ISO Enhancing Claims-Scoring System to Score WC Claims

Insurance Services Office, Inc. (ISO) is enhancing its ClaimDirectorSM claims-scoring service to score workers compensation claims — at first notice of loss and throughout the life of the claim.

ISO’s ClaimDirector, which already scores personal auto liability claims, is a fraud-fighting resource that analyzes claim attributes and industrywide claims histories, including workers’ compensation claims, to produce a claims-handling score for insurers and other entities involved in claims management.

As part of the ISO ClaimSearch’ suite of claims information products, ClaimDirector streamlines the claims-handling workflow and assists with loss assignment based on claim characteristics. ClaimDirector enables adjusters to expedite payment of legitimate claims and improve the quality of referrals to the special investigations unit (SIU).

ClaimDirector is an expert, rules-based claims-scoring system for claims handling — not an underwriting tool. The service assigns each claim a numerical score, ranging between 0 and 999. A high score means the presence of characteristics indicating the possibility of fraud. ClaimDirector analyzes the attributes of the claim and information from any matching claims in the database and compares those attributes against proven fraud indicators appropriate to the claim.

The service returns a result report with the score, information on the basis of the score, information on claim characteristics used for loss assignment, and a full match report. As updates to a claim are submitted to the ISO ClaimSearch database, insurers receive the most current score.

ClaimDirector is a flexible tool delivered with sets of default values for many elements, including weights applied to fraud indicators and loss assignment, and claims-handling characteristics. Companies can customize ClaimDirector’s scoring methodology to suit their organizational needs.

ClaimDirector can also flag claims according to a variety of data sources and advisory lists, including a list of case principals from NICB investigations. Claim departments can establish an e-mail system to notify SIU or other designated claim professionals of claims that require immediate attention.

Designed by ISO experts, industry claims and antifraud personnel, and National Insurance Crime Bureau (NICB) fraud investigators, ClaimDirector can help companies enhance productivity, improve fraud detection, reduce loss adjustment expenses and increase profitability.

ClaimDirector will issue detailed reports on workers’ compensation scoring activity and score levels by the office submitting the claim. This allows authorized claims-management personnel to view claim summary reports by group, company and office to evaluate the overall company experience, including trending information for advanced analysis.

In the coming months, ClaimDirector will add scoring of other types of personal and commercial claims, including homeowners, general liability, commercial auto liability and personal auto physical damage.