Medical and dental claims fraud – training for claims handlers

Phil Peart
ITIC Global 2019

This ITIC Global 2019 session looked in detail at the red flags associated with dental fraud, as well as major accidents

An entertaining presentation from Phil Peart, General Manager of Travel Claims Investigations for MJM Corporate Risk Services, gave clear insights into why training for call handlers is very important and highlighted some of the key indicators to look for when identifying medical, dental and major accident claims. There are many opportunistic, repeat and organised fraudsters in the travel insurance sphere, said Phil, including those who put in claims just to try and get back the cost of the airfare they’ve forked out on.

Besides using such tools as voice stress analysis and conducting link analysis to check for connections between claims that could highlight fraud, there are some key red flags to look out for that could indicate fraud, Phil warned. These include: claims for surgery where this has been carried out on the same day as an alleged accident, handwriting or signatures on medical documents and receipts that are the same, and receipts lacking vital information. Insurers need to look at medical and X-ray records, especially on high-value claims, to validate the timeline of events; validate that the staff signing the receipts actually work at the medical facility; and even where official hospital documents are used, make sure the patient was actually treated at that facility. 

Concluding, Phil said to make sure you validate your providers and that they’re qualified to do the work on the receipt. Insurers also need to be aware of trends that attract fraudulent activity, such as when a new iPhone is released.