| |
Law
and Public Safety
Office
of the Attorney General
Insurance
Fraud Detection Reward Program
Adopted New Rules:
N.J.A.C. 13:88-3
Proposed:
February 17, 2004 at 36 N.J.R. 917(a)
Adopted:
May 18, 2004 by Peter C. Harvey, Attorney General
of NJ
Filed:
June 14, 2004, without change.
Authority:
N.J.S.A. 2C:21-4.7, Executive Reorganization
Plan No. 7 (1998), Executive Order No. 9 (Hughes)
and N.J.S.A. 52:14B-1 et seq.
Effective Date:
July 6, 2004
Expiration Date: ---
Summary of Public Comments
and Agency Responses:
The Department of Law and Public Safety received
one timely comment from the Independent Insurance
Agents & Brokers of New Jersey.
COMMENT: The comment
supported the proposed rule and requested clarification
of proposed N.J.A.C. 13:88-3.10 as to whether
independent insurance producers were eligible
for the reward program.
RESPONSE: The Department
appreciates the support of its proposal and
further states that independent insurance producers
are not eligible for the reward program when
they come into possession of information during
the course of an insurance transaction in which
the independent insurance producer is working
on behalf of an insurance company.
COMMENT: The comment
also requested a change to N.J.A.C. 13:88-3.6
to permit individuals to submit the reward application
form within 60 days of the individual’s
initial report.
RESPONSE: Upon review, the Department
has determined not to change this provision.
The rules provide a number of different avenues
to obtain a reward application and thirty days
allows sufficient time in which to return a
completed reward application.
Federal Standards Statement
A Federal standards analysis is not required
as the proposed new rules regulate the insurance
fraud prevention and detection activities in
this State. These rules relate to an insurance
fraud reporting program which is the subject
of State law and are not subject to any Federal
requirements or standards.
Full
text of the adoption follows:
Chapter
88
Office of The Insurance Fraud Prosecutor
Subchapter 3
Insurance Fraud Reward Program
13:88-3.1 Scope
This
subchapter applies to all persons in the State
of New Jersey.
13:88-3.2 Definitions
For the purposes of this subchapter, the following
terms have the following meanings, unless the
context clearly indicates otherwise:
- “CLASS”
means
the Case Screening, Litigation, and Analytical
Support Section of the Office of the Insurance
Fraud Prosecutor.
- “Conviction”
means
the entry of a judgment of conviction at the
time sentence is imposed by the court.
- “Value
of the fraud”
means the direct or indirect gain or advantage
realized by the person or entities convicted
of the crime of insurance fraud, or the direct
or indirect gain or advantage that would have
been realized by the person or entities convicted
of the crime of insurance fraud if the fraud
had not been detected. The term does not include
amounts imposed or collected as interest,
penalties and/or fines.
13:88-3.3 Construction
-
(a)
These rules shall be liberally construed to
permit the OIFP to discharge its statutory
function.
- (b)
Upon
appropriate notice, these rules may be relaxed
for good cause in a particular situation in
order to effectuate the purposes of N.J.S.A.
2C:21-4.7. Statutory time limits shall not
be relaxed.
13:88-3.4 Fraud reporting procedure
- (a)
Individuals may report suspected cases of
health care claims fraud, insurance fraud
or any other criminal offense related to an
insurance transaction by one of the following
methods:
-
Call the OIFP toll free hotline at 1-877-55-
FRAUD (1-877-553-7283)
during regular business hours (Monday
through Friday 9:00 A.M. to 5:00 P.M.)
and speak to a hotline operator;
- Call
the OIFP toll free hotline number at 1-877-55-FRAUD
(1-877-553-7283) after
regular business hours and leave a detailed
message, including a name and phone number
at which the caller can be reached;
-
Log onto the OIFP Web site (www.NJInsuranceFraud.org)
and submit an online
report;
-
Send an electronic mail message to the
OIFP at njinsurancefraud@njdcj.org;
or
-
Write directly to the OIFP at the following
address:
New Jersey Department of Law and Public
Safety, Division of Criminal Justice,
Office of the Insurance Fraud Prosecutor,
P.O. Box 094, Trenton, N.J. 08625-0094,
Attention: CLASS.
13:88-3.5 Reward application procedure
- (a)
A
reward for information submitted to the OIFP
under N.J.A.C. 13:88-3.4 requires the completion
of a reward application form prescribed by
the OIFP, included in the subchapter Appendix
and incorporated herein by reference, in addition
to the provision of information to the OIFP
under N.J.A.C. 13:88-3.4. The reward application
form must be completed in its entirety, signed
and notarized. The reward application form
must be mailed to the OIFP at the address
listed in N.J.A.C. 13:88-3.4(a)5.
