Inside Job


By definition, inside jobs have someone on the inside of the insurance company who is actively participating in the fraud. The person may be acting alone or with the cooperation of outsiders.

How it goes down

The classic case is when a claims adjuster has an agreement with a vendor to approve payments higher than normal. In this scenario the services of the vendor are actually occurring, but rather than pay the correct amount, a larger payment is made and the excess is split between the vendor and the claims adjuster. This may also occur when a claims adjuster discovers fraud, but rather than report it, he/she asks for a bribe from the fraudsters.

How we spot it

We have proprietary algorithms that are constantly sifting through your data. We have calibrated these algorithms to detect patterns among vendors and your claims adjusters. We are analyzing your vendor table, the payments going out of your vendor table, and ties among your vendors and your claims adjusters. As soon as a problem becomes apparent, these claims are flagged and immediately given to the appropriate person within your organization.

Why are we different?

Our focus is to provide leads to SIU, not build a system that “pre-clears” claims. We have seen many algorithmic systems sold with the purpose of fast tracking claims. Whether you fast track a claim is your business; but we will analyze all claims and provide a lead to SIU when potential fraud is spotted. Furthermore, our algorithms are not fooled by people who have managed to stay out of databases related to past criminal activity, such as recent immigrant arrivals.

Examples in the news