§572.1. Insurance anti-fraud plan
A. Each authorized insurer, other than a "small company" as defined in R.S. 22:46,
and each health maintenance organization licensed to operate in this state shall prepare,
implement, maintain, and file with the commissioner an insurance anti-fraud plan for its
operations in this state.
B. The insurance anti-fraud plan required by Subsection A of this Section shall
outline specific procedures, actions, and safeguards that include how the authorized insurer
or health maintenance organization will do each of the following:
(1)Detect, investigate, and prevent all forms of insurance fraud, including fraud
involving its employees or agents; fraud resulting from misrepresentations in the application,
renewal, or rating of insurance policies; fraudulent claims;
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§572.1. Insurance anti-fraud plan
A. Each authorized insurer, other than a "small company" as defined in R.S. 22:46,
and each health maintenance organization licensed to operate in this state shall prepare,
implement, maintain, and file with the commissioner an insurance anti-fraud plan for its
operations in this state.
B. The insurance anti-fraud plan required by Subsection A of this Section shall
outline specific procedures, actions, and safeguards that include how the authorized insurer
or health maintenance organization will do each of the following:
(1) Detect, investigate, and prevent all forms of insurance fraud, including fraud
involving its employees or agents; fraud resulting from misrepresentations in the application,
renewal, or rating of insurance policies; fraudulent claims; and breach of security of its data
processing systems.
(2) Educate employees on fraud detection and the insurance anti-fraud plan.
(3) Provide for fraud investigations, whether through the use of internal fraud
investigators or third-party contractors.
(4) Report a suspected fraudulent insurance act, as defined by R.S. 22:1923(2), to
the Department of Insurance as well as law enforcement and other regulatory authorities
engaged in the investigation and prosecution of insurance fraud.
(5) Pursue restitution for financial loss caused by insurance fraud.
C. The commissioner shall review the insurance anti-fraud plan submitted pursuant
to Subsection A of this Section to determine compliance with the requirements of this
Section.
D. The commissioner may investigate and examine the records and operations of
authorized insurers and health maintenance organizations to determine if they have
implemented and complied with the insurance anti-fraud plan.
E. The commissioner may direct any modification to the insurance anti-fraud plan
necessary to comply with the requirements of this Section, and the commissioner may require
action to remedy substantial noncompliance with the insurance anti-fraud plan.
F.(1) The insurance anti-fraud plan and any summary report shall be filed with the
commissioner on or before April first of each calendar year.
(2) Either on a calendar year basis or such other interval that the commissioner
deems appropriate, the commissioner may require that each authorized insurer and each
health maintenance organization file a summary report of any material change to the
insurance anti-fraud plan, including the total number of claims and the number of claims
referred to the commissioner as suspicious, and all of the following information:
(a) The number of policies in effect.
(b) The amount of premiums written for policies.
(c) The number of claims received.
(d) The number of claims referred for investigation to the insurer's fraud
investigators.
(e) The number of claims investigated or accepted by the insurer's fraud
investigators.
(f) The number of insurance fraud matters investigated or accepted by the insurer's
fraud investigators that were not claim related.
(g) The number of cases referred to the department.
(h) The estimated dollar amount of losses attributable to fraudulent insurance acts,
organized by type of fraud, including claimant, employer, provider, agent, and other types.
(i) The estimated dollar amount of recoveries attributable to fraudulent insurance
acts, organized by type of fraud, including claimant, employer, provider, agent, and other
types.
(j) The dollar amount of claims denied or not paid based on fraud investigation
organized by product line.
(k) Quantification of the resources committed to investigating insurance fraud,
organized by line of business, for the prior year.
(3) The commissioner may prescribe the format of the summary report provided for
in this Subsection.
G. The insurance anti-fraud plan and any summary report required by this Section
are not public records and are exempt pursuant to R.S. 44:1 et seq., and specifically R.S.
44:4.1(B)(11), shall be and are hereby declared to be proprietary and confidential business
records not subject to public examination or subpoena.