You are an investigator at a large insurance company reviewing suspicious health

insurance claims from employee Group Benefits insurance plans. The triage team

reviewing transaction alerts from the data analytics software has referred a

suspected fraud case to you for further investigation. Here$$s the case information

gathered from the triage team:

$$ The plan member has submitted $25$ separate claims in the past $90$ days for a

range of medical services for themselves and two dependents.

$$ Total value of the claims is $$6,400.$ The claims include $23$ services worth

$$3,200$ in total from a physiotherapist, a chiropractor, and a massage therapist,

and $2$ claims for the purchase of two orthopedic leg braces at $$3,200$ in total.

$$ All of the services and practitioners are covered by the group benefit plan. The

plan member was reimbursed for $90\%$ of the claims cost as per the plan.

Another investigator in your unit is currently reviewing the chiropractor as part

of a separate investigation of a medical clinic.

$$ The triage team has not contacted the plan member or any of the service

providers.

What information should you gather to start the investigation?

Who is on your list of people to contact? In what order will you contact and

interview the people on the list? Are there any special considerations?