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•	 Cognizant Reports




Using Advanced Analytics to Combat
P&C Claims Fraud
Combating the growing complexity and sophistication of claims fraud
requires P&C insurers to embrace predictive and advanced analytics, such as
text, social media, link and geospatial analysis. By partnering with firms that
can deliver analytics as a service, insurers can improve their bottom lines,
enhance claims processing efficiencies and boost customer satisfaction.

      Executive Summary                                       analytics, insurers can establish relation-
      Insurance fraud is the second biggest white-collar      ships among various parties involved in a claim
      crime in the U.S. after tax evasion, according to       based on geographic location. This can help
      the National Insurance Crime Bureau.1 As insur-         detect highly sophisticated fraud, as well as
      ers deal with an uncertain economic climate and         organized crime rings.
      intense competition, they must also grapple with
      the increasing incidence and sophistication of          Achieving this level of sophistication requires
      fraud, not to mention the resulting losses. The         an efficient model and approach to enterprise-
      traditional methods of identifying fraud are no         wide data management. Insurers must focus on
      longer sufficient.                                      breaking down data silos and ensuring a con-
                                                              tinuous flow of quality data across various func-
      Advanced analytics can help insurers identify and       tional areas of the organization to enable a more
      reduce fraud-related losses, as well as condense        systematic use of advanced analytics that detect
      the claims cycle, resulting in improved customer        and prevent fraud. Getting there requires a
      satisfaction. Historical claims data, combined          cultural shift toward fact-based decision-making,
      with industry data, can be a starting point for         which demands a major commitment from senior
      insurers to identify common types of fraud early        leadership.
      in the claims process. Advanced analytics, such
      as social media analytics and text mining, can          However, many insurers still run their business
      help insurers sift through and draw inferences          on traditional database systems that operate
      from unstructured data more quickly and con-            in silos, resulting in data inconsistencies. One
      vert it into insights that quickly aid in identifica-   way to quickly and effectively extract value from
      tion and avoidance of fraudulent claims. By using       these vast data pools is to pursue analytics as a
      link analytics in combination with geospatial           service (AaaS), a new delivery model that enables




      cognizant reports | december 2012
insurers to work closely with specialists who            increased by 16% (see Figure 2, next page).
provide analytical insights on a pay-per-use             The prolonged weak economy is inflicting
basis. This model shifts the cost of owning tech-        significant economic hardships for consumers
nology infrastructure, processes and talent to the       and businesses, which is further increasing the
chosen partner.                                          cost of fraud, especially in personal lines, accord-
                                                         ing to 54% of the 143 insurers surveyed in August
Fraud: A Growing Menance                                 2012 by FICO and the Property Casualty Insurers
On average, insurers lose $30 billion annually           Association of America (PCI).5
to fraudulent claims, representing 10% of their
claims expenses, according to the Insurance Infor-       Fraud negatively impacts insurers’ bottom lines
mation Institute (see Figure 1).2 Insurance fraud        (reduced profitability due to the cost of fraudulent
can be divided into two categories: opportunistic/       claims that would otherwise not be incurred) and
soft fraud and professional/hard fraud. Oppor-           competitiveness (delays in claims processing). It
tunistic fraud is committed by individuals who           increases premiums for customers, as insurers
inflate damages or repairs in a legitimate claim or      charge them more to make up for the increase
provide false information to reduce the premium          in payouts. NICB estimates that fraud increases
amount. About half of P&C insurers lose 11 cents         premiums by $200 to $300 per family, annually.
to 30 cents or more per premium dollar to soft
fraud alone, according to the Insurance Research         The Need for Analytics
Council-Insurance Services Office.3                      The P&C insurance industry continues to
                                                         operate in an uncertain economic climate, with
Professional, or hard, types of fraud are                low interest rates hampering investment income.
committed by organized groups that steal                 The direct loss ratio rose by 2.7 points from
vehicles, deliberately damage property and stage         2010, to 67.5% in 2011,6 while the combined ratio
accidents. These gangs are well acquainted with          in the first half of 2012 was 102%.7 Fraud, along
fraud detection systems and collude with doctors,        with long-tail liabilities such as incurred but not
attorneys, insiders in insurance companies, body         reported (IBNR) liabilities, produce uncertainty,
shops, etc. to lodge fraudulent claims.                  making it much tougher to assess accurate claims
                                                         reserves and pricing of premiums.
A growing concern for insurers is the increas-
ing number of questionable claims4 referred to           Compliance with the Dodd-Frank Wall Street
the National Insurance Crime Bureau (NICB) by            Reform and Consumer Protection Act8 and
its member insurance companies. Between 2010             the expected impact of Solvency II9 beyond
and 2011, property-related questionable claims           EU borders requires U.S. insurers to invest
increased by 2%, while casualty-related claims           in enterprise risk management and related



Estimated Annual Loss* Due to Fraud
($B)
40
                                                                        34.3                         34.8
35
                                     30.1      31.2            30.2               30.9     31.3
30               28.0      28.7                        28.7
       27.2
25
20
 15
 10
  5
  0
       2001      2002      2003      2004      2005    2006    2007      2008     2009      2010     2011

*Assuming 10% of P&C claim expense
Source: Insurance Information Institute, July 2012
Figure 1



                                   cognizant reports     2
support systems, adding to already strained                                                 a shortage of qualified employees. Claims staff
operating costs. There has also been an increase                                            at many organizations must devote at least half
in the frequency of natural catastrophes (see                                               of their time to routine administrative tasks.
Figure 3, next page) and, consequently, in the                                              Identifying fraudulent claims early improves
cost of serving customers. Superstorm Sandy                                                 claims processing. It reduces cycle time as
cost insurers between $20 billion and $25 billion,                                          suspicious claims are weeded out and sent for
according to disaster-modeling company Risk                                                 further investigation, while legitimate claims
Management Solutions Inc.10 Insurers are there-                                             are prioritized. This, in turn, results in improved
fore looking to significantly reduce costs and                                              customer service, as well as significant savings
improve process efficiencies.                                                               for the organization.

Claims are at the heart of P&C insurer                                                      Insurers have always had systems in place to
operations and account for about 80% of their                                               identify fraudulent claims and special teams
costs. An efficient claims service is crucial for                                           to investigate suspicious claims. However, the
creating a sustainable customer relationship.                                               growing complexity of fraud and well-executed
Further, with long-tail liabilities looming, timely                                         fraud schemes have exposed the limitations
management of claims becomes very important.                                                of traditional fraud-detection systems, such as
                                                                                            internal audits, whistleblower hotlines to report
However, the claims departments at many                                                     fraud and software that flags anomalies based on
insurers are hamstrung by outdated tools and                                                a pre-defined set of rules.


