Life Imitates Art

The Mercury Insurance Special
Investigations Unit (SIU), which
 refers to itself as the CSI of the insurance industry, continues to uncover fraudulent claims, saving Mercury policy holders
hundreds of millions of dollars and per-
forming a service to all of the industry’s
SIUs and sleuths. From sophisticated
organized crime and sleazy lawyers and
doctors to low intelligence criminals chasing quick bucks, their files are amazing. It
is easy to learn just how crooked schemes
cost the average U.S. family $400 to $700
in increased premiums due to phony insurance payouts, according to Dan Bales of Mercury Insurance. “Many of today’s scammers are very tech savvy, but others, fortunately, are not too swift,” says Bales, who has investigated nearly 40,000 claims during his 28- year career at Mercury. “Either way, Mercury is tough. Exposing phony or exaggerated claims (such as arson, padding of medical expenses, auto and identity theft, property, homeowners and forensic data mining) helps keep Mercury’s costs down, and that means we can pass those savings on to our customers in the form of lower rates.” While Bales can’t reveal any trade secrets in the non-stop war against today’s complex, ultra-high- tech schemes, there are still some would-be criminals he cites for outright stupidity. “We had a recent insured who claimed her car windows and sunroof suddenly opened during a heavy rainstorm,” says Bales. “However, forensics helped determine her car was filled with tap water, not rain water; her supposed $46,000 BMW was actually purchased for $29,000; and her boyfriend’s mother had filed a similar claim in 2013 due to damage from snow. … There were no BMW recalls for electrical malfunctions for windows or sunroofs, no evidence of debris in the car due to supposed heavy rain, and, in fact, rainfall amounts for the date of loss were minimal. And that was only the beginning of the inconsistencies. Unlike CSI on TV, we win some and we lose some. But while the sophistication of some criminals is growing, so is our ability to address these phony claims. One of the most ridiculous claims ever filed with Mercury involved an accident with an RTD bus. Our insured bumped into an RTD bus and most passengers on the bus didn’t even know there had been an accident. When they realized our insured had struck the bus, two passengers overheard this and immediately went into full fraud mode. The woman fell to the floor screaming like she’d just broken her spine, but fortunately the bus had a video camera on board that caught the whole thing. It even had sound, which made it even easier to make our case. It also made for some great entertainment.” Kudos to Bales and his team. … As another birthday approaches in March, I hold my annual face off with health and healthcare, as I am sure our readers do. We are an aging lot, going by the stats on agents and executives in the business. So it comes as a souring of the birthday cake that Secretary of HHS Sylvia Mathews Burwell has just announced plans to move 50 percent of Medicare spending into Accountable Care Organizations and other so-called “payment for value” experimental formats. Patients and practicing physicians have no say in this latest power move by the administration’s minions. Burwell also announced the creation of a Health Care Payment and Learning and Action Network that would work with private health insurers, providers, employers, and state Medicaid programs to hasten the spread of alternative payment models outside Medicare, according to media sources. It seems that the leaders of “organized medicine,” i.e the societies, are on board with policies that will lead to the destruction of private medical practice, which depends completely on the much- maligned fee-for-service payment mechanism, the very bedrock of American medical care. Private medicine is the one part of the system holding down costs. Direct- pay medical practice is a model of efficiency. A patient visits the doctor and pays directly for the visit at the point of service. No bill to an insurance company is generated (though the patient may choose to submit a claim). According to Dr. Richard Amerling, a frequent contributor to these pages, “personnel dedicated to billing, obtaining various prior authorizations, and following up on denied claims, are eliminated and any incentive to churn the sys- tem to increase profits is opposed by the patient’s unwillingness to pay for services of no value, and reluctance to submit to possibly unnecessary or excessive treatments. And the physician is honor bound by a code of ethics not to harm the patient with overtreatment. The fee-for-service system aligns payment with actually pro- viding a service for a patient. Arguably, this is exactly what patients want, especially when they are facing serious disease. Patients expect timely care from a doctor who is representing their best interests. The ACO, like its predecessor, the HMO, provides the opposite. The push for ACOs continues the assault on private medicine, which is the last refuge of high quality, individualized care. Physicians and patients must stand up in opposition.” Thank you. Happy Birthdays to us all.[IA]