Cal. Code Regs. tit. 10 § 2698.97.1

Current through Register 2024 Notice Reg. No. 50, December 13, 2024

Section 2698.97.1 - County Plan

A county plan shall include the following elements:

(a) Problem Statement: A description of the disability insurance fraud problem in the county, including how it arose, why it is important, its unique aspects, if any, and what is needed to resolve the problem, including supporting data, evidence, or indicators of fraudulent activity related to disability insurance.

(b) Supporting data may include the following items:

(1) A narrative description of the disability insurance fraud activity in the county, including any supporting data, evidence or indicators of fraudulent related activity.

(2) A description of the general criminal activity, based upon the most recent California Crime Index Annual Report by the California Attorney General.

(3) Population density, based upon the most recent report compiled by the California Department of Finance, Demographic Research Unit.

(4) Disability insurance claims frequency.

(5) Number of disability fraud suspected fraudulent claims reported to the Division during a 36-month period immediately preceding the submission of the application.

(6) Evidence of prior and current disability insurance fraud activity.

(c) Qualifications: A description of the applicant's experience in investigating disability insurance fraud including:

(1) The total amount expended to support the district attorney's investigation and prosecution of disability insurance fraud, including the details of the following items:

(A) Personnel costs including salaries and benefits.

(B) Operations expenses, including space, equipment, travel and other expenses in support of the program.

(2) For applications submitted after fiscal year 2005-2006, the following factors shall be included in the County Plan:

(A) The total amount of funds received from the Disability Insurance Fraud Program by the local district attorney in previous years and a copy of the most recent annual report.

(B) The results obtained through implementation of the program, including:

1. The number of investigations initiated or coordinated with other law enforcement agencies.

2. The number of arrests or convictions.

3. The number of indictments or complaints.

4. A comparison of the amounts originally claimed in cases determined to be fraudulent compared to payments actually made.

(d) Program Strategy:

(1) Outreach. A description of the manner in which the district attorney will develop the district attorney's caseload, the source(s) for referrals for cases for investigation or prosecution, whether directly from the Fraud Division or from other law enforcement agencies and/or insurers.

(2) Personnel. Justification for the number of personnel, position titles and position justification for personnel which will 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.

(3) Program Coordination. A description of the manner in which the district attorney plans to coordinate involved sectors, including insurers, medical and legal provider communities, the Division, and local law enforcement agencies.

(4) Management Plan. A 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 staff will be organized and what internal quality control and budget monitoring procedures will be employed. This part shall also include how this program will be integrated with any other anti-fraud program(s) maintained within the district attorney's office.

(5) Staff Development. The plan for ongoing training of personnel on the investigation and prosecution of disability insurance fraud. Staff development may be addressed through coordination with the Division, insurers, or other entities.

(6) 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 funding cycle, including separate estimate of the number resulting from carryover investigations; and

(B) Estimated number of prosecutions to be initiated during the funding cycle.

Cal. Code Regs. Tit. 10, § 2698.97.1

1. New section filed 11-3-2005; operative 12-3-2005 (Register 2005, No. 44).
2. Change without regulatory effect amending subsection (d)(1) 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 1872.85, Insurance Code; and CalFarm Insurance Company, et al. v. Deukmejian, et al. (1989) 48 Cal.3d 805 and 824. Reference: Section 1872.85, Insurance Code.