Questionable Property Claims
8,000


6,000


4,000


2,000


     0
            Flood/water                Suspicious                       Inflated                Suspicious                  Fire/arson                   Hail damage
                                     disappearance/                     damage                   theft/loss
                                     loss of jewelry                                        (excluding vehicles)
            2009            2010           2011

Questionable Casualty Claims
20,000

16,000

12,000

 8,000

 4,000

     0
           Duplicate
              billing

                        Excessive
                        treatment

                                      Billing for
                                    services not
                                       rendered

                                                    Unbundling/


                                                                       Faked/
                                                                  exaggerated
                                                                        injury

                                                                                    Prior
                                                                                 injuries


                                                                                                Jump-in


                                                                                                          Inflated
                                                                                                            billing

                                                                                                                      Slip and fall



                                                                                                                                      Solicitation

                                                                                                                                                        Provider/facility
                                                                                                                                                     improperly licensed
                                                                                                                                                          /incorporated

                                                                                                                                                                            Staged/caused
                                                                                                                                                                                  accident
                                                      upcoding




            2009            2010           2011
Source: NICB, February 2012
Figure 2



                                                    cognizant reports                       3
Such systems can detect only some types of fraud                                            Analytics for Improved Fraud Detection
            (usually soft fraud) and not early enough for                                               Insurers generate large volumes of customer
            preventive action. They have also been known                                                data, such as policy details, previous claims
            to cause major embarrassment by flagging                                                    and information gathered from adjusters. This
            legitimate claims as fraudulent. Additionally, in                                           data can be used in combination with data from
            a bid to retain customers in a highly competitive                                           industry sources such as NICB to run predictive
            environment, insurers have refrained from                                                   analytics to identify fraudulent claims early in the
            making a serious effort to investigate suspi-                                               claims process.
            cious cases. Not surprisingly, fewer than 20% of
            fraudulent claims are detected.11                                                           For example, NICB’s ForeWARN database allows
                                                                                                        member companies to search and identify
         Insurers have large amounts of data that can                                                   whether a party had committed fraud in the past
         help identify fraud. However, the data is usually                                              and obtain additional information to develop
                              scattered across organiza-                                                fraudulent patterns and trends. NICB also pro-
Predictive analytics tional silos and exists as                                                         vides analytics support to member companies

helps to quickly and unstructured impossible to
                              it practically
                                              data, making                                              to identify fraud patterns and exposure, helping
                                                                                                        organizations in fraud investigations.12
    more accurately use it for gaining meaning-
           determine ful insights. To deal with                                                         Predictive analytics, which involves the use of

    whether a claim this, enterprise-wide adopt
                              an
                                     insurers must
                                                      data-
                                                                                                        regression models and advanced techniques such
                                                                                                        as neural networks, helps to quickly and more
      needs further centric approach, clean and                                                         accurately determine whether a claim needs fur-
       investigation integrate the historic claims                                                      ther investigation and to determine the complex-

  and to determine data and stored overdispa-
                              years
                                      collected
                                                   in
                                                        the                                             ity of the claim. This speeds up the processing of
                                                                                                        legitimate claims, resulting in improved customer
  the complexity of rate databases, and develop                                                         satisfaction, as well as preventing payouts for
            the claim. predictive models to gain a                                                      fraudulent claims. It also aids in assigning staff
                              complete view of custom-                                                  with the appropriate level of experience based on
         ers and their transactions. This can help identify                                             the severity of a claim. Insurers have also begun
         a variety of fraud types quickly and effectively,                                              deploying expert systems that apply artificial
         reducing losses significantly.                                                                 intelligence algorithms to proactively identify
                                                                                                        fraudulent activities.


            Catastrophe Insured Losses
            ($B)
            80
                                                                                                                                    71.7

             60


             40                         36.9                                                            33.9                 32.9                                             32.6
                                                      25.8                                                                                               28.5
                                                                                                                                                                                     25*
             20 13.7                                                                                                  15.9
                                               8.6
                                                             12.3 10.7             14 11.3
                                                                                                                                           10.3 7.3             11.2 14.1
                                 7.8                                                             6             7.4
                          4.7                                               3.7
              0
                   1989

                          1990

                                 1991

                                        1992

                                               1993

                                                      1994

                                                             1995

                                                                     1996

                                                                            1997

                                                                                   1998

                                                                                          1999

                                                                                                 2000

                                                                                                        2001

                                                                                                               2002

                                                                                                                      2003

                                                                                                                             2004

                                                                                                                                    2005

                                                                                                                                           2006

                                                                                                                                                  2007

                                                                                                                                                         2008

                                                                                                                                                                2009

                                                                                                                                                                       2010

                                                                                                                                                                              2011

                                                                                                                                                                                     2012




                           U.S. CAT losses in 2011 were the fifth highest in U.S. history on an inflation adjusted basis.

            * Only Sandy-related losses, as estimated by Risk Management Solutions, Inc.
            Note: 2001 figure includes $20.3B for 9/11 loss reported through 12/31/01. Includes only business and personal
            property claims, business interruption and auto claims. Non-property/BI losses = $12.2B ($15.6B in 2011 dollars).
            Source: Property Claims Service/ISO and Insurance Information Institute
            Figure 3



                                                                    cognizant reports                   4
In addition, by combining social network and           and accident descriptions, which usually consist
social media analytics, link analysis and geospa-      of short or incomplete sentences, misspelled
tial analysis, insurers can identify fraud that is     words and abbreviations. Based on the key words
hard to detect using traditional methods.              used to describe an incident, text analytics helps
                                                       insurers detect attempted fraud by flagging
Social Network and Social Media Analytics              questionable incidents, exaggerated injuries and
Customers share varying degrees of relationships       treatment costs, reckless driving, etc. and recom-
with other individuals with whom they share            mends actions.
group membership. Social network analytics,
for example, helps to identify proximities and         For example, an adjuster’s notes of an injured
relationships among people, groups, organiza-          customer that contains key phrases such as “car
tions and related systems. It reveals the strength     moving slowly,” “head-on collision with another
of the relationships and how information flows         slow-moving car,” “complains of severe neck
within the groups and, most importantly, group         pain,” “reports excessive treatment costs,” etc.
influencers. This provides valuable input on           can help insurers determine whether the claim
whether a customer is affiliated with any fraudu-      needs to be probed further. This ensures that only
lent group and helps to predict the chances of a       cases with strong fraud patterns are forwarded
particular customer committing fraud.                  to investigation units and improves an adjuster’s
                                                       ability to quickly process genuine claims.
Insurance companies are also increasingly min-
ing social media to detect and investigate fraud.      Link Analysis and Geospatial Analysis
With two out of three people in the U.S. using         An individual claim may not appear false at first
social networking sites, tracking customers’           glance. Often, it is only when it is seen in the
social media updates can help insurers investi-        context of previous fraudulent claims, or claims
gate suspicious claims. By tracking social media       with a high fraud score, that those anomalies
accounts and applying social network analytics         become apparent. Link analysis provides that
to the information on social media, insurers can       larger picture for a claim. In the case of a car
gain information about claimants, medical provid-      accident involving multiple claimants, link analy-
ers, body shops, etc., as well as a claimant’s con-    sis can use claimants’ addresses, phone numbers,
nection with organized crime networks. Investiga-      vehicle numbers, etc. to unearth links among the
tors in California recently used Facebook to find      claimants, the clinics where the claimants were
that four women, who staged an auto accident to        treated and the body shop they used, thus leading
defraud insurers of about $40,000 and denied           investigators to rings of professional fraudsters.
knowing each other, were in fact friends.
                                                       While link analysis allows investigators to under-
A majority of social media users are either            stand whether the parties involved in a large
ignorant of the security settings that hide their      group of injury claims are interrelated, geospatial
information from others or do not bother to            analysis can provide location-based information
enable them, thus providing claims’ investigators      related to a claim, as well as the physical prox-
with clues. For instance, Facebook’s location ser-     imity of the claimants and others involved in a
vice, which allows users to update their locations,    claim. In the case of a staged accident, geospatial
offers investigators insights into whether a car       analysis provides information about the loca-
driver visited a bar before hitting a tree.            tion of the accident, the distance between the
                                                       various claimants’ residences and their proximity
Text Mining                                            to resources such as a lawyer, a body shop and
Text mining and predictive modeling will be the        a medical provider. This provides investigators
primary tools that insurers will deploy to com-        with evidence to pursue a hunch and to identify
bat fraud in the next two years, according to a        potential fraud rings.
2012 study by SAS Institute and Coalition Against
Insurance Fraud (CAIF) of 74 U.S. insurance exec-      Geospatial analysis can also be used to identify
utives.13                                              the exact area affected by a natural disaster or
                                                       an explosion, which helps determine the amount
Text analytics helps companies gain critical           of risk to insured properties and weed out claims
insights from large volumes of unstructured data,      that are filed from areas that are not located in
such as adjuster notes, first notice of loss, e-mail   the affected zone.