- (b)
The
person submitting the application may, at
the discretion of the OIFP, be interviewed
by the OIFP with regard to the information
the applicant is submitting for consideration.
An applicant may also be required to give
his or her verbal statement under oath and
sign a written memorialization of his or her
statement.
- (c)
The
application form may be obtained by requesting
one in writing from the OIFP, calling the
OIFP toll free hotline and requesting one,
or logging onto the OIFP website and downloading
the form.
- (d)
The
OIFP shall acknowledge to the applicant, in
writing, receipt of his or her application.
13:88-3.6 Timely filing of applications for
reward
In all cases where relevant information is provided
by a person without the simultaneous filing
of a reward application pursuant to this subchapter,
that person may subsequently file an application
for reward consideration no later than 30 days
from the date on which the person initially
provided information to the OIFP pursuant to
N.J.A.C. 13:88-3.4.
13:88-3.7 Confidentiality
- (a)
Upon request of the applicant at the time
the application is made, the OIFP and any
other governmental agency involved in the
criminal proceeding shall not disclose the
identity of the applicant. This is subject,
however, to any statute, rule of Court or
judicial decision which may require divulgence
of such identity to certain parties including,
in certain circumstances, a criminal defendant.
- (b)
All information and materials received
by or maintained by the OIFP pursuant to these
rules are confidential and shall not be subject
to public access pursuant to the Open Public
Records Act, N.J.S.A. 47:1A-1 et seq.
13:88-3.8 Criteria for
evaluating a reward application
- (a)
The
OIFP may pay a reward upon the arrest, prosecution,
and conviction of a person or entity for health
care claims fraud, insurance fraud or any
other criminal offense involving or related
to an insurance transaction.
- (b)
A
person who provides information under N.J.A.C.
13:88-3.4 and submits a timely reward application
form under N.J.A.C. 13:88-3.5 shall be eligible
for a reward if the information:
- Led
to the arrest, prosecution and conviction
of a specific individual(s) or entity(ies)
for specified conduct occurring during
a particular time period, as detailed
in the reward program application submitted
by the informant pursuant to N.J.A.C.
13:88-3.5; or
- Directly
led to the arrest, prosecution and conviction
of other individuals or other entities
for specified conduct occurring during
a particular time period as detailed in
the reward program application submitted
by the informant pursuant to N.J.A.C.
13:88-3.5.
- (c)
The
OIFP shall not grant a reward for information
relating to an individual or entity that,
at the time the information is provided, is
already the subject of a referral to the OIFP;
is already the subject of an investigation
by the OIFP, either civilly or criminally;
or is already the subject of an investigation
by the New Jersey Department of Human Services;
the New Jersey Department of Health and Senior
Services; the Health Care Financing Agency
and the Office of the Inspector General; the
New Jersey Department of Banking and Insurance;
the New Jersey Department of Consumer Affairs
and its licensing boards; or any other Federal,
State, county or municipal agency.
13:88-3.9
Determination and notification of eligibility
for reward
- (a)
Upon
the conviction of persons or entities who
have committed health care claims fraud, insurance
fraud or any other criminal offense related
to an insurance transaction, the OIFP shall
notify the applicant within 90 days of the
conviction as to the OIFP’s determination
of the eligibility of the applicant for the
reward.
- (b)
Written notification shall contain the specific
reasons for a determination and inform the
applicant that:
- There
is insufficient causal relationship between
the information provided and the arrest,
prosecution and conviction of the individuals
or entities named in the matter and the
applicant is not eligible for a reward;
- The
information provided proximately resulted
in the arrest, prosecution and conviction
of the individuals or entities named in
the matter and the applicant is eligible
for a reward; or
-
There is a need for further examination
of the application necessitating a written
response and/or personal appearance of
the applicant for further information
before a determination as to eligibility
can be made.
