Fraud Prevention
This internal policy requires employees to report suspected fraud immediately.
What is Fraud Reporting Policy
Submitting a false or exaggerated claim for an injury that never happened is an example of this.
What is Insurance fraud?
Insurers sometimes use this technique to confirm whether an employee’s injury is legitimate.
What is Surveillance?
This percentage of global annual revenues is lost to fraud.
What is 5%?
Source: Association of Certified Fraud Examiners.
The tool used to discover claims history
If an email urges immediate action and asks for confidential information, it is likely this type of scam.
What is phishing?
When multiple parties conspire to stage an accident for financial gain, it is known as this kind of fraud.
What is a staged accident?
When an employer misclassifies employees as independent contractors to pay lower premiums, it’s called this.
What is premium fraud or employee misclassification?
Workers Compensation Fraud Accounts for $_____ in Insurance losses annually
What is $34 billion?
This number includes $9 billion in insurance losses from fraudulent workers’ compensation claims, as well as $25 billion in losses due to workers’ compensation premium losses.
Source: Insurance Coalition
The three elements to fraud are _____, _____, and ____
Opportunity, Pressure, and Rationalization
Customers are encouraged to do this to help prevent insurance fraud after a car accident.
What is document the scene/take photos and contact police?
This term describes intentionally misrepresenting facts to obtain a benefit one is not entitled to under an insurance policy.
What is material misrepresentation?
In New York these laws deal with the construction industry safety especially for those who work at an elevated height.
What is New York Labor Laws
In 2024 Report to the nations, fraud cases increased 24%.
________ to _______is the average number of months an occupational fraud scheme lasts before it is detected.
What is 12 - 14 months?
Source 2024 ACFE Report to the Nations -Global Study.
As a Claims Professional, there is a behavior that is consistent with Fraud Prevention
The behavior is Proactive Investigations
Document Verification
Witness interviews
Detect suspicious claim patterns
Determine RED Flags
Continuous Education
If a website URL has this small but crucial detail, it’s safer for entering sensitive information.
What is HTTPS (the “S” stands for secure)?
The process of reviewing previous claims history to spot patterns of abuse is known as this.
What is claims analysis or data analytics?
What are the top three forms of workers compensation fraud?
Claimant, Provider, Premium
In property many claims is estimated to be fraudulent and casualty insurance, about 1 in this
What is 1 in 10 claims or 10%
Source NICB and Coalition Against Insurance Fraud
These organizations offers free courses, to further education on trends and schemes.
NICB National Insurance Claim Bureau
NICTA -National Insurance Crime training Academy
These are the two main factors you should never share over the phone or email to prevent identity theft.
What are passwords and personal identification numbers (PINs)?
When an employee repeatedly files claims for minor injuries, it’s known as this pattern.
What is frequent filer or serial claimant?
Doctors or clinics that repeatedly submit inflated medical bills for minor injuries may be participating in this.
What is medical provider fraud or billing fraud?
What are the top three private industries with the most injuries and illness.
Service 24.0%
Transportation and material moving 22.4%
Production 10.0%
Healthcare practitioners and technical 10.0%
Looking into the future of fraud, what are Two elements needed to combat fraud at ZCIS?
What is Engagement and Technology.