                                 cognizant reports     5
Challenges                                               systems, insurers can build real-time analytical
Insurers generally use a combination of anti-            capabilities that help in creating a just-in-time
fraud technologies. Older technologies, such as          understanding of opera-
red flags/business rules and scoring capability,         tional    issues,   effective A large U.S.
still dominate the scene, according to the CAIF          fraud identification and
and SAS survey. Fewer than 50% of respondents            more      meaningful     and
                                                                                       insurance company
use more advanced techniques, such as workflow           timely decisions. A large that deployed
routing, text mining, predictive modeling and            U.S. insurance company real-time analytics
geographic data mapping, while 12% do not use            that deployed real-time
any anti-fraud technologies, the survey found.           analytics to sift through
                                                                                       to sift through
                                                         unstructured claims data unstructured claims
A major obstacle to embracing analytics is the           from two fraud-prone states data from two
lack of enterprise-wide data management at               found that more than 1,000
many insurers. While insurance companies are             insured customers were
                                                                                       fraud-prone states
data-rich, not many have made progress on                actually high-risk custom- found that more
the data management front. Much of their data            ers. Another insurer identi- than 1,000 insured
resides in numerous independent legacy systems,          fied actionable claims worth
often resulting in data inconsistency. It is, there-     $20 million within the first
                                                                                       customers were
fore, important that data structures across the          three months of deploying actually high-risk
organization be standardized and inconsistencies         fraud analytics.15            customers.
resolved to realize the full benefits of analytics.
                                                         Benefits
Other major challenges in deploying analytics            While there is no denying that deployment of
include the lack of IT resources and concerns            advanced analytics requires significant invest-
about return on investment, according to the CAIF        ment, the benefits far outweigh the costs. Some
and SAS study (see Figure 4).14 Some insurers also       examples:
cite legal and compliance issues that can arise
from using social media data for investigations.         •	 Efficient fraud detection reduces annual claims
                                                            payouts.
Overcoming Obstacles                                     •	 The number of false positives identified and
To leverage the benefits of advanced analytics,             pursued is minimized. This boosts employee
insurers need to focus on fresh approaches to               productivity, minimizes loss adjustment
data management that can integrate disparate                expenses and avoides customer ire and legal
systems and effectively deal with data overflow.            hassles. Advanced analytics helped a U.S.
By integrating predictive analytics with enterprise         insurer improve its false-positive detection
                                                            rate by 17%.16


Challenges in Deploying Analytics

                5%
           7%                                       Cost/benefit analysis (ROI)


                                                    Lack of IT resources
     14%
                            36%
                                                    Proof of concept and unknown effectiveness


                                                    Acquisition and integration of data
                38%

                                                    Legal and compliance issues



Source: The State of Insurance Fraud Technology, Coalition Against Insurance Fraud and SAS, September 2012
Figure 4



                                  cognizant reports      6
•	 Claims processing cycle time can be reduced,            to increase outlays by          Insurers
   resulting in faster processing of claims and            more than 10% per year
                                                                                           acknowledge
   increased customer satisfaction.                        (see Figure 5).
•	 Losses through payouts can be minimized,                                                that deploying
   thus eliminating the need to increase premi-            Major       insurers    have    predictive analytics
   ums and thereby helping to build strong cus-            employed statisticians and
                                                                                           is the most
   tomer relationships. Santam, a South African            predictive modelers and are
   short-term insurer, saved $2.4 million on fraud-        capable of building efficient   effective way to
   ulent claims within four months of deploying            fraud detection models.         combat fraud,
   analytics. It also improved fraud detection             However, many insurers
                                                                                           according to the
   capabilities and unearthed a motor fraud ring           are revisiting their decision
   within one month of deploying analytics.17              to build in-house capabili-     FICO and PCI study.
•	 Insurers committed to fighting fraud will be            ties due to the complexities
   able to send a strong message to fraudsters             involved in handling analytics and the expertise
   and enhance their image in the eyes of                  required for text mining, using social media and
   customers.                                              geospatial analysis. While in-house solutions offer
                                                           greater control over development, “operational-
Embracing Analytics as a Service                           izing” a fraud detection model and the infrastruc-
The growing complexity of fraud requires                   ture required to implement and run an analytical
organizations to move beyond rules-based and               solution can be expensive.18 Vendor solutions,
judgmental approaches toward more fact-based               on the other hand, offer lower total cost of
and self-learning analytical models. We believe an         ownership.
ideal fraud detection approach must combine the
best of analytics and rules-based approaches.              Open source projects, such as R and Apache
                                                           Hadoop, are being used by organizations to do
Insurers acknowledge that deploying predictive             more with big data. While Apache Hadoop helps
analytics is the most effective way to combat fraud,       to efficiently store and manage huge volumes
according to the FICO and PCI study. The increas-          of data, R is widely used for data manipula-
ing confidence in analytics is reflected in the rise in    tion, calculation and graphical display. Further,
data and analytics budgets. According to a recent          by combining R and Hadoop, organizations can
survey by Strategy Meets Action of 165 insur-              overcome the complexity of processing large
ers, three quarters of the respondents plan to             volumes of unstructured data and analyzing
increase their annual data and analytics spend-            social media networks in short periods.
ing between 2012 and 2014, with 19% planning




Insurers' IT Spending Plans for Data and Analytics (2012-14)
                   2%


                                                      Increase by more than 10% per year
                          19%
           23%
                                                      Increase by 6%-10% per year


                                                      Increase by 1%-5% per year
                                21%
                                                      Spending will remain flat
             35%

                                                      Decrease


n=165
Source: SMA Research, Data and Analysis, 2012
Figure 5



                                      cognizant reports    7
However, deploying analytics is no easy             The     partner     must  have   expertise  in
          task. Unstructured data accounts for about          extracting meaningful insights from insurance-
          80%19 of organizational data and is bound           related social networks and
          to grow at 60% annually,20 with the increas-        social media and perform Organizations
          ing chatter created on social media. The            complex analyses on the should seek a
          traditional IT infrastructure deployed by most      data. The technology com-
          insurers is insufficient to analyze such large      ponent includes the part-
                                                                                           partner that can
          volumes of data and requires organizations          ner’s ability to integrate seamlessly marry
          to invest in people, processes, IT tools and        advanced analytics with analytics with
          infrastructure.                                     insurers’ claims systems,
                                                              and create new claims effi-
                                                                                           technology rather
          Choosing the Right Partner                          ciencies and improve over- than a pure-play
          With process virtualization and cloud comput-       all claims effectiveness.    analytics player
          ing, opportunities now exist for cost-cutting
                            through global sourcing via       As analytics processes
                                                                                           that may not have
    The traditional the business process as a                 become standardized and industry domain
                            service (BPaaS) model. This       can uniformly be applied expertise.
  IT infrastructure can save precious Cap-Ex                  via cloud-enabled models
        deployed by by transferring the cost of               (harnessing the growing clout of utility comput-
     most insurers acquiring expensive hard-                  ing architectures), we believe that insurers stand
                            ware, software and key talent     to benefit greatly by associating themselves with
      is insufficient through consumption-based               partners that have invested in such capabilities.
   to analyze large pricing models.
  volumes of data                                             Looking Forward
                              A subset of BPaaS, analytics    To experience the potential of analytics, we
      and requires            as a service combines tradi-    believe that insurers should:
  organizations to            tional knowledge process out-
  invest in people,           sourcing (KPO) and business     •	 Develop an enterprise-wide data architecture.

