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Business Analysis in Insurance Antifraud Unit

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NH Hotels Milanofiori, Assago (MI) - 18 Oct. 13

Business Analysis in Insurance
– Antifraud Unit
Sergio Besana, Antifraud Unit, Insurance Company
Luigi Pantarotto, B.A. Leader, CBAP®, SAS Institute
Fraud

 Insurance fraud is a specific case of fraud, which is characterized by being devised against
the insurer, with the intent to fraudulently obtain some benefit or advantage to which they are
not otherwise entitled.
It is widespread in Italy and often not enough sanctioned by social disapproval.
The Italian Penal Code, due to the social significance of the phenomenon, has therefore
provided the specific crime of insurance fraud (Art 640 C.P.).
 Over recent years, a new awareness of the dangers connected to fraud has developed.
Organized crime rings can also be involved in insurance fraud, sometimes carrying out
schemes that are very complex.
"If you see fraud and don't shout fraud, you are a fraud"Nassim Taleb, Antifragile: Things That Gain From Disorder (2012)
2
© International Institute of Business Analysis
Italy, a Virtuous Country ?
 A percentage of 2.04% is a given
believable?
 A comparison with the data from UK (€
2.2 billion) shows the statistics do not
depict the Italian phenomenon in its
entirety

 Data published by IVASS (Italian
Insurance Authority) in 2011 reporting
scams officially ascertained and reported
by insurance companies operating in Italy
indicates only 54,000 fraudulent claims
UK

USA

France

Italy

10%

9%

5%

The Italian data can not be regarded as a
trusted!
Indeed, fraud identified, but not
contrasted, and those "hidden" - namely
perpetrated, but not discovered and
verified - are not counted.

 Conclusion: this percentage only
displays the tip of the iceberg

2%
3
© International Institute of Business Analysis
Impacts on Insurance Companies

 Lines of business most affected by fraudulent phenomena
 Motor Third Party Liability (TPL)
 Bodily injury: driver injury, injury to third parties (carried, pedestrians).
Of particular importance is the phenomenon concerning the claim of personal injury often
non-existent (the so-called "whiplash effect", or similar micro injuries) or injuries suffered
in an autonomous way and later connected to a traffic accident never really happened
 Also significant is the number of frauds relating to Property and Liability policies, or
accident and health policies, which carry a greater impact in economic terms
(compensations put in reserve are higher)

4
© International Institute of Business Analysis
Fraud Management: Organizational Models
 Following the changes in Italian law of 2012, every insurance company must have
an anti-fraud unit.
A research by CETIF, 2013, shows that the key success factors in counteracting
fraud arise from:
 adequate training of employees
 adequate level of sensitivity of the indicators of fraud and alerts adopted
 effectiveness of policies and corporate guidelines
 effectiveness of computer tools available to the claims settlement network /
fraud analysis unit
The detection of fraudulent behavior through analysis of the indicators of fraud, of
recurring names and links between the entities involved (damaged, lawyers,
body shops, other companies accidents), insurance policies, and the location
of events is a critical success factor
5
© International Institute of Business Analysis
Importance of Organizational Models and
Antifraud Information Systems
 Fraud management models
The more effective patterns of fraud management are those based on a high level
of maturity of both the organizational model and information systems
These include:
Fraud management responsibility over the entire cycle of the policy or claim,
transferring the case management to a centralized Fraud Unit
Data on all cases of suspected fraud up to date, with good quality and frequency
Information systems that provide integration with relevant internal and external
databases to the insurance company
Setting out a detailed system of rules that feed a alerting system for the
reporting of suspected cases

6
© International Institute of Business Analysis
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bawi2013-intervento-besana_pantarotto

