Premium Fraud – Piano Tuners and Window Washers?

Posted by Douglas Wood, Editor.

I came across a news article earlier this week regarding a business owner convicted of fraudulently avoiding worker’s compensation premiums. The link to that news article is below.

It brought to mind some fascinating work I was involved with a few years ago to help a state run Worker’s Compensation Bureau more effectively detect this kind of fraud.  Their biggest concern was recovering monies owed by companies who illegally misrepresent themselves for the purpose of reducing or avoiding the payment of premiums. Here’s how these scams work…

Intentional Misclassification: A crooked business claims that employees work safer jobs than they really do. Perhaps a high-rise window washer is falsely classified as a piano tuner. Much lower premiums, obviously.

Employee Misrepresentation: A business says it has fewer employees or a lower payroll than it actually does.

Coverage Avoidance/Experience Modification: A business simply doesn’t buy the required insurance, hoping state officials won’t notice. If the state learns of the avoidance, the company will simply close, then re-emerge as a ‘new’ company’ in order to avoid the payments.

So the state bureau I worked with needed to understand when, for example, a ‘piano tuner’ was requesting a permit for high rise window washing. Red flag, right?  Or when an five separate claims were filed by employees of a company who stated they had only 3 employees. Another red flag.

Oh, and what about a new company registrant whose owners, address, telephone number, and line of business are all suspiciously similar to those of a recently closed business who owed thousands of dollars in back premiums. BIG red flag.

The state itself had all of the data it needed to detect this fraud. The problem, as is often the case, is that the data sat in different jurisdictions. Working with our client, we helped those other jurisdictions – Business Registrations, Building Permits, Tax Departments, etc. – understand the value of sharing that data. That’s the key to this success story – data sharing. Without it, problems are much more difficult to solve.

Ultimately, we delivered a system that included business rules, anomaly detection, and social network analysis.  It provided the bureau with the ability to flag those anomalies using their existing data infrastructure and fraud alert output from those other state agencies.

With the tools in place to trigger those red flags, the agency immediately began recovering lost premiums, prosecuting offenders, and ultimately adding much needed revenue to the state coffers.

Fraudsters who choose to commit financial crimes are always coming up with new scams. Those of us committed to delivering true technology innovations through data sharing are starting to put a real dent in their chosen profession, though.

Maybe they can tune pianos instead. Do they need a building permit for that?

http://www.workerscompensation.com/compnewsnetwork/mobile/news/17511-investigation-leads-to-conviction-of-ca-business-owner-for-insurance-fraud.htmlgus

Posted by Douglas G. Wood. Click on ABOUT for more information and follow Financial Crimes Weekly on Twitter @FightFinCrime


Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s