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Insurers and Fraudsters Have This in Common

In some ways, fraudsters are a lot like you: They rely on data to make important decisions about their operations. While you use analytics to try to identify suspicious activity, they keep their own records — tracking adjuster moves, predicting cycle time, monitoring settlements, and identifying new opportunities for growth. Claims departments have spent decades reacting to the claims fraud threat, while the fraudsters themselves have been planning ahead. That’s about to change.

It would be inaccurate to say claims departments haven’t made progress in fighting insurance fraud. New systems have provided enhanced claims records through public data, shown patterns of behavior that can be relevant to an investigation, and flagged questionable claims that warrant a closer look. Insurers have invested significantly in fraud detection, and they see the returns every day. Nonetheless, the industry needs to do more. After all, every carrier success story leads to more fraudster innovation — and with it more questionable claims.

In the first half of 2013, ISO Claims Solutions plans to release a new tool to help carriers get ahead of suspicious activity. Our pilot programs have been successful, even leading to referrals to the NICB for investigation.

Our network fraud analytics system uses predictive modeling to identify cases of likely organized fraud. Unlike many predictive products, this one proactively and constantly scans ISO ClaimSearch® — which currently contains more than 850 million claims records from across the United States — providing the broadest view of suspicious activity. Rather than analyzing one carrier’s claims, this new tool will show indicators of organized fraud for several companies, making it easier to detect and take action on organized fraud in its earliest stages.

As a fraud syndicate develops its business plan and process, it moves from a start-up to a money-printing machine. Detection speed is the key attribute of ISO network analytics — the broad scale of the ISO ClaimSearch data helps identify the rings early on.

In the past, detecting organized fraud was reactive: SIU departments needed a starting point. With ISO network fraud analytics, however, investigators can take a proactive stance, as they’ll get notification of suspected organized fraud well before paying hundreds of millions of dollars in illegitimate claims.

Fraudsters have always had the advantage. Take that away from them this year: Protect your customers from the effects of organized fraud, and accelerate your detection process.

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.

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