Browse Definitions :
Definition

insurance claims analysis

Insurance claims analysis is the inspection and judgment of merit in the requests for coverage of incidents by insurance customer claims.

Insurance claims handlers perform analysis to decide which claims are valid -- and eligible for payout --and which may be fraudulent. Cases of potential fraud are referred to a special investigations unit (SIU) for further scrutiny.

The information a claims handler uses to judge a claim includes data about the incident and the claimant’s current coverage and history. Within an insurance provider’s own systems, the history visible to an agent may be limited to the claimant’s past with that provider.

When referred to an insurer’s SIU, a claim may be inspected through case tracking software systems. These systems have advanced in recent years and able to process a higher numbers of cases, including those with additional complexity. The software can be fine-tuned to distinguish between opportunistic individual fraud and larger scale, organized fraud rings.

Suspect claims can be detected more quickly by tracking recognized suspicious indicators through first notification of loss (FNOL) systems. Enhanced billing analytics can help isolate cases of inflated claims. However, these systems are still generally limited to an individual insurance provider’s silo of data, a limitation that can make it possible for an individual to defraud multiple insurers with the same scam.

Some providers use collaborative or third-party systems that show claims from multiple providers, enabling a complete picture of a given claimant’s behavior. These collected, collaborative systems can use predictive analytics to prevent false claims and fraud. ISO Claim Search, for example, has over 800 million claim records that insurers can use to gather valuable data.

As profit margins are dwindling and natural disasters are becoming more frequent, insurance companies are pressured to find any possible inefficiency to higher coverage demands and offset lower net profits. Insurance companies estimate that 10-25% of all claims contain some element of fraud. Use of newer fraud prevention methods can help raise the low 1% of claims investigated by SIU, improving the rate of which fraud is caught. Better systems also reduce the number of false flags and minimize any negative impact on customer service.

This was last updated in June 2017

Continue Reading About insurance claims analysis

SearchNetworking
  • network packet

    A network packet is a basic unit of data that's grouped together and transferred over a computer network, typically a ...

  • virtual network functions (VNFs)

    Virtual network functions (VNFs) are virtualized tasks formerly carried out by proprietary, dedicated hardware.

  • network functions virtualization (NFV)

    Network functions virtualization (NFV) is a network architecture model designed to virtualize network services that have ...

SearchSecurity
  • Domain-based Message Authentication, Reporting and Conformance (DMARC)

    The Domain-based Message Authentication, Reporting and Conformance (DMARC) protocol is one leg of the tripod of internet ...

  • data breach

    A data breach is a cyber attack in which sensitive, confidential or otherwise protected data has been accessed or disclosed in an...

  • insider threat

    An insider threat is a category of risk posed by those who have access to an organization's physical or digital assets.

SearchCIO
  • data privacy (information privacy)

    Data privacy, also called information privacy, is an aspect of data protection that addresses the proper storage, access, ...

  • leadership skills

    Leadership skills are the strengths and abilities individuals demonstrate that help to oversee processes, guide initiatives and ...

  • data governance policy

    A data governance policy is a documented set of guidelines for ensuring that an organization's data and information assets are ...

SearchHRSoftware
SearchCustomerExperience
  • data clean room

    A data clean room is a technology service that helps content platforms keep first person user data private when interacting with ...

  • recommerce

    Recommerce is the selling of previously owned items through online marketplaces to buyers who reuse, recycle or resell them.

  • implementation

    Implementation is the execution or practice of a plan, a method or any design, idea, model, specification, standard or policy for...

Close