SIU Referral Workflow
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Quick Answer
The SIU Referral Workflow uses AI to detect fraud indicators in claims and route suspicious cases to Special Investigation Units. AI analyzes claim patterns, documentation consistency, claimant history, and behavioral red flags to identify potential fraud—reducing false positives while catching schemes that might escape manual review.
Definition
Key Points
- Analyzes claims for fraud indicators across multiple dimensions
- Reduces false positive referrals vs. rule-based systems
- Detects organized fraud rings through network analysis
- Monitors claims activity for post-FNOL fraud indicators
- Prioritizes referrals by fraud risk score and claim value
- Preserves evidence and documents red flags automatically
- Integrates with fraud databases and external data sources
- Catches fraud that manual review might miss in high-volume environments
How It Works
Multi-Dimensional Analysis
Analyze claim across dimensions: timing, claimant history, documentation, witness behavior, damage consistency, provider patterns.
Pattern Recognition
Compare against known fraud patterns: staged accidents, inflated damages, phantom injuries, provider kickback schemes.
Network Analysis
Identify connections to known fraud rings: shared addresses, common providers, collision patterns, coordinated timing.
Documentation Review
Evaluate documentation inconsistencies: photo anomalies, conflicting statements, forged signatures, suspicious repair estimates.
Fraud Score Calculation
Calculate fraud risk score (0-100) weighing multiple indicators. Scores >75 trigger automatic SIU referral.
Evidence Package Creation
Compile evidence: flagged indicators, supporting data, linked claims, external database hits, timeline of events.
SIU Assignment
Route to SIU with priority based on fraud risk, claim value, and urgency. Notify adjuster to preserve evidence.
Continuous Monitoring
Continue monitoring claim activity. Flag new indicators that emerge during claim lifecycle.
Common Fraud Indicators
- ⚠Claim filed shortly after policy inception or reinstatement
- ⚠Claimant has history of frequent claims
- ⚠Accident occurred in known fraud hotspot area
- ⚠Multiple parties involved with shared addresses or relationships
- ⚠Documentation inconsistencies or suspicious timing
- ⚠Injuries inconsistent with described accident severity
- ⚠Damage estimates significantly exceed typical costs
- ⚠Claimant uses provider known for inflated billing
- ⚠Witness statements conflict with physical evidence
- ⚠Claimant resistant to recorded statements or examination