Date: October 29, 2013
Regarding: First 3 Quarters of 2011, 2012, 2013 Questionable Claim Referral Reason Analysis
Prepared By: David Fennig, Strategic Analyst
(Public Dissemination)
Executive Summary
An analysis of the National Insurance Crime Bureau (NICB) First 3 Quarters (Q1-Q3) of 2011, 2012, 2013
Questionable Claim (QC) referrals was performed to compare Property, Casualty, Commercial, Workers’
Compensation, Vehicle, and Miscellaneous QC referral reasons. Comparing the First 3 Quarters of 2012 and
2013, Casualty, Workers’ Compensation, Vehicle, and Miscellaneous showed increases, while Commercial
referral reasons showed a slight decrease and Property referral reasons showed no statistical change. Data
note: The QC referral database is a dynamic dataset. As such, claims in ISO ClaimSearch may be
voided, while others may be updated at any time.
During the First 3 quarters of 2011, there were 74,944 QCs. During the First 3 Quarters of 2012, that number
increased to 87,684. It increased again during the First 3 Quarters of 2013 to 93,053 QCs. Overall, comparing
the First 3 Quarters of 2011 and the First 3 Quarters of 2013, the numbers of QC’s increased 24%. It should
be noted that a single QC can contain up to seven different referral reasons.
Questionable Claims
First 3 Quarters 2011, 2012, 2013
100,000
90,000
87,684
80,000
70,000
60,000
93,053
74,944
50,000
40,000
30,000
20,000
10,000
0
First 3 Quarters 2011
First 3 Quarters 2012
First 3 Quarters 2013
First 3 Quarters 2011, 2012, 2013 Referral Reason Analysis
10/29/2013
Page 2 of 9
Comparing the First 3 Quarters 2012 to the First 3 Quarters 2013, the Miscellaneous category had the highest
increase in volume and the highest percentage increase. For a single referral reason, Medical Provider
referrals in the Miscellaneous category had the largest increase in volume, as well as the highest percentage
increase.
Referral Reason Distribution
First 3 Quarters 2011, 2012, 2013 Property QC Referral Reasons
Property QC
Referral Reason
Flood/Water
Damage
Inflated Damage
Q1-Q3
2011
Q1-Q3
2012
Difference
%
Change
Q1-Q3
2012
Q1-Q3
2013
Difference
%
Change
706
867
161
23%
867
1,050
183
21%
2,274
2,750
476
21%
2,750
2,877
127
5%
Fire/Arson
1,441
1,433
-8
-1%
1,433
1,481
48
3%
Suspicious Theft/
Loss (Not Vehicle)
5,100
7,834
2,734
54%
7,834
7,887
53
1%
Suspicious
Disappearance/
Loss of Jewelry
1,498
2,804
1,306
87%
2,804
2,578
-226
-8%
Hail Damage
861
1,035
174
20%
1,035
847
-188
-18%
Total Property QC
Referral Reasons
11,880
16,723
4,843
41%
16,723
16,720
-3
0%
Overall, Property QC referral reasons had no significant change when comparing the First 3 Quarters 2012 to
the First 3 Quarters 2013. This is significant because for the First 3 Quarters 2011 to the First 3 Quarters 2012,
Property QC referral reasons increased overall by 41%. Moreover, in the First 3 Quarters 2011 and the First 3
Quarters 2012, all but 1 of the referral categories displayed an increase. For the First 3 Quarters 2012 and the
First 3 Quarters 2013, 2 categories showed a negative percentage change. Flood/Water Damage referrals
showed the highest percent increase with a 21% increase from the First 3 Quarters 2012 to the First 3
Quarters 2013.
First 3 Quarters 2011, 2012, 2013 Referral Reason Analysis
10/29/2013
Page 3 of 9
First 3 Quarters 2011, 2012, 2013 Casualty QC Referral Reasons
Casualty QC Referral
Reason
Q1-Q3
2011
Q1-Q3
2012
Difference
%
Change
Q1-Q3
2012
Q1-Q3
2013
Difference
%
Change
Duplicate Billing
317
373
56
18%
373
470
97
26%
Unbundling/Upcoding
1,172
2,137
965
82%
2,137
2,567
430
20%
Inflated Billing
Solicitation
(Chasers and Cappers)
2,749
3,236
487
18%
3,236
3,773
537
17%
1,066
1,054
-12
-1%
1,054
1,202
148
14%
Jump-in
1,657
1,857
200
12%
1,857
1,984
127
7%
Billing for Services
Not Rendered
4,139
4,306
167
4%
4,306
4,404
98
2%
Excessive Treatment
Faked/Exaggerated
Injury
Prior Injuries
6,403
6,634
231
4%
6,634
6,718
84
1%
13,030
13,868
838
6%
13,868
13,423
-445
-3%
3,795
4,038
243
6%
4,038
3,867
-171
-4%
Slip and Fall
1,199
1,258
59
5%
1,258
1,157
-101
-8%
Staged/Caused Accident
Provider/Facility
Improperly
Licensed (IL)/
Incorporated
4,343
4,500
157
4%
4,500
4,035
-465
-10%
630
987
357
57%
987
876
-111
-11%
40,500
44,248
3,748
9%
44,248
44,476
228
1%
Total Casualty QC
Referral Reasons
Overall, Casualty QC referral reasons increased 1% from the First 3 Quarters 2012 to First 3 Quarters 2013.