13:88-3.10
Persons not eligible for a reward
- (a)
The
following persons are not eligible to receive
a reward under this subchapter:
- An
individual who was or is an immediate
family member of an officer or employee
of any of the agencies or entities listed
in N.J.A.C. 13:88-3.8(c), or any individual
working on behalf of any of the agencies
or entities listed in N.J.A.C. 13:88-3.8(c)
or who is an immediate family member of
an individual working on behalf of any
of the agencies or entities listed in
N.J.A.C. 13:88-3.8(c), at the time he
or she came into possession of, or divulged,
information leading to an arrest, prosecution
and conviction;
-
Any other Federal, State, county or municipal
employee, contractor or grantee shall
not be eligible for a reward under this
subchapter if the information submitted
came to their knowledge in the course
of their official duties;
-
Any individual who was or is an employee
of an insurance company, as defined in
N.J.S.A. 2C:21-4.5 ,or an individual working
on behalf of an insurance company as defined
in N.J.S.A. 2C:21-4.5, or the immediate
family member of an employee of an insurance
company as defined in N.J.S.A. 2C:21-4.5
or of an individual working on behalf
of an insurance company as defined in
N.J.S.A. 2C:21-4.5, at the time he or
she came into possession of, or divulged,
information leading to an arrest, prosecution
and conviction;
- An
individual or entity that participated
in or facilitated the offense with respect
to which payment of the reward would be
made;
-
An individual or entity who is eligible
for an award under any other state, Federal
or other reward program because the individual
previously reported to another state,
Federal or other entity substantially
the same information on suspected health
care claims fraud, insurance fraud or
any other criminal offense involving or
related to an insurance transaction, as
they subsequently reported to the OIFP
under these rules; and
-
An individual who knowingly provides false
information to the OIFP.
13:88-3.11
Post-determination claiming and payment of rewards
- (a)
Within 20 days of receipt of a notification
of reward eligibility pursuant to N.J.A.C.
13:88-3.8, the applicant shall make a formal
claim for such reward by forwarding to the
OIFP a written acknowledgment of the notification,
a request for the reward, and the name and
address to which the reward should be delivered.
- (b)
No reward shall exceed either five percent
of the value of the fraud or $25,000, whichever
is less; if more than one individual or entity
is eligible to receive a reward in a particular
case, the Insurance Fraud Prosecutor shall
allocate the total reward amount (of up to
five percent of the value of the fraud and
not exceeding $25,000, whichever is less),among
the eligible claimants.
- (c)
The
OIFP shall make reward payments as promptly
as possible, but in no event shall payment
be made before all direct appeals of the conviction
have been exhausted.
- (d)
No OIFP employee shall make an offer or promise
or otherwise bind the OIFP with respect to
payment of any reward under this subchapter
or the amount of the reward.
- (e)
If,
after a reward is accepted, the OIFP finds
that the recipient was ineligible to receive
the reward, the OIFP shall not be liable for
the reward and the recipient shall refund
all monies received to the OIFP.
- (f)
Reward amounts shall be reported to the appropriate
state and Federal taxing authorities as required
by law. Applicants shall provide all information
necessary to making such reports.
13:88-3.12
Multiple applications
- (a)
Except when a contrary result is required
to prevent manifest injustice, in cases where
two or more applicants submit substantially
identical information which proximately results
in the arrest, prosecution and conviction
of persons or entities who have committed
health care claims fraud, insurance fraud
or any other criminal offense related to an
insurance transaction, only the person who
has filed his or her application first in
time shall be considered for the receipt of
a reward pursuant to this subchapter.
- (b)
In cases where two or more applicants submit
different information which proximately results
in the arrest, prosecution and conviction
of persons or entities who have committed
health care claims fraud, insurance fraud
or any other criminal offense related to an
insurance transaction, thereby rendering both
applicants eligible for a reward pursuant
to this subchapter, the Insurance Fraud Prosecutor
may apportion the amount of the reward among
the applicants based upon consideration of
relevant factors including, but not limited
to:
- The
timing (chronological order) of each application
filed;
-
The relative overall accuracy of information
in each application filed; and
-
The relative extent of cooperation with
the prosecution by each applicant in the
particular case for which the information
has been provided.
- (c)
Upon such apportionment set forth in (b) above,
the Insurance Fraud Prosecutor shall provide
each eligible applicant with a written statement
of the reasons for the determination.
13:88-3.13
Dismissal of charges
Except when a contrary result is required to
prevent manifest injustice, if a person supplies
information which proximately results in the
arrest of and institution of criminal charges
against persons or entities for health care
claims fraud, insurance fraud or any other criminal
offense relating to an insurance transaction
and in the discretion of the OIFP those charges
are subsequently dismissed, no person shall
be eligible pursuant to this subchapter for
a reward from those proceedings.
13:88-3.14 Appeals
The decision of the Insurance Fraud Prosecutor
regarding reward eligibility and reward payment
pursuant to this subchapter shall be final unless
the reward recipients disagree, in which event,
the matter shall be referred to the Attorney
General whose decision shall be final and shall
not be subject to judicial review.
13:88-3.15 Severability
If any rule, sentence, paragraph or section
of these rules, or the application thereof to
any persons or circumstances, shall be adjudged
by a court of competent jurisdiction to be invalid,
or if by legislative action any rule shall lose
its force and effect, such judgment or action
shall not affect, impair or void the remainder
of these rules.
Rule
pdf (131k) I Reward
Application (97k pdf)
plug-in
Top |
|