processes, IT tools
                              process outsourcing (BPO)       •	 Identify key areas for deploying analytics.
                              capabilities with more effi-    •	 Design a comprehensive strategy for adoption
and infrastructure.           cient, cloud-enabled ways          and implementation of analytics, including
          of delivering analytical insights. This approach       information technology.
          allows organizations to deploy analytics solu-      •	 Develop a fact-based decision-making culture
          tions tailored to their needs. The service can be      focused on achieving specific goals.
          increased or decreased as business requirements     •	 Formulate customized strategies to capitalize
          dictate, providing more Op-Ex flexibility.             on unique data.
                                                              •	 Continuously innovate and renew analytics
          Organizations should seek a partner that can           implementation.
          seamlessly marry analytics with technology          •	 Enter into relationships with partners capable
          rather than a pure-play analytics player that          of providing AaaS to advance competitive
          may not have industry domain expertise. The key        advantage.
          analytical component is derived from the
          ability to understand various forms of insurance
          fraud — ranging from early payment defaults to
          more complex types of malfeasance — and devel-
          oping predictive models capable of understand-
          ing complex relationships and learning from his-
          torical data.




                                         cognizant reports    8
Footnotes
	“Insurance Fraud: Understanding The Basics,” NICB, April 21, 2011, https://www.nicb.org/File%
1

 20Library/Theft%20and%20Fraud%20Prevention/Fact%20Sheets/Public/insurancefraudpublic.pdf.
2
    	“Insurance Fraud,” Insurance Information Institute, June 2012, http://www.iii.org/assets/docs/pdf/
     InsuranceFraud-072112.pdf.
3
    	 “Fraud Stats,” Coalition Against Insurance Fraud, http://www.insurancefraud.org/statistics.htm.
4
     	 According to NICB, a questionable claim is one that NICB member insurance companies refer to NICB
       for closer review and investigation based upon one or more indicators of possible fraud. A single
       questionable claim can contain up to seven different referral reasons.
5
    	“FICO PCI Insurance Fraud Survey,” FICO, October 4, 2012, http://www.fico.com/en/Company/News/
     Pages/10-04-2012.aspx.
6
    	“Written Premium, Rising Loss Ratios Point to Continued Rate Increases,” PropertyCasualty360,
     March 27, 2012, http://www.propertycasualty360.com/2012/03/27/written-premium-rising-loss-ratios-
     point-to-contin.
7
    	 “Property Casualty Insurers Benefit From Drop In Catastrophe Losses,” Property Casualty Insurers
      Association of America, October 4, 2012, http://www.pciaa.net/LegTrack/web/NAIIPublications.nsf/
      lookupwebcontent/4003FCCDBDDDB35186257A8E006C244?opendocument.
8
     	The Dodd-Frank Wall Street Reform and Consumer Protection Act requires insurers to comply
      with data requests on sales, customer location, etc. from the Federal Insurance Office (FIO), Office of
      Financial Research (OFR), in addition to state regulators. Further, insurers with more than $50 billion
      in assets are identified as systematically important financial institutions (SIFI) and have to comply
      with heightened regulations. This means big insurers must rewire their legacy systems to create more
      effective reporting mechanisms, which is expensive and can result in a competitive disadvantage
      when compared with smaller insurance companies.
9
    	Scheduled to come into effect on January 1, 2014, Solvency II requires U.S. insurers operating in
     the European Union to comply with the regime’s new risk management and reporting and account-
     ing standards. Meeting the data requirements and reporting frequency of Solvency II requires U.S.
     insurers to invest in revamping and consolidating existing IT systems.
10
     	“Sandy May Cost Insurers Up To $25 Billion,” The Wall Street Journal, November 14, 2012, http://online.
      wsj.com/article/SB10001424127887324735104578119301366617508.html.
11
    	 “Predictive Analytics: A Powerful Weapon In Fight Against Fraud,” PropertyCasualty360, April 4, 2011,
      http://www.propertycasualty360.com/2011/04/04/predictive-analytics-a-powerful-weapon-in-fight-ag.
12
     	“Join NICB,” NICB, https://www.nicb.org/about-nicb/join_nicb.
13
     	“The State of Insurance Fraud Technology,” SAS Institute, September 2012, http://www.sas.com/reg/
      wp/corp/50373.
14
     	
     “The State of Insurance Fraud Technology,” Coalition Against Insurance Fraud, September 2012,
     http://www.insurancefraud.org/downloads/techStudy_2012.pdf.
15
     “Predictive Analytics Can End the Isolation,” PropertyCasualty360, October 1, 2012, http://www.
     	
     propertycasualty360.com/2012/10/01/predictive-analytics-can-end-the-isolation.
16
     	Ibid.
17
     	“Using IBM Analytics, Santam Saves $2.4 Million in Fraudulent Claims,” IBM, May 9, 2012, http://
      www-03.ibm.com/press/us/en/pressrelease/37653.wss.




                                    cognizant reports     9
18
     	“Operationalizing a Fraud Detection Solution: Buy or Build?” Insurance & Technology, August 20,
      2012, http://www.insurancetech.com/business-intelligence/operationalizing-a-fraud-detection-solut/
      240005814.

 	“Data Storage: Managing Unstructured Data in the Cloud: 12 Factors to Consider,” July 27, 2011, eWeek,
19

  http://www.eweek.com/c/a/Data-Storage/Managing-Unstructured-Data-in-the-Cloud-12-Factors-to-
  Consider-215018/.
20
     	 igital data, the majority of which is unstructured data, is expected to grow from 130 exabytes to
     D
     40,000 exabytes between 2005 and 2020, according to a 2012 survey by IDC and EMC.




References
•	“Uncertainty    Weighs Down U.S. Insurers,” Life Insurance International, July 2012, http://www.
     goldbergsegalla.com/sites/default/files/uploads/JW_LifeInsuranceInternational_July2012.pdf.

•	“You Know There Are Fraudulent Claims. Let’s Find Them Now,” Statsoft, 2011, http://www.statsoft.
     com/portals/0/solutions/StatSoft_InsuranceFraud_Brochurev.pdf.

•	 “The Three Best Targets For Attacking P&C Insurance Fraud,” FICO, September 2010, http://www.efma.
     com/efmaweb_files/file/Partnerships/Fico_Insights44_Insurance_Fraud.pdf.

•	
 “Driving      Operational Excellence in Claims Management,” February 2011, http://www.deloitte.
     com/assets/Dcom-UnitedStates/Local%20Assets/Documents/FSI/US_FSI_DrivingOperational
     ExcellenceInClaimsManagement_022311.pdf.

•	 “Advanced ‘Big Data’ Analytics with R and Hadoop,” Revolution Analytics, 2011, http://www.revolution-
     analytics.com/why-revolution-r/whitepapers/R-and-Hadoop-Big-Data-Analytics.pdf.

•	 “Identify Claims Fraud with Advanced Analytics: Uncover Fraud that Traditional Methods Cannot Find,”
     FICO, November 1, 2011, http://www.fico.com/en/FIResourcesLibrary/NewYorkInsuranceForum2011-3_
     Identify_Insurance_Claims_Fraud.pdf.

