The first week of 2026 saw me in a much different place physically than I was a year prior. I was at work and not in constant pain.

A recent healthcare fraud case highlights the need for insurers, healthcare providers, and policymakers to work together to protect healthcare resources, reduce fraud-related financial losses, and ensure patient care remains the top priority.

​Kizzie Masterson, Mark‑James Gill, Tyler Blake

“Was New Orleans always this fun?” we asked each other, weaving through a crowd of colleagues dressed in beads, grinning ear to ear.
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Between the unforgettable food, the late‑night laughs, the second‑line parade through the French Quarter, the music pouring from every doorway, and the incredible culture surrounding us, ICA 2025 in New Orleans was an absolute blast. But as great as the gumbo and jazz were, the best part was the people.

The Family and Medical Leave Act (FMLA) allows eligible workers up to 12 workweeks of unpaid, job-protected leave for qualifying family and medical reasons. But when it comes to temporary employees, especially those placed through staffing agencies, the rules can feel murky. Who’s responsible for what? And do temp workers even qualify?

​By Marlon Fearon

The views expressed in this article are those of the author in his capacity as a member of the ICA Fraud Committee and do not necessarily reflect the views of Swiss Re or its affiliated entities.
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Life and health insurance exist to provide financial protection during some of the most vulnerable moments in a person’s life—illness, injury, disability, or death. Unfortunately, those same features that make these products essential also make them highly attractive targets for fraud. Across the insurance industry, life and health lines consistently experience significant fraud exposure due to a unique mix of emotional, financial, and structural factors.

By Margo Jenkins (AAA Life) & Rob Strange (Evadata)
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The landscape of insurance fraud is rapidly evolving, and life insurance claims are no exception. With the accelerated development and accessibility of Artificial Intelligence (AI) and generative AI tools, claims examiners are facing sophisticated new threats. Understanding these emerging risks and adopting proactive AI-powered defenses are crucial to safeguarding your company’s financial health and maintaining trust with legitimate policyholders.

“Fraud prevention is easy”, said no person, ever.  An effective fraud prevention strategy is multi-faceted, requiring everyone in an organization to be on board – from the C-Suite to boots on the ground.  For an organization to manage fraud risks and the inherent financial or reputational losses, it needs to know what the risks are, where the risks are, who may exploit any weaknesses, and what the ultimate cost to the organization might be if fraud occurs.  The most effective and comprehensive way to identify such risks is via a fraud risk assessment.  This process seeks to proactively identify and address the organization’s vulnerabilities to internal and external fraud and determine how the organization will respond to these risks.

​Should CPT codes be used for billing or occupation analysis? The answer is both. 
 
In a recent lawsuit, an argument was raised that Current Procedural Terminology (CPT) codes were created and are used for billing purposes, so they should not be used in determining occupation for some reason.  One of the arguments made by an expert in the case was that charges were used, which is not a realistic measurement, as reimbursements and payments received are always less than the charge amount.  The counter argument is that charges are only one metric we use, and we recommend and use Relative Value Units (RVU) and units in all CPT analyzes.     
 
This blog will show why they can be used for both billing and the verification of a physician’s occupation.  

​Insurance fraud, waste and abuse (FWA) pose significant challenges to the integrity and financial stability of the insurance industry. These activities inflate costs, undermine trust, and divert resources away from legitimate claimants, ultimately impacting consumers, insurers and the economy. Combatting FWA requires a comprehensive understanding of its forms, particularly within vital areas such as life, health and disability insurance. This article explores these issues, providing detailed definitions, illustrative examples and real-world case studies to elucidate the nature of FWA and strategies to mitigate it.

Policies may be voided after the contestable period has expired.  There is a common myth that once a policy’s contestable period has expired, there is nothing an insurance company can do to void the policy if fraud is found.  While it is certainly true that the threshold of proof required to void a policy outside the contestable period is higher than rescinding a policy for material misrepresentation, the expiration of the contestable period does not bar action against fraudulent activity.