Solving the Insurance Fraud Dilemma


Crimes committed against insurance policies continue to get more sophisticated, organized crime rings are more prevalent and insured’s are committing increased amounts of insurance fraud given the depressed economy, yet insurance investigations aren’t necessarily keeping pace. In fact, the need to keep up with criminals targeting insurance products and services has never been greater.


In today’s economic times, investigative “business as usual” doesn’t cut it as the criminal element continually seeks new, and more technologically advanced, methods to exploit insurance company weaknesses and vulnerabilities, quickly outpacing resources dedicated to the battle.

What can we do? Claims and investigations processes need to be evaluated with an eye towards efficient process flow, as do procedures and technological capabilities. SIU’s can gain real ground on criminals through streamlined processes and procedures, utilizing skilled investigative employees more effectively and implementing new technology and analytic/intelligence gathering capabilities into existing business methodologies.

Attitude and Approach

There are real change management opportunities for SIU’s but this requires a new mindset, one of positive results, innovation and a new way of thinking. “Status quo” and “slow and steady” won’t win the race. Getting to the finish line ahead of insurance fraud criminals involves being better at the fraud game than they are: gathering useful intelligence, utilizing advanced analytics to identify red flags and potential fraud patterns, denying suspect claims before they are approved, shutting down claims that elude filters faster than we’ve previously done before, putting good cases into the prosecutorial pipeline and getting convictions.

In order to get a head of the criminal element targeting the insurance industry, and not always be two steps behind, we have to think about the fraud prevention, detection and investigation equation more holistically and change our current attitude and investigative approach.