White Paper
The New Face of Insurance Fraud Looks Just Like a Legitimate Claim
White Paper Summary
Every week, my team reviews claims that look, on the surface, like open-and-shut cases. The injury is plausible. The treatment records are in order. The documentation is clean. And increasingly, that’s precisely the problem.
The question we’ve had to learn how to ask is whether it’s actually real or just posing as legitimate enough to move through the system. In today’s fraud environment, the line between the two is blurring fast.
I’ve spent most of my career in technology and analytics, and I’d argue that the current moment is the most consequential shift I’ve seen in how fraud operates. Three forces are converging at the same time: AI tools that make document fabrication inexpensive and convincing; digital claims workflows that compress the window between submission and payment; and increasingly coordinated fraud networks that have mapped the detection gaps and built their schemes around them.
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