Tools for Fighting Fraud Come of Age

Insurance fraud, that ever-present nemesis of claims professionals, has a new opponent. A technology triple threat—the Internet, extensive and accessible databases and the pervasiveness of social media—has come of age, and the result is an increased exposure of workers’ compensation fraud and a rise in prosecutions. As with many industries, the tools used in fighting fraud have evolved over the years, and today’s high-tech resources are completely different from the tools employed a mere 20 years ago. In the pre-Internet era, employers and insurance industry professionals who suspected potential workers’ compensation fraud had limited, and often expensive, options to gather evidence. Even the initial paperwork was more cumbersome. The adjuster would first complete a hand-written referral form requesting investigative services, which would slowly pass through the fax machine to materialize in the investigator’s office. That’s much different from today’s data integration of claim systems with investigative partners, where a click of a button auto-fills the referral form, and the complete claim file is populated into the investigative company’s web-based case management system. For surveillance conducted pre-Internet, the investigator would review the Thomas Brothers map, load the large VHS video camera and extra batteries in the van and drive to the subject’s last known residence to roll the dice on filming the correct person. Employers were not able to email photos of employees, and there were no online social networks to locate vacation photos and other important information. Going From Print and Tape to Digital Today’s technology allows those fighting fraud to conduct a more comprehensive pre-surveillance investigation than they could have been imagined just a few years ago. Mapping technology provides a clear visual of the subject’s residence and surrounding neighborhood. This allows the investigator to create a detailed surveillance plan including routes, local and covert tail opportunities and other strategies. Online database searches, Department of Motor Vehicle records and social networking searches provide a plethora of information. Additional tools such as GPS tracking and video streaming also have improved the success rate of surveillance. Today’s video cameras do not resemble their older brothers from the '90s. The heavy cameras of the past were best used with a tripod to hold the weight, making quick maneuvers difficult. Getting out of the vehicle to obtain film from an on-foot pursuit was extremely challenging. A large duffle bag with a hole cut in the end for the lens was hard to keep clandestine approach. And covert cameras lacked the quality needed to prove identity. Today’s compact, powerful, digital HD video cameras provide high-quality video and fit comfortably in one hand. Additionally, current covert cameras are undetectable—the camera lens can easily be part of a hat, a shirt button or a keychain. Significantly, these tiny video cameras can capture clear footage almost on par with film obtained using a standard video camera. In addition to the VHS video camera, the tools of the trade back then included a pager, a heavy cellular phone with a large antenna, a stack of phone books, a shoebox full of maps, several proven pretext scenarios and, most importantly, a Rolodex. Information that we now find on the Internet certainly was obtainable before the Internet-era, but it had to be acquired with different and often creative methods. Digging for Information While investigators today have Internet connection in their vehicles and can quickly conduct database and social network searches while onsite, the pre-Internet investigator’s most valuable tool was relationships, as information was shared by people, not technology. The investigator often had little information about the subject upon initiation of the investigation and gathered details the old school way—by digging. Investigators could be found reviewing records at the voter registration office or scanning microfiche at the court to ascertain critical information. They spent a lot of time standing in lines at public agencies and searching through endless records stored in large ledgers, microfiche or index card catalogs. The information found in public records was invaluable—current and former addresses, real property data, encumbrances, marriage licenses, divorce records, birth certificates, bankruptcies, criminal records, traffic tickets, tax liens, civil lawsuits, evictions, business licenses, professional licenses and more. While this information was vital, it was tedious work retrieving it, especially if the subject had a common name or a maiden name or aliases. Successful investigators had to be not only good at investigation, they also had to be successful at establishing connections to build a Rolodex of contacts. An effective investigator leveraged strategic connections to successfully and quickly gather information. Making connections with the people who worked in the records departments of courts, law enforcement agencies, recorder’s office, voter registration, licensing bureaus and the like, then gathering phone numbers that rang directly to desks, was essential to efficiently obtain vital information. Likewise, networking with fellow investigators in other areas to trade resources saves time. Gaining Public and Private Details Public records have always been a critical source for identifying information, financial information, business records, criminal records, civil litigation records and the like. However, those records did not provide the personal insight that we can find on the Internet. Today, a search of social networking can yield information, insight and often photographic evidence of a subject’s habits, activities, interests, schedules and behavior. If obtained legally and ethically and stored appropriately for chain of custody, this online evidence can be submitted to medical providers and the Workers’ Compensation Board and used as evidence in Superior Court, including in criminal cases of workers’ compensation fraud. To learn personal information pre-Internet, one needed connections and creative sleuthing talent. Delivery companies, utilities, contest and sweepstakes promoters, magazines, debt collection agencies, credit reporting agencies, retail and catalog ordering companies often made additional revenue by selling their customers’ personal data. Today, calling people to obtain information has been replaced with Internet searches. Several companies provide database services, including instant access to credit reporting agencies, public records, utility company records and other information. Now, what previously took many hours, if not days, of phone calls and in-person searches and cost a significant amount is accomplished in mere seconds. Pretexting—the practice of presenting oneself as someone else to obtain private information—is one strategy that has carried over from pre-Internet days. Indeed, it was all but impossible to conduct a successful investigation without it before the Internet, and it remains useful today. Pretexting is legal in many states, and investigators have historically used it to obtain needed information. A successful pretext call results in a willingness by the subject or other source to share information and, if done correctly, leaves no footprint behind, so the people are never aware they spoke to an investigator. The successful investigator uses a combination of old and new to navigate today’s complex world of insurance fraud. Pretexting still works in some cases, relationships always will matter and technology continues to evolve and to provide even better data. Workers’ compensation fraud will, unfortunately, always be with us. However, old, new and yet-to-be developed techniques will bring that fraud to light, resulting in a better system for us all. See Darlene's interview here.