Anti-fraud Technology

Organized Chaos

Professional insurance fraud rings are sapping billions from the P&C insurance sector. Insurers are fighting back with sophisticated technology. 
By: | February 19, 2015 • 9 min read
02012015_38_Fraud_fake _ PB

It was like something out of a Hollywood crime drama. The gang’s operations were meticulously planned and ran like clockwork. The cartel was managed by a team of shady Russian characters. Money flowed like a river.

But it wasn’t drug money. And it wasn’t from gun running or human trafficking. It was the spoils of ill-gotten insurance money from staged car crashes throughout New York City.

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In 2013, an extended sting operation — involving the NYPD, the FBI, and the National Insurance Crime Bureau (NICB) — uncovered more than $400 million in fake injury claims from both real and set-up crashes in NYC.

The sting revealed dozens of key players, including doctors and lawyers on the take, a supporting cast of thousands of fake patients and patient recruiters, 100 phony medical clinics, and numerous crooked testing labs, medical-supply firms, and billing firms.

While most organized crime rings aren’t quite as ambitious as this one, they’re typically just as complex and also just as lucrative for the players involved.

Sophisticated professional fraud rings are actively bilking insurance companies of billions in no-fault auto/PIP, health care coverage, and workers’ comp claims fraud. Most operate using multiple false identities, targeting multiple organizations. They often recruit or “groom” insiders to assist in their schemes.

“These large rings, they’re highly adaptive,” said Tom Mulvey, assistant vice president, claim and SIU services, for ISO, an operating unit of Verisk. “It’s aggressive and it’s well camouflaged. These are dedicated perpetrators. They cross state lines and they spread their habit across a multitude of carriers. They’re not one-stop shopping — they make sure that everyone’s in play.

Tom Mulvey, assistant vice president, claim and SIU services, ISO

Tom Mulvey, assistant vice president, claim and SIU services, ISO

“Some of the camouflage they use is using numerous business names and locations,” he continued.

“They really work to cover their tracks; they artificially disburse their identities, they segment their volume. So rather than doing business with a carrier as a B2B, they [manipulate] their profile by operating as multiple businesses behind many identities.”

They’re also incredibly expensive to fight. But the cost of ignoring them is even higher.

According to information compiled by organizations such as the Insurance Information Institute (III) and the Coalition Against Insurance Fraud, property and casualty insurance fraud costs insurers approximately $33 billion a year — at least 10 percent of all losses, according to NICB.

But other organizations, including the FBI, place that number even higher, upwards of $40 billion.

Far from being a victimless crime, every policyholder foots the bill for this robust criminal activity, which continues to grow. NICB reports that the number of questionable insurance claims rose by 16 percent from 2011 to 2012.

The old wisdom was that a certain amount of fraud was simply a cost of doing business, and many insurers felt that a more proactive approach ran the risk of alienating good policyholders by investigating and delaying legitimate claims.

That strategy backfired, and fraudsters grew bolder and greedier. At some point, though, the costs rose so high that insurers realized they had to fight back.

Most insurance companies now employ special investigative units (SIUs), which utilize a variety of strategies and tools to detect and prevent fraud, with technology at the core of those tools.

A 2012 survey by the Coalition Against Insurance Fraud indicated that 95 percent of insurance companies are now using some form of anti-fraud technology. But this development is still fairly new — only half of survey respondents said they have been using this technology for more than five years, many had only been using it for two years at the time of the survey.

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As insurers work to establish and improve their anti-fraud programs, they face questions about which technologies to invest in. There’s no single magic-bullet tool that will cover every base.

Experts say that a multi-layered program must be in place in order to make any kind of substantive difference.

Finding Connections

The most common form of anti-fraud technology involves the use of business rules, or red flags. These systems test each transaction against a predefined set of algorithms or business rules to detect known types of fraud based on specific patterns of activity.

A rule might flag a claim for further investigation if it exceeds a certain dollar amount, occurs too soon after a policy is written, involves no witnesses, or if the claimant has submitted a high number of claims in the past year, for example.

The downside is that professional fraudsters are well aware of the various rules and thresholds typically used, and are skilled at flying just below the radar. They also know that flagged claims are likely to be subject to a database search such as ISO’s ClaimSearch, so they’ve even developed strategies to hoodwink the search engines.

