Rationale of provisions
It attacks insurance fraud at the source and can be used as a framework for additional laws, such as creating an insurance fraud bureau. The model will help reduce fraudulent claims paid by insurers. Since the model also covers fraud committed by insurers and those who purport to be insurers, it would curtail fraud committed against consumers and lessen financial disruption of the insurance industry.
Specifically, the model includes a cohesive attack on fraud with both civil and criminal penalties for committing what's defined as either a fraudulent insurance act or an unlawful insurance act.
The model addresses all forms of insurance fraud, including claims fraud, underwriting fraud, deceptive sales practices and scams by insurance operators.
The fraudulent act is an act based on an intent to defraud someone, whether an insurance company or a consumer. The unlawful insurance act requires a lower standard of proof and is designed to attack scams such as medical mills and fraud rings in which the leaders often are able to shield themselves from prosecution under current laws.
The model significantly expands the definition of insurance fraud that currently exists in state laws and other models, as well as the remedies available to both the consumer and insurer when defrauded. The bill affords the consumer an additional level of protection particularly when it comes to shutting down the bogus insurance companies.
The bill also sets strict penalties for licensed practitioners who are found in violation of the fraud act. The legislation puts insurers on the front line in the fight against fraud. Insurers would be required to cooperate with law enforcement in cases of suspected fraud.
In return, the model contains the broadest civil immunity for anyone who shares information about suspected fraud. The model also requires insurers to draft anti-fraud plans and to place fraud warnings on applications and claims forms, but avoids micro-management of anti-fraud efforts by insurance departments. Since the Coalition first proposed this model in , several states have utilized its provisions in their efforts to enact anti-fraud legislation. Tennessee enacted this model as a workers compensation fraud law in Colorado utilized the fraud plan provisions in enacting its fraud law in Arkansas utilized the fraud plan language in writing its regulations to meet the requirements of the state law requiring anti-fraud initiatives.
Nevada utilized the practitioner penalties provisions in drafting its law requiring license review; and New Jersey enacted in very strict medical provider sanctions similar to the Coalition's model language. New Mexico, Maine and Virginia all used elements of the model in enacting stricter anti-fraud laws in Definitions This section defines terms used in the legislation, including "insurance transaction" and "insurer. The bill also defines "practitioner" as any individual who is, or is required to be, a licensee of the state and whose services are compensated in whole or part by insurance proceeds.
This includes medical providers, lawyers, agents, building contractors, adjusters and automotive repair shops. These definitions are written to cover all forms of insurance fraud, as discussed above, as well as those who are most likely to commit fraud, and are designed to establish greater consistency from state to state.
Fraudulent Insurance Act A fraudulent insurance act is defined as an act committed by anyone who, knowingly and with intent, defrauds another person for gain. A fraudulent act includes claims fraud, application fraud and the legislation has a separate provision dealing with insurer fraud.
A conviction under these provisions must meet the criminal burden of proof beyond a reasonable doubt. Among the actions that fall under the fraudulent act is the preparation and presentation of false information affecting:.
This section makes all forms of insurance fraud, as well as attempts to commit fraud, a specific crime. Without definite language targeting attempts, conspiracies, and aiding or abetting fraud, an insurer often must pay false claims before a crime can be said to be committed; even then, others involved in the fraud may go free.
The provision protects consumers from unscrupulous operators by expanding the definition of fraud to include schemes perpetrated by insurers or those who claim to be in the insurance business. Unlawful Insurance Act An unlawful insurance act is defined as an act committed by anyone who commits or allows to be committed an act with "an intent to induce reliance.
Convictions under this section must meet the civil standard of proof, which requires a preponderance of evidence. The legislation separates the definition for unlawful insurance actions affecting claims and applications fraud from fraud committed by insurers.
This section expands the legal definition of insurance fraud into an entirely new arena. Those who have shielded themselves from the actual act of fraud-signing a false claim form, for example-can be charged through a civil action, which requires a different standard of proof. This provision is designed to punish individuals who create a fraudulent scheme, such as a medical mill, but have underlings execute it as the schemers reap the bulk of the illegal reward.