  • 1. NH Hotels Milanofiori, Assago (MI) - 18 Oct. 13 Business Analysis in Insurance – Antifraud Unit Sergio Besana, Antifraud Unit, Insurance Company Luigi Pantarotto, B.A. Leader, CBAP®, SAS Institute
  • 2. Fraud  Insurance fraud is a specific case of fraud, which is characterized by being devised against the insurer, with the intent to fraudulently obtain some benefit or advantage to which they are not otherwise entitled. It is widespread in Italy and often not enough sanctioned by social disapproval. The Italian Penal Code, due to the social significance of the phenomenon, has therefore provided the specific crime of insurance fraud (Art 640 C.P.).  Over recent years, a new awareness of the dangers connected to fraud has developed. Organized crime rings can also be involved in insurance fraud, sometimes carrying out schemes that are very complex. "If you see fraud and don't shout fraud, you are a fraud"Nassim Taleb, Antifragile: Things That Gain From Disorder (2012) 2 © International Institute of Business Analysis
  • 3. Italy, a Virtuous Country ?  A percentage of 2.04% is a given believable?  A comparison with the data from UK (€ 2.2 billion) shows the statistics do not depict the Italian phenomenon in its entirety  Data published by IVASS (Italian Insurance Authority) in 2011 reporting scams officially ascertained and reported by insurance companies operating in Italy indicates only 54,000 fraudulent claims UK USA France Italy 10% 9% 5% The Italian data can not be regarded as a trusted! Indeed, fraud identified, but not contrasted, and those "hidden" - namely perpetrated, but not discovered and verified - are not counted.  Conclusion: this percentage only displays the tip of the iceberg 2% 3 © International Institute of Business Analysis
  • 4. Impacts on Insurance Companies  Lines of business most affected by fraudulent phenomena  Motor Third Party Liability (TPL)  Bodily injury: driver injury, injury to third parties (carried, pedestrians). Of particular importance is the phenomenon concerning the claim of personal injury often non-existent (the so-called "whiplash effect", or similar micro injuries) or injuries suffered in an autonomous way and later connected to a traffic accident never really happened  Also significant is the number of frauds relating to Property and Liability policies, or accident and health policies, which carry a greater impact in economic terms (compensations put in reserve are higher) 4 © International Institute of Business Analysis
  • 5. Fraud Management: Organizational Models  Following the changes in Italian law of 2012, every insurance company must have an anti-fraud unit. A research by CETIF, 2013, shows that the key success factors in counteracting fraud arise from:  adequate training of employees  adequate level of sensitivity of the indicators of fraud and alerts adopted  effectiveness of policies and corporate guidelines  effectiveness of computer tools available to the claims settlement network / fraud analysis unit The detection of fraudulent behavior through analysis of the indicators of fraud, of recurring names and links between the entities involved (damaged, lawyers, body shops, other companies accidents), insurance policies, and the location of events is a critical success factor 5 © International Institute of Business Analysis
  • 6. Importance of Organizational Models and Antifraud Information Systems  Fraud management models The more effective patterns of fraud management are those based on a high level of maturity of both the organizational model and information systems These include: Fraud management responsibility over the entire cycle of the policy or claim, transferring the case management to a centralized Fraud Unit Data on all cases of suspected fraud up to date, with good quality and frequency Information systems that provide integration with relevant internal and external databases to the insurance company Setting out a detailed system of rules that feed a alerting system for the reporting of suspected cases 6 © International Institute of Business Analysis
  • 7. BA as Link Between Business and Information Technology BABoK® Guide Business to IT - round trip «B.A. is the set of tasks and techniques used to work as a liaison among stakeholders […] to recommend solutions that enable the organization to achieve its goals» «In particular, B.A. often plays a central role in aligning the needs of business units with the capabilities delivered by information technology»  Starting from the Enterprise Analysis Business Case, requirements analysis brings to a technical solution which is validated back to the original goals 7 © International Institute of Business Analysis
  • 8. BA Competencies for the Antifraud Process Business Analyst competencies Vs. Fraud Analyst job posting  Key Competencies Job description: Fraud Analyst - 00133288  Analytical Thinking and Problem Solving  Business Knowledge  Communication skills  Software Applications  Key Techniques        Benchmarking Business Rules Analysis Decision Analysis Document Analysis Process Modelling Risk Analysis Root Cause Analysis […] Person requirements – essential • Strong communication skills – written and oral including presentation skills • Accurate record keeping • A knowledge of Bank’s systems and processes • Ability to work to tight deadlines and be responsive to changing business priorities • Ability to appropriately challenge stakeholders, where necessary, to further fraud prevention • Ability to analyze information to make accurate decisions • A rational questioning approach to problem solving https://barclays.taleo.net/careersection/2/jobdetail.ftl?lang=en_GB&job=1267282 8 © International Institute of Business Analysis
