Current through Register Vol. 56, No. 24, December 18, 2024
(a) The
requirements with respect to fraud prevention and detection training programs
are set forth in this subsection. Except for automobile insurers that insure
fewer than 2,500 New Jersey automobile policies and health insurers that insure
fewer than 10,000 lives, the plan shall provide anti-fraud education for SIU
investigators, SIU specialists, claims adjusters, and underwriters that shall
include a detailed and comprehensive program of insurance fraud awareness and
education to prepare claims adjusting and underwriting personnel for insurance
fraud prevention and detection.
1. The
training program shall include Basic Entry Level Training and Continuing
Education Training for all adjusters, claims processors, underwriters, SIU
investigators, and SIU specialists, and shall be submitted to and approved by
the Department. The Continuing Education Training instructions format may be
classroom instruction, self-guided instruction, videotape, seminar, computer
based, or by any other means.
2.
The training programs referred to in (a)1 above shall be provided as follows:
i. In the case of automobile insurers,
training shall include, but not be limited to, the following areas as
appropriate: automobile theft investigations, automobile property damage and
fire investigations, personal injury protection investigations, bodily injury
liability claim investigation, statutory requirements for fraud referrals,
techniques for the identification of fraudulent applications for coverage,
insurance rate making practices, tier rating plans used by the insurer, PIP
medical expense benefits and medical treatment protocols and precertification
plans, and current indicators of fraud.
ii. In the case of health insurers, training
shall include, but not be limited to, the following areas as appropriate:
overcharging and overpayment detection, claims processing guidelines, medical
coding, duplicate bills, excessive charges, unnecessary services or supplies,
over-utilization, services never rendered, miscoded or misleading claim
information, hospital inpatient or outpatient billing abuse or inappropriate
commitment or confinement, abusive or fraudulent referrals, statutory
requirements dealing with fraud referrals, techniques for the identification of
fraudulent applications for coverage, the type, methods of service and
operating procedures of various health insurers, and current indicators of
fraud.
iii. Each company shall
submit for approval the Basic Entry Level Training, which shall be no less than
nine hours of classroom instruction for SIU personnel and no less than four and
one-half hours of classroom instruction for non-SIU personnel. Continuing
Education Training shall be no less than nine hours of training per year for
SIU personnel and no less than two hours per year for claims and underwriting
personnel. Basic Entry Level Training shall be given to all employees within
180 days from the commencement of their employment at each of these positions:
underwriters, adjusters, claims processors, SIU investigators, or SIU
specialists. The no less than two hours of continuing education training
provided to non-SIU personnel shall emphasize the responsibility of all
employees to identify and report indications of internal and external fraud to
the proper authority.
(b) The requirements with respect to fraud
prevention and detection procedures manuals are set forth in this subsection.
Except for insurers which insure fewer than 2,500 New Jersey automobile
policies, or health insurers fewer than 10,000 lives, the plan shall provide a
fraud prevention and detection procedure manual and disseminate it to, or make
it available to, as appropriate, all SIU, claims adjusters, and underwriting
personnel. The fraud prevention and detection procedure manual shall include,
at a minimum, the following:
1. Information
for claim adjusters, underwriting personnel, SIU investigators and SIU
specialists regarding general investigation guidelines; unfair claims
practices; conducting interviews; report writing; information disclosure; law
enforcement relations; and the New Jersey Insurance Fraud Prevention
Act;
2. The process to be employed
for reporting to OIFP when specific facts and circumstances are identified, in
connection with a claim or application, which upon further SIU investigation
leads to a reasonable conclusion that a violation of
N.J.S.A. 17:33A-4 has occurred;
3. For automobile insurers, the "fraud
indicators" used for automobile theft, automobile physical damage fraud,
personal injury claims fraud, bodily injury claims fraud, and application
fraud;
4. For health insurers,
"fraud factors" or "indicators" for health fraud, application fraud, and claims
fraud;
5. The duties and functions
of the SIU;
6. The procedure for
referral of a claim or application to the SIU;
7. The post-referral procedure for
communication between the claims unit and/or the underwriting unit and the SIU
regarding claim resolution and file closure;
8. All update pages for the protocol,
training program, and procedure manual shall include a description of the
content being updated, the page number, and its effective date;
9. Hard copy procedure manuals shall include
version/filing numbers in footers along with page numbering and a table of
contents;
10. Internet-based
procedure manuals shall provide home pages displaying hyperlinks or other
navigation to the required content; and
11. Updates shall be referenced in hard copy
and Internet manuals.
(c) As used in (b) above:
1. "Unfair claims practices" is understood to
include copies of or valid hyperlinks to both:
i.N.J.S.A. 17B:30-13 and N.J.A.C. 11:2-17,
Unfair Claim Settlement Practices, (health insurers); and
ii.N.J.S.A. 17:29B-4(9) and
N.J.A.C. 11:2-17, Unfair Claim Settlement Practices,
(property/casualty);
2.
"New Jersey Insurance Fraud Prevention Act" is understood to include copies of
or valid hyperlinks to both:
i.N.J.S.A. 17:33A-1 et seq., New Jersey
Insurance Fraud Prevention Act; and
ii. N.J.A.C. 11:16-6, Fraud Prevention and
Detection; and
3.
"Information disclosure" is understood to include copies of or valid hyperlinks
to:
i.
P.L.
106-102, Gramm-Leach-Bliley;
ii.
P.L.
104-191, Health Insurance Portability and
Accountability Act of 1996;
iii.N.J.S.A. 56:11-44 et seq., Identity Theft
Prevention Act;
iv.N.J.S.A. 17:23A-13, Disclosure limitations
and conditions; and
v. N.J.A.C.
13:45F, Identity Theft.
(d) Specimen formats of the anti-fraud
prevention and detection protocol, anti-fraud prevention and detection training
program, and anti-fraud prevention and detection procedure manual are available
for viewing on-line at
http://www.state.nj.us/dobi/division_consumers/insurance/mceu.html.
