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Visual Analysis For Insurance Fraud Detection and Investigation . Valerie A. Zicko CCA, CFE. Agenda. Finding Good Claims Data The Analytical Process Visual Analysis Visual Analysis And Visual Mining Software Examples of Visual Analysis Pros and Cons of the The Software.

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visual analysis for insurance fraud detection and investigation

Visual Analysis For Insurance Fraud Detection and Investigation

Valerie A. Zicko CCA, CFE

agenda
Agenda
  • Finding Good Claims Data
  • The Analytical Process
  • Visual Analysis
  • Visual Analysis And Visual Mining Software
  • Examples of Visual Analysis
  • Pros and Cons of the The Software
finding good claims data
Finding Good Claims Data
  • Finding Related Claims is the Heart of Case Investigation and Fraud Detection
  • Claims Databases are the Most Effective Tool for Finding Claims
finding good claims data1
Finding Good Claims Data
  • Their Effectiveness is Directly Related to the Quality and Completeness of the Database
    • Multiple identifiers for a person: Name, SSN, DOB, Address
    • Properly formatted address
    • SSN preferably a verified SSN
    • Service providers
slide6

Analysis

  • Is the process of adding meaning to collected information
  • Requires going beyond the facts
as a result of the analytical process we
As a Result of the Analytical Process We:
  • Identify what is known
  • Develop a hypothesis
  • Formulate a collection plan for the missing information
  • Develop leads for further investigation or research
slide12
The Hypothesis orTheory includes
  • Key Players WHO?
  • Criminal Activities WHAT?
  • Method of Operation HOW?
  • Geographical Scope WHERE?
slide13

SAMPLE HYPOTHESIS:

A group of claimants from Watery Mills, including Merry Hider, I.M. Pompous, and Daffy Von Flake, are staging accidents. Daffy Von Flake is steering the claimants to Dr. Frank N. Stein, who is providing treatment and medical bills to support PIP/BI claims for non-existent injuries.

Confidence Level: Somewhat confident

visual analysis
Examine the data in terms of entities (fields) and relationships to discover or verify patterns, relationships and anomalies.

Visual cues are used to graphically depict the relationships an entities.

Operates at the detail/transaction level

Visual Analysis
visual analysis1
Proactive

Seeks Out Patterns From Unrelated Data

General to Specific

Reactive

Seeks Additional Patterns in Related Data

Specific to General

Visual Analysis
visual analysis proactive
Large Segments of Analyzed to Discover Patterns

Claims for a Time Period

Claims for Geographic Area

Specific Claim Types

Subjects for Further Analysis May Emerge

Visual Analysis - Proactive
visual analysis reactive
Specific Entities Are Targeted for a Drill Down Analysis.

From a Pattern Analysis

From a Suspicious Claim

Related Records Are Fed to the Analyzer

Visual Analysis - Reactive
slide20

Visual Analysis Software

  • ALTA Analytics - NETMAP™
  • Harlequin - WATSON™
  • I2 - ANALYST’S NOTEBOOK™
  • Winshapes - CASELINK™
slide21

ALTA Analytics - NETMAP™

  • NETMAP for Claims
  • Works with your corporate database
  • NICB, AISG interface
  • Works on normal Ins. Link types
  • www.altaanlytics.com
  • Big Bucks -6 figures
slide22

Harlequin - WATSON™

  • Database + Chart Generator
  • Import your data
  • Pre-defined links
  • PC based
  • www.harlequin.com
  • Suite of programs
  • $1,000 to $15,000 per User
slide23

I2: ANALYST’S NOTEBOOK™

  • Chart Generator
  • Reads your database for charts
  • User Specified links
  • Suite of programs
  • www.I2.co.uk
  • PC based
  • $5,000 to $8,000 per User
slide24

Winshapes - CASELINK™

  • PC Based
  • Database + Chart Generator
  • Predefined Links
  • Designed for SIU
  • www.winshapes.com
  • $795 per user
visual analysis benefits
Links types are pre-defined by software

Enter data once - generate multiple charts

Auto update as new info added

Source data linked to chart

Can process large amounts of data

Data mining is intuitive

Visual Analysis Benefits
visual analysis disadvantages
Can Be Limited to Pre-defined Links

Auto-generated Charts Can Look Like Dish of Spaghetti

Learning = Time + Effort

Program Makes Decisions. You Must Know How to Ask to Get the Desired Results.

Non-standard Situations Are Forced

Visual Analysis Disadvantages
summary
Summary
  • Analytical methods help see beyond the obvious facts
  • Computer tools can make analysis easier and faster
  • Visual analysis software permits larger amounts of data to be analyzed more quickly
  • Visual analysis displays information in a graphical manner which aids clarity.
  • Nothing replaces digging for the facts.