Practice Areas
Our business has the ability to provide the following services:
Insurance Fraud
With 20 years experience undertaking investigations into all facets of Insurance Fraud for and on behalf of a number of high profile Insurers throughout Australia, Corporate Risk Management Solutions has the ability to support the needs of Insurers through high quality Investigative services.
We have extensive experience in the investigation of the following facets of potential insurance fraud:
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Home & Contents claims
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Motor claims
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Personal injury liability claims
Recent Notable achievements:
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2015 - $350,000 home arson investigation - claim withdrawn following evidence to link owner to fire.
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Savings achieved of over $1,000,000 in motor and home and contents insurance claims
Disciplinary/Misconduct
Investigations
It is a requirement for an employer to provide each new employee with a written statement of certain terms of his employment including specifying any disciplinary rules, or to refer the employee to a document which specifies such rules.
However, having properly documented procedures can also assist an organisation in avoiding allegations by an employee that his or her treatment was discriminatory or dismissal was procedurally unfair.
Effective disciplinary procedures are a valuable management tool in avoiding allegations of disparity in the treatment of employees and minimising the risk of an action for unlawful discrimination, constructive dismissal or procedurally unfair dismissal. There are many pitfalls in investigating matters internally, which in many instances results in worker injury claims being lodged, further impacting upon the organisation.
Corporate Risk Management Solutions has extensive experience in conducting impartial investigations into disciplinary matters relating to alleged staff misconduct and the use of an external resource in investigating matters of this nature can ultimately remove the potential for allegations of bias and a prejudice being raised against staff.
Corporate Risk Management Solutions can provide corporate entities with a cost effective means in managing staff disciplinary matters, based on our capability and experience.
Medical/Ancillary Audits
With the growth in utilisation of ancillary healthcare services, and the associated costs to both health insurance providers and their members, the importance of having programs and measures in place to detect errors, and/or deliberate false claiming by Registered Providers has increased significantly.
Our services include on-site reviews of provider records that have been identified by your organisation as being potentially problematic, which encompasses an in depth review and analysis of those records against claims made by a member.
Our Ancillary Audit Program can assist in the verification of claims made in the key ancillary claims areas to identify underlying issues, and ensure that claims made against your organisation can is supported by records for services actually rendered.
Our Ancillary Audit program can also assist in the verification of claims made in the key ancillary claims areas known to pose the greatest risk through on-site reviews to ensure the following:
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The practice facilities meet expectations of the fund
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That records exists to reflect the provision of services to a member where claims have been made, and were billed appropriately.
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That records maintained by the Registered Provider meet record keeping requirements of the fund; and
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That HICAPS records are managed and maintained by the Registered Provider in accordance with the HICAPS terms and conditions
The result of our efforts to date, has resulted in significant savings being achieved by Health Insurance Funds through a pro-active approach in detering fraud, coupled with changed behaviours by both providers and members.
Training / Presentations
In March 2015, Mr Setter was invited to be a guest speaker at the 2015 Health Insurance, Claims Leakage and Fraud Forum held at the Adelaide Conference Centre, South Australia.
Since then, Mr Setter has been invited to present information to organisations on corporate risk management, with the view to providing staff within those organisations with an insight into the risks posed by Identity Fraud and fraud in general.
Our experience in this area has been drawn upon from many years working within a criminal investigative environment, and being exposed to the ever changing modus operandi of persons who pursue a career in fraud and crime in general.
Civil Liability Investigations
Civil liability claims are an increasing financial risk to organisations and individuals. False claim will often be made by individuals for the sole purpose of obtaining a financial benefit, and it is these claims that warrant investigation.
Our extensive experience in fraud investigations places us in good stead to investigate claims on behalf of clients where there is a suspicion held the claim cannot be supported by facts, or is potentially fraudulent. These investigations are always undertaken at the criminal level in the manner in which evidence is gathered and witnesses interviewed, as there is a high likelihood they will result in being heard before a court of law.
Criminal Referrals
In the corporate world, fraud is an ever present risk, and it is an unfortunate reality that businesses and organisations regularly become the victim of financial losses through fraud.
In many instances businesses and organisations do not have the capacity, knowledge or experience to manage such an occurrence which requires a Brief of Evidence being prepared to a level, which will ensure acceptance by Police to pursue the matter for criminal prosecution and restitution sought.
With our extensive experience in the management of complex frauds and the preparation of Briefs of Evidence for referral for criminal prosecution, Corporate Risk Management Solutions has the ability to support organisations in gathering the necessary evidence, and preparing a Brief that will meet the expectations of both Police and the Public Prosecutor to ensure the matter is considered, and dealt with appropriately before the courts.
These matters will always require close consultation, along with an Investigation Plan being prepared to identify the clients needs and expectations to provide an accurate cost of the work required to determine whether costs outweigh the ultimate result.
With our extensive background and experience in fraud investigations, we are cognisant of the fact that fraud is a whole of community issue that warrants action where necessary. We are also mindful of the fact that matters of this nature require significant time and effort to bring the matter before the courts. As such, we will always be open to negotiate costs to work within the clients budget to ensure an outcome can be achieved.
Worker Injury Investigations
The term "accident" can be defined as an unplanned event that interrupts the completion of an activity, and that may (or may not) include injury or property damage.
When accidents are investigated, the emphasis should be concentrated on finding the root cause of the matter, rather than the investigation procedure itself to ensure your organisation can prevent a similar incident from occurring again.
The purpose is to find facts that can lead to actions, not to find fault and look for deeper causes, and not to simply record the steps of the event.
We consider the reasons to investigate a workplace accident to include:
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most importantly, to find out the cause of the incident, and to prevent similar incidents occuring in the future
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to fulfill legal requirements and obligations
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to determine the cost of an incident
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to determine compliance with applicable policies and regulations, and
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to process and manage workers' compensation claims in a manner which will withstand legal challenge.
Incidents that involve no injury or property damage should still be investigated to determine the hazards that should be corrected.
The same investigative principles apply to a quick inquiry of a minor incident and to the more formal investigation of a serious event.
Investigations into workplace injury claims can also expose fraud, through the lodgement of false and misleading information upon claims made by the injured party, and our experience in this field can support an organisation through this risk management process to ultimately reduce financial and reputational risk.