•	 “Fraud Detection Acid Test,” SAS Institute, October 4, 2012, http://www.sas.com/knowledge-exchange/
     risk/fraud-financial-crimes/fraud-detection-acid-test/index.html.




                                  cognizant reports      10
Credits
Author
Vinaya Kumar Mylavarapu, Senior Research Associate, Cognizant Research Center


Subject Matter Expert
Nipun Kapur, Director and Head of Analytics COE, Cognizant Analytics


Design
Harleen Bhatia, Creative Director
Suresh Sambandhan, Designer




About Cognizant

Cognizant (NASDAQ: CTSH) is a leading provider of information technology, consulting, and business process
outsourcing services, dedicated to helping the world’s leading companies build stronger businesses. Headquartered
in Teaneck, New Jersey (U.S.), Cognizant combines a passion for client satisfaction, technology innovation, deep in-
dustry and business process expertise, and a global, collaborative workforce that embodies the future of work. With
over 50 delivery centers worldwide and approximately 150,400 employees as of September 30, 2012, Cognizant is a
member of the NASDAQ-100, the S&P 500, the Forbes Global 2000, and the Fortune 500 and is ranked among the
top performing and fastest growing companies in the world.

Visit us online at www.cognizant.com for more information.


                                        World Headquarters                   European Headquarters                India Operations Headquarters
                                        500 Frank W. Burr Blvd.              1 Kingdom Street                     #5/535, Old Mahabalipuram Road
                                        Teaneck, NJ 07666 USA                Paddington Central                   Okkiyam Pettai, Thoraipakkam
                                        Phone: +1 201 801 0233               London W2 6BD                        Chennai, 600 096 India
                                        Fax: +1 201 801 0243                 Phone: +44 (0) 207 297 7600          Phone: +91 (0) 44 4209 6000
                                        Toll Free: +1 888 937 3277           Fax: +44 (0) 207 121 0102            Fax: +91 (0) 44 4209 6060
                                        Email: inquiry@cognizant.com         Email: infouk@cognizant.com          Email: inquiryindia@cognizant.com


©
­­ Copyright 2012, Cognizant. All rights reserved. No part of this document may be reproduced, stored in a retrieval system, transmitted in any form or by any
means, electronic, mechanical, photocopying, recording, or otherwise, without the express written permission from Cognizant. The information contained herein is
subject to change without notice. All other trademarks mentioned herein are the property of their respective owners.

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Using Advanced Analytics to Combat P&C Claims Fraud

