Insurance Claims Fraud Detection & Analysis
Detect insurance claim fraud through systematic pattern analysis and forensic investigation
What You Can Do
You systematically extract financial red flags from claim submissions, construct causal narratives linking evidence to fraud conclusions, and quantify potential loss exposure. This skill helps you distinguish between legitimate claim variations and fraud indicators, enabling you to generate investigation summaries defensible in litigation, settlement negotiations, or Special Investigation Unit (SIU) presentations.
Features
Automatically identify suspicious patterns across claim documentation, timeline inconsistencies, and financial anomalies
Calculate exposure amounts and potential fraud-related damages with forensic precision
Build legally defensible causal chains linking evidence directly to fraud conclusions
Compare multiple claims from the same claimant to detect systemic fraud schemes
Analyze business interruption, inventory, and casualty claims for inflated valuations or misrepresentation
Identify discrepancies between incident date, discovery, reporting, and claim submission
Generate structured investigation summaries formatted for coverage counsel and Special Investigation Unit presentation
Cross-reference claimant financial records against claimed damages for supporting documentation gaps
Example Output
Example 1: Staged Casualty Claim
- Red Flags Identified: Loss reported 3 days after policy inception; claimant's prior claims history shows 2 similar incidents in 18 months; supporting invoices use generic vendors with no contact verification
- Fraud Exposure: $125,000 (estimated replacement cost vs. salvage value)
- Narrative: Claimant pattern indicates serial filer with accelerated claim timeline relative to coverage inception, suggesting pre-planned loss scenario
Example 2: Inventory Inflation
- Red Flags Identified: Claimed inventory ($450K) exceeds 12-month average by 340%; tax returns show lower reported values; no independent appraisal provided
- Fraud Exposure: $280,000 (difference between claimed and verifiable inventory)
- Narrative: Financial records demonstrate systematic overstatement of inventory values, with claimed loss significantly exceeding IRS-reported amounts for same period
What's Included
- SKILL.md: Core instruction file with fraud detection methodology and investigative framework
- Red Flag Checklist: Comprehensive list of 50+ indicators across claim types, timeline analysis, and documentation gaps
- Fraud Exposure Quantification Template: Structured worksheet for calculating loss amounts, comparison benchmarks, and valuation discrepancies
- Forensic Narrative Framework: Step-by-step guide for constructing causal chains from evidence to conclusions with legal defensibility standards
- Pattern Analysis Matrix: Comparative tool for identifying systemic fraud schemes across multiple claims from same claimant
Who It's For
- Forensic Accountants — Conducting structured claim investigations with litigation-ready documentation
- Claims Adjusters & Investigators — Systematically analyzing claim submissions for fraud indicators before approval
- Special Investigation Units (SIU) — Building defensible cases for coverage denial or fraud referral
- Coverage Counsel & Attorneys — Developing fact patterns and quantified exposure for settlement or legal proceedings
- Risk Managers — Identifying systemic fraud schemes and claimant patterns across claim portfolios
Best For
- Detecting staged casualty and property claims with timeline inconsistencies
- Analyzing business interruption and inventory claims for valuation inflation
- Identifying serial filers and systemic fraud patterns across multiple claims
- Quantifying fraud exposure and calculating defensible loss amounts
- Constructing forensic narratives for litigation, SIU presentation, or settlement negotiation
- Verifying claimant financial records against claimed damages and lifestyle consistency
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