-up-november-2022/#_edn70) The bill would allow unions to override “right-to-work” laws in more than two-dozen states, curtail employer intervention in union elections, and introduce new monetary penalties for certain retaliatory actions, among several other labor-friendly reforms.[\[71\]](https://www.gibsondunn.com/new-york-attorney-generals-office-fall-round-up-november-2022/#_edn71) Although unlikely to pass the Senate this year, AG James’s support for the bill indicates her enthusiasm for expanding workers’ rights and union membership.[\[72\]](https://www.gibsondunn.com/new-york-attorney-generals-office-fall-round-up-november-2022/#_edn72) Throughout the past year, AG James has met with young organizers and made several statements in support of a coffeehouse chain’s employees’ ultimately successful union campaign in Buffalo.[\[73\]](https://www.gibsondunn.com/new-york-attorney-generals-office-fall-round-up-november-2022/#_edn73) She also expressed support for a health system’s employees’ decision to strike in late 2021.[\[74\]](https://www.gibsondunn.com/new-york-attorney-generals-office-fall-round-up-november-2022/#_edn74) Looking ahead, AG James has indicated that she plans to work alongside the Service Employees International Union (“SEIU”) to seek stronger protections for nursing home workers in light of staffing, wage, and operations issues that were brought to light during the COVID-19 pandemic.[\[75\]](https://www.gibsondunn.com/new-york-attorney-generals-office-fall-round-up-november-2022/#_edn75) AG James has been active across the labor and employment area. These efforts include the following: - After settling allegations of sexual harassment, unlawful sex discrimination, and retaliation against a celebrity chef in 2021, AG James’s Office has continued to investigate sexual harassment and discrimination in the entertainment and hospitality industries.[\[76\]](https://www.gibsondunn.com/new-york-attorney-generals-office-fall-round-up-november-2022/#_edn76) Following a 16-month investigation, on July 13, 2022, AG James’s Office announced a $500,000 settlement with the owner of a Manhattan bar on behalf of sixteen former employees. The settlement also requires the bar to update its training materials, post notices regarding anti-discrimination rights, and submit to periodic monitoring.[\[77\]](https://www.gibsondunn.com/new-york-attorney-generals-office-fall-round-up-november-2022/#_edn77) This spring, AG James also joined other attorneys general in issuing a warning to NFL Commissioner Roger Goodell that gender discrimination and sexual harassment would not be tolerated in any workplace.[\[78\]](https://www.gibsondunn.com/new-york-attorney-generals-office-fall-round-up-november-2022/#_edn78) - AG James’s lawsuit against an American multinational technology company over the company’s COVID-19 protocols was dismissed with finality this year when, after the First Department unanimously dismissed all of the Office’s claims in May, the court denied the Office’s motion for re-argument or, in the alternative, for leave to appeal, on September 13, 2022.[\[79\]](https://www.gibsondunn.com/new-york-attorney-generals-office-fall-round-up-november-2022/#_edn79) The court had previously found that the NYAG’s retaliation claims were federally preempted and that the workplace-safety claims were based on withdrawn guidance and, therefore, moot.[\[80\]](https://www.gibsondunn.com/new-york-attorney-generals-office-fall-round-up-november-2022/#_edn80) - As COVID-19 restrictions were lifted, AG James broadened her efforts related to workplace health and safety. Her Office continued to negotiate settlements related to COVID-19 safety issues, including a $400,000 settlement with a healthcare services company related to allegations of improper termination and denials of sick leave during the pandemic.[\[81\]](https://www.gibsondunn.com/new-york-attorney-generals-office-fall-round-up-november-2022/#_edn81) - The Office’s attention also shifted to a relatively novel employment issue: climate change. On January 27, 2022, AG James, along with other states attorneys general, asked the Occupational Safety and Health Administration to implement national standards to protect outdoor and indoor workers from occupational exposure to extreme heat. The suggested regulations would require employers to develop acclimatization plans; offer mandatory hydration and rest breaks in shaded or cool areas; and provide personal protective equipment, heat alert plans, and worker training and monitoring. The regulations would also require employers to keep records related to heat-related injuries and submit to more frequent workplace inspections. This new climate-focused regulatory push signals a potential new workplace safety focus for AG James as COVID-19 restrictions lift.[\[82\]](https://www.gibsondunn.com/new-york-attorney-generals-office-fall-round-up-november-2022/#_edn82) AG James has also focused on the rights of terminated employees. For example, in October 2021, AG James announced a $2.7 million settlement on behalf of 250 employees of a hotel and conference center after they were allegedly denied wages and terminated without sufficient legal notice under the New York Worker Adjustment and Retraining Notification Act.[\[83\]](https://www.gibsondunn.com/new-york-attorney-generals-office-fall-round-up-november-2022/#_edn83) In May 2022, AG James announced an agreement with a hotel company that would collectively provide 500 previously terminated workers with $2.95 million in severance pay following allegations that non-unionized workers had been promised, but not provided, the same or better benefits as unionized hotel workers, in violation of Section 63(12) of the Executive Law.[\[84\]](https://www.gibsondunn.com/new-york-attorney-generals-office-fall-round-up-november-2022/#_edn84) This year, AG James also brought suit against a religious diocese for allegedly depriving more than 1,100 former employees of pensions through various alleged violations of the New York Not-for-Profit Corporations Law and New York Estates, Powers & Trusts Law.[\[85\]](https://www.gibsondunn.com/new-york-attorney-generals-office-fall-round-up-november-2022/#_edn85) This lawsuit is currently pending.[\[86\]](https://www.gibsondunn.com/new-york-attorney-generals-office-fall-round-up-november-2022/#_edn86) AG James also settled several wage-and-hour cases this year, including two particularly large settlements in the home healthcare industry: - First, in November 2021, AG James entered into an $18.8 million-dollar settlement with two home healthcare agencies that allegedly violated the New York Labor Law and NYC Paid Safe and Sick Leave Law. In addition to the payout to 12,000 former employees, the two companies are also required to update their handbooks and leave processes and submit to monitoring by the Office and the New York City Department of Consumer and Worker Protection.[\[87\]](https://www.gibsondunn.com/new-york-attorney-generals-office-fall-round-up-november-2022/#_edn87) - Then, in March 2022, AG James announced the largest settlement to date for alleged violations of the Wage Parity Act. The combined $5.5 million-dollar settlement requires the two subject home healthcare agencies to revise company policies, retrain personnel, and report staff wages to the Office for six years.[\[88\]](https://www.gibsondunn.com/new-york-attorney-generals-office-fall-round-up-november-2022/#_edn88) This year, AG James also reached several smaller settlements related to alleged unpaid wages for apartment building superintendents ($130,000), restaurant workers ($175,000), and construction workers on certain public works contracts ($930,000).[\[89\]](https://www.gibsondunn.com/new-york-attorney-generals-office-fall-round-up-november-2022/#_edn89) We expect AG James will continue to advance the rights of and protections for workers in New York, as this has consistently been a primary focus for the Office. \* \* \* We expect that AG James will continue to pursue an active and progressive agenda in the remainder of 2022. We also anticipate that AG James will continue to work alongside state attorneys general around the country—forming coalitions with Democrats and Republicans alike—on matters of national import, including antitrust, the environment, consumer protection, data privacy, and financial fraud investigations and litigation. Gibson Dunn will continue to monitor the actions of the Office. **Topics:** Judicial/courts, Public Awareness --- ### [Eight indicted by Adair County grand jury](https://insurancefraud.org/news_archives/eight-indicted-by-adair-county-grand-jury/) **Published:** September 16, 2026 **Author:** Diane Beauchamp **Content:** Eight people were indicted by an Adair County grand jury recently. Those indicted included the following individuals: Steven A. Swift on charges of fleeing or evading police first degree, wanton endangerment of a police officer, fleeing or evading police on foot, leaving the scene of an accident, and being a persistent felony offender. Chasity Michelle Mann, also known as Chasity Deering or Chasity Wright, on charges of identity theft and insurance fraud less than $10,000. Douglas Edward Lawson on charges of wanton endangerment first degree and menacing. Gregory Wayne Richardson on charges of criminal mischief first degree, assault fourth degree, and public intoxication. Christopher D. Smothers on charges of possession of a handgun by a convicted felon, receiving a stolen firearm, and being a persistent felony offender. Amanda Dawn Graham on a charge of theft of services between $1,000 and $10,000. Catherine Green on a charge of criminal abuse in the second degree with a victim under the age of 12. Eugene Gregory Wilson on two counts of sodomy first degree and sexual abuse first degree with a victim under the age of 12. **Topics:** Fraud General, Synthetic Identity Theft --- ### [Smart ways to buy pet insurance](https://insurancefraud.org/news_archives/smart-ways-to-buy-pet-insurance/) **Published:** September 16, 2026 **Author:** Diane Beauchamp **Content:** If you own a dog or cat, [buying pet insurance may be something to consider](https://www.cbsnews.com/news/pet-insurance-benefits-new-owners/). Much like human health insurance plans, these can help offset or even fully cover any unexpected medical bills, surgeries or treatments your pet may need. In some cases, they [cover preventative care, too](https://www.cbsnews.com/news/how-much-does-pet-insurance-cost/). Just be aware: Not all pet insurance policies are equal. If you want to get the most benefit from your coverage, you’ll want to choose your plan, provider and [timing](https://www.cbsnews.com/news/best-times-to-buy-pet-insurance/) carefully. Use this guide to learn more about buying pet insurance — and [how to do it right](https://www.cbsnews.com/news/pet-insurance-dos-and-donts/). If you’re considering pet insurance then [start by getting a free price quote online now](https://secure.money.com/pr/ha195e5ebb53). ## **Smart ways to buy pet insurance** ### **1. Buy it when your pet is young** The younger your pet is, the less you’ll pay for insurance coverage. So insuring them while they’re still a pup or kitten? That could save you a good amount of money. Additionally, some pet insurers have age caps on their policies, so you may have trouble finding coverage once your pet turns 10 (or older). Another perk to buying insurance young is that you can ensure any accidents are covered while your pet is still learning and growing. If your puppy swallows something he’s not supposed to or your cat escapes and is injured, having insurance would keep you from footing a large medical bill for treatment. ### **2. Buy it when your pet is healthy** Don’t wait until your pet has many health conditions to get insurance. Not only will this cost you a higher premium, but those conditions (and the treatments for them) might not be covered. Many pet insurance providers refuse to cover [pre-existing conditions](https://www.cbsnews.com/news/pet-insurance-and-pre-existing-conditions/), except in rare circumstances. If you want to make sure your pet’s future health conditions are covered, getting insurance now — before they develop any — is critical. ### **3. Buy it when you’re on a budget** It sounds counterintuitive, but buying insurance [when you’re strapped for cash](https://www.cbsnews.com/news/reasons-to-get-pet-insurance-now/) is probably the best time to do it. Just think: If your pet was suddenly injured or diagnosed with a serious illness, would you have the funds to handle the large medical bill the treatment comes with? Would you have to put the charges on a costly, high-interest credit card? If so, paying $20 per month for insurance is probably a wise investment. ### **4. Buy it after you’ve shopped providers** Every provider offers different plans, coverages and premiums, so shopping around is vital if you want to get the best deal. Try to get quotes from at least three different insurers, and compare them each on coverage and costs. You should also take into account any [discounts](https://www.cbsnews.com/news/how-to-get-discounted-pet-insurance/) the insurers provide. Some companies offer premium reductions if you pay in full, are a military service member, are a senior or you bundle your coverage with other types of policies. These can save you quite a bit on your premiums. ## **Consider your savings** If you’re not sure whether pet insurance is the right move for your furry friend, consider the state of your savings account. Would you have enough to cover an emergency or injury if your pet were hurt? If not, a small monthly insurance premium [may be worth it](https://www.cbsnews.com/news/is-pet-insurance-worth-it/) for peace of mind. **Topics:** Public Awareness --- ### [Check VINs to Avoid Hurricane Ian Automotive Fraud in All States](https://insurancefraud.org/news_archives/check-vins-to-avoid-hurricane-ian-automotive-fraud-in-all-states/) **Published:** September 16, 2026 **Author:** Diane Beauchamp **Content:** Homeowners in Florida and Georgia are not the only ones who could fall victim to post-disaster fraud following Hurricane Ian. The National Insurance Crime Bureau (NICB), the insurance industry leading association dedicated to predicting, preventing, and prosecuting insurance crime, is warning consumers across the United States to stay vigilant when purchasing a used [ vehicle](https://www.autoconnectedcar.com/2022/12/check-vins-to-avoid-hurricane-ian-automotive-fraud-in-all-states/#) in the coming weeks and months. In the aftermath of disasters like Hurricane Ian, dishonest automobile dealers and other individuals buy flooded [ vehicles](https://www.autoconnectedcar.com/2022/12/check-vins-to-avoid-hurricane-ian-automotive-fraud-in-all-states/#), dry and clean them, and sell them to unsuspecting buyers as used vehicles. Many of these vehicles appear on the market in the weeks and months following a natural disaster, and not just in the states where the disaster occurred. NICB encourages purchasers across the U.S. to do their homework, including using NICB’s VINCheck®, a free tool that shows if a vehicle has had an insurance theft claim and has not been recovered, or has ever been reported as a salvage vehicle by participating NICB member insurance companies.If you are shopping for a used vehicle, NICB recommends doing your homework, including using NICB’s VINCheck®. “NICB assists with the identification of vehicles and works with insurance carriers to identify those to be declared a total loss,” said NICB President and CEO David Glawe. “Buyers must be particularly careful in these coming months, as thousands of flood damaged vehicles may appear for sale in their areas.” If you are shopping for a used vehicle, NICB recommends checking a few items that could indicate whether the vehicle is a flood recovery vehicle or not. Some steps to follow are: - Buy from a reputable car dealer. - Check the vehicle’s history, noting that it can take time for data related to such storms to catch up to these history reports. - Check the car thoroughly looking for water stains, mildew, sand and silt under the carpets, headliner, and behind the dashboard. - Get a pre-purchase inspection completed by a reputable service technician to determine if any telltale signs of water damage are present. - Look under the hood for signs of oxidation. Pull back the rubber “boots” around electrical and mechanical connections for these indicators. Ferrous (containing iron) materials will show signs of rust; copper will show a green patina; aluminum and alloys will have a white powder and pitting. If you believe you have been a victim of fraud, call the NICB at 1-800-TEL-NICB. For additional information, visit NICB’s website, www.NICB.org. **Topics:** Public Awareness --- ### [Hospital connected to data breach](https://insurancefraud.org/news_archives/hospital-connected-to-data-breach/) **Published:** September 16, 2026 **Author:** Diane Beauchamp **Content:** Some personal and private health information of patients who used St. Luke’s Health Brazosport services is part of a data breach reported at a law firm that handles corporate matters for the hospital. Polsinelli PC found some files were accessed from two discrete locations on its system Sept. 9 by an unauthorized person, the firm said in a news release. The firm identified the breach Sept. 27 and brought in a data security firm, which determined Polsinelli’s network and main document depository were unaffected. The investigation found files related to the firm’s representation of St. Luke’s Brazosport were among those affected. Polsinelli represented the hospital in a dispute with one of the hospital’s vendors that involved certain individuals’ health information, among other matters, the news release states. Personal information including the patient’s name, along with one or more of the patient’s Social Security number, date of birth, address, medical record number, patient account number, health insurance information and very limited clinical information had been improperly accessed, according to the release, and the firm notified the hospital of the incident in early October. Polsinelli has identified the people potentially affected and began sending written notifications to them Friday, it said. The firm did not specify how many patients’ information is involved. The notice will include information about how those potentially affected can protect themselves, such as by reporting any suspicious activity on their accounts and monitoring credit reports. Those who Social Security numbers were part of the breach will be offered free identify and credit fraud monitoring through Experian. Polsinelli does not believe any information has or will be used to commit individual fraud or identity theft, the firm said in its statement. Additional information about the incident is available by calling 855-842-6259 between 9 a.m. and 5 p.m. weekdays. Polsinelli PC is a national law firm headquartered in Kansas City, Missouri. It has 23 branch offices, including in Houston and Dallas. **Topics:** Public Awareness, Technology --- ### [Welcome to the 2022 Hall of Shame - Part 2](https://insurancefraud.org/news_archives/welcome-to-the-2022-hall-of-shame-part-2/) **Published:** September 16, 2026 **Author:** Diane Beauchamp **Content:** Editor’s Note: This is part 2 of a two-part series. Fraudsters operate under the mistaken belief that they are smarter than the average person and are unlikely to be caught perpetrating their brand of creative financing. However, the *Hall of Shame* shines a national public spotlight on the damage these individuals enact. The [Coalition Against Insurance Fraud](https://www.insurancefraud.org/) estimates that their damaging crime sprees steal [$308.6 billion every year](https://insurancefraud.org/wp-content/uploads/The-Impact-of-Insurance-Fraud-on-the-U.S.-Economy-Report-2022-8.26.2022-1.pdf). Fraud drives up premiums for millions of honest, hard-working Americans. People also are maimed, killed and driven to despair when they’re victimized by fraudsters they trusted. [Part 1](https://www.propertycasualty360.com/2022/12/05/10-fraudsters-enter-the-2022-hall-of-shame-part-1/) of this series introduced readers to a dentist who took his wife on safari to hunt her, an Army veteran who defrauded the government to the tune of $1 million, and a high school basketball coach and an attorney who filed false injury claims before committing suicide. This installment introduces readers to an equally exceptional group of fraudsters. **Toothless tooth con.** [A dentist in the Milwaukee](https://www.justice.gov/usao-edwi/pr/federal-jury-finds-grafton-dentist-guilty-healthcare-fraud-and-false-statements) area broke patients’ teeth so he could falsely bill insurers $4.2 million for new crowns. Scott Charmoli of Grafton, Wisc., convinced patients they needed crowns, then deliberately ruined their teeth with his dental drill (ugh, just thinking about that sound makes people cringe) and captured photos of the damaged teeth (his own twisted masterpiece) and took X-rays of the damage. The greedy scheme played out by Charmoli first showing the patients an X-ray of a healthy tooth but then pointing to a line or a spot he said showed a “fracture” or “decay.” He then pressed the patients into agreeing to get a crown to fix the problem. The images of the teeth purposely damaged by him were sent to insurers as he sought payment for every crown performed. Insurers believed the images were real and showed pre-operation damage, so they paid the submitted claims. Many of his patients also paid large co-pays, adding to his pockets. Reportedly, some of his patients were vulnerable individuals who were either involved in abusive relationships, recently widowed or survivors of cancer, meaning that many were scrounging paycheck to paycheck to afford the ridiculously hyped-up copays he charged them. The scheming dentist persuaded one patient named Todd Tedeschi to get two crowns in one sitting (who does that?!), even though his teeth seemed fine. In total, the unscrupulous dentist Charmoli performed over 700 procedures a year from 2016 to 2019 or approximately 2,100 crowns — he was at around the 95th percentile among dentists in the whole state. Charmoli received four-and-a-half years in prison. Let’s see him chew on that! **Urine becomes yellow gold.** Two men [bought small, struggling hospitals](https://www.wcjb.com/2022/06/27/jorge-perez-co-conspirator-convicted-rural-hospital-billing-scheme/) and then used them as pipelines for billing insurers for $1.4 billion of false urine tests. Even outside the city limits, healthcare fraud attracts the worst of the worst. Rural hospitals were ideal targets for the not-so-good intentional takeovers in Florida, Georgia, and Mississippi, by Jorge and Ricardo Perez. The hospitals they set their greedy sights on could charge insurers higher rates under agreements to “better serve” rural communities and it is a shame that they took that as an opportunity to execute their fraudulent behavior. Overall, the Perez brothers converted the rural hospitals into testing labs to bill insurers for phantom or inflated urine tests. The scheme made the hospitals appear to be legit facilities for the testing of urine of addicted patients. The sad reality is that other labs actually did the testing. Much of the lab testing billed through the rural hospitals involved unnecessary urine drug testing for vulnerable addiction treatment patients. Much too often patients were recruited through kickbacks paid to recruiters and med providers — frequently at sober homes or substance abuse treatment facilities. After private insurers began to question the bills, the Perezes moved on to another rural hospital to begin their sleazy profit scheme again. They always left the one they took over in the same or even a worse financial state as before. The results of these two sleazeballs is that three out of four rural hospitals they drained closed shortly thereafter. The Perez brothers were convicted and will be federally sentenced later. **Slip & fall ring tumbles.** A surgeon [performed worthless and unneeded back surgeries](https://www.justice.gov/usao-sdny/pr/new-york-doctor-who-performed-unnecessary-back-surgeries-pleads-guilty-participating) on homeless and addicted people so a slip-and-fall ring could exploit them to maximize $31 million of insurance payouts. Dr. Sady Ribeiro pled guilty. The ring recruited more than 400 patients in the New York City area and they were coached to lie that they tripped, fell and were hurt at pre-set locations. Sometimes they deliberately fell at sites such as cellar doors, cracks in concrete sidewalks and purported “potholes.” The supposedly injured patients were referred to colluding personal-injury attorneys, who falsely sued the site owners and their insurers. The patients were also told to receive ongoing chiro and other treatment from certain chiropractors and doctors, including Ribeiro. To continue with their lawsuits, the patients had to undergo two back surgeries. They were paid token sums $1,000-$1,500 after they completed surgery. The patients were desperate — addicted or recruited from homeless shelters. Many had to ask for food when they met with the lawyers. Often, they didn’t have clothing to stay warm during the winter. Litigation-funding companies financed the fraudulent lawsuits. “I will play a very honest ‘game’ with you. … I see the patient and I generate a very good dictation that justifies the treatment — there is a cost for that and I hope a profit,” Ribeiro emailed litigation-funding attorney Adrian Alexander. Ribeiro will serve up to five years and must forfeit $513,000. Alexander earlier pled guilty and could receive five years when sentenced. This was one time not to do what the doctor told you. **Fraud of the living dead?** Some [$17 million was falsely billed for medical equipment ordered by hundreds of people who turned out to be dead](https://www.usnews.com/news/best-states/north-carolina/articles/2022-07-06/north-carolina-woman-pleads-guilty-to-healthcare-fraud). A Raleigh, N.C. woman named Tanya Parrish Grant included a whopping 422 dead people in her bills. She reached out across the globe and paid firms in India and Pakistan to give her lists of Medicare patient names and personal identifiers. The lists came from overseas call centers that contacted Medicare patients to ask if they needed the equipment. Grant’s firms — Carolina Rehab Produces and Atlantic Brace — then turned around and billed Medicare. She charged Medicare without actually having physician orders and without shipping any of the products. Patients who received equipment and sent them back never triggered her to reimburse Medicare for the gear, solidifying her greed. When it came to being audited by Medicare contractors, Grant forged physician orders if no orders existed in her files. She used the money to buy a home near Raleigh; a townhome in Ft. Lauderdale; a Porsche and several Land Rovers. She also amassed more than $1 million in cash and investments. She pled guilty and will spend up to 10 years in prison when sentenced. **Yanking a contractor’s welcome mat.** Thousands of homeowners lost everything when the Tubbs wildfire barreled through Sonoma County, Calif., in 2017. Then along came contractor [Salvador Chiaramonte](https://www.pressdemocrat.com/article/news/this-defense-argument-for-leniency-killed-a-plea-deal-in-a-tubbs-fire-fraud/). He took more than $1 million of victims’ money and left them with unrepaired homes. The fire wrecked 4,600 homes. Victims signed about 40 construction contracts with Chiaramonte. He took money for work that was shoddily performed or not done at all. Chiaramonte missed deadlines, and broke promises on construction start dates. Victims saw their rebuilds drag on with no progress. One victim was D.M. Kelley, who lost his house. He met with Chiaramonte who repeatedly mentioned his Christian values. Chiaramonte took over $100,000 from Kelley and did almost no work. Kelley demanded his money back. Chiaramonte said he needed the money to save his own home. “I said, ‘What about us? We have no houses!” Kelley retorted. Chiaramonte pled no contest and faces a six-year jail term, including 18 months of probation. Meanwhile, some of Chiaramonte’s victims still haven’t rebuilt their homes with their insurance money stolen. “A lot of them are still very emotionally raw,” says attorney Rich Freeman, who represents 14 homeowners in a lawsuit. “The horror of what they went through, losing everything in the fires, the emotional trauma of that, coupled with battling with their insurance companies to find out what their coverage was, only to have this guy run off with or squander their money and leave them scrambling — there’s almost nothing that could make them whole again.” **Topics:** Coalition Against Insurance Fraud, Public Awareness --- ### [Construction company owner accused of fraud, threatening workers, criminal sexual conduct](https://insurancefraud.org/news_archives/construction-company-owner-accused-of-fraud-threatening-workers-criminal-sexual-conduct/) **Published:** September 16, 2026 **Author:** Diane Beauchamp **Content:** The former owner of a construction company in Minnesota was charged Monday with crimes including worker’s compensation insurance fraud, threatening workers, and criminal sexual conduct in a case dating back to 2017. Fabian Espinosa, who investigators say has since moved from Minnesota, is facing charges in the case related to his construction company he started in the fall of 2017. Count 1 At the time, investigators with the Minnesota Commerce Fraud Bureau say Espinosa filed for worker’s comp insurance but claimed he had no workers on his payroll to keep premium costs down – despite the fact investigators say he already had several employees at the time. Despite estimating he would have a $0 payroll for the upcoming year, investigators say Espinosa employed around 14 workers between October 2017 through January 2018. Count 2 It doesn’t end there. According to the criminal complaint, workers told investigators that, when people were hurt on the job, the injuries often weren’t reported or cared for by medical professionals, according to investigators. In one case when a worker suffered a bad finger cut from a saw blade, investigators say Espinosa told the employee to go to a pharmacy to get a first aid kit. Later, according to the complaint, when the worker pleaded that he needed to see a doctor, Espinosa went with the worker to Regions Hospital and told him to lie about how the injury occurred – threatening to turn the immigrant worker into the police if he didn’t lie. The worker did lie, claiming he had crushed his finger in a car door, the state says. A $2,400 bill for the treatment was sent to Espinosa’s home address in Richfield, investigators say, but was never paid. The injured worker ultimately quit when Espinosa demanded that he return to work a few days later. The worker told investigators he sought further treatment for his injured finger after leaving his job. Count 3 A woman who was employed by Espinosa also says she was attacked by Espinosa in December 2017. Before the alleged attack, investigators say Espinosa propositioned the worker and showed her his penis. The complaint says Espinosa called her “a lesbian” when she apparently rejected his advances. On December 20, 2017, police say Espinosa asked the worker to stay late to help on a project. She stayed briefly but ultimately got a ride back with another worker to the La Quinta in Bloomington, where the workers were staying. According to the charges, Espinosa was furious, fired the woman, and canceled her hotel room. The woman ended up staying with a friend in another room. Two days later, on about December 22, investigators say Espinosa entered the room where the woman was staying and assaulted her, pinning her on a bed, ripping her shirt, biting her, and putting his hands on her private parts. Two witnesses confirmed with investigators they saw the injuries the woman suffered after the attack, including bruising and a bite mark. Since 2017 Investigators say Espinosa left Minnesota in 2019 and has since been living in Baltimore. He was contacted by state investigations in December 2019. During the phone interview, investigators say Espinosa lied about the number of workers he had hired, claiming he only employed a father and son from Mexico for a few months. But later he admitted to having a female employee – who he again referred to as a “lesbian” when speaking with investigators — but claimed she did not stay at the La Quinta and only worked for him for a few days to a couple of weeks. Espinosa denied that he had ever touched the woman inappropriately and that anyone was hurt on his work sites. It appears Espinosa still lives in Baltimore. He has been summoned to appear in Hennepin County court on January 3 at 1:30 p.m. Charges in the case were filed on Monday. It’s unclear what took so long for investigators to bring charges. **Topics:** Work comp - employer **Categories:** Arrest --- ### [Car rental agency under investigation for insurance claims](https://insurancefraud.org/news_archives/car-rental-agency-under-investigation-for-insurance-claims/) **Published:** September 16, 2026 **Author:** Diane Beauchamp **Content:** A tip from a Farmers Insurance claims investigator to a local agent with the Department of Insurance prompted an ongoing, yearslong investigation into an alleged fraud suspected of involving victims from Santa Clarita to San Jose, according to court records. Court documents identify a husband-and-wife team behind AT Car Rental, as well as a third suspect, who have not yet been arrested, according to investigators, who also identified actual paid-out losses at around $250,000 and the potential losses of approximately $850,000. All three reportedly lived at addresses in the San Fernando Valley during the time the alleged fraud took place, according to documents obtained by The Signal. Investigators suspect the mail-drop business, which did not have a registered physical address, phone number or website as of this story’s publication, used the identities of its clients to obtain insurance policies and then filed 30 fraudulent claims on behalf of its customers, according to sworn affidavits. The initial investigation began after a Special Investigations Unit employee of Farmers filed a “suspected fraudulent claim referral” with the state Department of Insurance’s Fraud Division. The third suspect was tied to the investigation through a cellphone number on a Facebook page of the business. The Farmers investigator alleged that a principal for the rental agency used the identities of the business’ clients to obtain 30 personal auto insurance policies in their names and then filed claims for the rental cars based on fraudulent policies, according to sworn statements. Documents also indicate that as many as 47 claims were filed using the allegedly fraudulent policies between September 2018 and July 2020, and they were all attached to older model Hyundai and Kia vehicles that had salvaged titles sold from a San Bernardino used car dealership, according to court records. The policies were largely written through a Woodland Hills-based insurance agency that investigators suspect knowingly wrote fraudulent policies, as Farmers Insurance does not insure rental cars, according to court documents. Court records indicate that investigators seized more than $20,000 in cash during a search of the car-rental business owners’ residence, as well as a sheet titled “People who owe us.” A phone number associated with one of the owners of AT Car Rental reached Monday confirmed the business was active, but denied any knowledge of the allegations before ending the call. No charges have been filed against any of the parties identified in the court documents obtained by The Signal at this time, according to court records available online. The social media accounts associated with the car rental agency do not appear to be active. An agent with the Department of Insurance declined to comment on the record, citing the active and ongoing status of the investigation, as did an official for Farmers Insurance. “We decline comment on matters related to active investigations involving the California Department of Insurance,” wrote Luis Sahagun, director of external communications, corporate, for Farmers Insurance, in an email sent Friday afternoon. **Topics:** Business - padding/faking --- ### [Connected vehicle data will improve end-to-end insurance offerings in the USA](https://insurancefraud.org/news_archives/connected-vehicle-data-will-improve-end-to-end-insurance-offerings-in-the-usa/) **Published:** September 16, 2026 **Author:** Diane Beauchamp **Content:** UK-based Wejo Group Limited, a data, analytics and software-as-a-service provider, has announced the US expansion of its insurance offering with Ford Motor Company. The collaboration will enable insurance providers to better understand driving behaviors through connected vehicle data and will provide insights to support user-based intelligence for end-to-end insurance. Wejo and Ford successfully launched the same program throughout Europe in June. “Expanding our joint capabilities with Ford in the US enables mutual benefit to both policyholders and insurers as auto insurance companies leverage connected vehicle data for good,” says Richard Barlow, founder and CEO of Wejo. “We’re excited to embrace the estimated US$1.7 billion by 2030 total addressable user-based insurance market in the US by working with vehicle OEMs to help insurance providers leverage actionable data insights. Our expanded partnership with Ford for end-to-end insurance is a significant step toward reinventing auto insurance for a smarter, safer future.” When this offering is available, with customer consent, connected vehicle data can be used to establish usage-based vehicle insurance policies that reward customers based on their driving behaviors. This data can help the vehicle insurance industry better validate customer supplied details, identify and minimize insurance fraud, offer more accurate dynamic pricing models, and reduce risks for safer journeys and less stress on policymakers and customers. “We are excited to expand our insurance data services relationship with Wejo into the US market,” says Amy Graham, services marketing director at Ford Motor Company. “Connected vehicle data enables insurance providers to better understand driving behaviors which can result in discounts to policy holders and ultimately help reduce the total cost of vehicle ownership for our customers.” **Topics:** Public Awareness, Technology --- ### [New Zealand Health Insurer Investigates IT Provider Hack](https://insurancefraud.org/news_archives/new-zealand-health-insurer-investigates-it-provider-hack/) **Published:** September 16, 2026 **Author:** Diane Beauchamp **Content:** A cyber incident at an external IT infrastructure provider for New Zealand private health insurer Accuro may have affected the personal data of the underwriter’s 34,000 customers. The Wellington based not-for-profit insurer [said](https://www.accuro.co.nz/about/news/temporary-outage/) its investigation into the incident so far hasn’t revealed evidence of a data breach “but we cannot rule out this possibility.” A Thursday statement from CEO Lance Walker said day-to-day operations and customer service have been affected by the incident, warning of delays in service including claims processing. The company notified the New Zealand Government’s Computer Emergency Response Team and the Office of the Privacy Commissioner and has brought in outside cybersecurity support, the company said. Company Chief Financial Officer Joe Benbow wouldn’t confirm or deny the incident is a ransomware attack, [reported](https://www.nzherald.co.nz/business/health-insurer-accuro-says-30000-customers-data-potentially-exposed-in-hack/VGBX57GDBVBNFAYSQVMEOAO7HQ/) the New Zealand Herald. Benbow also declined to identify the third-party infrastructure provider. Ransomware hackers based in Russia attacked private health insurer Medibank in neighboring Australia in October and earlier this month dumped online data they characterized as a full set of stolen customer data (see: [*Medibank Hackers Dump Stolen Data on the Dark Web*](https://www.bankinfosecurity.com/medibank-hackers-dump-stolen-data-on-dark-web-a-20604)). ### Threat Landscape in New Zealand Reported cyber incidents have been on a steady rise. [CERT NZ](https://www.cert.govt.nz/about/quarterly-report/2021-report-summary/) reported last December year-end increases in phishing and credential harvesting as well as malware. The government agency’s most [recent quarterly report](https://www.cert.govt.nz/about/quarterly-report/quarter-two-cyber-security-insights-2022) shows New Zealanders reported $NZ3.9 million in direct financial losses due to cyber incidents from April to June, an amount that’s also the average for quarterly losses experienced over the past 24 months. Reports of phishing and credential harvesting in particular have spiked by nearly tenfold since 2017 to more than 3,700 known incidents. A recent [report](https://tuanz.org.nz/digital-priorities-report-2022/) by Technology Users Association of New Zealand on the state of Kiwi digital transformation warned that “leaders have their work cut out for them to prevent cyberattacks.” The report, based on interviews with senior corporate and public sector officials, found that high-profile attacks have increased awareness and nudged leaders into thinking beyond the security of access points and on to adopting security by design. “I think that New Zealand companies and organizations felt safe and secure by being down the bottom of the world,” association CEO Craig Young [told](https://securitybrief.co.nz/story/why-is-nz-lagging-behind-the-world-in-cybersecurity) SecurityBrief New Zealand in June. But physical isolation isn’t a defense in cyberspace, he added. “It only takes a couple of milliseconds for a message to come or leave New Zealand.” **Topics:** Public Awareness, Technology --- ### [Aviva reports 16% rise in application fraud over same period in 2021](https://insurancefraud.org/news_archives/aviva-reports-16-rise-in-application-fraud-over-same-period-in-2021/) **Published:** September 16, 2026 **Author:** Diane Beauchamp **Content:** **Aviva has recorded a 16% increase in the amount of motor insurance policy fraud it has detected through to October this year, compared to the same period last year.\*** The UK’s leading insurer has blocked more than 23,300 fraudulent or suspect motor insurance applications through the first ten months of this year, compared with just over 20,000 at this same point last year. The fraud findings come amidst a squeeze on the cost of living, and Aviva is warning motorists who may be tempted to lie to their insurer in an attempt to save a few pounds to think twice. **Iain Hamilton, Head of Motor Underwriting, Aviva, said,** “The overwhelming majority of our customers are honest, and we have a duty to make sure that we do everything we can to minimise the impact of fraud on their motor insurance premiums. But the increase in attempted application fraud shows that insurers cannot be complacent, and must do everything we can to reduce the impact of fraud on premiums for our customers. “One of the key ways we can do this is to educate motorists about various forms of application fraud so that they are aware of ghost brokers offering cheap but worthless insurance, while also ensuring that they fill out their insurance application as accurately as possible so they have the right cover for their needs. If motorists are in any doubt about their insurance, they should speak with their insurer or broker to confirm they are adequately covered.” ### **Ghost Broking** Ghost broking accounts for 15% of all policy fraud detected by Aviva. Ghost broking occurs when an unauthorised person acts as an insurance intermediary and purchases insurance policies using false or misleading information about the customer to acquire cheaper insurance on their behalf. Ghost brokers will usually amend the policy details before sharing with their ‘customer’ to show ‘proof’ of their insurance purchase. However, the insurance policy is all but worthless, as the ghost broker lied about the true identity and/or nature of the risk being insured (such as address, age of driver, etc.). Buying a bogus policy through a ghost broker can have serious consequences, including police seizing the car, a fixed penalty notice (£300) and being liable for any damage caused while driving without valid insurance. Further, the motorist will need to purchase valid insurance in order to get their car back on the road, after paying at least £150 to get their car released from the pound. However, these penalties do not deter everyone. Research on behalf of Aviva found that one in five (20%) motorists would consider buying insurance from an individual on social media offering cheap car insurance, even if they suspected the person was not a genuine insurance broker.\*\* One in four (25%) motorists said they have been approached by someone online offering cheap car insurance. As pressure mounts on the cost of living, motor insurance customers should be wary of insurance offers from unclear, unsolicited or unusual sources – especially online messaging platforms. If customers have any concerns about the legitimacy of an insurance offer, they can check the broker’s status on the Financial Conduct Authority or British Insurance Brokers’ Association websites, or alternatively contact the insurer directly. Ultimately, if a premium looks too good to be true, then it probably is. ### **Application fraud** But ghost broking is just one form of application fraud. The majority of fraudulent applications Aviva detects are from applicants who change relevant information about themselves or their driving history in attempt to secure cheaper cover. This could include, for example, saying the car is kept in a garage overnight, even though the customer doesn’t have a garage, or changing the driver’s age, how long they’ve held their licence, how many penalty points they have, their occupation, etc. Another common form of policy fraud is called ‘fronting’, with one in six (17%) motorists admitting they have fronted a policy. Fronting occurs when a motorist claims to be the main driver on a policy when they are not – for example, a parent ‘fronting’ a policy for their child, who is recorded as a named driver on the policy (or not on the policy at all), but in reality, is the main driver of the vehicle. Aviva recommends that parents who are looking for insurance for their children should try a telematics or connected car policy to get a more affordable insurance premium suitable for young drivers. ### **Taking action** Aviva’s research found that 88% of motorists believe insurance fraud is unacceptable and 85% of motorists want insurers to do more to combat insurance fraud. Aviva believes the fight against insurance fraud starts at the point of application, and is screening personal and commercial motor insurance applications for links to fraudulent behaviour and/or links to known or suspected fraudsters. This will stop fraudsters from accessing insurance products, while also preventing exposure to bogus insurance claims in the future. **Iain concludes,** “When it comes to applying for insurance, honesty really is the best policy. Motorists should avoid the temptation to change their details in attempt to save a few pounds, as the penalties for policy fraud can be costly and add pressure to motor insurance premiums for all motorists.” **Topics:** Public Awareness, Technology, Underwriting --- ### [Te Whatu Ora loses access to 14,000 health data following cyberattack](https://insurancefraud.org/news_archives/te-whatu-ora-loses-access-to-14000-health-data-following-cyberattack/) **Published:** September 16, 2026 **Author:** Diane Beauchamp **Content:** Te Whatu Ora Health New Zealand is currently investigating a cyber incident involving its IT service provider which impacted access to thousands of data relating to bereavement and cardiac services across its network. On Tuesday, the organisation said access to some information held by its IT service provider was blocked following a cyber attack. This includes approximately 8,500 bereavement care services records from Middlemore Hospital dating back to 2015 and 5,500 records from the cardiac inherited disease registry dating back to 2011 and accessed by clinicians in Auckland, Wellington, Tauranga, Waikato, and Nelson. The incident, however, did not cause any disruption to Te Whatu Ora health services as its systems were not directly targeted. Moreover, there is no evidence so far that the inaccessible data has been subject to unauthorised access or download. “We understand that this situation may be distressing for people. We want to reassure the public that we are working swiftly with other government agencies and cybersecurity experts to determine the full nature, extent, and potential impact of this incident. As further facts are established, we will work to communicate these as swiftly as possible,” Te Whatu Ora said in a statement. “These investigations are at a very early stage and will take some time to complete,” it further noted. Additionally, the incident has affected six other health regulatory authorities whose services are also hosted by the same IT service provider. These are the Optometrists and Dispensing Opticians Board of New Zealand, the Chiropractic Board, the Podiatrists Board, the New Zealand Psychologists Board, the Dietitians Board and the Physiotherapy Board of New Zealand. Te Whatu Ora has already reached out to each organisation to offer support. **THE LARGER TREND** Also on Tuesday, Te Whatu Ora released an independent analysis [report](https://www.healthcareitnews.com/news/anz/report-waikato-dhb-cyberattack-forwards-cybersecurity-recommendations) into last year’s cyberattack on the former [Waikato District Health Board](https://www.healthcareitnews.com/news/anz/waikato-dhb-making-good-progress-bringing-systems-back-online-says-chief-executive). Prepared by local cybersecurity specialist InPhySec Security, the report suggested among other things the upgrade of the health system’s Coordinated Incident Management System, systematic logging and monitoring of its data estate, and the conduct of cyberattack simulations. Aside from Te Whatu Ora and Waikato DHB, the [Pinnacle Midlands Health Network](https://www.healthcareitnews.com/news/anz/hackers-strike-again-midland-health-services) also recently reported an IT breach. In late September, hackers were able to access from its third-party IT server six years’ worth of health information and some of Pinnacle’s corporate information. The compromised data was confirmed to have been [leaked on the dark web](https://www.healthcareitnews.com/news/anz/pinnacle-hackers-leak-patient-info-data-web) in October. Pinnacle is still trying to identify whose information got exposed in the leak. **Topics:** Public Awareness, Technology --- ### [J&K resident fakes death twice to claim life insurance; CB Kashmir busts fraud, registers case](https://insurancefraud.org/news_archives/jk-resident-fakes-death-twice-to-claim-life-insurance-cb-kashmir-busts-fraud-registers-case/) **Published:** September 16, 2026 **Author:** Diane Beauchamp **Content:** The economic offence wing of the Crime Branch of Kashmir (CBK) produced a challan against three persons accused of producing fake death certificates to fraudulently extract insurance money. With the connivance of his parents, a resident of Kupwara produced fake death certificates twice and fraudulently extracted a huge amount from the insurance company by showing himself as dead in two accidents in two years. During the investigation, it was found that the “deceased” was alive and had faked episodes of two accidents just to cheat the insurance company. The Economic Offence Wing of Crime Branch Kashmir Produced Challan in Case FIR No. 15/2008 U/S 420, 467,468,471,201,120B RPC before the Hon’ble Court of Forest Magistrate Srinagar against Taveen Hussain Shah son of Sakhi Shah resident of Gundi Syedain Karnah, district Kupwara, Gul Fatima wife of Sakhi Shah and Sakhi Shah son of Mir Ali Shah. According to a statement issued by the Crime Branch, the instant case had been registered upon a receipt of a written complaint from Jatinder Pal Singh, Area Manager, ICICI Prudential Life Insurance Regulatory and Development Authority of India, Jammu, wherein it was alleged that one Taveen Ahmad Shah had opted for life insurance policies twice with ICICI Prudential Life Insurance and had fraudulently extracted the huge amount by showing himself as dead. Accordingly, a case FIR No. 15/2008 had been registered, and an investigation into the matter was set in motion. During the investigation, it has surfaced that the accused Taveen Shah had hatched a criminal conspiracy in league with his mother and father and misrepresented the facts before the ICICI insurance company and illegally, fraudulently extracted an amount of Rs 4.27 lakhs as insurance claim of one of his policies by producing his fake death certificate in a road accident. Within two years cheater “dies” twice According to the Crime Branch, after receiving the one insurance claim, the accused Taveen Shah executed another two policies for Rs. 52 lakhs and produced another death certificate of Road Traffic Accident (RTA) in Banihal. “During the course of the investigation, it was established that the accused Taveen Hussain Shah (policyholder) had not died in the road accident anywhere and had managed fake and forged death certificates to avail the insurance amount and has shown him as dead twice, but the fact is that the accused Taveen Hussain Shah is still alive. The offences were proved against him and the challan has been produced in the court of law.”, the statement reads. **Topics:** Life Insurance **Categories:** Arrest --- ### [Man who killed wife then faked own death in £790k insurance scam gets parole hearing](https://insurancefraud.org/news_archives/man-who-killed-wife-then-faked-own-death-in-790k-insurance-scam-gets-parole-hearing/) **Published:** September 16, 2026 **Author:** Diane Beauchamp **Content:** A man who murdered his wife will make a bid for freedom in the UK’s first public parole hearing. Russell Causley killed Carole Packman, 40, in 1985 after she sought a divorce from him. He then faked his death and evaded justice for more than a decade after staging a £790,000 insurance scam. He was jailed for Carole’s murder in 1996 and, after the conviction was quashed in 2003, jailed again in 2004. Causley, now 79, was the first person in Britain to be convicted of murder without there being a body. The public hearing is part of Government reforms to “increase transparency and improve victims’ experience of the parole system”. Justice Secretary Dominic Raab said: “Pulling back the curtain on the parole process by allowing hearings to be heard in public is a major step forward for victims who want to see justice being done first-hand. “It marks the first step in our reforms to overhaul the system – putting victims and public protection front and centre of the process.” Causley’s hearing was due to take place last month but was delayed as “compelling evidence” had emerged of a “long campaign” that risked his safety. He will give evidence today but will not appear on video amid further concerns for his safety. He had threatened to boycott the hearing and ­withhold evidence as he fought to keep his parole board private. He was released from prison in 2020 after serving 23 years for the murder but was brought back to jail by the Probation Service in November 2021 for breaching his licence conditions. Causley and Carole’s daughter, construction site manager Sam Gillingham, 53, has fought to keep her father locked up. She previously said: “He’s a coward. For nearly four decades he has refused to say what he did with my mother’s body. “That shows he’s not rehabilitated, what does that say to other inmates? I think he should die in jail. “What he’s done to us is like mental torture, coercive control, domestic abuse. I won’t step back, I will carry on pushing for him to stay in prison.” Carole disappeared from her home in Bournemouth, Dorset, a day after discussing divorce with a solicitor. Causley “disappeared” from a yacht in 1993 but police found him alive in Brighton. While serving a sentence for fraud, he told an inmate about killing Carole. He has never revealed what he did with her body. **Topics:** Life Insurance **Categories:** Conviction --- ### [New details emerge on how crypto trader charged with killing his own mother was accused of trying to scam her out of $500,000 - as his influencer girlfriend sends a heartfelt message to her millions of fans](https://insurancefraud.org/news_archives/new-details-emerge-on-how-crypto-trader-charged-with-killing-his-own-mother-was-accused-of-trying-to-scam-her-out-of-500000-as-his-influencer-girlfriend-sends-a-heartfelt-message-to-her-millions-o/) **Published:** September 16, 2026 **Author:** Diane Beauchamp **Content:** Details of fraud allegations faced by the cryptocurrency trader accused of killing his mother in her own home have been revealed. Andre Zachary Rebelo, 26, remains behind bars three weeks after he was charged with the murder of his mother, Colleen Rebelo, 58, at her home in the affluent Perth suburb of Bicton in May 2020. His long-time partner, Instagram influencer Gracie Piscopo broke her silence last week to express her utter shock about the allegations, telling her one million followers her sole focus is now on her three-year-old son Romeo. Ms Rebelo’s death was not deemed suspicious as she had no obvious signs of injury until an investigation was launched into her son’s alleged fraudulent dealings. It’s since been revealed that five months after Ms Rebelo died, her son first faced Fremantle Magistrates Court on six fraud offences. Police alleged at the time Rebelo fraudulently tried to obtain $500,000 between May 1 and August 25 2020, according to October 2020 court transcripts, The West Australian reported. That charge was subsequently discontinued in September. Rebelo still faces five charges of forgery with intent to defraud — which police allege involved forging a last will and testament for his mother just days after her death. He is accused of signing documents relating to medical information, and with forging a record ‘namely an automated voice message purporting to be a person named ‘Noreena Sadou’ over three separate days in July, the publication reported. Police also alleged Rebelo signed a ‘record of investigation into death’, which was dated July 29, 2020, and signed the name of WA Coroner Michael Jenkin. Rebelo has pleaded not guilty to the five fraud charges and is due to stand trial in the WA District Court in December next year. He remains behind bars for the murder charge and is next scheduled to face Stirling Gardens Magistrates Court next week. Meanwhile Rebelo’s model partner broke her silence on Instagram last week. ‘I’d like to thank everyone for their patience and understanding for my absence,’Ms Piscopo wrote. ‘For the past two weeks I have been in a complete state of shock and utter disbelief and I am deeply affected by the allegations. ‘I am grateful for everyone who has reached out and sent love and support, this has been an extremely difficult time and my focus right now is the wellbeing of my son. ‘Thank you to everyone for also understanding and respecting my privacy. Romeo and I will get through this.’ Ms Piscopo told the The West: ‘I’m just focusing on my son right now’ **Topics:** Life Insurance **Categories:** Arrest --- ### [Q&A: ‘Granular claims data with cross-search functionality has been a big blind spot for the market’ - LexisNexis Risk Solutions](https://insurancefraud.org/news_archives/qa-granular-claims-data-with-cross-search-functionality-has-been-a-big-blind-spot-for-the-market-lexisnexis-risk-solutions/) **Published:** September 16, 2026 **Author:** Diane Beauchamp **Content:** Insurance Times speaks with Carla McDonald, director of insurance claims product management at LexisNexis Risk Solutions, about how claims data can be better utilised to support brokers How much of an appetite have you seen from the insurance industry for market-wide claims data and what is driving this demand? The insurance industry has been vocal about the need for market-wide claims data that allows for searches to be carried out across multiple lines of business, so the appetite for our proposition that does this is strong. In fact, there has been a real force of support for our contributory database, LexisNexis Precision Claims, which means we are moving fast in terms of contributions from the market. When you consider the multiple challenges facing insurance providers right now – such as the rise in fraudulent insurance claims, increasing consumer willingness to commit application fraud, claims inflation and the need to price accurately to help new and renewing customers access insurance at a price that’s right for their risk – then it’s easy to see how market-wide claims data can support risk assessment at all points of the customer journey. Access via one platform to highly granular claims data gathered from across the market will help provide a true understanding of the insurance sector’s claims experience with an individual and their personal property. This will not only help the industry identify undisclosed claims, but in time, we can better predict claims losses based on an individual’s claims history, knowing that a motor loss can be predictive of a home loss and vice versa. What is the benefit of cross-checking home and motor claims? With LexisNexis Risk Solutions, insurance providers can access home and motor claims data for a person, a property and a vehicle, including the type of claim, the circumstances and the settlement. This allows insurance providers to cross-check claims history across motor and home for the first time. Claims data is already used in this way in the US. According to US analysis, the application of claims data to assess risk has found that 14% of consumers have at least one motor and one home claim, indicating a link between both lines of business. Plus, US insureds with three or more motor claims typically incur home claims losses that are approximately 40% higher in cost than those without any motor claims. So, the benefit of searching across both home and motor claims is clear. We recently held our annual customer advisory meeting and did a straw poll of the number of insurance providers that were interested in cross-searching home and motor claims. Perhaps not surprisingly, it was a sizeable response. Granular claims data with cross-search functionality has been a big blind spot for the market so far, potentially leading to less accurate pricing for the consumer and higher loss costs for insurance providers. The lack of a cross-market view may also have impacted the sector’s ability to fully understand customers’ needs. For example, if you know an individual has had three or more motor claims, then you know the cost of their home claims could be up to 40% higher. Understanding this may mean ancillary services or different products could be offered to help mitigate or reduce the risk of a home claim in the future. How can brokers utilise this type of claims data? Brokers are under huge pressure to deliver the right risks to their insurance partners. If they can present a risk with a full view of the individual’s claims history, plus the claims history for the vehicle or home, they vastly improve their ability to provide quotes that are right first time. Brokers are also experts in customer service – claims data gives them a fantastic opportunity to personalise the service they offer with risk mitigation advice, or products more suited to the risk presented. Also, while claims have traditionally been handed off to the relevant insurer, more and more brokers are offering claims services as a value-add to customers and a way to generate loyalty. It makes complete sense to do this in a market where pricing is so heavily regulated and brokers need to find key points of difference to attract and retain business. **Topics:** Public Awareness, Technology --- ### [Information of 360,000 people affected in Ontario vaccine data breach](https://insurancefraud.org/news_archives/information-of-360000-people-affected-in-ontario-vaccine-data-breach/) **Published:** September 16, 2026 **Author:** Diane Beauchamp **Content:** The Ontario government says it is notifying about 360,000 people whose personal information was involved in a vaccine database breach more than a year ago. The [breach happened on Nov. 16, 2021](https://toronto.citynews.ca/2021/11/23/opp-arrests-data-breach-vaccine-portal-ontario/) after the Ford government received reports that spam text messages were being sent out to some Ontarians who booked vaccination appointments through the system or accessed their proof of vaccination QR code. The Ontario Provincial Police investigated and charged two people, 22-year-old Rahim Abdu from Quebec and 21-year-old Ayoub Sayid of Gloucester, Ont. Sayid worked in a vaccine booking call centre and is a former employee of the Ministry of Government and Consumer Services. Since then, the government says it has been working with the police and privacy commissioner. The government says it takes time to determine the scale and impact of such a breach. The Ministry of Public and Business Service Delivery said in a statement that for more than 95 per cent of the 360,000 people affected, only their names and/or phone numbers were exposed in the breach. The ministry tells CityNews that four per cent of individuals had their health card number compromised. “Ontario’s COVID-19 vaccine booking system is regularly monitored and tested as part of the Ministry of Health’s cyber security protocols and we remain confident that the booking system continues to be a safe and secure tool for Ontarians to use,” the ministry said in a statement. **Topics:** COVID-19, Public Awareness, Technology --- ### [CareFirst Administrators Impacted By Phishing Scam at RCM Vendor](https://insurancefraud.org/news_archives/carefirst-administrators-impacted-by-phishing-scam-at-rcm-vendor/) **Published:** September 16, 2026 **Author:** Diane Beauchamp **Content:** CareFirst Administrators (CFA) notified 14,538 individuals of a phishing scam that occurred at Conifer Revenue Cycle Solutions, a provider of revenue cycle management services to healthcare organizations. The incident potentially impacted some members’ health information. In March 2022, Conifer discovered that an unauthorized party had gained access to certain Microsoft Office 365-hosted business email accounts via a phishing scam. Upon discovery, Conifer said it acted to prevent further unauthorized activity. The unauthorized party accessed the accounts between March 17 and March 22. Conifer notified CFA of the incident on June 23 and later determined that one of the impacted email accounts contained CFA member information. The account included names, addresses, health insurance information, dates of birth, medical information, and billing and claims information. Some Social Security numbers were also impacted by the phishing attack. “Conifer assured CFA that it has and continues to enhance its security controls and monitoring practices as appropriate to minimize the risk of any similar incident in the future,” CFA’s notice stated. “CFA and Conifer sincerely regret that this incident occurred and apologize for any inconvenience this incident may have caused.” ## Receivables Performance Management Breach Impacts 3.7M Individuals Receivables Performance Management (RPM) reported a ransomware attack to the Maine Attorney General’s Office that impacted 3.7 million individuals. RPM is a Washington-based debt collection company that provides accounts receivable management services to a variety of industries, including healthcare. RPM discovered a data security incident in May 2021 and immediately took its systems offline. In the following 36 hours, the company “rebuilt its shared servers from the ground up,” the notice explained. Further investigation determined that an unauthorized party had accessed RPM’s systems on April 8 and deployed ransomware on May 12, 2021. “While the findings of the forensic investigation were not conclusive, the data security incident may have resulted in unauthorized access to and/or acquisition of certain data on RPM’s systems,” the notice stated. “As a result, in an abundance of caution, RPM began undertaking extensive efforts to gather and review this data to identify the presence of any personal information.” RPM described these efforts as “extensive” due to the complexities of its server infrastructure. The process concluded in October 2022 and determined that Social Security numbers and other personal information were impacted by the ransomware attack. “Please be advised that RPM is continuing to work closely with leading security experts to identify and implement measures to further strengthen the security of their systems to help prevent this from happening in the future,” RPM stated. ## Suncoast Skin Solutions Provides Additional Information About 2021 Breach A notice provided to the Maine Attorney General’s Office shed additional light on a 2021 breach at Suncoast Skin Solutions that impacted 75,992 individuals. The Florida dermatology practice first detected unusual activity on its network on July 14, 2021. A forensic investigation found evidence that an unauthorized actor had accessed some of Suncoast’s files. Further review of its systems concluded in November 2021 and determined that some legacy patient information was impacted. Suncoast provided a substitute notice on its website and to local media outlets in January 2022 while it continued to investigate the incident internally. “Due to the nature and size of the potentially impacted data, the data mining process occurred from December to October 2022,” Suncoast explained. On November 28, Suncoast finalized its list of impacted individuals to notify and determined what information was implicated in the breach. Suncoast said it has no evidence that any sensitive information has been misused by third parties as a result of the incident. “Since the discovery of the incident, Suncoast moved quickly to investigate, respond, and confirm the security of our systems,” the notice explained. “Specifically, Suncoast disconnected all access to its network, changed all employee credentials, added logon hour restrictions for all hourly employees, increased its password complexity, enhanced its security measures, and took steps and will continue to take steps to mitigate the risk of future harm.” **Unauthorized Party Copies Files at San Gorgonio Memorial Hospital** San Gorgonio Memorial Hospital in Banning, California notified patients of a data breach. The hospital discovered that an unauthorized party had gained access to its network between October 29 and November 10, 2022. The unauthorized party copied some documents on the hospital’s system during that time. The documents contained names, addresses, medical record numbers, visit ID numbers, health insurance information, clinical information, and dates of birth. The investigation is ongoing, but the hospital said it would update patients if it discovered that any additional information was involved in the incident, such as financial account information or government-issued ID numbers. Upon discovery of the breach on November 10, San Gorgonio Memorial Hospital said it immediately initiated its incident response protocols and isolated select systems. The hospital encouraged patients to review statements they receive from their healthcare providers and insurers. **Topics:** Public Awareness, Technology --- ### [CommonSpirit Ransomware Breach Affects About 624,000 So Far](https://insurancefraud.org/news_archives/commonspirit-ransomware-breach-affects-about-624000-so-far/) **Published:** September 16, 2026 **Author:** Diane Beauchamp **Content:** The ransomware hacking incident at CommonSpirit affected the data of at least approximately 624,000 individuals, the hospital chain told federal regulators. The second-largest nonprofit hospital chain in the United States has slowly dribbled out information about the ransomware attack it first detected in early October (see: [*Patients Affected by Cybersecurity Event at Hospital Chain*](https://www.bankinfosecurity.com/patients-affected-by-cybersecurity-event-at-hospital-chain-a-20212)). A Monday update to the Department of Health and Human Services’ [HIPAA Breach Reporting Tool](https://ocrportal.hhs.gov/ocr/breach/breach_report.jsf) is the first data-driven indicator of the incident’s scope. The hacking incident involving a network server affected 623,774 individuals, the hospital chain says. Among the information compromised were names, addresses, phone numbers, birthdates, and a unique ID used only internally by the organization. CommonSpirit says it is reviewing additional files potentially affected by the ransomware incident, meaning the total number of affected individuals could increase. So far, CommonSpirit has not issued breach notifications for any other entities affected by the ransomware incident. Individuals known to be affected include patients who received services from any of seven hospitals in Washington state that are collectively part of [Virginia Mason Franciscan Health](https://www.commonspirit.org/update/notice-of-data-security-incident), an affiliated entity of CommonSpirit, as well as those patients’ family members or caregivers. The affected Virginia Mason Franciscan Health entities include St. Michael Medical Center, St. Anne Hospital, St. Anthony Hospital, St. Clare Hospital, St. Elizabeth Hospital, St. Francis Hospital and St. Joseph Hospital (see: [*CommonSpirit: Patients’ Data Breached in Ransomware Attack*](https://www.bankinfosecurity.com/commonspirit-patients-data-breached-in-ransomware-attack-a-20650)). As of publication, there is no report posted on the HHS OCR data breach website regarding Des Moines, Iowa-based hospital MercyOne, which was also affected by the CommonSpirit ransomware incident. MercyOne was previously jointly owned by CommonSpirit and Michigan-based Trinity Health before being acquired by Trinity Health this year. MercyOne still uses CommonSpirit’s IT systems, and the Iowa-based entity’s electronic health records access and other application functionality were affected for several weeks following the ransomware incident. **Topics:** Public Awareness, Technology --- ### [HIMSSCast: A corporate counsel's perspective on data breaches](https://insurancefraud.org/news_archives/himsscast-a-corporate-counsels-perspective-on-data-breaches/) **Published:** September 16, 2026 **Author:** Diane Beauchamp **Content:** At the HIMSS Healthcare Cybersecurity Forum in Boston this past week, I sat down with Roshal Marshall, managing chief counsel for global privacy and cybersecurity at McKesson. Our chat was focused primarily on corporate counsel’s perspectives on data breaches: how she works with chief information security officers and other IT leaders, advice on ensuring compliance, managing incident response, handling litigation and more. We also spoke about emerging challenges around artificial intelligence and algorithmic integrity, the 21st Century Cures and information blocking rules – and other data governance and compliance challenges. **Talking points:** - Why privacy, security and business continuity are now matters of patient safety. - Keys to communication, and getting security and IT pros on the same page with legal (hint: “speak English”). - How working on the provider side is different from working with a multinational vendor. - Perspective on managing different constituents (providers, payers and pharma) and serving different business units. - Why some health organizations still don’t understand that “security and privacy are their number one risks.” - Information blocking compliance: How to understand a set of complex and sometimes confusing set of rules. - New avenues of data privacy as artificial intelligence matures. **Topics:** Public Awareness, Technology --- ### [US HHS warns healthcare orgs of Royal Ransomware attacks](https://insurancefraud.org/news_archives/us-hhs-warns-healthcare-orgs-of-royal-ransomware-attacks/) **Published:** September 16, 2026 **Author:** Diane Beauchamp **Content:** ## The US Department of Health and Human Services (HHS) warns healthcare organizations of Royal ransomware attacks. The human-operated [Royal ransomware](https://securityaffairs.co/wordpress/138750/malware/dev-0569-google-ads-royal-ransomware.html) first appeared on the threat landscape in September 2022, it has demanded ransoms up to millions of dollars. The Health and Human Services (HHS) is aware of attacks against the Healthcare and Public Healthcare (HPH) sector. Unlike other ransomware operations, Royal doesn’t offer Ransomware-as-a-Service, it appears to be a private group without a network of affiliates. *“Royal is a human-operated ransomware that was first observed in 2022 and has increased in appearance. It has demanded ransoms up to millions of dollars. Since its appearance, HC3 is aware of attacks against the Healthcare and Public Healthcare (HPH) sector. Due to the historical nature of ransomware victimizing the healthcare community, Royal should be considered a threat to the HPH sector.” reads the [report](https://www.hhs.gov/sites/default/files/royal-ransomware-analyst-note.pdf) published by HHS.* Once compromised a victim’s network, the threat actors deploy the post-exploitation tool Cobalt Strike to maintain persistence and perform lateral movements. Originally, the ransomware operation used BlackCat’s encryptor, but later it started using Zeon. The ransom notes (README.TXT) include a link to the victim’s private negotiation page. Starting from September 2022, the note was changed to Royal. The Royal ransomware is written in C++, it infected Windows systems and deletes all Volume Shadow Copies to prevent data recovery. The ransomware encrypts the network shares, that are found on the local network and the local drives, with the AES algorithm. The Royal ransomware can either fully or partially encrypt a file depending on its size and the ‘-ep’ parameter. The malware changes the extension of the encrypted files to ‘.royal’. In November, researchers from the Microsoft Security Threat Intelligence team [warned](https://securityaffairs.co/wordpress/138750/malware/dev-0569-google-ads-royal-ransomware.html) that a threat actor, tracked as DEV-0569, is using Google Ads to distribute various payloads, including the recently discovered [Royal ransomware](https://www.fortinet.com/blog/threat-research/ransomware-roundup-royal-ransomware). The DEV-0569 group carries out malvertising campaigns to spread links to a signed malware downloader posing as software installers or fake updates embedded in spam messages, fake forum pages, and blog comments. HC3 added that threat actors continue to use multiple attack vectors associated with this ransomware, including phishing, Remote Desktop Protocol (RDP) compromises and credential abuse, compromises of exploited vulnerabilities, such as VPN servers, and compromises in other known vulnerabilities” HHS notes. *“Royal is a newer ransomware, and less is known about the malware and operators than others. Additionally, on previous Royal compromises that have impacted the HPH sector, they have primarily appeared to be focused on organizations in the United States. In each of these events, the threat actor has claimed to have published 100% of the data that was allegedly extracted from the victim.” concludes the report.* **Topics:** Public Awareness, Technology --- ### [Grand jury indicts Kansas woman in mail-order pharmacy scheme](https://insurancefraud.org/news_archives/grand-jury-indicts-kansas-woman-in-mail-order-pharmacy-scheme/) **Published:** September 16, 2026 **Author:** Diane Beauchamp **Content:** Three Florida residents and one Kansas resident have been charged with a scheme to defraud Medicare. A federal grand jury in Topeka indicted the Kansas woman and three Floridians for attempting to establish a fraudulent mail-order pharmacy. Court documents identified the four as Fawn J. Licking, 42, of Lawrence, Kansas; as well as Steven Churchhill, 36; Samson Solomon, 25; and Elaine Balsamo, 58, of Florida. The four are accused of using the Freestate Pharmacy to submit false claims to Medicare for prescriptions for patients who had not seen a doctor or requested the medication. Other charges include: - one count of conspiracy to commit health care fraud, mail fraud, and wire fraud - eight counts of healthcare fraud - six counts of mail fraud - four counts of wire fraud Churchill and Balsamo are also charged with four counts of money laundering. **Topics:** Drug Diversion, Medicare/Medicaid **Categories:** Arrest --- ### [Man pleads guilty in Medicaid fraud case in Brunswick Co. Superior Court](https://insurancefraud.org/news_archives/man-pleads-guilty-in-medicaid-fraud-case-in-brunswick-co-superior-court/) **Published:** September 16, 2026 **Author:** Diane Beauchamp **Content:** Terry Lee Sayre pleaded guilty, was given 5 years on probation and ordered to pay $31,882.50 to the North Carolina Medicaid Program in connection to a fraud case heard in Brunswick County Superior Court. Attorney General Josh Stein announced that Sayre pleaded guilty to felony obtaining property by false pretenses on Friday, Dec. 9. “Sayre and his co-defendant, Julie Ridgdill, submitted fraudulent transportation invoices and forms to the Brunswick County Department of Social Services (Brunswick DSS). As a result, Brunswick County paid the defendants $31,882.50 of Medicaid funds for transportation services that were not provided. Ridgdill previously pleaded guilty and was sentenced to 6-17 months in jail, which was suspended, and she was placed on supervised probation for 24 months and ordered to pay restitution,” said Stein’s office in the announcement. **Topics:** Medicare/Medicaid **Categories:** Conviction --- ### [One woman had hundreds of dollars of diabetes supplies billed to her Medicare account. The catch? She doesn't have diabetes. She said she hopes exposing the problem could spur people to report erroneous bills that might be Medicare fraud.](https://insurancefraud.org/news_archives/one-woman-had-hundreds-of-dollars-of-diabetes-supplies-billed-to-her-medicare-account-the-catch-she-doesnt-have-diabetes-she-said-she-hopes-exposing-the-problem-could-spur-people-to-report-errone/) **Published:** September 16, 2026 **Author:** Diane Beauchamp **Content:** Complaints across Texas Bennett’s complaints were not alone. KXAN obtained 10 other complaints filed with the Texas Office of Attorney General specifically citing charges from July through October from the same business. All the complaints note similar problems – diabetic testing supplies costing roughly $300 or $700 billed to their Medicare accounts. KXAN tracked down four of the people who complained, and all said they filed complaints with the fraud department of CMS. Linda Ferguson, of Waco, said she, too, was billed for diabetic supplies she never ordered from the business. Ferguson wondered how her Medicare information got out. “I’m old, but I keep my brain going, so my mind is like a steel trap, but what about the people that have nobody to turn to in a situation like this?” Ferguson said. “That bothers my heart.” KXAN reached out to the last owner listed on the company’s filing with the Texas Secretary of State. A representative of the company responded and said the original owner sold the business in May 2022 – prior to the dates of improper billing noted in the complaints. The business representative also provided a sales agreement and wire paperwork showing the business had been sold. KXAN could not reach the New York-based buyers noted in the sales agreement. A CMS spokesperson would not confirm or deny any investigation into the business. “To protect the integrity of the investigative process, CMS doesn’t comment on complaints and rarely comments on specific cases,” according to CMS. “Medicare fraud and abuse can happen anywhere, and usually results in higher health care costs and taxes for everyone.” The cost of Medicare fraud To understand if the business was still operating, KXAN visited the storefront in San Antonio. The business sign remained in place in early December, but it appeared shuttered. The store was locked, the lights off and the shop empty except for a computer monitor on the front desk and some health and pharmacy certificates pinned to the wall. Jennifer Salazar, Executive Director of Texas Senior Medicare Patrol, said anyone could be behind the billing problems. “Medicare fraud has been around since Medicare started in 1965. Every single year, we lose $60 billion in Medicare fraud error and abuse,” Salazar said. Texas Senior Medicare Patrol is funded by federal grants through the Better Business Bureau of Houston. It assists Medicare recipients in reporting Medicare billing problems. Medicare receives over 4.5 million claims per day, Salazar said, so it is up to recipients to spot and report possible fraud. She said people need to read their quarterly “Medicare summary notices,” or, if they use Medicare Advantage, their “explanation of benefits.” How to protect yourself “You need to look through there and if you see anything that looks wrong like you don’t recognize the doctor; you’re not a diabetic, but you’re getting diabetic supplies. If you didn’t order a knee brace, and you’re getting a knee brace, you need to call the Senior Medicare Patrol immediately and we can help you with that issue,” Salazar said. Right now, she said they are seeing a spike in billing problems involving durable medical supplies, like equipment for diabetics. Speaking generally about methods of how these problems can arise, Salazar said people potentially trying to take advantage of the system will use everything that’s on the Internet. “They will steal logos, billing addresses, doctors’ names. They’ll forge signatures. They will steal company names. They’ll do a lot of that to basically come up with fake claims,” she said. Salazar said her organization gathers information from people who suspect improper billing and sends it to authorities. It can take years for investigators to find and hold those responsible accountable, she said. The most important way to prevent billing problems, and protect yourself, Salazar said, is to report questionable claims and never give out your Medicare number. She added that you can reach a person at the Texas Senior Medicare Patrol Hotline at 1-888-341-6187 if you have any questions. CMS recommended all Texans take the following measures: Never accept medical supplies from a door-to-door salesman. If someone comes to your door claiming to be from Medicare, remember that Medicare and Medicaid do not send representatives to your home. Never give your Medicare card, Medicare number, Social Security card or Social Security number to anyone except your doctor or people you know should have it. Remember, nothing is ever “free.” Never accept offers of money or gifts for free medical care. Be wary of providers who tell you that the item or service isn’t usually covered, but they “know how to bill Medicare” so Medicare will pay. Bennett hopes sharing her experience can be a warning to others. She said she didn’t have to pay what the bill said she owed. “I just don’t like people being taken advantage of,” Bennett said. “I want to see … something done about this. I don’t want to just sit there and do nothing.” **Topics:** Medicare/Medicaid, Public Awareness --- ### [Former South Dakota Police Chief Murdered Pregnant Fiancée And Blamed It On An Accident](https://insurancefraud.org/news_archives/former-south-dakota-police-chief-murdered-pregnant-fiancee-and-blamed-it-on-an-accident/) **Published:** September 16, 2026 **Author:** Diane Beauchamp **Content:** On October 24, 2009, Russell Bertram, a former Sioux Falls, South Dakota police chief, called 911. He reported that while pheasant hunting his had shotgun accidentally went off as he loaded it back into his truck. The blast had hit his 26-year-old fiancée, Leonila “Nila” Stickney, in her chest. Bertram claimed that Leonila had “grabbed the shotgun,” investigators told “Accident, Suicide or Murder,” airing Saturdays at 8/7c on Oxygen. Leonila was rushed to the hospital, where she died from her injuries. Pheasants in Bertram’s truck backed up his hunting alibi. But police questioned how an experienced hunter like Bertram would have been holding the gun in a way that could lead to such a tragic mishap. Investigators learned that Leonila grew up in the Philippines. In 2004, after meeting South Dakota resident David Stickney, she returned to the U.S. with him. The couple married and had a son. She worked in a nursing home and sent money to support her family in the Philippines. But the Stickney marriage soured by 2008. Around the same time, Leonila met Bertram. An autopsy revealed that Leonila had no defensive wounds and that she had been shot at very close range. “The survivability of this type of injury is essentially zero,” said Dr. Brad Randall, former coroner for Minnehaha County, South Dakota. The forensic pathologist determined that the cause of death was the gunshot but could not distinguish if the shooting was an accident or a homicide. The autopsy also revealed that Leonila was a few weeks pregnant at the time of her death. Could her pregnancy have been a motive for the death? “Bertram told law enforcement that he didn’t know Nila was pregnant when she died,” Daily Republic journalist Jack Shama explained to “Accident, Suicide Or Murder.” On October 27, investigators collected Bertram’s shotgun to examine it for fingerprints. If Leonila’s prints were on the barrel, that would support Bertram’s account. But no fingerprints were found on the gun barrel. On November 30, though, the manner of Leonila’s death was listed as an accident.That was a plausible manner of death, according to Randall. “On the other hand,” he said, “there is a saying in South Dakota that if you want to murder someone, you take them hunting.” Despite that determination of the death as an accident, the case remained ongoing, according to Sheriff Tim Drey, of the Gregory County Sheriff’s Office. In December 2009, David Stickney contacted investigators. He told them he discovered that life insurance policies worth more than $900,000 had been taken out on Leonila. Neither he nor their son was the beneficiary. Bertram was the sole beneficiary. Bertram told law enforcement that Leonila took out the policies because she was a bad driver. He was made the beneficiary so that he could distribute money to Leonila’s family in the Philippines. The case stood at a standstill until detectives reinterviewed Stickney. He told them that besides Bertram, Leonila had another boyfriend: Nathan Meeter. On January 16, 2010, detectives interviewed Meeter, who said he’d met Leonila three months earlier. Meeter said he was unaware that Leonila had died. He also told police that while he knew she was going through a divorce, he didn’t know she was seeing Bertram. On October 22, two days before her death, Nila told Nathan that she was pregnant and that she believed he was the father, according to DiBenedetto. Meeter also told investigators the reason why he didn’t know Leonila was dead — the two exchanged text messages two weeks after the day she was shot. On November 5, Meeter texted Leonila, asking if they could get together. “Someone pretending to be Nila texted Nathan saying that she can’t see him anymore,” said Guy DiBenedetto, special agent, South Dakota Division of Criminal Investigation. At this point, investigators dug deeper into Bertram’s background. They found that he had filed for bankruptcy and was currently in debt for $86,000. “He has a very strong motive to try and get some money quickly,” said Paul Swedlund, South Dakota Asst. Attorney General. Detectives also learned that Bertram had married and divorced three times. Former wives told investigators that Bertram was obsessively jealous and suspicious and that he went through their phone records. Each woman had taken out restraining orders, the Associated Press reported. Investigators reasoned that if Bertram went through Leonila’s phone log he would have known about Meeter. The case looked less like an accident to detectives. On January 21, 2011, police questioned Bertram and raised the subject that Leonila thought she might be pregnant. He said that because he’d had a vasectomy he couldn’t be the father. Bertram also admitted sending texts to Meeter because he wanted to know for sure that Leonila was seeing another man. On October 17, 2011, a civil suit filed in regard to Leonila’s $900,000 life insurance policy was settled. A third of the money went to Bertram, and the remainder went to Stickney and his son. According to Bertram, that insurance money was to benefit Leonila’s family in the Philippines. If he paid that money to her family, it would decrease investigators’ suspicions, they said. Detectives waited to observe what happened. In September 2013, DiBenedetto went to Bertram’s home in Sioux Falls. He was stunned to find that Bertram had actually married Leonila’s older sister, Melliza Del Valle. The investigator decided to wait to do the interview. DiBenedetto returned four months later. Del Valle explained that during their conversations about Leonila, a relationship grew between her and Bertram. They wed in July 2013, and she moved to South Dakota with her daughter. More time passed. In January 2014, Bertram changed his story when questioned again by investigators. He admitted he had looked at Leonila’s phone records and that he knew she thought she was pregnant three or four days before her death. Investigators theorized that Bertram may have feared that Leonila would change the life insurance beneficiary. They needed to determine if Bertram had given the insurance payout to Leonila’s family. In August 2014, they spoke with Del Valle, who said the family had received just $200 a month. He had told them he hadn’t gotten any insurance payout. That wasn’t the only information he failed to give her family. “Russell Bertram told her family that Nila was handling the gun wrong and shot herself,” said Swedlund. “He didn’t tell them that he had any role in it.” Del Valle made the difficult choice to testify against Bertram. “I don’t want to see his face again,” she told producers. “But I have to be strong for my sister. Because I want to give her justice and also for my family.” On September 8, 2015, Bertram, was arrested and charged with first degree murder. In September 2016, the case went to trial. Bertram, 64, was found guilty of first-degree murder, the Associated Press reported. He was automatically sentenced to life in prison without parole. **Topics:** Life Insurance, Public Awareness --- ### [Prosecutors say Alex Murdaugh killed wife and son to 'escape' accountability for financial crimes](https://insurancefraud.org/news_archives/prosecutors-say-alex-murdaugh-killed-wife-and-son-to-escape-accountability-for-financial-crimes/) **Published:** September 16, 2026 **Author:** Diane Beauchamp **Content:** Alex Murdaugh, a prominent South Carolina personal injury attorney, was so desperate to “escape the accountability” for a string of financial crimes that he fatally shot his wife and son last year and sought to cover up the slayings to gain sympathy and buy himself more time, state prosecutors alleged on Friday. Chief prosecutor Creighton Waters laid out the state’s motive during a hearing ahead of a criminal trial slated for next month, when Murdaugh, 54, will face murder charges in the deaths of his wife Margaret, 52, and the couple’s youngest son, Paul, 22. “I think when this case started a lot of people assumed this was a murder case and then with some white collar \[crime\] running in there,” Waters said. “But the reality is, as we’ve done this extensive investigation, we’ve realized that this was a white-collar case that culminated with two murders.” Waters said that the state has evidence showing that from about 2011 to 2021, Murdaugh stole money from clients in “an unbroken chain of constant lies and misappropriation and thefts.” Since Murdaugh’s arrest last year in connection with an investigation into millions of dollars missing from a settlement involving the death of his longtime housekeeper, prosecutors have filed more than 80 financial-related charges against him, alleging he stole about $8.5 million from more than a dozen victims. His need for cash began when land deals in 2007 and 2008 went “upside down,” Waters said. Then, in 2019, Paul Murdaugh was involved in a boat crash that resulted in injuries and claimed the life of a 19-year-old passenger, Mallory Beach. Her family filed a wrongful death lawsuit against the Murdaughs, who owned the boat, and the convenience store chain that was alleged to have sold alcohol to the underage occupants. Waters said that the plaintiffs were expecting to get a “personal recovery” from Murdaugh, whose financial situation was growing increasingly bleaker. Murdaugh was on “a hamster wheel of constantly having to borrow and earn and steal just to keep kicking the can down the road and to stay above water,” Waters said. “An exhaustive hamster wheel. A slow burn that was heating up and heating up.” State grand jury subpoenas had been issued in the boat crash case in 2021, and at the time of the killings of Margaret and Paul Murdaugh on June 7, Paul Murdaugh was facing trial. The bodies of the wife and son were discovered by Alex Murdaugh at the family’s hunting estate in rural Islandton, about 65 miles west of Charleston. Both had been fatally shot, police said. Lawyers for Murdaugh have said that he had an alibi on the night of the killings and that he was spending time with his mother, who has dementia, and her caregiver. The lawyers deny that he was involved in the deaths. **Topics:** Financial Fraud, Public Awareness **Categories:** Arrest --- ### [Brentwood woman sentenced after $6.9M Medicare fraud](https://insurancefraud.org/news_archives/brentwood-woman-sentenced-after-6-9m-medicare-fraud/) **Published:** September 16, 2026 **Author:** Diane Beauchamp **Content:** A 49-year-old Brentwood optometrist has been sentenced to federal prison after she pleaded guilty to defrauding Medicare of nearly $7 million. Helen Boerman was sentenced Thursday to three-and-a-half years in prison plus one year of supervised release after she used her eye care practice to submit millions of dollars in false Medicare claims. She used her practice, Brentwood Eye Care, to submit false claims to Medicare over a period of three-and-a-half years. In addition, the federal judge ordered Boerman to pay nearly $6,970,583.50 in restitution. As part of her guilty plea, Boerman admitted she submitted false Medicare claims in the amount of approximately $11 million and received approximately $6.9 million. As an enrolled provider, she submitted false claims seeking reimbursements from Medicare for new wound care products she had not actually purchased or used because she split wound care products intended for single use. Boerman, through Brentwood Eye Care, submitted claims to Medicare in May 2022 on behalf of two patients who were Medicare beneficiaries for placement of wound care products on May 20, 23, 24, 25, 26, and 27, when the appointment data showed that the patients had appointments on May 20, 24 and 27 only, according to a release. Boerman then directed the staff at Brentwood Eye Care to create false records for the other dates to support the services fraudulently billed to Medicare. Federal court will now determine when Boerman will report to prison. No additional information was immediately released. **Topics:** Medicare/Medicaid **Categories:** Conviction --- ### [Abbott Laboratories Agrees to Pay Over $384 Million Nationwide to Settle Fraud Allegations Related to Powder Infant Formula](https://insurancefraud.org/news_archives/abbott-laboratories-agrees-to-pay-over-384-million-nationwide-to-settle-fraud-allegations-related-to-powder-infant-formula/) **Published:** September 16, 2026 **Author:** Diane Beauchamp **Content:** Attorney General Anthony G. Brown today joined 39 other states and the federal government to reach an agreement with Abbott Laboratories (Abbott) to settle allegations that the company defrauded government health programs by selling them infant formula and nutritional therapy products manufactured in plants that failed to meet state and federal safety standards for preventing contamination. Abbott, an Illinois-based healthcare company, will pay about $348.7 million to the United States to resolve False Claims Act allegations and another $35.5 million to the states for claims related to Medicaid programs. Maryland was one of five states to directly intervene in this lawsuit and will recover more than $3 million in the settlement. “Parents trust that the infant formula they feed their babies is safe, and Abbott betrayed that trust for their own profit,” **said Attorney General Brown.** “This settlement holds Abbott accountable for knowingly manufacturing formula in substandard conditions and defrauding programs that Maryland families rely on.” The national civil settlement resolves allegations that Abbott caused false claims to be submitted, between January 1, 2018, and December 31, 2022, to federal and state programs arising from Abbott’s failure to manufacture certain powder infant formula and nutritional therapy products at its Sturgis, Michigan, and Casa Grande, Arizona, facilities in compliance with federal and state statutory, regulatory, and contractual requirements. The federal and state governments allege that Abbott knowingly manufactured infant formula purchased with taxpayer dollars in an environment that put the products at unacceptable risk of microorganism contamination and significantly impacted the products’ reliability, quality, and safety. Specifically, as described in the lawsuit, roof leaks frequently occurred in the Sturgis plant, leading to water running and dripping over equipment. Water can be a breeding ground for dangerous microorganisms. Rather than permanently addressing the root causes, Abbott used temporary solutions, such as roof leak umbrellas, to try to divert leaks in product processing areas even though Abbott corporate leadership understood that the wet environment put the products at increased risk for contamination. Similarly, the lawsuit alleged that Abbott continued to run spray dryers, where liquid formula was transformed into a dry powder, even after Abbott documented cracks and pits in the dryers, which also increased the risk of contamination. Further, the lawsuit alleged that Abbott intentionally curtailed bacterial growth testing in order to avoid obtaining positive test results showing contamination, and that, in certain instances, when testing did show contamination, Abbott failed to disclose the test results to the U.S. Food and Drug Administration during 2019 and 2022 inspections at the Sturgis facility. This settlement arises out of a whistleblower lawsuit initially filed in 2022 in the United States District Court for the Western District of Michigan. On November 13, 2025, the United States filed a Complaint in Intervention alleging that Abbott caused federal WIC programs to purchase powder infant formula manufactured at the Sturgis facility despite the products’ failure to meet statutory, regulatory, and contractual requirements. On December 1, 2025, Maryland and four other states, California, Connecticut, Massachusetts, and Tennessee, also filed an intervention complaint. These states litigated the case against Abbott while a larger group of states, which had purchased Abbott’s products, negotiated a settlement. In making today’s announcement, Attorney General Brown thanked Medicaid Fraud and Vulnerable Victims Unit Director Zak Shirley as well as Assistant Attorney General Raja Mishra for their work on the case. This case was resolved through a coordinated effort between state and federal partners, including the Justice Department’s Civil Division Commercial Litigation Branch and the U.S. Attorney’s Office for the Western District of Michigan. A National Association of Medicaid Fraud Control Units (NAMFCU) Team participated in the investigation and conducted settlement negotiations with Abbott on behalf of the states. The Maryland Office of the Attorney General, Medicaid Fraud and Vulnerable Victims Unit receives 75 percent of its funding from the U.S. Department of Health and Human Services under a grant award totaling $7,119,096 for Federal fiscal year (FY) 2026. The remaining 25 percent, totaling $2,373,032 for FY 2026, is funded by the State of Maryland. **Topics:** Judicial/courts, Public Awareness --- ### [Reality star Steve McBee Sr. released from prison after federal crop insurance scheme](https://insurancefraud.org/news_archives/reality-star-steve-mcbee-sr-released-from-prison-after-federal-crop-insurance-scheme/) **Published:** September 15, 2026 **Author:** Diane Beauchamp **Content:** Steve McBee Sr., a Missouri-based farmer known for his role in a popular reality TV series, has been released from prison after serving two years for a multi-million-dollar federal crop insurance scheme. The patriarch of the McBee family and lead of the popular reality show “The McBee Dynasty: Real American Cowboys” returned to his Gallatin, Missouri, farm Friday, following a two-year sentence in a South Dakota federal prison. McBee pleaded guilty to one count of federal crop insurance fraud of more than $3 million back in November 2024. He was ordered to serve two years in prison with two years of supervised release and pay $4 million in restitution. **[From 2018 to 2020,](https://fox4kc.com/news/missouri-reality-tv-farmer-pleads-guilty-to-multi-million-dollar-fraud-scheme/)** McBee submitted fraudulent documents and underreported his total 2018 corn and soybean crop totals. These false reports resulted in McBee receiving more than $2.5 million in federal crop insurance benefits and more than $550,000 in federal crop insurance premium subsidies, totaling more than $3 million in federal compensation. He pleaded guilty to the charge and was sentenced in September 2025. However, McBee has since been released. He is now reunited with his family back in Missouri. **[Saturday was the first time McBee](https://www.instagram.com/p/DdNIsTLODhA/)** had personally posted on his Instagram since Dec. 1, 2025. He shared a video driving through his family farm with the song “Take Me Home, Country Roads” by John Denver playing in the background. He wrote in the post’s caption: “A little more appreciation for the simple things in life….Thank you Lord for all the blessings in my life…” According to an **[article from BravoTV](https://www.bravotv.com/the-daily-dish/steve-mcbee-sr-released-from-prison-details-september-2026)** — one of the streaming networks that airs the family’s reality show — McBee’s son, Steven Jr., was very excited about his dad’s return. **[Steven Jr. reportedly posted an Instagram story](https://www.instagram.com/stevenmcbee)** days before his father’s release, stating that he and his family had updated their dad’s lodge and his “new home office” in anticipation of his return. He also shared an Instagram story on the eve of his father’s release, showing a pile of books on the ground with the caption: “Got my old man a list of some of my favorite reads (about 20 more coming in tomorrow. Big believer that reading is single-handedly one of the best things you can do to immediately improve your life and outlook/mindset.” Despite the legal scandal, the McBee family still carried on with their reality TV series, celebrating the release of its third season back in June. **[According to BravoTV](https://www.bravotv.com/the-daily-dish/mcbee-dynasty-cast-updates-after-season-3-exclusive-interviews-august-2026)**, the third season tackled numerous instances of family drama, including a breakup, a rocky marriage, financial and business concerns, and, of course, the legal scandal of McBee Sr. **Topics:** Crop insurance --- ### [ONTARIO: Muhammad Raahim arrested in fraudulent auto insurance investigation](https://insurancefraud.org/news_archives/ontario-muhammad-raahim-arrested-in-fraudulent-auto-insurance-investigation/) **Published:** September 15, 2026 **Author:** Diane Beauchamp **Content:** ONTARIO’S Peel Regional Police have arrested and charged a 25-year-old Mississauga man following an investigation into the sale of fraudulent automobile insurance policies. Investigators allege that between April 2024 and August 2026, the accused sold fraudulent automobile insurance policies and knowingly provided victims with falsified proof of insurance documents across the Greater Toronto Area. To date, police have identified 15 incidents connected to the scheme, with reported victim losses exceeding $10,000. The accused was previously licensed to sell insurance and had been employed by several insurance brokerages. Investigators believe he continued selling insurance policies after he no longer had the legal authority or licence to do so. Victims were provided with insurance documentation that appeared legitimate, leading them to believe they had valid coverage. On August 26, Muhammad Raahim, 25, was arrested and charged with: Defraud the public The accused was released with conditions and is awaiting a future court appearance. Members of the public are reminded to exercise caution when purchasing automobile insurance and to verify that insurance providers, brokers, and agents are properly licensed before making payments or relying on proof of coverage documents. Consumers should also carefully review their policy information and confirm coverage directly with the insurance company when in doubt. For more information on fraud prevention and reporting fraud, visit the Canadian Anti-Fraud Centre. Investigators believe there may be additional victims. Anyone who purchased automobile insurance through Raahim is encouraged to contact the Fraud Bureau at 905-453-2121, ext. 3335. **Topics:** Auto - underwriting **Categories:** Arrest --- ### [Attorney General Brown Announces Sentencing of Former Home Health Care Employee for Medicaid Fraud](https://insurancefraud.org/news_archives/attorney-general-brown-announces-sentencing-of-former-home-health-care-employee-for-medicaid-fraud-2/) **Published:** September 15, 2026 **Author:** Diane Beauchamp **Content:** Attorney General Anthony G. Brown announced the conviction and sentencing of former HomeCentris employee, Falguni Patel, aged 60, of Howard County, for submitting over $25,000 worth of false claims relating to home healthcare services. Patel falsely claimed to be providing home healthcare services while she worked in person at another job or was out of the country. HomeCentris Healthcare, LLC, previously known as Personal Health Care, Inc., relied on Patel’s statements when submitting claims to Maryland Medicaid. “Every fraudulent Medicaid claim drains resources from Marylanders who rely on home healthcare to live safely and with dignity,” said Attorney General Brown. “My Office will continue rooting out fraud that exploits this vital program and the people who depend on it.” On August 3, 2026, Patel pleaded guilty to felony public health fraud before the Honorable Garret P. Glennon, Jr. of the Circuit Court for Baltimore County. Judge Glennon sentenced Patel to five years, suspending all but time served, with three years of supervised probation, and to pay restitution of $25,310.51. This case is part of an ongoing investigation, in partnership with the U.S. Department of Health and Human Services (HHS), the Federal Bureau of Investigation (FBI), the Maryland State Police, and the Maryland Department of Health into fraudulent claims in home healthcare. Attorney General Brown would like to thank the Medicaid Fraud and Vulnerable Victims Unit, particularly Unit Director Zak Shirley, Assistant Attorney General Kurt Davidson, Senior Investigator Carl Stambaugh, Deputy Chief of Investigations Paul Kidd, and Investigative Auditor Yelena Slutskaya for their work on this case, as well as our investigative partners. The Maryland Office of the Attorney General, Medicaid Fraud and Vulnerable Victims Unit receives 75 percent of its funding from the U.S. Department of Health and Human Services under a grant award totaling $7,119,096 for Federal fiscal year (FY) 2026. The remaining 25 percent, totaling $2,373,032 for FY 2026, is funded by the State of Maryland. **Topics:** Medicare/Medicaid **Categories:** Conviction --- ### [Omaha woman sentenced to federal prison for healthcare fraud](https://insurancefraud.org/news_archives/omaha-woman-sentenced-to-federal-prison-for-healthcare-fraud/) **Published:** September 15, 2026 **Author:** Diane Beauchamp **Content:** A federal judge sentenced a 49-year-old Omaha woman to five months in prison Thursday after the woman pleaded guilty in June to fraudulently billing Medicaid and other insurers for medical products meant for patients who never received them. Cassi Wigington also must pay $445,255.37 in restitution, U.S. District Court Judge Robert Rossiter ruled. Wigington will be on supervised release for three years after the conclusion of her prison sentence. Wigington’s sentence stems from a six-year period where, through her company New Image, she fraudulently billed patients, health insurance companies and benefits providers for breast prostheses that were never delivered to the patients who had undergone mastectomies. Insurance companies and benefits providers defrauded by Wigington included Nebraska Medicaid, Blue Cross Blue Shield, Aetna, Ironworkers Intermountain Health & Welfare Trust Fund and United Healthcare. Twenty-five patients never received the products Wigington had charged to their respective insurers, Assistant U.S. Attorney Sean Lynch wrote in a court document. Law enforcement began investigating Wigington’s fraud in summer 2022. Her attorney, Sean Conway, said Wigington immediately began cooperating and worked to make things right. Wigington’s fraudulent activity does not reflect “the person Cassi is today,” Conway said. At the time of the fraudulent activity, Wigington was suffering from substance abuse issues, Conway said. Wigington, in a tearful statement, said in court she made “serious errors in judgment” and fully accepts responsibility for her conduct. Wigington also noted she is the primary caregiver for her children and mother. Although a probation officer recommended Wigington receive five years of probation in lieu of prison, Lynch pointed to Wigington’s 2023 shoplifting arrest in Sarpy County as he argued for a one-year prison sentence. Online news site Iowa Capital Dispatch reported Wigington’s shoplifting consisted of stealing more than 300 items, which were worth $2,721, across 13 trips from the Hy-Vee in Gretna. The outlet reported Sarpy County prosecutors dismissed the charges after Wigington agreed to enter a diversion program. In sentencing Wigington, Rossiter agreed with Lynch that Wigington’s conduct warranted prison rather than probation due to the length of her scheme. “This went on for a long time,” Rossiter said, adding the patients Wigington defrauded were “already under a great deal of stress.” Wigington was a former public defender in Iowa, the Iowa Capital Dispatch noted. Her shoplifting arrest led the Iowa Supreme Court to suspend her law license in June 2025. The suspension was lifted last December. **Topics:** Healthcare Fraud **Categories:** Conviction --- ### [Texas Mutual Insurance Company Data Breach – Investigated by Federman & Sherwood](https://insurancefraud.org/news_archives/texas-mutual-insurance-company-data-breach-investigated-by-federman-sherwood/) **Published:** September 15, 2026 **Author:** Diane Beauchamp **Content:** Federman & Sherwood, a national consumer protection law firm, is investigating the **Texas Mutual Insurance Company data breach** following a notification filed with the Texas Attorney General. According to the filing, the Texas Mutual Insurance Company data breach affected approximately 2,065 Texas residents, with additional individuals potentially affected nationwide. The information potentially affected includes names, addresses, Social Security numbers, driver’s license numbers, government-issued identification numbers, medical information, health insurance information, and dates of birth. Insurance organizations may maintain extensive personal, medical, and insurance-related information. The exposure of Social Security numbers together with medical, health insurance, and government identification information may increase the risk of identity theft, medical identity theft, insurance fraud, and other forms of misuse. Federman & Sherwood is investigating whether Texas Mutual Insurance Company implemented reasonable cybersecurity safeguards to protect sensitive personal and health information and whether additional security measures could have prevented or reduced the impact of the data breach. The firm is also evaluating potential legal claims on behalf of affected individuals. The potentially compromised information may include: - **Names** - **Social Security numbers** - **Dates of birth** - **Addresses** - **Driver’s license numbers** - **Government-issued identification numbers** - **Medical information** - **Health insurance information** - **Other sensitive information** ## What is Texas Mutual Insurance Company? Texas Mutual Insurance Company is a major policyholder-owned provider of workers’ compensation insurance in Texas, providing coverage, workplace safety training, and claims administration services to employers and their workforce. Individuals affected by the Texas Mutual Insurance Company data breach may have legal rights and are encouraged to contact Federman & Sherwood to learn more about their options. **Topics:** Public Awareness, Technology --- ### [Eye Practice and Physician Owner Agree to Pay $350,000 to Resolve Allegations of False Claims to Medicare](https://insurancefraud.org/news_archives/eye-practice-and-physician-owner-agree-to-pay-350000-to-resolve-allegations-of-false-claims-to-medicare/) **Published:** September 15, 2026 **Author:** Diane Beauchamp **Content:** St. Michael’s Eye & Laser Institute, a Florida ophthalmology practice, and Dr. John Michaelos, an ophthalmologist and owner of St. Michael’s Eye & Laser Institute, have agreed to pay $350,000 to resolve allegations that they caused the submission of false claims to Medicare in violation of the False Claims Act. The United States alleges that from September 2015 through December 2020, St. Michael’s Eye & Laser Institute (St. Michael’s) and Dr. Michaelos caused the submission of false claims for transcranial doppler (TCD) tests to Medicare and the Veterans Health Administration. A TCD test is a non-invasive diagnostic test that can be used to estimate the blood flow through certain blood vessels in the brain by bouncing high-frequency sound waves off blood cells. As part of the settlement agreement, St. Michael’s and Dr. Michaelos admitted to and accepted responsibility for facts underlying the settlement agreement. St. Michael’s had contractual agreements with an independent medical diagnostics company, Eyecuity, PLLC (Eyecuity). During the relevant time, Eyecuity paid St. Michael’s for referrals that St. Michael’s made for TCD tests, even though the parties’ contracts called for payment based on the cost of office space, staff, and utilities, and not per-patient or per-test that St. Michael’s referred to Eyecuity. When documenting the purported medical necessity of these tests, Eyecuity submitted claims to Medicare that indicated that patients had Vertebro-Basilar Syndrome or Vertebrobasilar Insufficiency (VBI), a very rare condition. But St. Michael’s physicians did not have reason to believe that patients had a diagnosis of VBI. The United States contends that the claims for the TCD tests that St. Michael’s and Dr. Michaelos caused Eyecuity to submit to Medicare for payment were false because St. Michael’s received payments from Eyecuity that violated the Anti-Kickback Statute. United States Attorney Leah B. Foley and Roberto Coviello, Special Agent in Charge, Health and Human Services-Office of Inspector General made the announcement today. The Department of Veterans Affairs, Office of Inspector General provided valuable assistance. Assistant U.S. Attorney Charles B. Weinograd of the U.S. Attorney’s Office’s Affirmative Civil Enforcement Unit handled the case. **Topics:** Judicial/courts, Medicare/Medicaid --- ### [Carrier’s Fraud Allegations against Bricklayer Show Signs of Mistaken Identity](https://insurancefraud.org/news_archives/carriers-fraud-allegations-against-bricklayer-show-signs-of-mistaken-identity/) **Published:** September 15, 2026 **Author:** Diane Beauchamp **Content:** Case File When a carrier accused a bricklayer of concealing prior injuries, the Workers’ Compensation Board found the evidence failed to establish that the prior insurance claims actually involved the claimant. Case Matter of Loja-Saula v. Cosan Construction, No. CV-25-0822 (N.Y. App. Div. 09/03/26) What Happened? A New York bricklayer filed a claim for workers’ compensation benefits for work-related injuries after a piece of a concrete cinderblock fell on him. Following a hearing, a Workers’ Compensation Law Judge established the claim for injuries to the bricklayer’s head, left shoulder, and back, but disallowed the claim for injuries to his neck, left wrist, and left knee. On review, the Workers’ Compensation Board modified the WCLJ’s decision by amending the claim to include injuries to the neck, left wrist, and left knee. At a subsequent hearing, the employer’s carrier alleged that the bricklayer failed to disclose prior injuries to the sites listed in his C-3 claim form, which would violate Workers’ Compensation Law Sec. 114-a. The WCLJ found that the bricklayer had violated Workers’ Compensation Law § 114-a On administrative review, the Board found insufficient proof that the bricklayer violated Workers’ Compensation Law § 114-a and rescinded the WCLJ’s decision. The carrier appealed. Rule of Law In New York, a claimant who, for the purpose of obtaining workers’ compensation benefits, knowingly makes a false statement or representation as to a material fact shall be disqualified from receiving any compensation directly attributable to such false statement or representation. An omission of material information may constitute a knowing false statement or misrepresentation. What Appellate Division Said The court affirmed the Board’s decision. The court agreed that the carrier failed to present sufficiently reliable proof tying the bricklayer to the alleged prior claims. The Board found significant inconsistencies in the carrier’s ISO reports, including differing names, birth years, and addresses. Although some records matched the bricklayer’s identifying information, the Board concluded they could have referred to the April 2022 work injury rather than undisclosed prior injuries. According to the court, there were challenges with two Insurance Services Office reports that listed insurance claims the carrier alleged the bricklayer had filed pertaining to prior accidents that he purportedly failed to disclose in his C-3 form. In particular, the court pointed out: (1) The first ISO report was based upon a search for claims brought under the bricklayer’s name and found three matches, but two of the matches had slightly different names than the bricklayer and listed different home addresses than the address the bricklayer testified to as the only one he has had in this country. The third match contained bricklayer’s name and his address and indicated that he was involved in a motor vehicle accident in 2017 with an unspecified injury. (2) The second ISO report was based upon a search of claims brought under the bricklayer’s purported Social Security number. and it found 13 matches. Two such matches referenced the bricklayer’s correct name and address and indicated that he filed claims based upon an April 15, 2022, injury date, which is the date that the bricklayer was injured by the cinderblock. Both matches referenced injuries to bricklayer’s head, teeth, left shoulder and left side of neck, and one of the matches indicated that the claim was covered by a commercial liability policy, while the other match indicated that the claim was covered by a workers’ compensation policy and referenced the employer as the insured. The remaining 11 matches involved personal automobile insurance claims spanning from 1999 to 2014, which were made by individuals with different dates of birth and addresses than the bricklayer, as well as slightly different names. (3) The carrier also submitted a January 2024 arbitration award report that detailed a lawsuit brought by a pharmacy against an insurance carrier seeking payment for prescriptions provided to an individual with the bricklayer’s name who, according to the report, was involved in a motor vehicle accident on April 15, 2022, the same date as claimant’s work injury. The court pointed out that the bricklayer did not have a Social Security Number and never provided a number to anyone and that he did not get prescription medicine at the pharmacy involved in the arbitration. Based on these points, the court disagreed with the carrier’s contention that the Board erred in finding insufficient proof of a Workers’ Compensation Law § 114-a violation. **Topics:** Judicial/courts, Work comp - employer --- ### [Gary Man Sentenced to 15 Months in Prison for Postal Money Order Fraud Scheme](https://insurancefraud.org/news_archives/gary-man-sentenced-to-15-months-in-prison-for-postal-money-order-fraud-scheme/) **Published:** September 15, 2026 **Author:** Diane Beauchamp **Content:** Jordan C. Sneed, 32 years old, of Gary, was sentenced by United States District Court Judge Gretchen S. Lund after pleading guilty to conspiracy to commit bank fraud, announced United States Attorney Adam L. Mildred. McClendon was sentenced to 15 months in prison, 2 years of supervised release, and ordered to pay $41,426.14 in restitution to victims of the offense. Sneed is the last of five defendants to be sentenced in this case. Anthony Juan McClendon, the leader and organizer of the scheme, was sentenced on December 18, 2025, to 24 months in prison and 4 years of supervised release. On October 22, 2025, co-Defendant Reginald Russell was sentenced to 18 months’ imprisonment and 3 years of supervised release for his role in altering the Postal money orders used in the scheme, after having been previously convicted of a similar offense in the Northern District of Illinois. Co-defendants Austin Hartman and Santiago Andrade also received prison sentences for participating in the scheme. “Recidivist Jordan Sneed was sentenced to prison because he and his co-conspirators exploited the services of local banks and the United States Postal Service to make money through fraud. They used U.S. Postal Service money orders that had been altered to reflect higher face values than the amounts for which they had been purchased. In total, the conspiracy produced and negotiated over $120,000 worth of altered money orders at financial institutions throughout Northern Indiana. Unfortunately, Sneed engaged in this conduct within a matter of months after being released from a lengthy sentence in the Indiana Department of Corrections. Prior to this offense, Sneed had been incarcerated for approximately 10 years after a 2012 conviction for robbery resulting in serious bodily injury and carjacking in Vigo County, Indiana. Thanks to the partnership of the United States Postal Inspection Service, Porter County Sheriff’s Office, Cook County Sheriff’s Office, Munster Police Department, Hammond Police Department, Lansing (Illinois) Police Department, and NDIN AUSA Zachary D. Heater, repeat offenders and fraudsters will be held accountable in the Northern District of Indiana,” said U.S. Attorney Adam L. Mildred. This case was investigated by the United States Postal Inspection Service, with assistance from the Porter County Sheriff’s Office, Cook County Sheriff’s Office, Munster Police Department, Hammond Police Department, Lansing (Illinois) Police Department, and others. The case was prosecuted by Assistant United States Attorney Zachary D. Heater. On April 7, the Department of Justice announced the creation of the National Fraud Enforcement Division (“Fraud Division”). The Fraud Division is laser-focused on investigating and prosecuting those who commit fraud against the American people. The Department’s work to combat fraud supports President Trump’s Task Force to Eliminate Fraud, a whole-of-government effort chaired by Vice President J.D. Vance to eliminate fraud, waste, and abuse within Federal benefit programs **Topics:** Financial Fraud **Categories:** Conviction --- ### [Wisconsin Man Sentenced to 8 Years in Federal Prison for $14.25 Million Wire Fraud and Money Laundering Scheme](https://insurancefraud.org/news_archives/wisconsin-man-sentenced-to-8-years-in-federal-prison-for-14-25-million-wire-fraud-and-money-laundering-scheme/) **Published:** September 15, 2026 **Author:** Diane Beauchamp **Content:** Stanley Pophal, 64, of Wausau, Wisconsin, was sentenced last week in U.S. District Court by U.S. District Judge William M. Conley to 96 months in federal prison for wire fraud and money laundering. The sentence follows a comprehensive, multi-agency investigation into a scheme that defrauded 190 investors out of $14.25 million. “The successful resolution of this case underscores the vital cooperation among state, local, and federal authorities,” stated Iowa Insurance Commissioner Doug Ommen. “We extend our sincere gratitude to the Allamakee County Attorney’s Office, the Allamakee County Sheriff’s Office, and the Winneshiek County Sheriff’s Office. Their early collaboration with our Fraud Bureau was instrumental in identifying and halting this fraudulent activity.” In addition to its local Iowa partners, the Iowa Insurance Division recognizes the extensive collaborative efforts of the following agencies: Federal Law Enforcement & Prosecution: Internal Revenue Service (IRS) Criminal Investigation, Federal Bureau of Investigation (FBI), and the United States Attorney’s Office for the Western District of Wisconsin Wisconsin Local Law Enforcement: Marathon County Sheriff’s Office and the Wausau Police Department “This was a complex, interwoven case involving numerous victims and multiple agencies across Iowa and Wisconsin,” said Winneshiek County Sheriff Dan Marx. “Every participating agency dedicated countless hours to gathering evidence and holding Mr. Pophal accountable. Whether a case involves one victim or hundreds, our duty remains the same: to seek justice. Throughout this investigation, our focus was ensuring that the victims in Winneshiek County received the justice and representation they deserved.” Case Chronology May 2019 – June 2025: Operating under Bright with Silver, Inc. (formerly DBA Fromm Bros., Inc.), Pophal solicited investors to purchase promissory notes with guaranteed returns of at least 20%. He falsely claimed to possess vast personal wealth that protected investors’ principal from risk. Instead of investing funds as promised in sectors like cryptocurrency, real estate, and commodities, Pophal spent millions funding personal expenses, private plane rentals, mortgages, and purchasing over 600 items—including hundreds of snowmobiles, motorcycles, and vehicles. He maintained the scheme by making payments to early investors using funds from new victims. February 2025: An investigation was opened by Allamakee County Sheriff’s Office after a call from a concerned citizen. The Iowa Insurance Division’s Fraud Bureau also launched an investigation into unauthorized investment meetings conducted across Allamakee, Winneshiek, Mitchell, Wapello, Clayton, and Madison counties. April 10, 2025: Following the state investigation, Pophal and four co-defendants (David Halvorson, Casey Halvorson, Gary Halvorson, and Debra Mink) were charged with Class D felony counts for selling unregistered securities under Iowa law. Spring 2025: A federal criminal complaint was unsealed in the Western District of Wisconsin charging Pophal with wire fraud and money laundering. Upon the filing of the federal charges, local state charges against Pophal were dismissed to allow the federal prosecution to move forward. June 12, 2026: Pophal pleaded guilty in U.S. District Court in Madison to wire fraud and money laundering and agreed to forfeit all items purchased with investor funds. July 28, 2026: Online public auctions of Pophal’s forfeited assets—including hundreds of snowmobiles and vehicles—commenced through the U.S. Department of Justice and U.S. Department of Treasury to assist in victim restitution. September 2, 2026: Pophal was formally sentenced to 96 months in federal prison. Seized Assets and Restitution As part of the investigation, law enforcement agents seized more than 600 items Pophal purchased using investor funds, which he had stored in a rented warehouse. The forfeiture and ongoing public auction of these assets represent a crucial step toward helping victims recover what was stolen from them. Protect Your Investments It is always important for Iowans to double-check before investing. A quick call to the Iowa Insurance Division or a visit to iid.iowa.gov can help protect consumers from fraud by verifying that financial products and agents are properly licensed. The Iowa Insurance Division’s Fraud Bureau investigates potential insurance fraud and related financial crimes occurring across the state. Members of the public who suspect fraudulent activity are encouraged to contact the Fraud Bureau at 515-654-6556 or visit [www.iid.iowa.gov](http://www.iid.iowa.gov) . For additional prevention information, free consumer resources, and details on upcoming educational events, visit the Iowa Fraud Fighters at iowafraudfighters.gov . **Topics:** Financial Fraud **Categories:** Conviction --- ### [PIA New York closes staged-accident fraud loophole after years of lobbying](https://insurancefraud.org/news_archives/pia-new-york-closes-staged-accident-fraud-loophole-after-years-of-lobbying/) **Published:** September 15, 2026 **Author:** Diane Beauchamp **Content:** New York has passed legislation explicitly extending its insurance fraud statutes to cover individuals who hire, request, encourage, orchestrate or invite others to participate in staged auto accident schemes – closing a loophole the Professional Insurance Agents of New York had pushed to close for years. The association secured the win during a 2026 legislative session it has described as unusually productive despite a late state budget that consumed most of Albany’s calendar. PIANY also secured passage of third-party litigation funding regulation requiring greater transparency and fairness in lawsuit lending, and won repeal of a longstanding anti-arson application requirement in New York City that had created ongoing compliance burdens for property owners and agents. The staged-accident win connects to a broader national push. The Stop Auto Fraud Act of 2026, introduced in Congress this month, targets the same schemes at the federal level and carries backing from the [American Property Casualty Insurance Association](https://www.insurancebusinessmag.com/us/companies/american-property-casualty-insurance-association/587380/). New York’s state-level legislation closes the enforcement gap in the interim. ## **The annual meeting** The legislative wins formed the backdrop to PIANY’s annual business meeting, held September 9 at the Albany Hilton, where Jason Bartow was re-elected to a second term as president and Ed Chadwick of [Jencap](https://www.insurancebusinessmag.com/us/companies/jencap/587362/) Specialty Insurance Services was elected president-elect, with a full slate of vice presidents, treasurer and secretary also elected for 2026-27. Three insurance professionals received Awards of Distinction at the same meeting. Leslie Driscoll, owner of Tronilo Driscoll Insurance Agency in Ozone Park, received the Professional Agent of the Year award, given to an independent agent who has demonstrated excellence in insurance marketing and service alongside a personal commitment to professionalism and community contribution. Driscoll has served on PIANY’s Education, Sponsorship and Conference committees, and her Ozone Park office serves clients across New York City’s five boroughs. Robert Rovello, regional director at [Travelers](https://www.insurancebusinessmag.com/us/companies/travelers/67047/), received the Company Person of the Year award, given to individuals who build strong working relationships with agents and brokers. Rovello serves on PIANY’s MetroRAP Committee and has worked to strengthen ties between [Travelers](https://www.insurancebusinessmag.com/us/companies/travelers/67047/) and the association’s independent agency members. Assemblyman Ken Blankenbush received the Distinguished Insurance Service award, presented to individuals with a history of significant contributions to the regional insurance community. Blankenbush has served on the Assembly’s insurance committee for years and has maintained a consistently pro-agency record throughout his political career. Maria Thomas, vice president of brokerage sales and client relations for Friedlander Group, was named Committee Chair of the Year for her work chairing PIANY’s 2026 MetroRAP Committee. Thomas co-chairs the Long Island Insurance Community, which has raised more than $7 million for Long Islanders in need over the past 30 years, and previously served as president of the Insurance Professionals Association of Long Island. **Topics:** Legislation --- ### [Mecklenburg County Woman Charged with Medical Insurance Fraud](https://insurancefraud.org/news_archives/mecklenburg-county-woman-charged-with-medical-insurance-fraud/) **Published:** September 14, 2026 **Author:** Diane Beauchamp **Content:** The following information was released by the North Carolina Department of Insurance: North CarolinaInsurance Commissioner Mike Causey today announced the arrest of Remonica Corlishia Earl, 48, of 4209 Howie Circle, Charlotte. Earl was charged with insurance fraud. According to the arrest warrant, Earl is accused of submitting false and misleading information to UNUM Insurance Co. in connection with five accidental/disability insurance claims involving herself and her children. Special agents from the Department of Insurance Criminal Investigations Division accuse Earl of submitting altered medical records from Atrium Health and OrthoCarolina using incorrect addresses, listing a doctor who was not a provider at the facility and indicating that the doctor treated her or her children on dates when the doctor did not see them. The defendant received $6,980 in insurance payments related to the five claims. The offenses occurred on May 1, 2025. Earl was held on a $20,000 secured bond and will appear in a Mecklenburg County District Court on Sept. 23. Commissioner Causey encourages North Carolinians to help keep insurance premiums low by reporting suspicious fraud. “Insurance fraud hits consumers in the wallet,” Commissioner Causey said. “Approximately 20 cents of every insurance premium dollar goes to covering the cost of fraud. I’m fighting this by aggressively pursuing and prosecuting insurance fraud in North Carolina.” **Topics:** Disability **Categories:** Arrest --- ### [Owner of Erie County Home Health Care Agency Jailed, Ordered to Pay Restitution in $1.86M Medicaid Fraud Scheme](https://insurancefraud.org/news_archives/owner-of-erie-county-home-health-care-agency-jailed-ordered-to-pay-restitution-in-1-86m-medicaid-fraud-scheme/) **Published:** September 14, 2026 **Author:** Diane Beauchamp **Content:** Attorney General Dave Sunday announced that Tina Bell, owner and manager of Superior Health, Inc. — an Erie County home care agency — was sentenced to 11 to 23 months in prison for Medicaid fraud and endangering vulnerable individuals under her care. Bell, 56, received Medicaid reimbursement for her company’s multiple shared care homes when she perpetrated the fraud scheme. She billed Medicaid for services that were not provided and falsely reported the qualifications of caregivers. In doing so, she endangered the vulnerable residents her agency was responsible to care for, many of whom were wheelchair bound. Bell previously pleaded guilty to felony charges of Medicaid fraud, tampering with public records, and neglect of a care-dependent person. She was sentenced this week to the prison term, plus six years of probation, and was ordered to pay more than $1.8 million in restitution. She will also be precluded from being a Medicaid provider. She was taken to prison following Thursday’s sentencing hearing. “This defendant was determined in her efforts to defraud Medicaid, first by knowingly filing false reports, then by falsifying records when she knew she was being audited and investigated,” Attorney General Sunday said. “Her actions not only defrauded the Medicaid program but endangered the vulnerable Pennsylvanians who depended on her for safe and adequate care.” Bell also lost her nursing license as a result of this case. When the Pennsylvania Department of Health audited Superior Health, Bell falsified records to cover up short staffing, the absence of mandatory training, and the failure to conduct mandatory health screenings of employees. She also created false medical and financial documentation to justify fraudulent claims for payment. This case was prosecuted by Deputy Attorney General Samuel Zappala, and Attorney-In-Charge Kee Song from the Medicaid Fraud Control Section. **Topics:** Medicare/Medicaid **Categories:** Conviction --- ### [Patchogue Employer Charged with Workers’ Comp Insurance Fraud](https://insurancefraud.org/news_archives/patchogue-employer-charged-with-workers-comp-insurance-fraud/) **Published:** September 14, 2026 **Author:** Diane Beauchamp **Content:** Suffolk County District Attorney Raymond A. Tierney today announced that Joseph Arthurs, 56, of Patchogue, and his company, VGN Enterprise Corporation, have been charged with Fraudulent Practices and Failure to Secure Compensation. As alleged, the defendant intentionally misrepresented his company’s payroll, the number of employees and the work hazards involved to the worker’s compensation insurance company. The alleged fraud resulted in the underpayment of insurance premiums by more than $160,000. “Underrepresenting employees on worker’s compensation insurance means undercutting their safety,” said District Attorney Tierney. “This type of fraud strips workers of the safeguards they depend on, leaving them unprotected if they get hurt on the job. I thank the Offices of the New York State Inspector General for their help in holding this defendant accountable and keeping Suffolk County employees safe.” “New Yorkers who are hurt on the job deserve a workers’ compensation system they can rely on,” said New York State Workers’ Compensation Fraud Inspector General Lucy Lang. “Thank you to District Attorney Tierney and both of our teams for pursuing accountability for employers who put that vital protection at risk.” According to the investigation, Arthurs is the principal owner of VGN Enterprise Corporation (VGN), an asbestos removal company based in Patchogue. In March 2023, Arthurs applied for a workers’ compensation insurance policy from Wesco Insurance Company for coverage from April 2023 through April 2024, as required by New York State law. Arthurs allegedly stated on the application that his company employed a full-time building service contractor as the sole employee with an annual payroll of $50,000.\[SA1.1\]\[MM1.2\] Based on this application, the insurance company issued a workers’ compensation policy for VGN with an annual premium of $4,203. In September 2024, an investigation by the Offices of the New York State Inspector General determined\[SA2.1\] that Arthurs had obtained a New York State Department of Labor Asbestos License/Certification and filed multiple “Asbestos Project Notifications” with the agency. As alleged, the filings confirmed that the company was engaged in a more hazardous level of asbestos abatement and therefore required workers’ compensation coverage classified for that type of work. The investigation also determined that VGN had employed a multitude of workers during the course of the year,\[SA3.1\]\[MM3.2\] with an annual payroll of $354,112. As a result of these alleged misrepresentations, VGN significantly underpaid a total of $163,561.00 in insurance premiums on its workers’ compensation insurance policy. Arthurs was placed under arrest on August 25, 2026, and as required by law, a desk appearance ticket was issued. On September 9, 2026, Arthurs and VGN were arraigned before District Court Judge Alonzo G. Jacobs, on charges of Penalties for Fraudulent Practices, a Class E felony, and Effect of Failure to Secure Compensation, a Class E felony. Judge Jacobs ordered Arthurs released on his own recognizance. The charges are not bail-eligible under current New York state law. Arthurs and VGN are represented by James Hagney, Esq. Their next court dates are September 21, 2026. This case is being prosecuted by Assistant District Attorney Ryan Hunter of the Financial Crimes Bureau, and the investigation was conducted by Detective Investigator Daniel Ayrovainen of the Suffolk County District Attorney Detective Investigation Unit with assistance from the Offices of the New York State Inspector General. **Topics:** Work comp - employer **Categories:** Arrest --- ### [She Billed Medicaid for Services Never Provided and Overbilled Others. Former Healthcare Owner Gets 5 Years and $3.19 Million Restitution](https://insurancefraud.org/news_archives/she-billed-medicaid-for-services-never-provided-and-overbilled-others-former-healthcare-owner-gets-5-years-and-3-19-million-restitution/) **Published:** September 14, 2026 **Author:** Diane Beauchamp **Content:** A former Mississippi healthcare business owner has been sentenced to five years in prison after being convicted in a Medicaid fraud case involving claims for services that were never provided and substantial overbilling for other services. Katricia Smith, 47, of Olive Branch, formerly owned and operated KLS Medical Services LLC in DeSoto County. Her case was among the Mississippi prosecutions announced through the Justice Department’s 2026 National Health Care Fraud Takedown. Federal takedown materials said KLS submitted claims to the Mississippi Division of Medicaid for services that patients never received and substantially overbilled other services that were otherwise authorized under a district plan. Smith was ultimately convicted on one count of wire fraud. Madison County Circuit Court Judge Steve Ratcliff sentenced Smith to five years in the custody of the Mississippi Department of Corrections and ordered her to pay $3,190,017.93 in restitution to Mississippi Medicaid, DeSoto County News reported. The Claims Included Services That Were Never Provided The Justice Department’s case summary said Smith, as owner and operator of KLS Medical Services, fraudulently claimed that services had been provided to patients under a district plan when those services had never actually been rendered. Other claims involved services that were authorized under the plan but were substantially overbilled, according to the DOJ summary. The case resulted in Smith’s conviction on one count of wire fraud. The September 8 sentencing report said the conduct occurred during 2023 and 2024. Medicaid Had Paid About $4.48 Million on the Claims When Smith’s case was announced as part of the national healthcare fraud takedown, the Justice Department said the Mississippi Division of Medicaid had paid approximately $4,480,939.29 based on the false and fraudulent claims. The amount Smith was ordered to repay at sentencing is lower. Judge Ratcliff ordered $3,190,017.93 in restitution to the Mississippi Division of Medicaid. The available sentencing report and earlier federal case summary do not explain the difference between the approximately $4.48 million previously identified as Medicaid payments and the $3.19 million restitution order. Smith Was One of 11 Mississippi Defendants Announced in June Smith’s case was among 11 Mississippi indictments announced in June as part of the 2026 National Health Care Fraud Takedown. The Mississippi Attorney General’s Office said those state cases collectively involved more than $12.3 million in alleged Medicaid fraud. The defendants were charged in separate cases involving allegations such as billing for services that were never provided, fraudulent documentation and other improper Medicaid claims. Smith’s case has now moved beyond the allegation stage. Her wire fraud conviction resulted in the five-year prison sentence and multimillion-dollar restitution order. The Mississippi Attorney General’s Office and the Mississippi Division of Medicaid Program Integrity investigated the case, and the Attorney General’s Office prosecuted it. What to Do if Medicaid Is Billed for Care You Never Received The Mississippi Division of Medicaid specifically identifies billing for services that were never rendered as provider fraud or abuse. The agency also lists inappropriate billing that causes a loss to Medicaid, unsupported claims and falsified medical or treatment records among the conduct that can be reported. **Topics:** Medicare/Medicaid **Categories:** Conviction --- ### [New Fla. lawmakers to tackle property insurance](https://insurancefraud.org/news_archives/new-fla-lawmakers-to-tackle-property-insurance/) **Published:** September 14, 2026 **Author:** Diane Beauchamp **Content:** The new-look Florida Legislature is coming back to the Capitol to take on an old problem — homeowners insurance — which has worsened since Hurricane Ian tore through the state in September. It was just six months ago that lawmakers attempted to stabilize an overpriced and unreliable insurance market during a special session called by Gov. Ron DeSantis. This time, new Republican leaders elected to the House and Senate in November will tackle what continues to be a statewide crisis. House Speaker Paul Renner, R-Palm Coast, and Senate President Kathleen Passidomo, R-Naples, now face an even tougher task. The changes enacted following May’s session didn’t spawn much improvement. And since then, Hurricane Ian’s Category 4 damage has already drawn $10.2 billion in insurance claims, with estimates warning the eventual total will far exceed that, a potentially enormous threat to the finances of Floridians and their insurers. “We have a long, long way to go,” said Passidomo just weeks after the storm. Her Naples home, built in 1961, was destroyed by flooding from Ian. Renner and Passidomo made the session official Tuesday, formally calling lawmakers to the Capitol for Dec. 12-16, which overlaps with the first regularly scheduled committee week in advance of the 2023 legislative session, which begins in March. DeSantis and Republican lawmakers, who now hold super-majority control of the House and Senate, are expected again to focus on efforts to prop-up the industry. Renner has already warned that whatever is approved, “will not result in an overnight drop in insurance rates.” Florida homeowners pay the highest premiums in the country, almost three times the national average, according to the Insurance Information Institute, an industry organization. These premiums also are climbing at a rate of about 33% annually, compared to 9% boosts across the rest of the nation. But as long as the industry is troubled in Florida, high premiums will endure. More than a dozen insurance companies have stopped writing homeowners policies in Florida this year, including a half dozen that have gone out of business altogether. Industry certain to get what it wants Lawmakers have taken the approach that they will give the industry what it wants in a desperate bid to stop them from leaving a high-risk state. The insurance industry got lawmakers to do a lot of what it wanted in May. And the same theme is expected to dominate next week’s session. While little is known about why Florida insurers become troubled — some analysts say poor investments and bad management are to blame. Yet the industry blames the cost and financial risk of lawsuits, and soaring prices for reinsurance — basically, insurance for insurance companies — for its woes. Ian’s insurance damages are estimated to top $50 billion, making it second only to 2005’s Hurricane Katrina as the biggest insurance loss in U.S. history. While the industry is demanding help, not everyone is convinced. “It’s obvious, the insurance industry wants to maximize profit and take advantage of the political climate it has right now, to look anemic, to scare everyone that they might leave Florida and push through legislation that will have lasting and long-term effects,” said Amy Boggs, a St. Petersburg lawyer who leads the Florida Justice Association’s property insurance committee. Similar fears of an industry collapse drove the spring session, when lawmakers steered $2 billion in taxpayer money into a reinsurance fund to provide more available funds for companies. Other steps included setting aside $150 million for making homes more hurricane resilient, adding a new separate insurance deductible for roof damage, which will make homeowners pay more for roof replacements, and putting new limits on their ability to sue insurers. CAT FUND took a hit with Ian This time around, it’s likely the Legislature will put more taxpayer money into the state’s reinsurance pool, the Florida Hurricane Catastrophe Fund, whose $12.7 billion surplus has taken a hit following Ian. And another push to discourage homeowner lawsuits against their insurance companies is almost certain. A report this week by the conservative James Madison Institute echoed industry figures that found 80% of all insurance lawsuits nationwide are from Florida, even though only 9% of all insurance claims are filed in the state. JMI also says 92% of the $15 billion in insurance payouts since 2013 went to lawyers and legal expenses, not policyholders. The number of lawsuits has eased since limits were enacted by lawmakers in 2021, state insurance officials acknowledge. But the latest crisis will entice the Legislature to act again — possibly by eliminating the requirement that insurance companies pay the attorney fees of homeowners who win lawsuits. Eliminating such “one-way attorney fees,” will make homeowners shoulder more of the costs of suing. Critics say that will put homeowners in a tough spot even if they win a lawsuit, since a large chunk of their settlement would now go to paying their own attorneys’ fees. ‘David and Goliath fights’ “We have these David and Goliath fights, of an individual homeowner fighting against a multi-billion dollar insurance company and industry, because they all work in lockstep,” Boggs said, adding that imbalance will worsen with new lawsuit restrictions. But some experts say that in a state so hurricane prone, reducing risks in other areas like lawsuits is the only way to convince insurers to stay and write policies. “You’re looking to incentivize new company formation or keeping the companies that actually are here,” said Dr. Chuck Nyce, who teaches insurance and risk management at Florida State University. “That won’t work until you show companies and their investors that litigation has been reduced substantially. “You’ve got to show you’ve improved the marketplace before you attract new companies to come here,” he added. One easy fix, expected during next week’s session, will be a move to provide property tax rebates for Florida residents who’ve lost their homes in Hurricane Ian. Lawmakers also will likely approve sending dollars to counties to make up for these tax losses, to ensure that local services continue. DeSantis already delayed property tax payments in the 26 counties affected by Ian until next June. The Legislature had passed legislation earlier this year providing tax relief for storm-damaged property — but that law doesn’t take effect until Jan. 1. Lawmakers will change that effective date next week, to give Floridians a break on their Ian-battered homes. DeSantis spent much of the latter stage of his re-election campaign focused on responding to Hurricane Ian and its aftermath. His Democratic opponent, Charlie Crist, called DeSantis, “the worst property insurance governor in Florida history. Period.” DeSantis criticism? Didn’t stick But the state’s wide-ranging insurance problem didn’t seem to stick to the Republican governor, who won re-election by a landslide 19% margin. He called for next week’s session in October, and is widely seen as directing the session’s agenda. Another issue sure to get some attention will be Citizens Property Insurance, Corp., the state-backed insurer of last resort for Floridians. Citizens now has 1.1 million customers, double what it had just two years ago, and the Republican-led Legislature generally bristles at the state being in the insurance business. Lawmakers may tackle some longer-term steps aimed at prompting homeowners to leave Citizens, once the industry gets better. In their proclamation announcing the session, Renner and Passidomo included a lineup of aspirational goals they have for next week. They included improving the “financial stability” of Citizens and to “foster the transition” of these policies to the private market. Other goals are to “reduce the cost of litigation regarding property insurance claims,” helping with reinsurance, improving claims-handling and increasing “oversight of property insurance market participants.” A Cabinet member, Chief Financial Officer Jimmy Patronis, has a series of proposals focused on ridding the insurance market of fraud, which he blames for much of the industry’s problems. Patronis wants to tighten oversight of public adjusters, ban the use of Assignment of Benefits (AOB) coverage, which many homeowners rely on to avoid battling directly with their insurers, and creating a statewide prosecutor solely focused on insurance fraud. But a newly elected Democrat, Rep. Hillary Cassel of Dania Beach, is an attorney who has worked in property insurance for years. She said that, too often, Florida lawmakers put more of the blame on consumers than insurers for the state’s problems. “We’ve never addressed claims handling, we’ve never looked at the other side of this issue,” Cassel said. “It’s always been that those of us who advocate for consumers are on the chopping block of reform, and we turn a completely blind to how these insurance companies respond to these catastrophic losses. And I don’t see that changing right now.” **Topics:** Public Awareness, Regulatory actions --- ### [New Orleans hotel owner accused of conspiring with NOPD officer to file false reports](https://insurancefraud.org/news_archives/new-orleans-hotel-owner-accused-of-conspiring-with-nopd-officer-to-file-false-reports/) **Published:** September 14, 2026 **Author:** Diane Beauchamp **Content:** New details on a federal investigation into a well-known political campaign contributor and owner of a historic hotel show that he may have conspired with a New Orleans Police Department officer to commit fraud. According to court documents, Fouad Zeton was charged in an indictment on Thursday on charges of conspiracy to commit fraud. Zeton is accused of working with an NOPD officer to file a false report with his homeowners’ insurance company regarding stolen art. Court documents claim that Zeton and the officer worked together to make a false report that valuable paintings were taken from Zeton’s home. The Department of Justice says Zeton’s art was never stolen and was valued at much lower than he had reported to his insurance company. The officer accused of working with Zeton was promised money from the insurance payout for filing the false reports, according to court documents. The documents go on to say that the officer and Zeton had a phone call prior to the 911 call placed about the stolen art. Both were seen pretending not to know each other in the video recorded on the officer’s body-worn camera, according to the court documents. The DOJ says Zeton was recorded on the body-worn camera making the false claims that the art was valued at $128,500. The police officer is accused of submitting the fake report to a claims adjuster for Zeton’s homeowners’ insurance. This comes just over a year after WDSU Investigates broke the story of a raid at Zeton’s business on Prytania Street. FBI agents went into the business and carried out large boxes. The investigation centered on art fraud. WDSU cameras were rolling in June of 2021 when the FBI took the pieces of art out of the Magnolia Mansion in the Lower Garden District. Zeton’s lawyers David Courcelle and Scott Stansbury say he is a fighter and will get through this. Six months ago Zeton declined to say anything about the raid. Since then, he has leased the property to two people but went to court in May to have them evicted. Tourists staying at the mansion say they had no idea about the legal issues Zeton faced. Zeton met with the federal government multiple times since the raid in 2021. His arraignment date is to be determined. Earlier reports: New information on a story WDSU Investigates broke yesterday and continues to follow today — sources confirm that the FBI raid at Magnolia Mansion centers on art. Multiple sources tell WDSU investigates that pieces of art are inside the packages that were removed from the bed and breakfast yesterday in the Lower Garden District. Only our cameras were rolling while the FBI was there taking out the paintings and loading them on a van. Why they were removed has yet to be discovered. We spoke to the property owner, Fouad Zeton, and his lawyer today but both declined to comment, saying they are working through the situation. Zeton is a Syrian businessman with ties to political leaders in the city. He’s become a fixture at election night campaign events. **Topics:** Homeowners - fake **Categories:** Arrest --- ### [Leesburg Police looking for Costco fraud suspect](https://insurancefraud.org/news_archives/leesburg-police-looking-for-costco-fraud-suspect/) **Published:** September 14, 2026 **Author:** Diane Beauchamp **Content:** Police in Leesburg are looking for someone who they say tried to pick up a fraudulent prescription at Costco. According to the Leesburg Police Department, the person pictured tried to pick up a fake prescription from the Costco, located at 1330 Edward Ferry Road NE, on Sunday, Dec. 4. After leaving the store, person was seen leaving the parking lot in the car pictured (right). Anyone who recognizes the person or car pictured is asked to call Leesburg Police at 703-771-4500. **Topics:** Drug Diversion --- ### [Progressive lawmakers call on CMS to cull companies with history of Medicare fraud from ACO REACH](https://insurancefraud.org/news_archives/progressive-lawmakers-call-on-cms-to-cull-companies-with-history-of-medicare-fraud-from-aco-reach/) **Published:** September 14, 2026 **Author:** Diane Beauchamp **Content:** More than 20 progressive lawmakers are raising concerns about ACO REACH in a new letter to the CMS, arguing the model gives insurers with a history of defrauding Medicare another toehold in the program and asking regulators to eject those entities from the alternative payment model. ACO REACH, slated to begin in January, is a [redesign of the direct contracting model](https://www.healthcaredive.com/news/cms-direct-contracting-medicare-biden-value/619507/) called the Global and Professional Direct Contracting Model. It’s meant to tie traditional payments in Medicare to value and improve care coordination. Direct contracting entities from the original model are allowed to enroll as ACOs in REACH provided they meet the new requirements, and the majority are expected to stay on as the program swells from [99 participants](https://innovation.cms.gov/media/document/gpdc-model-participant-summary) in 2022 to [as many as 202 currently planned in 2023](https://www.warren.senate.gov/imo/media/doc/221208%20ACO%20REACH%20Letter%20to%20CMS%20with%20Signatures.pdf). At least 10 of those organizations have records of healthcare fraud, abuse and lawbreaking prior to 2021, but might still be [allowed to transition into ACO REACH](http://www.warren.senate.gov/imo/media/doc/221208%20ACO%20REACH%20Letter%20to%20CMS%20with%20Signatures.pdf), according to the letter. “Given our concerns, we ask that CMS closely examine the participants in the ACO REACH program, including those transitioning from the GPDC program, and take action to prevent those with histories of fraud and abuse from participating in the newly designed program in 2023,” the lawmakers, led by Sen. Elizabeth Warren, D-Mass., and Rep. Pramila Jayapal, D-Wash., wrote. The direct contracting program, which allows private and for-profit entities to assume full or partial risk to manage patient care in traditional Medicare, has proved controversial. Single-payer advocates [and progressive Democrats](https://www.warren.senate.gov/newsroom/press-releases/at-hearing-warren-calls-for-crackdown-on-corporate-greed-to-protect-medicares-financial-sustainability-and-expand-coverage) have called the model a veiled effort to privatize the Medicare fee-for-service program. However, providers and ACO groups have argued [that criticisms of privitization aren’t based on facts](https://www.healthcaredive.com/news/direct-contracting-medicare-reach-cms-controversy/622969/) and that direct contracting allows physicians to better provide team-based, preventative care. Following the controversy, the CMS announced in February it was retaining the model with some fundamental changes and a new name: the Accountable Care Organization Realizing Equity, Access, and Community Health Model. Among other tweaks, ACO REACH has a stronger focus on health equity and provider governance. However, the CMS did not bar companies that include private equity investors or other profit-seeking entities from participating — a key criticism levied by the program’s detractors and one re-upped by the legislators in the letter. As a result of such organizations’ participation, ACO REACH poses a “significant threat” to traditional Medicare by “extending the reach of many of the same bad actors that have driven tens of billions in excess costs in Medicare Advantage,” the lawmakers argued. **Topics:** Public Awareness, Regulatory actions --- ### [KHN Investigation: The System Feds Rely On to Stop Repeat Health Fraud Is Broken](https://insurancefraud.org/news_archives/khn-investigation-the-system-feds-rely-on-to-stop-repeat-health-fraud-is-broken-2/) **Published:** September 14, 2026 **Author:** Diane Beauchamp **Content:** The federal system meant to stop health care business owners and executives from repeatedly bilking government health programs fails to do so, a KHN investigation has found. That means people are once again tapping into Medicaid, Medicare, and other taxpayer-funded federal health programs after being legally banned because of fraudulent or illegal behavior. In large part that’s because the government relies on those who are banned to self-report their infractions or criminal histories on federal and state applications when they move into new jobs or launch companies that access federal health care dollars. The Office of Inspector General for the U.S. Department of Health and Human Services keeps a [public list](https://exclusions.oig.hhs.gov/default.aspx) of those it has barred from receiving any payment from its programs — it reported excluding more than 14,000 individuals and entities since January 2017 — but it does little to track or police the future endeavors of those it has excluded. The government explains that such bans apply to “the excluded person” or “anyone who employs or contracts with” them. Further, “the exclusion applies regardless of who submits the claims and applies to all administrative and management services furnished by the excluded person,” [according to the OIG](https://oig.hhs.gov/faqs/exclusions-faq/). Federal overseers largely count on employers to check their hires and identify those excluded. Big hospital systems and clinics typically employ compliance staff or hire contractors who routinely vet their workers against the federal list to avoid fines. However, those who own or operate health care businesses are typically not subject to such oversight, KHN found. And people can sidestep detection by leaving their names off key documents or using aliases. “If you intend to violate your exclusion, the exclusion list is not an effective deterrent,” said [David Blank](https://www.agg.com/professionals/david-blank/), a partner at Arnall Golden Gregory who previously was senior counsel at the OIG. “There are too many workarounds.” KHN examined a sample of 300 health care business owners and executives who are among more than 1,600 on OIG’s exclusion list since January 2017. Journalists reviewed court and property records, social media, and other publicly available documents. Those excluded had owned or operated home health care agencies, medical equipment companies, mental health facilities, and more. They’d submitted false claims, received kickbacks for referrals, billed for care that was not provided, and harmed patients who were poor and old, in some cases by stealing their medication or by selling unneeded devices to unsuspecting Medicare enrollees. One owner of an elder care home was excluded after he [pleaded guilty](https://www.documentcloud.org/documents/23378955-floro-sentencing-and-guilty-two-counts?responsive=1&title=1) to [sexual assault](https://www.arkansasonline.com/news/2018/dec/04/bentonville-man-jailed-in-sexual-assaul/). Among those sampled, KHN found: - Eight people appeared to be serving or served in roles that could violate their bans; - Six transferred control of a business to family or household members; - Nine had previous, unrelated felony or fraud convictions, and went on to defraud the health care system; - And seven were repeat violators, some of whom raked in tens of millions of federal health care dollars before getting caught by officials after a prior exclusion. The exclusions list, according to Blank and other experts, is meant to make a person radioactive — easily identified as someone who cannot be trusted to handle public health care dollars. But for business owners and executives, the system is devoid of oversight and rife with legal gray areas. One man, Kenneth Greenlinger, [pleaded guilty](https://www.documentcloud.org/documents/23321299-greenlinger-plea-agreement?responsive=1&title=1) in 2016 to submitting “false and fraudulent” claims for medical equipment his California company, Valley Home Medical Supply, never sent to customers that totaled more than $1.4 million to Medicare and other government health care programs, [according to his plea agreement](https://www.documentcloud.org/documents/23321299-greenlinger-plea-agreement?responsive=1&title=1). He [was sentenced](https://www.documentcloud.org/documents/23321018-greenlinger-sentencing-fina?responsive=1&title=1) to eight months in federal prison and ordered to pay restitution of more than $1 million, according to court records. His company [paid more than $565,000](https://www.justice.gov/usao-cdca/pr/san-fernando-valley-medical-supply-company-defrauded-federal-health-care-programs-pays) to resolve allegations of false claims, according to the Justice Department website. Greenlinger was handed a 15-year exclusion from Medicare, Medicaid, and any other federal health care program, starting in 2018, according to the OIG. But this October, Greenlinger announced a health care business with government contracts for sale. [Twice on LinkedIn](https://www.documentcloud.org/documents/23321014-greenlingerselldme?responsive=1&title=1), Greenlinger [announced](https://www.documentcloud.org/documents/23321022-greenlinger-saying-owns-dme-company?responsive=1&title=1): “I have a DME \[durable medical equipment\] company in Southern California. We are contracted with most Medicare and Medi-Cal advantage plans as well as Aging in Place payers. I would like to sell,” adding a Gmail address. Reached by phone, Greenlinger declined to comment on his case. About the LinkedIn post, he said: “I am not affiliated directly with the company. I do consulting for medical equipment companies — that was what that was, written representing my consulting business.” His wife, Helene, who previously worked for Valley Home Medical Supply, is now its CEO, according to [LinkedIn](https://www.documentcloud.org/documents/23321023-greenlingerhelenelinkedin?responsive=1&title=1) and documentation from the [California Secretary of State](https://www.documentcloud.org/documents/23321017-greenlinger-wife-on-biz-docs?responsive=1&title=1) office. Although Helene has a LinkedIn account, she told KHN in a telephone interview that her husband had posted on her behalf. But Kenneth posted on and commented from his LinkedIn page — not his wife’s. At Valley Home Medical Supply, a person who answered the phone last month said he’d see whether Kenneth Greenlinger was available. Another company representative got on the line, saying “he’s not usually in the office.” Helene Greenlinger said her husband may come by “once in a while” but “doesn’t work here.” She said her husband doesn’t do any medical work: “He’s banned from it. We don’t fool around with the government.” “I’m running this company now,” she said. “We have a Medicare and Medi-Cal number and knew everything was fine here, so let us continue.” **No Active Enforcement** Federal regulators do not proactively search for repeat violators based on the exclusion list, said Gabriel Imperato, a managing partner with Nelson Mullins in Florida and former deputy general counsel with HHS’ Office of the General Counsel in Dallas. He said that for decades he has seen a “steady phenomenon” of people violating their exclusions. “They go right back to the well,” Imperato said. That oversight gap played out during the past two years in two small Missouri towns. Donald R. Peterson co-founded Noble Health Corp., a private equity-backed company that bought two rural Missouri hospitals, just months after he’d agreed in August 2019 to [a five-year exclusion](https://oig.hhs.gov/fraud/enforcement/kansas-infusion-company-owner-agrees-to-voluntary-exclusion/) that “precludes him from making any claim to funds allocated by federal health care programs for services — including administrative and management services — ordered, prescribed, or furnished by Mr. Peterson,” said Jeff Morris, an attorney representing Peterson, [in a March letter to KHN.](https://www.documentcloud.org/documents/21969554-2022_03_14-morris?responsive=1&title=1) The prohibition, Morris said, also “applies to entities or individuals who contract with Mr. Peterson.” That case involved a company Peterson created called IVXpress, now operating as IVX Health with infusion centers in multiple states. Peterson left the company [in 2018](https://www.documentcloud.org/documents/23316421-2022_03_15-don-peterson_linkedin?responsive=1&title=1), according to his LinkedIn, after the settlement with the government showed [a whistleblower accused him](https://www.documentcloud.org/documents/21719400-1#document/p1/a2103683) of altering claims, submitting false receipts for drugs, and paying a doctor kickbacks. He settled the resulting federal charges [without admitting wrongdoing](https://www.documentcloud.org/documents/23379071-2#document/p1/a2179859). His settlement agreement provides that if he violates the exclusion, he could face “criminal prosecution” and “civil monetary penalties.” In January 2020, Peterson was listed in [a state registration document](https://www.documentcloud.org/documents/21881941-2020_01_14-biennialregistration?responsive=1&title=1) as one of two Noble Health directors. He was also listed as the company’s secretary, vice president, and assistant treasurer. Four months later, in April 2020, Peterson’s name appears on a [purchasing receipt](https://www.documentcloud.org/documents/23321057-fmc-inv01_0001#document/p2/a2177362) obtained under the Freedom of Information Act. In addition to Medicare and Medicaid funds, Noble’s hospitals had received [nearly $20 million](https://kffhealthnews.org/news/article/noble-health-platinum-health-private-equity-hospital-workers-fired/) in [federal covid relief money](https://taggs.hhs.gov/Coronavirus/Providers). A social media account with a photo that appears to show Peterson announced the launch of Noble Health in [February 2020](https://www.documentcloud.org/documents/21718326-2020_02_29_noble_nueterra-screen-grab?responsive=1&title=1). Peterson identified himself on Twitter as [executive chairman](https://www.documentcloud.org/documents/21760158-2021_09_07peterson-twitter) of the company. It appears federal regulators who oversee exclusions did not review or approve his role, even though information about it was publicly available. Peterson, whose name does not appear on the hospitals’ [Medicare applications](https://www.documentcloud.org/documents/21985869-working-copy-855a_responsive-documents_100120217026?responsive=1&title=1), said by email that his involvement in Noble didn’t violate his exclusion in his reading of the law. He said he owned only 3% of the company, citing OIG guidance — federal regulators may exclude companies if someone who is banned [has ownership of 5% or more](https://www.documentcloud.org/documents/23321079-2013-oig-guideline#document/p11/a2177376) of them — and he did not have a hand in operations. Peterson said he worked for the corporation, and the hospitals “did not employ me, did not pay me, did not report to me, did not receive instructions or advice from me,” he wrote in a November email. A [2013 OIG advisory](https://www.documentcloud.org/documents/23321079-2013-oig-guideline#document/p8/a2178518) states that “an excluded individual may not serve in an executive or leadership role” and “may not provide other types of administrative and management services … unless wholly unrelated to federal health care programs.” Peterson said his activities were apart from the business of the hospitals. “My job was to advise Noble’s management on the acquisition and due diligence matters on hospitals and other entities it might consider acquiring. … That is all,” Peterson wrote. “I have expert legal guidance on my role at Noble and am comfortable that nothing in my settlement agreement has been violated on any level.” For the two hospitals, Noble’s ownership ended badly: The Department of Labor opened [one of two investigations](https://www.documentcloud.org/documents/22127911-2022-03-02-dol_noble?responsive=1&title=1) into Noble this March in response to [complaints from employees](https://kffhealthnews.org/news/article/noble-health-platinum-health-private-equity-hospital-workers-fired/). Both Noble-owned hospitals suspended services. Most employees were furloughed and then lost their jobs. Peterson said he left the company in August 2021. That’s the same month state regulators cited one hospital for deficiencies that put patients “[at risk for their health and safety](https://www.documentcloud.org/documents/21719887-2021_08_25-callaway-documents-working-copy#document/p3/a2104986).” If federal officials determine Peterson’s involvement with Noble violated his exclusion, they could seek to claw back [Medicaid and Medicare payments](https://oig.hhs.gov/exclusions/effects_of_exclusion.asp#:~:text=An%20excluded%20individual%20or%20entity%20that%20submits%20a%20claim%20for,D%29%20of%20the%20Act%29.) the company benefited from during his tenure, according to OIG records. **Topics:** Public Awareness, Regulatory actions --- ### [Insurance Fraud Costs Americans $309 Billion a Year -- Here's How to Protect Yourself](https://insurancefraud.org/news_archives/insurance-fraud-costs-americans-309-billion-a-year-heres-how-to-protect-yourself/) **Published:** September 14, 2026 **Author:** Diane Beauchamp **Content:** A [recent study](https://insurancefraud.org/wp-content/uploads/The-Impact-of-Insurance-Fraud-on-the-U.S.