3 Tips for Spotting Fraudulent Claims

/0 Comments/in /by Karla Ellison

Most property and casualty claims adjusters will tell you that spotting fraudulent claims is sometimes more difficult than it seems. One case may seem blatantly obvious as fake, while it is in fact completely true. Another might appear to be simple, but really be a part of a larger insurance scam.

So, how do you tell the difference between the two? Here are a few tips to make spotting a fraudulent claim easier.

Ask Questions

One of the easiest ways to spot insurance fraud is by simply asking questions. Request further clarification on anything that seems a little strange or isn’t completely clear. Also, don’t be afraid to ask the same question multiple times over the course of various conversations. If the information is valid, it will often stay close to the same each time. If it is not, there’s a good chance that it will change each time the claimant or insured answers. (Hint: Insurance transcription services can help you easily spot the difference between the two.)

Use a Map

Another way to spot fraud is by simply utilizing something that you already have available to you—the internet. Google Maps and other similar websites are great for looking up the topography of intersections. This can help you determine whether or not an accident statement makes sense or whether it is even possible for a collision to happen in the manner initially described. In addition, understanding the exact layout of where an incident took place can even assist you in making a clear and complete liability decision.

Use Social Media

In today’s society, sharing thoughts and stories on the internet as they happen has become quite commonplace—even for those attempting to commit insurance crimes. Another way to spot fraudulent claims is by taking a peek at the social media profiles of suspicious insureds or claimants. Public photos and status updates often give great insight into whether or not a specific injury claim actually caused harm or if an accident really happened in the manner in which described. Many carriers have found this to be an excellent way to dispel untruthful injury claims and accident reports, simply because the party trying to commit fraud decided to brag online.

Utilize Recorded Insurance Transcriptions

Recorded statement transcriptions can also help you spot a fraudulent claim. How? It is often easier to notice differences in an insured or claimant’s description of what happened when it is in front of you as text. After the transcription process has taken place, compare the conversations to determine if there are any discrepancies. Any obvious differences should be cause for concern and earn a second look by your department’s special investigation unit.

While these are just three of the many ways you can help spot fraudulent claims, there is still one major tool you can rely on—your own instinct. As a claims professional, you know what sounds right for an incident and what doesn’t. Trust that intuition and decide when it is appropriate to dig a little further before settling a claim. After all, the best case scenario is that there is no fraud happening and that you were able to prove so.

5 Common Indicators of Workers’ Compensation Fraud

/2 Comments/in /by Karla Ellison

As most workers’ compensation adjusters will tell you, sometimes the facts of a claim just don’t add up. In those instances, it is up to the file handler to dig a little deeper to determine whether or not they are dealing with a case of workers’ compensation fraud.

However, this task becomes much easier if you know ahead of time what you should be looking for. Here are five common indicators for spotting workers’ compensation fraud.

#1: Refusal to See a Medical Provider

One of the biggest indicators of fraud in workers’ compensation claims is when someone refuses to see a medical provider for their condition. Often, this means that there is no valid claim and that a doctor would be unable to corroborate whether or not the injury actually happened. Another variation of this red flag is a claimant that refuses to turn over medical records related to the incident. Both scenarios indicate that there is a reason why the person doesn’t want you to see that report and should be explored further.

#2: Reporting Delays

Another way to spot a fraudulent workers’ compensation claim is by determining if the claimant waited to report the injury after the incident. This is especially true when it comes to overexertion or soft tissue injuries. In most cases, it an injury is real, parties will file with an insurer either immediately or within a few days. Waiting weeks or filing a claim after a weekend can sometimes be an indicator of fraudulent activity.

#3: Selecting Certain Providers

Many habitual perpetrators of workers’ compensation fraud are smart—or at least think that they are. They opt to use certain attorneys or providers on a regular basis to ensure they are getting the maximum payout of a claim. Often, this is continued with claims against different insurers either simultaneously or in succession. Some workers’ compensation insurers allow adjusters to run C.L.U.E. reports on individual parties or providers, which can sometimes offer insight into whether this practice is happening.

#4: History of Changes in Personal Information

One more way to help detect a fraud claim is by looking at a claimant’s history. If they’ve moved around suddenly, changed phone numbers frequently, or recently switched jobs, there is certainly a need for further investigation. They may also be hard to reach at home when they are supposedly recuperating and out of work. This is one of those situations that could turn out to be harmless, but definitely needs a second look to see if this is a regular pattern for the person.

#5: Conflicting Descriptions

Another instance that could indicate insurance fraud is a conflicting description of what happened in the incident. For most people who experience a significant injury, they should be able to tell you directly what happened to cause the incident. If the story varies, there is a good chance that it is either false or mostly false. Many adjusters even opt to print out copies of the workers’ compensation transcriptions from recorded statements and compare them side by side to help spot discrepancies.

Why This Matters to Workers Compensation Adjusters

So, why do these indicators matter to workers’ compensation adjusters? Insurers pay out millions of dollars each year in fraudulent workers’ compensation claims. These payouts take away money from the company’s bottom line—which includes your bonuses, pay raises, and other company-funded benefits. Having a good eye for spotting false claims is one way to protect the firm you work for and ensure job security over the long run.