Fraud Detection & Prevention
We are committed to protecting employers, injured workers and policyholders through a comprehensive fraud detection and prevention program. Our approach combines experienced investigative professionals, data-supported detection and strong industry partnerships to identify suspicious activity, investigate potential fraud and meet applicable state reporting requirements.
Fraud can occur at multiple points in the insurance lifecycle, including application, underwriting, premium determination and claims. Early identification, investigation and appropriate reporting help protect our customers and the integrity of the insurance system.
How we detect potential fraud
We use a layered approach that combines professional review, available data resources and industry-recognized fraud indicators.
- Dedicated Special Investigations Unit (SIU): Our in-house investigative professionals have experience in law enforcement, surveillance, fraud investigations, claims handling and medical bill review. SIU evaluates referrals, conducts appropriate investigations and reports suspected fraud when required.
- Data-supported detection: Claim information, industry fraud indicators, ISO ClaimSearch and other available investigative resources help identify suspicious claims, billing activity and potential fraud patterns.
- Medical provider monitoring: Medical bill review, pharmacy programs, investigative referrals and industry alerts help identify suspicious treatment or billing patterns, including services not rendered, upcoding, unbundling and potentially unnecessary referrals.
How we help prevent fraud
Prevention efforts emphasize oversight, education and collaboration to reduce fraud risk and encourage timely referrals.
- Premium and payroll controls: Premium audits, classification reviews, exposure validation and fraud-awareness procedures help identify potential payroll misrepresentation, premium avoidance and other irregularities. Potential fraud identified through the audit process may be referred to SIU for further review.
- Training and awareness: Fraud-awareness training and reference materials help employees and agents recognize red flags, understand reporting expectations and refer concerns through appropriate channels. A red flag does not establish fraud; it indicates that additional review may be appropriate.
- Industry collaboration: We coordinate, as appropriate, with agents, employers, the National Insurance Crime Bureau, regulatory agencies, law enforcement and other industry partners to monitor emerging fraud trends and support investigations.
- Vendor oversight and data protection: Investigative vendors are subject to licensing, compliance and performance expectations. These efforts are supported by organizational information-security and data-integrity controls.
How to report suspected fraud
If you suspect insurance fraud or other suspicious activity, please report it as soon as possible. Providing specific details can help support a timely and appropriate review.
- Call the fraud hotline: 800-944-FRAUD (3728). The hotline is available 24 hours a day, seven days a week, and callers may remain anonymous.
- Submit an online referral: Use the fraud referral form below to provide the available details.
Privacy and anonymity: Reports are handled with appropriate confidentiality. Callers to the fraud hotline may remain anonymous.