-Economy-Report-2022-8.26.2022.pdf) conducted by the Coalition Against Insurance Fraud found that insurance fraud costs Americans $309 billion every year. With such a huge financial burden being placed on American families, it’s no wonder that many people are looking for ways to [protect themselves](https://www.fool.com/money/insurance/homeowners/articles/is-your-home-insured-for-a-natural-disaster/?luri=%2Finsurance%2Farticles%2Finsurance-fraud-costs-americans-309-billion-a-year-heres-how-to-protect-yourself%2F&furi=%2Finsurance%2Farticles%2Finsurance-fraud-costs-americans-309-billion-a-year-heres-how-to-protect-yourself%2F&fuuid=bba6d683-9247-452d-aabe-f755d1d46efb&luuid=bba6d683-9247-452d-aabe-f755d1d46efb<yp=txt) from becoming victims of insurance fraud. ## What is insurance fraud? Insurance fraud is any type of deception used to obtain an insurance payout. It can be committed by policyholders, insurers, or third-party providers. There are many different types of insurance fraud, according to the report some of the most common include: - **Workers’ compensation fraud:** This is when someone files a claim for benefits they are not entitled to receive. For example, they may exaggerate the extent of their injuries. - **Premium fraud:** This is when someone misrepresents information in order to pay a smaller premium. For example, an applicant may misrepresent the safety features of their car, its location, the drivers, and vehicle use to get a [lower auto insurance premium](https://www.fool.com/money/insurance/auto/?luri=%2Finsurance%2Farticles%2Finsurance-fraud-costs-americans-309-billion-a-year-heres-how-to-protect-yourself%2F&furi=%2Finsurance%2Farticles%2Finsurance-fraud-costs-americans-309-billion-a-year-heres-how-to-protect-yourself%2F&fuuid=bba6d683-9247-452d-aabe-f755d1d46efb&luuid=bba6d683-9247-452d-aabe-f755d1d46efb<yp=txt). - **Healthcare fraud:** This is where a provider bills for services not rendered or submits a claim for a more complex service with a higher reimbursement rate. ## How does insurance fraud affect you? Insurance fraud affects everyone in the United States. Because insurance companies have to pay out fraudulent claims, they ultimately raise the cost of premiums and out-of-pocket expenses for all policyholders. The 2022 study found that insurance fraud cost Americans $309 billion a year. This is the equivalent of $900 per person, or $3,800 for a family of four. ## How to protect yourself from insurance fraud There are a few things you can do to protect yourself from becoming a victim of insurance fraud. First, be aware of the most common types of fraud. This will help you identify the signs of insurance fraud. For example, if you’re in an accident and the other driver seems eager to settle out of court or pushes you to use a certain repair shop, they may be trying to commit fraud. If you receive an unsolicited call from someone claiming to be from your insurance company, beware! It could be a scammer trying to get your personal information. If you suspect that someone is trying to commit insurance fraud, you can report it to your state’s Department of Insurance. All suspected fraud that is reported to the consumer hotline is typically forwarded to the fraud division for investigation. Other organizations you can contact are the FBI, the National Insurance Crime Bureau (NICB), the Coalition Against Insurance Fraud (CAIF), and the National Association of Insurance Commissioners (NAIC). If you think you may have personally been the victim of insurance fraud, file a police report and contact the relevant organizations. Don’t forget to also contact your insurance company, as they may also have a department to investigate the potential fraud. By taking these steps, you can help protect yourself and others from falling prey to this costly crime. No one wants to become the victim of insurance fraud, but unfortunately, it’s something that happens far too often. By being aware of the types of fraud that exist and taking steps to protect yourself, you can help ensure that you don’t become another statistic. Do your research and always be on the lookout for red flags that could indicate someone is trying to commit fraud. If you think you may have been the victim of fraud, take action immediately by reporting it to the proper authorities. **Topics:** Coalition Against Insurance Fraud, Public Awareness --- ### [Brandon Nurse Pleads Guilty To Unlawful Drug Distribution And Acquiring Controlled Substances By Fraud](https://insurancefraud.org/news_archives/brandon-nurse-pleads-guilty-to-unlawful-drug-distribution-and-acquiring-controlled-substances-by-fraud/) **Published:** September 14, 2026 **Author:** Diane Beauchamp **Content:** United States Attorney Roger B. Handberg announces that Jacquelyn DeVito (40, Brandon) has pleaded guilty to 10 counts of unlawful distribution of a controlled substance and 1 count of acquiring a controlled substance by fraud. DeVito faces a maximum penalty of 20 years in federal prison for each unlawful drug distribution count and up to 4 years in federal prison for acquiring a controlled substance by fraud. DeVito has also agreed to forfeit and relinquish her Florida advanced practice registered nurse (“APRN”) license and her registered nurse (“RN”) license and not to reapply for a DEA registration number. According to the plea agreement, between March 2020 and June 2022, DeVito worked as an ARNP and RN at an urgent care medical office where she introduced herself to patients and offered to provide separate home health services through her privately-owned company, Bee Home Medical LLC. By signing up these patients, she acquired their names and dates of birth for the purpose of using the information to prescribe oxycodone, a Schedule II controlled substance, without their knowledge or consent (collectively “Victim Patients”). DeVito issued prescriptions for oxycodone in the names of the Victim Patients to local retail pharmacies for the pharmacists to dispense the controlled substances. When the prescriptions were filled and ready to be picked up, DeVito went to the pharmacies and acquired the controlled substances by misrepresenting and deceiving the pharmacists by telling them she was the Victim Patients’ caregiver and was picking up the controlled substances on their behalf. During the Drug Enforcement Administration’s investigation, several Victim Patients were identified who had no knowledge DeVito issued the prescriptions in their names and confirmed that there was no legitimate need for them to receive oxycodone medication. DeVito prescribed and acquired more than 2,900 oxycodone pills. This case was investigated by the Drug Enforcement Administration—Tampa District Office and the Opioid Fraud and Abuse Detection Unit. The Opioid Fraud and Abuse Detection Unit was created by the Department of Justice to help combat the devastating opioid crisis. The Opioid Fraud and Abuse Detection Unit focuses specifically on opioid-related health care fraud, using data to identify and prosecute individuals contributing to the prescription opioid epidemic. The case is being prosecuted by Assistant United States Attorney Greg Pizzo. **Topics:** Drug Diversion **Categories:** Conviction --- ### [Health care 'freeloaders' targeted by Yoon in insurance reform push](https://insurancefraud.org/news_archives/health-care-freeloaders-targeted-by-yoon-in-insurance-reform-push/) **Published:** September 14, 2026 **Author:** Diane Beauchamp **Content:** President Yoon Suk-yeol took aim at healthcare “freeloaders,” saying that the overly generous benefits offered first under the previous administration have to be scaled back to prevent fraud and waste. “The reckless health insurance coverage expansion based on populist policies is bankrupting the national health insurance program,” Yoon said during the cabinet meeting on Tuesday. “The normalization of health insurance, which is the last safeguard in protecting the people’s health, is urgent,” Yoon said. “In the last five years, some 20 trillion won was spent to strengthen coverage. “Yet as the government has ignored medical service abuse and freeloaders, that cost has been paid by the majority of the people.” Reforming health care is not a choice, he argued, but a necessity. “We need to strengthen the requirements for health insurance recipients and prevent waste and leakage in health insurance,” Yoon said. “The resources saved will then be used to support people caught in medical blind spots.” Health care benefits can be reduced by the executive by adjusting policy, though any increase in benefits might require legislation. The president stressed that the central purpose of national health insurance is to provide medical bill coverage for people in need, such as patients with serious illnesses whose medical bills are high. “We will improve sustainability while strengthening the necessary medical services and the treatment of patients with serious illnesses,” Yoon said. The government also plans to change rules for foreigners in Korea, as some recent arrivals have sought expensive care. Abuse of national health insurance has become a major key concern. According to a study by the Finance Ministry and the Health Ministry, in one case, a person in his or her 60s last year received 1,425 outpatient treatments, including physical therapy, at 19 different medical centers. On one day, the person visited eight medical centers. The government noted that some patients treated physical therapy as massages while billing national health insurance. In another case, a 40-year-old patient with a simple headache last year was given several tests, including an MRI. The national health insurance paid 720,000 won for the MRI, which turned out to be unnecessary. A 52-year-old with indigestion was given six different medical tests including an ultrasound test, and 1.15 million won was covered by national health insurance. The cost for national health insurance-covered MRIs, which was one of key symbols of expanded medical service under the previous administration, surged from 189.1 billion won in 2018 to 1.8 trillion won last year. This year, the national health insurance is expected to record a 1 trillion won surplus, which is a drop from 2.8 trillion won last year. Next year it is expected to record a 1.4 trillion won deficit. Policyholder reserves, currently 21 trillion won, will be exhausted by 2028. A rapidly aging population is heavily taxing health insurance finances, and the expanded coverage under the previous administration made the situation worse. Measures being considered by the Health Ministry include a limit to testing covered by national health insurance and capping the number of medical centers a person can visit in a single day. **Topics:** Public Awareness, Regulatory actions --- ### [Ecommerce Fraud in Kenya Goes Up 42 Percent Compared to 2021](https://insurancefraud.org/news_archives/ecommerce-fraud-in-kenya-goes-up-42-percent-compared-to-2021/) **Published:** September 14, 2026 **Author:** Diane Beauchamp **Content:** E-commerce is a big thing in many economies, including Kenya, because it allows shoppers to access products and services from the comfort of their internet-enabled devices. Hundreds of these platforms exist in the country and continue [to grow from time to time](https://techweez.com/2022/12/05/ecommerce-kapu-launches-in-kenya/). However, a new study has determined that 15% of all global e-commerce transactions reviewed between November 24-28 were potentially fraudulent. For transactions originating from Kenya, **5.4%** of e-commerce transactions during that period were suspected to be fraudulent. The analysis, which was done by TransUnion, also determined that the average number of suspected digital fraud attempts on any given day during that holiday period globally was 82% higher than during the rest of the year (Jan. 1, 2022, to Nov. 23, 2022). For transactions originating in Kenya, this percentage was 15% lower than during the rest of the year and 42% higher than in the same period in 2021. The study also revealed the share of suspected digital fraud attempts for each individual day in the holiday shopping period for transactions in Kenya and globally. TransUnion also revealed in the analysis the top types of fraudulent e-commerce transactions globally. This year, promotion abuse (user abuses site promotions such as refer-a-friend, free giveaways, etc.) and account takeover (someone other than the owner of an account uses it without permission, indicating that the account has been maliciously compromised) were the top types of digital fraud in retail. **Risky Transactions During Holiday Period** | **Day** | **Transactions in Kenya** | **Globally** | |---|---|---| | Thursday, November 24 | 25% | 14% | | Friday, November 25 | 20% | 25% | | Saturday, November 26 | 16% | 21% | | Sunday, November 27 | 15% | 18% | | Monday, November 28 | 23% | 22% | The increase of suspected digital fraud during the traditional busiest days of the holiday shopping season occurred as consumers express concern about being victimized. TransUnion’s 2022 Consumer Holiday Shopping Survey found that 63% of Kenyan consumers are concerned with being victimized by online fraud this holiday season. TransUnion monitors digital fraud attempts reported by businesses in varied industries such as gambling, gaming, financial services, healthcare, insurance, retail, and travel and leisure, among others. The conclusions are based on intelligence from billions of transactions and more than 40,000 websites and apps. “Online retailers must equip themselves with the proper tools to detect fraud at the first warning sign, and without inhibiting the consumer journey,” said Morris Maina, chief executive officer TransUnion Kenya. “It’s more important than ever that these online retailers implement holistic fraud solutions that are able to verify customer identity and authenticity at the very beginning of a transaction without resulting in false positives that may cost them legitimate transactions.” **Topics:** Financial Fraud, Technology --- ### [Delhi: Police bust insurance fraud, seized forged government documents](https://insurancefraud.org/news_archives/delhi-police-bust-insurance-fraud-seized-forged-government-documents/) **Published:** September 14, 2026 **Author:** Diane Beauchamp **Content:** Delhi Police have busted a gang committing insurance fraud in the name of union finance ministry, officers aware of the matter said on Tuesday, adding that the accused used to pose as ministry officials and used documents on which they had forged finance minister Nirmala Sitharaman’s signature. Deputy commissioner of police (Intelligence Fusion and Strategic Operations) Prashant Gautam said the accused have been identified as Mehtab Alam (33), Sartaj Khan (31), Mohammed Junaid (29) and Deen Mohammed (27). Police said they also received a communication from ministry regarding financial fraud, impersonation and using forged documents, with a fake letter issued bearing the minister’s signature also attached. In the complaint that led to the case, the victim said he received a call from a person who identified himself as Chaman Lal, who told him that some amount was sanctioned against his lapsed insurance policy. The victim was then asked to provide his email id. Subsequently, a letter was sent to the victim via <dicgc@rbidepartment.org.in> — a fake email id — wherein he was informed that an amount of ₹12,46,518 was sanctioned against his lapsed insurance policies. “He was initially asked to pay ₹44,000 as processing charges. When he paid the said amount, he was again asked to pay ₹27,000 as No Objection Certificate charges and when the victim paid the asked amount, a fake cheque of ₹12,46,518 was sent to the victim by the fraudsters through post,” DCP Gautam said. When the victim received the cheque, he was asked to pay ₹52,000 as the final fund release charges, and was told that without paying the said amount, he would not get the money on the cheque, taking the total amount he was cheated of to ₹1,27,000, police said. Based on the complaint, a case was registered and investigation was taken up. With the help of technical surveillance, police zeroed in on the location and identity of the suspects, who were found changing their locations. Thereafter, a police team conducted raids at and around their last known locations and apprehended Alam, the mastermind of the syndicate, from Mustafabad. Three of his associates — Khan, Junaid and Mohammed — were also traced and arrested. During interrogation, police said, it was revealed that the accused previously worked at insurance companies. They used to call insurance policy holders posing as officials from the Insurance Regulatory and Development Authority (IRDA), Reserve Bank of India (RBI) or finance ministry and lured them on pretext of providing the maturity amount against their existing or lapsed policies. In order to convince policy holders, the accused would send them emails with forged documents seemingly issued from government agencies, and would send fake cheques to the victims by post and then ask for various charges, such as processing charges, NOC charges and fund-releasing charges. “Upon getting the cheques, the gullible victims used to transfer the amount into the accounts provided by accused persons and then the accused would withdraw the cheated amount from different locations in Delhi,” the DCP said. **Topics:** Financial Fraud **Categories:** Arrest --- ### [Law firm busted for insurance fraud by impersonating a client](https://insurancefraud.org/news_archives/law-firm-busted-for-insurance-fraud-by-impersonating-a-client/) **Published:** September 14, 2026 **Author:** Diane Beauchamp **Content:** Asons Solicitors, a defunct medico-legal firm, has been found liable for making a fraudulent claim by impersonating a client without their knowledge. The case was brought by insurer First Central, represented by specialist law firm HF. According to HF, the claim by Asons came after a road traffic accident in October 2014. This claim included a medical report prepared by Dr Michaela Coman, a GP expert instructed by Asons via TMT Medicals. In a strikingly similar scenario. Haroon Karim, a former director of TMT Medicals, was sentenced to jail time in 2019 for his role in advancing a claim, again via Asons Solicitors, in the name of a man who had no knowledge of the proceedings, HF said. The supposed claimant did not engage with the litigation, which led to HF securing a costs order against him for around £8,000. However, when HF pursued him for the payment, the claimant revealed that he had no knowledge of the claim and that he was not even involved in an accident. After the supposed claimant proved that he had nothing to do with the incident, First Central and AF pursued Asons, Coman and Karim for wasted costs of around £30,000. “Insurers and the public must have trust in those representing claimants,” said Alex Wilkinson, partner at HF. “Asons Solicitors have been shown time and again to have singularly failed in establishing that trust. Haroon Karim, too, is someone who I have tackled before in respect of his dishonest conduct. Their actions, and the actions of Dr Coman in not carrying out her duties to the required standard, cast a stain over the whole industry. First Central’s decision to tackle this shoddy practice will, I hope, send a message that, if claims are advanced dishonestly, then those responsible – including the ‘professionals’ running the claim – should expect to face punishment.” “We are committed to properly compensating those who have genuine claims arising out of road traffic accidents,” said Paul Priestley, counter fraud director at First Central. “We vigorously investigate potential dishonesty, and it is a disappointing facet of the current claims industry that those investigations too often end up with dishonesty being found on the part of a claimant’s representatives. I am pleased we have been able to send out a message to the industry that standards must be better and demonstrated our willingness to take action against enablers when appropriate.” **Topics:** Insider Fraud, Judicial/courts --- ### [Expensive Living: Alberta faces highest auto insurance rates of any province, says ICBC report](https://insurancefraud.org/news_archives/expensive-living-alberta-faces-highest-auto-insurance-rates-of-any-province-says-icbc-report/) **Published:** September 14, 2026 **Author:** Diane Beauchamp **Content:** Albertans are paying the highest auto insurance rates in Canada, according to a Insurance Corporation of British Columbia (ICBC) report released Dec. 8. According to the [original report from the ICBC website,](https://www.icbc.com/about-icbc/company-info/Documents/Canadian-Insurance-Rate-Comparisons-Oct-2022.pdf) data was compiled from automotive insurance rates starting from Sept. 1, across nine provinces. Out of 27 customer profiles varying by demographic, number of drivers, vehicle and accident history, Alberta’s rates were the highest of any province for 26 of these profiles. This data was criticized by an Insurance Bureau of Canada (IBC) spokesperson, dismissing it as an ICBC commissioned report that reflected favourably on ICBC. “That’s not how anyone shops around, and that’s not how any consumer makes a decision,” said Aaron Sutherland, v-p of IBC who questioned why the report did not factor in discounts, benefit rates across provinces or the highest and lowest quotes sampled. According to the [2021 report by Alberta’s superintendent of insurance](https://open.alberta.ca/dataset/3d9d1330-365e-45b5-afbe-184bd20de918/resource/08e33b43-12ec-4345-a833-02612105cfd3/download/tbf-superintendent-of-insurance-annual-report-2021.pdf), Albertan insurers collected $6.1 billion in premiums and paid out $3.7 billion in claims in 2021—a 60 percent payout. By contrast, 2020 saw a 77 percent payout while 2019 saw a 79 percent payout. The report highlights that the payout metric does not account for other costs, such as operational and administrative fees. The initial ICBC report was further contested by the Insurance Brokers Association of Alberta, with IBAA president Barry Haggis criticizing it for “appearing to extoll the virtues of public insurance, should be read with a healthy dose of skepticism.” “We have serious concerns that the methodology used paints a skewed picture of Alberta’s auto insurance market and presents misleading findings as to the prices drivers are paying,” elaborates Haggis. ICBC is [projected to lose $298 million](https://www.collisionrepairmag.com/cash-for-the-furnace-insurance-bureau-says-icbc-on-track-to-lose-298-million-this-year/) in the 2022/23 fiscal year, according to a recent IBC report. **Topics:** Public Awareness --- ### [Top court says Yoon's mother-in-law innocent in health fraud case](https://insurancefraud.org/news_archives/top-court-says-yoons-mother-in-law-innocent-in-health-fraud-case/) **Published:** September 14, 2026 **Author:** Diane Beauchamp **Content:** The Supreme Court on Thursday finalized a not-guilty verdict for President Yoon Suk-yeol’s mother-in-law accused of taking state health insurance benefits after illegally opening a care hospital. The 76-year-old mother of first lady Kim Keon-hee was charged with opening the long-term care hospital for the elderly in February 2013 without a medical license and illegally accepting 2.29 billion won ($1.76 million) in state benefits from the National Health Insurance Service until 2015 in collaboration with three business partners. Choi pleaded innocence, saying she merely listed herself as a co-chair of a medical foundation overseeing the hospital after offering a loan for the establishment of the foundation. She also claimed she was not involved in opening or operating the facility. A district court had given her a three-year jail term last year, finding her guilty of “active involvement” in establishing and managing the hospital. The Seoul High Court in January struck down the prison sentence and acquitted her of all the charges, citing a lack of evidence. The Supreme Court on Thursday upheld the lower court’s acquittal of Choi, again citing insufficient evidence. “If prosecutors’ case against a defendant fails to be convincing enough to shake off the judge’s reasonable doubt, the court is required to rule in favor of the defendant despite lingering suspicions,” a court official said of the verdict. An investigation into the case began in 2015, but only the three business partners were implicated and convicted at that time. The case was later reopened after a group of people, including now opposition lawmaker Rep. Choe Kang-wook, filed a complaint in April 2020 over various allegations involving Yoon and his family. Yoon was serving as prosecutor general when the complaint was filed. **Topics:** Judicial/courts, Unlicensed entities --- ### [Former agent receives eight-year industry ban in Singapore](https://insurancefraud.org/news_archives/former-agent-receives-eight-year-industry-ban-in-singapore/) **Published:** September 14, 2026 **Author:** Diane Beauchamp **Content:** The Monetary Authority of Singapore ([MAS](https://www.insurancebusinessmag.com/asia/companies/mas/61360/)) has issued eight-year prohibition orders (POs) against Selvarajulu s/o Subramaniam, a former representative of The [Great Eastern](https://www.insurancebusinessmag.com/asia/companies/great-eastern/61348/) Life Assurance Company, after he was convicted of cheating. The POs, which take effect today, prohibit Selvarajulu from providing any financial advisory services, and from taking part in the management, acting as a director, or becoming a substantial shareholder of any financial advisory firm under the Financial Advisers Act 2001, the MAS said. He is also prohibited from carrying on business as, and from taking part in the management of, any insurance intermediary under the Insurance Act 1966. In September 2021, Selvarajulu was convicted of four counts of cheating, having defrauded nine customers for a total of $G58,000 between September 2017 and July 2019. Another seven counts of cheating were taken into consideration, and he was sentenced to 17 months’ imprisonment. In two of the victims’ cases, they were made to believe that they would be able to reinstate the cash value of their policies through a “refunding plan”, which was in fact a policy loan. Selvarajulu later instructed them to transfer part of the monies they had received from the policy loan to him. One victim was made to believe that he was required to pay penalty fees to keep his Great Eastern insurance policies active, but Selvarajulu pocketed the money. Another victim was deceived into giving Selvaraju money, after the fraudster said he was being treated for lung cancer. “Mr Selvarajulu’s convictions gave MAS reason to believe that he has not performed, and will not perform, the type of financial advisory service for which he was appointed honestly,” the regulator said. **Topics:** Insider - agent, Life Insurance **Categories:** Conviction --- ### [EACC Earmarks Dozens of Hospitals in New NHIF Scam](https://insurancefraud.org/news_archives/eacc-earmarks-dozens-of-hospitals-in-new-nhif-scam/) **Published:** September 14, 2026 **Author:** Diane Beauchamp **Content:** The Ethics and Anticorruption Commission (EACC) renewed its efforts to deal with dozens of hospitals involved in corrupt deals touching on National Health Insurance Fund (NHIF) claims. In addition to that, the anti-graft body disclosed that it was investigating individuals who connived with the hospitals to defraud the fund of millions of [shillings through fictitious claims.](https://www.kenyans.co.ke/node/37272) Speaking during the official launch of the Integrity Programme for the board of directors of the NHIF at a Naivasha hotel on Wednesday, December 14, EACC Chairperson Archbishop (Rtd) Eliud Wabukala indicated that the agency had taken a proactive approach in the deal with graft. “The commission has averted a loss of approximately Ksh32.5 billion through proactive investigations and disruption of graft networks,” Wabukala revealed. Wabukala also indicated that EACC is pursuing the forfeiture of corruptly acquired assets and unexplained wealth worth Ksh33 billion in courts across the country. “We want to see whether people at the board level of management for institutions embrace culture change,” Wabukala highlighted. He noted that the fraud was making the provision of health services very expensive thus affecting thousands of Kenyans who could not pay. “The fraud is happening between a hospital and a citizen and our public education awareness is geared towards making Kenyans know that participating in that is just making health very expensive,” he stated. Speaking at the same event, NHIF Chairman Lewis Nguyai admitted that the fake claims were there but quickly added that the introduction of biometrics for all members was helping address it. “In August last year, we concluded 100 per cent biometric registration, nowadays you don’t need to have an NHIF card,” Nguyai indicated adding that the move [curbed the issue of impersonation.](https://www.kenyans.co.ke/node/37416) Nguyai also warned that any facility found to have presented fake claims faces a three-year ban while the management would be prosecuted. In the last couple of years, some private hospitals were in the limelight after it emerged that they had defrauded NHIF through fake medical claims. **Topics:** Public Awareness, Regulatory actions --- ### [4 suspects, agri dept officials booked for crop insurance fraud](https://insurancefraud.org/news_archives/4-suspects-agri-dept-officials-booked-for-crop-insurance-fraud/) **Published:** September 14, 2026 **Author:** Diane Beauchamp **Content:** Four suspects along with other unidentified officials of the Haryana agriculture department were booked for an alleged attempt to claim insurance against destroyed crops by forging documents, police said on Tuesday. The suspects alleged that their crops were destroyed in Jamalpur village in Bilaspur and tried to claim insurance under the Pradhan Mantri Fasal Bima Yojana (PMFBY), when there has been no natural calamity in the village in the last four years, police added. Investigators said that the matter came to light when a few agriculture department officials reached the village on September 7, and started surveying agricultural land owned by Vikram Singh. They said that villagers informed Singh about the survey over the phone and he reached the spot to know that compensation for crop damage on his land was claimed under the PMFBY. Police said a woman from a nearby village, Ghosgarh, had allegedly submitted documents to the agriculture department, stating that she had taken the land on rent from Singh and had grown cotton, but it was damaged due to a natural calamity. Investigators said that Singh came to know that his signatures were forged to prepare fake rent documents and affidavit for claiming the insurance. An FIR has been filed against four persons, including the woman, her husband, his father, a block technology manager and unidentified agriculture department officials, police said. **Topics:** Crop insurance **Categories:** Arrest --- ### [Police unearth vehicle insurance scam](https://insurancefraud.org/news_archives/police-unearth-vehicle-insurance-scam/) **Published:** September 14, 2026 **Author:** Diane Beauchamp **Content:** Police have busted a fraud syndicate that was stage managing road traffic accidents countrywide and then making false police reports to claim money from insurance companies which cumulatively runs into thousands of United States dollars. The matter came to light after police separately arrested seven suspects in Harare who are linked to the scam. Police have also recovered various ZRP fake date stamps for several officers-in-charge of the traffic section which the suspects were using to forge documents to claim money from insurance companies. The suspects are the director of Panel Tech Motors, Henrics Providence Dhonga (30), Lloyd Makuzva (45) who is the company’s operations manager, Reality Njabulo Chuma (30) an insurance broker, Moheleza Kihahila (27) who is self-employed, Tinevimbo Clarence Marufu (31) who is employed by Tinogold Clothing Shop, Kudakwashe Kennedy Nyandoro (32), a surveyor with Forit Contractors Company, Onward Dewa (49) who was a salesman at the Bridge Car Sales in Groombridge and another suspect only identified as Munyaradzi Ramewa who is still at large. Some of the suspects have since appeared in court while others are assisting with investigations. It is alleged that sometime in May this year, Dhonga was approached by Munyaradzi Ramewa who told him that his vehicle was involved in an accident and was parked at his house in Mutare and asked him to repair it. On May 16, Dhonga is alleged to have insured Ramewa’s car, a white VW Touareg for US$90 000 through Chuma and the insurance had an expiry date of August 31, 2022. On August 14, Dhonga and Ramewa went to Mutare where they stage managed an accident involving the VW Touareg vehicle as a sole party. They then proceeded to ZRP Mutare Traffic to make a false report. It is alleged that on September 20, the two then made an insurance claim through Chuma to the effect that the car had been extensively damaged on its front, suspension, engine and gear box. The case came to light when Old Mutual Insurance Company officials discovered that the photos that were sent by Dhonga and Ramewa to them were different from those taken by a towing company, Road Angels, at the scene. A report was made. Further investigations by police revealed that in May 2022, Chuma had contacted one Debbie Tapera Dhonga who wanted his Nissan Tiida vehicle (AFR 9992) to be re-painted. During the same month, Dhonga sent one of his employees to collect the Nissan Tiida, which was parked at his company premises. Dhonga is alleged to have instructed his employee to side swipe the Nissan Tiida with a maroon Landcruiser belonging to one of his clients resulting in the Nissan Tiida having a scratch on the driver’s side as well as on the fenders. On May 15, 2022, Dhonga filled in a Cell Insurance Company claim alleging that the Nissan Tiida had been involved in an accident at the intersection of Jason Moyo Avenue and Julius Nyerere Way in Harare with a Toyota Passo (AEH 9457). The Toyota Passo belonged to Talent Mercy Muskwe who had a third party insurance under Alliance Insurance. However, Dhonga then used a fake police date stamp to authenticate the claim forms which they submitted to the insurance company but the matter came to light when the officials received a tip-off that the documents were fake. Acting on a tip off last Saturday, police arrested Dhonga and Makuzva at their workplace before they led detectives to the recovery of various police stamps in a black satchel at the back seat of a Mazda CX5 (AFF 1002). The recovered stamps are for Mutengi and Nkomo Attorneys, Member-in-Charge ZRP Chitungwiza Traffic, Officer-in-Charge ZRP Chegutu, Officer-in-Charge Operations ZRP Southerton Traffic, ZRP Traffic Marondera, Officer-in-Charge Administration Avondale Traffic, Officer-in-Charge ZRP Traffic Process, ZRP Warren Park Traffic in of Charge Crime, the Officer-in-Charge ZRP Norton, Member-in-Charge Crime ZRP Mbare Traffic and a plain date stamp. On Sunday, police also arrested Chuma after he was implicated in the scam. They appeared before Harare magistrate Mr Dennis Mangosi on Monday who denied Dhonga bail while Makuzva and Chuma were granted $50 000 bail each. Further investigations revealed that sometime in January, the other suspect, Kihahila was involved in an accident while driving an unregistered Mazda Atenza and he then approached Dhonga and Makuzva who promised to help him have full cover insurance for his car. They then made a false claim at Old Mutual Insurance company before completing an insurance claim form through the insurance broker, Chuma alleging that Kihahila had an accident with a Toyota Camry and a Ford Ranger. The suspects also made a false report at ZRP Southerton Traffic and Kihahila reported that his vehicle had been extensively damaged on the boot, boot lights, the whole left side, front lights, bumper back, bumper front, grille and bonnet. The insurance company then paid US$7 000 cash to Kihahila before they were tipped about the scam leading to the arrest of the suspect. Also on February 22, the fifth suspect, Marufu was involved in an accident with a woman driving a Mercedes Benz while he was driving his VW Golf 6 GTI (AFD 1478), which had a third party insurance cover. The scene was attended by police before Marufu towed the car to his house. At the end of February, Marufu was linked to Dhonga again who, again using the same modus operandi, claimed full insurance through Old Mutual, claiming US$9 000. Marufu was later arrested for the offence. The other suspects, Nyandoro was assisted to claim insurance from Old Mutual for his Nissan Sunny (AFH 4318) for US$1 200 when it had not been involved in an accident. The seventh suspect, Dewa was involved in an accident on Arcturus Road near Support Unit Chikuribi, Harare while driving his Toyota Mark II (AEL 2838) and he later had the vehicle towed to his home. He was referred to Dhonga who falsely made an insurance claim from Old Mutual Insurance alleging that on May 28, Nyandoro was involved in an accident along Prince Edward Road in Harare with Marufu who was driving a VW Golf 6 (AFD 1478), claiming insurance amounting to US$2 000. **Topics:** Auto - staged **Categories:** Arrest --- ### [Man staged road accident, roped in whole family to commit insurance fraud](https://insurancefraud.org/news_archives/man-staged-road-accident-roped-in-whole-family-to-commit-insurance-fraud/) **Published:** September 14, 2026 **Author:** Diane Beauchamp **Content:** After staging a road accident, he roped in his entire family to commit insurance fraud. Tan Lek Keong, 28, was jailed for eight months and 12 weeks and fined $4,400 on Thursday. He was also disqualified from driving for 10 months from the date of his release. He pleaded guilty to one count each of abetment by conspiracy to do a rash act and abetment by conspiracy to give false information, and two counts of abetment by conspiracy to cheat. Another four charges of engaging in a conspiracy to cheat were taken into consideration during sentencing. Tan worked for Teamwork Garage from February to May 2021 and was responsible for finding customers involved in accidents and explaining to them the benefits of getting their cars repaired at his workshop instead of authorised workshops. In March 2021, Tan and two colleagues from the workshop – Chew Kuo Choon, 25, and Koh Yi Ming, 28 – agreed to stage an accident using Tan’s car and lodge fraudulent insurance claims. This was so Chew could get commission for referring the damaged car to the workshop, and Tan could get free repairs for his car and any money from injury and damage claims. On March 24, Tan drove Chew and Koh around trying to stage an accident, but failed. The next day, they agreed Koh would drive instead, but Tan would falsely claim to be the driver. Only the three of them were in the car. At around 11.20am, they intentionally collided with a car along Marymount Road, damaging its bumper, which subsequently cost $200 to repair. No one was injured in the collision. Tan pretended to be the driver of the car, and later took his parents, wife and brother to a doctor. They all lied about experiencing pain in their necks and lower backs as a result of the accident, even though Tan’s family members were all at home during the “incident”. All five of them were given medical leave from March 25 to 29. Tan also made a false police report on March 26, lying that he was the driver of the car and his family members were in the car with him. False insurance claims were then made against Liberty Insurance through Teamwork Garage. In total, the claims for property damage and personal injury to Tan and his family amounted to more than $70,000. None of the money was paid out in the end. But Tan received $1,000 from Chew and Koh for using his family members as phantom passengers, and also around $2,500 for the vehicle damage and $900 for his personal injury claim from Teamwork Garage as commission for allowing his car to be repaired there. Deputy Public Prosecutor Seah Ee Wei said that while Tan’s charges were for abetment, his role was closer to that of a mastermind who had “marshalled his entire family to act as phantom passengers”. Koh and Chew’s cases are still before the courts, while Tan’s family members have not been charged. Tan is expected to begin serving his sentence on Nov 1. If he does not pay the fine by then, he will have to serve an additional two weeks’ jail as default. For each charge of abetting by conspiracy to cheat, Tan could have been jailed for up to 10 years and fined. **Topics:** Auto - staged **Categories:** Conviction --- ### [NSW man linked to $10m NDIS fraud syndicate jailed three years](https://insurancefraud.org/news_archives/nsw-man-linked-to-10m-ndis-fraud-syndicate-jailed-three-years/) **Published:** September 14, 2026 **Author:** Diane Beauchamp **Content:** A New South Wales man was today (Friday 16 December) sentenced to three years behind bars for his role in a multi-million-dollar fraud against the National Disability Insurance Scheme (NDIS). The Merrylands man, 24, faced the Sydney Downing District Court charged with dealing with proceeds of crime, over $1 million in value. He is linked to five people involved in an alleged Western Sydney crime syndicate charged for fraudulent NDIS claims totalling over $10 million in April 2021. The AFP launched Operation Pegasus in December 2020, in partnership with the National Disability Insurance Agency (NDIA), AUSTRAC (Australian Transaction Reports and Analysis Centre) and Services Australia, investigating several suspected fraudulent NDIS providers based in Western Sydney. In April 2021, AFP officers, forensic specialists and more than 50 partner agency members, conducted operational activity across Sydney, resulting in the arrests of five males and one female. Police identified the syndicate was allegedly operating across three companies to defraud the NDIS of millions of dollars in false claims. The man was linked to facilitating the withdrawal of the illicit funds from a bank account on behalf of the three companies. He pleaded guilty to: Dealing with proceeds of crime, over AUD1,000,000 in value, being cash with a total value of AUD2,197,050.00, contrary to Section 400.3(1) of the Criminal Code 1995 (Cth). He was sentenced to a non-parole period of three years and 18 months. **Topics:** Disability **Categories:** Conviction --- ### [Connecticut Physician and Urgent Care Practice Pay Over $4.2 Million to Settle False Claims Act Allegations](https://insurancefraud.org/news_archives/connecticut-physician-and-urgent-care-practice-pay-over-4-2-million-to-settle-false-claims-act-allegations/) **Published:** September 14, 2026 **Author:** Diane Beauchamp **Content:** Vanessa Roberts Avery, United States Attorney for the District of Connecticut, and Phillip Coyne, Special Agent in Charge for the U.S. Department of Health and Human Services, Office of the Inspector General, today announced that JASDEEP SIDANA, M.D. and DOCS MEDICAL GROUP, INC. (doing business as Docs Medical), DOCS MEDICAL INC., DOCS URGENT CARE LLP, LUNG DOCS OF CT, P.C., EPIC FAMILY PHYSICIANS, LLP, and CONTINUUM MEDICAL GROUP, LLC (collectively, “DOCS”), have entered into a civil settlement agreement with the federal and state governments in which they will pay a total of $4,267,950.21 to resolve allegations that they submitted false claims for payment to Medicare and the Connecticut Medicaid program for medically unnecessary allergy services, unsupervised allergy services, and services improperly billed as though provided by Sidana. The agreement also resolves allegations that Sidana and DOCS improperly billed for certain office visits associated with COVID-19 tests. Sidana is a physician who specializes in pulmonology and is the owner and Chief Executive Officer of DOCS, a medical practice with more than 20 facilities throughout Connecticut that offers a variety of services to its patients, including primary and urgent care, allergy testing and treatment, and COVID testing. Medicare and Connecticut Medicaid pay only for services or items that are medically necessary. Some services also have supervision requirements, and allergy tests and the preparation of allergy immunotherapy must be directly supervised by a physician. Direct supervision requires the supervising physician to be present in the same office suite, and immediately available to render assistance if needed. In early 2014, DOCS and Sidana started providing allergy testing and treatment services to their patients. The government alleges that between October 1, 2016, and September 30, 2017, DOCS and Sidana submitted false claims to Medicare and Medicaid for immunotherapy services that were not medically necessary, and were not directly supervised by a physician. The allegations also involve claims to Medicare and Medicaid for medically unnecessary annual re-testing of allergy patients between January 1, 2014, and November 11, 2018. The government also alleges that between January 1, 2014, and January 1, 2019, DOCS and Sidana submitted claims for medical services performed by Sidana on dates of service when he was traveling internationally and did not perform or supervise the services. Instead, the services were actually performed by lower-level providers, who typically receive a lower reimbursement rate from Medicare and Medicaid for such services. Finally, the government contends that when administering tests for COVID, DOCS and Sidana improperly billed Medicare and Connecticut Medicaid for certain evaluation and management (“E&M”) services, commonly referred to as office visits. The government alleges that between April 1, 2020, and December 31, 2020, on the same dates that patients received COVID-19 tests, DOCS and Sidana submitted claims for moderately complex “level 3” E&M services, when those level 3 office visits were not in fact provided. “Depriving Medicare and Medicaid programs of federal funds that have been set aside for the care and treatment of beneficiaries is disgraceful,” said U.S. Attorney Avery. “Medical services billed to Medicare and Medicaid must be provided based on each patient’s individual medical needs. Providers who participate in government programs must only bill for medically necessary services, and must accurately bill for the services provided. This office is committed to vigorously pursuing health care providers who submit false or fraudulent claims to federal health care programs.” “Healthcare providers are expected to closely follow Medicare rules and bill properly — nothing more, nothing less,” said Special Agent in Charge Phillip M. Coyne of the U.S. Department of Health and Human Services, Office of Inspector General. “When that obligation is violated, government health care programs – and American taxpayers – pay the price. We are committed to pursuing these types of allegations along with our law enforcement partners as we work to protect the integrity of our federal healthcare system.” As part of this settlement, DOCS and Sidana have entered into a three-year Integrity Agreement with the Department of Health and Human Services, Office of the Inspector General that is designed to ensure future compliance with the requirements of federal healthcare programs. This matter was investigated by the Office of the Inspector General for the Department of Health and Human Services, and the Connecticut Office of the Attorney General. This case was prosecuted by Assistant U.S. Attorney Sara Kaczmarek, with the assistance of Auditor Kevin Saunders, and by Deputy Associate Attorney General Gregory O’Connell of the Attorney General’s Office. **Topics:** Judicial/courts, Medicare/Medicaid --- ### [Police warn residents of Hamilton phone scam](https://insurancefraud.org/news_archives/police-warn-residents-of-hamilton-phone-scam/) **Published:** September 14, 2026 **Author:** Diane Beauchamp **Content:** A warning from Hamilton police. Scammers are calling you and pretending to be police officers. During the call, scammers will say they they have warrants for your arrests because of missing jury duty. They go on to tell you that a fine needs to be paid. They’re demanding up to $1500. One woman became a victim. “This guy was very nice,” Lori Vaughn said. “He knew the law. He had all the instructions, and everything sounded legit.” She said the caller ID even displayed Hamilton police department’s actual number. It’s why she thought it was real. During the phone call, she said the scammer wouldn’t let her hang up. Along with saying she had to pay a fine, he also made other bogus claims. “He said there was a certified letter that was mailed to my house that was signed by me,” Vaughn said. “ I couldn’t recall so I was frantic because I’m not a criminal. I started crying because I don’t have that kind of money.” He originally demanded $1300 but accepted $300 instead. She was told to transfer the money to a Zelle account. However, she later realized it was a scam after talking to her relatives. she fell for what experts say is the core of scammers techniques. “They really try and take advantage of your emotions,” cognitive psychologist Alan Castel said. “Really putting you in stressful situations, making you rush to make decisions. “ It’s important to remember, that police would never call and demand money from you to take care of a warrant. The best thing to do is hang up and call the police to confirm if you spoke to an actual officer. Experts say speaking up also makes a difference. “You shouldn’t feel ashamed because other people are in the same boat,” Castel said. “In fact you might be helping them by telling them about this scam that’s out there.” It’s exactly what Vaughn is doing. “It is embarrassing, but I guess it was just a lesson learned,” Vaughn said. **Topics:** Public Awareness --- ### [Justice Department Files Nationwide Lawsuit Against AmerisourceBergen Corp. and Subsidiaries for Controlled Substances Act Violations](https://insurancefraud.org/news_archives/justice-department-files-nationwide-lawsuit-against-amerisourcebergen-corp-and-subsidiaries-for-controlled-substances-act-violations-2/) **Published:** September 14, 2026 **Author:** Diane Beauchamp **Content:** In a civil complaint filed today, the Department of Justice alleges that AmerisourceBergen Corporation and two of its subsidiaries, AmerisourceBergen Drug Corporation and Integrated Commercialization Solutions, LLC (together “AmerisourceBergen”), collectively one of the country’s largest wholesale pharmaceutical distributors, violated federal law in connection with the distribution of controlled substances to pharmacies and other customers across the country, contributing to the prescription opioid epidemic. The complaint alleges that this unlawful conduct resulted in at least hundreds of thousands of violations of the Controlled Substances Act (CSA). The Justice Department seeks civil penalties and injunctive relief. “The Department of Justice is committed to holding accountable those who fueled the opioid crisis by flouting the law,” said Associate Attorney General Vanita Gupta. “Companies distributing opioids are required to report suspicious orders to federal law enforcement. Our complaint alleges that AmerisourceBergen — which sold billions of units of prescription opioids over the past decade — repeatedly failed to comply with that requirement.” “AmerisourceBergen, one of the largest wholesale distributors of opioids in the world, had a legal obligation to report suspicious orders to the Drug Enforcement Administration (DEA), and our complaint alleges that the company’s repeated and systemic failure to fulfill this simple obligation helped ignite an opioid epidemic that has resulted in hundreds of thousands of deaths over the past decade,” said DEA Administrator Anne Milgram. “The men and women of the DEA will stop at nothing to hold accountable registrants that fail to uphold their responsibility of saving American lives by filing suspicious order reports.” Pharmaceutical distributors that sell controlled substances, including AmerisourceBergen, have a longstanding legal obligation to monitor the orders that they receive from pharmacies and other customers and must inform the DEA each and every time they receive a suspicious order. The complaint filed in the U.S. District Court for the Eastern District of Pennsylvania alleges that over the course of nearly a decade, from 2014 through the present, AmerisourceBergen violated the CSA by failing to report at least hundreds of thousands of suspicious orders of controlled substances to the DEA as required by law. The alleged unlawful conduct includes filling and failing to report numerous orders from pharmacies that AmerisourceBergen knew were likely facilitating diversion of prescription opioids. Today’s filing is the result of a multi-year investigation by the DEA, the Civil Division’s Consumer Protection Branch and several U.S. Attorneys’ Offices. “For years, AmerisourceBergen put its profits from opioid sales over the safety of Americans,” said U.S. Attorney Philip R. Sellinger for the District of New Jersey. “According to the complaint, this was part of a brazen, blatant and systemic failure by one of the largest companies in America to comply with its obligations to report suspicious opioid orders, contributing to the epidemic of opioid abuse throughout this country.” “Companies like AmerisourceBergen that sell controlled substances across the country have a significant responsibility to ensure that their product is handled appropriately and that they comply with their federal legal obligations,” said U.S. Attorney Jacqueline C. Romero for the Eastern District of Pennsylvania. “The allegations against AmerisourceBergen are disturbing, especially for a company that is headquartered only a few miles from neighborhoods in Philadelphia devastated by the opioid epidemic.” “When drug distributors like AmerisourceBergen fail to alert the DEA of suspicious orders of prescription drugs by pharmacies, they shirk a key obligation in dealing with addictive drugs that can end lives,” said U.S. Attorney Cole Finegan for the District of Colorado. “This complaint makes clear that the Department of Justice will continue to hold accountable corporations that disregard the public’s safety for their own profit.” “We allege that AmerisourceBergen, a wholesale drug distributor, flagrantly and repeatedly violated its obligation to notify DEA of suspicious orders for controlled substances, which directly contributed to the epidemic of prescription opioid abuse across the United States,” said U.S. Attorney Breon Peace for the Eastern District of New York. The government’s complaint specifies several pharmacies for which AmerisourceBergen allegedly was aware of significant “red flags” suggesting the existence of diversion of prescription drugs to illicit markets. The complaint asserts that AmerisourceBergen nevertheless continued to distribute drugs to the pharmacies for years and reported few suspicious orders to the DEA. The five examples include: two pharmacies, one in Florida and one in West Virginia, for which AmerisourceBergen knew the drugs it distributed were likely being sold in parking lots for cash; a New Jersey pharmacy that has pleaded guilty to unlawfully selling controlled substances; another New Jersey pharmacy whose pharmacist-in-charge has been indicted for drug diversion; and a Colorado pharmacy that AmerisourceBergen knew was its largest purchaser of oxycodone 30mg tablets in all of Colorado. The government further alleges that for this Colorado pharmacy, AmerisourceBergen specifically identified eleven patients as potential “drug addicts” whose prescriptions likely were illegitimate. Two of those patients subsequently died of overdoses. The complaint further alleges that AmerisourceBergen not only ignored red flags of diversion, but also relied on internal systems to monitor and identify suspicious orders that were deeply inadequate, both in design and implementation. These systems allegedly flagged only a tiny fraction of suspicious orders, thereby enabling diversion and AmerisourceBergen’s failure to report orders it was legally obligated to identify to the DEA. In fact, the complaint asserts that in the midst of the opioid epidemic, AmerisourceBergen intentionally altered its internal systems in a way that reduced the number of controlled substances reported as suspicious. Even for the small percentage of orders that AmerisourceBergen did identify as suspicious, the company routinely failed to report them to the DEA. The government’s complaint alleges that for years AmerisourceBergen flouted its legal obligations and prioritized profits over the well-being of Americans. If AmerisourceBergen is found liable, it could face escalating civil penalties depending on when each violation occurred and the type of controlled substance at issue, specifically, up to $10,000 for each reporting violation before November 2015, up to $16,864 for each violation between November 2015 and October 2018 and for each violation relating to a suspicious order for a non-opioid controlled substance not reported after October 2018, and up to $109,374 for each violation relating to a suspicious opioid order not reported after October 2018, potentially totaling billions of dollars in penalties. The court also may award injunctive relief to prevent AmerisourceBergen from committing future CSA violations. The United States is represented in the filed action by Trial Attorneys Michael Wadden, Amy DeLine and Deborah Sohn of the Justice Department’s Civil Division’s Consumer Protection Branch, Assistant U.S. Attorneys Hayden M. Brockett and Jordann R. Conaboy for the District of New Jersey, Assistant U.S. Attorneys Anthony D. Scicchitano and Landon Jones for the Eastern District of Pennsylvania, Assistant U.S. Attorneys Amanda Rocque and David Moskowitz for the District of Colorado, and Assistant U.S. Attorneys Elliot M. Schachner and Diane Leonardo for the Eastern District of New York. The DEA collaborated with the Civil Division’s Consumer Protection and the U.S. Attorneys’ Offices to investigate the case. **Topics:** Drug Diversion, Judicial/courts --- ### [Doctor and Office Manager Indicted in Scheme to Defraud Medicare, Manufacture and Distribute Fentanyl: Office of Regulatory Affairs](https://insurancefraud.org/news_archives/doctor-and-office-manager-indicted-in-scheme-to-defraud-medicare-manufacture-and-distribute-fentanyl-office-of-regulatory-affairs/) **Published:** September 14, 2026 **Author:** Diane Beauchamp **Content:** Dr. David J. Smith, a pain management physician, and his office manager, Julia Ann Oertle, are charged in a federal grand-jury indictment with perpetuating a long-running scheme to commit healthcare fraud and to manufacture and distribute adulterated fentanyl. Smith made his initial appearance today before U.S. Magistrate Judge Bernard G. Skomal. Smith’s bond was set at $1 million, secured by real property, with a limitation on his ability to practice medicine. Oertle was still at large. According to allegations in the indictment, Smith purports to specialize in the installation and maintenance of intrathecal pain pumps which are surgically placed in a patient’s stomach with two catheters implanted on the spine; pain medicine is then infused into a reservoir in the pump periodically and meted out directly into the spine. Beginning in December 2017, Smith and Oertle began compounding fentanyl citrate into vials, in a room at Smith’s principal medical practice, San Diego Comprehensive Pain Management Center. According to the indictment, this compounding practice was grossly improper and resulted in the production of adulterated fentanyl. Smith nevertheless directed administration of this fentanyl to patients repeatedly. The indictment alleges that beyond providing patients with adulterated fentanyl, Smith violated the applicable standards of care by, among other things, prescribing materially excessive quantities of fentanyl, prescribing unnecessary oral opioid medications in conjunction with pain-pump medication, and installing pain pumps in patients without proper assessments for patient need. Smith then had false and fraudulent reimbursement claims submitted to Medicare for these administrations. Among other things, the claims were inflated by nearly 60 percent; they sought reimbursement for large volumes of unnecessarily manufactured fentanyl; they falsely represented that excess fentanyl had been discarded, when in fact it was used; and they did not disclose that the fentanyl was adulterated. According to the indictment, Oertle illegally ordered fentanyl citrate for compounding; compounded fentanyl with Smith; and helped direct the illegal billing practices. “We are supposed to be able to trust our doctors with our lives,” said U.S. Attorney Randy Grossman. “This office will use all its resources to protect vulnerable patients from doctors who use them to make money, with no regard for their safety.” Grossman thanked the prosecution team, the FBI, the DEA, the FDA, and the other members of the investigative team for their excellent work on the case. “Criminal misconduct within the healthcare system is not only deceitful, but also destructive,” said Special Agent in Charge Stacey Moy of the FBI’s San Diego Field Office. “David Smith and Julia Oertle allegedly abused their positions of trust by manufacturing and propagating this toxic poison to patients over an extended period of time, further unraveling the fentanyl crisis our country is experiencing. This investigation clearly demonstrates that the threat of the opioid crisis extends far beyond street level dealing. The FBI will continue to work with our law enforcement partners to protect our communities and ensure justice is served.” “The DEA is committed to bringing to justice doctors that take the public’s trust and abuse it for their own purposes,” said DEA Special Agent in Charge Shelly S. Howe. “We are grateful for our relationships with the U.S. Attorney’s Office, the FBI and the other agencies who worked to bring these defendants to justice.” “U.S. consumers must be able to trust that their medicines meet FDA’s required standards of safety and effectiveness,” said Acting Special Agent in Charge Christopher M. Alston, FDA Office of Criminal Investigations Los Angeles Field Office. “Our office will continue to pursue and bring to justice those who jeopardize the public’s health and the public’s trust.” “According to allegations in the indictment, these defendants were trusted with the medical care of their patients but instead used treatments that were not medically necessary in order to gain financially,” stated Special Agent in Charge Tyler Hatcher of the IRS Criminal Investigation’s Los Angeles Field Office. “We will continue to serve the public and help put a stop to schemes like this that take advantage of our medical system and put patients’ care at risk.” In California, patients receiving treatment at this practice who feel they want to change providers may contact their primary care provider for continued care. Individuals seeking access to primary care or pain management service can find a provider through a local Federal Qualified Health Center. Patients with insurance should contact their health insurance company. Those who are struggling with their intake of opioids can find local providers at Choose Change CA or 1-800-879-2772. Those needing emergency access to substance-use treatment or who are experiencing opioid withdrawal can visit a California Bridges Emergency Room. In Nevada, patients receiving treatment at this practice who feel they want to change providers may contact their primary care provider for continued care. Individuals needing access to primary care or pain management service can find a new provider through a local Federal Qualified Health Center. Patients with insurance should contact their health insurance company. Those who are struggling with opioid addiction may contact the Nevada Substance Abuse Help Line: 1-775-825-4357 or toll free 1-800-450-9530. Individuals can also contact the Nevada 24-hour help line at 1-800-273-8255 or Text CARE to 839863. DEFENDANTS David James Smith Age: 62 Rancho Santa Fe, California Julia Ann Oertle Age: 52 Las Vegas, Nevada SUMMARY OF CHARGES Conspiracy -18 U.S.C. 371 Conspiracy to Manufacture and Distribute Controlled Substances -21 U.S.C. 841(a), 841(b)(1)(C), 846 Healthcare Fraud – 18 U.S.C. 1349 False Claims – 18 U.S.C. 287 Manufacture of Controlled Substances – 21 U.S.C. 841(a) Adulteration of Fentanyl – 21 U.S.C. 331, 333 Maximum penalty: Life in prison and a mandatory minimum term of 10 years in prison; a $10,000,000 fine; supervised release for a maximum of life, and a mandatory minimum term of 5 years; $100 special assessment per count of conviction. AGENCIES Federal Bureau of Investigation Drug Enforcement Administration Food and Drug Administration U.S. Department of Health and Human Services U.S. Marshal Service Internal Revenue Service \*The charges and allegations contained in an indictment or complaint are merely accusations, and the defendants are considered innocent unless and until proven guilty. **Topics:** Drug Diversion, Medicare/Medicaid **Categories:** Arrest --- ### [Emory Healthcare employee inappropriately accesses 1,600 patient records](https://insurancefraud.org/news_archives/emory-healthcare-employee-inappropriately-accesses-1600-patient-records/) **Published:** September 14, 2026 **Author:** Diane Beauchamp **Content:** On Aug. 24, the Labor Department notified the health system that one of its employees had been involved in a data privacy incident and disclosed several hundred patients’ demographic information to individuals involved in unemployment benefits fraud, according to a Dec. 6 news release from the health system. On Nov. 30, the Justice Department arrested the former Emory Healthcare employee in connection with the fraud scheme. Emory Healthcare said the individual had access to patient files that contained information such as names, dates of birth and Social Security numbers. The health system said it found no indication any medical histories, tests and laboratory results, diagnosis and treatment plans, or insurance information were involved in the breach. Emory has since terminated the employee and is notifying the patients whose records were accessed during the breach. **Topics:** Public Awareness, Technology --- ### [Phone scammers back in action, U.S. Attorney warns](https://insurancefraud.org/news_archives/phone-scammers-back-in-action-u-s-attorney-warns/) **Published:** September 14, 2026 **Author:** Diane Beauchamp **Content:** Phone scammers are at it again, this time posing as government officials to collect or extort money from their victims, according to a recent warning from the U.S. Attorney’s Office. The callers claim to be attorneys or law-enforcement officers to add credibility to their schemes, going so far as to “spoof” — or falsify data — to make it appear as though the call is coming from a legitimate government office. Scammers frequently target the elderly, threatening to show up at their victims’ homes if they don’t pay for outstanding legal fees, according to Lauren Horwood, public affairs officer for the U.S. Attorney’s Office in Sacramento. “The U.S. Attorney’s Office will never call members of the public and threaten to arrest them and demand payment of unspecified ‘legal fees,’ ” Horwood said. “We encourage members of the public to be alert for potential phone scams against themselves and their family members.” Authorities urge phone-scam victims to look for the following warning signs: \* Being told you have won a prize or sweepstakes, and need to send money for taxes and insurance in order to receive the winnings. \* Being asked to provide or to confirm your Social Security number, bank account or credit-card numbers, or other personal information, such as addresses and dates of birth. \* Use of scare tactics, such as claiming a loved one is in danger, or that you risk being arrested if you do not take immediate action. \* Asking for payment with money transfers, cryptocurrency or gift cards. \* Pressure to act immediately. \* Promises to recover money you have lost in other scams, for a fee. \* Demands that taxes be paid without giving taxpayers the opportunity to question or appeal the amount owed. Anyone who has received calls like this is urged to report them to the Federal Trade Commission online at [reportfraud.ftc.gov](http://reportfraud.ftc.gov/), or by calling 877–FTC–HELP ([877-382-4357](http://877-382-4357/)). The FBI also accepts fraud reports for possible law-enforcement action at [www.justice.gov/criminal-fraud/report-fraud](http://www.justice.gov/criminal-fraud/report-fraud). Horwood also offered the following tips for avoiding phone-scam fraud: \* Never trust the caller ID number, since the displayed telephone number can be manipulated with software (“spoofing”). \* Always consider sending unsolicited phone calls to voicemail. Many scam-call centers will not leave a message. \* Never click on links contained in unsolicited emails or text messages. The links may route you to fake websites or deploy malicious software. \* Protect your personal and financial information and never provide it in response to unsolicited text messages, emails or social media posts claiming to be from a government agency. **Topics:** Public Awareness --- ### [Holiday Tips for Helping Family Fight Financial Fraud](https://insurancefraud.org/news_archives/holiday-tips-for-helping-family-fight-financial-fraud-2/) **Published:** September 14, 2026 **Author:** Diane Beauchamp **Content:** Tis’ the season for giving, which means you should be on high alert for bad actors. In 2020, Kansans ages 60 and up fell victim to financial fraud to the tune of $48 million. Making fraud prevention a family affair is one of the most effective ways to stop bad actors in their tracks. “Families are often the first line of defense against bad actors,” said State Insurance Commissioner Vicki Schmidt. “New tactics and scams are constantly being deployed by fraudsters, especially during the holiday season.” Here are several family-focused fraud prevention tips to consider when helping loved ones protect their pocketbooks. Check in often. Regular communication with your elderly loved ones is the best way to detect behavior changes that could indicate if someone has gained unwarranted influence over their investment and financial decision-making. Do not shame. We have all been tricked before and victims of fraud should be comforted when coping with the fallout of deceptive actions. Keep an empathetic tone when dealing with fraud as it will increase the victim’s willingness to open up about the experience. Encourage verification. Encourage them to inquire about whether the individual selling the investment is registered. Not all investments sold require the entity or individual to be registered, but investment opportunities not backed by a registered entity or person deserve additional scrutiny. Visit SmartInvestKS.com for guidance on preventing investment fraud. Call 785-296-3071 or visit insurance.kansas.gov/securities if you believe that you or a loved one may have already been the victim of investment fraud. **Topics:** Public Awareness --- ### [Raleigh-Area Physician Agrees to Pay $385,000.00 to Resolve Allegedly Fraudulent Medicare and Medicaid Claims](https://insurancefraud.org/news_archives/raleigh-area-physician-agrees-to-pay-385000-00-to-resolve-allegedly-fraudulent-medicare-and-medicaid-claims-2/) **Published:** September 14, 2026 **Author:** Diane Beauchamp **Content:** United States Attorney Michael Easley announced today that Haritha Nadendla, M.D., and Triangle Women’s Center, P.C., (hereinafter referred to as “Triangle”), an OB/GYN practice that Dr. Nadendla owns and operates in the Raleigh, North Carolina area, have agreed to pay $385,000 to settle civil False Claims Act liability concerning allegations that Triangle submitted false claims to the Medicaid program for certain patient visits. The Government contends that it has certain civil claims against Triangle arising from Triangle’s submission of claims to the North Carolina Medicaid Program for medical services from January 1, 2018, through December 31, 2021, including claims for CPT 99215 – Evaluation & Management for an established patient in an office or outpatient location, which the Government contends were not supported by the medical record and were not medically necessary. The Government contends that Triangle’s submission of such claims for payment to the North Carolina Medicaid Program violates the Federal and North Carolina False Claims Acts. “This civil fraud case demonstrates our firm commitment to protect taxpayer money and to guard the integrity of federal programs,” said U.S. Attorney Michael Easley. “Our office will zealously pursue those who misuse or abuse government funds.” “My office’s Medicaid Investigations Division is committed to holding accountable health care providers who waste taxpayer resources,” said North Carolina Attorney General Josh Stein. “I thank U.S. Attorney Easley and his team for their continued partnership to protect Medicaid funds for North Carolinians.” This matter was investigated by the United States Attorney’s Office for the Eastern District of North Carolina and the Medicaid Investigations Division of the North Carolina Attorney General’s Office (“MID”). Special Deputy Attorney General Michael M. Berger, who also serves as a Special Assistant United States Attorney, represented the United States and the State of North Carolina. The allegations were originally made in a lawsuit filed under the whistleblower provisions of both the Federal and North Carolina False Claims Act by Hannah Turnbull. The respective False Claims Acts permit private parties to sue for false claims on behalf of the United States and the State of North Carolina, as well as potentially sharing in any recovery. As for the recovery, the False Claims Acts allow the United States and the State of North Carolina to recover triple the money falsely obtained, plus civil penalties for each false claim submitted. The civil claims settled by this False Claims Act agreement are allegations only; there has been no determination of civil liability. **Topics:** Judicial/courts, Medicare/Medicaid, Public Awareness --- ### [Proposed N.Y. legislation requiring contractors to disclose legal violations gets mixed reviews](https://insurancefraud.org/news_archives/proposed-n-y-legislation-requiring-contractors-to-disclose-legal-violations-gets-mixed-reviews/) **Published:** September 14, 2026 **Author:** Diane Beauchamp **Content:** Proposed New York state legislation that would require all contractors bidding on public projects to disclose any past legal violations through a public registry has a strong lobby of support. But the bill is not without its critics. If passed, it would “significantly help to reduce wage theft, tax fraud and workers’ compensation fraud,” says Gary LaBarbera, president of the New York State Building and Construction Trades Council (NYSBCTC). But Brian Sampson, president of the Associated Builders and Contractors (ABC) Empire State chapter, sees the bill as an attack on the non-unionized sector which has been increasingly winning public contracts, normally the domain of unionized builders. The ABC represents more than 420 members in the non-unionized sector. The bill’s lead sponsor, Democratic Senator Sean Ryan says under current legislation when county and small municipal governments tender contracts, they don’t have access to everything they need to know about their bidders. If these municipalities pull a contract when their contractor has problems meeting its obligations those municipalities often don’t have the money to withstand lawsuits from the contractor, he told the Daily Commercial News. “It is why you need to be transparent and get the information out there first.” LaBarbera says the current VendRep System to certify contractors to bid on contracts does not apply “the entire scope of projects covered by the bill, nor does it provide a publicly accessible database to view contractor information.” Currently, contractors can provide fewer details to municipalities on issues such as unemployment insurance and workers’ compensation, apprenticeship status and worker safety records, LaBarbera says. “This (legislation) will give those municipalities the toolbox to do that. It is a simple matter of transparency,” says Ryan. While all bidders on public projects in the state are subject to a prevailing wage law, Sampson says open shop contractors can often do projects for less because “collective bargaining agreement(s) and the antiquated work jurisdictional rules make the cost of public construction more expensive” for unionized contractors. He says the bill backed by the Carpenters’ Union is an attempt to “blacklist” non-union contractors from public projects. LaBarbera says while the building trades “are obviously always pushing for union jobs in construction, the bill doesn’t tip the scale in favor of the union. If anything, it tilts the scale in favor or law-abiding businesses.” The Carpenters’ Union president asks why upstanding contractors would have a problem disclosing information for a small fee ($200) in order to rid construction of “bad actors.” “This bill has fees and small fines but is not punitive in nature,” adds LaBarbera. Ryan says the New York State Comptroller currently collects some of the information on contractors for state departments but counties, towns and school districts don’t have access to the data. He says in one case a small municipality let a contract to a firm which lied about being veteran-owned and had previously been caught on that lie and was hit with a $3 million state violation. He says he doesn’t know how big the problem is but the public registry accessible to all municipalities created under the proposed legislation would resolve many issues. Sampson sees it creating “an extra level of work” for contractors. GCs will be required to submit the list of subcontractors in the original bid, information they won’t always know, particularly on design-build contracts, he points out. Sampson adds he fears contractors making “honest mistakes” on paperwork required (be them unionized on non-unionized firms) could be unfairly penalized under the legislation. “Somebody keys in a wrong number or misinterprets a chart and now you’re the bad person (contractor), whether you did it intentionally or not.” Furthermore, he says the Department of Labor “will often reinterpret a rule or regulation when there is a turnover in (their) staff. There is so little consistency on the enforcement side. “I have not come across anyone in the industry that is reading it the way the senator would like us all to believe it is written,” Sampson adds. But LaBarbera says the bill has “tremendous support. We have had productive conversations with the (state) chamber and other stakeholders and are answering any questions as they come up. Governor (Kathy) Hochul has long been a proponent of fair contracting policies and government transparency. This legislation fits right into those categories.” By Dec. 31, Governor Hochul could sign, amend and sign, veto the bill, or it could die on the order table. Ryan, who hasn’t seen a lot of opposition “other than Brian Sampson’s group,” says he optimistic it will pass. “I’m optimistic it will save the taxpayers a lot of money.” **Topics:** Legislation, Public Awareness --- ### [The DEA is alleging Truepill, Cerebral's former pharmacy partner, broke the law in filling prescriptions for highly regulated drugs](https://insurancefraud.org/news_archives/the-dea-is-alleging-truepill-cerebrals-former-pharmacy-partner-broke-the-law-in-filling-prescriptions-for-highly-regulated-drugs/) **Published:** September 14, 2026 **Author:** Diane Beauchamp **Content:** The US Drug Enforcement Administration just put Truepill on notice that it may revoke its ability to fill controlled substances, citing allegations that the online pharmacy startup unlawfully dispensed stimulants used to treat ADHD, including Adderall. The Order to Show Cause requires that Truepill show evidence to justify its prescribing practices for controlled substances, which are highly regulated drugs. If the evidence isn’t convincing, the pharmacy startup could have its DEA license revoked, which would leave the company unable to fill prescriptions for controlled substances. It’s the first public signal that the DEA is paying attention to the rise of companies profiting from online prescriptions for controlled substances. **Topics:** Public Awareness, Regulatory actions --- ### [He bought insurance after Jersey City hit-and-run, then tried to collect on it: prosecutor](https://insurancefraud.org/news_archives/he-bought-insurance-after-jersey-city-hit-and-run-then-tried-to-collect-on-it-prosecutor/) **Published:** September 14, 2026 **Author:** Diane Beauchamp **Content:** An insurance company won’t have to cover damages to a pricey 2019 BMW because the car involved in a Jersey City hit-and-run was not insured at the time, Hudson County Prosecutor Esther Suarez said. Shingai Marandure, 30, of New Brunswick in Middlesex County, was arrested Wednesday by members of the Hudson County Prosecutor’s Office Insurance Fraud Unit on charges he falsified information he provided to the auto insurance company. He was charged with one count of insurance fraud, a second-degree offense. He was released on a summons pending his first court appearance. An investigation determined Marandure learned his uninsured 2019 BMW 430 was involved in a hit-and-run collision in Jersey City and opened a Progressive auto insurance policy on April 28. Immediately after obtaining the policy, Marandure notified police of the damage to his vehicle and then filed a claim with Progressive the following day. Investigators later determined the vehicle was damaged April 21. **Topics:** Auto - underwriting **Categories:** Arrest --- ### [Up to 254,000 Medicare beneficiaries are getting new ID cards due to data breach at subcontractor. What they need to know](https://insurancefraud.org/news_archives/up-to-254000-medicare-beneficiaries-are-getting-new-id-cards-due-to-data-breach-at-subcontractor-what-they-need-to-know/) **Published:** September 14, 2026 **Author:** Diane Beauchamp **Content:** Up to 254,000 Medicare beneficiaries’ personal information may have been compromised in an online ransomware attack at a government subcontractor, officials warned this week. Letters are being sent to the beneficiaries who were impacted by the potential data breach, said the Centers for Medicare & Medicaid Services. Those affected — who represent less than 0.4% of Medicare’s 64.5 million beneficiaries — will also receive a replacement [Medicare](https://www.cnbc.com/2022/11/15/new-medicare-enrollment-rules-ending-coverage-gaps-take-effect-in-2023.html) card with a new identification number in the next few weeks. “The safeguarding and security of beneficiary information is of the utmost importance to this agency,” CMS Administrator Chiquita Brooks-LaSure said in the announcement. “We continue to assess the impact of the breach involving the subcontractor, facilitate support to individuals potentially affected by the incident, and will take all necessary actions needed to safeguard the information entrusted to CMS,” Brooks-LaSure said. The personal information that could have been compromised include name, address, date of birth, phone number, [Social Security](https://www.cnbc.com/2022/12/11/what-to-know-as-record-8point7percent-social-security-cola-goes-into-effect.html) number, Medicare beneficiary identifier, banking information (including routing and account numbers) and Medicare entitlement, enrollment and premium information. Free credit-monitoring also is being offered to the impacted individuals; the letters being sent include information on how to sign up for the service. No CMS systems were breached, and no Medicare claims data were involved, according to the announcement. The agency also is not aware of any reports of identity fraud or improper use of the personal information as a direct result of the incident. The subcontractor, Healthcare Management Solutions, experienced the ransomware attack on its corporate network on Oct. 8, according to CMS. The company handles the agency data as part of processing Medicare eligibility and entitlement records, as well as premium payments. CMS was alerted the day after the attack, and on Oct. 18, officials “determined with high confidence that the incident potentially included personally identifiable information and protected health information for some Medicare enrollees,” according to the CMS release. For its part, Healthcare Management Solutions told CNBC that it acted swiftly to take its network offline to contain the cybersecurity incident and an investigation remains ongoing. In a statement, the company said it also regrets “any concern this incident may have caused our community and will notify impacted individuals pursuant to legal and contractual obligations.” In the first half of 2022, more than 53 million individuals in the U.S. were affected by data compromises, according to Statista. In 2021, the three most affected industries were healthcare, financial services and manufacturing. **Topics:** Public Awareness, Technology --- ### [Many Victims Struggle With Mental Health in Scams’ Aftermath](https://insurancefraud.org/news_archives/many-victims-struggle-with-mental-health-in-scams-aftermath/) **Published:** September 14, 2026 **Author:** Diane Beauchamp **Content:** Rose Stein’s life took a disastrous turn this year, and it all started with a nine-word Instagram post. Stein, 75, who’s divorced and lives in the Los Angeles suburbs, had long admired a certain TV journalist. When she found his profile on social media last April, she decided to post a little kudos: “You did a great job on the last show.” Later she received a message that appeared to be from the journalist: “Thank you so much for being a fan.” The message suggested they start communicating through Skype for more privacy, and they began a friendly repartee. Then one day, Stein remembers, “he writes to me, and he says, ‘I’m going to send you a gift.’ And I said, ‘I don’t want anything. I’m just happy with our friendship.’ And he said, ‘No, when I have special fans, I want to send them a gift.’ ” She had no idea that this “gift,” which he told her was coming from Switzerland, would become a life-altering nightmare that grew increasingly bizarre. The supposed shipping company began to ask her to pay fees and taxes to continue the international shipment, and the “journalist” urged her to pay because his own money “was tied up.” Eventually, the company told her it had discovered that the package contained cash, and she’d be charged with money laundering if she didn’t pay $15,000. It continued demanding ever more money — sometimes through wire transfer or in the form of [gift cards](https://www.aarp.org/money/scams-fraud/gift-card-payment/) or [Bitcoin](https://www.aarp.org/money/scams-fraud/cryptocurrency-schemes-ftc/) — even after she told the company she only had $500 left to buy groceries and pay her bills. Too bewildered and ashamed to tell anyone, Stein says, “I’m crying every day. I don’t know what to do. And I’m taking money out of my retirement and my savings that I had saved for years.” At one point, she adds, through tears, “I was going to kill myself.” She drove herself to a hospital, where she was quickly admitted. When she told the psychiatrist on duty her story, he said, with sympathy, “You’ve been scammed.” Stein ended up losing about $70,000 to the [scammer impersonating the journalist](https://www.aarp.org/money/scams-fraud/crooks-celebrities-impostors/) she so admired. She’s been dealing with the emotional fallout ever since. ### **Beyond money loss** Americans reported losing a record-breaking $6.1 billion to fraud in 2021 — skyrocketing from more than $3.3 billion the previous year, according to the Federal Trade Commission (FTC). Those numbers don’t begin to reveal the real impact of these crimes, however. Not only are scams widely thought to be grossly underreported, but victims’ suffering goes far beyond drained bank accounts. Two-thirds of scam victims in a [2015 FINRA (Financial Industry Regulatory Authority)](https://www.finrafoundation.org/sites/finrafoundation/files/non-traditional-costs-financial-fraud.pdf) survey reported experiencing negative emotional consequences specifically as a result of the fraud. “That ranged from severe anxiety, to sleep disorders, depression, PTSD,” says Christine Kieffer, senior director at the FINRA Investor Education Foundation. “So these are real trauma symptoms.” Although victims of other kinds of crime may have similar reactions, fraud adds a few different elements, says Stacey Wood, co-editor of the 2022 book *A Fresh Look at Fraud*, a compendium of the latest research on fraud. Wood, a psychology professor at Scripps College, works extensively with scam victims. “What’s different with fraud victims, is that their constellation of symptoms includes negative thoughts about themselves. And so they could be thinking, are they not smart? Is there something wrong with their cognitive abilities, their ability to judge others?” If someone breaks into your house and takes your television, Wood notes, “that’s very scary and violating, yes, but it doesn’t make you think, ‘I’m not good at making decisions.’ ” And robbery victims may receive more sympathy and support from others, Kieffer says, because “we don’t necessarily put the onus on the victim,” as people do in fraud cases. Nearly half (47 percent) of the FINRA survey respondents blamed themselves for the crime; 61 percent said they were too trusting. A majority reported feeling angry, regretful, betrayed, helpless and embarrassed. Everyone’s reaction to being victimized by a scammer may be a bit different, says Amy Nofziger, director of victim support for the [AARP Fraud Watch Network](https://www.aarp.org/money/scams-fraud/about-fraud-watch-network/): “I can tell you I’ve had every single solitary emotional response from victims. I’ve had people cursing and screaming, I’ve had people crying, I’ve had people numb, I’ve had people in shock. There is no necessarily right way to respond.” A common reaction, though, is to feel profound shame and self-blame — as detailed in [“Blame and Shame in the Context of Financial Fraud,”](https://www.aarp.org/content/dam/aarp/money/scams_fraud/2022/07/aarp-fraud-victim-blaming-report-06-07-22.pdf) a report this year from the AARP Fraud Watch Network and the FINRA Investor Education Foundation. Stein says she felt deeply ashamed by her experience, so much so that when the psychiatrist told her healing would start by sharing her story with friends and family, she responded, “I don’t think I could tell my kids. I don’t think I could tell anybody. I’m so ashamed, I feel like my soul is tarnished. … I can’t believe that it went on for so many months and I believed all this. I felt stupid, like I had no value anymore.” Briefly, death seemed like the only way to free herself from the pain. Nofziger, who oversees the toll-free [AARP Fraud Watch Network Helpline](https://www.aarp.org/money/scams-fraud/helpline/) (877-908-3360), says, “We hear that on the phone: ‘I don’t know what else to do. I might as well just kill myself.’ ” She notes that the trained volunteers who take Helpline calls “take all harm threats seriously” and assist victims in finding the help they need. There are no statistics on the number of people who have died by [suicide](https://www.aarp.org/health/conditions-treatments/suicide-risk-signs/) after a scam, but the anecdotal evidence is disturbing, including an 82-year-old Alabama man who died by suicide last year after losing his life’s savings to a prize-winning scam. [Teenagers](https://www.aarp.org/money/scams-fraud/protecting-teen-targets/) around the country have died by suicide after being targeted for sextortion, when victims are threatened or coerced into sending explicit images online, then blackmailed. (The FBI warned of an increase in sextortionists targeting teenagers, which “has resulted in an alarming number of deaths by suicide.”) The amount of money lost — or the importance of the loss to someone’s overall budget — can affect the emotional toll. If a victim loses $10,000 and has no other savings, for instance, they may experience more symptoms of trauma than someone who lost the same amount but had more in the bank, Kieffer says. Another factor that can exacerbate a victim’s trauma, according to Kieffer: If another person, such as a spouse, is negatively affected by his or her involvement in a scam, that “secondary victimization compounds your sense of responsibility.” Mental health issues affect the physical body as well. Stein says that during her four-month ordeal, she lost more than 20 pounds, started smoking two packs of cigarettes a day (she’d usually have one or two cigarettes, at most), couldn’t sleep and her [blood pressure](https://www.aarp.org/health/conditions-treatments/surprising-causes-high-blood-pressure/) soared. ### **Grief** Nofziger compares recovery after a scam to the grieving process: “Tomorrow, you might feel a little bit better than today, but you are not going to necessarily forget about what happened to you.” That’s particularly true if you’ve lost a lot of money, because “you’re going to have to be reminded on a daily basis when you have to cut your costs and redo your budget.” The grieving can be deepest in the case of a [romance scam](https://www.aarp.org/money/scams-fraud/romance/), Kieffer says: “We all know that when you break up with somebody, even when on good terms, there’s a sense of loss. So imagine what you’d feel like if it was all built on lies.” It can be like mourning a death, Nofziger says of romance scams, “because this person did technically die to you. The dream died. So there’s no quick getting over it. There’s no ‘you need to move on.’ Like, you don’t say that to someone who just lost a spouse — ‘It’s time to move on.’ I think letting people express their sadness and their anger is a healthier thing.” You also could be more isolated than you were before meeting the scammer, notes Jessica Krough, a program manager with AARP’s Fraud Watch Network. “You might have lost friendships because you’ve been spending your time chatting with this other person, and now \[when you realize they’re a scammer\], you don’t have friends to rely on,” just when you need kindness and support. ### **Sharing your experience** Recovery often starts with telling others about your experience, says Nofziger, who suggests “reaching out for help to any place you feel comfortable,” whether that’s AARP (see below), your therapist, your physician or a trusted friend or family member. But many scam victims don’t tell their closest friends and relatives after they’ve lost money in a scam. Wood says she’s talked to victims who kept silent about their experience for years, “and it was just eating them up inside and creating this distance from family members. But they found that when they just admitted that they had lost this money, they were able to start the healing.” It’s important to realize that in sharing your truth, you may help others avoid victimization. Kieffer says that when scam victims realize they have a positive role in this way, “it gives them a sense of empowerment, a sense of control over what happened.” A few days after Stein was admitted to the hospital, she asked a good friend if she could come over and talk. They spent the day together, and she unspooled the story. “I started feeling a little better when I unloaded it with her,” she says. The hardest thing to do was to tell her son. “I have something horrible to tell you,” she said. “I’ve been scammed.” Afterward, “I felt a sense of relief. … He’s been very kind,” as have her close friends. It’s been a process. For a while, Stein says, “I was waking up screaming in the middle of the night,” and she’s had panic attacks. She’s joined the AARP support group several times and found it helpful, particularly hearing the experiences of other scam victims — including one woman who lost more than $200,000. “Oh my God, this is a smart lady,” she thought. “This can happen to anybody.” That is an important point for victims to internalize, says Alan Castel, author of *Better With Age: The Psychology of Successful Aging*. Castel, a psychology professor at the University of California, Los Angeles, studies the aftereffects of scams. “This can happen to anyone, just like anyone can get into a car accident or anyone can get robbed.” He notes that scammers are [skilled manipulators](https://www.aarp.org/money/scams-fraud/seven-criminal-tactics/), targeting victims when they’re at their most vulnerable, often when they’re in a heightened emotional state. Perpetrators of fraud are “psychologists working in the wild, basically,” who have amassed an incredible amount of data that helps them determine what works and what doesn’t. Several months after the scam was revealed, Stein knows the likelihood that she’ll get that money back is slim — though she reported the incident to the police and the FBI. But, she says, “I think I’m much better. … I’m starting to have an interest in doing things. I know I’m going to get through this.” As for the actual journalist Stein thought she’d contacted? “I do watch him,” she says. “I’ve separated him from the scammer.” ### **Where to find mental health support** **AARP Fraud Watch Network™ support group** The VOA ReST (Resilience, Strength and Time) program, a collaboration between AARP and Volunteers of America (VOA), offers free online facilitated emotional support sessions for fraud victims. You can attend as many sessions as you’d like, just register in advance [online](https://www.aarp.org/money/scams-fraud/voa-rest-program/). **Cybercrime Support Network’s (CSN) Peer Support Program** CSN, in collaboration with the FINRA foundation, offers a free support program for romance scam survivors, who can attend 10 one-hour group sessions, facilitated by a mental health counselor. Its focus is on helping victims combat feelings of loss, embarrassment and isolation, while teaching cybercrime awareness and education. Find out more [here](https://www.fightcybercrime.org/peer-support/). **Successful Aging through Financial Empowerment (SAFE)** Wayne State University’s Institute of Gerontology provides free financial counseling for older fraud victims. You can find free workshops and financial resilience resources on its [website](https://iog.wayne.edu/outreach/success-after-financial-exploitation--safe-). ### **How to help a loved one who’s been victimized by fraud** **Listen without judgment.** “A lot of people are afraid to tell a loved one they are a victim because they’re afraid of how they’ll react,” Krough says. “Don’t judge or scold.” **Lead with kindness and empathy.** “Say, ‘I don’t know how to fix this. But I’ll walk through this with you. And I’ll be there for you,’ ” Nofziger suggests. **Help them disconnect from the scammer.** If the scam came via email, text message or phone, and the target isn’t very tech-savvy, you can help them block the criminal to make sure they’re no longer in contact. **Keep them engaged.** Invite your loved one to a movie or out to lunch; “help them reenter the world,” Nofziger says, “just as you would do if they were grieving a death.” **Topics:** Public Awareness --- ### [McCutcheon financially linked to CEO guilty of kickbacks, fraud — Records show favorable treatment from BCBS during tenure](https://insurancefraud.org/news_archives/mccutcheon-financially-linked-to-ceo-guilty-of-kickbacks-fraud-records-show-favorable-treatment-from-bcbs-during-tenure/) **Published:** September 14, 2026 **Author:** Diane Beauchamp **Content:** From around 2013 to 2016, outgoing House Speaker Mac McCutcheon (R-Monrovia) worked as a “consultant” for an Alabama-based medical testing company called QBR LLC, which has recently been a target of the U.S. Department of Justice. John Hornbuckle, the president and CEO of QBR LLC, of Huntsville, was indicted by a federal grand jury for defrauding health care benefit programs and paying and receiving kickbacks from December 2012 to January 2018, according to an indictment filed in U.S. District Court in the Northern District of Alabama in April 2022. After initially pleading not guilty, Hornbuckle pleaded guilty to one count of conspiracy to commit health care fraud and one count of conspiracy to receive kickbacks in November. QBR was in the business of conducting electro-diagnostic testing, including nerve conduction velocity tests (NCV tests) and sensory evoked potential tests (SEP tests), according to court records. Numerous others associated with the company have been either convicted or pleaded guilty to healthcare-related charges in 2022. All of them are currently awaiting sentencing. McCutcheon and his son, Christopher McCutcheon, and their various roles in this company have eluded public scrutiny, given the Department of Justice press statements have focused on indictments and guilty pleas. According to financial documents obtained by 1819 News, Mac McCutcheon and his Practical Approach Consulting Group were paid at least $90,000 by QBR LLC in 2013, the latter half of 2015, and the first half of 2016. A draft organizational chart from 2012, around the time the company got started, described Mac McCutcheon’s role at QBR as “government liaison, business and public relations.” Other documents described his role as a “customer relationship manager.” According to Alabama Secretary of State records, Practical Approach Consulting was incorporated in December 2014. Christopher McCutcheon, Mac’s son and a former 49% owner of QBR, is listed as the initial registered agent. Mac McCutcheon is listed as the president, secretary and treasurer. The payments to McCutcheon and his consulting group ranged from a rate of $2,500 to $5,000 per month, according to the documents. Mac McCutcheon was first elected to the House in 2006. Before becoming speaker, McCutcheon served as the House Rules Committee chair. He has served as Alabama’s House Speaker since 2016, assuming the role after his predecessor, former House Speaker Mike Hubbard (R-Auburn), was removed from office for felony ethics convictions. McCutcheon did not seek re-election in 2022. “I have been going back in my records to get the information/dates you are inquiring about,” Mac McCutcheon told 1819 News in an emailed response to questions about his involvement in the company. “My association with QBR was based on helping the company get started. I was contracted to do consultant work for the business start-up. I was retiring from the City of Huntsville in 2013 and began my consulting business as a source of income due to the fact that the Legislative work is part-time. I never did any lobbying work for QBR or any other client. As QBR got operational as a company I discontinued my services. “ QBR LLC was formed in September 2011 by Hornbuckle and Christopher McCutcheon, according to the Alabama Secretary of State’s Office. The McCutcheons haven’t been charged or accused of any wrongdoing by federal authorities, but their clout and influence were used to help with regulatory and legal hurdles the company faced at the state level, according to emails obtained by 1819 News. Chris McCutcheon emailed Mac McCutcheon and Hornbuckle in January 2012, letting Mac know that “we, as QBR representatives, are presenting this services agreement to you for review and stated opinion from the State Attorney General’s office.” “We would like to receive the assessment from the AG’s office in order to ensure that we \[are\] operating within the specified guidelines of the medical industry as well as the State of Alabama,” Chris told Mac in the email. “Please pass this agreement to state personnel and advise when completed so that we can move forward with the current agreement or make the required changes to do so.” The services agreement outlines a process whereby providers are paid $200 per hour that “shall not vary based on the volume or value of referrals.” According to the indictment of Hornbuckle, the hourly payments for the provider’s time and the time of the provider’s staff were “disguised,” and the “provider was actually compensated on a per-patient basis.” Chris McCutcheon wrote to Mac McCutcheon two months later in March to ask for a meeting for a business partner with a Blue Cross Blue Shield of Alabama high-ranking official. “Thank you for spending time with us last week, giving us the tour and assisting us with the meeting with \[the\] Medical License Director,” Chris McCutcheon said in an email to Mac McCutcheon and John Hornbuckle in March 2012. “We would like to request a meeting for Brian Bowman, our business partner in Birmingham, with Robyn at BCBS. You and John \[Hornbuckle\] should remain in the driver’s seat from a meeting coordination and attendance perspective if possible. We, as QBR, want to remain in the power position in regards to meetings that you help us setup because it helps us in the future from a political perspective. Brian has the following agenda in mind with regards to the meeting with Robyn/BCBS: He would like to become a preferred provider for BCBS of Alabama within the Lab \[Bloodwork/Urine Panels\] space.” Brian Bowman of Attalla, an entrepreneur who marketed QBR’s electro-diagnostic testing to medical providers through Compass Labs, which he part-owned, pleaded guilty to one count of healthcare fraud conspiracy in December 2021 after initially pleading not guilty to multiple counts in 2020, according to U.S. District Court Northern District of Alabama Court records and a Department of Justice press release. The person referred to as “Robyn” in the email is apparently Robin Stone, former vice president of government affairs at Blue Cross Blue Shield of Alabama. Stone contacted Hornbuckle nearly three years later in January 2015 via email. “Mac McCutcheon asked me to contact you,” Stone said in the email. “We are looking \[into\] requirements for the Arkansas plan for in-network lab status. I’ve got a few questions …” Hornbuckle emailed Chris and Mac McCutcheon again in February 2015 to say, “please let me know if we can help create transparency between physicians and BCBS” over concerns about how a proposed Blue Cross Blue Shield policy dealing with urine drug testing in pain management going into effect the following month would hurt Bowman’s Compass Labs. “Per Compass \[Labs\], we have a lot of upset physicians on our hands in Alabama that feel like this is going to affect their ability to prescribe medications,” Hornbuckle said in the email. “These physicians use the urine drug screen as a tool to pre screen patients to ensure compliance. With the limited ability to test, many physicians feel that patients will become more comfortable and more likely to abuse not only prescription drugs, but illicit drugs as well. Our state is already in the top 5 states for prescription drug abuse and it may continue to rise if this draft is implemented. Please let me know if we can help create transparency between the physicians and BCBS. I really enjoyed the inauguration and seeing you sir.” Mac McCutcheon replied to Hornbuckle, saying, “I will contact BCBS to get more info.” “We should be pro-active on this,” Mac McCutcheon said in the email. “How is that relationship with Compass going?” The last payment 1819 News could verify from QBR LLC to Practical Approach Consulting was for $1,250 on July 15, 2016. The business relationship between Hornbuckle and Chris McCutcheon apparently started to sour in 2016, according to court documents. Christopher McCutcheon filed a civil complaint against Hornbuckle in August 2016 in Madison County Circuit Court requesting compensatory and punitive damages for, in part, Hornbuckle allegedly “taking action as a majority owner to remove \[Christopher\] McCutcheon as the treasurer, CFO and secretary.” “Additionally, counsel for Hornbuckle sent letters to outside entities such as Bryant Bank informing it that \[Christopher\] McCutcheon was no longer able to conduct any business on behalf of QBR,” G. Bartley Loftin III, Christopher McCutcheon’s attorney, wrote in the complaint. “These actions were all in an attempt to exclude \[Christopher\] McCutcheon from any involvement in the business.” Loftin also wrote in the complaint that “the result is that \[Christopher\] McCutcheon has been totally squeezed out of the operations of QBR despite the fact that he was the initial investor and is still 49% owner of QBR.” W. Patton Hahn and Julie Schiff, Hornbuckle’s attorneys, responded with a counterclaim requesting compensatory and punitive damages from Christopher McCutcheon in September 2016. “\[W\]hile working with QBR’s outside accountants, who were his wife and father-in-law, \[Christopher\] McCutcheon has caused QBR’s financial statements to be incorrect and incomplete and has consistently failed to update QBR’s financial statements on the company’s accounting system, Peachtree,” Hornbuckle’s attorney stated as part of the reason for the counterclaim. Christopher McCutcheon denied allegations he caused harm to QBR in an answer to Hornbuckle’s counterclaim in October 2016. The civil claim was eventually settled in April 2017. **Topics:** Public Awareness --- ### [CMS Responds to Third-Party Data Breach Impacting 254K Medicare Beneficiaries](https://insurancefraud.org/news_archives/cms-responds-to-third-party-data-breach-impacting-254k-medicare-beneficiaries/) **Published:** September 14, 2026 **Author:** Diane Beauchamp **Content:** A third-party data breach potentially impacted the protected health information (PHI) and personally identifiable information (PII) of 254,000 Medicare beneficiaries, the Centers for Medicare & Medicaid Services (CMS) [announced](https://www.cms.gov/newsroom/press-releases/cms-responding-data-breach-subcontractor). No Medicare claims data were involved, and no CMS systems were breached during the incident. On October 8, Healthcare Management Solutions (HMS) discovered that it was subject to a ransomware attack on its corporate network. HMS is a subcontractor of ASRC Federal Data Solutions. CMS uses ASRC Federal Data Solutions and HMS to resolve system errors related to beneficiary entitlement and premium payment records. HMS also supports the collection of Medicare premium payments, but it does not handle Medicare claims information directly. “Initial information indicates that HMS acted in violation of its obligations to CMS and that the incident involving HMS has the potential to impact up to 254,000 Medicare beneficiaries’ personally identifiable information out of the over 64 million beneficiaries that CMS serves,” CMS stated. On October 9, CMS was notified that the subcontractor had suffered a cybersecurity incident but was told that its systems were not involved. Later that month, CMS “determined with high confidence” that the incident may have included the PII and PHI of some of its beneficiaries. The information involved in the ransomware attack potentially included names, addresses, phone numbers, Social Security numbers, Medicare Beneficiary identifiers, banking information, dates of birth, and Medicare entitlement, enrollment, and premium information. “The safeguarding and security of beneficiary information is of the utmost importance to this Agency,” CMS Administrator Chiquita Brooks-LaSure said in a press release. “We continue to assess the impact of the breach involving the subcontractor, facilitate support to individuals potentially affected by the incident, and will take all necessary actions needed to safeguard the information entrusted to CMS.” CMS is in the process of mailing new Medicare cards with new numbers to impacted individuals. “In October 2022, Healthcare Management Solutions, LLC (HMS) experienced a cybersecurity incident involving unauthorized access to our network which impacted limited systems. HMS acted swiftly to take the network offline in order to contain the incident. Industry-leading external cybersecurity experts were engaged to launch an investigation into the incident, which remains ongoing,” HMS said in a statement provided to *HealthITSecurity*. “Patient privacy has always been our top priority, and we have steadfastly maintained our obligation to patients and to any agency or contractor with which we have worked. We regret any concern this incident may have caused our community and will notify impacted individuals pursuant to legal and contractual obligations.” **Topics:** Public Awareness, Technology --- ### [Murder trial for woman accused of poisoning two men wraps up; verdict expected Friday](https://insurancefraud.org/news_archives/murder-trial-for-woman-accused-of-poisoning-two-men-wraps-up-verdict-expected-friday/) **Published:** September 14, 2026 **Author:** Diane Beauchamp **Content:** The trial for a woman accused of poisoning her husband and long-term boyfriend came to its closing arguments Thursday morning after being delayed several times by medical emergencies and investigators skipping court. Meshell Hale is accused of killing her boyfriend, Damian Skipper, in Baton Rouge by poisoning him, and detectives suspect she did something similar to her husband, Arthur Noflin, about a year later in New Orleans. Detectives testified that Hale — or a person using her name, contact information, credit card, and computer — purchased barium acetate online on three different occasions. The same compound was found in both men’s systems after they died. Prosecutors say the motive was insurance money. Hale finessed a $10,000 payment from Skipper’s life insurance despite not legally being his wife. The state argues she got greedy and wanted more, going after her actual husband, Noflin, who had a $750,000 policy. The verdict is expected to be announced sometime Friday morning. **Topics:** Life Insurance **Categories:** Arrest --- ### [Police Warn of Contractor Scams As Tornado Clean Up Continues in North Texas](https://insurancefraud.org/news_archives/police-warn-of-contractor-scams-as-tornado-clean-up-continues-in-north-texas/) **Published:** September 14, 2026 **Author:** Diane Beauchamp **Content:** Grapevine Police are warning residents of scammers on the move throughout North Texas. Police say repair crews – some who might not have good intentions – have been knocking on doors in the last couple of days. Not all of them are up to no good but experts say it can be really common for fraud to happen during desperate times after a storm. Grapevine police tweeted an alert on Thursday, in an effort to prevent anyone from becoming a victim of fraud. The North Central Texas Better Business Bureau always sounds the alarm on these issues after every storm. They say any weather event can bring about unscrupulous contractors, sometimes referred to as “storm chasers.” BBB also has these specific tips for victims of the storm: **Contact your insurance company.** Ask about your policy coverage and specific filing requirements. Save all receipts, including those for food, temporary lodging, or other expenses that may be covered under your policy. Your insurance company may also have recommended contractors. **Do your research.** Find businesses you can trust on [BBB.org](https://urldefense.com/v3/__https:/www.bbb.org/search__;!!PIZeeW5wscynRQ!98uwMN4Qs65dgJrvosmh_1I6BpQPTPwoT7oBCExzsjhp-e_xemWnoJYShyJ_3BpqT40$). Check your local city government agency responsible for registering and/or licensing contractors. Get references from friends and relatives. **Resist high-pressure sales.** Some storm chasers use tactics such as the “good deal” you’ll get only if you hire the contractor on the spot. Be pro-active in selecting a contractor and not re-active to sales calls on the phone or door-to-door pitches. Disaster victims should never feel forced to make a hasty decision or to choose an unknown contractor. **Be especially careful of door-to-door contractors.** Many municipalities require a solicitation permit if sales people go door-to-door. Ask for identification. Check their vehicle for a business name, phone number, and license plates for your state. **Don’t sign over insurance checks to contractors.** Get an invoice from the contractor and pay them directly (preferably with a credit card, which offers additional fraud protection over other forms of payment). Don’t sign any documents that give the contractor any rights to your insurance claims. If you have questions, contact your insurance company or agent. **Be wary regarding places you can’t see.** While most contractors abide by the law, be careful allowing someone you do not know to inspect your roof and other areas of your house. An unethical contractor may actually create damage to get work. The same goes for attics, crawl spaces, ducts, and other places you cannot easily access or see for yourself. BBB is also warning contractors to beware of storm chasers who offer to pay local construction companies substantial amounts of money to use the business’s established name, reputation, and phone. They masquerade as a local business, collect the insurance money and then move on, leaving the real business to deal with unsatisfied customers due to bad workmanship, unfinished work, or unfulfilled warranties. **Topics:** Public Awareness --- ### [Biden Administration Proposes Crackdown on Scam Medicare Ads](https://insurancefraud.org/news_archives/biden-administration-proposes-crackdown-on-scam-medicare-ads/) **Published:** September 14, 2026 **Author:** Diane Beauchamp **Content:** The Biden administration on Wednesday proposed a ban on misleading ads for Medicare Advantage plans that have targeted older Americans and, in some cases, convinced them to sign up for plans that don’t cover their doctors or prescriptions. The rule, proposed by the Centers for Medicare and Medicaid Services, would ban ads that market Medicare Advantage plans with confusing words, imagery or logos. The new regulation would also prohibit ads that don’t specifically mention a health insurance plan by name. It’s an aggressive step to tackle [a growing problem in the Medicare Advantage marketplace](https://apnews.com/article/health-business-medicare-government-and-politics-1b77c8584602a1abaaa3dfd297f0dbe7), a booming business that offers privately run versions of the government’s Medicare program for people who are 65 and older or have disabilities. Nearly half of all Medicare enrollees — about 28 million — are now turning to Medicare Advantage plans. And some have been deceived by television commercials, online ads and mailers put out by the marketing agencies and brokers that some insurers have hired to win over customers. The proposed rule “takes important steps to hold Medicare Advantage plans accountable for providing high quality coverage and care to enrollees,” said agency Administrator Chiquita Brooks-LaSure in a statement. The problem has become so pervasive that CMS agents have been secretly shopping for plans by calling the phone numbers in advertisements, finding in some cases that brokers have overstated the benefits that enrollees would get and the money they would save in the new plans. Democrats on the Senate Finance Committee released an investigative report last month showing that several states also reported an increase in complaints about deceptive marketing schemes in 2021. The committee’s investigation found that older adults in Ohio, for example, were sent mailers resembling federal government tax forms promising bigger Social Security checks if they enrolled in a new Medicare Advantage plan. Nationwide TV commercials featuring celebrities have also misled some customers by telling viewers they’ll get “money back to your Social Security check” but fail to mention that the plans they’re selling vary by ZIP code or don’t cover all providers. “These proposals are an important step towards protecting seniors in Medicare from scammers and unscrupulous insurance companies and brokers,” the committee chairman, Sen. Ron Wyden, D-Ore., said in a statement on Wednesday. The federal agency on Wednesday also proposed regulations that would establish new wait-time standards for mental health providers that are in-network for Medicare Advantage plans. The standards would recommend that enrollees be able to access mental health care appointments within 10 days. **Topics:** Medicare/Medicaid, Public Awareness, Regulatory actions --- ### [Ocenture LLC and Carelumina LLC Settle Allegations of False Claims for Unnecessary Genetic Testing](https://insurancefraud.org/news_archives/ocenture-llc-and-carelumina-llc-settle-allegations-of-false-claims-for-unnecessary-genetic-testing/) **Published:** September 14, 2026 **Author:** Diane Beauchamp **Content:** Ocenture LLC, a privately held company headquartered in Jacksonville, Florida, and its subsidiary, Carelumina LLC (collectively, “Ocenture”), have agreed to pay $3 million to resolve allegations that they caused the submission of false claims to Medicare by paying and receiving kickbacks in connection with genetic testing samples. The United States alleged that Ocenture participated in a genetic testing fraud scheme with other marketers and clinical laboratories. As part of the alleged scheme, Ocenture solicited genetic testing samples from Medicare beneficiaries directly and through other marketers. Ocenture then paid physicians to falsely attest that the genetic testing was medically necessary and arranged for the laboratories to process the tests and receive reimbursement from Medicare, with a portion of that reimbursement being paid to Ocenture. “The Anti-Kickback Statute prohibits paying or receiving remuneration for referring services paid for by federal health care programs,” said Principal Deputy Assistant Attorney General Brian M. Boynton, head of the Justice Department’s Civil Division. “The department will hold accountable those who undermine the integrity of these programs by knowingly engaging in illegal kickback schemes that distort physician decision-making and waste taxpayer dollars.” “Kickback schemes corrupt the clinical judgments of providers and may lead to unnecessary medical services paid for by taxpayers,” said U.S. Attorney for the Middle District of Florida Roger Handberg. “The resolution of this civil case confirms our district’s resolve in protecting our federal health programs from these fraudulent practices.” “Entities involved in kickbacks that bilk Medicare funds threaten the program’s fiscal stability and abuse patients’ trust,” said Special Agent in Charge Omar Pérez-Aybar for the Department of Health and Human Services Office of Inspector General (HHS-OIG). “With our partners, HHS-OIG without relent investigates providers that allegedly distort the practice of genetic testing to defraud federal health care programs.” The civil settlement includes the resolution of claims brought under the *qui tam* or whistleblower provisions of the False Claims Act by Christopher Improta and Peter Brandt, two marketers who were approached by Ocenture to participate in the alleged kickback scheme. Under those provisions, a private party can file an action on behalf of the United States and receive a portion of any recovery. The *qui tam* case is captioned *U.S. ex rel. Improta, et al. v. Ocenture, et al.*, Civil Action No. 3:19-cv-358 (M.D. Fla.). As part of today’s resolution, Messrs. Improta and Brandt will receive approximately $570,000. The resolution obtained in this matter was the result of a coordinated effort between the Justice Department’s Civil Division, Commercial Litigation Branch, Fraud Section, and the U.S. Attorney’s Office for the Middle District of Florida, with assistance from the HHS-OIG and the FBI. The investigation and resolution of this matter illustrates the government’s emphasis on combating health care fraud. One of the most powerful tools in this effort is the False Claims Act. Tips and complaints from all sources about potential fraud, waste, abuse, and mismanagement can be reported to the Department of Health and Human Services at 800-HHS-TIPS (800-447-8477). The matter was handled by Senior Trial Counsel Laurie A. Oberembt and Assistant U.S. Attorney Ronnie S. Carter. *The claims resolved by the settlement are allegations only, and there has been no determination of liability.* **Topics:** Judicial/courts, Medicare/Medicaid, Public Awareness --- ### [Need an ambulance? Depending on the state, it will cost you](https://insurancefraud.org/news_archives/need-an-ambulance-depending-on-the-state-it-will-cost-you/) **Published:** September 14, 2026 **Author:** Diane Beauchamp **Content:** Although the U.S. [outlawed most surprise medical bills](https://www.cbsnews.com/news/surprise-medical-bills-illegal-new-law/) starting this year, people who face a health emergency could still find themselves on the hook for hundreds of dollars — or more — in out-of-network fees. For patients with health insurance, an ambulance ride can set someone back between $500 and $1,000, according to a report from the Public Interest Research Group [released](https://pirg.org/media-center/news-release-national-solution-needed-to-put-breaks-on-ambulance-surprise-bills/) Tuesday. “Ground ambulances are the highest out-of-network biller of all of our health care services,” Patricia Kelmar, PIRG’s senior director of health care campaigns, told CBS MoneyWatch. Some 3 million patients go to the hospital in an ambulance each year, more than half of whom will end up with a surprise bill, according to the consumer advocacy group. One study found that between 2010 and 2016, 85% of ambulance patients were hit with a surprise bill for out-of-network services, also known as a balance bill. The size of the bill can vary tremendously among states. In Washington, D.C., for example, the median surprise ambulance bill is just $37, according to a [study](https://www.healthaffairs.org/doi/10.1377/hlthaff.2019.01484) published in Health Affairs in 2020. By contrast, patients in California, Massachusetts and Minnesota can expect to pay over $1,000 out of pocket for an ambulance ride, after whatever costs their insurance provider covers. In California, the median bill for an ambulance ride is about $1,200, while in Massachusetts it’s $1,024 and $1,133 in Minnesota. ## Patchwork system One reason for the disparity in ambulance billing is the proliferation of different types of ambulance services. Modern ambulance networks were [established in the 1970s](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1470509/) thanks to a major federal push and dedicated funding. But after congressional money dried up in the 1980s, states took over and many programs were cut or privatized, Kelmar said. “Different communities responded in different ways,” she said. “Some municipalities set up funding programs \[for ambulance services\], some got absorbed into fire departments, some hospitals started ambulance services and private services started up as well.” In recent years, private equity firms have also taken over ambulance services — a change in ownership that often results in aggressive billing and debt collection, PIRG noted. There are about 14,000 different ambulance services around the county, Kaiser Health News has [estimated](https://khn.org/news/taken-for-a-ride-ambulances-stick-patients-with-surprise-bills/). Patients are also more likely to be stuck with surprise ambulance bills in certain states. For instance, Maryland bars volunteer ambulances, or those owned by the local government or fire department, from billing patients. Only half of ambulance rides in Maryland result in a surprise bill, according to the Health Affairs study, which looked at patients in a large national health insurance plan. On the other end of the spectrum, 93% of ambulance rides in Oregon and nearly 90% of those in Washington state result in a surprise bill, the study found. Altogether, 10 states have laws to limit balance billing for ambulance rides, but even those protections have large gaps. Most notably, they leave out the 60% of insured Americans whose health care is covered by self-funded large insurer plans. ## “Roll of the dice” Unlike a patient who schedules a doctor’s visit and can check if those medical services are within their health insurance network, someone calling 911 for a medical emergency has no such ability. Ambulance patients often may not know who operates the transport service. “You’re not going to consult a directory when you’re dialing for an ambulance,” Kelmar said. “Of course, when you call 911, they’re just dispatching the closest available ambulance …. It’s a roll of the dice if you’ll get that out-of-network bill.” PIRG is pushing Congress to include ambulance bills in the recently passed [No Surprises Act](https://www.cms.gov/nosurprises), which protects patients in emergency situations from being billed for out-of-network services they didn’t agree to. While the law doesn’t regulate ambulances, it has directed a [committee](https://www.cms.gov/regulations-guidance/advisory-committees/advisory-committee-ground-ambulance-and-patient-billing-gapb) to study the issue and make recommendations. “We have figured out how to solve surprise billing with the No Surprises Act. It’s working, and people aren’t having to face those bills they couldn’t avoid. Ground ambulances are the same thing,” Kelmar said. “We shouldn’t be price-gouging those unlucky few who have an emergency.” **Topics:** Legislative, Public Awareness --- ### [Sturdy Memorial Hospital & North Shore Pain Management Settle Data Breach Lawsuits](https://insurancefraud.org/news_archives/sturdy-memorial-hospital-north-shore-pain-management-settle-data-breach-lawsuits/) **Published:** September 14, 2026 **Author:** Diane Beauchamp **Content:** Two healthcare organizations in Massachusetts have chosen to settle class action lawsuits that were filed by patients whose protected health information was stolen in cyberattacks. ## Sturdy Memorial Hospital Sturdy Memorial Hospital in Attleboro, MA, has agreed to settle a lawsuit filed in response to a September 2021 ransomware attack, where the attackers gained access to the data of approximately 60,000 patients, such as names, addresses, dates of birth, Social Security numbers, financial information, and health information. The attackers exfiltrated patient data and threatened to release the information publicly. The hospital chose to pay the ransom. The lawsuit – *Shedd, et al. v. Sturdy Memorial Hospital Inc.* – alleged the hospital had maintained patient information in a reckless manner, as the information was stored on a system vulnerable to cyberattacks and the data was not encrypted. The lawsuit alleged the hospital did not follow Federal Trade Commission guidelines and violated Massachusetts laws by delaying sending notification letters to patients for almost 4 months. Sturdy Memorial Hospital admitted no wrongdoing and chose to settle the lawsuit to avoid ongoing legal costs. Under the terms of the settlement, class members can claim up to $375 for ordinary losses, including out-of-pocket expenses and up to three hours of lost time at $20 per hour. Claims can also be submitted for documented extraordinary losses incurred between February 9 and February 14, 2021, up to a maximum of $5,000. The settlement also includes free credit monitoring services for class members. Class members have until January 14, 2023, to exclude themselves from or object to the settlement. Claims must be submitted by February 14, 2023. The fairness hearing is scheduled for February 16. 2023. ## North Shore Pain Management North Shore Pain Management, which operates pain management clinics in Beverley and Woburn, MA, and its vendor, Revolve I.T. Inc, have chosen to settle a class action lawsuit filed in response to an April 2020 ransomware attack. The attackers gained access to its network and exfiltrated patient data prior to encrypting files. The AKO ransomware gang claimed to have stolen 4GB of data, and that data was leaked when the ransom wasn’t paid. The stolen data included patient names, dates of birth, health insurance information, account balances, financial information, diagnosis and treatment information, and for certain patients, ultrasound and MRI images and/or Social Security numbers. 12,472 current and former patients were affected. North Shore Pain Management and Revolve I.T. maintain they had implemented adequate defenses to protect against cyberattacks and denied any wrongdoing. The decision was taken to settle the lawsuit to avoid further legal costs and the uncertainty of trial. Under the terms of the settlement, a fund of $200,000 will be created to cover claims from class members for economic losses and lost time related to the data breach. Each class member may claim up to $150 for ordinary economic losses and lost time and claims up to a maximum of $1,500 are permitted for extraordinary losses. The settlement also includes 36 months of credit monitoring services or a $25 payment in lieu of the credit monitoring services and reimbursement of economic losses. Claims will be paid pro rata if the claims total exceeds $200,000. Class members have until December 14, 2022, to exclude themselves from or object to the settlement. Claims must be submitted by January 13, 2023. The fairness hearing is scheduled for January 10, 2023. **Topics:** Judicial/courts, Public Awareness, Technology --- ### [Kaye-Smith Announces Data Breach Potentially Affecting MultiCare Patients](https://insurancefraud.org/news_archives/kaye-smith-announces-data-breach-potentially-affecting-multicare-patients/) **Published:** September 14, 2026 **Author:** Diane Beauchamp **Content:** On December 9, 2022, Kaye-Smith reported a data breach with the Office of Consumer Protection of the Montana Attorney General after hackers successfully obtained access to confidential consumer information following a ransomware attack. The breach affected information the company received from MultiCare, a large regional health network for which Kaye-Smith processes personal information as a part of the mailing services it provides. According to Kaye-Smith, the breach resulted in the names, addresses and Social Security numbers being compromised. Recently, Kaye-Smith sent out data breach letters to all affected parties, informing them of the incident and what they can do to protect themselves from identity theft and other frauds. **If you receive a data breach notification from Kaye-Smith or MultiCare, it is essential you understand what is at risk and what you can do about it.** As is the case with most third-party data breaches, you may not have known that a company named Kaye-Smith existed—let alone possessed your personal information. However, as we’ve discussed in prior posts, that doesn’t affect the duty Kaye-Smith had to protect your information. To learn more about how to protect yourself from becoming a victim of fraud or identity theft and what your legal options are in the wake of the Kaye Smith data breach, please see our recent piece on the topic [here](https://www.myinjuryattorney.com/consumer-privacy-data-breach-lawyers/if-your-information-has-been-compromised-in-a-data-breach/). ## What We Know About the Kaye Smith Data Breach The available information regarding the Kaye Smith breach comes from the company’s data breach letter, filed with the Office of Consumer Protection of the Montana Attorney’s General office. According to this source, in June 2022, Kaye-Smith learned of a potential data security incident when it detected suspicious activity throughout its computer network. In response, the company worked with outside experts to investigate the incident and determine whether any confidential consumer information was leaked as a result. The Kaye Smith investigation confirmed that the company had been the victim of a ransomware attack. As a result of the cyberattack, hackers were able to gain access to certain files stored on the Kaye-Smith network. Further investigation revealed that some of these files contained sensitive information pertaining to one of the company’s corporate clients, MultiCare. Upon discovering that sensitive consumer data was made available to an unauthorized party, Kaye Smith began to review the affected files to determine what information was compromised and which consumers were impacted. While the breached information varies depending on the individual, it may include your name, address, and Social Security number. On December 9, 2022, Kaye Smith sent out data breach letters to all individuals whose information was compromised as a result of the recent data security incident. While the Kaye Smith data breach letter does not mention whether customers of any of the company’s other clients were affected, we know that the Kaye-Smith data breach affected certain MultiCare patients. ## More Information About Kaye-Smith and MultiCare Founded in 1908, Kaye-Smith is a business services company based in Renton, Washington. The company provides its corporate clients with various solutions related to branded merchandise, statement processing and billing services, inventory management, direct mail marketing, web applications, warehousing and distribution, data management and personalized fulfillment. Kaye-Smith operates three locations in Renton, WA, Portland, OR, and Boise, ID. Kaye Smith employs more than 170 people and generates approximately $39 million in annual revenue. Founded in 1882, MultiCare is a not-for-profit healthcare company based in Tacoma, Washington. MultiCare is the largest, not-for-profit, community-based, locally-owned health system in Washington State. MultiCare operates 11 hospitals in the region, including: - MultiCare Allenmore Hospital in Tacoma - MultiCare Auburn Medical Center in Auburn - MultiCare Capital Medical Center in Olympia - MultiCare Covington Medical Center in Covington - MultiCare Deaconess Hospital in Spokane - MultiCare Good Samaritan Hospital in Puyallup - Mary Bridge Children’s Hospital in Tacoma - MultiCare Tacoma General Hospital in Tacoma - MultiCare Valley Hospital in Spokane Valley - Navos Behavioral Health Hospital in West Seattle - Wellfound Behavioral Health Hospital in Tacoma MultiCare also operates MultiCare Behavioral Health Network, MultiCare Indigo Health, Mary Bridge Children’s Hospital & Health Network, Pulse Heart Institute and MultiCare Rockwood Clinic. MultiCare employs more than 20,000 people and generates approximately $2 billion in annual revenue. **Topics:** Public Awareness, Technology --- ### [California hospital breach exposed patients’ Social Security numbers, medical info](https://insurancefraud.org/news_archives/california-hospital-breach-exposed-patients-social-security-numbers-medical-info/) **Published:** September 14, 2026 **Author:** Diane Beauchamp **Content:** A hospital in California’s Riverside County has reported a data breach to its patients including sensitive information like Social Security numbers and the details of medical care following an incident in the fall. According to the notice, beginning on October 29 an “unauthorized party” accessed the computer network of San Gorgonio Memorial Hospital, a 79-bed nonprofit facility in the small town of Banning. The hacker had access until November 10, when the breach was detected and “select” network systems isolated and shut off. The hospital hired an undisclosed third-party forensic firm. “At this time, we have identified documents containing patient names, addresses, dates of birth, medical record numbers, visit ID numbers, and/or clinical information, such as dates of service, provider names, and/or department names,” the hospital wrote in [a notice posted to its website](https://sgmh.org/). “In some instances, patients’ Social Security numbers, drivers’ license numbers, financial account information, and/or health insurance information may have also been reflected in the documents involved.” The hospital did not disclose how many patients were potentially impacted in the breach, nor if the incident was a ransomware attack. The Record has contacted hospital administration for comment. The news outlet Patch [reported in November](https://patch.com/california/banning-beaumont/san-gorgonio-memorial-hospital-back-online-after-malware-attack) that the hospital’s electronic records system was shut down for six days during the attack and staff reverted to taking handwritten notes. Ransomware attacks have been an ever-growing threat to the healthcare industry. A [Sophos survey published in May](https://www.thomsonreuters.com/en-us/posts/investigation-fraud-and-risk/ransomware-attacks-against-healthcare/) found that two-thirds of healthcare organizations had been targeted by ransomware in the previous year, nearly double the amount in 2020. Last week, the U.S. Department of Health and Human Services [warned of attacks on the healthcare industry](https://therecord.media/us-dept-of-health-warns-of-increased-royal-ransomware-attacks-on-hospitals/) from the Royal ransomware group. **Topics:** Public Awareness, Technology --- ### [New York Enacts Law Protecting Hate Crime Victims in Insurance Dealings](https://insurancefraud.org/news_archives/new-york-enacts-law-protecting-hate-crime-victims-in-insurance-dealings/) **Published:** September 14, 2026 **Author:** Diane Beauchamp **Content:** New York Governor Kathy Hochul has signed legislation (S.7658-B/A.8869-B) to protect individuals and organizations that are victims of hate crimes from unfair insurance practices. The new law prohibits insurers from canceling an insurance policy, raising premiums, refusing to issue a policy or refusing to renew a policy solely on the basis that one or more claims have been made for a loss that is a result of a hate crime. This new law will apply to individuals, religious organizations, or nonprofits organized and operated for religious, charitable or educational purposes. “If an individual is targeted for a hate crime, the last thing they should worry about is losing their insurance, and with this legislation we are taking action to protect victims and ensure every New Yorker is treated with dignity and respect,” Hochul said. The legislation applies where hate-crime related claims have been made against the policy during the preceding five years. The insured must provide evidence that the loss resulted from a hate crime. Hochul also [announced](https://gcc02.safelinks.protection.outlook.com/?url=https%3A%2F%2Fwww.governor.ny.gov%2Fnews%2Fgovernor-hochul-announces-96-million-improve-safety-nonprofit-community-based-organizations&data=05%7C01%7CMichelle.Etelzon%40oasas.ny.gov%7C5834699673b343b683be08dadc615548%7Cf46cb8ea79004d108ceb80e8c1c81ee7%7C0%7C0%7C638064607870426761%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C3000%7C%7C%7C&sdata=9%2B9cCPNXrxlw31fR%2BYCK6GMwCon5ekt2y7NggClPtv8%3D&reserved=0) $50 million to strengthen security measures at nonprofit, community-based organizations at risk of hate crimes, in addition to $46 million in federal funding to 240 nonprofit organizations across the state facing an increased risk of terrorist attack. **Topics:** Legislation, Public Awareness --- ### [Healthcare billing fraud: 11 recent cases](https://insurancefraud.org/news_archives/healthcare-billing-fraud-11-recent-cases/) **Published:** September 14, 2026 **Author:** Diane Beauchamp **Content:** 1. Connecticut psychologist pleads guilty to $2.6M billing fraud Connecticut psychologist Michael Lonski pleaded guilty to a $2.6 million billing fraud scheme. He admitted to billing for services not rendered, including billing insurers for deceased patients, and for dates of service when he or his fellow provider were out of the country. Connecticut Medicaid lost $1.1 million due to the scheme. 2. 2 pharmacy workers arrested in $10M fraud scheme New York pharmacy workers Hua Huang and Huiling Wu were arrested for their alleged role in a Medicare and Medicaid fraud scheme that reached $10.5 million via medically unnecessary prescriptions. 3. Tenet-owned Massachusetts hospital to pay $1.78M to settle false claim allegations Worcester, Mass.-based St. Vincent Hospital will pay more than $1.78 million to settle allegations it received impermissible payments from Medicare by inflating charges and failing to fully reimburse the government. 4. Medical marketing company owner charged in $64M fraud scheme James Feeley, the owner of a medical marketing company, was charged in connection with an alleged billing fraud and kickback scheme that defrauded federal payers out of at least $64 million. 5. Medical equipment company CEO gets 80 months for $50M fraud scheme Tanya Grant was sentenced to 80 months in prison for the healthcare fraud scheme that caused two companies she controlled to bill Medicare for more than $50 million in durable medical equipment between 2014 and 2021. 6. Florida physician gets 40 months for kickbacks, bribes Steven Chun, MD, was sentenced to 40 months in prison for his role in a scheme involving the fentanyl spray Subsys that caused Medicare Part D to pay more than $4.5 million for prescriptions he wrote. 7. Dignity, 2 Tenet affiliates to resolve billing fraud allegations for $22.5M San Francisco-based Dignity Health, along with Tenet affiliated California facilities Twin Cities Community Hospital and Sierra Vista Regional Medical Center paid $22.5 million to settle allegations it submitted claims to Medi-Cal for services that were not allowed medical expenses, did not reflect the fair market value of the enhanced services provided or were duplicated services. 8. 9 arrested in Florida for allegedly orchestrating $37M scheme to defraud Blue Cross Blue Shield Nine Florida residents were arrested for allegedly paying kickbacks to employees of JetBlue Airways, AT&T and TJX Companies — who were Blue Cross beneficiaries — to be patients at 30 South Florida physical therapy clinics the defendants owned. 9. New Jersey opioid treatment group to pay $3.15M to settle fraud allegations Camden (N.J.) Treatment Associates agreed to pay $3.15 million to resolve criminal and civil allegations it solicited kickbacks, obstructed a federal audit and fraudulently billed Medicaid. 10. New York testing facility owners get prison for $18M fraud scheme New York City-based testing facility owners Tea Kaganovich, and Ramazi Mitaishvili were each sentenced to three years in prison for their roles in an $18 million healthcare fraud scheme. 11. Minnesota psychologist pleads guilty to defrauding BCBS Minnesota Prior Lake, Minn.-based psychologist Charles Jorenby pleaded guilty to billing Blue Cross Blue Shield of Minnesota for fraudulent treatment of 29 members of the Shakopee Mdewakanton Sioux Community. **Topics:** Healthcare Fraud, Judicial/courts, Public Awareness **Categories:** Conviction --- ### [Greenwich Psychologist Billed For Dead Patients In Insurance Scam: Feds](https://insurancefraud.org/news_archives/greenwich-psychologist-billed-for-dead-patients-in-insurance-scam-feds/) **Published:** September 14, 2026 **Author:** Diane Beauchamp **Content:** Michael Lonski, a 71-year-old Greenwich psychologist, waived his right to be indicted and pleaded guilty Monday before U.S. District Judge Sarala V. Nagala in Hartford to health care fraud, according to a news release from U.S. Attorney for the District of Connecticut Vanessa Roberts Avery. Health care fraud carries a maximum prison term of 10 years, Avery noted. Lonski is released on bond pending sentencing, which is scheduled for March 10, 2023. Lonski is a licensed psychologist, who has practiced out of a home office in Old Greenwich with another licensed psychologist identified only as “Individual 1,” according to court documents and statements made in court. Lonski and Individual 1 were authorized providers for the Connecticut Medicaid program, Medicare and other health care benefit programs. “Lonski assumed responsibility for submitting claims for reimbursement for services allegedly provided by himself and by Individual 1, both at their home office and at various skilled nursing facilities within Connecticut,” Avery said in a news release. In pleading guilty, Lonski admitted that he billed insurers for services that he knew were not rendered, including by billing for patients who were deceased, for dates of service when he was out of the country, for dates of service when Individual 1 was out of the country, and for dates of service when he was hospitalized, Avery explained. These fraudulent claims resulted in a loss of over $2,651,296, including a loss of $1,157,292 to the Connecticut Medicaid program and a loss of $119,092 to Medicare., Avery said. As part of the latest plea, Lonski has agreed to pay full restitution. In 2002, Lonski settled a federal lawsuit alleging health care fraud offenses, which was brought by the government in the Southern District of New York, Avery said. Lonski agreed to pay $4 million in restitution and was excluded from participating in the Medicare program from April 2003 to November 2007. He was reinstated to the Medicare program in approximately December 2008, Avery said. **Topics:** Medicare/Medicaid **Categories:** Conviction --- ### [Florida legislature passes massive property insurance bill](https://insurancefraud.org/news_archives/florida-legislature-passes-massive-property-insurance-bill/) **Published:** September 14, 2026 **Author:** Diane Beauchamp **Content:** Republicans in the state legislature put their supermajority power on display this week when they passed a massive property insurance package less than five days after it was filed without including input from Democrats. “The work that we’ve been putting in to provide relief to consumers over the years in the property insurance market has culminated in the biggest, meatiest, beefiest property insurance reform legislation that the state has ever seen,” said bill sponsor Rep. Tom Leek (R-Daytona Beach) during a press conference after the measure passed in the House on Wednesday. It seeks to cut back on fraud and litigation—two factors the industry says are driving up costs. Republicans say the changes will lead to lower rates. But the measure contains no guarantees rates will go down. And that was a problem for Democrats. The measure passed the House (84-33) on Wednesday along party lines after the Senate passed it (27-13) the day before. In the Senate, two Republicans voted against the bill — Sen. Ileana Garcia of Miami Dade and Sen. Erin Grall of Vero Beach — and one Democrat — Sen. Linda Stewart of Orlando — voted in favor of it. Gov. Ron DeSantis is expected to sign it into law. Leading up to the special legislative session this week, Republicans and Democrats agreed that rates should go down as a result of any measure they pass. However, they were in disagreement on how to get there and when that should happen. Democrats proposed forcing insurers to lower rates, giving homeowners immediate relief. Republicans took a market-based approach to getting prices down and rejected every proposed amendment from the minority party’s caucus. After the bill cleared both chambers, Republican House Speaker Paul Renner of Palm Coast explained that they believe rates will come down under the measure, but it will take at least a couple of years. Renner said the measure is expected to keep the state’s private insurers from going out of business in the more immediate future. “There is an immediate win, but not on premiums,” Renner said during press conference after the measure passed the legislature on Wednesday. “The win today is the hope that we can continue to have insurance for everyone.” Renner also described the bill as “a pro-consumer,” even though critics of the measure have characterized it as a threat to consumers. “It’s pro-consumer from the standpoint that if you don’t have insurance, that’s not good for consumers.” House Minority Leader Rep. Fentrice Driskell (D-Tampa) likened the measure to a “one-billion dollar- bailout to insurance companies” with “no real rate relief to Florida homeowners.” “We always talk about how elections have consequences,” Driskell said. “This is a substantial consequence.” **Topics:** Homeowners Fraud, Legislation, Public Awareness --- ### [Humana Suit Accuses United Therapeutics of Insurance Fraud](https://insurancefraud.org/news_archives/humana-suit-accuses-united-therapeutics-of-insurance-fraud/) **Published:** September 14, 2026 **Author:** Diane Beauchamp **Content:** United Therapeutics Corp. is using a tax-exempt program to earn “obscene” profits—at the expense of Medicare—off drugs it sells to patients at highly reduced costs, a private health insurer alleges. UT partnered with a patient-assistance charity in a “cynical scheme that has become inherent to the pharmaceutical industry,” Humana Inc. [says](https://www.bloomberglaw.com/public/document/HumanaIncvUnitedTherapeuticsCorporationDocketNo822cv03211DMdDec13?doc_id=X3J6VJM90CG87NPMIR24216CLUS) in a complaint filed in the US District Court for the District of Maryland Tuesday. In the scheme, drugmakers pay kickbacks to patients to induce them to use particular drugs, thereby eliminating cost-sharing obligations imposed by Medicare and insurers as an economic check on drug prices, the complaint says. … **Topics:** Judicial/courts, Public Awareness --- ### [Lawmakers push CMS to prevent fraud, abuse in ACO REACH model](https://insurancefraud.org/news_archives/lawmakers-push-cms-to-prevent-fraud-abuse-in-aco-reach-model/) **Published:** September 14, 2026 **Author:** Diane Beauchamp **Content:** U.S. Senator Elizabeth Warren, D-Mass., and Representative Pramila Jayapal, D-Wash., are spearheading an effort by lawmakers to compel the Centers for Medicare and Medicaid Services to look at the ACO REACH model, with an eye toward preventing program participation in 2023 for organizations with a history of fraud. According to CMS, the ACO REACH model will replace the Global and Professional Direct Contracting Model beginning in January, with participants in the latter allowed to enroll in the former if they agree to meet the compliance requirements. Warren, Jayapal and others wrote a letter to the agency expressing reservations about the model, saying it may allow insurers and providers to harm the Medicare system. According to the letter, a preliminary review of these Direct Contracting Entities (DCEs) participating in the GPDC found at least 10 of these organizations have records – in some cases, extensive records – of healthcare fraud, abuse and violations of healthcare laws prior to 2021. “These entities were accepted into the GPDC program in 2021 and have continued to operate in the program, even as CMS pushes for additional oversight, vetting and transparency,” lawmakers wrote. They’re particularly alarmed by the findings of a preliminary review of the DCEs conducted by Physicians for a National Health Program (PNHP), which lawmakers said identified at least 10 participating organizations that have documented cases of defrauding Medicare and other government health programs. “The inclusion of these DCEs in the Global and Professional Direct Contracting Model is a significant concern after these companies’ previous failures to follow the law,” they wrote. “The ability of organizations with known histories of fraud and abuse to take part in the program increases the risks for Medicare beneficiaries and raises concerns that CMS screening procedures for participants are inadequate, putting taxpayer dollars at risk.” **WHAT’S THE IMPACT?** The letter singled out several major insurers by name in citing cases of fraud and abuse. For instance, they cite an audit by the [Department of Health and Human Services](https://www.healthcarefinancenews.com/directory/us-department-health-and-human-services-hhs) [Office of Inspector General](https://www.healthcarefinancenews.com/directory/office-inspector-general-oig) finding that Humana, which operates a DCE in 13 states, improperly collected nearly $200 million in 2015 through upcoding and “overstating how sick some patients were.” Clover Health, meanwhile, was investigated by Congress for allegedly giving Wall Street insiders opportunities to make millions “while retail investors lost over 65% of their stock value,” lawmakers said. And Bright Health, the parent company to multiple DCEs, described the Medicare [fee-for-service](https://www.healthcarefinancenews.com/directory/fee-service-ffs) market as a “$430 billion opportunity” in a 2021 regulatory filing. The Colorado Division of Insurance received over 100 consumer and healthcare provider complaints regarding Bright Health since 2021, leading to a $1 million fine and a formal agreement with the company to address operational improvements, according to *The Wall Street Journal.