Cal. Code Regs. tit. 10 § 2698.55

Current through Register 2024 Notice Reg. No. 45, November 8, 2024

Section 2698.55 - County Plan

Each district attorney's program award shall be based on the evaluation of the County Plan. The County Plan shall be evaluated by a Review Panel to be comprised of two members of the Fraud Assessment Commission, the Chief of the Fraud Division or the Chief of the Fraud Division's designee, the Director of the Department of Industrial Relations or the Director of the Department of Industrial Relations' designee, and an expert in consumer crime investigation and prosecution to be designated by the Commissioner.

The County Plan shall include but need not be limited to the following elements detailing the county's qualifications and the manner in which the district attorney will use the funds to investigate and prosecute workers' compensation insurance fraud:

(a) Qualifications.

(1) A description of the district attorney's experience in investigating and prosecuting workers' compensation insurance fraud. Relationships with other public or private entities which may be useful to the program should also be included.. Specific activity during the past two years should be detailed as follows:

(A) Number of investigations initiated, specifying number of identified suspects per investigation;

(B) Number of warrants or indictments issued, specifying number of suspects and/or defendants;

(C) Number of arrests made;

(D) Number of convictions obtained, specifying number of defendants, number obtained by trial verdict and number obtained by plea or settlement;

(E) Amount of fines and penalty assessments ordered and collected, specifying number of defendants; and

(F) Amount of restitution ordered and collected, specifying number of defendants and victims.

(2) The panel shall consider each applicant county's population size in proportion to its historic commitment of resources to insurance fraud investigation and prosecution.

(b) Plan. The district attorney's plan for investigation and prosecution of workers' compensation fraud, including, at a minimum, the following elements:

(1) Problem Statement. A description of the extent and nature of the problem in the county, including its sources and causes, its economic and social impact, its unique aspects, if any, and what is needed to resolve the problem. Supporting data, evidence, or indicators of fraudulent activity related to workers' compensation insurance should be included. The data and information may be derived from third party administrators, self-insured employers, other local law enforcement entities, insurers or the Fraud Division or the Investigation Bureau of the California Department of Insurance.

(2) Program Strategy. This section shall specify how the district attorney will use prgram funds to address the problem defined above including:

(A) Outreach. A description of the manner in which the district attorney will develop the district attorney's caseload, the source(s) for referrals of cases for investigation and/or prosecution, whether directly from the Division and/or directly from self-insured employers, third-party administrators and insurers or a combination;

(B) Personnel. The number, position titles and position justification of personnel to be funded fully or in part through grant funds, including descriptions of the qualifications of personnel to be assigned to the program and an organization chart identifying positions to be funded;

(C) Program Coordination. A description of the manner in which the district attorney plans to coordinate involved sectors, including employers, insurers, medical and legal provider communities, the Fraud Division and the Investigation Bureau of the California Department of Insurance;

(D) Management Plan. The detailed plan and schedule of the steps the district attorney will complete in achieving the objectives of the program and a discussion of how the program will be organized and what internal quality control and budget monitoring procedures will be employed. This part should also include how this program will be integrated with any other anti-fraud program(s) maintained within the district attorney's office;

(E) Staff Development. The plan for ongoing training of personnel on the workers' compensation system and the investigation and prosecution of fraud. Staff development may be addressed through coordination with the Division insurers or other entities.

(3) Objectives. This section shall outline the district attorney's anticipated achievements in the following areas:

(A) Estimated number of investigations to be initiated during the grant period, including a separate estimate of the number resulting from carryover investigations; and

(B) Estimated number of prosecutions to be initiated during the grant period.

Cal. Code Regs. Tit. 10, § 2698.55

1. New section filed 10-8-93; operative 11-8-93 (Register 93, No. 41).
2. Change without regulatory effect amending first paragraph and subsection (b)(2)(A) filed 7-14-2021 pursuant to section 100, title 1, California Code of Regulations (Register 2021, No. 29). Filing deadline specified in Government Code section 11349.3(a) extended 60 calendar days pursuant to Executive Order N-40-20.

Note: Authority cited: Section 1872.83, Insurance Code; CalFarm Insurance Company, et al. v. Deukmejian, et al. (1989) 48 Cal.3d 805, 824. Reference: Section 1872.83, Insurance Code.