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Claims Fraud Investigations: Look Smarter, Not Harder

Today’s SIUs are facing pressure to do more with less — necessitating creative and innovative solutions. Because the ISO ClaimSearch® database continues to grow and gain additional detection functionality, more claim information is available now than ever before. Investigators take advantage of this extensive database every day. Last year, the database received 26 million investigative inquiries, a 12 percent increase over 2010.

With access to comprehensive industry data, investigators are uncovering patterns and associations more quickly and thoroughly. In past years, investigators would explore every avenue looking for pertinent information to resolve an assignment. Today, that degree of thoroughness is a challenge.

That challenge leads to the use of new data sets and sophisticated tools that help narrow down and prioritize which cases to initiate. Assignment loads dictate that SIUs can’t conduct in-depth investigations of every claim that may appear somewhat questionable. The initial review and triage are more important than ever.

In addition, SIU leaders are turning to technology to determine which leads to investigate. The key now is to become more productive in sequencing the steps of an investigation.

The industry faces an environment in which fraudsters are continually hatching new insurance fraud schemes and scams. The commitment to continued improvement in technology is vitally necessary to keep pace with the onslaught and ultimately reduce risk and improve results.

This article is part of the State of Insurance Claims series

Thomas Mulvey

Thomas Mulvey has been in the business of insurance investigations for more than 27 years. In his current position, he serves ISO as assistant vice president of SIU and claim services. He is also the coordinator of ISO’s Insurance Fraud Management Conference.