* “The ACO REACH model’s 2022 request for applications includes required disclosures of any sanctions, corrective actions, and fraud investigations faced by the organization or any individuals with ownership interests, but similar requirements did not appear to be able to keep these organizations out of the predecessor Direct Contracting program,” lawmakers wrote. “In addition, if these organizations are automatically included in the ACO REACH program without further review of their histories of fraud and abuse will further undercut these requirements.” They suggest that, before the ACO REACH program begins, CMS should halt participation by any organizations that have committed healthcare fraud, and terminate DCEs that don’t meet the new standards for the program. **THE LARGER TREND** The ACO REACH Model will require all participating ACOs to have a robust plan describing how they will meet the needs of people with traditional Medicare in underserved communities and make measurable changes to address health disparities. This includes greater access to enhanced benefits, such as telehealth visits, home care after leaving the hospital, and help with copays, [CMS said in February](https://www.healthcarefinancenews.com/news/cms-changing-direct-contracting-aco-gets-mixed-reaction). CMS said it would use an innovative payment approach to better support care delivery and coordination for people in underserved communities. REACH ACOs can include primary and specialty care physicians. The Global and Professional Direct Contracting Model was [controversial](https://www.healthcarefinancenews.com/news/over-200-healthcare-organizations-ask-hhs-keep-direct-contracting) because opponents, including progressive Democrats, believed it would lead to the privatization of Medicare. Physicians for a National Health Program, an organization of 25,000 doctors who support Medicare for All and oppose Medicare privatization, has rejected the ACO REACH model, as it did the GPDC. Others applauded CMS’s redesign, including Premier and The National Association of ACOs. **Topics:** Legislative, Public Awareness, Regulatory actions --- ### [Gov. DeSantis calls for grand jury to investigate COVID-19 vaccines and possible fraudulent claims](https://insurancefraud.org/news_archives/gov-desantis-calls-for-grand-jury-to-investigate-covid-19-vaccines-and-possible-fraudulent-claims/) **Published:** September 14, 2026 **Author:** Diane Beauchamp **Content:** DeSantis wants the grand jury impaneled for at least one year, possibly 18 months. Gov. **Ron DeSantis** wants the state Supreme Court to impanel a statewide grand jury to investigate crimes and wrongdoings the pharmaceutical industry may have committed against the state’s residents regarding the COVID-19 vaccine. The Governor made the announcement, along with news that he was establishing a Public Health Integrity Committee, after holding a roundtable discussing purported adverse events — such as coagulation disorders, acute cardiac injuries, Bell’s palsy, encephalitis, appendicitis and shingles — as a result of the mRNA vaccines. The Public Health Integrity Committee will be overseen by State Surgeon General and Department of Health Secretary **Joseph Ladapo** and will have seven members. The goal of the committee is to tailor federal guidance and recommendations to ensure they reflect the state’s priorities for Florida communities. DeSantis is asking the Supreme Court to impanel a statewide grand jury for at least a year, and possibly up to 18 months, according to the [**petition**](https://www.flgov.com/wp-content/uploads/2022/12/Vaccine-Grand-Jury-Petition.pdf). For the “convenience” of prospective grand jury witnesses, law enforcement officers, and others, DeSantis is asking the state’s high court to designate Florida’s [**5th**](https://www.circuit5.org/), [**6th**](http://www.jud6.org/), [**10th**](https://www.jud10.flcourts.org/), [**12th**](https://www.jud12.flcourts.org/) and [**13th**](https://www.fljud13.org/) judicial circuits as the “home base” for the grand jury. DeSantis said in the petition that he chose those locations because they are easily accessible. Meanwhile, the statewide prosecutor in the Attorney General’s Office will serve as the legal advisor to the statewide grand jury. The Florida Department of Law Enforcement will serve as the primary investigator for the group, though the petition makes clear that the statewide grand jury may seek the assistance of “any law enforcement entity or agency in Florida.” The Governor wants the grand jury to examine including a law that prohibits fraudulent practices, including the dissemination of false or misleading advertisements of a drug and the use of any representation or suggestion in any advertisement relating to a drug that an application of a drug is effective when it is not. “The pharmaceutical industry has a notorious history of misleading the public for financial gain. Questions have been raised regarding the veracity of the representation made by the pharmaceutical manufacturers of COVID-19 vaccines, particularly with respect to transmission, prevention, efficacy and safety,” the petition notes. “An investigation is warranted to determine whether the pharmaceutical industry has engaged in fraudulent practices. The people of Florida deserve to know the truth.” The Tuesday morning announcement came after DeSantis, during a Republican holiday gathering at the Governor’s mansion earlier this month, told a group that “we are going to hold these manufacturers accountable for this mRNA, because they said there are no side effects, and we know there have been a lot.” DeSantis cited an analysis released by Ladapo in October about an increased risk of cardiac-related deaths among males 18-39 after taking a COVID-19 mRNA vaccine. That analysis has drawn sharp criticism from medical experts as flawed. In addition to impaneling a grand jury and establishing the ethics committee, DeSantis announced the state is collaborating with the University of Florida**,** where Ladapo is on contract, to compare Florida research into the sudden deaths of individuals who received the COVID-19 vaccine with studies done in other countries. Ladapo said in a prepared statement that DeSantis’ actions “will shed light on the forces that have obscured truthful communication about the COVID-19 vaccines.” **Topics:** COVID-19, Judicial/courts, Public Awareness --- ### [Independent Adjusters Charge Florida Insurers With Doctoring Damage Estimates](https://insurancefraud.org/news_archives/independent-adjusters-charge-florida-insurers-with-doctoring-damage-estimates/) **Published:** September 14, 2026 **Author:** Diane Beauchamp **Content:** Do some Florida property insurance companies hire independent adjusters to inspect property claims, then routinely alter their inspection reports to reduce estimated losses? Yes, and it’s a widespread and fraudulent practice, according to three adjusters who spoke Tuesday at a Florida House of Representatives committee hearing. “The insurance companies were directing file reviewers to change my estimates to repair the roofs rather than replace a totaled roof,” said Ben Mandell, a licensed all-lines adjuster. “However, the insurer was leaving my name on the estimates in a fraudulent effort to make it appear that I had written this bogus estimate.” The scheme was repeated over and over again, he said. Another adjuster who works part-time in Louisiana also said that he has witnessed the practice numerous times in both states, with insurers redacting whole sections of his reports and leaving out thousands of dollars of needed repairs. “The problem is, they’re leaving our name on the estimates,” adjuster Mark Vinson told the committee members. “When they send it to the policyholder, they (the policyholders) are under the impression that it’s a legitimate estimate, and it’s not.” Adjuster Jordan Lee, who also works in Texas, said that insurance companies and adjustment firms have manipulated reports and deleted photographs and other key information in order to drastically limit payouts to policyholders. The chairman of the House Commerce Committee, which had convened Tuesday to review House Bill 1A, an insurance crisis reform bill, said that if adjuster reports had been doctored, it could mean fraud, which should be investigated by the state attorney general. Rep. Bob Rommel then met with the adjusters in his office after the hearing. Two of the adjusters said they presented the chairman with evidence – copies of reports that they said had been altered by insurance companies. Later Tuesday, Mandell told the Insurance Journal that several insurers have engaged in the practice in Florida and Louisiana. Vinson said that “most carriers” in Florida and several in Louisiana have altered his reports, without his permission. Vinson said that Universal Property & Casualty Insurance Co., Florida’s second-largest carrier, behind the state-created Citizens Property Insurance Corp., was one of the most frequent perpetrators. ![](https://ra.wellsmedia.com/www/delivery/lg.php?bannerid=0&campaignid=0&zoneid=162&loc=https%3A%2F%2Fwww.insurancejournal.com%2Fnews%2Fsoutheast%2F2022%2F12%2F14%2F699370.htm&cb=16362f9983)An attorney for Fort Lauderdale-based Universal “categorically” denied that the carrier would allow such a tactic. “That’s absolutely not the case with Universal,” said attorney Travis Miller. “The company simply has never in its history had a practice of altering, manipulating or doctoring independent adjusters’ reports for delivery to insureds.” He suggested that the adjusters had confused Universal with United Property & Casualty Insurance, which was the defendant in a lawsuit this year that alleged similar actions by United employees. The adjusters said they were not confused and Vinson said he was not aware of the United suit. That lawsuit was brought by SFR Services, a south Florida restoration firm, and claimed to have text messages from United desk adjusters and other company personnel that instructed field adjusters to avoid estimating wind damages altogether, to downplay damage estimates in hundreds of claims, or to add false information. A [federal judge in October dismissed the suit](https://www.insurancejournal.com/news/southeast/2022/10/14/690229.htm), noting that federal law leaves it to states to regulate the insurance business. A similar suit is now pending in state court in Martin County. Mandell and Vinson are now working with Jacksonville plaintiffs’ attorney Steven Bush, who said he plans to file a class-action lawsuit against property insurers over the reportedly altered adjuster reports. The lawyer said 21 independent adjusters have come to him and are expected to be part of the lawsuit. Criminal charges may also result, the adjusters said. “This is a rampant problem,” Bush said Tuesday afternoon. He promised to provide documentation of the practices later this week. Bush also has posted YouTube videos of interviews with adjusters, speaking about the alleged actions by some insurers. Another longtime independent Florida adjuster told the Insurance Journal that the adjusters’ allegations are no surprise to anyone in the industry. “It’s extremely widespread,” said Mark Boardman, president of Claims Management Services Inc., based in Maitland, Florida. “Can I prove it? No. But I have had a lot of anecdotal conversations with adjusters about it.” Independent adjusters are different from public adjusters, and are often hired by insurance companies to supplement in-house adjustment staff. Until now, many have been reluctant to speak out about the purported practices, fearing that they could lose out on insurance company business, Boardman explained. Mandell and Vinson acknowledged that they risk losing lucrative contracts, but they said they agreed to testify because the problem has grown much worse in recent months. If the adjusters go along with the practice, they, too, could be held culpable, Mandell said. After the Florida Legislature’s first special session on the insurance crisis, held in May, some insurers appear to be emboldened to scrub the estimates and deny claims, Mandell said. “Claims just aren’t getting paid now, and it’s not good for consumers or legitimate insurance companies,” he said, adding that he’d rather not work for insurers who engage in the measures. Mandell, of Haines City, Florida, has been an adjuster since 2017 but was in construction for years, and said he knows construction costs and building codes. He said he became aware of the alteration issue when he adjusted a claim in Louisiana more than a year ago. The policyholder later called him, complaining that his estimate had left out large amounts of damage from a storm. The homeowner sent him a copy of the report from the insurer, and Mandell said he was surprised to see his name on an estimate that was significantly different from the one he had submitted to the insurance company. “I told them to hire an attorney,” Mandell said. This year, the tactics seem to have become much more common in Florida, Mandell and Vinson told the Insurance Journal. In one recent hurricane claim report, Vinson said he noted that the entire shingle roof of a home was heavily damaged and needed full replacement. He documented the damage with more than 100 photos. But the altered report, sent by the insurer to the homeowner, had left the roof section out of the report altogether, lowering the repair estimate by some $30,000, he said. “And that was with photo proof, mind you,” Vinson said. The adjusters were three of dozens of people who spoke at the House Commerce Committee hearing Tuesday. Several urged lawmakers to vote against HB 1A. The bill has been hailed by the insurance industry as it aims to end one-way attorney fees and outlaw assignment-of-benefits agreements in order to curb the huge amount of claims litigation in Florida. Mandell and Vinson agreed that Florida’s insurance market is in trouble, but they said that insurers have themselves to blame, partly due to altered adjuster reports and low-balled payment offers. “If they had just paid, as the estimates showed in the first place, there wouldn’t be all these other problems,” Vinson said. “It makes things worse for everyone,” said Mandell. “The good insurance companies will be forced to adopt these same fraudulent practices in order to compete.” Others at the hearing, and at a Senate committee meeting on Monday, testified about other alleged tactics by insurers. Several homeowners and attorneys said that some insurers have frustrated policyholders by sending as many as eight adjusters to look at a property after a claim. And carriers have required engineering reports in some claims, but have refused to provide those reports to the policyholders, speakers said at the committee meetings. Democratic House committee members Tuesday offered 12 policyholder-protection type amendments to HB 1A. None of the amendments passed, and the bill was adopted without changes. By a vote of 27-13, the full Senate late Tuesday also approved the nearly identical Senate version of the property insurance bill, SB 2A. The Florida Legislature’s special session on the insurance crisis is expected to conclude late Wednesday after the bills are voted on by the full House chamber. **Topics:** Legislative, Public Awareness --- ### [Kreidler issues $367,500 in fines for violations in November](https://insurancefraud.org/news_archives/kreidler-issues-367500-in-fines-for-violations-in-november/) **Published:** September 14, 2026 **Author:** Diane Beauchamp **Content:** Insurance Commissioner Mike Kreidler issued fines in November totaling $367,500 against insurance companies, producers, brokers, and individuals who violated state insurance laws and regulations. ## Insurance companies **Aetna Life Insurance Company**, Hartford, Conn.; fined $50,000 ([order 22-0615](https://fortress.wa.gov/oic/consumertoolkit/Orders/OrderProfile.aspx?OrderNumber=S4WDs97K1kqXt59OKcFcCA%253D%253D)). - Aetna failed to include a required Balance Billing Protection Act standard message in correspondence with providers and did not provide a timely response to predetermination and prior-authorization requests. **American Family Mutual Insurance Company S.I.**, Madison, Wis.; fined $10,000 ([order 22-0618](https://fortress.wa.gov/oic/consumertoolkit/Orders/OrderProfile.aspx?OrderNumber=ffpX7bVmZ1FiRa45r0zqzA%253D%253D)). - American Family Mutual failed to refund 50 Washington policyholders more than 30 days after cancellation was requested. **Carnival Cruise Lines**, Miami, Fla.; fined $30,000 ([order 22-0653](https://fortress.wa.gov/oic/consumertoolkit/Orders/OrderProfile.aspx?OrderNumber=jm5DABdi%2frfJpp6d1rgqoA%253D%253D)). - Carnival Cruise Lines conducted insurance business in Washington without a license by soliciting Washington residents to purchase travel insurance. **Standard Insurance Company**, Portland, Ore.; fined $25,000 ([order 22-0395](https://fortress.wa.gov/oic/consumertoolkit/Orders/OrderProfile.aspx?OrderNumber=fL%252BUVnIvMlM2aDnU9Fkhgg%253D%253D)). - Standard failed to provide the Office of the Insurance Commissioner with policy forms and premium rates for disability insurance policies contracted before those policies went into effect on January 1, 2021. **Kaiser Foundation Health Plan of Washington & Kaiser Foundation Health Plan of Washington Options, Inc.**, Seattle, Wash.; fined $150,000 ([order 22-0549](https://fortress.wa.gov/oic/consumertoolkit/Orders/OrderProfile.aspx?OrderNumber=R2wxfosW7bJpIvz1STZ4Ug%253D%253D)). - The two Kaiser companies failed to meet state chiropractic parity requirements, which resulted in underpayments on over 156,000 claims totaling more than $2.4 million. **Providence Health Plan**, Portland, Ore.; fined $50,000 with $25,000 suspended ([order 22-0595](https://fortress.wa.gov/oic/consumertoolkit/Orders/OrderProfile.aspx?OrderNumber=%252Br9iOdppGC22RctC3l%252Bkvg%253D%253D)). - Providence failed to provide consumers with the required quality and price transparency tools, as well as the required information for verifying network statuses in its providers directory. Providence also violated utilization management standards by requiring prior authorization for chiropractic services. ## Unauthorized & unlicensed insurance **American Partnership Group LP**, Georgia; fined $50,000 with $25,000 suspended ([order 22-0106](https://fortress.wa.gov/oic/consumertoolkit/Orders/OrderProfile.aspx?OrderNumber=%2fOTiUmwaj3JtvycNoG%252BxWw%253D%253D)). **Data Partnership Group LP**, Georgia; fined $25,000 with $12,500 suspended ([order 22-0107](https://fortress.wa.gov/oic/consumertoolkit/Orders/OrderProfile.aspx?OrderNumber=dYBUeOJmh%252Banxs9NPde7Cw%253D%253D)). - APG and DPG were fined for transacting insurance business without a certificate of authority and acting as unauthorized insurers. APG had one consumer in Washington state, and DPG had two, as of March 2021. **FlyHomes Closing**, LLC, Bothell, Wash.; fined $30,000 ([order 22-0419](https://fortress.wa.gov/oic/consumertoolkit/Orders/OrderProfile.aspx?OrderNumber=ImulP3QDo8T8GTIR%252B1xrFg%253D%253D)). - FlyHomes was fined for selling, soliciting, or negotiating insurance without an active title license. FlyHomes’ title license expired November 19, 2020 and was not reinstated until October 11, 2021. During that time, FlyHomes reported opening 143 transactions that were ultimately concluded and earning $241,561.89 in net commissions. However, overall, the agency sustained a business loss because of its license lapse. ## Producers & brokers - Berg Benefits, Inc., Tacoma, Wash.; fined $1,000 ([order 22-0556](https://fortress.wa.gov/oic/consumertoolkit/Orders/OrderProfile.aspx?OrderNumber=GdJie1sC74y90CoBsf6b%2fg%253D%253D)). Berg failed to transfer 18 clients’ policies after the clients signed letters asking for their policies to be transferred. - Dana Treadwell; fined $1,000 ([order 22-0605](https://fortress.wa.gov/oic/consumertoolkit/Orders/OrderProfile.aspx?OrderNumber=u3idxdnIYHKHDBaARgGvdg%253D%253D)). Treadwell acted as an unlicensed independent adjuster. - Aon Risk Insurance Services West Inc., Lincolnshire, Ill.; fined $1,000 ([order 22-0654](https://fortress.wa.gov/oic/consumertoolkit/Orders/OrderProfile.aspx?OrderNumber=bt1Vazme7WstL9KoVaDZZg%253D%253D)). - National Discount Cruise Company, Allentown, Penn., fined $500 ([order 22-0656](https://fortress.wa.gov/oic/consumertoolkit/Orders/OrderProfile.aspx?OrderNumber=IJT8TAr6wL4dLN75qra6dg%253D%253D)). - Jacquelyn Sarah Nash, Boerne, Texas; fined $500 ([order 22-0648](https://fortress.wa.gov/oic/consumertoolkit/Orders/OrderProfile.aspx?OrderNumber=BEVzPd7OLx%252BCfirhCx%252BmiQ%253D%253D)). - Pivot True Health, Washington, Utah; fined $500 ([order 22-0650](https://fortress.wa.gov/oic/consumertoolkit/Orders/OrderProfile.aspx?OrderNumber=I8Um7AZjfgC0qj440P3SIQ%253D%253D)). - Ivy Victoria Lease, Philadelphia, Penn.; fined $250 ([order 22-0662](https://fortress.wa.gov/oic/consumertoolkit/Orders/OrderProfile.aspx?OrderNumber=%252Bwq6%2fgGOcUQ50s19CzLS6Q%253D%253D)). - Nyeesha Riley, Seattle, Wash.; fined $250 ([order 22-0651](https://fortress.wa.gov/oic/consumertoolkit/Orders/OrderProfile.aspx?OrderNumber=0vYSrCiZ43XVMV6yTqBijA%253D%253D)). - John James Forster, Richardson, Texas; fined $250 ([order 22-0631](https://fortress.wa.gov/oic/consumertoolkit/Orders/OrderProfile.aspx?OrderNumber=Hz3VuMz6yAAE%252BHbTfniA4g%253D%253D)). - Jack Philip Hanks, Scottsdale, Ariz.; fined $250 ([order 22-0633](https://fortress.wa.gov/oic/consumertoolkit/Orders/OrderProfile.aspx?OrderNumber=KMEiOUfJcY8YIg3P0PFS9Q%253D%253D)). - United Aline Co., Ltd., Great Neck, NY; fined $500 ([order 22-0644](https://fortress.wa.gov/oic/consumertoolkit/Orders/OrderProfile.aspx?OrderNumber=c%2f6a%2fkDd1MyC6XzLCYGlsw%253D%253D)). - BrightClaim LLC, Sandy Springs, Ga.; fined $250 ([order 22-0625](https://fortress.wa.gov/oic/consumertoolkit/Orders/OrderProfile.aspx?OrderNumber=GbQufwjuWXijnAHBTUiL7Q%253D%253D)). - LCM Holdings LLC, Orlando, Fla.; fined $250 ([order 22-0647](https://fortress.wa.gov/oic/consumertoolkit/Orders/OrderProfile.aspx?OrderNumber=y7kXwMVj%2f2emo2TM2mjpPg%253D%253D)). - Eva Marie Hambsch, Westport, Conn.; fined $250 ([order 22-0489](https://fortress.wa.gov/oic/consumertoolkit/Orders/OrderProfile.aspx?OrderNumber=TC03xXjv8JUVevR3JCVe7g%253D%253D)). - Stuckey Insurance, Phoenix, Ariz.; fined $250 ([order 22-0610](https://fortress.wa.gov/oic/consumertoolkit/Orders/OrderProfile.aspx?OrderNumber=O7ltvDlr1HNLOtf9USReMQ%253D%253D)). - Geico General Insurance Company, Omaha, Neb.; fined $250 ([order 22-0589](https://fortress.wa.gov/oic/consumertoolkit/Orders/OrderProfile.aspx?OrderNumber=et%252B01xSJDpJMnXXLhjCAVA%253D%253D)). - Cassandra Evans, Memphis, Tenn.; fined $250 ([order 22-0436](https://fortress.wa.gov/oic/consumertoolkit/Orders/OrderProfile.aspx?OrderNumber=b7yfxR25NbMQeskmkjx%2f%2fw%253D%253D)). - Custard Insurance Adjusters Inc., Norcross, Ga.; fined $250 ([order 22-0626](https://fortress.wa.gov/oic/consumertoolkit/Orders/OrderProfile.aspx?OrderNumber=viu0JEnHDCsW8and2IslSA%253D%253D)). - Multi-State Insurance Services LLC, Huntington Beach, Calif.; fined $250 ([order 22-0620](https://fortress.wa.gov/oic/consumertoolkit/Orders/OrderProfile.aspx?OrderNumber=pc9GQdDqXxzt%2fJyXgrUqoA%253D%253D)). - Brian Albee, Marietta, Ga.; fined $250 ([order 22-0624](https://fortress.wa.gov/oic/consumertoolkit/Orders/OrderProfile.aspx?OrderNumber=NO4lkQ6d6CvCiLvtdjzQbg%253D%253D)). - SureCo Insurance Solutions LLC, Santa Ana, Calif.; fined $250 ([order 22-0640](https://fortress.wa.gov/oic/consumertoolkit/Orders/OrderProfile.aspx?OrderNumber=OfZQBb1JOlRTSwceBX3IlA%253D%253D)). - Maria Candice Ann Santos Rezzo, Norfolk, Va.; fined $500 ([order 22-0475](https://fortress.wa.gov/oic/consumertoolkit/Orders/OrderProfile.aspx?OrderNumber=OObpY0IasD4kwuJfkdX3VA%253D%253D)). - Julliette Torres, Cape Coral, Fla.; fined $250 ([order 22-0627](https://fortress.wa.gov/oic/consumertoolkit/Orders/OrderProfile.aspx?OrderNumber=%252BnJLJXbixpEBcjchIGRACQ%253D%253D)). - Kouame N’Dri, Charlotte, N.C.; fined $250 ([order 22-0664](https://fortress.wa.gov/oic/consumertoolkit/Orders/OrderProfile.aspx?OrderNumber=i1yLNaM6Ec%2f%2f4st%2fMibTsQ%253D%253D)). **Topics:** Public Awareness, Regulatory actions --- ### [Another state settles Medicaid fraud allegations with Centene](https://insurancefraud.org/news_archives/another-state-settles-medicaid-fraud-allegations-with-centene/) **Published:** September 14, 2026 **Author:** Diane Beauchamp **Content:** Oregon last week became the latest state to settle fraud claims with Medicaid managed-care giant Centene. The Clayton-based company, the largest Medicaid managed-care provider in the United States, agreed to pay Oregon $17 million, according to a statement from the state’s attorney general and its insurance commissioner. Centene has emphasized that it admits to no wrongdoing in a series of such settlements, while the Oregon statement said its “investigation focused on whether Centene failed to provide certain pharmacy discounts in Oregon, resulting in inflated fees paid to Centene.” The announcement makes Oregon at least the [13th state](https://ohiocapitaljournal.com/2022/09/23/centene-settles-with-texas-over-conduct-first-detected-in-ohio/) to settle with Centene over similar fraud claims. The dispute started in Ohio when Attorney General Dave Yost sued the company in March of 2021. That suit accused Centene subsidiary Buckeye Health Plan of working through two Centene-owned pharmacy middlemen to overcharge taxpayers by millions of dollars for prescription drugs. The investigation followed reporting in 2018 by The Columbus Dispatch showing that a year earlier, Buckeye charged the state $20 million for services provided by its drug middleman. [But those same services appeared to have been rendered by a separate company](https://stories.usatodaynetwork.com/sideeffects/taxpayers-may-paying-twice-medicaid-drug-services/) — CVS — that was also paid, the story said. Both Centene and CVS denied that they were double-dipping. In June of 2021, just three months after the suit was filed, Yost and Centene announced a settlement agreement that would pay Ohio $88.3 million. Centene also announced that it was setting aside more than $1 billion to settle similar claims with as many as 20 more states. In August of 2021 — just six months after the Ohio attorney general accused Centene of massive fraud against Ohio taxpayers — the Ohio Department of Medicaid signed a [new contract worth billions ](https://ohiocapitaljournal.com/2021/08/17/six-months-after-claiming-massive-fraud-ohio-awards-contract-worth-billions-to-health-giant/)with the company. The department justified the move by saying that it would no longer use the company for pharmacy benefit management services. As a managed care provider, Centene’s Buckeye contracts with the Medicaid department to sign up patients and create networks of providers such as doctors and dentists to care for them. Pharmacy benefit managers, on the other hand, contract with such managed care organizations to create lists of covered drugs, contract with pharmacies and reimburse them for the drugs they dispense. In the wake of the Ohio settlement, Centene in November 2021 announced that it was exiting the pharmacy benefit management business altogether. In the Oregon settlement, officials emphasized that they were protecting the poor and vulnerable, but they were silent on whether the state would continue doing business with Centene. [The Oregon Health Authority’s website](https://www.oregon.gov/oha/HSD/OHP/Pages/cco-plans.aspx) indicates that the state continues to do business with Centene’s Trillium Health Plan. “This pharmacy partnership with Centene was meant to help some of our most vulnerable, but this company took advantage of Oregon,” Attorney General Ellen Rosenblum said in a statement. “This settlement is one more way we can help reign in the price of prescription drugs.” **Topics:** Judicial/courts, Medicare/Medicaid, Public Awareness --- ### [Most of the 10 largest healthcare data breaches in 2022 are tied to vendors](https://insurancefraud.org/news_archives/most-of-the-10-largest-healthcare-data-breaches-in-2022-are-tied-to-vendors/) **Published:** September 14, 2026 **Author:** Diane Beauchamp **Content:** Ninety percent of 10 largest healthcare data breaches reported this year were caused by third-party vendors, much like in 2021. The fallout for many of these cyberattacks resulted in impacts for multiple connected providers, with two of these vendor incidents affecting hundreds of providers. These incidents should serve as a warning to revisit third-party vendor relationships, ensure the entity is at least annually performing a review of vendors, and consider consolidating vendors where possible. There are two points of clarification needed given the attention-grabbing Pixel reports over the last six months and multiple, weeks-long outages brought on by ransomware that did not make this list. In calculating this list, SC Media listed the pixel incidents as single events because the tools were not caused directly by the vendor. Indeed, the pixels operated as intended. The incidents were instead caused by the providers failing to consider possible privacy implications of using tracking tools on patient-facing sites and The Health Insurance Portability and Accountability Act compliance requirements. Secondly, the list in no way includes some of the largest cyberattack-related fallouts experienced in the industry this year. Two of those incidents, Kronos and CommonSpirit Health, could rightly be considered among the largest health compromises reported this year. In a strong example, despite its systems being down across dozens of its care sites for more than a month, the CommonSpirit ransomware attack only resulted in data theft at seven hospitals and for 623,774 patients. However, the patient care impacts are simply not as easy to calculate. SC Media will delve into patient safety impacts from this year in the near-future, as the lessons learned from these outages warrant a separate look. 1. OneTouchPoint: 4.11 million patients In one of the most expansive data breaches reported this year, more than 30 health plans and a total of 4.11 million individuals were affected by a ransomware attack on printing and mailing vendor OneTouchPoint that was first discovered on April 28. With over 326,278 impacted patients, Aetna ACE was among the hardest hit by the third-party incident. The OTP notice disclosed that a threat actor accessed several servers one day before deploying the ransomware payload. The vendor was unable to determine just what files were accessed during the dwell time and instead reported based on the data contained within the servers, like patient names, member IDs, and information gathered from health assessments. Only one of the affected health plans saw SSNs compromised during the incident. 2. Eye Care Leaders: Roughly 3.6 million patients In what is undoubtedly the most complex and headline-grabbing stories in healthcare this year, Eye Care Leaders’ reported ransomware attack and the drama that followed is the second-largest breach reported this year. Patient notices began as far back as May, with one provider waiting until November to inform individuals of the impact to their health data. As meticulously reported by SC Media, ECL first came under the microscope in April after several providers filed a lawsuit against the ophthalmology-specific EHR and practice management system vendor for “concealing” multiple ransomware attacks and related outages that began in March 2021. Despite informing ECL of the “crippling effect” these outages had on their practices and billing, the vendor allegedly failed to respond to their concerns or misrepresented the situation. Even now, there is no ECL breach notice listed on the Department of Health and Human Services reporting tool and the vendor has vehemently denied these claims. In a surprising twist, ECL began to report in May that it was, indeed, hit with a ransomware attack — except, the incident was not related to the outages reported in the lawsuit. Summit Eye Associates and EvergreenHealth were the first to report on the incident, caused by the deployment of ransomware on Dec. 4, 2021. The attacker first gained access to the systems weeks before the cyberattack, using their access to databases to delete data and system configuration files. The evidence could not rule out access to provider data, which included patient names, Social Security numbers, dates of birth, medical record numbers, health insurance, and treatment information. Other provider notices showed greater or lesser data impacts. While the initial lawsuit against ECL has since been joined by patient-led lawsuits filed in the wake of the public reports, there is still a lot the public does not know about the 2021 incidents at ECL. What’s clear is that ECL failed to notify providers impacted by the December 2021 incident until at least 30 days after the HIPAA-required timeframe. 3. Advocate Aurora Health: 3 million patients The second major U.S. health system to report unauthorized disclosure due to the use of Pixel was Advocate Aurora Health, which is actively defending itself against multiple class action lawsuits brought in the wake of the Pixel fallout. Reported in late October, Advocate Aurora informed patients that their health information was shared with Google and Facebook as a result of its use of Pixel on its patient portals, websites, applications and scheduling tools. Pixel was used by Advocate Aurora to better understand how patients were interacting with these sites. However, the tech also disclosed protected health information, as well as “certain details about interactions with our websites, particularly for users that are concurrently logged into their Google or Facebook accounts and have shared their identity and other surfing habits with these companies,” officials explained. The pixels have since been removed or disabled, but not before the accidental disclosure of patients’ IP addresses, appointment dates, times, and/or locations, proximity to Advocate Aurora Health locations, provider details, procedure types, communications between the patient and others on the MyChart platform, insurance information, and proxy names. Advocate Aurora is continuing to assess the impacts of its pixel use, while it works to reduce the risk of unauthorized disclosures. Providers concerned about possible data scraping by the use of similar tracking tools should refer to the recent HHS alert that warns the use of these types of tools without a business associate agreement violates HIPAA. 4. Connexin Software: 2.2 million patients Earlier this month, a pediatric electronic medical records and practice management software vendor known as Connexin Software reported a network hack and data theft incident that impacted 119 provider offices and over 2.2 million patients. Connexin first discovered a “data anomaly” back on Aug. 26. Two weeks later, they discovered an actor “accessed an offline set of patient data used for data conversion and troubleshooting” and removed it from the network. The stolen data varied by individual and could involve names, contact details, SSNs, guarantor names, parent or guardian names, dates of birth, highly specific health insurance information, treatments, procedures, diagnoses, prescriptions, provider names, medical record numbers, and billing and/or claims data. Connexin stressed that its live EMR system wasn’t hacked during the incident, nor were any systems, EMRs, or databases belonging to physician practice groups. But notably absent from its notice was the cause behind the lengthy delay in notifying patients and their families. 5. Shields Health Care Group: 2 million individuals For just a few weeks this year, Shields Health Care Group held the dubious title of largest data breach reported in healthcare in 2022 with its early June patient notice describing a systems hack and data theft in March. Shields is a third-party vendor that provides MRI, PET/CT, and outpatient surgical services for the sector. Two million patients tied to 60 healthcare providers were told their data was compromised and likely stolen during a two-week hack from March 7 to March 21, but was not discovered by Shields until March 28. “Although Shields identified and investigated a security alert on or around March 18, data theft was not confirmed at that time,” according to the notice. The subsequent investigation confirmed the actors stole a range of data that included SSNs, medical record numbers, patient IDs, treatment information, insurance details, billing information, and diagnoses, among other data. The incident forced Shields to rebuild the entirety of the affected systems. The notice did not explain why it issued its notices far outside the required 60-day HIPAA timeframe. 6. Professional Finance Company: 1.91 million individuals The “sophisticated” ransomware attack on Professional Finance Company in February is a prime example of how a single incident can impact hundreds of entities in healthcare. The attack on the debt collections firm affected 657 healthcare and the access of patient data for nearly two million patients. What’s more, the attack was found and stopped on the same day it occurred. Even with only a short amount of dwell time, the attack was able to access patient names, SSNs, contact details, accounts receivable balances, payment information, dates of birth, insurance information, and medical treatments. The incident forced PFC to wipe and rebuild the entirety of the systems impacted by the incident. 7. Baptist Medical Center/Resolute Health in Texas: 1.71 million patients Baptist Medical Center and Resolute Health Hospital is the only provider on this list to report an incident not caused by a vendor. In June, the Texas health system notified patients that their health information was likely stolen during a systems’ hack in March. The intrusion was not discovered for several weeks after it began. On April 20, the security detected malicious code installed on certain systems, which was later found to have provided attackers with the ability to remove patient data from the network. The stolen data varied by patient and may have included demographic details, SSNs, insurance data, diagnoses, treatments, reason for visit, claims data, and a host of other information. 8. Community Health Network: 1.5 million users The fourth provider to report accidentally disclosing patient data to Meta and Google for marketing purposes was Community Health Network in Indiana. The CHN notice confirmed some suspected hypotheses about the use of pixel tools: namely, many of the impacted organizations were unaware of the potential HIPAA violations that could arise from the use of the tracking tool. CHN installed Pixel as part of an effort to improve access to information about critical care services and manage the function of its patient-facing websites. In fact, CHN only launched its investigation after learning about the alleged pixel data scraping. Their investigation soon confirmed the installed pixels had collected and disclosed user data to the tech giants. CHN has since removed or disabled the pixels from its impacted platforms. The unauthorized disclosure varied by patient and depended on how the configuration of the users’ devices and activities on the CHN website. The more a user interacted with the site, “the greater the disclosure.” The data could include IP addresses, appointment details, provider names, portal communications, appointment or procedure types, and other sensitive data. 9. Novant Health: 1.36 million individuals North Carolina-based Novant Health was the first healthcare covered entity to report that it may have inadvertently disclosed health information to Meta through the use of the Pixel tracking tool on its website and patient portal. The breach notice was sent just weeks after the June investigative reports on the Meta Pixel tracking tool, “in an effort to be as transparent as possible.” It remains unclear whether the reports prompted the discovery of the data scraping, or if it was an internal investigation. Calling it an incorrect misconfiguration, the use of Pixel led to Meta receiving patients’ demographic details, contact information, emergency contacts or advanced care planning, appointment types and date, provider names, button or menu selections, “and/or content typed into free text boxes.” The data varied by individual. 10. Broward Health: 1.35 million patients Brought on by the hack of a connected third-party vendor, the Broward Health breach was one of the first healthcare incidents reported this year. The data of 1.35 million patients and employees was stolen after an attacker gained access to the Broward Health network through an access point connected to one of its service providers. The threat actor remained on the network for four days and exfiltrated a wide range of patient and employee information from the network, including SSNs, financial or bank account information, medical histories, conditions, treatments, diagnoses, medical record numbers, and driver’s licenses, among other sensitive data. Like several other providers this year, the notice fell outside the 60-day HIPAA requirement. But Broward Health informed individuals the delay was directly caused by a Department of Justice request to hold the breach notice to prevent compromising the ongoing law enforcement investigation. Several lawsuits were filed against Broward Health in the wake of the patient notifications, some of which have been dismissed. **Topics:** Public Awareness, Technology --- ### [8 largest healthcare data breaches of 2022 tied to vendors](https://insurancefraud.org/news_archives/8-largest-healthcare-data-breaches-of-2022-tied-to-vendors/) **Published:** September 14, 2026 **Author:** Diane Beauchamp **Content:** 1. [Advocate Aurora Health](https://www.beckershospitalreview.com/cybersecurity/advocate-aurora-health-says-pixel-data-breach-may-affect-3-million-patients.html): In October, three million patients were impacted by a pixel breach at Advocate Aurora Health, dually headquartered in Downers Grove, Ill., and Milwaukee. The health system said it had installed the tracking pixel on its website to better understand patient behaviors but that the data may have been sent to Google or Facebook parent company Meta. The pixel tool has since been removed from the health system’s website. 2. [OneTouchPoint](https://www.beckershospitalreview.com/cybersecurity/vendor-ransomware-attack-affects-2-7m-healthcare-organizations.html): More than 30 health plans were affected by a ransomware attack on printing and mailing vendor OneTouchPoint. The attack led to 2.7 million patients’ data being compromised. 3. [Shields Health Care Group](https://www.beckersspine.com/orthopedic/54806-2-orthopedic-facilities-affected-in-shields-health-care-group-data-breach.html?__hstc=77465994.5c968581e5cce3859502527707cb8f4a.1785759381916.1788106604038.1789389940525.8&__hssc=77465994.1.1789389940525&__hsfp=f576a03af1d5782fbfc3990a905d447d): In July, Shields, a third-party vendor that provides MRI, PET/CT and outpatient surgical services for the healthcare sector, reported a data breach that affected an estimated two million patients at over 50 facilities. 4. [Professional Finance Company](https://www.beckershospitalreview.com/cybersecurity/ransomware-attack-on-finance-company-affects-600-hospitals-practices.html): A February ransomware attack on debt collections firm Professional Finance Company affected more than 600 healthcare organizations, causing the data of 1.91 million patients to be compromised. 5. [Baptist Medical Center and Resolute Health](https://www.beckershospitalreview.com/cybersecurity/two-texas-hospital-networks-infected-by-malicious-code.html): The IT networks at San Antonio, Texas-based Baptist Medical Center and New Braunfels, Texas-based Resolute Health Hospital were infected by malicious code that allowed an unauthorized user to access the personal health information of some patients. Due to the event, the data of 1.71 million patients was compromised. 6. [Community Health Network](https://www.beckershospitalreview.com/cybersecurity/community-health-network-s-pixel-breach-may-have-compromised-patient-data.html): The Indianapolis-based health system accidentally disclosed patient data to Meta and Google for marketing purposes, causing [1.5 million](https://ocrportal.hhs.gov/ocr/breach/breach_report.jsf) individuals’ data to be compromised in November. 7. [Novant Health](https://www.beckershospitalreview.com/cybersecurity/facebook-tracker-compromised-phi-of-1-3m-novant-health-patients.html): The Charlotte, N.C.-based health system notified 1.36 million patients on Aug. 12 that their protected health information might have been improperly disclosed because of a Facebook tracking tool used in a May 2020 marketing campaign. 8. [Broward Health](https://www.beckershospitalreview.com/cybersecurity/broward-health-notifies-patients-of-october-data-breach.html): On Jan. 2, the Fort Lauderdale, Fla.-based health system notified 1.35 million patients that a hacker gained access to the Broward Health network through an access point connected to one of its service providers. **Topics:** Public Awareness, Technology --- ### [Family, police search for answers 10 years after killing](https://insurancefraud.org/news_archives/family-police-search-for-answers-10-years-after-killing/) **Published:** September 14, 2026 **Author:** Diane Beauchamp **Content:** Sherese Walker Bingham had been married for 28 years but without children, she was devoted to her two German Shepherds, and so devoted were those dogs to their owner that Keith Walker said he was leery about visiting his sister with the pets nearby. “I been over to her house a couple times and I told her to put them dogs up. She said I’d be alright, but I was still scared. The way they looked at you and walked around you. I didn’t want her to leave the room,” he said. “You could not get near her without her putting the dogs on a leash or she’d tell them to come by her and stand by her. You had to know her personally and the dog to even touch her.” Which is why Walker and Indiana State Police detectives are still puzzled by the death of Bingham with her own handgun on the banks of the White River at the IUPUI campus on the night of December 12, 2012, death investigators insist was not a suicide. “That’s the puzzle piece. That’s the piece we are still researching,” said Walker. “The State Police is still investigating.” In 2014, detectives convinced prosecutors they had a case against Bingham’s husband, the only person family members said could get close to the woman without provoking a protective response from the dogs, and Bingham was in the process of seeking a divorce at the time of her death. “I think she was having problems in her marriage before Thanksgiving,” said Walker. “She was in the process after she found out to end her marriage. She pawned her wedding band.” Following his sister’s death, Walker waged an unsuccessful court battle to deny Bingham’s husband $850,000 in life insurance proceeds. An ISP detective told Fox 59 News that the case against Bingham’s husband rested on cell phone tracking data that cast doubt on the man’s alibi for that evening. “They had to drop charges because of lack of evidence,” said Walker. “They just didn’t have enough conclusive evidence that it was the ping of the cell phone down here.” Now, ten years later, Walker thinks he knows who murdered his sister, but is relying on someone who the killer confided in to come forward with the truth. “If he mentioned that to anyone or if anyone know, it’s the one that he is married with now.” If you have any information about the death of Sherese Walker Bingham on the banks of the White River near the IUPUI campus ten years ago tonight, call Indiana Crimestoppers at (317) 262-TIPS. Your tip could lead to a $1,000 reward. **Topics:** Life Insurance, Public Awareness --- ### [Verisk Launches Fraud Discovery Platform](https://insurancefraud.org/news_archives/verisk-launches-fraud-discovery-platform/) **Published:** September 14, 2026 **Author:** Diane Beauchamp **Content:** Verisk (Nasdaq: VRSK), a leading strategic data analytics and technology partner to the global insurance industry, today announced Verisk Fraud Discovery, a fraud prevention platform that unifies fraud intelligence, advanced analytics, network analysis, digital media forensics, and case management into a single, scalable solution. The launch comes at a time when insurance fraud is evolving rapidly, with economic pressures driving more opportunistic fraud and organised fraud networks increasingly exploiting technology and data gaps to evade detection. In 2024, UK insurers detected £1.16bn in fraudulent claims across 98,400 cases, according to the Association of British Insurers (ABI), which estimates a similar amount may go undetected. As fraud networks become more sophisticated, insurers are seeking connected intelligence, investigation and case management capabilities that help reveal patterns and relationships that might otherwise remain hidden. “The insurance industry is facing increasingly complex fraud risks that often span multiple parties, claims and points in the insurance journey,” said James Burge, Global Head of Fraud at Hiscox. “As fraud becomes more organised and interconnected, insurers need better ways to connect intelligence across underwriting, claims and investigations. Verisk’s approach helps create greater visibility into potential fraud networks and further strengthens our evolving fraud prevention capabilities.” Verisk’s Fraud Discovery platform combines fraud intelligence, analytics, network analysis, digital media forensics and investigation workflows to help organisations: · Uncover hidden relationships across people, organisations, policies and claims · Detect opportunistic, organised and coordinated fraud activity · Analyse images and documents for signs of manipulation, alteration and deepfakes · Prioritise investigations and resources using risk insights and intelligence-led decisioning · Streamline investigations and case management through a single workflow · Improve fraud visibility and collaboration across underwriting, claims and fraud teams · Transform data into actionable intelligence Designed as a modular platform, organisations can adopt capabilities based on their fraud maturity and operational requirements, from early-stage fraud detection to advanced investigative workflows. This flexibility enables insurers to strengthen fraud prevention efforts while creating a foundation for more connected investigative operations over time. **Early adoption by leading insurers and legal partners** Hiscox, Allianz and law firm Weightmans are among the organisations adopting Verisk Fraud Discovery at launch, reflecting demand for more connected approaches to fraud investigation, intelligence sharing, and case management. Mike Brown, head of fraud at Weightmans, said, “Fraud continues to undermine both the UK and global economy. Our collaboration with Verisk represents a major step forward in equipping us and our clients with advanced technology to better identify and respond to fraud.” For decades, Verisk has helped insurers combat fraud through trusted industry data, advanced analytics and investigation technologies. Its anti-fraud solutions help organisations identify suspicious activity, uncover connections between people, claims and businesses, and focus investigative resources where they can have the greatest impact. Today, Verisk supports fraud detection and investigations across the insurance ecosystem and continues to develop connected intelligence solutions that help insurers respond to increasingly complex and organised fraud activity. **Topics:** Public Awareness, Technology --- ### [The Hidden Tax on Honest Customers: What Insurance Fraud Really Costs](https://insurancefraud.org/news_archives/the-hidden-tax-on-honest-customers-what-insurance-fraud-really-costs/) **Published:** September 14, 2026 **Author:** Diane Beauchamp **Content:** Most honest customers have no idea they’re paying for other people’s insurance fraud; after all, it doesn’t show up as an added extra when they purchase a policy. Instead, it silently bumps up the price of every premium. But it does more than just add to customers’ costs; it directly influences who gets cover in the first place, and who doesn’t. **A tax that lands hardest on the people who can least afford it** Fraud is genuinely difficult to spot, and it isn’t spread evenly. It tends to cluster in lower-income areas, often linked to organised groups rather than one-off opportunists. Faced with that, a lot of insurance providers reach for the simplest lever to pull: they price up entire postcodes where fraud has occurred frequently in the past, or they refuse to quote them at all. It’s an understandable shortcut, but it’s not a fair one. It punishes everyone on a street for the behaviour of a handful of people, and it does so regardless of whether any individual customer has ever made a dishonest claim. The result is that the people who are already the most financially exposed, the ones with the least savings to fall back on if something goes wrong, are often the ones locked out of cover altogether; or they are asked to pay higher premiums than they otherwise would. Essentially, it’s a hidden tax. It isn’t paid by insurance providers, but by honest customers: in higher premiums if they’re lucky enough to get a quote, and by being rejected for cover altogether if they’re not. **Where AI actually earns its place** Fraud detection is where AI has made the biggest difference for us. Rather than solely relying on a customer’s postcode as a proxy for risk, we look at how people actually behave when they interact with us and manage their policies. We think it’s fairer to judge people on what they actually do, rather than on assumptions about where they live. A genuine customer buys insurance in a fairly ordinary way; but someone with fraudulent intent often behaves differently (for example, buying a policy incredibly quickly), and we often see those unusual behavioural loops repeat themselves. We are using AI to tackle this by searching through unstructured behavioural signals and analysing patterns across the entire customer and claims journey. It’s rarely a single red flag that gives someone away, but a pattern or combination of small signals that, taken together, reliably indicate fraudulent intent. We set a very high bar for acting on that, because making a mistake means unfairly penalising someone who did nothing wrong, and that’s not a trade-off we’re willing to make lightly. Done properly, this kind of approach can support far higher eligibility rates than postcode-based pricing typically allows, without taking on extra risk. It works because we’re better at spotting the difference between a genuine customer in a difficult postcode and someone trying to game the system. For me, this is where AI proves its real value: when it has a genuine, measurable impact on customers. **Why this is a fairness issue, not just a fraud one** It would be easy to frame all of this purely as catching fraudsters: insurance providers catching criminals, tightening up their numbers, protecting their loss ratios. But that misses the point of why it matters to ordinary customers. Every fraudulent claim that gets paid out has to be funded from somewhere, and that somewhere is everyone else’s premiums. Over 440,000 cases of insurance fraud were recorded in the National Fraud Database in 2025, the highest number ever and a 6% increase from 2024. For every postcode written off because fraud is too hard to police, a group of honest people pays the price for a problem they didn’t cause. Tackle fraud properly, using the right tools to catch the right people, and you can do two things at once: bring genuinely better value for money to honest customers, and open the door to people the market has quietly written off for years. That’s a fairness question as much as it is a technology one. The real test is whether it leads to lower prices and wider access to cover. Financial inclusion and fraud prevention are usually talked about as separate topics. In practice, they’re two sides of the same problem, and solving one properly is often the fastest way to make progress on the other. **What the industry should take from this** Insurance fraud will never disappear entirely, and no single company will solve it alone. But treating it seriously, and treating it as a customer fairness issue rather than just a commercial tactic or a way to manage risk, is something the whole industry could do more of. The behaviour of others shouldn’t decide whether a person or a home can get covered, and for insurance providers, it is the fairest thing they can do for customers. **Topics:** Public Awareness --- ### [Insurers back new bill to make staged car crashes a federal crime](https://insurancefraud.org/news_archives/insurers-back-new-bill-to-make-staged-car-crashes-a-federal-crime/) **Published:** September 14, 2026 **Author:** Diane Beauchamp **Content:** The [American Property Casualty Insurance Association](https://www.insurancebusinessmag.com/us/companies/american-property-casualty-insurance-association/587380/) (APCIA) has issued a statement commending Reps. Laura Gillen, D-NY., Troy Nehls, R-TX., Josh Gottheimer, D-NJ, and Vince Fong, R-CA, for introducing the bipartisan Stop Auto Fraud Act of 2026, which would make staging or fabricating a motor vehicle crash to file a fraudulent insurance claim a federal crime for the first time. Sam Whitfield, APCIA’s senior vice president of federal government relations, tied the bill directly to rising premiums. “Auto claims fraud, including intentional crashes, staged accidents, fabricated medical bills, and AI-altered photo evidence, drives up costs throughout the system and ultimately raises auto insurance premiums for everyone. States that have enacted targeted anti-fraud and staged accident reforms have strengthened enforcement, disrupted organized fraud rings, and helped stabilize auto insurance markets, with some states even experiencing premium reductions,” Whitfield said. ## **What the bill actually does** The legislation, introduced September 3, would establish federal criminal penalties for anyone who knowingly stages or fabricates a motor vehicle crash to submit a fraudulent insurance claim. Penalties scale with harm – up to 10 years in prison for a staged crash causing no injury, up to 20 years if the crash causes serious bodily injury, and up to life in prison if it results in death. Any fines collected would flow into the Highway Trust Fund, the federal account that finances road, bridge and public transit projects, a structural choice lawmakers have framed as tying enforcement directly to infrastructure funding rather than general revenue. Rep. Nehls framed the bill around who ultimately bears the cost of this kind of fraud. “Bad actors across the country are deliberately causing, staging and fabricating car wrecks and filing phony [insurance claims](https://www.insurancebusinessmag.com/us/glossary/insurance-claims/559065/), and it’s the hardworking American families who end up paying the price with high insurance rates. It’s time we put an end to this, make it a federal crime, and hold these fraudsters accountable,” Nehls said. Meanwhile, Rep. Gottheimer noted the interstate nature of many fraud operations specifically: “Insurance fraudsters send premiums skyrocketing and drive up the cost of living for Jersey families. The fraud rings behind them don’t stop at state lines.” ## **A federal version of a concept states adopted years ago** The bill’s core idea, criminalizing the act of staging a crash specifically rather than relying on general fraud statutes, isn’t new; it’s a federal extension of reforms several states enacted years earlier. New York passed its own version in 2019, known as Alice’s Law after Alice Ross, a Queens grandmother killed in 2003 when a driver intentionally crashed into her car as part of an insurance fraud scheme. That law made staging an accident a distinct felony in New York rather than leaving prosecutors to rely solely on broader fraud or reckless endangerment statutes. The Stop Auto Fraud Act effectively nationalizes that same logic, giving federal prosecutors a dedicated tool for fraud rings that, as Gottheimer noted, frequently operate across state lines in ways state-level statutes alone can’t fully reach. ## **The scale of the problem the bill is meant to address** The fraud categories the bill targets are a documented and costly problem industry-wide. The [Coalition](https://www.insurancebusinessmag.com/us/companies/coalition/587387/) Against Insurance Fraud estimates fraudulent claims cost the US approximately $308.6 billion annually, adding roughly $900 to the average policyholder’s yearly insurance costs, a figure the National Insurance Crime Bureau has cited repeatedly in its own public awareness campaigns. Staged and fabricated accidents specifically have shown up as a persistent regional problem in NICB’s own analysis. The organization has identified staged vehicle accidents as the top insurance fraud issue in states like South Carolina, and federal investigators have pursued organized staged-accident rings through operations targeting commercial vehicle crashes in cities including New Orleans. The bill’s explicit reference to AI-altered photo evidence in Whitfield’s statement also reflects a genuinely newer wrinkle in this fraud category, as image-generation tools make fabricating convincing damage or injury evidence easier than in years past. ## **Why this matters for insurers and claims professionals** For claims adjusters and special investigations units, a federal staged-crash statute would give investigators an additional prosecutorial avenue when a fraud ring’s activity crosses state lines, a structural gap state-level laws like Alice’s Law were never designed to close on their own. For insurers more broadly, the bill’s fate is worth tracking as a potential data point on whether Congress is willing to treat organized auto fraud as a distinct federal offense rather than leaving enforcement entirely to a patchwork of state statutes, a shift that, if it holds and the bill advances, could eventually factor into how carriers model expected fraud-related loss trends in states that currently lack their own dedicated staged-accident statute. **Topics:** Auto - staged, Legislation, Public Awareness --- ### [Illegal Alien Pleads Guilty to Healthcare Benefit Fraud and Aggravated Identity Theft](https://insurancefraud.org/news_archives/illegal-alien-pleads-guilty-to-healthcare-benefit-fraud-and-aggravated-identity-theft/) **Published:** September 14, 2026 **Author:** Diane Beauchamp **Content:** A Dominican national unlawfully residing in Dorchester, Mass. pleaded guilty on Sept. 2, 2026 in federal court in Boston to healthcare benefit fraud and aggravated identity theft. Manuel Antonio Baez, 52, pleaded guilty to one count of falsely representing a Social Security number, one count of making false statements relating to health care matters and one count of aggravated identity theft. U.S. District Court Chief Judge Denise J. Casper scheduled sentencing for Dec. 2, 2026. In May 2026, Baez was arrested and charged and has been held in custody since his arrest. Baez used the stolen identity of a U.S. citizen, including the citizen’s Social Security number, to obtain government benefits. Specifically, Baez represented that he was a U.S. citizen when applying for healthcare benefits in Massachusetts and submitted a sworn affidavit falsely alleging the same. Baez ultimately obtained over $80,000 in MassHealth benefits using the stolen identity. Baez also committed drug offenses in the name of the U.S. citizen, including a 2018 conviction for trafficking heroin and a 2007 conviction for possession with intent to distribute a Class B substance. The charge for falsely representing a Social Security number provides for a sentence of up to five years in prison, three years of supervised release and a fine of $250,000. The charge of making false statements relating to a health care program provides for a sentence of up to five years in prison, three years of supervised release and a fine of $250,000. The charge of aggravated identity theft provides for a mandatory two-year sentence to run consecutively to any other sentence imposed, one year of supervised release and a fine of $250,000. The defendant is subject to deportation upon completion of any sentence imposed. Sentences are imposed by a federal district court judge based upon the U.S. Sentencing Guidelines and statutes which govern the determination of a sentence in a criminal case. On March 26, 2026, United States Attorney Leah B. Foley announced the creation of the Benefit & Voter Fraud Team, a district-wide initiative established in response to the rampant fraud being uncovered across Massachusetts. Members of the public are encouraged to report suspected benefit fraud in Massachusetts by calling 1-855-SCAM-MA-1 (855-722-6621). On April 7, 2026, the Department of Justice announced the creation of the National Fraud Enforcement Division. The core mission of the Fraud Division is to zealously investigate and prosecute those who steal or fraudulently misuse taxpayer dollars. Department of Justice efforts to combat fraud support President Trump’s Task Force to Eliminate Fraud, a whole-of-government effort chaired by Vice President J.D. Vance to eliminate fraud, waste and abuse within Federal benefit programs. United States Attorney Leah B. Foley; Jeff Grimming, Acting Special Agent in Charge of Homeland Security Investigations in New England; and Roberto Coviello, Special Agent in Charge of the Department of Health and Human Services, Office of Inspector General made the announcement today. Assistant U.S. Attorney Colin T. Missett of the Health Care Fraud Unit is prosecuting the case. **Topics:** Healthcare Fraud, Social Security fraud, Synthetic Identity Theft **Categories:** Conviction --- ### [Foreign National Pleads Guilty To Health Care Fraud Scheme Targeting Medicare Advantage Programs](https://insurancefraud.org/news_archives/foreign-national-pleads-guilty-to-health-care-fraud-scheme-targeting-medicare-advantage-programs/) **Published:** September 14, 2026 **Author:** Diane Beauchamp **Content:** Sevindik Huseynov, a national of Azerbaijan, pleaded guilty in federal court today to three counts of health care fraud in connection with a $137 million scheme targeting Medicare Advantage Programs. Huseynov, 48, formerly of Sunnyvale, California and a national of Azerbaijan was indicted by a federal grand jury on September 25, 2025. Under the plea agreement, Huseynov pleaded guilty to three counts of health care fraud. In pleading guilty, Huseynov, who was the Chief Executive Officer of a fraudulent durable medical equipment (DME) company, Vonyes Inc., admitted to aiding and abetting a scheme to submit thousands of fraudulent claims to Medicare Advantage Organizations (MAOs). The claims were submitted on behalf of unsuspecting beneficiaries and sought reimbursement for medical equipment such as wound dressing and orthotic braces. Beginning in January 2025 and continuing until Huseynov was arrested on June 17, 2025, he participated in the scheme with other individuals in the United States and abroad to submit large volumes of claims to MAOs offering Medicare Part C benefit plans. In total, Huseynov, through Vonyes, sought reimbursements of at least $137 million from MAOs for medical equipment that was not provided, not needed by patients, and not authorized by a medical provider. Huseynov admitted to receiving reimbursement checks for $2.8 million and depositing those checks in Vonyes bank accounts he set up. After the money was deposited, Huseynov wired most of the money to bank accounts in Hong Kong. Huseynov is currently in federal custody. Huseynov’s sentencing hearing is scheduled for February 2, 2027 at 1:30 PM before U.S. District Judge Noel Wise. Huseynov faces a maximum statutory penalty of 10 years in prison and a $250,000 fine for a violation of 18 U.S.C. § 1347, health care fraud. Any sentence will be imposed by the court after consideration of the U.S. Sentencing Guidelines and the federal statute governing the imposition of a sentence, 18 U.S.C. § 3553. The case is being prosecuted by Assistant U.S. Attorney Maya Karwande with the assistance of Lynette Dixon, Ambereise McElrath, and Mimi Lam. The prosecution is the result of an investigation by the U.S. Department of Health and Human Services Office of Inspector General and the Federal Bureau of Investigation. On April 7, 2026, the Department of Justice announced the creation of the National Fraud Enforcement Division (“Fraud Division”). The Fraud Division is investigating and prosecuting those who commit fraud against the American people. The Department’s work to combat fraud supports President Trump’s Task Force to Eliminate Fraud, a whole-of-government effort chaired by Vice President J.D. Vance to eliminate fraud, waste, and abuse within Federal benefit programs. **Topics:** Medicare/Medicaid **Categories:** Conviction --- ### [Two arrested for alleged auto financing fraud in Hawkesbury](https://insurancefraud.org/news_archives/two-arrested-for-alleged-auto-financing-fraud-in-hawkesbury/) **Published:** September 14, 2026 **Author:** Diane Beauchamp **Content:** The Hawkesbury Detachment of the Ontario Provincial Police (OPP) has charged two individuals following a fraud investigation. On September 2, the OPP received information from Service de Police Ville de Mercier, Quebec, related to individuals attempting to purchase motor vehicles at local dealerships using fraudulent documents. On September 3, officers arrested two individuals in the town of Hawkesbury. Veronica Espinal Correa, 41-years-old, of Montreal-Nord, Québec, and Adriana Saintelmy, 30-years-old, of Saint-Laurent, Québec, were charged with the following offences: ``` Personation with intent (identity fraud) Personation with Intent – intent to obtain property (identity fraud) Identity Theft – obtain or possess another person’s identity information Forgery – two counts Fraud over $5000 ``` Veronica Espinal Correa was held for a bail hearing on Thursday September 3, in L’Orignal. Adriana Saintelmy was released from custody and will appear in court in L’Orignal on December 2, 2026. What is auto financing fraud? Vehicle finance fraud occurs when fraudsters use compromised personal information to create synthetic identities and obtain vehicle financing. Using stolen identities, credit card information, and altered insurance documents, they apply for auto loans through dealerships to fraudulently purchase vehicles. Anyone who suspects they have been the victim of cybercrime or fraud should report it to their local police and to the Canadian Anti-Fraud Centre’s online reporting system or by phone at 1-888-495-8501. If not a victim, you should still report the incident to the CAFC. Anyone with information regarding this scam is asked to contact the OPP or report anonymously through Crime Stoppers at 1-800-222-TIPS (8477). **Topics:** Auto fraud, Synthetic Identity Theft **Categories:** Arrest --- ### [CMS bars 11 suppliers from MA payments after $3.4B fraud probe](https://insurancefraud.org/news_archives/cms-bars-11-suppliers-from-ma-payments-after-3-4b-fraud-probe/) **Published:** September 14, 2026 **Author:** Diane Beauchamp **Content:** CMS has been cracking down on possible fraud with medical equipment suppliers for months, sharing two major updates in recent weeks. CMS announced that it is barring 11 medical supply companies focused on durable medical equipment, prosthetics, orthotics and supplies from earning future Medicare Advantage Part C and Part D payments. In 2025 and 2026, these companies had more than $3.4 billion in suspected fraudulent billing practices, CMS [said](https://www.cms.gov/newsroom/press-releases/cms-cracks-down-massive-3-4-billion-medical-equipment-supplier-fraud-scheme) in a Sept. 8 news release. CMS claimed the 11 DMEPOS suppliers did not submit claims before 2025, used “improper” billing practices, billed for deceased beneficiaries’ medical equipment and supplied equipment to beneficiaries who did not request or receive it. Four of the 11 suppliers had already lost their original Medicare privileges, instead billing MA plans. Just weeks prior, a six-month Medicare enrollment moratorium affecting some DMEPOS suppliers [expired](https://dmeposcompetitivebid.cms.gov/node/788) Aug. 27, according to CMS. The moratorium, which [went](https://www.beckershospitalreview.com/supply-chain/cms-blocks-durable-medical-equipment-enrollments-halts-5-7b-in-medicare-payments/) into effect Feb. 27 and [addressed](https://public-inspection.federalregister.gov/2026-03971.pdf) fee-for-service Medicare, was part of CMS’ sweeping healthcare fraud [initiatives](https://www.beckerspayer.com/policy-updates/the-federal-healthcare-fraud-crackdown-explained/). Just a few months later, CMS also [imposed](https://www.beckershospitalreview.com/healthcare-information-technology/telehealth/cms-freezes-new-hospice-home-health-enrollments-amid-fraud-crackdown/) a six-month freeze on new Medicare enrollments for hospices and home health agencies. The agency [can extend](https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-424/subpart-P/section-424.570) moratoria in six-month increments. However, CMS confirmed national provider enrollment contractors have resumed accepting initial enrollment applications from these DMEPOS suppliers. The agency encouraged suppliers planning to bid in DMEPOS Competitive Bidding Program Round 2028 to “submit any completed enrollment applications as soon as possible,” allowing contractors sufficient time to review applications before the bidding window. As [established](https://www.cms.gov/newsroom/fact-sheets/fy-2027-inpatient-rehabilitation-facilities-irf-prospective-payment-system-pps-final-rule-cms-1845-f) by the 2027 Inpatient Rehabilitation Facilities Prospective Payment System Final Rule, CMS [elevated](https://dmeposcompetitivebid.cms.gov/node/724) the required bid surety bond amount from $50,000 to $100,000 for bids submitted under a Remote Item Delivery Competitive Bidding Program. The RID competitive bidding area [will be](https://dmeposcompetitivebid.cms.gov/node/712) nationwide, as well. **Topics:** Medicare/Medicaid, Public Awareness, Regulatory actions --- ### [East Orange Clinic Owner Admits Unlicensed Gynecological Care, False Medicaid Billing, AG Says](https://insurancefraud.org/news_archives/east-orange-clinic-owner-admits-unlicensed-gynecological-care-false-medicaid-billing-ag-says/) **Published:** September 14, 2026 **Author:** Diane Beauchamp **Content:** An Essex County woman admitted providing gynecological services without a medical license at the now-defunct Bessie Mae Women and Family Health Center in East Orange and submitting about 2,500 Medicaid claims for those services under the names of licensed doctors, state authorities said. Esney Davis-Sharpe, 63, of East Orange, pleaded guilty to second-degree healthcare claims fraud, third degree Medicaid fraud and third-degree unlicensed practice of medicine before Superior Court Judge Michael L. Ravin in Newark, state Attorney General Jennifer Davenport and the Office of the Insurance Fraud Prosecutor said in a statement Friday. Davis-Sharpe pleaded guilty Aug. 17, court records show. The state will recommend a sentence of 180 days in jail and four years’ probation, the Attorney General’s Office said. The state will barr Davis-Sharpe from owning, operating or acting as the chief executive officer or chief financial officer of any medical facility with patients, authorities said. Sentencing is scheduled for Oct. 5, authorities said. ‘Public Deserves Confidence’ “Patients deserve to know that the individuals providing their medical care are properly licensed and qualified. And the public deserves confidence that Medicaid funds are being used as intended,” Davenport said. “We will continue to protect patients and safeguard the integrity of New Jersey’s Medicaid program.” Davis-Sharpe owned and operated the Bessie Mae center, which offered, among other services, obstetrics/gynecology, primary care and family care services, authorities said. A website for the Bessie Mae Women and Family Health Center remains active. However, a person answering the phone at a number listed on the website said Davis-Sharpe can no longer be reached at the number. The person, who did not give her name, said the center has been closed for several years. Website Still Up Despite this closure, the website still boasts a “State Board Certified Obstetrician and Gynecologist.” It says this OB/GYN is, “equipped to handle more specialized or severe cases relating to reproductive health.” The website says the healthcare center had been operating since 2012. The website’s continued operation could not immediately be reconciled with the clinic’s reported closure. In August 2023, the state Division of Consumer Affairs referred the matter to Office of the Insurance Fraud Prosecutor for investigation into the unlicensed practice of medicine, authorities said. On Jan. 25, 2024, the state Department of Health served Davis-Sharpe with a cease-and-desist order directing Bessie Mae to cease providing services at the facility. 2,500 Fraudulent Claims According to the state Attorney General’s Office, the Bessie Mae center submitted about 2,500 claims for reimbursement to the state’s Medicaid program. All the claims named a doctor – identified as “Dr. N.J.” in the indictment — and another provider, identified as “Dr. K.R.,” without the permission, knowledge or consent of those doctors, authorities said. The clinic submitted the claims December 2020 to February 2024, authorities said. Court records list David B. Littman, of Linden, as the attorney representing Davis-Sharpe. Littman did not immediately respond to a request for comment. Bessie Mae was among 27 organizations the state awarded funding to in 2024. The grants were to help connect uninsured residents to health coverage through the New Jersey’s official health insurance marketplace, according to a state Department of Banking and Insurance news release. The health center received $86,388 in funding, officials said. In January, authorities indicted Davis-Sharpe along with Nataliya Lushchak, 48, of Lower Gwynedd, Pennsylvania, the Attorney General’s Office then stated. Authorities charged both with one count each of conspiracy to commit health care claims fraud, unlicensed practice of medicine, health care claims fraud and Medicaid fraud, officials said. **Topics:** Medicare/Medicaid, Unlicensed entities **Categories:** Conviction --- ### [California Man Sentenced to 30 Years for Orchestrating $270M Medication Reimbursement Fraud Scheme Targeting Medi-Cal](https://insurancefraud.org/news_archives/california-man-sentenced-to-30-years-for-orchestrating-270m-medication-reimbursement-fraud-scheme-targeting-medi-cal/) **Published:** September 11, 2026 **Author:** Diane Beauchamp **Content:** A California man was sentenced today to 30 years in federal prison for masterminding a massive health care fraud scheme in which nearly $270 million in fraudulent claims were submitted over an 11-month span to Medi-Cal, the California Medicaid program, for expensive prescription drugs containing generic ingredients that were medically unnecessary and, many times, were not provided to the purported recipients. The sentence marks one of the highest health care fraud sentences in the Central District of California’s history. Paul Richard Randall, 67, of Orange, California, was also ordered to pay $178,746,556.22 in restitution. “Paul Randall exploited a temporary change in Medi-Cal’s prescription drug reimbursement system to steal millions of hard-earned taxpayer dollars meant to help California’s most vulnerable residents,” said Assistant Attorney General Colin M. McDonald of the National Fraud Enforcement Division. “Today’s sentence sends a clear message to those who would abuse our public benefit programs to line their own pockets: The Fraud Division will aggressively prosecute you and seek to hold you accountable to the fullest extent under the law.” “This case exposes unbridled greed at the expense of patients and taxpayers. Stealing funds meant for essential care and corrupting medical decisions through kickbacks is deeply harmful and erodes trust in our health care system,” said Acting Deputy Inspector General for Investigations Miranda L. Bennett of the Department of Health and Human Services Office of Inspector General (HHS-OIG). “HHS-OIG, together with our law enforcement partners, will continue to pursue those who exploit federal health care programs and ensure they are held fully accountable.” “This defendant took advantage of California’s weak systems allowing him to submit $270 million in fraudulent claims to Medi-Cal in less than a year,” said First Assistant U.S. Attorney Bill Essayli of the Central District of California. “Today’s prison sentence underscore’s our department’s determination to aggressively punish criminals who steal from public health programs.” According to court documents, Randall, along with pharmacist and pharmacy owner Kyrollos Mekail, 38, of Moreno Valley, California, and nurse practitioner Patricia Anderson, 59, of West Hills, California, took advantage of Medi-Cal’s suspension of its requirement that health care providers obtain prior authorization before providing certain h medications as a condition of reimbursement. The suspension of the prior authorization requirement was part of an ongoing transition of Medi-Cal’s prescription drug program to a new payment system. Through a business called Monte Vista Pharmacy (Monte Vista), Randall and his co-conspirators exploited Medi-Cal’s prior authorization suspension by billing Medi-Cal tens of millions of dollars per month for dispensing high-reimbursing, non-contracted generic drugs through Monte Vista. The medications, which included pain creams and Folite tablets, a vitamin available over the counter, were billed for thousands of dollars each, including approximately $13,424 for one prescription of meloxicam 5 mg, a generic drug that typically costs between $5 and $25 for a 30-day supply in larger dosages. Normally, these high-cost reimbursement medications would have required prior authorization under Medi-Cal’s previous payment system. Medication involved in this scheme was medically unnecessary, frequently not dispensed to patients, and procured by illegal kickbacks. In furtherance of the scheme, Randall paid illegal kickbacks to patient marketers in exchange for Medi-Cal beneficiary information and to Anderson to sign pre-filled prescriptions for the medications. Anderson never met the patients, reviewed their medical records, or otherwise determined that the medications were medically necessary before signing the prescriptions. From May 2022 to April 2023, Randall caused at least $269,120,829 in false and fraudulent claims to be submitted to Medi-Cal, of which Medi-Cal paid at approximately $178,746,556. Randall committed this offense while on release in another criminal tax case in the Central District of California (United States v. Paul Richard Randall, No. CR 20-00031-GW). Randall and his co-conspirators laundered their illicit proceeds by transferring them to a third party to pay hundreds of thousands of dollars in illegal kickbacks to Anderson in exchange for Anderson signing the fraudulent prescriptions. In April 2026, Randall pleaded guilty to one count of wire fraud. In his plea agreement, Randall agreed to forfeit property obtained from the fraud, including bank account balances exceeding $17 million, three vehicles, seven real properties, and sports memorabilia. To date, the government has seized approximately $126.5 million in assets that Randall and his co-conspirators accumulated from the scheme, including $111 million in bank funds and securities, nine luxury vehicles totaling approximately $1 million, nine luxury real properties totaling approximately $13.5 million, and more than $1 million worth of sports memorabilia. FBI, HHS-OIG, and the California Department of Justice investigated the case. Trial Attorney Siobhan M. Namazi of the Fraud Division’s Health Care Fraud Section and Assistant U.S. Attorney Roger A. Hsieh for the Central District of California prosecuted the case. Assistant U.S. Attorney James E. Dochterman for the Central District of California’s Asset Forfeiture and Recovery Section is handling asset forfeiture matters in this case. On April 7, the Department of Justice announced the creation of the National Fraud Enforcement Division. The Fraud Division is laser-focused on investigating and prosecuting those who commit fraud against the American people. The Department’s work to combat fraud supports President Trump’s Task Force to Eliminate Fraud, a whole-of-government effort chaired by Vice President J.D. Vance to eliminate fraud, waste, and abuse within Federal benefit programs. The Department of Justice’s Health Care Fraud Strike Force Program, currently comprised of nine strike forces operating in federal districts across the country, has charged more than 6,200 defendants who collectively billed federal health care programs and private insurers more than $45 billion since 2007. In addition, the Centers for Medicare & Medicaid Services, working in conjunction with the Office of the Inspector General for the Department of Health and Human Services, are taking steps to hold providers accountable for their involvement in health care fraud schemes. More information can be found at [www.justice.gov/criminal-fraud/health-care-fraud-unit](http://www.justice.gov/criminal-fraud/health-care-fraud-unit). **Topics:** Medicare/Medicaid **Categories:** Conviction --- ### [Brooklyn Adult Daycare Owner Sentenced to 76 Months in Prison for Leadership Role in $68 Million Medicaid Fraud Scheme](https://insurancefraud.org/news_archives/brooklyn-adult-daycare-owner-sentenced-to-76-months-in-prison-for-leadership-role-in-68-million-medicaid-fraud-scheme/) **Published:** September 11, 2026 **Author:** Diane Beauchamp **Content:** Earlier today, in federal court in Brooklyn, Zakia Khan was sentenced by United States District Judge Natasha C. Merle to 76 months in prison in connection with her leadership role in carrying out a $64 million Medicaid fraud and illegal kickback scheme at her two social adult daycare centers and a home health care company. In August 2025, Khan pleaded guilty to conspiracy to commit health care fraud and conspiracy to defraud the United States and pay health care kickbacks. As part of her sentence, Khan was also ordered to pay over $56 million in restitution and to forfeit $5 million in fraud proceeds, including two properties, cash, and gold jewelry seized during a search of her home, as pictured below. ![](https://insurancefraud.org/wp-content/uploads/image-20-7.jpg)Joseph Nocella, Jr., United States Attorney for the Eastern District of New York; Colin M. McDonald, Assistant Attorney General of the Justice Department’s National Fraud Enforcement Division; Pete Gizas, Acting Special Agent in Charge, Homeland Security Investigations, New York (HSI New York); Miranda L. Bennett, Acting Deputy Inspector General for Investigations, U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG); and Jessica S. Tisch, Commissioner, New York City Police Department (NYPD) announced the sentence. “Today’s sentencing sends a strong message of deterrence in our District,” stated United States Attorney Nocella. “Our Office and the Justice Department are focused on protecting American taxpayers from fraudsters and as such, we will vigorously prosecute corrupt health care owners and operators in our district.” “Khan acted with staggering greed, leading a scheme to defraud Medicaid of millions of dollars intended for people in need. She and her co-conspirators set up social adult daycares but, instead of providing care and services to our most vulnerable neighbors, they enriched themselves with cash, gold, and property,” said HSI Acting Special Agent in Charge Gizas. “Today’s sentence sends a message: we will be relentless in our pursuit of justice against fraudsters. HSI is working side by side with our law enforcement partners to uncover and dismantle complex fraud networks like this one.” “Social adult day care and home health services are designed to support seniors, not line the pockets of fraudsters,” said HHS-OIG Acting Deputy Inspector General Bennett. “Today’s sentence sends an important message that anyone who illicitly exploits the Medicaid program will be held accountable to the full extent of the law.” “Zakia Khan stole $64 million from Medicaid through bribes and kickbacks—money meant to support the most vulnerable,” said NYPD Commissioner Tisch. “This was not only deeply illegal but also immoral, and the NYPD will continue to investigate anyone who exploits government programs for personal gain. I thank our NYPD investigators and all our partners in law enforcement for their work in stopping this criminal and bringing this case to a close.” According to court documents, Khan owned two social adult daycare centers—Happy Family Social Adult Day Care Center Inc. (Happy Family) and Family Social Adult Day Care Center Inc. (Family Social) in the Coney Island section of Brooklyn. She also owned a home health care fiscal intermediary called Responsible Care Staffing Inc. and an entity she used to receive and disguise fraud proceeds called Tanwee Services Inc. From approximately October 2017 through July 2024, in exchange for kickbacks and bribes, a web of marketers referred Medicaid recipients to Khan’s social adult daycare centers. As depicted in the pictures below, Khan and the marketers paid kickbacks and bribes to the Medicaid recipients to induce them to sign up for services that Khan then billed to Medicaid. These services were never actually provided as represented to Medicaid. Between 2017 and 2024, Happy Family and Family Social fraudulently billed Medicaid approximately $64 million. Medicaid paid approximately $56 million based on these false and fraudulent claims. Khan and her co-conspirators used multiple business entities to launder the fraud proceeds and generate the cash used to pay kickbacks and bribes to the marketers and the Medicaid recipients. HHS-OIG, HSI New York, and NYPD investigated the case. Deputy Chief Patrick J. Campbell and Trial Attorney Leonid Sandlar of the National Fraud Enforcement Division’s Health Care Fraud Section are prosecuting the case with the assistance of Assistant U.S. Attorney Claire Kedeshian for the Eastern District of New York, who is handling forfeiture matters. On April 7, the Department of Justice announced the creation of the National Fraud Enforcement Division (Fraud Division). The Fraud Division is laser-focused on investigating and prosecuting those who commit fraud against the American people. The Department’s work to combat fraud supports President Trump’s Task Force to Eliminate Fraud, a whole-of-government effort chaired by Vice President J.D. Vance to eliminate fraud, waste, and abuse within Federal benefit programs. The Defendant: ZAKIA KHAN Age: 55 Brooklyn, New York E.D.N.Y. Docket No.: 24-CR-409 (NCM) Contact John Marzulli Denise Taylor United States Attorney’s Office (718) 254-6323 **Topics:** Medicare/Medicaid **Categories:** Conviction --- ### [GEICO sues equipment supplier over $3.7 million alleged No-Fault fraud](https://insurancefraud.org/news_archives/geico-sues-equipment-supplier-over-3-7-million-alleged-no-fault-fraud/) **Published:** September 11, 2026 **Author:** Diane Beauchamp **Content:** GEICO has sued a New York medical-equipment supplier, alleging it billed more than $3.7 million for braces, cushions and stimulators that patients never needed. The insurer filed suit on September 8, 2026 in the US District Court for the Eastern District of New York. It names the supplier, APEX Health Products Inc., along with its owner and up to 10 unnamed “John Doe” defendants. The case turns on New York’s No-Fault system, which is meant to give people hurt in car accidents a fast way to cover their medical care. APEX billed GEICO for “medically unnecessary, illusory, and otherwise non-reimbursable” equipment supplied to people who said they were injured in New York crashes and were covered under No-Fault policies, according to the complaint. The gear included joint-stimulation devices, heat pads with pumps, percussors, wheelchair back cushions and lumbar braces – what the filing calls the “Fraudulent Equipment.” GEICO says the scheme began no later than September 2024 and is still running. It alleges it paid out more than $2.1 million and is now fighting another $1.3 million in pending bills, out of more than $3.7 million billed to GEICO alone. The complaint says APEX never operated as a real supplier. Instead, GEICO alleges, its owner struck “collusive” deals with the operators of several No-Fault clinics, paying “kickbacks and other financial incentives” for a steady flow of prescriptions. Those prescriptions were routed straight to APEX, the filing says, so patients never took them to a legitimate supplier who might ask questions. Many prescriptions carried “photocopied or otherwise duplicated” signatures, according to the complaint. A doctor whose name appeared on some of them told GEICO he signs each prescription by hand, that no two signatures should ever match, and that he never authorized anyone to copy his signature. The coding is where the case matters most for insurers. GEICO says APEX’s owner is not a licensed medical provider, yet decided which devices to bill for – using vague prescriptions, such as a generic “Lumbar Support,” to reach for the billing code that paid the most. It often billed for costlier items than the ones it actually supplied, the insurer alleges. The filing lists examples. It says a “Lumbar Cushion” was billed at $282.02 under a wheelchair-cushion code, when the item matched a positioning-cushion code capped at $22.04. An “Orthopedic Car Seat” was billed at $756.03 using a code meant for special-needs seating for children with conditions such as cerebral palsy. A “massager” was billed at $355.56 under a code for an airway-clearance device used by patients with cystic fibrosis or chronic bronchitis. And prescriptions for an “EMS Unit” were billed instead as joint-stimulation devices at $808.25. GEICO also takes aim at how the bills were collected. It says APEX hired law firms to file large numbers of separate No-Fault collection cases, one bill at a time, making it hard for any single arbitrator or judge to see the full picture. GEICO says it has to process claims within 30 days, and that the paperwork looked valid enough to pay. The suit brings six claims, including two under the federal anti-racketeering law known as RICO, plus fraud and unjust enrichment. GEICO wants its $2.1 million back, a ruling that it owes nothing on the pending bills, and – under RICO – triple damages plus legal fees. The allegations have not been tested, and no court has ruled on the claims. **Topics:** Healthcare Fraud, Judicial/courts, Public Awareness --- ### [Treasury Uncovers $17.5 Billion in Suspected Health Care Fraud](https://insurancefraud.org/news_archives/treasury-uncovers-17-5-billion-in-suspected-health-care-fraud/) **Published:** September 11, 2026 **Author:** Diane Beauchamp **Content:** The U.S. Department of the Treasury today announced that its Financial Crimes Enforcement Network (FinCEN) has identified approximately **$17.5 billion in suspicious financial activity potentially linked to health care fraud**, underscoring the Trump Administration’s commitment to eliminating fraud, protecting taxpayers, and safeguarding the integrity of federal health care programs. “By identifying and reporting this suspicious activity, financial institutions have given law enforcement critical insight into the illicit actors who deliberately exploit U.S. health care benefits programs,” said **Treasury Secretary Scott Bessent.** “Treasury will continue working alongside our law enforcement partners to disrupt fraud wherever it occurs, protect Americans, and safeguard the integrity of taxpayer-funded programs.” A new FinCEN [*Financial Trend Analysis*](https://www.fincen.gov/system/files/2026-09/FTA-Health-Care-Fraud.pdf) finds that, over a one-year period, financial institutions filed more than 5,700 Bank Secrecy Act (BSA) reports flagging activity potentially connected to health care fraud. The findings provide law enforcement with critical financial intelligence to identify, investigate, and disrupt illicit schemes that exploit taxpayer-funded health care benefits. Health care fraud drains resources from the Americans who rely on these programs, drives up health care costs, and can put patients at serious risk. Treasury is using every available tool to support President Trump’s agenda to eliminate waste, fraud, and abuse across the federal government. Working with the White House Task Force to Eliminate Fraud led by Vice President Vance, Treasury is encouraging whistleblowers to report credible information related to fraud, money laundering, sanctions violations, and tax-law violations. Tips from whistleblowers, combined with financial institutions’ BSA reporting, can help Treasury and its law enforcement partners uncover criminal networks, recover taxpayer funds, and hold bad actors accountable. Treasury will continue to leverage financial intelligence, strengthen coordination across government, and pursue those who seek to profit by defrauding American taxpayers and endangering patients. FinCEN analyzed 5,702 BSA reports filed by financial institutions between March 1, 2025 and February 28, 2026, and found the following prominent trends: ### DEPOSITORY INSTITUTIONS ACCOUNTED FOR MAJORITY OF HEALTH CARE FRAUD-RELATED BSA REPORTS - Depository institutions filed approximately 89 percent of reports in the dataset and accounted for nearly 87 percent of the reported suspicious activity amounts. ### POTENTIAL HEALTH CARE FRAUD SCHEMES SPANNED MEDICARE, MEDICAID, AND PRIVATE INSURANCE - Potentially fraudulent funds were often received from a combination of federal and state programs, as well as private insurance companies. - Medicare payments frequently originated from Medicare Administrative Contractors whereas Medicaid payments originated from state-level administrators. ### AN OVERWHELMING MAJORITY OF SUBJECTS WERE LOCATED IN THE UNITED STATES - Filers identified subjects located in every U.S. state, as well as Puerto Rico, Guam, and the U.S. Virgin Islands. - Of the approximately 13,000 subject addresses in the dataset, approximately 1.5 percent had a foreign address. ### HOME HEALTH CARE BUSINESSES ACCOUNTED FOR THE LARGEST SHARE OF SUSPECTED FRAUDULENT PROVIDERS - Home health care businesses were identified as the suspected fraudulent provider in 20 percent of all health care fraud-related BSA reports. - Other frequently identified providers included hospice care companies, mental and/or behavioral health and addiction treatment providers and companies, medical equipment providers, and adult or child daycares. ### SUSPECTED FRAUD PROCEEDS FUNDED PERSONAL SPENDING, LUXURY PURCHASES, AND OVERSEAS TRANSFERS - Suspected perpetrators employed a range of money laundering techniques before spending the suspected fraudulently obtained health care payments. - In many cases, proceeds of suspected health care fraud that did not appear to go through a complex funds transfer process were used on personal expenses and luxury goods, with some funds being sent internationally. ### SOME SUSPECTED HEALTH CARE FRAUD PERPETRATORS WERE POTENTIALLY INVOLVED IN CRIMINAL NETWORKS - A small percentage of filers reported suspected health care fraud activity potentially involving large fraud rings or criminal networks, as well as some potential connections to foreign entities. Today’s FTA is FinCEN’s second health care fraud-related product issued this year. In March, FinCEN issued an Advisory on [Health Care Fraud Schemes Targeting Medicare, Medicaid, and Other Federal and State Health Care Benefit Programs](https://www.fincen.gov/system/files/2026-03/FinCEN-Advisory-Health-Care-Fraud.pdf). Although BSA reports filed after the issuance of the Advisory were not included in the scope of this FTA, the typologies and trends in the post-Advisory BSA filings are consistent with the trends reported in the FTA. FinCEN’s analysis of threat pattern and trend information derived from BSA data on additional topics can be found on its [Financial Trend Analyses](https://www.fincen.gov/resources/financial-trend-analyses) page. **Topics:** Healthcare Fraud, Public Awareness, Regulatory actions --- ### [Construction Worker Convicted](https://insurancefraud.org/news_archives/construction-worker-convicted/) **Published:** September 11, 2026 **Author:** Diane Beauchamp **Content:** On September 1st, 2026, the Special Investigative Unit of RJN Investigations, Inc. was notified that the Riverside County District Attorney’s Office was successful in prosecuting the claimant who was found to be working at a construction site while also collecting Temporary Total Disability Payments from the insured. During the course of a subsequent AOE/COE investigation, the claimant denied working anywhere since his date of injury. Based on the statement, combined with the surveillance footage, the case was submitted to both the Riverside County District Attorney and California Department of Insurance Fraud Division. The claimant was arrested, notified of his charges and arraigned. Over the course of several months of hearings, the claimant would accept a plea deal in which he was ordered to pay $10,000.00 “upfront” in court-ordered restitution. As part of the plea deal, the claimant was ordered to repay the remaining balance before June of 2027 (amount to be determined at that time.) **Topics:** Work comp - worker **Categories:** Conviction --- ### [New Report Looks at Speed of AI Adoption in Insurance Sector](https://insurancefraud.org/news_archives/new-report-looks-at-speed-of-ai-adoption-in-insurance-sector/) **Published:** September 11, 2026 **Author:** Diane Beauchamp **Content:** *Many companies have embraced AI, whilst others try to apply some AI automation to existing legacy tech systems. It’s hard to know exactly which is the best approach long term. Meanwhile govt departments continue to get less reliable in terms of accuracy when it comes to data. If insurers utilise that weak, or politically edited data, as a baseline, then the entire risk pricing model is going to fail.* *That’s just one problem with speed when it comes to AI, rather than verifying the data you start with.* *Here’s the word on this new report;* [Clearspeed](https://link.mediaoutreach.meltwater.com/ls/click?upn=u001.W8erpX3zVGZuUyt20q7F9t4gGoSCIVZyuvhnGcD6cNsFN7x-2BXBwT7U32l4A9iBwu3snk_pIbxPfpDI69aAybPrpOfgz2gF26eNuAUJp2L8tsiwA9TJAvRPU9LjyFzS-2FIWAvCrG7uDOb6YWfkSLHbKQAMBHxuZlzKnONw5ouhgBXFU7ds9zrDKcph1A1LeGKo0mJ5aQiXOyjbPEtusqvnd3qAynIk-2FAVsvC7wznVHGfZa7fkSeRHMU5KaBxtLvWQEpWgVcTWEsZBUzE1tPRA5tEjsgMtZ6US5BhspJdID-2BI74mcA9vWXYKKYlG8yNG9dSpvsIMS9CiucQbrIPD3lVhc9x5iP42cw48TbGa4i-2Ff-2Btdc-2B4AODqOXgaZvY-2F1u1wsZHH5BQhB5HzpwoUKBG1NpVJo9Gb5JEB-2BwF6inQBMCA07LyOG1DpgD2cUnQJpGBcMRKDxW2-2B-2Bf-2BxI5c-2B6g2QydasbdOw-3D-3D), the global leader in voice-based risk assessment, today released new research examining the growing challenge for insurers to move faster with AI and automation while determining whether the information those systems act on can be trusted. *The Speed of Trust: Building the Trust Intelligence Layer for Insurance in the Age of Agentic AI*, commissioned by Clearspeed and independently authored by insurance innovation strategist [Sabine VanderLinden](https://link.mediaoutreach.meltwater.com/ls/click?upn=u001.W8erpX3zVGZuUyt20q7F9suOt4sHivmyrag5MHmkEOkBqOOA2JbuDthl6k23-2BBh7g-2BHSacsJPd4rwT9fVbm7yw-3D-3DYAaV_pIbxPfpDI69aAybPrpOfgz2gF26eNuAUJp2L8tsiwA9TJAvRPU9LjyFzS-2FIWAvCrG7uDOb6YWfkSLHbKQAMBHxuZlzKnONw5ouhgBXFU7ds9zrDKcph1A1LeGKo0mJ5aQiXOyjbPEtusqvnd3qAynIk-2FAVsvC7wznVHGfZa7fkSeRHMU5KaBxtLvWQEpWgVcTWEsZBUzE1tPRA5tEjsgMtZ6US5BhspJdID-2BI74mcA-2F1qvYvC1-2Bkmdb-2BzumTrLa2d2Qd3llcZ8KMZ-2FycHT44S5QAFBBFstK3f-2By7ORac1NwxFWVtqWePtD-2BLn-2FCJxhZ09qVIBmiheWeKlHLJgGVr3TtWqO62Eo3mq0f2-2FUNmBpeo9EUFF3x3d-2BDc-2BmlbcADyavmgyoZ5meteY0KNCPGbIA-3D-3D), CEO of Alchemy Crew Ventures, draws on a review of 76 public filings from 49 insurers and reinsurers, 31 industry studies, and 16 interviews with claims and underwriting leaders at insurance companies across the United States and United Kingdom. The research identifies a paradox emerging as insurers rapidly adopt AI and automation: **the industry is automating decisions, handoffs, evidence review, and customer interactions faster than it is building the infrastructure needed to clear those interactions confidently.** Simultaneously, AI is making it faster and easier to create convincing false or manipulated photos, documents, voices, and identities that can enter insurance workflows. **Reserving Against A Risk Not Yet Named** “Industry research published in March 2026, based on a survey of 300 U.S. insurance claims professionals, found that 98% agree AI editing tools are driving a rise in digital media fraud, while just 32% say they are very confident they could identify a deepfake.” “That is the verification gap: the distance between what the industry can see coming and what it can currently detect,” said VanderLinden. “Insurance is automating decisions faster than it can verify the information behind them.” Alchemy Crew Ventures researchers searched 76 annual reports, 10-K filings, proxy statements, and statutory returns from 49 insurers and reinsurers for a dozen terms related to AI-generated and manipulated evidence, media, and imagery. The analysis found: - Zero mentions of synthetic media, synthetic identity, or voice cloning across all 76 filings - Just six of 49 companies mention deepfakes — and only as a cybersecurity concern, never in connection with evidence used in claims or underwriting decisions - Five of the world’s top 10 reinsurers were analyzed; none mention deepfakes, synthetic media, or AI-generated evidence in their most recent annual reporting “There is a striking gap between where this risk is discussed and where capital is committed,” said VanderLinden. “In the filings that set reserves, uncertainty, litigation pressure, and adverse development are all named. The trust problem beneath them is not.” **Genuine Customers Are Paying the Price** Most claimants are genuine. According to the Coalition Against Insurance Fraud, fraud accounts for roughly 10% of property and casualty losses, with the trust deficit draining at least $308.6 billion annually from the U.S. insurance system. But the deeper issue is not simply the cost of fraud alone. Until insurers have a consistent way to determine which interactions need speed, scrutiny, or human judgment, the industry pays for trust twice: once through leakage from the few bad actors, and again through friction imposed on the genuine majority. “90%+ of customers who make a claim are honest, good people for whom we should be just sorting out their service needs as quickly as possible,” Ian Thompson, former Group Chief Claims Officer at Zurich Insurance, told researchers. “But how many of those genuine customers get the feeling that they’re not being trusted, because we’re trying to catch the other 10%?” **Making the Trust Intelligence Layer Operational** In the report, VanderLinden argues that insurers should work to address this challenge by making trust a measurable infrastructure layer across the policyholder journey. Rather than using more AI merely to catch more fraud, insurers should establish a Trust Intelligence Layer: a continuous, regulator-ready risk indicator running across the policyholder journey that is designed to help insurers clear the genuine majority quickly while directing human judgment to the exceptions. The signal informs a decision rather than making one, produces an audit trail rather than an automated denial, and does not require demographic or historical knowledge of the individual being assessed. “In the age of agentic AI, deepfake evidence, embedded distribution, and automated workflows, insurers can no longer treat trust as a soft value or a late-stage consideration. The opportunity for carriers is to establish trust earlier and make it a measurable operating layer across the policyholder journey,” said VanderLinden. “Trust is our most vital currency: it is the hardest thing to gain and the easiest thing to lose,” said Alex Martin, co-founder and CEO of Clearspeed. “Today’s promise of AI should yield a faster, richer experience for genuine customers, but that must begin with verifying where to extend trust.” **Vision 2030: Trusting the Conversation** The report also looks ahead to 2030, when a material share of insurance interactions will be agent-to-agent: a customer’s AI agent transacting with an insurer’s AI agent, at machine speed, with no human in the loop for routine business. In that world, the verification question does not disappear; it migrates and intensifies. When the action is always executed correctly, the question left is whether the interaction behind it can be trusted. The report describes this as a shift in what gets verified, not whether verification is still needed. As more insurance interactions become AI-to-AI, the human input behind each transaction — the information a person provides, however it enters the system — still has to be trusted before automated systems act on it. The report argues insurers will need an auditable way to establish that trust at the moment of interaction. The organizations that build that capability now, while the interactions are still human-led, will define the standard when those interactions become machine-to-machine. The report concludes that “the arms race is symmetrical. The only durable advantage is to establish trust earlier and faster than the adversary can manufacture doubt.” *The Speed of Trust: Building the Trust Intelligence Layer for Insurance in the Age of Agentic AI* is available at [The Speed of Trust](https://link.mediaoutreach.meltwater.com/ls/click?upn=u001.W8erpX3zVGZuUyt20q7F9t4gGoSCIVZyuvhnGcD6cNt5UaESQPc7-2Be7-2Fjmb-2FQrhfjhYa4-2BkL0kuoei7kkeGn1mcMQHnr-2Fn-2FcwbdMfIic472pPZ-2BAyMX9ubtLxwIGWAth8XuwMeJIMyGEM5BOC8Ov5JoF2F1nP-2FOMIhEvlE0bwSFBnzSTCpm1eh5VPkcEZSrNXGdY-2F13H5uuQ46WLzcd1CQ-3D-3DVhB-_pIbxPfpDI69aAybPrpOfgz2gF26eNuAUJp2L8tsiwA9TJAvRPU9LjyFzS-2FIWAvCrG7uDOb6YWfkSLHbKQAMBHxuZlzKnONw5ouhgBXFU7ds9zrDKcph1A1LeGKo0mJ5aQiXOyjbPEtusqvnd3qAynIk-2FAVsvC7wznVHGfZa7fkSeRHMU5KaBxtLvWQEpWgVcTWEsZBUzE1tPRA5tEjsgMtZ6US5BhspJdID-2BI74mcA-2FjomP5QzBButRJMvapqoZsSE-2BLQWAniUK8IrRvjlpfZnw6TbeMrfk5-2Fkr7nGqjvmHwIKw-2FSm0kpmfjVYRKlWoGuXvhY-2Fzbuy-2BfWp9xZxjKuyiTVqmfBRxLHDexGbtLzVUgauzM7Q1BwFJCiVdj5QAq-2FfNfz-2FWe4S60Fq7h0ulkYg-3D-3D). **Topics:** Public Awareness, Technology --- ### [The FTC Is Now Coming for the Payment Processors That Enable AI Fraud](https://insurancefraud.org/news_archives/the-ftc-is-now-coming-for-the-payment-processors-that-enable-ai-fraud/) **Published:** September 11, 2026 **Author:** Diane Beauchamp **Content:** On September 4, 2026, the Federal Trade Commission (FTC) announced a **$4.85 million settlement** with Canadian payment processor Nuvei Corporation. Filed in the U.S. District Court for the District of Arizona, the action stems from allegations that Nuvei knowingly facilitated merchant fraud between 2017 and 2023. Specifically, the agency found that Nuvei processed over $30 million for Reimage, an offshore tech support scam, while also onboarding merchants previously terminated by other processors for excessive chargebacks or fraudulent activity, such as DK Automation and American Tax Service. The settlement mandates $4.85 million in consumer redress, imposes a ban on payment services for tech support telemarketing, and requires strict merchant screening and monitoring protocols. While the Nuvei case is not explicitly branded as part of **Operation AI Comply**, it functions as a logical extension of the FTC’s broader enforcement strategy against the infrastructure that enables AI-related fraud. Operation AI Comply, launched in September 2024, initially targeted companies engaged in AI washing. The scope of this enforcement has evolved, as seen in the March 2026 permanent ban of [Air AI](https://www.ftc.gov/news-events/news/press-releases/2026/03/ftc-action-permanently-bans-air-ai-and-its-founders-deceptive-business-opportunity-claims)—and its defendants Caleb Maddix, Ryan O’Donnell, and Thomas Lancer—from marketing business opportunities, which included $50,000 in consumer relief. Despite a policy shift marked by the December 2025 decision to set aside the Rytr consent order under the Trump FTC, the agency continues to pursue aggressive enforcement, with both the Nuvei and Air AI cases passing by 2-0 votes. The Nuvei settlement highlights a **three-tiered enforcement architecture** that the FTC is currently deploying. At the application layer, the agency targets AI companies directly, as seen in the initial phase of Operation AI Comply. At the infrastructure layer, the focus shifts to the financial conduits that allow these scams to operate. The FTC’s consistent pursuit of financial intermediaries, evidenced by the [$26 million settlement with Reimage operators in 2024](https://www.ftc.gov/news-events/news/press-releases/2024/04/ftc-announces-litigation-win-recover-more-26-million-consumers-harmed-massive-tech-support-scam), the $5 million settlement with Paddle in 2025, and now the $4.85 million Nuvei settlement, demonstrates a strategic prioritization of payment processor liability. Finally, at the algorithmic layer, the FTC is scrutinizing AI-driven individualized pricing. As noted in previous Forkast coverage, the agency’s draft policy on personalized pricing remains a critical area of interest, with the comment period extended to September 25, 2026. These enforcement actions signal that the FTC is moving beyond simple oversight of AI marketing claims. By targeting the payment processors that facilitate these operations, the agency is effectively raising the cost of doing business for entities that ignore fraud indicators. Christopher Mufarrige, Director of the FTC Bureau of Consumer Protection, underscored this stance regarding the Nuvei settlement: **‘Consumers deserve a payment system that is competitive, transparent and fortified against fraud—and we will take action anytime those standards are threatened.’** The persistence of these enforcement actions, even amidst shifting political administrations, suggests that the underlying regulatory philosophy remains focused on systemic accountability. Whether through direct intervention in AI business models or by dismantling the financial infrastructure that supports them, the FTC is signaling that the technical complexity of AI will not shield companies from liability. As the agency continues to refine its approach to personalized pricing and algorithmic transparency, market participants should anticipate continued scrutiny of both their internal AI practices and their external financial partnerships. **Topics:** Judicial/courts, Regulatory actions --- ### [Is RHOP Star Eddie Osefo Still Able to Practice Law Amid Fraud Case? His Bar Status is Confirmed as Fans Weigh in](https://insurancefraud.org/news_archives/is-rhop-star-eddie-osefo-still-able-to-practice-law-amid-fraud-case-his-bar-status-is-confirmed-as-fans-weigh-in/) **Published:** September 11, 2026 **Author:** Diane Beauchamp **Content:** Real Housewives of Potomac star Eddie Osefo and his wife, Wendy Osefo, are in the midst of an ongoing insurance fraud case. But can he still practice law? Following the news of Eddie’s new career in real estate, his status with the Bar has been confirmed. “According to the D.C. Bar information I found, Eddie is currently listed as an ACTIVE member in GOOD STANDING. The D.C. Bar says an attorney in good standing has no current suspension,” Vanessa, of Realitea Recap on Instagram, revealed in a post shared on Instagram on September 3. “His Happy Eddie website also appears to still be active,” she continued. “So, based on what I found, there’s nothing indicating that he’s entering real estate because he has been barred or suspended from practicing law.” In an accompanying screenshot, it was revealed that Eddie was admitted to the Bar on January 10, 2014. Vanessa also reminded her followers that “being in good standing with the Bar does not determine the outcome of the criminal case.” “And remember, Wendy & Eddie’s insurance fraud case is still pending, with their jury trial currently scheduled for January 25–29, 2027,” she added. After the information was shared, several users pointed out that Eddie would likely remain in good standing unless he was found guilty at his upcoming insurance fraud trial. “He wouldn’t be suspended or disbarred before a conviction,” one person wrote. “Ever heard ‘Innocent until proven guilty?’” asked another. “Let’s see what happens when a verdict is passed.” “He’s innocent until proven guilty,” agreed a third. Meanwhile, others suspected Eddie would “definitely lose” his right to practice law once the trial began. “If this case goes south, he could lose his license even if he doesn’t necessarily go to jail,” a commenter noted. As RHOP fans will recall, Eddie and Wendy were accused of staging a fake home robbery in April 2024 and collecting on insurance checks. As they await trial, Eddie announced he’d joined the Baltimore-based firm Garner & Co. “I’m excited to announce a new venture as a licensed REALTOR!” he shared in a September 1 post. As an attorney, I have always been intrigued by real estate development, investing, and building generational wealth through assets.” this case goes south, he could lose his license even if he doesn’t necessarily go to jail,” a commenter noted. As RHOP fans will recall, Eddie and Wendy were accused of staging a fake home robbery in April 2024 and collecting on insurance checks. As they await trial, Eddie announced he’d joined the Baltimore-based firm Garner & Co. “I’m excited to announce a new venture as a licensed REALTOR!” he shared in a September 1 post. As an attorney, I have always been intrigued by real estate development, investing, and building generational wealth through assets.” “If this case goes south, he could lose his license even if he doesn’t necessarily go to jail,” a commenter noted. As RHOP fans will recall, Eddie and Wendy were accused of staging a fake home robbery in April 2024 and collecting on insurance checks. As they await trial, Eddie announced he’d joined the Baltimore-based firm Garner & Co. “I’m excited to announce a new venture as a licensed REALTOR!” he shared in a September 1 post. As an attorney, I have always been intrigued by real estate development, investing, and building generational wealth through assets.” **Topics:** Homeowners - fake **Categories:** Arrest --- ### [Upcoming fraud trial](https://insurancefraud.org/news_archives/upcoming-fraud-trial/) **Published:** September 10, 2026 **Author:** Diane Beauchamp **Content:** Of the dozens and dozens of federal fraud cases we’ve been tracking, very few have actually gone to trial, and not one in more than a year. A case captioned USA v. Sharmaine Meadows (File No. 26-cr-90) appears set to break that streak. The case was charged back in May and the trial is scheduled to begin on September 25 and extend into early October. In this world, that’s lightning speed. Meadows is accused of defrauding the Medicaid program through a now-discontinued program called Housing Stabilization Services (HSS) through her company, Cradle of Love LLC. The feds allege (Indictment, p. 7), She was originally charged with three counts of health care fraud. On Wednesday (September 2) the grand jury handed down a superseding indictment, which added two additional fraud counts. Meadows is described as aged 45 out of Lake Elmo. In her first court appearance, a consular notice was read into the record, suggesting the possibility that she may not be an American citizen. Developing… **Topics:** Medicare/Medicaid **Categories:** Arrest --- ### [Somoza Outsmarted Transamerica. The DOJ Made Him Pay For It.](https://insurancefraud.org/news_archives/somoza-outsmarted-transamerica-the-doj-made-him-pay-for-it/) **Published:** September 10, 2026 **Author:** Diane Beauchamp **Content:** THE PROGRAM In the early 2000s, Rev. J. Benjamin Hardwick wanted to find a way to provide burial insurance for the poor in his South Los Angeles congregation. In 2003, he went to financier and tech developer Curtis Somoza in Beverly Hills. Somoza found a way to finance life insurance policies for Hardwick’s parishioners in a group of more than a thousand congregants. His plan was this: outsmart the insurance companies. The church would own the policies. The poor who signed up for the pool—and whom Somoza selected—would get free life insurance that paid $15,000 upon their deaths. In addition, the church would get $20,000 for each death. Investors would pay the premiums. The key was who was selected. Somoza did the selecting. He also got the investors, more than 50 altogether. The investors weren’t doing charity. Somoza promised them a return. It all depended on Somoza outsmarting the insurance company, in this case Transamerica. THE MODEL The trick was to select a group of insureds that would likely die younger over a 30-year period than Transamerica predicted. Transamerica would base its rates on its actuarial tables. Insurance companies, including Transamerica, priced their group life insurance on mortality assumptions derived largely from Whites, with a heavy admixture of executives — people expected, statistically, to live longer, more stable lives than Blacks, Hispanics, and poor Whites who lived in high- crime, high-drug areas like South Los Angeles where Hardwick’s church was located. Somoza says he spent 600 hours building his mortality model. Transamerica predicted 1.6 deaths in the first year for a pool of roughly 1,200 mostly Black insureds. Somoza predicted 8.3 deaths. Somoza raised about $33 million from investors for the insurance program. Upon every death, Transamerica was to pay a $275,000 death benefit. The church got $20,000. The insured’s family got $15,000. The investors would get around $30,000, although it varied with the velocity of the deaths and the age of the premiums. The rest of the $275,000 death benefits – around $210,000 per death – was to go to pay the annual premiums. DEATH COMES EARLY By Somoza’s account, the first insured died within 48 hours. Five died in five months. None of the five, he says, was over 50. Some died by violence, some by drugs, some perhaps by poor health conditions that poverty brings, something Transamerica had not considered. Or maybe could not consider. The Catch-22 for Transamerica was that it could not discriminate by race or zip code, which in banking would be called redlining. By the time Transamerica’s underwriters realized they had been outsmarted, Somoza had insured 2,500 poor people for free. Transamerica stopped issuing new policies under the program. But then, when suddenly faced with millions in death benefits within the first two years, Transamerica invoked the contestability period, the two-year window in which an insurer may check whether an applicant told the truth. Every insurer does that. It is typically a file review, and then a check. Transamerica did not send a check. It went to federal court, deposited the death benefits with the clerk, and let others fight over them. Had John Smith, a poor Black man in South Los Angeles, held a $275,000 policy on his own, his family would have had their money in weeks. But John Smith held it as one of 2,500 in Somoza’s pools. His family waited on a lawsuit. By the time that case ended, Transamerica had deposited about $3.6 million. Transamerica’s refusal to pay delayed death benefits, keeping investors from getting paid on time. That became part of the U.S. Attorney for the Central District of California’s proof that Somoza’s underlying enterprise was fraudulent. Transamerica held the money. Somoza got the blame. WHAT BECAME OF THE POLICIES The policies did not disappear. They remained in force. The death benefits were ultimately paid to the families of those who died, and the church also got paid. And the policies on the living — the majority — remain in force 20 years later. The investors were another matter. Most of them lost their money. Not because the policies failed. They didn’t. Not because Somoza’s model was wrong. But because it was right and Transamerica balked. First, Transamerica delayed, then the Justice Department stopped the plan before it could pay out. The Justice Department counted every dollar the investors had not yet been paid as a dollar Somoza had stolen. The investors did not lose the asset. The Justice Department took it from them, in the name of protecting them. Then it called them Somoza’s victims. Injustices like that happen in America from time to time. The irony lies in the name of the actor: The Department of Justice. **Topics:** Judicial/courts, Life Insurance --- ### [Erekle Gugava Charged in $1.3B Health Care Fraud](https://insurancefraud.org/news_archives/erekle-gugava-charged-in-1-3b-health-care-fraud/) **Published:** September 10, 2026 **Author:** Diane Beauchamp **Content:** A federal grand jury in Massachusetts has indicted Erekle Gugava, 33, a Georgian national, on a money laundering conspiracy charge tied to an alleged $1.3 billion health care fraud operation that federal prosecutors say was connected to a transnational criminal organization operating from Russia and elsewhere. The U.S. Department of Justice announced the indictment Friday, Sept. 4, describing the underlying organization as responsible for the largest health care fraud case the department has ever prosecuted. The broader investigation, known as Operation Gold Rush, targets an alleged international operation designed to exploit Medicare and other health insurers. Gugava was charged with one count of conspiracy to commit money laundering. The DOJ said he was illegally in the United States during the alleged conduct. According to the U.S. Attorney’s Office for the District of Massachusetts, Gugava left the United States in July 2025 following the alleged activity. Erekle Gugava – ND Medical allegedly submitted $1.3 billion in claims Federal prosecutors allege Gugava purportedly owned ND Medical Solutions LLC, a durable medical equipment company located in Pennsylvania, for approximately five months between February and July 2025. During that relatively short period, prosecutors say ND Medical submitted at least $1.3 billion in allegedly fraudulent durable medical equipment claims. The claims were submitted to Medicare as well as private health insurance companies providing Medicare supplemental policies, employer-sponsored health plans and other insurers, according to charging documents. The extraordinary amount represents claims submitted rather than money successfully collected. According to the Justice Department, insurers actually paid ND Medical approximately $6.5 million. Prosecutors allege Gugava helped move those proceeds. According to the charging documents, he opened several bank accounts in ND Medical’s name and was the sole signatory. Checks received from Medicare supplemental insurers and other insurance companies were allegedly deposited into those accounts. Federal authorities contend that the money was subsequently transferred to various overseas bank accounts for the benefit of the transnational organization. Assistant Attorney General Colin M. McDonald of the Justice Department’s National Fraud Enforcement Division said preventing fraud organizations from laundering and transmitting proceeds is an important part of protecting taxpayer resources. “As alleged in this indictment, Gugava allegedly helped facilitate a massive fraud on the American people,” McDonald said, adding that the money allegedly moved through domestic and international financial channels. Erekle Gugava – Stolen identities allegedly supported fraudulent claims The allegations extend beyond false billing. Prosecutors say stolen identities belonging to people in Massachusetts, elsewhere in New England and across the United States were used in part to support the fraudulent claims. Some of the affected individuals were elderly or disabled Americans. According to the DOJ, people reported concerns after receiving explanation-of-benefits documents indicating that medical equipment had supposedly been provided to them, even though they had never received it. In some instances, the paperwork allegedly identified physicians the beneficiaries had never visited and listed ND Medical as the equipment supplier even though the beneficiaries were unfamiliar with the company. Those allegations illustrate how health care billing fraud can affect patients even when money is being sought primarily from Medicare or an insurance company. Fraudulent claims can attach services, providers, or medical equipment to a beneficiary’s identity, even when the beneficiary has no involvement in the transaction. Federal prosecutors further allege that the organization exploited the legitimate U.S. financial system because payments originated from Medicare and established insurance companies. That distinction is important to the government’s money laundering allegations. Once an insurer issued a reimbursement payment, the funds came from an otherwise legitimate financial source, potentially giving the proceeds an initial appearance of legitimacy before they were allegedly moved elsewhere. Operation Gold Rush targets massive fraud network Gugava’s case is part of the much larger Operation Gold Rush investigation. DOJ’s 2026 health care fraud case summaries describe Operation Gold Rush as involving an alleged transnational criminal organization based in Russia and elsewhere that targeted Medicare through durable medical equipment companies. In another Operation Gold Rush case, prosecutors alleged supervisory members of the organization were connected to more than $10.6 billion in fraudulent Medicare claims for durable medical equipment. According to the government, the organization acquired dozens of DME companies that could already submit claims to Medicare and Medicare supplemental insurers and allegedly used nominee owners to execute the scheme. The allegations against Gugava therefore represent one component of a substantially larger federal investigation rather than a stand-alone $1.3 billion billing case. The government’s latest allegations also demonstrate why investigators increasingly focus on the financial infrastructure surrounding major fraud operations. A scheme that produces fraudulent insurance payments generally needs bank accounts, account signatories, transfers, and other mechanisms to move or conceal the resulting proceeds. The Justice Department alleges Gugava served that function by facilitating deposits and transfers associated with ND Medical. Erekle Gugava faces up to 20 years if convicted Gugava has been charged with one count of money laundering conspiracy. If convicted, he faces a maximum statutory penalty of 20 years in federal prison, according to the Justice Department. A federal judge would ultimately determine any sentence after considering federal sentencing guidelines and other statutory factors. The investigation involves several federal agencies, reflecting the scope of the alleged conduct. Investigating agencies identified by the Justice Department include: U.S. Department of Health and Human Services Office of Inspector General Federal Bureau of Investigation U.S. Postal Inspection Service IRS Criminal Investigation Homeland Security Investigations U.S. Department of Labor Employee Benefits Security Administration Deputy Chief Kevin Lowell, Assistant Deputy Chief Jim Hayes, and Trial Attorneys Tiffany Wynn and Sarah Rocha of the National Fraud Enforcement Division’s Health Care Fraud Section are prosecuting the case, along with Assistant U.S. Attorney Meghan Cleary for the District of Massachusetts. The Employee Benefits Security Administration’s involvement is also notable because the alleged fraudulent claims were not limited to Medicare. Prosecutors say ND Medical submitted claims to private employer-sponsored plans and other insurers in addition to Medicare-related programs. DOJ expands fight against health care fraud The Gugava indictment comes amid a broader federal effort to investigate large-scale fraud involving government benefit programs. The Justice Department said its Health Care Fraud Strike Force Program currently consists of nine strike forces operating in federal districts around the country. Since 2007, the program has charged more than 6,200 defendants who collectively billed federal health care programs and private insurers more than $45 billion, according to DOJ figures. The department also created its National Fraud Enforcement Division in April 2026, with a stated focus on investigating and prosecuting fraud against Americans. Meanwhile, the Centers for Medicare & Medicaid Services and the Department of Health and Human Services Office of Inspector General continue working on administrative and investigative measures intended to identify fraudulent providers and protect federal health programs. The Gugava prosecution underscores the increasingly international nature of some major health care fraud investigations. The government alleges that while a Pennsylvania medical equipment company generated fraudulent claims and payments passed through U.S. financial institutions, money was ultimately transferred to overseas accounts for the benefit of a foreign-based organization. It also highlights the enormous gap between fraudulent claims submitted and actual losses. In the ND Medical case, prosecutors allege at least $1.3 billion was billed in approximately five months, while insurers paid approximately $6.5 million. That means, based on the figures released by federal prosecutors, the vast majority of the alleged fraudulent billings were not paid. The case will now proceed through the federal criminal justice system. Importantly, an indictment is a formal accusation and is not evidence of guilt. The allegations against Gugava have not been proven at trial, and he is presumed innocent unless and until the government proves his guilt beyond a reasonable doubt in court. **Topics:** Healthcare Fraud, Medicare/Medicaid, Synthetic Identity Theft **Categories:** Arrest --- ### [Glen 'Big Baby' Davis blows the whistle on Kendrick Perkins, others involved in insurance fraud](https://insurancefraud.org/news_archives/glen-big-baby-davis-blows-the-whistle-on-kendrick-perkins-others-involved-in-insurance-fraud/) **Published:** September 10, 2026 **Author:** Diane Beauchamp **Content:** Former NBA forward Glen ‘Big Baby’ Davis was sentenced to 40 months in prison for an alleged scheme to defraud the association’s health care benefits plan, while others, including ESPN’s Kendrick Perkins, received no jail time for their involvement. Big Baby ended up serving 17 months in prison. Upon his release, Davis claimed he was labeled the fall guy by the NBA, and doubled down on those claims in a recent interview. Davis says the NBA picked him over other retired players mentioned in the investigation, leading him to spend nearly two years in prison in addition to three years of supervision. Big Baby expressed his frustration with the process that led to his imprisonment while others mentioned in the indictment, including his former Boston Celtics teammates Kendrick Perkins and Tony Allen, didn’t, he explained, per Locked In with Ian Bick. “They literally wanted to make me out to be an example. There was a lot of people that got investigated,” Davis said. “Kendrick Perkins, you see him on ESPN. Tony Allen—he was literally the third person on the indictment, with his wife. He’s not walking in jail. Darius Miles—he’s not walking in jail. And these guys got money, like thousands of dollars. How’d I end up in jail and these guys are on probation/walking free; their whole life is still intact. “I think the NBA let the feds pick who they wanted to choose. 180 people were investigated/supenoed. We didn’t hear about all those people. We just heard about the 22 people that got caught, or that got jammed in the situation. A lot of people pleaded out. They didn’t go to jail. They didn’t even go get time served.” Glen ‘Big Baby’ Davis, claiming his finances were managed poorly after his NBA career ended following the 2014-15 season, says others took a lot more amid a scheme to defraud the league’s health care benefits plan, and received lesser punishments. “They actually stole money. Thousands — hundreds of thousands of dollars. Your favorite podcast, people you see on different podcasts,” Davis added. “Matt Barnes, Stephen Jack; all those people were investigated. Gilbert Arenas, Corey Maggette, Cutino Mobley; thousands of NBA players were investigated. They just let some of them go to jail. Some of them, the fed got, like, Tony Allen. He didn’t go to jail. Whatever he did to get free.” Davis says the arrest has tarnished his name. “You lose relationships that you’ve been building up for years. Your image is tainted. All the hard work you put in as a role model is now depleted,” Davis added. “You gotta start over, and you have to be a special person to start over, you know what I mean? To look that in the face and be like, oh OK, I’m going to move on and keep going. That’s hard to do. That’s hard to do when you build yourself up to be this person in the world. But it’s something I can do because I’m a special individual.” After winning a championship with Kendrick Perkins, and the Celtics in 2008, Davis played three more seasons in Boston before his trade to the Orlando Magic, and then spent his last two years with the LA Clippers between 2013 and 2015. Glen ‘Big Baby’ Davis explains why he was arrested Three years removed from his last season in the NBA, Glen ‘Big Baby’ Davis joined Ice Cube’s Big 3 basketball league. A lingering foot injury from his last season in the NBA led him to seek medical attention that was provided by the league during the season. However, he believes this was ultimately his downfall. It was around this time that Davis and his advisor were approached by Alan Anderson and Terrence Williams, both of whom played in the Big 3 league. “I didn’t know what was truly going on,” Davis said. “When they came to me, Alan Anderson and Terrence Williams, when they came to me, right? I didn’t know how to do it. I just knew, alright, cool, we got this money. So, let me get my financial advisor and my business manager and see what I can do to get my money back. They all came to me. I didn’t know. So, I was like, hey, financial advisor, can you help me? Edgar Abrams. “He’s like, “Yeah, I can do this.” He said, “Review it, sign it, send it back.” So now, I’m a part of the plan. Whatever these guys — Terrence Williams — did to convince my guy to do it. Now, I’m in it. I never got any money from the initial, right? They kept investigating me.” Williams was sentenced to 10 years in prison in 2023. He’s scheduled for release in 2030. Anderson received a 24-month prison sentence. “When we go to court, my financial advisor testifies against me, and this doctor, who’s been recruiting me from the Big 3, he basically pleads the fifth; doesn’t show up to court. We can’t ask him no questions,” Davis added. “And I go to jail for $40,000.” Davis played one season in the Big 3, winning a championship with Power in 2018. He’s also made cameos in TV shows like Showtime’s “Shameless” and Starz’s “Power Book IV: Force.” Davis says he hopes to continue his acting career. **Topics:** Healthcare Fraud **Categories:** Conviction --- ### [Life insurance fraud scheme lands former Schererville insurance agent in federal prison](https://insurancefraud.org/news_archives/life-insurance-fraud-scheme-lands-former-schererville-insurance-agent-in-federal-prison/) **Published:** September 7, 2026 **Author:** Diane Beauchamp **Content:** A fraudulent life insurance scheme that netted a former Northwest Indiana insurance agent over $5 million has also earned him 70 months in federal prison. Thomas Lemmen, 51, of Schererville, pleaded guilty to wire fraud in the U.S. District Court for the Northern District of Indiana in November 2025 and was sentenced to 70 months in federal prison on Tuesday. Once released, he will have two years of supervised release and will be required to pay $1.6 million in restitution to the victims of the offense. Prosecutors said that, between 2020 and 2022, Lemmen operated a “Ponzi-style fraud scheme” where he wrote more than 2,000 fraudulent life insurance policies “in the names of current, former and prospective clients without their knowledge or consent.” During the course of his scheme, Lemmen also used sensitive information such as Social Security numbers, family history details, and more, according to the U.S. Attorney’s Office in Hammond. He forged signatures on documents and improperly forged digital signatures, causing disclosure of the medical records and pharmaceutical information of unsuspecting individuals, according to a release. These 2,000 life insurance policies led Lemmen to $5 million in commissions, and he used some of that money “to fund the continued operation of the scheme and for his own personal spending.” These personal items included the installation of an outdoor pool, frequent travel and “significant” spending on home furnishings and renovations. The Indiana Department of Insurance stopped the renewal of Lemmen’s license in April 2023. He was first charged in federal court in October 2024. U.S. Attorney Adam Mildred announced the results of the sentencing and said, “The public can see that those who choose to commit fraud will be held accountable.” FBI Indianapolis Special Agent in Charge Timothy O’Malley said the FBI is following the money in these “complicated fraud schemes” and seeking to hold people like Lemmen accountable. “Lemmen took advantage of his position and ripped off a lot of people — including seniors — just to line his own pockets,” O’Malley said. “He took information people trusted him with and used it against them. These people thought they were protecting their families, and instead, he made them victims.” **Topics:** Insider - agent, Life Insurance **Categories:** Conviction --- ### [Ocean County Nurse Admits to Assaulting and Neglecting Elderly Nursing Home Resident](https://insurancefraud.org/news_archives/ocean-county-nurse-admits-to-assaulting-and-neglecting-elderly-nursing-home-resident/) **Published:** September 7, 2026 **Author:** Diane Beauchamp **Content:** Attorney General Jennifer Davenport and the Office of the Insurance Fraud Prosecutor (OIFP) announced that a nurse admitted to assaulting and neglecting an elderly resident at a rehabilitation center in Ocean County, New Jersey. Lisa L. Erikson, 57, of Manchester, New Jersey, pleaded guilty before Superior Court Judge Kimarie Rahill in Ocean County to second-degree aggravated assault, third-degree possession of a weapon for an unlawful purpose, and third-degree neglect of an elderly adult. As part of the plea, she will permanently forfeit her nursing license, and the state will recommend 364 days in county jail as a condition of probation. Sentencing is scheduled for November 13, 2026. “The conduct at issue in this case is deeply disturbing,” said Attorney General Davenport. “This defendant was entrusted with the care of an elderly resident and instead assaulted and neglected him. Such conduct is wholly unacceptable, and those who abuse or neglect elderly residents in their care must be held accountable.” “Nursing professionals are entrusted with the care of their residents, and our office remains committed to protecting those residents from abuse and neglect,” said Acting Insurance Fraud Prosecutor Bernard J. Cooney. According to documents filed in this case and statements made in court, on March 19, 2025, Erikson, a licensed practical nurse working at a rehabilitation and nursing center in Whiting, New Jersey, assaulted an elderly man with dementia, depression, and anxiety. Erikson retrieved her personal oleoresin capsicum spray ― commonly known as pepper spray ― walked toward the victim and sprayed him at close range as he attempted to shield himself. She then sprayed him again before leaving him on the floor. He remained unattended for several minutes before he crawled to stand up and entered another resident’s room. Erikson and another person then forcibly removed the victim from the other resident’s room, placed him inside his own room, and shut the door, where they left him without providing any aid. Police and emergency medical services later responded to the center, treated the victim, and transported him to a hospital. As part of her plea, Erikson admitted using the oleoresin capsicum spray for an unlawful purpose and spraying the resident several times when she was not authorized to do so. She also admitted leaving the resident without care despite having a duty to provide care to him. This case is being prosecuted by OIFP – Medicaid Fraud Control Unit (MFCU) Deputy Attorney General Camille McKnight. The investigation was conducted by Detective Yvette Vasquez. New Jersey MFCU’s total funding for federal fiscal year (FY) 2026 is $11.6 million. Of that total, 75 percent is awarded under a grant from the U.S. Department of Health and Human Services. The remaining 25 percent is funded by the State of New Jersey. **Topics:** Elderly Fraud **Categories:** Conviction --- ### [Attorney General Brown Announces Sentencing of Former Home Health Care Employee for Medicaid Fraud](https://insurancefraud.org/news_archives/attorney-general-brown-announces-sentencing-of-former-home-health-care-employee-for-medicaid-fraud/) **Published:** September 7, 2026 **Author:** Diane Beauchamp **Content:** Attorney General Anthony G. Brown announced the conviction and sentencing of former HomeCentris employee, Falguni Patel, aged 60, of Howard County, for submitting over $25,000 worth of false claims relating to home healthcare services. Patel falsely claimed to be providing home healthcare services while she worked in person at another job or was out of the country. HomeCentris Healthcare, LLC, previously known as Personal Health Care, Inc., relied on Patel’s statements when submitting claims to Maryland Medicaid. “Every fraudulent Medicaid claim drains resources from Marylanders who rely on home healthcare to live safely and with dignity,” said Attorney General Brown. “My Office will continue rooting out fraud that exploits this vital program and the people who depend on it.” On August 3, 2026, Patel pleaded guilty to felony public health fraud before the Honorable Garret P. Glennon, Jr. of the Circuit Court for Baltimore County. Judge Glennon sentenced Patel to five years, suspending all but time served, with three years of supervised probation, and to pay restitution of $25,310.51. This case is part of an ongoing investigation, in partnership with the U.S. Department of Health and Human Services (HHS), the Federal Bureau of Investigation (FBI), the Maryland State Police, and the Maryland Department of Health into fraudulent claims in home healthcare. Attorney General Brown would like to thank the Medicaid Fraud and Vulnerable Victims Unit, particularly Unit Director Zak Shirley, Assistant Attorney General Kurt Davidson, Senior Investigator Carl Stambaugh, Deputy Chief of Investigations Paul Kidd, and Investigative Auditor Yelena Slutskaya for their work on this case, as well as our investigative partners. **Topics:** Medicare/Medicaid **Categories:** Conviction --- ### [Florida Men Sentenced to Prison for $34.8M Health Care Fraud Scheme Targeting Medicare Beneficiaries](https://insurancefraud.org/news_archives/florida-men-sentenced-to-prison-for-34-8m-health-care-fraud-scheme-targeting-medicare-beneficiaries/) **Published:** September 7, 2026 **Author:** Diane Beauchamp **Content:** Two Florida men were sentenced to multiple years in prison for their roles in a $34.8 million health care fraud conspiracy billing Medicare for thousands of orthotic braces sent to Medicare beneficiaries who did not need them. “These fraudsters billed Medicare $34.8 million for braces that patients didn’t need and didn’t request — and now they’re paying the price,” said Assistant Attorney General Colin M. McDonald of the Justice Department’s National Fraud Enforcement Division. “They paid kickbacks for fake doctors’ orders, shuffled billing among several companies to dodge payment suspensions, and pocketed millions that belonged to American taxpayers. Their prison sentences make clear: if you steal from Medicare, you will be caught, you will be prosecuted, and you will be held accountable.” “Medicare is not a blank check for fraudsters,” said U.S. Attorney Jason A. Reding Quiñones for the Southern District of Florida. “These defendants built a $34.8 million scheme around medically unnecessary braces, fraudulent doctors’ orders, and illegal kickbacks, all to enrich themselves at the expense of American taxpayers. Today’s sentences reinforce a simple message: if you steal from our health care programs, we will find you, prosecute you, and hold you accountable.” According to court documents, Kenneth Charles Kessler III, 43, of Miami, Florida, and Michael Andrew Gomez, 43, of Miramar, Florida, owned and operated seven durable medical equipment (DME) supply companies based in Florida. Through these DME companies, they submitted millions of dollars in false claims to Medicare for medically unnecessary orthotic braces. Kessler and Gomez also paid illegal kickbacks and bribes to obtain fraudulent signed doctors’ orders. They used these orders to ship orthotic braces to Medicare beneficiaries nationwide, including to beneficiaries who neither requested nor needed the braces, and then claimed payment for those braces from Medicare. Kessler and Gomez used their multiple DME companies to evade Medicare payment suspensions by shifting their fraudulent billing between their DME companies. Kessler profited more than $1.4 million, and Gomez profited more than $2.3 million from the fraudulent scheme. Kessler was sentenced to 33 months of in prison, and Gomez was sentenced to 24 months of in prison. In May 2026, Kessler and Gomez each pleaded guilty to one count of conspiracy to commit health care fraud. Assistant Attorney General Colin M. McDonald of the Justice Department’s National Fraud Enforcement Division; U.S. Attorney Jason A. Reding Quiñones for the Southern District of Florida; Special Agent in Charge Brett Skiles of the FBI Miami Field Office; and Acting Deputy Inspector General for Investigations Miranda Bennett of the U.S. Department of Health and Human Services, Office of Inspector General (HHS-OIG) made the announcement. FBI and HHS-OIG investigated the case. Trial Attorneys Aisha Schafer Hylton and Owen Dunn of the National Fraud Enforcement Division’s Health Care Fraud Section prosecuted the case. On April 7, the Department of Justice announced the creation of the National Fraud Enforcement Division (Fraud Division). The Fraud Division is laser-focused on investigating and prosecuting those who commit fraud against the American people. The Department’s work to combat fraud supports President Trump’s Task Force to Eliminate Fraud, a whole-of-government effort chaired by Vice President J.D. Vance to eliminate fraud, waste, and abuse within Federal benefit programs. The Department of Justice’s Health Care Fraud Strike Force Program, currently comprised of nine strike forces operating in federal districts across the country, has charged more than 6,200 defendants who collectively billed federal health care programs and private insurers more than $45 billion since 2007. In addition, the Centers for Medicare & Medicaid Services, working in conjunction with the Office of the Inspector General for the Department of Health and Human Services, are taking steps to hold providers accountable for their involvement in health care fraud schemes. More information can be found at [www.justice.gov/criminal-fraud/health-care-fraud-unit](http://www.justice.gov/criminal-fraud/health-care-fraud-unit). **Topics:** Medicare/Medicaid **Categories:** Conviction --- ### [Fraudsters who stage crashes would face up to 10 years in prison under new bill](https://insurancefraud.org/news_archives/fraudsters-who-stage-crashes-would-face-up-to-10-years-in-prison-under-new-bill/) **Published:** September 7, 2026 **Author:** Diane Beauchamp **Content:** A bipartisan House bill introduced today would increase penalties for staging automobile crashes to collect a payout. On September 3, U.S. Reps Laura Gillen, osh Gottheimer, and Vince Fong introduced the [Stop Auto Fraud Act of 2026](https://gillen.house.gov/sites/evo-subsites/gillen.house.gov/files/evo-media-document/gillen_087_xml.pdf). If passed, the bill would make it a federal crime to stage a motor vehicle crash for the purposes of making fraudulent insurance claims, with increased penalties for fraudsters. Under the bill, a person who stages a non-injury crash could be imprisoned for up to 10 years. If the staged crash results in an injury, a prison sentence of 20 years could be imposed. If a person stages a crash that results in death, they could face a maximum prison sentence of life in prison. Lawmakers say that increasing penalties for staged crashes will improve highway safety and lower insurance rates nationwide. “Long Islanders pay some of the highest car insurance rates in the country and ‘crash for cash’ schemes on our roads are driving rates even higher,” said Rep. Gillen. “When fraudsters stage car wrecks to scam their way to huge payouts, they’re putting lives at risk and forcing responsible drivers to bear the costs. I’m proud to lead this bipartisan bill to hold these criminals accountable, make our roads safer and lower sky-high car insurance costs.” The bill is endorsed by groups including the National Insurance Crime Bureau, American Trucking Associations, American Bus Association, Truck Renting and Leasing Association, American Property Casualty Insurance Association, National Association of Mutual Insurance Companies, National Tank Truck Carriers Association, Truckload Carriers Association, Trucking Association of New York, Texas Trucking Association and Southwest Movers Association. “On highways across the country, brazen criminals are intentionally colliding with other motorists in an attempt to score a big payday, and commercial trucks are a top target. Their selfish actions put the lives of innocent Americans at risk and contribute to soaring insurance premiums that raise costs for all consumers,” said Alex Rosen, SVP of Legislative Affairs, American Trucking Associations. “We need stronger penalties to deter those who perpetrate these schemes, which is why ATA strongly supports the Stop Auto Fraud Act. The trucking industry commends Reps. Laura Gillen and Troy Nehls for their leadership to make our roads safer and alleviate the financial burden imposed on families and businesses.” “The Stop Auto Fraud Act of 2026 represents an important step toward protecting motorists, reducing insurance fraud, and improving roadway safety. The Truckload Carriers Association (TCA) strongly supports legislation that would make the submission of a fraudulent insurance claim arising from a staged motor vehicle accident a criminal offense. Staged crashes are not victimless crimes. These deliberate schemes place innocent drivers, passengers, first responders, and other road users at risk of serious injury or death. We commend Representatives Gillen and Nehls for recognizing the growing threat posed by staged vehicle accidents and for advancing a practical, bipartisan solution,” said Jim Mullen, President, Truckload Carriers Association. “The National Tank Truck Carriers is proud to support the Stop Auto Fraud Act. Tank truck carriers operate in a uniquely high-risk environment, transporting valuable and often hazardous cargoes that make reliable insurance coverage essential to protecting their employees, equipment, customers, and the motoring public. Fraudulent insurance claims undermine the integrity of that system and drive up costs on carriers already managing significant operational risks. NTTC is grateful for the leadership of Representatives Gill and Nehls in combating insurance fraud and protecting responsible motor carriers,” said Ryan Streblow, President & CEO, National Tank Truck Carriers. A similar bill called the *[Staged Accident Fraud Prevention Act](https://www.moody.senate.gov/press-releases/senator-moody-introduces-staged-accident-fraud-prevention-act-to-protect-all-drivers-on-our-roads-and-prevent-con-artists-from-driving-up-the-cost-of-insurance/)* introduced in July would make it a federal crime to stage a crash with a commercial vehicle. **Topics:** Auto - staged, Legislation, Public Awareness --- ### [Jury Convicts Sean Alfortish for Role in Staged Collision Scheme](https://insurancefraud.org/news_archives/jury-convicts-sean-alfortish-for-role-in-staged-collision-scheme/) **Published:** September 7, 2026 **Author:** Diane Beauchamp **Content:** Today, U.S. Attorney David I. Courcelle announced that a jury returned a verdict of guilty for Sean Alfortish (“Alfortish”), convicting him of his role in a years-long scheme to defraud trucking and insurance companies. Specifically, Sean Alfortish was found guilty of conspiracy to commit mail and wire fraud, two counts of mail fraud, obstruction of justice, and witness tampering. The jury did not reach a verdict on charges against Alfortish and codefendant Leon Parker (“Parker”) relating to the murder of Cornelius Garrison, III (“Garrison”), a cooperating witness for the FBI. Chief U.S. District Judge Wendy B. Vitter declared a mistrial on those counts. Alfortish was also convicted on one count of obstruction of justice and one count of witness tampering relating to Garrison. Specifically, Alfortish was convicted of offering to move Garrison out of the country and offering him $500,000 to take the fall for the staged wrecks scheme. Alfortish was found not guilty on two counts alleging that he had paid an inmate in St. Charles Parish Jail to lie under oath. In total, Alfortish faces a total statutory sentence of 90 years. Parker previously pleaded guilty to conspiracy and two counts of mail fraud. He faces a total statutory sentence of 60 years. “Today’s verdict is an important step towards justice for the victims of this scheme,” said U.S. Attorney David I. Courcelle. “Alfortish and Parker exploited the courts to benefit themselves and their confederates. The jury’s verdict demonstrates the dedication of the Department of Justice to preserving the integrity of our justice system.” “The FBI and U.S. Attorney’s Office worked hundreds of hours to make sure justice would be done for Mr. Garrison and his family, and for the people of Louisiana,” said Special Agent in Charge Jonathan Tapp of the FBI New Orleans Field Office. “We will continue our work to expose criminal wrongdoing, undeterred.” This verdict was the result of countless hours of hard work by the investigators, support teams, and prosecutors assigned to this case. The dedication to duty and cooperation between the U.S. Attorney’s Office, the Department of Justice Criminal Division, and FBI New Orleans, paved the way for today’s successful outcome. U.S. Attorney Courcelle, and the Money Laundering, Narcotics and Forfeiture Section of the Criminal Division, U.S. Department of Justice, would like to acknowledge the tremendous work of the Federal Bureau of Investigation, the New Orleans Police Department, and the Louisiana State Police with this matter, and extend their thanks for the assistance of the United States Marshals Service, the St. Tammany Parish Sheriff’s Office, the Jefferson Parish Sheriff’s Office, the St. Charles Parish Sheriff’s Office, and the Metropolitan Crime Commission. The prosecution of this case is being handled by Assistant U.S. Attorney Matthew R. Payne, Senior Litigation Counsel; Assistant U.S. Attorney Brian M. Klebba, Deputy Chief of the Criminal Division and Chief of the Financial Crimes Unit; Assistant U.S. Attorney Mary Katherine Kaufman; and U.S. Department of Justice Trial Attorneys J. Ryan McLaren and Samir Paul, of the Money Laundering, Narcotics and Forfeiture Section. **Topics:** Auto - staged **Categories:** Conviction --- ### [Research Finds Verification Gap as Insurers Accelerate AI Adoption](https://insurancefraud.org/news_archives/research-finds-verification-gap-as-insurers-accelerate-ai-adoption/) **Published:** September 7, 2026 **Author:** Diane Beauchamp **Content:** Researchers said insurers face the challenge of determining which interactions require faster processing, greater scrutiny, or human judgment. New research examining insurers’ use of artificial intelligence found a gap between the industry’s AI adoption and its ability to verify the information used in increasingly automated claims and underwriting processes. The report, [*The Speed of Trust: Building the Trust Intelligence Layer for Insurance in the Age of Agentic AI*](https://www.prnewswire.com/news-releases/new-research-examines-insurances-verification-gap-amid-rapid-ai-adoption-302868370.html), was commissioned by Clearspeed and independently authored by insurance innovation strategist Sabine VanderLinden, CEO of Alchemy Crew Ventures. Researchers reviewed 76 public filings from 49 insurers and reinsurers, 31 industry studies, and 16 interviews with claims and underwriting leaders at insurance companies in the U.S. and U.K. ## Filings Rarely Address Manipulated Evidence The research found insurers are automating decisions, handoffs, evidence reviews, and customer interactions as AI makes it easier to create manipulated photos, documents, voices, and identities. Researchers searched annual reports, 10-K filings, proxy statements, and statutory returns for terms related to AI-generated and manipulated evidence, media, and imagery. None of the 76 filings mentioned synthetic media, synthetic identity, or voice cloning. Six of the 49 companies mentioned deepfakes, but only in the context of cybersecurity, not evidence used in claims or underwriting decisions. Researchers also analyzed five of the world’s top 10 reinsurers. None mentioned deepfakes, synthetic media, or AI-generated evidence in their most recent annual reporting. Separately, industry research published in March 2026 found that 98% of 300 U.S. insurance claims professionals surveyed agreed that AI editing tools are contributing to increased digital media fraud. However, only 32% said they were very confident they could identify a deepfake. ## Fraud and Customer Trust According to the Coalition Against Insurance Fraud, fraud accounts for about 10% of property and casualty losses, while the trust deficit costs the U.S. insurance system at least $308.6 billion annually. The report examines how verification processes also affect legitimate claimants. Researchers said insurers face the challenge of determining which interactions require faster processing, greater scrutiny, or human judgment. Ian Thompson, former group chief claims officer at Zurich Insurance, told researchers that more than 90% of customers who file claims are honest. However, efforts to identify the remaining fraudulent claims can leave legitimate customers feeling distrusted. ## Report Proposes Trust Intelligence Layer VanderLinden argues that insurers should make trust a measurable infrastructure layer throughout the policyholder journey. The report describes a Trust Intelligence Layer as a continuous, regulator-ready risk indicator designed to help insurers clear legitimate interactions quickly while directing human judgment toward exceptions. The indicator would inform decisions rather than make them, produce an audit trail instead of an automated denial, and operate without requiring demographic or historical knowledge about the person being assessed. The report also examines a future in which more insurance interactions occur between customers’ AI agents and insurers’ AI agents. It argues that insurers will still need auditable methods to verify the human-provided information behind those automated transactions before systems act on it. **Topics:** Coalition Against Insurance Fraud, Public Awareness, Technology --- ### [Ex-superintendent, business partner for Dohn Community HS indicted in $8M fraud scheme](https://insurancefraud.org/news_archives/ex-superintendent-business-partner-for-dohn-community-hs-indicted-in-8m-fraud-scheme/) **Published:** September 7, 2026 **Author:** Diane Beauchamp **Content:** The former superintendent for the now-closed Dohn Community High School, as well as a business partner for the school, are facing charges in a multimillion dollar fraud and kickback scheme. “Ultimately led to the demise of Dohn,” U.S. Attorney Dominick S. Gerace II said. A federal indictment alleges former superintendent Leando Ramone Davenport and a contractor/vendor for the school Jonathan Larry Ballew, took part in a multi-year fraud and kickback scheme targeting the school. Prosecutors say Davenport ran Dohn while Ballew controlled several companies that did business with the school. Both are charged with four counts of wire fraud/honest-services fraud and multiple counts of engaging in monetary transactions in criminally derived property. Wire fraud carries a maximum prison term of 20 years, money laundering carries a maximum prison term of 10 years. Davenport was arrested in Hamilton County and Ballew in the Phoenix area. The indictment alleges that from 2021 to 2024, Ballew’s companies submitted false or inflated invoices to Dohn for work never performed, or was performed at a fraction of the cost by third parties. It also alleges Davenport concealed his relationship with Ballew from Dohn and used his role of authority to approve payments and then got a cut of the proceeds through his controlled entities. Overall, the indictment alleges Davenport authorized over around $8 million in payments to Ballew’s companies, with Ballew kicking-back $4 million to Davenport. In one instance, it’s alleged Ballew collected over $1 million for a construction project on Gilbert Avenue that was never performed, Davenport got $350,000 from the project. The indictment alleges the proceeds were spent on luxury vacation rentals in Florida, luxury vehicles like a Bentley and Rolls-Royce. According to federal officials, Davenport and Ballew both signed a two-year rental agreement for a luxury vacation property near Miami for $30,000 per month. “While the mission of Dohn was to serve educationally at risk students in an orderly and safe manner, our federal indictment alleges these two defendants used the school as their own personal piggy banks to steal money from Ohio and American taxpayers,” Gerace said. Dohn closed at the end of the 2024-25 school year. Created as an addiction recovery program for high school students, the school had been around since 2001. At the time of the announced closure, Dohn enrolled about 650 students. According to the indictment, Dohn allegedly materially overstated the number of students enrolled at Dohn while Cincinnati Charter School Collaborative was operator. Ohio Auditor of State Keith Faber said a tip came into his office in late-2024 around when Davenport’s position as superintendent ended. When the school closed, Faber confirmed there was an open investigation that involved Dohn. **Topics:** Contractor fraud **Categories:** Arrest --- ### [Former Lawrence Co. Deputy federally indicted in insurance scheme](https://insurancefraud.org/news_archives/former-lawrence-co-deputy-federally-indicted-in-insurance-scheme/) **Published:** September 