Detecting Worker’s Comp Claims Fraud Through Technology

The struggling economy has hit insurers hard and has taken its toll in particular on the workers’ compensation system. In addition to premium abuses by employers, claims fraud and abuse by workers and service providers have produced significant losses. As a result, insurers are constantly seeking new understandings that will allow them to gain a competitive advantage, reduce costs and improve risk management. While there are numerous opportunities to improve processes using traditional business intelligence, new automated core systems are driving a shift particularly in worker’s compensation claims to focus on advanced analytics.

Number of Comp Claims Decrease While Questionable Claims Rise
The National Insurance Crime Bureau (NICB) reported that workers compensation claims that were reported from January 1, 2011, through June 30, 2013 were on the decline. In 2011, 3,349,925 workers’ compensation claims were found in the Insurance Services Office (ISO) Claim Search database. That number decreased to 3,244,679 in 2012, and is likely to decrease further in 2013 – only 1,498,725 claims were received in the first half of this year.

At the same time the number of Questionable Claims (QC) referred to NCIB for workers compensation was 3,474 in 2011 (3.5% of total QC’s) That number increased to 4,460 in 2012—a 28 percent rise when total workers’ compensation QCs accounted for 3.8 percent of the total.  Through the first half of 2013, 2,325 workers’ compensation QCs have been already referred to NICB (3.7 percent of total QCs).

The three top reasons for a Questionable Claim referral remain unchanged in the three year period as: claimant fraud, a prior injury not related to work and malingering.

Improvements in System Functionality and Predictive Analysis
According to a survey conducted by the Aite Group fraudulent claims in all lines are on the rise over the last three years for insurers, with nearly $80 billion in fraudulent claims made each year in the U.S. alone.

In the past, insurers relied heavily on claims adjusters to manually flag suspected fraud situations.

Advancements in mobile solutions and enterprise content management (ECM) solutions however have help insurers to not only speed claims processing and increase client support, but also to spot patterns in data to better detect fraud.

Latest developments in mobile solutions and ECM solutions helped insurers to speed-up claims processing and increase client support and to spot patterns in data detect fraud.

New Core Claims Systems that contain better data quality including detailed text descriptions are able to provide more sophisticated and more automated predictive analytical solutions to help identify potential fraud situations more frequently and with greater accuracy. The shift in focus is no small wonder since Increasing the rate of claims fraud detection, can impact insurance bottom line profitability by as much as 3% to 5%.

The use of industry shared database to leverage claims history can be invaluable in detecting fraud. A thorough analysis of prior claim activity can uncover questionable patterns of behavior including preexistent injuries. The industry claims database has swelled from 147 million claims in 1998 to more than 680 million claims today —a growth of 362 percent. Advanced analytic techniques, such as social network analysis, regression analysis, and text mining, can scrutinize large numbers of claims and their attributes at record speed. Claims systems today can examine huge amounts of data, transform the data into strategic insight, score claim characteristics and identify red flags and patterns of claims. Advanced analytics delivers the power to improve.

JDi Data Corporation has provided insurance claims software since 1992. Our product suite includes workers compensation software and claims management systems for property and casualty, medical malpractice, and specialty lines to be administered by insurers, risk managers, and third party administrators. JDi Data has built a reputation in quality claims management software with special emphasis on complex litigation.