The identification, investigation and pursuit of suspicious and fraudulent claims are critical to a company’s financial and reputational stability. Earlier this year, my colleague published a blog on the exponential rise of insurance fraud in recent years and misguided societal attitudes toward fraud as a “harmless” crime. Here, I’d like to build on those arguments and explore the regulatory environments in which insurance carriers, claims examiners, corporations, investigators and law enforcement operate around the world in working to combat fraud.
Scope of the issue
According to the Coalition Against Insurance Fraud, about $309 billion is lost to insurance fraud each year in the U.S. alone. That is a staggering number — especially when you consider that the annual number was about $80 billion a decade ago. To break it down further, fraudulent payments associated with property and casualty insurance claims are estimated to total $45 billion a year (with auto theft accounting for $7.4 billion); workers’ compensation fraud represents about $34 billion annually.
While the figures overseas are somewhat lower, insurance fraud remains a significant challenge to businesses throughout the world when it comes to preserving their financial and reputation stability. According to a 2017 estimate (which is likely even higher today), fraudulent claim payments cost Europe over €13 billion (about $14 billion USD) each year.
These numbers may sound overwhelming, but hope is not lost. Strategic approaches to fighting fraud can be very effective! One such approach is regulation.
U.S. landscape
Insurance fraud became a federal crime in the United States with the 1994 enactment of the Insurance Fraud Prevention Act. Since 2001, it has been regulated by the National Association of Insurance Commissioners (NAIC), which governs the insurance industry by establishing standards and best practices and providing ongoing oversight.
Each of the 50 states has a department of insurance (DOI) that manages the insurance business within its jurisdiction in accordance with NAIC guidelines and regulations. Every DOI has a fraud division that provides guidelines to insurance carriers, self-insured entities and third party claims administrators (TPAs) for reporting suspected insurance fraud. Because each state has its own reporting requirements and points of contact, many large organizations operating across multiple jurisdictions opt to partner with a TPA (like Sedgwick) to help them manage the various DOI relationships and compliance demands.
In the U.S. regulatory environment, several organizations play key roles in supporting the fight against insurance fraud. Two such associations are the Coalition Against Insurance Fraud and the National Insurance Crime Bureau. Both nonprofit organizations focus on preventing and deterring insurance fraud through training, legislative advocacy and public awareness.
The Coalition — whose members include insurers, TPAs, government agencies and legislators — works to enact anti-fraud legislation, educate the public, provide anti-fraud advice, and serve as a resource for regulatory guidelines. In addition, they conduct critical research on topics such as the economic impact of insurance fraud, anti-fraud technologies and the ethics of using data to fight fraud.
The membership of the NICB comprises over 1,200 property-casualty insurers, vehicle rental and finance companies, auto auctions and self-insured organizations. They conduct investigations in collaboration with domestic and international law enforcement, technology experts, government officials, prosecutors and the public in a united effort to combat insurance crime.
Comparative analysis
While the landscape in the U.S. fosters inter-state coordination and cross-agency collaboration in fighting fraud, the international front is far more fractured. Few other countries have centralized agencies and mandatory reporting requirements for insurance fraud. Many have private organizations, like France’s Agence de Lutte contre la Fraude à l’Assurance (ALFA), that collect data and report on the impact of insurance fraud to their nation’s economy.
On a positive note, data sharing between countries and their law enforcement agencies is on the rise. Since 2019, these efforts have generated more than 60,000 fraud alerts. However, some countries (particularly in the EU) remain reticent to share information, citing privacy concerns.
Another nuance in how insurance fraud is addressed in the U.S. and abroad relates to the way investigations are performed. Surveillance is a standard technique used in the U.S. to confirm suspicions of fraudulent activity; it’s particularly common in workers’ compensation, due to the complexity of the U.S. system. But in many other countries, where property and auto claims are the dominant lines, insurance companies avoid using surveillance on account of perceived reputational concerns. They presume their brand will take a hit if they are caught in the act of surveilling.
Sedgwick is here to help
As insurance fraud has ramped up in recent years, we have expanded our investigative and counter-fraud capabilities to help clients around the world.
- In the U.S., our SIU comprises 80 specialist colleagues with over 1,000 years of collective experience in reducing claims fraud, waste and abuse. We also partner with 18 leading vendors who provide a network of more than 3,000 investigative nationwide resources. In addition to conducting surveillance and investigations, we support corporations and insurance carriers in navigating complex regulatory environment and compliance requirements — often serving as the voice between clients and regulators.
- Internationally, we continue to expand and now have Sedgwick counter-fraud experts in 10 countries: Belgium, France, Hong Kong, Ireland, Malaysia, Netherlands, Portugal, South Africa, Spain and United Kingdom. Our teams are knowledgeable in the regulatory requirements and cultural sensitivities from around the world and are dedicated to helping clients reduce the cost of fraud.
You can refer to our website for more on Sedgwick’s strategic and innovative efforts to help companies combat claims fraud. If we might be able to assist your organization, please reach out to our team (via the form toward the bottom of the page) or email me.
Tags: Brand reputation, Brands, Compliance, Fraud, Insurance, Investigation, Preserving brands, regulation, Regulatory, Reputation management