Is your SIU getting the referrals necessary to protect your company?

Is your Special Investigation Unit (SIU) getting all the referrals needed to protect your company from bad claims and fraud? If not, you may have unwarranted claims inflating your benefit dollars. At Diligence and The Claim Lab, we have developed tools to meet today’s challenges to assist SIUs and ensure that they are getting the referrals required to protect your company from unwarranted or fraudulent claims. For example, one tool that we have is a complex but easy to use method of using psychosocial metrics to automatically evaluate disability and waiver of premium claimants. This will assist the Claims Department identify those claims which may no longer be valid (or may be fraudulent). This can then assist the SIU in getting the referrals it needs to fulfill its role of protecting the company.

Detecting fraud, whether during the procurement of policies or after a claim has been filed, is a relentless match between the would-be fraudsters and the insurers they target. Schemes and techniques have adapted along with processes and the environment, and insurers must adapt to meet the ever-changing challenge; unfortunately, as an industry, we only catch a portion of the actual crimes that are committed. This results in reduced margins and higher, less competitive premiums.

Every area within a company plays a role in reducing fraud risk, but there are three areas which are critical to the risk management function: the Claims Department, the Underwriting Department, and the SIU. In most companies, the SIU is reliant on referrals from the two former departments (and others) to carry out its all-important role of identifying fraud. In the past 24 months, changes in our underwriting and claim processes have created new opportunities for fraudulent behavior to go undetected. This raises the question of whether SIUs are getting the referrals they need to protect their respective companies.

Processes that have impacted the claims and underwriting processes are numerous and include:

  • Increased emphasis at underwriting of straight-through processing
  • Higher accelerated underwriting limits
  • Deemphasis on traditional underwriting protections such as fluids
  • Increased emphasis on approving claims using without original documents, or no documents at all.
  • Increased productivity pressure on staff due to increased volume and fewer workers
  • Increased pressure to reduce costs

SIUs are typically reliant on other areas to refer potentially nefarious behavior to their area for a thorough investigation. Because of the above, it is understandable to question whether SIUs are getting the referrals needed to fulfil their duties to protect the company. If not, then SIUs may not be living up to their potential and the company may be suffering the financial consequences. Processes will inevitably change over time, but so do the illicit actors change their methods. Awareness and education in all areas is important, and so are the right tools to make sure that SIUs get the referrals that may be costing time and money.

Whether at time of claim or underwriting, or somewhere in between, Diligence and The Claim Lab want to be your risk management partner to help you stay on the forefront of managing your fraud risk. Please contact Kevin Glasgow for more information on the tools we have available to assist you. We are eager to hear what your pain-points are and discuss options to assist you in maximizing your value to your company. Kevin can be reached at Kevin.Glasgow@DIGroup-US.com and 972-301-8454.

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