investigations in data heavy industries...• extract claims data processed by alleged fraudster =...
TRANSCRIPT
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PRESENTED BY: JERRY CHETTY
INVESTIGATIONS IN DATA HEAVY INDUSTRIES
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What is data heavy industries?
2/13/2018
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Fraud by numbers
• Health care R22 billion
• Card fraud R600 million
• Cybercrime R35 billion
• Short-Insurance R2-3 billion
• Inflated costs R233 billion
• Long-term insurance R870 million
2/13/2018
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Some facts about fraudsters
2/13/2018
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Fraudsters gather intelligence
2/13/2018
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An investigator’s ME time
2/13/2018
What are the latest fraud trends?
What are the red flags?
What did we learn from the last fraud?
How difficult can we make it for
fraudster?
What intel do we have on suspects?
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What is data heavy industries?
2/13/2018
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Imagine conducting an investigation here!
2/13/2018
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PHYSICAL EVIDENCE VS.
EVIDENCE IN DATA
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Sherlock Holmes vs Data mentalist
2/13/2018
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2/13/2018
Life is all about how
we see things
&
Sometimes we can
only see one thing
at a time
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2/13/2018
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Who would you
employ?
2/13/2018
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Suggested approach
2/13/2018
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2/13/2018
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Insurance and it’s complex model
4. CLAIMS
PROCESS
SOS
INTER-
MEDIARY
INFLATED
FALSE CLAIMS
BACKDATING OF
COVER
CHANGING
CIRCUMSTANCES
OF CLAIMS
SUBMIT FALSE
CLAIMS ON
CLIENTS POLICY
2. ISSUE
POLICY
3. PAY
PREMIUM
DEBIT
ORDER
(D/O)
INTER-
MEDIARY
THEFT OF
PREMIUMS
CONTRAVENTION
OF S45 of STI
1. SELL
COVER
CONTACT
CENTRE
SANTAM
MANDA-
TED
INTER-
MEDIARY
PREVIOUS
CLAIMS
SECURITY
REQUIREMENTS
UNDERWRITING
FRAUD
FRAUD
MATERIAL
AFFECTS FACTS
PREMIUM
UNDERWRITING
FRAUD
5. ASSESOR
INTERNAL EXTERNAL
6. SERVICE
PROVIDER
CORRUPTION
FALSE INVOICES
INFLATED
REPAIR COSTS
(FALSE CLAIMS)
INFERIOR
REPAIRS
SUPPLIER
FRONTING
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Methods of committing fraud in the insurance
industry?
1 Opportunistic crime
One person
Random act High incident
Low rand value
Low incident
High rand
value
2
Organised crime
One or more people
Elaborate
scheme with
an element of
collusion
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Our case study – Investigating in big data
1 incident = R21 000
Evidence to prove
Great case solved
or is it?
Examine all claims:
records
Traditional tests =
zero results
Profile fraudster
What’s in a surname?
R1.8m
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Our case study – Investigating in numbers
FRAUDULENT THIRD PARTY CLAIMS
• R22 000 only one incident
• Sufficient evidence to prove this
• Great case solved!
• Or is it?
• Extract claims data processed by alleged fraudster = lines (Overwhelming)
• Traditional analysis = Investigation = zero results (Frustration)
• Profile existing fraudulent transaction and alleged fraudster
• Refine analysis = investigation = What’s in a surname? = R1.4m
DOES LIGHTNING STRIKE IN THE SAME PLACE TWICE?
• Extract claims data for entire department = lines
• Analysis = Investigation = R1.2m fraud
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Learning's • Huge opportunity for using data in investigations
• Uncover more fraud
• Provides most accurate financial impact of fraud incident
• Develop detective and proactive anti fraud strategies
• Results from any form of data analysis does not prove FRAUD
• Still need hard-core investigations
• Need the skill of both an investigator and the data mentalist – collaborative effort
• Using one person to execute both functions is NOT a collaborative effort
• Data heavy is the way of the future – need to embrace its usefulness
FRAUDSTERS DO!
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Hiding within
those mounds of
data is knowledge
that could change
the life of a
patient, or change
the world.”
Atul Butte, Stanford School
of Medicine
“Without big data,
you are blind and
deaf in the middle
of a freeway”
Geoffrey Moore,
management consultant
and theorist
“Information is
the oil of the 21st
century, and
analytics is the
combustion
engine.”
Peter Sondergaard,
Gartner Research
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QUESTIONS
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