Like the provisions against fraudulent acts, this section also protects consumers from unscrupulous operators by expanding the definition of fraud. Criminal Penalties The criminal penalties only apply to those persons charged with committing a fraudulent insurance act. The provisions are meant to dovetail with the existing penalties already in place in the states for other similar crimes. The penalties would allow the courts and the prosecution to segregate or aggregate the economic loss suffered by the persons defrauded.
The highest felony charge includes those charged with committing a fraudulent insurance act where the offense places anyone at risk of death or serious bodily injury. Criminal sanctions must be severe enough to act as a deterrent rather than be treated by perpetrators as part of the cost of doing the business of fraud. The commonly used stepladder approach deters repeat offenders as well as particularly egregious forms of fraud; states are left free to define those levels as the legislature sees fit.
Restitution Anyone convicted of committing a fraudulent act would be required to make monetary restitution for any financial loss due to the violation. The legislation grants the court the ability to order the restitution to be paid in a lump sum or installments. Restitution for victims is codified both for the purpose of providing justice and as a way to seize perpetrators' ill-gotten gains.
Also, by allowing the court to decide the payment schedule, you assure that the person involved has the financial ability to give restitution to the victims of the fraud. Administrative Penalties The legislation includes language requiring notification of the appropriate state licensing authority if any practitioner is found guilty of a fraudulent insurance act.
The licensing authority would be required to hold a hearing to consider whether administrative sanctions including license revocation are in order against practitioners convicted of a fraudulent insurance act. Practitioner is defined in the act to include all individuals who are licensed by the state and compensated through the insurance system. Appropriate sanctions against licensed practitioners are included because depriving them of their primary livelihood is an additional deterrent, especially against repeat offenses.
By mandating licensing authorities to have hearings on those practitioners who have violated this act, you assure that the public will be protected from those individuals who through their fraudulent activity violate the public trust. Civil Remedies Individuals charged with an unlawful insurance act face these provisions.
Thank you for your interest in republishing this story. You are are free republish it so long as you do the following:. Here is one of our approved ads from Facebook: Positions that involve the inspection of slaughtered meat and poultry exclusively are entitled Food Inspector Slaughter.
Positions that involve the inspection of processed products only are designated as Food Inspector Processed Products. Mixed positions and any other positions that do not fall in the established specializations are designated as Food Inspector, without parenthetical designation. The prefix "Supervisory" is to be added to positions involving substantial supervisory responsibility.
The food inspection occupation covers both meat and poultry slaughter inspection; and meat, poultry, and fish processing inspection. The meat and poultry inspection program of the Federal Government is established under legislation that requires that all meat and poultry products in interstate commerce be wholesome, not adulterated, and properly marked, labeled, and packaged. Legislation also requires that meat, poultry, and meat and poultry products in intrastate commerce be inspected by State authorities in accordance with standards that are equal to those established by the Federal Government for interstate commerce.
In the absence of an effective State inspection program equal to the Federal program, the Federal Government can assume responsibility for the inspection of meat and poultry products in intrastate commerce on its own authority, or at the request of the State.
This series covers positions which supervise, lead, or perform aviation law enforcement operations to detect, interdict, apprehend, and prevent terrorists and other persons, weapons, and contraband from illegally entering or attacking the United States.
All of the federal government employees in this series are all employed by the Department of Homeland Security. Positions covered by this series have in common the dual paramount requirement for knowledge of the customs and border protection activities which form the basis for the flying assignments and the knowledge and skills necessary to pilot aircraft. These responsibilities are carried out through a variety of duties, which may vary because of sector requirements, geographical considerations, and program goals or objectives.
The major objectives of the work are to assess customs duties and associated taxes to be paid on imported merchandise, and to ensure compliance with related laws and regulations. All of the 1, federal government employees in this series are all employed by the Department of Homeland Security. Work requires knowledge of:.
Located at seaports, international airports, border crossings, and other strategic inland locations, import specialists examine document packages submitted by importers or by representatives, called customhouse brokers.
Importers or brokers must submit document packages known as "formal entries" to legally enter foreign merchandise into the commerce of the United States. Import specialists must be alert for potential acts of misrepresentation and fraud. They request financial audits and criminal investigations when they suspect illegal activity.