  • 9. BA Enterprise Analysis for the Antifraud Project  Antifraud brings complex challenges. New project initiatives needs to be:  Assessed & prioritized based on ROI  Finally selected and funded  Enterprise Analysis provides a framework to estimate the Business Case for the antifraud solution 9 © International Institute of Business Analysis
  • 10. An Antifraud Business Case - Context  Motor Third Party Liability Insurance Company  Total premiums: ca. 200 mil. €  Number of contracts: 500.000  Number of claims vs. number of contracts: 10%  Value of claims/year: 70 mil. €  Number of brokers: 2.000 Parameter Current Value # of fraud cases in a year Average value A. Total value of frauds Δ Future Notes Investigated and proven Recovered from frauds 150 3,000 € 450,000 € 1,900,000 € - Suspicious Rate 1.2% 1.2 p.p. - Detection Rate 0.2% 1.2 p.p. B. Costs of investigation 200,000 € 190.000 € Total Saving (Value of A. - B.) 250,000 € Expected increase at regimen (from year 5) +1.710.000 € 10 © International Institute of Business Analysis
  • 11. An Antifraud Business Case – ROI Project Roadmap Timeline Year 1 Year 2 Year 3 Year 4 Year 5 Data Mgmt. & Prep. Business Rules, DB Searching, Anomaly Detection Predictive Analytics Social Network Analysis  Uncertainties and risk managed through sensitivity analysis:  Realistic Scenario: Suspicious Rate and Detection Rate up to 1.7 p.p.  Aggressive: Suspicious Rate & Detection Rate up to 2.2 p.p.  The finale Return on the Investment indicators have been key for the GO! Realistic Scenario Conservative Scenario Aggressive Scenario NPV > 6,000,000 € > 4,000,000 € > 7,000,000 € IRR > 300% > 200% > 400% < 6 months < 10 months < 4 months ROI Indicator Payback 11 © International Institute of Business Analysis
  • 12. Wrap-up Antifraud Unit… … and Business Analysis      BA as a ‘link’ between Business and Technology  BA competencies for the Antifraud process  BA Enterprise Analysis for an Antifraud project  An Antifraud Business Case Fraud Italy, a virtuous country? Impacts on insurance companies Fraud management: organizational models BABoK® Guide «A business analyst is any person who performs BA activities, no matter what their job title or organizational role may be. Business analysis practitioners include not only people with the job title of business analyst…» 12 © International Institute of Business Analysis
  • 13. We’re glad to answer to your questions. Thank you sergio.besana@gmail.com luigi.pantarotto@sas.com
  • 14. BA competencies for the Antifraud process  Fraud Analyst job posting – further details [1/2] https://barclays.taleo.net/careersection/2/jobdetail.ftl?lang=en_GB&job=1267282 Department Overview The Fraud Management Operations Team brings together a range of activities from Lending Application Reviews to recommendations based on the findings of these reviews. The recommendation element includes interaction with Senior stakeholders. Main function The overall team is focussed on assisting the front line in understanding the risks associated with financial crime, proactively spotting the warning signs and dealing with attempts and losses. Main duties and responsibilities Investigate and prevent fraudulent activity perpetrated against Corporate Banking (80%) Hunter 2 Review referrals generated by fraud prevention detection / analysis software. Investigate, identify and advise on suspicious or fraudulent lending and account opening applications. Input searches onto the Hunter 2 systems Manage stakeholders impacted by fraud investigation & decline decisions. Liaise with relationship points that have raised fraud concerns. Provide reviews and recommendations to the strategy areas of Fraud Management. These will be recommendations reached as a result of the review and investigation activity. As a result of investigations assist with the identification of fraud trends and patterns and ensure that they are reported to the appropriate business area. 14 © International Institute of Business Analysis
  • 15. BA competencies for the Antifraud process  Fraud Analyst job posting – further details [2/2] https://barclays.taleo.net/careersection/2/jobdetail.ftl?lang=en_GB&job=1267282 General Investigations Investigate fraud cases that have been escalated to Fraud Operations as directed by the Head of Fraud Operations. As a result of investigations, assist with the identification of fraud trends and patterns and ensure that they are reported to the appropriate business area in conjunction with the Fraud Strategy Manager Contribute to the design of new fraud detection systems as a result of information identified in fraud cases. Maintain accurate and detailed records of all cases investigated Recover and prevent fraud losses for clients. Develop and maintain relationships with other Financial Institutions to assist with the investigation of fraud cases. Ensure all cautions and preventative measures are applied to protect the Bank where fraud is identified Work with the Head of Fraud Operations to complete root cause analysis, identify control failures and report these to the appropriate business areas Training/Communications (5%) Prepare and deliver fraud training to target audiences (to include both internal and external clients) as required by the Head of Fraud Operations and Analytics. Relationship Management (15%) Manage the day to day relationship with internal stakeholders such as Coverage, Middle Office and Servicing Centres to ensure that the appropriate strategy is applied to fraud cases involving Corporate and its clients. Provide guidance and support to areas of Corporate impacted by fraud Manage the day to day relationships with senior stakeholders and keep them updated of case progress and advise them on issues and impacts to their business area. 15 © International Institute of Business Analysis