The Association of Certified Fraud Examiners (ACFE) expects 2015 to be the year “technology gives fraudsters an edge.” Not only does the association believe fraudsters will tip the scales in their favor this year, but it believes the sophistication of schemes is likely to increase, giving program administers and IT staffs headaches.
“More and more we are reacting to reports of fraud with, ‘how did they do that?’” said Managing Director – Global Forensics for BDO Consulting Gerard Zack. “It’s a reflection of schemes becoming more complex and capitalizing on technology, including some of the new technology deployed by companies in the interest of improving efficiency. While simple frauds still exist, we are seeing a distinct proliferation of more complex fraud schemes.”
Zack also explains, however, that technology is a double-edged sword. While technology can enable certain schemes, investment in counter-technology by industry can be leveraged to prevent and catch perpetrators. “There will be more breakthroughs in the use of technology to detect fraud – particularly in the use of visual analytics and also in the use of tools to mine unstructured data,” explained Zack. “Tools that were thought of as cutting-edge just a year or two ago will seem ancient in another year or two.”
That’s where CNSI is able to help. More than ever, it is important to prevent fraud by utilizing state-of-the-art technology, especially when it comes to massive government health care programs. Conservative estimates put the amount of insurance fraud in health care each year around $50 billion.
Software and technology developed by CNSI in the past few years have provided a means to detect fraud as soon as a claim is filed. But to further improve fraud response, CNSI has also created solutions that are able to analyze big data, using the visual analytics and data mining that ACFE envisions, to predict which claims will be fraudulent.
The use of key data elements within a claim administration system assists in the production of detailed characterizations of every claim. The technology automatically reviews claim characteristics and identifies claims that fit historical patterns of fraud, and detects fraud by recognizing differences between valid and fraudulent claims. The system completes processing of inputs and produces fraud-risk scores and explanations, with the higher scores indicating a higher risk that the claim is currently fraudulent.
Solutions like this will help prove ACFE’s prediction in favor of the fraudsters wrong by allowing governments and companies to stay at least one step ahead. In the meantime, we’ll be hard at work developing the next breakthrough.