  • 1. • Cognizant Reports Using Advanced Analytics to Combat P&C Claims Fraud Combating the growing complexity and sophistication of claims fraud requires P&C insurers to embrace predictive and advanced analytics, such as text, social media, link and geospatial analysis. By partnering with firms that can deliver analytics as a service, insurers can improve their bottom lines, enhance claims processing efficiencies and boost customer satisfaction. Executive Summary analytics, insurers can establish relation- Insurance fraud is the second biggest white-collar ships among various parties involved in a claim crime in the U.S. after tax evasion, according to based on geographic location. This can help the National Insurance Crime Bureau.1 As insur- detect highly sophisticated fraud, as well as ers deal with an uncertain economic climate and organized crime rings. intense competition, they must also grapple with the increasing incidence and sophistication of Achieving this level of sophistication requires fraud, not to mention the resulting losses. The an efficient model and approach to enterprise- traditional methods of identifying fraud are no wide data management. Insurers must focus on longer sufficient. breaking down data silos and ensuring a con- tinuous flow of quality data across various func- Advanced analytics can help insurers identify and tional areas of the organization to enable a more reduce fraud-related losses, as well as condense systematic use of advanced analytics that detect the claims cycle, resulting in improved customer and prevent fraud. Getting there requires a satisfaction. Historical claims data, combined cultural shift toward fact-based decision-making, with industry data, can be a starting point for which demands a major commitment from senior insurers to identify common types of fraud early leadership. in the claims process. Advanced analytics, such as social media analytics and text mining, can However, many insurers still run their business help insurers sift through and draw inferences on traditional database systems that operate from unstructured data more quickly and con- in silos, resulting in data inconsistencies. One vert it into insights that quickly aid in identifica- way to quickly and effectively extract value from tion and avoidance of fraudulent claims. By using these vast data pools is to pursue analytics as a link analytics in combination with geospatial service (AaaS), a new delivery model that enables cognizant reports | december 2012
  • 2. insurers to work closely with specialists who increased by 16% (see Figure 2, next page). provide analytical insights on a pay-per-use The prolonged weak economy is inflicting basis. This model shifts the cost of owning tech- significant economic hardships for consumers nology infrastructure, processes and talent to the and businesses, which is further increasing the chosen partner. cost of fraud, especially in personal lines, accord- ing to 54% of the 143 insurers surveyed in August Fraud: A Growing Menance 2012 by FICO and the Property Casualty Insurers On average, insurers lose $30 billion annually Association of America (PCI).5 to fraudulent claims, representing 10% of their claims expenses, according to the Insurance Infor- Fraud negatively impacts insurers’ bottom lines mation Institute (see Figure 1).2 Insurance fraud (reduced profitability due to the cost of fraudulent can be divided into two categories: opportunistic/ claims that would otherwise not be incurred) and soft fraud and professional/hard fraud. Oppor- competitiveness (delays in claims processing). It tunistic fraud is committed by individuals who increases premiums for customers, as insurers inflate damages or repairs in a legitimate claim or charge them more to make up for the increase provide false information to reduce the premium in payouts. NICB estimates that fraud increases amount. About half of P&C insurers lose 11 cents premiums by $200 to $300 per family, annually. to 30 cents or more per premium dollar to soft fraud alone, according to the Insurance Research The Need for Analytics Council-Insurance Services Office.3 The P&C insurance industry continues to operate in an uncertain economic climate, with Professional, or hard, types of fraud are low interest rates hampering investment income. committed by organized groups that steal The direct loss ratio rose by 2.7 points from vehicles, deliberately damage property and stage 2010, to 67.5% in 2011,6 while the combined ratio accidents. These gangs are well acquainted with in the first half of 2012 was 102%.7 Fraud, along fraud detection systems and collude with doctors, with long-tail liabilities such as incurred but not attorneys, insiders in insurance companies, body reported (IBNR) liabilities, produce uncertainty, shops, etc. to lodge fraudulent claims. making it much tougher to assess accurate claims reserves and pricing of premiums. A growing concern for insurers is the increas- ing number of questionable claims4 referred to Compliance with the Dodd-Frank Wall Street the National Insurance Crime Bureau (NICB) by Reform and Consumer Protection Act8 and its member insurance companies. Between 2010 the expected impact of Solvency II9 beyond and 2011, property-related questionable claims EU borders requires U.S. insurers to invest increased by 2%, while casualty-related claims in enterprise risk management and related Estimated Annual Loss* Due to Fraud ($B) 40 34.3 34.8 35 30.1 31.2 30.2 30.9 31.3 30 28.0 28.7 28.7 27.2 25 20 15 10 5 0 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 *Assuming 10% of P&C claim expense Source: Insurance Information Institute, July 2012 Figure 1 cognizant reports 2
  • 3. support systems, adding to already strained a shortage of qualified employees. Claims staff operating costs. There has also been an increase at many organizations must devote at least half in the frequency of natural catastrophes (see of their time to routine administrative tasks. Figure 3, next page) and, consequently, in the Identifying fraudulent claims early improves cost of serving customers. Superstorm Sandy claims processing. It reduces cycle time as cost insurers between $20 billion and $25 billion, suspicious claims are weeded out and sent for according to disaster-modeling company Risk further investigation, while legitimate claims Management Solutions Inc.10 Insurers are there- are prioritized. This, in turn, results in improved fore looking to significantly reduce costs and customer service, as well as significant savings improve process efficiencies. for the organization. Claims are at the heart of P&C insurer Insurers have always had systems in place to operations and account for about 80% of their identify fraudulent claims and special teams costs. An efficient claims service is crucial for to investigate suspicious claims. However, the creating a sustainable customer relationship. growing complexity of fraud and well-executed Further, with long-tail liabilities looming, timely fraud schemes have exposed the limitations management of claims becomes very important. of traditional fraud-detection systems, such as internal audits, whistleblower hotlines to report However, the claims departments at many fraud and software that flags anomalies based on insurers are hamstrung by outdated tools and a pre-defined set of rules. Questionable Property Claims 8,000 6,000 4,000 2,000 0 Flood/water Suspicious Inflated Suspicious Fire/arson Hail damage disappearance/ damage theft/loss loss of jewelry (excluding vehicles) 2009 2010 2011 Questionable Casualty Claims 20,000 16,000 12,000 8,000 4,000 0 Duplicate billing Excessive treatment Billing for services not rendered Unbundling/ Faked/ exaggerated injury Prior injuries Jump-in Inflated billing Slip and fall Solicitation Provider/facility improperly licensed /incorporated Staged/caused accident upcoding 2009 2010 2011 Source: NICB, February 2012 Figure 2 cognizant reports 3
  • 4. Such systems can detect only some types of fraud Analytics for Improved Fraud Detection (usually soft fraud) and not early enough for Insurers generate large volumes of customer preventive action. They have also been known data, such as policy details, previous claims to cause major embarrassment by flagging and information gathered from adjusters. This legitimate claims as fraudulent. Additionally, in data can be used in combination with data from a bid to retain customers in a highly competitive industry sources such as NICB to run predictive environment, insurers have refrained from analytics to identify fraudulent claims early in the making a serious effort to investigate suspi- claims process. cious cases. Not surprisingly, fewer than 20% of fraudulent claims are detected.11 For example, NICB’s ForeWARN database allows member companies to search and identify Insurers have large amounts of data that can whether a party had committed fraud in the past help identify fraud. However, the data is usually and obtain additional information to develop scattered across organiza- fraudulent patterns and trends. NICB also pro- Predictive analytics tional silos and exists as vides analytics support to member companies helps to quickly and unstructured impossible to it practically data, making to identify fraud patterns and exposure, helping organizations in fraud investigations.12 more accurately use it for gaining meaning- determine ful insights. To deal with Predictive analytics, which involves the use of whether a claim this, enterprise-wide adopt an insurers must data- regression models and advanced techniques such as neural networks, helps to quickly and more needs further centric approach, clean and accurately determine whether a claim needs fur- investigation integrate the historic claims ther investigation and to determine the complex- and to determine data and stored overdispa- years collected in the ity of the claim. This speeds up the processing of legitimate claims, resulting in improved customer the complexity of rate databases, and develop satisfaction, as well as preventing payouts for the claim. predictive models to gain a fraudulent claims. It also aids in assigning staff complete view of custom- with the appropriate level of experience based on ers and their transactions. This can help identify the severity of a claim. Insurers have also begun a variety of fraud types quickly and effectively, deploying expert systems that apply artificial reducing losses significantly. intelligence algorithms to proactively identify fraudulent activities. Catastrophe Insured Losses ($B) 80 71.7 60 40 36.9 33.9 32.9 32.6 25.8 28.5 25* 20 13.7 15.9 8.6 12.3 10.7 14 11.3 10.3 7.3 11.2 14.1 7.8 6 7.4 4.7 3.7 0 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 U.S. CAT losses in 2011 were the fifth highest in U.S. history on an inflation adjusted basis. * Only Sandy-related losses, as estimated by Risk Management Solutions, Inc. Note: 2001 figure includes $20.3B for 9/11 loss reported through 12/31/01. Includes only business and personal property claims, business interruption and auto claims. Non-property/BI losses = $12.2B ($15.6B in 2011 dollars). Source: Property Claims Service/ISO and Insurance Information Institute Figure 3 cognizant reports 4
