APEX Special Investigations Unit (SIU) Services

The function of the APEX SIU is to investigate suspected fraud while operating as a liaison between the California Department of Insurance (CDI) and the District Attorney (DA). Suspected fraud cases are investigated by our professional staff where an analysis report is prepared outlining the allegations and evidence. Our SIU program is designed to help our clients detect and combat fraud. The SIU supports the client/employer in its management of loss costs by investigation of potential fraud or loss. It does so by:

Identification of Fraud
SIU works directly with other departments within APEX (Claims, Surveillance, Social Media – Background) to assist in identifying red flags on cases where investigations are being conducted. At APEX, we believe communication is essential in combating fraud. When red flags are identified a plan of action and recommendations are made in opening an SIU investigation.  SIU provides assistance to claims examiners on potentially fraudulent cases where red flags exist.

SIU will review the claim file where red flags exist to make a determination if a reasonable belief threshold is met to submit a fraud referral with the California Department of Insurance and appropriate District Attorney’s Office. While conducting the investigation it is the goal of SIU in determining if the elements of fraud are met. When necessary, recommendations will be made by SIU to further strengthen a fraud referral. At APEX, we take a strategic approach with our SIU investigations where there is an increase in successful prosecutions.

Compliance and Training
Anti-fraud training of claims personnel on the function and purpose of the SIU; the procedures established by the SIU regarding the identification, documentation, and referral of the incidents of suspected fraud to the SIU; identification and recognition of red flag indicators; any changes to current procedures of suspected insurance fraud to the SIU; insurance fraud reporting requirements; and introduction and review of existing and emerging insurance fraud trends.
Fraud Analysis
Documented Fraud Referral (DFR)
Assessment and Training

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