Audit

321. What is an audit?


As required by Section 10.3 of the Settlement Agreement, the Claims Administrator, with the cooperation of Class Counsel and Counsel for the NFL Parties, established procedures to detect and prevent fraudulent submissions and payments of fraudulent claims from the Monetary Award Fund. Claims may be audited using the following processes and criteria:

(a) Random Sampling of Claims that Qualify for Monetary Awards or Derivative Claimant Awards: On a monthly basis, the Claims Administrator audits 10% of the total claims found eligible for Monetary Awards or Derivative Claimant Awards during the previous month.

(b) Mandatory Fact Pattern Audits: The Claims Administrator audits all claims that fit any of the following three fact patterns:

(1) The Monetary Award is based on a Qualifying Diagnosis of Level 1.5 or Level 2 Neurocognitive Impairment when the Retired NFL Football Player participated in the BAP in the past 365 days and did not receive the asserted Qualifying Diagnosis during the BAP exam.

(2) The Monetary Award is based on a Qualifying Diagnosis when the Player (or his Representative Claimant) submitted a prior claim in the past 365 days alleging the same diagnosis by a different physician and the Settlement Program denied the prior claim.

(3) The Monetary Award is based on a Qualifying Diagnosis that resulted from a medical examination conducted at a location other than a standard treatment or diagnosis setting, for example, a hotel room.

(c) Audit of Claims Identified During Review: The Claims Administrator audits claims with reliability questions raised by the documents, data analytics, or reports from the public.


322. How does an audit affect the regular processing of my claim?


The claims processing deadlines in the Settlement Agreement are suspended when the Claims Administrator places a claim in audit. The Claims Administrator will not issue a Notice of Monetary Award Claim Determination, Notice of Derivative Claimant Award Determination, or payment to a Settlement Class Member while his or her claim is undergoing an audit review.


323. Why did I receive a Notice of Audit of Claim?


Your claim is in audit under Section 10.3 of the Settlement Agreement. The Settlement Agreement requires that the Claims Administrator notify you, Class Counsel and Counsel for the NFL Parties that your claim is in audit. The Notice of Audit of Claim lists the information and/or records that you need to provide to complete the audit and continue processing your claim. You should submit the requested information and/or records by the Response Date listed at the top of the Notice.


324. I received a Notice of Audit of Claim after I received a Notice of Monetary Award Claim Determination or a Notice of Denial of Monetary Award Claim. How does the audit affect my claim?


The claims processing deadlines in the Settlement Agreement are suspended when the Claims Administrator places a claim in audit. If, at the time you receive a Notice of Audit of Claim, you have already received a Notice of Monetary Award Claim Determination or a Notice of Denial of Monetary Award Claim and the deadline to appeal the determination has not yet expired, your right to appeal will be preserved and the Claims Administrator will stay the appeal process. After the Claims Administrator concludes the audit, the Claims Administrator will issue a Notice of Monetary Award Claim Determination or Notice of Denial of Monetary Award Claim for any claim not yet in the appeal process, and for any claim in the appeal process, the Claims Administrator will resume processing the appeal.


325. Are there any rules covering the audit of claims?


Yes. The Special Masters adopted the Rules Governing the Audit of Claims, which cover the proceedings before the Special Masters on potentially fraudulent claims for Monetary Awards and Derivative Claimant Awards referred to them by the Parties and the Claims Administrator after the Claims Administrator has done an audit investigation. These Rules are available here.


326. Who is the Special Investigator?


The Court appointed the Honorable Lawrence F. Stengel (Retired) as Special Investigator to assist the Special Masters in implementing Section 10.3 of the Settlement Agreement, which deals with audits of claims. The Special Investigator has the authority to conduct investigations at the direction of the Special Masters. Those investigations will focus on the role of attorneys or healthcare professionals involved in potentially fraudulent claims for Qualifying Diagnoses made before the Effective Date. However, under certain circumstances, the Special Masters may authorize the Special Investigator to investigate other entities and/or matters.

The Special Investigator has retained HML Group to help with investigations. Click here to read information from the Special Investigator about his retention of HML Group.


327. Why did I receive a Notice of Referral to Special Investigator?


You previously received a Notice of Audit of Claim that your claim is in audit under Section 10.3 of the Settlement Agreement. The Special Masters now have referred your file to the Special Investigator for investigation and recommendations. A referral to the Special Investigator does not mean that the Special Masters have already made a finding of fraud or wrongdoing. It only means that the Special Masters have requested the assistance of the Special Investigator in the course of the audit related to your claim. You and others may receive requests for information from the Special Investigator or from the HML Group, the investigation firm retained by the Special Investigator. Full and timely cooperation with such requests is required for the Special Investigator to complete his review.