Brandie Llewelyn
Brandie LlewelynProduct Manager, ACL



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Insurance fraud is costing you more money; more money to conduct business, more money as a consumer, more money as an employee, just more money all around. The cost of insurance fraud is estimated by the Coalition Against Insurance Fraud to be at least $80 billion in fraudulent claims made every year.1 And the FBI estimates that the average US family pays between $400 and $700 in increased premiums due to insurance fraud.2

Between claims fraud, provider billing fraud, fee-churning and ghosting, it’s no wonder that sophisticated fraud rings have emerged. There’s a big payout to be had and everyone wants their share.

The general attitude toward insurance fraud is somewhat laissez-faire. Many view insurance fraud as a victim-less crime, and fraudsters see it as a low-risk, high-reward endeavor. Although consequences and penalties are becoming more severe, convictions for “soft-fraud” are often just misdemeanors and may only involve probation or a fine.

“Soft” or “opportunistic” fraud typically involves more minor offences such as exaggerated injuries, where the claimant is an opportunist taking advantage of a bad situation. Hard or premeditated fraud is more serious and can lead to severe penalties. “Hard” fraud is any deliberate act with the intention of causing a loss. The ultimate goal of either type of fraud is to increase personal monetary gain, often with complete disregard for innocent individuals and, especially, the insurance company paying the claim.

What these fraudsters fail to realize is that their actions actually hurt everyone around—including the neighbor next door trying to feed a family, the market on the corner trying to keep costs down, and the large organization providing health benefits to its employees. Every individual the fraudster has contact with is affected in one way or another through increased premiums, higher prices for goods and services, and in some cases, severe injury or death.

What can you do?

As an insurance company, you have the most difficult task when it comes to fraud. You are getting hit by fraud on all fronts. You have your employees and agents, your customers, your providers, your vendors, and even people who are not your customers, all trying to take their undeserving share of your profits.

It may feel like a losing battle, but the good news is that the evidence is there—it’s hiding in your data. Even better news is that we can help you find it! Data analysis helps you review every claim to detect anomalies and examine data across all lines of business to compare claimant details, frequencies, and dates to highlight similarities that could indicate fraud.

Here are 7 insurance fraud red flag finders where ACL technology can help:

  1. Review all previous claims history to identify excessive claims
  2. Cross-check insured/claimant details and policy/claim dates
  3. Flag injury mills: witnesses, doctors, providers whom are associated with excessive claims
  4. Review for suspicious billing from medical or 3rd party vendors
  5. Cross-check claims by address and name
  6. Survey claimants and providers to cross-check facts, billing, services rendered/received
  7. Implement a Complaints Handling Hotline

Insurance fraud runs wide and deep, but you can make a difference and ACL has the technology to give you a fighting chance.



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