They identify and recommend potential areas of inquiry and explain the significance of information developed by auditors and investigators related to those inquiries. Based on their knowledge of repeat importers, they recommend whether and to what extent to consider the explanations given by penalized importers. They possess an in-depth knowledge of particular commodities and the manner in which the commodities are bought, sold, packaged, and shipped.
Import specialists apply this knowledge as members of special enforcement teams established to combat fraud and smuggling. This series includes all classes of positions the duties of which are to administer, supervise, or perform work involving the examination, acceptance, processing, or issuance of documents required for the entry of imported merchandise into the United States and the initial classification of merchandise covered by the entries; the final determination of the statutory classification of merchandise covered by the entries; the determination of customs duties and applicable internal revenue taxes accruing on such merchandise; the ascertainment of drawback to be paid on exported articles manufactured with the use of duty-paid or tax-paid imported merchandise or substituted domestic merchandise; and the determination of the validity of protests against liquidation decisions on formal entries.
These standards apply to positions the duties of which involve a the initial receipt, examination, and acceptance of entry documents; initial classification of merchandise; approval of estimates of duty and internal revenue tax payable; designation of packages and merchandise for the appraisers' examination; examination and acceptance of bonds; issuance of permits to deliver merchandise; assistance in the enforcement of import restrictions and prohibitions; and the furnishing of information to the importing public concerning entry requirements, rates, customs regulations, and similar matters; and b the final determination of the statutory classification of imported merchandise; the final determination of duties and applicable taxes due; the ascertainment of drawback to be refunded on imported merchandise used in the manufacture of articles to be exported; and the analysis of protests against decisions concerning the classification of merchandise.
This series covers positions which supervise, lead, or perform work involving detecting and preventing terrorists and instruments of terror from entering the United States, and enforcing and administering laws relating to the right of persons to enter, reside in, or depart from the United States, Puerto Rico, Guam, and the U.
All of the 21, federal government employees in this series are all employed by the Department of Homeland Security. The work requires knowledge of laws, regulations, policies and procedures concerning the legal entry of persons and merchandise into the United States.
Some of the aspects impacting the work are:. CBP Officers must deal with large numbers of people and nationalities e. There is a certain stress created by the examination process due to the numbers of people or amount of cargo, and the time spent waiting to be processed. People have often traveled great distances, and by the time they present themselves for examination, are tired, short-tempered, and even hostile.
All of the 20, federal government employees in this series are all employed by the Department of Homeland Security. Border patrol agents constitute a vital part of the enforcement function of the Federal Government. Their work includes a focus on preventing terrorists and terrorist weapons, including weapons of mass destruction, from entering the United States.
Individuals who enter the United States illegally may cross the border by a variety of means including walking, riding, flying, tunneling under, or swimming across the borders. Border patrol agents work autonomously in vast stretches of rugged terrain, where they are required to use their best judgment.
They conduct daily risk assessments to identify, prepare for, and mitigate the hazards associated with the areas to which they are assigned. Border patrol agents must deal effectively with individuals of different nationalities and cultural backgrounds. In their work, they may develop, evaluate, use, and control informants. Border patrol agents use standard investigative techniques, such as interviewing witnesses, searching records and databases, conducting surveillance, and analyzing intelligence information.
Depending on the situation, they may use a variety of equipment and vehicles, including two-way radios, night scopes, remote-monitored sensor and video systems, and 4—wheel drive vehicles. Border patrol agents conduct interviews, interrogations, searches, seizures, and arrests in compliance with laws and precedents regarding the rights of citizens and aliens.
In order to make an arrest, there must be probable cause and reasonable suspicion a violation has occurred and the person of interest has committed it. Border patrol agents are authorized to execute warrants and other processes issued under laws regulating the admission, exclusion, or expulsion of aliens; administer oaths; take statements; and take and consider evidence.
Border patrol agents may represent the United States in misdemeanor smuggling and illegal entry cases before a magistrate. Job Series Definitions These position descriptions are excerpted from the qualification standards for select job titles in this group. A brief introduction for major occupations within this group is provided below.
