Inside Job
Founded on the principles of professionalism, integrity, and service which are paramount to the success of any investigation.
Worldwide Resources, Inc
Inside Job
Inside jobs occur when someone within an insurance company actively participates in fraud.
The person may be acting alone or with the cooperation of outsiders.
How it happens
In a common scenario, a claims adjuster secretly teams up with a vendor to approve payments higher than usual. Even though the vendor provides legitimate services, the adjuster intentionally signs off on inflated payments and shares the extra money with them. This unethical behavior not only distorts costs but also damages the credibility of the claims process. Moreover, it's not uncommon for adjusters to ignore fraud they discover and instead demand bribes from the culprits. Such actions not only breach ethical standards but also erode trust, which is crucial for the insurance industry's reliability.
How we spot it
Our proprietary algorithms continuously analyze your data, specifically focusing on patterns between vendors and claims adjusters. By calibrating these algorithms, we've optimized their ability to detect any irregularities. They sift through your vendor table, track payments, and identify connections between vendors and adjusters. Once an issue is detected, the system immediately flags it and directs it to the relevant person in your organization for immediate attention.
Why are we different?
Our focus is to provide leads to SIU, not build a system that “pre-clears” claims. We've observed numerous algorithmic systems marketed to expedite claims processing, but our focus remains on thorough analysis. While you're free to determine the pace of claim processing, our algorithms meticulously scrutinize all claims. They're designed to detect potential fraud and promptly alert the SIU when suspicious activity is identified. Additionally, our algorithms are adept at uncovering fraud even among individuals who may not have a documented history of criminal activity, such as recent immigrants.