Insurance & Claims// topic
Claims Handling, Fraud Flags and Recovery
In short
What happens after assignment: adjuster workload and diary, reserves and estimate review, fraud red flags and SIU referral, subrogation identification, and the payment and recovery steps that actually close a file.
6 pages
definitions
- Claims leakage: what the term actually counts, and what it quietly cannotLeakage is a subtraction where 1 of the 2 numbers came from a reviewer imagining a file that never happened. The standard is part of the answer.definition6 min
- Subrogation referral: the facts a file needs before recovery is possibleRecovery teams argue about which files deserve attention. The argument disappears once referability is written as 4 conditions, each pointing at a field.definition6 min
- The claim diary: a scheduling primitive, not a to-do listA diary entry is a dated obligation with an owner, an escalation target and a condition that says when it is met. Without that condition it is a reminder, and reminders leave files untouched.definition6 min
diagnostics
- Fraud indicators fire on a third of the book and nobody reads them any moreInvestigators ignoring alerts is the symptom. The finding underneath is almost always that nobody can say what any single indicator's firing rate buys in accepted referrals.diagnostic9 min
- Reserves get set in the first week and never move until the file closesA reserve that has not moved in nine months is not a stable claim. It is an unasked question, and the repair is a set of file-event triggers rather than a better first estimate.diagnostic10 min
- The oldest and newest files move; the ones in the middle of a caseload stopNew files move because a clock is running and old files move because someone escalated them. The band in between has no forcing function at all, and that is where inventory quietly accumulates.diagnostic10 min
Other topics in Insurance & Claims
See allClaims Intake, FNOL and TriageEverything between the loss happening and the file reaching the right queue: how notice arrives, what gets captured at first touch, and how a claim is scored, routed and clocked before an adjuster ever opens it.9 pagesThe Forms: Extraction and ClassificationThe artifacts insurance runs on — ACORD applications, declaration pages, loss runs, endorsements, schedules and carrier supplements — treated as engineering objects, with the structural quirks that make generic extraction fail on each of them.3 pages
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