General Inspection, Investigation, Enforcement, and Compliance GS This series covers positions which supervise, lead, or perform inspection, investigation, enforcement, or compliance work. The work performed falls primarily in one of the following categories: Inspections where determinations are based on visual or other specific inspection techniques and are made based on relatively clear-cut considerations such as the presence or absence of required documents or the obvious physical condition of an item or premises.
These inspections are governed by specific procedures and serve as bases for action by compliance program officials. Typically, such work includes both initial and follow-up inspections including obtaining samples and performing well-established field tests, if appropriate.
Technical support to inspections or investigations such as searching for, gathering, screening, and providing factual information or explanations related to the subject of an inspection or investigation or to the compliance program itself. These tasks are performed following prescribed or established procedures to assist compliance inspectors, investigators, and program officials in their fact finding or program administration responsibilities.
The work includes activities such as obtaining background information on subjects of inspections or investigations by means of record searches, structured interviews, automated information retrieval, telephone inquiries, or correspondence; providing information to authorized persons concerning the status of particular investigations; explaining licensing or other requirements, including exceptions or exemptions, to persons or organizations subject to regulations; compiling final investigative reports with necessary exhibits; and maintaining required administrative reports on topics such as manpower, case load, and case status.
Work primarily requires knowledge of: Federal laws and regulations relevant to the work being performed; entities, operations, activities, products, or items subject to the laws and regulations; and techniques and methods to locate, sort, and evaluate information. Work in this series primarily requires: Work in this series includes investigating: Keith said that he became a special agent because, "I felt it was a great responsibility and challenge to lead this office.
It provided stability to the office and has allowed our program to continue to develop and evolve. I was lucky to have many great mentors at the county, state and federal level as my career progressed like Danny James and Nick Sisals to name a few. This position has allowed me to share some of that experience, but as General Gray said when I joined the Marine Corps years ago 'you are first and foremost a rifleman, everything else is secondary. Air Safety Investigating, GS Positions included in this series have duties involving the investigation and prevention of accidents and incidents involving United States aircraft anywhere in the world, and in the establishment of programs and procedures to provide for the notification and reporting of accidents.
Two major categories of work are included in this series: Work primarily related to military aircraft and military aviation; Work primarily related to civil aircraft and civil aviation Positions in the Civil Aeronautics Board, the agency charged by statute with performance of the investigative duties in relation to civil aviation.
Mine Safety and Health Inspection, GS This series covers positions which supervise, lead, or perform work involving underground and surface mining and milling operations associated with coal, metal, and nonmetal mines, and plants where ores are processed for distribution. Positions in this series require: Aviation Safety, GS This series includes positions that involve primarily developing, administering, or enforcing regulations and standards concerning civil aviation safety, including 1 the airworthiness of aircraft and aircraft systems; 2 the competence of pilots, mechanics, and other airmen; and 3 safety aspects of aviation facilities, equipment, and procedures.
They perform the following types of duties: Examining and issuing certificates to pilots and other airmen. Evaluating and approving training methods, facilities, and equipment for pilots, mechanics, and other aviation personnel. Issuing certificates and inspecting and evaluating activities of aviation organizations, such as air carriers, air taxis, and repair stations for conformance with the terms of their certification.
Monitoring the activities of aviation organizations including changes in their equipment, facilities, organization, key personnel, and overall scope of operations. Monitoring, inspecting, and investigating civil aviation activities in their geographic areas to ensure compliance with Federal regulations and safety requirements, instituting appropriate enforcement action as necessary.
Inspectors have authority to decide whether legal or administrative action is requirements and their decisions are final. Participating in accident investigations from the standpoint of Federal regulatory authority. Advising persons desiring to enter some segment of the aviation industry on regulatory requirements, and on the facilities, equipment, personnel, and organization needed to operate safely.
Inspecting the airworthiness of aircraft, particularly those which have undergone alteration or major repair. Inspecting plants that manufacture aircraft and aircraft parts to determine whether equipment, facilities, personnel, methodology, and quality control systems are adequate to produce the part or aircraft in conformance with the design specifications.
The authorized titles for nonsupervisory positions are: Wage and Hour Investigation, GS This series covers positions which supervise, lead, or perform work involving: Work requires knowledge of: Equal opportunity investigators collect and analyze data to: There are two approved specializations in this series: