Transforming Claims Data into Investigative Intelligence
As an investigator or claims manager, you know that the gap between a "suspicious feeling" and a "prosecutable case" is often measured in hundreds of man-hours. In an environment governed by the NAIC Model Act and 18 USC 1033, the difference between success and liability lies in the depth of your analytical framework.
I have developed a specialized analytical tool designed to function as an Expert Fraud Analyst. This system integrates 15+ years of Special Investigations Unit (SIU) expertise directly into your workflow, allowing you to move from raw data to a comprehensive evidence package with clinical precision.
Advanced Behavioral and Pattern Recognition
Unlike standard flag-based systems, this tool utilizes a multi-indicator behavioral framework. It doesn't just look for anomalies; it identifies specific fraud typologies—from soft fraud exaggerations to complex organized rings involving staged incidents and provider mills.
- Quantitative Risk Stratification: Claims are scored on a 0-100 scale calibrated to your specific loss exposure and fraud probability.
- Peer-Benchmark Analysis: The system identifies billing anomalies like upcoding and unbundling by comparing data against statistically significant peer benchmarks.
- Network Mapping: It automatically connects the dots between shared addresses, phone numbers, and provider referral networks to expose organized activity.
Cross-Source Intelligence Integration
True investigative thoroughness requires looking outside the claim file. This tool structures a deep-dive validation process across multiple intelligence layers:
- Credential Verification: Real-time cross-referencing against OIG LEIE and state exclusion lists to flag sanctioned providers immediately.
- OSINT & Social Media: Targeted analysis of open-source intelligence to identify physical activities that contradict claimed disabilities or injuries.
- Database Correlation: Integration of NICB data and prior litigation history to identify high-frequency claimants and serial litigators.
Regulatory Compliance and Prosecution Readiness
Every analysis is performed with the end goal in mind: recovery and deterrence. The output isn't just a report; it is an investigation-ready evidence package designed to meet the Coalition Against Insurance Fraud protocols.
The system automatically calculates financial exposure, recovery potential, and cost-benefit ratios, ensuring your resources are allocated where they will have the highest ROI. It tracks statute of limitations deadlines and ensures that every referral meets the evidentiary standards required for state fraud bureau reporting or law enforcement coordination.
Operational Efficiency for the Modern SIU
This is designed for high-volume environments where adjusters and investigators need actionable intelligence, not more noise. By maintaining a low false-positive rate and providing clear, documented justifications for every risk score, the tool protects your organization from liability while significantly increasing your catch rate.