Social media like Facebook is proving a useful tool for investigators
Social media analysis and data analytics are fast-becoming the insurance industry's most powerful weapons in its fight against fraud. There are many success stories of investigators who were able to uncover fraudulent claims by scanning social media. For example, one woman claimed to have lost her wedding rings in the ocean, but investigators found a picture on social media where she was wearing her "lost" wedding rings.
Another man tried to receive a payment from his car company for an accident. However, upon investigation, the company found a video online captured by a bystander of the "accident". The video showed the owner intentionally driving his car into water.
Other things investigators are on the lookout for include social media connections between multiple parties involved in the claim, changes in job titles when an insured party is receiving disability benefits, or older posts trying to sell something that has now become conveniently damaged in an "accident". Examples like these point out the possibility of fraud, and, when confronted, claimants will often immediately admit to their fraudulent behaviour.
Photos, Facebook posts, and uploaded videos found on social media now often serve as powerful evidence of fraud.
VHI Healthcare's dedicated Special Investigations Unit (SIU) is an expert in the field of claims benefit recovery and fraud prevention. It made savings of over €18.5m in 2015. The SIU, which investigates incorrect or inappropriate billing, has recovered nearly €60m since its creation.
The most common anomalies identified last year were: incorrect accommodation fees being invoiced by the hospital (for example, where a patient is billed for a private room when the patient has actually occupied a semi-private room); inappropriate lengths of stay; charges being raised for cancelled procedures; as well as inappropriate invoicing for certain specified drugs, tests and prostheses.
"The SIU works closely with VHI's Data Analytics Team in the identification of fraudulent claim trends and abnormalities and invested further in this area in 2015," said a VHI spokesperson.
"We have also put in place a robust investigation casework management system to ensure we can identify and investigate any potential issues at the earliest possible opportunity. In addition, in recent years we have added more medical personnel to the SIU team and we now have medical advisors and clinical nurse specialists to analyse claims, review medical notes and identify instances where VHI may have been inappropriately billed."
The spokesperson continued: "In addition to recovering the money involved in any instances of incorrect billing, we also include penalties (fines), interest and investigation costs, thereby adding a financial cost to the offender which sends a strong message that there are consequences to their actions and activities. Where cases of fraud are detected, they are escalated to An Garda Siochana for further investigation."
The VHI SIU won the 2015 Investigator of the Year Award Ireland/UK at the Health Insurance Counter-Fraud Group Annual Awards, the industry's most prestigious fraud investigation award.
Sunday Indo Business