Systems and methods for assessing the potential for fraud in business transactions

Abstract

Methods and systems are provided for assessing the potential for fraud of an insurance claim. In some embodiments, request data may be provided to a computer system. In some embodiments, at least one fraud potential indicator may be assessed to the request data from at least one comparison of at least one request data element to at least one fraud model. In some embodiments, a fraud potential indicator may be an estimate of the potential for fraud in an insurance claim. In some embodiments, at least one fraud potential indicator for request data may be assessed based on at least one comparison of at least one request data element to additional insurance data. Some embodiments may include assessing at least one fraud potential indicator for request data based on at least one fraud potential indicator.

Description

BACKGROUND OF THE INVENTION [0001] 1. Field of the Invention [0002] The present invention generally relates to detecting the potential for fraud. In particular, embodiments relate to systems and methods of assessing fraud potential in multiple industries. [0003] 2. Description of the Related Art [0004] While fraud affects many companies, it may be difficult to detect. For example, insurance fraud may be difficult to detect because insurance criminals may not be easily identifiable. Insurance criminals may range from organized fraud rings to dishonest individuals. Other types of fraud may include mortgage loan fraud, banking fraud, and health care fraud. [0005] Furthermore, property and casualty insurers typically rely on adjustors and special investigation units (SIUs) within their companies to investigate potentially fraudulent requests (e.g., insurance claims, bank checks, loan applications, and health care billing—i.e., “requests” for financial transactions from customers of a fi...

AI Technical Summary

Benefits of technology

[0010] In some embodiments, a method of assessing the potential for fraud in a request may include assessing at least one first fraud potential indicator for request data from at least one comparison of at least one request data element to other data. For example, a database of suspicious names, places, cars, etc. may be maintained and compared against data from current requests. In some embodiments, a “watch-list” of data elements to look for may also be maintained (e.g., by an adjustor) and compared to current request data. In some embodiments, matches and near matches may be used to assign a “score” or fraud potential indicator for a request. In some embodiments, types of matches, frequency of matches, and frequency of near-matches may indicate a higher or lower potential of fraud. In some embodiments, the types and frequency of matches may be weighted to assign a score relative to the potential for fraud in the request.

Problems solved by technology

In various embodiments, a potential for fraud may be assessed (e.g., in insurance claims, mortgage loans, banking transactions, and health care billing) using a computer system to which data is provided.

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