Finding Good Claims Data F Finding Related Claims is the Heart of Case Investigation and Fraud Detection F Claims Databases are the Most Effective Tool for Finding Claims
Finding Good Claims Data F 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
F Is the process of adding meaning to collected information F Requires going beyond the facts
As a Result of the Analytical Process We: F Identify what is known F Develop a hypothesis F Formulate a collection plan for the missing information F Develop leads for further investigation or research
The Hypothesis or Theory includes KKey Players WHO? CCriminal ActivitiesWHAT? MMethod of OperationHOW? GGeographical ScopeWHERE?
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 F Examine the data in terms of entities (fields) and relationships to discover or verify patterns, relationships and anomalies. F Visual cues are used to graphically depict the relationships an entities. F Operates at the detail/transaction level
Visual Analysis Benefits F Links types are pre-defined by software F Enter data once - generate multiple charts F Auto update as new info added F Source data linked to chart F Can process large amounts of data F Data mining is intuitive
Visual Analysis Disadvantages F Can Be Limited to Pre-defined Links F Auto-generated Charts Can Look Like Dish of Spaghetti F Learning = Time + Effort F Program Makes Decisions. You Must Know How to Ask to Get the Desired Results. F Non-standard Situations Are Forced
Summary F Analytical methods help see beyond the obvious facts F Computer tools can make analysis easier and faster F Visual analysis software permits larger amounts of data to be analyzed more quickly F Visual analysis displays information in a graphical manner which aids clarity. F Nothing replaces digging for the facts.