  • 5. In addition, by combining social network and and accident descriptions, which usually consist social media analytics, link analysis and geospa- of short or incomplete sentences, misspelled tial analysis, insurers can identify fraud that is words and abbreviations. Based on the key words hard to detect using traditional methods. used to describe an incident, text analytics helps insurers detect attempted fraud by flagging Social Network and Social Media Analytics questionable incidents, exaggerated injuries and Customers share varying degrees of relationships treatment costs, reckless driving, etc. and recom- with other individuals with whom they share mends actions. group membership. Social network analytics, for example, helps to identify proximities and For example, an adjuster’s notes of an injured relationships among people, groups, organiza- customer that contains key phrases such as “car tions and related systems. It reveals the strength moving slowly,” “head-on collision with another of the relationships and how information flows slow-moving car,” “complains of severe neck within the groups and, most importantly, group pain,” “reports excessive treatment costs,” etc. influencers. This provides valuable input on can help insurers determine whether the claim whether a customer is affiliated with any fraudu- needs to be probed further. This ensures that only lent group and helps to predict the chances of a cases with strong fraud patterns are forwarded particular customer committing fraud. to investigation units and improves an adjuster’s ability to quickly process genuine claims. Insurance companies are also increasingly min- ing social media to detect and investigate fraud. Link Analysis and Geospatial Analysis With two out of three people in the U.S. using An individual claim may not appear false at first social networking sites, tracking customers’ glance. Often, it is only when it is seen in the social media updates can help insurers investi- context of previous fraudulent claims, or claims gate suspicious claims. By tracking social media with a high fraud score, that those anomalies accounts and applying social network analytics become apparent. Link analysis provides that to the information on social media, insurers can larger picture for a claim. In the case of a car gain information about claimants, medical provid- accident involving multiple claimants, link analy- ers, body shops, etc., as well as a claimant’s con- sis can use claimants’ addresses, phone numbers, nection with organized crime networks. Investiga- vehicle numbers, etc. to unearth links among the tors in California recently used Facebook to find claimants, the clinics where the claimants were that four women, who staged an auto accident to treated and the body shop they used, thus leading defraud insurers of about $40,000 and denied investigators to rings of professional fraudsters. knowing each other, were in fact friends. While link analysis allows investigators to under- A majority of social media users are either stand whether the parties involved in a large ignorant of the security settings that hide their group of injury claims are interrelated, geospatial information from others or do not bother to analysis can provide location-based information enable them, thus providing claims’ investigators related to a claim, as well as the physical prox- with clues. For instance, Facebook’s location ser- imity of the claimants and others involved in a vice, which allows users to update their locations, claim. In the case of a staged accident, geospatial offers investigators insights into whether a car analysis provides information about the loca- driver visited a bar before hitting a tree. tion of the accident, the distance between the various claimants’ residences and their proximity Text Mining to resources such as a lawyer, a body shop and Text mining and predictive modeling will be the a medical provider. This provides investigators primary tools that insurers will deploy to com- with evidence to pursue a hunch and to identify bat fraud in the next two years, according to a potential fraud rings. 2012 study by SAS Institute and Coalition Against Insurance Fraud (CAIF) of 74 U.S. insurance exec- Geospatial analysis can also be used to identify utives.13 the exact area affected by a natural disaster or an explosion, which helps determine the amount Text analytics helps companies gain critical of risk to insured properties and weed out claims insights from large volumes of unstructured data, that are filed from areas that are not located in such as adjuster notes, first notice of loss, e-mail the affected zone. cognizant reports 5
  • 6. Challenges systems, insurers can build real-time analytical Insurers generally use a combination of anti- capabilities that help in creating a just-in-time fraud technologies. Older technologies, such as understanding of opera- red flags/business rules and scoring capability, tional issues, effective A large U.S. still dominate the scene, according to the CAIF fraud identification and and SAS survey. Fewer than 50% of respondents more meaningful and insurance company use more advanced techniques, such as workflow timely decisions. A large that deployed routing, text mining, predictive modeling and U.S. insurance company real-time analytics geographic data mapping, while 12% do not use that deployed real-time any anti-fraud technologies, the survey found. analytics to sift through to sift through unstructured claims data unstructured claims A major obstacle to embracing analytics is the from two fraud-prone states data from two lack of enterprise-wide data management at found that more than 1,000 many insurers. While insurance companies are insured customers were fraud-prone states data-rich, not many have made progress on actually high-risk custom- found that more the data management front. Much of their data ers. Another insurer identi- than 1,000 insured resides in numerous independent legacy systems, fied actionable claims worth often resulting in data inconsistency. It is, there- $20 million within the first customers were fore, important that data structures across the three months of deploying actually high-risk organization be standardized and inconsistencies fraud analytics.15 customers. resolved to realize the full benefits of analytics. Benefits Other major challenges in deploying analytics While there is no denying that deployment of include the lack of IT resources and concerns advanced analytics requires significant invest- about return on investment, according to the CAIF ment, the benefits far outweigh the costs. Some and SAS study (see Figure 4).14 Some insurers also examples: cite legal and compliance issues that can arise from using social media data for investigations. • Efficient fraud detection reduces annual claims payouts. Overcoming Obstacles • The number of false positives identified and To leverage the benefits of advanced analytics, pursued is minimized. This boosts employee insurers need to focus on fresh approaches to productivity, minimizes loss adjustment data management that can integrate disparate expenses and avoides customer ire and legal systems and effectively deal with data overflow. hassles. Advanced analytics helped a U.S. By integrating predictive analytics with enterprise insurer improve its false-positive detection rate by 17%.16 Challenges in Deploying Analytics 5% 7% Cost/benefit analysis (ROI) Lack of IT resources 14% 36% Proof of concept and unknown effectiveness Acquisition and integration of data 38% Legal and compliance issues Source: The State of Insurance Fraud Technology, Coalition Against Insurance Fraud and SAS, September 2012 Figure 4 cognizant reports 6
  • 7. • Claims processing cycle time can be reduced, to increase outlays by Insurers resulting in faster processing of claims and more than 10% per year acknowledge increased customer satisfaction. (see Figure 5). • Losses through payouts can be minimized, that deploying thus eliminating the need to increase premi- Major insurers have predictive analytics ums and thereby helping to build strong cus- employed statisticians and is the most tomer relationships. Santam, a South African predictive modelers and are short-term insurer, saved $2.4 million on fraud- capable of building efficient effective way to ulent claims within four months of deploying fraud detection models. combat fraud, analytics. It also improved fraud detection However, many insurers according to the capabilities and unearthed a motor fraud ring are revisiting their decision within one month of deploying analytics.17 to build in-house capabili- FICO and PCI study. • Insurers committed to fighting fraud will be ties due to the complexities able to send a strong message to fraudsters involved in handling analytics and the expertise and enhance their image in the eyes of required for text mining, using social media and customers. geospatial analysis. While in-house solutions offer greater control over development, “operational- Embracing Analytics as a Service izing” a fraud detection model and the infrastruc- The growing complexity of fraud requires ture required to implement and run an analytical organizations to move beyond rules-based and solution can be expensive.18 Vendor solutions, judgmental approaches toward more fact-based on the other hand, offer lower total cost of and self-learning analytical models. We believe an ownership. ideal fraud detection approach must combine the best of analytics and rules-based approaches. Open source projects, such as R and Apache Hadoop, are being used by organizations to do Insurers acknowledge that deploying predictive more with big data. While Apache Hadoop helps analytics is the most effective way to combat fraud, to efficiently store and manage huge volumes according to the FICO and PCI study. The increas- of data, R is widely used for data manipula- ing confidence in analytics is reflected in the rise in tion, calculation and graphical display. Further, data and analytics budgets. According to a recent by combining R and Hadoop, organizations can survey by Strategy Meets Action of 165 insur- overcome the complexity of processing large ers, three quarters of the respondents plan to volumes of unstructured data and analyzing increase their annual data and analytics spend- social media networks in short periods. ing between 2012 and 2014, with 19% planning Insurers' IT Spending Plans for Data and Analytics (2012-14) 2% Increase by more than 10% per year 19% 23% Increase by 6%-10% per year Increase by 1%-5% per year 21% Spending will remain flat 35% Decrease n=165 Source: SMA Research, Data and Analysis, 2012 Figure 5 cognizant reports 7
