FCPA

How Can Insurers Improve Operations by Fighting Fraud?

on July 19, 2013
The processes that Sanjeev Kumar discusses in the recent piece Fighting Fraud Offers Insurers Operational Improvements for fighting insurance fraud reflect human reasoning applied to the automation of claims analysis. I agree that multiple advanced analytics techniques can be applied to a variety of information including structured and unstructured data included in claims and policy systems as well as syndicated and social data that can apply context to the claims and policy information. The scenario Sanjeev describes is one where leveraging the knowledge and experience with claims adjusters and fraud investigators with analytics tools that can implement their experiences into an automated process for acquiring the right data and analyzing is the solution. I don’t think the answer is to hire a partner with analytics specialists. Rather, it makes more sense to enable the process experts in organizations so that they can more easily apply their knowledge and experience. Claims adjusters have seen enough claims that they know when something may not be right. These are the exceptions or outliers that go to the investigators. Investigators know how to analyze the exceptions to understand whether there has really been a fraudulent act. They know what information can help make the final determination including information that resides both within the insurance company as well as information available from external sources. The best solutions are those that leverage this “inside knowledge”. In other words, we need solutions that turn business experts into “data scientists” when they apply their experience to analytics solutions.
spend-analysis-vol3