7, 2026 **Author:** Diane Beauchamp **Content:** Federal prosecutors have indicted a former Lawrence County deputy and his wife on charges accusing them of using stolen personal information to file fraudulent life insurance policies. The indictment charges Brandon Hood and Heather Lynn Hood, also known as Heather Bolan, with conspiracy to commit wire fraud, wire fraud, and aggravated identity theft. Hood is the former Leighton police chief. Investigators say Brandon Hood, while working for the Lawrence County Sheriff’s Office, illegally accessed law enforcement databases to obtain dates of birth and Social Security numbers for family members, friends, co-workers and their spouses. Prosecutors allege the couple used the stolen information to electronically file fake life insurance applications, paid the first month’s premium from their own bank accounts, and collected commissions as high as 80% of the first nine months of payments. According to the indictment, the couple submitted policies with a combined face value of more than $24 million. Most victims did not learn about the policies until they received cancellation notices for coverage they never knew existed, the indictment says. The case dates back to September 2023, when the State Bureau of Investigation notified the Lawrence County Sheriff’s Office about an ongoing investigation into then-Deputy Hood involving identity theft and insurance fraud. Hood submitted his resignation immediately after leaving an interrogation room, according to the report. The Sheriff’s Office released a statement saying, in part, “This breach of integrity is deeply disturbing to all of us who wear the badge. Any employee who breaks the law and breaks the trust of this office will be held fully accountable.” He will be in court on September 18. **Topics:** Insider - agent, Life Insurance **Categories:** Arrest --- ### [Bowie Insurance Agent Used Hispanic Names In Scam Because He Thought They Were Undocumented: AG](https://insurancefraud.org/news_archives/bowie-insurance-agent-used-hispanic-names-in-scam-because-he-thought-they-were-undocumented-ag/) **Published:** September 7, 2026 **Author:** Diane Beauchamp **Topics:** Insider - agent, Life Insurance **Categories:** Conviction --- ### [ATA Backs Bipartisan Bill to Crack Down on Staged Accidents](https://insurancefraud.org/news_archives/ata-backs-bipartisan-bill-to-crack-down-on-staged-accidents/) **Published:** September 7, 2026 **Author:** Diane Beauchamp **Content:** Today, ATA welcomed the introduction of the Stop Auto Fraud Act of 2026, bipartisan legislation to make motor vehicle collision fraud a federal crime, improve safety for drivers, and lower insurance rates nationwide. The legislation—which was introduced by U.S. Representatives Laura Gillen (D-NY), Troy Nehls (R-TX), Josh Gottheimer (D-NJ), and Vince Fong (R-CA)—targets insurance fraud schemes in which bad actors deliberately cause, stage, or fabricate motor vehicle accidents to file false claims to obtain large cash payouts. “On highways across the country, brazen criminals are intentionally colliding with other motorists in an attempt to score a big payday, and commercial trucks are a top target. Their selfish actions put the lives of innocent Americans at risk and contribute to soaring insurance premiums that raise costs for all consumers,” said Alex Rosen, SVP of Legislative Affairs, American Trucking Associations. “We need stronger penalties to deter those who perpetrate these schemes, which is why ATA strongly supports the Stop Auto Fraud Act. The trucking industry commends Reps. Gillen, Nehls, Gottheimer, and Fong for their leadership to make our roads safer and alleviate the financial burden imposed on families and businesses.” “The Trucking Association of New York (TANY) thanks Congresswoman Gillen for taking a strong stand against those who put others at risk using staged accidents for their own financial gain,” said Kendra Hems, President, Trucking Association of New York (TANY). “These are serious crimes and should be treated as such. The Stop Auto Fraud Act does just that and is an important step to reign in fraud and abuse of the insurance system. For the trucking industry, fraudulent and staged claims contribute directly to unsustainable increases in commercial auto insurance costs, putting additional pressure on carriers that are working hard to operate safely and keep our economy moving. We appreciate Congresswoman Gillen’s leadership and look forward to continuing to work with her on the issue.” Numerous schemes in recent years have targeted trucking companies, and these sophisticated fraudsters often have ties to organized crime. One such criminal ring exposed in Louisiana was the subject of a recent documentary. The saga began when a con artist deliberately crashed into a truck belonging to a third-generation, family-owned trucking business. Eventually, federal investigators unraveled a vast conspiracy involving dozens of “slammers,” “spotters,” and corrupt lawyers who orchestrated numerous operations that targeted multiple companies. In an attempted coverup, a federal witness was killed. The Stop Auto Fraud Act would make it a federal crime to knowingly stage or fabricate a motor vehicle crash with any vehicle and submit a fraudulent claim. The bill would impose penalties, including possible jail time, for violations. Any collected fines would be paid into the Highway Trust Fund. ATA is also backing similar legislation—the Staged Accident Fraud Prevention Act—that was introduced by Representatives Mike Collins (R-GA) and Brandon Gill (R-TX) and Senator Ashley Moody (R-FL). This bill would make it a federal crime to engineer a crash specifically with a commercial motor vehicle. **Topics:** Auto - staged, Legislation, Public Awareness --- ### [SLED: Greenville woman charged after claiming false water damage for insurance claims](https://insurancefraud.org/news_archives/sled-greenville-woman-charged-after-claiming-false-water-damage-for-insurance-claims/) **Published:** September 7, 2026 **Author:** Diane Beauchamp **Content:** The South Carolina Law Enforcement Division has charged an Upstate woman with insurance fraud and forgery after investigators say she submitted multiple false insurance claims totaling in the thousands. SLED reported on Thursday that 25-year-old Kelsey Michelle Moore falsely claimed her water heater failed, causing damage to her clothes, shoes, and other personal items. According to warrants then submitted an insurance claim to USAA Casualty Insurance Company and a forged dry-cleaning receipt from Uptown Dry Cleaning for $2,231.40. During an investigation, the property manager confirmed no water heater failure had occurred, and the dry-cleaning company did not exist. Through the false claims, authorities say Moore was given $4,916.58 from USAA. Moore was charged with presenting a false claim for insurance – value more than $2,000 but less than $10,000 and three counts of forgery – value less than $10,000. Moore was booked into the Greenville County Detention Center following her arrest. The South Carolina Department of Insurance requested the SLED investigation. The case will be prosecuted by the South Carolina Department of Insurance. **Topics:** Renter's Insurance **Categories:** Arrest --- ### [KY wound care provider to pay $2.6M settlement in ‘skin scam’ investigation](https://insurancefraud.org/news_archives/ky-wound-care-provider-to-pay-2-6m-settlement-in-skin-scam-investigation/) **Published:** September 7, 2026 **Author:** Diane Beauchamp **Content:** A Kentucky wound care specialist will pay more than $2.6 million to resolve allegations it overbilled federal health insurance programs for costly skin substitute products. Louisville-based Heuser Health has agreed to the settlement, which is part of the broader investigative program known as “Operation Skin Scam,” aimed at uncovering fraud schemes that involve expensive skin substitute materials used in wound treatment, according to a news release from the U.S. District Court. Skin substitutes are bioengineered or tissue-derived materials used to replace, imitate or regenerate damaged skin. According to the court’s release, Heuser Health used the products to treat Medicare and TRICARE beneficiaries with chronic and acute wounds. Federal rules required Heuser Health to bill its products based on invoice price. However, the U.S. alleged Heuser Health submitted claims using invoice amounts higher than the company’s true purchase prices, which led to inflated reimbursements paid by Medicare and TRICARE, the health benefits program for active-duty military service members. In a statement to the Herald-Leader, Heuser Health Chief Operating Officer Chip Heuser said the business “did nothing wrong and settled a potential case stemming from the billing practices of its wound care suppliers. The settlement agreement acknowledges no admission of liability, and we remain fully committed to providing care to those in need.” Medicare covers skin substitutes that are reasonable and necessary, which is often determined on a case-by-case basis. Insurance pays for skin substitutes based on the number of service units billed ranging from approximately $100 to more than $1,000 per square centimeter, according to the U.S. Department of Health and Human Services and Office of Inspector General. “Healthcare providers must bill federal healthcare programs accurately and transparently,” said U.S. Attorney Kyle G. Bumgarner for the Western District of Kentucky. “When providers seek reimbursement beyond what they are entitled to receive, it undermines the integrity of Medicare and TRICARE and misuses taxpayer funds. This settlement — part of our wide ‘Skin Scam’ effort — reflects our commitment to enforcing federal billing rules and protecting these essential programs from abuse.” The “Operation Skin Scam” is part of the Trump administration’s attempt to crack down on potentially fraudulent Medicare and Medicaid claims. A task force and the U.S. Department of Justice said in July that in the past six years, there had been a 7,100% spike in Medicare claims for skin substitutes. **Topics:** Judicial/courts, Public Awareness --- ### [N.C. Insurance Dept.: Cabarrus County Woman Faces Insurance Fraud Charges](https://insurancefraud.org/news_archives/n-c-insurance-dept-cabarrus-county-woman-faces-insurance-fraud-charges/) **Published:** September 7, 2026 **Author:** Diane Beauchamp **Content:** The North Carolina Department of Insurance issued the following news release on Sept. 2, 2026: --- Cabarrus County woman faces insurance fraud charges North Carolina Insurance Commissioner Mike Causey today announced the arrest of Daffney Davis, 48, of 6126 Fernwood Drive, Concord. Davis was charged with two counts of insurance fraud, and one count of accessing computers to commit fraud, all felonies. Special agents from the Department of Insurance Criminal Investigations Division accuse Davis, while employed as an adjuster by Ahold Delhaize Services, of accessing the computer system without authorization and making false statements regarding two claims she was entrusted to handle for the company’s insurer, Chubb-Ace American Insurance Co. According to arrest warrants, Davis altered the claims to disperse checks to both Nicole Davis and PatLou Inc., neither of which were entitled to any payout regarding these insurance claims. The checks totaled more than $44,000. The offenses occurred between Sept. 25, 2024, and Jan. 24, 2025. Davis turned herself in on Aug. 26. and was released under a $5,500 secured bond. Her next scheduled court appearance is Nov. 18 in Rowan County District Court. Commissioner Causey encourages North Carolinians to help keep insurance premiums low by reporting suspicious fraud. “Insurance fraud is not a victimless crime,” Commissioner Causey said. “It hits all of us in the pocket through higher premiums.” **Topics:** Insider - agent **Categories:** Arrest --- ### [Fraud alert: Workers’ compensation claimants targeted](https://insurancefraud.org/news_archives/fraud-alert-workers-compensation-claimants-targeted/) **Published:** September 7, 2026 **Author:** Diane Beauchamp **Content:** The Department of Inspections, Appeals, and Licensing (DIAL) is warning the public about an active scheme targeting individuals receiving or seeking workers’ compensation benefits. Scammers have impersonated State regulatory authorities, conducting bogus hearings and using official-looking correspondence to try to deceive injured workers into paying fictitious upfront fees. In a recent reported incident, an injured worker was contacted via a fraudulent letter on counterfeit letterhead designed to mimic the Workers’ Compensation Division of DIAL. The worker contacted the scammers who scheduled and conducted a “hearing” with the worker. After the hearing took place, the scammers notified the worker that he had prevailed and was entitled to more than $180,000 in benefits. The scammers issued a “decision” on what appeared to be DIAL letterhead. However, the “decision” required the worker to pay $6,000 in upfront fees before release of the awarded funds. Fortunately, the worker contacted DIAL to confirm the legitimacy of the award and upfront payment. DIAL was able to let the worker know that this was a very elaborate scam and advised him not to send any money. ### Key Warning Signs of the Scam Demands for Upfront Payment. Legitimate State agencies and administrative law courts never require cash payments, wire transfers, or upfront fees to release a workers’ compensation award or settlement. Forged Letterhead. Fraudsters frequently copy state agency logos and letterhead to appear authentic. Always verify the source directly using officially published contact numbers. Pressure Tactics. Scammers often create a false sense of urgency, claiming that funds will be forfeited if the requested fee is not paid immediately. ### What to Do If You Receive Suspected Fraudulent Communications Do NOT Send Money. Never transfer funds, wire money, or provide gift card codes to secure a settlement or legal award. Verify Directly. Contact DIAL or your workers’ compensation attorney directly using verified contact details found on official State websites, not the numbers or email addresses printed on the suspicious document. Report the Incident. File a complaint with local law enforcement and report the fraudulent communication to the Iowa Attorney General’s Consumer Protection Division at 1.888.777.4590 or online at [www.iowaattorneygeneral.gov](http://www.iowaattorneygeneral.gov/). If you or someone you know has been targeted by a similar scam, retain all letters, emails, and phone numbers involved to assist authorities with their investigation. The Iowa Department of Inspections, Appeals, and Licensing is committed to protecting the health and safety of Iowans through regulation and oversight of health care, food, gaming, building and construction, and labor practices; professional licensure; application of administrative law; and investigation of Medicaid and welfare fraud. **Topics:** Public Awareness, Workers Comp --- ### [GEICO alleges $1.2 million No-Fault DME fraud scheme in RICO suit](https://insurancefraud.org/news_archives/geico-alleges-1-2-million-no-fault-dme-fraud-scheme-in-rico-suit/) **Published:** September 7, 2026 **Author:** Diane Beauchamp **Content:** [GEICO](https://www.insurancebusinessmag.com/us/companies/geico/116487/) says two medical-equipment suppliers billed it more than $1.2 million in fraudulent No-Fault claims for equipment patients never needed. The auto insurer filed a federal complaint on September 1, 2026, in the US District Court for the Eastern District of New York. It targets two durable medical equipment (DME) companies and the three men who allegedly own and run them. The complaint brings 12 claims, six of them under the Racketeer Influenced and Corrupt Organizations Act, better known as RICO. According to the complaint, the two companies were not the independent businesses they appeared to be. GEICO alleges they were two arms of a single scheme, set up to bill GEICO and other New York auto insurers for equipment that was either never needed, never properly supplied, or both. The filing says the scheme has run since 2019. GEICO alleges it has already paid out more than $451,000 on fraudulent claims and is staring at another $588,000 in pending bills it says it should not have to pay. All told, the two companies billed GEICO more than $1.2 million, according to the filing. The complaint lays out how it says the scheme worked. The DME companies, it alleges, got their prescriptions through “collusive arrangements” with unnamed operators of six clinics across the New York metropolitan area – people the filing calls “Clinic Controllers” – and with healthcare providers working out of those clinics. The clinics named in the complaint include locations in Middletown, Corona, Brooklyn, Yonkers, and Queens Village. Rather than hand the prescriptions to patients, the filing says, the clinics routed them straight to the DME companies. GEICO alleges this cut patients out of the decision and kept the orders flowing – orders a legitimate retailer would likely have questioned. The complaint alleges that “kickbacks and other financial incentives were paid” so the companies would keep receiving large volumes of prescriptions. None of the three individual defendants is a licensed healthcare provider, the complaint states. One of them allegedly owns and controls both companies; the other two co-own one of the companies alongside him. At the heart of the case is what the complaint calls “predetermined fraudulent protocols.” GEICO alleges that nearly every patient – whatever their age, condition, or how bad their accident was – got the same package of gear: lumbar (lower-back) braces, cervical (neck) collars, and in some cases cervical traction units, cold therapy units, continuous passive motion machines, and deep vein thrombosis prevention devices. Most of these patients, the filing says, were in minor “fender-bender” crashes and either skipped the hospital or were seen briefly and sent home with a sprain or strain. One of the sharper allegations is about billing codes. The complaint says the companies routinely billed GEICO under code L0631 for “custom-fitted” lower-back braces at roughly $800 each – when the braces actually handed out, if handed out at all, were off-the-shelf items a patient could adjust by tightening the straps. The complaint states that sworn testimony from one of the owners, given during questioning under oath about the two companies, confirmed the back braces billed under that code “were not custom-fitted and only required minimal self-adjustment.” In all, GEICO alleges the companies billed it more than $580,000 for these braces under code L0631. The filing also alleges the companies padded their rental rates. GEICO says one of them billed cold therapy units, continuous passive motion machines, and clot-prevention devices under a catch-all “miscellaneous” code at $75 a day – when the proper codes carried far lower rates. Under the fee schedule, the complaint says, cold therapy units maxed out at $5.48 a week, and the passive motion machines at $132.16 a week, or $18.88 a day. The complaint alleges one company also billed neck collars at $300 apiece under code L0172, when the fee schedule capped that item at $75. GEICO further alleges the prescriptions behind the bills were often signed with “photocopied or otherwise forged” signatures, sometimes appearing on prescriptions from several clinics on dates the provider never saw the patient. In one instance, the filing says, a provider swore in an affidavit that he “did not sign numerous prescriptions” generated at clinics using his name, and that he “does not allow anyone to photocopy his signature nor does he permit anyone to sign prescriptions on his behalf.” The companies had little real-world presence, the complaint alleges. One used a New Jersey address the filing describes as “essentially a mail-drop location”; the other allegedly ran out of “a garage at a residential house in Nassau County.” Neither advertised to the public, according to the filing. On the medical-necessity question, the complaint points to a national coverage determination from the Centers for Medicare and Medicaid Services stating that continuous passive motion machines are only needed after a handful of serious procedures, such as total knee replacement or ACL repair. It adds that the American Academy of Orthopedic Surgeons has found the machines do not improve outcomes in knee-replacement surgery. The patients here, the filing says, got them after minor arthroscopic procedures while they were up and walking and already in physical therapy. GEICO makes similar arguments about the cold therapy units – unnecessary, it says, when a patient can use an ice pack – and the clot-prevention devices. GEICO’s complaint brings 12 claims in all. It asks the court to declare the insurer owes nothing on the $588,000 in pending bills. It brings six RICO claims – RICO is a federal law first aimed at organized crime that lets plaintiffs recover triple their losses – against the three owners and the unnamed clinic operators. It also brings fraud claims and claims that the companies and owners were unjustly enriched, meaning they kept money they had no right to. GEICO is seeking triple damages on the RICO claims, plus punitive damages, costs, and legal fees, and has asked for a jury trial. The allegations in this complaint have not been proven, and no court has ruled on the claims. **Topics:** Judicial/courts --- ### [Former Prince George’s County Insurance Agent Pleads Guilty in Felony Insurance Theft Scheme](https://insurancefraud.org/news_archives/former-prince-georges-county-insurance-agent-pleads-guilty-in-felony-insurance-theft-scheme/) **Published:** September 7, 2026 **Author:** Diane Beauchamp **Content:** Attorney General Anthony G. Brown announced today that Corrie Dewayne Alston, 51, of Bowie, pleaded guilty to one count of felony theft scheme and one count of felony insurance fraud in the Circuit Court for Prince George’s County before the Honorable Nicholas E. Rattal. Alston stole $5,122.87 in the form of commission payments from Senior Life Insurance Company for fraudulent applications for life insurance. The investigation was led by the Attorney General’s Fraud and Corruption Unit and the Maryland Insurance Administration. While employed as an information technology specialist for the federal government, Alston also worked a secondary job as a licensed Maryland insurance agent for the Don Pope Insurance Agency, selling policies for Senior Life Insurance Company. The investigation revealed that Alston submitted 21 applications for fictitious individuals in order to be paid commissions on these fraudulent policies. In an interview with investigators, Alston later admitted that he deliberately chose Hispanic surnames because he believed Senior Life would conclude they were undocumented individuals and not attempt to further verify the Social Security Numbers that he had provided in the applications. His charges were previously announced in May 2026. A sentencing hearing is scheduled for November 18, 2026. In making today’s announcement, Attorney General Brown thanked his Criminal Division, specifically Criminal Division Chief Katie Dorian, Fraud and Corruption Unit Chief Alexander Huggins, and Assistant Attorney General Michael Palisano, who is prosecuting this case. Attorney General Brown also thanked Maryland Insurance Administration Forensic Auditor Shervonne Thomas and Investigator Dimitri Goodwin for their assistance with this investigation. Finally, Attorney General Brown also thanked State’s Attorney for Prince George’s County Tara H. Jackson for her assistance with this prosecution. **Topics:** Insider - agent, Life Insurance **Categories:** Conviction --- ### [Kansas Woman Sentenced to Probation for Insurance Fraud](https://insurancefraud.org/news_archives/kansas-woman-sentenced-to-probation-for-insurance-fraud-2/) **Published:** September 7, 2026 **Author:** Diane Beauchamp **Content:** Kansas Insurance Commissioner Vicki Schmidt announced an Atchison County woman has been sentenced to 12 months of probation for insurance fraud. Amber Conner, aged 30, pleaded guilty on July 13, 2026, in Atchison County District Court to one felony count of insurance fraud. Conner opened a new policy with her insurance company, knowing her vehicle had already been damaged in a previous event, then falsely reported the date of loss in an attempt to gain coverage for damage to her vehicle. She was sentenced on August 24, 2026, to 12 months of probation. “Every time someone commits insurance fraud, it causes families and businesses across Kansas to pay more,” said Commissioner Vicki Schmidt. “The Department will continue to hold these individuals accountable.” This case was investigated by the Kansas Department of Insurance and prosecuted by the Kansas Attorney General’s Office. **Topics:** Auto - padding/false claim **Categories:** Conviction --- ### [Ohio uncovers more alleged Medicaid fraud payments](https://insurancefraud.org/news_archives/ohio-uncovers-more-alleged-medicaid-fraud-payments/) **Published:** September 7, 2026 **Author:** Diane Beauchamp **Content:** A northeast Ohio behavioral health agency received $1.2 million in improper Medicaid payments, Ohio’s auditor said. The state wants $1.4 million in repayment, adding interest, from New Destiny Treatment Center in Summit County, Auditor Keith Faber said. New Destiny was paid $11.5 million from Jan. 1, 2021, through Dec. 31, 2023, for substance abuse disorder, mental health and other services, Faber said. “Issues identified in Tuesday’s compliance audit included missing documentation to support reimbursements and instances where treatment plans did not match services that were provided, among other issues,” the auditor said. Medicaid is the joint-state federal health insurance program for low-income residents. State law requires prior authorization for before a patient can be admitted for treatment. “The 425 payments examined contained 45 instances in which prior authorization was not obtained after 30 consecutive days of admission through day 50 of admission,” the audit states. “New Destiny should ensure that prior authorization is obtained when required. New Destiny should address the identified issues to ensure compliance with Medicaid rules and avoid future findings.” The audit also examined patient treatment plans “to confirm if the treatment plan indicated the service was authorized and that the treatment plan was signed by the recording practitioner,” the audit said. “The 78 payments examined contained 60 instances in which the treatment plan authorized a higher level of care than what was provided and four instances in which there was no treatment plan.” These 64 errors are included in the projected improper payment amount of $1.1 million, the audit said. Nationally, there has been a crackdown on Medicaid fraud this year. Last month, the state of Minnesota filed criminal charges against two people for $1.5 million in alleged Medicaid Fraud, the state’s attorney general said, including one who was reportedly honored by the state as an “outstanding refugee.” **Topics:** Medicare/Medicaid, Public Awareness, Regulatory actions --- ### [Guilford County man charged with insurance fraud](https://insurancefraud.org/news_archives/guilford-county-man-charged-with-insurance-fraud/) **Published:** September 7, 2026 **Author:** Diane Beauchamp **Content:** A Guilford County man was arrested on multiple fraud-related charges. North Carolina Insurance Commissioner Mike Causey announced the arrest of Victor Deontray Bannerman, 43, on Wednesday. Bannerman was charged with insurance fraud, attempting to obtain property by false pretenses, common law forgery and common law uttering, all felonies. Special agents with the Department of Insurance Criminal Investigations Division accuse Bannerman of producing a forged invoice from Kirk Sineath Towing to support a fraudulent insurance claim on his automobile policy with Erie Insurance Co. The department said Bannerman created the invoice to show an inflated towing charge of $1,581.06, submitted the invoice as a supporting document to the claim and also spoke with the Erie adjuster, claiming the same information to be true. Bannerman was arrested on Aug. 31. He was given no bond and is scheduled to appear in court on Oct. 14. **Topics:** Auto - padding/false claim, Towing Fraud **Categories:** Arrest --- ### [Kern County man convicted of arson, auto insurance fraud; faces 25 years to life](https://insurancefraud.org/news_archives/kern-county-man-convicted-of-arson-auto-insurance-fraud-faces-25-years-to-life/) **Published:** September 7, 2026 **Author:** Diane Beauchamp **Content:** A Kern County man faces over 25 years to life after being convicted of arson and auto insurance fraud for stripping and burning a Jeep near McFarland in December 2025. The Kern County District Attorney’s Office said on August 31, 2026, a Kern County jury found Daniel Montes guilty of arson and automobile insurance fraud. According to the DA’s office, on September 1, 2026, the jury found true that Montes had two prior strike convictions. The jury also found true the following aggravating factors: the crime involved damage of great monetary value, Montes’s prior convictions were numerous and of increasing seriousness, he had served a prior term in prison, he was on probation when this crime was committed, and that his prior performance under supervision was unsatisfactory. The DA’s office said in December 2025, Montes drove a Jeep Gladiator from the Hard Rock Casino to a rural area outside of McFarland to remove the rims and set the car on fire. The crime was discovered when Montes made calls to his girlfriend, who was an inmate at the Kern County jail, telling her that he had a job that would pay him enough to bail her out of jail. According to the DA’s office, during the jail calls, Montes explained to his girlfriend that he was hired to take the car and burn it so the owner could make an insurance claim on the car because the owner could not afford the payments on the Jeep. After Montes was arrested, his phone was searched, revealing not only further conversations with other conspirators about the plan to take the car, but also videos of the Jeep being set on fire, according to the DA’s office. On January 8, 2025, the McFarland Police Department recovered the burned vehicle. When officers arrived, they found the Jeep destroyed and the rims stripped off. An insurance claim was filed by the owner of the vehicle, but it was quickly denied due to the results of the McFarland Police Department’s investigation. District Attorney Cynthia Zimmer commented on the conviction, saying, “The District Attorney’s Office has a dedicated unit focused on combating the various types of insurance fraud that occur in our community. Submitting false insurance claims is a serious crime, and as insurance fraud increases, so do insurance premiums for everyone else. If you see something that appears suspicious or fraudulent, I urge the community to report it.” Montes’ sentencing is set for October 1, 2026, where he faces up to 25 years to life, plus 11 years and 4 months. He is also a third strike offender. **Topics:** Auto arson **Categories:** Conviction --- ### [Texas court rules contractor did not act as unlicensed adjuster](https://insurancefraud.org/news_archives/texas-court-rules-contractor-did-not-act-as-unlicensed-adjuster/) **Published:** September 4, 2026 **Author:** Diane Beauchamp **Content:** A Texas homeowner who accused her contractor of acting as an unlicensed public adjuster could not void their contract – and still owes the bill. On August 20, 2026, the Court of Appeals for the Sixth Appellate District of Texas [affirmed](https://search.txcourts.gov/SearchMedia.aspx?MediaVersionID=7e76d613-0cd5-4609-9693-4cd77c1cfb82&coa=coa06&DT=Opinion&MediaID=398cea2a-0927-4f6d-9603-fdd692acad35) a trial court’s finding that a restoration contractor stayed on the right side of the law when it dealt with the homeowner’s carrier over storm-damage repairs. The trouble started with winter storm Uri. On February 18, 2021, burst pipes flooded the homeowner’s Dallas County house while she was in California. Her [Travelers](https://www.insurancebusinessmag.com/us/companies/travelers/67047/) policy covered the water damage, with a dwelling limit of $197,000 and personal property capped at $98,461. She hired the contractor, and its crew arrived the next day to pull water off the property. On March 4, 2021, she signed an “Emergency Work Agreement & Authorization.” It let the contractor “perform certain work and/or make repairs” and made her “solely responsible for payment of the total cost.” If insurance fell short, she “unconditionally and irrevocably” guaranteed to pay the balance on demand. A week later she signed a third-party form letting the contractor contact Travelers “to request inspections, claim status information and updates.” As damage surfaced, the repair estimate climbed – one version reached $166,300.36 – and Travelers denied many line items. The homeowner paid weekly, covering $72,724.59, before telling the contractor to stand down in September 2021. She then brought in a public adjuster and a second builder. When the contractor billed the balance, she sued, arguing it had acted as a public insurance adjuster without a license under Section 4102.051 of the Texas Insurance Code – which, she said, let her void the deal. The statute bars anyone from acting as a public adjuster without a license, meaning a person who “acts on behalf of an insured in negotiating for or effecting the settlement of a claim or claims.” The court drew the line plainly. A contractor may discuss damage, repair scope, and cost with an insurer, it said, but may not advocate for the consumer or discuss the policy’s coverages and exclusions. The agreement did neither: it did not tie the final price to what Travelers approved, and it did not let the contractor settle anything. An expert witness, a licensed public adjuster, testified the contractor only discussed scope and line items – conduct the code allows. The trial court believed him, and the appeals court left that finding in place. The contractor did not get everything it wanted, either: it lost a bid to reopen the case and prove up $195,966.13 in legal fees, which it had raised only after judgment. The homeowner was left owing the contractor $60,709.69. **Topics:** Judicial/courts, Public Awareness --- ### [Owatonna woman charged in insurance forgery scheme](https://insurancefraud.org/news_archives/owatonna-woman-charged-in-insurance-forgery-scheme/) **Published:** September 4, 2026 **Author:** Diane Beauchamp **Content:** An Owatonna woman has been charged with felony forgery related to an incident involving a forged insurance document. Court documents identified the woman as Crystal Elizabeth Gasner, 44. The Rice County Sheriff’s Office responded to a report of ongoing fraud at 300 30th street southeast in Morristown. The individual who made the report sells insurance and had been asked to verify the legitimacy of an insurance document that that been sent to her office. However, she was unable to locate the owner of the policy as the document contained a false policy number along with her own signature. Fearing identity theft, her agency reported the incident to the state and called the sheriff’s office. Reports indicate that the party who made the initial inquiry was Thomas Michael Weber, of Northfield, who wanted to make sure that a contractor he had hired to clean some trees at his property had insurance. The company he had hired “Innovated Solutions LLC” was run by Jared Ronald Kotek, of Northfield, who allegedly gave the fraudulent policy to Weber. On March 10, deputies received the results of a search warrant, which indicated the fraudulent Docusign event bearing the name of the insurance agent who had reported the incident had taken place on Jan. 28 in Owatonna on an account associated with Chrystal Elizabeth Gasner. The email address used by Gasner to send the fraudulent insurance certificate was associated with The Claremont Insurance Agency and reports indicate that she had been employed with the agency before being terminated for unrelated reasons. On June 23, deputies made contact with Kotek, who allegedly tried to minimize his involvement in the scheme but once presented with the evidence admitted to obtaining what he knew to be a fraudulent document from Gasner in order to procure work. Kotek also showed police texts between he and Gasner in which she allegedly agreed to make the document for him. Steele County Attorney Robert J. Jarrett said the only charges filed in Steele County at this point in the investigation are against Gasner. The Rice County Sheriff’s Office, which filed the complaint against Gasner, will be sending reports to the Rice County Attorney’s Office for review regarding any crimes that may have occurred in that jurisdiction, Jarrett said. **Topics:** Contractor fraud, Insider Fraud **Categories:** Arrest --- ### [Seventh Circuit Outlines Potential Path to Dismissal of Outsiders’ Qui Tam Actions](https://insurancefraud.org/news_archives/seventh-circuit-outlines-potential-path-to-dismissal-of-outsiders-qui-tam-actions/) **Published:** September 4, 2026 **Author:** Diane Beauchamp **Content:** The record for [the highest number of *qui tam* actions filed in a single year](https://www.justice.gov/opa/pr/false-claims-act-settlements-and-judgments-exceed-68b-fiscal-year-2025) was set last year, according to the U.S. Department of Justice (DOJ). [The DOJ explained](https://www.justice.gov/opa/pr/civil-division-announces-focus-initiative-data-miners-filing-qui-tam-complaints) that data miners who analyze publicly available data to identify indications of fraud have driven much of the surge, rather than company insiders who have traditionally filed *qui tam* actions. Embracing the work of data miners, the DOJ earlier this year launched an initiative called Fraud Oversight Through Careful Use of Statistics (FOCUS), inviting submissions from data miners who suspect fraud against the government. The initiative includes a [questionnaire for data miners](https://www.justice.gov/opa/media/1453091/dl) to complete describing their analyses. The DOJ commits to data miners that if the “data analysis reflects a data signal with a reasonably strong correlation to potential fraud that is not already known to the government, we will follow up with you to schedule a meeting to discuss in greater detail your work and potential *qui tam* filings.” On August 17, 2026, the U.S. Court of Appeals for the Seventh Circuit highlighted the difficulties that company outsiders face in meeting the pleading standards for *qui tam* actions, outlining a potential path to dismissal in cases where a relator lacks inside information. In *[United States of America and The State of Illinois, ex rel. A. Samuel Enloe v. Heritage Operations Group, LLC, and Green Tree Pharmacy, Inc](https://media.ca7.uscourts.gov/cgi-bin/OpinionsWeb/processWebInputExternal.pl?Submit=Display&Path=Y2026/D08-17/C:24-1431:J:Maldonado:aut:T:fnOp:N:3592430:S:0)*., No. 24-1431, the Seventh Circuit affirmed the dismissal of an outsider’s *qui tam* complaint for failing to plead sufficient factual details about the allegedly false claims. The court’s majority noted that “we do not hold that an outsider can never bring a *qui tam* action alleging violations of the FCA,” but that an outsider cannot “assume unlawful practices” with no particularized factual basis. ## Background The federal False Claims Act (FCA)[1](https://www.skadden.com/insights/publications/2026/08/seventh-circuit-outlines-potential-path-to-dismissal#ftn1) imposes civil liability on individuals and companies that knowingly submit to the federal government, or cause to be submitted, false or fraudulent claims for payment. Not only may the DOJ bring FCA claims, private individuals may sue in the name of the U.S. government.[2](https://www.skadden.com/insights/publications/2026/08/seventh-circuit-outlines-potential-path-to-dismissal#ftn2) These individuals are known as relators, and the lawsuits they bring are referred to as *qui tam* actions. The DOJ can elect to intervene in a *qui tam* action or seek its dismissal, and a relator may continue to pursue a *qui tam* action even if the DOJ does not intervene. The relator generally can receive up to 25% of any recovery if the DOJ intervenes and up to 30% if the DOJ does not intervene, along with attorneys’ fees and reasonable expenses.[3](https://www.skadden.com/insights/publications/2026/08/seventh-circuit-outlines-potential-path-to-dismissal#ftn3) To state a viable claim under the FCA, a relator “must allege with particularity that: (1) the defendant made a statement in order to receive money from the government; (2) the statement was false; and (3) the defendant knew the statement was false.”[4](https://www.skadden.com/insights/publications/2026/08/seventh-circuit-outlines-potential-path-to-dismissal#ftn4) A defendant can also be liable under the FCA for submitting a claim for payment from the government while knowingly failing to disclose noncompliance with statutory, regulatory or contractual requirements, when compliance with those requirements is material to the government’s payment decision.[5](https://www.skadden.com/insights/publications/2026/08/seventh-circuit-outlines-potential-path-to-dismissal#ftn5) This is sometimes called an “implied false certification” theory of liability. A relator is not required to allege facts about a specific invoice to the government, but the relator “must inject precision and some measure of substantiation into the fraud allegations to survive dismissal.”[6](https://www.skadden.com/insights/publications/2026/08/seventh-circuit-outlines-potential-path-to-dismissal#ftn6) ## Recent Seventh Circuit Opinion The relator in *U.S. ex rel. Enloe* alleged that the operator of approximately 40 long-term-care facilities in Illinois and the pharmacy that serviced them, owned by the same family as the facilities’ operator, dispensed medications including opioids to the facilities’ residents without valid prescriptions in violation of the Controlled Substances Act.[7](https://www.skadden.com/insights/publications/2026/08/seventh-circuit-outlines-potential-path-to-dismissal#ftn7) The relator alleged that claims submitted to Medicare for reimbursement for these medications violated the FCA by implying that the medications were lawfully prescribed. The relator did not work for either of the defendant companies. He had, however, spent his career in the long-term-care pharmacy industry. After working for a large corporation for 20 years, he founded his own pharmacy that competed with the defendant pharmacy. The relator’s allegations involved the defendants’ practices for dispensing certain controlled substances in emergencies arising between 5:30 p.m. and 9 a.m. and on Sundays — periods when the pharmacy was closed. Under the Controlled Substances Act, according to the Seventh Circuit, a pharmacist may dispense certain drugs without a signed prescription from a physician in emergency situations upon receiving an oral prescription from a physician that is immediately reduced to writing by the pharmacist and followed by a written prescription from the physician within seven days.[8](https://www.skadden.com/insights/publications/2026/08/seventh-circuit-outlines-potential-path-to-dismissal#ftn8) Nurses at the long-term-care facilities allegedly had access to emergency narcotics kits when the pharmacy was closed. According to the relator, the pharmacy’s policy allowed nurses to dispense controlled substances in the emergency kits when the pharmacy was closed once a physician left a voicemail on the pharmacy’s voicemail system, even if a pharmacist did not receive the voicemail until the following day. The relator alleged that this violated the Controlled Substances Act because it cut out the pharmacist’s role and allowed nurses to dispense controlled substances before a pharmacist actually received any prescription. ## Court’s Analysis Two of the three judges on the panel agreed with the district court that the relator did not allege sufficient details in support of his claims, including materiality, and affirmed the dismissal of his complaint. The concurring judge agreed that the relator did not adequately plead materiality, although she asserted that his claims otherwise contained sufficient detail. The majority began its analysis by explaining that successful *qui tam* actions are often brought by company insiders with inside information about fraud within the company. The majority noted that this relator is “differently situated than the typical relator.” In affirming the district court’s dismissal of the relator’s complaint for failing to state a claim, the majority first noted that the Controlled Substances Act violation the relator alleged involved a gray area. The majority stated that that it was not clear that the Controlled Substances Act and related regulations prohibit a nurse from dispensing certain controlled substances in emergency situations immediately after a doctor leaves a voicemail with a pharmacy, even if no pharmacist hears the message until the next day. Second, the majority held that the relator failed to allege sufficient details about false certifications to Medicare. The court explained that the relator’s only source of knowledge about the defendants’ drug dispensing practices came from the narcotics policy, and that the relator’s allegations otherwise relied on speculation and assumptions. The majority concluded by stating that “we do not hold that an outsider can never bring a *qui tam* action alleging violations of the FCA. But what a relator cannot do is assume unlawful practices on the part of a competitor based on vague regulations and guidance with no particularized factual basis.” The concurring judge disagreed with the notion that the relevant regulations are vague, stating that the relator adequately pled a violation of the Controlled Substances Act if the facts he alleged were true. The judge also stated that the relator’s complaint sufficiently described the “who, what, when, where, and how” of the alleged false claims, citing precedent cautioning against an “overly rigid view” of pleading requirements for fraud claims. Nevertheless, the judge agreed that the relator did not adequately plead that the alleged deficiencies in the defendants’ claims for payment were material to the government’s payment decisions and therefore agreed with affirming the dismissal of the complaint. ## Practical Implications for Defendants The Seventh Circuit’s opinion is likely to provide valuable support for defendants in *qui tam* actions brought by company outsiders, including data miners. The majority criticized the relator’s lack of support for his allegations other than a company policy, describing the rest of his factual allegations as speculation and assumptions. In contrast, the concurring judge was not troubled by the lack of support for the remaining allegations, finding that they sufficiently alleged a basis for FCA liability, assuming materiality. Many outsiders, including data miners, are likely to face the same challenges. They might present statistics that support a theory that a defendant’s claims for payment are fraudulent, but without more, they will be vulnerable to challenges that their allegations of fraud depend on speculation and assumptions about what is driving those statistics. Without concrete insider information, many outside relators might struggle to plead facts in sufficient detail to defeat a motion to dismiss, regardless of the strength of their data analysis. ## Conclusion The DOJ’s encouragement of data mining; prospective relators’ increased access to powerful analytical tools, including artificial intelligence; and the prospect of multimillion-dollar rewards are likely to fuel dramatic growth of outsider *qui tam* actions. The Seventh Circuit’s opinion in *U.S. ex rel. Enloe* could provide valuable support for defeating actions at the pleading stage. **Topics:** Judicial/courts, Public Awareness --- ### [‘Cockroaches in My Food’ Claim Leads to Insurance Fraud Charge](https://insurancefraud.org/news_archives/cockroaches-in-my-food-claim-leads-to-insurance-fraud-charge/) **Published:** September 4, 2026 **Author:** Diane Beauchamp **Content:** A Warren County, North Carolina man has been charged with insurance fraud for allegedly seeking an insurance payment from a restaurant where he claims he found cockroaches in his food. Investigators say it was one of four similar cockroach complaints he has filed against eateries. North Carolina Insurance Commissioner Mike Causey announced the arrest of Melvin Junior Jones of Norlina. Jones was charged with one count of insurance fraud and one count of attempting to obtain property by false pretense. Both are felonies. Special agents with the Department of Insurance Criminal Investigations Division have accused Jones of falsely reporting that he found two cockroaches in his food at a Creedmoor KFC. His insurance claim sought approximately $4,000 in payment from the restaurant’s business policy with PMA Insurance Group. Investigators said they discovered that Jones had also filed similar claims regarding two separate Waffle House locations and a Denny’s Restaurant. The four instances occurred between Aug. 15, 2024, and Aug. 7, 2025. Jones was released under a $40,000 secured bond pending future court dates. “Insurance fraud is not a victimless crime,” Causey said. “It hits all of us in the pocket through higher premiums and higher prices.” **Topics:** Fraud General **Categories:** Arrest --- ### [Jesse LaCoste Sentenced to 30 Years in Northwest Florida Fraud Case](https://insurancefraud.org/news_archives/jesse-lacoste-sentenced-to-30-years-in-northwest-florida-fraud-case/) **Published:** September 4, 2026 **Author:** Diane Beauchamp **Content:** A former Northwest Florida contractor has been sentenced to 30 years in state prison after being convicted of racketeering and organized fraud in a case prosecutors say involved more than $2 million in losses to homeowners across the region. Jesse LaCoste was sentenced Monday, August 31, following his conviction Thursday on charges of racketeering under Florida’s Racketeer Influenced and Corrupt Organizations Act and organized fraud. The two 30-year sentences will run concurrently. Prosecutors said LaCoste used his construction business to defraud dozens of homeowners between 2018 and 2022. Victims included homeowners in Escambia, Santa Rosa and Okaloosa counties, including people who were attempting to repair or rebuild their homes following Hurricane Sally. According to the State Attorney’s Office, some homeowners paid tens or even hundreds of thousands of dollars for construction work that was never completed or, in some cases, never started. State Attorney Ginger Bowden Madden said the case went beyond financial losses because homeowners trusted LaCoste with their homes and insurance proceeds as they attempted to recover from the hurricane. “These were not simply financial crimes,” Bowden Madden said. “Many families trusted Mr. LaCoste with their homes, their insurance proceeds, and their chance to rebuild after the destruction of Hurricane Sally.” The State Attorney’s Office said some victims were forced to use retirement savings or take out second mortgages to address the damage left behind. Jury Conviction Came Quickly A six-person jury deliberated for less than an hour Thursday before finding LaCoste guilty of racketeering and organized fraud involving more than $50,000. Both charges are first-degree felonies, each carrying a maximum sentence of 30 years. The judge ultimately imposed 30 years on each count, with the sentences running at the same time. LaCoste was already serving a 10-year state prison sentence following a 2025 conviction for grand theft and contractor fraud. In that earlier case, he was ordered to pay more than $506,000 in restitution to a victim and prohibited from working in the construction industry. The latest sentence adds to that prison term. Case Spanned Multiple Northwest Florida Counties The broader investigation involved allegations that LaCoste’s construction operations defrauded homeowners, insurance companies, subcontractors and suppliers. Prosecutors alleged that LaCoste used his companies to engage in a pattern of racketeering activity that included theft, insurance fraud, false statements and other misconduct. The case has affected homeowners across the First Judicial Circuit, which includes Escambia, Santa Rosa, Okaloosa and Walton counties. LaCoste has faced additional criminal proceedings stemming from allegations in the region. Bowden Madden credited the victims for coming forward and continuing to pursue the case, as well as law enforcement officers and prosecutors involved in the investigation. She specifically recognized Assistant State Attorney Paul Gillespie and his Financial Crimes Unit, along with former Assistant State Attorneys Russ Edgar and Mikaela Ziko. “If you use a business to defraud the citizens of our Circuit, there will be severe consequences,” Bowden Madden said. The 30-year sentence is the latest development in a criminal case that has stretched across several Northwest Florida counties and involved homeowners who said they were left with unfinished construction projects and significant financial losses. **Topics:** Contractor fraud **Categories:** Conviction --- ### [Scammers Stealing Insurance Licensing Credentials to Buy Fraudulent Health Insurance Policies to Collect Payments and Scam Federal Government Subsidies](https://insurancefraud.org/news_archives/scammers-stealing-insurance-licensing-credentials-to-buy-fraudulent-health-insurance-policies-to-collect-payments-and-scam-federal-government-subsidies/) **Published:** September 4, 2026 **Author:** Diane Beauchamp **Content:** The Iowa Insurance Division is aware of an active, sophisticated licensing and identity theft scheme operating in multiple states. Job seekers, potential future insurance producers, and consumers should be on notice for scammers as state regulators have recently received numerous reports detailing fraudulent solicitation attempts aimed at prospective insurance producers. ## **How the Scheme Operates** Step 1 -Recruitment: The scammer contacts Iowans in an unsolicited manner and encourages them to apply for and obtain an Iowa resident insurance producer license. The scammers promise to handle policy administration, manage sales leads, and assist with policy sales on the newly licensed individual’s behalf. Step 2 – Credential Exploitation: Once the individual obtains their insurance producer license, the scammer acquires their National Producer Number (NPN) and personal licensing credentials to “assist” the newly licensed insurance producer as the scammer stated during their recruitment of the individual. Step 3 – Unauthorized Policy Generation: Scammers generally operating from offshore locations then use the NPN to issue unauthorized health and life insurance policies under the names of unwitting consumers to collect commissions and federal health insurance subsidies. The consumer’s information is often altered or fabricated to receive maximum payment from federal Advanced Premium Tax Credits (APTC) that provide subsidies for individuals buying insurance through the ACA marketplace. ## **Critical Warnings & Red Flags** **For Job Seekers & Prospective Insurance Producers:** Receiving unsolicited communications urging you to obtain a resident insurance producer license—paired with promises that a third party will write or manage policies under your name—is an immediate red flag. Allowing offshore entities to use your NPN exposes you to legal liability, license revocation, and potential criminal charges for fraud. **For Consumers:** If you receive insurance documents, bills, or tax notices regarding an insurance policy you never authorized or requested, your identity may have been compromised in this scheme. ## **Report Suspected Activity** If you have been contacted by individuals offering this arrangement or if you discover an unauthorized insurance policy in your name, please contact the Iowa Insurance Division immediately at 515-654-6556 or online at [https://ofrs.naic.org/](https://links-1.govdelivery.com/CL0/https:%2F%2Fofrs.naic.org%2F%3Futm_medium=email%26utm_source=govdelivery/1/010001a05e58d04a-bead6a52-a75f-495d-957f-532c67ee3ab6-000000/Y0QRUCRVIbCl1KpYZdzMppRVh8axjSYXsokIBfFQmJ8=452). **Topics:** Insider - agent, Public Awareness, Unlicensed --- ### [Convicted Felon Fraud Promoter Sentenced to Federal Prison for Scheme Involving $6.5 Million in Stolen Checks](https://insurancefraud.org/news_archives/convicted-felon-fraud-promoter-sentenced-to-federal-prison-for-scheme-involving-6-5-million-in-stolen-checks/) **Published:** September 4, 2026 **Author:** Diane Beauchamp **Content:** Shamarri Tache Brooks, a multi-convicted felon and rapper, was sentenced to federal prison for a fraud scheme involving thousands of checks stolen from the mail. “In addition to personally committing bank fraud, Brooks brazenly marketed and sold fraud tutorials and trafficked thousands of stolen checks worth millions of dollars. Thankfully, Brooks’s ineptitude matched his boldness—his efforts to negotiate the checks failed, sparing his victims from any known loss,” said U.S. Attorney Theodore S. Hertzberg. “Although Brooks sought to teach his followers how to commit fraud, the real lesson here is that crime does not pay. We will catch you, and you will go to prison—even if your scheme is unsuccessful.” “This defendant built a criminal enterprise around stealing checks, exploiting bank accounts, and teaching others how to commit fraud. His actions put millions of dollars at risk and victimized individuals and financial institutions across our community,” said Marlo Graham, Special Agent in a Charge of FBI Atlanta. “This sentence reflects the serious consequences of turning fraud into a business, and the FBI and our law enforcement partners will continue to pursue those who profit from stealing from others.” “The sentencing in this case brings the defendant to justice for facilitating a scheme that stole thousands of checks worth millions of dollars,” said Special Agent in Charge Kyle A. Myles, of the Federal Deposit Insurance Corporation Office of Inspector General (FDIC OIG), Atlanta Region. “The FDIC OIG remains committed to working with our law enforcement partners to hold those who commit financial crimes accountable, as we seek to preserve the integrity of the Nation’s financial system and protect depositors.” “The defendant’s brazen criminal conduct disrupted the lives of countless victims and, by sharing his fraud techniques with others for a fee on social media, he created even more victims,” said Rob Donovan, U.S. Secret Service Atlanta Field Office. “Brooks’s sentence is the reflection of the severity of his crimes and is the result of the cooperation of our local and federal law enforcement partners. We are grateful for the opportunity to work alongside the dedicated men and women of each of the agencies involved to bring this case to the appropriate end – the defendant in prison.” “Brooks’s sentencing sends a clear signal to fraudsters that bank fraud and mail theft will not be tolerated,” said Special Agent in Charge Jonathan Ulrich of the U.S. Postal Service Office of Inspector General. “Our special agents, in collaboration with our federal and local law enforcement partners, are committed to thoroughly investigate these federal crimes to protect the sanctity of the U.S. Mail and maintain the integrity of these essential services.” According to U.S. Attorney Hertzberg, the indictment, and other information presented in court: From at least January 2022 through November 2025, Brooks committed bank fraud by negotiating checks stolen from the mail. As part of the scheme, Brooks used social media to recruit individuals with existing bank accounts to use as depository accounts for stolen checks. Brooks altered the stolen checks to list the cooperating accountholders as the intended recipients or payees of the checks. Brooks deposited altered checks at ATMs throughout the Atlanta area, often wearing balaclava-style masks with a logo stating “No Free Sauce.” Brooks also promoted and sold tutorials for committing various forms of financial fraud, including check fraud. He sold a collection of these tutorials under the name “Sauce Book” or “SB.” Brooks also sold images of stolen checks, referred to as “slips,” as a part of his fraud business. Although Brooks and his associates stole checks with a combined face value of $6,574,288, law enforcement recovered many of these checks from Brooks’s home, and there is no evidence that Brooks succeeded in negotiating the remainder. On August 27, 2026, Shamarri Tache Brooks, a/k/a Juney Knotzz, 34, of Stone Mountain, Georgia, was sentenced to six years in prison to be followed by five years of supervised release. On May 7, 2026, Brooks pleaded guilty to bank fraud and aggravated identity theft. His lengthy criminal history includes convictions for drug trafficking, weapon possession, obstruction of law enforcement, and battery. This case was investigated by the Federal Bureau of Investigation, Federal Deposit Insurance Corporation-Office of the Inspector General, the U.S. Secret Service, and the U.S. Postal Service, Office of Inspector General. The Dunwoody Police Department and the U.S. Treasury Inspector General for Tax Administration provided valuable assistance in the investigation. To protect yourself from becoming the victim of mail theft and check fraud, law enforcement recommends the following steps: Pick up your mail promptly after delivery. Do not leave mail in your mailbox overnight or for long periods of time. If you are heading out of town, submit a USPS Hold Mail™ request asking your local Post Office to hold your mail until you return. Sign up for Informed Delivery® at USPS.com to receive daily email notifications of incoming mail and packages. Contact the sender if you do not receive a check, credit card or other valuable mail you are expecting. Consider buying and using security envelopes to conceal the contents of your mail. When mailing checks or other important mail use Signature Confirmation™ for the intended recipient. Use the letter slots inside your local Post Office to send mail. When using checks, educate yourself about the steps you can take to prevent fraudsters from exploiting stolen checks, such as setting up positive pay with your financial institution. If you think you were targeted by fraudsters, file a report with your bank and request copies of all fraudulent checks. If you believe you are the victim of mail theft-related check fraud, report to your local police, the United States Postal Service Office of Inspector General at <https://hotlineform.uspsoig.gov/en-US/Hotline> or the United States Postal Inspection Service at uspis.gov/report or (877) 876-2455. Assistant United States Attorney Jessica C. Morris prosecuted the case. **Topics:** Fraud General **Categories:** Conviction --- ### [Charlotte woman sentenced for defrauding the North Carolina Medicaid program](https://insurancefraud.org/news_archives/charlotte-woman-sentenced-for-defrauding-the-north-carolina-medicaid-program/) **Published:** September 4, 2026 **Author:** Diane Beauchamp **Content:** Crystal Sherrell Jackson of Charlotte was sentenced today to 48 months in prison followed by three years of supervised release for submitting fraudulent bills to the North Carolina Medicaid Program (NC Medicaid) for psychotherapy services and urine drug testing that were never provided, announced Russ Ferguson, U.S. Attorney for the Western District of North Carolina. Jackson was also ordered to pay $1,623,983.08 in restitution. “Medicaid fraud is a crime on all of us – it steals taxpayer money, makes healthcare more expensive, and compromises the integrity of our entire healthcare system,” said U.S. Attorney Russ Ferguson. “In addition, it is a nightmare for those whose identities are stolen. We are grateful for the teamwork essential to combatting this widespread fraud.” “The only acceptable level of Medicaid fraud is zero, and we’re going to work with our law enforcement partners to investigate and prosecute fraud at every instance,” said North Carolina Attorney General Jeff Jackson. “I’m grateful to U.S. Attorney Freguson and his team for their partnership in prosecuting this fraudster and winning back Medicaid dollars for taxpayers.” According to court documents and court proceedings, Jackson was a North Carolina-licensed clinical addiction specialist-associate and NC Medicaid enrolled provider who owned and operated a company called Jackson Consulting and Services, LLC (JCS). JCS held itself out as a mental health agency, clinical laboratory, and consulting business. Jackson also enrolled JCS with NC Medicaid so that both she and the company could bill NC Medicaid for those services they purportedly provided to eligible NC Medicaid recipients. However, between 2020 and 2024, Jackson and JCS submitted over $1.9 million in sham claims for payment to NC Medicaid for drug testing and psychotherapy services that were either never performed at all or for which they were already paid. To carry out the scheme, Jackson obtained licensure under the Clinical Laboratory Improvement Amendments (CLIA), which enabled Jackson to bill NC Medicaid for the highest allowable reimbursement rates for drug testing, by submitting false documents. Jackson then filed fraudulent claims for expensive urine drug testing, and psychotherapy services, using the personal information of NC Medicaid recipients, including their names, addresses, dates of birth, and unique NC Medicaid recipient numbers. Jackson obtained the personally identifiable information of these Medicaid recipients in a variety of ways, including having a prior or unrelated treatment relationship, and from associates. In most cases, the NC Medicaid recipients did not know their information was used by Jackson and JCS to submit fraudulent claims for reimbursement, did not authorize the filing of fraudulent claims on their behalf, and never received the services for which Jackson and JCS billed the NC Medicaid Program. Jackson targeted a vulnerable Medicaid population, and her victims included more than a dozen children, incarcerated individuals, and even submitted bogus bills for services she claimed she performed for Medicaid recipients who were deceased at the time the services were purportedly rendered. As Jackson previously admitted in court, she also engaged in transactional money laundering by spending the proceeds of her unlawful scheme. In announcing Jackson’s sentence, U.S. District Judge Kenneth D. Bell said, it is “an assault on society for benefits programs to be defrauded,” and stressed the importance of general deterrence. Jackson pleaded guilty in March 2026 to healthcare fraud and transactional money laundering. She is currently in federal custody and will be transferred to the custody of the Federal Bureau of Prisons upon designation of a federal facility. In making today’s announcement, U.S. Attorney Ferguson thanked IRS-Criminal Investigation and the FBI in Charlotte, the North Carolina Attorney General’s Medicaid Investigations Division for their investigative work in this case. Assistant U.S. Attorney Katherine Armstrong, and Special Assistant U.S. Attorney Kristina Fleisch, with the North Carolina Medicaid Division, prosecuted the case. On April 7, the Department of Justice announced the creation of the National Fraud Enforcement Division (Fraud Division). The Fraud Division is laser-focused on investigating and prosecuting those who commit fraud against the American people. The Department’s work to combat fraud supports President Trump’s Task Force to Eliminate Fraud, a whole-of-government effort chaired by Vice President J.D. Vance to eliminate fraud, waste, and abuse within Federal benefit programs. IRS-CI is the law enforcement arm of the IRS, responsible for conducting financial crime investigations, including tax fraud, narcotics trafficking, money laundering, public corruption, healthcare fraud, identity theft and more. It is the only federal law enforcement agency with investigative jurisdiction over violations of the Internal Revenue Code. IRS-CI has 16 field offices located across the U.S. and maintains an international presence through attaché posts abroad. **Topics:** Medicare/Medicaid **Categories:** Conviction --- ### [Air Force Veteran Convicted in 2001 Murder-for-Hire Plot Scheduled for Execution](https://insurancefraud.org/news_archives/air-force-veteran-convicted-in-2001-murder-for-hire-plot-scheduled-for-execution/) **Published:** September 4, 2026 **Author:** Diane Beauchamp **Content:** A U.S. Air Force veteran convicted in a 2001 Oklahoma murder is scheduled to be executed this November. His attorneys plan to raise his military service in an effort to spare his life. James Pavatt, 72, is currently scheduled to die by lethal injection on Nov. 12 at the Oklahoma State Penitentiary in McAlester, according to an announcement made Aug. 28 by the Oklahoma Court of Criminal Appeals. If it is carried out, the execution would be the state’s fourth and final one of 2026. Pavatt, a former life insurance agent, was convicted of first-degree murder in the killing of Robert “Rob” Andrew, a 39-year-old Oklahoma City advertising executive, according to the Oklahoma Voice. Andrew was shot with a shotgun in the garage of his home on Nov. 20, 2001, after arriving to pick up his two children. Prosecutors alleged that Pavatt and Andrew’s wife, Brenda, with whom Pavatt was having an affair, plotted the killing to collect on an $800,000 life insurance policy. Pavatt, who had worked with the family through a church, had helped set up that policy, according to trial testimony. Claims of Innocence and a Clemency Plea Pavatt has maintained his innocence. His lead attorney, Hunter Labovitz, argued that there is no credible evidence that Pavatt fired the fatal shots. “There’s absolutely no credible evidence that Jim shot and killed Rob Andrew, and that’s what he’s under a sentence of death for,” Labovitz, also an assistant federal defender, said in court, according to local ABC affiliate KOCO 5. His defense is focused on clemency. Pavatt’s application to the Oklahoma Pardon and Parole Board is due Sept. 18. The board is scheduled to hold a clemency hearing on Oct. 14. If the board recommends mercy, Republican Gov. Kevin Stitt could commute the sentence to life in prison without the possibility of parole. Among the arguments his attorneys are expected to raise is his time in the Air Force. Pavatt served in the military before his conviction. His defense has described him as a decorated veteran who had never been in trouble with the law. His execution date will arrive two days after his 73rd birthday. Two Death Sentences Brenda Andrew was tried separately and also sentenced to death. She is the only woman on Oklahoma’s death row and is appealing her conviction. She is being held at the Mabel Bassett Correctional Center, a women’s prison. After the killing, Pavatt and Brenda Andrew reportedly fled to Mexico with the couple’s two children before they were arrested and returned, according to multiple news outlets. Pavatt was tried first, in 2003. A jury recommended a death sentence after convicting him of first-degree murder and conspiracy. A judge formally imposed the sentence that October. He has since spent more than two decades on death row, exhausting a series of appeals that have upheld his conviction. The path now narrows down to the clemency process and any remaining court action. Barring a commutation or a stay, Pavatt is scheduled to become the fourth person executed by Oklahoma this year. Pavatt’s execution remains subject to the outcome of his clemency hearing, as well as any late appeals. His attorneys said they intend to keep fighting the sentence in the weeks leading up to the execution. **Topics:** Life Insurance **Categories:** Conviction --- ### [Maryland brothers argue CareFirst’s $50M fraud lawsuit is too late](https://insurancefraud.org/news_archives/maryland-brothers-argue-carefirsts-50m-fraud-lawsuit-is-too-late/) **Published:** September 4, 2026 **Author:** Diane Beauchamp **Content:** Two Maryland brothers accused of an international healthcare conspiracy argued Friday that CareFirst of Maryland’s racketeering lawsuit against them was filed after the statute of limitations had passed. As such, the company’s $50 million claim should be dismissed, they say. Ex-insurance broker Avraham Rappaport and his brother, financial adviser Eliezer Rappaport, are accused of flying clients to Maryland from other states and Israel to receive specialized care under CareFirst’s domestic insurance policies. According to the 30-page complaint, at least 259 patients were improperly reported as living in Maryland between 2018 and 2022. Together, they received unqualified benefits topping $51.1 million in CareFirst payouts, the insurer said, while the “Rappaport enterprise” netted hundreds of thousands of dollars in commissions. In their lawsuit, attorneys for the Baltimore-based insurance company described the alleged scheme as intricate, unquestionably successful and “breathtaking” in scale. On Friday, the Rappaports’ attorneys said they would “avoid unnecessarily belaboring” disagreements on the allegations to focus on the statute or limitations. Referencing a company report, the brothers say CareFirst began investigating Avraham Rappaport’s “billing practices” in March 2022. Because the law allows injured parties to file a racketeering lawsuit within four years of their injury, or their discovery of the injury, the Rappaports say CareFirst’s lawsuit in mid-June should be tossed out. “A complete, or even more fulsome, understanding of the facts underlying the alleged injury is not required to start the clock on the statute of limitations,” Friday’s motion states. It did not address the allegations themselves, A spokesperson for CareFirst declined to comment on the pending litigation. Attorneys for both Rappaport brothers did not respond to media inquiries on Monday. The June lawsuit was filed under the Racketeer Influenced and Corrupt Organizations Act (RICO), a bill established to combat the mafia and other organized crime syndicates. It describes an interstate and international network of service providers, property owners, religious organizations and charities that helped establish and support fake identities and fraudulent claims. In order to sell invalid policies, the Rappaports allegedly instructed their clients to apply for insurance using Baltimore-area addresses controlled by themselves or their associates. Other entities would then provide referrals, transportation, lodging and documentation to bolster the claims, even when CareFirst challenged them, according to the lawsuit. Although criminal charges have not been filed against the Rappaport brothers, CareFirst accused them of federal wire fraud in civil court, saying they “had no reason to suspect” anything was wrong “until the volume and nature of the claims” spiked. According to the complaint, one address, the lawsuit states, had 21 policy holders registered to it, amassing 473 claims in total. Another less than a mile away allegedly housed 10 subscribers who made 655 claims. Similarly, between 2019 and 2022, Avraham Rappaport allegedly sold 58 policies to subscribers with addresses at a string of ten side-by-side duplexes in Baltimore. Those homes, which helped accrue $11.3 million in CareFirst payments, were also less than a mile away from the others. Early in its complaint, the insurance company referenced the criminal case against attorney Jacob Rappaport, the defendants’ brother, who was sentenced to 15 months in prison for a bank fraud conspiracy earlier this year, barely a week after the healthcare lawsuit was filed. “Indeed,” CareFirst’s lawyers wrote, “it seems that fraud has become something of a family tradition for the Rappaports.” **Topics:** Healthcare Fraud, Judicial/courts, Public Awareness --- ### [Charlotte brothers plead guilty in Wake County roofing scam](https://insurancefraud.org/news_archives/charlotte-brothers-plead-guilty-in-wake-county-roofing-scam/) **Published:** September 4, 2026 **Author:** Diane Beauchamp **Content:** North Carolina Insurance Commissioner Mike Causey announced this week that two Mecklenburg County brothers have pleaded guilty to charges related to a roofing scam sting in Wake County late last year. Brett William Bentley, 28, and Robert Allen Bentley, 36, both of 6617 Elmstone Drive, Charlotte, offered guilty pleas in Wake County District Court earlier in August. Brett Bentley pleaded guilty to misdemeanor injury to real property and paid court-ordered restitution of $27,678.50 to N.C. Farm Bureau Insurance along with court cost. Robert Bentley pleaded guilty to felony injury to real property and attempting to obtain property by false pretense. He was sentenced to 24 months of supervised probation and ordered to complete 50 hours of community service within 180 days. He was also ordered to pay court costs, a community service fee and a $50 fine. He is prohibited from working in the roofing industry during his probation. His case is scheduled for review Aug. 17, 2027. The two worked for A&M Premier Roofing & Construction. The Department of Insurance’s Criminal Investigations Division worked with Farm Bureau’s Special Investigations Unit in the sting operation. The fraud investigation employed a “bait house,” which is used to catch employees of roofing companies intentionally damaging a roof to create repair work for themselves and to support a fraudulent insurance claim. “This conviction demonstrates that insurance fraud has real consequences,” Causey said. “Roofing scams are serious crimes, and I want to thank Farm Bureau for partnering with our special agents throughout this investigation.” **Topics:** Contractor fraud **Categories:** Conviction --- ### [Attorney charged in alleged Hurricane Ida insurance fraud scheme](https://insurancefraud.org/news_archives/attorney-charged-in-alleged-hurricane-ida-insurance-fraud-scheme/) **Published:** September 1, 2026 **Author:** Diane Beauchamp **Content:** As Louisiana homeowners worked to rebuild after Hurricane Ida, federal prosecutors say a Texas-based law firm sent insurance companies false information about their roof-repair claims. Richard William Huye III, 34, formerly of New Orleans and now living in Texas, was charged Aug. 28 with conspiracy to commit wire fraud. Here’s what to know about the case. What happened? Huye was charged by bill of information in federal court. Prosecutors accuse him of working with a Texas-based law firm and an Alabama roofing company after Hurricane Ida struck Southeast Louisiana on Aug. 29, 2021. The law firm later opened a New Orleans office. Prosecutors said the roofing company signed up hundreds of Louisiana homeowners using assignment-of-benefits agreements. Those agreements involved insurance claims for roof repairs. Many Louisiana homeowners’ insurance policies included anti-assignment language or required prior approval, according to federal prosecutors. What is Huye accused of doing? Prosecutors said the law firm instructed the roofing company to sign attorney retention agreements for Louisiana homeowners without their knowledge or authorization. Huye allegedly sent letters to hundreds of insurance companies claiming the law firm represented only the homeowners. The letters did not disclose the roofing company’s assignment-of-benefits agreements, prosecutors said. The law firm allegedly made similar representations in other communications, mediations and court filings. How many homeowners were affected? The bill of information describes eight Louisiana homeowners whose property damage claims were affected. Prosecutors said most of the homeowners either did not receive money intended for roof repairs or received less because of unauthorized attorney fees and expenses. In some cases, prosecutors said a managing partner endorsed settlement checks without proper authorization and deposited money intended for homeowners into the law firm’s bank account. How did investigators uncover the alleged scheme? The allegations surfaced during federal court proceedings in February 2023. At the time, attorneys for the law firm acknowledged sending at least 856 letters that prosecutors described as false or misleading. They also acknowledged settling at least nine cases through mediation without disclosing the roofing company’s assignment-of-benefits agreements. What punishment could Huye face? Huye faces up to five years in prison, three years of supervised release and a fine of up to $250,000. The fine could also equal twice the gross gain to a defendant or twice the gross loss to a victim. What happens next? The FBI, Louisiana Department of Insurance and Louisiana State Police investigated the case, according to federal prosecutors. The case is being handled by Assistant U.S. Attorneys Edward J. Rivera and Tracey N. Knight. A bill of information is a charge. Huye is presumed innocent unless and until proven guilty beyond a reasonable doubt. Why it matters The allegations involve hundreds of Louisiana homeowners who sought help with insurance claims after Hurricane Ida. Federal prosecutors say the alleged scheme resulted in homeowners losing repair money or having their payments reduced by unauthorized fees and expenses. **Topics:** Contractor fraud, Insider Fraud **Categories:** Arrest --- ### [Healthcare data breach exposes 3.75M patient records](https://insurancefraud.org/news_archives/healthcare-data-breach-exposes-3-75m-patient-records/) **Published:** September 1, 2026 **Author:** Diane Beauchamp **Content:** You can be careful with your passwords and still get caught in a breach at a company you may have never heard of. That is one of the frustrating parts of the CareCloud data breach. More than 3.75 million people had personal information and medical records stolen after hackers gained access to a CareCloud cloud environment earlier this year. CareCloud provides electronic medical record technology and other services to tens of thousands of healthcare providers across the U.S. So, even if you never created a CareCloud account, a doctor’s office or another healthcare provider could have used its technology to handle your information. Now, we are getting a much clearer picture of just how much information hackers took. ## CareCloud data breach affects more than 3.75 million people The cyberattack dates back to March 2026. According to a breach notice filed with the California Attorney General, CareCloud experienced a network disruption on March 16. The company brought in outside cybersecurity experts to investigate. CareCloud later determined that an unauthorized third party had access to one of its Amazon Web Services environments between March 10 and March 16, 2026. The company said the attacker claimed to have taken data from databases inside that environment. CareCloud also said it found no evidence of continued unauthorized activity after March 16. Early disclosures showed hundreds of thousands of people were affected. However, that figure later climbed dramatically. CareCloud has now reported that more than 3.75 million people were affected, according to federal health regulators. The disclosure places the incident among the largest healthcare data breaches reported so far in 2026. ## What hackers stole in the CareCloud data breach Here is where this breach becomes especially concerning. The stolen information goes well beyond an email address or phone number. What was exposed varies from person to person, but the data may include: - Names and postal addresses - Social Security numbers - Medical and health information - Driver’s license numbers, passport information and other government-issued IDs - Banking and other financial information Think about how much a criminal can learn from that combination. A Social Security number can help fuel identity theft. Banking information could put financial accounts at risk. Medical records can also give criminals deeply personal details that make phishing emails and scam calls far more convincing. Then there is another threat many people rarely think about: medical identity theft. ## Why stolen medical information can follow you for years You can change a password after a breach. Your medical history is much harder to replace. A criminal could use stolen insurance or personal information to seek medical care under someone else’s identity. Fraudulent claims can also appear under a victim’s health insurance. In some cases, incorrect treatment or medical information could eventually make its way into someone’s records. That creates problems that can extend beyond financial fraud. The Federal Trade Commission advises people who suspect medical identity theft to review their medical records and insurance statements. Look closely for unfamiliar treatments, providers, prescriptions or charges. We recently covered this growing problem in [Medical identity theft follows you into the doctor’s office.](https://www.foxnews.com/tech/medical-identity-theft-follows-you-into-doctors-office) ## What CareCloud says happened after the attack CareCloud says it brought in outside cybersecurity specialists after discovering the incident. The company also reported the attack to law enforcement and secured the affected environment. According to its breach notice, investigators found no continued unauthorized access after the incident was contained. CareCloud has also offered affected individuals complimentary identity protection services through IDX. If you received a notification letter, check it carefully for enrollment instructions and the amount of time you have to sign up. CyberGuy reached out to CareCloud for comment, but we did not hear back before our deadline. ## How to protect yourself after the CareCloud data breach A breach involving Social Security numbers, medical records and financial information deserves your attention even if you have not noticed anything suspicious yet. Here are the steps I recommend taking. ### 1) Read your CareCloud breach notice carefully Start with the letter or notification you received. Look for the specific types of information CareCloud says were involved in your case. Not every affected person necessarily had the same information exposed. If you were offered free identity protection or credit monitoring, review the terms and enrollment deadline. Consider signing up while the service remains available. ### 2) Freeze your credit If your Social Security number was exposed, consider freezing your credit with Equifax, Experian and TransUnion. A credit freeze limits access to your credit file. That can stop many criminals from opening new credit accounts in your name. Federal law allows you to freeze and unfreeze your credit for free. However, a credit freeze cannot block every form of identity theft. Someone could still attempt to take over an existing account or misuse your personal information in other ways. For a deeper look at those limitations, read [Why a credit freeze isn’t the end of identity theft.](https://www.foxnews.com/tech/why-credit-freeze-isnt-end-identity-theft) ### 3) Check your credit reports and financial accounts Keep an eye on your bank accounts, credit cards and credit reports. Look for purchases you do not recognize, unfamiliar credit inquiries or accounts you never opened. If something looks suspicious, contact the bank or financial institution directly. Use the phone number printed on your card or listed on the company’s official website. Be wary of anyone who unexpectedly contacts you and claims they need personal information to investigate the CareCloud breach. ### 4) Review your medical records and insurance claims Do not limit your monitoring to your credit report. Sign in to your healthcare portals and review your records. Also look carefully at the explanation of benefits statements from your health insurer. Watch for unfamiliar doctors, procedures you never received or claims that make no sense. If something looks wrong, contact both your healthcare provider and insurer. Medical identity fraud may never trigger a traditional credit alert, which makes checking these records particularly important. ### 5) Protect your online accounts Use strong and unique passwords for important accounts, especially email, banking and healthcare services. If you reuse the same password on multiple sites, change it. A[ password manager ](https://www.foxnews.com/tech/passkeys-vs-password-managers-why-you-shouldnt-ditch-password-manager)can generate and securely store complex passwords so you do not have to remember them all. Turn on two-factor authentication ([2FA](https://www.foxnews.com/tech/what-two-factor-authentication-should-enable-it)) whenever it is available. That extra verification step can make it harder for someone to get into an account even if they obtain your password. Pay extra attention to your primary email account. Criminals can use access to your inbox to reset passwords for other services. ### 6) Use strong antivirus software A stolen medical record could give a scammer enough personal information to send you a very convincing message. You might receive an email that appears to come from a doctor, health insurer or breach-response company. The message could include a malicious attachment or direct you to a fake login page. Strong antivirus software can help detect malicious links, dangerous downloads and other threats that arrive through phishing emails or scam messages. The best way to safeguard yourself from malicious links that install malware, potentially accessing your private information, is to have strong antivirus software installed on all your devices. This protection can also alert you to phishing emails and ransomware scams, helping keep your personal information and digital assets safer. Get my picks for the best 2026 antivirus protection winners for your Windows, Mac, Android & iOS devices at Cyberguy.com ### 7) Watch closely for personalized scams This breach creates another problem. Scammers may now have enough real information about victims to sound believable. Be skeptical if someone suddenly contacts you claiming to represent CareCloud, your doctor, your insurance company or a credit-monitoring service. A criminal might know your name, address or other personal details. That knowledge does not make the person contacting you legitimate. Avoid clicking links in unexpected messages. Instead, open the organization’s official website yourself or call a number you already trust. Also be suspicious of anyone demanding immediate payment or asking you to provide a verification code. ### 8) Use a personal data removal service The information stolen from CareCloud can become even more useful to criminals when they combine it with data that already appears online. People-search websites and data brokers can contain your phone number, current or previous addresses and other identifying information. Scammers can combine those details with breached data to build a more complete profile of you. A personal data removal service can help reduce your online footprint by sending removal requests to data brokers on your behalf. Some services also continue checking to see whether your information reappears. No service can guarantee that every piece of personal information will disappear from the internet. Still, removing information from data broker databases can make it harder for scammers to gather additional details about you. You can make removal requests yourself as well. However, doing it manually can be time-consuming and may require repeated requests. Check out my top picks for data removal services and get a free scan to find out if your personal information is already out on the web by visiting Cyberguy.com ### 9) Report identity theft quickly If you discover that someone is using your information, act quickly. Visit the Federal Trade Commission’s IdentityTheft.gov website to report identity theft and create a personalized recovery plan. Keep records of suspicious transactions, emails and letters related to the fraud. Save copies of any reports you file as well. The sooner you spot suspicious activity, the sooner you can start limiting the damage. ## Kurt’s key takeaways What bothers me most about the CareCloud breach is how little control you may have over where your medical information ends up. You can choose a doctor you trust. You can create strong passwords and protect your own devices. Yet some of your most sensitive information may still pass through another company’s systems behind the scenes. That leaves millions of people dealing with the consequences when something goes wrong. If your information was involved, I would take the notification seriously even if everything looks normal today. A stolen Social Security number or medical record can remain useful to criminals long after the original breach fades from the news. Freeze your credit if your Social Security number was exposed. Watch your medical records and financial accounts over time. Then be especially cautious when an unexpected email, call or text seems to know surprisingly personal details about you. I would also reduce what data brokers can easily find about you and keep strong antivirus protection running on your devices. Those added layers can make follow-up attacks harder for scammers to pull off. **Topics:** Public Awareness, Technology --- ### [Maryland Man Pleads Guilty In D.C. Medicaid Fraud Scheme Topping $250,000](https://insurancefraud.org/news_archives/maryland-man-pleads-guilty-in-d-c-medicaid-fraud-scheme-topping-250000/) **Published:** September 1, 2026 **Author:** Diane Beauchamp **Content:** A Silver Spring man pleaded guilty Wednesday in federal court for his role in a scheme that billed D.C. Medicaid for mental health services that were never provided or were dramatically inflated, causing more than $250,000 in losses. Said Nassor, 46, pleaded guilty Aug. 26, 2026, before U.S. District Judge Emmet G. Sullivan to one count of conspiracy to commit health care fraud. Nassor began working in August 2022 as a community support worker for a D.C. Medicaid provider authorized to deliver mental health rehabilitative services to youth and adolescent beneficiaries. From approximately January 2022 through at least February 2025, prosecutors said Nassor conspired with company employees and other community support workers to submit false and fraudulent claims for reimbursement to D.C. Medicaid. According to court documents, workers were directed to bill the maximum number of units allowed for each patient regardless of medical necessity or whether the services were actually provided. Community support workers were also instructed to bill a full hour for every telehealth encounter, regardless of how long the call lasted, and were trained to shave a few minutes off claims — such as billing 54 minutes instead of 60 — to make the calls appear more realistic. Workers were further directed to bill three hours, and later one hour, for diagnostic assessments regardless of how much time was actually spent with the patient. From July 27, 2022, through June 23, 2023, Nassor documented more than 701 hours of telehealth services across six patients. Call records showed he had actually spent only about 172 minutes on the telephone with them. On Oct. 21, 2024, Nassor also created and billed for three telehealth encounters involving an undercover FBI employee posing as a patient. Prosecutors said none of those encounters actually took place. Investigators determined Nassor’s role in the conspiracy caused more than $250,000 in losses to Medicaid. The investigation was conducted by the FBI Washington Field Office and the D.C. Office of the Inspector General’s Medicaid Fraud Control Unit. Assistant U.S. Attorney Jason Facci of the Fraud, Public Corruption and Civil Rights Section prosecuted the case. **Topics:** Medicare/Medicaid **Categories:** Conviction --- ### [Former social services director ordered to pay restitution in fraud case](https://insurancefraud.org/news_archives/former-social-services-director-ordered-to-pay-restitution-in-fraud-case/) **Published:** August 31, 2026 **Author:** Diane Beauchamp **Content:** A former director with Contentment Social Services has been sentenced to 12 months in jail for defrauding a client. Shum Shabat Yousouf was arrested in 2025 after police say she used her position of trust to gain access to a victim’s bank account and took money without their consent. She was sentenced last week and ordered to pay $73,598.99 in restitution. A charge of theft over $5,000 was withdrawn. Contentment Social Services made the news in March 2024 after it was revealed that clients were being housed in hotels and motels after being discharged from hospital. The housing provider was ultimately removed from the government’s list of agencies used to advise patients being discharged from hospitals. **Topics:** Insider Fraud **Categories:** Conviction --- ### [Kouri Richins ordered to pay over $1.3M in life insurance after murder conviction](https://insurancefraud.org/news_archives/kouri-richins-ordered-to-pay-over-1-3m-in-life-insurance-after-murder-conviction/) **Published:** August 31, 2026 **Author:** Diane Beauchamp **Content:** The Kamas mom, who is spending life in prison without the possibility of parole after being found guilty of killing her husband and insurance fraud, was ordered Friday to repay two life insurance companies. Kouri Richins’ attorney, Wendy Lewis, said she didn’t contest the amount prosecutors requested. Both attended the hearing remotely, with Kouri Richins at the prison. Third District Judge Richard Mrazik ordered her to pay $1,017,018.49 to Auto Owner’s Insurance and $352,562.61 to TruStage. Because she is in prison, he ordered the balance turned over to the Utah Office of Debt Collection. Prosecutors asked the court to order Kouri Richins to repay the money the insurance companies paid to her as the beneficiary of her husband’s life insurance policies. They said if she had not killed her husband, Eric Richins, the insurance companies would not have paid the money to her. “Their payment was not only foreseeable but also (Kouri Richins’) motive for murdering Eric Richins,” the prosecutors claimed. Kouri Richins, a former real estate agent, was convicted in March of poisoning her husband, 36-year-old Eric Richins, with fentanyl, causing his death on March 4, 2022. She was sentenced in May. She was arrested over a year after her husband’s death, and used that time to hire a ghostwriter to help publish a children’s book about grief. Lewis asked Mrazik to put the restitution amount on hold while Kouri Richins seeks to appeal her case; Mrazik, however, said he did not think he had the authority to do that, and Deputy Summit County attorney Brad Bloodworth agreed. Kouri Richins’ attorney said she would look into the matter and may file a request contesting that with the court handling her appeal. She is still facing five counts of mortgage fraud, seven counts of money laundering, pattern of unlawful activity and communications fraud, second-degree felonies; five counts of forgery, a third-degree felony; and seven counts of issuing a bad check, three a second-degree felony and four a third-degree felony. Her next hearing in that case, which Mrazik ordered would go to trial separately from the other charges, will be held on Oct. 9. **Topics:** Life Insurance **Categories:** Conviction --- ### [CMS Prevents $1.6 Billion in Fraudulent Medicare Laboratory Payments](https://insurancefraud.org/news_archives/cms-prevents-1-6-billion-in-fraudulent-medicare-laboratory-payments/) **Published:** August 31, 2026 **Author:** Diane Beauchamp **Content:** Centers for Medicare & Medicaid Services (CMS) enforcement actions have stopped more than $1.6 billion in potentially improper Medicare laboratory payments since the start of the Trump Administration – further evidence that CMS’ efforts to crush fraud are working to protect taxpayer dollars and improve Medicare program integrity. This includes $732 million in savings from the revocation of 157 fraudulent lab providers from the Medicare program. “When laboratories bill Medicare for tests they never performed, it drains the Medicare Trust Fund and diverts resources away from beneficiaries who need them,” said **CMS Administrator Dr. Mehmet Oz.** “That’s why, under the leadership of the White House Anti-Fraud Task Force, CMS has built a technology-powered fraud prevention operation to root out scammers all across our health care system, from laboratory testing and hospice care to medical equipment and autism therapy. We won’t stop until we’ve restored program integrity and ensured that fraudsters have nowhere left to hide.” The $1.6 billion in enforcement actions taken by CMS include the following: - Savings of $732 million from 157 fraudulent providers revoked from the Medicare program; - Over $500 million in potentially fraudulent payments halted from 185 payment suspensions from CMS’ investigation of 600 labs; - More than $276 million recouped from 442 identified overpayments already paid out to suspect labs; and - $127 million in potentially fraudulent payments prevented as the result of 85 law enforcement referrals from a CMS contractor. The savings in fraudulent payments were the result of CMS’ use of advanced analytics, including Artificial Intelligence (AI) and machine-learning models, to mine Medicare fee-for-service claims, looking for unusual billing patterns and other indicators of potential fraud, waste, or abuse. AI can help identify potential laboratory fraud by learning what normal billing and laboratory activity looks like and flagging unusual combinations of testing, results, billing, documentation, and relationships that may indicate manipulation or fraudulent activity. When these analytics identify high-risk billing patterns, CMS can use that information to automatically flag claims for further review and, when appropriate, hold, reject, or deny claims before any Medicare funds are released. CMS has targeted several types of lab fraud, including billing for medically unnecessary services to beneficiaries with no established relationship with the ordering provider, as well as labs billing for services that were not rendered or for up-coded services. These fraudulent billing patterns can occur across a range of laboratory services including pathogen detection, high-complexity drug tests, and genetic testing. Examples of fraudulent laboratory activity flagged by CMS: - One individual who owned a consulting company enrolled 14 labs in Medicare fee-for-service and billed more than $24 million for services that could not have been rendered because none of the labs were found to be operational. CMS suspensions are currently holding $12 million―half of the labs’ total amount paid. CMS has recouped an additional $7 million in fraudulent payments from these entities and coordinated action has resulted in the revocation of the Medicare enrollments of 11 of the 14, while investigations continue for the remaining three. - A Texas lab suspected of billing for services not rendered began billing at the end of February 2026 and received minimal payment before CMS detected the suspicious activity. The agency denied $1.2 million of the laboratory’s claims before the lab shifted billing practices in early April in an attempt to circumvent CMS controls. CMS analysts continued monitoring the lab, and a swift payment suspension prevented more than $150,000 in additional suspect payments. The provider was subsequently revoked that same month. - Another Texas lab suspected of billing for services not rendered began billing in earnest in May 2026, following two days of test claim submissions in January and March 2026. CMS denied $1.9 million of the laboratory’s claims, while a payment suspension captured an additional $1.7 million. The provider is under CMS review for revocation. Under the Trump Administration, CMS Medicare fraud prevention efforts have resulted in a record-shattering $42 billion in savings in Fiscal Year 2025 alone. So far in 2026, CMS has identified $1.8 billion in Medicare overpayments through medical review, collected $378 million in overpayments from post-payment reviews, and suspended more than $539 million in suspected fraudulent Medicare payments. Since January 1, 2026, the CMS Fraud Defense Operations Center has accounted for more than $371 million in Medicare suspended payments involving 267 providers and suppliers including: - More than $226 million for suspect durable medical equipment billing; - More than $53 million to suspect providers/suppliers billing for skin substitutes; and - More than $23 million to suspect hospice providers. **Topics:** Medicare/Medicaid, Public Awareness, Regulatory actions --- ### [Overland Park chiropractor pleads guilty to federal fraud charges](https://insurancefraud.org/news_archives/overland-park-chiropractor-pleads-guilty-to-federal-fraud-charges/) **Published:** August 31, 2026 **Author:** Diane Beauchamp **Content:** An Overland Park, Kansas, chiropractor has pleaded guilty to a federal health care fraud charge stemming from insurance claims submitted for services that prosecutors said were never provided. Kenya Laser, 35, pleaded guilty before U.S. Magistrate Judge W. Brian Gaddy to health care fraud. The prosecution is among federal fraud cases pursued under the leadership of President Donald Trump and through the establishment of the Task Force to Eliminate Fraud. According to information presented in court, Laser was enrolled as a provider with Blue Cross and Blue Shield of Kansas City, also known as Blue KC, and was authorized to submit claims seeking reimbursement for chiropractic and related services.Legal Federal prosecutors said Laser carried out a scheme from approximately March 2022 through March 2025 to obtain payments from Blue KC for health care services that were not provided as billed. Laser submitted insurance claims seeking payment for services purportedly provided to patients on dates when Laser knew those patients had not visited Laser Chiropractic and had received no medical treatment. As part of the scheme, Laser used an individual’s information to bill for services between October 2024 and March 2025, despite knowing the individual had never received treatment from Laser. Under federal law, Laser faces a maximum sentence of 10 years in federal prison without parole. The maximum statutory penalty is established by Congress and does not determine the sentence Laser will ultimately receive. The court will determine the sentence after considering the advisory sentencing guidelines and other factors required by federal law. A sentencing hearing will be scheduled after the United States Probation Office completes a presentence investigation. Assistant U.S. Attorney Rudolph R. Rhodes IV is prosecuting the case. The Federal Bureau of Investigation conducted the investigation. **Topics:** Healthcare Fraud **Categories:** Conviction --- ### [NYS Department of State’s Division of Consumer Protection Warns New Yorkers of a Surge in AI Investment Scams](https://insurancefraud.org/news_archives/nys-department-of-states-division-of-consumer-protection-warns-new-yorkers-of-a-surge-in-ai-investment-scams/) **Published:** August 31, 2026 **Author:** Diane Beauchamp **Content:** ### NYS Department of State’s Division of Consumer Protection Warns New Yorkers of a Surge in AI Investment Scams Consumers Reported Losing Over $8 Billion to Investment-Related Scams in 2025, a 38% Increase from 2024 Scammers Are Looking for Ways to Capitalize on Those Seeking Financial Security Scams Are Seemingly Attractive Income Opportunities and Quick False Wealth Schemes **August 27, 2026** The New York Department of State’s Division of Consumer Protection urges New Yorkers to remain vigilant against increasingly sophisticated investment scams driven by artificial intelligence (AI). According to the [Federal Trade Commission (FTC)](https://public.tableau.com/app/profile/federal.trade.commission/viz/FraudReports/StateSubcategories), 144,041 consumers reported losing over $8 billion to investment scams in 2025, a 38% increase from 2024. Consumers reported a median loss of $10,560 in 2025. This makes investment scams the costliest category of fraud tracked by the FTC for the year. Investment scams may begin through social media, text messages, dating apps, online advertisements, email or even a seemingly friendly conversation. Understanding how these scams work can help consumers recognize warning signs before they send money. “New Yorkers are always looking for ways to increase their financial standings and investing in new financial products may help to maximize short or long term dividends,” **Secretary of State Walter T. Mosley**. “New Yorkers need to be vigilant against scammers, who may be able to create increasingly sophisticated and realistic messaging using AI technology or other means to steal your hard-earned money. If it seems too good to be true, it probably is.” “As scams become more sophisticated, New Yorkers must stay vigilant,” **said Department of Financial Services Acting Superintendent Kaitlin Asrow.** “DFS works every day to combat fraud and ensure access to quality and affordable financial services.” **How Investment Scams Work** Scammers capitalize on those seeking financial security by fabricating attractive income opportunities and quick wealth schemes. They use a variety of strategies to convince victims: from exploiting human connection to build trust, to developing highly sophisticated AI schemes using fake voices, faces, social media celebrity endorsements and phishing messages. To convince victims the investment is real, scammers may use fake but professional-looking web applications or platforms that display phony account balances, investment returns or trading activity. Fake investment dashboards make it look like the victim’s money is growing, and in some cases, victims may be allowed to withdraw a portion of their money to deepen the trust before being encouraged to reinvest much larger amounts. **Common Types of Investment Scams** **Relationship Investment Scams:** These scams often take a longer time to develop and begin with an unexpected text message, social media contact, dating-app match or online friendship. The relationship may be romantic, friendly or professional, and rather than immediately asking for money, the scammer will build trust over time. Once trust is built, scammers may groom the victim by talking about their own investment success. They may share visuals of fake platforms showing huge financial growth to convince the victim that making money is easy and that they are missing out on large returns. The scammers may suggest certain investments, promise insider information, or recommend a “guaranteed” investment opportunity. **Social Media and Celebrity or Financial Experts Impersonation:** Scammers use AI to create convincing ads on social media featuring recognizable figures and celebrities that promise exclusive insider memberships or guaranteed high return investment tips. Scammers often clone voices and make deep-fake videos of celebrities or financial experts without their permission. **Most reputable broker-dealers and investment advisors do not post specific investment advice on social media platforms**. To learn more about this type of investment scam and victim stories, please read the [New York State Attorney General investor alert](https://ag.ny.gov/press-release/2026/investor-alert-attorney-general-james-warns-new-yorkers-investment-scams-meta) on this topic. **Fake Cryptocurrency Projects:** Cryptocurrency is a type of digital currency that exists only electronically. Scammers may create convincing impersonations of established businesses to lure victims into investing in a cryptocurrency market that doesn’t exist. - The advertised crypto coins and tokens are a scam to steal money from the people who buy them. - Always verify any advertised information directly through the advertised company’s official channels before investing. **Precious Metals and Gold Scams:** Scammers may promote fraudulent investments involving precious metals such as gold or falsely claim that buying gold is the only way to protect your money. - They may impersonate government officials and direct victims to buy gold bars and give them to a courier for ‘safekeeping.’ - Legitimate government agencies will not instruct consumers to do this. **Investment Recovery Scams:** Consumers who have already lost money may later be contacted by someone promising to recover the funds for a fee. These offers are frequently another scam and can lead to additional losses. **Know The Warning Signs of an Online Scam** - Offers of guaranteed or unusually high returns or pressure to invest immediately. - Unsolicited investment recommendations. - Requests to move conversations to private messaging apps. - Opportunities that require payments using cryptocurrency or wire transfers. - Demands for additional fees after investing or before withdrawals. - Overly complicated explanations and limited information. - Claims of “insider information” or a “secret method” to generate wealth. **Protect Yourself Before Investing** Before investing, **verify** four important things: - Verify the person. - Verify the company. - Verify the investment. - Verify where your money is going. **Confirm identities independently and research companies using official government resources, such as** [**Investor.gov**](https://gcc02.safelinks.protection.outlook.com/?url=https%3A%2F%2Fwww.investor.gov%2F&data=05%7C02%7CEleanor.Wright%40dos.ny.gov%7Cc62b2ad336704491b4fa08df03834ec1%7Cf46cb8ea79004d108ceb80e8c1c81ee7%7C0%7C0%7C639233534641678334%7CUnknown%7CTWFpbGZsb3d8eyJFbXB0eU1hcGkiOnRydWUsIlYiOiIwLjAuMDAwMCIsIlAiOiJXaW4zMiIsIkFOIjoiTWFpbCIsIldUIjoyfQ%3D%3D%7C0%7C%7C%7C&sdata=RG%2Bcbu76Z%2B2mV0SERsDtMMPh4HomuZXSBcMEoVtjRkw%3D&reserved=0) **hosted by the U.S. Securities and Exchange Commission** (“SEC”). The SEC can confirm if the investment professional is licensed, registered and if they have a disciplinary history or customer complaints; verify an investment product or company is registered with the SEC; provide their financial reports for review; and provide information on common investment scams. **Understand how the investment works and confirm that any account or cryptocurrency wallet belongs to the business you intend to pay**. Never invest in something you don’t understand. Be sure to always read the investment prospectus or disclosure statement carefully and ask a trusted professional for guidance if you aren’t completely clear on the details. **Take your time before making an investment decision**. Resist pressure to act quickly. Research the opportunity yourself, using contact information you locate independently rather than information supplied by the promoter. Discuss significant investments with a trusted family member, friend or independent financial professional. Remember that popularity on social media, celebrity endorsements and positive online reviews are not proof that investment is legitimate. **If You Think You’ve Been Scammed** - Stop sending money immediately. - Do not pay additional fees to release your funds. - Contact your financial institution, preserve emails, text messages and payment records, and report the fraud promptly. - Be cautious of anyone who later promises to recover your money for a fee. **Report Investment Scams** Consumers can report suspected investment scams to the [Federal Trade Commission](https://reportfraud.ftc.gov/), the [FBI Internet Crime Complaint Center](https://www.ic3.gov/), the [U.S. Securities and Exchange Commission](https://www.sec.gov/submit-tip-or-complaint), and the [New York State Attorney General](https://ag.ny.gov/file-complaint/finance-investment-lending). To report cryptocurrency fraud or file a complaint against a virtual currency company in New York State, contact the [New York State Department of Financial Services](https://www.dfs.ny.gov/complaint). **About the New York State Division of Consumer Protection** Follow the New York Department of State on [Facebook](https://www.facebook.com/NewYorkDepartmentOfState/), [X](https://x.com/NYSDOS) and [Instagram](https://www.instagram.com/nysdos/?hl=en) and check in every Tuesday for more practical tips that educate and empower New York consumers on a variety of topics. Sign up to receive consumer alerts directly to your email or phone [here](https://public.govdelivery.com/accounts/NYSDOS/subscriber/new). The New York State Division of Consumer Protection provides voluntary mediation between a consumer and a business when a consumer has been unsuccessful at reaching a resolution on their own. The Consumer Assistance Helpline 1-800-697-1220 is available Monday to Friday from 8:30am to 4:30pm, excluding State Holidays, and consumer complaints can be filed at any time at [www.dos.ny.gov/consumer-protection](https://dos.ny.gov/consumer-protection). The Division can also be reached via X at [@NYSConsumer](https://x.com/NYSConsumer) or [Facebook](https://www.facebook.com/nysconsumer). **Topics:** Public Awareness, Technology --- ### [Two people arrested and charged in connection with 2025 Cass County “Pub” fire](https://insurancefraud.org/news_archives/two-people-arrested-and-charged-in-connection-with-2025-cass-county-pub-fire/) **Published:** August 31, 2026 **Author:** Diane Beauchamp **Content:** Cass County Sheriff Bryan Welk announced that two people have been arrested and charged in connection with a commercial fire near State Highway 200 Northeast in Remer Township. According to Sheriff Welk, arrest warrants were issued for Kory Alvin Wagner, 52, of Hill City and Heather Pero, 36, of Grand Rapids. Both were arrested in Itasca County and taken to the Itasca County Detention Center. The fire was first reported at 5:30 a.m. on Sunday April 27, 2025, at 6691 State Highway 200 Northeast. Responders found “The Pub,” a bar, engulfed in flames. Fire crews from Remer and Longville worked to control the fire, which caused significant loss. According to court documents, Wagner purchased the Pub in March 2023 and listed in for sale in the fall of 2024. The criminal complaint states that Wagner and Pero admitted to being at “The Pub around 4:00 a.m. that morning to get some food. Law enforcement also met with staff who commented that they heard Wagner and Pero make comments about burning the building and even asked some staff if they be interested in burning the building, according to the criminal complaint. Court documents state that the fire originated from two places in the building, that there was no evidence the fire started as a result of a mechanical or electrical issue in the building, and that the fires did seem to be a “deliberate human act”. Wagner faces charges of aiding and abetting first-degree arson, aiding and abetting second-degree arson and attempted insurance fraud. Pero is charged with aiding and abetting first-degree arson and aiding and abetting second-degree arson. Formal court appearances for Wagner and Pero are pending in Cass County District Court. **Topics:** Business - arson **Categories:** Arrest --- ### [Fraudster Who Impersonated DEA Agent Sentenced to Federal Prison](https://insurancefraud.org/news_archives/fraudster-who-impersonated-dea-agent-sentenced-to-federal-prison/) **Published:** August 31, 2026 **Author:** Diane Beauchamp **Content:** Matthew John Sanguine (49, Orlando) has been sentenced by U.S. District Judge Anne-Leigh Gaylord Moe to five years and five months in federal prison for bank fraud, aggravated identity theft, and impersonating an officer of the United States. Sanguine pleaded guilty on December 4, 2025. As part of his sentence, the court also entered an order of forfeiture in the amount of $10,000, the proceeds of bank fraud conviction. United States Attorney Gregory W. Kehoe made the announcement. According to court documents, on May 2, 2022, Sanguine was stopped by the Orlando Police Department while driving a stolen vehicle. Officers found a Florida driver license bearing Sanguine’s photo but listing the identity of an Arizona resident (“J.R.”). The officers kept that fraudulent document as part of the evidence involved in that case. While his case was progressing in state court in Orlando, Sanguine presented the State Attorney’s Office with a fraudulent letter that was purportedly authored by an agent with the Drug Enforcement Administration. The fake letter included claims that Sanguine was authorized to have the false driver license bearing the name “J.R.” because Sanguine was working as an informant for the DEA. The letter demanded that the State Attorney’s Office return the confiscated driver license because Sanguine needed this fake identity to avoid detection by drug cartels. The letter warned of a “grave risk” unless the license was returned to Sanguine “immediately” and all records of this license were removed from the court records. The State Attorney’s Office suspected the letter was not authentic and referred the matter to the FBI. The FBI’s investigation revealed that Sanguine was using “J.R.’s” identity for at least a decade and had used it to perpetrate bank fraud for $10,000. This case was investigated by Federal Bureau of Investigation, with assistance from the Orlando Police Department and the State Attorney’s Office for the Ninth Judicial Circuit. It was prosecuted by Assistant United States Attorney Michael P. Felicetta and Dana E. Hill. The forfeiture is being handled by Assistant United States Attorney Nicole M. Andrejko. **Topics:** Synthetic Identity Theft, Unlicensed entities **Categories:** Conviction --- ### [Berkeley County Woman Sentenced for Defrauding Small Business Out of Nearly $300,000](https://insurancefraud.org/news_archives/berkeley-county-woman-sentenced-for-defrauding-small-business-out-of-nearly-300000/) **Published:** August 31, 2026 **Author:** Diane Beauchamp **Content:** A Martinsburg, West Virginia, woman will spend nearly four years in federal prison for defrauding a small business out of nearly $300,000, announced U.S. Attorney Matthew L. Harvey. Brittaney Allura Hall, 37, was sentenced to 46 months in federal prison for wire fraud. Hall worked as an office manager and accountant for a business in Martinsburg, giving her access to accounts and financial information for the company. Hall caused overpayments of payroll in reimbursements and commissions for her own benefit, wrote checks to herself without authority, and created false invoices which caused unauthorized payments to be made in her name. Hall was ordered to pay $258,143.51 in restitution. Assistant U.S. Attorney Eleanor Hurney prosecuted the case on behalf of the government. The FBI and the Berkeley County Sheriff’s Office investigated. U.S. District Judge Gina M. Groh presided. **Topics:** Insider Fraud **Categories:** Conviction --- ### [Maine Fraud Cases Pile Up as Federal Investigators Face Resource Crunch](https://insurancefraud.org/news_archives/maine-fraud-cases-pile-up-as-federal-investigators-face-resource-crunch/) **Published:** August 31, 2026 **Author:** Diane Beauchamp **Content:** When Vice President J.D. Vance paid his second visit to Maine, he was there in Brewer to bang the drum for Republican U.S. Senator Susan Collins’ Senate race and ME-CD2 frontrunner Gov. Paul LePage – two household names vying for offices that could well determine whether President Donald Trump has a cooperative GOP Congress for his final two years in office. Yet for Vance, tapped by President Trump to head the White House Fraud Task Force amid a national reckoning over welfare fraud committed disproportionately by noncitizens and immigrants, one question lingered in the minds of even the most diehard MAGA fans: When will the fraudsters get arrested? When will the thieves get justice? The question is all the more pressing because of the brazenness of the fraud, with dozens of newly minted MaineCare businesses rapidly rising to tens of millions in annual billing as their CEOs acquire high-end homes and luxury vehicles. While some of these Medicaid moguls have had their funding cut off, dozens more continue to bill taxpayers with impunity, and no one has even hinted that jail time and restitution might be in the picture. Detailed Medicaid data, released by the Trump Administration in January, tells a story of explosive cost growth in the very programs where fraud allegations are piling up — cost growth that should have been glaringly obvious to any government official tasked with protecting the integrity of public benefit programs. Home health care spending in Maine went from $42.6M in 2018 to $116M in 2024 — an increase of 175 percent — while the number of Mainers getting “home care” went from 2,488 to 3,192, an increase of just 28 percent. MaineCare has paid out $512.5 million during this period to provide help with daily household activities for fewer than 3,200 people. Autism group homes also exploded in growth. From 2019 to 2024, according to federal data, 27 new autism group home companies were founded in Maine, at a cost of $473 million. Even more alarming, these MaineCare start-ups are billing at a mathematically improbable rate over the autism care providers that existed in the state prior to 2019. Federal data shows that Maine had 48 firms billing under the T2016 code for autism residential services in 2018, for an annual total of $250.5 million. That works out to about $12,380 per month per patient. From 2018, as the flood of new group home operators entered the scene, nine of the older providers went out of business. The new group home operators proceeded to out-bill the older companies on a per-client basis by 32-47 percent, depending on the year. While the incumbent providers charged a monthly average of $19,896 per client in 2024, the 27 new firms averaged $28,450 per beneficiary per month. One of the most expensive of the new firms averaged $39,235 per client per month — or $470,820 annually for a single patient. So when the fraud is mathematically screaming out of the databases, why can’t state or federal investigators stop the fraudsters from looting the treasury in a poor state like Maine? A source in the District of Maine’s U.S. Attorney’s Office, who requested anonymity to speak openly about challenges facing the Trump Administration’s effort to combat systemic welfare fraud and foreign criminal cartels, said the volume of potential fraud cases and cases related to transnational criminal organizations has far exceeded the small office’s capacity to properly investigate. Compounding the problem is former U.S. Attorney Darcie McElwee, an ally of Democratic Gov. Janet Mills who was appointed by President Joe Biden, refused to prosecute most drug and welfare fraud cases, meaning President Donald Trump’s U.S. Attorney, Andrew Benson, inherited almost no major fraud cases that were near completion. “We’re starting from scratch with an understaffed office, a state Attorney General who has prosecuted no new cases of fraud, and a state government that has turned a blind eye to unprecedented levels of welfare fraud and organized crime for eight years,” the source said. The source said there were at least seven major welfare fraud investigations in the District of Maine that are on hold due to a lack of resources and manpower. “We could quintuple the number of lawyers and investigators working fraud and racketeering cases and everyone would still be working overtime,” the source said. Conditions in the U.S. Attorney’s office align with what’s known publicly and what sources have told the Maine Wire about the lack of effort by Maine Attorney General Aaron Frey and the Department of Health and Human Services to investigate and prosecute major Medicaid and Food Stamp fraud cases. McElwee’s record on Medicaid fraud was anemic, relying primarily on cases that preceded her appointment. Most of the Medicaid fraud cases she handled involved individuals lying about their income to obtain benefits, as opposed to the multi-million dollar provider-side fraud cases now surfacing in places like Minnesota, California, New York, and Maine. The largest provider case McElwee handled involved a therapist in Corinna who was given three years probation, a $2,500 fine, and ordered to pay $13,087.62 in restitution. Separate from the situation in the U.S. Attorney’s office, two individuals familiar with the state of Maine’s fraud investigations under the Mills administration told the Maine Wire about a fraud investigation that exemplifies how DHHS and left-wing district attorneys have turned a blind eye to brazen benefits theft. Both individuals spoke on the condition of anonymity out of fear of retaliation by government agencies. Together, they told the story of how Antoine R. Bikamba, 53, flitted around the small world of left-wing Portland area non-profits, allegedly stole multiple debit cards and EBT cards belonging to clients, was effectively caught red-handed but never prosecuted and instead went on to start an autism company that has billed MaineCare nearly $8 million. Bikamba, according to both sources as well as other public records, worked for Preble Street as a caseworker, then at Spurwink as a Direct Support Professional (DSP), for the Greater Portland Immigrant Welcome Center board, and then for Shalom House. During his time working for Shalom House, the sources said, Bikamba was subcontracting for the Portland Housing Authority (PHA). During this time, his contract was terminated after he was accused of stealing and using a clients debit card and multiple EBT cards. “He stole a Portland Housing Authority client’s debit card and made unauthorized transactions with that client’s debit card at an ATM,” one source said. “Portland Housing Authority told that client that they needed to file a police report… You’re telling me that you’re telling a client to go file a police report when they have freaking case managers? Because they are an individual that is not capable of taking care of themselves.” The theft was never reported to the Portland Police Department. A subsequent investigation into the use of an EBT card by an individual who had died led once again to Bikamba. “Lo and behold, someone was also calling into the department, pretending to be the client at least 10 times after they had passed to follow up on their SNAP benefits, and when we did a reverse search on the phone number that was calling, it came back to Antoine Bikamba’s phone number,” the source said. Further investigation found that Bikamba had attempted to call Maine DHHS regarding the EBT card benefits of multiple other individuals, the sources said. That included the EBT card of an individual who was found wandering the streets of Portland in July of 2020 in a state of apparent dementia. The individual, a non-English speaking illegal alien from an unknown African country, was hospitalized at taxpayer expense for more than a year. Eventually, Maine’s Office of Aging and Disability Services (OADS) took custody of that individual, whose medical condition required 24/7 intensive long-term care, and secured a no-bid contract worth more than $800,000 to put them in a long-term care facility in Oakland. [That no-bid contract was the subject of a previous Maine Wire report last year.](https://www.themainewire.com/2025/04/maine-paid-over-800000-to-put-a-single-illegal-alien-in-specialized-residential-care-for-5-years-through-no-bid-contract/) According to the sources, the entire investigation into Bikamba’s alleged welfare fraud and identity theft were given to Cumberland County District Attorney Jackie Sartoris, a far left progressive who won office in 2022 thanks to $385,000 in campaign spending from George Soros-affiliated political groups. “It was gift wrapped and packaged off to Jackie Sartoris’s office, and the last we were aware, it was still sitting there,” the source said. Sartoris’s office refused to respond to multiple inquiries about the status of Bikamba’s case. Bikamba, in a phone interview, said he was unaware of any case involving him and denied ever having used another person’s EBT card benefits. Multiple inquiries to the Maine DHHS regarding Bikamba went unanswered. ## Pastor Tony Moves from EBT Cards to Autism Group Homes Bikamba, a self-described Rwandan migrant who sometimes goes by Pastor Tony, arrived in Maine in 2008. didn’t have to scrounge for EBT cards for long. While the prosecution referral was collecting dust on Sartoris’s desk, Bikamba was busy forming Green Leaf Residential Care, LLC, a multi-million-dollar MaineCare provider that operates autism group homes throughout Maine. From 2022 to 2025, Bikamba collected $6.8 million in MaineCare payments, according to records obtained under the Freedom of Access Act. In a phone interview, Bikamba acknowledged running the autism group homes, but he denied that he ever brought any disabled migrants to the state and denied ever improperly using another individual’s EBT card. “I’m not aware of that,” he said. Although Bikamba began billing MaineCare in 2022, state records show that his company was not licensed to provide residential care until Oct. 2025. State records show that Green Leaf operates group homes on Garland Road and Cardinal Way in Bangor, Hotel Road in Auburn, Holyoke Street in Brewer, and Hallowell Road in Durham. The same records show that Green Leaf underwent what DHHS refers to as a “desk review,” wherein a government employee inspects the company over the telephone, and was found to have no deficiencies. If Bikamba’s wheels are any indication, business is booming. Public records show he owns a 2016 Mercedes GLC and a 2021 Mercedes GLE. Prior to that, he owned a BMW X5, an Audi Q7, and an Audi Q5. But before he tapped into the MaineCare cash flow, Bikamba relied on more humble wheels – a 2008 Nissan Rogue that he purchased in 2012 with Jocelyne Ininhazwe, the former CEO of the now-defunct Paradise Residential Services, an autism group home company that bills the same exact program as Green Leaf Residential. While Green Leaf remains in business, Paradise’s operations were terminated on an emergency basis earlier this year after state inspectors found serious deficiencies that threatened the health and well-being of their clients. From 2022 to 2026, Paradise managed to bill nearly $25 million. Like Bikamba, Ininahazwe is an immigrant from Central Africa and, like Bikamba, she’s a fan of German luxury vehicles, with both her and her son owning a Mercedes E-Series and a Mercedes G-Wagon. In the phone interview, Bikamba said he and Ininahazwe are just friends, and he declined to comment on the remarkable coincidence that both of them struck it rich in Maine’s autism group home industry. Green Leaf Residential Care and Paradise Residential Services are just two examples of “New Mainers” running start-up MaineCare businesses that exploded in cost under the Mills administration with next to no scrutiny from regulators until the Trump administration and CMS Administrator Oz began bearing down on the state. In response to an April Freedom of Access Act request for records related to Ininahazwe, Bikamba, and several of their associates in the autism group home industry, DHHS asked the *Maine Wire* to pay more than $40,000 for records that would take more than one year to deliver. “Given the scope of your request, the Department’s initial, good faith, non-binding estimate to retrieve, compile, and review the responsive records that are subject to FOAA will be $41,085.50 for 1,645.42 hours of work in which the estimated time to be completed in 411 days from the time a check is received,” the agency said. ## Maine’s Fraud Squad AWOL Although the Maine DHHS claims that it refers cases of suspected fraud to the Attorney General’s office, there’s little evidence that Attorney General Aaron Frey treats the theft of millions of taxpayer dollars — or the abuse and neglect of disabled Mainers — with the same seriousness and alacrity that he does amicus briefs for [transvestites](https://www.themainewire.com/2022/12/maine-ag-aaron-frey-backs-taxpayer-funded-castrations-for-west-virginians/) in West Virginia or [symbolic lawsuits](https://www.themainewire.com/2024/11/maine-ag-aaron-frey-facing-far-left-challenger-files-symbolic-suit-against-energy-companies/) against Exxon-Mobil. Frey, a former Democratic lawmaker, was tapped by Democratic lawmakers to serve as AG in 2018. Since that time, his office has assisted with just three cases of Medicaid fraud — and all of them related to the same federal conspiracy case that was investigated and built two years before he came into office. That case, which resulted in guilty pleas from Abdirashid Ahmed, Garat Osman, and Nancy Ludwig, was spearheaded by the FBI and the Department of Homeland Security beginning in 2016, when both President Donald Trump and Gov. Paul LePage were in office. In a March letter to Centers for Medicare and Medicaid Administrator Dr. Mehmet Oz, the Mills Administration said that Maine DHHS made four criminal referrals to the AG’s office in 2021 — all of which were declined. From 2022 to 2025, DHHS referred 18 cases for criminal prosecution but, as of Feb. 2026, only one resulted in a guilty plea. Apart from cases that began before he took the job, there’s no public record of Frey pursuing a single welfare or MaineCare provider fraud case — even as total spending and fraudulent spending ballooned on his watch. In the high-profile instance of Gateway Community Services, a migrant services agency that has been credibly accused of defrauding the state as it billed roughly $5 million per year the entire time Frey was in office, the Attorney General actually awarded Gateway a $400,000 opioid grant *after* whistleblower allegations were published by The Maine Wire and replayed throughout national media. To date, Frey has announced no charges against anyone involved in Gateway’s alleged fraud scheme, and Somali-American founder Abdullahi Ali has absconded to Kenya. Although Mills initially brushed off Centers for Medicare and Medicaid Administrator Dr. Mehmet Oz’s critical audits of Maine’s Medicaid mismanagement as political attacks, behind the scenes she and her allies were scrambling to create some semblance of fraud enforcement. In August, following Administrator Oz’s interview with The Maine Wire, DHHS issued a press release touting its enforcement actions, the majority of which involved canceling the provider agreements of businesses that never billed MaineCare in the first place. Of the providers suspended by Mills and her DHHS Commissioner Sara Gagne-Holmes, only seven were actively billing MaineCare and account for more than $138 million in taxpayer spending, according to state and federal payment records. Records released by the Mills administration revealed that, on the same day Mills blasted Oz as a “TV doctor,” her administration issued the termination letters to Paradise Residential Services and Beyond Residential Care. Felix R. Hagenimana, the founder of [Beyond Residential Care](https://www.themainewire.com/2026/08/rwandan-immigration-lawyer-faces-bar-complaint-after-13m-autism-mainecare-biz-axed/), has also been accused by the Maine State Bar Association of using ChatGPT to file bogus asylum claims for nearly 1,500 central African illegal aliens – the same population from which most of the African-owned autism firms draw their non-English-speaking employees. Hagenimana, himself a Rwandan migrant, has denied the allegations in the Maine Bar complaint. The same release touted by the Mills administration also include Gateway, which was suspended almost a year ago. In all seven of the cases the Mills administration as pointed to as evidence of their tough stance on fraud, there have been no arrests, no orders of restitution, and no indications that taxpayers will ever be repaid. Beyond the financial fraud, state investigators described harrowing conditions of neglect, abuse, and rights violations at the group homes controlled by the two companies. In a termination letter obtained under a Freedom of Access Act request, state officials said the two autism residential care providers were found violating the disability rights of autistic Mainers and putting their lives in immediate jeopardy, with homes described as filthy, dangerous, and understaffed. In light of the U.S. Attorney of Maine’s apparent lack of resources to confront widespread fraud within the home health care sector, but also the residential autism care industry, it’s worth asking how many other lives are currently in jeopardy because the state hasn’t effectively ensured that multi-million dollar Medicaid businesses are protecting Maine’s disabled population. In a comment to the Maine Wire, Oz reiterated his commitment to snuffing out fraud in the Pine Tree State. “Fraud doesn’t just waste taxpayer dollars — it erodes trust in the programs millions of Americans rely on,” said Oz. “When credible instances of fraud emerge, taxpayers and beneficiaries deserve to see swift action,” he said. “We need all stakeholders including state leaders in Maine to move with urgency and work aggressively with federal partners to root out fraud, protect taxpayer dollars, and ensure Medicaid is there for the people it was meant to serve.” **Topics:** Public Awareness, Regulatory actions --- ### [OC Judge Who Conspired With LA Doctor Sentenced For Workers' Comp Fraud](https://insurancefraud.org/news_archives/oc-judge-who-conspired-with-la-doctor-sentenced-for-workers-comp-fraud/) **Published:** August 31, 2026 **Author:** Diane Beauchamp **Content:** Former Orange County Superior Court Judge Israel Claustro was sentenced Thursday to one year of probation for workers’ compensation fraud. Claustro, who was also ordered to pay a $5,000 fine, pleaded guilty Jan. 12 to one count of mail fraud and agreed to resign from the bench. The Commission on Judicial Performance subsequently issued a public censure and barred him from holding future judicial office. Under federal sentencing guidelines, Claustro initially faced four to 10 months behind bars and a fine ranging from $2,000 to $20,000, but prosecutors recommended a reduction based on his early acceptance of responsibility and agreement to resign. “We appreciate the careful evaluation by the government and the fair sentence by the court,” Claustro’s attorney, Paul Meyer, said. “This was a just result.” Claustro engaged in the fraud scheme with Dr. Kevin Tien Do while Claustro was a prosecutor with the Orange County District Attorney’s Office. Do pleaded guilty Jan. 3, 2025, to one count each of conspiracy to commit mail fraud and subscribing to a false tax return. Do is awaiting sentencing Sept. 15. “Judge Claustro violated the law for his personal financial benefit,” First Assistant U.S. Attorney Bill Essayli said following Claustro’s guilty plea. “We will not hesitate to prosecute anyone — judges included — who defraud public benefits intended to help those in need.” Meyer said previously that Claustro “deeply regrets his wrongful 2022 participation in a business venture that did not involve any part of his work as a district attorney and ended before he became a judge. He takes full responsibility for his actions, and cooperated fully in the investigation. In good faith, with sadness, he is voluntarily resigning his judicial office.” Orange County Superior Court spokesman Kostas Kalaitzidis said his office was prohibited from commenting because of court ethics rules. Claustro had served in Family Law court since his election and had been on leave since the beginning of the year before entering his plea, Kalaitzidis said. According to Claustro’s plea agreement, prosecutors agreed to recommend probation or up to six months of home confinement and not to pursue charges related to taxes. Federal prosecutors remain free to prosecute Claustro “for any other unlawful past conduct or any unlawful conduct that occurs after the date of this agreement,” according to the deal. Claustro operated Rancho Cucamonga-based Liberty Medical Group Inc. even though state law requires such businesses to be operated by a doctor or medical professional, prosecutors said. When Do was charged in 2024, prosecutors referred to Claustro as an unnamed co-conspirator. In his plea agreement, Do acknowledged that Claustro was the actual owner and that Do was unable to perform the work because he had been suspended following a 2003 conviction for felony health care fraud. “I was paid $306,111 for work I should not have done,” Do said in court when he pleaded guilty last year. Prosecutors said Claustro was aware of Do’s prior criminal conviction and inability to work in the program. Do appealed his suspension and informed Claustro when he lost the appeal in October 2018, prosecutors said. “I knew Dr. Do prepared medical reports after being suspended from the workers’ compensation program,” Claustro said at his change-of-plea hearing. In his plea agreement, Claustro admitted defrauding the state’s Subsequent Injuries Benefits Trust Fund, part of the workers’ compensation system that provides benefits to injured workers with preexisting disabilities. Claustro paid Do to prepare medical reports, prosecutors said. The scheme involved using other doctors’ names on billing forms and reports. Prosecutors pegged the loss at about $38,670 and said the state paid more than $3 million in billings submitted by the company. Do hired a medical professional to conduct patient evaluations, but that person died of natural causes in December 2021, prosecutors said. Afterward, Claustro continued to pay Do for medical evaluations, medical record reviews and preparation of med-legal reports, according to prosecutors. The $38,670 loss was determined to be the amount Claustro paid Do “after defendant became aware that co-schemer Do was actually providing the services,” prosecutors said in the plea agreement. Do also admitted failing to report $66,227 in income on his 2021 tax return. The income was paid to an entity he controlled rather than directly to him to conceal the fraud, prosecutors said. Do was previously convicted in August 2003 of aiding and abetting health care fraud, according to the Medical Board of California. He was sentenced to a year in federal prison in October 2003 and ordered to pay $366,031.24 in restitution. Do participated in a scheme to defraud Medi-Cal from April 1997 through the end of 1998, according to the medical board. In his current case, Do admitted in his plea agreement that from October 2018 through February 2024, he participated in a scheme to defraud the state out of millions of dollars in workers’ compensation funds, prosecutors said. Do prepared workers’ compensation-related medical reports that were billed to the state’s Subsequent Injuries Benefits Trust Fund, prosecutors said. Do fraudulently listed other doctors’ names on billing forms and medical reports because he was prohibited from performing the work, prosecutors said. He admitted in his plea agreement that Liberty received more than $3 million from the state for reports submitted after his 2018 suspension. According to Do’s plea agreement, about $1.5 million went to the company’s owner and his wife. **Topics:** Insider Fraud, Workers Comp **Categories:** Conviction --- ### [Attorney General Brown Sues United Healthcare and Optum for Allegedly Defrauding Maryland Medicaid Program with Defective Computer System ](https://insurancefraud.org/news_archives/attorney-general-brown-sues-united-healthcare-and-optum-for-allegedly-defrauding-maryland-medicaid-program-with-defective-computer-system/) **Published:** August 31, 2026 **Author:** Diane Beauchamp **Content:** Attorney General Anthony G. Brown filed a lawsuit against UnitedHealth Group (also known as United Healthcare) and Optum, Inc., a wholly-owned subsidiary of United Healthcare, for allegedly providing a defective computer system to Maryland Medicaid’s behavioral health program that crashed on its first day of use and never functioned properly, costing state taxpayers tens of millions of dollars. United Healthcare is the nation’s largest healthcare company. The crash was so severe that the Maryland Medicaid program had to take its system off-line for eight months in 2020, putting the program that provides mental health and substance abuse care to the 1.5 million Marylanders on Medicaid in jeopardy. “Marylanders in crisis and the providers who care for them rely on Maryland’s Medicaid program for essential mental health and substance abuse care. Optum provided a defective system that failed them for years,” **said Attorney General Brown.** “My Office will hold United Healthcare and Optum accountable and recover the money Maryland taxpayers are owed.” The case arises from Optum’s contract with the state’s Medicaid behavioral services program from 2019 to 2024. The state contracted with Optum for $126.9 million to run the Maryland Medicaid program’s Administrative Services Organization program, which processes and pays medical providers for behavioral health services. The lawsuit alleges that Optum, just months before its system was slated to go live, swapped out its own proprietary claims management software and installed an inadequately-tested, inadequately-vetted system made by a subcontractor. The software platform immediately crashed and could not distinguish between medically necessary and frivolous services. It also denied legitimate claims, failed to provide receipts to large-scale providers like hospitals that, in turn, struggled to run their businesses, paid incorrect amounts to providers, and failed to block rampant, multi-million-dollar fraud in areas such as substance abuse treatment and laboratory urine testing. The problems threatened the entire system, prompting state Department of Health officials to take it offline and use *ad hoc* estimates to pay providers and keep the system afloat. This forced measure likely cost the state tens of millions of dollars, according to the lawsuit, which also lists numerous other ways the crash led to state monetary losses and expenditure of resources. The lawsuit alleges that Optum’s conduct constituted a violation of the state False Claims Act and seeks up to triple the contract price it paid in damages, about $380 million. The lawsuit also alleges a number of common law causes of action, including breach of contract, unjust enrichment, and intentional misrepresentation. The lawsuit was filed in Baltimore City Circuit Court.​ **Topics:** Judicial/courts, Public Awareness --- ### [Anaheim woman admits to $2.2M Medicare hospice fraud](https://insurancefraud.org/news_archives/anaheim-woman-admits-to-2-2m-medicare-hospice-fraud/) **Published:** August 31, 2026 **Author:** Diane Beauchamp **Content:** An Anaheim woman pleaded guilty Thursday to submitting more than $2.2 million in fraudulent Medicare claims for hospice care for patients who were not terminally ill, federal prosecutors announced. Lynn Galbraith, 60, pleaded guilty to one count of health care fraud, according to the U.S. Attorney’s Office for the Central District of California. Galbraith was the co-owner and operator of Garden Grove-based Azure Hospice Care Inc. from September 2019 until July 2022, when she became its sole owner. She remained the owner until February 2024. During that time, prosecutors said Galbraith knowingly submitted claims to Medicare for hospice services provided to patients who did not have a terminal illness with a life expectancy of six months or less, as required to qualify for the benefit. According to her plea agreement, Galbraith either knew the patients did not qualify for hospice care or knew there were insufficient medical records to support diagnoses and prognoses that would make them eligible. Prosecutors said she also did not routinely coordinate with patients’ primary care physicians about their purported conditions or terminal prognoses. In one example cited by federal officials, Galbraith submitted a $6,600 Medicare claim in October 2022 for hospice services provided to a patient despite knowing there was insufficient medical documentation to establish that the person was eligible for hospice care. In all, Galbraith submitted approximately $2.27 million in false claims on behalf of Azure Hospice Care, according to prosecutors. Medicare paid the company approximately $2.14 million. Galbraith is scheduled to be sentenced Dec. 3 by U.S. District Judge John A. Kronstadt. She faces a statutory maximum sentence of 10 years in federal prison. **Topics:** Medicare/Medicaid **Categories:** Conviction --- ### [Two people arrested for alleged insurance fraud](https://insurancefraud.org/news_archives/two-people-arrested-for-alleged-insurance-fraud/) **Published:** August 31, 2026 **Author:** Diane Beauchamp **Content:** Raleigh County Sheriff Frank Priddy says deputies have arrested two people following an alleged false burglary report on June 13. According to a press release, Lucas Boggess and Adrianna Smith initially told deputies that multiple items were stolen from their home. However, investigators learned of multiple inconsistencies with what they were told and what was told to the suspects’ insurance. The investigation showed evidence that the reported burglary and insurance claims were allegedly false. Lucas Boggess and Adrianna Smith are both facing charges including insurance fraud and attempted fraudulent schemes. Boggess’s bond is set for $400,000, and Smith’s bond is set for $300,000. **Topics:** Homeowners Fraud **Categories:** Arrest --- ### [Two Conspirators Sentenced For Staging Car Crashes On New York City Highways](https://insurancefraud.org/news_archives/two-conspirators-sentenced-for-staging-car-crashes-on-new-york-city-highways/) **Published:** August 31, 2026 **Author:** Diane Beauchamp **Content:** Queens District Attorney Melinda Katz and New York Governor Kathy Hochul announced today that Jaime Huiracocha and Victor Murillo have been sentenced for their roles in staging three car crashes on New York City highways and seeking insurance payouts for damages and purported injuries. Huiracocha orchestrated the collisions by recruiting participants with promises of cash payouts while Murillo drove the vehicles involved in the crashes. DA Katz said: “Staged auto collisions not only terrify the drivers who are targeted, they put other motorists at risk and ultimately lead to increased insurance costs for all New Yorkers. Thanks to a brave victim who came forward with dashcam video, and an investigation by my Financial Frauds Bureau with our partners at the NYPD and New York State Department of Financial Services, we secured convictions against two defendants who orchestrated three crashes. I thank Governor Kathy Hochul for being a nationwide leader on the issue of insurance fraud and enacting a series of reforms that will help prosecutors bring more cases and save New Yorkers money.” New York State Governor Kathy Hochul said: “Today we’re sending a message to would-be-fraudsters everywhere: If you stage crashes, try to defraud or endanger New Yorkers, you will be held accountable. This kind of reckless, illegal behavior has been driving up auto insurance costs for millions of New Yorkers for far too long. By cracking down, we’re not just getting dangerous criminals off our roads, we’re putting money back into the pockets of everyday drivers.” New York State Department of Financial Services Acting Superintendent Kaitlin Asrow said: “Insurance fraud leads to higher costs for all drivers and is a strain on New York’s insurance system. Fraud enforcement is part of DFS’s continued work to enact Governor Hochul’s comprehensive plan to lower insurance costs for New Yorkers. I thank the Governor, Queens District Attorney, and the New York Police Department for their partnership.” NYPD Commissioner Jessica S. Tisch said: “Staging auto collisions on our roadways puts countless drivers at serious risk and exploits insurance coverage meant to protect people when they truly need it. Jaime Huiracocha and Victor Murillo only cared about the thousands of dollars they stood to make from this dangerous and illegal insurance fraud scheme. Thanks to the hard work of our investigators, these criminals drove themselves straight into the hands of justice, and today’s sentencing confirm that. I thank the Queens District Attorney’s Office and Governor Hochul for continuing to prioritize the safety of New Yorkers.” Anyone who thinks they may have been a victim of insurance fraud is urged to call the Insurance Fraud Hotline at 888-372-8369 or visit dfs.ny.gov/consumers to file an online report. Huiracocha, 53, of Brooklyn, pleaded guilty on May 27 to insurance fraud in the third degree and conspiracy in the fifth degree. Queens Supreme Court Justice Jerry Iannece sentenced him on August 24 to one to three years in prison on the first charge and one year in jail on second charge, to run concurrently. Murillo, 34, of Brooklyn, pleaded guilty to staging a motor vehicle accident in the second degree, insurance fraud in the fourth degree and conspiracy in the fifth degree. Justice Iannece sentenced him on August 3 to two years in prison on the first two charges and one year incarceration on the third charge to be served concurrently. DA Katz said that, according to the investigation and charges, between August 24, 2024, and October 16, 2024, Huiracocha and Murillo conspired to stage car crashes on New York City highways as part of an insurance fraud scheme. The defendants recruited individuals to participate in three separate car crashes and enticed them with promises of cash payouts. Murillo acted as the designated driver for these staged crashes during this time frame. During each of the staged collisions, the defendant suddenly and deliberately stepped on the brakes of the car he was driving, causing the vehicle behind him to rear-end the car he was operating. In one instance, when the car behind him braked in time to avoid a collision, Murillo reversed into that vehicle and caused a crash. During the three staged crashes, Huiracocha drove in a separate vehicle and trailed Murillo on the highway. He was in constant communication with his co-defendant and directed Murillo on exactly when and how to stage the collisions. After the crashes, Murillo climbed into the front passenger seat of each vehicle and exited the car from the passenger side. His actions were obscured by passengers in the back seat who covered the rear window with a tarp or plastic bag. Murillo then fled the scene each time in a getaway car that had pulled in front of the car he drove. In the three collisions, the remaining occupants of Murillo’s car exited the vehicle and pretended to be injured. The occupants were directed by Huiracocha to visit specific medical clinics after the crashes. The three stages crashes occurred on the following dates: On August 24, 2024, at approximately 8 a.m., a 47-year-old woman from Long Island was driving westbound on the Belt Parkway near the Erskine Street exit. A silver Honda Civic driven by Murillo merged into the lane directly in front of her and stopped, forcing her to collide with the car. Dashcam footage from the victim’s car captured Murillo exiting the Honda and entering a red Kia that had stopped directly in front of it after the crash. On October 3, 2024, at approximately 12 p.m., a 44-year-old man from New Jersey was driving his tractor trailer in the middle lane of the Nassau Expressway near Cross Bay Boulevard in Lindenwood. A Nissan Xterra, driven by Murillo suddenly cut into the middle lane directly in front of the truck. The truck driver was unable to avoid hitting the Nissan. Murillo got out of the Nissan, entered another vehicle that stopped in front of him and quickly left the scene. At the same time, a female claimed to the truck driver that she had been the one driving the Nissan during the collision. After the getaway car drove off with Murillo, another car stopped at the scene. Huiracocha exited and spoke to the truck driver. On October 16, 2024, at approximately 12 p.m., a 31-year-old woman from Queens was driving north in the left lane of the Belt Parkway in Rosedale near the Nassau County border. A Honda Civic driven by Murillo cut in front of the woman’s vehicle and abruptly came to a stop. The victim was forced to step on her brakes to avoid a collision. Murillo then quickly reversed the Honda and backed into the victim’s vehicle, damaging both her car and the Honda. Dashcam footage showed not only the collision, but also a red Kia Sportage following the woman’s car. After the crash, the Kia stopped in front of the Honda. Murillo, who climbed to the front passenger’s seat, exited the Honda from that side. He then entered the Kia and was driven away from the scene. Defendants Maikel Martinez and Ivon Matus-Martinez, participants in the crashes, also pleaded guilty and are expected to be sentenced next month. The investigation was conducted by Detective James McCormack, Detective Michael Fahrbach, and Sergeant Daisy Ramirez of the NYPD Fraudulent Collision Investigation Squad along with Lieutenant Charles Hyland of the NYPD Criminal Enterprise Division, Investigator Michael Dominguez and other members of the New York State Department of Financial Services, and Investigative Accountant Silvana Sutich of the District Attorney’s Financial Frauds Bureau. Assistant District Attorney Talia Vogel, Deputy Chief of the District Attorney’s Financial Frauds Bureau, prosecuted the case under the supervision of Assistant District Attorney Hana C. Kim, Bureau Chief, and under the overall supervision of Executive Assistant District Attorney for Investigations Joseph T. Conley III. **Topics:** Auto - staged **Categories:** Conviction --- ### [New York Holocaust survivors and families being warned of potential fraud](https://insurancefraud.org/news_archives/new-york-holocaust-survivors-and-families-being-warned-of-potential-fraud/) **Published:** August 31, 2026 **Author:** Diane Beauchamp **Content:** New York officials are warning Holocaust victims and their families of a potential fraud. Ellie Rubinstein, the son of Holocaust survivors, received a letter offering to help him file claims for everything from slave labor to looted assets and unpaid insurance policies seized by Nazis. “It looked awfully convincing,” Rubinstein said. “There was information about this money comes from the German government.” Gov. Kathy Hochul said letters like these are a fraud. She said the state cannot verify the legitimacy of the sender listed as “Jewish Holocaust Claims Center” or “JHCC.” Its website, deemed fraudulent by the state, has been taken down. “This is the lowest of the low,” said Masha Pearl, executive director of The Blue Card, which assists many of the 31,000 Holocaust survivors in the United States. The median age of survivors is 87, according to the Claims Conference. “These survivors are living on very small incomes and savings. This can really wipe out everything,” Pearl said. For decades, survivors and their heirs have been working to recover assets taken during Nazi persecution, including bank accounts, unpaid insurance proceeds and looted art. New York State has an office that helps families pursue those claims, free of charge. Alan Mindel, the chairman of Long Island’s Holocaust Memorial and Tolerance Center and the son of survivors, said the center is reaching out to other survivors to remind them of the legitimate avenues for claims. “You couldn’t have a more vulnerable population, period,” he said. “These are people that have suffered the worst atrocities of humankind that are now dealing with this.” Agencies CBS News New York spoke to are not aware of losses as a result of the fraud. It’s unknown how the fraudsters got the names and contact information of Holocaust survivors. Survivors and their families can check if a communication they received is fraudulent with the Department of Financial Services. Holocaust survivors and their families who believe they may be eligible for compensation or restitution, or who want to verify a communication came from or is affiliated with the HCPO, should contact the New York State Holocaust Claims Processing Office at (800) 695-3318 or claimsques@dfs.ny.gov. **Topics:** Fraud General, Public Awareness --- ### [Democratic officials charged with fraud due to alleged COVID relief funds scam](https://insurancefraud.org/news_archives/democratic-officials-charged-with-fraud-due-to-alleged-covid-relief-funds-scam/) **Published:** August 31, 2026 **Author:** Diane Beauchamp **Content:** Authorities arrested a Democratic Party official for alleged COVID fraud for the second time this month on Wednesday. US Attorney Leah Foley says police arrested Massachusetts state Rep. Francisco Paulino early Wednesday morning, charging him with 11 counts related to pandemic unemployment insurance fraud, pandemic loan fraud and money laundering. “According to the Paulino indictment, Mr. Paulino devised a scheme to obtain more than $700,000 in federal pandemic relief funds. It is alleged that Paulino used some of the money for his own personal use, including real estate expenses, loan payments and transfers to his campaign account,” Foley said. “Other money he flipped around and lent to other individuals at higher interest rates than the pandemic loan rate,” she continued. The indictment says Paulino’s alleged fraud began in 2020 when he signed up for COVID relief funding on behalf of “an unwitting 77-year-old relative.” Paulino’s arrest comes roughly a week after the FBI arrested Lawrence Mayor Brian DePeña on similar charges. He was arrested earlier this month. “Everyone listening today knows how difficult it was for Americans during the pandemic,” Foley said. “The money these two individuals allegedly scammed was meant for hardworking Americans and struggling business owners, not for two greedy individuals who lied and stole for their own personal benefit.” “It is never a proud moment when we arrest a public official, but we will continue to do it until the message is received: No one is above the law, and no one gets a pass,” she added. **Topics:** COVID-19 **Categories:** Arrest --- ### [Bridgeport Business Owner Charged with Failure to Provide Workers’ Compensation Insurance Coverage](https://insurancefraud.org/news_archives/bridgeport-business-owner-charged-with-failure-to-provide-workers-compensation-insurance-coverage/) **Published:** August 31, 2026 **Author:** Diane Beauchamp **Content:** The owner of a Bridgeport business has been arrested and charged with failing to provide the required workers’ compensation insurance coverage for employees. Dave Benbow age 54, of Bridgeport, was arrested on August 21, 2026 by Inspectors from the Workers’ Compensation Fraud Control Unit in the Office of the Chief State’s Attorney and charged with one count of Noncompliance with Insurance Requirements, in violation of Connecticut General Statutes § 31-288(f)/53a-11. An investigation showed that the defendant’s company, All-Pro Abatement LLC, did not have a valid workers’ compensation insurance policy at the time of a workplace accident in West Haven, in which an All-Pro employee was injured. The defendant surrendered himself at the Rocky Hill Police Department, where he was released on a $5,000 non-surety bond. He is scheduled to appear at Milford Superior Court, Geographical Area No. 22, on August 31, 2026. The charges are merely accusations, and the defendant is presumed innocent unless and until proven guilty in a court of law. Noncompliance with Insurance Requirements is a class D felony, punishable by one to five years of imprisonment and up to a $5,000.00 fine. The case will be prosecuted by the Workers’ Compensation Fraud Control Unit in the Office of the Chief State’s Attorney. **Topics:** Work comp - employer **Categories:** Arrest --- ### [New Jersey man sentenced in $50M insurance fraud scheme](https://insurancefraud.org/news_archives/new-jersey-man-sentenced-in-50m-insurance-fraud-scheme/) **Published:** August 31, 2026 **Author:** Diane Beauchamp **Content:** A New Jersey pharmaceutical sales representative who orchestrated a scheme that defrauded state health insurance programs of more than $50 million has been sentenced to 27 months in federal prison. On Aug. 18, U.S. District Judge Edward Kiel sentenced William Hickman on one count of conspiracy to commit healthcare fraud and wire fraud and one count of conspiracy to commit money laundering, both of which he pleaded guilty to in June 2020. Mr. Hickman was also ordered to pay $51.7 million in restitution. The largest share of that amount, roughly $45.1 million, is owed to the New Jersey Division of Pension and Benefits. Other victims listed in the judgment include Anthem Blue Cross Blue Shield, AmeriHealth, Horizon Blue Cross Blue Shield of New Jersey, the Department of Defense and the County of Bergen. Mr. Hickman was indicted in March 2019 along with six co-defendants in what became one of the largest healthcare fraud cases in New Jersey history. The 50-count indictment alleged that Mr. Hickman, while employed as a pharmaceutical sales representative, created a side business called Boardwalk Medical LLC under his wife’s name and used it to run a kickback-driven prescription fraud ring. The scheme, which ran from roughly July 2014 through April 2016, worked by recruiting state and local government employees who carried state-funded health benefits, including teachers, police officers and firefighters. Mr. Hickman and his network of recruiters persuaded those employees to obtain medically unnecessary compound prescriptions for products like pain creams, libido creams, scar creams and vitamin combinations from a Louisiana compounding pharmacy. The pharmacy would bill New Jersey’s pharmacy benefits administrator for the medications, which were often thousands of dollars for a single month’s supply. The pharmacy then paid Boardwalk Medical a percentage of the insurance reimbursement for each prescription Mr. Hickman’s network secured, according to the indictment. In total, Boardwalk Medical received more than $26 million of those payments. The broader conspiracy has resulted in more than 40 convictions and guilty pleas across New Jersey, with public employees and executives at the Louisiana compounding pharmacy among those convicted. **Topics:** Drug Diversion **Categories:** Conviction --- ### [DermTech Inc. to Pay Up to $5M to Resolve Allegations It Submitted False Claims to Medicare for Unreliable Skin Cancer Tests](https://insurancefraud.org/news_archives/dermtech-inc-to-pay-up-to-5m-to-resolve-allegations-it-submitted-false-claims-to-medicare-for-unreliable-skin-cancer-tests/) **Published:** August 31, 2026 **Author:** Diane Beauchamp **Content:** A skin cancer testing company formerly known as DermTech Inc., which was headquartered in San Diego, has agreed to settle allegations that it violated the False Claims Act by knowingly submitting false claims for unreliable skin cancer tests to the Medicare program. DermTech is now liquidating as DTech Liquidating Inc. after filing for Chapter 11 bankruptcy in the District of Delaware in June 2024. As part of the resolution announced today, the United States received an Allowed Class Three General Unsecured Claim of $5,038,011 in the bankruptcy proceeding. The settlement resolves allegations that DermTech submitted claims to Medicare for skin cancer tests despite knowing the tests had quality control issues. First, from October 2022 to March 2023, DermTech billed Medicare for skin cancer tests that it conducted after switching to an unvalidated positive control range for one of the test’s two key melanoma markers. Without a validated positive control range, it is impossible to confirm that the positive control is working and thus impossible to verify whether the test results are accurate. Second, from January 2020 to February 2022, DermTech billed Medicare for skin cancer tests that did not contain enough patient RNA to be tested but still generated positive or negative test results. For both categories of tests, DermTech reported results to patients. When concerns were raised about these tests, DermTech neither retracted the test results nor adequately refunded Medicare. “The Justice Department is committed to protecting Medicare patients, especially in an area as serious as skin cancer testing,” said Assistant Attorney General Brett A. Shumate of the Justice Department’s Civil Division. “We will hold accountable health care providers who put patients at risk by billing Medicare for grossly substandard services.” “This company billed Medicare for unreliable tests that may have misled patients and their doctors,” said U.S. Attorney Adam Gordon for the Southern District of California. “This settlement is a perfect example of why the Department’s focus on fraud against the taxpayer directly leads to improved health and safety for Medicare patients.” “Patients must be able to rely on the accuracy and integrity of diagnostic testing when making critical healthcare decisions,” said Acting Deputy Inspector General for Investigations Miranda L. Bennett of the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG). “Submitting claims to Medicare for tests that fail to meet established clinical standards undermines patient safety and public trust. HHS-OIG remains committed to ensuring that healthcare providers deliver services that meet federal requirements and to pursuing accountability for alleged misconduct.” “DermTech Inc. allegedly administered inadequate skin cancer tests that led to the fraudulent billing of Medicare, raising serious concerns about the company’s practices,” said Special Agent in Charge Mark Remily of the FBI San Diego Field Office. “FBI San Diego, along with our law enforcement partners, remains committed to investigating any company whose illicit actions may undermine the integrity of our healthcare system and ensure they are held accountable.” The civil settlement includes the resolution of claims brought under the qui tam or whistleblower provisions of the False Claims Act by a former DermTech employee. Under those provisions, a private party can file an action on behalf of the United States and receive a portion of any recovery. The qui tam case is captioned U.S. ex rel. Luong v. DermTech, Inc. et al., No. 3:23-cv-01404 (S.D. Cal.). Ms. Luong will receive 20% of the recovery received from the bankruptcy court in connection with the settlement. The claims resolved by the settlement pertain to DermTech Inc., a company that is now bankrupt. These claims do not pertain to DermTech LLC, a company that purchased DermTech Inc.’s assets in 2024 as part of the bankruptcy proceedings. The resolution obtained in this matter was the result of a coordinated effort between the Justice Department’s Civil Division, Commercial Litigation Branch, Fraud Section, and the U.S. Attorney’s Office for the Southern District of California, with assistance from the Federal Bureau of Investigation and the Department of Health and Human Services, Office of the Inspector General. This year the Administration launched the Task Force to Eliminate Fraud and the National Fraud Enforcement Division to enhance the Administration’s war on fraud, waste, and abuse in federal programs. When unscrupulous actors exploit these programs for their own financial gain, they defraud the government, harm the people these programs are designed to aid and protect, and undermine American businesses that play by the rules. The Civil Division’s FCA enforcement plays a critical role in combatting such fraudulent schemes, recovering billions of dollars for the American taxpayers, and holding wrongdoers accountable. FCA matters will continue to be on the forefront of the battle against fraud, and the Civil Division’s FCA work will support and advance the mission of the Task Force to Eliminate Fraud and the National Fraud Enforcement Division. This matter was handled by Assistant U.S. Attorney Stephen H. Wong for the Southern District of California and Department of Justice Trial Attorney Clare Elizondo. **Topics:** Judicial/courts, Public Awareness --- ### [The Villages Health System LLC Agrees to $541.5M Settlement to Resolve False Claims Act Allegations](https://insurancefraud.org/news_archives/the-villages-health-system-llc-agrees-to-541-5m-settlement-to-resolve-false-claims-act-allegations/) **Published:** August 31, 2026 **Author:** Diane Beauchamp **Content:** The Villages Health System LLC (TVH), a healthcare provider group headquartered in The Villages, Florida, has [agreed](https://www.justice.gov/opa/media/1459281/dl) to a $541.5 million settlement to resolve self-disclosed allegations that it violated the False Claims Act by causing the submission of false diagnosis codes in order to increase payments that they received from the Medicare Advantage program. “The Medicare Advantage program relies on accurate diagnoses to protect the federal fisc,” said Assistant Attorney General Brett A. Shumate of the Justice Department’s Civil Division. “Today’s settlement reflects that we will hold accountable entities that inflate payments through invalid diagnoses; at the same time, we will continue to credit organizations that disclose wrongdoing, take appropriate remedial actions, and fully cooperate with the government’s investigation.” “The Villages Health System LLC knowingly submitted false diagnosis codes to increase their payments from the Medicare Advantage program and increase their profits,” said U.S. Attorney Gregory W. Kehoe for the Middle District of Florida. “Our Office will continue protecting the integrity of the Medicare program and hold those who seek to defraud federal health care programs accountable.” “The accuracy of diagnosis information submitted to Medicare Advantage is vital to protecting taxpayer dollars,” said Acting Deputy Inspector General for Investigations Miranda L. Bennett of the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG). “This case underscores that entities will be held accountable when they submit unsupported information that inflates payments. The provider’s use of the OIG Self Disclosure Protocol and its cooperation were important factors in resolving this matter, and the protocol remains available for managed care entities and other providers that bill managed care entities that seek to disclose potential liability.” Under the Medicare Advantage (MA) Program, also known as Medicare Part C, Medicare beneficiaries may opt out of traditional Medicare and enroll in private health plans offered by insurance companies known as Medicare Advantage Organizations, or MAOs. The Centers for Medicare & Medicaid Services (CMS) pays the MAOs a fixed monthly amount for each Medicare beneficiary enrolled in their plans. CMS adjusts these monthly payments to account for various “risk” factors that affect expected health expenditures for the beneficiary. In general, CMS pays MAOs more for sicker beneficiaries expected to incur higher healthcare costs and less for healthier beneficiaries expected to incur lower costs. To make these “risk adjustments,” CMS collects medical diagnosis codes from the MAOs. The diagnoses must be supported by the medical record from a face-to-face visit between a patient and a provider, and for outpatient visits, must have required or affected patient care, treatment, or management at the visit. Providers generally submit diagnosis codes to MAOs that are, in turn, submitted to CMS to increase payments. At times, MAOs agree to pay provider groups like TVH a set percentage of what the MAO receives from CMS. Under such agreements, the provider groups receive more reimbursement for sicker beneficiaries expected to incur higher healthcare costs and less reimbursement for healthier beneficiaries expected to incur lower costs. On Dec. 27, 2024, TVH made a submission pursuant to the HHS-OIG’s Health Care Fraud Self-Disclosure Protocol disclosing that it had submitted invalid diagnosis codes to multiple MAOs for certain beneficiaries enrolled in their plans and that these diagnosis codes increased the capitated payments made by CMS to the MAOs under the MA program. The settlement announced today resolves allegations that, from 2020 through 2024, TVH violated the False Claims Act, 31 U.S.C. §§ 2729-3733, by knowingly submitting false diagnosis codes to MAOs and causing MAOs to submit false diagnosis codes to the MA program resulting in inflated payments from CMS to MAOs. The diagnosis codes were invalid because they did not have adequate support in the patient’s medical record or were based on amendments to the medical record that were not initiated by the rendering provider and were not timely or were not approved by the rendering provider. TVH’s knowing submission of the unsupported and/or undocumented codes identified above caused CMS to make inflated payments to the MAOs, which inflated the MAOs’ payments to TVH. In connection with the settlement, the United States acknowledged that TVH took a number of significant steps entitling them to credit for cooperating with the government. TVH promptly took remedial actions and self-disclosed the invalid diagnoses to HHS-OIG. TVH also provided the government with a detailed and thorough written disclosure and cooperated with the government throughout its investigation. On July 3, 2025, TVH filed a Chapter 11 bankruptcy petition in the U.S. Bankruptcy Court for the Middle District of Florida. *In re Villages Health System, LLC*, Case No. 6:25-bk-04156-LVV (Bankr. M.D. Fla.). The bankruptcy court approved the settlement announced today on Aug. 25. TVH submitted the invalid diagnosis codes covered by the settlement announced today to three MAOs: Humana Inc., UnitedHealthcare (UnitedHealthcare Insurance Company, United Healthcare of Florida Inc., Preferred Care Partners Inc., and Care Improvement Plus South Central Insurance Company, Inc.), and GuideWell Mutual Holding Corporation (Blue Cross and Blue Shield of Florida Inc. and Florida Blue Medicare Inc.). Pursuant to their contracts with CMS, the MAOs are returning overpayments they received as a result of TVH’s conduct by deleting invalid codes and/or by entering into agreements with the Department of Justice and CMS to return the funds. This year the Administration launched the Task Force to Eliminate Fraud and the National Fraud Enforcement Division to enhance the administration’s war on fraud, waste, and abuse in federal programs. When unscrupulous actors exploit these programs for their own financial gain, they defraud the government, harm the people these programs are designed to aid and protect, and undermine American businesses that play by the rules. The Civil Division’s FCA enforcement plays a critical role in combatting such fraudulent schemes, recovering billions of dollars for the American taxpayers, and holding wrongdoers accountable. FCA matters will continue to be on the forefront of the battle against fraud, and the Civil Division’s FCA work will support and advance the mission of the Task Force to Eliminate Fraud and the National Fraud Enforcement Division. The resolution obtained in this matter was the result of a coordinated effort between the Justice Department’s Civil Division, Commercial Litigation Branch, Fraud Section and the United States Attorney’s Office for the Middle District of Florida, with assistance from HHS-OIG. The investigation and resolution of this matter illustrate the government’s emphasis on combating healthcare fraud. One of the most powerful tools in this effort is the False Claims Act. Tips and complaints from all sources about potential fraud, waste, abuse and mismanagement, can be reported to the Department of Health and Human Services at [www.oig.hhs.gov/fraud/report-fraud/](http://www.oig.hhs.gov/fraud/report-fraud/) or 800-HHS-TIPS (800-447-8477). The matter was handled by Fraud Section Attorneys Edward Crooke and Martha Glover and Assistant U.S. Attorney Christopher Emden for the Middle District of Florida. **Topics:** Judicial/courts, Public Awareness --- ### [New York StateWide Senior Action Council (www.nysenior.org) Announces It's Medicare Fraud of the Month for December: Ending Medical Debt for Seniors](https://insurancefraud.org/news_archives/new-york-statewide-senior-action-council-www-nysenior-org-announces-its-medicare-fraud-of-the-month-for-december-ending-medical-debt-for-seniors/) **Published:** August 30, 2026 **Author:** Diane Beauchamp **Content:** New York StateWide Senior Action Council (StateWide), an organization dedicated to advocacy for the rights of seniors in New York State today announced its Medicare Fraud of the Month for December; **Ending Medical Debt for Seniors.