Enhancing Special Investigations: The Role of Modern Case Management in Insurance

Over the last 20 years the insurance industry has taken a more focussed approach to countering the fraud that impacts their bottom line, embracing new organisational structure, process, technology and sources of data that help prevent and detect fraud. More recently, the pace of technological progress means that insurers have been investing heavily in new technology to detect and prevent fraud, and that this increased detection places increased demands on the Special Investigations Unit. We have seen SIUs achieve significant gains in productivity of over 45% along with the ability to handle 3x the case volume with the same number of staff. Attending the recent Altus Consulting launch of their whitepaper “Service Disruption: Next Stop for Claims” I was particularly struck by three well-made points; 

• The customer has to be at the heart of your decision making and processes, with the new Consumer Duty rules focussing on good rather than just fair outcomes 

• The claims department is in a perennial state of transformation 

• Don’t focus on the how, focus on the why and the what 

Let’s examine the case for modern Case Management Software through those lenses. 

The Why 

1. Investments in counter fraud technology detection demand a return. As you detect more fraud there are more cases for the SIU to review and investigate. Ultimately, the return on investment for your improved detection solutions will only be realised when fraud is proven (or the claimant/policyholder walks away). It follows that increased detection volumes means more capacity is needed.  

   
   

2. Just because fraud is suspected, the customer is still your customer. Not all referrals result in an investigation and proven fraud. If it is a false positive, you need a slick process to get the claim or policy back on track as soon as possible. A customer whose journey is interrupted is a potential complaint (or even a loss of that customer) waiting to happen.  

   
   

3. Feedback is truly a gift (although sometimes we don’t like what we hear!), and in the fraud detection world it is an absolute necessity. Without feedback, our fraud models and algorithms will stagnate and become less effective over time. Gathering effective, robust and granular feedback on all referrals and their outcomes is key to that improvement. If that data is not readily to hand or even better automated, the road to improvement will be long and windy. 

   
   

4. Fraud investigators have a specialist skill set and their valuable time needs to be spent wisely in the most productive way possible, and not on laborious and repetitive tasks. 

   
   

5.  Monitoring both workload and outcomes can be a time-consuming affair for managers and directors having to dip in and out of disparate platforms and spend time pulling together management reports. That time could be more wisely spent.  

What capabilities should an insurer look for in a modern insurance fraud case management solution? 

1. Integration is a key component to a successful deployment of modern insurance fraud software. Whilst you can experience gains with a standalone system, true efficiency comes from integrating a modern case management system to your claims or policy admin system to ensure that data transfers both to and from the case management solution, reducing the need for rekeying and the potential of errors that can arise from that. 

   
   

2. Once data is smoothly transferred a modern case management solution can help you effectively manage triage, presenting all the information about the claim or policy to the investigator along with the reasons for the referral. By incorporating third party data connections the investigator can gather supplemental information to more effectively inform the decision to investigate further or determine whether this was a false positive and select the next action accordingly, whether to proceed or return the case to the underwriter or adjuster to make sure the customer is not inconvenienced. Being able to be efficient is one way to improve triage, but in addition you need to be able to measure productivity and performance against SLAs. Transparent dashboards that allow all interested parties to see the status of all cases, and to intervene when cases are outside of SLA’s, reallocate workloads where necessary, mean that nothing will be allowed to sit and stagnate. 

   
   

3. When it comes to insurance fraud investigations one size does not necessarily fit all. Whilst insurers deal with similar problems and processes in their investigations, they will differ in the way of requirements and execution. The line of business will also affect this. The process flow of a motor theft investigation is different from a motor personal injury investigation which is different from a home claim investigation which is different…you get the picture. To enable investigators to handle their cases in the most efficient manner the ability to tailor workflows to the specific needs of their business is vital. 

   
   

4. To further remove repetitive and time-consuming activities, providing the ability to connect to third party data and retrieve open-source intelligence to help build the case is an important benefit. In addition, certain activities can be automatically assigned to team members with the most appropriate skillset, enabling insurers to focus key activities on the investigators with the most experience.  

   
   

5. Having all the information about an investigation in one centralised place with all data gathered, captured and easily accessible means your management information is at your fingertips, informing decisions in that moment in real time rather than waiting for weekly or monthly reports. The granular information on outcomes means that effective feedback can be provided to your detection models. This can happen automatically if the solutions are integrated meaning rapid improvement in detection and precision of the models. 

   
   

6. The IT department of insurance companies is usually under pressure with competing priorities from multiple departments, consequently any small changes to workflows and adding data sources can sometimes take a while. This is where SaaS solutions that can add data sources or deploy low/no code software are the most desirable to put you in command of your own destiny and manage your own system to reflect your ongoing changing requirements. 

A system with these attributes enables you to become a slick and efficient Special Investigation Unit, handling cases with maximum efficiency, focussing your resources where they will have the most benefit. Handling more cases allows you to not only gain a return on investment in the Case Management solution but also deliver an increasing return on investment in the detection solutions you have deployed, making sure honest customers who are subject to false positives are returned to normal processes as rapidly as possible making sure they receive good outcomes as required by  Consumer Duty requirements. All the while you will be gathering the feedback to improve your models going forward to ensure a continuous cycle of improvement.