02 — Capability · BC-1750.50
Claims Fraud
Stop paying for staged, exaggerated or fabricated claims while keeping genuine claimants moving, by scoring claims, investigating suspicious ones and acting on organized fraud. Fraud on payments, cards and bank accounts sits in the financial crime lens.
- Insurance Claims Fraud
- Claims Counter-Fraud
- SIU
In scope
- Fraud indicators and scoring on claims, including application misrepresentation found at claim
- Special investigation of suspicious claims
- Analysis of linked claims and fraud rings
- Referral of insurance fraud to industry bodies and authorities
Out of scope
- Payments, card and banking fraud (see BC-1770.40)
- Suspicious activity reports on money laundering (see BC-1770.50)
Realized by · 0
- No product in the catalog yet.
Used in · 1
Build it · 0
- Nothing in the library points here yet.
Decomposes into · 4
- BC-1750.50.10Suspicious Claim FlaggingScore claims at intake and as they develop against fraud indicators, and send high scores for review without delaying low-risk claims.
- BC-1750.50.20Claims Fraud InvestigationInvestigate referred claims through interviews, records and surveillance, and recommend payment, reduction or denial with evidence.
- BC-1750.50.30Fraud Ring AnalysisLink claims, people, vehicles, providers and repairers across many claims to expose organized fraud that single claims hide.
- BC-1750.50.40Insurance Fraud ReferralReport confirmed or suspected insurance fraud to industry databases, fraud bureaus and authorities as the law requires.