Claim investigators' fact-finding missions are driven by careful attention to detail and practical experience, and the information that they uncover can play a valuable role in the overall claims resolution process.
To use claim investigative services in a meaningful and effective way, it's important for risk managers to have a sound understanding of what these services entail, when to deploy them, and how they can contribute to a valuable outcome.
Risk managers have several variables to consider when deciding whether to use outside investigative services. When the claim examiner is unable to obtain the necessary information or documentation to appropriately adjudicate a claim, for example, or when potential “red flags” or other suspicious indicators are identified by a claim examiner, it may be appropriate to seek the assistance of an investigator.
Facts are key
The need for investigative services can occur at any time during the life of a claim and can necessitate additional or ongoing investigative interventions. Investigators' expertise can be instrumental in helping examiners make qualified claim decisions, determine claim valuations, and ensure regulatory and legal guidelines have been met.
All investigative services are not the same and outcomes can vary. When choosing an investigative service provider, you need to consider such issues as pretexting, surveillance, aerial surveillance, neighborhood canvasses or contact with a represented claimant.
Ascertaining the facts is key to achieving a positive result. Most often, the facts of the loss are consistent with a legitimate claim, and the claim examiner is able to adjust the claim expediently.
Other facts may suggest inconsistencies that need additional investigation to determine the validity of the information or claim itself. In these instances, investigative services can be beneficial and result in lower claim costs, quicker claim resolution, and identification of non-meritorious claims.
1. Explain the claim in detail
When deploying investigative services, you need to develop an action plan. This may involve consulting with the service provider for recommendations on the best approach.
Investigators must clearly understand the objectives of the assignment and the client's expectations. They also need to be completely apprised of the claim you’ve asked them to look into. You must explain the essence of the claim, its stage in the claim life cycle, and any unique circumstances related to the situation.
In this context, less is not more, and you want to ensure that the investigator is fully briefed.
2. Stay in touch
The investigator should maintain meaningful and frequent contact with the claims examiner throughout the process to ensure adherence to expectations, timelines and quality guidelines.
Investigators must understand your company's claims process and the nuances associated with specific lines of insurance. Investigators also need to be well versed in legal and regulatory matters related to investigative services and the insurance industry.
3. Evaluate internet research first
In today's technology-driven world, much information can be gathered by conducting thorough Internet research first. Social media channels have opened the doors to a wealth of information about individuals and surrounding circumstances that can be used in claims investigations, and they can enhance surveillance and other field investigative efforts to achieve optimal outcomes.
Using Internet investigative techniques can yield critical information; however, it can also lead to higher levels of scrutiny of the processes and methods used to obtain and document the information. Engaging a reputable investigative service provider is essential to ensuring the methodology and documentation are presented clearly, without bias or prejudice.
4. Ask who is investigating
When selecting and purchasing investigative services, it's important to understand that some companies have their own in-house investigative teams while others subcontract the work to private investigation firms. You should ask some basic questions before agreeing to hire the investigator to determine whether the service provider has the resources and expertise needed for the assignment.
You should also spend time vetting a service provider to determine the provider's reputation in the insurance industry and marketplace. An investigative services firm must be dependable, knowledgeable and ethical.
Further, the service provider's technology and product deliverables must align with your company's internal processes and your expectations.
5. Bring in your company's legal counsel
As a potential client for an investigative services company, you should engage the expertise of your company's legal or compliance department to assist with contract negotiation and development. This is necessary to protect your company from any adverse actions that might arise.
You need contractual agreement to address areas such as service rates, timely deliverables, quality expectations, data privacy and security, regulatory compliance and liability insurance requirements.
6. Measure the investigator's effectiveness
As is common in most industries, measuring effectiveness is typically a quest for a quantifiable return on investment (ROI). Because the goal of claim investigative services is to provide factual information that can impact the claim outcome, it's often difficult to quantify effectiveness in terms of dollars.
Here are some common questions that have been used to determine the investigator's effectiveness:
Did the investigative services provide actionable information?
Did the investigation impact the claim? If yes, how?
Did the investigation rule out suspicious indicators?
Did the investigation result in claim denial or withdrawal?
How much was saved on the claim as a result?
The goal of a claim examiner is to properly evaluate and resolve a claim. Claim investigative services can and should be deployed when an examiner needs assistance in obtaining the information necessary to meet those goals. Each situation is different and requires careful reflection and consideration as to expectations and objectives. Moreover, the selection of a claim investigative service provider is anything but routine, and a proven track record and strong reputation are essential to maximize success.
Linda Wisneski is vice president, Special Investigation Unit, Sedgwick. She can be reached at firstname.lastname@example.org.