保険不正探知システム購入のための手引書：2024年版

2024/09/22

Key capabilities and functionality to meet current threats

Abstract

The ability to detect insurance claims fraud is, in some ways, easier than ever. With each year, the datasets that insurers have access to are expanded and refined by carriers, vendor partners, and industry groups. It’s got to the point where, to the keen investigator with a well-appointed and tuned dashboard, networks of bad actors can seem to jump right off the screen.

At the same time, however, the interconnected, digital world provides more vectors for criminals to interrupt legitimate insurance processes. And the industry also faces a talent crunch, where those keen investigators, whose years of experience gave them a leg up in interpreting the data in front of them, are retiring.

With that background, it’s crucial for insurance companies to implement fraud-detection systems that can comprehensively access and synthesize data, and also maintain a user-friendliness that makes it easier for a range of experiences and skill sets in the SIU to leverage their insights.

The advent of generative AI (Gen AI) in the year leading up to the production of this report and its companion 2024 Fraud Detection reports holds a lot of promise for insurance fraud detection. But this technology is still nascent—and should not be expected to replace the value of experienced investigators in interpreting data.

The goal of this report is to help insurers define their claims fraud-detection solution requirements. Then, if they are looking to select a partner, this report can be used with our Solutionscapes to create a short list of vendors for evaluation. Insurers continue to have a broad spectrum of systems and vendors to consider when looking for a solution to fit their needs.

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