** The StateWide Fraud of the Month is a component of the **Senior Medical Patrol**, the definitive resource for New York State’s senior citizens and caregivers to detect, prevent, and report healthcare fraud, errors, and abuse. StateWide is New York’s grantee/administrator for this Federal Program. StateWide is working to educate older citizens about their rights when facing hospital out of pocket costs that are unaffordable and eradicate this crippling debt. According to Maria Alvarez, StateWide’s Executive Director, “Hospitals in the state ***should*** be explaining how to get assistance with paying your outstanding bills, no matter whether you have insurance that is not meeting your needs or are uninsured.” She added, “Medical debt has plagued many Americans, including those who are “fully” insured, underinsured and uninsured.” A recent *Journal of General Internal Medicine* study revealed that out-of-pocket medical expenditures in the five years prior to an individual’s death totaled more than $38,000…**leaving 1 in 4 seniors approaching bankruptcy.** The impact of medical debt for seniors is far reaching: - Negative impact on health: studies show that these debts can rollover into further medical issues such as stress & high blood pressure — leading to even more medical costs/debt. - Patients in debt sacrifice accessing health care because of costs (e.g., delayed care, avoided care, cut pills, or didn’t fill a prescription). - Negative impact on consumer credit ratings, leading to higher interest on loans, mortgages & more. - Two thirds of all bankruptcies filed in the United States are tied to medical expenses. - Medical debt judgments disproportionately impact low-income New Yorkers and people of color - Between 2015 and 2020, over 52,000 New Yorkers were sued by hospitals for payment of medical debt Alvarez continued, “Often hospital bills contain errors. Do not ignore them! Check your hospital bills. Review your insurer’s Explanation of Benefits or Medicare Summary notice and **Get help from StateWide – call our SMP hotline 800-333-4374.”** “Federal law requires hospitals to offer charity care in order to keep their tax-exempt status. New York’s Hospital Financial Assistance Law requires hospitals to have payment relief program for patients under 300% of the Federal Poverty Level (FPL). NYS provides hospitals with billions for uncompensated care.” she stated. But hospitals don’t have to tell you. Hospitals can send your case to collection even while you are applying for their debt relief program. Hospitals can each have their own confusing system, application, and requirements. However, there is help. Call StateWide’s Health Insurance, Patients’ Rights & Fraud Prevention Helpline at 1-800-333-4374 for assistance. StateWide is actively working to assist elders in eradicating crippling medical debt. It is calling for: - Enacting the NY Health Act (NYS) and Improved Medicare for All (federal) to end all out-of-pocket health care costs. - Establishing a uniform application for hospital medical debt - Expanding the income limits for hospital debt relief programs from 300% of the FPL to 600% FPL - Prohibiting hospitals from sending unpaid balances to collection before hospital payment application processes have been exhausted, or insurance appeals have been finalized. - Improve NYS Dept of Health audits of hospitals’ compliance with requirements regarding debt assistance and increase consequences for failure. It is also seeking your help. “We need our State’s older residents to tell their stories to amplify the need for change,” Alvarez stated. ‘Share your story. You are not alone. Your experience can empower others to conquer medical debt. Your stories can illustrate the need to question unfair hospital debt collection practices and seek improvements for all,” she concluded It is estimated that Medicare fraud costs New York taxpayers over $5 billion dollars a year. To help combat this illicit industry StateWide earlier this year announced its **Fraud of the Month** program to highlight these scams being perpetrated on the State’s seniors. **Topics:** Medicare/Medicaid, Public Awareness --- ### [Progressive lawmakers demand fraud probe into Medicare privatization scheme](https://insurancefraud.org/news_archives/progressive-lawmakers-demand-fraud-probe-into-medicare-privatization-scheme/) **Published:** August 30, 2026 **Author:** Diane Beauchamp **Content:** A group of progressive lawmakers led by Sen. Elizabeth Warren and Rep. Pramila Jayapal is calling on Biden health officials to immediately launch a fraud probe into the organizations taking part in ACO REACH, a slightly reformed version of a Medicare privatization scheme that the Trump administration set in motion during its final months in power. In a Thursday letter to Chiquita Brooks-LaSure, head of the Centers for Medicare and Medicaid Services (CMS), 21 members of Congress voiced alarm that the ACO REACH pilot “provides an opportunity for healthcare insurers with a history of defrauding and abusing Medicare and ripping off taxpayers to further encroach on the Medicare system.” “No matter the name, these systems are designed to create profit for private insurers by delaying or denying care.” The newest version of the program, which entails shifting some traditional Medicare recipients onto privately run insurance plans without their knowledge or consent, is scheduled to formally begin on January 1, months after CMS announced largely cosmetic changes to the Trump-era Global and Professional Direct Contracting (GPDC) model. The lawmakers noted in their letter that Physicians for a National Health Program (PNHP)—a doctor-led group pushing for the complete termination of ACO REACH—has identified at least 10 GPDC Direct Contracting Entities (DCEs) with records of “healthcare fraud, abuse, and violations of healthcare laws prior to 2021.” Those organizations, the lawmakers stressed, “have continued to operate in the program even as CMS pushes for additional oversight, vetting, and transparency.” “In its three-year history, the Medicare Direct Contracting program, now ACO REACH, has roughly doubled in size each year: it had 53 participants in its first year, 99 in the second year, and as many as 202 participants planned for 2023,” the letter continued. “The exponential growth of the program heightens our concerns about the potential for fraud and abuse of taxpayer Medicare dollars.” One example the letter cites is Centene, a healthcare firm that is the parent company of three DCEs currently operating in 27 states. DCEs are paid by the federal government to fund a portion of Medicare enrollees’ care and act as private middlemen between patients and healthcare providers. Under ACO REACH, which has faced mounting opposition at the local and national levels in recent months, the middlemen will be able to keep 40% of what they don’t spend on care as profit and overhead. Critics of the pilot, set to run at least through 2026, argue that such an incentive invites fraud and other abuse of patients—practices that have been rife in privately run Medicare Advantage (MA) plans, which now provide coverage to nearly half of the eligible Medicare population. The lawmakers point out in their letter that Centene “paid over $97 million in 2021 to settle allegations of ‘duplicate and inflated claims submitted to the Department of Veterans Affairs’ that occurred while its subsidiary, Health Net, was acting as a third-party administrator for VA medical care.” Centene is hardly an outlier, as the letter makes clear. “AdventHealth, which operates a DCE in Florida, was the subject of one of the largest healthcare fraud settlements in 2015, paying $115 million to settle allegations that the organization ‘submitted false claims to the Medicare and Medicaid programs,'” the lawmakers note. “An audit by the Department of Health and Human Services Office of Inspector General found that Humana, which operates a DCE in 13 states, improperly collected nearly $200 million in 2015 through upcoding and ‘overstating how sick some patients were.'” Warren (D-Mass.), Jayapal (D-Wash.), Sen. Bernie Sanders (I-Vt.), Rep. Alexandria Ocasio-Cortez (D-N.Y.), and the letter’s other signatories warned that the presence of entities with long records of fraud and abuse puts “patients and taxpayer dollars at risk” and called on Biden’s CMS to “quickly to address these risks and protect patients before the new ACO REACH program begins operations.” Specifically, the lawmakers urged the Biden administration to “closely examine” ACO REACH participants, halt participation by “any organizations that have committed healthcare fraud,” and terminate “DCEs that do not meet the new standards for the ACO REACH program.” “We have long been concerned about ensuring this model does not give corporate profiteers yet another opportunity to take a chunk out of traditional Medicare,” they wrote. “The continued participation of corporate actors with a history of fraud and abuse threatens the integrity of the program.” As lawmakers push for reforms to bar bad corporate actors from the program and enhance oversight, patient advocates are demanding that the program be cut off entirely, arguing that it poses a fundamental threat to traditional Medicare and cannot be salvaged with policy tweaks. In a tweet on Sunday, the progressive advocacy group Social Security Works warned that “no matter the name, these systems are designed to create profit for private insurers by delaying or denying care.” “We need to expand and improve Medicare—not destroy it with backdoor privatization,” the group added. **Topics:** Legislative, Medicare/Medicaid, Public Awareness --- ### [Greenacres small business owner warns others after falling for Zelle scheme](https://insurancefraud.org/news_archives/greenacres-small-business-owner-warns-others-after-falling-for-zelle-scheme/) **Published:** August 30, 2026 **Author:** Diane Beauchamp **Content:** The owner of a medical and psychiatric services clinic called Contact 5 after losing $40,000 when her Zelle account was hacked by someone claiming to be with Chase Bank. “It was on a Wednesday. I receive a text message that appeared to be from Chase because it had all the Chase messages in it, asking me if I was trying to make a transaction – $60,000 to someone, I believe, in Ohio,” Acelise Alexis, owner of KA Comprehensive Medical and Psychiatric Services, told Contact 5. Worried someone had stolen her information, Alexis said she trusted the person on the other line. The owner of a medical and psychiatric services clinic called Contact 5 after losing $40,000 when her Zelle account was hacked by someone claiming to be with Chase Bank. “It was on a Wednesday. I receive a text message that appeared to be from Chase because it had all the Chase messages in it, asking me if I was trying to make a transaction – $60,000 to someone, I believe, in Ohio,” Acelise Alexis, owner of KA Comprehensive Medical and Psychiatric Services, told Contact 5. Worried someone had stolen her information, Alexis said she trusted the person on the other line. The owner of a medical and psychiatric services clinic called Contact 5 after losing $40,000 when her Zelle account was hacked by someone claiming to be with Chase Bank. “It was on a Wednesday. I receive a text message that appeared to be from Chase because it had all the Chase messages in it, asking me if I was trying to make a transaction – $60,000 to someone, I believe, in Ohio,” Acelise Alexis, owner of KA Comprehensive Medical and Psychiatric Services, told Contact 5. Worried someone had stolen her information, Alexis said she trusted the person on the other line. The other option is to just hang up and call your bank directly and ask if this was a legitimate call or email, which is what Alexis said she’ll be doing next time. “Hang up right away,” Alexis said. “Don’t give any information. Don’t talk to them. Call the bank, whatever is the number behind your card. Call it and find out if they’re trying to call you and, you know, make sure that it’s not what happened to me.” Alexis told Contact 5 she is now working with her attorneys to try to get her money back. **Topics:** Public Awareness, Technology --- ### [Lawmakers Ask CMS to Inspect ACO REACH Model to Prevent Fraud, Abuse](https://insurancefraud.org/news_archives/lawmakers-ask-cms-to-inspect-aco-reach-model-to-prevent-fraud-abuse/) **Published:** August 30, 2026 **Author:** Diane Beauchamp **Content:** Allowing organizations with records of healthcare fraud and abuse to participate in the ACO REACH model would put Medicare beneficiaries and taxpayer dollars at risk, the legislators said. A group of lawmakers, spearheaded by US Senator Elizabeth Warren (D-Mass.) and Representative Pramila Jayapal (D-Wash.), has [asked](https://www.warren.senate.gov/oversight/letters/warren-jayapal-urge-cms-to-examine-aco-reach-program-for-medicare-fraud) CMS to examine the ACO REACH model to prevent organizations with a history of fraud and abuse from participating in the program in 2023. In a [letter](https://www.warren.senate.gov/imo/media/doc/221208%20ACO%20REACH%20Letter%20to%20CMS%20with%20Signatures.pdf) to CMS Administrator Chiquita Brooks-LaSure, the lawmakers voiced concern that the model may still allow healthcare insurers and providers to cause harm to the Medicare system. In February 2022, [CMS announced that the ACO REACH model would replace the Global and Professional Direct Contracting (GPDC) model](https://www.techtarget.com/revcyclemanagement/news/366599804/CMS-Replaces-Direct-Contracting-Model-with-New-ACO-REACH-Model) starting in January 2023. Participants in the GPDC model will be allowed to enroll in the ACO REACH model if they maintain a strong compliance record and agree to meet the requirements of the ACO REACH model. As the number of program participants has grown since the launch of direct contracting, the lawmakers noted concerns about the potential for fraud and abuse of taxpayer Medicare dollars, especially as several [Direct Contracting Entities](https://www.techtarget.com/revcyclemanagement/news/366600633/APG-Direct-Contracting-Entities-Helped-Save-Medicare-70M-in-2021) (DCEs) have records of healthcare fraud and abuse. In addition to asking CMS to examine ACO REACH participants, the legislators requested CMS to clarify whether DCEs accepted into the GPDC model will be automatically grandfathered into ACO REACH, even if they do not meet the program’s stated standards. The letter claimed that the [GPDC model introduced a for-profit model and privatized healthcare plans into traditional Medicare](https://www.techtarget.com/revcyclemanagement/news/366599808/Over-50-Lawmakers-Urge-Administration-to-End-Direct-Contracting), threatening the Medicare program and beneficiaries. Most DCEs in 2021 were private equity and investor-controlled, leading the legislators to worry that these organizations view direct contracting as a backdoor to higher profits. According to findings from the preliminary review conducted by Physicians for a National Health Program (PNHP), 10 DCEs that participated in the GDPC model in 2021 had prior records of healthcare fraud. For example, Centene, the parent company to three DCEs operating in 27 states, paid over $97 million in 2021 to settle allegations of duplicate and inflated claims submitted to the Department of Veterans Affairs. Centene’s pharmacy benefits managers also allegedly overcharged state Medicaid programs on prescription drugs, leading to settlements with seven states totaling over $260 million. [Humana, which operates a DCE in 13 states](https://www.techtarget.com/healthcarepayers/news/366604528/Humana-Joins-Traditional-Medicare-Value-Based-Contracting-Model), improperly collected almost $200 million in 2015 through upcoding and overstating how sick patients were, according to an audit from the HHS Office of Inspector General (OIG). Other DCEs with [records of fraud and abuse](https://www.techtarget.com/revcyclemanagement/feature/Top-Healthcare-Fraud-Waste-and-Abuse-Takedowns-of-the-Year) include Sutter Health, Clover Health, AdventHealth, Vively Health, Cigna, Bright Health, and Nivano Physicians. “The inclusion of these DCEs in the Global and Professional Direct Contracting Model is a significant concern after these companies’ previous failures to follow the law,” the letter stated. “The ability of organizations with known histories of fraud and abuse to take part in the program increases the risks for Medicare beneficiaries, and raises concerns that CMS screening procedures for participants are inadequate, putting taxpayer dollars at risk. We respectfully ask the agency to reevaluate the decision to allow these DCEs to participate in the program.” The legislators have also requested CMS provide written responses to several questions by January 16, 2023. They want to know how organizations that have already been accepted into the GPDC model have been screened for acceptance into the ACO REACH model and what specific methods CMS will use to screen participants. In addition, they requested an up-to-date list of all ACO REACH participating organizations that indicates which organizations have a history of misconduct or fraud and which have been the subject of any civil or criminal actions related to participating in a federal healthcare program. The letter also asked what other protections CMS will include in the ACO REACH program to protect Medicare beneficiaries from fraud and abuse and if CMS has found evidence of fraud and upcoding from any DCE with a history of these practices. **Topics:** Legislative, Medicare/Medicaid, Public Awareness --- ### [Surprise bills from ground ambulances is next up in the move toward reform](https://insurancefraud.org/news_archives/surprise-bills-from-ground-ambulances-is-next-up-in-the-move-toward-reform/) **Published:** August 30, 2026 **Author:** Diane Beauchamp **Content:** Good morning, y’all. Following the spending negotiations on Capitol Hill? Tell us what we should know: <rachel.roubein@washpost.com>. **Today’s edition:** The Biden administration is proposing to make it easier for those who lose Medicaid coverage to buy Obamacare plans. Abortion rights groups in Ohio look to potential ballot measures. **But first …** ### Ground ambulances were left out of surprise billing legislation. Experts will meet next month to consider how to wrangle them. The Biden administration is set to kick off the work of a key advisory committee designed to help stop patients from getting hit with pricey surprise medical bills from ground ambulances, The Health 202 has learned. **It took roughly two years for the new committee to get its start.** But the panel’s meetings are now set to begin in the new year, with the first scheduled for Jan. 17-18. A critical report will be due 180 days later on how to prevent patients from[ owing hundreds of dollars](https://www.commonwealthfund.org/blog/2021/protecting-consumers-surprise-ambulance-bills) for receiving out-of-network ambulance rides through no fault of their own. That’s according to a **Centers for Medicare and Medicaid Services**[ webpage](https://www.cms.gov/regulations-guidance/advisory-committees/advisory-committee-ground-ambulance-and-patient-billing-gapb?utm_campaign=wp_the_health_202&utm_medium=email&utm_source=newsletter&wpisrc=nl_health202) detailing information about the advisory committee’s membership and its initial meeting, neither of which have been officially announced. CMS cites a Dec. 16, 2022, notice in the federal register, which suggests the information may have been inadvertently published early on the agency’s website. **The upcoming launch of the advisory committee’s work is a step forward in fulfilling part of a law Congress passed in**[ **December 2020**](https://www.govinfo.gov/content/pkg/BILLS-116hr133enr/pdf/BILLS-116hr133enr.pdf)**.** The legislation shielded patients from getting slapped with large bills when they unknowingly get care from an out-of-network provider, including for air ambulance flights. Yet, it didn’t apply to ground ambulances, instead mandating key federal departments appoint an advisory committee to recommend options for preventing such bills. - “The ground ambulance loophole is a big gap that harms consumers,” said **Madeline O’Brien,** a research fellow at Georgetown University’s **Center on Health Insurance Reforms.** “We’ve been waiting almost two years for the committee to get off the ground and \[are\] very excited for the actions that they could be taking to protect consumers in this really critical space.” About the commission **The details:** The charter for the advisory committee was officially[ signed in November 2021](https://www.cms.gov/newsroom/press-releases/biden-harris-administration-announces-steps-protect-consumers-and-improve-ground-ambulance-billing), and the Biden administration began soliciting nominees to serve on the panel. **Roughly a year later, the committee’s membership is coming into focus.** According to the CMS webpage, **Asbel Montes** will serve as the committee chair. He’s a[ managing partner](https://www.solutionsgroup.com/about-us) at **Solutions Group,** which does health consulting and tech work, and leads the **American Ambulance Association**’s payment reform task force, according to his work bio. He referred The Health 202 to CMS for comment. - Committee members from the federal government include **Rogelyn McLean,** of the **Department of Health and Human Services; Ali Khawar,** of the **Labor Department;** and **Tom West,** of the **Department of Treasury.** - **Other members consist of a cross-section of the health industry, state and local government representatives, advocates and others.** This includes **Loren Adler,** of the **USC-Brookings Schaeffer Initiative for Health Policy; Adam Beck,** of the major insurer lobby; and **Patricia Kelmar,** of **PIRG,** a public interest group. **The view from CMS:** In a statement, a spokesperson said the agency is looking forward to hearing the committee’s recommendations, which will help inform new policies aimed at “preventing balance billing, improving communication as it relates to insurance options for service, and by providing upfront and easy to understand disclosures of charges and fees for ground ambulance service.” State of play **Ground ambulance billing is particularly complex.** For instance, many emergency medical transport services are operated by municipal and county governments, and so they must adhere to state and local regulations. Meanwhile, some municipal services[ may not contract](https://www.healthsystemtracker.org/brief/ground-ambulance-rides-and-potential-for-surprise-billing/#Share%20of%20emergency%20ground%20ambulance%20rides,%20by%20organization%20type,%202020) with private insurance companies, according to the **Kaiser Family Foundation.** “The reality is there’s so much unknown that there’s wisdom to convening a panel of experts,” said **Adam Buckalew,** the founder of **alb solutions** who helped negotiate the surprise billing law as a GOP aide on the Senate health committee. The ground ambulance panel has been of particular interest to the **House Education and Labor Committee**. Chairman **Robert C. “Bobby” Scott** (D-Va.) and ranking Republican **Virginia Foxx** (N.C.) sent a letter, first shared with The Health 202, Friday afternoon urging HHS to “prioritize and complete its establishment expeditiously.” (The CMS webpage appears to be updated with information about the ground ambulance committee before the lawmakers sent their letter, though an Education and Labor aide said HHS had been alerted last month that the letter was coming.) **Jamie Pafford-Gresham,** the secretary of the **American Ambulance Association**, said patients should be protected from surprise bills, but a “balanced approach” to addressing the payment is needed. She contends getting it wrong could jeopardize access to emergency care, particularly in underserved areas. **Onward:** The report is just another step toward potentially banning patients from receiving surprise bills from ground ambulances. Congress will likely need to legislate in this space to make good on upcoming policy recommendations. ## Agency alert ### The new (proposed) rules of the road for Obamacare are here The Biden administration is proposing [to make it easier](https://www.hhs.gov/about/news/2022/12/12/hhs-releases-policies-to-make-coverage-more-accessible-and-expand-behavioral-health-care-access.html) to buy Affordable Care Act plans, particularly for those losing their Medicaid or Children’s Health Insurance Program coverage. CMS released its [draft rule](https://www.cms.gov/newsroom/fact-sheets/hhs-notice-benefit-and-payment-parameters-2024-proposed-rule) yesterday governing the health insurance marketplaces for 2024. The proposal aims to make it easier for consumers to choose a plan by limiting the number of non-standard ACA plans an insurer can offer. The agency is also seeking to give marketplaces the option to create a special enrollment period for people who lose their Medicaid or CHIP coverage. Shoppers would have 60 days before, or 90 days after, they lose coverage to choose an ACA plan, which CMS says is aimed at mitigating gaps in health coverage. This comes as millions [could fall off](https://www.washingtonpost.com/health/2022/03/14/medicaid-loss-of-coverage/) the safety net program’s rolls in the months after the public health emergency for the coronavirus expires. **Topics:** Legislative, Medicare/Medicaid, Public Awareness --- ### [Fraudulent websites are collecting user information in the name of fake schemes](https://insurancefraud.org/news_archives/fraudulent-websites-are-collecting-user-information-in-the-name-of-fake-schemes-2/) **Published:** August 30, 2026 **Author:** Diane Beauchamp **Content:** Another [post](https://www.facebook.com/permalink.php?story_fbid=pfbid0uU9yeQompMb2j5mUcea7dxWBLsuRLzdWdXrdUfhvrNv7KK1d985FZh35XopGuKb6l&id=100090854324711) is being shared on social media claiming that the government is providing Rs. 2 Lakh pension every month to retired Indian NRIs above 30 years of age. The post shared a URL link and asked users to avail the benefits of the scheme. The URL provided in the post directs to a [website](https://nriupdates.live/nriv2?fbclid=IwAR0nuGwmmr2hYXHrF4mtuFlaMIigha8sdFEVo0x9rAAzvXyETEmU_EXEZi4) named NRI Updates, and further clicking on the options provided on the dubious website. The [website](https://trk.clmbtrck.in/click?campaign_id=769&pub_id=733&url_id=25&p1=6524e38fb011fc0001ce77de&p2=&p3=&source=) directs to an unrelated inactive website ‘trk.clmbtrck.in’. The Indian government did not announce any such pension scheme for NRIs above 30 years of age. The details regarding National Pension Scheme benefits available for NRIs can be seen [here](https://www.mea.gov.in/images/pdf/nps-for-nri.pdf). **Update (09 October 2023):** Another social media [post](https://www.facebook.com/permalink.php?story_fbid=pfbid0LKjJ8rD1j7EycjaDuRdXUZd5veGemPA9LzpHXqA9wJUuXLU3rSbDypcV8DHGCFEXl&id=100092400737794) claims that the US government is providing $100,000 easy loan to eligible salaried or unsalaried US citizens even if they have a poor credit history. The post shared a URL link and asked users to avail the benefits of the scheme. Upon clicking the URL link provided in the post, the URL [directs](https://financeupdate.live/blog/us-loan/f/usplss2607/index.php?ad_id=%7B%7Bad.id%7D%7D&adset_id=%7B%7Badset.id%7D%7D&campaign_id=%7B%7Bcampaign.id%7D%7D&ad_name=%7B%7Bad.name%7D%7D&adset_name=%7B%7Badset.name%7D%7D&campaign_name=%7B%7Bcampaign.name%7D%7D&source=%7B%7Bsite_source_name%7D%7D&placement=%7B%7Bplacement%7D%7D&cpid=e162b607-52a4-4cab-849e-9a69d66b657e&lpid=4b3c3711-cbf1-4ad2-aa53-f9005ed80ac1&fbclid=IwAR16ohqUjrw0yB6aZ89aSVnY9Z2QmVTMYnGboxgUd5OIXGdVca-WJFwNw1Y) to a website named “financeupdate.live” and further clicking on the ‘*Check Eligibility Here*’ button provided on the dubious website, the URL directs to another unrelated inactive website ‘[t.amatrck.com’](https://t.amatrck.com/aff_c?offer_id=1011442&aff_id=3183&aff_sub=roifb&aff_sub2=dkkb1bs5cpiacu5sic2vt7eg&aff_sub3=91dc95e9411d4c2d9fbcc6760897a9bf). On searching for further details regarding this website, we [found](https://www.whois.com/whois/amatrck.com) that this website with the domain name ‘https://amatrck.com/’ was registered with “*Domains By Proxy, LLC*” in January 2019. The US government did not announce any such financial assistance scheme and it is in no way associated with any of these fraudulent websites alluring fake loans to US citizens. **Update (02 August 2023):** Another [post](https://www.facebook.com/100094651511530/videos/6493175974054521) advertising a subsidy of $5200 for US citizens with low income is being shared on social media. The narration in the video states, “*This may be your last chance to secure free cash to help you pay for essential bills like food, rent or medical expenses. Individuals can apply by using the official links available under this video*.” The video says that the subsidy was only available for struggling Americans below the age of 65 and asks the users to register in the link provided below the post to avail benefits of the new scheme. Let’s verify the claim made in the post. > **Claim:** Website to avail $5200 subsidy provided for low-income US citizens below the age of 65. > > **Fact:** The link provided in the post directs to a private website requesting users’ annual income and the Public Health Insurance Program they are registered with. The link provided in the post is not affiliated with any of the US Government Public Health Insurance Programs like Medicare or Medicaid. Social Security Administration (SSA) warned users not to click on malicious links and give away personal information to prevent identity theft. Hence, the claim made in the post is Misleading. On clicking the link provided in the post, it redirects to a private website [‘https://pmc.usacashrelief.com/](https://pmc.usacashrelief.com/)‘, requesting information about the user’s annual income and the Public Health Insurance Program they are registered with. Upon providing the information, the website asks users to call a number to avail of the benefits of a $5200 subsidy and $0 health plan. The purported website is not affiliated with any of the US Government Public Health Insurance Programs like [Medicare](https://www.medicare.gov/) or [Medicaid](https://www.medicaid.gov/). No such [subsidy](https://www.cms.gov/search/cms?keys=subsidy), as mentioned in the post, was [listed](https://www.cms.gov/search/cms?keys=%255200+subsidy) on the official website of the Centers for Medicare & Medicaid Services (CMS). The [Low-Income Subsidy (LIS](https://www.cms.gov/medicare/eligibility-and-enrollment/lowincsubmedicareprescov)) implemented by the US Government helps people with Medicare pay for prescription drugs and lowers the costs of Medicare prescription drug coverage. The [eligibility for this subsidy](https://www.cms.gov/medicare/eligibility-and-enrollment/lowincsubmedicareprescov/downloads/statelisguidance021009.pdf) assistance can be determined by either the Social Security Administration (SSA) or their State Medicaid office. Depending on the monthly income and resource limits, the subsidy is provided to the citizens. Officials from the US National Consumers League and Center for Medicare Advocacy [confirmed](https://factcheck.afp.com/doc.afp.com.33P9996?fbclid=IwAR3z2bGxDhKlLqPDsBJgP20FmRslyFLmYrbTQBDSttSI9JGRkDDMpDufeac) to AFP that the viral post appears to be *“illegitimate or at best highly misleading*”. Moreover, the Social Security Administration [warns users](https://www.ssa.gov/fraud/#:~:text=How%20to%20report%20fraud,oig.ssa.gov%2F.) not to click on malicious links and give personal information as it may lead to identity & monetary theft. **Update (01 February 2023):** Another [post](https://www.facebook.com/permalink.php?story_fbid=pfbid037R4Vs4eeMf69wH1KSG9ALMdaZAMVkiSMbJ8j6saZG51Znmh4QUTJvwWseEQZdgd8l&id=100084854530257) is being shared on social media platforms asking senior citizens to register on the website given in the post to get $3034 yearly added to their Social Security checks. Let’s verify the claim made in the post. **Claim:** Social media post asking users to click on a website link and enter personal information to get $3034 yearly added to their Social Security checks. **Fact:** No such scheme is listed on the official Social Security Administration (SSA) website. The website in the post acts as a referral source to match customers with insurance companies. SSA warned users not to click on malicious links and give away personal information to prevent identity theft. Hence the claim made in the post is **MISLEADING.** No such scheme is mentioned on the [official website](https://www.ssa.gov/manage-benefits) of the Social Security Administration. In some cases, a citizen may be eligible for [increased benefits](https://www.ssa.gov/potentialentitlement/?tl=0), but one needs to apply for these benefits on the official website and not through third-party sites. The website given in the post describes itself as a non-Governmental referral source that provides information and access to helplines to match consumers with companies that may provide certain insurance coverage to them. This site also asks for the personal information of the users like Medicare eligibility & age. Moreover, the Social Security Administration [warns users](https://www.ssa.gov/fraud/#:~:text=How%20to%20report%20fraud,oig.ssa.gov%2F.) not to click on malicious links and give personal information as it may lead to identity & monetary theft. ![](https://factly.in/wp-content/uploads//2023/02/beware--1024x548.jpg)**Published (13 December 2022):** A [video](https://www.facebook.com/100070223990033/videos/828335895111118) is being shared on social media claiming that the American Government has released a sum of $540/month under ‘Health Give Back Program’ for people with an annual income of less than $50,000. Similarly, [another post](https://www.facebook.com/100068491092536/videos/800468127846366/) claims that people aged 40-80 years with no life insurance are getting $150k in lumpsum payment. These posts ask the users to click the link provided in the description to apply. Let’s verify the claims made in these posts. ![](https://insurancefraud.org/wp-content/uploads/image-20-6.jpg)**Claim:** American Government has released a sum of $540/month under ‘Health Give Back Program’ for people with an annual income of less than $50,000. **Fact:** No such scheme is launched by the US Government. Federal Trade Commission warns users not to enter personal details in unauthorised websites as it may lead to identity theft. All the government websites and emails end with ‘.gov’ and not with ‘.com’ or ‘.org’. Though the US government helps certain sections of low-income uninsured citizens through state subsidised health insurance or Medicaid, money is directly paid to the health care providers and not to the individuals. Hence the claim made in the post is **FALSE**. We searched [irs.gov](https://www.irs.gov/), [usa.gov](https://www.usa.gov/) and prominent [news websites](https://apnews.com/) but couldn’t find any information regarding this scheme. Moreover, the link given in the description redirects to an unauthorised [website](https://theamericansaver.com/u65/?fbclid=IwAR05hfYch_bWcjC-T8QMtyYKWQgYSO4Gd93ajQ7-B5lfDVJtEroDw-y_Qm0) which asks for the personal details of the person. Further, the disclaimer on the website says, *“THIS IS AN ADVERTORIAL AND NOT AN ACTUAL NEWS ARTICLE, BLOG, OR CONSUMER PROTECTION UPDATE”* [Federal Trade Commission (FTC)](https://consumer.ftc.gov/features/pass-it-on/health-care-scams) and [Healthcare.gov](https://www.healthcare.gov/how-can-i-protect-myself-from-tax-scams/) warned users on multiple occasions not to share personal information with these unauthorised websites as it may lead to identity theft. All the government websites and emails of the US government end with ‘.gov’ and not with ‘.com’ or ‘.org’. Even though US government helps certain sections of low income uninsured citizens through state subsidised health insurance or [Medicaid](https://www.hhs.gov/answers/medicare-and-medicaid/what-is-the-medicaid-program/index.html), money is directly paid to the health care providers and not to the individuals. ![](https://insurancefraud.org/wp-content/uploads/image-20-6.jpg)**Claim:** Americans aged 40-80 years with no life insurance are getting $150k in lumpsum payment. **Fact:** No such scheme is launched by the US Government. Federal Trade Commission warns users not to enter personal details in unauthorised websites as it may lead to identity theft. All the government websites and emails end with ‘.gov’ and not with ‘.com’ or ‘.org’. Though the U.S government helps certain sections of low-income uninsured citizens through state subsidised health insurance or Medicaid, money is directly paid to the health care providers and not to the individuals. Hence the claim made in the post is **FALSE**. We searched the [irs.gov](https://www.irs.gov/), [usa.gov](https://www.usa.gov/) and prominent [news websites](https://apnews.com/) but couldn’t find any information regarding this scheme. Moreover, the link provided in the posts redirects to an unauthorised [website](https://quotes.lifeinsuranceyes.org/fv3/lifeinsuranceyes/890/?tpl=890&offer=1738&affid=7271&mediacid=8705&r=176677441&sub_id=brtcmntdrct®ion=AP&fpt=1&s5=f2,129331731#/current-address) which asks for personal details. [Federal Trade Commission (FTC)](https://consumer.ftc.gov/features/pass-it-on/health-care-scams) and [Healthcare.gov](https://www.healthcare.gov/how-can-i-protect-myself-from-tax-scams/) warned users on multiple occasions not to give the personal information to these unauthorised websites as it may lead to identity theft. All the government websites and emails of the US government end with ‘.gov’ and not with ‘.com’ or ‘.org’. Even though U.S government helps certain sections of low-income uninsured citizens through [state subsidised health insurance](https://www.healthcare.gov/glossary/subsidized-coverage/#:~:text=Health%20coverage%20available%20at%20reduced,known%20as%20subsidized%20coverage%20too.) or [Medicaid](https://www.hhs.gov/answers/medicare-and-medicaid/what-is-the-medicaid-program/index.html), money is directly paid to the health care providers and not to the individuals. To sum it up, fraudulent websites are asking for personal details of users in the name of FAKE Health Schemes. **Topics:** Public Awareness, Technology --- ### [Greenwich Psychologist Admits Defrauding Medicaid, Medicare and Private Insurers](https://insurancefraud.org/news_archives/greenwich-psychologist-admits-defrauding-medicaid-medicare-and-private-insurers/) **Published:** August 30, 2026 **Author:** Diane Beauchamp **Content:** Vanessa Roberts Avery, United States Attorney for the District of Connecticut, Phillip Coyne, Special Agent in Charge for the U.S. Department of Health and Human Services, Office of Inspector General, and David Sundberg, Special Agent in Charge of the New Haven Division of the Federal Bureau of Investigation, today announced that MICHAEL LONSKI, 71, of Greenwich, waived his right to be indicted and pleaded guilty yesterday before U.S. District Judge Sarala V. Nagala in Hartford to health care fraud. According to court documents and statements made in court, Lonski is a licensed psychologist who, along with another licensed psychologist (“Individual 1”), has operated a practice out of his home office in Old Greenwich. Lonski and Individual 1 were authorized providers for the Connecticut Medicaid program (“Medicaid”), Medicare and other health care benefit programs. Lonski assumed responsibility for submitting claims for reimbursement for services allegedly provided by himself and by Individual 1, both at their home office and at various skilled nursing facilities within Connecticut. In pleading guilty, Lonski admitted that he billed insurers for services that he knew were not rendered, including by billing for patients who were deceased, for dates of service when he was out of the country, for dates of service when Individual 1 was out of the country, and for dates of service when he was hospitalized. These fraudulent claims resulted in a loss of over $2,651,296, including a loss of $1,157,292 to the Connecticut Medicaid program and a loss of $119,092 Medicare. Health care fraud carries a maximum term of imprisonment of 10 years. Judge Nagala scheduled sentencing for March 10. As part of his plea, Lonski has agreed to pay full restitution. Lonski is released on bond pending sentencing. In 2002, Lonski settled a federal lawsuit alleging health care fraud offenses, which was brought by the government in the Southern District of New York. Lonski agreed to pay $4 million in restitution and was excluded from participating in the Medicare program from April 2003 to November 2007. He was reinstated to the Medicare program in approximately December 2008. This investigation has been conducted by the U.S. Department of Health and Human Services, Office of the Inspector General (HHS-OIG), and the Federal Bureau of Investigation. The case is being prosecuted by Assistant U.S. Attorney Susan L. Wines. **Topics:** Healthcare Fraud, Medicare/Medicaid **Categories:** Conviction --- ### [LA driver arrested for auto insurance fraud after intentional collision injured victim](https://insurancefraud.org/news_archives/la-driver-arrested-for-auto-insurance-fraud-after-intentional-collision-injured-victim/) **Published:** August 30, 2026 **Author:** Diane Beauchamp **Content:** Kenneth McDaniel, 32, was arrested yesterday on four felony counts of insurance fraud and assault with a deadly weapon after a Department of Insurance investigation found he allegedly caused a vehicle collision in order to receive an undeserved insurance payout. McDaniel’s alleged actions left a victim with injuries and a totaled vehicle. The Department began an investigation after being contacted by the California Highway Patrol following an auto accident. On July 30, 2022, McDaniel’s alleged victim was driving and got onto the 405 freeway when McDaniel in his Ram pickup truck crossed over the gore area between the traffic lane and freeway entrance at a high speed and got behind the victim. McDaniel then cut over two lanes and sped past other vehicles to intentionally cut in front of the victim and then abruptly stopped the vehicle for no reason. The entire collision was captured on dash cam on both the front and back of the victim’s vehicle. The type of alleged scheme in this case is called a swoop and squat and is used to force a victim to remain in their lane so a collision cannot be avoided. These types of intentional collisions are extremely dangerous, not only for those involved, but for anyone on the road. Drivers should be cautious while driving and if anyone believes they have been targeted by this or any other type of auto fraud scheme, contact the Department at 800-927-4357. The victim’s vehicle was totaled and they suffered soft tissue damage because of the intentional collision. McDaniel’s alleged actions also resulted in a loss of $25,062 for the victim’s totaled vehicle. McDaniel was booked into the West Hollywood Sheriff’s Station and bail is set at $30,000. The Los Angeles County District Attorney’s Office is prosecuting this case. **Topics:** Auto - staged **Categories:** Arrest --- ### [Handwriting Specimens Delay Insurance Fraud Trial](https://insurancefraud.org/news_archives/handwriting-specimens-delay-insurance-fraud-trial/) **Published:** August 30, 2026 **Author:** Diane Beauchamp **Content:** A report on handwriting specimens from the Namibia Police Forensic Science Institute is at the root cause of an almost year-long delay in the trial of Ondangwa-based magistrate, Liwena Walter Mikiti, in the Windhoek High Court before acting Judge Eileen Rakow. ExploringTravel Maps The report, which is to determine the handwriting on claims submitted, is still outstanding, and Judge Rakow postponed the matter to 14 February next year for status hearing. Mikiti is accused of duping insurance giant Santam Namibia of N$234 555 in fraudulent insurance claims. He pleaded not guilty to the charges when his trial started in November last year. He did not enter a plea explanation, and only confirmed his not guilty pleas through Section 115 plea, read into the record by then-legal representative advocate Slysken Makando. According to the 115 plea, he put the proof of all the allegations on the State and make use of his right to remain silent. The charges emanate from an alleged car insurance fraud committed during June 2014. According to the charge sheet, Mikiti was the owner of a 2009 Mercedes Benz C180K BE Classic that was insured by Santam Namibia through Welwitchia Insurance Brokers. The vehicle was involved in a chain collision with three other vehicles on the Oshakati Main Road near Oneshila on 13 June 2014 and sustained minor damages but could still be driven afterwards. However, the indictment read, Mikiti submitted a claim that indicated the accident occurred on 14 June 2014 and that his motor vehicle sustained extensive damages that rendered it a total write-off. It is further alleged that Mikiti used the particulars of the accident of 13 June 2014 and the accident report issued for that accident when he claimed from the insurance. According to the State, it was on the basis of those particulars that Sanlam Namibia paid Mikiti the total sum. According to the State, Mikiti misrepresented to Sanlam that his motor vehicle was involved in an accident on 14 June and not 13 June 2014, and that it sustained damages beyond economical repairs; that it was a 2010 model instead of a 2009 model; that the other party in the accident was a Johannes Kaujeua; that the accident scene on the 14th was attended by a police officer, and that he was entitled to claim from his insurance. He did this, the State alleges, while he knew the damages that caused his vehicle to a write-off was not sustained during the accident of 13 June 2014 and that he made alterations to the accident report prepared on 13 June. The trial is continuing today, and Mikiti, who is now represented by Pieter Greyling, is free on bail. The prosecution is represented by advocate Timo Itula. **Topics:** Auto - padding/false claim **Categories:** Arrest --- ### [3,668 cyber crime cases in Mumbai till Sep 2022, more than 1,000 account for online/credit card fraud](https://insurancefraud.org/news_archives/3668-cyber-crime-cases-in-mumbai-till-sep-2022-more-than-1000-account-for-online-credit-card-fraud/) **Published:** August 30, 2026 **Author:** Diane Beauchamp **Content:** The Mumbai Polices cyber crime wing has registered 3,668 cases till September this year, of which 1,073 account for online or credit card fraud, an official said.Of the 3,668 cases, 214 were cracked with the arrest of 334 people, he said.Currently Mumbais population is more than two crore and cases related to cyber crime are increasing day by day. As many as 1,073 cases pertaining to credit card or online fraud were registered, in which 16 people were arrested. The Mumbai Police’s cyber crime wing has registered 3,668 cases till September this year, of which 1,073 account for online or credit card fraud, an official said. Of the 3,668 cases, 214 were cracked with the arrest of 334 people, he said. ”Currently Mumbai’s population is more than two crore and cases related to cyber crime are increasing day by day. Therefore, 220 police personnel, including constables, are being trained to deal with such cases,” the official said. Out of the total cases, 299 were related to obscene emails or MMS posts in which 94 people were arrested, he said. ”For fake social media profiles or morphing e-mails, 108 cases were reported and 25 people were arrested. As many as 1,073 cases pertaining to credit card or online fraud were registered, in which 16 people were arrested. Also, 1,141 cases of cheating were registered in which 41 people were arrested,” he said. Seven cases of tampering with computer source code, 31 cases of phishing or spoofing mail, 22 cases of pornography, 46 cases of hacking, 66 of gift fraud and 154 of purchase fraud. There were also 85 cases of job fraud 85, 16 insurance fraud, four admission fraud, 47 fake website, 27 matrimonial fraud, 16 crypto currency fraud, 96 loan fraud 96, 143 data theft, 65 sextortion, among others, registered by the cyber cell. **Topics:** Public Awareness, Technology --- ### [Four People Indicted for Medicare Fraud](https://insurancefraud.org/news_archives/four-people-indicted-for-medicare-fraud/) **Published:** August 30, 2026 **Author:** Diane Beauchamp **Content:** A federal grand jury in Topeka returned an indictment charging a Kansas woman and three Florida residents in connection with a scheme to defraud Medicare. According to court documents, Steven A. Churchill, 36, of Boca Raton, Florida, Samson K. Solomon, 25, of Margate, Florida, Elaine J. Balsamo, 58, of Boca Raton, Florida, and Fawn J. Lickteig, 42, of Lawrence, Kansas, are charged with: - one count of conspiracy to commit health care fraud, mail fraud, and wire fraud; - eight counts of health care fraud; - six counts of mail fraud; and - four counts of wire fraud. Churchill and Balsamo are also charged with four counts of money laundering. Despite claiming to be a retail pharmacy, the defendants are accused of establishing a fraudulent mail order pharmacy. Between February 2020 and February 2021, the defendants allegedly used Freestate Pharmacy to submit false claims to Medicare for prescriptions for patients who had not spoken with the doctor and who had not requested the medication. The U.S. Department of Health and Human Services – Office of Inspector General and the Federal Bureau of Investigation (FBI) are investigating the case. Assistant U.S. Attorneys Christine Kenney and Skip Jacobs are prosecuting the case. An indictment is merely an allegation, and all defendants are presumed innocent until proven guilty beyond a reasonable doubt in a court of law. **Topics:** Drug Diversion, Medicare/Medicaid **Categories:** Arrest --- ### [3 providers to pay $22.5M to settle Medicaid fraud allegations in California](https://insurancefraud.org/news_archives/3-providers-to-pay-22-5m-to-settle-medicaid-fraud-allegations-in-california/) **Published:** August 30, 2026 **Author:** Diane Beauchamp **Content:** Three providers will pay out $22.5 million across two separate settlements to resolve false claims allegations in California, the Department of Justice (DOJ) announced. Dignity Health and two Tenet Healthcare subsidiaries will settle allegations that they violated both federal and state false claims laws by submitting fraudulent claims to California’s Medicaid program, Medi-Cal. Dignity Health will pay $13.5 million to the U.S. government and $1.5 million to the state to resolve the allegations. Twin Cities Community Hospital and Sierra Vista Regional Medical Center, the Tenet affiliates, will pay $6.75 million to the U.S. and $750,000 as part of the settlement, DOJ said. “These health care providers siphoned critical Medicaid funding for their own gain instead of using it to provide health care services to patients most in need,” said U.S. Attorney Martin Estrada for the Central District of California in the release. “These major settlements demonstrate our commitment to hold accountable health care providers that seek to exploit the Medicaid program and harm the American taxpayer.” California expanded its Medicaid program under the Affordable Care Act in January 2014, providing coverage to a larger adult population. The feds cover the costs for the adult population in the first three years of the program, and states were required to use at least 85% of those funds to cover medical costs. States had to repay the federal government the difference between what was actually spent and that 85% figure. The settlements resolve allegations that Dignity Health submitted false claims for “enhanced services” provided to the expansion population between Feb. 1, 2015, and June 30, 2016. Twin Cities and Sierra Vista will resolve allegations for claims submitted between Jan. 1, 2014, and April 30, 2016. The federal government and the state determined the submitted charges were not “allowed medical expenses” under the program—represented predetermined amounts that did not reflect the value of services provided and/or were duplicative services. “When health care providers misuse Medicaid funds, they undermine the integrity of the Medicaid program and waste taxpayer funds,” said Deputy Assistant Attorney General Michael Granston of the DOJ’s Civil Division. “These settlements demonstrate the Department’s continued commitment to prevent providers from inappropriately using Medicaid or other federal health care programs for their own financial gain.” **Topics:** Judicial/courts, Medicare/Medicaid, Public Awareness --- ### [South Carolina prosecutors reveal alleged motive in Murdaugh murder case](https://insurancefraud.org/news_archives/south-carolina-prosecutors-reveal-alleged-motive-in-murdaugh-murder-case/) **Published:** August 30, 2026 **Author:** Diane Beauchamp **Content:** South Carolina prosecutors have put forth what they believe was Alex Murdaugh’s motive for killing his wife and son. He wanted to distract attention from the illicit schemes he was running to avoid financial ruin, they allege in a motion filed Thursday. “The evidence will show Murdaugh accrued substantial debts over a period of years and to uncover those debts began engaging in illicit financial crimes,” prosecutors wrote in the filing. “The evidence will further show these financial crimes were about to come to light at the time of the killings, more specifically on the date of the killings.” “Ultimately,” wrote prosecutors, “the murders served as Murdaugh’s means to shift the focus away from himself and buy himself some additional time to try and prevent his financial crimes from being uncovered, which, if revealed, would have resulted in personal legal and financial ruin for Murdaugh.” The bodies of Maggie Murdaugh, 52, and their 22-year-old son, Paul Murdaugh, were found on the family property in rural Colleton County on June 7, 2021. Alex Murdaugh has been charged with murdering both. He has pleaded not guilty. He also faces dozens of charges related to the theft and misappropriation of money from his clients and his own law firm. **Topics:** Life Insurance **Categories:** Arrest --- ### [Beware of your vendors: 3rd parties source of 50% of healthcare data breaches](https://insurancefraud.org/news_archives/beware-of-your-vendors-3rd-parties-source-of-50-of-healthcare-data-breaches/) **Published:** August 30, 2026 **Author:** Diane Beauchamp **Content:** The Department of Health and Human Services’ HIPAA breach reporting website showed that half of the 10 largest healthcare-related data breaches reported this year were caused by vendors or business associates. Security experts said this demonstrates the importance of vetting third-party providers and including cybersecurity standards in contracts and regular audits. They also said healthcare providers need to ensure a layered approach to security to defend against attacks that come through third-party breaches. “The reason business associate data breaches have skyrocketed is a simple numbers game,” said Paul Hales, regulatory attorney of the Hales Law Group. “Criminals know that one successful business associate attack yields protected health information from hundreds of covered entities. In a sense, business associates are just couriers. Covered entities are the real targets.” Since 2018, the attacks on business associates have doubled. Some hospitals and health systems that have reported compromised patient information due to a third-party data breach include [Seattle Children’s](https://www.beckershospitalreview.com/cybersecurity/seattle-children-s-notifies-6-750-patients-of-third-party-data-breach.html) and Houston-based [St. Luke’s Health](https://www.beckershospitalreview.com/cybersecurity/st-luke-s-suffers-3rd-party-data-breach.html). **Topics:** Public Awareness, Technology --- ### [Illinois physician pleads guilty to Medicaid fraud](https://insurancefraud.org/news_archives/illinois-physician-pleads-guilty-to-medicaid-fraud/) **Published:** August 30, 2026 **Author:** Diane Beauchamp **Content:** Monique Brotman, DO, based in Oak Park, Ill., has pleaded guilty to misdemeanor Medicaid fraud, the [*Wednesday Journal*](https://www.oakpark.com/2022/12/06/oak-park-physician-pleads-guilty-to-misdemeanor-medicaid-fraud/) reported Dec. 6. Dr. Brotman was charged for billing nearly $59,000 to Medicaid for ultrasounds and additional services between December 2008 and February 2015 that were not provided. She said the discrepancies were on account of administrative errors and not monitoring a former billing department employee, who she said she believes did not intend to commit fraud. “I’m still responsible. I should have been more careful,” Dr. Brotman told the Wednesday Journal. “This wasn’t done out of malice. There was no intent. Just a lapse of judgment.” Dr. Brotman has allegedly paid the full amount charged to the Illinois Department of Healthcare and Family Services Office of the Inspector General. She will not be allowed to bill Medicare or Medicaid for services for the next five years, she must have legal permission before traveling, and she has to complete 40 hours of community service. Her medical license has also been suspended for an undetermined period of time, until the state medical board reviews her case. **Topics:** Medicare/Medicaid **Categories:** Conviction --- ### [Governor Hochul Announces New Regulation to Protect Consumers Who Relied on Incorrect Provider Network Information](https://insurancefraud.org/news_archives/governor-hochul-announces-new-regulation-to-protect-consumers-who-relied-on-incorrect-provider-network-information/) **Published:** August 30, 2026 **Author:** Diane Beauchamp **Content:** Governor Kathy Hochul today announced that the New York State Department of Financial Services has adopted a regulation to protect consumers from unfair, surprise costs when they relied on incorrect information in their insurer’s healthcare provider directory. The new regulation addresses a longstanding concern for consumer advocacy groups by ensuring consumers who use providers they believe are in-network based on misinformation provided by their insurers will pay no more than their in-network cost-sharing. The Governor included this initiative in her 2022 State of the State address. “New Yorkers should never be blindsided by surprise costs due to incorrect information in their insurer’s healthcare provider directory,” **Governor Hochul said**. “This new regulation will help protect consumers from surprise costs and ensure they pay no more than their in-network cost-sharing. This initiative is part of my administration’s commitment to ensuring consumers are treated fairly, and I’m proud that we are taking this action to deliver on that promise.” **Department of Financial Services Superintendent Adrienne A. Harris said**, “Insurers are responsible for supplying accurate provider information, and consumers should be able to rely on that information as they make important decisions about medical care for themselves and their families. This long overdue regulation is basic common sense – insurers should not profit by charging consumers out-of-network fees when the insurer was at fault for giving incorrect information that a health care provider was in-network.” Under the final regulation, provider directory misinformation occurs when: - A provider who does not participate in the insurer’s network is incorrectly listed as an in-network provider in the insurer’s online or hard copy provider directory; - In response to a consumer’s request for information by telephone or through electronic means, an insurer indicates in writing that a provider is in-network when the provider is not in-network; or - An insurer fails to provide network status information in writing to a consumer within a certain number of days of the consumer’s request for such information by telephone or through electronic means. The regulation is consistent with the federal No Surprises Act requirements protecting consumers against provider directory misinformation. A copy of the final regulation can be found on the DFS website. **Topics:** Public Awareness, Regulatory actions --- ### [Don't fall for health insurance scams in NM](https://insurancefraud.org/news_archives/dont-fall-for-health-insurance-scams-in-nm/) **Published:** August 30, 2026 **Author:** Diane Beauchamp **Content:** Open enrollment for New Mexico’s health insurance marketplace, beWellnm, is underway and runs through Jan. 15, 2023. During this time, New Mexicans can enroll in a quality, affordable health plan that, per the Affordable Care Act (ACA), is guaranteed to cover a full list of benefits, caps out-of-pocket costs, and has an established network of providers. This year, plans through beWellnm are even more affordable thanks to additional discounts at the federal and state level, putting coverage in reach for more New Mexicans. During open enrollment, predatory companies will also scam hundreds of New Mexicans into junk insurance, leaving them uncovered and at risk of debt. These companies make their profit by impersonating government websites like [healthcare.gov](http://healthcare.gov/) or [beWellnm.com](http://bewellnm.com/), convincing consumers that they are selling legitimate ACA plans, or falsely claiming that their plans provide full coverage at a better price. Unfortunately, this is not an uncommon scenario. Having heard about open enrollment, a New Mexican might open their web browser and type in “affordable health insurance New Mexico.” The first three results are ads for non-government sites claiming to sell quality coverage at low prices. They click on the first link, enter their address and contact information, and receive a call from an agent claiming to be authorized to help them choose a plan. The individual picks a plan, provides credit card information over the phone for $40 a month, and receives an insurance card in the mail. A month later, this person is in an emergency situation for which costly care is immediately necessary. The receptionist comes into the room once the patient is stable with the bad news that their supposed insurance is worthless, and that they will need to pay out of pocket for any care received that day. Not only are they now dealing with the fallout of a medical emergency, but also an astronomical medical bill and no recourse for making a claim. Health coverage should be considered a necessity. The unfortunate reality is that anyone could end up in a situation where quality coverage is the difference between a manageable cost-sharing payment and life-altering medical debt. Shopping through beWellNM online ([bewellnm.com](http://bewellnm.com/)) or over the phone (1-833-862-3935), or through a certified broker or enrollment counselor is the only way to ensure you are purchasing a plan that will actually provide that security. While shopping for coverage, be wary of unsolicited phone calls, paid advertisements, and any entities other than beWellnm claiming to sell coverage in New Mexico. Always ask for documentation on the plan you’re selecting – know its benefits, network and full cost before purchasing. You may want to check directly with your doctor and pharmacy beforehand to make sure they accept that insurance. If you receive any assistance, make sure to request the person’s name and license number; if they won’t provide it, end your communication immediately. And if you’ve been scammed into paying for a junk insurance plan, report the incident to the Office of the Superintendent of Insurance by visiting [http://www.osi.state.nm.us](http://www.osi.state.nm.us/) or calling 855-427-5674. Legal action can be taken against these predatory companies, and your experience will help another New Mexican family avoid falling into a trap. Don’t waste your money or fall for a scam – only shop through beWellnm this open enrollment. **Topics:** Commercial Fraud, Healthcare Fraud, Public Awareness --- ### [SRSO: Pensacola contractor Jesse LaCoste's arrest stems from unfulfilled $15K home remodel](https://insurancefraud.org/news_archives/srso-pensacola-contractor-jesse-lacostes-arrest-stems-from-unfulfilled-15k-home-remodel/) **Published:** August 30, 2026 **Author:** Diane Beauchamp **Content:** The Santa Rosa County Sheriff’s Office fulfilled its arrest warrant for Pensacola contractor Matt Banks’ brother-in-law after he failed to begin a home remodel for a Gulf Breeze woman. The Gulf Breeze woman told authorities she hired Jesse LaCoste and his company, LaCoste Construction Group LLC, just after Hurricane Sally in November 2020, just after Hurricane Sally, but LaCoste has allegedly failed to begin the work after they both signed a contract. When a deputy responded on Aug. 31, 2022, the woman told the deputy she paid LaCoste $15,385.21 on July 16, 2021, and “work has not been started.” The deputy then advised she submitted a demand letter for LaCoste to either finish the work or provide a full refund and allowed 30 days for the company to respond. “On Sept. 19, 2022, (she) received the certified mail package back undelivered and unable to be forwarded to LaCoste Construction,” the arrest report states. “(She) has attempted numerous times through phone calls and email to contact LaCoste but has had no response.” The Gulf Breeze woman has not had further correspondence with LaCoste, and the arrest report states deputies were unsuccessful in their attempts to contact him. LaCoste was booked into Santa Rosa County Jail around 5:30 p.m. Wednesday on one count of larceny and released at 1:25 a.m. Thursday on $10,000 bond, according to the jail website. Escambia and Santa Rosa counties revoked both LaCoste and Banks’ contractor licenses earlier in August after the counties were inundated with complaints that both contractors took clients’ money and failed to begin or finish home remodels. Both contractors have had dozens of cases come before Escambia County’s Contractor Competency Board and Santa Rosa’s County’s Building Code Board of Adjustment and Appeals, where they have been ordered to pay millions of dollars back to clients who allege they failed to conduct or finish contractually obligated home renovations. **Topics:** Contractor fraud **Categories:** Arrest --- ### [Fraud and ransomware dominate cyber insurance claims](https://insurancefraud.org/news_archives/fraud-and-ransomware-dominate-cyber-insurance-claims/) **Published:** August 30, 2026 **Author:** Diane Beauchamp **Content:** Ransomware accounts for 23 percent of cyber insurance claims, while while fraudulent funds transfer (FFT) accounts for 28 percent according to insurance specialist [Corvus](https://www.corvusinsurance.com/), which has released its latest Risk Insights Index. The impact and consistency of FFT is growing, accounting for 36 percent of all claims in the last quarter (Q3 2022), an all-time high. Indeed this metric has not dropped below 25 percent for the past six quarters. The rise in FFT incidents is linked to business email compromise (BEC), with FFT representing 70 percent of all BEC-related claims, showing that it’s a highly effective way for threat actors to monetize social engineering attacks. “Global cybercrime is growing more complex by the day, presenting security leaders with new challenges. With the power of security insights and dynamic claims data feeding Corvus’s technologies, we can help our policyholders improve their cybersecurity posture by informing them of emerging threats and best practices,” says Jason Rebholz, chief information security officer at Corvus Insurance. “While ransomware continues to be a dominant risk, we are seeing tactics change, including the rise of other forms of extortion as well as funds transfer fraud. The findings from our report serve as a reminder to all security leaders that cybersecurity is fluid and attackers will shift their methods, even revisiting old tactics, so long as they continue to reap financial benefits.” Corvus also observed a 66 percent increase in third-party breaches in 2022, including a 20 percent increase in the share of third-party ransomware attacks. Data exfiltration has seen a 25 percent increase from H2 2021 to H1 2022 too. It now occurs on nearly 50 percent of ransomware claims, a historic high, suggesting that attackers are attempting to generate additional points of leverage to increase the likelihood of a ransom payment. “It’s vital that the cybersecurity and insurance industries stay connected to remain agile in the changing threat landscape,” adds Rebholz. “Rising instances of data exfiltration show that cybercriminals will respond quickly to thwart security professionals, and identify creative ways to increase leverage in ransom negotiations. Insurers have visibility into these changes, enabling us to take an informed, proactive approach with our brokers, policyholders, and partners. It’s Corvus’s responsibility as a leading insurtech to not only make our policyholders safer, but also to help empower the industry at large to make the world a safer place.” The [Risk Insights Index](https://insights.corvusinsurance.com/cyber-risk-insight-index-q4-2022/) is available on the Corvus site. **Topics:** Public Awareness, Technology --- ### [Waterbury Woman Charged with Workers' Compensation Fraud and Larceny](https://insurancefraud.org/news_archives/waterbury-woman-charged-with-workers-compensation-fraud-and-larceny/) **Published:** August 27, 2026 **Author:** Diane Beauchamp **Content:** The Office of the Chief State’s Attorney today announced that a Waterbury woman has been arrested and charged with illegally collecting Workers’ Compensation benefits in the amount of $19,082.00 during her employment at a Waterbury hospital. Tashia McKenzie, age 36, of Waterbury, was arrested on June 30, 2026 by Inspectors from the Workers’ Compensation Fraud Control Unit in the Office of the Chief State’s Attorney and charged with one count of Fraudulent Claim or Receipt of Benefits, in violation of Connecticut General Statutes § 31-290c, one count of Larceny in the Second, in violation of Connecticut General Statutes § 53a-123(a)(2). The defendant surrendered herself at the Rocky Hill Police Department where she was released on a $10,000 non-surety bond. She is scheduled to appear at Waterbury Superior Court, Geographical Area No. 4 on August 27, 2026. According to the arrest warrant affidavit, on July 21, 2021, the defendant reported sustaining a work-related back injury while employed as a certified nursing assistant at St. Mary’s Hospital in Waterbury. As a result of her injury, she received temporary partial disability payments and total temporary disability benefits. Temporary Partial Disability (TPD) is a wage replacement benefit for which an employee may be eligible, if they are able to perform some type of work, including “light duty” or “restricted” work, but not the same kind of work or the number of hours they worked at the time of the injury, and the employer cannot accommodate the restrictions. To receive these benefits, the recipient is considered to have limited work capacity and must inform the employer of any improvements in their injuries. They also are required to report any income beyond the benefits provided. Temporary Total Disability (TTD) is a wage replacement benefit paid by the employer’s workers’ compensation insurance carrier while the claimant is unable to perform any type of work due to a work-related injury or illness. The investigation found that while the defendant was out on workers’ compensation disability from St. Mary’s Hospital, she was employed by Hale Home Care, LLC as a home care provider, performing duties similar to those of a certified nursing assistant as well as being employed as a certified nursing assistant at Waterbury Hospital. While receiving workers’ compensation benefits from St. Mary’s Hospital, the defendant failed to disclose her other employment and her ability to resume home care/certified nursing assistance duties at St. Mary’s Hospital. The defendant received indemnity payments from St. Mary’s Hospital totaling $19,082.00, which she was not entitled to. Documentation showed that while receiving payments, she exceeded the physical restrictions set forth by her treating physicians and that she could have returned to full duty work capacity. The case will be prosecuted by the Workers’ Compensation Fraud Control Unit of the Office of the Chief State’s Attorney in Rocky Hill. The charges are merely accusations, and the defendant is presumed innocent unless and until proven guilty in a court of law. **Topics:** Work comp - worker **Categories:** Arrest --- ### [Owner of Redding landscaping company charged for allegedly operating without workers’ compensation insurance](https://insurancefraud.org/news_archives/owner-of-redding-landscaping-company-charged-for-allegedly-operating-without-workers-compensation-insurance/) **Published:** August 27, 2026 **Author:** Diane Beauchamp **Content:** The owner of a Redding landscaping company was arrested and charged with operating a business without a proper workers’ compensation insurance policy, the Office of the Chief State’s Attorney said. Matthew Lang, 44, owner of Shoots to Roots Plant Care Corp., was arrested on Aug. 5 by Inspectors from the Workers’ Compensation Fraud Control Unit on a charge of noncompliance with insurance requirements. He turned himself in at the Rocky Hill Police Department on Aug. 5 and was released on a $10,000 bond. Connecticut state law requires business owners to carry workers’ compensation insurance. Lang is scheduled to appear in court on Sept. 28. **Topics:** Work comp - employer **Categories:** Arrest --- ### [Governor Abbott directs TDI to lower property insurance costs](https://insurancefraud.org/news_archives/governor-abbott-directs-tdi-to-lower-property-insurance-costs/) **Published:** August 27, 2026 **Author:** Diane Beauchamp **Content:** Governor Greg Abbott today directed the Texas Department of Insurance (TDI) to take several actions that put consumers first and make property and casualty insurance more affordable for Texans who invest in their homes. “The average annual homeowners’ insurance premium in Texas has risen 79 percent in six years,” said Governor Abbott. “High insurance costs hit Texas families hard. Today I direct the Texas Department of Insurance to put consumers first and take action that makes property and casualty insurance more affordable.” Actions directed for the Texas Department of Insurance Governor Abbott directed TDI to: Require insurers to include a home’s FORTIFIED roof status in their rate setting calculation to reduce the cost of insurance premiums.Prohibit insurers from refusing to write or renew residential property insurance policies based on the age of the property, including individual components such as the age of the roof.Issue a bulletin for all TDI-regulated products that bans the practice of “price optimization,” whereby insurers use personal data unrelated to insured risk to set prices.Create an Insurance Fraud Task Force to clamp down on insurance fraud, which harms all consumers by making insurance more expensive.Conduct a study on the impact of excessive, unnecessary, and inflated claims costs on the Texas commercial auto, personal auto, and homeowner insurance markets. TDI shall also identify additional administrative actions that can be taken immediately and any statutory changes needed to protect consumers and make insurance products more affordable. These recommendations are due to the Office of the Governor by Monday, September 14, 2026. Governor Abbott will work with the Legislature next session to further enhance consumer protections for insurance policyholders and curb premium increases. **Topics:** Legislative, Public Awareness, Regulatory actions --- ### [Columbia woman arrested for insurance fraud in Caldwell Parish arson investigation](https://insurancefraud.org/news_archives/columbia-woman-arrested-for-insurance-fraud-in-caldwell-parish-arson-investigation/) **Published:** August 27, 2026 **Author:** Diane Beauchamp **Content:** State Fire Marshal deputies announced they have arrested a Columbia woman on Monday in connection with a June house fire that investigators determined was intentionally set as part of an insurance fraud scheme. 64-year-old Cynthia Lisenby, faces one count of insurance fraud, according to the Louisiana Office of State Fire Marshal (SFM). Deputies said they arrested Lisenby on Aug. 24 following a multi-week investigation. Deputies said the probe began after the Hebert Fire Department requested assistance from the SFM Fire Investigations Unit. Firefighters had responded to a house fire in the 1700 block of Templeton Bend Road in Columbia at approximately 4:30 a.m. on June 22, which ultimately destroyed the residence. Investigators later determined the blaze was started intentionally to defraud an insurance provider. The Louisiana State Fire Marshal’s Office reminds the public that anyone with information regarding fire-related crimes can submit an anonymous tip by visiting lasfm.org and selecting the “Arson Fires” icon. **Topics:** Homeowners - arson **Categories:** Arrest --- ### [Pennsylvania personal care attendants charged with padding work hours for $1.5 million in reimbursements](https://insurancefraud.org/news_archives/pennsylvania-personal-care-attendants-charged-with-padding-work-hours-for-1-5-million-in-reimbursements/) **Published:** August 27, 2026 **Author:** Diane Beauchamp **Content:** Two Pennsylvania-based personal care attendants are facing charges after they allegedly defrauded Medicaid by submitting nearly $1.5 million in reimbursements for work that wasn’t done, according to Pennsylvania Attorney General Dave Sunday. According to the DA’s office, Ashley Griffin, 27, and Yolanda Wright, 49, are facing felony Medicaid fraud, theft by deception, and conspiracy charges in connection with the investigation. The investigation, completed by the AG’s office Medicaid Fraud Control Section, found that Griffin submitted more than 64,000 work hours for $1.2 million in reimbursements between 2020 and 2023, knowing she did not complete the work, per the AG’s office. **Topics:** Medicare/Medicaid **Categories:** Arrest --- ### [Florida man allegedly staged car crash that hurt family of four, deputies say](https://insurancefraud.org/news_archives/florida-man-allegedly-staged-car-crash-that-hurt-family-of-four-deputies-say/) **Published:** August 27, 2026 **Author:** Diane Beauchamp **Content:** More than a year after a family of four was hurt in a crash in Orange County, Florida, detectives have arrested a man for allegedly staging the crash, known as the “left turn wave-thru.” What is a left turn wave-thru? Big picture view: Detectives described the left turn wave-thru as a “well-known and well-used staged crash tactic.” According to the report, the alleged criminal typically stopped at an intersection where there are no traffic signals and motions to let someone make a left turn in front of them. Once the person starts to make the turn, the criminal then speeds up, crashes into the vehicle, and claims the other vehicle ran the stop sign. I tried to cross the road, and then he just came like with a superfast speed and he hit our car. What they’re saying: The crash happened on Aug. 16, 2025, at the intersection of Dr. Phillips Boulevard and Forrest Brook Lane, just outside a neighborhood. FOX 35’s Alexus Cleavenger talked with the woman who was inside the vehicle with her husband and their two children. “This is not a normal accident. Everything was not normal,” she said. “Very scary—this was my first car crash ever in my life, also in my husband’s life.” She said the family pulled up to the stop sign and stopped. That’s when another driver in a Jeep stopped in the middle of the road – later identified as Jaboule Casimir – and waived them across the street. “I was stopping at a stop sign, and then there was someone inside a Jeep Wrangler… he was just in the middle of the road,” she recalled. She said Casimir, who had no stop sign, waved to her to go. “It was about like 10 to 12 seconds—’go, no you go,’ just with hand signs,” she said. “And then I tried to cross the road, and then he just came like with a superfast speed and he hit our car. The impact of the crash caused the vehicle’s airbags to deploy. Their 8-month-old baby was hit in the head by the airbag, their 6-year-old child’s glasses shattered, leaving pieces of glass inside his eye, and the mom broke her arm and hurt her ear. The charges What we know: According to the report, Casimir admitted to detectives that he held up traffic on purpose and crashed into the family’s vehicle. He was arrested and booked into jail on several charges: Aggravated battery with a deadly weapon Staging/participating in an intentional motor vehicle crash Insurance fraud Criminal mischief Perjury Unlawful use of a two-way communication device A judge granted him a $54,000 bond. Why you should care: While staged crashes are often associated with financial schemes, automotive experts stress the physical danger they pose to innocent drivers. “It’s a safety issue because the crashes themselves might be staged, but the collisions are very real and people can get severely hurt,” said said Mark Jenkins, spokesman for AAA – The Auto Club Group. What to Do If You Suspect a Staged Crash What you can do: If you ever find yourself involved in a collision that feels suspicious or staged, safety experts recommend taking the following steps: Call Law Enforcement: Always get law enforcement to the scene immediately to file an official report. Document Everything: Take photos and videos of all vehicles involved, the exact damage, license plates, and the surrounding roadway/intersection. Gather Witnesses: Look around for witnesses and collect their names and contact information before they leave. **Topics:** Auto - staged **Categories:** Arrest --- ### [California Man Sentenced to 36 Months’ Imprisonment for Defrauding Former Employer, Optum, Inc.](https://insurancefraud.org/news_archives/california-man-sentenced-to-36-months-imprisonment-for-defrauding-former-employer-optum-inc/) **Published:** August 27, 2026 **Author:** Diane Beauchamp **Content:** United States Attorney Daniel N. Rosen announced that Karan Gupta, 48, of Walnut Creek, California, was sentenced to 36 months in prison for one count of conspiracy to commit wire fraud, ten counts of wire fraud, and one count of conspiracy to commit money laundering. Gupta was sentenced before U.S. District Judge Kate M. Menendez on August 24, 2026. He had previously been found guilty on February 17, 2026, following a six-day jury trial. According to court documents and evidence introduced at trial, between 2015 and 2020, Gupta led a scheme to defraud his employer, Optum, Inc., by creating a no-show job for his lifelong friend, Shangraf Kaul, 45, of East Stroudsburg, Pennsylvania, as a data engineering manager and pocketing over half of Kaul’s salary as a kickback. Gupta, who was a senior director at Optum, hired Kaul to work on his team in late 2015, despite Kaul’s lack of qualifications for the position. For over three years, Kaul performed no work at Optum while collecting a six-figure salary. Gupta, as Kaul’s supervisor, facilitated Kaul’s no-show employment and demanded Kaul pay him approximately 60% of his unearned salary in kickbacks. Gupta then devised a plan for him and Kaul to conceal the kickback payments, first through cash deposits into Gupta’s own bank account, then through a designated checking account to which Gupta had access. Gupta’s fraud was ultimately discovered by Optum after his termination from the company in November 2019 for engaging in a similar no-show employee fraud. Optum investigated and referred the case to federal law enforcement. In total, Gupta’s fraud against Optum totaled more than $950,000. Gupta’s co-conspirator, Kaul, pleaded guilty on February 26, 2025, to one count of conspiracy to commit wire fraud and is currently awaiting sentencing. “Defrauding a private company is not a victimless crime. Gupta’s actions ultimately undermine a healthcare provider that millions of Americans depend on, and today’s sentencing reflects the seriousness of his crimes,” said United States Attorney Daniel N. Rosen. “The FBI is committed to investigating complex fraud schemes that exploit trust and defraud victims through deliberate deception, including schemes in which the defendant creates a no-show position at the very company that employs him, using that position to victimize his own employer. The jury’s verdict and today’s sentencing demonstrate the seriousness with which our justice system treats fraud,” said FBI Minneapolis Special Agent in Charge Christopher D. Dotson. “The FBI, in strong partnership with the U.S. Attorney’s Office, is sending a clear message that those who use their positions of trust to orchestrate sophisticated schemes, conceal criminal proceeds, and defraud the companies that employ them will be held accountable.” This case is the result of an investigation conducted by the FBI. Assistant United States Attorneys Matthew D. Forbes and Rebecca E. Kline prosecuted the case. **Topics:** Insider Fraud **Categories:** Conviction --- ### [SC woman doctored receipts to collect thousands from insurance, officials say](https://insurancefraud.org/news_archives/sc-woman-doctored-receipts-to-collect-thousands-from-insurance-officials-say/) **Published:** August 27, 2026 **Author:** Diane Beauchamp **Content:** A Lexington County woman collected thousands of dollars from an insurance company by using doctored receipts to file fraudulent claims, according to the South Carolina Law Enforcement Division. Morica Dyshalik Rivers, 34, collected thousands of dollars from American Bankers, a Florida-based insurance company, by filing claims using fake receipts from high-end retailers — like Louis Vuitton, according to an arrest warrant. She was charged Monday with seven counts of forgery — value less than $10,000 and presenting a false claim for insurance payment — value more than $2,000 but less than $10,000, a news release said. Besides Louis Vuitton, Rivers — formerly known as Morica Gleaton — submitted fake receipts from Alexander McQueen, Coach, Gucci and Sprint, collecting a total of $8,465 from American Bankers, according to an arrest warrant. Rivers was booked into the Lexington County Detention Center. **Topics:** Homeowners - fake **Categories:** Arrest --- ### [Missouri Contractor Sentenced for Fraud Scheme](https://insurancefraud.org/news_archives/missouri-contractor-sentenced-for-fraud-scheme/) **Published:** August 27, 2026 **Author:** Diane Beauchamp **Content:** Missouri Attorney General Catherine Hanaway announced that a contractor has pled guilty to defrauding consumers through his residential contracting business. Gene M. Matlock, owner of Matlock Construction, pled guilty on August 17 to one felony count of deceptive business practices and one felony count of stealing. According to the investigation, Matlock solicited large, upfront payments from consumers for home‑construction and contracting services. After receiving payment, he either performed negligible work before abandoning the projects or failed to complete any work or deliver any materials, leaving customers without the services they paid for and facing significant financial losses. As part of his guilty plea, Matlock was sentenced to four years in prison on the deceptive business practices conviction and five years on the stealing conviction. The Court also ordered him to pay $191,975 in restitution to victims. This restitution amount includes every victim identified by the Attorney General’s Office, not only those named in the criminal case. Matlock was additionally placed on a five‑year term of supervised probation. **Topics:** Contractor fraud **Categories:** Conviction --- ### [OIG Removes Federal Approval Gate for State Medicaid Fraud Data Mining](https://insurancefraud.org/news_archives/oig-removes-federal-approval-gate-for-state-medicaid-fraud-data-mining/) **Published:** August 27, 2026 **Author:** Diane Beauchamp **Content:** On August 13, 2026, the U.S. Department of Health and Human Services Office of Inspector General (OIG) eliminated a longstanding federal checkpoint that has constrained how state Medicaid Fraud Control Units (MFCUs) deploy data analytics against Medicaid claims. Under State Fraud Policy Transmittal No. 2026-1 (the “Transmittal”), MFCUs no longer need OIG approval before conducting federally funded data mining, and they no longer need to renew that approval every three years. OIG accomplished the change by waiving the prior-approval requirements in 42 C.F.R. § 1007.20(a)(4) in their entirety. **State fraud investigators can now move faster and look deeper into provider billing data using advanced analytics, machine learning, and other modern detection technologies—without first obtaining federal permission.** Although the regulatory change is narrow on paper, its practical implications are far-reaching. State fraud investigators can now stand up, continue, or significantly expand claims-based data-mining operations, including the use of AI-driven pattern recognition, population-level algorithms, and real-time anomaly detection, without first presenting their analytical methods, data sources, staffing, security measures, and proposed program to OIG and CMS for advance review. The change does not create new MFCU jurisdiction or establish a new theory of liability. It does, however, remove the procedural gate that previously slowed and limited state-level deployment of sophisticated analytics. MFCUs are now free to screen entire Medicaid claims populations at scale for unusual billing patterns, utilization outliers, and provider anomalies, and are doing so much faster and with more powerful tools than ever before. **Why the Change Matters for Providers** Before this change, OIG’s public list reflected approved data-mining programs in only 25 states and the District of Columbia. That list may no longer provide a reliable indication of where sophisticated Medicaid claims analysis is occurring. MFCUs in states that did not previously appear on the list no longer need to obtain OIG’s permission before using federal funds to conduct the work, while Units with existing approvals may continue without returning to OIG for renewal. The immediate concern for providers is not that every billing outlier represents fraud. Many unusual patterns have legitimate explanations, including patient acuity, specialization, geography, referral patterns, service mix, and differences in local access to care. The concern is that large-scale claims screening can identify the pattern before an investigator understands its cause. A provider may therefore become the subject of an inquiry because its claims data look different, leaving the provider to reconstruct and document the operational or clinical explanation after the flag has already been generated. Those flags may become investigative leads that move across civil, criminal, and administrative enforcement channels. The OIG waiver itself does not authorize payment suspensions, and an analytical outlier alone is not a finding of fraud. But when claims analysis contributes to a credible allegation of fraud and an investigation is pending, the state Medicaid agency’s separate payment-suspension obligations may be implicated. *See* 42 C.F.R. § 455.23. The operational consequences can therefore arise well before a final determination of liability and may include document demands, expanded claims review, payment disruption, repayment exposure, exclusion risk, licensure consequences, or parallel civil and criminal inquiries. OIG has retained several forms of oversight under the Transmittal. MFCUs must continue coordinating with their state Medicaid agencies, identifying responsible personnel, training staff who conduct data mining, and addressing those requirements in the written MFCU–Medicaid agency agreement. *See* 42 C.F.R. §§ 1007.9(d), 1007.20(a)(1)–(3). Units must also continue reporting the costs, staff time, cases, outcomes, recoveries, and return on investment associated with their data-mining activities. *See* 42 C.F.R. § 1007.17(a)(1)(ii). The change is therefore not the elimination of federal oversight; it is the replacement of advance federal approval with review through reporting, recertification, and inspection. **Providers Should Modernize Compliance Across the Organization** Providers should treat this development as an enterprise compliance issue rather than a discrete coding, data, or information-technology project. The information visible to government analytics is produced across revenue cycle, coding, pharmacy, clinical operations, managed care, physician arrangements, contracting, credentialing, and finance. A provider’s compliance program should be able to bring those perspectives together and identify the same patterns that may be visible to an outside reviewer. That does not require every provider to purchase an advanced artificial-intelligence platform. It does require an auditing and monitoring structure that is appropriately data-enabled for the organization’s size and risk profile. Providers should know which Medicaid billing areas present their greatest exposure, what patterns would appear unusual when reviewed across providers, locations, services, or time periods, and who is responsible for examining and explaining those patterns. The methodology should be documented, the records should be queryable, and findings should have assigned owners, deadlines, corrective actions, and closure criteria. Providers should also examine whether their internal data remain fragmented across operational silos. A coding review may not reveal a referral-pattern issue, and a revenue-cycle report may not explain a legitimate difference in clinical acuity. Data modernization should therefore include governance, including but not limited to defined data sources, consistent fields, documented thresholds, responsible owners, and an escalation path that connects an analytical flag to the people who understand the underlying operations. Finally, organizations should know when an outlier has moved beyond routine monitoring. A finding suggesting intentional misconduct, a potentially systemic overpayment, or facts that overlap with a government inquiry may require a transition to a counsel-directed investigation, preservation of relevant records, quantification of potential exposure, and evaluation of repayment or disclosure obligations. *See* 42 U.S.C. § 1320a-7k(d). That transition should be designed in advance rather than improvised after an agency has already made contact. OIG’s new policy does not create liability where none existed. It does increase the likelihood that existing weaknesses, unexplained billing patterns, and operational inconsistencies can be identified at scale and earlier in the enforcement process. Medicaid providers should ensure that their compliance programs are not merely collecting more data, but are capable of using that data across the organization to identify risk, document legitimate variation, and act before an external analytics program generates the first meaningful review. **Topics:** Public Awareness, Regulatory actions --- ### [Chief Financial Officer Blaise Ingoglia Announces Arrest Following Vehicle Insurance Fraud Scheme](https://insurancefraud.org/news_archives/chief-financial-officer-blaise-ingoglia-announces-arrest-following-vehicle-insurance-fraud-scheme/) **Published:** August 27, 2026 **Author:** Diane Beauchamp **Content:** Today, Chief Financial Officer Blaise Ingoglia announced the arrest of Adam Otrok following a vehicle insurance fraud scheme. The arrest was made by the Department of Financial Services Criminal Investigations Division (CID) after Otrok fraudulently submitted 41 vehicle insurance applications on luxury vehicles that he never owned. He allegedly attempted to defraud $206,000 by requesting a full refund of his premium. Chief Financial Officer Blaise Ingoglia said, “Florida has long been the law-and-order state, but we are now making it the anti-fraud state. If you want to commit financial crimes, my investigators will be close behind you. Fraudsters beware—your crimes will not go unpunished in Florida.” CID investigators discovered that Otrok used counterfeit and fictitious personal identification information to submit the vehicle insurance applications. Additionally, he would stop the payment of his premium from his insufficiently funded bank account. Otrok would then request a refund before his insurance company was aware of the invalid payment. The investigation confirmed that he attempted to defraud the company of $206,000 for his own financial gain and successfully obtained $44,704 in fraudulent funds. Adam Otrok was arrested on August 6, 2026. He has been charged with organized scheme to defraud, insurance fraud, grand theft, and fraudulent use of personal identification. If convicted, Otrok could face up to 10 years in prison. Prosecution of this case falls under the jurisdiction of the Broward State Attorney’s Office. The Department of Financial Services encourages anyone with knowledge of fraud to report it at FraudFreeFlorida.com \| Florida Department of Financial Services. **Topics:** Auto - underwriting **Categories:** Arrest --- ### [Congress must now do its part on Medicare fraud](https://insurancefraud.org/news_archives/congress-must-now-do-its-part-on-medicare-fraud/) **Published:** August 27, 2026 **Author:** Diane Beauchamp **Content:** When Vice President JD Vance — President Trump’s appointed fraud czar — stood before the Cabinet at Camp David at the end of July, he rattled off some eye-popping numbers. His team had uncovered $230 billion in fraud and stopped $56 billion of it before a dime went out the door. A week later, Vance took the same case to Capitol Hill, hosting a roundtable with lawmakers and urging Congress to make the crackdown permanent rather than let it lapse with a future change in executive leadership. Congress should heed his advice, and quickly. The relevant committees — Senate Finance and House Energy and Commerce chief among them — should draft legislation this fall that locks in the Medicare and Medicaid’s enforcement authority, funding levels, and enrollment moratoriums by statute. Otherwise, everything this administration has built through executive and regulatory action can be undone the same way: by a future administration that simply chooses not to enforce the law. Only Congress can make these wins permanent. The case for urgency is not abstract. Just this month, prosecutors in Philadelphia unsealed charges against 19 people in a home-healthcare scheme that reads almost like parody. One caregiver allegedly billed for visits made while she was traveling abroad. Another claimed to be caring for seven patients at once, racking up more billed hours than exist in a single day. The government says that one fraud ring alone cost taxpayers more than $4 million. That is the kind of abuse the administration’s crackdown is built to catch. Under Health and Human Services Director Robert F. Kennedy Jr., CMS Administrator Mehmet Oz and Center for Medicare Director John Brooks, the executive branch has suspended billions of dollars in suspect Medicare payments, imposed nationwide moratoriums on new enrollment for hospice, home health, and durable medical equipment suppliers, and revoked billing privileges from thousands of providers. This year’s national health care fraud takedown produced charges against more than 450 defendants tied to roughly $6 billion in alleged false claims. California and Minnesota have had more than $1 billion in Medicaid reimbursements frozen while they prove the money is reaching real patients. But the same enforcement tools that catch fraud can just as easily overcorrect and choke off legitimate care — which is exactly why these decisions should not be left to agency discretion alone. Take remote patient monitoring, the technology that lets seniors managing diabetes, high blood pressure, or heart disease take readings at home and send them straight to their care team, instead of waiting months for an appointment or driving hundreds of miles to a doctor’s office. Regulators recently found real fraud in the program: companies cold-calling or robocalling seniors into monitoring plans they never asked for, then billing Medicare for monitoring that did not meaningfully happen. CMS deserves credit for catching it. But unelected career staff have now drafted a proposal broad enough to effectively kill physicians’ ability to use outside companies to run remote patient monitoring at all — even though those companies are often what keeps monitoring running for practices too short-staffed to do it themselves, in a country already facing a serious doctor shortage. The problem with leaving fixes to rulemaking is that it makes overbroad fixes more likely. And either way, a future administrator can rewrite it again. Congress doesn’t have that problem. Lawmakers could write a fix directly into statute — banning the cold-calling of beneficiaries that has fueled most of the abuse, and requiring a physician’s sign-off before any patient is enrolled. As the Heritage Foundation’s Peter St. Onge has noted, those two changes alone would stop most of the fraud without gutting a program that seniors, especially in underserved rural areas, depend on. And that’s exactly what Congress should be across the board. It should take the enforcement gains the administration has already made, and the fixes still being worked out at the agency level, and write them into law before the moment passes. Protecting Medicare from fraud should not be a partisan project. Both parties have an interest in a program that serves the seniors who paid into it for decades. The administration has done its part; the crackdown has been thorough and, so far, effective. As Vance made clear on Capitol Hill, the next move belongs to Congress. Lawmakers should introduce that bill while they still have the momentum to get it done. **Topics:** Legislative, Medicare/Medicaid, Public Awareness --- ### [Medicare Advantage Provider Monogram Health Agrees to Pay $2.4 Million to Settle False Claims Act Lawsuit](https://insurancefraud.org/news_archives/medicare-advantage-provider-monogram-health-agrees-to-pay-2-4-million-to-settle-false-claims-act-lawsuit/) **Published:** August 27, 2026 **Author:** Diane Beauchamp **Content:** Monogram Health Professional Services PC and Monogram Health Inc., headquartered in Tennessee, have [agreed to pay $2.4 million](https://www.justice.gov/opa/media/1458886/dl) to resolve allegations that they violated the False Claims Act by causing the submission of false diagnosis codes to increase payments that they received from the Medicare Advantage program. “When it comes to how federal money is being spent, taxpayers deserve to know that this Justice Department is looking out for them,” said First Assistant U.S. Attorney Bill Essayli. “My office will continue to work to ensure that money for public health programs is spent how it’s intended, as today’s settlement shows.” “When companies submit false diagnosis codes, they unlawfully exploit a system built to support vulnerable seniors,” said Assistant Attorney General Brett A. Shumate of the Justice Department’s Civil Division. “This settlement reinforces the Department’s commitment to protecting taxpayer money and ensuring that Medicare Advantage payments are based on accurate information.” “Health care companies that seek to inflate profits by inaccurately reporting the medical conditions of Medicare Advantage enrollees will be held accountable,” said Acting Deputy Inspector General for Investigations Miranda L. Bennett of the Department of Health and Human Services Office of Inspector General (HHS‑OIG). “This settlement underscores HHS‑OIG’s commitment to protecting the integrity of taxpayer‑funded federal health care programs. Medicare Advantage exists to deliver medically necessary care to beneficiaries, not to serve as a vehicle for improper financial gain.” Under the Medicare Advantage (MA) Program, also known as Medicare Part C, Medicare beneficiaries may opt out of traditional Medicare and enroll in private health plans offered by insurance companies known as Medicare Advantage Organizations, or MAOs. The Centers for Medicare & Medicaid Services (CMS) pays the MAOs a fixed monthly amount for each Medicare beneficiary enrolled in their plans. CMS adjusts these monthly payments to account for various “risk” factors that affect expected health expenditures for the beneficiary. In general, CMS pays MAOs more for sicker beneficiaries expected to incur higher healthcare costs and less for healthier beneficiaries expected to incur lower costs. To calculate the payment amounts, CMS uses a health-based risk adjustment model — the Hierarchical Conditions Category (HCC) model — that considers diagnoses reported by healthcare providers. In general, the more severe the diagnosis or costly the associated treatment, the higher the risk score and the higher the corresponding payments to the MAO. The diagnoses must be supported by the medical record of a face-to-face visit between a patient and a provider, and for outpatient visits, must have required or affected patient care, treatment, or management at the visit. Monogram provides in-home care and related services to Medicare beneficiaries enrolled in MA Plans pursuant to contracts with certain MAOs. Under these contracts, Monogram was eligible to be paid more by the MAOs if the beneficiaries in its care had higher risk scores because the MAO received higher payments from CMS for those beneficiaries. These risk sharing arrangements gave Monogram a financial incentive to submit additional diagnosis codes to increase its patients’ risk scores and the corresponding payments made by CMS. The settlement announced today resolves allegations that, during the period from January 1, 2021 through December 31, 2023, Monogram knowingly submitted diagnosis codes within the following four HCCs that were not clinically accurate, not supported by documentation in the beneficiary’s medical records, and/or did not require or affect patient care, treatment or management: HCC 21 (Protein-Calorie Malnutrition), HCC 55 (Substance Use Disorder); HCC 48 (Coagulation Defects and Other Specified Hematological Disorders), and HCC 88 (Angina Pectoris). The submission of these diagnosis codes resulted in false claims that inflated the risk scores of the Medicare Advantage beneficiaries, thereby causing CMS to make higher capitated payments to the MAOs than it would have paid without these diagnosis codes. The civil settlement includes the resolution of claims brought under the qui tam or whistleblower provisions of the False Claims Act by Dr. Ajay Gupta, a physician formerly employed by Monogram. Under those provisions, a private party can file an action on behalf of the United States and receive a portion of any recovery. Dr. Gupta will receive approximately $380,000 as his share of the recovery in this case. The lawsuit is captioned *United States of America ex rel. Dr. Ajay Gupta v. Monogram Health Professional Services, et. al.*, Case No. 2:22-cv-08758 MWF-JCx (C.D. Calif.). Monogram received credit under the Department of Justice’s guidelines in Justice Manual § 4-4.112 for taking cooperation into account in cases involving False Claims Act allegations. This year the Administration launched the Task Force to Eliminate Fraud and the National Fraud Enforcement Division to enhance the administration’s war on fraud, waste, and abuse in federal programs. When unscrupulous actors exploit these programs for their own financial gain, they defraud the government, harm the people these programs are designed to aid and protect, and undermine American businesses that play by the rules. The Civil Division’s FCA enforcement plays a critical role in combatting such fraudulent schemes, recovering billions of dollars for the American taxpayers, and holding wrongdoers accountable. FCA matters will continue to be on the forefront of the battle against fraud, and the Civil Division’s FCA work will support and advance the mission of the Task Force to Eliminate Fraud and the National Fraud Enforcement Division. The resolution obtained in this matter was the result of a coordinated effort between the Justice Department’s Civil Division, Commercial Litigation Branch, Fraud Section, and the U.S. Attorney’s Office for the Central District of California with assistance from the U.S. Department of Health and Human Services Office of Inspector General. The investigation and resolution of this matter illustrate the government’s emphasis on combating health care fraud. One of the most powerful tools in this effort is the False Claims Act. Tips and complaints from all sources about potential fraud, waste, abuse, and mismanagement, can be reported to the Department of Health and Human Services at 800-HHS-TIPS (800-447-8477). The matter was investigated by Assistant United States Attorney Hunter B. Thomson of the Civil Division’s Civil Fraud Section and Justice Department Fraud Section Attorney Jennifer Cook. *The claims resolved by the settlement are allegations only and there has been no determination of liability.* **Topics:** Judicial/courts, Public Awareness --- ### [Mills County Sheriff’s Office Reports 10 Arrests, Including Drug, Abuse and Fraud Charges](https://insurancefraud.org/news_archives/mills-county-sheriffs-office-reports-10-arrests-including-drug-abuse-and-fraud-charges/) **Published:** August 27, 2026 **Author:** Diane Beauchamp **Content:** The Mills County Sheriff’s Office reports multiple arrests over the past two weeks. Douglas James Fox, 58, of Pacific Junction, was arrested on August 21st for Possession of a Controlled Substance. Bond was set at $5,000. Rochelle Rose Reyes, 37, of Wathena, Kansas, was arrested on August 20th for Administering Harmful Substance, Dependent Adult Abuse, and Wanton Neglect of Healthcare Facility Resident. Bond was set at $7,300. Dylan Scott Gaines, 30, of Bellevue, Nebraska, was arrested on August 20th on an out of county/state warrant. He was held on no bond. Travis Nelson, 41, of Preston, Minnesota, was arrested on August 20th for Possession of a Controlled Substance and Possession of Drug Paraphernalia. Bond was set at $1,300. Logan Neil Petersen, 27, of Omaha, Nebraska, was arrested on August 18th for Trespass 1st Offense and Interference with Official Acts. Bond was set at $1,000. Makayla Rae Smith, 25, of Malvern, was arrested on August 17th for Driving While License Denied/Revoked. Bond was set at $1,000. Kinzey Kay Long, 31, of Oakland, was arrested on August 16th for Insurance Fraud – False Information. Bond was set at $5,000. Randy Lee Hammers, 58, of Emerson, was arrested on August 14th for OWI 1st Offense. Bond was set at $1,000. Randall Perry Hughes, 40, of Des Moines, was arrested on August 13th for Driving While Barred. Michael Reuban Foster, 33, of Council Bluffs, was arrested on August 10th for Driving Under Suspension. Bond was set at $300. **Topics:** Fraud General **Categories:** Arrest --- ### [Attorney General James Secures $6 Million from Three Buffalo Nursing Homes for Years-Long Fraudulent Billing Scheme](https://insurancefraud.org/news_archives/attorney-general-james-secures-6-million-from-three-buffalo-nursing-homes-for-years-long-fraudulent-billing-scheme/) **Published:** August 26, 2026 **Author:** Diane Beauchamp **Content:** New York Attorney General Letitia James today secured $6 million from three nursing homes in the Buffalo region, Safire Rehabilitation of Northtowns, Safire Rehabilitation of Southtowns, and Williamsville Suburban Nursing Home (the Safire homes), for submitting tens of thousands of fraudulent claims to Medicaid to boost their revenue. A joint investigation between the Office of the Attorney General’s (OAG) Medicaid Fraud Control Unit (MFCU) and the United States Attorney’s Office for the Western District of New York (WDNY) revealed that from July 1, 2016 through December 31, 2020, the Safire homes submitted false data that artificially increased their reimbursement rates from Medicaid, allowing them to earn millions of dollars more than they should have by filing fraudulent claims. Under settlements with OAG and WDNY, the Safire homes will repay a total of $9 million and implement new procedures to prevent false billing and ensure all residents get the proper services they need. “Nursing homes that commit financial fraud are stealing funds meant to provide care for our most vulnerable,” said Attorney General James. “The Safire homes used fraudulent data to rake in millions of dollars from Medicaid without regard for the needs of the residents they were supposed to be serving. My office has rooted out fraud and resident neglect in nursing homes throughout New York, and we will continue to investigate Medicaid fraud to protect New Yorkers.” “Medicare and Medicaid fraud drains taxpayer funds and weakens these vital government programs,” said U.S. Attorney for the Western District of New York Michael DiGiacomo. “This settlement reinforces our commitment to safeguarding federal funds and ensuring seniors receive the care they deserve.” Nursing homes are required to submit data accurately reflecting the care required by their residents to the New York Department of Health (DOH). The DOH uses that data to calculate the nursing homes’ Medicaid reimbursement rates for all claims submitted within the following six months. The OAG’s investigation found that for years, the Safire homes falsely inflated the amount of rehabilitative services certain residents needed during periods that impacted their Medicaid reimbursement rates. During periods that did not impact the Medicaid reimbursement rates, the Safire homes reduced the amount of rehabilitation services provided to certain residents, regardless of their need. As a result of their fraud, the Safire homes received millions of dollars from Medicaid at inflated rates. Under the settlement announced today, the Safire homes admit wrongdoing and will pay $6 million to Medicaid, of which $3.6 million will go directly to New York. The remaining $2.4 million will be paid to the federal government. The Safire homes will also pay an additional $3 million to the federal government for defrauding Medicare. In addition, the facilities must adopt new policies and procedures to ensure that residents covered by Medicaid receive all the services they need and that services are properly documented to prevent future fraud. The OAG and WDNY began this investigation after a whistleblower filed a complaint in December 2020 under the qui tam provisions of the New York False Claims Act and the federal False Claims Act in the U.S. District Court for the Western District of New York. The New York False Claims Act allows individuals to file actions on behalf of the government and share in any recovery. Reporting Medicaid Provider Fraud: MFCU defends the public by addressing Medicaid provider fraud and protecting nursing home residents from abuse and neglect. If an individual believes they have information about Medicaid provider fraud or about an incident of abuse or neglect of a nursing home resident, they can file a confidential complaint online or call the MFCU hotline at (800) 771-7755. If the situation is an emergency, please call 911. The MFCU investigation was conducted by Auditor-Investigator Rebecca Whitescarver, under the supervision of Regional Chief Auditor Mary Henry. Support was provided by Data Analytics Team members Si Lok Chao and Elise Roche. Chief Auditor Dejan Budimir supervised the audit and data analytics teams. The settlement was handled by Special Assistant Attorneys General Jill D. Brenner and Amanda L. Raimondi, under the supervision of Chief of Civil Enforcement Alee Scott and Buffalo Regional Director Paul C. Parisi. MFCU is led by Director Amy Held and Assistant Deputy Attorney General Thomas O’Hanlon. MFCU is part of the Division for Criminal Justice, which is led by Chief Deputy Attorney General José Maldonado and overseen by First Deputy Attorney General Meghan Faux. New York MFCU’s total funding for federal fiscal year (FY) 2026 is $70,793,651. Of that total, 75 percent, or $53,095,240, is awarded under a grant from the U.S. Department of Health and Human Services. The remaining 25 percent, totaling $17,698,411 for FY 2026, is funded by New York State. **Topics:** Judicial/courts, Medicare/Medicaid, Public Awareness --- ### [How Zohran Mamdani’s pied-à-terre tax exposed an epidemic of ‘ghost cars’ instead](https://insurancefraud.org/news_archives/how-zohran-mamdanis-pied-a-terre-tax-exposed-an-epidemic-of-ghost-cars-instead/) **Published:** August 26, 2026 **Author:** Diane Beauchamp **Content:** It’s not an uncommon sight to see out-of-state plates in New York. For one, it is the self-described greatest city in the world, so of course people embark on road trips to see all the sights of the five boroughs. But on the other hand, plenty of those plates are New Yorkers who register their cars in New Jersey, Pennsylvania, or elsewhere specifically to dodge New York’s high insurance premiums, while actually living in and driving around the Big Apple. In New York City specifically, a Streetsblog analysis of city violation data found nearly 21,000 vehicles registered outside the tri-state area (plus Pennsylvania) that picked up at least one violation in the city in every single quarter of the year: a pattern strongly suggesting these cars are actually garaged and driven in New York full-time, with owners registering elsewhere purely to dodge the state’s high insurance rates. The City Council’s Oversight and Investigations Division surveyed more than 3,500 parked vehicles last year across precincts chosen for high volumes of out-of-state-plate summonses. Of 768 non–New York-plated vehicles found, one in five had mismatched, temporary, or fraudulent “no-hit” plates that don’t trace back to any valid registration. Those vehicles owed nearly two-and-a-half times more in outstanding fines than properly registered cars, and paid only 16% of what they owed, versus 63% for validly plated ones. But Mayor Zohran Mamdani’s pied-à-terre tax—a surcharge for anyone who owns a second home in New York valued at over a certain limit—is effectively acting as an extra tax auditor. The question is simple: Are you a New York City resident? Then present your driver’s license or income taxes. Did you happen to file out of state though you lay your head in the five boroughs? Technically, that makes you a nonresident—and someone defrauding the city, per the Department of Finance (DOF). The DOF has quietly audited residency status for years through the STAR exemption and the Senior Citizen Homeowners’ Exemption, both of which require a property to be the owner’s actual primary residence, and both of which have turned up real fraud when checked. One comptroller’s audit alone found the DOF had improperly granted the senior exemption to properties whose owners had died and to corporations that were never eligible, a loss of at least $59.2 million over five years. The pied-à-terre tax flips that same question around: Instead of catching people wrongly claiming a primary-residence break, it catches properties wrongly claimed as primary, to avoid the surcharge. What we’re describing here is rate evasion, or “garage fraud,” a recognized form of insurance fraud nationally, not just a New York quirk. Insurers price premiums based on a car’s garaging ZIP code, since accident and theft risk vary sharply by density, creating a built-in incentive to register a car at a cheaper address than where it’s actually kept. A 2011 New York State Independent Democratic Conference paper on the practice found it goes well beyond individual drivers fudging an address: It documented organized rings registering dozens of vehicles at a single out-of-state address, then buying and reselling cheap out-of-state policies in bulk. If someone genuinely lives in New York full-time, proving it is simple: A tax return with the address on it settles the question. The letters only become a real problem for someone who filed as a non–New York resident while actually living in the city, exactly the asymmetry being exposed by the Mamdani tax. Domestically, it’s not just New York New York’s own state government has escalated its response accordingly. Governor Kathy Hochul made ghost plates and out-of-state registration fraud a centerpiece of her 2026 State of the State address, citing an estimated $300-a-year cost to every law-abiding New York driver, and has since run multiagency crackdowns—state police, DMV, and the Thruway Authority working with local departments—that pulled more than 200 vehicles off the road in a single recent sweep. California is chasing a parallel scheme aimed at taxes rather than insurance. Prosecutors charged 14 people with felony tax evasion in March 2026 over the “Montana LLC” loophole, in which owners register expensive vehicles through Montana shell companies to dodge sales tax and registration fees. Philadelphia, meanwhile, launched a public reporting tool for so-called ghost cars and towed more than 50 within two weeks, with officials explicitly framing the issue as a quality-of-life problem that bleeds into public safety. In Europe, it’s Italy and France The Neapolitan word furbo directly translates to being sly, but in reality, it’s so much more. It’s finding a way to get home after curfew without getting in trouble; of avoiding detention in school; of finding a loophole around a law. So that’s why it’s not surprising this whole issue is dubbed in Polish the przekręt neapolski, or the “Neapolitan scam.” This week, Polish authorities admitted they’re cracking down on a scheme in which Neapolitan car owners deregister their vehicles from Italy’s public motor registry, have it “exported” to Poland and reregistered under Polish plates through a long-term rental agreement, then get them back, often without the cars ever physically leaving Italy. Mandatory liability insurance in Naples, among Italy’s most expensive, can run €600 to over €2,000 a year; the Polish-plate workaround drops that to roughly €350 a year after the first year. It’s been illegal since 2022, when Italy banned residents from driving foreign-plated cars not also registered domestically. But in 2025 alone, Naples province registered 14,066 foreign vehicles, almost all Polish-plated. And nationally, Italy has 68,228 Polish-plated vehicles on the road, concentrated overwhelmingly around Naples. Payouts tied to uninsured Polish-plated cars in Italy jumped from €1.5 million in 2024 to more than €4.2 million in 2025. Poland’s Infrastructure Ministry is now drafting a reform requiring photographic proof during inspections that a car is actually sitting in a Polish garage. The Naples scheme is a story about individual drivers gaming an insurance market. France’s version shows how the same address-arbitrage logic scales into organized crime: The state auditor Cour des Comptes found roughly 1 million illegally registered vehicles currently on French roads, enabled by fraudulent “ghost dealerships” manipulating the national vehicle registry for a fee. The report put losses at €550 million in unpaid fees and fines just between 2022 and 2024 alone, and found the same registry fraud used to dodge luxury-car environmental taxes, disguise stolen vehicles, and support drug-trafficking logistics. In New York, with a driver simply registering a Honda in New Jersey, they’re part of a greater tax and insurance fraud scheme. **Topics:** Auto - underwriting, Legislative, Public Awareness --- ### [Community Health Network reports online tracking data breach affecting 1.5 million](https://insurancefraud.org/news_archives/community-health-network-reports-online-tracking-data-breach-affecting-1-5-million/) **Published:** August 25, 2026 **Author:** Diane Beauchamp **Content:** Community Health Network said it discovered on September 22 that the configuration of certain pixels on its digital properties allowed for a broader scope of patient information collection and transfer to third-party vendors, such as Meta and Google, than it realized. **WHY IT MATTERS** Companies that provide online tracking tools have been accused in class-action lawsuits of allegedly targeting ads to people based on information regarding their health that was collected through healthcare system websites and patient portals. Community announced November 16 on its website that it launched an investigation into its own data-tracking practices and hired a third-party forensic team. “That investigation confirmed that third-party tracking technologies were installed on Community’s website, including the MyChart patient portal and on some of our appointment scheduling sites,” the health network said in the statement. “When we learned of this, we immediately began working with our service providers to disable and/or remove certain technologies from our websites and applications as we continued our internal investigation in hopes of better understanding the nature of the information that these technologies were collecting and transmitting.” Community also said that the investigation has not found evidence that misuse or fraud has occurred as a result of the breach, and it “cannot say with certainty what information was involved.” The data could be computer IP address; dates, times and/or locations of scheduled appointments; information about an individual’s healthcare provider; type of appointment or procedure scheduled; communications through MyChart – which may have included first and last name and medical record number; information about whether an individual had insurance and if an individual had a proxy MyChart account, and the name of the proxy. “We have no indication that any Social Security numbers, financial account numbers or debit/credit card information was collected by or transmitted through the third-party tracking technologies at any time,” Community said. **THE LARGER TREND** This past week, the U.S. Department of Health and Human Services issued [guidance on the use of online tracking tools in healthcare](https://www.healthcareitnews.com/news/hhs-issues-guidance-use-online-tracking-tools-healthcare-crm). It comes after months of confusion and class-action lawsuits as health systems manage a new front for patient privacy and security. Community Health Network joins a number of healthcare providers that are discovering they were unaware of how, when and what patient data was being transmitted for third-party marketing efforts. Pixel technology uses a Java tracking script to send an organization’s data to the technology owner, which could be shared with network marketing partners who target individuals with relevant offers and advertisements. Because patient data cannot be shared under HIPAA, consumer data mining practices – which are generally criticized for lacking transparency – have long elicited medical privacy concerns. A [class-action lawsuit](https://www.healthcarefinancenews.com/news/meta-platforms-sued-alleged-unlawful-collection-patient-data) filed in June against Meta Platforms, owned by Facebook, alleges the social media giant knowingly received patient data from at least 664 hospitals or medical providers and monetized the information for targeted advertising. “This unlawful collection of data is done without the knowledge or authorization of the patient, like plaintiffs, in violation of federal and state laws as well as Facebook’s own contract with its users,” the [court document](https://docs.reclaimthenet.org/Doe-v-Meta-Platforms-FB-Tracking-Pixels.pdf) said. “When a patient communicates with a healthcare provider’s website where the Facebook Pixel is present on the patient portal login page, the Facebook Pixel source code causes the exact content of the patient’s communication with their healthcare provider to be redirected to Facebook in a fashion that identifies them as a patient.” In October, for instance, [Advocate Aurora Health](https://www.healthcareitnews.com/news/advocate-aurora-notifies-patients-potential-tracking-pixel-breach) sent letters informing 3 million patients in Illinois and Wisconsin about a potential data breach involving tracking pixels. In August, Novant Health announced it had let 1.3 million of its patients know about its third-party data breach. The recent lawsuits suggest [potential liability for failing to provide patient privacy protections](https://www.healthcareitnews.com/video/what-are-providers-liabilities-new-era-patient-data-tracking) that healthcare organizations are obligated to uphold under the law. Andrew Mahler, a former investigator with HHS Office for Civil Rights and now VP of privacy and compliance at CynergisTek, stressed the importance of healthcare organizations performing thorough risk analyses, providing proper training and education and seeking independent third-party review of policies, processes and systems. “What makes this situation especially complex and troubling is that the healthcare organizations themselves may not have been aware that the Meta Pixel tool had been embedded in its website and/or that it was tracking, comparing and receiving data about patients, including \[protected health information\],” he told *Healthcare IT News* earlier this month when asked about [privacy challenges and best practices where websites track users’ online behaviors](https://www.healthcareitnews.com/news/new-healthcare-privacy-challenges-online-data-tracking-sharing-methods-evolve). **ON THE RECORD** “Community used the applicable third-party tracking technologies from April 6, 2017, until most of them were disabled and/or removed from August to November 2022 as our investigation progressed,” the health provider said in a separate [FAQ](https://www.ecommunity.com/notice-third-party-tracking-technology-data-breach/faqs) on its website. **Topics:** Public Awareness, Technology --- ### [County medical examiner warns of possible phone scam](https://insurancefraud.org/news_archives/county-medical-examiner-warns-of-possible-phone-scam/) **Published:** August 25, 2026 **Author:** Diane Beauchamp **Content:** ## The Office of the Medical Examiner says it has gotten a high volume of calls from people in the public saying they have missed a call from the county office. County officials say the office will never leave a message or make a call without giving the name of the investigator and a number to call back. Individuals who are contacted by the Office of the Medical Examiner will always get a call back if no one is there to answer and if it is a legitimate call. County officials want to remind the public that it will not make phone calls or leave a message without providing the important details listed above. **Topics:** Public Awareness --- ### [Man Staged Murders Of His Wife And Son As Accidents To Collect Life Insurance](https://insurancefraud.org/news_archives/man-staged-murders-of-his-wife-and-son-as-accidents-to-collect-life-insurance/) **Published:** August 25, 2026 **Author:** Diane Beauchamp **Content:** On New Year’s Day 1991, fire emergency services were called to a residential fire in Murphys, California at 2:26 p.m. They were confronted by [Karl Karlsen](https://www.uniondemocrat.com/news/article_59bf1134-46b0-11ea-bb38-c36b09dba36f.html), who said he just rescued his three children from inside the burning home — but that someone else was still inside. He said “he wasn’t able to get inside to save his wife, Christina,” Calaveras Enterprise reporter Dakota Morlan told [Accident, Suicide or Murder,”](https://www.oxygen.com/accident-suicide-or-murder)airing**Saturdays at 8/7c on Oxygen.** First responders found Christina’s body in the bathroom of the rundown house. Karl told officials that the fire may have started because of a utility light that had fallen. Fire officials determined that the origin of the fire was directly outside the bathroom. Christina had been taking a bath while Karl worked in the garage. Officials observed some red flags, according to John Cleere, Lieutenant of Investigations, Seneca County Sheriff’s Office.The window in the bathroom where Christina died was boarded up. The odor of kerosene was prominent. However, Karlsen told investigators they couldn’t afford to fix the broken pane. He said that they used kerosene to heat the house and that a container of it had spilled and seeped into the carpet days before the blaze. “On its face it looks like it could be an accident,” said Cleere. “But when someone dies, the default is to consider it suspicious until you know better.” “The investigators weren’t going to just accept that this was an accidental fire based upon Karl Karlsen’s story,” added former State Trooper Jeff Arnold. An autopsy was performed the following day, while investigators looked for leads on the cause of the fire. The physician found soot in Christina’s lungs but no evidence indicating she was injured or incapacitated before the blaze. The autopsy determined Christina died from smoke inhalation. It didn’t conclude if the death was an accident or a homicide. The day after the fire, Karlsen surprised Christina’s family and authorities when he announced he was moving with his [daughters, Erin and Kati, and son, Levi](https://abcnews.go.com/US/daughters-losing-mother-brother-dad-killed-insurance-payouts/story?id=71029005), to his hometown in Seneca County, New York. “He didn’t stay for any funeral services or purchase a headstone. He just packs up and leaves,” said Cleere. Christina’s family was so suspicious they decided to collect their own evidence, according to “Accident, Suicide or Murder.” Despite their efforts, on March 3, 1991, Christina’s death was officially ruled an accident. “There just wasn’t enough hard evidence to prove otherwise,” said Morlan. State Farm Insurance paid a life insurance policy of approximately $215,000 to Karlsen. “I’ve worked with insurance investigators and if an arrest is not made insurance policies are not going to deny the claim,” explained Cleere. Was that payout a motive for murder? Investigators considered that. Karlsen moved on and purchased a section of a farm from his parents. About a year later, he married Cindy Best. On November 20, 2008, 17 years after Christina’s death, Cindy called 911. She frantically told the dispatcher that their truck had fallen off a jack. Levi, now 23 with a family of his own, was pinned underneath. He wasn’t breathing. Officials found that Levi had a crushing compression type of wound to his chest. All indications showed that he had perished hours ago. According to Karlsen, Levi was working on the truck when he and Cindy left to go to a funeral. When they returned he was crushed under the half-ton vehicle. The family doctor signed off on the death as accidental, according to investigators. There was no autopsy done. [Christina’s mother, Arlene Meltzer](https://www.recordnet.com/story/news/courts/2013/06/06/family-feels-calaveras-neglecting-possible/45739377007/), heard the news about Levi. “I felt really bad but I didn’t think it was an accident. I thought, ‘It’s happened again,’” she said. [In February 2012, Cleere received a call](https://www.syracuse.com/news/2013/11/cindy_karlsen_lived_a_double_life_waiting_for_police_to_arrest_her_husband_karl.html#:~:text=That%20cousin,%20Jackie%20Hymel,%20who%20lives%20in%20Kentucky,,to%20live%20a%20double%20life%20for%20a%20year.) from Levi’s cousin, Jackie Hymel, who asked if he had investigated Levi’s death, he told producers. “She said, ‘There’s a good chance he was murdered by his father.’” Through conversations with Cindy, Hymel had heard things that had raised her suspicions. “She talks about the fact that Karl had made money off of Christina’s death, and that Christina’s children had never seen any of that money,” Morlan told producers. Karlsen had taken out insurance policies on the lives of Christina and Levi shortly before their deaths. He was the beneficiary in both cases. Investigators reopened the case into Levi’s death. On April 9, 2012, they called Cindy Karlsen, who was estranged from her husband. She agreed to cooperate and was interviewed numerous times over the following months. A profile of Karlsen emerged as a controlling and emotionally abusive narcissist. According to Cindy, Karlsen and his son had been at odds for quite awhile but appeared to be mending fences. Karlsen had been the one to convince Levi to get the $700,000 life insurance policy, which was taken out 17 days before Levi’s death. “Cindy said she didn’t find out about it until after Levi was dead. Karl had pretty much blown most of the money on a get-rich-quick scheme,” said Cleere. Before separating from Karlsen, Cindy had a private investigator do some digging on her husband, and learned Karlsen had taken out an insurance policy on her. Cindy agreed to wear a wire to catch Karlsen talking about his son’s death. Although he didn’t confess, Karlsen made an admission that enabled police to bring him in for questioning. Karlsen’s version of the events before Levi’s death were inconsistent. He initially said Levi had been crushed before going to his aunt’s funeral. Karlsen then said he caused the truck to fall, freaked out, and left. “I don’t believe it for a second that he accidentally dropped the truck on his son,” said Cleere. “But for legal purposes, it doesn’t really matter. Under New York State law that’s depraved indifference … That’s murder in the second degree.” Karlsen was arrested for second-degree murder and insurance fraud. He pleaded guilty to second-degree murder and was sentenced to 15 years. In a stroke of good luck, an investigator in California has preserved copies of all the records related to the death of Christina Karlsen. It had been determined that kerosene had been poured on the floor just before the fire was lit. On December 8, 2012, the Calaveras County District Attorney’s office officially reopened the investigation into her death. Karlsen’s trial for her murder began in 2020, nearly three decades after her death. On February 3, 2020, a jury [convicted him of first-degree murder](https://www.oxygen.com/crime-news/karl-karlsen-guilty-of-killing-wife-christina-for-insurance-also-killed-son-levi). Karlsen was sentenced to life in prison without parole. **Topics:** Life Insurance **Categories:** Conviction --- ### [Department of Insurance investigation leads to $23.8 million settlement with Essilor Laboratories of America, Inc.](https://insurancefraud.org/news_archives/department-of-insurance-investigation-leads-to-23-8-million-settlement-with-essilor-laboratories-of-america-inc/) **Published:** August 25, 2026 **Author:** Diane Beauchamp **Content:** Insurance Commissioner Ricardo Lara announced that Essilor Laboratories of America, Inc. (Essilor) has agreed to a $23.8 million [settlement](https://www.insurance.ca.gov/0400-news/0100-press-releases/2022/upload/nr084EssilorSettlement.pdf) in a lawsuit which alleged the company violated the Insurance Frauds Prevention Act. The suit alleged Essilor provided kickbacks and other unlawful incentives to eye care providers that ultimately hurt consumers by unfairly driving them toward more expensive services. Essilor manufactures, markets, and distributes optical lenses and equipment used to produce optical lenses throughout California and the nation. “This settlement is an important victory for consumers and patients who were the targets of corporate greed,” said Commissioner Lara. “Health insurance fraud causes billions of dollars of premium losses annually, resulting in increased cost to Californians. This settlement sends a strong signal that fraudulent practices that hurt California consumers will not be tolerated and will be prosecuted to the full extent of the law. It also will restore key protections for eyecare patients so they receive care and recommendations that are in their best interest.” This settlement brings to a close a 2016 whistleblower lawsuit brought against Essilor. After investigating the allegations, the Commissioner filed a complaint in intervention in 2021. The lawsuit alleged that Essilor provided unlawful kickbacks to eye care providers, with an up-front payment of tens of thousands of dollars, or sometimes hundreds of thousands of dollars, in exchange for these providers’ promises to send business to Essilor for a period of anywhere between three to five years. The providers were free to use the up-front payment from Essilor in any manner that they chose so long as they hit the volume requirements pursuant to the agreement. Additionally, the lawsuit alleged Essilor further provided kickbacks to California eye care providers through a program called “PracticeBuilder” where providers were given cash payments for using Essilor lenses and laboratory services. The cash payments through the PracticeBuilder program were done to reward the eye care providers who prescribed and dispensed Essilor’s more expensive lenses and coatings and to use its laboratory services. Unlawful incentives, like those alleged in the lawsuit, are prohibited under the Insurance Frauds Prevention Act as these illegal acts can, and do, influence medical decision making. California laws are in place to protect patients and encourage medical decision makers to act solely in the best interest of their patient. The lawsuit further alleges Essilor knowingly submitted false claims to California private payors, including insurance companies, health care savings plans, and vision benefit organizations. The resolution is the result of a collaborative prosecution between the Commissioner and the whistleblower’s counsel, Baron & Budd, P.C., The Weiser Law Firm, and Keller Grover, LLP. **Topics:** Judicial/courts, Public Awareness --- ### [Gartner analysts reveal 8 cybersecurity predictions for 2023](https://insurancefraud.org/news_archives/gartner-analysts-reveal-8-cybersecurity-predictions-for-2023/) **Published:** August 25, 2026 **Author:** Diane Beauchamp **Content:** Cyber risks never stand still. With the [Russia-Ukraine](https://venturebeat.com/security/russias-war-in-ukraine-3-cybersecurity-takeaways-for-enterprises/) war continuing and economic uncertainty looming over the horizon, organizations need to be prepared for an increase in cyberthreats. Recently, some of Gartner’s top analysts connected with VentureBeat to share their top cybersecurity predictions for 2023. Predictions included a continuation of [supply chain](https://venturebeat.com/2022/05/25/what-you-need-to-know-about-managing-the-modern-supply-chain/) and geopolitical risk, DevSecOps emerging as a critical methodology for security teams and developers, and human-operated ransomware remaining a prominent threat. Below is an edited transcript of their responses: ## 1. Supply chain and geopolitical risk will dominate cybersecurity “A broad array of geopolitical risks continue to affect organizations worldwide and in 2023; many will emerge as supply chain exposures. The pandemic, social and political polarization, digital ethics and privacy challenges, and climate change impact partners and trusted third parties. “This puts enterprises and their supply chains at increased risk for malware attacks, attacks on cloud infrastructure, attacks on system integrity and availability, such as distributed denial of service ([DDoS](https://venturebeat.com/security/report-ddos-attacks-have-increased-4-5-times-since-last-year/)), and data theft or loss. “Organizations must build in effective security controls to manage all types of supply chain risks that they face. In 2023, supply chain cybersecurity risks must be addressed as a socio-technical challenge. “These are not solely IT security risks, but rather they emerge from challenges such as hardware and software sourcing, business continuity and transportation problems.” ### VP Analyst at Gartner, Richard Bartley --- ## 2. Emerging architectural patterns will streamline security “Security teams must be able to dynamically identify gaps resulting from either new IT strategies — such as moving to the cloud or increasing use of [container](https://venturebeat.com/security/report-75-of-containers-found-to-be-operating-with-severe-vulnerabilities/) technologies — or emerging threats, so that risks can be prioritized and addressed. “Large security vendors are building out unified cybersecurity platforms, defined by their underlying [data lake](https://venturebeat.com/data-infrastructure/what-is-a-data-lake-definition-benefits-architecture-and-best-practices/)-oriented capabilities, as cybersecurity mesh architectures (CSMAs). These solutions aim to implement a single console; provide integrated [machine learning (ML)](https://venturebeat.com/ai/aws-unveils-machine-learning-ml-tools-for-data-science-in-the-cloud/), orchestration and automation; and support third-party integration. “These platforms are built over time, \[and\] expand with new types of capabilities and integration as client needs arise. CSMAs will help organizations simplify the complexity of managing multiple point products.” ### VP Analyst at Gartner, Patrick Hevesi --- ## 3. Zero trust will play a key role in risk management “Gartner defines [zero-trust architecture (ZTA)](https://venturebeat.com/security/zero-trust-architecture/) as an ‘architecture that replaces implicit trust with continuously assessed risk and trust levels based on identity and context that adapts to risk-optimize the security posture.’ This means that trust must be explicit, with any request to access a ZTA resource requiring a risk calculation. “The risk calculation takes into consideration various signals such as device location, believability of user assertion, device hygiene, threat intelligence, time of day, day of week, and the data sensitivity of the application being requested. “Access is granted only when the calculated risk is less than the value of extending the access. In 2023, enterprises will increasingly use ZTA to enhance and risk-optimize the organization’s overall security posture.” ### VP Analyst at Gartner, Thomas Lintemuth --- ## 4. DevSecOps will become business-critical “The continuous growth and diversity of [API](https://venturebeat.com/security/api-security-incidents-2/) and application deployments is creating an extensive attack surface for malicious actors. “Organizations must therefore treat the secure development and deployment of APIs and applications as business critical. To do this effectively without impacting velocity, security must be automated into application delivery processes using [DevSecOps](https://venturebeat.com/programming-development/devsecops-what-enterprises-need-to-know/) techniques. “DevSecOps blurs the boundaries between infrastructure and applications. Security teams will find that considerations relating to infrastructure security go hand in hand with those relating to application and data security. A clear example is the development pipeline, which is a critical piece of the [software supply chain](https://venturebeat.com/security/the-software-supply-chain-new-threats-call-for-new-security-measures/). “Attackers are exploiting weaknesses in this critical component to gain access to source code, sensitive data and application components. In 2023, security teams will increasingly align security and [devops](https://venturebeat.com/business/devops-adoption-hampered-by-infrastructure-challenges/) practices for a holistic DevSecOps approach. Security must become an integral part of development processes and automation.” ### Senior Director Analyst at Gartner, William Dupre ## 5. Security operations (secops) with automation will enhance proactive and detective capabilities “Automation for security operations is in a renaissance period. We are seeing a move from general purpose security automation platforms to objective-driven automation led by domain experts in areas such as alert pipeline management ([SIEM](https://venturebeat.com/security/report-80-of-cyberattack-techniques-evade-detection-by-siems/)), threat intelligence (TI), ticketing and workflow (ITSM), and threat detection systems (XDR/TDIR). “It is important to note automation serves no purpose unless it makes ‘something else’ better, faster, cheaper or otherwise measurably improved. “Even the most technically capable automation platforms can’t achieve these goals without intimate knowledge of the domain (problem area) and the subject matter expertise to develop playbooks that produce gains over the non-automated approach. “In 2023, security operations professionals should seek gains in their program through automation, but be selective. Carefully weigh the unbiased freedom of an independent [SOAR](https://venturebeat.com/security/elastic-automates-security-with-soar-practices-open-security/) vendor with the objective-specific knowledge provided by a domain expert, as part of their core platform.” ### Senior Director Analyst at Gartner, Eric Ahlm --- ## 6. Data-centric cybersecurity will be key to a ‘data everywhere’ world “Data is proliferating, both within and outside the organizations that collect and take initial responsibility for protecting it. Keeping track of all this data has not been a top priority for many organizations, so there is very little visibility into it. “Stored data that the business has zero visibility into is considered [dark data](https://venturebeat.com/datadecisionmakers/dark-data-managing-the-data-you-cant-see/), and estimates point to anywhere from 55% to over 80% of the data that a business stores as being dark. Lurking in this dark data are unknown data risks. “Securing data and enabling privacy compliance within data warehouses and big data/advanced analytics pipelines is of increasing concern, especially where regulations may conflict directly with the needs of the business. “Data-centric security is essential for [data protection](https://venturebeat.com/security/data-protections-biggest-secret-1-in-10-employees-will-leak-ip-data/) in today’s ‘always on,’ ‘data everywhere’ world. In 2023, organizations must focus on overlaying their core security architecture with a data-centric view.” ### Director Analyst at Gartner, Anthony Carpino --- ## 7. Endpoints and workloads will need adaptable protection against emerging and established threats “Endpoints remain a big target for advanced adversaries. Instead of just stealing sensitive information from endpoints, adversaries are now using them as a foothold to launch more commercially attractive attacks, such as [ransomware](https://venturebeat.com/security/ransomware-is-still-cybersecuritys-biggest-challenge-warns-uks-ncsc-ceo/) and [business email compromise](https://venturebeat.com/security/fbi-business-email-compromise/). “Furthermore, the use of employee-owned devices outside of corporate networks has accelerated, and organizations must also deal with a growing number of devices such as [IoT](https://venturebeat.com/datadecisionmakers/how-iot-data-is-changing-legacy-industries-and-the-world-around-us/) and virtual [personal assistants](https://venturebeat.com/ai/charli-ai-ceo-on-training-ai-driven-personal-assistants/) that need access to corporate networks, applications or data. “As the attack surface continues to expand in 2023, security professionals should review [malware protection](https://venturebeat.com/security/10-top-malware-protection-solutions-definition-and-key-features/) architectures across networks, client endpoints and server endpoints. “Solutions such as [endpoint detection and response (EDR)](https://venturebeat.com/security/xdr-vs-mdr-how-to-pick-the-right-one-for-your-security-needs/) and managed threat detection (MTD) can provide not only prevention capabilities, but also detection and response capabilities that help reduce the time to recover from a successful attack.” ### Director Analyst at Gartner, Eric Grenier --- ## 8. Human-operated ransomware will become a bigger threat “As advanced attacks continue to emerge, human-operated ransomware is becoming an inevitable threat. As these ransomware gangs use increasingly sophisticated techniques, security teams must adapt their protection strategies accordingly. “The preattack and peri-attack stages of a ransomware attack are predominantly where prevention happens. “Once the attacker has successfully infiltrated, detection controls become imperative to identify anomalous attacker behaviors. “To provide effective defenses against sophisticated ransomware, organizations must have a mix of multiple detection and prevention controls and a solid backup/recovery process, alongside a program of foundational security techniques and processes. “No single technique or control is a ‘silver bullet,’ but implementing the right balance of multiple techniques assures a robust endpoint security ecosystem. [Extended detection and response (XDR)](https://venturebeat.com/security/why-extended-detection-and-response-xdr-is-seeing-enterprise-growth/) is an emerging offering from endpoint protection platform (EPP) and EDR vendors. ### Senior Analyst at Gartner, Jon Amato **Topics:** Public Awareness, Technology --- ### [Opioid Abuse Treatment Facility to Pay $3.15 Million for Kickback Violations, Obstructing Federal Audit, and False Claims Submitted to Government Insurance Programs](https://insurancefraud.org/news_archives/opioid-abuse-treatment-facility-to-pay-3-15-million-for-kickback-violations-obstructing-federal-audit-and-false-claims-submitted-to-government-insurance-programs/) **Published:** August 25, 2026 **Author:** Diane Beauchamp **Content:** An opioid abuse treatment facility in Camden will pay a total of $3.15 million to resolve criminal and civil claims that it caused kickbacks, obstructed a federal audit, and fraudulently billed Medicaid, Attorney for the United States Vikas Khanna announced today. Camden Treatment Associates LLC (CTA) agreed to pay $1.5 million in criminal penalties to resolve allegations that it violated the federal Anti-Kickback Statute and obstructed a Medicaid audit. As part of the resolution, a criminal information was filed on December 2, 2022 in Camden federal court charging CTA with this conduct. CTA entered into a three-year deferred prosecution agreement (DPA) that requires it to abide by certain measures to avoid conviction. CTA also entered into a civil settlement agreement to pay $1.65 million to the United States to resolve claims that it violated the federal False Claims Act by submitting fraudulent claims to Medicaid. ***Criminal Resolution*** According to CTA’s admissions in the DPA: Between 2009 and 2015, CTA and a second company were owned and managed by related parties. CTA had a kickback relationship with the second company in which CTA ordered all of its methadone mixing services from the second company and paid it more than $125,300 for those services. This arrangement resulted in kickbacks being paid because the second company paid the profits it made on CTA’s orders of methadone mixing to the related parties who owned and managed both companies. As a result, CTA was induced to order services from the second company and to have CTA patients receive treatment using methadone mixed only by that company. CTA received more than $2.78 million from Medicaid for methadone administration services. In a separate criminal scheme, CTA obstructed a Medicaid contractor’s 2016 audit of CTA’s claims for payment. CTA submitted falsified materials to the auditor purporting to justify its claims to Medicaid. Specifically, CTA added patient and counselor signatures to patient files, altered names of counselors listed as providing services, added credentials for staff listed as performing services, added sign-off dates for services and, in some instances, submitted entire patient notes to files to justify services rendered. Metadata from CTA’s electronic patient software program revealed that CTA employed these fraudulent means. ***Civil Resolution*** The settlement resolves the civil allegations that CTA submitted false claims to Medicaid stemming from the kickback relationship with the methadone mixing company described above. The settlement further resolves allegations that between 2013 and 2016, CTA failed to comply with certain federal and state regulations governing substance abuse treatment facilities. Specifically, CTA allegedly failed to maintain proper supervision and staffing at its facility. Instead, CTA typically used non-credentialed “counselor interns” to perform services at the facility and did not have sufficient licensed staff to properly supervise the interns. Consequently, CTA’s claims submitted to Medicaid for payment, which were contingent on CTA’s certified compliance with these regulations, were false. The claims settled by this agreement are allegations only, and there has been no determination of liability. ***Compliance Obligations*** As part of the DPA, CTA is required to adopt several compliance measures, including: - have an effective compliance program, including enhanced compliance policies and annual compliance training regarding federal health care laws; - retain an independent health care compliance consulting firm specializing in substance abuse disorder facilities to conduct a comprehensive review of its compliance program and to make improvement recommendations; - create an independent board of advisors to oversee company compliance relating to federal health care laws; - have a chief compliance officer to oversee compliance-related functions at the company; - annually certify that its compliance program is effective; and - provide written reports to the United States every six months over a three-year period detailing its progress in developing and enhancing its compliance program. Attorney for the United States Khanna credited agents of the U.S. Department of Health and Human Services Office of Inspector General, under the direction of Acting Special Agent in Charge Susan Frisco, with the investigation and prosecution of the case. He also thanked the FBI Health Care Fraud Unit Data Analysis Response Team at FBI Headquarters in Washington, D.C., under the direction of Special Agent Greg Heeb; IRS-Criminal Investigation, under the direction of Special Agent in Charge Tammy Tomlins in Newark; and the FBI’s South Jersey Resident Agency, under the direction of Special Agent in Charge Jacqueline Maguire in Philadelphia, for their assistance with the case. The criminal case was prosecuted by Acting Chief of the Health Care Fraud Unit Christina O. Hud, Chief of the Opioid Abuse Prevention and Enforcement Unit R. David Walk, Jr., and Assistant U.S. Attorney Diana V. Carrig of the Criminal Division in Camden. The civil case was prosecuted by Assistant U.S. Attorney Kruti Dharia of the Opioid Abuse Prevention and Enforcement Unit and Assistant U.S. Attorney Andrew A. Caffrey III of the District of Massachusetts and formerly of the District of New Jersey. **Topics:** Drug Diversion, Judicial/courts --- ### [State: Firm owner didn't carry workers comp, falsified proof of insurance to 3 area cities](https://insurancefraud.org/news_archives/state-firm-owner-didnt-carry-workers-comp-falsified-proof-of-insurance-to-3-area-cities/) **Published:** August 25, 2026 **Author:** Diane Beauchamp **Content:** The owner of a maintenance company is facing criminal charges after the state said he wasn’t carrying the required workers compensation insurance. Not only that, the company had contracts with three area municipalities and the investigator said the owner sent each of them falsified proof of coverage. The tip was self-generated by the Florida Department of Financial Services and covers the period from Aug. 18, 2020, through Dec. 31, 2021. Total Maintenance had workers compensation coverage until 2018. According to the Bureau of Insurance Fraud, “A search of the Coverage and Compliance Automated System (“CCAS”) to verify workers compensation insurance showed Total Maintenance had workers compensation coverage until 2018. The last policy shown for Total Maintenance was through Associated Industries Insurance Company, which expired July 27, 2018. It also showed \[Edward\] Galbraith had a workers compensation exemption which was applied for in 1995. The records from CCAS indicated Galbraith’s workers compensation exemption had no expiration date.” The state found Galbraith was using a money service business in Jupiter to cash business-to-business checks for Total Maintenance. …including approximately $669,092 in 2021 from the city of West Palm Beach The investigator wrote, “These records showed from January 2021 to May 2022, Galbraith cashed over $1 million in business-to-business checks issued to Total Maintenance at this location, including approximately $669,092 in 2021 from the city of West Palm Beach, approximately $2,101 from the city of Palm Beach Gardens, and approximately $16,626 from the town of Palm Beach. It should be noted, from January 2021 to June 2022, Galbraith reported approximately $887,429 in payroll through Paymaster.” He went to the West Palm Beach clerk’s office “for information and documents pertaining to the business relationship between WPB and Total Maintenance.” I observed multiple indications the COIs were possibly fictitious. A contract from 2014 turned up, along with certificates of insurance, or COIs. The investigator was shown two and wrote, “I observed multiple indications the COIs were possibly fictitious. The first COI, dated 08/18/20, had text in a different font size and color from the other text on the certificate. It showed workers compensation coverage through Nationwide Insurance Corporation, policy number \[\], with effective dates of 10/31/20 to 10/31/21. “The second certificate of insurance, dated 09/09/21, had the same font and color discrepancies, listed the same workers compensation policy number and insurance company, and showed the policy to be effective 09/09/21 through 10/31/22. I am aware that workers compensation policies are only effective for one year. “Through my professional training and experience, I am aware that workers compensation policies are only effective for one year. Policy numbers for workers compensation coverage change each policy period, as well.” Then, he went to Jupiter and met with an employee of Insurance Agency of America (“IOA”) who “was listed as the producer on both of the COIs given to WPB. I showed him copies of the COIs provided to WPB by Galbraith. He stated the certificates were not issued by IOA. “He stated the certificates were not issued by IOA. \[He\] pointed out multiple differences between COIs issued by his company and those presented to WPB. He stated the color and consistency of the way the numbers were entered into boxes were not consistent with COIs issued by his company. The policy numbers listed on the COIs were numbers from expired policies or from policies which did not exist. He also specified the contact person listed on the COIs for IOA \[name\] had not been employed at IOA since 2019 and the email address listed for her was not accurate. “\[He\] stated IOA did it one time provide services for Total Maintenance including workers compensation, automotive, and general liability insurance, but based on internal records had not provided coverage for Total Maintenance since 2018. He also stated, based on internal records, IOA had not provided any services for Total Maintenance since 2019, including issuing any COIs. the fictitious COIs were knowingly presented and included false information “Total Maintenance did not have active workers compensation insurance coverage at the time the COIs were presented to WPB. Therefore, the fictitious COIs were knowingly presented and included false information as proof of coverage, in violation of \[the law\].” Next was the town of Palm Beach (“TPB”), where the investigator wrote about meeting with two employees of the Purchasing Division. One of them provided two COIs that Total Maintenance gave the town. “The first COI was dated 10/21/20 and listed commercial general liability, automobile liability, and workers compensation and employers liability coverage. IOA was listed as the producer and \[the same former employee\] was listed as the contact for IOA. “The second IOA was dated 09/09/21 and listed commercial general liability, automobile liability, and workers compensation and employers liability coverage. IOA was listed as the producer and \[that same former employee\] was listed as the contact for IOA. … the person who received this COI was no longer employed… “Also included was a printout of a page documented by \[name\] showing a COI was received on April 6, 2020, at 10:36 p.m. \[The town’s employee\] stated the person who received this COI was no longer employed with TPB. “Total Maintenance did not have active workers compensation insurance coverage at the time the COIs were presented to TPB. Therefore, the fictitious COIs were knowingly presented and included false information as proof of coverage in violation of \[state law\].” Then to Palm Beach Gardens (“PBG”), where “A Purchase Award Transmittal document was signed in 2020 for PBG. This document showed Total Maintenance was awarded a contract totaling $1,250,000 for ‘Contract Labor Services for Golf Course.’ This contract appeared to be signed by Galbraith on page 7. must maintain certain types of insurance including workers compensation “The invitation for bidding stated the vendor would provide all labor and must maintain certain types of insurance including workers compensation insurance and general liability insurance. COIs needed to be provided to PBG as proof of coverage.” The city’s purchasing and contracts director showed the investigator, “The first COI was provided via email to \[name\], the risk management coordinator for PBG, on July 25, 2020, at 7:51 a.m., by Galbraith’s \[son-in-law, listed as a manager\]. This COI was dated 10/21/19 and listed commercial general liability, automobile liability, and workers compensation coverage. The producer listed on this COI was IOA. “The second COI was provided via email to \[the risk management coordinator\] on Oct. 7, 2021, at 11:33 a.m. from Galbraith. This COI was dated 09/09/21 and listed commercial general liability, automobile liability, and workers compensation coverage. The producer listed on this COI was IOA. “Total Maintenance did not have active workers compensation insurance coverage at the time the COIs were presented to PBG. Therefore, the fictitious COIs were knowingly presented and included false information as proof of coverage in violation of \[state law\].” He admitted to not having insurance for ‘two or three years.’ After that, the investigator spoke with Galbraith and according to the arrest report, “He admitted to not having insurance for ‘two or three years.’ When he assumed ownership of the business, he believed workers compensation was being withheld by Paymaster, the payroll company used by Total Maintenance. Prior to assuming the administrative responsibilities for Total Maintenance, he was aware workers compensation was required to be held by the business. Galbraith stated he made them on his computer and provided them. “Galbraith stated \[his son-in-law\] was an employee of Total Maintenance and the company had 10 or 11 employees. When asked about the certificates of insurance which were presented to the municipalities, Galbraith stated he made them on his computer and provided them. “Upon learning Total Maintenance did not have insurance coverage, Galbraith obtained coverage for the business. He provided certificates of insurance which showed Total Maintenance had a workers compensation policy with Cornerstone Capital Group and general liability through US Specialty Insurance Company. required taxes were withheld, workers compensation was not “Records obtained from Paymaster showed Total Maintenance had been utilizing the company’s payroll services since 2001 and although required taxes were withheld, workers compensation was not.” And finally, “Records from Cornerstone Capital showed Total Maintenance began utilizing their payroll service on June 8, 2022 and listed the number of employees as 10. … Galbraith obtained workers compensation insurance coverage upon learning his company did not have the required active coverage. These actions confirmed Galbraith was aware workers compensation coverage was statutorily required for his company, Total Maintenance, yet failed to obtain it.” Last, the investigator wrote in his conclusion, “Galbraith, as the owner and officer of Total Maintenance, meets the definition of employer and is the party responsible for compliance with \[state law\]. a systematic, organized manner with the intent to defraud one or more persons “\[The law says\] every employer shall secure the payment under this chapter. “Galbraith did knowingly present multiple false, forged, or altered documents (i.e., certificates of insurance) as evidence of compliance with Florida State Statutes pertaining to workers compensation coverage. Galbraith did so in a systematic, organized manner with the intent to defraud one or more persons, or to obtain property from one or more persons by false or fraudulent pretenses or representations.” Edward Galbraith was charged with one count of failing to secure workers compensation insurance, which is the first-degree felony; and three counts of presenting false certificates of workers compensation insurance, which is a third-degree felony. He was booked on Nov. 22 at 6:23 a.m. and released in lieu of $12,000 bond about 12 hours later, at 6:50 p.m. **Topics:** Work comp - employer **Categories:** Arrest --- ### [10 Fraudsters enter the 2022 Hall of Shame - Part 1](https://insurancefraud.org/news_archives/10-fraudsters-enter-the-2022-hall-of-shame-part-1/) **Published:** August 25, 2026 **Author:** Diane Beauchamp **Content:** America’s most-notorious insurance criminals were dishonored with induction into the *Insurance Fraud Hall of Shame*. The No-Class of 2022 was elected by the[ Coalition Against Insurance Fraud](http://www.insurancefraud.org/). This year’s 10 convicted sultans of scandal committed a wide array of fraud crimes — from doing useless surgery on bogus slip-and-fall patients to hunting wives for life insurance on a safari to breaking patients’ teeth (ouch). The *Hall of Shame* shines the national public spotlight onto a persistent and damaging crime spree that steals[ $308.6 billion every year](https://insurancefraud.org/wp-content/uploads/The-Impact-of-Insurance-Fraud-on-the-U.S.-Economy-Report-2022-8.26.2022-1.pdf), the Coalition estimates. Fraud drives up premiums for millions of honest, hard-working Americans. People also are maimed, killed and driven to despair when they’re victimized by fraudsters they trusted. Publicly spotlighting and recounting the Shamers’ cases helps build public opinion against insurance fraud. The Coalition’s extreme schemers also help deter this crime. They’re all convicted. Thus, the *Shamers* spread a potent consumer message that fraud investigators and prosecutors relentlessly pursue justice. The reward for greed: hard time in a cold jail cell. So, remember the Shamers and enjoy reading about their crimes*,* sort of. [**Dentist kills wife on safari**](https://www.nytimes.com/2022/08/02/us/larry-rudolph-dentist-found-guilty.html)**.** A rich, unscrupulous Pennsylvania dentist planned to [murder his wife during a safari trip](https://nypost.com/2022/08/02/millionaire-pennsylvania-dentist-larry-rudolph-found-guilty-of-killing-wife-on-african-safari/) in Africa without her having a clue, such a nice husband indeed. Why, you ask? Take a wild guess. If you thought money, then you are correct. It was silly since he really did not need a $5 million insurance payout, but the “loving” husband’s premeditated cover plan was that they were hunting a leopard in Kafue National Park in 2016 so his wife could attain her goal of shooting a leopard, husband of the year… NOT! However, there was more than just greed involved, there was also adultery. The murdering dentist was Larry Rudolph. The wife he assassinated was Bianca Rudolph, and this occurred in a remote cabin in Zambia. It is said that after killing his wife, he looked lovingly into his mistress’s eyes and said, “I killed my f\*\*\*ing wife for you,” at a steakhouse dinner in Phoenix, Arizona, after he learned that the FBI was investigating his late wife’s death in 2020. Thankfully, someone at the next table overheard his conversation in a public place. The 67-year-old dentist was charged with murder and mail fraud. Life behind bars or worse, the death penalty, was on the table. His mistress was charged with lying to the grand jury and being an accessory to the murder after the fact. Not surprisingly, Rudolph denied being responsible for his wife’s 2016 death and told the Zambian police his wife “accidentally” shot herself as she packed away a shotgun while he was conveniently in another room as they were getting ready to return home. His lawyer reportedly exclaimed, “They’ve chosen speculation over science. They’ve chosen fiction over fact,” during his opening statement. The safari murder trial took place in Colorado since that is where the insurance payments were made. Rudolph was found guilty in August 2022 and faces life in prison or the death penalty when he is sentenced in February 2023. There is no laughing gas where he’s headed. **Blinded by greed.** John Paul Cook [committed disability fraud](https://www.justice.gov/usao-wdnc/pr/army-veteran-sentenced-prison-receiving-nearly-1-million-veteran-benefits-fraudulent) for 30 years to the tune of $1 million following an eye injury while on duty in 1986. The Asheville, N.C. man claimed his condition worsened over the next three decades. He was discharged from the Army and said his “severe visual deficit” made him unemployable. The VA eventually declared Cook legally blind. While he was considered blind and 100% disabled, he managed to renew his driver’s license several times and legally owned and registered 30 vehicles. He also made many overnight excursions, taught archery and was a BB gun instructor for the Boy Scouts of America. He was also certified to read maps and used a compass (which was not in braille!). In addition to his disability benefits, Cook also received home remodeling assistance. An anonymous tip in 2017 and a vigilant Veterans Affairs investigator caught onto his long-running scheme. Cook pled guilty on July 19, 2021, to defrauding the U.S. Department of Veterans Affairs and received 10 months in federal prison and was ordered to repay all of the disability money that could have gone to an actual veteran. **Arsonist burns out.** Wandale J. Fulton’s [blizzard of home arsons](https://www.justice.gov/usao-wdmo/pr/lee-s-summit-man-pleads-guilty-arson-insurance-fraud-conspiracy), fake property thefts and bogus auto thefts finally crashed and burned in Kansas City, Mo. Fulton stole at least $322,000 overall. Fulton and his wife bought a $617,000 mansion and someone kicked in the door and stole $85,000 worth of possessions. They included two air conditioning units, three furnaces, a $6,500 lawn mower and 10 leather jackets he told his insurer. Yet Fulton billed American Family up to $300,000 and then dropped the claim when challenged. Next, he bought a fixer-upper for $500 and insured it for $177,600. The place mysteriously burned down a year later. Fulton claimed he spent thousands renovating the home. Yet his supposed contractors didn’t exist — his forged invoices listed fake contractors who were his buddies. More houses then burned down for insurance money. Fulton also created a phony car dealership. He stole people’s IDs and used their good credit to buy cars at auto auctions. Fulton sold the cars to his pals, who falsely told insurers that someone stole their vehicles. An innocent teacher invested his retirement savings in Fulton’s bogus car dealership. Fulton then stole his ID to buy auction cars. Fulton pled guilty in federal court and awaits sentencing. **Holy firestarter scam.** Frosting on a dessert bar outed the torching of a struggling Christian outreach center for $500K of insurance in Detroit Lakes, Minn. A sweet capture indeed. The Refuge was about to fold when its owners allegedly hired Gary John Bogatz, Jr. to burn down the place. Bogatz and another man planned a break-in into the Refuge building and ignite a fire using lawn mower gasoline after allegedly being asked to do so by a Refuge board member and another individual in connection to the building. What kind of people are part of this board? He claimed people connected to the center told him it would close soon unless “something happened” wink-wink, and the building had “a lot of insurance.” Bogatz said he was instructed to make it look like a burglary and to burn the place down. The fire generated a $500,000 insurance claim. Investigators were led to Bogatz [because he ate a frosted dessert bar](https://www.dl-online.com/news/local/fingerprints-from-frosted-dessert-lead-to-conviction-in-2018-fire-at-the-refuge) from the fridge at the Refuge before setting the fire. He had frosting on his fingers (maybe the frosting was not tasty enough to lick off his fingers), then opened a back door, leaving a beautifully preserved frosted fingerprint on the door handle. The Minnesota Bureau of Criminal Apprehension analyzed the fingerprint recovered from the rear door-handle and matched the fingerprint to Bogatz. He received five years and eight months in prison. This gives “guilty” pleasures a whole new meaning. **Crash claim turns deadly.** A [former high school boys basketball](https://www.twincities.com/2022/05/24/former-south-st-paul-basketball-coach-dies-by-suicide-two-days-before-sentencing-on-federal-fraud-case/);l coach killed himself two days before his sentencing for a false crash-damage claim while working as a personal-injury attorney. Matthew McCollister was found dead in his home in Twin Cities, Minn. McCollister was an acclaimed coach of the South St. Paul hoops team and an attorney until his disbarment in February 2022. A chiro introduced McCollister to a confidential informant who was working with the Minnesota Commerce Fraud Bureau. The informant posed as a recruiter of supposed crash victims for bogus chiro treatment billed to auto insurers. McCollister met with the runner at the Red Cow restaurant and asked him to find people who supposedly were injured. McCollister wanted the victims to get treated with him representing the patients to bring the bogus injury claims against auto insurers. He offered to pay the pretend runner $300 or more for each person recruited. McCollister then unknowingly directed one of two undercover patients to be “treated” by chiro Huy Nguyen. McCollister’s fate was sealed when the undercover runner had lunch with McCollister, Nguyen and an MRI specialist named Quincy Chettupally in Minneapolis. The lunch was secretly video recorded, with the conspirators openly discussing the scheme. This ring and others were broken up by Operation Back Cracker — an ongoing effort by the Commerce Fraud Bureau, FBI and U.S. Attorney’s Office. McCollister stood to spend up to 16 months in federal prison. We guess that is one lunch meeting that did not sit too well. Part 2 of this series will introduce readers to a dentist who broke patients’ teeth, a shady slip & fall ring and several other notorious fraudsters. **Topics:** Coalition Against Insurance Fraud, Public Awareness --- ### [Atlanta Woman Submits Three Fraudulent Insurance Claims](https://insurancefraud.org/news_archives/atlanta-woman-submits-three-fraudulent-insurance-claims/) **Published:** August 25, 2026 **Author:** Diane Beauchamp **Content:** Insurance and Safety Fire Commissioner John F. King announced today that Jasmine Hemphill, 32, of Atlanta, has been charged with three counts each of insurance fraud and forgery. “In December of 2020, Ms. Hemphill initiated three separate claims with her insurance company for alleged broken vehicle glass,” said Commissioner King. “Upon review, investigators quickly determined the repair receipt submitted by Ms. Hemphill indicated that work was performed on her vehicle by a fake repair company. The suspect attempted to secure a payout of approximately $5,000 from her insurance company through these claims.” Warrants were taken out against Ms. Hemphill in Fulton County on November 22nd. She is still wanted at this time. **Topics:** Auto - padding/false claim **Categories:** Arrest --- ### [Fullerton insurance agent arraigned after allegedly embezzling over $35,000 in premium payments from clients](https://insurancefraud.org/news_archives/fullerton-insurance-agent-arraigned-after-allegedly-embezzling-over-35000-in-premium-payments-from-clients/) **Published:** August 25, 2026 **Author:** Diane Beauchamp **Content:** Angelica Maria Holst, 54, of Fullerton, was arraigned this week on four felony counts of theft after an investigation by the California Department of Insurance found she allegedly embezzled over $35,000 from several clients while working as a licensed insurance agent and operating her own business. The investigation began after receiving a complaint against Holst alleging that while working as a licensed insurance agent and operating her business, Highway & Environmental Services, Inc., she failed to remit commercial insurance policy payments from several victims. Instead of submitting the collected funds to her managing general agent for the policies, Holst pocketed the payments for personal use. The investigation found that between July 2018 and December 2018, Holst embezzled a total of $35,789 in premium commercial insurance policy payments from multiple victims meant to secure policies. Holst’s managing general agency stepped in to cover the losses so that no client had a lapse in coverage and were left uninsured. The Department of Insurance has filed an accusation against Holst and is seeking to revoke her insurance license. Holst is scheduled to return to court on January 19, 2023. This case is being prosecuted by the Orange County District Attorney’s Office. **Topics:** Insider - agent **Categories:** Arrest --- ### [ODI: New Report Reveals Cost of Insurance Fraud](https://insurancefraud.org/news_archives/odi-new-report-reveals-cost-of-insurance-fraud/) **Published:** August 25, 2026 **Author:** Diane Beauchamp **Content:** Insurance fraud is one of the costliest forms of fraud crimes in the United States and globally. A new report from the Coalition Against Insurance Fraud estimates that the economic impact of insurance fraud is a $308.6 billion annual cost to U.S. consumers and businesses, equaling about $932 annually for every American and more than $70,000 over a person’s lifetime. The mission of the Ohio Department of Insurance is to serve and protect Ohio insurance consumers. This includes a significant prioritization of investigating, taking administrative action, and assisting in the prosecution of insurance fraud and insurance professional misconduct because insurance wrongdoing drives up the cost of insurance for all Ohioans. Our investigators partner with investigators from insurance companies, government entities, law enforcement agencies, and prosecutors to take action against those who commit insurance fraud or engage in crimes associated with insurance. The Ohio Department of Insurance, from July 1, 2021, to June 30, 2022, received more than 7,433 allegations of insurance fraud and insurance agent misconduct from insurance companies, consumers, government agencies, and law enforcement entities. As a result, the department opened 1,116 administrative and criminal investigations, identified 132 potential law violations, and took administrative and/or criminal action against 162 individuals. . The negative impacts of insurance fraud and insurance professional misconduct are far-reaching and the consequences of committing wrongdoing are severe, including legal fees, fines, jail time, and personal and professional shame. Join us in the fight against insurance wrongdoing. I encourage anyone who suspects or is aware of insurance fraud and insurance professional misconduct to report it to the department at 800-686-1527 or on our website: https://insurance.ohio.gov/ **Topics:** Coalition Against Insurance Fraud, Public Awareness --- ### [CommonSpirit Health Provides Cyberattack Update and Notification of Data Breach Involving Virginia Mason Franciscan Health in Washington state](https://insurancefraud.org/news_archives/commonspirit-health-provides-cyberattack-update-and-notification-of-data-breach-involving-virginia-mason-franciscan-health-in-washington-state/) **Published:** August 25, 2026 **Author:** Diane Beauchamp **Content:** CommonSpirit Health and its affiliated entities (“CommonSpirit”) take the protection and proper use of personal information very seriously. Regrettably, CommonSpirit recently experienced a ransomware event that impacted some personal information. **What happened?** On October 2, 2022, CommonSpirit detected activity on its IT network that was later determined to be ransomware. CommonSpirit immediately took steps to secure the network, which included proactively taking certain systems offline, and began an investigation with the assistance of leading external cybersecurity specialists. The investigation determined that an unauthorized third party gained access to certain portions of CommonSpirit’s network September 16, 2022 and October 3, 2022. During that time, the unauthorized third party may have gained access to certain files, including files that contained personal information. While a review of these files is ongoing, CommonSpirit identified that some of this data included personal information for individuals who may have received services in the past, or family members or care givers of those individuals, from Franciscan Medical Group and/or Franciscan Health in Washington state. Franciscan Health includes St. Michael Medical Center (formerly Harrison Hospital), St. Anne Hospital (formerly Highline Hospital), St. Anthony Hospital, St. Clare Hospital, St. Elizabeth Hospital, St. Francis Hospital, and St. Joseph Hospital. Those facilities are now known collectively as Virginia Mason Franciscan Health, which is an affiliated entity of CommonSpirit. **What information was involved?** While the review of the files is ongoing, we identified that the information in some of the files related to patients, family members of patients, or caregivers of patients and included: Name, address, phone number(s), date of birth, and a unique ID used only internally by the organization (not the Medical Record Number or insurance ID). CommonSpirit has no evidence that any personal information has been misused as a result of the incident. **What we are doing.** Upon discovering the ransomware attack, CommonSpirit quickly mobilized to protect its systems, contain the incident, begin an investigation, and maintain continuity of care. In addition, CommonSpirit notified law enforcement and is supporting their ongoing investigation. Once secured, systems were returned to the network with additional security and monitoring tools. **Actions you may wish to take.** Though CommonSpirit has no evidence that any personal information has been misused as a result of the incident, it is always prudent for patients to review health care statements for accuracy and report any services or charges that were not incurred to the provider or insurance carrier. **Topics:** Public Awareness, Technology --- ### [Patient data among files accessed in Virginia Mason Franciscan Health data breach](https://insurancefraud.org/news_archives/patient-data-among-files-accessed-in-virginia-mason-franciscan-health-data-breach/) **Published:** August 25, 2026 **Author:** Diane Beauchamp **Content:** A hacking incident in October that impacted workers at Virginia Mason Franciscan Health and its patients was determined to be ransomware and patient information was accessed, according to a statement from CommonSpirit Health, a parent company. In October, VMFH released a statement that it had taken certain IT systems offline as a precaution, which impacted health records and other systems. VMFH provided a statement in October, saying, “We take our responsibility to ensure the privacy of our patients and IT security very seriously. As a result of this incident, we have rescheduled some patient appointments.” On Thursday, CommonSpirit Health said an investigation revealed an unauthorized third party gained access to portions of their network, which including files that contained personal information. CommonSpirit Health noted it had no evidence that any personal information had been misused as a result of the incident. A review of the data is ongoing, but data in the files related to patients, family members or caregivers of patients could possibly include locations St. Joseph Hospital, St. Francis Hospital, St. Elizabeth Hospital, St. Clare Hospital, St. Anthony Hospital, St. Anne Hospital, St. Michael Medical Center and clinics associated with Franciscan Health. Letters to those affected by the breach were being sent by U.S. mail, starting Thursday. **Topics:** Public Awareness, Technology --- ### [Five reasons why we can expect a major cyberattack on a healthcare organization in 2023](https://insurancefraud.org/news_archives/five-reasons-why-we-can-expect-a-major-cyberattack-on-a-healthcare-organization-in-2023/) **Published:** August 25, 2026 **Author:** Diane Beauchamp **Content:** The upcoming year will see the most catastrophic attack against a healthcare delivery organization (HDO) to date—and that isn’t all that bold of a prediction. [Healthcare systems](https://www.scworld.com/health) remain top targets for hackers, drawn by the potential jackpot of breaching systems with sensitive personal data and carrying out subsequent identity theft or ransomware attacks. Combine that with underfunded security budgets and challenges unique to healthcare security, and HDOs will remain soft targets. One of the largest-yet attacks on an HDO occurred just weeks ago when CommonSpirit Health, a chain including 140 hospitals and more than 1,000 care sites, [experienced an incident](https://www.scworld.com/analysis/ransomware/commonspirit-cyberattack-renews-patient-safety-concerns-amid-outages-care-delays) that caused system shutdowns, ambulance diversions, and other disruptions. Escalating cyberattack trends make it all but a sure thing that 2023 will surpass this past year in average data breach cost, and include a singular attack of unprecedented severity. In shifting away from this dire status quo we must understand why HDOs remain so particularly vulnerable to attacks. The Top 5 reasons include: - **Extreme resource constraints limit healthcare IT security.** Inadequate budget commitments are the clear number-one issue keeping HDOs from achieving more effective cybersecurity protections. A BreachQuest study finds [HDOs spend just 4-7% of their IT budgets on cybersecurity](https://www.theguardian.com/technology/2022/jul/14/ransomware-attacks-cybersecurity-targeting-us-hospitals). In recent years, the impacts of the COVID pandemic hampered HDO budgets with significant investments in digital transformation and telehealth initiatives, further contributing to IT security budget woes. And it’s not *just* security technology itself that needs proper budget. HDOs also must ensure they have sufficient internal staffing – or managed services – to deploy and manage it. - **Attackers are highly incentivized to target sensitive patient data for theft or ransom. HDOs are then incentivized to give in to their demands.** Sensitive data representing the most private and exploitable patient information is essential to healthcare delivery. That same data entices identity thieves and ransomware attackers who know full well that HDOs can’t afford system downtime. This assessment that HDOs are easy money has been borne out by observed behavior: 61% of HDOs hit by ransomware in 2021 opted to pay the ransom. However, it’s hard to judge HDOs for making those decisions given the literal life-and-death stakes they face. - **Traditional cybersecurity best practices aren’t always congruent with HDO priorities.** In most industries, IT security teams have free rein in securing their environments—from removing devices with security flaws to implementing security scanning and utilizing traditional generic network and IoT security strategies. However, HDOs rightfully prioritize patient outcomes above all else. IT security teams cannot unilaterally remove high-risk Internet-of-Medical-Things (IoMT) devices, but must confer with clinical practitioners and ultimately follow their decisions. If those practitioners recognize a device’s vital impact on patient health or the patient experience, IT security teams must work around known security flaws as best they can. HDOs can also suffer when internal IT and healthcare technology management teams have vague ownership roles, making it unclear who should field the ball in a timely security crisis. - **Tight healthcare regulations slow internal HDO processes, while loose IoMT device manufacturing regulations leave HDOs to secure systems themselves.** Healthcare is a heavily regulated industry, requiring HDOs to ensure their technologies and practices comply with [HIPAA](https://www.scworld.com/analysis/privacy/hhs-looks-to-address-hipaa-privacy-challenges-for-substance-abuse-patients) and other pertinent regulatory compliance frameworks. This presents two issues. First, internal bureaucratic processes intended to “dot every i” in adhering to regulations make for a slow evolution in security capabilities. Second, HDOs tend to view security from a compliance perspective when they should maintain a broader viewpoint: an HDO can stay compliant without being that secure. At the same time, the U.S. government recently [came close—but failed—to enact security requirements](https://www.scworld.com/analysis/device-security/fda-bill-passes-without-cybersecurity-requirements-for-medical-devices) for medical device manufacturers that would have made them responsible for pre-market cybersecurity assessments and transparent vulnerability insights. Without those requirements, HDOs must continue to make their own way in discovering and addressing device security flaws. - **HDO modernization and adopting more IoMT devices and internet-connected endpoints offer an expanding attack surface.** HDOs continually adopt new devices and systems in pursuit of more effective and modernized care. The result has caused extensive IoMT inventories and a device churn rate of 15% per year that’s unparalleled in other industries. That activity inevitably creates security challenges, as teams work to protect vast device fleets and learn the security profiles of new solutions. Worse, many IoMT devices are far more vulnerable than those in other industries because they don’t receive patches with the same frequency, and are also more expensive and difficult to replace. While HDOs face a steep challenge in changing their fate in the face of increasing attacks and data breach expenses and dangers, a clear understanding of what they’re up against can help set a new path. By expanding IT security budgets, building best practices unique to HDO needs, and narrowly targeting the true risks to IoMT devices, HDOs can begin to reverse recent trends and leave record-setting attacks in the past. **Topics:** Public Awareness, Technology --- ### [Dallam Hartley Counties Hospital District Reports Data Breach Affecting over 69k Patients](https://insurancefraud.org/news_archives/dallam-hartley-counties-hospital-district-reports-data-breach-affecting-over-69k-patients/) **Published:** August 25, 2026 **Author:** Diane Beauchamp **Content:** On November 23, 2022, Dallam Hartley Counties Hospital District reported a data breach with the U.S. Department of Health and Human Services Office for Civil Rights after the organization learned that an unauthorized party was able to access confidential patient information contained on its computer network. According to DHCHD, the breach resulted in patients’ names, Social Security numbers, health insurance information, demographic information, and medical information being compromised. Recently, DHCHD sent out data breach letters to all affected parties, informing them of the incident and what they can do to protect themselves from identity theft and other frauds. If you are a patient at one of the Dallam Hartley Counties Hospital District facilities and you received a data breach letter from the organization, it means that your “private” information is no longer private. As we’ve discussed in previous [posts](https://www.myinjuryattorney.com/consumer-privacy-data-breach-lawyers/2022-data-breach-trends-and-statistics/), healthcare data breaches are increasingly common, as hackers specifically seek out patients’ protected health information to commit a range of frauds, including healthcare identity theft. However, there are steps you can take to limit your risks. Additionally, if evidence emerges that DHCHD was negligent in maintaining your information, you may be eligible for compensation through a data breach lawsuit. ## What We Know About the Dallam Hartley Counties Hospital District Data Breach The available information regarding the Dallam Hartley Counties Hospital District breach comes from the company’s filing with the U.S. Department of Health and Human Services Office for Civil Rights. DHCHD also posted a “Notice of Data Incident” on its website. According to these sources, on September 28, 2022, Dallam Hartley Counties Hospital District first learned of a potential data security incident that impacted some of the organization’s computer servers. In response, DHCHD took measures to contain the incident, reported the breach to law enforcement, and then launched an investigation with the assistance of a third-party forensic firm that specializes in cybersecurity matters. As a result of the DHCHD investigation, it was confirmed that an unauthorized party was able to access certain portions of the organization’s computer network between September 27, 2022 and September 28, 2022. It was also determined that the unauthorized actor removed a subset of the files, some of which contained confidential patient information. Upon discovering that sensitive consumer data was made available to an unauthorized party, Dallam Hartley Counties Hospital District began to review the affected files to determine what information was compromised and which consumers were impacted. While the breached information varies depending on the individual, it may include your name, Social Security number, health insurance information, demographic information, and medical information. On November 23, 2022, Dallam Hartley Counties Hospital District sent out data breach letters to all individuals whose information was compromised as a result of the recent data security incident. ## More Information About Dallam Hartley Counties Hospital District Dallam Hartley Counties Hospital District is a healthcare organization based in Dalhart, Texas. DHCHD operates several hospitals and other medical providers in the area, including Coon Memorial Hospital, Dalhart Physical Therapy and Sports Medicine, Dalhart Family Medicine Clinic, Coon Memorial Home Health & Hospice, High Country Community Rural Health Clinic, Legacy Assisted Living, and Coon Memorial Nursing Home. Dallam Hartley Counties Hospital District employs more than 223 people and generates approximately $23 million in annual revenue. **Topics:** Public Awareness, Technology --- ### [Empowering seniors to avoid Medicare fraud schemes](https://insurancefraud.org/news_archives/empowering-seniors-to-avoid-medicare-fraud-schemes/) **Published:** August 25, 2026 **Author:** Diane Beauchamp **Content:** We’ve all heard of Medicare scams costing Vermont seniors millions, but there are resources to help seniors avoid a financial nightmare. [The schemes can involve salespeople pitching Medicare Advantage or prescription drug plans all the way to offers of genetic testing services or diabetic supplies through the mail, by phone, or by email.](https://www.vermontelders.org/vermont-senior-medicare-patrol) Darren Perron spoke with Michelle Kessler with the group Community of Vermont Elders to discuss services available to seniors to prevent Medicare or any type of health insurance fraud. To report suspected fraud: 802-229-4731 or [VERMONTELDERS.ORG](http://vermontelders.org/) **Topics:** Medicare/Medicaid, Public Awareness --- ### [UnitedHealthcare loses lawsuit to TeamHealth — again — in ongoing battle over billing](https://insurancefraud.org/news_archives/unitedhealthcare-loses-lawsuit-to-teamhealth-again-in-ongoing-battle-over-billing/) **Published:** August 25, 2026 **Author:** Diane Beauchamp **Content:** ### Dive Brief: - UnitedHealthcare has lost another legal fight with TeamHealth in the latest billing salvo between the nation’s largest payer and the private-equity backed provider group. - A three-judge arbitration panel in Florida ruled this week that UnitedHealthcare underpaid a TeamHealth clinician group from 2017 to 2020, and awarded $10.8 million to TeamHealth. TeamHealth also expects an “additional award of millions of dollars” in prejudgment interest and costs, according to a release. - But TeamHealth was awarded “only a fraction of what it was undeservedly seeking,” and the panel also ruled against TeamHealth’s implied contract and unjust enrichment causes of action allegations, a UnitedHealthcare spokesperson told Healthcare Dive. ### Dive Insight: The dispute between UnitedHealthcare and TeamHealth stretches back years and has emerged in a string of litigation as the two jockey over rates — and as [TeamHealth’s finances are increasingly pressured](https://www.healthcaredive.com/news/fitch-downgrade-teamhealth-er-volumes-pricing-pressure/636576/) by falling emergency room volumes and pricing. The panel in Tampa, Florida, was deliberating whether UnitedHealthcare, which is operated by UnitedHealth, underpaid TeamHealth subsidiary Gulf-to-Bay Anesthesiology Associates. Judges this week decided that UnitedHealthcare paid TeamHealth clinicians 30% of the amount that they determined to be fair compensation for the care provided. UnitedHealthcare’s settlement payments against TeamHealth have reached some half a billion dollars against multiple lawsuits, according to TeamHealth Chief Clinical Officer Jay Mesrobian. Last December, a Las Vegas jury found that UnitedHealthcare had underpaid thousands of claims for emergency treatment, and [awarded TeamHealth almost $63 million](https://www.healthcaredive.com/news/nevada-jury-unitedhealthcare-guilty-teamhealth-reimbursement-surprise-billing/610681/) in punitive damages and other awards. The physician group argues that UnitedHealthcare routinely underpays its doctors. TeamHealth medical groups currently have eight additional lawsuits pending challenging UnitedHealthcare’s payment practices, including one in the same Florida court alleging underpayment from February 2020 onward. “We will continue to fight United until they change course and start fairly compensating providers,” Mesrobian said in a statement. “TeamHealth continues to use litigation to distract from the real reason it no longer participates in our network; it expects to be paid double or even triple the median rate we pay other physicians providing the same services,” the UnitedHealthcare spokesperson said. “TeamHealth’s actions are driving up the cost of health care for everyone.” Physician groups like TeamHealth are often fingered as a major driver of out-of-network spending, as their clinicians are often out-of-network even at in-network facilities, leaving them free to charge patients unexpected, rates even after collecting a portion of the bill from a patient’s insurer. A 2016 study found out-of-network charges increased significantly [after TeamHealth took over a hospital emergency room](https://www.nejm.org/doi/full/10.1056/NEJMp1608571). [Studies have shown there’s little incentive](http://isps.yale.edu/sites/default/files/publication/2019/03/oon_doctors_dec2018.pdf) for physician staffing companies to come in-network with payers, as it’s often impossible for patients to shop for the services their clinicians provide, like emergency medicine and anesthesiology. That means it’s unlikely they’ll see a reduction in patient volume, even if they fail to negotiate contracts with insurers. Insurers have raised the alarm about such practices being acquired by profit-driven private equity firms. TeamHealth, which was acquired by PE firm Blackstone in 2017 for $6.1 billion, has swelled into a massive emergency medicine provider with more than 15,000 clinicians at 2,700 facilities that control their own billing for services. In another pending lawsuit filed last October in Tennessee, UnitedHealthcare is suing TeamHealth over allegations TeamHealth refuses to join its networks, and billed the payer more then $100 million in fraudulent claims. TeamHealth isn’t the only physician network in UnitedHealth’s crosshairs. In 2020, the [payer giant cut ties with Mednax](https://www.healthcaredive.com/news/unitedhealthcare-terminates-mednax-from-its-network-over-pricing-squabble/572734/), alleging it was charging more than 60% higher than other firms for similar services; and canceled its in-network contracts with PE-backed U.S. Anesthesia Partners in Texas. And, after threatening to drop investment firm KKR-owned Envision from its network in 2018, UnitedHealthcare made good on its warning in 2021 when [the payer cut Envision’s 25,000 clinicians from its network](https://www.healthcaredive.com/news/envision-cut-from-unitedhealthcares-network/592824/), citing high prices. **Topics:** Judicial/courts, Public Awareness --- ### [Psychologist admits collecting more than $500,000 in bogus claims from Mdewakanton Sioux](https://insurancefraud.org/news_archives/psychologist-admits-collecting-more-than-500000-in-bogus-claims-from-mdewakanton-sioux/) **Published:** August 25, 2026 **Author:** Diane Beauchamp **Content:** A Twin Cities psychologist has admitted in court that he falsely collected more than $500,000 from the Shakopee Mdewakanton Sioux Community for counseling services he did not provide. Charles Howard Jorenby, 57, of Chanhassen, pleaded guilty this week in U.S. District Court in St. Paul to felony health care fraud for a billing scheme that spanned more than seven years involving his business, Life Dynamics Inc. in Prior Lake. As part of his guilty plea, Jorenby admitted to an additional fraudulent claim to State Farm Insurance in 2017 following a fire at his business office. Jorenby said he inflated his lost-income claim to include earnings associated with his fraudulent billings, totaling an additional $104,930. Jorenby is scheduled to be sentenced on April 27 and remains free on $25,000 bond. State records show that his license to practice psychology in Minnesota remains active. Federal guidelines call for him to receive a sentence of anywhere from 2½ to slightly more than three years in prison and for him to repay the tribe in full for its losses, and to reimburse State Farm for no less than $50,000. Federal judges have wide discretion and are not bound by the guidelines. According to court documents: From January 2013 through February 2020, Jorenby defrauded Blue Cross Blue Shield Minnesota and the Shakopee Mdewakanton Sioux Community, which is responsible for funding the account that the insurer draws from in order to process health care claims for tribal members. Jorenby submitted bills to the health care insurer for services for at least 29 tribal members. In reality, he used their names and dates of birth without their knowledge and collected at least $555,000 from the Sioux band. **Topics:** Healthcare Fraud **Categories:** Conviction --- ### [Massachusetts Insurance Agent Sentenced for Disability Fraud](https://insurancefraud.org/news_archives/massachusetts-insurance-agent-sentenced-for-disability-fraud/) **Published:** August 25, 2026 **Author:** Diane Beauchamp **Content:** The former owner and operator of an Arlington-based insurance agency was sentenced earlier this month for fraudulently receiving disability benefits from the Department of Veterans Affairs (VA) and the Social Security Administration (SSA). Patrick Quinn was sentenced to one year and one day in prison followed by one year of supervised release, according to the office of U.S. Attorney Rachael S. Rollins. U.S. District Court Judge Richard G. Stearns also ordered Quinn to pay restitution of $98,940 to the VA. Quinn has already paid restitution in the amount of $281,439 to SSA, according to court documents. On April 12, 2022, Quinn was convicted by a federal jury of two counts of theft of public funds and two counts of making false statements. Since January 2012, Quinn stole more than $380,000 in Veterans Affairs benefits and Social Security benefits by falsely telling the VA and SSA that he was unable to work due to a disability, when in reality, he owned and operated Quinn Insurance Group. Quinn also served as the president, of Insurance Management Consultants, Inc. from 2000 through 2007, despite telling the VA and SSA that the company fired him in 2005. While operating his own insurance company, Quinn regularly received payments ranging in amounts of $6,500 to $15,000 and grew his business significantly through acquisitions of nine smaller insurance companies at various times between 2012 through 2019. Additionally, Quinn was appointed by 65 insurance companies to conduct business on their behalf and renewed his insurance producer license on numerous occasions. **Topics:** Disability, Insider - agent **Categories:** Conviction --- ### [Duo in Sunnyside pleads guilty to theft in car insurance fraud](https://insurancefraud.org/news_archives/duo-in-sunnyside-pleads-guilty-to-theft-in-car-insurance-fraud/) **Published:** August 25, 2026 **Author:** Diane Beauchamp **Content:** Two people from Sunnyside pleaded guilty to first-degree theft in an insurance fraud case from 2017 in Yakima County, according to a press release from the Office of the Insurance Commissioner (OIC). In October 2017, 31-year-old Andrew Rodriguez filed a claim with the National General Insurance Company regarding damage to a Nissan Versa he was loaned while his car was in the shop, according to the press release. He claimed he was driving when the Nissan rear-ended an Acura in a collision police did not respond to. National General paid for the damage to the Versa and Acura, then paid the garage repairing Rodriguez’ car for the loss of the loaner car, according to the release. In January 2018, National General learned that a police report actually had been filed after the crash, contradicting Rodriguez’ claim. The police report says that 28-year-old Marissa Lopez was the driver, not Rodriguez. Lopez was not on Rodriguez’ policy, according to the OIC. The National General investigative team then interviewed the driver of the Acura, who confirmed Lopez had been driving at the time of the crash. National General reported the information to the OIC Criminal Investigations Unit in January 2019, as companies are required by law to report insurance fraud to the commissioner. Investigators also found that Lopez had been driving, further reporting that Rodriguez had not been in the car during the crash. They also found text messages from Lopez, asking the Acura driver to lie to National General, according to the press release. The two were sentenced to 80 hours of community service and $17,022 in restitution in October 2022. **Topics:** Auto - padding/false claim **Categories:** Conviction --- ### [Battling back the scammers: Six steps the elderly can take to avoid being fraud victims](https://insurancefraud.org/news_archives/battling-back-the-scammers-six-steps-the-elderly-can-take-to-avoid-being-fraud-victims/) **Published:** August 25, 2026 **Author:** Diane Beauchamp **Content:** In 2021 it [has been estimated](https://www.fool.com/research/elder-fraud-financial-abuse-statistics/) that senior citizens in the U.S. lost over $1.7 billion at the hands of scammers. This very high figure singularly demonstrates the importance of preventing what the finance industry refers to as ‘elder fraud’. In the U.K., [according to a report by Age UK](https://www.equifax.co.uk/resources/identity-protection/how-to-protect-older-people-from-being-scammed.html), 43 percent of people aged 65 and over, which is almost five million people, believe they have been targeted by scammers One such company that has focused on assessing the impact of elder fraud [is Proxyrack](https://www.proxyrack.com/). The firm has revealed to *Digital Journal* six key tips to help minimise the risk of elder fraud and the steps that can be taken. [Examples of elder fraud](https://www.comparitech.com/identity-theft-protection/senior-scam-statistics/) include romance scams and lottery and sweepstakes scams. Some measures that can be taken include: **Share personal information with care** Online and telephone phishing scams frequently target senior citizens, encouraging them to hand over personal information. Encourage elderly relatives to always consult with you or another trusted person before giving any personal or financial information to a stranger. **Be aware of current scams** Digital scammers are becoming increasingly sophisticated and adaptable, often capitalizing on current affairs to trick unsuspecting victims, for example grandparent and prescription scams. Make sure to check the news regularly to keep up to date with cybercrime trends and warn your elderly relatives about these types of scams and how to spot them. **Set up credit monitoring protection** The easiest way to protect yourself or your loved one’s from elder fraud is to sign up for credit monitoring. Credit monitoring services can monitor statements and will alert you of any suspicious or fraudulent activity. This is particularly useful to protect against Identity Theft fraud which disproportionately targets senior citizens. **Spot the signs of email scams** Email scams are one of the most common types of elder fraud, so ensure that elderly relatives are able to spot the key signs. Advise elderly relatives not to click on any attachments or links from emails in their spam inbox and to check if the sender’s email address matches the company they are claiming to be from. Further, urge them to be cautious of emails with bad grammar and spelling. **Keep open communication with elderly relatives** Scammers often build relationships with seniors and then coerce them out of money, so make sure to keep regular contact with elderly relatives and be alert for any changes in behaviour. **Remove contacts from call lists** Senior citizens report that scammers most commonly contact them by phone, with scammers often finding phone numbers from telemarketing lists. You can remove a number from these lists by signing up for the National Do Not Call registry, which will reduce the likelihood of elder fraud. As more seniors embrace technology, it becomes increasingly important that measures are put in place to help to protect this section of the community. **Topics:** Public Awareness --- ### [Harare man in court for insurance fraud](https://insurancefraud.org/news_archives/harare-man-in-court-for-insurance-fraud/) **Published:** August 25, 2026 **Author:** Diane Beauchamp **Content:** A Harare man is in trouble for insurance fraud after he allegedly swindled Old Mutual Insurance Company of US$2000 through a false claim for his motor vehicle which had been involved in an accident. Onward Dewa (48) appeared before Harare magistrate Dennis Mangosi charged with fraud. Dewa was granted $50000 bail, and was remanded to February 13 next year. The complainant is Old Mutual Insurance Company represented by Kudakwashe Rufudza, a claims manager. It is the state’s case that on the dates unknown to the prosecutor but during in May this year, , Dewa approached Henrics Providence Dhonga, who is already on remand on the some charge, at his garage in Willowvale, Industrial Site, Harare and informed him that his Toyota Mark 2 motor vehicle had been involved in a road accident and wanted it repaired. It is alleged that Dhonga and Tinevimbo Clarence Marufu, who is also on remand on the same charge, hatched a plan to defraud Old Mutual insurance Company through fake insurance claims. On May 5, the trio staged a road traffic accident along Prince Edward Road, Harare involving the accused’s motor vehicle as the first party and Marufu’s as the second party. It is alleged that on June 2,Dewa made a false insurance claim for his vehicle to the sum of US$2 000-00. Acting on misrepresentation, Old Mutual Insurance Company paid the claim. **Topics:** Auto - staged **Categories:** Arrest --- ### [Insurance Scam: Main Mastermind, 2 Aides Remanded in Custody for 5 Days](https://insurancefraud.org/news_archives/insurance-scam-main-mastermind-2-aides-remanded-in-custody-for-5-days/) **Published:** August 25, 2026 **Author:** Diane Beauchamp **Content:** According to sources, the mastermind, identified as Latifur Rahman, along with his two aides, identified as Baharul Islam and Gafur Ali were remanded in custody for questioning. Notably, last Thursday, the Crime Branch conducted raid at several places in the concrete city of Guwahati along with Nalbari and Barpeta. The branch, during the raid, had arrested a gang who provided fake death certificates. The raid was carried out at the city’s Paltan Bazar, Hatigaon and Mukalmua in Nalbari. The gang committed fraud in several banks including ICIC and Axis Bank. At first, they apply for insurance and then they provide fake death certificates to extort money. So far, the branch has arrested at least nine persons, including a woman, in connection to the scam of extorting money. **Topics:** Life Insurance **Categories:** Arrest --- ### [Insurance scam: Police sniff involvement of doctors, Asha workers in Guwahati](https://insurancefraud.org/news_archives/insurance-scam-police-sniff-involvement-of-doctors-asha-workers-in-guwahati/) **Published:** August 25, 2026 **Author:** Diane Beauchamp **Content:** The police sniffed the involvement of doctors, Asha workers and agents in insurance companies’ involvement in the insurance scam. The Crime Branch of [**Guwahati** ](https://www.sentinelassam.com/guwahati-city/one-dies-in-accident-near-basistha-temple-guwahati-628629)got such a signal during the grilling of gaon burha Jyotika Das. Das is under police custody. According to police sources, the racketeer contact gaon burhas first to get information regarding deceased people and collect their related documents and forge them to open bank accounts. A total of nine persons have been arrested so far in the insurance scam that came to light recently. **Topics:** Public Awareness --- ### [Cyberattacks on hospitals thwart India's push to digitize health care](https://insurancefraud.org/news_archives/cyberattacks-on-hospitals-thwart-indias-push-to-digitize-health-care/) **Published:** August 25, 2026 **Author:** Diane Beauchamp **Content:** In late November, as a thick layer of smog settled on the All India Institute of Medical Sciences in New Delhi, patients began to experience extended wait times. Long lines snaked along the vast building and backed up for several yards. Computers at the hospital had stopped working, so medical reports could not be generated. Though patients were still being treated, paper bills were being handed out. After a few days, people who feared that traveling back home would be too expensive began to sleep under a nearby overpass to wait it out. A massive cyberattack had compromised the health data of millions of patients, from those who live in extreme poverty to high-profile politicians, bureaucrats and judges. The Delhi Police had a bigger problem at hand. They were in possession of an email that read, “What happened? Your files are encrypted? What is the price to repair? The price depends on how fast you can pay to us,” [reported](https://urldefense.com/v3/__https:/theprint.in/india/foreign-sabotage-ransomware-espionage-angles-under-probe-in-aiims-cyberattack/1248736/__%3B!!Iwwt!RrU2st-9OEEWOiw1JnWfjk6_Q49fuNvgVxyqrb7_GVopaKC91wdZxKTu6RyLlZCOwKeTyuNemNWuOW5xc7PI$) news sources. The Delhi police initially [denied](https://urldefense.com/v3/__https:/zeenews.india.com/india/aiims-cyber-attack-hackers-demanding-rs-200-cr-in-cryptocurrency-delhi-police-deny-claim-2541420.html__%3B!!Iwwt!RrU2st-9OEEWOiw1JnWfjk6_Q49fuNvgVxyqrb7_GVopaKC91wdZxKTu6RyLlZCOwKeTyuNemNWuObc1U3ya$) reports of a ransom demand. But they later confirmed that the servers at AIIMS were attacked and data was being held for ransom. Police sources were quoted as saying the attack [originated](https://indianexpress.com/article/explained/the-aiims-cyberattack-and-its-china-links-8324982/) from China and Hong Kong. Two weeks later, servers at AIIMS are just now [limping](https://www.hindustantimes.com/cities/delhi-news/aiims-website-restoration-continues-lab-services-are-back-online-101670955661707.html) back to normal. ### A digital health ID for every Indian Cybersecurity experts express larger concerns. Because India does not have robust cybersecurity systems or strong data protection laws, the breach has made observers uneasy about Prime Minister Narendra Modi’s ambitious plan to digitize the health records of all Indians. In 2020, most people around the world were just hearing about COVID-19. Indians were forced into a sudden lockdown, and no one knew when vaccines or a semblance of normal life would return. Against that backdrop, Modi announced that every Indian would get a health ID under the [National Digital Health Mission](https://urldefense.com/v3/__https:/ndhm.gov.in/__%3B!!Iwwt!RrU2st-9OEEWOiw1JnWfjk6_Q49fuNvgVxyqrb7_GVopaKC91wdZxKTu6RyLlZCOwKeTyuNemNWuOdATtrzr$): “Your every test, every illness, what doctors prescribed and when, your reports will be on a single health ID.” These health records can be accessed by health-care professionals only after the informed consent of the ID holder, Modi clarified. Cybersecurity experts are doubtful about getting informed consent as that concept is relatively new in the country. “Citizens being forced to get a health ID and digitize their health records without the right safeguards is making them vulnerable,” says Srinivas Kodali, a technology expert and researcher with [Free Software Movement of India](https://fsmi.in/). “With plans for ubiquitous sharing of health records across hospitals, doctors, insurance agencies and health tech firms, Indians’ health data is expected to be more prone to leaks, data breaches and exploitation,” he adds. More than 170,000 hospitals across the country have signed up for the National Digital Health Mission already. Registration is mandatory for government-run hospitals. Right across from AIIMSis another massive government-run hospital, where thousands of people line up for treatment. Around the same time that AIIMS reported the ransomware attack, Safdarjung Hospital also [reported](https://urldefense.com/v3/__https:/timesofindia.indiatimes.com/gadgets-news/safdarjung-hospital-faces-hacking-attack-how-it-is-different-from-aiims-cyberattack-and-other-details/articleshow/95968168.cms__%3B!!Iwwt!RrU2st-9OEEWOiw1JnWfjk6_Q49fuNvgVxyqrb7_GVopaKC91wdZxKTu6RyLlZCOwKeTyuNemNWuOQ-_TDer$) a cyberattack that incapacitated its servers for a day. Data was not breached and the servers were restored quickly. Currently, the safety of a patient’s data will depend on how safe the hospital servers are. Under the National Digital Health Mission, all hospitals will be responsible for storing and protecting the patient data they collect. Patients at Safdarjung were merely lucky that their data was not breached. Kodali says if there is a plan to have one unique national health ID, then the cybersecurity of the such massive amounts of data should be the responsibility of the government. “To expect hospitals to deal with their own cybersecurity is like asking an IT professional to medically operate on himself,” he says. In a 2022 [white paper](https://urldefense.com/v3/__https:/cloudsek.com/whitepapers_reports/increased-cyber-attacks-on-the-global-healthcare-sector/__%3B!!Iwwt!RrU2st-9OEEWOiw1JnWfjk6_Q49fuNvgVxyqrb7_GVopaKC91wdZxKTu6RyLlZCOwKeTyuNemNWuOT2bljjg$), the artificial intelligence company CloudSEK said that cyberattacks on the global health care industry rose by more than 95% compared to last year. Attacks mostly occurred on systems in the U.S., followed by India. ### Cyberthreats loom Observers warn against large-scale digitization before necessary checks are in place. “In large systems, digitalization can bring in efficiencies, but it also creates the possibility of disruption to information flows with cascading impacts for society,” says Anita Gurumurthy, director of the non-profit [IT for Change](https://itforchange.net/), which works on tech policy and human rights. Indian authorities agree that the country is facing increasing cyberthreats. The Indian Computer Emergency Response Team (CERT-IN), the national cybersecurity watchdog, noted a 51% increase in the number of ransomware attacks, including on critical infrastructure, from the year before. In the absence of a personal data protection bill, as well as a law governing the digital health ecosystem, Gurumurthy says, the regulatory system is not conducive to maintaining large data sets. In addition, users’ lack of awareness about cyber risks and the use of old, legacy technologies contribute to vulnerability, [according](https://urldefense.com/v3/__https:/www.orfonline.org/people-expert/rajeswari-pillai-rajagopalan/__%3B!!Iwwt!RrU2st-9OEEWOiw1JnWfjk6_Q49fuNvgVxyqrb7_GVopaKC91wdZxKTu6RyLlZCOwKeTyuNemNWuOYp0cehR$) to Rajeswari Pillai Rajagopalan, director of the Centre for Security, Strategy and Technology (CSST) at the think tank [Observer Research Foundation](https://www.orfonline.org/). “India also needs to study the evolving tactics, techniques and procedures \[TTPs\] of hackers and criminals to be able to prevent these attacks. India will pay a serious price if it is seen as an easy target.” **Topics:** Public Awareness, Technology --- ### [N.W.T. announces latest case of private health information mishandled](https://insurancefraud.org/news_archives/n-w-t-announces-latest-case-of-private-health-information-mishandled/) **Published:** August 25, 2026 **Author:** Diane Beauchamp **Content:** A privacy breach affecting people who stayed at a COVID-19 isolation centre is the latest in a long line of cases of health information being mishandled in the Northwest Territories. Late last week, the N.W.T. Department of Health and Social Services issued notice of the “low-risk” breach involving about 2,000 COVID-19 isolation forms, which include names, phone numbers, addresses and emails of people who stayed at an isolation centre in Yellowknife between August 2020 and April 2021. It said a box containing the documents left behind by the disbanded COVID-19 Secretariat was discovered at a government warehouse in late June. While the records never left the territorial government’s custody, there have been several recent cases where private health information was publicly disclosed. “Inadvertent mistakes or lack of paying attention is often a disturbingly large cause of these things,” said N.W.T. information and privacy commissioner Andrew Fox. “There are others though. Once in a while, something will happen like this where some system or administrative procedure hasn’t been followed and documents are left potentially unsecured.” In his latest annual report, Fox says between April 1, 2021, and March 31, 2022, his office investigated 234 new violations of the territory’s Health Information Act, nearly triple the 87 files in the previous year. He said the increase was likely due to more thorough reporting and changes in operations, staffing and training during the pandemic. Of the new files, 55 involved the COVID-19 Secretariat, some of which are still under investigation. One troubling cause of privacy breaches, Fox said, has been the territory’s continued use of faxes, an issue over which the commissioner’s office has long chastised the government. There has also been an increasing number of cases where private health information was improperly disclosed via email, Fox said. Others involved the misidentification of patients and records, and a lack of reasonable security measures for paper records. Fox said the territory needs to devote more staff and provide more training to ensure private information is protected. He noted the COVID-19 Secretariat was “missing some key individuals in the privacy aspect.” “Training is expensive. It’s time consuming. There’s no question. However … privacy training is mandatory,” he said. While the Department of Health and Social Services established a mandatory privacy training policy for all its employees in 2017, Fox said he was told in 2021 they were “barely hitting” 50 per cent of staff. Chief health privacy officer Livia Kurinska-Hrdlickova said the department is continually working to improve privacy practices, including training. “The Department of Health is committed to ensure the protecting of personal information of residents at all times,” she said. Kurinska-Hrdlickova acknowledged there were challenges during the pandemic as some staff were redeployed to areas they didn’t normally work in and many were under stress with high workloads. While health custodians and territorial governments have pledged to decrease the use of faxes, Kurinska-Hrdlickova said they are sometimes still required when other types of communication are absent or there are restrictions when communicating between jurisdictions. She added safeguards implemented for emails include the use of secure file transfers. Health and Social Services Minister Julie Green’s office declined an interview, saying the matter was “more operational in nature.” There have been several noteworthy health privacy breaches in the N.W.T. over the past decade. In November 2014, a doctor with the Stanton Territorial Hospital lost an unencrypted USB stick containing the private information of more than 4,000 people, including medical advice for 52 patients. It was found and returned the following month. In June 2018, the territorial government announced an unencrypted laptop containing the health information of more than 33,000 N.W.T. residents — the majority of the territory’s population — was stolen from a locked vehicle in Ottawa that May. CBC later reported internal documents indicated more than 39,000 N.W.T. residents, plus hundreds of non-residents, were affected. A proposed class-action lawsuit was filed against the territorial government over that breach in 2019. Then in December 2018, a resident told CBC he had found thousands of private health records left in a public area at the dump in Fort Simpson, N.W.T. In reviewing the breach, however, then-privacy commissioner Elaine Keenan-Bengts said she could not determine how the 124 file folders turned over to her came into the resident’s possession. While Keenan-Bengts warned health officials the territory was “ripe for a similar breach to occur,” less than a year later, in July 2019, another resident found more than 60 CDs with private health information at the dump in Yellowknife. The commissioner said the breach was related to Stanton Territorial Hospital’s move to a new building where contractors were not given privacy training. **Topics:** COVID-19, Public Awareness, Technology --- ### [Aberdeen police warn of potential scam](https://insurancefraud.org/news_archives/aberdeen-police-warn-of-potential-scam/) **Published:** August 25, 2026 **Author:** Diane Beauchamp **Content:** Representatives of the [Aberdeen Police Department](https://www.facebook.com/AberdeenPD/posts/pfbid02PfQpKU4Dzb3BXaxwzTQ9MZ39yA3urntjLkPpXYmjDCZBEghaRo7qkK6WFyJMjd24l) say phone scammers claim they are collecting donations on behalf of the department. According to the Aberdeen, SD Police Department Facebook post, the officers with the department say they are unsure if these callers are legitimate since they are claiming to be with an organization they have never heard of or are affiliated with. In general, the officers say they do not call asking for random donations and urge the public to use their best judgment. **Topics:** Public Awareness --- ### [Federman & Sherwood Investigates Avem Health Partners for Data Breach](https://insurancefraud.org/news_archives/federman-sherwood-investigates-avem-health-partners-for-data-breach/) **Published:** August 25, 2026 **Author:** Diane Beauchamp **Content:** The law firm of Federman & Sherwood has initiated an investigation into Avem Health Partners with respect to their vendor, 365 Data Centers’ data breach. On September 9, 2022, Avem Health Partners, notified the healthcare organizations they provide administrative and technology services to that the company experienced a data breach after an unauthorized party accessed sensitive consumer data entrusted to the company. According to 365 Data Centers, on May 16, 2022, they determined that information stored on their serves may have been subject to unauthorized access prior to May 14, 2022. On October 6, 2022, Avem Health Partners determined that the files in the breach resulted in the names, addresses, Social Security numbers, driver’s license numbers, medical information and health insurance information of individuals being compromised. If you wish to discuss this action, obtain further information and participate in this litigation contact Lacrista A. Bagley either by email at <lab@federmanlaw.com> or visit our firm’s website [www.federmanlaw.com](https://cts.businesswire.com/ct/CT?id=smartlink&url=http%3A%2F%2Fwww.federmanlaw.com&esheet=53093437&newsitemid=20221219005654&lan=en-US&anchor=www.federmanlaw.com&index=1&md5=a908fd10d29cd18a290776f80ee7a355): ## Contacts Lacrista A. Bagley FEDERMAN & SHERWOOD (405) 235-1560 **Topics:** Public Awareness, Technology --- ### [GA Health System Reports Healthcare Data Breach](https://insurancefraud.org/news_archives/ga-health-system-reports-healthcare-data-breach/) **Published:** August 25, 2026 **Author:** Diane Beauchamp **Content:** Georgia-based Emory Healthcare reported a healthcare data breach that impacted more than 1,000 individuals and potentially exposed protected health information (PHI). Through a notice from the United States Department of Labor (DOL), Emory Healthcare became aware of an employee inappropriately accessing at least 1,600 patient records between December 2020 and December 2021. Further investigation revealed that the now-former employee released demographic information from several hundred employees to individuals involved in unemployment benefits fraud. The potentially impacted demographic information included names, dates of birth, and Social Security numbers. Investigators found no evidence that any medical histories, tests, laboratory results, diagnosis and treatment plans, or insurance information were compromised. During the investigation, Emory Healthcare stated it has “fully cooperated with law enforcement during the investigation, arrest, and prosecution of individuals involved in the matter and will continue to do so as the case moves forward. EHC followed the instructions of the DOJ regarding the timing of this notification and is now notifying patients whose information is believed to have been involved in this incident and for whom EHC had last known addresses.” **Healthcare Management Company Discloses Data Security Incident** Epic Management, a healthcare management company, [experienced](https://www.prnewswire.com/news-releases/epic-management-provides-notice-of-data-security-incident-301703362.html) a data security incident involving the exposure of some patient information. Epic noticed unusual activity in its digital environment on September 2, 2021. Upon the unusual discovery, the organization said it immediately followed through with steps to secure the domain. Later, Epic engaged independent cybersecurity experts to undergo an intensive investigation, learning that some PHI may have been impacted on December 9, 2022. This security event may have included names, dates of birth, Social Security numbers, health insurance information, medical information, driver’s licenses, passport numbers, financial account numbers, routing numbers, biometric data, as well as usernames and passwords, Since its investigation, there has been no evidence to suggest any information was misused, and it was unclear how many individuals were impacted by the breach. “While Epic has no evidence that any information potentially involved in this incident has been misused, out of an abundance of caution, Epic is informing affected individuals about the steps they can take to help protect their information,” the report stated. **Missing Hard Dive Poses Data Security Risk for Over 2K Patients** NYC Health + Hospitals informed 2,174 patients of a data security incident that may have [impacted](https://www.nychealthandhospitals.org/pressrelease/notification-of-possible-compromised-phi/) personal and medical information. The incident was discovered in June, and the integrated healthcare system began notifying patients on November 29. According to a notice on its website, NYC Health + Hospital incident involving potentially comprised PHI stemmed from a missing, defective hard drive that was removed from a visual field-testing device at the organization’s Woodhull location. The organization noted that no financial information or other personal identifiers were impacted by the security incident. However, the hard drive did store PHI, including dates of birth, medical record numbers, and visual field test result. The investigators have not found evidence that any information has been misused but out of an absence of caution, notifying all individuals affected by this incident. Following this incident, the integrated healthcare system will take several steps to avoid future incidents, such as educating employees on existing policies and practices of the proper chain of custody for devices containing PHI. “In order to minimize any potential future compromise of PHI, NYC Health + Hospitals has begun implementing a data removal process for the visual field-testing device to ensure that data is removed on a regular basis,” the report said. Additionally, the organization stated, “NYC Health + Hospitals will enhance its training to ensure that all staff are aware of the need to promptly notify the OCC of any incident in which patients’ PHI might be compromised.” **Topics:** Public Awareness, Technology --- ### [CMS Subcontractor Data Breach Potentially Exposes Data of 254,000 Customers](https://insurancefraud.org/news_archives/cms-subcontractor-data-breach-potentially-exposes-data-of-254000-customers/) **Published:** August 25, 2026 **Author:** Diane Beauchamp **Content:** The Centers for Medicare & Medicaid Services (CMS) is responding to a data breach at Healthcare Management Solutions, LLC (HMS) – a subcontractor to CMS – that may have exposed personally identifiable information of up to 254,000 Medicare beneficiaries. In a **[press release](https://www.cms.gov/newsroom/press-releases/cms-responding-data-breach-subcontractor?utm_campaign=wp_the_cybersecurity_202&utm_medium=email&utm_source=newsletter&wpisrc=nl_cybersecurity202)**, CMS said the subcontractor was subject to a ransomware attack on its corporate network on Oct. 8, 2022. However, no CMS systems were breached and no Medicare claims data were involved. “The safeguarding and security of beneficiary information is of the utmost importance to this agency,” said CMS Administrator Chiquita Brooks-LaSure. “We continue to assess the impact of the breach involving the subcontractor, facilitate support to individuals potentially affected by the incident, and will take all necessary actions needed to safeguard the information entrusted to CMS.” Out of an abundance of caution, CMS is mailing a letter this week to beneficiaries that have been potentially impacted to notify them of the breach. Additionally, CMS said it will provide them with an updated Medicare card with a new Medicare Beneficiary Identifier and free credit monitoring services. A draft of the letter says that HMS acted in violation of its obligations to CMS, and that the agency will continue to investigate the incident. HMS is a subcontractor of ASRC Federal Data Solutions, LLC (ASRC Federal). “The services provided to CMS under the contract with ASRC Federal include resolving system errors related to Medicare beneficiary entitlement and premium payment records,” CMS said. “The contractors’ services also support the collection of Medicare premiums from the direct-paying beneficiary population. The contractor does not handle Medicare claims information.” CMS said it is not aware at this time of any reports of identity fraud or improper use of customer information as a direct result of the incident. “In October 2022, Healthcare Management Solutions, LLC (HMS) experienced a cybersecurity incident involving unauthorized access to our network which impacted limited systems,” HMS said in a statement to MeriTalk. “HMS acted swiftly to take the network offline in order to contain the incident. Industry-leading external cybersecurity experts were engaged to launch an investigation into the incident, which remains ongoing.” “Patient privacy has always been our top priority, and we have steadfastly maintained our obligation to patients and to any agency or contractor with which we have worked,” HMS added. “We regret any concern this incident may have caused our community and will notify impacted individuals pursuant to legal and contractual obligations.” **Topics:** Public Awareness, Technology --- ### [Raleigh-Area Physician Agrees to Pay $385,000.00 to Resolve Allegedly Fraudulent Medicare and Medicaid Claims](https://insurancefraud.org/news_archives/raleigh-area-physician-agrees-to-pay-385000-00-to-resolve-allegedly-fraudulent-medicare-and-medicaid-claims/) **Published:** August 25, 2026 **Author:** Diane Beauchamp **Content:** United States Attorney Michael Easley announced today that Haritha Nadendla, M.D., and Triangle Women’s Center, P.C., (hereinafter referred to as “Triangle”), an OB/GYN practice that Dr. Nadendla owns and operates in the Raleigh, North Carolina area, have agreed to pay $385,000 to settle civil False Claims Act liability concerning allegations that Triangle submitted false claims to the Medicaid program for certain patient visits. The Government contends that it has certain civil claims against Triangle arising from Triangle’s submission of claims to the North Carolina Medicaid Program for medical services from January 1, 2018, through December 31, 2021, including claims for CPT 99215 – Evaluation & Management for an established patient in an office or outpatient location, which the Government contends were not supported by the medical record and were not medically necessary. The Government contends that Triangle’s submission of such claims for payment to the North Carolina Medicaid Program violates the Federal and North Carolina False Claims Acts. “This civil fraud case demonstrates our firm commitment to protect taxpayer money and to guard the integrity of federal programs,” said U.S. Attorney Michael Easley. “Our office will zealously pursue those who misuse or abuse government funds.” “My office’s Medicaid Investigations Division is committed to holding accountable health care providers who waste taxpayer resources,” said North Carolina Attorney General Josh Stein. “I thank U.S. Attorney Easley and his team for their continued partnership to protect Medicaid funds for North Carolinians.” This matter was investigated by the United States Attorney’s Office for the Eastern District of North Carolina and the Medicaid Investigations Division of the North Carolina Attorney General’s Office (“MID”). Special Deputy Attorney General Michael M. Berger, who also serves as a Special Assistant United States Attorney, represented the United States and the State of North Carolina. The allegations were originally made in a lawsuit filed under the whistleblower provisions of both the Federal and North Carolina False Claims Act by Hannah Turnbull. The respective False Claims Acts permit private parties to sue for false claims on behalf of the United States and the State of North Carolina, as well as potentially sharing in any recovery. As for the recovery, the False Claims Acts allow the United States and the State of North Carolina to recover triple the money falsely obtained, plus civil penalties for each false claim submitted. The civil claims settled by this False Claims Act agreement are allegations only; there has been no determination of civil liability. **Topics:** Judicial/courts, Public Awareness, Regulatory actions --- ### [NYAG sues LI nursing home for alleged massive fraud](https://insurancefraud.org/news_archives/nyag-sues-li-nursing-home-for-alleged-massive-fraud/) **Published:** August 25, 2026 **Author:** Diane Beauchamp **Content:** New York Attorney General Letitia James has filed a lawsuit against Cold Spring Hills Center for Nursing and Rehabilitation for alleged financial [fraud](https://libn.com/tag/fraud/?taxo-tag-body) and abuse of its residents. The lawsuit claims the owners of the Cold Spring Hills facility in Woodbury diverted over $22.6 million in Medicaid and Medicare funds from resident care through a fraudulent network of companies that were used to conceal up-front profit taking. The alleged self-dealing led to “severe understaffing and resident neglect and harm,” according to a statement from the AG’s office. The lawsuit alleges that long before the COVID-19 pandemic, the owners repeatedly cut staffing at the 588-bed facility, which created poor working conditions and endangered residents. Through the lawsuit, the attorney general seeks to prevent new residents from entering the facility, install monitors to oversee the facility’s operations and finances, and ban existing and hidden owners from their roles. The operators of Cold Spring Hills used 13 companies to create the appearance that they were paying for services for the nursing home but were in fact diverting Medicaid and Medicare funds to themselves as up-front profit instead of using the funds for resident care, according to the statement. The network of companies was also used to hide the real owners of the nursing home and to orchestrate multiple deceptive schemes to extract funds for their personal financial benefit, while disregarding the nursing home’s duty to provide required care, the lawsuit alleges. From 2017 through 2021, Cold Spring Hills received over $157 million from New York’s Medicaid program and over $88 million from Medicare to provide critical care to its elderly and disabled residents. The AG’s lawsuit alleges that the facility’s operators used three primary fraudulent schemes to siphon over $22.6 million in Medicaid and Medicare funds from Cold Spring Hills, including paying more than $15.3 million in fraudulent “rent” to Cold Spring Realty, which is owned by the same individuals who operate the nursing home. The lawsuit alleges that the respondents paid more than $5.2 million to several deceptive entities for supposed “consulting” and that the respondents engaged in a $2 million fraudulent promissory note scheme when they purchased the facility. The lawsuit claims the Cold Spring Hill facility’s owners also funneled another $10.6 million in concealed self-dealing transactions through what were ostensibly insurance companies, and another $8.1 million through an entity that purportedly provided services and supplies to Cold Spring Hills. In total, the respondents transferred over $42.4 million to its owners and related parties from 2016 to 2021, according to the AG’s statement. “Cold Spring Hills’ owners put profits over patient care and left vulnerable New Yorkers to live in heartbreaking and inhumane conditions,” James said in the statement. “From Buffalo to Long Island, every nursing home in New York must abide by laws that require the best care for New Yorkers. As attorney general, I am determined to use the full force of my office to hold [nursing homes](https://libn.com/tag/nursing-homes/?taxo-tag-body) to that standard, and ensure New Yorkers are protected. I encourage anyone who has witnessed alarming conditions, resident neglect, or abuse at a nursing home to contact my office.” In addition to the alleged financial fraud, the lawsuit maintains that residents of the Cold Spring Hills facility were abused and neglected. Testimony from staff and family members of residents describe bleak conditions at the facility. Family members of residents often observed that the facility was unclean and that critical care equipment, such as wheelchairs, beds, shower chairs, and air conditioners, were broken, according to the statement. The AG said that residents were routinely left sitting in soiled briefs and were not bathed for long periods of time and that Cold Spring Hills repeatedly failed to provide proper wound care and prevention for residents, causing wounds to develop and existing wounds to deteriorate, leading to infections. In addition, Cold Spring Hills’ staff confirmed that insufficient staffing was a problem at the facility before the pandemic, and that it continued into 2022, according to the AG’s office. From March 1, 2020 to June 4, 2020, 166 residents of Cold Spring Hills died, 98 from COVID-19 and 68 from other causes. Cold Spring Hills fraudulently failed to report 51 of those 98 COVID-19 deaths to DOH, underreporting by 52 percent, according to the statement. The companies named in the lawsuit are Cold Spring Hills, the actual facility; Cold Spring Realty Acquisition, LLC (Cold Spring Realty), which owns the property where the nursing home is located; Ventura Services, LLC, Highview Management Inc., B&L Consulting, LLC, all of which claim to provide consulting services to nursing homes; Graph MGA, LLC, Graph Management, LLC, Graph Insurance Company A Risk Retention Group, which purportedly act as insurance brokerages; Philipson Family, LLC, which is a partial owner of Cold Spring Realty; Lifestar Family Holdings, which is a partial owner of Cold Spring Realty; Comprehensive Care Solutions, LLC, which purported to provide services and supplies; and Ross CSH Holdings, LLC, Rosewell Associates, LLC, and ZBL Management, LLC, all pass-through companies. Also named in the suit is the principal owner, Bent Philipson, whose role was allegedly concealed, Benjamin Landa, whose ownership is also alleged to have been concealed; Joel Leifer; David Zahler, his wife Chaya Zahler, their adult children Rochel David, Leah Friedman, Chaim Zahler, and Jacob Zahler, Avi Philipson (Bent Philipson’s adult son), Esther Farkovits (Benjamin Landa’s adult daughter), Rochel David and Leah Friedman (the Zahlers’ daughters) who were straw owners of the nursing home, allegedly put in place to conceal their fathers’ control. Also named in the suit is Cheskel Berkowitz, Joel Zupnick, and the Estate of Deborah Philipson. The lawsuit respondents were unable to be reached for comment. In the lawsuit filed today, Attorney General James seeks to prohibit Cold Spring Hills from admitting any new residents unless and until staffing levels meet appropriate standards; require Cold Spring Hills to engage and pay for a financial monitor to oversee the facility’s financial operations; and require Cold Spring Hills to engage and pay for an independent healthcare monitor to oversee the facility’s healthcare operations and ensure residents’ outcomes improve. The AG also seeks to remove Bent Philipson, Avi Philipson, Joel Leifer, Esther Farkovits, Rochel David, and Leah Friedman, and any of their related entities, from further serving or having any role at Cold Spring Hills; direct all respondents to fully disgorge any and all funds wrongfully received as part of the scheme; and direct all respondents corporate and individual to pay restitution and penalties. **Topics:** Judicial/courts, Public Awareness --- ### [Spokane nurse practitioner, business hit with 68-count criminal complaint alleging widespread Medicaid fraud](https://insurancefraud.org/news_archives/spokane-nurse-practitioner-business-hit-with-68-count-criminal-complaint-alleging-widespread-medicaid-fraud/) **Published:** August 25, 2026 **Author:** Diane Beauchamp **Content:** A 59-year-old registered nurse practitioner from Spokane, accused of defrauding Medicaid of $5 million, faces 68 criminal charges. Paul B. Means, registered owner of the firm Abilia Healthcare based on Spokane’s South Hill, was formally charged Thursday with felonies including leading organized crime, theft, use of proceeds of criminal profiteering, money laundering, false Medicaid statements and witness tampering. Means is scheduled to appear before a judge in Spokane on Jan. 4, according to court records, following a three-year investigation by the Washington Attorney General Office’s Medicaid Fraud Control Division. A message left at a phone number Means used to register Abilia Healthcare with the state was not immediately returned Friday. Phone and email messages left with an attorney representing Means in his civil case on Friday also were not returned. According to a 247-page complaint filed by Scott Tollackson, a supervising special agent with the AG’s fraud division, the investigation into Means and Abilia began with an audit of Medicaid billing in 2019. Investigators discovered that certain codes the firm used in billing the government health program designed to help the poor far exceeded other institutions in the state, including major hospitals and service providers, beginning in 2017, and that there was no documentation to support the billing. Review of records obtained during a November 2020 search of Means’ homes on the South Hill and subsequent interviews with patients and staff at American Behavioral Health Systems, where Means and his employees provided services, showed that Means would bill Medicaid for face-to-face services as described in Medicaid codes lasting up to an hour or more. Those services were instead provided via videoconferencing and often lasted less than 15 minutes. Means met with investigators in November 2020, according to the complaint, and described his billing processes. During that interview, Means said “he did not know much about the specific codes that he billed,” according to Tollackson’s report. He also told investigators he’d hired contract workers, whom he referred to as “back office” staff, in the Philippines for data entry. Investigators allege nurses working for Means would prepare notes based on the services they provided a patient, and that Means would then access those notes and alter them to increase the billing amount from Medicaid using an automated system. Authorities recovered videos believed to be used to train those working in the Philippines how to use the automated text system to prepare falsified patient reports for billing. Nurses working for Means later told investigators when reviewing their notes they did not enter text that appeared to be created by the automated system and increased the billing amounts for Medicaid. Investigators concluded that the nurses were “generally not able to see their prior encounter notes so they were not aware that Means was altering the notes.” A day after authorities served a search warrant at Means’ residences, he emailed a contact in the Philippines informing them that “we have been shut down” and requesting that they not speak to “anyone trying to contact you.” Those emails, and internal messages, were later obtained by investigators. Investigators allege the proceeds of the fraud were used to purchase several vehicles and two homes, one on the South Hill and one in Cheney. A separate civil case filed in November 2020 in Spokane County Superior Court has been placed on hold while the criminal charges are resolved. Abilia ceased operations and Medicaid billing following the November 2020 search of Means’ home, according to court records. Means remains a licensed nurse practitioner in the state, according to the Washington Department of Health, and there are no disciplinary actions on his record. The charges Means faces are all felonies, the most serious of which – leading organized crime – carries a potential life prison sentence and a fine of up to $50,000. The Attorney General’s Office, in a news release Friday, indicated it would seek a sentence above what is known as the standard range, a calculation of time of imprisonment based on a person’s criminal history, citing “the high degree of sophistication, lengthy period of time, and scale of the monetary loss.” **Topics:** Medicare/Medicaid **Categories:** Arrest --- ### [A Montana addiction clinic wants to motivate people with rewards. Then came a Medicaid fraud probe.](https://insurancefraud.org/news_archives/a-montana-addiction-clinic-wants-to-motivate-people-with-rewards-then-came-a-medicaid-fraud-probe/) **Published:** August 25, 2026 **Author:** Diane Beauchamp **Content:** A Montana addiction clinic’s plan to give people with substance use disorders as much as $1,966.50 in gift cards and vouchers to follow its treatment program is raising questions about the use of financial incentives with patients. The tug of war over the effective but largely unregulated tool is playing out in the northwestern Montana town of Kalispell, where a local government grant is financing rewards for people who stick with treatment provided by the outpatient clinic Oxytocin. Such incentives have gained momentum among individual health clinics and states in recent years. Since 2021, California, Washington, and Wisconsin have started incentive-based programs. Some private clinics offer their own rewards, such as giving clients gift cards for successfully passing a drug test. In Montana, where Republican Gov. Greg Gianforte has made expanding behavioral health care a priority, a state pilot program offers prizes to people with addictions who stay off drugs. Oxytocin’s program, while funded by a government grant, is separate from the pilot program. The allowable value of prizes that go to beneficiaries of federal health programs, like Medicaid, is a legal gray area, so totals vary from one program to the next. The federal government doesn’t have a rule limiting the size of financial awards or guidelines detailing best practices, said Richard Rawson, professor emeritus in the Department of Psychiatry and Biobehavioral Sciences at UCLA. “People don’t know where to look to understand this method, so states and providers make it up as they go along,” said Rawson, who has studied such incentives for about 20 years. In June, Montana’s Flathead County awarded the Kalispell clinic, Oxytocin, a $500,000 grant funded by state alcohol tax revenue. Of that money, $300,000 was earmarked for incentives for participants to attend treatment, according to the clinic’s proposal. It proposed that over a 20-week treatment course, participants could earn as much as $1,966.50 in either gift cards or vouchers. In Oxytocin’s program, a client has multiple chances each week to earn an incentive by passing urine tests and attending treatment. The dollar amount increases with consecutive successes. The county chose Oxytocin from among four clinics that applied for the substance use treatment funding. By November, at least one complaint had been filed with state agencies accusing Oxytocin of committing Medicaid fraud by paying its clients — most of whom are Medicaid recipients — that high of a reward to attend treatment. Oxytocin clinical director Pamela Liccardi declined requests to be interviewed but said in an email that the business had done nothing wrong. “There is a reason the community stands behind us and it is not because we do fraudulent things,” she wrote. Research shows that motivational incentives, called contingency management, can reduce the number of days someone takes illicit stimulants, such as methamphetamines, and can promote abstaining from other substances, such as opiates, by reinforcing healthy behavior with prizes, privileges, or cash. “We know people are dying from methamphetamine now,” said Michael McDonell, a community and behavioral health professor at Washington State University, who has helped states create incentive programs. “Contingency management is the only evidence-based intervention for methamphetamine use disorder. It’s the only intervention that’s shown consistently to be impactful.” But clinicians are wary of running afoul of a 1972 federal anti-kickback statute that prohibits offering something of value to a federal beneficiary, such as a Medicaid recipient, to induce them to select a particular provider. There are “safe harbors” meant to protect certain programs that are unlikely to lead to corruption. But a February legal advisory opinion from the U.S. Department of Health and Human Services’ Office of Inspector General said those exceptions don’t include incentives aimed at beneficiaries. Federal officials have long been concerned that those types of offers could lead to fraud and abuse. “Programs that involve giving remuneration to beneficiaries can corrupt medical care decision-making, which could result in overutilization, increased costs, steering to particular providers or suppliers, or inappropriate medical choices,” the advisory opinion says. Whether programs that offer incentives to beneficiaries of federal health programs violate the anti-kickback law is decided on a case-by-case basis, the inspector general’s office wrote. Among the factors is the value of the incentives, says the advisory opinion, without setting a specific benchmark. Rawson and other researchers said most providers consider a total of $75 per client a year to be safe, based on a 2016 statement from the inspector general’s office on inexpensive gifts to beneficiaries. However, Rawson said research indicates that amount is likely too low to work well as an incentive. Another annual limit that programs encounter is $600 per client, the threshold for reporting taxable income to the IRS. Exceeding that amount could cause beneficiaries to exceed Medicaid income limits, which could lead to loss of coverage. Last year, Montana officials began a pilot program that expands stimulant use disorder treatments and includes incentives. Tammera Nauts, with the Montana Primary Care Association, said the state was careful to avoid raising any red flags for the federal government in the rules it set for the state program. For example, participating clinics can’t give patients prizes to participate in treatment the federal government covers, such as therapy sessions. State pilot sites’ incentives also can’t go over $315 total per beneficiary a year — a cap Montana was allowed through a Centers for Medicare & Medicaid Services waiver. Providers may offer their own rewards program without going through the state, and Nauts said Oxytocin is not one of the pilot sites tethered to Montana’s program. KHN obtained a copy of a complaint filed against Oxytocin. In addition to the allegations of Medicaid fraud, it accuses Oxytocin of having several providers who offer services outside of their area of expertise or without a license. The document KHN received did not include the name of the person who filed the complaint, and state officials declined to provide details. The complaint was filed with the state’s Department of Public Health and Human Services and Department of Justice. Health department spokesperson Jon Ebelt said it would be premature to comment on the case before the review is complete. Department of Justice spokesperson Emilee Cantrell said the agency’s Medicaid fraud unit was working with the health department but said she couldn’t provide details because an active complaint is considered confidential criminal justice information. **Topics:** Medicare/Medicaid, Public Awareness --- ### [Doctor and Office Manager Indicted in Scheme to Defraud Medicare, Manufacture and Distribute Fentanyl](https://insurancefraud.org/news_archives/doctor-and-office-manager-indicted-in-scheme-to-defraud-medicare-manufacture-and-distribute-fentanyl/) **Published:** August 25, 2026 **Author:** Diane Beauchamp **Content:** Dr. David J. Smith, a pain management physician, and his office manager, Julia Ann Oertle, are charged in a federal grand-jury indictment with perpetuating a long-running scheme to commit healthcare fraud and to manufacture and distribute adulterated fentanyl. Smith made his initial appearance today before U.S. Magistrate Judge Bernard G. Skomal. Smith’s bond was set at $1 million, secured by real property, with a limitation on his ability to practice medicine. Oertle was still at large. According to allegations in the indictment, Smith purports to specialize in the installation and maintenance of intrathecal pain pumps which are surgically placed in a patient’s stomach with two catheters implanted on the spine; pain medicine is then infused into a reservoir in the pump periodically and meted out directly into the spine. Beginning in December 2017, Smith and Oertle began compounding fentanyl citrate into vials, in a room at Smith’s principal medical practice, San Diego Comprehensive Pain Management Center. According to the indictment, this compounding practice was grossly improper and resulted in the production of adulterated fentanyl. Smith nevertheless directed administration of this fentanyl to patients repeatedly. The indictment alleges that beyond providing patients with adulterated fentanyl, Smith violated the applicable standards of care by, among other things, prescribing materially excessive quantities of fentanyl, prescribing unnecessary oral opioid medications in conjunction with pain-pump medication, and installing pain pumps in patients without proper assessments for patient need. Smith then had false and fraudulent reimbursement claims submitted to Medicare for these administrations. Among other things, the claims were inflated by nearly 60 percent; they sought reimbursement for large volumes of unnecessarily manufactured fentanyl; they falsely represented that excess fentanyl had been discarded, when in fact it was used; and they did not disclose that the fentanyl was adulterated. According to the indictment, Oertle illegally ordered fentanyl citrate for compounding; compounded fentanyl with Smith; and helped direct the illegal billing practices. “The DEA is committed to bringing to justice doctors that take the public’s trust and abuse it for their own purposes,” said DEA Special Agent in Charge Shelly S. Howe. “We are grateful for our relationships with the U.S. Attorney’s Office, the FBI and the other agencies who worked to bring these defendants to justice.” “We are supposed to be able to trust our doctors with our lives,” said U.S. Attorney Randy Grossman. “This office will use all its resources to protect vulnerable patients from doctors who use them to make money, with no regard for their safety.” “Criminal misconduct within the healthcare system is not only deceitful, but also destructive,” said Special Agent in Charge Stacey Moy of the FBI’s San Diego Field Office. “David Smith and Julia Oertle allegedly abused their positions of trust by manufacturing and propagating this toxic poison to patients over an extended period of time, further unraveling the fentanyl crisis our country is experiencing. This investigation clearly demonstrates that the threat of the opioid crisis extends far beyond street level dealing. The FBI will continue to work with our law enforcement partners to protect our communities and ensure justice is served.” “U.S. consumers must be able to trust that their medicines meet FDA’s required standards of safety and effectiveness,” said Acting Special Agent in Charge Christopher M. Alston, FDA Office of Criminal Investigations Los Angeles Field Office. “Our office will continue to pursue and bring to justice those who jeopardize the public’s health and the public’s trust.” “According to allegations in the indictment, these defendants were trusted with the medical care of their patients but instead used treatments that were not medically necessary in order to gain financially,” stated Special Agent in Charge Tyler Hatcher of the IRS Criminal Investigation’s Los Angeles Field Office. “We will continue to serve the public and help put a stop to schemes like this that take advantage of our medical system and put patients’ care at risk.” AGENCIES Federal Bureau of Investigation, United States Attorney’s Office, Food and Drug Administration, U.S. Department of Health and Human Services, U.S. Marshal Service, and the Internal Revenue Service **Topics:** Drug Diversion **Categories:** Arrest --- ### [Undertaken - Insurance fraud murder of Frankie Pullian](https://insurancefraud.org/news_archives/undertaken-insurance-fraud-murder-of-frankie-pullian/) **Published:** August 25, 2026 **Author:** Diane Beauchamp **Content:** When Frankie Pullian’s body was found under a car, it seemed he’d succumbed to a terrible accident. But when it was found there were nine separate insurance policies on his life, signs pointed to murder. Elbert Lee White and his wife Erna became fairly well known in the town of Paterson, New Jersey. White operated one of the more successful black-owned funeral homes in Paterson. By all accounts, White’s business was a trusted and respected institution in the Paterson area, and it became a regular stop-off for police. One early morning in 1980, a young handyman who worked for E. Lee White was found dead under a car in a desolate neighborhood. Frankie Pullian ran errands and cleaned the funeral home’s limos, and his sudden demise shocked residents and raised immediate questions. Why had Frankie been out walking in this remote area of Paterson so early in the morning? Who did the car that seemingly struck him belong to? And did the evidence from the scene support a hit-and-run tragedy? The car was found to have been stolen a month before the accident from a retired police officer. Whoever had been driving it in the early morning hours of April 8th seemed to have struck Frankie and then fled the scene on foot. But as investigators surveyed the area, details were inconsistent with an accident. There were no skid marks behind the vehicle. There was blood in the tire tracks behind the car even though Frankie’s body came to rest underneath the vehicle. And finally, there was fresh blood inside the car. Since these discoveries seemed to indicate the early morning accident scene had been staged, Frankie Pullian’s death was ultimately considered a homicide. But why had someone taken this young man’s life? Investigators decided to find out who would benefit from Frankie’s death – and they found no shortage of suspects. It didn’t take long to learn that Frankie Pullian, who only earned about $10k per year, was covered by nine different life insurance policies. The annual premiums on these policies were almost half of Frankie’s income. And the most recent of these insurance policies had been procured just five days before Frankie’s death. Police discovered four different people stood to cash in on Frankie Pullian’s death. His boss, E. Lee White, was named on a number of the policies. So was White’s wife Erna. And two other associates of White’s were listed as Pullian’s cousins and additional life insurance beneficiaries. It certainly seemed the circumstantial evidence pointed to a clear case of insurance fraud, but would it be enough to convince a jury of a murder? Last Words 1980 was the year when the plans of ring leader E. Lee White culminated in the homicide of Franklin Pullian. The murder-for-profit scam was easily uncovered. It’d be another seven years until Michael Douglas’ Wall Street character Gordon Gekko would utter his famous quotation: “Greed is right, greed works. Greed clarifies, cuts through, and captures the essence of the evolutionary spirit.” In White’s and his cohorts’ case, greed was their plan’s downfall. The annual premium for all the policies on Frankie Pullian totaled $3500. For a man who earned less than $10k annually, this alone would’ve been more than suspicious. It seems in the 1980s, before the prevalence of networked computers and digital record keeping, each individual policy was not suspicious. But when a total of NINE policies are considered, the signals of insurance fraud are clear. Little evidence but smart investigators The awareness of the scene’s investigators was essential in resolving the case. Without their initial suspicion about the inconsistencies with an accidental hit-and-run, it’s likely the first medical examiner’s cause of death would’ve gone unquestioned. But the blood in the tire tracks behind the vehicle and the misplaced articles of Frankie’s clothing were red flags. The passive blood drops on the passenger door threshold and the medium velocity impact spatter on the dashboard and windshield were clear indicators of scene staging. Serology identified the blood’s type as O. This was a clue in 1980, but far from the specificity we have with DNA today. Similar to Robert Knight’s murder of Dawn Bruce where serology identified blood type A from a semen sample, type O blood includes nearly 40% of the U.S. population too. A watch face found at the scene was also considered part of the collection of evidence. If this was truly an item worn by either the victim or the perpetrators, where were the watch’s straps? It’s possible one of the men simply carried the watch without straps, and it’s possible someone was merely awaiting replacement straps. I considered that the watch face might have not been connected to the scene at all. Was the watch working when discovered? E. Lee White and his two henchmen It’s clear the E. Lee White felt his scene staging and his preparation of Pullian’s body for autopsy would mislead any potential investigators. But White made two huge mistakes: he trusted two hoodlums to stage the accident scene, and he was exceptionally greedy. It’s likely Lawrence Scott and William Brown lured Pullian out to the remote location in the early morning hours of April 8, 1980. These hoodlums took advantage of Frankie Pullian’s trusting nature. Frankie had not remained enlisted in the military due to apparent cognitive impairment. Instead of thugs like Scott and Brown (and White) taking advantage of Frankie, these men should have been looking out for him. The immorality it takes to victimize a man like Frankie Pullian is unfathomable. But thankfully, these clowns weren’t criminally sophisticated, despite Brown’s prior run-in with law enforcement for fraud a few years prior. It’s certainly plausible that being struck by a motor vehicle can knock a person out of their shoes, but Scott and Brown must’ve also thought it could knock someone’s jacket off. They drove over Frankie’s bleeding body, and then repositioned the car on top of his body. They did not fabricate any damage on the car itself, specifically on the frontend which would’ve been the likeliest point of impact. And probably dumbest of all, they assaulted Frankie inside the car itself, depositing his blood on multiple surfaces. They had the sense to remove their fingerprints from inside the car, but they didn’t stop to think of the story the victim’s blood would tell police. As the ring leader and likely the smartest of the bunch, E. Lee White should’ve coached his stooges on how to make the murder look like an accident. Convincing police and the insurance investigators was key to their hairbrained plan’s success. But even a more convincing “accident” scene might not have worked – the sheer greed in obtaining a total of nine life insurance policies is stunning. I suppose the ploy here was to keep any specific insurance company/agent from knowing about any of the other policies. But it didn’t seem this information was difficult to unearth. And the police’s mantra in all cases of potential murder-for-profit is “follow the money”. White probably believed that distributing the policies’ beneficiaries among multiple people would look less suspicious. But it’s logically unreasonable for anyone to secure so many policies at such an outlandish combined premium. In addition to the beneficiaries, police probably discovered White himself was paying the premiums of these policies and not Frankie Pullian. When this money trail was uncovered, E. Lee White admitted to purchasing the policies (and sending his goons to stand in for Frankie at the physical examinations), but he denied involvement in the murder. Whether or not he was directly involved, the scene-staging and circumstantial evidence make him guilty as the others. I’m simply stunned at the audacity of these idiots’ plan. The last life insurance policy on Frankie was begun just five days before his murder. This fact alone would’ve been cause for an investigation. And wouldn’t Erna “Boone” plus Scott and Brown need to prove they were Pullian’s sister and cousins respectively? Imagine if White would’ve used discretion – he might have pulled off his scheme. Calculating for inflation, the $980k White hoped to net in 1980 would’ve been over $3 million in 2020, and even more today. Other items in Frankie Pullian’s case If testimony during the trial revealed an imposter at Frankie Pullian’s physical examination was actively referencing handwritten notes in order to answer questions, why was this not a red flag during the exam? The doctor was negligent in not reporting this anomaly, especially to the insurance company. If White and his accomplices took the time to draft notes to use when faking Pullian’s physical examinations, why didn’t they also practice forging his signature? In the samples shown around the episode’s 14:35 mark, it’s clear that no effort was made to make their versions of Frankie’s signature look legitimate. With what seems in hindsight as clear evidence of a staged accident scene, why did it take police over three years of legal wrangling to finally obtain an order to exhume Frankie Pullian’s body? Despite the original autopsy indicating Pullian’s cause of death to be accidental, the blood inside the car alone should’ve been enough to convince a judge a dire mistake had originally been made. Dr. Natarajan’s second autopsy clearly indicated the blunt force trauma focused on a small area of Frankie’s skull. I’m no forensic pathologist, but this had the hallmarks of a blow from a hammer. But this made we wonder, could it be possible for such an injury to occur from being hit by a car? Unlikely, sure, but possible? A protrusion on the frontend of the car, the victim’s head is just such a position – these don’t seem unreasonable. Of course, with no frontend damage on the front of the stolen Maverick, this is moot. How many active players in this deadly game? It’s clear that E. Lee White was the orchestrator behind this heinous crime. It’s also clear that Lawrence Scott and William Brown were criminally involved – they likely committed the actual murder. But how did Erna Boone White play into the scheme? I read that Erna was tried separately from White so she wouldn’t have to testify against her husband. It seems none of the other conspirators rolled over on her, so Erna was ultimately only convicted of fraud and theft by deception. I’m not sure why the judge was lenient during her sentencing – Boone received only probation. I feel she was at least aware of the plot and did nothing to stop it. Where is E. Lee White now in 2026? E. Lee White found guilty of murdering Frankie Pullian in January 1985. He was denied parole for a third time in 2013. The board felt that White continued to adhere “to a version of events that downplayed his culpable actions.” When the parole board accounted that White had not shown rehabilitative progress in the 28 years he’d served, they imposed a 96-month “future eligibility term” (FET). E. Lee White lost an appeal to this eight-year term. Including White’s pattern of earned credits, he was eligible for parole again in early 2018. When Elbert Lee White died on May 22, 2019, he was living in Washington DC. He had apparently finally earned parole after serving 33 years. Quotable Quotes “Well first of all, under a car or in front of the car, there’s no wood. Why would there be wood splinters in his skull?” – Walter Suhaka: Accident Reconstruction Expert “The medical examiner who did the autopsy and who issued the initial death certificate was not a forensic pathologist. He was not even a pathologist – he was general practitioner. He did what best he could do under the circumstance, but he was not trained formally in pathology or in forensic pathology.” – Geetha Natarajan, M.D.: Forensic Pathologist “When I started reading the reports, they said there was blood inside the car. I had to read the report twice – it didn’t make sense.” – Walter Suhaka: Accident Reconstruction Expert “It’s very unusual that you would take out almost a million dollars’ worth of insurance, and then within a few short months, someone should die. I mean, that to me that raises a flag automatically.” – Richard Falcone: Homicide Investigator (Ret.) “The person who represented himself to be Mr. Pullian had notes, handwritten notes. And every time he was asked a question about his life, his lifestyle, he referred to his notes. Which I would think would cause some concern, but apparently did not.” – Amos Saunders: Superior Court Judge “He \[the medical examiner\] did not go to the scene. He did not look at the vehicle. He did not talk to the officers who were at the scene. He did not look at any photographs. He did not examine the clothing of the victim. These are all types of things that one would expect would be done following a proper protocol of an autopsy.” – Bruno Mongiardo: Prosecutor **Topics:** Life Insurance **Categories:** Conviction --- ### [Holiday tips for helping family fight financial fraud](https://insurancefraud.org/news_archives/holiday-tips-for-helping-family-fight-financial-fraud/) **Published:** August 25, 2026 **Author:** Diane Beauchamp **Content:** Tis’ the season for giving, which means you should be on high alert for bad actors. In 2020, Kansans ages 60 and up fell victim to financial fraud to the tune of $48 million. Making fraud prevention a family affair is one of the most effective ways to stop bad actors in their tracks. “Families are often the first line of defense against bad actors,” said Insurance Commissioner Vicki Schmidt. “New tactics and scams are constantly being deployed by fraudsters, especially during the holiday season.” Here are several family-focused fraud prevention tips to consider when helping loved ones protect their pocketbooks: Check in often – Regular communication with your elderly loved ones is the best way to detect behavior changes that could indicate if someone has gained unwarranted influence over their investment and financial decision-making. Do not shame – We have all been tricked before, and victims of fraud should be comforted when coping with the fallout of deceptive actions. Keeping an empathetic tone when dealing with fraud as it will increase the victim’s willingness to open up about the experience. Encourage verification – Encourage them to inquire about whether the individual selling the investment is registered. Not all investments sold require the entity or individual to be registered, but investment opportunities not backed by a registered entity or person deserve additional scrutiny. Visit [SmartInvestKS.com](http://smartinvestks.com/) for guidance on preventing investment fraud. Call 785-296-3071 or visit [insurance.kansas.gov/securities](http://insurance.kansas.gov/securities) if you believe that you or a loved one may have already been the victim of investment fraud. **Topics:** Public Awareness --- ### [What We Learned From Cybersecurity Attacks in Healthcare in 2022](https://insurancefraud.org/news_archives/what-we-learned-from-cybersecurity-attacks-in-healthcare-in-2022/) **Published:** August 25, 2026 **Author:** Diane Beauchamp **Content:** This year has been a [tough one](https://www.forbes.com/sites/emilsayegh/2022/12/13/2022-in-review-an-eventful-cybersecurity-year/?sh=6f4e2c89352f) when it comes to organizations protecting their data — across all industries, not just healthcare. And experts predict that 2023 likely won’t be any better. Cybersecurity incidents involving patient data hit an all time high in 2021 — [more than 50.4 million patient records](https://www.globenewswire.com/news-release/2022/03/10/2400998/0/en/Hacking-Incidents-Dominate-Health-Data-Breaches-According-to-New-Breach-Barometer-Report.html) were breached. As 2022 comes to a close, it looks like the record might get broken again. A closer review of the breaches affords some clues as to how they can be avoided although health systems need to continue to invest in cybersecurity protocols, experts said. In 2021, healthcare organizations reported a total of [714 incidents](https://www.hhs.gov/hipaa/for-professionals/security/guidance/cybersecurity-newsletter-october-2022/index.html) in which 500 or more patient records were breached. Between January 1 and October 31 of this year, [594 data breaches](https://www.hipaajournal.com/october-2022-healthcare-data-breach-report/) like this have been reported, with an average of 60 data breaches being reported each month. Just like last year, most of this year’s largest healthcare data breaches were associated with third-party vendors. For example, [Advocate Aurora Health](https://medcitynews.com/tag/advocate-aurora-health/), a health system based in Wisconsin and Illinois, announced a data breach that affected 3 million people in October. Advocate Aurora said the data breach involved Meta Pixel, a third-party analytics software it had installed on its website and patient portal. North Carolina-based [Novant Health](https://www.novanthealth.org/) and Indiana-based [Community Health Network](https://www.ecommunity.com/) also reported data breaches this year that stemmed from their use of Meta Pixel — both incidents compromised the information of more than a million patients. Institutions such as [HHS](https://www.hhs.gov/about/news/2022/12/01/hhs-office-for-civil-rights-issues-bulletin-on-requirements-under-hipaa-for-online-tracking-technologies.html) and [ECRI](https://medcitynews.com/2022/11/hospitals-should-be-wary-of-using-meta-pixel-other-third-party-analytics-tools/) have issued alerts this year warning providers about the cybersecurity risks associated with the use of third-party analytics tools. Tools like Meta Pixel, Google Analytics and Adobe Analytics are usually free and can give providers insight into the way consumers use their websites, but the tech companies who provide this software can also use patient data to profile Internet users as they browse. This exposed patient data may be misused to tailor advertisements based on consumers’ medical conditions. These inappropriately targeted advertisements could push unproven treatments and lead patients away from seeking appropriate care. Additionally, exposing patients’ sensitive information could also result in fines, legal action and patient distrust of providers, according to HHS and ECRI’s reports. Data breaches also have a direct impact on patient lives, said Mike Hoey, founder of healthcare software company [Source Meridian](https://sourcemeridian.com/). “[Research](https://www.proofpoint.com/us/cyber-insecurity-in-healthcare) points out how cyberattacks against healthcare organizations caused more than 20% to experience an increase in mortality rates,” Hoey said. “In one instance, [Broward Health](https://www.browardhealth.org/) reported a breach that affected more than 1.3 million people — and according to the health system, the incident took place on account of someone gaining access through a third-party medical provider.” While third-party data breaches and ransomware have been the most common threats to the healthcare sector, medical device security is a growing concern, Hoey declared. As more medical devices become connected to the internet, healthcare providers will continue to see an uptick in hacks, according to research from software review and selection platform [Capterra](https://www.capterra.com/). The company [found](https://www.capterra.com/resources/medical-internet-of-things-iot-security/) that healthcare organizations with more than 70% of their devices connected to the internet are 24% more likely to experience a cyberattack than organizations with 50% or fewer connected devices. It’s important to remember that data breaches can be incredibly costly for health systems. [Research](https://rs.ivanti.com/reports/ivi-2732-press-reset-2023-cybersecurity-status-report.pdf) shows that a single data breach costs a healthcare organization an average of $4.3 million. Zach Capers, Capterra’s senior security analyst, said his company has conducted extensive research this year to prove that downtime is the biggest impact of a ransomware attack. “Far more money goes into the downtime than the actual payment for the ransomware,” he said. “You’re looking at lost patient care, disruption of schedules, and moving patients from critical care. In this situation, every minute counts, and it’s actually impacting people’s safety from a healthcare standpoint.” The safety standpoint Capers brought up is another critical consideration to remember. For example, [CommonSpirit Health](https://medcitynews.com/tag/commonspirit-health/) suffered a [ransomware cyberattack](https://medcitynews.com/2022/10/commonspirit-takes-it-systems-offline-amid-cybersecurity-incident/) in October. Due to the downtime, a 3-year-old in Iowa was given an improper dose of pain medication that [almost killed him](https://www.nbcnews.com/tech/security/ransomware-attacks-hospitals-take-toll-patients-rcna54090). Healthcare providers are not doing enough to protect themselves against these compromising situations, Capers declared. His research shows that 57% of providers don’t always change the default username and password for each new connected medical device they put into use, and 68% don’t always update their connected devices when a protective cybersecurity patch is available. And in the coming year, cybersecurity leaders aren’t very confident in their ability to fend off threats, according to a recent survey from software firm [Ivanti](https://www.ivanti.com/). One in five cybersecurity leaders said they [wouldn’t wager a candy bar](https://rs.ivanti.com/reports/ivi-2732-press-reset-2023-cybersecurity-status-report.pdf) on their organization’s ability to protect against a data breach in 2023. Ransomware attacks, cloud attacks and weak medical device security will all persist and increase next year, Hoey predicted. In his view, the healthcare sector’s lack of cybersecurity expertise is a key reason these threats will continue to proliferate. “In my opinion, the most powerful resource a healthcare provider can acquire is training for its employees to defend against cyberattacks. Historically, the healthcare industry has been slower to adopt and implement emerging technologies, and training can play an important role here,” Hoey said. Since cyber threats only seem to be getting worse, healthcare executives as a whole are planning on increasing their cybersecurity budgets for increased training and infrastructure, according to Ivanti’s research. The report predicted cybersecurity budgets to increase by 11% in 2023, which is well above projected inflation. Even though providers are facing strong economic headwinds, a robust cybersecurity budget will be a necessity next year, said Chris Bowen, CISO and founder at healthcare cybersecurity company [ClearDATA](https://www.cleardata.com/). “With the introduction of every new healthcare app or technology, the attack surface multiplies, and the need increases to secure the environment. Patients will demand it, attorneys general and the Office for Civil Rights will investigate it, and class action lawyers will continue to profit from it. To meet these demands, healthcare organizations will increase cybersecurity budgets – in some cases by more than 15% compared to 2022,” Bowen declared. **Topics:** Public Awareness, Technology --- ### [California one of 18 states to reach $5.7 billion opioid settlement with Walgreens](https://insurancefraud.org/news_archives/california-one-of-18-states-to-reach-5-7-billion-opioid-settlement-with-walgreens/) **Published:** August 25, 2026 **Author:** Diane Beauchamp **Content:** California Attorney General Rob Bonta, alongside 17 other attorneys general, has announced a $5.7 billion settlement agreement with the pharmacy retailer Walgreens for its alleged contribution to the opioid epidemic. The settlement reached Monday resolves a multistate lawsuit alleging Walgreens fueled and profited from the opioid addiction crisis by dispensing substances without proper oversight. The abatement funds, which will be split amongst participating states, may bring in over $500 million to California’s ongoing efforts to provide treatment and services to those addicted to opioids. “This settlement is another win in our ongoing fight to bring help and healing to California communities harmed by the opioid crisis,” Bonta said. “To all those struggling with substance abuse disorders, to all those desperately in need of treatment and recovery options — help is on the way.” Walgreens also has to satisfy court-ordered requirements to help prevent another substance abuse crisis from occurring again. The company agreed to create a program to train employees on drug diversion prevention, investigate “suspicious” prescriptions before dispensing them and allow for site visits at pharmacy locations. Walgreens also agreed to provide sales data from its distributor to drug manufacturers, in efforts to help identify and prevent times where prescription medicines are obtained illegally Last month, Walmart also reached a multi-billion-dollar settlement agreement with state attorneys general to resolve a lawsuit with similar claims. California is currently assessing settlement terms with CVS, another retail pharmacy chain that attorneys general alleged to have fueled the opioid crisis. **Topics:** Judicial/courts, Public Awareness --- ### [The system feds rely on to stop repeat health fraud is broken, a KHN investigation shows](https://insurancefraud.org/news_archives/the-system-feds-rely-on-to-stop-repeat-health-fraud-is-broken-a-khn-investigation-shows/) **Published:** August 25, 2026 **Author:** Diane Beauchamp **Content:** ## A months-long examination found gaping holes and expansive gray areas through which banned individuals slip to repeatedly bilk Medicaid, Medicare and other taxpayer-funded federal programs. The federal system meant to stop health care business owners and executives from repeatedly bilking government health programs fails to do so, a KHN investigation has found. That means people are once again tapping into Medicaid, Medicare, and other taxpayer-funded federal health programs after being legally banned because of fraudulent or illegal behavior. In large part that’s because the government relies on those who are banned to self-report their infractions or criminal histories on federal and state applications when they move into new jobs or launch companies that access federal health care dollars. The Office of Inspector General for the U.S. Department of Health and Human Services keeps a [public list](https://exclusions.oig.hhs.gov/default.aspx) of those it has barred from receiving any payment from its programs — it reported excluding more than 14,000 individuals and entities since January 2017 — but it does little to track or police the future endeavors of those it has excluded. The government explains that such bans apply to “the excluded person” or “anyone who employs or contracts with” them. Further, “the exclusion applies regardless of who submits the claims and applies to all administrative and management services furnished by the excluded person,” [according to the OIG](https://oig.hhs.gov/faqs/exclusions-faq/). Federal overseers largely count on employers to check their hires and identify those excluded. Big hospital systems and clinics typically employ compliance staff or hire contractors who routinely vet their workers against the federal list to avoid fines. However, those who own or operate health care businesses are typically not subject to such oversight, KHN found. And people can sidestep detection by leaving their names off key documents or using aliases. “If you intend to violate your exclusion, the exclusion list is not an effective deterrent,” said [David Blank](https://www.agg.com/professionals/david-blank/), a partner at Arnall Golden Gregory who previously was senior counsel at the OIG. “There are too many workarounds.” KHN examined a sample of 300 health care business owners and executives who are among more than 1,600 on OIG’s exclusion list since January 2017. Journalists reviewed court and property records, social media, and other publicly available documents. Those excluded had owned or operated home health care agencies, medical equipment companies, mental health facilities, and more. They’d submitted false claims, received kickbacks for referrals, billed for care that was not provided, and harmed patients who were poor and old, in some cases by stealing their medication or by selling unneeded devices to unsuspecting Medicare enrollees. One owner of an elder care home was excluded after he [pleaded guilty](https://www.documentcloud.org/documents/23378955-floro-sentencing-and-guilty-two-counts?responsive=1&title=1) to [sexual assault](https://www.arkansasonline.com/news/2018/dec/04/bentonville-man-jailed-in-sexual-assaul/). Among those sampled, KHN found: - Eight people appeared to be serving or served in roles that could violate their bans; - Six transferred control of a business to family or household members; - Nine had previous, unrelated felony or fraud convictions, and went on to defraud the health care system; - And seven were repeat violators, some of whom raked in tens of millions of federal health care dollars before getting caught by officials after a prior exclusion. The exclusions list, according to Blank and other experts, is meant to make a person radioactive — easily identified as someone who cannot be trusted to handle public health care dollars. But for business owners and executives, the system is devoid of oversight and rife with legal gray areas. One man, Kenneth Greenlinger, [pleaded guilty](https://www.documentcloud.org/documents/23321299-greenlinger-plea-agreement?responsive=1&title=1) in 2016 to submitting “false and fraudulent” claims for medical equipment his California company, Valley Home Medical Supply, never sent to customers that totaled more than $1.4 million to Medicare and other government health care programs, [according to his plea agreement](https://www.documentcloud.org/documents/23321299-greenlinger-plea-agreement?responsive=1&title=1). He [was sentenced](https://www.documentcloud.org/documents/23321018-greenlinger-sentencing-fina?responsive=1&title=1) to eight months in federal prison and ordered to pay restitution of more than $1 million, according to court records. His company [paid more than $565,000](https://www.justice.gov/usao-cdca/pr/san-fernando-valley-medical-supply-company-defrauded-federal-health-care-programs-pays) to resolve allegations of false claims, according to the Justice Department website. Greenlinger was handed a 15-year exclusion from Medicare, Medicaid, and any other federal health care program, starting in 2018, according to the OIG. But this October, Greenlinger announced a health care business with government contracts for sale. [Twice on LinkedIn](https://www.documentcloud.org/documents/23321014-greenlingerselldme?responsive=1&title=1), Greenlinger [announced](https://www.documentcloud.org/documents/23321022-greenlinger-saying-owns-dme-company?responsive=1&title=1): “I have a DME \[durable medical equipment\] company in Southern California. We are contracted with most Medicare and Medi-Cal advantage plans as well as Aging in Place payers. I would like to sell,” adding a Gmail address. Reached by phone, Greenlinger declined to comment on his case. About the LinkedIn post, he said: “I am not affiliated directly with the company. I do consulting for medical equipment companies — that was what that was, written representing my consulting business.” His wife, Helene, who previously worked for Valley Home Medical Supply, is now its CEO, according to [LinkedIn](https://www.documentcloud.org/documents/23321023-greenlingerhelenelinkedin?responsive=1&title=1) and documentation from the [California Secretary of State](https://www.documentcloud.org/documents/23321017-greenlinger-wife-on-biz-docs?responsive=1&title=1) office. Although Helene has a LinkedIn account, she told KHN in a telephone interview that her husband had posted on her behalf. But Kenneth posted on and commented from his LinkedIn page — not his wife’s. At Valley Home Medical Supply, a person who answered the phone last month said he’d see whether Kenneth Greenlinger was available. Another company representative got on the line, saying “he’s not usually in the office.” Helene Greenlinger said her husband may come by “once in a while” but “doesn’t work here.” She said her husband doesn’t do any medical work: “He’s banned from it. We don’t fool around with the government.” “I’m running this company now,” she said. “We have a Medicare and Medi-Cal number and knew everything was fine here, so let us continue.” **No Active Enforcement** Federal regulators do not proactively search for repeat violators based on the exclusion list, said Gabriel Imperato, a managing partner with Nelson Mullins in Florida and former deputy general counsel with HHS’ Office of the General Counsel in Dallas. He said that for decades he has seen a “steady phenomenon” of people violating their exclusions. “They go right back to the well,” Imperato said. That oversight gap played out during the past two years in two small Missouri towns. Donald R. Peterson co-founded Noble Health Corp., a private equity-backed company that bought two rural Missouri hospitals, just months after he’d agreed in August 2019 to [a five-year exclusion](https://oig.hhs.gov/fraud/enforcement/kansas-infusion-company-owner-agrees-to-voluntary-exclusion/) that “precludes him from making any claim to funds allocated by federal health care programs for services — including administrative and management services — ordered, prescribed, or furnished by Mr. Peterson,” said Jeff Morris, an attorney representing Peterson, [in a March letter to KHN.](https://www.documentcloud.org/documents/21969554-2022_03_14-morris?responsive=1&title=1) The prohibition, Morris said, also “applies to entities or individuals who contract with Mr. Peterson.” That case involved a company Peterson created called IVXpress, now operating as IVX Health with infusion centers in multiple states. Peterson left the company [in 2018](https://www.documentcloud.org/documents/23316421-2022_03_15-don-peterson_linkedin?responsive=1&title=1), according to his LinkedIn, after the settlement with the government showed [a whistleblower accused him](https://www.documentcloud.org/documents/21719400-1#document/p1/a2103683) of altering claims, submitting false receipts for drugs, and paying a doctor kickbacks. He settled the resulting federal charges [without admitting wrongdoing](https://www.documentcloud.org/documents/23379071-2#document/p1/a2179859). His settlement agreement provides that if he violates the exclusion, he could face “criminal prosecution” and “civil monetary penalties.” In January 2020, Peterson was listed in [a state registration document](https://www.documentcloud.org/documents/21881941-2020_01_14-biennialregistration?responsive=1&title=1) as one of two Noble Health directors. He was also listed as the company’s secretary, vice president, and assistant treasurer. Four months later, in April 2020, Peterson’s name appears on a [purchasing receipt](https://www.documentcloud.org/documents/23321057-fmc-inv01_0001#document/p2/a2177362) obtained under the Freedom of Information Act. In addition to Medicare and Medicaid funds, Noble’s hospitals had received [nearly $20 million](https://khn.org/news/article/noble-health-platinum-health-private-equity-hospital-workers-fired/) in [federal COVID relief money](https://taggs.hhs.gov/Coronavirus/Providers). A social media account with a photo that appears to show Peterson announced the launch of Noble Health in [February 2020](https://www.documentcloud.org/documents/21718326-2020_02_29_noble_nueterra-screen-grab?responsive=1&title=1). Peterson identified himself on Twitter as [executive chairman](https://www.documentcloud.org/documents/21760158-2021_09_07peterson-twitter) of the company. It appears federal regulators who oversee exclusions did not review or approve his role, even though information about it was publicly available. Peterson, whose name does not appear on the hospitals’ [Medicare applications](https://www.documentcloud.org/documents/21985869-working-copy-855a_responsive-documents_100120217026?responsive=1&title=1), said by email that his involvement in Noble didn’t violate his exclusion in his reading of the law. He said he owned only 3% of the company, citing OIG guidance — federal regulators may exclude companies if someone who is banned [has ownership of 5% or more](https://www.documentcloud.org/documents/23321079-2013-oig-guideline#document/p11/a2177376) of them — and he did not have a hand in operations. Peterson said he worked for the corporation, and the hospitals “did not employ me, did not pay me, did not report to me, did not receive instructions or advice from me,” he wrote in a November email. A [2013 OIG advisory](https://www.documentcloud.org/documents/23321079-2013-oig-guideline#document/p8/a2178518) states that “an excluded individual may not serve in an executive or leadership role” and “may not provide other types of administrative and management services … unless wholly unrelated to federal health care programs.” Peterson said his activities were apart from the business of the hospitals. “My job was to advise Noble’s management on the acquisition and due diligence matters on hospitals and other entities it might consider acquiring. … That is all,” Peterson wrote. “I have expert legal guidance on my role at Noble and am comfortable that nothing in my settlement agreement has been violated on any level.” For the two hospitals, Noble’s ownership ended badly: The Department of Labor opened [one of two investigations](https://www.documentcloud.org/documents/22127911-2022-03-02-dol_noble?responsive=1&title=1) into Noble this March in response to[complaints from employees](https://khn.org/news/article/noble-health-platinum-health-private-equity-hospital-workers-fired/). Both Noble-owned hospitals suspended services. Most employees were furloughed and then lost their jobs. Peterson said he left the company in August 2021. That’s the same month state regulators cited one hospital for deficiencies that put patients “[at risk for their health and safety](https://www.documentcloud.org/documents/21719887-2021_08_25-callaway-documents-working-copy#document/p3/a2104986).” If federal officials determine Peterson’s involvement with Noble violated his exclusion, they could seek to claw back [Medicaid and Medicare payments](https://oig.hhs.gov/exclusions/effects_of_exclusion.asp#:~:text=An%20excluded%20individual%20or%20entity%20that%20submits%20a%20claim%20for,D%29%20of%20the%20Act%29.) the company benefited from during his tenure, according to OIG records. **Enforcement in a Gray Zone** [Dennis Pangindian](https://www.paulhastings.com/en-GB/professionals/dennispangindian), an attorney with the firm Paul Hastings who had prosecuted Peterson while working for the OIG, said the agency has limited resources. “There are so many people on the exclusions list that to proactively monitor them is fairly difficult.” He said whistleblowers or journalists’ reports often alert regulators to possible violations. KHN found eight people who appeared to be serving or served in roles that could violate their bans. OIG spokesperson Melissa Rumley explained that “exclusion is not a punitive sanction but rather a remedial action intended to protect the programs and beneficiaries from bad actors.” But the government relies on people to self-report that they are banned when applying for permission to file claims that access federal health care dollars through the Centers for Medicare & Medicaid Services. While federal officials are aware of the problems, they so far have not fixed them. Late last year, the Government Accountability Office [reported that](https://www.gao.gov/assets/gao-22-103850.pdf) 27 health care providers working in the federal Veterans Affairs system were on the OIG’s exclusion list. If someone “intentionally omits” from applications they are an “excluded owner or an owner with a felony conviction,” then “there’s no means of immediately identifying the false reporting,” said Dara Corrigan, director of the center for program integrity at CMS. She also said there is “no centralized data source of accurate and comprehensive ownership” to check for violators. The [OIG exclusion list website](https://www.oig.hhs.gov/exclusions/tips.asp), which health care companies are encouraged to check for offenders, notes that the list does not include altered names and encourages those checking it to vet other forms of identification. Gaps in reporting also mean many who are barred may not know they could be violating their ban because exclusion letters can go out months after convictions or settlements and may never reach a person who is in jail or has moved, experts said. The exclusion applies to federal programs, so a person could work in health care by accepting only patients who pay cash or have private insurance. In its review, KHN found some on the exclusion list who were working in health care businesses that don’t appear to take taxpayer money. OIG said its exclusions are “based largely on referrals” from the Justice Department, state Medicaid fraud-control units, and state licensing boards. A lack of coordination among state and federal agencies was evident in exclusions KHN reviewed, including cases where years elapsed between the convictions for health care fraud, elder abuse, or other health-related felonies in state courts and the offenders’ names appearing on the federal list. ProviderTrust, a [health care compliance group](https://www.providertrust.com/our-company/team/), found that the lag time between state Medicaid fraud findings and when exclusions appeared on the federal list averaged more than 360 days and that some cases were never sent to federal officials at all. The NPI, or [National Provider Identifier record](https://npiregistry.cms.hhs.gov/search), is another potential enforcement tool. Doctors, nurses, other practitioners, and health businesses register for NPI numbers to file claims to insurers and others. KHN found that NPI numbers are not revoked after a person or business appears on the list. The NPI should be “essentially wiped clean” when the person is excluded, precluding them from submitting a bill, said [John Kelly](https://btlaw.com/people/john-kelly), a former assistant chief for health care fraud at the Department of Justice who is now a partner for the law firm Barnes & Thornburg. Corrigan said the agency didn’t have the authority to deactivate or deny NPIs if someone were excluded. **The Family ‘Fronts’** Repeat violators are all too common, according to state and federal officials. KHN’s review of cases identified seven of them, noted by officials in press releases or in court records. KHN also found six who transferred control of a business to a family or household member. One common maneuver to avoid detection is to use the names of “family members or close associates as ‘fronts’ to create new sham” businesses, said Lori Swanson, who served as Minnesota attorney general from 2007 to 2019. Blank said the OIG can exclude business entities, which would prevent transfers to a person’s spouse or family members, but it rarely does so. Thurlee Belfrey stayed in the home care business in Minnesota after his 2004 exclusion for state Medicaid fraud. His wife, Lanore, a former winner of the Miss Minnesota USA title, created a home care company named Model Health Care and “did not disclose” Thurlee’s involvement, [according to his 2017 plea agreement.](https://www.documentcloud.org/documents/23321310-2017_09_14-belfrey-plea-agreement#document/p2/a2177399) “For more than a decade” Belfrey, his wife, and his twin brother, Roylee, made “millions in illicit profits by cheating government health care programs that were funded by honest taxpayers and intended for the needy,” according [to the Justice Department](https://www.justice.gov/usao-mn/pr/health-care-business-owners-sentenced-prison-multi-million-dollar-fraud-and-tax). The brothers spent the money on a Caribbean cruise, high-end housing, and attempts to develop a reality TV show based on their lives, the DOJ said. Federal investigators deemed more than $18 million in claims Model Health Care had received were fraudulent because of Thurlee’s involvement. Meanwhile, Roylee operated several other health care businesses. [Between 2007 and 2013,](https://www.documentcloud.org/documents/23321310-2017_09_14-belfrey-plea-agreement#document/p3/a2179788) the brothers deducted and collected millions from their employees’ wages that they were supposed to pay in taxes to the IRS, the Justice Department said. Thurlee, Lanore, and Roylee Belfrey all were convicted and served prison time. When reached for comment, the brothers said the government’s facts were inaccurate and they looked forward to telling their own story in a book. Roylee said he “did not steal people’s tax money to live a lavish lifestyle; it just didn’t happen.” Thurlee said he “never would have done anything deliberately to violate the exclusion and jeopardize my wife.” Lanore Belfrey could not be reached for comment. Melchor Martinez settled with the government after he was accused [by the Department of Justice](https://www.justice.gov/usao-edpa/pr/united-states-obtains-3-million-consent-judgment-and-federal-healthcare-exclusions-0) of[violating his exclusion](https://www.justice.gov/usao-edpa/pr/united-states-obtains-3-million-consent-judgment-and-federal-healthcare-exclusions-0) and for a second time committing health care fraud by enlisting his wife, Melissa Chlebowski, in their Pennsylvania and North Carolina community mental health centers. Previously, Martinez was convicted of Medicaid fraud [in 2000](https://www.justice.gov/usao-edpa/pr/united-states-obtains-3-million-consent-judgment-and-federal-healthcare-exclusions-0) and was excluded from all federally funded health programs, according to DOJ. Later, Chlebowski failed to disclose on Medicaid and Medicare enrollment applications that her husband was managing the clinics, according to allegations by theJustice Department. Their Pennsylvania clinics were the largest providers of mental health services to Medicaid patients in their respective regions. They also had generated $75 million in combined Medicaid and Medicare payments from 2009 through 2012, according to the [Justice Department](https://www.justice.gov/usao-edpa/pr/united-states-obtains-3-million-consent-judgment-and-federal-healthcare-exclusions-0). Officials accused the couple of employing people without credentials to be mental health therapists and the clinics of billing for shortened appointments for children, according to [the DOJ](https://www.justice.gov/usao-edpa/pr/united-states-obtains-3-million-consent-judgment-and-federal-healthcare-exclusions-0). They agreed, without admitting liability, to pay $3 million and to be excluded — a second time, for Martinez — [according to court filings in the settlement with the government.](https://www.documentcloud.org/documents/23334928-martinezchlebowskisettlement) They did not respond to KHN’s attempts to obtain comment. **‘Didn’t Check Anything’** In its review of cases, KHN found nine felons or people with fraud convictions who then had access to federal health care money before being excluded for alleged or confirmed wrongdoing. But because of the way the law is written, Blank said, only certain types of felonies disqualify people from accessing federal health care money — and the system relies on felons to self-report. [According to the DOJ court filing,](https://www.documentcloud.org/documents/23321331-us_v_bianco_-_information-1#document/p6/a2177418) Frank Bianco [concealed his ownership](https://www.documentcloud.org/documents/23379311-cr-80133-factual-basis_felony-discussion#document/p2/a2179941) in Anointed Medical Supplies, which submitted about $1.4 million in fraudulent claims between September 2019 and October 2020. Bianco, who opened the durable medical equipment company in South Florida, said in an interview with KHN that he did not put his name on a Medicare application for claims reimbursement because of his multiple prior felonies related to narcotics. And as far as he knows, Bianco told KHN, the federal regulators “didn’t check anything.” Bianco’s ownership was discovered because one of his company’s contractors was under federal investigation, he said. Kenneth Nash had been convicted of fraud before he operated his Michigan home health agency and submitted fraudulent claims for services totaling more than $750,000, [according to the Justice Department](https://www.justice.gov/usao-wdmi/pr/2021_0212_Nash). He was sentenced to more than five years in prison last year, according to the DOJ. Attempts to reach Nash were unsuccessful. “When investigators executed search warrants in June 2018, they shut down the operation and seized two Mercedes, one Land Rover, one Jaguar, one Aston Martin, and a $60,000 motor home — all purchased with fraud proceeds,” [according to a court filing in his sentencing.](https://www.documentcloud.org/documents/23321313-nash-sentencing-court-doc#document/p2/a2177480) “What is readily apparent from this evidence is that Nash, a fraudster with ten prior state fraud convictions and one prior federal felony bank fraud conviction, got into health care to cheat the government, steal from the Medicare system, and lavishly spend on himself,” [the filing](https://www.documentcloud.org/documents/23321313-nash-sentencing-court-doc#document/p2/a2177481) said. As Kelly, the former assistant chief for health care fraud at the Justice Department, put it: “Someone who’s interested in cheating the system is not going to do the right thing.” --- ### [Texas Medical Association heads to court again in second challenge to surprise billing ban](https://insurancefraud.org/news_archives/texas-medical-association-heads-to-court-again-in-second-challenge-to-surprise-billing-ban/) **Published:** August 25, 2026 **Author:** Diane Beauchamp **Content:** This is the second time the Texas Medical Association will argue in front of Kernodle over implementation of the No Surprises Act that banned surprise billing. Kernodle [ruled in favor of the Texas Medical Association in February](https://www.healthcaredive.com/news/texas-judge-strikes-down-part-surprise-billing-rule/619357/) over a similar but separate case. The central issue in both cases is how much arbiters should rely on the qualified payment amount, or the median in-network rate, when resolving pricing disputes. The No Surprises Act was a win for consumers who found themselves stuck with hefty medical bills after being caught between provider and payer pricing disputes. Patients were sometimes left with the remaining balance of a medical bill when a provider was out-of-network and the insurer would only pay some — or none — of the bill. Patients were sometimes surprised by these bills after going to an in-network facility and unknowingly treated by an out-of-network clinician. The law set up a process for how payers and providers could resolve disputes by allowing parties to enter baseball-style arbitration. Unable to come to pricing terms, each side submits an offer to a third-party, known as an arbiter, who is then supposed to select one offer. Regulators’ guidance on what arbiters should consider before selecting one offer has generated the most pushback from providers. In a draft rule, regulators said arbiters should start with the “presumption” that the QPA, or the median in-network rate, is the correct amount. Providers argued that presumption effectively sets