P&C Medical Fraud: 5 Insights for Investigators

By Andy Tolsma  |  March 5, 2014

Medical fraud perpetrated against property/casualty insurers costs the industry tens of billions of dollars each year. Until recently, special investigations units (SIUs) have struggled to address the problem, with challenges such as lack of access to data or scant tools designed specifically for the property/casualty industry. With the introduction of ISO MedSentry, that’s changing. The tool provides a new opportunity in fraud investigation and risk mitigation for the SIU community. New insights can help guide SIUs toward more efficient and productive investigations.

Check out these five insights you can use to improve your investigations of suspicious medical providers:

1. The long haul: Investigations of suspect medical providers are time- and resource-intensive. An investigation probably requires more than only a few months, and its complexity can mount quickly. Be prepared to invest significant time, but understand that a successful investigation can unearth millions of dollars in exposure to questionable medical bills.

2. Disparate data: Historically, finding the data needed to complete an investigation involving a suspicious medical provider has been difficult. Medical bill data was tough to access, and bringing in additional sources of information (such as claims data) only made the process more complicated. ISO MedSentry provides a significant advantage, helping to identify cases that might otherwise have gone undetected.

3. Crucial connections: Data alone doesn’t tell a full story — you must put the pieces together. That includes finding the hidden connections among claimants, medical providers, and other associated parties who might not be immediately apparent. Using advanced analytics, ISO MedSentry can aid you in recognizing distant connections to help develop a case and identify exposure to suspicious billing activity.

4. Real and unreal: How does a chiropractor bill 36 hours in a single day? When you sift through the medical bill data you submit to ISO MedSentry, the tool will help look for anomalies that warrant further investigation. Some will be obvious, having been concealed only by the amount of data available and the past challenges you’ve had accessing it. Others will be subtle, requiring sophisticated analytical tools to ferret them out.

5. The early bird: Speed to detection is crucial. If you can identify evidence of suspicious activity around a medical provider sooner, you can take swift action to mitigate your company’s exposure. The longer the behavior continues, however, the greater its effect on your company and potentially the insurance industry as a whole. Organized fraud operates much like a legitimate business — it’s most vulnerable in its earliest stages.