IEF-003 ClaimsGator with EAGL detects accident mills

Systemic fraud and abuse is a longstanding problem for insurers. Large and complex fraud rings among service providers exist and have evolved to beat the system. To counter this abuse the network of service providers should be monitored as a composite. Monitoring claims or service providers individually may not be sufficient to detect patterns of collusion. The EAGL toolkit within ClaimsGator is a powerful means for flagging suspicious associations in the service provider ecosystem.

Introduction
A client reported the following case study. The leader of an accident mill in a North American city would recruit four or more participants for every staged accident. Post accident the claimants would all visit the same rehabilitation service and be prescribed equipment such as neck braces or egg crate mattresses for their fake ailments. From the claimant to the equipment seller, all participants were complicit in the fraud and got a portion of the claim. The ring was broken once the insurer, with our participation, started linking the claims information across different entities back to the policy holders. The same principle has been expanded into a proprietary technology (EAGL) for monitoring an insurer’s ecosystem. The Entity Association-Graph Linkages (EAGL) toolkit is now part of the ClaimsGator software and is used to isolate unusual behavioral patterns across service providers.