a ceiling on prices. [A federal judge agreed](https://www.healthcaredive.com/news/texas-judge-strikes-down-part-surprise-billing-rule/619357/) with the Texas Medical Association and struck down that language in a February ruling. It forced regulators to [nix the language in the final rule](https://www.healthcaredive.com/news/federal-regulators-nix-contested-language-surprise-billing-final-rule/630145/). Even though regulators removed the “presumption” language in the amended rule, TMA filed suit again arguing the final version has the same effect. The final rule requires arbiters to evaluate the credibility of the information presented to them — except the QPA — and tells arbiters to dismiss information that is not credible, TMA said. Regulators “did not grapple with the reality that, in most cases, the QPA will be an unaudited number calculated by the insurer,” TMA argued. Regulators disagree. There is no mention in the final rule that arbiters must defer to the QPA, regulators said, arguing TMA and its co-plaintiffs, including a Texas physician and Texas hospital, lack standing in the case. The final rule instructs arbiters to pick “the offer that best represents the value of the item or service, regardless of whether that offer happens to be closest to the qualifying payment amount,” regulators argue. If Kernodle rules in favor of TMA again, it may halt the arbitration process, Zachary Baron, associate director of [health policy and the law initiative](https://oneill.law.georgetown.edu/initiatives/health-policy-and-the-law/) at the O’Neill Institute at Georgetown, said. “It is unclear what would happen to disputes that are currently in the midst of the arbitration process, they may need to be paused and re-evaluated. Disputes that are in the queue for arbitrators could also be paused until further guidance is provided,” Baron said. **Topics:** Judicial/courts, Public Awareness --- ### [Zimbabwe: Insurance Council Speaks On Fraudulent Claims](https://insurancefraud.org/news_archives/zimbabwe-insurance-council-speaks-on-fraudulent-claims/) **Published:** August 25, 2026 **Author:** Diane Beauchamp **Content:** The Insurance Council of Zimbabwe wants a vibrant insurance fraud office following an upsurge of insurance fraud, which even includes the recent police discovery of a syndicate staging road accidents, making false police reports, and then claiming from insurance companies, hitting them for thousands of US dollars. The accident fraud came to light after police separately arrested seven suspects in Harare who are linked to the scam. **Topics:** Public Awareness, Regulatory actions --- ### [Suspected telehealth scam Dr ASAP linked to failed Tristar Medical Group](https://insurancefraud.org/news_archives/suspected-telehealth-scam-dr-asap-linked-to-failed-tristar-medical-group/) **Published:** August 25, 2026 **Author:** Diane Beauchamp **Content:** An online telehealth service suspected to be a scam is linked to failed national GP chain Tristar Medical Group, which collapsed earlier this year owing millions of dollars to doctors and the government. [Concerns have been raised to the ABC](https://www.abc.net.au/news/2022-12-16/tristar-phone-scam-family-doctor-horsham/101781842) over a website called Dr ASAP, which advertises private telehealth services for an out-of-pocket cost of $80. The site requests patients’ personal details along with their Medicare number before booking. The website states it is a fully private service: “There is no Medicare or other government subsidy rebate”. But some patients across Victoria, including in Ballarat, Horsham, and Eaglehawk, reported that they never received a consultation and their money was lost. One person posted on Facebook to say she was so concerned about identity theft after paying $80 that she changed her bank card. “There is nowhere and nobody to contact about my money, they have my personal details and Medicare,” she said. “I couldn’t cancel the appointment. “I’ve been stressed out of my mind, contacting the bank and the police … all because this website lacks the bare minimum of customer service communication.” The website is owned by Kure Medical Group[, a former subsidiary](https://acurus.com.au/case-study/kure-medical-solutions/) of Tristar. The phone numbers of former Tristar clinics redirect patients to Dr ASAP. Tristar’s former director now works at Kure Medical, which has two clinics listed in Victoria and one in New South Wales. Kure Medical has been contacted for comment. ## Medicare billing inconsistencies Leaked billing and medical documents obtained by the ABC show suspected fraud, billing errors, and overservicing by Tristar doctors to Medicare. Patient records indicate some GPs may have exaggerated consultation times to claim higher Medicare rebates and that they billed for some services without adequate patient documentation. A string of face-to-face patient visit records shows that one doctor saw 50 patients in under six hours, with a quarter of those involving mental health and long consultations, which must be at least 20 minutes long under Medicare. It meant less than two minutes per patient for the rest of the day. On a separate day, the GP allegedly charged Medicare for up to 11 hours of face-to-face patient consultations for seven hours worked. On some days, it allegedly worked out to be 5.8 minutes per patient, despite MBS item numbers showing varying times for consults, between 10 to 20 minutes, up to an hour per patient. Tristar’s business model was based on hiring international GPs on visas and taking up to 50 per cent of the billing income. ## Regulators alerted A Consumer Affairs Victoria spokesperson said Dr ASAP can be reported to Consumer Affairs or the Australian Competition and Consumer Commission (ACCC). They said people who had lost money in a scam paid by credit charge could be able to seek a chargeback from their bank or credit card provider. A chargeback is a reversal of a charge on your credit card and is similar to a refund. The Australian Health Practitioner Regulation Agency (Ahpra), which is responsible for regulating registered health practitioners in Australia, says it does not have any powers to require payment of refunds. “If any person has information that a registered medical practitioner is acting dishonestly by charging for a health service they have not provided, they could report that matter to Ahpra,” a spokesperson said. The code of conduct for doctors in Australia says doctors must be “honest and transparent” in their financial dealings with patients. The ACCC and Victoria Police said scams should be reported to Scamwatch. The Australian Taxation Office said it could not comment on the tax affairs of any individual or entity due to confidentiality laws. ## Watchdogs failed to act Former Tristar employees and associates have claimed some of Australia’s most powerful watchdogs failed to act on their warnings about Tristar, which, at its peak, was one of Australia’s largest bulk-billing GP chains. A former worker said financial mismanagement was rife throughout the company, including one colleague who was mining bitcoin in overseas infrastructure under the company name. “They didn’t have a proper financial system, there was no real way to know how the money was being spent,” he said. “They were flying by the seat of their pants.” An email provided to the ABC showed the former employee tipped off the federal health department about Tristar’s possible fraudulent activity back in 2018. “I also tipped off ASIC via their hotline and there was no feedback. That was years before we got to this stage,” he said. > “Why, with all that information being put to numerous parties, was it allowed to continue?” ## Doctors, staff pleading for pay Claims of doctors not being paid by Tristar first [surfaced a number of years ago](https://www.abc.net.au/news/2019-08-09/staff-at-regional-tristar-medical-clinics-waiting-for-pay/11394462). All who spoke to the ABC did so anonymously for fear it would jeopardise their job prospects, with many having moved to Australia to be trained through Tristar. A former GP said she was not paid for six months and was owed close to $60,000 from Tristar. “We never got paid in full or on time,” she said. “We would send emails, and when we tried to call there was no-one to speak to. > “It was too exhausting, I resigned.” One former receptionist worked for Tristar for 10 years and has been owed superannuation. She has lost hope in seeing the money owed to her. “Not only was my super not being paid but my salary sacrificing has been kept as well,” she said. “I just assume it’s gone and I can’t get it because there are so many people that are owed money I doubt they’ll be able to get enough back to pay everybody.” In an email chain obtained by the ABC, another former doctor accused the company of withholding her salary. “\[You are\] deliberately under-reporting the figures for the amount received from Medicare, even though we have the clinic’s report showing the actual amount billed and received,” she said. She said the company ignored her emails and calls. Administrators McGrath Nicol estimated Tristar was likely insolvent since 2019. Tristar has approximately 282 unsecured creditors who are collectively owed more than $20 million, including 26 doctors, its latest report shows. Tristar Property owns a number of commercial and residential properties. One property has been sold and the liquidators are in the process of selling the eight remaining properties. **Topics:** Healthcare Fraud, Public Awareness --- ### [Stolen NZ data listed for sale on dark web](https://insurancefraud.org/news_archives/stolen-nz-data-listed-for-sale-on-dark-web/) **Published:** August 25, 2026 **Author:** Diane Beauchamp **Content:** Multiple New Zealand businesses caught in a large-scale ransomware attack have had their data listed for sale on the dark web. The businesses were all customers of Wellington information technology firm Mercury IT, itself the victim of a ransomware attack understood to be by a cybercriminal gang known as Lockbit. Health insurer Accuro, architecture firm Catalyst Group, business mentoring programme Business Central, commercial flooring business Polyflor, and Mercury IT itself all have had data listed for sale on the dark web for prices between US $99,000 (NZ$157,000) and US $999,999. Mercury IT also performed contract work for Te Whatu Ora and Health NZ. The attack is said to involve 14,500 coronial files and 4000 post-mortem reports from those organisations, but so far this information has not been listed on the dark web. Brett Callow​, a threat analyst at cybersecurity firm Emsisoft and a leading international expert on ransomware, said it was hard to describe how big this incident was for New Zealand security. “This is possibly the most significant cybersecurity incident New Zealand has had. I can’t think of any other incident that has simultaneously affected so many organisations,” Callow said. Most ransomware attacks in New Zealand focused on stealing or compromising the data of a single company, but this attack had targetted Mercury IT, a managed service provider that worked with multiple businesses. The group behind the attack, a ransomware gang called Lockbit, were formed in 2019 and is thought to be based in Russia or in Eastern Europe. The group often operated as ransomware as a service, meaning people could hire the group to commit attacks anywhere in the world. Recently a Canadian resident had been arrested in relation to a Lockbit attack, he said. “Because of this, these attacks can often originate much closer to home than people may initially think,” Callow​ said. **Topics:** Public Awareness, Technology --- ### [Gore woman pleads guilty to forging prescription](https://insurancefraud.org/news_archives/gore-woman-pleads-guilty-to-forging-prescription/) **Published:** August 25, 2026 **Author:** Diane Beauchamp **Content:** A woman has pleaded guilty to forgery and using a forged document when she appeared in the Gore District Court on Wednesday. Judge Bernadette Farnan granted the woman, 38, interim name suppression, and she was remanded at large to reappear on March 22. The woman is charged forging a document (a prescription) to obtain property, using a forged document, both on August 19; and forging a document (a prescription), on September 29. Two other charges were withdrawn by police. The woman’s lawyer, Bill Wright, told the court there were major health and mental health issues in relation to the offending, and he was seeking a long period of remand. The woman was also due to travel overseas, he told the court. The summary of facts relating to the offending were not read in court. Judge Farnan ordered a pre-sentence be prepared with appendices for community detention. The woman will also take part in the restorative justice process. Gore Health Ltd chief executive Karl Metzler said the woman was a contractor for the organisation, and was not an employee. **Topics:** Drug Diversion **Categories:** Conviction --- ### [A look at the shady business of road touting, and the cost to victims](https://insurancefraud.org/news_archives/a-look-at-the-shady-business-of-road-touting-and-the-cost-to-victims/) **Published:** August 25, 2026 **Author:** Diane Beauchamp **Content:** When the SG Road Vigilante group uploaded videos of men caught harassing motorists who had just met with an accident, netizens’ comments came fast and furious. Several said touting has been a long-standing issue; others recounted their own experiences with road touts. Lawyer Sarjeet Singh, who represents insurers dealing with motor accident claims, says touting is “still prevalent”, a year after those videos were [uploaded](https://www.youtube.com/watch?v=PRzAPd4jIo8). “Thanks to the lifting of (pandemic) restrictions, you can see traffic’s back to normal,” he notes. “Business is back.” And there is a wider impact, [Talking Point](https://www.youtube.com/watch?v=b-cr-KzKGOY) hosts Steven Chia and Shrey Bhargava find out as they join forces to investigate how different parties are involved in this shady business. ## THE TARGET One motorist, Lee (not his real name), was in a chain collision four years ago, with his car rear-ending the second car. He and his wife were unhurt. But as it was his first road accident, he was in a state of shock. “I panicked,” he recalls. “I didn’t realise I needed to call the insurance company.” A middle-aged man crossed the road to help him in no time. “(He) gave a name card and said … ‘I can settle all your claims. I can do everything — no headache, nothing. Follow me to the workshop. (We’ll) drive together,’” Lee recounts. The other two drivers agreed, so Lee followed suit. After reaching the workshop, the so-called good Samaritan asked him if he wanted to claim insurance. Lee did not want to because his car was not damaged. Then the man told him it was an opportunity to “do up (his) car, make it nicer”. At this point, Lee grew sceptical but did not think too much until his insurance company notified him that it had settled a claim for more than S$30,000. He realised he must have encountered a road tout: Someone who commits insurance fraud by taking advantage of a driver who is stressed and confused after an accident. ## THE CLAIMS PROCESS When an accident happens, the drivers involved can choose between settling the matter privately, with no insurance claim made, or the victim can file a third-party claim against the party at fault. That is where road touts come in, offering to file the claim on the victim’s behalf, as the filing process is “very strenuous”, says Julian Kho, general manager of vehicle trading website sgCarMart. He has got a few tips on what to do instead. Drivers should check for injuries first. If there is none, drivers should exchange details such as name, address and identification, contact and vehicle registration numbers as well as company name if a company-registered vehicle is involved. They should take photos of all the vehicles involved and any skid marks. Finally, they should note the date, time and accident location. On top of the advice given by Kho, drivers must call their insurer’s hotline and get their car to an approved reporting centre or authorised workshop for repairs in the Motor Claims Framework endorsed by insurance companies. As Lee had left the tout to settle everything, third-party repairs that might have cost S$1,000 ballooned instead. Medical expenses made up half of the total amount, even though the claimant said earlier that he had no injuries. ## DISHONEST WORKSHOPS, ROGUE SURVEYORS Touts work in cahoots with some workshops trying to beat the competition they face from roughly 2,000 other workshops. For example, after touts approached former workshop owner Tan (not his real name) to service a few cars, he started dangling referral fees of up to S$3,000 and received at least “one or two” referrals a month. According to him, touts regularly ply roads with a “high accident rate” owing to factors such as heavy traffic, ongoing construction and the presence of heavy vehicles. The touts usually choose straightforward collision cases and target the accident victims. “The car workshop doesn’t want to deal with the offender. And (the touts) only deal with cases that are close to a 100 per cent win,” says Tan. He has heard touts say that “in a good month, they can earn, easily, S$20,000”. The workshops, meanwhile, may inflate charges by 200 per cent. For repair costs to be approved, finding other collaborators is key. Since April 2016, motorists making third-party claims should appoint a surveyor to assess the damage incurred in an accident before the workshop starts on repairs. Surveyors were previously licensed. But in 2005, authorities discontinued this requirement to “reduce red tape and regulatory burden on businesses”, then Minister of State (Finance) Lim Hwee Hua said when the Appraisers and House Agents (Amendment) Bill was given its second reading in Parliament. Singapore Automobile Appraisers Association honorary secretary Kelvin Teo believes this change has led to a rise in the number of rogue surveyors. “They’re not qualified, and nobody regulates them,” he says. And they “do whatever they deem fit” because surveyors’ fees are “derived from the estimate put up by the workshop” — that is, a high estimate means a high fee. Teo, who has seen his share of inflated claims in his 20-plus years of experience, thinks reinstating the licensing requirement would help. “Once we’re licensed and regulated, there’ll be a form of disciplinary action that we can (take against) rogue surveyors,” he says. ## COMBATTING THE FRAUD As things stand, if a motorist does not go to an authorised workshop, the insurance claim may be inflated by the time it reaches the insurer. The question of intent then comes into play, says Thomas Kapeller, the group head of insurance in fintech firm Hyphen Group. For instance, a car may not look damaged after a “minor bumper accident”, but an inspection reveals structural damage. The repair cost would then be higher, which is a case of “non-intentional inflation”. Intentional inflation, on the other hand, occurs when “someone says it costs more than it really (does) to make a profit (on) it”, says Kapeller. “If there’s an intentionally inflated claim, that’s called fraud.” Police recently charged six men with motor insurance fraud in five traffic accidents in 2020 and last year. At least one of them has been jailed already. To help combat fraud, the General Insurance Association of Singapore (GIA) launched its Fraud Management System in 2017. To date, more than 300 claims have been flagged, with 13 proven to be fraudulent. “While (the number) might not sound big, the more information we provide to this system that (uses) data analytics and artificial intelligence … the better this system’s going to get,” says Kapeller. To encourage the public to fight fraudulent claims, the GIA also came up with an incentive-based scheme known as [GIA Insurance Fraud Tip-Off](https://gia.org.sg/gift-reward-scheme.html). “If (individuals) find and can prove fraudulent behaviour, (they) can earn up to S$10,000,” Kapeller cites. All these measures are cold comfort to Lee, who has lost the no-claim discount on his premium he had for as long as he never made a claim on his motor insurance policy. Following the claim arising out of his accident, his annual premium has shot up by 250 per cent to S$3,500. And as Bhargava concludes, if the touting continues, “the rest of us have to pay higher premiums”. **Topics:** Auto - padding/false claim, Public Awareness --- ### [Retired Cop Seeking Help With Pension Conned By Cyber Thugs, Loses Over Rs 8 Lakh by Sharing OTP](https://insurancefraud.org/news_archives/retired-cop-seeking-help-with-pension-conned-by-cyber-thugs-loses-over-rs-8-lakh-by-sharing-otp/) **Published:** August 25, 2026 **Author:** Diane Beauchamp **Content:** In yet another case of fraud, cyber thugs have conned a retired government official of more than Rs 8 lakh of his hard-earned income and that too on the pretext of assisting him with procedures to ensure a regular pension. What’s more significant is that the victim is a retired police sub-inspector living in Greater Noida of Uttar Pradesh. Bijendra Singh Malik retired from the police service on July 31, 2022 only and is a native of Saharanpur district. He apparently wanted to relocate to his home district and withdraw pension there only, for which he had filed an application. However, little did the former cop know that he could also get conned by the cyber thugs, who are always out in search of easy targets. According to the FIR lodged by Malik, he got a phone call from an unknown number on November 21 in which the person on the other side introduced himself as an official of the UP government’s treasury department in Saharanpur. In order to further convince the retired official, the conman shared the details of his application which mentioned his postings during duty period and other professional information. The conman said he had called Malik to assist him with his pension application and that he was in fact handling his case. “This person then told me that he was preparing the file of my pension case and in order to proceed further he would send me an OTP on the phone number linked to my bank account which I must share with him,” Malik stated in the complaint. “When I got the OTP number, I shared it with treasury officer who then followed up on his inquiry with some more questions related to my bank accounts and I shared those with him, too. Shortly thereafter, I got two notifications on my phone informing me of withdrawals totaling Rs 8,62,000 from my bank account,” the former cop said. Meanwhile, the FIR of the case has been lodged at the Cyber Crime police station in Noida’s Sector 36 and officials said they have taken up probe in the matter. The unidentified accused has been booked under sections 420 (cheating), 419 (cheating by impersonation) of the Indian Penal Code besides provisions of the Information Technology (IT) Act. **Tips To Dodge Cyber Thugs:** – Always make sure that you do not share your information related to banking online or over phone, especially with strangers – Remember, banks have often issued advisories to say that they, or their representatives never ask for OTP or PIN numbers – If necessary, make sure that you share details with genuine person or authentic website only – In case of cyber fraud, immediately report the matter at dedicated helpline number 1930 – If you use internet, you can also report the fraud at www.cybercrime.gov.in. **Topics:** Public Awareness --- ### [Two NDIS fraudsters imprisoned as new crime taskforce ramps up](https://insurancefraud.org/news_archives/two-ndis-fraudsters-imprisoned-as-new-crime-taskforce-ramps-up/) **Published:** August 25, 2026 **Author:** Diane Beauchamp **Content:** Two people have been sentenced to more than eight years’ combined prison time over fraud against the National Disability Insurance Scheme (NDIS). A Sydney woman has been sentenced to more than five years in prison after pleading guilty to charges of Obtaining Financial Advantage by Deception and Dealing in the Proceeds of Crime. The 67-year-old woman will also be forced to pay back almost $250,000 after the NDIA supported NSW Police in developing evidence following her arrest last year. Her sentence came on the same day a 24-year-old man, also from Sydney, was sentenced to serve three years in prison over a separate matter which involved a six-person criminal syndicate claiming more than $10 million in NDIS funding. “This should be a warning to people looking to rip off the NDIS,” Minister for the NDIS, the Hon. Bill Shorten MP said. “The recent establishment of the Fraud Fusion Taskforce allows the National Disability Insurance Agency (NDIA) to partner closely with other Government agencies, and strengthens the ability to catch people looking to fraudulently obtain money from the NDIS.” The new Fraud Fusion Taskforce continues to investigate potential fraud against the NDIS, with recent investigations in Melbourne and Sydney. Those actions follow recent charges laid against the director of a disability provider in Perth. Minister Shorten said the Taskforce signalled a determination to protect the NDIS by catching people looking to siphon funding intended for people living with disability. “This Taskforce has resources right across the country, which means an increased capacity to investigate and prosecute anyone looking to rip off the NDIS,” Minister Shorten said. “Our participants and their families should feel assured that the Government will continue doing everything in its power to protect the Scheme.” **Topics:** Disability **Categories:** Conviction --- ### [‘Bloke got mad’: Man throws himself onto car in shopping centre car park](https://insurancefraud.org/news_archives/bloke-got-mad-man-throws-himself-onto-car-in-shopping-centre-car-park/) **Published:** August 24, 2026 **Author:** Diane Beauchamp **Content:** An utterly bizarre road rage video filmed in the parking lot of a suburban Sydney shopping centre is doing the rounds on social media. The baffling dashcam footage shows a man flopping onto the bonnet of a car amid what is understood to be a minor case of road rage. The car is shown inching forward as a man steps into its path and softly falls onto the hood. “Bloke got mad because I didn’t let his wife through when he had to give way to me in Macquarie car park,” the poster said. “So he decides to jump out the back seat and ragdoll on top of my car.” The footage, posted on numerous platforms by the account Humans of Eastwood, was reportedly filmed on Sunday in the Macquarie Shopping Centre undercover carpark in Sydney’s north. Some said it appeared the man might have been doing it on purpose for some sort of financial entrapment. “Kind of looks like fraud to me more than anything like he’s trying to get insurance,” one person speculated. “He wouldn’t even know this footage exists until we met again in a courtroom,” another suggested. “This is why I tell my hubby I need a camera.” added another. In 2016, the New South Wales government established a task force to detect and prosecute CTP (compulsory third-party insurance) fraud claims, of which the video appears to fit the bill. “CTP fraud can include exaggerated claims, staged accidents, lying about a claim or providing false or misleading information to an insurer, doctor, health professional or lawyer,” the NSW government website states. Others online said it was the proof they needed to avoid the Christmas shopping rush. “How good is online shopping,” one person joked. “This is why I’m staying away from Macquarie until after Christmas,” another said. **Topics:** Auto - staged, Public Awareness --- ### [Family of ex-Premier League footballer think death was 'faked' in fireball car crash](https://insurancefraud.org/news_archives/family-of-ex-premier-league-footballer-think-death-was-faked-in-fireball-car-crash/) **Published:** August 24, 2026 **Author:** Diane Beauchamp **Content:** The family of a former Premier League player who was killed in a fireball crash are convinced his death was faked. Former Bolton and Aston Villa defender Jlloyd Samuel lost his life in 2018 when his Range Rover crashed into van in Cheshire whilst he was driving down a country lane. The impact of the crash caused the £100,000 motor to burst into flames, and Samuel’s body was burnt beyond recognition. Tributes poured in for the former England U21 star, and his old club Villa wore black armbands to honour him in their Championship play-off tie against Middlesbrough. But in a shocking turn of events, his family insisted that Samuel’s death was faked by his wife so she could cash out on an elaborate insurance fraud plot. Samuel married his wife Emma in 2018, and the pair had three children together. However, his sister Leslie-Ann purported that Samuel wasn’t behind the wheel of his car, and was infact still alive. Leslie-Ann produced a picture of a letter from the coroner’s office that stated her brother’s remains were identified by dental records and radiographs carried out at Warrington hospital on May 17, 2018. But Leslie-Ann and her parents complained that they were prevented from conducting their own DNA tests from the car by police and the coroner. Samuel’s sibling then took to social media to vent her fury, where she posted the letter, and a string of stunning outbursts. In one post, she raged: “Jlloyd we WILL see you soon, in this life.” She followed this up by writing: “Jlloyd brother we know you are ALIVE and well and we know the DNA the pathologist have is not your DNA .. 100%… Lies…” But Leslie-Ann wasn’t done yet and she also made a complaint into Cheshire Police’s handling of the matter. But her complaint was shut down by senior officers who ruled that “the investigation into Mr Samuel’s death was proportionate, timely and of the standard required.” A statement from the Cheshire Police revealed that “The decision was verified in a peer review by an independent police force.” And the spokesman for the force explained that Leslie-Ann never appealed the ruling in the 28-day period given to do so. Samuel’s wife also dismissed Leslie-Ann’s allegations as “fake news” in a statement. She said: “I do not wish to make any comment at this time. My only concern right now is getting through next week’s inquest and protecting my three beautiful children who have had to not only deal with the tragic loss of their father but also witness relentless fake news, threats and personal attacks on social media. “I will make a short statement at the conclusion of the inquest and would ask for our privacy to be respected until then.” Leslie-Ann’s crusade suffered another blow when a coroner at the inquest held looking into Samuel’s death ruled that the body found irrefutably belonged to the ex-Prem ace. But Leslie-Ann still wasn’t satisfied with the ruling and pleaded with Coroner Alan Moore to release DNA so she and her family could test it privately. Mr Moore denied her request as he could only release tissue from Samuel if his wife gave the go ahead. However, the coroner did advise Leslie-Ann that she could appeal the decision at another court – which she vowed to do. And years after Leslie-Anne’s failed attempt to prove Emma had faked Samuel’s death, the footballer’s interior designer wife has finally opened up about her ordeal. In an ITV documentary, she said: “Leslie-Ann approached me and said, ‘I know you’ve got something to do with this and I’m going to get to the bottom of it’. “And that’s when the accusations all started being published on Instagram – ‘it’s a fake death and I’ve got something to do with it’; ‘he’s still alive and I’ve got something to do with his disappearance’. “I’m having all these accusations thrown at me. I’m still having to sort through all the paperwork; bills – how I’m going to pay for everything? I’ve had investors knocking on my door wanting money, wanting to know where their money has gone. And I felt so much pressure.” However, a third party believes Leslie Anne’s theory that Samuel is still alive – his second secret wife Helia Sahimi, based in Iran. She met Samuel during his eight-year spell in the Middle East during the latter stages of his career and they got hitched in 2011, three months after he moved there, according to Helia. When she was contacted for the documentary about his death, Helia said: “I believe my husband is still alive.” However, his first wife Emma was dumbfounded when it was revealed that Samuel had another partner, and she said: “I was trying to grieve my husband and find he has another life. Who is my husband – do I really know him?” **Topics:** Life Insurance --- ### [Consumer Intelligence: Motor insurance premiums rise 17.4% in the past year](https://insurancefraud.org/news_archives/consumer-intelligence-motor-insurance-premiums-rise-17-4-in-the-past-year/) **Published:** August 24, 2026 **Author:** Diane Beauchamp **Content:** The average cost of the most competitive motor insurance deals has increased 17.4% in the past year, according to [Consumer Intelligence](http://www.claimsmag.co.uk/tag/Consumer-Intelligence). The latest [motor insurance price index](https://www.consumerintelligence.com/motor-insurance-market) from Consumer Intelligence shows that price rises in car insurance are outstripping inflation for the economy as a whole at 10.7%, with average premiums now costing £877. Georgia Day, senior analyst at Consumer Intelligence, commented: “The surge has been expected this year following the ban on price walking. We have not found it surprising that prices have increased as a result.” She added: “What is surprising, however, is the number of product launches we are seeing, especially the growing number of essentials products. To highlight this, the number of total brands quoting across the PCW market reached its highest point since our tracking began in 2014.” Premium rises for the over-50s are running at 21%—or more than double the rate for the under-25s at 9.1%, with motorists in Wales facing the biggest increases at 24.5%. Prices have increased just 0.1% for the under-25s in the past three months, which saw premiums for the market as a whole rise 3.4%. Telematics quotes are playing a more prominent role in the most competitive deals, according to Consumer Intelligence. The data shows telematics quotes make up 32% of the best deals, which is the highest level since Consumer Intelligence first started tracking it in 2014. Average overall premiums have increased 32.3% since October 2013 when Consumer Intelligence first started collecting data. But premiums are down 24.7% over the period for the under-25s, while they have increased 67.7% for the over-50s and 44.2% for those aged between 25 and 50. **Topics:** Auto fraud, Public Awareness --- ### [Beware these insurance scams on the rise in South Africa](https://insurancefraud.org/news_archives/beware-these-insurance-scams-on-the-rise-in-south-africa/) **Published:** August 24, 2026 **Author:** Diane Beauchamp **Content:** Insurer Hollard has warned that insurance sale, claim, and recruitment scams are on the rise in South Africa, with holidaymakers at particular risk as they tend to let their guard down over the festive season. The group advised policyholders to familiarise themselves with the latest insurance scams and take proactive action to protect themselves from falling prey to fraudsters who are always lurking in the shadows, determined to rob them of their hard-earned money. According to Hollard, the outbreak of Covid-19 triggered a spike in fraudulent activities and noted that this time of the year always sees a rise in unscrupulous schemes as many people let their guard down as they get busy with festive season plans. Outlining some of the insurance swindles consumers should be wary of, Hollard said there had been a steady increase in insurance sales and claims scams over the past few months. **Insurance sales scams** refer to a customer applying for a loan and are requested to make a deposit into the scammer’s bank account. The scammers claim that the deposit is required to conduct background checks to process the client’s application. The unsuspecting customer is then lured to a website purporting to be an official insurance website, where they then divulge their bank account details. Another scam – the **insurance claim scam** – occurs when a policyholder lodges a claim with an insurer and is contacted by a caller who claims to be an employee at the insurance company. The client is informed that additional benefits have accrued to them. Unsuspecting policyholders are then requested to confirm their banking details, which are used to defraud them. Hollard also cautioned people to be on the lookout for **recruitment scams**, where job seekers are requested to share their CVs and duped into depositing money into the fraudsters’ bank account under the pretext that the funds will be used to conduct background checks. Policyholders and would-be job applicants can take a few practical steps to protect themselves against such scams. “Should policyholders receive a suspicious call or be asked to deposit money into some bank account, Hollard urges consumers to contact their insurer’s call centre or service area directly to verify the legitimacy of the transaction,” the group said Insurers will never ask customers to share their banking details over the phone or ask them to share their CVV numbers. Secondly, Hollard strongly encourages policyholders not to click on any suspicious links, whether on their laptops or on a cell phone, as these links are used to intercept their personal information to defraud them. Equally important, if asked to share your banking details over the phone with anyone claiming to be an insurance agent, call your insurer directly to verify the call’s authenticity, or alternatively, use the anonymous hotline to report fraudulent activities. **Beware social and public spaces** Hollard warned that fraudsters are very active on social media platforms and unsecured public Wi-Fi networks are vulnerable spaces where scammers constantly lurk. The insurer advises policyholders to desist from sharing personal information on social media platforms or doing sensitive transactions on unsecured public Wi-Fi networks, as such information can easily be intercepted. “Cybercrime has become more prevalent now than ever and is anticipated to increase. Fraudsters are using all kinds of technologies and more sophisticated methods to gain access to policyholder personal information,” the group said. “It is very important to err on the side of caution by keeping your personal information to yourself and flagging and verifying any suspicious call or activity directly with your insurer. Do not even share details with family members.” The South African Banking Risk Information Centre (SABRIC) noted earlier this year that there had been a worrying trend of a rise in cybercrime in South Africa as well. It estimates that South African businesses lose about R250 million each year due to phishing attacks and internet fraud. The South African Reserve Bank (SARB) also identified cybercrime and emerging technologies as growing threats to South Africa’s banking sector. One of the common tricks that fraudsters use is social engineering, where they duplicate emails and then send them to unsuspecting customers who are scheduled to make a payment, instructing them to make a deposit into an alternative account. Often the fraudulent mail will only differ by one digit, which may not be easily detectable. The fraudsters will then request the unsuspecting customer to click on a link that is embedded with malware, which then gives the fraudsters access to the customer’s device as soon as they click on it. Hollard warned customers that fraudsters constantly seek to intercept communication between brokers and clients and target email traffic with specific words such as invoice, payment and banking details. “The onus, therefore, is on the policy payer to ensure they have the correct creditor’s details before making any payment. Hollard also advises consumers to verify telephonically with their creditors should they receive an email requesting that they make payment to alternative bank accounts.” **Topics:** Public Awareness --- ### [CBI conducts raids in medical fraud case](https://insurancefraud.org/news_archives/cbi-conducts-raids-in-medical-fraud-case/) **Published:** August 24, 2026 **Author:** Diane Beauchamp **Content:** Central Bureau of Investigation (CBI) conducted raids in different parts of the state in connection with certificate fudge case of Foreign Medical Graduate Examination (FMGE) since Friday. Reliable sources said that any doctor, who completed medical education in any foreign country, requires FMGE certificate for practicing in India. However, there are gangs, who sell fake certificates to such medical graduates so that they could bypass the actual examination for practicing in the country, which not only compromises the health sector but also poses a threat to the lives of patients. Saturday’s raids were part of a CBI investigation initiated by CBI headquarters, New Delhi, sources said. Since Friday, sleuths of CBI Imphal branch conducted raids at the houses of over 10 medical graduates, who completed medical education in foreign countries and collected FMGE certificates. Verification of the certificates is underway, sources added. **Topics:** Public Awareness, Testing Fraud --- ### [2022 Marked A Turbulent Year For Cybersecurity. What Can We Expect From 2023?](https://insurancefraud.org/news_archives/2022-marked-a-turbulent-year-for-cybersecurity-what-can-we-expect-from-2023/) **Published:** August 24, 2026 **Author:** Diane Beauchamp **Content:** We witnessed many cyberattacks in 2022, making it quite a turbulent year for cybersecurity globally. Looking back at 2022, here are some cybersecurity trends to watch out for in the upcoming year. We witnessed many cyberattacks in 2022, making it quite a turbulent year for cybersecurity globally. Looking back at 2022, here are some cybersecurity trends to watch out for in the upcoming year. ## Newer ways of social engineering attacks Next year, there will be more cyber-attacks using psychological manipulation to trick people into giving away sensitive information or doing things that hurt their personal or work security. These attacks will be advanced, using deepfake and phishing. Deepfake attacks using AI to make fake videos and images will become increasingly common and will be harder to tell from real ones, compromising the security of an individual or organisation. To protect against these scams, it is important to use AI detection software and avoid signing up for unknown face recognition or comparison apps. As for phishing, in 2023, business collaboration tools will be targeted more by phishing attacks. To stop these threats, organisations must have strong security measures including user training, and strong authentication. ## With 5G comes new vulnerabilities The adoption of 5G technology will likely result in more IoT devices connected to networks, creating new opportunities for cybercriminals to launch larger and more sophisticated attacks. Network slicing, which allows for the isolation and management of different types of traffic on the same network, will make it easier for attackers to target specific types of traffic, such as IoT devices. Furthermore, the new architecture of 5G networks increases the likelihood of security issues arising for users, including denial of service attacks, botnet attacks, and man-in-the-middle attacks. ## Increased adoption of cyber insurance The demand for cyber insurance will rise in the coming year as technology and internet usage will continue to grow and cybercriminals will innovate new ways to do cyber financial frauds. Cyber insurance helps individuals and businesses to protect themselves against financial losses resulting from cyber-attacks, such as digital payment fraud, data breaches, and identity theft. The cyber insurance market is projected to reach $20 billion by 2025, indicating significant growth in the coming years. Soon, it will be a crucial component of companies’ and individuals’ overall risk management strategies. SafeHouse Tech is the first cybersecurity company in India to offer cyber insurance to individuals, along with comprehensive cybersecurity protection with its flagship product – BodyGuard app. **Topics:** Technology --- ### [242 people used fake death certificates to avail life insurance money: FIR](https://insurancefraud.org/news_archives/242-people-used-fake-death-certificates-to-avail-life-insurance-money-fir/) **Published:** August 24, 2026 **Author:** Diane Beauchamp **Content:** As many as 242 people submitted fake death certificates to claim life insurance policies of a private company. The fraud surfaced during an internal audit following which an FIR was lodged with the cyber cell on Thursday. The FIR was lodged by an insurance company representative. The FIR alleges that the company which issues insurance coverage to account holders of various banks has issued Pradhan Mantri Jeevan Jyoti Bima Yojna (PMJJBY) policies to several customers in Sambal, Aligarh, Moradabad, Bareilly and other locations of Uttar Pradesh. Recently, the company carried out internal/external verification/investigation to validate the genuineness of the death claims. “It surfaced that in 242 cases there was attempt to fraud and fake death certificates were submitted,” the FIR said. It added that the death certificates were further scrutinized by scanning the QR Code but it was redirected to the private links, which showed all such certificates as genuine. However, it was found that the above link is not of any government website but was a private link. Company representative said that the fake link was created by unknown fraudsters with an intention to dupe the company and cause losses. SP, Cyber Cell, Triveni Singh, said that an FIR has been registered under the charges of punishment for cheating by personation, and dishonestly inducing delivery of property. “We are working to trace the gang involved in such acts and arrests will be made soon,” he said. **Topics:** Life Insurance --- ### [Rs 77 lakh for release of insurance](https://insurancefraud.org/news_archives/rs-77-lakh-for-release-of-insurance/) **Published:** August 24, 2026 **Author:** Diane Beauchamp **Content:** The gang duped a diamond trader living in Pal of Rs 77 lakh online on the pretext of releasing his mother’s insurance of Rs 16 lakh. A complaint has been lodged with the Cyber Crime Police. According to the details, Shailesh Jayantibhai Savaliya (39, originally from Amreli), a resident of Shripad Ananta near Sanjeev Kumar Auditorium in Pal, is a diamond trader. In September last year, he received a call from an unknown number on his mobile. The caller identified himself as an officer of Max Line Insurance Company. In this way, he instilled innocence in the conversation. The man transferred Rs 42,115 to Shaileshbhai by giving his Yash Bank account number to get Rs 16.28 lakh from his mother’s Max Life Insurance. Subsequently, a Notice of Fund Clearance letter was sent on WhatsApp on the letter pad of the Insurance Regulatory Authority of India. After that, the money was transferred online in the form of transfer fees and various clearances. In this way, on the pretext of releasing the insurance amount, Rs 77.03 lakh was transferred online and Rs 16.28 lakh was not released. The smugglers had also sent fake notices about receiving the money. Shailesh Savaliya lodged a complaint with cyber crime after realising the fraud. **Topics:** Public Awareness, Technology --- ### [Duminda Silva’s Rs. 17 million fraud crashes – Dumnida threatened Insurance boss](https://insurancefraud.org/news_archives/duminda-silvas-rs-17-million-fraud-crashes-dumnida-threatened-insurance-boss/) **Published:** August 24, 2026 **Author:** Diane Beauchamp **Content:** **The Police hasn’t taken any action against [Duminda Silva’s](http://colombotelegraph.com/2011/10/11/%E2%80%9Cduminda-silva-is-not-my-man-he-is-gota%E2%80%99s-man%E2%80%9D-mr-said-to-bharatha-and-rathnasiri/) Rs 17 million insurance fraud and the threat he made to the insurance company the Colombo Telegraph learnt. The police think there is sufficient evidence to act against MP Duminda Silva but they cannot go further due to extreme political pressure. “We would have been in deep trouble if we raised any issue then,” said one of them familiar with the case.** Duminda Silva MP, submitted the fake claim for Rs 17 million to Janashakithi Insurance. Janashakthi Insurance were told in August 2011 that his four-wheel drive vehicle had met with a horrible accident. It had hit even telephone posts before coming to a halt and was beyond repair. As reported the story unfolds as follows; The vehicle had been towed to the Talanagamaa police station even before an insurance appraiser arrived. He had later staked his claim for Rs 17 million to buy another brand new vehicle. While the insurance company was processing his claim, it also got in touch with its lawyer. He in turn sought the help of a private investigation agency to check on the claims made by the Duminda Silva. It came to light that the vehicle had been insured only two days before the accident. Thereafter, they continued the probe into other aspects. It was to reveal more startling facts — the accident had taken place six days before the vehicle was insured. That meant there was no insurance cover at the time of the accident. That is not all. Some of the photographs submitted after the assessor was allegedly threatened showed another wrecked luxury vehicle that was beyond identification. It came to light that the engine and chassis number of the vehicle that lay at the police station, configured in such a way that the worst accident would not obliterate the markings, was intact and not damaged. Nor was the front area of the vehicle except for sections. There were mounting threats on the insurance company executives to make payment. At first it came from a relative of Duminda Silva. The threats were directed at the insurance company branch in the suburbs. Later, Duminda Silva raised issue with those at the branch office and at their headquarters in Colombo. They were on the verge of approving payment when another eminent counsel with strong political connections was consulted. He was annoyed at the way threats had been brought on the insurance executives on a fraudulent claim and promised to pursue the matter. He said he would even raise it at the highest levels. One day, the insurance top boss received a call from Duminda Silva. He identified himself and poured out a verbal barrage in choice obscenity. He asked, “what happened to my claim?” The boss replied that the matter was now in the hands of the influential senior counsel and mentioned his name. “I don’t care,” he thundered. He went into a rage and warned that if the Rs. 17 million was not paid pronto, the consequences would be disastrous. The boss said he detested the tone in which Duminda was intimidating him. “You wait and see. My tone would be worse when something happens to you,” and banged the telephone. What Duminda least realised was that the boss’ lawyer was also present when the call was made. The speaker phone was switched on. They took note of the entire conversation. Immediately thereafter, they went to the Police Station and lodged an entry giving the fuller details. The lawyer, who also made a statement, said he was witness to the episode. The OIC Talangama is unavailable for comment. The Police Officer who answered to Colombo Telegraph call told he is unaware of the case. **Topics:** Public Awareness --- ### [More Aussies find out they’re caught up in major Medibank data breach months after cyber attack | 7NEWS](https://insurancefraud.org/news_archives/more-aussies-find-out-theyre-caught-up-in-major-medibank-data-breach-months-after-cyber-attack-7news/) **Published:** August 24, 2026 **Author:** Diane Beauchamp **Content:** More Australians are learning their personal information was stolen by cyber criminals and released on the dark web months after health insurer Medibank was hit in a data breach. Several Medibank travel insurance customers this week reported receiving confirmation from the health insurer that some of their personal details had been released on the dark web as part of the major breach in October. A spokesperson for the insurer told 7NEWS.com.au it had previously announced that the travel arm was affected in the October breach. However, emails were sent to individual customers this week formally alerting them which aspects of their data had been compromised. “Our travel insurance customers would have recently received their formal notification from us which informs them about what data of theirs was impacted in the recent cybercrime, as well as advice and support available to them,” the spokesperson said. Customer Peter Anderson said he thought his personal data had managed to be kept private but received news on Thursday he was included in the breach. “Here I was thinking I’d escaped the Medibank breach but of course, I haven’t because the travel insurance arm – which I had assumed was a white label – was also breached. What a cluster,” Anderson said. “I thought I’d managed to escape all of the recent date breaches unscathed. Alas,” another travel insurance customer Jeremy Kirk shared. Based on [its investigation](https://www.medibank.com.au/health-insurance/info/cyber-security/customer-notice/), Medibank says it believes the cyber crooks accessed travel insurance customer data including first names and surnames, date of birth, addresses, email addresses, phone numbers and policy start dates. One customer told 7NEWS.com.au their passport information was not included in the breach. Kirk also said the insurer informed him passport details had not been stolen. The hackers stole the health records of almost 10 million current and former customers and published the entirety of the data on the dark web, including records of procedures and conditions related to abortions and mental health disorders. Medibank says there has been no further suspicious activity detected inside its systems since the attack, and this month pledged to work alongside Australia’s information commissioner in an investigation following the data breach. The Office of the Australian Information Commission confirmed earlier in December it would be examining the insurer after having enough evidence to press further. The investigation will centre on whether the health insurer did enough to protect personal information and if the company took reasonable steps to comply with privacy guidelines. The commissioner can seek civil penalties through the Federal Court of up to $2.2 million for each privacy contravention. A Medibank spokesperson said earlier the insurer was continuing to work with customers affected by the data breach, including mental health and wellbeing support measures. **Topics:** Technology --- ### [Pierce County roofing contractor accused of faking injury in $54K workers’ comp scam](https://insurancefraud.org/news_archives/pierce-county-roofing-contractor-accused-of-faking-injury-in-54k-workers-comp-scam/) **Published:** August 24, 2026 **Author:** Diane Beauchamp **Content:** Workers’ compensation funds are meant to help injured workers by partially replacing lost wages and covering medical expenses. But state investigators observed Patrick Dean Farthing walking on roofs, removing roof tiles, and moving construction equipment and heavy materials – the same kinds of tasks he did when working as a roofer before his injury. Farthing, 63, is scheduled to be arraigned on one count of first-degree theft, a felony offense, in Thurston County Superior Court in Olympia on Dec. 27. The Lakewood man is charged with wrongfully taking the thousands of dollars in wage replacement payments from the Washington State Department of Labor & Industries (L&I) from mid-2014 to January 2021. Farthing, who was caught working as an unregistered contractor, also used the alias Adam Lay and sometimes did business as Pat Farthing Roofing. “When we hear about fraud, we investigate,” said Celeste Monahan, assistant director for L&I’s Fraud Prevention and Labor Standards division. “Cheaters seem to think that stealing workers’ comp benefits doesn’t hurt anyone. “But it’s taking money from legitimately injured workers, and everyone whose hard-earned dollars support the workers’ compensation system.” The Washington State Attorney General’s Office is prosecuting the case based on L&I’s investigation of Farthing. Tip leads to two-year investigation Farthing injured his shoulder in 2010 while repairing a roof. His medical provider determined the injury was so serious he couldn’t work as a roofer. That assessment, coupled with Farthing’s declarations that he wasn’t working in any job, allowed him to qualify first for wage replacement payments, which are temporary, and then for a pension. In 2018, L&I launched a two-year investigation into Farthing after receiving a tip he was working as a roofer. A team of L&I investigators determined Farthing had been running his own business that performed roofing jobs throughout the South Sound. Investigators photographed Farthing remove and install roofs, direct work crews, and move equipment and materials on and off job sites, according to charging papers. They obtained Farthing’s bank records, and building supply invoices showing he was buying roofing materials starting in 2014, sometimes using the name Adam Lay. Cited for unregistered contracting As part of the investigation, construction compliance inspectors caught Farthing and his work crews roofing houses in Spanaway and Olympia in 2018, according to inspection records. They issued him civil infractions for unregistered contracting, with penalties totaling $5,000 that remain unpaid. When the inspector at the Spanaway site asked Farthing if he wanted to register as a contractor, Farthing responded, “he was not interested,” the inspector’s statement said. L&I oversees the state workers’ compensation system, which helps employees injured on the job heal and get back to work. Employees who can’t work because of their injury and who meet certain conditions can receive payments for part of their lost wages. **Topics:** Work comp - worker **Categories:** Arrest --- ### [Attorney General James Ends Harmful Labor Practices at Top Title Insurance Company](https://insurancefraud.org/news_archives/attorney-general-james-ends-harmful-labor-practices-at-top-title-insurance-company/) **Published:** August 24, 2026 **Author:** Diane Beauchamp **Content:** New York Attorney General Letitia James announced a [settlement with ](https://ag.ny.gov/sites/default/files/stewart_aod_fully_executed.pdf)[one of the largest title insurance underwriters, Stewart Title Guaranty Corporation (Stewart)](https://ag.ny.gov/sites/default/files/stewart_aod_fully_executed.pdf), ending harmful no-poach agreements between Stewart and its competitors and requiring Stewart to pay $2.5 million for its wrongdoing. The Office of the Attorney General (OAG) discovered that Stewart and its competitors agreed not to take each other’s workers, an illegal practice that reduces workers’ earning potential. As a result of today’s agreement, Stewart will terminate any existing no-poach agreements, pay the state $2.5 million, and cooperate with OAG’s ongoing investigations in the industry. “No-poach agreements harm New York workers and break New York laws,” said **Attorney General James**. “When business owners collude to stifle workers’ abilities to earn higher salaries and grow within their career fields, it hurts hardworking New Yorkers. Businesses that try to hold workers hostage will face the consequences of their illegal actions.” Stewart issues title insurance policies either directly through its own agency or indirectly through independent title insurance agencies. Direct agents and independent agencies are competitors in the labor market and should be able to compete for employees on the basis of salaries, benefits, and career opportunities. Stewart’s no-poach policies with other companies prevented that from happening. A no-poach policy is an agreement between two or more companies not to solicit, recruit, or hire each other’s employees. In a well-functioning labor market, employers don’t need no-poach agreements and instead compete by offering higher wages or enhanced benefits to attract the most valuable talent for their needs. These agreements reduce competition for employees and disrupt the normal compensation-setting mechanisms which in turn harm the interests of employees. The OAG’s investigation concluded that Stewart entered into no-poach agreements with other title insurance companies, and that these agreements effectively reduced career opportunities and wages for workers. Today’s agreement ends Stewart’s no-poach agreements and requires the company to pay $2.5 million to the state and cooperate with OAG’s ongoing investigations in the industry. This agreement builds on Attorney General James’ past efforts to protect workers and stop these harmful no-poach agreements. In July 2022, Attorney General James [ended the use of “no-poach” agreements by two top title insurance companies, AmTrust and First Nationwide](https://ag.ny.gov/press-release/2022/attorney-general-james-ends-harmful-labor-practices-top-title-insurance-companies). In September 2021, [Attorney General James ended the use of “no-poach” agreements by another top national title insurer, Old Republic National Title.](https://ag.ny.gov/press-release/2021/attorney-general-james-ends-harmful-labor-practices-one-nations-largest-title) In March 2019, [Attorney General James and a coalition of attorneys general from around the nation entered into an agreement with four national fast food franchisors — Dunkin’, Arby’s, Five Guys, and Little Caesars — that ended their use of “no-poach” agreements](https://ag.ny.gov/press-release/2019/attorney-general-letitia-james-joins-multistate-settlement-cease-fast-food-usage). Additionally, in July 2019, [Attorney General James and a coalition of attorneys general submitted comments to the Federal Trade Commission, urging collaboration between regulators to protect workers from anticompetitive labor practices, including no-poach agreements](https://ag.ny.gov/press-release/2019/attorney-general-james-urges-regulators-protect-workers-harmful-anticompetitive), that depress wages, restrict job mobility, and limit opportunities for advancement. This matter was handled by Senior Enforcement Counsel Bryan Bloom, Assistant Attorney General Michael Schwartz, and Deputy Bureau Chief Amy McFarlane, under the supervision of Bureau Chief Elinor Hoffmann — all of the Antitrust Bureau. The Antitrust Bureau is a part of the Division for Economic Justice, which is overseen by Chief Deputy Attorney General Chris D’Angelo and First Deputy Attorney General Jennifer Levy. **Topics:** Regulatory actions, Title Insurance --- ### [National medical records data breach includes 65,000 from the Central Valley](https://insurancefraud.org/news_archives/national-medical-records-data-breach-includes-65000-from-the-central-valley/) **Published:** August 24, 2026 **Author:** Diane Beauchamp **Content:** A Pennsylvania-based software company announced it was the victim of a recent data security incident that may impact people in the Central Valley. Connexin Software provides electronic medical records management support to healthcare organizations. The company confirmed a data security breach that could impact more than 2.2 million people nationwide and around 65,000 of those are connected to Valley Children’s Medical Group patients and parents/guardians in the greater Fresno area. > The incident did not involve Valley Children’s own information technology systems. Connexin reports that the incident occurred on August 26, 2022, and that the following patient and parent/guardian information may have been accessed. The information may include names, addresses, dates of birth, social security numbers, health insurance information, medical and treatment information, and billing/claims information. Valley Children’s was not made aware of the incident at Connexin until Monday, December 19, 2022. Valley Children’s relationship with Connexin ended in October 2021. “We are asking current and former patients and families of Fresno Children’s Pediatrics, Sky Park Pediatrics and Dakota Pediatrics in Fresno; Magnolia Pediatrics in Clovis; Olivewood Pediatrics in Merced; and Greenfield Pediatrics (now closed) in Hanford to please be on the lookout for a letter from Connexin,” Valley Children’s Hospital said. “Only those potentially impacted by the incident will receive notifications. Families are also encouraged to carefully review credit reports and statements and promptly report suspicious activity.” Valley Children’s is monitoring the situation and advocating on behalf of Fresno-area families. Connexin is offering identity monitoring services to those whose social security numbers were potentially involved. Connexin has also set up a call center for families to call with questions about the incident. That toll-free number is 855-532-0912. You can also email Valley Children’s Privacy team at <Privacy@valleychildrens.org>. **Topics:** Public Awareness, Technology --- ### [Notice of Data Security Incident](https://insurancefraud.org/news_archives/notice-of-data-security-incident/) **Published:** August 24, 2026 **Author:** Diane Beauchamp **Content:** The privacy and security of the personal information is of the utmost importance to Cincinnati State Technical Community College (“CSTCC”). This notice contains information regarding a recent security incident that may have involved certain personal information collected and maintained by CSTCC. CSTCC wanted to provide individuals with information about the incident, explain the services being made available to certain individuals, and let individuals know that CSTCC continues to take significant measures to protect personal information. On November 2, 2022, Cincinnati State Technical Community College detected unauthorized access to its network as a result of a cybersecurity incident that resulted in the potential exposure of data CSTCC maintains. Upon learning of this issue, CSTCC contained the threat by disabling all unauthorized access to its network and restoring its systems as needed. In addition, CSTCC immediately launched an investigation in consultation with outside cybersecurity professionals who regularly investigate and analyze these situations to analyze the extent of any compromise to its network. CSTCC also reported this incident to law enforcement. After an extensive forensic investigation and manual document review, CSTCC discovered on November 15, 2022, that certain files were removed from portions of the CSTCC network between October 30, 2022, and November 2, 2022, contained personal information pertaining to individuals. This type of information included, where applicable, full names, addresses, dates of birth, Social Security numbers, driver’s licenses or state identification numbers, health insurance information, and financial account information. The elements of information involved in this incident varied per individual. Out of an abundance of caution, CSTCC notified individuals whose information was included in the impacted files and folders. Notification was mailed via U.S. mail on December 23, 2022. Impacted individuals are encouraged to take steps to protect themselves against identity fraud, including placing a fraud alert/security freeze on their credit files, obtaining free credit reports, and remaining vigilant in reviewing financial account statements and credit reports for fraudulent or irregular activity on a regular basis. In addition, individuals who may have had their Social Security number impacted are encouraged to enroll in complimentary credit monitoring services provided in the notification letter. The security and privacy of personal information is of the utmost importance. Since the incident, CSTCC has worked with its Information Technology department to implement additional security measures in an effort to prevent a similar event from occurring in the future. Individuals may also review the guidance contained under “Steps Individuals Can Take to Protect Personal Information” for more information. For individuals who have questions or need additional information regarding this incident or to determine if they are impacted, CSTCC has established a dedicated toll-free response line at 1-855-763-5165. This response line is staffed with professionals familiar with this incident. The response line is available Monday through Friday 9:00am ET – 900 pm ET, excluding U.S. Holidays. {10838281: } 1. – OTHER IMPORTANT INFORMATION – Placing a Fraud Alert on Your Credit File. Whether or not you choose to use the complimentary 12-month credit monitoring services, we recommend that you place an initial one-year “Fraud Alert” on your credit files, at no charge. A fraud alert tells creditors to contact you personally before they open any new accounts. To place a fraud alert, call any one of the three major credit bureaus at the numbers listed below. As soon as one credit bureau confirms your fraud alert, they will notify the others. Equifax P.O. Box 105069 Atlanta, GA 30348-5069 <https://www.equifax.com/personal/cre> dit-report-services/credit-fraud-alerts/ (800) 525-6285 Experian P.O. Box 9554 Allen, TX 75013 <https://www.experian.com/fraud/center>. html (888) 397-3742 Consider Placing a Security Freeze on Your Credit File. TransUnion Fraud Victim Assistance Department P.O. Box 2000 Chester, PA 19016-2000 <https://www.transunion.com/fra> ud-alerts (800) 680-7289 If you are very concerned about becoming a victim of fraud or identity theft, you may request a “Security Freeze” be placed on your credit file, at no charge. A security freeze prohibits, with certain specific exceptions, the consumer reporting agencies from releasing your credit report or any information from it without your express authorization. You may place a security freeze on your credit report by contacting all three nationwide credit reporting companies at the numbers below and following the stated directions or by sending a request in writing, by mail, to all three credit reporting companies: Equifax Security Freeze P.O. Box 105788 Atlanta, GA 30348 <https://www.equifax.com/personal/credit-> report-services/credit-freeze/ 1-800-349-9960 Experian Security Freeze P.O. Box 9554 Allen, TX 75013 <http://experian.com/freeze> 1-888-397-3742 TransUnion Security Freeze P.O. Box 2000 Woodlyn, PA 19094 <https://www.transunion.com/credit-> freeze 1-888-909-8872 In order to place the security freeze, you’ll need to supply your name, address, date of birth, Social Security number and other personal information. After receiving your freeze request, each credit reporting company will send you a confirmation letter containing a unique PIN (personal identification number) or password. Keep the PIN or password in a safe place. You will need it if you choose to lift the freeze. If your personal information has been used to file a false tax return, to open an account or to attempt to open an account in your name or to commit fraud or other crimes against you, you may file a police report in the City in which you currently reside. 3\. Obtaining a Free Credit Report. reporting Under federal law, you are entitled to one free credit report every 12 months from each of the above three major nationwide credit companies. Call 1-877-322-8228 or request your free credit reports online at [www.annualcreditreport.com](http://www.annualcreditreport.com). Once you receive your credit reports, review them for discrepancies. Identify any accounts you did not open or inquiries from creditors that you did not authorize. Verify all information is correct. If you have questions or notice incorrect information, contact the credit reporting company. 4\. Additional Helpful Resources. {10838281: } Even if you do not find any suspicious activity on your initial credit reports, the Federal Trade Commission (FTC) recommends that you check your credit reports periodically. Checking your credit report periodically can help you spot problems and address them quickly. If you find suspicious activity on your credit reports or have reason to believe your information is being misused, call your local law enforcement agency and file a police report. Be sure to obtain a copy of the police report, as many creditors will want the information it contains to absolve you of the fraudulent debts. You may also file a complaint with the FTC by contacting them on the web at [www.ftc.gov/idtheft](http://www.ftc.gov/idtheft), by phone at 1-877-IDTHEFT (1-877-438-4338), or by mail at Federal Trade Commission, Consumer Response Center, 600 Pennsylvania Avenue, NW, Washington, DC 20580\. Your complaint will be added to the FTC’s Identity Theft Data Clearinghouse, where it will be accessible to law enforcement for their investigations. In addition, you may obtain information from the FTC about fraud alerts and security freezes. If your personal information has been used to file a false tax return, to open an account or to attempt to open an account in your name, or to commit fraud or other crimes against you, you may file a police report in the city in which you currently reside. Iowa Residents: You may contact law enforcement or the Iowa Attorney General’s Office to report suspected incidents of identity Theft: Office of the Attorney General of Iowa, Consumer Protection Division, Hoover State Office Building, 1305 East Walnut Street, Des Moines, IA 50319, [www.iowaattorneygeneral.gov](http://www.iowaattorneygeneral.gov), Telephone: (515) 281-5164 Massachusetts Residents: Under Massachusetts law, you have the right to obtain a police report in regard to this incident. If you are the victim of identity theft, you also have the right to file a police report and obtain a copy of it. Maryland Residents: You may obtain information about avoiding identity theft from the Maryland Attorney General’s Office: Office of the Attorney General of Maryland, Consumer Protection Division, 200 St. Paul Place, Baltimore, MD 21202, [www.oag.state.md.us/Consumer](http://www.oag.state.md.us/Consumer), Telephone: 1-888-743-0023. North Carolina Residents: You may obtain information about preventing identity theft from the North Carolina Attorney General’s Office: Office of the Attorney General of North Carolina, Consumer Protection Division, 9001 Mail Service Center, Raleigh, NC 27699-9001, [www.ncdoj.gov/](http://www.ncdoj.gov/), Telephone: 877-566-7226. New York Residents: You may obtain information about preventing identity theft from the New York Attorney General’s Office: Office of the Attorney General, The Capitol, Albany, NY 12224-0341; <https://ag.ny.gov/consumer> frauds-bureau/identity-theft; Telephone: 800-771-7755. Oregon Residents: You may obtain information about preventing identity theft from the Oregon Attorney General’s Office: Oregon Department of Justice, 1162 Court Street NE, Salem, OR 97301-4096, [www.doj.state.or.us/](http://www.doj.state.or.us/), Telephone: 877-877-9392 New Mexico Residents: You have rights under the federal Fair Credit Reporting Act (FCRA). These include, among others, the right to know what is in your file; to dispute incomplete or inaccurate information; and to have consumer reporting agencies correct or delete inaccurate, incomplete, or unverifiable information. For more information about the FCRA, please visit [www.consumer.ftc.gov/articles/pdf-0096-fair-credit-reporting-act.pdf](http://www.consumer.ftc.gov/articles/pdf-0096-fair-credit-reporting-act.pdf) or [www.ftc.gov](http://www.ftc.gov). In Addition, New Mexico Consumers Have the Right to Obtain a Security Freeze or Submit a Declaration of Removal As noted above, you may obtain a security freeze on your credit report to protect your privacy and ensure that credit is not granted in your name without your knowledge. You may submit a declaration of removal to remove information placed in your credit report as a result of being a victim of identity theft. You have a right to place a security freeze on your credit report or submit a declaration of removal pursuant to the Fair Credit Reporting and Identity Security Act. The security freeze is designed to prevent credit, loans, and services from being approved in your name without your consent. When you place a security freeze on your credit report, you will be provided with a personal identification number, password, or similar device to use if you choose to remove the freeze on your credit report or to temporarily authorize the release of your credit report to a specific party or parties or for a specific period of time after the freeze is in place. To remove the freeze or to provide authorization for the temporary release of your credit report, you must contact the consumer reporting agency and provide all of the following: {10838281: } 1. The unique personal identification number, password, or similar device provided by the consumer reporting agency; 2. Proper identification to verify your identity; and 3. Information regarding the third party or parties who are to receive the credit report or the period of time for which the credit report may be released to users of the credit report. A consumer reporting agency that receives a request from a consumer to lift temporarily a freeze on a credit report shall comply with the request no later than three business days after receiving the request. As of September 1, 2008, a consumer reporting agency shall comply with the request within fifteen minutes of receiving the request by a secure electronic method or by telephone. A security freeze does not apply in all circumstances, such as where you have an existing account relationship and a copy of your credit report is requested by your existing creditor or its agents for certain types of account review, collection, fraud control, or similar activities; for use in setting or adjusting an insurance rate or claim or insurance underwriting; for certain governmental purposes; and for purposes of prescreening as defined in the federal Fair Credit Reporting Act. If you are actively seeking a new credit, loan, utility, telephone, or insurance account, you should understand that the procedures involved in lifting a security freeze may slow your own applications for credit. You should plan ahead and lift a freeze, either completely if you are shopping around or specifically for a certain creditor, with enough advance notice before you apply for new credit for the lifting to take effect. You should contact a consumer reporting agency and request it to lift the freeze at least three business days before applying. As of September 1, 2008, if you contact a consumer reporting agency by a secure electronic method or by telephone, the consumer reporting agency should lift the freeze within fifteen minutes. You have a right to bring a civil action against a consumer reporting agency that violates your rights under the Fair Credit Reporting and Identity Security Act. To place a security freeze on your credit report, you must send a request to each of the three major consumer reporting agencies: Equifax, Experian, and TransUnion. You may contact these agencies using the contact information provided above. Rhode Island Residents: You may contact law enforcement, such as the Rhode Island Attorney General’s Office, to report incidents of identity theft or to learn about steps you can take to protect yourself from identity theft. You can contact the Rhode Island Attorney General at: Rhode Island Office of the Attorney General, 150 South Main Street, Providence, RI 02903, [www.riag.ri.gov](http://www.riag.ri.gov), (401) 274-4400. As noted above, you may obtain a security freeze on your credit report to protect your privacy and ensure that credit is not granted in your name without your knowledge. You have a right to place a “security freeze” on your credit report pursuant to chapter 48 of title 6 of the Identity Theft Prevention Act of 2006. The security freeze is designed to prevent credit, loans, and services from being approved in your name without your consent. When you place a security freeze on your credit report, within five (5) business days you will be provided a personal identification number or password to use if you choose to remove the freeze on your credit report or to temporarily authorize the release of your credit report for a specific period of time after the freeze is in place. To provide that authorization, you must contact the consumer reporting agency and provide all of the following: 4. The unique personal identification number or password provided by the consumer reporting agency. 5. Proper identification to verify your identity. 6. The proper information regarding the period of time for which the report shall be available to users of the credit report. A consumer reporting agency that receives a request from a consumer to temporarily lift a freeze on a credit report shall comply with the request no later than three (3) business days after receiving the request. A security freeze does not apply to circumstances where you have an existing account relationship and a copy of your report is requested by your existing creditor or its agents or affiliates for certain types of an account review, collection, fraud control, or similar activities. {10838281: } If you are actively seeking a new credit, loan, utility, telephone, or insurance account, you should understand that the procedures involved in lifting a security freeze may slow your own applications for credit. You should plan ahead and lift a freeze — either completely, if you are shopping around, or specifically for a certain creditor — with enough advance notice before you apply for new credit for the lifting to take effect. You have a right to bring a civil action against someone who violates your rights under the credit reporting laws. The action can be brought against a consumer reporting agency or a user of your credit report. To place a security freeze on your credit report, you must send a request to each of the three major consumer reporting agencies: Equifax, Experian, and TransUnion. These agencies can be contacted using the contact information provided above. In order to request a security freeze, you may need to provide the following information: 7. Your full name (including middle initial as well as Jr., Sr., II, III, etc.); 8. Social Security number; 9. Date of birth; 10. Complete address; 11. Prior addresses; 12. Proof(s) of identification (state driver’s license or ID card, military identification, birth certificate, etc.); 13. If you are a victim of identity theft, a copy of either the police report, investigative report, or complaint to a law enforcement agency concerning identity theft. There was 1 Rhode Island residents impacted by this incident. Washington D.C. Residents: You may obtain information about preventing identity theft from the Office of the Attorney General for the District of Columbia, 400 6th Street NW, Washington D.C. 20001, <https://oag.dc.gov/consumer-protection>, Telephone: 1-202-442-9828. **Topics:** Public Awareness, Technology --- ### [Third-Party Data Breach Impacts 271K at Oklahoma Healthcare Administrative, Tech Services Company](https://insurancefraud.org/news_archives/third-party-data-breach-impacts-271k-at-oklahoma-healthcare-administrative-tech-services-company/) **Published:** August 24, 2026 **Author:** Diane Beauchamp **Content:** Oklahoma-based Avem Health Partners, which provides administrative and technology services to healthcare organizations, notified 271,303 individuals of a healthcare data breach that occurred at 365 Data Centers, a vendor used by a third-party service provider utilized by Avem. 365 Data Centers discovered that an unauthorized party may have accessed information on its servers in May 2022. “Subsequently, Avem conducted a review of the Avem files that were stored on the 365 Data Centers server,” Avem explained. “Based on this review, which was completed on October 6, 2022, Avem determined that the files contained patient information, including patient names, dates of birth, Social Security numbers, driver’s license numbers, health insurance information, and diagnosis and treatment information.” Avem plans to mail letters to patients whose information was potentially involved in the breach and said it is in the process of evaluating its vendor relationships. Prairie Lakes Healthcare System Suffers Third-Party Data Breach Prairie Lakes Healthcare System (PLHS) in South Dakota notified more than 1,000 individuals of a third-party data breach that originated at its collections vendor, Advanced Asset Alliance (AAA) Collections. AAA discovered that the “incident” occurred between September 5 and 7, 2022, and potentially compromised the data of current and former PLHS and former Glacial Lakes Orthopaedics patients. The information involved in the breach may have included names, birth dates, addresses, provider and facility names, diagnoses, medical record numbers, payment information, and dates of service. AAA mailed notification letters to impacted patients in mid-December. “PLHS is committed to ensuring the security and protection of patient information within its control and is working with AAA to prevent a similar event from occurring in the future,” PLHS stated. “PLHS understands the inconvenience or concern that this matter may cause and encourages affected individuals to remain vigilant, monitor accounts, and immediately report any suspicious activity or suspected misuse of personal information.” Work Health Solutions Notifies Patients of Email Breach Work Health Solutions (WHS), an occupational health services company, disclosed a data breach that occurred when an unauthorized party accessed an email account between February 16 and March 24, 2022. The breach impacted more than 13,000 individuals. WHS conducted an investigation that determined that the email account may have contained files and folders with protected health information (PHI), such as health insurance information, medical information, Social Security numbers, driver’s license numbers, and full names. WHS said it had not received any reports of information being misused as a direct result of the incident. “At WHS, protecting the privacy of personal information is a top priority. WHS is committed to maintaining the privacy of information pertaining to its service recipients and have taken many precautions to safeguard it,” the notice stated. “WHS continually evaluates and modifies its practices to enhance the security and privacy of its service recipients’ information, including the education and counseling of its workforce regarding service recipient privacy matters.” **Topics:** Technology --- ### [November 2022 Healthcare Data Breach Report](https://insurancefraud.org/news_archives/november-2022-healthcare-data-breach-report/) **Published:** August 24, 2026 **Author:** Diane Beauchamp **Content:** November was a relatively quiet month for healthcare data breaches with 31% fewer breaches reported than the previous month. November’s total of 49 breaches of 500 or more records was also well below the 12-month average of 58 breaches a month. 643 healthcare data breaches have been reported to the HHS’ Office for Civil Rights so far in 2022, which makes this year the second worst year to date for healthcare data breaches. ![](https://insurancefraud.org/wp-content/uploads/image-20-4.jpg)Despite the fall in reported breaches, the number of breached records increased by 10% from October. November was the worst month of 2022 in terms of the number of breached healthcare records, with 6,904,441 records exposed or impermissibly disclosed – Well above the 12-month average of 3.99 million records a month. So far in 2022, 44,852,648 healthcare records have been breached. ![](https://insurancefraud.org/wp-content/uploads/image-21-3.jpg)## Largest Healthcare Data Breaches in November 17 breaches of 10,000 or more records were reported to OCR in November, five of which involved more than half a million records and three incidents involved the impermissible disclosure of more than 1 million records. The largest data breach was a hacked network server at the Pennsylvania-based business associate Connexin Software – A provider of electronic medical records to pediatric practices. An unauthorized individual gained access to an offline set of patient data that was used for data conversion and troubleshooting. The records of 2,216,365 patients were exposed and potentially stolen. The Indiana-based healthcare provider, Community Health Network, reported an impermissible disclosure of the protected health information of up to 1.5 million patients. Tracking code had been added to its website that resulted in patient information being transferred to third parties such as Meta and Google, without obtaining consent from patients or having a business associate agreement in place. Several healthcare providers have reported similar breaches this year, prompting [OCR to issue a warning](https://www.hipaajournal.com/ocr-website-tracking-technology-without-baa-hipaa-violation/) to HIPAA-regulated entities this month over the use of tracking technologies on websites and mobile applications. Doctors’ Center Hospital in Puerto Rico suffered a ransomware attack that exposed the protected health information of up to 1,195,220 patients. Major ransomware attacks were also reported by the Michigan-based prosthetics and orthotics provider, Wright & Filippis, and Health Care Management Solutions in West Virginia. | **Name of Covered Entity** | **State** | **Covered Entity Type** | **Individuals Affected** | **Type of Breach** | **Cause of Data Breach** | |---|---|---|---|---|---| | Connexin Software, Inc. | PA | Business Associate | 2,216,365 | Hacking/IT Incident | Hacking of network server | | Community Health Network, Inc. as an Affiliated Covered Entity | IN | Healthcare Provider | 1,500,000 | Unauthorized Access/Disclosure | Website tracking code transmitted PHI to third parties | | Doctors’ Center Hospital | PR | Healthcare Provider | 1,195,220 | Hacking/IT Incident | Ransomware attack | | Wright & Filippis LLC | MI | Healthcare Provider | 877,584 | Hacking/IT Incident | Ransomware attack | | Health Care Management Solutions, LLC | WV | Business Associate | 500,000 | Hacking/IT Incident | Ransomware attack on subcontractor of CMS business associate | | Gateway Rehabilitation Center | PA | Healthcare Provider | 130,000 | Hacking/IT Incident | Hacking of network server | | Mena Regional Health System | AR | Healthcare Provider | 84,814 | Hacking/IT Incident | Hacking of network server | | Dallam Hartley Counties Hospital District | TX | Healthcare Provider | 69,835 | Hacking/IT Incident | Hacking of network server (data theft confirmed) | | Consumer Directed Services in Texas, Inc. | TX | Healthcare Provider | 56,728 | Hacking/IT Incident | Hacking incident at a business associate | | Stanley Street Treatment and Resources, Inc. | MA | Healthcare Provider | 45,785 | Hacking/IT Incident | Hacking of network server (data theft confirmed) | | South Walton Fire District | FL | Healthcare Provider | 25,331 | Hacking/IT Incident | South Walton Fire District | | Rosenfeld VanWirt, PC | PA | Business Associate | 18,719 | Hacking/IT Incident | Hacking incident affecting multiple affiliates of the Lehigh Valley Health Network | | CCA Health Plans of California, Inc d/b/a CCA Health CA | CA | Health Plan | 14,631 | Hacking/IT Incident | Hacking of network server (data theft confirmed) | | CareFirst Administrators | MD | Health Plan | 14,538 | Hacking/IT Incident | Phishing attack on business associate | | Work Health Solutions | CA | Healthcare Provider | 13,157 | Hacking/IT Incident | Phishing attack | | New York-Presbyterian Hospital | NY | Healthcare Provider | 12,000 | Hacking/IT Incident | Hacking of network server | | Epic Management LLC | TN | Healthcare Provider | 10,862 | Hacking/IT Incident | Unauthorized email account access | ## Causes of November Data Breaches All but one of the 17 data breaches of 10,000 or more records were due to hacking incidents, several of which were ransomware attacks. Many hacking incidents involve ransomware, although it is common for HIPAA-regulated entities not to disclose the exact nature of these attacks. It is therefore difficult to determine the extent to which ransomware is used in cyberattacks on the healthcare industry. 5,374,670 records were exposed or stolen in these hacking incidents – 77.8% of all records breached in November. The average breach size was 134,367 records and the median breach size was 7,158 records. ![](https://insurancefraud.org/wp-content/uploads/image-20-4.jpg)There were 8 unauthorized access/disclosure incidents reported that involved the records of 1,521,788 individuals. The majority of those records were impermissibly disclosed by one healthcare provider. The average breach size was 190,224 records and the median breach size was 2,275 records. There was also one theft incident reported involving the records of 7,983 individuals. In the majority of reported incidents, the breached protected health information was located on network servers. There were also 7 incidents involving breaches of email data, and four incidents involving electronic health records. ![](https://insurancefraud.org/wp-content/uploads/image-21-3.jpg)## HIPAA-Regulated Entities Affected by Data Breaches Healthcare providers were the worst affected entities in November, with 26 reported breaches, one of which occurred at a business associate but was reported by the healthcare provider. 6 data breaches were reported by health plans, with one of those breaches occurring at a business associate. Business associates self-reported 17 breaches in November. The pie chart below shows the breakdown of data breaches based on where they occurred, rather than the entities reporting the data breaches. ![](https://insurancefraud.org/wp-content/uploads/image-20-4.jpg)## Healthcare Data Breaches by State Data breaches were reported by HIPAA-regulated entities in 18 states and Puerto Rico. Pennsylvania was the worst affected state with 12 breaches, which involved 34.8% of the month’s breached records. 10 of those breaches were due to a hacking incident involving healthcare providers that are part of the Lehigh Valley Health Network. HIPAA-regulated entities in California reported 6 breaches, but these were relatively minor, only involving the protected health information of 41,382 patients. | **State** | **Breaches** | |---|---| | Pennsylvania | 12 | | California | 6 | | Florida & New York | 4 | | Texas | 3 | | Arkansas, Connecticut, Indiana, Maryland, Massachusetts & Tennessee | 2 | | Georgia, Michigan, New Jersey, Nevada, Oregon, Washington, West Virginia, and Puerto Rico | 1 | ## HIPAA Enforcement Activity in November No civil monetary penalties or settlements were announced by OCR in November. Even so, 2022 has seen more HIPAA enforcement actions than in any other year since OCR was given the authority to enforce HIPAA compliance. The majority of the financial penalties in 2022 have been imposed for violations of the HIPAA right of access, and 55% of the year’s enforcement actions over HIPAA violations were on small healthcare providers. In November, the state of Massachusetts announced that Aveanna Healthcare had been fined $425,000 for a breach of the PHI of 166,000 individuals, 4,000 of whom were Massachusetts residents. Aveanna Healthcare had suffered a phishing attack, with the Massachusetts Attorney General discovering a lack of safeguards such as multi-factor authentication and security awareness training. **Topics:** Public Awareness, Technology --- ### [Fake doctor scammed Houston County woman out of $30,000](https://insurancefraud.org/news_archives/fake-doctor-scammed-houston-county-woman-out-of-30000/) **Published:** August 24, 2026 **Author:** Diane Beauchamp **Content:** A Houston County judge sentenced a Florida man who pretended to a doctor to 202 years in prison last week. Court documents show the man scammed at least $30,000 from an elderly woman. May 2, 2017, according to court documents, is when Jimmy Lee Taylor first treated Annette Johnson for a foot ailment. He called it “stem cell therapy,” and that first treatment cost her $2,500 cash, but when a grand jury indicted Taylor three years ago, prosecutors said he took at least $30,000 from her. Court records say that over the next 10 months, Taylor made at least 20 visits to the woman’s home on Arena Road outside Perry, but prosecutors say her condition continued to get worse. Johnson died of skin cancer in April 2018, just a few days after she contacted the Houston County Sheriff’s Office and they launched an investigation. Now, investigators say Taylor was pretending to be a doctor and used drugs and medical supplies believed to come from Mexico. They say they found victims in at least four other states and took his payments in cash, and prosecutors say Taylor’s treatments caused serious harm to some of them. A Houston County jury last week convicted Taylor of 44 counts of elder abuse and 23 counts of practicing medicine without a license. Sergeant Greg Pennycuff with Houston County and assistant DA Lauren Fletcher with Crisp County, who investigated and prosecuted the case, declined to comment. **Topics:** Unlicensed **Categories:** Conviction --- ### [Whistleblower Alleges Billing Fraud, Lax Care at Baptist Health South Florida Hospital](https://insurancefraud.org/news_archives/whistleblower-alleges-billing-fraud-lax-care-at-baptist-health-south-florida-hospital/) **Published:** August 24, 2026 **Author:** Diane Beauchamp **Content:** Domenico Calcaterra began working at Bethesda Hospital East in January 2020 as the new chief of cardiac surgery tasked with revamping the hospital’s heart surgery program. In a whistleblower complaint in Miami court, he claims that it was only months into his job at the Boynton Beach hospital when he discovered fraudulent billing to the tune of millions of dollars, severe understaffing in the intensive care unit, and violations of clinical standards that he says caused patient harm. Calcaterra voiced his concerns repeatedly to the hospital administration and top executives, but his grievances were largely ignored, according to the lawsuit. He says he was fired a year after his hiring in retaliation for bringing the hospital’s dysfunction to light. “Defendants retaliated against Calcaterra by harassing, isolating, and terminating him from all positions solely on account of his protected activity,” the complaint alleges. The lawsuit was filed in Miami-Dade County Court against Bethesda Health Physician Group and Baptist Health South Florida, a nonprofit hospital company. It lists counts for employment retaliation under the Florida Private Whistleblower Act and the False Claims Act, a federal law that protects whistleblowers and provides compensation if they uncover fraud against a government entity or program. Baptist Health South Florida is [one of the largest healthcare organizations](https://baptisthealth.net/) in the region, operating 12 South Florida hospitals and more than 100 outpatient and urgent care facilities. It acquired Bethesda East hospital as part of a 2017 merger with Bethesda Health, which has been operating in Palm Beach County since 1959. When reached by *New Times,* Baptist Health South Florida said it had not been served in the case and does not comment on pending litigation. In July 2020, an uninsured 48-year-old Black patient opted not to have surgery to address his heart condition after one of Bethesda East’s doctors told him and his wife the operation was not worth the risk, the lawsuit alleges. According to the complaint, two other physicians were so concerned by their colleague’s advice that they sought a second opinion from Calcaterra. Upon examining the patient, Calcaterra found the man had a life-threatening aortic dissection, a condition that could result in a fatal rupture of the aorta if not surgically repaired immediately. “Incredibly, the treating physician did not document these details in the patient’s chart, but did document in the medical records that the patient had ‘refused the operation,’” the lawsuit states. Calcaterra believed that the patient was at risk of a rupture within a matter of days and needed an emergency operation. After consulting with Calcaterra, the complaint claims, the man elected to move forward with the surgery. The surgeon says the incident was part of a “pattern at Bethesda hospital” whereby the facility would “withhold treatment including needed operations to the uninsured to avoid the expenditure of resources for which there would be no compensation or compensation at a rate far less than an insured or Medicare patient would generate.” “This was confirmed when Dr. Calcaterra brought this near-tragic incident to the attention of the director of defendant’s risk management office, who stated that the hospital administration had been unwilling to address such issues… for years,” the lawsuit alleges. ## “We Take Care of Each Other” Calcaterra claims to have witnessed several forms of fraudulent billing practices while working as the hospital’s head of cardiac surgery. Among other alleged misconduct, Calcaterra says he noticed the hospital systematically conducting unnecessary post-surgical patient consultations to inflate invoices. The surgeon says the incident was part of a “pattern at Bethesda hospital” whereby the facility would “withhold treatment including needed operations to the uninsured to avoid the expenditure of resources for which there would be no compensation or compensation at a rate far less than an insured or Medicare patient would generate.” “This was confirmed when Dr. Calcaterra brought this near-tragic incident to the attention of the director of defendant’s risk management office, who stated that the hospital administration had been unwilling to address such issues… for years,” the lawsuit alleges. ## “We Take Care of Each Other” Calcaterra claims to have witnessed several forms of fraudulent billing practices while working as the hospital’s head of cardiac surgery. Among other alleged misconduct, Calcaterra says he noticed the hospital systematically conducting unnecessary post-surgical patient consultations to inflate invoices. Within a month of his hiring, Calcaterra says he asked another doctor at Bethesda East why he had ordered so many specialist consults on a patient. The doctor allegedly responded, “We take care of many uninsured patients here, and we have to compensate for the work we do for free, so we take care of each other.” Calcaterra reported the practice, known as “overutilization,” to the hospital’s assistant vice president, chief medical officer, and chief operating officer, but the issue was swept under the rug, according to the lawsuit. A few weeks after Calcaterra met with the chief operating officer to report the issue, she “was abruptly fired,” the lawsuit alleges. Calcaterra says he also found that the hospital was misclassifying medical services as “critical care time” to inflate billing. The facility allegedly disregarded the Centers for Medicare and Medicaid Services guidelines for defining and coding critical care. “These unlawful practices related to billing of ‘critical care time’ account for tens of millions of dollars per year of fraudulent billing at the different Baptist Hospitals,” the lawsuit asserts. “Calcaterra, in person, along with one of his critical care physician colleague\[s\]… reported verbally and in writing these facts to the Bethesda chain of command.” ## Lax Care Claims The doctor, who completed his cardiothoracic surgery fellowship in 2007 at the University of Miami’s Miller School of Medicine, recounts in the lawsuit how Bethesda East allegedly dragged its feet in hiring more physician assistants (PAs) to help out in operating rooms and the intensive care unit. He says he expressed his concerns several times during the summer of 2020, telling the administration the lack of ICU coverage put patients’ lives at risk. In an August 2020 email, Calcaterra reached out to the hospital about the understaffing, noting that hospital employees were reluctant to speak up for fear of retaliation, he says. Then in November of that year, not long before he was fired, he emailed administration about an incident in which the hospital allegedly had a “lack of any personnel” to deal with a patient in distress in the intensive care unit. Though Calcaterra worked at Bethesda East at the onset of COVID-19 pandemic, during which South Florida hospitals struggled to maintain sufficient personnel, he presents evidence that allegedly shows the hospital had financially motivated misgivings about hiring more physician assistants. The lawsuit claims that in response to Calcaterra’s concerns, the president of Bethesda Physicians Group once wrote that the hospital was “being asked to spend an awful lot of money here,” while questioning why an already-hired physician assistant would not suffice. While an executive at Baptist Health South Florida acknowledged “significant coverage issues and difficulty managing the workload,” she did little to resolve the situation and failed to investigate the ICU understaffing, Calcaterra argues. “The many concerns I have brought up through the months about problems with operations, processes, and quality of care have not been addressed and acknowledged,” Calcaterra wrote in a grievance cited in the case. A “lack of basic equipment needed for adequate medical care,” including emergency dialysis, along with an inability to quickly process coagulation lab results, prompted yet another grievance from Calcaterra, according to the lawsuit. He claims that when he parted ways with the hospital, the lab issue still had not been addressed. During his tenure at the hospital, he claims, he had to address missteps in the hospital’s handling of central line catheters, its use of intravenous anti-arrhythmia medication, and its purported “practice of booking and then canceling cases,” all of which he claims put patients at risk. In one of the more alarming alleged mishaps cited in the complaint, Calcaterra claims the hospital allowed a general surgeon to carry out a pacemaker surgery despite a lack of qualifications to perform the operation. “The pacemaker was improperly implanted, and contrary to any clinical justification,” the doctor says, noting that the patient wound up dying. Calcaterra claims his employment was terminated around January 2021 in retaliation for his complaints about the hospital’s “unlawful activity.” The doctor, a University of Rome medical school graduate, says he’s entitled to job reinstatement, backpay, and other financial damages. He is represented by Gary Costales in Miami and Tina Glandian of Geragos & Geragos in New York. “There appears to be a practice or modus operandi of a cover-up… No investigation has taken place to the best of our knowledge, and we look forward to investigators uncovering the truth and substantiating our client’s claims,” Geragos & Geragos spokesperson Holly Baird said in a statement. **Topics:** Judicial/courts --- ### [Unlicensed Group Home Owner Pleads Guilty to Medicaid Health Care and Wire Fraud Schemes](https://insurancefraud.org/news_archives/unlicensed-group-home-owner-pleads-guilty-to-medicaid-health-care-and-wire-fraud-schemes/) **Published:** August 24, 2026 **Author:** Diane Beauchamp **Content:** A Chester woman pleaded guilty today to charges of conspiracy to commit health care fraud, health care fraud, and wire fraud, all stemming from her operation of a Richmond metro-area health care services company. According to court documents, between 2014 and 2021, Sharon Johnson, 58, owned and operated “Sharon Y. Johnson & Associates” (SYJA). Johnson’s company purportedly provided Medicaid-reimbursed services that included both Service Facilitator services—supervising a Medicaid recipient’s personal care plan and provider— and personal care services—home health care aid services designed to allow a recipient to remain at home, rather than entering a nursing home or group home. Johnson signed up numerous of her Service Facilitator clients, often without their awareness or informed consent, to receive personal care services from her company. Johnson utilized her personal residence in Chester—a single-story, three-bedroom, 1,326-square foot structure—as an unlicensed group home, housing up to a half-dozen Medicaid recipients, in addition to Johnson and another SYJA employee, at any given time. Between 2014 and 2021, Johnson fraudulently billed Medicaid for personal care services purportedly provided to at least 14 of her patients, knowingly submitting timesheets to Medicaid that falsely claimed that certain SYJA aides had provided services, when, in fact, those purported SYJA employees had not provided home health care services to the patients in question. To execute this fraud scheme, Johnson and her co-conspirators created online patient portal accounts in the names of her patients, and thereafter assumed those patients’ identities when “approving” and routing billing requests for SYJA home health care services that had not, in fact, been provided. Separately, Johnson also executed a scheme to defraud the Virginia Retirement System (VRS) of pension payments paid by the VRS to one of Johnson’s unlicensed group home residents. To obtain control over her patient’s financial affairs, Johnson submitted fraudulent documents to the VRS including a “Medical Power of Attorney” form, and, after her patient’s death, changed the direct deposit location of her now-deceased patient’s VRS pension payments to Johnson’s own bank account. VRS thereafter paid at least 8 monthly pension payments into Johnson’s bank account before belatedly confirming the patient’s death. Johnson, knowing she was not entitled to those VRS funds, spent those payments for her own purposes. Johnson is scheduled to be sentenced on April 18, 2023. She faces a maximum penalty of 20 years in prison. Actual sentences for federal crimes are typically less than the maximum penalties. A federal district court judge will determine any sentence after taking into account the U.S. Sentencing Guidelines and other statutory factors. Jessica D. Aber, U.S. Attorney for the Eastern District of Virginia, and Stanley M. Meador, Special Agent in Charge of the FBI Richmond Field Office, made the announcement after U.S. District Judge Hannah M. Lauck accepted the plea. The Virginia Medicaid Fraud Control Unit assisted in the investigation. Assistant U.S. Attorneys Thomas A. Garnett and Shea Gibbons are prosecuting the case. **Topics:** Medicare/Medicaid **Categories:** Conviction --- ### [Healthcare billing fraud: 8 recent cases](https://insurancefraud.org/news_archives/healthcare-billing-fraud-8-recent-cases/) **Published:** August 24, 2026 **Author:** Diane Beauchamp **Content:** 1\. [Massachusetts physician indicted for role in healthcare fraud scheme ](https://www.beckersasc.com/asc-coding-billing-and-collections/massachusetts-physician-indicted-for-role-in-healthcare-fraud-scheme.html?__hstc=77465994.5c968581e5cce3859502527707cb8f4a.1785759381916.1787581494747.1787605859700.6&__hssc=77465994.1.1787605859700&__hsfp=7559bef16460f6b4c1e333b80bd29b1a) Brookline, Mass.-based sleep medicine physician Pankaj Merchia, MD, is accused of billing former patients’ insurance companies for monthly rentals of continuous positive airway pressure and bilevel positive airway pressure machines years after the patients discontinued the use of them. 2\. [Mistrial declared in $158M Texas healthcare fraud case](https://www.beckershospitalreview.com/legal-regulatory-issues/mistrial-declared-in-158m-texas-healthcare-fraud-case.html) A federal judge declared a mistrial Dec. 19 in a $158 million Texas healthcare fraud case amid concern the jury may not be able to recall testimony after an attorney’s medical emergency caused a monthlong delay. Four Texans — including a surgeon, a pharmacist, a pharmacy owner and one of his business associates — were facing various charges of conspiracy, healthcare fraud, money laundering and tax evasion. 3\. [New York physician convicted in $31M trip-and-fall fraud scheme ](https://www.beckersasc.com/asc-news/new-york-physician-convicted-in-31m-trip-and-fall-fraud-scheme.html?__hstc=77465994.5c968581e5cce3859502527707cb8f4a.1785759381916.1787581494747.1787605859700.6&__hssc=77465994.1.1787605859700&__hsfp=7559bef16460f6b4c1e333b80bd29b1a) Orthopedic surgeon Andrew Dowd, MD, and lawyer George Constantine have been convicted of defrauding businesses and insurance companies in a $31 million trip-and-fall fraud scheme. Dr. Dowd and Mr. Constantine, among others, engaged in a fraud scheme where patients were recruited to stage trip-and-fall accidents and then undergo medically unnecessary surgeries to increase the value of personal injury lawsuits. 4\. [Texas lab tech arrested for role in $7M fraudulent COVID-19 testing scheme](https://www.beckershospitalreview.com/legal-regulatory-issues/texas-lab-tech-arrested-for-role-in-7m-fraudulent-covid-19-testing-scheme.html) Two Texas residents are accused of defrauding major health insurers out of more than $7 million by claiming to have performed COVID-19 testing at diagnostic laboratories that did not exist. 5\. [Connecticut physician to pay $4.2M to settle fraud allegations](https://www.beckershospitalreview.com/legal-regulatory-issues/connecticut-physician-to-pay-4-2m-to-settle-fraud-allegations.html) Connecticut physician Dr. Jasdeep Sidana and his medical practice have agreed to pay more than $4.2 million to settle allegations that he submitted claims for immunotherapy services that were not medically necessary and were not directly supervised by a physician. 6\. [Chicago physician charged for role in $9.5M+ kickback scheme ](https://www.beckersasc.com/asc-coding-billing-and-collections/chicago-physician-charged-for-role-in-9-5m-kickback-scheme.html?__hstc=77465994.5c968581e5cce3859502527707cb8f4a.1785759381916.1787581494747.1787605859700.6&__hssc=77465994.1.1787605859700&__hsfp=7559bef16460f6b4c1e333b80bd29b1a) Chicago-based Benjamin Toh, MD, has been charged for his role in a more than $9.5 million healthcare fraud scheme. Dr. Toh, who is licensed in several states and operated as a consulting provider for telemedicine companies, assigned orders for cancer genetic testing in exchange for kickbacks. The orders were signed without regard to medical necessity, and Dr. Toh was not the treating physician of the patients. 7\. [Lab owner convicted for $463M Medicare fraud, faces years in prison](https://www.beckershospitalreview.com/legal-regulatory-issues/lab-owner-convicted-for-463m-medicare-fraud-faces-years-in-prison.html) Minal Patel, owner of Georgia-based LabSolutions, was convicted of billing Medicare for expensive genetic testing that was not necessary. 8\. [Connecticut psychologist pleads guilty to $2.7M fraud scheme](https://www.beckersasc.com/asc-news/connecticut-psychologist-pleads-guilty-to-2-7m-fraud-scheme.html?__hstc=77465994.5c968581e5cce3859502527707cb8f4a.1785759381916.1787581494747.1787605859700.6&__hssc=77465994.1.1787605859700&__hsfp=7559bef16460f6b4c1e333b80bd29b1a) Greenwich, Conn.-based psychologist Michael Lonski, PhD, admitted that he billed insurers for services he knew were not rendered, including billing for deceased patients, for dates of services when he was out of the country and for dates of service when he was hospitalized. **Topics:** Healthcare Fraud, Judicial/courts --- ### [Settlement Reached in New York Home Health Agency Medicaid Fraud](https://insurancefraud.org/news_archives/settlement-reached-in-new-york-home-health-agency-medicaid-fraud/) **Published:** August 24, 2026 **Author:** Diane Beauchamp **Content:** New York Attorney General Letitia James has reached two agreements with White Glove Community Care, Inc., (White Glove), a Brooklyn-based home health agency that was recently found to have submitted false claims to Medicaid and underpaid its home health aides. The two agreements are with the Office of the Attorney General’s (OAG) Labor Bureau and OAG’s Medicaid Fraud Control Unit (MFCU). A joint investigation by the OAG and the United States Attorney’s Office for the Eastern District of New York (EDNY) found that White Glove fraudulently obtained over a million dollars in Medicaid funding by submitting false claims and “cheated” its home health aides out of wages they earned. Having admitted to wrongful conduct, White Glove has agreed to pay $2 million in unpaid wages to employees and $1.2 million to the state’s Medicaid program. Of the $1.2 million, approximately $758,425.47 will go to the state of New York, with the remainder going to the federal government. “Home health aides work tirelessly to provide critical care for our most vulnerable neighbors, and they deserve to receive adequate and fair compensation for their hard work,” James said in a statement. “White Glove cheated their employees, and they cheated the everyday New Yorkers whose tax dollars fund the Medicaid program. My office will always stand up against bad actors, and ensure all workers get fair pay for their work.” As part of the agreement, White Glove will revise its policies and procedures; train its personnel on updated policies—subject to OAG’s approval—and regularly report staff wages and policy implementations to OAG for three years. Failure to comply with these terms or properly compensating its aides will result in OAG bringing civil action against the agency and $15,000 in damages for “violating its legal obligations.” “The arduous work that these aides do, day after day, ensures that some of our most vulnerable neighbors receive the care and are shown the dignity that they deserve,” U.S. Attorney Breon Peace said in a statement. “This settlement—the third in our continuing investigation of certain licensed home care service agencies—reflects this Office’s ongoing commitment to providing home health aides the hard-earned benefits guaranteed them under New York law and the Medicaid program.” **Topics:** Judicial/courts --- ### [Former Delano insurance agent sentenced after embezzling clients’ premium payments](https://insurancefraud.org/news_archives/former-delano-insurance-agent-sentenced-after-embezzling-clients-premium-payments/) **Published:** August 24, 2026 **Author:** Diane Beauchamp **Content:** Formerly licensed insurance agent Anaiza Villarreal Lopez, 30, of McFarland, was sentenced yesterday in Kern County Superior Court on one count of grand theft by embezzlement after pocketing clients’ premium payments and leaving several of them uninsured. After receiving a complaint, the Department of Insurance launched an investigation in February 2020 which found Lopez stole more than $1,200 from seven clients by pocketing their premium payments meant to secure automobile insurance policies. Most of the victims were low income and primarily Spanish speaking. During the investigation, Lopez admitted to diverting the premium payments from her clients’ access cards to her personal “Square” account and using the funds for personal gain. A “Square” account is a point of sale purchasing process from credit and debit cards for business and personal accounts. Lopez was able to mislead her victims by naming her personal “Square” account “Auto Insurance” in order to lead them to believe their payments were going toward the purchase of auto insurance. In one instance, Lopez’s actions led to an uninsured loss of $4,166, which was fortunately covered by the insurance broker that employed Lopez. Lopez has been ordered to pay restitution to each of her victims, including her employer. Lopez’s license was revoked on October 5, 2022. This case was prosecuted by the Kern County District Attorney’s Office. **Topics:** Insider - agent **Categories:** Conviction --- ### [Uber’s California Racketeering Case Against Lawyers, Doctors Moves Forward](https://insurancefraud.org/news_archives/ubers-california-racketeering-case-against-lawyers-doctors-moves-forward/) **Published:** August 24, 2026 **Author:** Diane Beauchamp **Content:** Uber Technologies Inc. cleared an important early hurdle in a federal lawsuit accusing California personal-injury lawyers and medical providers of participating in a scheme to inflate injury claims, extending the ride-hailing company’s broader effort to use federal racketeering law against alleged insurance fraud. U.S. District Judge Sherilyn Peace Garnett allowed most of Uber’s claims under the Racketeer Influenced and Corrupt Organizations Act, or RICO, to proceed while dismissing one conspiracy count, according to [Reuters](https://www.reuters.com/legal/litigation/uber-defeats-bid-dismiss-racketeering-lawsuit-against-california-lawyers-doctors-2026-08-21/?utm_source=chatgpt.com). The ruling was made public Thursday, Reuters reported. The decision keeps alive a case that could test how aggressively large companies can deploy a statute historically associated with organized crime against networks of attorneys and medical professionals accused of coordinating fraudulent civil claims. According to Reuters, Uber alleges that personal-injury lawyers steered clients toward medical providers who performed treatment that was unnecessary or unrelated to their injuries. The company contends the arrangements were part of a kickback operation intended to increase the value of injury claims. Two law firms named as defendants — Downtown LA Law Group and the Law Offices of Jacob Emrani — sought protection under the Noerr-Pennington doctrine, which generally shields efforts to petition the government from certain forms of liability. Garnett concluded that the doctrine does not insulate sham litigation, Reuters reported. The firms have denied wrongdoing. At this stage of the proceedings, Uber sufficiently alleged that the firms made misleading representations involving clients’ injuries, medical care and lien arrangements, according to Reuters’ account of Garnett’s ruling. The decision does not determine whether Uber’s allegations are true; it allows the surviving claims to move deeper into litigation. The outcome wasn’t an across-the-board victory for Uber. Garnett dismissed a RICO conspiracy claim involving all defendants, though she gave the company an opportunity to try to revive it. She also ordered Uber to pay legal fees to three defendants, including the Emrani firm and a California surgeon, after concluding that the company abandoned some claims rather than defend them against arguments involving a California law designed to prevent litigation from being used to suppress protected activity, Reuters reported. The California dispute is part of a wider litigation campaign. Uber and other large companies have filed at least 20 civil RICO cases against plaintiffs’ attorneys in federal courts during the past two years, according to Reuters. Uber has pursued similar litigation involving law firms in Miami, New York and Philadelphia. Successful civil RICO plaintiffs can potentially recover three times their proven damages. **Topics:** Auto - padding/false claim, Judicial/courts --- ### [State implements AI tech to combat Medicaid fraud, more Health Headlines](https://insurancefraud.org/news_archives/state-implements-ai-tech-to-combat-medicaid-fraud-more-health-headlines/) **Published:** August 24, 2026 **Author:** Diane Beauchamp **Content:** On Monday, Aug. 17, the Colorado Department of Health Care Policy and Financing (HCPF) announced its implementation of a new AI-enabled technology to deter fraud, waste and abuse in the state’s Medicaid program. According to a department press release, the FWA (fraud, waste and abuse) Finder analyzes large datasets on Medicaid providers, patients, claims and spending to identify outliers and anomalies. Those irregularities are passed along to HCPF staff, which HCPF Medicaid Operations Division Director Ralph Choate said allows them to quickly triage and investigate referrals and track overpayments and recovery efforts. Since the AI’s implementation was federally approved in May, the technology has produced more than 80 leads “that otherwise would have been difficult and time-consuming for HCPF staff to detect with old methods.” “This is just one of the new tools that HCPF is implementing to allow us to focus resources where we can achieve the most impact, save the state the most money and ensure proper billing through targeted provider auditing and education,” HCPF FWA Division Director Ashley Dirienzo said. “The FWA Finder tool gives the department insight into provider comparisons to help us target individuals or groups that may be high-risk compared to their peers.” A new batch of data on state Supplemental Nutrition Assistance Program (SNAP) enrollment revealed [an additional decline of 6,000 enrollees](https://www.cbpp.org/research/food-assistance/snap-tracker-people-are-losing-food-assistance-as-the-harmful-2025#:~:text=47%-,Colorado,-June) between April and June of this year. The latest figures supplemented a [Center on Budget and Policy Priorities report](https://www.cbpp.org/research/food-assistance/snap-tracker-people-are-losing-food-assistance-as-the-harmful-2025#:~:text=47%-,Colorado,-June) on enrollment trends through April 2026. In total, the research institute estimated that over 33,000 fewer Coloradans are accessing the program since the “One Big Beautiful Bill Act,” or H.R. 1, was enacted in July 2025. Of the state-level enrollment losses, 37% (roughly 12,600) were children. With more than 570,000 residents still enrolled overall, that translates to a 5% reduction statewide, compared to the national average of a 12% decrease. A statement from the office of U.S. Sen. John Hickenlooper (D-Colorado) added that the trend could only worsen, with H.R. 1 offloading substantial program costs onto state budgets in October 2027. In June of last year, before H.R. 1 was officially passed, [23 states including Colorado,](https://www.hickenlooper.senate.gov/wp-content/uploads/2026/06/2025.06.24-Multi-Gov-Letter-on-SNAP_FINAL.pdf) wrote a letter to Congress stating that the shift in federal funding will force states to drastically reduce or entirely eliminate their SNAP programs. Analysis from [the Georgetown University Law Center](https://www.georgetownpoverty.org/issues/snap-changes-will-upend-state-budgets) estimated last year that Colorado will be on the hook for about $272 million in program costs under the new rules — a 188% jump from the current $94 million expense. Earlier this August, Garfield County Finance Administrator Kathy Lancaster was dubbed “Colorado’s 2026 National Immunization Champion,” an accolade presented by the state and U.S. Centers for Disease Control and Prevention. According to a press release from the Colorado Department of Public Health and Environment, Lancaster received the award for her “exceptional leadership, collaboration, innovation and advocacy to advance immunization in their communities.” Specifically, CDPHE stated that Lancaster has consistently went above and beyond her job requirements of budgets and spreadsheets over her 45-year tenure in public service, coordinating and volunteering at off-site vaccine clinics to create welcoming experiences that expanded the clinics’ reach into communities with barriers to care. According to CDPHE, Lancaster’s passion for public health is rooted in her personal experience as a cancer survivor and lifelong connection with Garfield County, where she also volunteers at her church and organizes senior dinners. The department added that Lancaster is a consistent advocate for the vulnerable (like homebound older adults or people with a disability) taking the initiative to make calls, coordinate schedules and recruit nurses for home-based vaccinations. “Inside the clinic, Lancaster’s humanity shines during pediatric appointments,” CDPHE stated. “When children struggle with fear during vaccinations, she steps in with a calm presence — holding a hand or offering a reassuring voice — helping families feel supported and ensuring the process goes smoothly.” **Topics:** Public Awareness, Technology --- ### [Kentucky receives $1.5 million in DOJ grants to crack down on fraud, trafficking](https://insurancefraud.org/news_archives/kentucky-receives-1-5-million-in-doj-grants-to-crack-down-on-fraud-trafficking/) **Published:** August 24, 2026 **Author:** Diane Beauchamp **Content:** The commonwealth is working to cut down on fraud and trafficking crimes in Kentucky cities. On Friday, the state Attorney General Russell Coleman announced that Kentucky was awarded $1.5 million in a competitive federal grant from the Department of Justice to help combat fraud and both human and drug trafficking. The Attorney General’s Office said this money will go towards hiring more state-level prosecutors who will serve as Special Assistant United States Attorneys. “From violent crime to benefits fraud, to deadly drug cases, we are consistently working with our partners in the AG’s Office to deliver the best possible outcomes. This federal grant will make us more effective at our mission: keeping your family safe,” said Jason Parman, first assistant U.S. attorney for the Eastern District of Kentucky. The goal is to increase the number of indictments resulting from healthcare fraud, drug trafficking, and human trafficking investigations. Kentucky is one of the first states to join the Special Attorneys Grant Program. **Topics:** Public Awareness, Regulatory actions --- ### [How to spot a ghost broker](https://insurancefraud.org/news_archives/how-to-spot-a-ghost-broker/) **Published:** August 3, 2026 **Author:** Diane Beauchamp **Content:** Insurance fraud continues to be a major challenge within the industry, with one emerging threat being ghost broking—a deceptive practice that exposes unsuspecting customers to significant financial and legal risks. Ghost brokers impersonate legitimate insurance agents, enticing consumers with seemingly irresistible policies offered at shockingly low rates. Unfortunately, these policies are often either entirely fictitious or packed with inaccuracies, resulting in dire consequences when customers attempt to make claims. For brokers, recognizing the signs of ghost broking is not just important; it is essential for protecting clients and maintaining the integrity of the insurance market. By staying vigilant and informed, brokers can play a critical role in helping customers avoid these scams and secure legitimate coverage. ## **A growing threat in the Canadian market** According to Jamie Lee (pictured), head of fraud and financial crime at [Aviva](https://www.insurancebusinessmag.com/ca/companies/aviva/398484/), ghost broking has deep roots in the UK and is now increasingly being seen in North America. “Probably over the last two to three years, we’ve started to become aware that this was moving into the Canadian market.” Earlier this month, Aviva issued a press release [warning](https://www.aviva.ca/en/press-releases/2024/ghost-brokers-alberta/) clients and brokers about a threat actor advertising on social media platforms like Facebook, falsely claiming to be affiliated with Aviva and selling fake insurance. Reflecting on the incident, Lee emphasized the importance of proactive measures: “We have been actively trying to identify where these ghost brokers are and create awareness for our customers as much as possible, because that’s really the best thing we can do is try and stop it before the customer even takes out the policy in the first place.” ## **How do ghost brokers operate?** Ghost brokers typically offer consumers insurance at unusually low prices, promising significant savings. However, this reality is far from true, as these devasting scams can cost unsuspecting victims in the long run. “One way these fraudsters operate is by taking the full payment from the customer upfront and keeping it without ever setting up a legitimate policy,” Lee explained. More commonly, ghost brokers take out policies for clients with insurance companies using falsified information to secure the lowest premiums possible. Lee shared: “They’ll tell customers they are fully covered for their property or vehicle, but when it comes time to file a claim, the details don’t match.” As a result, customers may find themselves financially responsible for claims they believed were covered. Ghost brokers also take advantage of informal communication channels, making it harder for customers to verify their legitimacy. Lee highlighted how these scammers often contact potential victims through social media platforms or messaging apps like WhatsApp or Facebook Messenger, often requesting cash payments or e-transfers. “Typically, they won’t have a professional website or a formal email address—often using personal accounts like Gmail or Hotmail,” Lee said. These fraudsters may even try to arrange to meet in public places rather than at an official office, which is another red flag customers should be wary of. ## **Tips for reporting suspicious activity** Brokers play a vital role in safeguarding their clients, colleagues, and the wider insurance industry. Key tips for brokers on how to report ghost broking activity include: - **Document everything:** Keep detailed records of any interactions with suspected ghost brokers, including names, contact information, and the nature of the communication. - **Contact regulatory bodies:** Report suspicious activities to the appropriate regulatory agencies, such as the insurance commission or authority in your jurisdiction. Provide them with all relevant details. - **Notify insurance providers:** Inform the insurance companies that may be involved. They can take action to investigate the fraudulent activities and warn other brokers and customers. - **Educate colleagues:** Share information about ghost brokers with fellow brokers to raise awareness and encourage them to report any suspicious activity they encounter. - **Use anonymous reporting channels:** If available, take advantage of anonymous reporting options offered by regulatory agencies or industry bodies to report ghost brokers without disclosing your identity. - **Follow up:** After reporting, follow up with the relevant authorities to ensure the issue is being addressed and to provide any additional information if necessary. **Topics:** Fraud General, Public Awareness --- ### [After Slip and Fall Fraud Trial US Asks For Another Month on Duncan Forfeiture New Info](https://insurancefraud.org/news_archives/after-slip-and-fall-fraud-trial-us-asks-for-another-month-on-duncan-forfeiture-new-info/) **Published:** August 24, 2026 **Author:** Diane Beauchamp **Content:** Bryan Duncan was convicted in a slip and fall insurance fraud conspiracy and has been awaiting sentencing, with restitution to be determined. On May 29 he called the Chambers voicemail of U.S. District Court for the Southern District of New York Judge Sidney H. Stein. Judge Stein ordered Duncan “to have no further direct contact with chambers,” and scheduled a July 10 proceeding. Inner City Press, which covered the trial, covered this as well. Duncan’s new lawyer Patrick Megaro, based in Florida and having now having tested positive for Coronavirus, on July 17 continued to argue for a reduction in restitution and to file exhibits under seal, which he has. He said he would appear by phone at Duncan’s sentencing on July 27. Now now on July 26, the day before already delayed sentencing, the US Attorney’s Office has asked for another month: ” Re: United States v. Bryan Duncan, S2 18 Cr. 289 (SHS) Dear Judge Stein: With the consent of counsel for the above-referenced defendant, the Government respectfully requests a one-month adjournment of the sentencing proceeding scheduled for tomorrow, July 27, 2020, at 11:00 am… Since July 17, the Government has been investigating the defendant’s arguments and, earlier this afternoon, learned information from a cooperating witness that may alter the Government’s position on forfeiture. Accordingly, and regrettably at this late hour, the Government respectfully requests a one-month adjournment of tomorrow morning’s sentencing proceeding. The adjournment will allow the Government to further investigate newly-obtained information about the percentage of fraudulent proceeds that are attributable to trip-and-fall cases verses non-trip-and-fall cases. Based on the defendant’s July 17 submission, the Government also intends to revise its request for restitution, but no further investigation is required on that score. The proposed adjournment will also allow defense counsel, who recently tested positive for COVID-19, to appear at the sentencing proceeding in person.” Will Judge Stein grant this? And what is in the sealed exhibits? Inner City Press will continue to report on this case. The case is US v. Duncan, 18-cr-289 (Stein) **Topics:** Healthcare Fraud **Categories:** Conviction --- ### [Centene agrees to pay Iowa $44 million to settle Medicaid fraud claims](https://insurancefraud.org/news_archives/centene-agrees-to-pay-iowa-44-million-to-settle-medicaid-fraud-claims/) **Published:** August 24, 2026 **Author:** Diane Beauchamp **Content:** Missouri-based Centene Corp. has agreed to pay Iowa $44.4 million to settle claims that it defrauded the state’s Medicaid system. That makes it the latest state to settle claims that were originally raised in Ohio in 2021. Centene, the nation’s largest Medicaid managed-care company, agreed to pay the money over claims that its subsidiary, Iowa Total Care, overbilled taxpayers for prescription drugs in transactions handled by a Centene-owned drug middleman, Envolve. Medicaid managed-care companies such as Iowa Total Care contract with state Medicaid agencies to sign up patients and create networks of providers such as doctors and dentists to care for them. Pharmacy benefit managers such as Envolve contract with such managed-care organizations to create lists of covered drugs, contract with pharmacies and reimburse them for the drugs they dispense. In March 2021, Ohio Attorney General Dave Yost sued his state’s Medicaid managed-care provider, Buckeye Health Plan. That suit accused the company of working through Envolve and another Centene-owned pharmacy middlemen to overcharge taxpayers by millions of dollars for prescription drugs. The investigation followed reporting in 2018 by The Columbus Dispatch showing that a year earlier, Buckeye charged the state $20 million for services provided by its drug middleman. [But those same services appeared to have been rendered by a separate company](https://stories.usatodaynetwork.com/sideeffects/taxpayers-may-paying-twice-medicaid-drug-services/) — CVS — that was also paid, the story said. Both Centene and CVS denied that they were double-dipping. In June 2021, just three months after the suit was filed, Yost and Centene announced a settlement agreement that would pay Ohio $88.3 million. Centene also announced that it was setting aside more than $1 billion to settle similar claims with as many as 20 more states. In August 2021 — just six months after the Ohio attorney general accused Centene of massive fraud against Ohio taxpayers — the Ohio Department of Medicaid signed a [new contract worth billions ](https://ohiocapitaljournal.com/2021/08/17/six-months-after-claiming-massive-fraud-ohio-awards-contract-worth-billions-to-health-giant/)with the company. The department justified the move by saying that it would no longer use the company for pharmacy benefit management services. Other states settling similar claims with Centene include Arkansas, Illinois, Kansas, Mississippi, New Hampshire, New Mexico, Texas, Oregon, Massachusetts and Washington. It’s unclear whether any of those states cut ties with the company over allegations of fraud. For its part, Centene has emphasized that in entering into the settlements, it wasn’t admitting wrongdoing. “We respect the deep and critically important relationships we have with our state partners,” [Iowa Public Radio](https://www.iowapublicradio.org/state-government-news/2022-12-15/iowa-announces-44-million-settlement-medicaid-managed-care-organization-centene) quoted a Centene statement as saying. “This no-fault agreement reflects the significance we place on addressing their concerns and our ongoing commitment to making the delivery of health care local, simple and transparent. Importantly, this allows us to continue our relentless focus on delivering high-quality outcomes to our members. **Topics:** Judicial/courts --- ### [Judge Denies Motion to Stop Health Data Scraping by Meta](https://insurancefraud.org/news_archives/judge-denies-motion-to-stop-health-data-scraping-by-meta/) **Published:** August 24, 2026 **Author:** Diane Beauchamp **Content:** A federal judge has denied granting a preliminary injunction sought against Meta to stop the company’s Pixel tracking code in third-party healthcare websites from allegedly collecting and disseminating patient information for advertising purposes. Plaintiffs in a proposed consolidated class action lawsuit in a San Francisco federal court sought the injunction, alleging that Facebook’s parent company violated medical privacy laws by obtaining data from its web tracking Pixel tool embedded into patient portals and scheduling apps. In his [ruling](https://ismg-cdn.nyc3.cdn.digitaloceanspaces.com/asset_files/external/orderdenyingpreliminaryinjunction-in-meta-case-dec-22-2022.pdf) on Thursday, U.S. District Judge William Orrick of the Northern District of California said that while the allegations against Meta are disturbing, the plaintiffs “do not meet the high standard required for a mandatory injunction” to be granted. “To secure a mandatory injunction … plaintiffs need to show ‘that the law and facts clearly favor \[their\] position, not simply that \[they are\] likely to succeed,”’ he wrote. “Our nation recognizes the importance of privacy in general and health information in particular: The safekeeping of this sensitive information is enshrined under state and federal law,” Orrick wrote. Meta’s core defense in the case is that the company has measures in place, including policies and filtering, to address the alleged receipt of sensitive health information scraped by Pixel from websites upon which the tracking code is used (see: [*Federal Judge Skeptical of Facebook in Patient Privacy Suit*](https://www.bankinfosecurity.com/federal-judge-skeptical-facebook-in-patient-privacy-suit-a-20446)). Meta argues that it would be “unfairly burdensome and technologically infeasible for the company to take further action,” the judge wrote. “In light of the systems in place that Meta has created to block receipt of this sensitive information and the factual uncertainties, it is too early to find that the public interest supports a mandatory injunction,” Orrick ruled. But he added, “Of course, my perspective may evolve as the factual record develops in the case.” ### Controversy Grows The [lawsuit](https://www.bankinfosecurity.com/lawsuit-facebook-collecting-patient-data-millions-a-19424) seeks damages and is part of a wave of pressure against Meta regarding its collection and use of medical data. The issue surfaced this summer following the U.S. Supreme Court’s decision to overturn precedent guaranteeing nationwide access to abortion. The ruling, known as Dobbs, increased concerns that tech companies track and possibly disclose individual health data to third parties. Sen. Mark Warner, D-Virginia, [wrote](https://www.bankinfosecurity.com/pressure-on-meta-mounts-over-pixel-collecting-health-data-a-20327) to Meta CEO Mark Zuckerberg in October to express concern over the company’s ability to use its website tracking tools to obtain sensitive health data, including medical conditions, appointment dates and treating physician names. So far, at least three healthcare entities have reported their use of Pixel as a [HIPAA](http://www.healthcareinfosecurity.com/hipaa-hitech-c-282) breach – North Carolina-based [WakeMed Health and Hospitals](https://www.bankinfosecurity.com/second-health-entity-reports-breach-tied-to-meta-pixel-use-a-20377); [Advocate Aurora Health](https://www.bankinfosecurity.com/health-entity-says-tracking-code-breach-affects-3-million-a-20315), a Midwest health system; and Indiana-based [Community Health Network](https://www.bankinfosecurity.com/indiana-health-entity-reports-breach-involving-tracking-code-a-20569). **Topics:** Judicial/courts, Technology --- ### [50 states sign up for Walmart's opioid settlement framework](https://insurancefraud.org/news_archives/50-states-sign-up-for-walmarts-opioid-settlement-framework/) **Published:** August 24, 2026 **Author:** Diane Beauchamp **Content:** Walmart said it has reached settlement agreements with all 50 US states as part of a $3.1 billion nationwide opioid settlement [announced last month.](https://www.cnn.com/2022/11/15/business/walmart-opioid-settlement/index.html) In November, the retailer [announced a settlement](https://www.cnn.com/2022/11/02/us/cvs-walgreens-walmart-opioid-settlement) from multiple states’ attorneys general that accused the company of failing to regulate opioid prescriptions contributing to the nationwide opioid crisis. The settlement, according to the office of New York Attorney General Letitia James, who co-led a coalition of attorneys general in the negotiation, will also “include broad, court-ordered requirements Walmart must comply with, such as robust oversight to prevent fraudulent prescriptions and flag suspicious prescriptions.” In this week’s announcement, Walmart said that the agreements with the 50 states “are intended to resolve substantially all opioids-related lawsuits brought by state and local governments against Walmart.” “Walmart believes these settlements are in the best interest of all parties and will provide significant aid to communities across the country in the fight against the opioid crisis, with aid reaching state and local governments faster than any other nationwide opioid settlement to date, subject to satisfying all settlement requirements,” the company said in the statement. Walmart added that it “strongly disputes the allegations in these matters, and these settlements do not include any admission of liability.” “Promising negotiations,” are still underway with other pharmacies including Walgreens and CVS, James’ office said last month. Those two chains have tentatively agreed to pay a combined $10 billion to settle lawsuits brought by states and local governments alleging the retailers mishandled prescriptions of opioid painkillers. US states, cities and counties have filed more than [3,000 lawsuits](https://www.cnn.com/2022/07/26/business/teva-settlement/index.html) against opioid manufacturers, distributors and pharmacies, accusing them of downplaying the addiction risk and failing to stop pills from being diverted for illegal use. More than 500,000 overdose deaths over the past two decades — including more than 80,000 in 2021 alone — are blamed on the [US opioid crisis](https://www.cnn.com/2017/09/18/health/opioid-crisis-fast-facts), government data show, with an estimated 9.5 million Americans age 12 and older reported in 2020 to have misused opioids, including 9.3 million prescription pain reliever abusers and 902,000 heroin users. **Topics:** Drug Diversion, Judicial/courts --- ### [Nearly 40% of Patients Find Medical Bills Confusing](https://insurancefraud.org/news_archives/nearly-40-of-patients-find-medical-bills-confusing/) **Published:** August 24, 2026 **Author:** Diane Beauchamp **Content:** Medical bills are more likely to come across as confusing than straightforward to patients, according to a YouGov **[survey](https://akasa.com/press/nearly-40-of-americans-confused-by-medical-bills/)** commissioned by revenue cycle firm AKASA. Responses were fielded from 2,206 Americans between March 9 and March 14, 2022, to gauge patient burden with the billing experience. The results show that patients are confused by bills in general and have frustrations with specific parts of the billing process. Nearly one in five respondents (19%) said bills were extremely confusing, while another 19% found bills somewhat confusing. On the other end of the spectrum, 11% answered that bills were not confusing at all and 14% leaned towards bills not being confusing. The most chosen answer, by 37% of respondents, was neutrality on the confusion of bills. **Topics:** Public Awareness --- ### [Insurance remains industry with the most global digital fraud growth](https://insurancefraud.org/news_archives/insurance-remains-industry-with-the-most-global-digital-fraud-growth-2/) **Published:** August 24, 2026 **Author:** Diane Beauchamp **Content:** For the second quarter in a row, the insurance industry saw the largest year-over-year growth in digital fraud attempts with an increase of 159% from Q2 2021 to Q2 2022, according to TransUnion’s latest quarterly fraud analysis report. In Q1 2022, the insurance sector saw a 134% growth in digital fraud from Q1 2021. The only other industry that saw an increase in digital fraud from Q2 2021 to Q2 2022 was logistics – a field which is impacted most by shipping fraud – with a 13% jump. The most common type of insurance fraud, they found, involved first-party application. First-party application fraud occurs when a person submits an application to an insurer containing false or manipulated information in order to receive certification, a lower rate or better terms for a policy. Despite the jump in fraudulent activity in insurance, TransUnion found that across all industries, global digital fraud actually decreased 14% from Q2 2021 to Q2 2022. “We have observed interesting trends in the first half of 2022 with suspected fraudulent activity in the insurance industry continuing to be elevated during the first six months of the year,” Shai Cohen, senior vice president of global fraud solutions at TransUnion, said in a release about the Q2 2022 report. “In recent years, we’ve seen fraudsters shift their industry focus each quarter. At this time, we believe the insurance industry is seeing more ‘soft fraud’ because some consumers may be representing their policies incorrectly in an effort to save money, especially in a high inflation environment that places more pressure on their wallets.” The industries in the United States that saw the largest declines in digital fraud year-over-year were gaming (-65%), gambling (-49%), retail (-32%) and financial services (-28%). “For industries experiencing stabilization of fraud instances, the focus has been identifying more of the good transactions and customers to allow them to pass with less friction,” Sean Donnelly, senior vice president and go-to-market global fraud solutions at TransUnion said in a press release. “Strong fraud and authentication practices decrease false positives and focus fraud-fighting resources on the minority of interactions that warrant scrutiny. By reducing the pool of manual reviews and customer interrogations, organizations can dramatically reduce costs, increase revenue, and improve the overall customer experience.” **Topics:** Public Awareness --- ### [Where health insurance premiums are rising and falling](https://insurancefraud.org/news_archives/where-health-insurance-premiums-are-rising-and-falling/) **Published:** August 24, 2026 **Author:** Diane Beauchamp **Content:** The cost of health care has been rising for years, but where you live heavily influences how much you pay, data compiled by consumer research company ValuePenguin shows. **The big picture:** [Private health insurance](https://www.axios.com/2022/08/25/health-prices-faster-private-sector-medicare) premiums are increasing in 36 states next year, with the cost of an individual health insurance plan for a 40-year-old on a silver plan increasing by 4% to an average cost of $560 a month. **By the numbers:** In Georgia, health insurance costs will jump more than 20%, but will cost a 40-year-old buying a silver plan $474 a month. - Those in Wyoming will see the highest costs, with the same level plan going up 15% to a cost of $882 a month. - Meanwhile, in New Hampshire, costs for that same plan will increase by 3% next year but will be the lowest in the nation at $372 a month. **Topics:** Public Awareness --- ### [North Dakota lawmakers urged to look at drug costs, fraud restitution](https://insurancefraud.org/news_archives/north-dakota-lawmakers-urged-to-look-at-drug-costs-fraud-restitution/) **Published:** August 24, 2026 **Author:** Diane Beauchamp **Content:** North Dakota lawmakers are scheduled to return to Bismarck early next month. They’ll hear calls to help older residents, with the cost of prescription drugs at the top of the list. State lawmakers debated how to deal with rising costs during the last session, including the adoption of [a price transparency program](https://www.insurance.nd.gov/prescription-drug-cost-transparency). But advocates say more needs to be done. Janelle Moos – advocacy director for AARP North Dakota – said based on their outreach, these costs remain a top concern, while adding it’s not just something that impacts those 50 and older. “The high cost of medicine impacts all North Dakotans,” said Moos, “and so we’re really looking at policies that could help continue to put some downward pressure on those prices.” An interim committee recently studied the issue, and a bill that surfaced calls for the creation of [a pilot program tied to the Public Employees Retirement System](https://ndlegis.gov/assembly/67-2021/interim/23-0092-01000.pdf). It would look at the top 25 costliest medications and compare them to Canadian prices with the hope of making them more affordable. Moos acknowledged that plans like these will encounter pushback from the pharmaceutical industry. More broadly, the Pharmaceutical Research and Manufacturers of America says such efforts will lead to fewer new cures and treatments. Meanwhile, as law enforcement and consumer advocates amplify warnings about scams and their impact on vulnerable residents, AARP is asking for a restitution fund. Moos said the prevalence of these cases should prompt compensation. “We’re not trying to make victims whole, but we’re really looking at ways to shine a light that consumer fraud is a crime,” said Moos. “And there are victims that are impacted by it, often losing hundreds of thousands of dollars.” Funding accessible and affordable housing, as well as safe and cost friendly long-term care services are other priorities of senior advocates. Lawmakers will have additional issues commanding their attention, including childcare improvements and debates over agriculture regulations. **Topics:** Legislative --- ### [CT pediatrician surrenders license to avoid criminal charges for illegally prescribing opioids](https://insurancefraud.org/news_archives/ct-pediatrician-surrenders-license-to-avoid-criminal-charges-for-illegally-prescribing-opioids/) **Published:** August 24, 2026 **Author:** Diane Beauchamp **Content:** An East Hartford pediatrician who served a federal sentence for illegally prescribing oxycodone and failing to pay more than $177,000 in employee withholding taxes to the IRS has voluntarily surrendered his medical license. Since Dr. Sheikh Ahmed, of Orange, who operated the East Hartford Medical Center, has turned in his license, the state Medical Examining Board on Tuesday agreed to drop its charges against him. If he tries to reinstate his license in the future, the charges will be deemed true, according to an affidavit from Ahmed. State Department of Public Health records accuse Ahmed of engaging in illegal and negligent conduct by prescribing oxycodone, an opioid painkiller, to people in exchange for money without examining them in 2017 and 2018. He also increased their dosage of the drug without justification, DPH records show. The U.S. State’s Attorney’s office said in 2020 that two people paid Ahmed $500 for 30-day supplies of oxycodone. It added that he counseled the people to increase the dosages gradually to avoid scrutiny from pharmacists. The ages of the people are unclear, but records show he treated adults as well as children. **Topics:** Drug Diversion **Categories:** Conviction --- ### [St. Albans Barracks / Home Improvement Fraud](https://insurancefraud.org/news_archives/st-albans-barracks-home-improvement-fraud/) **Published:** August 24, 2026 **Author:** Diane Beauchamp **Content:** STATE OF VERMONT DEPARTMENT OF PUBLIC SAFETY VERMONT STATE POLICE NEWS RELEASE CASE#: 22A2005816 RANK / TROOPER FULL NAME: Trooper Justin Wagner STATION: St. Albans CONTACT#: 802-524-5993 DATE/TIME: 10/12/2022 at approximately 10:21 AM INCIDENT LOCATION: Carpenter Hill, Georgia VIOLATION: Home Improvement Fraud ACCUSED: David Johnson AGE: 46 CITY, STATE OF RESIDENCE: Sheldon, VT SUMMARY OF INCIDENT: On October 12, 2022 at approximately 10:21 AM Vermont State Police – St. Albans was contacted in regard to possible home improvement fraud occurring on Carpenter Hill Rd. in the Town of Georgia. Through investigation, probable cause was found to charge 46-year-old David Johnson with Home Improvement Fraud. On 12/22/22 Johnson was issued a criminal citation to appear in Franklin County Superior Court to answer to the charge. COURT ACTION: Yes COURT DATE / TIME: 2/14/23 at 8:30 AM COURT: Franklin County Superior Court LODGED: No LOCATION: N/A BAIL: N/A MUG SHOT: No **Topics:** Contractor fraud **Categories:** Arrest --- ### [Retired teacher accused of killing younger boyfriend with antifreeze](https://insurancefraud.org/news_archives/retired-teacher-accused-of-killing-younger-boyfriend-with-antifreeze/) **Published:** August 24, 2026 **Author:** Diane Beauchamp **Content:** A retired Massachusetts schoolteacher was charged with murder last week after being accused of poisoning her boyfriend’s coffee shakes with antifreeze. Judy Church, 64, of Salisbury, appeared briefly in court on Friday, one day after she was arrested on suspicion of poisoning Leroy Fowler, 55, with ethylene glycol, WCVB reported. Church called emergency services shortly after 8 p.m. Nov. 11 to report that Fowler was in “medical distress,” according to records obtained by NBC Boston. Explaining to dispatchers that her boyfriend “must have ingested something,” Church alleged that he was “pulling the bedroom apart, and had a bloody nose.” Fowler was transferred to three different hospitals for care, where doctors eventually determined his kidneys were failing due to antifreeze poisoning. The discovery prompted Fowler’s family to contact police. Fowler was pronounced dead on Nov. 13. Investigators eventually discovered unidentified containers on surveillance footage around Church’s apartment. Fowler’s stepson, Michael Hawkins, told investigators that Fowler suggested “out of the blue” that Church was poisoning him just two weeks before. Fowler allegedly said he “‘felt better’” when he left Church’s home, but he still relied on her for most of his meals. Fowler’s sister, Tammy Carbone, reported similar suspicions, telling police that her brother claimed Church might be contaminating the coffee shakes she frequently made for him. Although Church’s motive remains unclear, Hawkins divulged to authorities that Fowler was known to “go back and forth” between Church and a second girlfriend. Citing court documents, NBC Boston alleged that Hawkins claimed to have overheard Church saying she “wanted to murder” the other girlfriend. Church also reportedly took out a life insurance policy on Fowler one year before his death. A common ingredient in antifreeze, ethylene glycol can be unknowingly ingested because of its syrupy texture and sweet flavor. Though symptoms of antifreeze poisoning can appear anywhere from 30 minutes to 12 hours after ingestion, even small amounts can be fatal. In a brief statement to the Daily Beast, Fowler’s son, also called Leroy, described his father as “a good guy.” “Not perfect but he was a good guy,” he said, noting that Fowler was especially close to his 8-year-old grandson. Church was denied bail on Friday. She is due back in court on Jan. 23 for a probable cause hearing. In a comment on Church’s Facebook page, Carbone expressed outrage over her brother’s fate. “I can’t wait to see \[Church’s\] face tomorrow when she can’t walk out \[of jail\],” the grieving sister wrote before Church’s arraignment. “To think she thought she could get away with it.” **Topics:** Life Insurance **Categories:** Arrest --- ### [Missouri man indicted on six counts of manufacturing and selling fake vehicle temporary tags](https://insurancefraud.org/news_archives/missouri-man-indicted-on-six-counts-of-manufacturing-and-selling-fake-vehicle-temporary-tags/) **Published:** August 24, 2026 **Author:** Diane Beauchamp **Content:** A man from St. Louis was arrested Thursday on an indictment that accuses him of manufacturing and selling fake temporary vehicle license tags. Mario C. Cooks, 34, was indicted in U.S. District Court in St. Louis Wednesday on six felony counts of fraudulent transfer of an authentication feature. The indictment says Cooks used a fake watermark and seal of the Missouri Department of Revenue on temporary motor vehicle license tags produced between June 28 and December 6. In a court-approved search, Thursday morning of Cooks’ home in the 5300 block of Claxton Avenue, the United States Secret Service, St. Louis Metropolitan Police Department, St. Charles Police Department, and the Missouri Department of Revenue seized computer equipment, counterfeit temporary motor vehicle documents, and counterfeit motor vehicle titles.Geographic Reference In an affidavit filed to obtain the search warrant, an agent of the U.S. Secret Service said the investigation began when police in St. Charles learned that Cooks was offering fraudulent temporary motor vehicle tags as well as a fraudulent license plate that appeared to have been issued by the State of Missouri to a licensed car dealership. An undercover police officer then purchased a series of fraudulent temporary motor vehicle tags and automobile insurance cards from Cooks, the affidavit says. Cook’s federal charge carries a penalty of up to five years in prison, a $250,000 fine, or both. The case was investigated by the St. Charles Police Department, the St. Louis Metropolitan Police Department, the U.S. Secret Service, and the Missouri Department of Revenue. Assistant U.S. Attorney Tracy Berry is prosecuting the case. **Topics:** Auto fraud **Categories:** Arrest --- ### [Taylor Regional Hospital Sued Over 2021-2022 Patient Data Breach](https://insurancefraud.org/news_archives/taylor-regional-hospital-sued-over-2021-2022-patient-data-breach/) **Published:** August 24, 2026 **Author:** Diane Beauchamp **Content:** Kentucky’s Taylor Regional Hospital faces a proposed class action over a data breach that reportedly lasted from November 2021 to January 2022. Taylor Regional Hospital faces a proposed class action over its alleged failure to reasonably safeguard the sensitive personal and health information of patients whose data was compromised in a cyberattack from November 2021 to January 2022. The 58-page [data breach lawsuit](https://www.classaction.org/data-breach-lawsuits) says patients’ first and last names, Social Security numbers, dates of birth, health insurance information, home addresses, and medical treatment details were stolen by cybercriminals in the months-long breach. Per the suit, Campbellsville, Kentucky-based Taylor Regional Hospital did not begin to notify victims until April of this year, five months after the data breach began. The suit claims the information was maintained by Taylor Regional “in a condition vulnerable to cyberattacks,” including through ransomware. According to the complaint, victims of the Taylor Regional Hospital data breach will face an increased risk of identity theft and fraud, possibly for the rest of their lives. To date, there has been “no assurance offered by Taylor Regional that all impacted Private Information or copies thereof have been recovered or destroyed,” the suit says. The plaintiff, a Liberty, Kentucky resident, was treated at Taylor Regional for a work-related injury, the case explains. According to the complaint, the man was unable to secure employment benefits earlier this year because another party, using his stolen information, was “able to fraudulently obtain” unemployment benefits in his name. “Plaintiff greatly values his privacy especially while receiving medical services and would not have paid the amount that he did to receive medical services had he known that Taylor Regional would negligently disclose his Private Information as it did,” the filing says. The suit shares that Taylor Regional discovered “unauthorized activity” on its computer systems in January and first provided notice to victims in April. In its notice, the hospital offered no explanation for the delay between its initial discovery of the incident and when it notified affected patients, the case says. This delay likely caused victims to “suffer\[\] harm they otherwise could have avoided had a timely disclosure been made,” the lawsuit contends. Further, the hospital’s notice itself was “woefully deficient” in that it lacked basic details about the cyberattack, including how Taylor Regional’s networks were accessed, whether the information was encrypted or otherwise protected, how the hospital learned of the breach, and how many patients were affected, among other specifics, the lawsuit states. To date, Taylor Regional has offered data breach victims no help as far as credit monitoring services, and instead “simply encourag\[ed\] \[victims\] to take on the task of monitoring their credit themselves,” the suit says. The lawsuit claims Taylor Regional’s failure to implement adequate cybersecurity measures is “especially egregious” given that the healthcare industry has, especially recently, been the target of scammers and hackers. Specifically, Taylor Regional failed to have in place a variety of anti-ransomware training tools, perform regular training, and “\[c\]raft and tailor different approaches to different employees” based on their knowledge of cybersecurity, the suit states. The lawsuit looks to cover all persons in the United States whose private information was compromised as a result of the Taylor Regional data breach discovered by the hospital around January 2022. **Topics:** Judicial/courts, Public Awareness, Technology --- ### [Millions to lose Medicaid coverage under Congress' plan](https://insurancefraud.org/news_archives/millions-to-lose-medicaid-coverage-under-congress-plan/) **Published:** August 24, 2026 **Author:** Diane Beauchamp **Content:** Millions of people who enrolled in Medicaid during the COVID-19 pandemic could start to lose their coverage on April 1 if Congress passes the $1.7 trillion spending package leaders unveiled Tuesday. The legislation will sunset a requirement of the COVID-19 public health emergency that prohibited states from booting people off Medicaid. The Biden administration has been under mounting pressure to declare the public health emergency over, with 25 Republican governors asking the president to end it in a letter on Monday, which cited growing concerns about bloated Medicaid enrollment. “This is a positive for states in terms of planning, however, this will come at the cost of some individuals losing their health care,” said Massey Whorley, a principal at health consulting firm Avalere. Millions are expected to be bumped from the program, which grants health care coverage to nearly 80 million low-income people throughout the country. The federal government will also wind down extra funds given to states for the added enrollees over the next year under the proposal. Many will be eligible for health insurance coverage through employers, the Affordable Care Act or, in the case of kids, the Children’s Health Insurance Program. Advocates have raised concerns about how states will notify enrollees if they are being kicked off the program and what their options are. The effort will be particularly challenging for some of the country’s poorest people, who may not have stable home address or access to internet or phone services to check their status. If passed, the spending package would allow states to start kicking people off the program as early as April, but require them to notify enrollees first. People who are on Medicaid should make sure their contact information is up to date on their accounts and that they check the mail frequently to keep an eye on their eligibility status as that April 1 date nears, said Robin Rudowitz, the director of Medicaid at Kaiser Family Foundation. “There is likely to be people who fall through the cracks,” she said. The move will free up additional funds, however, to pay for more stable health insurance coverage for children in low-income households by requiring states to keep those children on Medicaid for at least a year once they’ve enrolled. A push require states to extend Medicaid to new mothers for a 12-month period after giving birth, however, failed to make the cut. The District of Columbia and 27 states currently extend coverage for a 12-month period for postpartum mothers. The spending package also extends the telehealth flexibilities that were introduced during the COVID-19 pandemic and led health care systems around the country to overhaul their approach to deliver care by smartphone or computer more frequently. Under the proposal, the restrictions that once tightly governed telehealth care under Medicare will stay loosened through the end of 2024. That will give Congress more time to study telehealth and how widespread fraud is in this program, said Andrew Hu of the Bipartisan Policy Center, a Washington think tank, which has studied the use of telehealth during the pandemic. “We can get some more time to assess where the benefits are with telehealth,” Hu said. The Senate is expected to vote on the spending bill first, and Democrats are looking for support from at least 10 Republican senators to pass the measure before sending to the House for consideration. **Topics:** Legislative, Medicare/Medicaid, Public Awareness --- ### [New York State Department of Health: Thinking of Getting a Fraudulent COVID-19 Vaccination Card? You May Get Arrested](https://insurancefraud.org/news_archives/new-york-state-department-of-health-thinking-of-getting-a-fraudulent-covid-19-vaccination-card-you-may-get-arrested/) **Published:** August 24, 2026 **Author:** Diane Beauchamp **Content:** As the holiday season has kicked off a rise in COVID-19 cases and other respiratory illnesses, the New York State Department of Health is reminding New Yorkers that obtaining a fraudulent COVID-19 vaccination card not only doesn’t help protect them and others from becoming seriously ill or hospitalized with COVID-19, it is a serious crime that carries significant penalties. The Department’s Vaccination Complaint Investigations Team was recently honored by the Federal Law Enforcement Foundation for its work alongside the New York State Police, New York County District Attorney’s Office, and United States Postal Service Office of Inspector General in the investigation of numerous individuals for their role in a conspiracy that supplied forged COVID-19 vaccination cards to buyers through a popular social media platform. To date, fifteen defendants have been arrested and charged with felony offenses as a result of the investigation, including thirteen individuals who purchased the forged cards for their own use or purchased the cards and paid for the fraudulent vaccination information to be entered into New York’s immunization registry. “While I thank the Federal Law Enforcement Foundation for recognizing the efforts of our Department’s Vaccination Complaint Investigations Team and its partners in federal, state, and local law enforcement, this award should also serve as a warning to those who choose to engage in vaccine-related fraud that we will investigate and refer for prosecution anyone who creates, distributes, buys, or uses fraudulent proof of Covid-19 vaccinations,” **State Commissioner of Health Dr. Mary T. Bassett said.