2013 Louisiana Laws
Revised Statutes
TITLE 22 - Insurance
RS 22:572.1 - Insurance anti-fraud plan

§572.1. Insurance anti-fraud plan

A. Each authorized insurer and each health maintenance organization licensed to operate in this state shall prepare, implement, and maintain an insurance anti-fraud plan for the insurer's or health maintenance organization's operations in this state.

B. The insurance anti-fraud plan utilized by each authorized insurer and each health maintenance organization in this state shall be filed with the commissioner of insurance and shall outline specific procedures, actions, and safeguards that are applicable, relevant, and appropriate to the type of insurance the authorized insurer writes or the type of coverage offered by the health maintenance organization in this state and shall include how the authorized insurer or health maintenance organization will:

(1) Detect, investigate, and prevent all forms of insurance fraud, including fraud involving the insurer's or health maintenance organization's employees or agents; fraud resulting from misrepresentations in the application, renewal, or rating of insurance policies; fraudulent claims; and security of the insurer's or health maintenance organization's data processing systems.

(2) Educate appropriate employees on fraud detection and the insurer's or health maintenance organization's 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(1), to the Department of Insurance as well as appropriate 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, when applicable, relevant, and appropriate.

C. The commissioner shall review the insurance anti-fraud plan submitted by each authorized insurer and each health maintenance organization to determine compliance with the requirements of this Section.

D. The commissioner shall have the authority to investigate and examine the records and operations of each authorized insurer and each health maintenance organization to determine if the insurer or health maintenance organization has implemented and maintained compliance with the insurance anti-fraud plan.

E. The commissioner is authorized to direct any authorized insurer or health maintenance organization to make any modification to the insurer's or health maintenance organization's insurance anti-fraud plan necessary to obtain and maintain compliance with the requirements of this Section, and the commissioner may require any other reasonable remedial action to the insurer's or health maintenance organization's insurance anti-fraud plan if the investigation and examination reveals substantial noncompliance by the insurer or health maintenance organization with the terms of the insurer's or health maintenance organization's insurance anti-fraud plan.

F. The anti-fraud plan and any summary report shall be filed with the commissioner on or before April first of each calendar year. Either on a calendar year basis or on whatever other interval he deems appropriate, the commissioner is authorized to 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 the commissioner is authorized to direct each insurer and each health maintenance organization as to the format of the summary report.

G. The insurance anti-fraud plan submitted to the department, as well as the summary report of the insurer's or health maintenance organization's insurance anti-fraud activities and results, are not public records and are exempt pursuant to R.S. 44:1 et seq., and specifically R.S. 44:4.1(B)(10), shall be and are hereby declared to be company proprietary and business confidential records and not subject to public examination or subpoena.

Acts 2010, No. 688, §1, eff. Jan. 1, 2011.