“For every new technology, the thieves or fraudsters are going to be enthusiastically looking for ways to defeat the technologies,” said Jim Schweitzer, senior vice president and COO of NICB.

“The key is to find out who they are and what they’re doing before they get really good and begin to cause real harm to the industry and the general public.” — Tom Mulvey, assistant vice president, claim and SIU services, ISO

One attempt to get ahead of the thieves involves new software solutions called link analysis systems. These systems allow for a broader view than a straight database search, and can help identify the connections between players in a fraud ring, even when efforts have been made to blur those connections.

“Let’s say two vehicles have an accident,” said Stuart Rose, global insurance marketing director for SAS, a technology company involved in this area.

“You may have three or four different passengers involved. Two get injured and they go off to one medical provider. In six months’ time another accident occurs.

“It’s completely separate when looked at in isolation, but when you start to look at them combined, you start to see that the same insured was involved in both accidents. It may have been different vehicles.

“He may have been a passenger in both of them. But he’s going to the same medical provider. Another six months and the same thing happens.”

You start to see the same key person involved in all of these claims, said Rose.

Stuart Rose, global insurance marketing director, SAS

Stuart Rose, global insurance marketing director, SAS

“It’s a little like how LinkedIn or Facebook works. You start seeing all of those connections and how many degrees of separation there are from the insured.”

There are several key advantages to link analysis software. It can spot easily missed connections, such as multiple claim payments going to the same bank account, even when they’re all under different names. It can also catch the minor detail variations that fraud rings use to avoid detection.

“The payee, instead of Stuart Rose, may be Stuart Ross, or maybe even Steve Rose. They manipulate the ID just a little bit,” Rose said.

The Power of Volume

The more data that could be shared across the industry, the easier it would be for insurers to connect the dots. But insurers have been resistant to engage in any type of substantive data sharing due to privacy concerns.

Emerging tools on the market are a step in the right direction. ISO has been developing ClaimSearch DNA, an advanced link analysis program that works in conjunction with its existing ClaimSearch database. That allows users the benefits of link analysis beyond their own organizations’ data.

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“It’s been built to uncover the camouflage and graphically demonstrate connections of entities through an ISO visual analysis tool called NetMap,” said ISO’s Mulvey. “It really unravels the cover-up that conspirators work so hard to develop.”

The DNA system works on top of the ClaimSearch database, which contains nearly a billion loss records. It is designed to search constantly for anomalies and associations in the database.

“The proactive nature of this approach really lends itself to operate as an early warning system using the broad scale of industry loss data,” said Mulvey. “So rather than waiting for an individual carrier to recognize suspicious activity, this will speed things up and recognize the emerging group very early in its development. That time to detection is very important.”

“Once you put those safeguards in place, it’s amazing how quickly those fraudsters disappear. It’s not always about catching them,” said Rose. “It’s more about deterring them or deflecting them.” — Stuart Rose, global insurance marketing director, SAS

Professional fraud rings are a lot like any other business, in that they need to go through a development stage, getting the right people and resources in place. In the meantime, these startup rings will be orchestrating claims to produce cash flow.

“The key is to find out who they are and what they’re doing before they get really good and begin to cause real harm to the industry and the general public,” said Mulvey.

02012015_38_Fraud_chartTo that end, some insurers have begun using predictive modeling to shorten that time to detection. Chubb reports a high degree of success using predictive models on its casualty claims for the past eight years.

Chubb’s Don Siegrist, vice president, home office SIU and recovery manager, said that the company has built models based on the attributes of its successfully closed SIU cases.

The models have yielded a high success rate in identifying the claims that should be referred to the SIU, and are able to do so weeks or sometimes months before adjusters might have been able to flag them — sometimes in a matter of days.

“What it does is, it changes the tone of the investigation,” said Siegrist.

“The evidence is fresher. People’s minds are fresher; they still remember what occurred in the incident. The evidence that’s there is more available and nothing’s been changed. It makes for a much more powerful investigation.”

Supporting Tools

Text mining is another technology that should be a key part of a fraud-fighting program. Much of what fraud investigators have to work with is unstructured data — the information that doesn’t fit into neat little boxes on a form or in a database field, such as doctors’ notes, police reports or adjusters’ notes.

“You’ll start to see things like maybe the same phrase is being used by multiple different claimants,” said Rose of SAS.