** “Simply put, it is illegal for people to fabricate, buy, sell, or use fake vaccination records—criminal conduct that endangers not only their own health but also that of their friends, family, and coworkers. When the offender works in the healthcare system, which is too often the case, the conduct puts at risk the safety of patients who may be particularly vulnerable and whose wellbeing the system exists to protect.” Including the initial August 2021 case recently recognized by the Federal Law Enforcement Foundation, the Department’s Vaccination Complaint Investigations Team has conducted investigations of vaccination fraud that have so far resulted in felony arrests in Albany, Bronx, Erie, Genesee, Monroe, New York, Oneida, Orange, Queens, Rensselaer, Suffolk, Ulster and Westchester counties. New Yorkers can report vaccine-related fraud by calling 833-VAX-SCAM (833-829-7226) or emailing <STOPVAXFRAUD@health.ny.gov>. All New Yorkers 6 months and older should [get vaccinated](https://covid19vaccine.health.ny.gov/) and get their [booster dose](https://covid19vaccine.health.ny.gov/booster-doses) when eligible. New Yorkers should continue to wear a mask where appropriate and follow all other health guidelines. COVID vaccines are widely available at pharmacies, local health departments, clinics, Federally Qualified Health Centers and other locations across the state. To schedule an appointment for a booster, New Yorkers should contact their local pharmacy, county health department, or healthcare provider; visit [vaccines.gov](https://www.vaccines.gov/); text their ZIP code to 438829, or call 1-800-232-0233 to find nearby locations. FDA fact sheets for recipients and caregivers on each vaccine are available: [Pfizer-BioNTech/Cominarty](https://www.fda.gov/emergency-preparedness-and-response/coronavirus-disease-2019-covid-19/pfizer-biontech-covid-19-vaccines#additional); [Moderna](https://www.fda.gov/media/144638/download); [Johnson & Johnson](https://www.fda.gov/media/146305/download); [Novavax](https://www.fda.gov/media/159897/download). The [COVID-19 website](https://coronavirus.health.ny.gov/home) has resources for the public, schools, adult care facilities and medical laboratories. More information about vaccine efficacy is available [here.](https://www.health.ny.gov/prevention/immunization/vaccine_safety/) **Topics:** COVID-19, Public Awareness --- ### [Brookline doctor Pankaj Merchia indicted for money laundering in two health care fraud schemes](https://insurancefraud.org/news_archives/brookline-doctor-pankaj-merchia-indicted-for-money-laundering-in-two-health-care-fraud-schemes/) **Published:** August 24, 2026 **Author:** Diane Beauchamp **Content:** A doctor from Brookline was indicted on Tuesday for money laundering and healthcare fraud, according to U.S. Attorney Rachael Rollins. Pankaj Merchia, 49, a sleep medicine physician of Brookline and of Boca Raton, Florida, was indicted on three counts of money laundering and one count of health care fraud, Rollins said. Merchia self-surrendered and was in federal court at 3 p.m. on Tuesday in Boston, according to the attorney. The indictment stated Merchia committed two different healthcare fraud schemes. The first was that Merchia had allegedly continued to bill former patients’ insurance companies for the use of sleep apnea machines (the CPAP and BiPap machines) for years after the former patients had stopped using the machines or returned them to Merchia’s office. According to the attorney, Merchia allegedly used the money he received from the fraud to buy an expensive house in Brookline. The second scheme Merchia allegedly committed was against a family member of a patient — the doctor allegedly billed the family member over $400,000 for a monthly CPAP machine rental, even though he knew the insurance carrier wouldn’t pay for treatment through a patient’s family member. The attorney said Merchia used the money from this scheme to wire transfer $250,000, and purchase at least $140,000 in securities, or stock. **Topics:** Healthcare Fraud **Categories:** Arrest --- ### [Cyberattacks in 2022 and what hospitals, health systems can learn going into 2023](https://insurancefraud.org/news_archives/cyberattacks-in-2022-and-what-hospitals-health-systems-can-learn-going-into-2023/) **Published:** August 24, 2026 **Author:** Diane Beauchamp **Content:** Between Jan. 1 and Oct. 31 of 2022, the HHS’ Office for Civil Rights [reported](https://ocrportal.hhs.gov/ocr/breach/breach_report.jsf) that 594 data breaches took place, with an average of 60 data breaches being reported each month. Most of these large breaches were [tied](https://www.beckershospitalreview.com/cybersecurity/8-largest-healthcare-data-breaches-of-2022-tied-to-vendors.html?utm_campaign=bhr&utm_source=website&utm_content=most-read) to third-party vendors. For instance, the largest healthcare data breach of this year has been [Advocate Aurora Health](https://www.beckershospitalreview.com/cybersecurity/advocate-aurora-health-says-pixel-data-breach-may-affect-3-million-patients.html), dually headquartered in Downers Grove, Ill., and Milwaukee. The health system reported that it had installed a third-party tracking tool, dubbed Meta Pixel, onto its website and patient portal, which in turn caused 3 million patient records to be compromised. The health system hasn’t been the only one to have installed a tracking tool that has compromised patient information. Hospitals such as Charlotte, N.C.-based [Novant Health](https://www.beckershospitalreview.com/cybersecurity/facebook-tracker-compromised-phi-of-1-3m-novant-health-patients.html) and Indianapolis-based [Community Health Network](https://www.beckershospitalreview.com/cybersecurity/community-health-network-s-pixel-breach-may-have-compromised-patient-data.html) have been transparent about the potential information breach via the “pixel” advertising tracking tools. While other health systems, such as Chicago-based Rush University System for Health; University of Chicago Medical Center; Raleigh, N.C.-based WakeMed; Durham, N.C.-based Duke Health; Northwestern Memorial Hospital in Chicago; UCSF Medical Center and Dignity Health, both in San Francisco; and Pittsburgh-based UPMC are [facing](https://www.beckershospitalreview.com/healthcare-information-technology/hospitals-transmitting-patient-data-to-twitter-facebook-5-things-to-know.html) patient-led lawsuits for allegedly using the tool that transmits personal information about their website visitors to social media sites such as Facebook, Instagram and Twitter. These breaches have spurred HHS to [release](https://www.beckershospitalreview.com/healthcare-information-technology/hhs-pixel-trackers-in-patient-portals-may-violate-hipaa.html) a bulletin stating that entities covered by HIPAA can’t use pixel trackers if they transmit protected health information without patient consent or if they don’t have a signed business associate agreement with the technology tracking vendors. While third-party data breaches have been the cause behind some of the biggest healthcare data breaches this year, ransomware attacks are still among the most common threats to the healthcare sector. According to FBI data, 25 percent of ransomware attacks in 2022 have been [targeted](https://www.beckershospitalreview.com/cybersecurity/25-of-ransomware-attacks-aimed-at-healthcare-industry-fbi-says.html) at the healthcare sector. In 2021, the healthcare and public health sector had the most ransomware reports of any of the 14 critical infrastructure industries, with 148 out of 649 attacks. One of the most prolific ransomware attacks on a healthcare organization this year occurred at the nation’s second-largest nonprofit hospital system, Chicago-based CommonSpirit Health. The health system was hit with a [ransomware attack](https://www.beckershospitalreview.com/cybersecurity/commonspirit-health-confirms-ransomware-attack.html) in October that forced its EHRs and payroll systems to go offline at many of its facilities across the country, as well as delayed patient care and surgeries at some of its affiliated hospitals. Since cyber threats only seem to be getting worse, healthcare executives as a whole are planning on increasing their cybersecurity budgets for increased training and infrastructure in 2023 in order to fend off these kinds of attacks, according to a recent [survey](https://www.ivanti.com/lp/security/assets/s1/2023-cybersecurity-status-report) from software firm Ivanti. **Topics:** Public Awareness, Technology --- ### [Medicare data breach affects up to 254,000 beneficiaries](https://insurancefraud.org/news_archives/medicare-data-breach-affects-up-to-254000-beneficiaries/) **Published:** August 24, 2026 **Author:** Diane Beauchamp **Content:** A recent data breach may have exposed the personally identifiable information and protected health information of up to 254,000 Medicare beneficiaries. On Dec. 14, The Centers for Medicare & Medicaid Services (CMS) issued a statement announcing that it responded to a data breach at Healthcare Management Solutions LLC (HMS). HMS is a subcontractor of ASRC Federal Data Solutions LLC and helps resolve system errors related to Medicare beneficiary entitlement and premium payment records, CMS says. The exposed information may have included names, addresses, dates of birth, phone numbers, Social Security numbers, Medicare beneficiary identifiers, banking information, including routing and account numbers and Medicare entitlement, enrollment and premium information, the CMS says. No claims data was exposed in the incident. As a result of the Medicare data breach, the agency notified Medicare beneficiaries whose information may have been put at risk that they will receive an updated Medicare card with a new Medicare Beneficiary Identifier. CMS will also offer free-of-charge credit monitoring services through Equifax Complete Premier credit-monitoring service. Medicare data breach caused by HMS violation, CMS says Initial information indicates that HMS acted in violation of its obligations to CMS, the agency says. It says it is not aware of any reports of identity fraud or improper use of information as a direct result of this incident so far. However, CMS asked that after beneficiaries receive their new cards, they destroy the old ones and inform providers that they have new cards. It also asks that people with concerns contact their financial institution and let them know their banking information may have been compromised. CMS is not currently facing legal action over the data breach, but Top Class Actions follows recalls closely as they sometimes lead to class action lawsuits. Dropbox, U.S. Bank, Bed Bath & Beyond, Verizon, Microsoft, Michigan Medicine and Advocate Aurora all recently experienced data breaches. **Topics:** Public Awareness, Technology --- ### [Six Data Breaches Reported by Healthcare Providers and Business Associates](https://insurancefraud.org/news_archives/six-data-breaches-reported-by-healthcare-providers-and-business-associates/) **Published:** August 24, 2026 **Author:** Diane Beauchamp **Content:** Work Health Solutions, a San Jose, CA-based occupational health services provider, has confirmed that the protected health information of 13,157 individuals has been exposed and potentially obtained by unauthorized individuals who had access to an employee email account between February 16, 2-022 and March 24, 2022. Following an investigation by third-party cybersecurity professionals, Work Health Solutions determined that the email account contained files that included the information of individuals who had received services from the company. The manual review of those files concluded on October 11, 2022. Work Health Solutions then verified contact information and sent notifications on November 9, 2022. The exposed files contained names, Social Security numbers, driver’s license numbers, health insurance information, and/or medical information. Complimentary credit monitoring services have been offered to individuals whose Social Security numbers were potentially compromised. Work Health Solutions said it continuously evaluates and modifies its practices to improve privacy and security, which includes educating its workforce regarding privacy matters. ## Epic Management Email Account Breach Affects More Than 10,500 Individuals The healthcare management company, Epic Management LLC, has recently announced that unauthorized individuals gained access to its digital environment and accessed files and data stored in its email system. Epic Management did not disclose when the breach occurred but said the review of affected files was complex and time-consuming, and that process was completed on December 9, 2022. The information in the email system included first and last names, dates of birth, Social Security numbers, health insurance information, medical information, driver’s licenses, passport numbers, financial account numbers and routing numbers, biometric data, usernames and passwords, and/or payment card numbers and expiration dates and/or security codes. Credit monitoring and identity theft protection services have been offered to individuals whose Social Security numbers were exposed and updates have been made to its cyber environment to prevent similar incidents in the future. ## NYC Health + Hospitals Alerts Patients About Loss of Device Containing PHI NYC Health + Hospitals says a defective hard drive that contained the protected health information of 2,174 patients was discovered to be missing from a visual field testing device located at its NYC Health + Hospitals/Woodhull facility in Brooklyn, NY. Because the drive could not be located it was not possible to tell if the data on the device could be accessed, but it was confirmed that the device contained patients’ names, dates of birth, medical record numbers, and visual field test results. In response, NYC Health + Hospitals has re-educated staff on its policy for the proper chain of custody for devices containing protected health information when those devices are taken out of service. Further, a new policy has been implemented that requires PHI to be removed from visual testing devices on a regular basis. [Training](https://www.hipaajournal.com/hipaa-training-requirements/) has also been enhanced to ensure all employees are aware of the need to promptly notify officials about potential breaches of PHI. ## Missouri Law Firm Discovers Unauthorized System Access Polsinelli PC, a Kansas City, MO-based law firm that provides corporate legal services to hospitals, says files that contained patient information were accessed on September 9, 2022, from two locations by unauthorized individuals. A third-party cybersecurity firm was engaged to investigate the breach and determined that its network and main document repository were not affected; however, the files that were accessed included limited patient information, including names, addresses, Social Security numbers, birth dates, medical record numbers, patient account numbers, health insurance information, and very limited clinical information. Patients of St. Luke’s Health Brazosport are known to have been affected. Credit monitoring and identity theft protection services have been offered to individuals whose Social Security numbers were involved, although the law firm does not believe that any of the compromised information will be used for identity theft or fraud. The breach has been reported to the HHS’ Office for Civil Rights as affecting 1,220 individuals. ## Patient Data Exposed in Cyberattack on Hawaiian Eye Center Hawaiian Eye Center in Wahiawa, HI, has recently started notifying certain patients that some of their protected health information was stored on a server that was accessed by unauthorized individuals. The server was discovered to be unresponsive on November 2, 2022, with the investigation confirming the server and the network had been accessed by an unauthorized individual. The investigation confirmed that files containing patient information had been exfiltrated from its system by the attackers. Those files contained names, addresses, email addresses, dates of birth, Social Security Numbers, driver’s license numbers, medical record numbers, and health insurance information. Affected individuals have been notified and provided with single-bureau credit monitoring services. Third-party cybersecurity experts have been engaged to conduct a review of its security practices and systems, and appropriate upgrades will be implemented to prevent further incidents in the future. The [HIPAA](https://www.hipaajournal.com/hipaa-compliance-checklist/) breach has been reported to the HHS’ Office for Civil Rights as affecting 14,524 individuals. ## The Elizabeth Hospice Identifies Insider Data Breach The Elizabeth Hospice, a non-profit hospice with locations in Carlsbad, Escondido, San Diego, and Temecula, CA, has discovered that a former employee had been forwarding emails from her work email account to a personal account while she was employed by the hospice. A review of the emails was completed on November 14, 2022, and confirmed they contained first and last names, dates of admission, dates of discharge, patient account numbers, and basic health information. The Elizabeth Hospice said it is unaware of any actual or attempted misuse of patient data but has advised affected individuals to be vigilant and monitor their accounts and statements for unauthorized activity. The HHS’ Office for Civil Rights breach portal indicates 35,496 individuals were affected. **Topics:** Public Awareness, Technology --- ### [Health care giant pays Iowa $44M to settle fraud claims with Iowa](https://insurancefraud.org/news_archives/health-care-giant-pays-iowa-44m-to-settle-fraud-claims-with-iowa/) **Published:** August 24, 2026 **Author:** Diane Beauchamp **Content:** The nation’s largest Medicaid managed-care company last week agreed to pay Iowa $44.4 million to settle claims that it defrauded the state’s Medicaid system. That makes it the latest state to settle claims that were originally raised in Ohio in 2021. St. Louis-based Centene agreed to pay the money over claims that its subsidiary, Iowa Total Care, overbilled taxpayers for prescription drugs in transactions handled by a Centene-owned drug middleman, Envolve. Medicaid managed-care companies such as Iowa Total Care contract with state Medicaid agencies to sign up patients and create networks of providers such as doctors and dentists to care for them. Pharmacy benefit managers such as Envolve contract with such managed-care organizations to create lists of covered drugs, contract with pharmacies and reimburse them for the drugs they dispense. In March of 2021, Attorney General Dave Yost sued Ohio’s Medicaid managed-care provider, Buckeye Health Plan. That suit accused the company of working through Envolve and another Centene-owned pharmacy middlemen to overcharge taxpayers by millions of dollars for prescription drugs. The investigation followed reporting in 2018 by The Columbus Dispatch showing that a year earlier, Buckeye charged the state $20 million for services provided by its drug middleman. [But those same services appeared to have been rendered by a separate company](https://stories.usatodaynetwork.com/sideeffects/taxpayers-may-paying-twice-medicaid-drug-services/) — CVS — that was also paid, the story said. Both Centene and CVS denied that they were double-dipping. In June of 2021, just three months after the suit was filed, Yost and Centene announced a settlement agreement that would pay Ohio $88.3 million. Centene also announced that it was setting aside more than $1 billion to settle similar claims with as many as 20 more states. In August of 2021 — just six months after the Ohio attorney general accused Centene of massive fraud against Ohio taxpayers — the Ohio Department of Medicaid signed a [new contract worth billions ](https://ohiocapitaljournal.com/2021/08/17/six-months-after-claiming-massive-fraud-ohio-awards-contract-worth-billions-to-health-giant/)with the company. The department justified the move by saying that it would no longer use the company for pharmacy benefit management services. Other states settling similar claims with Centene include Arkansas, Illinois, Kansas, Mississippi, New Hampshire, New Mexico, Texas, Oregon, Massachusetts and Washington. It’s unclear whether any of those states cut ties with the company over allegations of fraud. For its part, Centene has emphasized that in entering into the settlements, it wasn’t admitting wrongdoing. “We respect the deep and critically important relationships we have with our state partners,” [Iowa Public Radio](https://www.iowapublicradio.org/state-government-news/2022-12-15/iowa-announces-44-million-settlement-medicaid-managed-care-organization-centene) quoted a Centene statement as saying. “This no-fault agreement reflects the significance we place on addressing their concerns and our ongoing commitment to making the delivery of health care local, simple and transparent. Importantly, this allows us to continue our relentless focus on delivering high-quality outcomes to our members.” **Topics:** Judicial/courts, Public Awareness --- ### [Government watchdog warns of Medicare fraud after relaxing provider requirements](https://insurancefraud.org/news_archives/government-watchdog-warns-of-medicare-fraud-after-relaxing-provider-requirements/) **Published:** August 24, 2026 **Author:** Diane Beauchamp **Content:** A government watchdog agency is urging federal health regulators to speed up checks on providers and conduct background checks after raising concerns about the risk for fraud following the coronavirus pandemic. The CMS relaxed provider enrollment requirements during the pandemic to ensure continuity for both providers and enrollees during the public health emergency. However, a report from the Government Accountability Office raised concerns about the fraud risk some of these providers may pose to the program. The GAO found that about 222,000 providers were able to enroll between March 2020 and March 2022 through the relaxed requirements. Suppliers of durable medical equipment represented a small share of those who enrolled during this period but represented 83% of those who were later revoked from the Medicare program by the CMS. “While this is not a large share of enrollments, [even a small number of providers can cause significant financial harm](https://www.gao.gov/products/gao-23-105494?utm_source=onepager&utm_medium=email&utm_campaign=email_hc_medicareproviderwaivers) if they commit fraud,” the GAO said in its report released Monday. The GAO is recommending that the CMS conduct background checks on high-risk providers who enrolled during the public health emergency, speed up provider checks and evaluate its own performance to inform policies for future emergencies. Florida, California and Texas were home to the largest number of durable medical equipment suppliers enrolled during the pandemic who were later revoked from the program. The Medicare program is expected to spend roughly $940 billion on healthcare services for 65 million members in 2022, and the GAO estimates a total of $47 billion in improper payments. **Topics:** Public Awareness, Regulatory actions --- ### [Brookfield Counselor Pleads Guilty to Fraudulently Receiving $1 Million From Medicaid](https://insurancefraud.org/news_archives/brookfield-counselor-pleads-guilty-to-fraudulently-receiving-1-million-from-medicaid/) **Published:** August 24, 2026 **Author:** Diane Beauchamp **Content:** A man who owned and operated a Brookfield counseling business has pleaded guilty to defrauding Medicaid of more than $1 million, according to the U.S. Attorney’s Office. Federal officials said 50-year-old Gregory Banks, of Brookfield, is facing charges for healthcare fraud. Court documents show that Banks, who owns North East Counseling & Trauma Services and Gregory Banks Counseling LLC, submitted fraudulent claims to Medicaid for counseling services that he says were provided to patients. This happened between Jan. 2018 and July 2022. Officials said Banks submitted claims for dates of services when no services were provided. Court documents state that Banks was enrolled individually as a Medicaid provider, but his companies were not. In Oct. 2020, the state Department of Social Services audited Banks and his businesses. During the process, Banks allegedly made multiple false statements in an effort to delay the progress of the audit. He defrauded Medicaid of $1.044 million and as a part of his plea, he’s agreed to pay back the full amount, according to officials. A sentencing date has been set for March 13, 2023 and he faces up to 10 years in prison. The incident remains under investigation. **Topics:** Medicare/Medicaid **Categories:** Conviction --- ### [North Texan Pair Arrested For Alleged COVID-19 Related Fraud](https://insurancefraud.org/news_archives/north-texan-pair-arrested-for-alleged-covid-19-related-fraud/) **Published:** August 24, 2026 **Author:** Diane Beauchamp **Content:** On Thursday, December 15, a North Texan pair was charged with submitting fraudulent COVID-19 testing claims to multiple insurance agencies, as announced in an official statement by U.S. Attorney for the Northern District of Texas Leigha Simonton. According to court documents, the duo managed to allegedly get over $7 million in the scheme. Terrance Bernard, 39 and Connie Jo Clampitt, 51 were indicted on Dec. 5 on charges of committing healthcare fraud, aggravated identity theft and conspiracy to commit money laundering. The defendants allegedly set up a scheme where Bernard would take advantage of his position as a contract lab technician in several medical clinics to gather patients’ personal information including names, addresses, dates of birth and most importantly for the scheme, insurance subscriber information. Once the information was collected, Clampitt would allegedly inform the patients’ insurers that they had COVID-19 testing performed at sophisticated diagnostic labs which resulted to be nonexistent, as were the testings. Once the pair allegedly received the fraudulently-obtained reimbursement checks, they deposited them in bank accounts they opened for the fake laboratories, to later transfer the proceeds into personal accounts. The indictment alleges they later used the money to purchase real estate and luxury vehicles. “Since the start of this pandemic, the Justice Department has seized over $1.2 billion in relief funds that criminals were attempting to steal, and charged over 1,500 defendants with crimes in federal districts across the country,” Attorney General Merrick B. Garland said in a statement. According to the Department of Justice, pandemic-related fraud has been so rampant it made the establishment of COVID-19 Fraud Strike Force Teams comprised of prosecutors and agents from the Department of Labor Office, the Small Business Administration Office, the Department of Homeland Security Office, the FBI, the U.S. Secret Service, Homeland Security Investigations, Internal Revenue Service Criminal Investigations and the U.S. Postal Inspection Service. “The COVID-19 pandemic has presented the most challenging circumstances our healthcare providers and insurers have faced in generations,” said U.S. Attorney Leigha Simonton. “Schemes to financially exploit the system when providers and insurers are facing these monumental challenges must be dismantled, and those responsible must be held to account.” After being arrested last Thursday, the defendants made their initial appearances Friday morning and pleaded not guilty to all charges. If convicted, the pair faces up to ten years in federal prison for each count of healthcare fraud, conspiracy to commit healthcare fraud, conspiracy to commit money laundering and up to two years in federal prison for each count of aggravated identity theft. **Topics:** COVID-19 **Categories:** Arrest --- ### [Wichita daughter, father plead guilty to thousands in Medicaid fraud](https://insurancefraud.org/news_archives/wichita-daughter-father-plead-guilty-to-thousands-in-medicaid-fraud/) **Published:** August 24, 2026 **Author:** Diane Beauchamp **Content:** A father and daughter pair from Wichita has pleaded guilty to thousands of dollars in Medicaid fraud. Kansas Attorney General Derek Schmidt says that Kyla Kongvongsay, 22, of Wichita, has pleaded guilty and been sentenced to repay more than $16,000 to the Kansas Medicaid system for convictions on two Medicaid fraud charges. AG Schmidt indicated that Kongvongsay pleaded guilty on Friday, Dec. 16, in Sedgwick Co. District Court to one count of making a false claim, statement or representation to the Medicaid program and one count of unlawful acts concerning computers. Retired Judge Ben Burgess accepted the plea to the two misdemeanors and sentenced her to repay a total of $16,089.67 and to serve 12 months of supervised probation. Schmidt noted that an investigation found that Kongvongsay and her father, Johnson Kongvongsay, at different points were working as personal care assistants for a relative who was a Medicaid beneficiary. It found that the pair had submitted false claims and purported to be providing personal care services when they were actually working other jobs. Investigators found they committed $30,947.45 worth of fraud. The AG said Johnson pleaded guilty on Thursday to the same charges. Judge Kevin O’Connor accepted this plea and scheduled sentencing for Jan. 26. Schmidt said the cases are being jointly investigated by federal and state authorities and prosecuted by the Medicaid Fraud and Abuse Division. **Topics:** Medicare/Medicaid **Categories:** Conviction --- ### [7 Ways to Avoid Predatory Towing Companies](https://insurancefraud.org/news_archives/7-ways-to-avoid-predatory-towing-companies/) **Published:** August 24, 2026 **Author:** Diane Beauchamp **Content:** Companies that engage in disreputable towing — sometimes referred to as predatory towing — practices are preying on trucks in areas known to have an elevated frequency of crashes. They may even use nefarious means to contribute to likelihood of an accident. This is the latest scam affecting long haul and moving and storage trucking. Case in point: A driver recently incurred significant damage when attempting to drive their tractor trailer under a Chicago bridge, whose “low bridge” sign had been suspiciously removed. As soon as the accident happened, an unsolicited tow truck appeared. In the driver’s distress and haste to rectify the situation as quickly as possible, the driver accepted towing services without a quote. Soon after, the moving and storage company received a bill for the $75,000 towing, a service that should have cost around $2,500.[\[1\]](https://www.insurancejournal.com/blogs/iat/2022/12/20/699896.htm#_ftn1) While predatory towing scams like this and others are occurring around the country and raising concerns amongst fleets,[\[2\]](https://www.insurancejournal.com/blogs/iat/2022/12/20/699896.htm#_ftn2) they have been particularly prominent in Chicago. So much so that Chicago’s City Council’s Committee on License and Consumer Protection passed an ordinance calling on the city to establish a license for tow truck operators to corral rogue tow truck drivers who rush to accident scenes, snare damaged vehicles and hold them hostage until rattled truckers pay exorbitant fees*.*[\[3\]](https://www.insurancejournal.com/blogs/iat/2022/12/20/699896.htm#_ftn3) ## 7 Best practices for fleet carriers Fleets and truckers must protect themselves against tow truck companies that run illegal or unethical operations. The following best practices offer key guidance for your fleet. 1. **Plan your routes.** Don’t let your truckers wing it when they are picking up goods or hauling a load. Proper route planning will not only ensure safety and increase driving efficiency by avoiding both known and unknown hazards but will also incorporate breaks and help determine the best route depending on what time of day a trucker is on the road. Digital route planning tools are available to help with this as well.[\[4\]](https://www.insurancejournal.com/blogs/iat/2022/12/20/699896.htm#_ftn4) 2. **Be suspicious.** Towing companies standing by on the scene when an incident occurs is not the norm. Train your drivers to be on the lookout for scamming tow trucks waiting in the wings. Prepare your drivers before an accident takes place to alleviate unnecessary stress; inform them that they may not be responsible for the underpass they just clipped if the low bridge sign was illegally removed, for example. That information should help them think more clearly in these situations. 3. **Call the police.** Summon them to the scene and request an accident report. If this does happen to you or one of your drivers, ask local police at the scene for guidance on selecting reputable, local towing company. 4. **Get it in writing.** Make sure the cost of a tow is in writing — not open-ended — with all charges clearly itemized. Avoid verbal agreements at all costs. Signed documents with clear cost pricing is essential to protecting the fleet from being scammed. Ask for the towing company’s business license and, if possible, confirm the information before accepting any assistance. 5. **Have protocols in place** for dealing with accidents. This includes contacting managers and dispatchers right away, calling the police and preventing drivers from signing or authorizing a tow without management approval. Providing drivers clear protocols beforehand significantly reduces the probability of making a mistake when a tow is required. 6. **Consider partnering with towing companies.** Establishing agreements with national or local towing companies where your fleet frequents can help your organization sidestep dishonest tow trucks. With such agreements already in place, truckers can immediately contact these companies, avoiding the need to source one on the spot. 7. **Report to local officials.** If your driver or fleet falls prey to a shady towing incident, reach out to local officials for support. Reporting all of these incidents will help local jurisdictions take regulatory action to prevent this from happening again, as they did in Chicago. ## Towing costs Even with all these precautions in place, towing is expensive. Factors like the weight and size of the truck and the distance to be towed legitimately impact the price. Consequently, fleets should also not assume they are dealing with a nefarious towing company if they are looking at an expensive quote. Due to the rise in these scenarios, the American Transportation Research Institute is asking motor carriers and drivers to participate in data collection on the impact of predatory towing. Find the link to the short survey [here](https://www.research.net/r/ATRI-Pred-Towing-Survey). **Topics:** Public Awareness, Towing Fraud --- ### [Attorney General James Secures Over $2 Million in Medicaid Settlement from Western New York Doctor to Resolve Findings of Illegal Billing](https://insurancefraud.org/news_archives/attorney-general-james-secures-over-2-million-in-medicaid-settlement-from-western-new-york-doctor-to-resolve-findings-of-illegal-billing/) **Published:** August 24, 2026 **Author:** Diane Beauchamp **Content:** New York Attorney General Letitia James today announced that her office [has reached a civil settlement with Dr. David B. DiMarco, M.D. and his companies D.B. DiMarco, M.D., P.C. (D.B. DiMarco) and DiMarco Vein Centers LLC (DiMarco Vein Centers)](https://ag.ny.gov/sites/default/files/mfcu_dimarco_settlement_exhibit.pdf), securing more than $2 million for Medicaid. The settlement resolves an investigation by the Office of the Attorney General (OAG) into illegal Medicaid billing practices for vein treatments performed by Dr. DiMarco. The OAG found that Dr. DiMarco submitted more than 1,000 claims for procedures to Medicaid without sufficient documentation to show what procedures were actually performed or why the procedures were medically necessary, resulting in overpayment of Medicaid reimbursement. As a result of the settlement announced today, DiMarco will pay $2,139,037 to Medicaid and he will also withdraw from the New York State Medicaid program. “When providers scam Medicaid, they take resources and medical care away from New Yorkers in need,” said **Attorney General James**. “My office investigated Dr. DiMarco’s illegal billing practices, and now we are returning more than $2 million in critical funding to the Medicaid program. My office will continue to hold Medicaid providers accountable to ensure we protect the integrity of this critical program.” Dr. DiMarco owns D.B. DiMarco and DiMarco Vein Centers, medical practices with several locations in Western New York, including Lakewood, Olean, and Ellicottville. The OAG found that, between March 2015 and October 2021, Dr. DiMarco submitted claims to Medicaid for procedures without adequate documentation. The OAG investigation into these claims found that Dr. DiMarco’s records did not show which procedures were actually performed, nor did they indicate why the procedures were medically necessary and thus eligible for Medicaid reimbursement. The investigation was initiated by MFCU Lead Data Scientist Si Lok Chao, under the supervision of Director of Data Analytics Michael Wassell, and was conducted by Research Analyst Brandon Andrews and Detective Investigator Chris Canfield, under the supervision of Detective Supervisor James Zablonski and Deputy Chief Investigator William Falk. Both the investigation and settlement were handled by Special Assistant Attorneys General Soo-young Chang of the MFCU Buffalo Regional Office and Logan J. Gowdey of the MFCU Civil Enforcement Division. The Buffalo Regional Office is led by Buffalo Regional Director Maura O’Donnell and the Civil Enforcement Division is led by Civil Enforcement Division Chief Alee N. Scott. MFCU is a part of the Division for Criminal Justice and is led by Director Amy Held and Assistant Deputy Attorney General Paul J. Mahoney. The Division for Criminal Justice is overseen by Chief Deputy Attorney General José Maldonado and First Deputy Attorney General Jennifer Levy. **Reporting Medicaid Provider Fraud:** MFCU defends the public by addressing Medicaid provider fraud and protecting nursing home residents from abuse and neglect. If you have information about Medicaid provider fraud or know about abuse or neglect of a nursing home resident, please [file a confidential complaint online](https://urldefense.com/v3/__https:/lnks.gd/l/eyJhbGciOiJIUzI1NiJ9.eyJidWxsZXRpbl9saW5rX2lkIjoxMDAsInVyaSI6ImJwMjpjbGljayIsImJ1bGxldGluX2lkIjoiMjAyMjA4MDEuNjE2MDE2ODEiLCJ1cmwiOiJodHRwczovL2FnLm55Lmdvdi9tZWRpY2FpZC1mcmF1ZC9jb250YWN0In0.oHimSQcYvqgbFTVcVu2gShlQZkE2AHSyOhRI_VlXONE/s/777987213/br/141882064160-l__;!!Ke5ujdWW74OM!9ccccvOysMSWUbItFiIMTdMGVYXWXL7V30oOMsGLCBxrJ3qkBypGVyn_cHPl0HI7yLgYD0f3Qu9_-dw6rv8xB81jvfkYiSbRMpNvbL8Y%24) or call the MFCU hotline at (800) 771-7755. If the situation is an emergency, please call 911. New York MFCU’s total funding for federal fiscal year (FY) 2023 is $65,717,936. Of that total, 75 percent, or $49,288,452, is awarded under a grant from the U.S. Department of Health and Human Services. The remaining 25 percent, totaling $16,429,484 for FY 2023, is funded by New York state. Through MFCU’s recoveries in law enforcement actions, it regularly returns more to the state than it receives in state funding. **Topics:** Judicial/courts, Medicare/Medicaid, Public Awareness --- ### [Class Action Data Breach Lawsuit Settled by Morley Companies](https://insurancefraud.org/news_archives/class-action-data-breach-lawsuit-settled-by-morley-companies/) **Published:** August 24, 2026 **Author:** Diane Beauchamp **Content:** Morley Companies has agreed to settle a class action lawsuit filed on behalf of individuals affected by a major data breach that occurred on or around August 1, 2022. A fund of $4.3 million has been created to cover claims from individuals affected by the data breach. On or around August 1, 2021, Morley Companies, a Saignaw, MI-based provider of business services, suffered a [cyberattack](https://www.hipaajournal.com/phi-of-521000-individuals-compromised-in-security-breach-at-morley-companies/) in which hackers gained access to parts of its network. Morley Companies said the attack prevented access to its information systems when files were encrypted, with the investigation confirming that the attackers exfiltrated files containing protected health information. Approximately 628,000 breach notification letters were mailed, and the breach was reported to the HHS’ Office for Civil Rights as involving the protected health information of 521,046 individuals. The breached information included names, addresses, Social Security numbers, birthdates, client identification numbers, medical diagnostic and treatment information, and health insurance information. Morley Companies accepts no liability for the incident and has admitted no wrongdoing but chose to settle the lawsuit to avoid further legal costs and the uncertainty of trial. Under the terms of the settlement, class members can submit a claim to receive reimbursement of up to $2,500 for documented out-of-pocket expenses that are reasonably traceable to the cyberattack and data breach. These can include unreimbursed losses relating to fraud or identity theft, professional fees including attorneys’ and accountants’ fees, and fees for credit repair services, costs associated with freezing or unfreezing credit with any credit reporting agency, credit monitoring costs incurred on or after August 1, 2021, and miscellaneous expenses such as notary, data charges, fax, postage, copying, mileage, cell phone charges, and long-distance telephone charges (conditions apply). Class members can also claim up to four hours of lost time at a rate of $20 per hour, and residents of California at the time of the breach can claim a payment of $75. In addition, individuals who did not previously claim the credit and identity monitoring services provided by Morley Companies through IDX will be provided with a new offer and activation code valid for 90 days to claim 3-bureau credit monitoring for a three-year period from the effective date of the settlement. Class members will also be provided with a one-year membership to the Dashlane password management service. Class members have until February 7, 2023, to object to or exclude themselves from the settlement. Claims must be submitted by March 20, 2023. The final approval hearing for the settlement has been scheduled for April 19, 2023. **Topics:** Judicial/courts, Public Awareness --- ### [Settlement: Scripps Health agrees to pay $3.5 million to patients affected in 2021 data breach](https://insurancefraud.org/news_archives/settlement-scripps-health-agrees-to-pay-3-5-million-to-patients-affected-in-2021-data-breach/) **Published:** August 24, 2026 **Author:** Diane Beauchamp **Content:** Scripps Health has agreed to pay more than $3.5 million dollars to victims of a [massive data breach last year ](https://www.cbs8.com/article/news/health/lingering-frustration-for-patients-amid-scripps-cyber-attack/509-cf4d5020-c62e-4e1a-ac5c-2a11cb20e162)that compromised the personal information of more than one million patients. CBS 8 obtained a copy of the settlement agreement, which still needs the judge’s approval. The May 1, 2021 ransomware attack crippled the healthcare company’s computer system. In the breach, hackers obtained customers’ health information and personal financial data and placed more than one million people at risk of identity theft. Scripps’ computer system was impacted for nearly a month as the company scrambled to prevent additional data breaches from occurring. Since the May 1 breach, Scripps’ customers whose information was obtained [began filing class action lawsuits](https://www.cbs8.com/article/news/health/scripps-data-breach-new-letters-sent-to-patients/509-4a3b29bd-f0e7-490d-9f0e-77f12cd4a9e9) against the healthcare provider. In recent months, Scripps and attorneys for the patients have agreed to end the lawsuit. As part of the agreement, Scripps Health has agreed to pay $3.57 million in “minimum cash settlements” of $100 for each plaintiff. In addition, the healthcare company will pay up to $7,500 to those whose identities were stolen and who qualified for, according to the settlement, “extraordinary out-of-pocket expenses.” In addition, Scripps has also agreed to provide credit monitoring and identity theft protection to the nearly 1.2 million people who joined the lawsuit. In a statement to CBS 8, a spokesperson for Scripps stated, “Since the incident, Scripps has notified impacted parties, conducted a full investigation, and implemented a variety of additional safeguards to help reduce the likelihood of a similar incident occurring again. As a reminder, there was no unauthorized access to MyScripps (MyChart) patient portal or Scripps’s electronic medical records application.” As for the settlement, the spokesperson told CBS 8, “We are pleased to have reached a settlement that Scripps believes is beneficial to those who may have been affected. The parties have not yet received final approval from the court, but preliminary approval has been granted and the parties will complete mailing notification postcards within 30 days of the approval order to the settlement class members. Settlement class members can go to [www.ScrippsSettlement.com](https://www.scrippssettlement.com/) or call the settlement administrator’s helpline at ­­­­­­­­­­­­­­­­­­­­­­800-708-8796 to ask questions or file a claim. If final approval of the settlement is granted, Scripps will compensate settlement class members for the benefits they are entitled to receive and validly claimed under the settlement, including eligible monetary losses.” According to the settlement website, those who feel they were included in the breach still have time to file a claim. According to the Scripps Data Breach Settlement Website, if you *do* submit a claim, you sign away your right to sue the health agency. In order to receive a cash payment or reimbursement for out-of-pocket losses you must submit your claim by March 23, 2023. You do *not need* to file a claim to receive identity theft protection and fraud resolution services. If you decide to object, you may submit an objection to the court explaining why you don’t agree with the settlement. If you opt to exclude yourself, you will not receive a cash payment or have the chance to enroll in the free identity theft protection and fraud resolution services but *are* eligible to file your own lawsuit against Scripps. This must be done by March 8. Lastly, if you chose to do nothing, you will remain in the settlement class and lose the right to get cash payments and reimbursement of any out-of-pocket losses. You’ll still be eligible to enroll and sign up for free identity theft protection and fraud resolution services. **Topics:** Judicial/courts, Public Awareness --- ### [She didn't get shoulder surgery but was billed anyways and sent to collections](https://insurancefraud.org/news_archives/she-didnt-get-shoulder-surgery-but-was-billed-anyways-and-sent-to-collections/) **Published:** August 24, 2026 **Author:** Diane Beauchamp **Content:** Grace Elizabeth Elliott was surprised when she got a $1,100 surgery bill from a hospital in Venice, Florida. The California resident said she initially thought it was a scam but after calling the hospital discovered it was a result of a clerical error. She was charged for a hospital visit by 81-year-old Grace A. Elliott who had done a shoulder replacement and rehabilitation services at Venice Regional Medical Center, later renamed ShorePoint Health Venice in 2021. Grace E. Elliott’s information was still in the hospital’s database from a 2013 stay for a kidney infection while she was visiting family. But despite the hospital admitting the error, Medical Data Systems, a debt collection agency, kept going after Grace E. for the debt. Worried that this was going to impact her credit score, Grace E. appealed the bill — only to be denied. She tried again and was denied for a second time. “The debt collector told me, ‘We can’t speak to you about this account. You need to talk to the hospital.’ And the hospital told me. ‘Well, we fixed everything,'” Grace E. said. The debt collector kept billing the younger Grace Elliott and even sent her the older patient’s medical records. Frustrated, Grace E. used that information to locate the original patient and inform her of what was happening. “I wanted to let her know about all of this so that she could, No. 1, know that her personal information was out there,” she said. After months of frustration, Grace E. asked [Kaiser Health News ](https://khn.org/news/article/mistaken-identity-two-grace-elliotts-medical-billing-mystery/?ftag=YHF4eb9d17)to investigate and soon received a written apology from the hospital. In a statement, ShorePoint Health told CBS News that “the hospital clearly made a mistake here. The error has been corrected and steps have been taken to ensure it will not happen again.” Medical Data declines to comment about the case but told Kasier Health News that it “follows all state and federal rules and regulations.” While Grace E. said the collection letters have stopped, she said that the entire ordeal was a stressful, drawn-out experience. “We’re coming on a year later and that’s it’s wasted a lot of my time. This could have been fixed so easily,” she said. **Topics:** Public Awareness --- ### [U.S. Acts on Qui Tam Whistleblowers’ Complaint Against Chiropractor and Modern Vascular](https://insurancefraud.org/news_archives/u-s-acts-on-qui-tam-whistleblowers-complaint-against-chiropractor-and-modern-vascular/) **Published:** August 24, 2026 **Author:** Diane Beauchamp **Content:** On December 13, the U.S. Department of Justice (DOJ) [announced](https://www.justice.gov/opa/pr/united-states-files-false-claims-act-complaint-against-chiropractor-modern-vascular-office) it is filing a complaint under the False Claims Act against a chiropractor, 15 Modern Vascular office-based labs, and 5 Modern Vascular-affiliated companies owned by the chiropractor. In this action, the U.S. is intervening in [*qui tam*](https://whistleblowersblog.org/faqs/what-is-qui-tam/) lawsuits filed by whistleblowers. The *qui tam* provisions of the False Claims Act enable private citizens to file lawsuits on behalf of the government if they know of an individual or company defrauding the government. *Qui tam* whistleblowers are eligible to receive between 15 and 30% of the government’s recovery, if one occurs. The U.S. alleges “that from at least Jan. 1, 2018, through June 30, 2022, Yury Gampel and the Modern Vascular defendants offered physicians the opportunity to invest in Modern Vascular office-based labs to induce them to refer their Medicare and TRICARE patients to Modern Vascular for the treatment of peripheral arterial disease.” Additionally, Gampel allegedly “pressured vascular surgeons and interventional radiologists employed at the Modern Vascular office-based labs to increase the number of invasive surgical procedures performed by tracking procedures and setting aggressive weekly and monthly goals for such procedures.” According to the press release, the U.S. “filed its complaint in three consolidated lawsuits pending in the United States District Court for the District of Arizona” under the False Claims Act’s *qui tam* provisions. The U.S. intervened in whistleblower cases for this action, and the [complaint](https://www.justice.gov/opa/press-release/file/1557626/download) sheds more light on the whistleblowers. The complaint mentions six whistleblowers, five of whom never worked for any of the defendants. Dr. Jay Radhakrishnan of Texas and Dr. William Julien of Florida, both board-certified interventional radiologists who had never worked for any of the defendants, “filed the first case of consolidated actions” in January 2020. Dr. David Terry, a board-certified vascular surgeon, Dr. Chandrahas Patel, a cardiothoracic surgeon, and Dr. Lannery Lauvao, a board-certified vascular surgeon, together “filed the second of these consolidated actions” in January 2021. All three individuals are in Arizona. The third action was brought by Katherine Diggins, a former vascular surgery physician’s assistant, in July 2021. Unlike the other whistleblowers, Diggins “was employed by Defendant Modern Vascular of Denver, LLC,” the complaint states. This settlement — and [plenty of other *qui tam* whistleblower cases](https://whistleblowersblog.org/false-claims-qui-tam-news/) — show how whistleblowers are critical to uncovering waste, fraud, and abuse, especially in the medical and health care industry. Fraudulent schemes can be particularly harmful to patients and erode trust in the medical system. In[ Fiscal Year 2021](https://whistleblowersblog.org/false-claims-qui-tam-news/doj-releases-fy2021-false-claims-act-stats-whistleblower-payouts-continue-to-dip/), *qui tam* whistleblowers helped the DOJ recover $1.6 billion in settlements. The DOJ[ highlighted](https://www.justice.gov/opa/pr/justice-department-s-false-claims-act-settlements-and-judgments-exceed-56-billion-fiscal-year) health care fraud as “the leading source of the department’s False Claims Act settlements and judgments.” Senator Chuck Grassley (R-IA), who has been consistently championed as the [“patron saint” of whistleblowers](https://whistleblowersblog.org/editorial/grassley-and-the-whistleblowers/), proposed [amendments](https://www.grassley.senate.gov/imo/media/doc/117s2428_-_false_claims_amendments_act.pdf.pdf) to the False Claims Act in 2021 that would strengthen protections for whistleblowers and clarify existing law. The amendment was widely supported by whistleblower organizations and advocates. However, *WNN* sources [discovered](https://whistleblowersblog.org/false-claims-qui-tam-news/pharma-lobby-backchannels-a-shutdown-of-essential-fca-judicial-amendments/) that the pharmaceutical lobby intervened with the amendment’s passage. The [National Whistleblower Center](https://www.whistleblowers.org/) (NWC) is urging Congress to protect the False Claims Act: learn more [here](https://nationalwhistleblowercenter.salsalabs.org/falseclaimsactamendmentspush/index.html). **Topics:** Judicial/courts, Public Awareness --- ### [Mark Sievers, on death row for wife's 2015 murder-for-hire, demands hearing](https://insurancefraud.org/news_archives/mark-sievers-on-death-row-for-wifes-2015-murder-for-hire-demands-hearing/) **Published:** August 24, 2026 **Author:** Diane Beauchamp **Content:** A Bonita Springs man on death row for hiring two individuals to murder his wife in 2015 has filed a motion for a rehearing in hopes of reversing a recent ruling. A jury convicted Mark Sievers, 54, on Dec. 4, 2019, in the slaying of Teresa Sievers, a 46-year-old Southwest Florida doctor. A judge denied Sievers’ death row appeal last month. The motion, filed Dec. 1, claims the court dismissed two 2016 interviews with co-conspirator Curtis Wayne Wright Jr. — a full video and a short excerpted clip, both exhibits in the case. Sievers asked to include an excerpt of a February 2016 meeting where Wright attempts to negotiate terms of a plea deal to spare his wife. “And the full video shows that Wright was being coached by the investigators, which goes to how the investigation unfolded,” the motion reads in part. The exclusion of the “crucial” video evidence violated Sievers’ constitutional rights under the Fifth, Sixth,and Fourteenth Amendments, the motion argues. The motion also addresses the exclusion of a neighbor’s testimony recounting snippets of an argument she overheard between husband and wife a weeks before the murder. Sievers’ defense alleges that the court overlooked the possibility that the jury improperly used the testimony to corroborate Wright’s testimony as to Sievers’ motivation. The jury apparently discounted any motivation, which left only Wright’s testimony about Sievers’ marital problems to explain a motive, the motion says. Sievers’ lawyers claim that Wright’s testimony alone will not satisfy the Constitutional standards to justify Sievers’ conviction and death sentence given the lack of corroboration, the terms of the deal made with Wright, and his alleged propensity to lie to the police and prosecutors. Lastly, the motion tackles the court’s notice of intent to seek the death penalty. The habitual offender provision doesn’t provide for any defined time limit before sentencing, while it provides a specific purpose to be served by the notice requirement. According to the motion, written notice should be served on Sievers and his attorney with enough time before entering a plea or imposing of sentence. What happened in 2015? On June 28, 2015, Teresa Sievers, left a family vacation and returned alone to her Bonita Springs home. After she pulled into the garage, retrieved her luggage and walked into the house, Wright and Jimmy Ray Rodgers beat her in the head with hammers. Court records indicate the plot began weeks earlier, when Mark Sievers traveled to Missouri for Wright’s May wedding. Wright agreed to “take care of it” for at least $100,000 in life insurance proceeds, the records show. Wright later recruited Rodgers. Kyle sentenced Rodgers to life in prison, convicted of second-degree murder and trespassing by a Lee County jury in October 2019. On Feb. 10, 2020, Kyle sentenced Wright to 25 years for his role in Teresa Sievers’ murder. **Topics:** Judicial/courts, Life Insurance **Categories:** Conviction --- ### [KHN Investigation: The System Feds Rely On to Stop Repeat Health Fraud Is Broken](https://insurancefraud.org/news_archives/khn-investigation-the-system-feds-rely-on-to-stop-repeat-health-fraud-is-broken/) **Published:** August 24, 2026 **Author:** Diane Beauchamp **Content:** The federal system meant to stop health care business owners and executives from repeatedly bilking government health programs fails to do so, a KHN investigation has found. That means people are once again tapping into Medicaid, Medicare, and other taxpayer-funded federal health programs after being legally banned because of fraudulent or illegal behavior. In large part that’s because the government relies on those who are banned to self-report their infractions or criminal histories on federal and state applications when they move into new jobs or launch companies that access federal health care dollars. The Office of Inspector General for the U.S. Department of Health and Human Services keeps a [public list](https://exclusions.oig.hhs.gov/default.aspx) of those it has barred from receiving any payment from its programs — it reported excluding more than 14,000 individuals and entities since January 2017 — but it does little to track or police the future endeavors of those it has excluded. The government explains that such bans apply to “the excluded person” or “anyone who employs or contracts with” them. Further, “the exclusion applies regardless of who submits the claims and applies to all administrative and management services furnished by the excluded person,” [according to the OIG](https://oig.hhs.gov/faqs/exclusions-faq/). Federal overseers largely count on employers to check their hires and identify those excluded. Big hospital systems and clinics typically employ compliance staff or hire contractors who routinely vet their workers against the federal list to avoid fines. However, those who own or operate health care businesses are typically not subject to such oversight, KHN found. And people can sidestep detection by leaving their names off key documents or using aliases. “If you intend to violate your exclusion, the exclusion list is not an effective deterrent,” said [David Blank](https://www.agg.com/professionals/david-blank/), a partner at Arnall Golden Gregory who previously was senior counsel at the OIG. “There are too many workarounds.” KHN examined a sample of 300 health care business owners and executives who are among more than 1,600 on OIG’s exclusion list since January 2017. Journalists reviewed court and property records, social media, and other publicly available documents. Those excluded had owned or operated home health care agencies, medical equipment companies, mental health facilities, and more. They’d submitted false claims, received kickbacks for referrals, billed for care that was not provided, and harmed patients who were poor and old, in some cases by stealing their medication or by selling unneeded devices to unsuspecting Medicare enrollees. One owner of an elder care home was excluded after he [pleaded guilty](https://www.documentcloud.org/documents/23378955-floro-sentencing-and-guilty-two-counts?responsive=1&title=1) to [sexual assault](https://www.arkansasonline.com/news/2018/dec/04/bentonville-man-jailed-in-sexual-assaul/). Among those sampled, KHN found: - Eight people appeared to be serving or served in roles that could violate their bans; - Six transferred control of a business to family or household members; - Nine had previous, unrelated felony or fraud convictions, and went on to defraud the health care system; - And seven were repeat violators, some of whom raked in tens of millions of federal health care dollars before getting caught by officials after a prior exclusion. The exclusions list, according to Blank and other experts, is meant to make a person radioactive — easily identified as someone who cannot be trusted to handle public health care dollars. But for business owners and executives, the system is devoid of oversight and rife with legal gray areas. One man, Kenneth Greenlinger, [pleaded guilty](https://www.documentcloud.org/documents/23321299-greenlinger-plea-agreement?responsive=1&title=1) in 2016 to submitting “false and fraudulent” claims for medical equipment his California company, Valley Home Medical Supply, never sent to customers that totaled more than $1.4 million to Medicare and other government health care programs, [according to his plea agreement](https://www.documentcloud.org/documents/23321299-greenlinger-plea-agreement?responsive=1&title=1). He [was sentenced](https://www.documentcloud.org/documents/23321018-greenlinger-sentencing-fina?responsive=1&title=1) to eight months in federal prison and ordered to pay restitution of more than $1 million, according to court records. His company [paid more than $565,000](https://www.justice.gov/usao-cdca/pr/san-fernando-valley-medical-supply-company-defrauded-federal-health-care-programs-pays) to resolve allegations of false claims, according to the Justice Department website. Greenlinger was handed a 15-year exclusion from Medicare, Medicaid, and any other federal health care program, starting in 2018, according to the OIG. But this October, Greenlinger announced a health care business with government contracts for sale. [Twice on LinkedIn](https://www.documentcloud.org/documents/23321014-greenlingerselldme?responsive=1&title=1), Greenlinger [announced](https://www.documentcloud.org/documents/23321022-greenlinger-saying-owns-dme-company?responsive=1&title=1): “I have a DME \[durable medical equipment\] company in Southern California. We are contracted with most Medicare and Medi-Cal advantage plans as well as Aging in Place payers. I would like to sell,” adding a Gmail address. Reached by phone, Greenlinger declined to comment on his case. About the LinkedIn post, he said: “I am not affiliated directly with the company. I do consulting for medical equipment companies — that was what that was, written representing my consulting business.” His wife, Helene, who previously worked for Valley Home Medical Supply, is now its CEO, according to [LinkedIn](https://www.documentcloud.org/documents/23321023-greenlingerhelenelinkedin?responsive=1&title=1) and documentation from the [California Secretary of State](https://www.documentcloud.org/documents/23321017-greenlinger-wife-on-biz-docs?responsive=1&title=1) office. Although Helene has a LinkedIn account, she told KHN in a telephone interview that her husband had posted on her behalf. But Kenneth posted on and commented from his LinkedIn page — not his wife’s. At Valley Home Medical Supply, a person who answered the phone last month said he’d see whether Kenneth Greenlinger was available. Another company representative got on the line, saying “he’s not usually in the office.” Helene Greenlinger said her husband may come by “once in a while” but “doesn’t work here.” She said her husband doesn’t do any medical work: “He’s banned from it. We don’t fool around with the government.” “I’m running this company now,” she said. “We have a Medicare and Medi-Cal number and knew everything was fine here, so let us continue.” **No Active Enforcement** Federal regulators do not proactively search for repeat violators based on the exclusion list, said Gabriel Imperato, a managing partner with Nelson Mullins in Florida and former deputy general counsel with HHS’ Office of the General Counsel in Dallas. He said that for decades he has seen a “steady phenomenon” of people violating their exclusions. “They go right back to the well,” Imperato said. That oversight gap played out during the past two years in two small Missouri towns. Donald R. Peterson co-founded Noble Health Corp., a private equity-backed company that bought two rural Missouri hospitals, just months after he’d agreed in August 2019 to [a five-year exclusion](https://oig.hhs.gov/fraud/enforcement/kansas-infusion-company-owner-agrees-to-voluntary-exclusion/) that “precludes him from making any claim to funds allocated by federal health care programs for services — including administrative and management services — ordered, prescribed, or furnished by Mr. Peterson,” said Jeff Morris, an attorney representing Peterson, [in a March letter to KHN.](https://www.documentcloud.org/documents/21969554-2022_03_14-morris?responsive=1&title=1) The prohibition, Morris said, also “applies to entities or individuals who contract with Mr. Peterson.” That case involved a company Peterson created called IVXpress, now operating as IVX Health with infusion centers in multiple states. Peterson left the company [in 2018](https://www.documentcloud.org/documents/23316421-2022_03_15-don-peterson_linkedin?responsive=1&title=1), according to his LinkedIn, after the settlement with the government showed [a whistleblower accused him](https://www.documentcloud.org/documents/21719400-1#document/p1/a2103683) of altering claims, submitting false receipts for drugs, and paying a doctor kickbacks. He settled the resulting federal charges [without admitting wrongdoing](https://www.documentcloud.org/documents/23379071-2#document/p1/a2179859). His settlement agreement provides that if he violates the exclusion, he could face “criminal prosecution” and “civil monetary penalties.” In January 2020, Peterson was listed in [a state registration document](https://www.documentcloud.org/documents/21881941-2020_01_14-biennialregistration?responsive=1&title=1) as one of two Noble Health directors. He was also listed as the company’s secretary, vice president, and assistant treasurer. Four months later, in April 2020, Peterson’s name appears on a [purchasing receipt](https://www.documentcloud.org/documents/23321057-fmc-inv01_0001#document/p2/a2177362) obtained under the Freedom of Information Act. In addition to Medicare and Medicaid funds, Noble’s hospitals had received [nearly $20 million](https://kffhealthnews.org/news/article/noble-health-platinum-health-private-equity-hospital-workers-fired/) in [federal covid relief money](https://taggs.hhs.gov/Coronavirus/Providers). A social media account with a photo that appears to show Peterson announced the launch of Noble Health in [February 2020](https://www.documentcloud.org/documents/21718326-2020_02_29_noble_nueterra-screen-grab?responsive=1&title=1). Peterson identified himself on Twitter as [executive chairman](https://www.documentcloud.org/documents/21760158-2021_09_07peterson-twitter) of the company. **Topics:** Public Awareness, Regulatory actions --- ### [Police issue warning about Medicare phone scams](https://insurancefraud.org/news_archives/police-issue-warning-about-medicare-phone-scams/) **Published:** August 24, 2026 **Author:** Diane Beauchamp **Content:** Watertown police are warning people against scam phone calls about Medicare. They say scammers are getting more sophisticated. They pretend to be from Medicare or a legitimate health care provider. Police say if you hear any of these pitches, it’s a scam: – Medicare is issuing new cards. – Your Medicare coverage is about to be canceled. – You can receive early access to special vaccines. – You have an appointment for free genetic testing. – You qualify for free medical supplies. – You’re eligible for a refund. – You’re preapproved for a cheaper or better plan. Police say Medicare will never call directly unless you call them with a request, so any unsolicited calls are a scam. **Topics:** Medicare/Medicaid, Public Awareness --- ### [Top 10 Most Popular Roofing Articles of 2022](https://insurancefraud.org/news_archives/top-10-most-popular-roofing-articles-of-2022/) **Published:** August 24, 2026 **Author:** Diane Beauchamp **Content:** Amidst the multiple mergers and acquisitions, supply chain woes and stories of fraud, roofing contractors were interested in a variety of topics in 2022. *RC* examined its top articles published in 2022 to see what caught the interest and eyeballs of our readers. A lot of this year’s most popular entries centered around the goings-on in Florida, whether it was Hurricane Ian recovery, insurance reform or cases of fraud. Others are anticipated mainstays in *RC’s* annual content. Below are the top most-read articles published in 2022. ### **10. Taken Right From Under Your Own Roof** National Roofing Partners uncovered [$1.3 million in missing money](https://www.roofingcontractor.com/articles/97312-taken-right-from-under-your-own-roof) spent on cash bonuses and lavish personal items for the people involved, which included members of its top leadership. National Roofing Partners shared its story and what roofing contractors can do to prevent fraud from happening in their companies. ### **9.** **How to Hire and Pay Workers Without Social Security Numbers** This [column](https://www.roofingcontractor.com/articles/96850-how-to-hire-and-pay-workers-without-social-security-numbers) from James G. Aldrich, an attorney with Dykema, dispels the myth that it’s illegal for an employer to pay an employee who does not have a social security number. Aldrich offers advice on how contractors can handle this situation, especially when dealing with young and/or foreign workers without a number. ### **8. Gauge Capital Acquires Two Roofing Companies to Create Apple Roofing** Mergers and [acquisitions](https://www.roofingcontractor.com/keywords/8344-acquisition) became a recurring topic throughout 2022, including roofing manufacturers, distributors and contractors alike. One story in particular rose above the rest: the [creation of Apple Roofing](https://www.roofingcontractor.com/articles/96825-gauge-capital-acquires-two-roofing-companies-to-create-apple-roofing) through Gauge Capital’s acquisition of Crest Exteriors and Apple Roofing in March. Both companies have appeared on *RC’s* Top 100 list. ### **7. Hurricane Ian Cleanup: Out-of-State Roofing Contractors Beware** Hurricane Ian caused an estimated $50.2 billion in damage throughout Florida in late September. As a result, roofing contractors headed to the state to take part in the rebuilding effort. Trent Cotney, partner at Adams and Reese, [warned contractors](https://www.roofingcontractor.com/articles/97482-hurricane-ian-cleanup-out-of-state-roofing-contractors-beware) coming from out of state that they need to be aware of the state’s complex construction licensing laws if they wanted to work properly. ### **6. Win the Storm 2022 Heads to Dallas Feb. 14-16** Storm Ventures Group’s 8th annual [Win the Storm Conference and Trade Show](https://www.roofingcontractor.com/articles/96129-win-the-storm-2022-heads-to-dallas-feb-14-16) headed to the Lone Star State this year. The annual conference helps contractors learn the tactics and strategies needed to expand their businesses while helping property owners recover from storms, so it’s no surprise contractors wanted to learn more about the 2022 event. ### **5. STATE OF THE INDUSTRY 2022** It’s been a tough couple of years for the roofing industry, let alone for the rest of the world as it endured post-pandemic economic stresses and supply chain issues. *RC* issued its annual [State of the Industry](https://www.roofingcontractor.com/articles/2022-soi-report) survey to check the pulse of the roofing industry and determine what trends or strategies contractors could utilize heading into 2022. ### **4. Florida DFS Arrests Two Roofing Contractors in Insurance Fraud Scheme** An unfortunate reality of the roofing industry is that bad players will use it to scam people out of thousands of dollars, sullying the industry’s reputation in the process. However, in [this story](https://www.roofingcontractor.com/articles/96801-florida-dfs-arrests-two-roofing-contractors-in-insurance-fraud-scheme), some of those bad players got their just desserts after they were caught running a scheme to defraud people in Florida. ### **3. RC’s Top 100 2022: The Top 10 Roofing Contractors for 2022** One of the most popular features *RC* offers is the Top 100 list, which ranks commercial and residential roofing contractors from around the nation based on revenue. In the weeks leading up to the full list reveal, we provided a [sneak peek](https://www.roofingcontractor.com/articles/97239-rcs-top-100-2022-the-top-10-roofing-contractors-for-2022) at the top 10 of the Top 100 for 2022. ### **2. Top 100 2022 List** As mentioned above, the [Top 100](https://www.roofingcontractor.com/articles/97262-top-100-2022-list) is an annual list *RC* generates by asking contractors to report their annual revenue. The result is a list ranking the top-performing roofing contractors in the nation. This year was the 14th consecutive list, and remains an important marketing and publicity tool for contractors. Check back next month for the chance to submit your company for the 2023 list. ### **1. New Florida Insurance Law’s Impact on the Roofing Industry** In May, Florida [signed into law](https://www.roofingcontractor.com/articles/97099-new-florida-insurance-laws-impact-on-the-roofing-industry) new insurance policies that affect how roofing contractors can do business in the state in an attempt to stop property insurance price hikes. The law rippled through the roofing industry, sparking concerns other states would pass similar laws. Then, in late September, Hurricane Ian tore a path of destruction through the state. Roofing contractors around the nation responded, heading to the state to [help rebuild](https://www.roofingcontractor.com/articles/97506-roofing-contractors-share-conditions-of-rebuilding-florida-after-hurricane-ian). As a result, that this article detailing the impact the law has on Florida roofing quickly became the most read on *RC’s* site in 2022 as contractors educated themselves. “What comes out of California on the west or Florida on the east, it all moves over, and that’s the key thing — it’s not a Florida-centric type bill … it is something you might need to worry about in the future,” said Trent Cotney, partner at Adams and Reese. **Topics:** Contractor fraud, Public Awareness --- ### [System intended to stop repeat health care fraud is flawed](https://insurancefraud.org/news_archives/system-intended-to-stop-repeat-health-care-fraud-is-flawed/) **Published:** August 24, 2026 **Author:** Diane Beauchamp **Content:** An investigation by Kaiser Health News (KHN) indicates a federal system created to stop health care business owners and executives from repeatedly “bilking” government health programs is deeply flawed. “That means people are once again tapping into Medicaid, Medicare, and other taxpayer-funded federal health programs after being legally banned because of fraudulent or illegal behavior,” writes KHN reporters Sarah Jane Tribble and Lauren Weber. “In large part that’s because the government relies on those who are banned to self-report their infractions or criminal histories on federal and state applications when they move into new jobs or launch companies that access federal health care dollars.” As the reporters explain, the Office of Inspector General for the U.S. Department of Health and Human Services maintains a public list of individuals and entities barred from receiving any payment from its programs. “But it does little to track or police the future endeavors of those it has excluded,” according to Tribble and Weber. “Federal overseers largely count on employers to check their hires and identify those excluded. Big hospital systems and clinics typically employ compliance staff or hire contractors who routinely vet their workers against the federal list to avoid fines. However, those who own or operate health care businesses are typically not subject to such oversight, KHN found. And people can sidestep detection by leaving their names off key documents or using aliases.” KHN — a Kaiser Family Foundation program that produces in-depth reports on health statistics — analyzed 300 of the more than 1,600 health care business owners and executives on the OIG’s exclusion list since January 2017. Many had owned or operated home health care agencies, medical equipment companies, mental health facilities, and other entities, according to the report, which was published on KHN’s website as well as USA Today. “They’d submitted false claims, received kickbacks for referrals, billed for care that was not provided, and harmed patients who were poor and old, in some cases by stealing their medication or by selling unneeded devices to unsuspecting Medicare enrollees,” KHN notes. “If you intend to violate your exclusion, the exclusion list is not an effective deterrent,” says David Blank, a partner at the Washington, D.C.-based law firm Arnall Golden Gregory, who previously worked as senior counsel at the OIG. “There are too many workarounds.” **Topics:** Public Awareness, Technology --- ### [Data Breach at Louisiana Healthcare Provider Impacts 270,000 Patients](https://insurancefraud.org/news_archives/data-breach-at-louisiana-healthcare-provider-impacts-270000-patients/) **Published:** August 24, 2026 **Author:** Diane Beauchamp **Content:** **Southwest Louisiana healthcare provider Lake Charles Memorial Health System (LCMHS) is informing roughly 270,000 patients that their personal and medical information was compromised in a data breach.** A regional community healthcare system consisting of several facilities, LCMHS identified the cyberattack on October 25 and started informing the impacted patients of the incident on December 23. In a [notification](https://www.securityweek.com/saic-teams-university-maryland-cybersecurity/) on its website, LCMHS says that ‘an unauthorized third party’ gained access to its network between October 20 and October 21. The attackers accessed and likely exfiltrated certain files containing patient data, the healthcare provider says. The stolen files contained patient information such as names, addresses, birth dates, health insurance information, medical record numbers, patient identification numbers, payment data, and details regarding care received at LCMH. Social Security numbers were also compromised in some cases. On December 22, the healthcare provider informed the US Department of Health and Human Services that approximately [270,000 individuals were impacted ](https://ocrportal.hhs.gov/ocr/breach/breach_report.jsf)by the incident. While LCMH has not shared details on the type of cyberattack it fell victim to, the Hive ransomware gang has already claimed responsibility for the incident. The hacking group boasted about the cyberattack on their Tor website, claiming to have exfiltrated from LCMH’s network various business files (bills of materials and contracts), medical records, file scans, and other types of data. **Topics:** Public Awareness, Technology --- ### [Myers named chief deputy commissioner at N.C. Department of Insurance](https://insurancefraud.org/news_archives/myers-named-chief-deputy-commissioner-at-n-c-department-of-insurance/) **Published:** August 24, 2026 **Author:** Diane Beauchamp **Content:** Insurance Commissioner Mike Causey has named Chuck Myers as chief deputy commissioner of the North Carolina Department of Insurance, effective Oct. 1. Myers, who has extensive experience in insurance regulation and law enforcement, will succeed Chief Deputy Commissioner Jackie Obusek, who is retiring after 30 years with the department. Myers most recently spent three and a half years as deputy commissioner for the Louisiana Department of Insurance, where he oversaw the Office of Property and Casualty. He chaired the Louisiana Auto Insurance Plan, helped restructure the Louisiana Fortified Homes Program and led the Title Insurance Working Group at the National Association of Insurance Commissioners. “I believe Chuck will be a real asset to our mission at NCDOI of protecting consumers and fighting fraud,” Causey said. “His impressive insurance, accounting, law enforcement and leadership experience will make the transition of losing Jackie much smoother.” Myers said he was honored to join the North Carolina Department of Insurance and thanked Causey and Obusek for the opportunity. “It’s a big honor joining the team at NCDOI,” he said. “I’m humbled by the opportunity to come to such a great place and carry forward the incredible legacy established by the Commissioner, Jackie and the hardworking NCDOI employees. I cannot wait to get to work for the Department and the people of North Carolina.” Before joining the Louisiana Department of Insurance, Myers held insurance regulation and law enforcement positions in Virginia. He managed the Real Estate Settlement Agents Investigations Section of the Virginia Bureau of Insurance and investigated a case that received the Virginia State Police Fraud Fighters Award. The investigation resulted in a conviction and the return of nearly $200,000 to consumers. Myers previously served as a special agent accountant with the Virginia State Police, where he led complex white-collar investigations involving elected officials, financial crimes, fraud and forensic audits. He also directed data-driven investigative strategies, documented crime scenes as a certified crime scene analyst and trained law enforcement personnel. Myers spent more than 20 years as a licensed insurance agent in Florida and Virginia. He is a chartered property-casualty underwriter, certified fraud examiner, senior professional insurance regulator and sworn law enforcement officer. He holds a Master of Science in Risk Management and Insurance from Florida State University and a Bachelor of Arts in psychology from the University of Central Florida. **Topics:** Public Awareness, Regulatory actions --- ### [Man gets 12.5 years in Medi­caid fraud case](https://insurancefraud.org/news_archives/man-gets-12-5-years-in-medicaid-fraud-case/) **Published:** August 24, 2026 **Author:** Diane Beauchamp **Content:** The former operator of a Milwaukee supportive home care business was sentenced to 12.5 years in prison for his role in a drug trafficking and fraud scheme that stole millions in taxpayer dollars meant to help people with disabilities. Phillip Daniels Sr., 50, was charged in 2022 in U.S. District Court in Milwaukee as part of a sprawling investigation that uncovered not only a drug trafficking conspiracy but a scheme to defraud one of the state’s Medicaid long-term care programs. The investigation has resulted in more than a dozen convictions. Last year, he pleaded guilty to four federal charges: conspiracy to distribute or possess with the intent to distribute a controlled substance, conspiracy to commit money laundering, possession of a firearm in relation to a drug trafficking crime, and health care fraud. Chief U.S. District Judge Pamela Pepper followed prosecutors’ recommendation and sentenced Daniels to a term below the federal sentencing guideline range of about 26 to 32 years. Prosecutors recommended 12.5 years, citing Daniels’ decision to plead guilty instead of going to trial and to testify as a witness for the prosecution against others charged in the case. Pepper also ordered Daniels to pay back $1.7 million. “The amount of criminal activity that you were involved in is mind-boggling,” Pepper said at the Aug. 18 sentencing. “For Milwaukee, … this was huge.” For years, Daniels ran a business in Milwaukee called First Response Supportive Care and worked closely with two other men also convicted in the fraud scheme who ran similar businesses: Roy Henton, 68, and Lenard R. Monroe, 52. They claimed to help Medicaid recipients with disabilities live independently in their homes. But an investigation found the men were falsely billing the state Medicaid program called IRIS for work that was never performed. IRIS – an acronym for Include, Respect, I Self-Direct – serves adults with physical or cognitive disabilities and older people in Wisconsin who need help meeting their everyday needs. The program, which is funded by state and federal taxpayer dollars, pays for care workers to help with everything from bathing to grocery shopping. The investigation found Daniels recruited clients enrolled in IRIS for his and the other men’s businesses and received illegal kickbacks worth more than $600,000 from Monroe for referrals to his business, according to court records. Clients reported receiving little to no care, and investigators found falsified timesheets with forged signatures, improbable work hours, and inconsistencies showing care workers in two places at once, court records said. Daniels recruited clients by offering them reduced-rate housing at properties he rented, in exchange for their Medicaid information, which the men used to bill the state Medicaid program for services that were never provided, court records say. In wiretapped calls, investigators also heard Daniels coaching clients to fake disabilities so they would qualify for more help, and so Daniels could maximize the sum of money he could bill Medicaid for, according to court records. In one call, he advised a client who had a college education to pretend she couldn’t read or write and needed help going through her mail. Federal agents found Daniels also was a central player in a drug trafficking conspiracy that sourced drugs from the West Coast and distributed them throughout the Midwest. Agents alleged he coordinated drug shipments, oversaw drug couriers, and helped prepare the narcotics for sale, including fentanyl, cocaine and methamphetamine, according to court records. He deposited drug money into business bank accounts to hide the source of the proceeds. At his sentencing, Daniels said his main goal was providing for his wife and children, and asked for another chance in society to make it right to his family “I truly, truly, deeply apologize,” he said. “What I did was wrong.” Some of Daniels’ children were in the courtroom and said the criminal charges don’t define him. They said he was a good father who had made bad decisions. **Topics:** Drug Diversion, Medicare/Medicaid **Categories:** Conviction --- ### [Scam Spotlight: Worker’s Compensation Fraud Scheme](https://insurancefraud.org/news_archives/scam-spotlight-workers-compensation-fraud-scheme/) **Published:** August 24, 2026 **Author:** Diane Beauchamp **Content:** The Wisconsin Department of Workforce Development (DWD) has alerted the public about a possible multi-state fraud scheme targeting injured workers, in which fraudsters trick people into participating in fake worker’s compensation hearings. This leads injured workers to believe they are awarded money but are now responsible for paying fees to finalize the case. The scams primarily target Spanish-speaking workers, but anyone can be a target, and claim to come from fake agencies with names like the “Workers’ Compensation Board.” They usually arrive as emails from domains like “@WorkCompCourt.org.” Consumers are told to attend an online hearing using a video call platform, and this fake hearing involves a judge, bailiff, and attorneys. It can be very convincing. Always verify information. The real Wisconsin Worker’s Compensation Division schedules hearings only through written letters, and all phone numbers from the Department of Workforce Development will have Wisconsin area codes. If someone has received a suspicious message about a worker’s compensation hearing, they should contact a real DWD worker’s compensation specialist at 608-266-1340 or visit dwd.wisconsin.gov/wc/fraud for more information. Consumers who have been scammed should contact DATCP right away. **Topics:** Public Awareness, Workers Comp --- ### [Orange County financier arrested in nearly $100 Million bank fraud scheme](https://insurancefraud.org/news_archives/orange-county-financier-arrested-in-nearly-100-million-bank-fraud-scheme/) **Published:** August 24, 2026 **Author:** Diane Beauchamp **Content:** An Orange County man is facing federal bank fraud charges after investigators say he orchestrated one of the largest individual financial frauds recently seen in Southern California. Mahender Makhijani, 44, of Corona del Mar, was arrested on a federal criminal complaint alleging he defrauded a federally insured bank out of nearly $100 million by falsifying title insurance policies and manipulating lien positions on real estate‑backed loans. Federal prosecutors say Makhijani controlled Newport Beach‑based Cantor Group V LLC, which had a lending relationship with Bank #1. Under the agreement, the bank advanced nearly $100 million for Cantor to originate or purchase loans secured by real estate. Cantor was required to pledge only loans backed by first‑lien collateral, ensuring the bank would be first in line to foreclose if borrowers defaulted. Instead, investigators allege Makhijani falsified title insurance policies between September 2024 and April 2025 to make it appear Cantor held first‑lien positions when other creditors actually had priority. According to the affidavit, Makhijani or a subordinate edited legitimate title policies using Adobe software, removed or altered metadata, and in some cases printed and rescanned documents to obscure tampering. He then directed an employee to submit the falsified policies to the bank and participated in teleconferences where he allegedly lied about discrepancies the bank identified. In December 2024, he submitted a spreadsheet containing false explanations for the title issues. The bank relied on these misrepresentations when making lending decisions. Had it known the true lien positions, prosecutors say the bank would have declared Cantor in default and demanded immediate repayment of the full amount. Additional Details Reported by Other Media Other outlets report that the alleged fraud may have touched multiple lenders, including Western Alliance Bank, Zions Bancorp, and Preferred Bank, suggesting broader exposure across the financial sector. Media coverage also notes that Makhijani was ordered by an arbitrator to pay $1.34 billion to Laguna Beach real estate investor Mohammad Honarkar in a separate civil fraud case—an indicator of the scale of financial misconduct under scrutiny. A federal judge recently denied Makhijani bail, citing flight‑risk concerns, alleged threats against a witness, and evidence that associates lied about the source of funds used for his previous bail bond. Court filings also state he is a dual citizen of India and owns property abroad. According to the affidavit, Makhijani or a subordinate edited legitimate title policies using Adobe software, removed or altered metadata, and in some cases printed and rescanned documents to obscure tampering. He then directed an employee to submit the falsified policies to the bank and participated in teleconferences where he allegedly lied about discrepancies the bank identified. In December 2024, he submitted a spreadsheet containing false explanations for the title issues. The bank relied on these misrepresentations when making lending decisions. Had it known the true lien positions, prosecutors say the bank would have declared Cantor in default and demanded immediate repayment of the full amount. Additional Details Reported by Other Media Other outlets report that the alleged fraud may have touched multiple lenders, including Western Alliance Bank, Zions Bancorp, and Preferred Bank, suggesting broader exposure across the financial sector. Media coverage also notes that Makhijani was ordered by an arbitrator to pay $1.34 billion to Laguna Beach real estate investor Mohammad Honarkar in a separate civil fraud case—an indicator of the scale of financial misconduct under scrutiny. A federal judge recently denied Makhijani bail, citing flight‑risk concerns, alleged threats against a witness, and evidence that associates lied about the source of funds used for his previous bail bond. Court filings also state he is a dual citizen of India and owns property abroad. What This Means for Orange County Businesses and Lenders Banks and credit unions may tighten due‑diligence requirements for real estate‑backed loans. Title companies could increase verification protocols for metadata and document authenticity. Real estate investors may face heightened scrutiny when pledging collateral or structuring multi‑lien transactions. Consumers and small businesses could see slower loan processing times as lenders adopt more conservative risk‑management practices. **Topics:** Title Insurance **Categories:** Arrest --- ### [One of FBI's most-wanted found working as yoga teacher in Mexico after 12 year search](https://insurancefraud.org/news_archives/one-of-fbis-most-wanted-found-working-as-yoga-teacher-in-mexico-after-12-year-search/) **Published:** August 23, 2026 **Author:** Diane Beauchamp **Content:** A 12-year search for one of the FBI’s most-wanted fugitives has finally come to an end after the killer was found working as a yoga teacher in sunny Mexico. Jorge Rueda Landeros, now known as León Ferrara, was seized earlier this month in Mexico’s western city of Guadalajara. Landeros is suspected of being responsible for a murder from more than a decade ago. In 2010, American University professor Sue Marcum, 52, was found dead at the bottom of her basement staircase of her new home in Bethesda, Maryland. Blunt force trauma and asphyxiation were listed as Ms Marcum’s cause of death, investigators confirmed at the time. Cops later found the DNA from under her nails and the crime scene belonged to Landeros, FBI reports have claimed. Detectives also discovered a life insurance policy totalling $500,000 (£415,000) with Landeros listed as the beneficiary. The lecturer had become fascinated with him after the pair became yoga buddies and Landeros taught her Spanish. The pair couldn’t be romantically linked, reports say. He now faces charges of first-degree murder and unlawful flight. After the 2010 killing, cops tipped Landeros as the prime suspect but he couldn’t be found. But the murder didn’t deter Landeros from continuing with the eastern meditative practice, with him setting up a popular studio and teaching a loyal group of students when he arrived in Mexico. In an interview with Spanish outlet El Pais while he was locked up, Landeros denied any involvement in Ms Marcum’s killing. He said: “I am innocent… not of everything, obviously, but of what I’m being accused of. “Once I disappeared from the radar, I completely forgot about the investigation. “I still have difficulty responding to the name Jorge – I hardly have any of him inside of me anymore.” Landeros – who is a dual US and Mexican citizen – is thought to be awaiting extradition to the US. His arrest has stunned his yoga students, El Pais reports. Maria, a yoga student, said she reported Landeros missing after he failed to show up for their class. She said: “When I filed the report, the cops said ‘your friend isn’t missing, he’s in custody and has an Interpol file… We can’t tell you more’. “I feel like I’m grieving, I know León, but I don’t know who Jorge is. “If I ever have the opportunity to sit down with him, I’ll have to ask him a lot of questions.” After he disappeared, his students launched a huge manhunt to track him down after hearing that he was last seen taking his two Pomeranians for a walk but failing to return home. Having no partner, kids or close relatives in the city, it was up to his pals to track him down. But after filing a missing persons case, they found that his name didn’t exist in the population register. Three days of worry passed before his students were told the truth about their beloved instructor. Montgomery County, the office in charge of his case, has praised the international community for helping them to carry out justice. Police Chief Marcus Jones said: “We are happy they were able to snatch him after all the years. “This is a fabulous outcome to get this guy in custody.” **Topics:** Life Insurance **Categories:** Arrest --- ### [Police to look into possible violations in Covid medical supply deals](https://insurancefraud.org/news_archives/police-to-look-into-possible-violations-in-covid-medical-supply-deals/) **Published:** August 23, 2026 **Author:** Diane Beauchamp **Content:** The Government Inspectorate has transferred to the police three cases involving possible fraud at the Ministry of Health in procuring Covid medical supplies in 2020-21. The Ministry of Public Security would investigate borrowing and procurement of medical equipment by the Pasteur Institute in Ho Chi Minh City, which shows signs of “violation of regulations on bidding causing serious consequences,” the inspectorate said Friday. The second case relates to the Hanoi-based Tai Loc Technology Service and Trading Co. Ltd, which won many large bids to supply to hospitals under the ministry but did not buy directly from importers and instead involved many intermediaries, causing the prices of supplies to rise by 2-3.1 times. The third involves the approval of two bidding packages by the ministry for a bronchoscopy system made by Olympus and a digital portable X-ray machine made by Fujifilm, which too showed signs of fraud, according to the inspectorate. **Topics:** Public Awareness --- ### [Jakel rubbishes claim Shah Alam outlet fire was insurance fraud bid](https://insurancefraud.org/news_archives/jakel-rubbishes-claim-shah-alam-outlet-fire-was-insurance-fraud-bid/) **Published:** August 23, 2026 **Author:** Diane Beauchamp **Content:** Jakel group managing director Datuk Seri Mohamed Faroz Mohamed Jakel has dismissed allegations that the fires at its Shah Alam outlet on Sunday and today were started in an attempt to make fraudulent insurance claims. He said the claim, which has been circulating on social media, did not make sense as the Shah Alam branch of the textile company was the second most profitable among its outlets. “In the current situation, with the year-end sales, the shop was full and business is thriving. We don’t want to resort to any dirty work. “Moreover, the (fire) insurance claim would not even match Jakel’s sales volume, especially during festivities and the year end,” he was quoted as saying in a Free Malaysia Today (FMT) report. Faroz said making an insurance claim was not easy and time consuming. “Insurance claims cannot be done in a month, not even six months. That’s one thing. The other is the missed opportunity, people who want to do business can make a profit, now that Hari Raya is near. “During Raya, how much are Jakel’s sales? A few million ringgit? How much is the insurance coverage worth? It’s illogical. It’s illogical because Jakel is not a problematic company. “Even more so, Jakel Shah Alam is the second most thriving outlet after Jakel Mall (in Kuala Lumpur),” he said. After Sunday’s fire, Faroz was reported to have said that Jakel could lose up to RM100 million. It was reported that the outlet could rake in RM300 million in sales a year. Another fire broke out just past midnight today and was brought under control by about 3am. Selangor Fire and Resuce Department investigators and sniffer dogs were seen today poring over the site to determine the cause of the blaze. **Topics:** Business - arson, Public Awareness --- ### [New IFB counter-fraud strategy targets keeping pace with change](https://insurancefraud.org/news_archives/new-ifb-counter-fraud-strategy-targets-keeping-pace-with-change/) **Published:** August 23, 2026 **Author:** Diane Beauchamp **Content:** The Insurance Fraud Bureau ([IFB](https://www.claimsmag.co.uk/tag/IFB)) recently unveiled its new counter-fraud strategy. Called [Forward Together](https://insurancefraudbureau.org/media-centre/news/2022/forward-together-ifb-unveils-brand-new-strategy/) and covering IFB’s work until 2025, the strategy holds innovation and future proofing at its heart. The strategy calls on IFB to remove outdated, legacy technology to improve efficiency and member experience, as well as address and improve data quality. It will also see IFB review how its membership will work in the future. Ursula Jallow, who was recently appointed to as the permanent director at IFB, led work on the new strategy. She said: “Times are changing and fast, especially in our current landscape with the impacts of COVID and the broader economic crisis being felt in a number of ways. Ultimately, this means insurance fraud risk needs to be front and centre of what we do, and how we do it. “We know our member data sharing technology is ageing and fails to match members’ expectations. We’re committed to keep pace and adapt to deliver the products, services and user experience via the modern technology that you expect.” Jallow added: “However, to be clear, there are no silver bullets or overnight solutions to deliver these focus areas. They are complex in nature, and, in order for IFB to be more agile than ever before, we will need full buy-in and mutual support from all our members, stakeholders and the wider insurance market along the way. “This plan lays out a roadmap for a shared industry journey to realise these goals and the full potential of IFB. This is a joint venture: with you, for you. So I invite you to read our plans for the next three years and work with us to help realise that shared vision. “I look forward to working with you all, to take the IFB and industry on its next chapter, fighting the ongoing risk of insurance fraud.” **Topics:** Public Awareness, Regulatory actions --- ### [Thousands of security guards ‘robbed’ of their health benefit contributions](https://insurancefraud.org/news_archives/thousands-of-security-guards-robbed-of-their-health-benefit-contributions/) **Published:** August 23, 2026 **Author:** Diane Beauchamp **Content:** Scores of security guards have been left counting their losses, after they are unable to receive their health benefits following health companies – moonlighting as health insurance – deducted more than R25 million from thousands of workers since March 2021. Union leaders say at least 30 000 workers are affected; many have been turned away from hospitals and clinics while trying to access health care, because their medical aid cards did not qualify over non-payment. The workers pay R150 monthly from their salaries under the understanding that the money will go towards their medical benefits. The National Bargaining Council for Private Security Services approved Health Insurance, administered by Affinity Health in accordance with the main collective agreement, became effective on March 1 last year. The health insurance cover is compulsory for all security officers and the cost is R250 a month. The benefits are supposed to include chronic disease management and medication, doctors’ consultations, accidental hospital and casualty benefit, a hospital care plan, and an HIV and TB management programme. But thousands of security guards have discovered to their shock that they are not covered. Companies moonlighting as health insurance companies are allegedly colluding with registered companies to dupe the workers. A letter written by union attorneys MT Raselo Incorporated, addressed to the Council for Medical Schemes (CMS), asks companies, including Imvula Group – alleged to be complicit – to stop moonlighting as the appointed health beneficiary service provider, because it is Affinity Health (Pty) Limited. The attorneys represent the Kungwini Amalgamated Workers Union, the SA Transport and Allied Workers Union, and Abanqobi Workers Union. The letter reads in part: “We demand that you forthwith attend to this complaint, (on failure of which) we hold instructions to approach the court on an urgent basis for an appropriate order … ” The letter said in terms of the collective agreement, Affinity was appointed as the designated health service provider to provide hospital cover and group health insurance. The letter added that Imvula Group’s brochure purports that it is the designated health service provider, creating a mala fide misrepresentation in an illicit attempt to poach business from Affinity Health.” Pretoria News sent questions to CMS by email early in December, but had not received any response by deadline. One of the security workers, who preferred to stay anonymous for fear of reprisals, said he was forced to queue for hours at a government clinic after he was turned away at a private medical facility because his medical aid did not work. “I was seriously sick. Even now I’m not sure where I stand, but money is deducted from my salary every month.” Efforts to reach the Imvula group proved fruitless. **Topics:** Public Awareness --- ### [Lab Fined $16K for Long Delay in Providing Patient Records](https://insurancefraud.org/news_archives/lab-fined-16k-for-long-delay-in-providing-patient-records-2/) **Published:** August 23, 2026 **Author:** Diane Beauchamp **Content:** Federal regulators have kicked off the New Year with a $16,000 HIPAA penalty against an Atlanta-based medical testing laboratory for failure to provide timely access to a patient records request. The lab also agreed to implement a corrective action plan under its settlement with the Department of Health and Human Services. The [agreement](https://www.hhs.gov/hipaa/for-professionals/compliance-enforcement/agreements/life-hopes-ra-cap/index.html) with Life Hope Labs – which is HHS’ Office for Civil Rights’ 43rd enforcement action in a “right of access” case since launching an initiative in April 2019 to improve compliance with that HIPAA provision – involves a 2021 dispute involving the records of a deceased patient. HHS OCR says that on Aug. 24, 2021, it received a complaint against Life Hope Labs from the personal representative of a patient’s estate. The complaint alleges that Life Hope Labs failed to provide the individual with a copy of the patient’s medical records in response to July 2021 access requests. Life Hope Labs did not send the requested records until Feb. 16, 2022 – 225 days after the initial access request. Under the resolution agreement with HHS OCR, Life Hope Labs also agreed to implement a corrective action plan, including revising and implementing policies and procedures to comply with the [HIPAA](http://www.healthcareinfosecurity.com/hipaa-hitech-c-282) privacy rule, and to distribute those policies and provide related training to its workforce and business associates involved in fulfilling patient record access requests. “Access to medical records, including lab results, empowers patients to better manage their health, communicate with their treatment teams, and adhere to their treatment plans,” says Melanie Fontes Rainer, HHS OCR director, in a statement. “The HIPAA Privacy Rule gives individuals and personal representatives a right to timely access to their medical records from all covered entities, including laboratories,” she says. Last month, HHS OCR also slapped a primary care practice, Health Specialists of Central Florida, with a $20,000 settlement and corrective action plan in the wake of a November 2019 complaint that the provider took four months and 29 days to respond to an Orlando woman’s request for access to her deceased father’s medical records (see: [*Medical Practice Pays $20K to Settle ‘Right of Access’ Case*](https://www.bankinfosecurity.com/medical-practice-pays-20k-to-settle-right-access-case-a-20716)). **Topics:** Public Awareness, Regulatory actions --- ### [Jet Medical and Related Companies Agree to Pay More Than $700,000 to Resolve Medical Device Allegations](https://insurancefraud.org/news_archives/jet-medical-and-related-companies-agree-to-pay-more-than-700000-to-resolve-medical-device-allegations/) **Published:** August 23, 2026 **Author:** Diane Beauchamp **Content:** Pennsylvania-based medical device distributor Jet Medical Inc. (Jet) agreed to pay $200,000 to resolve criminal allegations relating to a migraine headache treatment, and Jet and two related companies agreed to pay another $545,000 in a civil settlement involving the same device. In a criminal information filed Wednesday in the Southern District of Illinois, the government alleged that, between April 2014 and April 2019, Jet introduced into interstate commerce devices that were misbranded under the Federal Food, Drug and Cosmetic Act (FDCA) because Jet did not obtain approval or clearance from the U.S. Food and Drug Administration (FDA) prior to distributing the devices. Jet’s device, the Allevio SPG Nerve Block Catheter (Allevio), was intended to treat migraine headaches by administering nerve blocks to the sphenopalatine ganglion (SPG), a collection of nerves located deep in the midface of the skull. The information alleges that Jet never sought approval or clearance from FDA to distribute the Allevio for this intended use, nor did Jet conduct an investigational study regarding the Allevio’s safety and effectiveness when used as intended. The resolution includes a deferred prosecution agreement and criminal penalties totaling $200,000. As part of the deferred prosecution agreement, which must be approved by the court, Jet admitted that it distributed misbranded devices in violation of the FDCA and agreed to implement enhanced compliance measures. The resolution also includes a civil settlement with the federal government under the False Claims Act (FCA) totaling $545,133. Along with Jet, related companies Medical Components Inc. (MedComp) and Martech Medical Products Inc. (Martech) are parties to the civil settlement. “The FDA approval and clearance process serves an important role in ensuring that devices used to treat patients are safe, effective, and medically appropriate,” said Principal Deputy Assistant Attorney General Brian M. Boynton, head of the Justice Department’s Civil Division. “We will not permit companies to circumvent that process and put profits over patient safety.” “Medical device companies put vulnerable patients at risk when they fail to follow FDA’s standards and requirements,” said U.S. Attorney Rachelle Aud Crowe for the Southern District of Illinois. “This resolution reflects our commitment to holding companies accountable for violating the integrity of the FDA approval process and placing profits over people.” “Doctors and their patients rely on FDA oversight to ensure that the medical devices they depend upon are safe and effective for their intended uses. Device manufacturers who circumvent the proper regulatory path in bringing their products to market endanger patients and put the public health at risk,” said Assistant Commissioner for Criminal Investigations Catherine A. Hermsen of the FDA Office of Criminal Investigations. “We will continue to investigate and bring to justice companies that ignore the law and jeopardize the public health.” “This medical device distributor undermined the integrity of the FDA approval process and disregarded patient safety for personal profit,” said Special Agent in Charge Curt L. Muller of the Department of Health and Human Services, Office of Inspector General (HHS-OIG). “Working closely with our law enforcement partners, we will continue to investigate and hold accountable those who put the health and safety of patients at risk and waste valuable taxpayer dollars.” The civil settlement resolves a lawsuit filed under the qui tam or whistleblower provision of the False Claims Act in the Southern District of Illinois. That lawsuit alleged that Jet, MedComp, and Martech violated the FCA by causing medical providers to submit false claims to the Medicare Program for procedures using the Allevio. The lawsuit alleged the Allevio was not approved or authorized by the FDA for use in SPG nerve blocks for the treatment of headaches, and that the procedure was not covered by Medicare. The suit alleged that Jet, MedComp, and Martech instructed, coached, and encouraged medical providers to submit improper billing codes to Medicare for reimbursement of services using the Allevio device. The resolution of this matter illustrates the government’s emphasis on combating health care fraud. The FCA is one of the most powerful tools in this effort. Tips and complaints from all sources about potential fraud, waste, abuse, and mismanagement can be reported to the Department of Health and Human Services at 900-HHS-TIPS (800-447-8477). Assistant U.S. Attorney Luke Weissler for the Southern District of Illinois and Trial Attorney David Hixson of the Civil Division’s Consumer Protection Branch, with assistance from the FDA’s Office of Chief Counsel, represented the government in the criminal case. Assistant U.S. Attorney Laura Barke for the Southern District of Illinois represented the government in the civil case. The FDA’s Office of Criminal Investigations conducted the investigation. Except as to conduct admitted in connection with the deferred prosecution agreement, the claims settled by the civil agreement are allegations only and there has been no determination of civil liability. **Topics:** Judicial/courts, Public Awareness --- ### [Cyber Insurance Struggling for Growth in Nigeria](https://insurancefraud.org/news_archives/cyber-insurance-struggling-for-growth-in-nigeria/) **Published:** August 23, 2026 **Author:** Diane Beauchamp **Content:** While addressing the attendees of a two-day symposium on internet governance and cyberspace security in Abuja, the Nigerian Communications Commission (NCC) claimed that it was collaborating with the Alliance-Africa Attorney General (AGA) to create a standard cyber insurance policy for internet governance. However, cyber insurance is not widely used in Nigeria. At the event eight months ago, Prof. Umar Danbatta, Executive Vice Chairman of the NCC, stated that the symposium was about internet governance, where the internet fits in, and how to obtain a standard cyber insurance policy. Sadly, the cyber insurance policy that was intended to cover all costs and expenses incurred as a result of a breach, such as when an organization is hacked or when client or employee information is stolen and lost, has failed. Better people say that businesses have had access to cyber insurance since it was introduced as a product line in insurance nearly 25 years ago as a means of covering their liability in the event of a data breach. Despite the fact that a significant portion of the world’s population is online, cyber insurance is often overlooked by Nigerians. Notwithstanding the fact that this industry is now widely recognized, many individuals do not consider how to best safeguard their personal lives, businesses, or transactions in light of its global importance. By 2026, the global market for cyber-insurance will be worth over $28 billion, according to Fitch Ratings. An industry stakeholder, Allianz Nigeria, reported that only 51% of Nigerian businesses are confident in the ability of their security team to act. In addition, since the COVID-19 pandemic began in 2020, 71% of businesses have reported an increase in the threat of data breaches, with financial institutions bearing the brunt of each attack. The source stated, “Cyberfraud causes annual losses of over 127 billion dollars, or about 10% of Nigeria’s GDP, and cyber insurance will not cover any of those losses.” Given Nigeria’s growing number of tech startups and establishments, experts wonder if Nigerian businesspeople are well-positioned to profit from data-targeting cyberattacks. On August 6, 2020, Allianz Nigeria hosted an interactive webinar titled “The Ever-Increasing Impact of Cyber Attacks” with four industry experts to educate business owners on how to safely mitigate these risks and raise awareness of the issue. Professionals lamented that the Federal Government had its fair share of cybercrimes when an anonymous Internet hacker group known as “NaijaCyberHacktivists” hacked the websites of the National Poverty Eradication Programme and the Niger Delta Development Commission in 2011. The website of the Economic and Financial Crimes Commission was also the target of an attack in 2013. In the Nigerian Electronic Fraud Forum’s 2016 Annual Report, 19,531 instances of bank fraud were documented. Traditional channels recorded the lowest number. In addition, it stated that electronic payment fraud results in annual losses of $2.19 billion. The experts say that these kinds of risks are usually not covered by traditional commercial general liability policies, or at least they aren’t specifically defined in them. Most people believe that big businesses like banks only need cybersecurity insurance. However, the source continued by stating that any electronic information that is stored on one’s personal devices—such as name, email address, phone number, financial records, medical records, payment information, government documents, and so on—can be hacked quickly and easily by a skilled hacker. According to findings, despite the growing concern about cyber security, Nigeria still lags far behind the rest of the world when it comes to enforcing privacy and security laws for businesses. Similarly, the attack’s persistence and widespread nature affect small, medium, and large businesses. In the 2019 Verizon Data Breach Investigation Report, 43% of online attacks target small businesses. As a result, cyber insurance is becoming more and more important as the costs of cybersecurity to limit a company’s exposure and liabilities rise. Even though data suggests that the Insurance Act of 2003 (the “Act”) does not mention cyber insurance, a closer look at the law reveals that the creation of such a policy is not explicitly prohibited. The statement goes further, pointing out that an insurer “may be authorized to transact any new category of miscellaneous insurance business,” as stated in Section 2(5) of the Act. In a similar manner, the Act’s Section 16 offers a framework for the approval of new products. In a similar vein, the risk-based cybersecurity framework developed by the Central Bank of Nigeria stipulated that the security assurance program for Payment Service Providers should take into account cyber-insurance coverage. A Proposition for Cyber Insurance, it was discovered that, since the virus began, 71% of security professionals had reported an increase in security threats or attacks. Phishing (55 percent), malicious websites (32 percent), malware (28 percent), and ransomware (19 percent) are among the cyber-risk trends that are most likely to affect businesses, investigation revealed. The need for organizations to focus on cyber resilience rather than just cyber security was one of the other points of emphasis made by the speakers. This requires combining strategies for business continuity and information security. To put it another way, an organization’s cyber resilience is its capacity to withstand failures or attacks and quickly return to normal operations. In light of this, Mr. Uzodinma Ibe of Casualty & Liability Underwriting, General Insurance, stated that because more and more businesses are connecting to the internet and the internet is part of their day-to-day operations, insurance protection against cyber attacks is necessary. Leadway Assurance, a major insurer in Nigeria, was worried that individuals, businesses, religious groups, and institutions should take the necessary insurance measures to safeguard their computer networks and databases from cyber attacks. This was emphasized about two years ago at a Leadway Assurance virtual training workshop on “Understanding Cyber Insurance.” Industry experts are worried that there isn’t a good operational insurance company that can protect businesses from risks related to information technology. Either a lack of understanding and awareness of the product or a lack of incentive for insurance providers to offer cyber insurance products for the Nigerian market account for the lack of growth in Nigeria, they say. Also, the Insurance Act of 2004 does not explicitly allow for it, but a careful reading of the law does not explicitly forbid the creation of such a policy. “May be authorized to transact any new category of miscellaneous insurance business if he shows evidence of adequate reinsurance arrangements in respect of that category of insurance business, requisite capital where necessary, and other conditions as may be required from time to time,” states Section 2(5) of the Act 3. Mr. Raymond Akalonu, Head of Enterprise Risk Management and Compliance at FBN Insurance Limited, mentioned that the country’s cyber-insurance policy was written by international brokers. He claims that domesticating cyber-insurance in the country will necessitate the use of reinsurance. According to Mr. Temitope Adaramola, Assistant Executive Secretary of the Nigerian Council of Registered Insurance Brokers, less than 10% of underwriters were offering cyber-insurance policies through international brokers. In order to fill this gap, stakeholders and regulators must act quickly to create a regulatory framework that makes it easier for cyber-insurance companies to expand in Nigeria. But Leadway claims that their Cyber Enterprise Risk Management Insurance policies aim to assist any organization in mitigating risk exposure for certain recovery-related costs and expenses. Mr. Ibe explained that Leadway Cyber Insurance provides organizations with first-party and third-party liability risk coverage against cyberattacks. Sources showed that he did not specify who is being covered or who is being indemnified. It was observed that in the event of a data breach or compromise, the policyholder—the individual or business that purchases the insurance—covers the costs of a private investigation to inform a number of customers about the breach. Companies are protected from losses incurred by others as a result of third-party liability coverage, such as defamation, failure to safeguard data, and errors and omissions; in addition to regular security audits, post-incident expenses for public relations and investigation, and funds for criminal reward. This was because the Global Threat Impact Index 2017 ranked Nigeria, along with four other African nations, among the nations with the highest risk of cyber attacks worldwide. Checks revealed that due to a lack of awareness and underwriting experience, a lack of industry data on cybercrime and related losses, the unpredictability of cyber risks, and the high correlation of one type of cyber risk with another, among other factors, experts argue that the cost of a cyber-insurance policy will depend on a variety of different factors, including the size of the business and its annual revenue. This is a new phenomenon in the country. The business’s industry, the kind of data it typically deals with, and the network’s overall security may also be important considerations, they say. A cyber-insurance policy from a company with a good reputation for security will almost certainly cost more to cover than one from a company with a history of being hacked or having a data breach. On the other hand, it is thought that digitalization is gradually replacing manual services in every industry, including Nigeria’s government parastatals. Work related to cyber insurance could also be a gold mine for insurance industry professionals. By collaborating with foreign insurance companies with extensive cyber insurance experience to offer a variety of products, Nigerian insurance brokers could take advantage of these opportunities. Against this backdrop, the National Insurance Commission (NAICOM) held a sensitization workshop on the enforcement of compulsory insurance in at least the Federal Capital Territory (FCT) in June 2022 in order to deepen insurance penetration in Nigeria as a pilot programme. Because many Nigerians are reluctant to purchase insurance unless forced to do so, the security agents who make up the Joint Task Force were integral to the enforcement. The workshop’s purpose, according to NAICOM spokesperson Rasaq Salami, was to educate Task Force members about the law’s requirements for compulsory insurances and the enforcement strategies of the Task Force Committee. Experts believe that insurances are required by law. Unit Head of Reinsurance at Allianz Nigeria Insurance Plc., Aima Higo, said that understanding cyber security is the first step in protecting oneself and the people with whom they interact in a connected world, emphasizing that risks can only be reduced to an acceptable level through the implementation of a set of measures and the acquisition of cyber insurance, even though there is no such thing as total cyber security. Industry pundits say insurance is the best way to help reduce losses caused by cyber risks, so financial institutions, in particular, need to learn cyber resilience, evaluate how quickly they can return to operational mode following a cyberattack, and, most importantly, transfer risks. They went further to say that over the course of time, the number of cyberattacks will continue to rise, and all that is required for an operational entity to suffer detrimental exposure to data privacy and information is a weak or vulnerable area. Regardless of whether the pandemic is over, they say that organizational cultures must emphasize the need for a cyber-security management system and incorporate cyber insurance into their strategic objectives. **Topics:** Public Awareness, Technology --- ### [Los Angeles car thefts sped up in 2022](https://insurancefraud.org/news_archives/los-angeles-car-thefts-sped-up-in-2022/) **Published:** August 23, 2026 **Author:** Diane Beauchamp **Content:** A car theft epidemic in Los Angeles accelerated last year. The city recorded 25,400 stolen vehicles, the highest annual count since the Los Angeles Police Department began making its [data publicly available](https://data.lacity.org/Public-Safety/Crime-Data-from-2020-to-Present/2nrs-mtv8) in 2010. Car thefts have always been a problem in the city, and the figure has bounced around. There were 19,143 vehicles stolen in 2017, but just 15,724 two years later. Thefts [shifted into high gear](https://xtown.la/2022/10/20/car-thefts-in-los-angeles-continue-at-a-rapid-pace/) with the onset of the pandemic. Initially thieves targeted cars sitting on the street for extended periods as many people reduced their driving. But even as vehicular activity picked back up, thefts kept rising. The 2022 count is a 4.3% increase over the previous year, and a staggering 61.5% higher than in 2019. ![](https://insurancefraud.org/wp-content/uploads/image-19.png)According to the [National Insurance Crime Bureau](https://www.nicb.org/), an organization that works to combat and prevent insurance crime, there is no single root cause for the increase, which has been [seen in cities across the country](https://www.cbsnews.com/news/auto-thefts-carjackings-major-u-s-cities-spike-new-report/). “The pandemic led to an economic downturn, the value of used cars is up substantially right now, there are supply chain issues, and some cars that are stolen are later used in more violent crimes,” said NICB Public Affairs Specialist Danielle Naspinski. Other reasons for the rise include unemployment and low wages, inflation’s impact on the economy, higher costs of living and insufficient security, according to the [Insurance Information Institute](https://www.iii.org/). “Insurance companies include the costs of fraud and theft in insurance rates over time as this impacts the loss costs paid out. We all pay for auto theft,” said Janet Ruiz, the organization’s Strategic Communications Director. In the entire 2010s, there was not a single month with more than 2,000 auto thefts. In 2022, that figure was surpassed nine times, according to LAPD data. However, there may be a ray of hope, with a decline in activity toward the end of the year. November brought 1,921 auto thefts, and there were 1,887 in December. ![](https://insurancefraud.org/wp-content/uploads/image-20-1.jpg)## **Social media problem** One contributing factor to the 2022 figures was the [“Kia Challenge.”](https://www.lamag.com/citythinkblog/tiktok-challenge-leads-to-skyrocketing-kia-and-hyundai-thefts-in-l-a/) A series of videos demonstrating how to use a USB port to override the locking mechanism and start the engine of many Kia and Hyundai models went viral. It began in Milwaukee and caught on nationwide. Insurance industry groups are seeking to get such videos removed from YouTube. The NICB last week stated that police departments across the country have had to contend with a surge of thefts of Kias and Hyundais. “Posting videos such as these harms American consumers by increasing auto thefts and increasing premiums,” said Matthew Smith, executive director of the [Coalition Against Insurance Fraud](https://insurancefraud.org/), in a [statement released by the NICB](https://www.nicb.org/news/news-releases/kia-and-hyundai-thefts-spiking-insurance-industry-associations-encourage-youtube). “It is time for practices such as these to stop.” Yet more than those makes are going missing. Commonly stolen vehicles, according to the NICB’s [“Hot Wheels Report,”](https://www.nicb.org/news/news-releases/chevrolet-and-ford-full-size-pick-ups-most-stolen-vehicles-second-year-row) which tracks annual car thefts across the country, are Chevrolet full-size pick-up trucks and Ford pick-ups. [Thieves notoriously target older vehicle models](https://xtown.la/2022/07/19/stoeln-vehicle-record-los-angeles-first-half-2022/) with key-based ignition systems, including Hondas from 1995-2010 and Kias from 2010-2021. ## **Billions in losses** The situation in Los Angeles is also playing out across the country. Vehicle thefts nationwide in 2022 were the highest they have been since 2008, according to the NICB. [During the first three quarters of 2022](https://www.nicb.org/news/news-releases/over-745000-stolen-vehicles-reported-so-far-2022), more than 745,000 cars were stolen in the United States. That represents an estimated $6.6 billion worth of vehicle theft, according to NICB data. In Los Angeles, LAPD Chief Michel Moore has said that many stolen cars are recovered within days of going missing, and often in the same neighborhoods. He has said this indicates vehicles are often taken for transportation, as opposed to being sold overseas or dismantled for parts. [Downtown](https://products.xtown.la/neighborhood/downtown) in 2022 recorded 1,371 stolen car reports, the highest number of any neighborhood in the city for the second year in a row. Other frequently targeted communities in 2022 included [Boyle Heights](https://products.xtown.la/neighborhood/boyle-heights) (861 reports) and [Westlake](https://products.xtown.la/neighborhood/westlake) (763). ![](https://insurancefraud.org/wp-content/uploads/image-21-1.jpg)Law enforcement and insurance groups are united in the effort to prevent vehicle theft. However, deterrents such as steering-wheel locks and alarms are not always enough. “While a great many after-market solutions exist, there’s always someone determined to find a way to defeat it,” said Naspinski. The NICB and LAPD urge common-sense steps that drivers in a hurry sometimes forget. These include reminders to roll up windows, lock doors, park in well-lit areas, and not leave a key fob in the vehicle. **How we did it:** We examined [publicly available vehicle theft data](https://data.lacity.org/Public-Safety/Crime-Data-from-2020-to-Present/2nrs-mtv8) from the Los Angeles Police Department from Jan. 1, 2010–Dec. 31, 2022. LAPD data only reflects crimes that are reported to the department, not how many crimes actually occurred. In making our calculations, we rely on the data the LAPD makes publicly available. LAPD may update past crime reports with new information, or recategorize past reports. Those revised reports do not always automatically become part of the public database. **Topics:** Auto fraud, Public Awareness --- ### [A baby spent 36 days at an in-network hospital. Why did her parents get a huge bill?](https://insurancefraud.org/news_archives/a-baby-spent-36-days-at-an-in-network-hospital-why-did-her-parents-get-a-huge-bill/) **Published:** August 23, 2026 **Author:** Diane Beauchamp **Content:** Brenna Kearney was seven months pregnant in December 2019 when she experienced what she thought were bad flu symptoms. Her husband, Casey Trumble, drove her from their Chicago home to her OB-GYN’s office at Northwestern Medicine Prentice Women’s Hospital downtown. With suddenly elevated blood pressure and protein in her urine, she was diagnosed with preeclampsia, a potentially fatal but treatable pregnancy complication. Doctors admitted her to the hospital, saying she could expect to stay up to six weeks and have an induced delivery. Then Kearney developed a bad headache and her blood platelet count plummeted, signs she was experiencing a rare, dangerous type of preeclampsia and required an immediate delivery by cesarean section. Kearney’s daughter, Joey, born at 31 weeks, was placed on a ventilator and moved to the hospital’s neonatal intensive care unit. Small but healthy, she slowly began breathing on her own and eating normally. She was discharged in late January 2020, after 36 days in the NICU. Then the bill came. **The patient:** Josephine “Joey” Trumble, now 3, was covered by her mother’s health plan through her employer, an advertising agency. For 2019, it was an Aetna plan, and for 2020, it was a plan from Blue Cross and Blue Shield of Illinois. Both policies were fully insured plans governed by Illinois laws. **Medical service:** Neonatology physician services provided in January 2020. Joey needed tube feeding and ventilator care to provide oxygen. **Service provider:** Ann & Robert H. Lurie Children’s Hospital of Chicago, whose staff physicians treated Joey at Northwestern Medicine Prentice Women’s Hospital. Ownership-wise, Lurie is independent of Northwestern Medicine, but it is physically connected to Prentice Women’s by an enclosed walkway. Lurie has a [collaboration agreement](https://www.feinberg.northwestern.edu/newsletters/my-northwestern-medicine/2012/6_6/Lurie_childrens_move_update_NM.pdf) with Northwestern Medicine to provide neonatology and pediatric physician services to Prentice Women’s patients. **Total bill:** Aetna paid for nearly all of Joey and her mother’s hospital and physician charges in December, while Blue Cross picked up nearly all of Joey’s hospital charges in January. Physician charges from Lurie in January totaled $14,624.55, of which the family was asked to pay $12,531.58 after payments from Blue Cross. **What gives:** It took Kearney months of calls to Blue Cross and the two hospitals to find out why Lurie billed more than $14,000 for physician services: The physicians treating her daughter at Prentice Women’s — an in-network hospital under her health plan— actually worked for a separate, out-of-network hospital. Illinois law bars insurers from charging patients out-of-network rates for neonatal care at in-network hospitals. Kearney said no one had told her or her husband that Lurie doctors were treating their daughter. She said the family never signed an agreement consenting to receive care from out-of-network doctors. Though it did not happen here, many patients unknowingly sign broad financial agreements — saying they’ll pay for almost anything their insurance doesn’t cover — in the piles of paperwork they receive upon admission to a hospital. In many cases, they are simply asked to sign on a screen, without seeing the document. Blue Cross agreed to pay Lurie the in-network rate for the doctors’ services, reducing the bill to about $12,500 — which Lurie expected the family to pay. In November 2020, Kearney started receiving letters from ICS Collection Service, a collection agency. “Talking to Blue Cross was impossible, and Lurie said it’s not their problem and just wanted to put us on a payment plan,” Kearney said. Joey’s 36-day stay in the NICU happened before the federal government implemented the No Surprises Act barring surprise out-of-network billing. A state law prohibiting it, though, was in effect. Since 2011, [Illinois law ](https://www.ilga.gov/legislation/publicacts/fulltext.asp?Name=096-1523)has prohibited insurers from charging out-of-network rates [for neonatologists, anesthesiologists, and certain other physicians](https://www.bcbsil.com/member/member-resources/surprise-medical-bills) when patients are treated at in-network hospitals. Kearney said she repeatedly mentioned the law to Lurie and Blue Cross representatives, who denied knowledge of the provision. “It definitely appears that under the 2011 law, Brenna can only be billed for in-network cost sharing,” said Kathy Mikos, a registered nurse and patient advocate with the Navocate Group in Woodridge, Illinois, who is not involved with Kearney’s case. In December 2020, an insurance broker working for Kearney’s employer persuaded Blue Cross to pay the full out-of-network charges for the Lurie doctors, leaving the family owing $289.63 for coinsurance, which they promptly paid. Having spent nearly the first year of her daughter’s life fighting medical bills from her birth, Kearney thought the ordeal was over. Then, last month, she got a call from the collection agency, which again demanded payment at the full out-of-network rate for Lurie physician services provided to her daughter three years ago — the bill she believed Blue Cross had paid. It took five hours on the phone for Kearney to piece together what had happened. Blue Cross had indeed paid the out-of-network charges in December 2020 — but, two days later, had taken back the money, ultimately paying Lurie’s doctors only the in-network rate. A Lurie representative said Kearney and her husband still owed thousands of dollars. A Blue Cross representative suggested she set up a payment plan. “I was at wits’ end, and I didn’t know how to fight this anymore,” Kearney said. Lurie, Blue Cross, and Northwestern Medicine repeatedly declined to comment on the case. Lurie cited patient privacy, despite receiving a release from Kearney regarding the federal Health Insurance Portability and Accountability Act, or HIPAA, which authorized the hospital to discuss Joey’s case with KHN. **The resolution:** After KHN contacted Lurie and Blue Cross, a Lurie representative called Kearney offering to accept payment at the in-network rates after all. Kearney said Tracy A. Spicer, manager of consolidated services at Lurie, told her Lurie has a “long-standing policy” of accepting in-network rates for Lurie physician services provided at Prentice Women’s. Spicer subsequently described it as a “long-standing courtesy,” then explained that acceptance of in-network rates was subject to “case-by-case consideration,” Kearney said. Spicer said the family owed about $3,000, for their coinsurance share, and offered to set up a payment plan. A day later — following additional requests by KHN for comment — Spicer called Kearney and said she would remove all physician charges for her daughter’s care. Spicer did not return KHN’s call seeking comment. “I’m certain I’m not the only person still dealing with this” kind of predicament, Kearney said. Kearney has filed complaints with the Illinois Department of Insurance and the Illinois Attorney General’s Office. The attorney general’s office told KHN it had never enforced the 2011 law barring certain out-of-network billing. Presented with the facts of Kearney’s case, state Sen. Ann Gillespie, who sponsored a 2022 state law expanding consumer protections against out-of-network bills, told KHN she plans to contact Lurie, Blue Cross, and Northwestern Medicine to ask about their billing arrangement and whether they are in compliance with state law. “We’ll see if it was a pattern and whether they need to look back and see if refunds are warranted,” Gillespie said. The attorney general’s office told KHN it will investigate Kearney’s complaint, including whether Lurie violated the state Consumer Fraud and Deceptive Business Practices Act by telling her it was extending a “courtesy” by charging her only in-network rates, when that is what the 2011 law required. The insurance department also said it would investigate the complaint. **The takeaway:** Even resourceful consumers who appear to have the law on their side, like Kearney, may find themselves in a losing, time-consuming battle with medical billing bureaucracies and facing collection actions. Gillespie, the state senator, said Lurie, Northwestern Medicine, and Blue Cross should have known about the state law. She said patients who believe they have been improperly charged should file complaints with their state’s insurance department, which can trigger a broader investigation. The federal No Surprises Act, which took effect last year, prohibits medical providers or insurers from billing patients for out-of-network physician charges at an in-network hospital, [unless the patient formally consents](https://khn.org/news/article/podcast-an-arm-and-a-leg-no-surprises-act-billing-rights/) to an out-of-network doctor. To be safe, patients should ask treating doctors whether they are in or out of network, even at an in-network hospital. While the federal law offers patients new protections from out-of-network bills, many Americans still face problems from before the law took effect, said Loren Adler, associate director at the USC-Brookings Schaeffer Initiative for Health Policy. Illinois is one of [relatively few states](https://www.healthaffairs.org/do/10.1377/forefront.20170201.058570/full/) that had prior laws to protect consumers. Also, some out-of-network physicians continue to bill patients, despite the new federal protections. So know your rights. Cite the new law. And don’t write the check. **Topics:** Legislative, Public Awareness --- ### [Multiple Vulnerabilities Found In Healthcare Software OpenEMR](https://insurancefraud.org/news_archives/multiple-vulnerabilities-found-in-healthcare-software-openemr/) **Published:** August 23, 2026 **Author:** Diane Beauchamp **Content:** Alessandro Mascellino reports: > Researchers have found three separate vulnerabilities in [OpenEMR](https://www.open-emr.org/), an open-source software for electronic health records and medical practice management. > > Clean code experts at [Sonar](https://www.sonarsource.com/) published an [advisory](https://www.sonarsource.com/blog/openemr-remote-code-execution-in-your-healthcare-system/) Wednesday about the discovered flaws by security researcher Dennis Brinkrolf. Thanks to responsible disclosure, the vulnerabilities were addressed in October 2022. Anyone using OpenEMR should update to one of the updated versions. In 2018, Project Insecurity released their report on [18 vulnerabilities](https://www.databreaches.net/openemr-patches-serious-vulnerabilities-uncovered-by-project-insecurity/) they had found. **Topics:** Public Awareness, Technology --- ### [Medical identity theft: Why your medical records make scammers big bucks](https://insurancefraud.org/news_archives/medical-identity-theft-why-your-medical-records-make-scammers-big-bucks/) **Published:** August 23, 2026 **Author:** Diane Beauchamp **Content:** We have reported on many scams that can affect your wallet, but one alarming trend can impact your money and your health: medical identity theft. That private information has become very valuable to hackers who can sell it to people who use it to file insurance claims, and that’s just the start. Most people, like Stephanie Hazelhurst in Greenville, don’t know the dangers until they’re a part of a breach. “I never even considered that they can get my health benefits and my insurance information and go run up charges that way,” Hazelhurst said. Hazelhurst got a notice from Upstate Carolina Radiology in September about a breach that had been identified nine months earlier. “I was just completely shocked. The fact that someone can use my insurance card to get benefits is very scary,” she said. Think that sounds farfetched? Think again. ## Why is medical info valuable? The digital security company [Aura](https://www.aura.com/learn/medical-identity-theft), which tracks the dark web marketplace, said scammers are using stolen medical files to gain illegitimate access to health services, prescription drugs and submit fraudulent medical claims. “I can buy a stolen credit card online for a few dollars, maybe 4 or 5 bucks per card. A Social Security card is probably about $1 per number,” Zulfikar Ramzan, at Aura, said. “A medical record or really medical information that can lead to someone usurping your insurance information, that can be worth upwards of $1000 per instance.” Ramzan said the reason why it’s so lucrative, is not only because the costs of medical procedures and drugs are so high, but also because most people don’t catch the theft for months or years. Which also allows scammers to continue to collect on things like bogus disability claims. ## It’s not just from hacks Ed Rollings, in Greenwood County, experienced a different type of medical fraud, not the theft of his information, but the exploitation of his deceased wife’s end-of-life medical care. “It’s a personal violation of myself plus her legacy,” he told 7NEWS. Several months after he lost his wife, Barbara, to congestive heart failure, he got yet another medical bill, but something was off. He showed 7NEWS the bill. “This phone number is not correct, there is no reference to Abbeville Area Medical Center. The account number is not the format they used. So, my thought was this may not be a legitimate document so that’s when we pull up the actual billing that the hospital uses and it’s in color,” he said. “You just start seeing these clues in the document which the hospital confirmed it was not legitimate.” Fortunately, Rollings never paid the bogus bill, but Hazelhurst is still worried about her private information. “I was very upset. That’s almost a year of somebody possibly having my medical information,” Hazelhurst said. In a statement to 7NEWS Upstate Carolina Radiology said, “Investigations into these types of incidents take time, and we notified affected individuals as soon as we were able. At this time, all patients who may have been affected by this incident have been mailed a notification letter with the steps they can take.” ## How to protect yourself First, let’s address all the private information you have to give out at the doctor’s office. 7NEWS checked with the SC Hospitals Association which found that there is no legal requirement to give out your Social Security Number or your driver’s license to any hospital or doctor’s office, though your insurance company may need it to file a claim. In other words, protect yourself by not filling in your Social Security Number on every medical document that requests it. That is not necessary. You can also protect yourself by: - reading over all of your explanation of benefits statements (EOB) - setting up a security freeze of your credit and if you are a part of a breach - setting up fraud alerts with each credit reporting agency - changing your password to online medical portals - keeping original medical documents on file The [South Carolina Department of Consumer Affairs](https://consumer.sc.gov/identity-theft-unit/security-breach-notices) warns healthcare and insurance companies have been the biggest targets in recent years for breaches. “Medical ID theft is the most expensive form of ID theft that we see reported to us. It’s tens of thousands of dollars that often go lost to Medical ID theft,” Bailey Parker, with SCDCA, said. Hazelhurst has this advice, “I think just pay attention to everything you get from your insurance company.” Both Hazelhurst and Rollings hope their stories will help warn others to be on alert. “I hate that we have people in this world who will actually take advantage of people in these kinds of circumstances to do something like that, so malevolent. Especially somebody as good as a person as she was. It just staggers me that somebody would do that,” Rollings said. **Topics:** Public Awareness, Technology --- ## Venues ### [Hilton Long Beach, Long Beach, CA](https://insurancefraud.org/venue/hilton-long-beach-long-beach-ca/) **Published:** January 8, 2026 **Author:** Coalition Against Insurance Fraud --- ### [Renaissance Orlando at SeaWorld](https://insurancefraud.org/venue/renaissance-orlando-at-seaworld/) **Published:** December 26, 2025 **Author:** Coalition Against Insurance Fraud --- ### [Sheraton New Orleans](https://insurancefraud.org/venue/sheraton-new-orleans/) **Published:** December 4, 2025 **Author:** Coalition Against Insurance Fraud --- ### [Hyatt Regency Monterey](https://insurancefraud.org/venue/hyatt-regency-monterey/) **Published:** October 27, 2025 **Author:** Coalition Against Insurance Fraud --- ### [Orlando, Fl (Omni Orlando Resort at ChampionsGate)](https://insurancefraud.org/venue/orlando-fl-omni-orlando-resort-at-championsgate/) **Published:** December 9, 2021 **Author:** Coalition Fraud --- ### [1012 14th Street NW Washington, DC 20005](https://insurancefraud.org/venue/sample-venue/) **Published:** July 15, 2020 **Author:** Coalition Against Insurance Fraud --- ### [Caribe Royale - Orlando, FL](https://insurancefraud.org/venue/caribe-royale-orlando-fl/) **Published:** December 19, 2020 **Author:** Coalition Against Insurance Fraud --- ### [Crystal City, VA](https://insurancefraud.org/venue/crystal-city-va/) **Published:** July 24, 2020 **Author:** Coalition Against Insurance Fraud --- ### [New Orleans, LA](https://insurancefraud.org/venue/new-orleans-la/) **Published:** July 24, 2020 **Author:** Coalition Against Insurance Fraud --- ## Organizers ### [Orlando, FL (Caribe Royale)](https://insurancefraud.org/organizer/orlando-fl-caribe-royale/) **Published:** March 8, 2022 **Author:** Coalition Against Insurance Fraud --- ### [Sheraton Pentagon City Hotel - Washington, DC](https://insurancefraud.org/organizer/) **Published:** September 24, 2021 **Author:** Coalition Against Insurance Fraud --- ## Categories ### [Blog](https://insurancefraud.org/category/blog/) --- ## Topics ### [Drug Diversion](https://insurancefraud.org/topics/drug-diversion/) --- ### [Fraud General](https://insurancefraud.org/topics/fraud-general/) --- ### [Life Insurance](https://insurancefraud.org/topics/life-insurance/) --- ### [Public Adjuster](https://insurancefraud.org/topics/public-adjuster/) --- ### [Public Awareness](https://insurancefraud.org/topics/public-awareness/) --- ### [Coalition Against Insurance Fraud](https://insurancefraud.org/topics/coalition-against-insurance-fraud/) --- ### [Legislation](https://insurancefraud.org/topics/legislation/) --- ### [Workers Comp](https://insurancefraud.org/topics/workers-comp/) --- ### [Healthcare Fraud](https://insurancefraud.org/topics/healthcare-fraud/) --- ### [Auto Rate Evasion](https://insurancefraud.org/topics/auto-rate-evasion/) --- ### [Homeowners Fraud](https://insurancefraud.org/topics/homeowners-fraud/) --- ### [Insider Fraud](https://insurancefraud.org/topics/insider-fraud/) --- ### [Commercial Fraud](https://insurancefraud.org/topics/commercial-fraud/) --- ### [Disability](https://insurancefraud.org/topics/disability/) --- ### [Liability](https://insurancefraud.org/topics/liability/) --- ### [Regulatory actions](https://insurancefraud.org/topics/regulatory-actions/) --- ### [Contractor fraud](https://insurancefraud.org/topics/contractor-fraud/) --- ### [Medical ID theft](https://insurancefraud.org/topics/medical-id-theft/) --- ### [Crop insurance](https://insurancefraud.org/topics/crop-insurance/) --- ### [Unlicensed entities](https://insurancefraud.org/topics/unlicensed-entities/) --- ### [Auto fraud](https://insurancefraud.org/topics/auto-fraud/) --- ### [Underwriting](https://insurancefraud.org/topics/underwriting/) --- ### [Auto - give up](https://insurancefraud.org/topics/auto-give-up/) --- ### [Insider - insurer](https://insurancefraud.org/topics/insider-insurer/) --- ### [Homeowners - fake](https://insurancefraud.org/topics/homeowners-fake/) --- ### [Auto - underwriting](https://insurancefraud.org/topics/auto-underwriting/) --- ### [Insider - agent](https://insurancefraud.org/topics/insider-agent/) --- ### [Medical - false claims](https://insurancefraud.org/topics/medical-false-claims/) --- ### [Work comp - worker](https://insurancefraud.org/topics/work-comp-worker/) --- ### [Work comp - employer](https://insurancefraud.org/topics/work-comp-employer/) --- ### [Homeowners - arson](https://insurancefraud.org/topics/homeowners-arson/) --- ### [Auto - padding/false claim](https://insurancefraud.org/topics/auto-padding-false-claim/) --- ### [Legislative](https://insurancefraud.org/topics/legislative/) --- ### [Auto - staged](https://insurancefraud.org/topics/auto-staged/) --- ### [Liability - false claim](https://insurancefraud.org/topics/liability-false-claim/) --- ### [Homeowners - padding](https://insurancefraud.org/topics/homeowners-padding/) --- ### [Technology](https://insurancefraud.org/topics/technology/) --- ### [To be determined](https://insurancefraud.org/topics/to-be-determined/) --- ### [Judicial/courts](https://insurancefraud.org/topics/judicial-courts/) --- ### [Work comp - provider](https://insurancefraud.org/topics/work-comp-provider/) --- ### [Medicare/Medicaid](https://insurancefraud.org/topics/medicare-medicaid/) --- ### [Business - arson](https://insurancefraud.org/topics/business-arson/) --- ### [Business - padding/faking](https://insurancefraud.org/topics/business-padding-faking/) --- ### [Unlicensed](https://insurancefraud.org/topics/unlicensed/) --- ### [COVID-19](https://insurancefraud.org/topics/covid-19/) --- ### [Pet insurance fraud](https://insurancefraud.org/topics/pet-insurance-fraud/) --- ### [Auto arson](https://insurancefraud.org/topics/auto-arson/) --- ### [Synthetic Identity Theft](https://insurancefraud.org/topics/synthetic-identity-theft/) --- ### [Renter's Insurance](https://insurancefraud.org/topics/renters-insurance/) --- ### [Social Security fraud](https://insurancefraud.org/topics/social-security-fraud/) --- ### [Third party litigation funding](https://insurancefraud.org/topics/third-party-litigation-funding/) --- ### [Long-Term Care Insurance](https://insurancefraud.org/topics/long-term-care-insurance/) --- ### [Elderly Fraud](https://insurancefraud.org/topics/elderly-fraud/) --- ### [Unemployment Insurance](https://insurancefraud.org/topics/unemployment-insurance/) --- ### [Title Insurance](https://insurancefraud.org/topics/title-insurance/) --- ### [Veterans Benefits Fraud](https://insurancefraud.org/topics/veterans-benefits-fraud/) --- ### [Traveler's Insurance](https://insurancefraud.org/topics/travelers-insurance/) --- ### [Funeral Director Fraud](https://insurancefraud.org/topics/funeral-director-fraud/) --- ### [Testing Fraud](https://insurancefraud.org/topics/testing-fraud/) --- ### [Towing Fraud](https://insurancefraud.org/topics/towing-fraud/) --- ### [Financial Fraud](https://insurancefraud.org/topics/financial-fraud/) --- ### [Employment fraud](https://insurancefraud.org/topics/employment-fraud/) --- ## Features ### [Hall of Shame](https://insurancefraud.org/features/hall-of-shame/) --- ### [Fraud News Weekly](https://insurancefraud.org/features/fraud-news-weekly/) **Description:** Fraud News Weekly Cases, trends, legislation and Coalition updates. Published every Friday. --- ### [FraudBlog](https://insurancefraud.org/features/fraud-blog/) **Description:** FraudBlog Insight and analysis on key trends. Coalition staff and guest experts share their vision on how to better fight fraud. --- ## State ### [Alabama](https://insurancefraud.org/state/alabama/) --- ### [Alaska](https://insurancefraud.org/state/alaska/) --- ### [Arizona](https://insurancefraud.org/state/arizona/) --- ### [Arkansas](https://insurancefraud.org/state/arkansas/) --- ### [California](https://insurancefraud.org/state/california/) --- ### [Colorado](https://insurancefraud.org/state/colorado/) --- ### [Connecticut](https://insurancefraud.org/state/connecticut/) --- ### [Delaware](https://insurancefraud.org/state/delaware/) --- ### [District of Columbia](https://insurancefraud.org/state/district-of-columbia/) --- ### [Florida](https://insurancefraud.org/state/florida/) --- ### [Georgia](https://insurancefraud.org/state/georgia/) --- ### [Hawaii](https://insurancefraud.org/state/hawaii/) --- ### [Idaho](https://insurancefraud.org/state/idaho/) --- ### [Illinois](https://insurancefraud.org/state/illinois/) --- ### [Indiana](https://insurancefraud.org/state/indiana/) --- ### [Iowa](https://insurancefraud.org/state/iowa/) --- ### [Kansas](https://insurancefraud.org/state/kansas/) --- ### [Kentucky](https://insurancefraud.org/state/kentucky/) --- ### [Louisiana](https://insurancefraud.org/state/louisiana/) --- ### [Maine](https://insurancefraud.org/state/maine/) --- ### [Maryland](https://insurancefraud.org/state/maryland/) --- ### [Massachusetts](https://insurancefraud.org/state/massachusetts/) --- ### [Michigan](https://insurancefraud.org/state/michigan/) --- ### [Minnesota](https://insurancefraud.org/state/minnesota/) --- ### [Mississippi](https://insurancefraud.org/state/mississippi/) --- ### [Missouri](https://insurancefraud.org/state/missouri/) --- ### [Montana](https://insurancefraud.org/state/montana/) --- ### [Nebraska](https://insurancefraud.org/state/nebraska/) --- ### [Nevada](https://insurancefraud.org/state/nevada/) --- ### [New Hampshire](https://insurancefraud.org/state/new-hampshire/) --- ### [New Jersey](https://insurancefraud.org/state/new-jersey/) --- ### [New Mexico](https://insurancefraud.org/state/new-mexico/) --- ### [New York](https://insurancefraud.org/state/new-york/) --- ### [North Carolina](https://insurancefraud.org/state/north-carolina/) --- ### [North Dakota](https://insurancefraud.org/state/north-dakota/) --- ### [Ohio](https://insurancefraud.org/state/ohio/) --- ### [Oklahoma](https://insurancefraud.org/state/oklahoma/) --- ### [Oregon](https://insurancefraud.org/state/oregon/) --- ### [Pennsylvania](https://insurancefraud.org/state/pennsylvania/) --- ### [Rhode Island](https://insurancefraud.org/state/rhode-island/) --- ### [South Carolina](https://insurancefraud.org/state/south-carolina/) --- ### [South Dakota](https://insurancefraud.org/state/south-dakota/) --- ### [Tennessee](https://insurancefraud.org/state/tennessee/) --- ### [Texas](https://insurancefraud.org/state/texas/) --- ### [Utah](https://insurancefraud.org/state/utah/) --- ### [Vermont](https://insurancefraud.org/state/vermont/) --- ### [Virginia](https://insurancefraud.org/state/virginia/) --- ### [Washington](https://insurancefraud.org/state/washington/) --- ### [West Virginia](https://insurancefraud.org/state/west-virginia/) --- ### [Wisconsin](https://insurancefraud.org/state/wisconsin/) --- ### [Wyoming](https://insurancefraud.org/state/wyoming/) --- ### [Federal](https://insurancefraud.org/state/federal/) --- ## Statute Areas ### [Anti-Runner Provisions](https://insurancefraud.org/statute_areas/anti-runner-provisions/) --- ### [Attempted Fraud](https://insurancefraud.org/statute_areas/attempted-fraud/) --- ### [Claims Fraud](https://insurancefraud.org/statute_areas/claims-fraud/) --- ### [False Claims Act](https://insurancefraud.org/statute_areas/false-claims-act/) --- ### [Fraud Bureau](https://insurancefraud.org/statute_areas/fraud-bureau/) --- ### [Immunity](https://insurancefraud.org/statute_areas/immunity/) --- ### [Insurance Fraud - Definition](https://insurancefraud.org/statute_areas/insurance-fraud-definition/) --- ### [Mandatory Restitution](https://insurancefraud.org/statute_areas/mandatory-restitution/) --- ### [Practitioner Penalites](https://insurancefraud.org/statute_areas/practitioner-penalites/) --- ### [Premium Fraud](https://insurancefraud.org/statute_areas/premium-fraud/) --- ### [Range of Criminal Penalties](https://insurancefraud.org/statute_areas/range-of-criminal-penalties/) --- ### [Range of Civil Penalties](https://insurancefraud.org/statute_areas/range-of-civil-penalties/) --- ### [Underwriting Fraud](https://insurancefraud.org/statute_areas/underwriting-fraud/) --- ### [Staged Accidents](https://insurancefraud.org/statute_areas/staged-accidents/) --- ### [State Insurance Antifraud Laws & Regulations](https://insurancefraud.org/statute_areas/state-insurance-antifraud-laws-regulations/) --- ## Requirement Types ### [Fraud Warning](https://insurancefraud.org/requirement_types/fraud-warning/) --- ### [Mandatory Reporting](https://insurancefraud.org/requirement_types/mandatory-reporting/) --- ### [Fraud Plan](https://insurancefraud.org/requirement_types/fraud-plan/) --- ### [SIU Education](https://insurancefraud.org/requirement_types/siu-education/) --- ### [SIU Requirement](https://insurancefraud.org/requirement_types/siu-requirement/) --- ### [Annual Reporting](https://insurancefraud.org/requirement_types/annual-reporting/) --- ## Categories ### [Conviction](https://insurancefraud.org/news_categories/conviction/) --- ### [Arrest](https://insurancefraud.org/news_categories/arrest/) --- ## Categories ### [Consumer Privacy](https://insurancefraud.org/current_legislation_categories/consumer-privacy/) --- ### [Public Adjusters](https://insurancefraud.org/current_legislation_categories/public-adjusters/) --- ### [Counterfeit Airbags](https://insurancefraud.org/current_legislation_categories/counterfeit-airbags/) --- ### [Identity Theft](https://insurancefraud.org/current_legislation_categories/identity-theft/) --- ### [Immunity](https://insurancefraud.org/current_legislation_categories/immunity/) --- ### [Assignment of Benefits](https://insurancefraud.org/current_legislation_categories/assignment-of-benefits/) --- ### [Workers Compensation](https://insurancefraud.org/current_legislation_categories/workers-compensation/) --- ### [Data Privacy](https://insurancefraud.org/current_legislation_categories/data-privacy/) --- ### [Fraud Act Updates](https://insurancefraud.org/current_legislation_categories/fraud-act-updates/) --- ### [Fraud Bureau Authority](https://insurancefraud.org/current_legislation_categories/fraud-bureau-authority/) --- ### [Insurance Fraud Penalties](https://insurancefraud.org/current_legislation_categories/insurance-fraud-penalties/) --- ### [Auto Damage Estimates](https://insurancefraud.org/current_legislation_categories/auto-damage-estimates/) --- ### [Auto Damage Appraisals](https://insurancefraud.org/current_legislation_categories/auto-damage-appraisals/) --- ### [Medical Fraud](https://insurancefraud.org/current_legislation_categories/medical-fraud/) --- ### [Towing](https://insurancefraud.org/current_legislation_categories/towing/) --- ### [Policy Misrepresentations](https://insurancefraud.org/current_legislation_categories/policy-misrepresentations/) --- ### [Runners](https://insurancefraud.org/current_legislation_categories/runners/) --- ### [Staged Accidents](https://insurancefraud.org/current_legislation_categories/staged-accidents/) --- ### [Fraud Warnings](https://insurancefraud.org/current_legislation_categories/fraud-warnings/) --- ### [Insurance Fraud Prevention Act](https://insurancefraud.org/current_legislation_categories/insurance-fraud-prevention-act/) --- ### [Fraud Reporting](https://insurancefraud.org/current_legislation_categories/fraud-reporting/) --- ### [Disaster Claims](https://insurancefraud.org/current_legislation_categories/disaster-claims/) --- ### [Telematics](https://insurancefraud.org/current_legislation_categories/telematics/) --- ### [Insurer Practices](https://insurancefraud.org/current_legislation_categories/insurer-practices/) --- ### [Health Insurance](https://insurancefraud.org/current_legislation_categories/health-insurance/) --- ### [Vehicle Photo Inspections](https://insurancefraud.org/current_legislation_categories/vehicle-photo-inspections/) --- ### [Assignment of Benefits - Property](https://insurancefraud.org/current_legislation_categories/assignment-of-benefits-property/) --- ### [Artificial Intelligence](https://insurancefraud.org/current_legislation_categories/artificial-intelligence/) --- ### [Dental Fraud](https://insurancefraud.org/current_legislation_categories/dental-fraud/) --- ### [Bail Bond Antifraud Regulations](https://insurancefraud.org/current_legislation_categories/bail-bond-antifraud-regulations/) ---