What is Enterprise Case Management? How does it improve insurance fraud detection?

In the world of fraud management technology, Enterprise Case Management does not get a lot of attention. It is not as sexy as predictive modeling or social network analysis. But don’t let that fool you. When properly implemented, an Enterprise Case Management system is an essential component of a proactive insurance fraud detection program.

What is Enterprise Case Management?
Enterprise Case Management (ECM) is a system that simplifies the investigative process while amplifying the value of investigative intelligence. While it can stand alone as a repository for investigative research, ECM is best deployed as an integrated solution that connects with other systems. For example, when referrals are made to a Special Investigation Unit (SIU) either from claim adjusters or automated detection systems like the SAS Fraud Framework for Insurance, they are automatically routed to ECM for evaluation. ECM will pull in data from multiple systems – claims, policy, HR and third party data – and present the investigator with all of the information needed to make a decision on whether or not to investigate a claim further in one handy interface. If the claim warrants further investigation, ECM then tracks the complete investigation process, manages workflow, tracks activity, serves as a diary management system, and records electronic evidence like photos, documents, recorded statements and even video.

Intelligence Sharing
While tracking all of that information in one place is great, the biggest value from ECM comes when people leverage that information in new ways. For example, if an investigator conducts a clinic inspection or develops intelligence about a suspicious individual, the information can be uploaded into ECM even if it is not associated with a current claim or investigation. Then, all the investigators in the organization can access that information in the future, reducing rework and improving the usefulness of the intelligence gathered in the field.

But here comes the best part … when ECM is integrated with a fraud detection solution, that same intelligence information can be fed automatically into the alert generation system. So, if any new instances of that suspicious clinic or individual appear in new claims or policies, SIU is notified immediately. That’s how you get to be proactive.

Keeping Up With the Changing Times
As time passes and investigations are recorded in ECM, managers and administrators can analyze the aggregated data and determine which fraud detection techniques are delivering the best results and which need tweaking. This information can also aid managers in conducting in-depth file reviews to identify effective field investigation techniques and break down the data by geography, investigator, business line or other key criteria. This is critical because fraudsters are constantly changing their tactics. As they learn the red flags and thresholds, they modify their behavior to circumvent these protective measures. ECM provides fraud program administrators with the information they need to identify these changes in behavior and make modifications to the system to account for them. Fraud management is a complex process. Take a closer look at Enterprise Case Management to help you stay one step ahead of fraudsters.

I’m James D. Ruotolo, Principal for Insurance Fraud Solutions at SAS. Connect with me on LinkedIn and Twitter.