Current through Register 2024 Notice Reg. No. 38, September 20, 2024
A county plan shall include the following elements:
(a) Problem Statement: A description of the
disability insurance fraud problem in the county, including how it arose, why it is
important, its unique aspects, if any, and what is needed to resolve the problem,
including supporting data, evidence, or indicators of fraudulent activity related to
disability insurance.
(b) Supporting
data may include the following items:
(1) A
narrative description of the disability insurance fraud activity in the county,
including any supporting data, evidence or indicators of fraudulent related
activity.
(2) A description of the
general criminal activity, based upon the most recent California Crime Index Annual
Report by the California Attorney General.
(3) Population density, based upon the most recent
report compiled by the California Department of Finance, Demographic Research
Unit.
(4) Disability insurance claims
frequency.
(5) Number of disability
fraud suspected fraudulent claims reported to the Division during a 36-month period
immediately preceding the submission of the application.
(6) Evidence of prior and current disability
insurance fraud activity.
(c)
Qualifications: A description of the applicant's experience in investigating
disability insurance fraud including:
(1) The
total amount expended to support the district attorney's investigation and
prosecution of disability insurance fraud, including the details of the following
items:
(A) Personnel costs including salaries and
benefits.
(B) Operations expenses,
including space, equipment, travel and other expenses in support of the
program.
(2) For applications
submitted after fiscal year 2005-2006, the following factors shall be included in
the County Plan:
(A) The total amount of funds
received from the Disability Insurance Fraud Program by the local district attorney
in previous years and a copy of the most recent annual report.
(B) The results obtained through implementation of
the program, including:
1. The number of
investigations initiated or coordinated with other law enforcement
agencies.
2. The number of arrests or
convictions.
3. The number of
indictments or complaints.
4. A
comparison of the amounts originally claimed in cases determined to be fraudulent
compared to payments actually made.
(d) Program Strategy:
(1) Outreach. A description of the manner in which
the district attorney will develop the district attorney's caseload, the source(s)
for referrals for cases for investigation or prosecution, whether directly from the
Fraud Division or from other law enforcement agencies and/or insurers.
(2) Personnel. Justification for the number of
personnel, position titles and position justification for personnel which will be
funded fully or in part through grant funds, including descriptions of the
qualifications of personnel to be assigned to the program and an organization chart
identifying positions to be funded.
(3)
Program Coordination. A description of the manner in which the district attorney
plans to coordinate involved sectors, including insurers, medical and legal provider
communities, the Division, and local law enforcement agencies.
(4) Management Plan. A detailed plan and schedule
of the steps the district attorney will complete in achieving the objectives of the
program and a discussion of how the program staff will be organized and what
internal quality control and budget monitoring procedures will be employed. This
part shall also include how this program will be integrated with any other
anti-fraud program(s) maintained within the district attorney's office.
(5) Staff Development. The plan for ongoing
training of personnel on the investigation and prosecution of disability insurance
fraud. Staff development may be addressed through coordination with the Division,
insurers, or other entities.
(6)
Objectives. This section shall outline the district attorney's anticipated
achievements in the following areas:
(A) Estimated
number of investigations to be initiated during the funding cycle, including
separate estimate of the number resulting from carryover investigations;
and
(B) Estimated number of prosecutions
to be initiated during the funding cycle.
1. New section
filed 11-3-2005; operative 12-3-2005 (Register 2005, No. 44).
2. Change
without regulatory effect amending subsection (d)(1) filed 7-14-2021 pursuant to
section 100, title 1, California Code of
Regulations (Register 2021, No. 29). Filing deadline specified in Government Code
section
11349.3(a)
extended 60 calendar days pursuant to Executive Order
N-40-20.
Note: Authority cited: Section
1872.85,
Insurance Code; and CalFarm Insurance Company, et al. v. Deukmejian, et al. (1989)
48 Cal.3d 805 and 824. Reference: Section
1872.85,
Insurance Code.