“That’s because they’ve been taught by these fraud rings to know exactly what to say to the insurance companies.”

“For every new technology, the thieves or fraudsters are going to be enthusiastically looking for ways to defeat the technologies,” — Jim Schweitzer, senior vice president and COO, NICB.

Social media analysis is sometimes part of the mix, although its use may be more limited in its effectiveness against professional fraud. Still, in a case like the NYC ring with thousands of minor players, it could have been used to investigate the many “patients” involved, some of whom undoubtedly failed to keep up the pretense of their injuries. Some may have even boasted about the scam.

“It’s amazing what people are willing to brag about,” said NICB’s Schweitzer.

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“Law enforcement every day are solving cases where the individuals involved talked about [their crimes] with friends on Facebook or Twitter or some other social media. There is that human need for attention … letting people know, ‘Hey, I got away with this.’ It’s crazy but it’s true.”

Of course, none of these tools can wholly prevent fraud, Rose cautioned. But they can help insurers spot trends sooner, develop strategies based on those trends and get critical information to adjusters early on.

“Once you put those safeguards in place, it’s amazing how quickly those fraudsters disappear. It’s not always about catching them,” said Rose. “It’s more about deterring them or deflecting them.”

Michelle Kerr is associate editor of Risk & Insurance. She can be reached at mkerr@lrp.com
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Sponsored: Berkshire Hathaway Specialty Insurance

Healthcare: The Hardest Job in Risk Management

Do you have the support needed to successfully navigate healthcare challenges?
By: | April 1, 2015 • 4 min read

BrandedContent_BHSIThe Affordable Care Act.

Large-scale consolidation.

Radically changing cost and reimbursement models.

Rapidly evolving service delivery approaches.

It is difficult to imagine an industry more complex and uncertain than healthcare. Providers are being forced to lower costs and improve efficiencies on a scale that is almost beyond imagination. At the same time, quality of care must remain high.

After all, this is more than just a business.

The pressure on risk managers, brokers and CFOs is intense. If navigating these challenges wasn’t stress inducing enough, these professionals also need to ensure continued profitability.

Leo Carroll, Senior Vice President, Healthcare Professional Liability, Berkshire Hathaway Specialty Insurance

Leo Carroll, Senior Vice President, Healthcare Professional Liability, Berkshire Hathaway Specialty Insurance

“Healthcare companies don’t hide the fact that they’re looking to reduce costs and improve efficiencies in practically every facet of their business. Insurance purchasing and financing are high on that list,” said Leo Carroll, who heads the healthcare professional liability underwriting unit for Berkshire Hathaway Specialty Insurance.

But it’s about a lot more than just price. The complexity of the healthcare system and unique footprint of each provider requires customized solutions that can reduce risk, minimize losses and improve efficiencies.

“Each provider is faced with a different set of challenges. Therefore, our approach is to carefully listen to the needs of each client and respond with a creative proposal that often requires great flexibility on the part of our team,” explained Carroll.

Creativity? Flexibility? Those are not terms often used to describe an insurance carrier. But BHSI Healthcare is a new type of insurer.

The Foundation: Financial Strength

BrandedContent_BHSIBerkshire Hathaway is synonymous with financial strength. Leveraging the company’s well-capitalized balance sheet provides BHSI with unmatched capabilities to take on substantial risks in a sustainable way.

For one, BHSI is the highest rated paper available to healthcare providers. Given the severity of risks faced by the industry, this is a very important attribute.

But BHSI operationalizes its balance sheet in many ways beyond just strong financial ratings.

For example, BHSI has never relied on reinsurance. Without the need to manage those relationships, BHSI is able to eliminate a significant amount of overhead. The result is an industry leading expense ratio and the ability to pass on savings to clients.

“The impact of operationalizing our balance sheet is remarkable. We don’t impose our business needs on our clients. Our financial strength provides us the freedom to genuinely listen to our clients and propose unique, creative solutions,” Carroll said.

Keeping Things Simple

BrandedContent_BHSIHealthcare professional liability policy language is often bloated and difficult to decipher. Insurers are attempting to tackle complex, evolving issues and account for a broad range of scenarios and contingencies. The result often confuses and contradicts.

Carroll said BHSI strives to be as simple and straightforward as possible with policy language across all lines of business. It comes down to making it easy and transparent to do business with BHSI.