  • 8. However, deploying analytics is no easy The partner must have expertise in task. Unstructured data accounts for about extracting meaningful insights from insurance- 80%19 of organizational data and is bound related social networks and to grow at 60% annually,20 with the increas- social media and perform Organizations ing chatter created on social media. The complex analyses on the should seek a traditional IT infrastructure deployed by most data. The technology com- insurers is insufficient to analyze such large ponent includes the part- partner that can volumes of data and requires organizations ner’s ability to integrate seamlessly marry to invest in people, processes, IT tools and advanced analytics with analytics with infrastructure. insurers’ claims systems, and create new claims effi- technology rather Choosing the Right Partner ciencies and improve over- than a pure-play With process virtualization and cloud comput- all claims effectiveness. analytics player ing, opportunities now exist for cost-cutting through global sourcing via As analytics processes that may not have The traditional the business process as a become standardized and industry domain service (BPaaS) model. This can uniformly be applied expertise. IT infrastructure can save precious Cap-Ex via cloud-enabled models deployed by by transferring the cost of (harnessing the growing clout of utility comput- most insurers acquiring expensive hard- ing architectures), we believe that insurers stand ware, software and key talent to benefit greatly by associating themselves with is insufficient through consumption-based partners that have invested in such capabilities. to analyze large pricing models. volumes of data Looking Forward A subset of BPaaS, analytics To experience the potential of analytics, we and requires as a service combines tradi- believe that insurers should: organizations to tional knowledge process out- invest in people, sourcing (KPO) and business • Develop an enterprise-wide data architecture. processes, IT tools process outsourcing (BPO) • Identify key areas for deploying analytics. capabilities with more effi- • Design a comprehensive strategy for adoption and infrastructure. cient, cloud-enabled ways and implementation of analytics, including of delivering analytical insights. This approach information technology. allows organizations to deploy analytics solu- • Develop a fact-based decision-making culture tions tailored to their needs. The service can be focused on achieving specific goals. increased or decreased as business requirements • Formulate customized strategies to capitalize dictate, providing more Op-Ex flexibility. on unique data. • Continuously innovate and renew analytics Organizations should seek a partner that can implementation. seamlessly marry analytics with technology • Enter into relationships with partners capable rather than a pure-play analytics player that of providing AaaS to advance competitive may not have industry domain expertise. The key advantage. analytical component is derived from the ability to understand various forms of insurance fraud — ranging from early payment defaults to more complex types of malfeasance — and devel- oping predictive models capable of understand- ing complex relationships and learning from his- torical data. cognizant reports 8
  • 9. Footnotes “Insurance Fraud: Understanding The Basics,” NICB, April 21, 2011, https://www.nicb.org/File% 1 20Library/Theft%20and%20Fraud%20Prevention/Fact%20Sheets/Public/insurancefraudpublic.pdf. 2 “Insurance Fraud,” Insurance Information Institute, June 2012, http://www.iii.org/assets/docs/pdf/ InsuranceFraud-072112.pdf. 3 “Fraud Stats,” Coalition Against Insurance Fraud, http://www.insurancefraud.org/statistics.htm. 4 According to NICB, a questionable claim is one that NICB member insurance companies refer to NICB for closer review and investigation based upon one or more indicators of possible fraud. A single questionable claim can contain up to seven different referral reasons. 5 “FICO PCI Insurance Fraud Survey,” FICO, October 4, 2012, http://www.fico.com/en/Company/News/ Pages/10-04-2012.aspx. 6 “Written Premium, Rising Loss Ratios Point to Continued Rate Increases,” PropertyCasualty360, March 27, 2012, http://www.propertycasualty360.com/2012/03/27/written-premium-rising-loss-ratios- point-to-contin. 7 “Property Casualty Insurers Benefit From Drop In Catastrophe Losses,” Property Casualty Insurers Association of America, October 4, 2012, http://www.pciaa.net/LegTrack/web/NAIIPublications.nsf/ lookupwebcontent/4003FCCDBDDDB35186257A8E006C244?opendocument. 8 The Dodd-Frank Wall Street Reform and Consumer Protection Act requires insurers to comply with data requests on sales, customer location, etc. from the Federal Insurance Office (FIO), Office of Financial Research (OFR), in addition to state regulators. Further, insurers with more than $50 billion in assets are identified as systematically important financial institutions (SIFI) and have to comply with heightened regulations. This means big insurers must rewire their legacy systems to create more effective reporting mechanisms, which is expensive and can result in a competitive disadvantage when compared with smaller insurance companies. 9 Scheduled to come into effect on January 1, 2014, Solvency II requires U.S. insurers operating in the European Union to comply with the regime’s new risk management and reporting and account- ing standards. Meeting the data requirements and reporting frequency of Solvency II requires U.S. insurers to invest in revamping and consolidating existing IT systems. 10 “Sandy May Cost Insurers Up To $25 Billion,” The Wall Street Journal, November 14, 2012, http://online. wsj.com/article/SB10001424127887324735104578119301366617508.html. 11 “Predictive Analytics: A Powerful Weapon In Fight Against Fraud,” PropertyCasualty360, April 4, 2011, http://www.propertycasualty360.com/2011/04/04/predictive-analytics-a-powerful-weapon-in-fight-ag. 12 “Join NICB,” NICB, https://www.nicb.org/about-nicb/join_nicb. 13 “The State of Insurance Fraud Technology,” SAS Institute, September 2012, http://www.sas.com/reg/ wp/corp/50373. 14 “The State of Insurance Fraud Technology,” Coalition Against Insurance Fraud, September 2012, http://www.insurancefraud.org/downloads/techStudy_2012.pdf. 15 “Predictive Analytics Can End the Isolation,” PropertyCasualty360, October 1, 2012, http://www. propertycasualty360.com/2012/10/01/predictive-analytics-can-end-the-isolation. 16 Ibid. 17 “Using IBM Analytics, Santam Saves $2.4 Million in Fraudulent Claims,” IBM, May 9, 2012, http:// www-03.ibm.com/press/us/en/pressrelease/37653.wss. cognizant reports 9
  • 10. 18 “Operationalizing a Fraud Detection Solution: Buy or Build?” Insurance & Technology, August 20, 2012, http://www.insurancetech.com/business-intelligence/operationalizing-a-fraud-detection-solut/ 240005814. “Data Storage: Managing Unstructured Data in the Cloud: 12 Factors to Consider,” July 27, 2011, eWeek, 19 http://www.eweek.com/c/a/Data-Storage/Managing-Unstructured-Data-in-the-Cloud-12-Factors-to- Consider-215018/. 20 igital data, the majority of which is unstructured data, is expected to grow from 130 exabytes to D 40,000 exabytes between 2005 and 2020, according to a 2012 survey by IDC and EMC. References • “Uncertainty Weighs Down U.S. Insurers,” Life Insurance International, July 2012, http://www. goldbergsegalla.com/sites/default/files/uploads/JW_LifeInsuranceInternational_July2012.pdf. • “You Know There Are Fraudulent Claims. Let’s Find Them Now,” Statsoft, 2011, http://www.statsoft. com/portals/0/solutions/StatSoft_InsuranceFraud_Brochurev.pdf. • “The Three Best Targets For Attacking P&C Insurance Fraud,” FICO, September 2010, http://www.efma. com/efmaweb_files/file/Partnerships/Fico_Insights44_Insurance_Fraud.pdf. • “Driving Operational Excellence in Claims Management,” February 2011, http://www.deloitte. com/assets/Dcom-UnitedStates/Local%20Assets/Documents/FSI/US_FSI_DrivingOperational ExcellenceInClaimsManagement_022311.pdf. • “Advanced ‘Big Data’ Analytics with R and Hadoop,” Revolution Analytics, 2011, http://www.revolution- analytics.com/why-revolution-r/whitepapers/R-and-Hadoop-Big-Data-Analytics.pdf. • “Identify Claims Fraud with Advanced Analytics: Uncover Fraud that Traditional Methods Cannot Find,” FICO, November 1, 2011, http://www.fico.com/en/FIResourcesLibrary/NewYorkInsuranceForum2011-3_ Identify_Insurance_Claims_Fraud.pdf. • “Fraud Detection Acid Test,” SAS Institute, October 4, 2012, http://www.sas.com/knowledge-exchange/ risk/fraud-financial-crimes/fraud-detection-acid-test/index.html. cognizant reports 10
  • 11. Credits Author Vinaya Kumar Mylavarapu, Senior Research Associate, Cognizant Research Center Subject Matter Expert Nipun Kapur, Director and Head of Analytics COE, Cognizant Analytics Design Harleen Bhatia, Creative Director Suresh Sambandhan, Designer About Cognizant Cognizant (NASDAQ: CTSH) is a leading provider of information technology, consulting, and business process outsourcing services, dedicated to helping the world’s leading companies build stronger businesses. Headquartered in Teaneck, New Jersey (U.S.), Cognizant combines a passion for client satisfaction, technology innovation, deep in- dustry and business process expertise, and a global, collaborative workforce that embodies the future of work. With over 50 delivery centers worldwide and approximately 150,400 employees as of September 30, 2012, Cognizant is a member of the NASDAQ-100, the S&P 500, the Forbes Global 2000, and the Fortune 500 and is ranked among the top performing and fastest growing companies in the world. Visit us online at www.cognizant.com for more information. World Headquarters European Headquarters India Operations Headquarters 500 Frank W. Burr Blvd. 1 Kingdom Street #5/535, Old Mahabalipuram Road Teaneck, NJ 07666 USA Paddington Central Okkiyam Pettai, Thoraipakkam Phone: +1 201 801 0233 London W2 6BD Chennai, 600 096 India Fax: +1 201 801 0243 Phone: +44 (0) 207 297 7600 Phone: +91 (0) 44 4209 6000 Toll Free: +1 888 937 3277 Fax: +44 (0) 207 121 0102 Fax: +91 (0) 44 4209 6060 Email: inquiry@cognizant.com Email: infouk@cognizant.com Email: inquiryindia@cognizant.com © ­­ Copyright 2012, Cognizant. All rights reserved. No part of this document may be reproduced, stored in a retrieval system, transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the express written permission from Cognizant. The information contained herein is subject to change without notice. All other trademarks mentioned herein are the property of their respective owners.