Filed Under:Claims, Education & Training

Building A Better Mouse Trap

Nabbing Fraudsters With Multi-Agency Approach

In the recent high-profile busts in New York and Florida—two states known for the most significant and costly proliferation of PIP fraud in the country—investigators successfully dismantled organized rings that siphoned close to $300 million (combined) from insurers.

Thirty-six people were indicted in the New York sting, which has been called the most extensive of its kind to date, while more than a dozen suspects, including a physician, were apprehended in the Florida bust.

Law enforcement may then employ undercover agents to ultimately penetrate rings, as was the case with both busts. To immobilize “Operation Whiplash,” for instance, suspicions about clinics’ odd traffic patterns gave way to a full-blown sting operation involving undercover agents posing as willing participants to stage auto accidents and then later file claims for injury and subsequent treatment.

Predictive analytics also plays a huge role in breaking down complex patterns of suspicious behavior. Insurers can determine if the same names, social security numbers, and clinics keep cropping up. Are multiple claims originating from the same neighborhood? Does a particular clinic log a staggering number of claims compared to the norm?

Mining social media for clues is now an essential investigative tool for insurers, as well. “People love to brag about their scams and don’t know what they are up against—namely a sophisticated analytical force scouring the Internet for every possible clue for behavior,” Quiggle says.

Quiggle relayed one example where an insurance company investigator came across a bicycle club to which a claimant belonged. The avid cyclist bragged about a recent 50-mile ride, all while claiming to have been “flat on his back” because of an injury at the office for which he was receiving workers’ compensation benefits.

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