“Our goal is to be as straightforward as we can and at the same time provide coverage that’s meaningful and addresses the exposures our customers need addressed,” Carroll said.

Claims: More Than an After Thought

Complex litigation is an unfortunate fact of life for large healthcare customers. Carroll, who began his insurance career in medical claims management, understands how important complex claims management is to the BHSI value proposition.

In fact, “claims management is so critical to customers, that BHSI Claims contributes to all aspects of its operations – from product development through risk analysis, servicing and claims resolution,” said Robert Romeo, head of Healthcare and Casualty Claims.

And as part of the focus on building long-term relationships, BHSI has made it a priority to introduce customers to the claims team as early as possible and before a claim is made on a policy.

“Being so closely aligned automatically delivers efficiency and simplicity in the way we work,” explained Carroll. “We have a common understanding of our forms, endorsements and coverage, so there is less opportunity for disagreement or misunderstanding between what our underwriters wrote and how our claims professionals interpret it.”

Responding To Ebola: Creativity + Flexibility

BrandedContent_BHSIThe recent Ebola outbreak provided a prime example of BHSI Healthcare’s customer-centric approach in action.

Almost immediately, many healthcare systems recognized the need to improve their infectious disease management protocols. The urgency intensified after several nurses who treated Ebola patients were themselves infected.

BHSI Healthcare was uniquely positioned to rapidly respond. Carroll and his team approached several of their clients who were widely recognized as the leading infectious disease management institutions. With the help of these institutions, BHSI was able to compile tools, checklists, libraries and other materials.

These best practices were immediately made available to all BHSI Healthcare clients who leveraged the information to improve their operations.

At the same time, healthcare providers were at risk of multiple exposures associated with the evolving Ebola situation. Carroll and his Healthcare team worked with clients from a professional liability and general liability perspective. Concurrently, other BHSI groups worked with the same clients on offerings for business interruption, disinfection and cleaning costs.

David Fields, Executive Vice President, Underwriting, Actuarial, Finance and Reinsurance

David Fields, Executive Vice President, Underwriting, Actuarial, Finance and Reinsurance, Berkshire Hathaway Specialty Insurance

Ever vigilant, the BHSI chief underwriting officer, David Fields, created a point of central command to monitor the situation, field client requests and execute the company’s response. The results were highly customized packages designed specifically for several clients. On some programs, net limits exceeded $100 million and covered many exposures underwritten by multiple BHSI groups.

“At the height of the outbreak, there was a lot of fear and panic in the healthcare industry. Our team responded not by pulling back but by leaning in. We demonstrated that we are risk seekers and as an organization we can deploy our substantial resources in times of crisis. The results were creative solutions and very substantial coverage options for our clients,” said Carroll.

It turns out that creativity and flexibly requires both significant financial resources and passionate professionals. That is why no other insurer can match Berkshire Hathaway Specialty Insurance.

To learn more about BHSI Healthcare, please visit www.bhspecialty.com.

Berkshire Hathaway Specialty Insurance (www.bhspecialty.com) provides commercial property, casualty, healthcare professional liability, executive and professional lines, surety, travel, programs, and homeowners insurance. It underwrites on the paper of Berkshire Hathaway’s National Indemnity group of insurance companies, which hold financial strength ratings of A++ from AM Best and AA+ from Standard & Poor’s. Based in Boston, Berkshire Hathaway Specialty Insurance has regional underwriting offices in Atlanta, Boston, Chicago, Los Angeles, New York, San Francisco, Toronto, Hong Kong, Singapore and New Zealand. For more information, contact info@bhspecialty.com.

The information contained herein is for general informational purposes only and does not constitute an offer to sell or a solicitation of an offer to buy any product or service. Any description set forth herein does not include all policy terms, conditions and exclusions. Please refer to the actual policy for complete details of coverage and exclusions.

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This article was produced by the R&I Brand Studio, a unit of the advertising department of Risk & Insurance, in collaboration with Berkshire Hathaway Specialty Insurance. The editorial staff of Risk & Insurance had no role in its preparation.




Berkshire Hathaway Specialty Insurance (www.bhspecialty.com) provides commercial property, casualty, healthcare professional liability, executive and professional lines, surety, travel, programs, and homeowners insurance.
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