Prior Injuries, Faked/Exaggerated Injury, Staged/Caused Accident, Slip and Fall, and Provider/Facility
Improperly Licensed (IL)/Incorporated referrals showed a percentage decrease between the First 3 Quarters
First 3 Quarters 2011, 2012, 2013 Referral Reason Analysis
10/29/2013
Page 4 of 9
2012 and First 3 Quarters 2013, though Faked/Exaggerated Injury referrals continues to display the highest
volume for any individual referral reason. Duplicate Billing, Unbundling/Upcoding, Inflated Billing, Solicitation
(Cappers and Chasers), and Jump-In referrals respectively topped the above table.
First 3 Quarters 2011, 2012, 2013 Commercial QC Referral Reasons
Commercial QC
Referral Reason
Q1-Q3
2011
Q1-Q3
2012
Difference
%
Change
Q1-Q3
2012
Q1-Q3
2013
Difference
%
Change
Construction/Farm/Heavy
Equipment (Not Theft)
26
17
-9
-35%
17
26
9
53%
Vehicle Theft
93
103
10
11%
103
120
17
17%
Inflated Inventory
139
177
38
27%
177
168
-9
-5%
Theft (Not Vehicle)
Suspicious Foreign
Object in Food
Slip and Fall
278
380
102
37%
380
335
-45
-12%
149
193
44
30%
193
163
-30
-16%
489
585
96
20%
585
492
-93
-16%
Fire/Arson
58
80
22
38%
80
63
-17
-21%
False/Inflated
Business Interruption
67
102
35
52%
102
80
-22
-22%
Product Liability
70
91
21
30%
91
71
-20
-22%
Cargo Theft
50
45
-5
-10%
45
35
-10
-22%
Farm Loss
7
9
2
29%
9
3
-6
-67%
Total Commercial QC
Referral Reasons
1,426
1,782
356
25%
1,782
1,556
-226
-13%
First 3 Quarters 2011, 2012, 2013 Referral Reason Analysis
10/29/2013
Page 5 of 9
Commercial QC referral reasons decreased in volume in 9 out of 11 categories when comparing the First 3
Quarters 2012 and the First 3 Quarters 2013. Commercial QC referral reasons decreased overall by 13%.
Construction/Farm/Heavy Equipment (Not Theft) referrals had the highest percentage increase in the category.
By volume, it only increased by 9, from 17 to 26.
First 3 Quarters 2011, 2012, 2013 Workers’ Compensation QC Referral Reasons
Workers' Compensation
QC Referral Reason
Q1-Q3
2011
Q1-Q3
2012
Difference
%
Change
Q1-Q3
2012
Q1-Q3
2013
Difference
%
Change
Disability
149
160
11
7%
160
253
93
58%
False SSN
False Mileage
Reimbursement
Working While Collecting
173
127
-46
-27%
127
178
51
40%
6
8
2
33%
8
11
3
38%
319
311
-8
-3%
311
389
78
25%
False Loss of Wages
Prior Injury/Not Related to
Work
False Loss Statements
141
127
-14
-10%
127
151
24
19%
631
800
169
27%
800
834
34
4%
257
342
85
33%
342
356
14
4%
X-Mod Evasion
2
2
0
0%
2
2
0
0%
Claimant Fraud
1,524
2,200
676
44%
2,200
2,186
-14
-1%
Inflated Medical Billing
Material Misrepresentation
on:
Employment Application
Premium Fraud
242
187
-55
-23%
187
167
-20
-11%
43
64
21
49%
64
53
-11
-17%
40
61
21
53%
61
47
-14
-23%
First 3 Quarters 2011, 2012, 2013 Referral Reason Analysis
10/29/2013
Page 6 of 9
Material Misrepresentation
on:
Fraud Warning Form
30
26
-4
-13%
26
20
-6
-23%
Duplicate Billing
34
55
21
62%
55
15
-40
-73%
Total Workers'
Compensation
QC Referral Reasons
3,591
4,470
879
24%
4,470
4,662
192
4%
Overall, Workers’ Compensation QC referral reasons increased 4% when comparing the First 3 Quarters 2012
to the First 3 Quarters 2013. Disability and False SSN referrals topped the percentage increases with 58%
and 40% respectively. Disability referrals had the highest increase of volume in the Workers’ Compensation
category when comparing the First 3 Quarters 2012 to the First 3 Quarters 2013; while Claimant Fraud
remains the largest Workers’ Compensation referral reason by over 2 ½ times the next highest referral reason.
First 3 Quarters 2011, 2012, 2013 Vehicle QC Referral Reasons
Vehicle QC Referral
Reason
Q1-Q3
2011
Q1-Q3
2012
Difference
%
Change
Q1-Q3
2012
Q1-Q3
2013
Difference
%
Change
Water/Flood Damage
224
260
36
16%
260
391
131
50%
Unperformed Repairs
Suspicious Hit While
Parked
Auto Repair/Body Shop
1,596
2,045
449
28%
2,045
2,477
432
21%
2,822
3,745
923
33%
3,745
4,527
782
21%
1,498
1,890
392
26%
1,890
2,051
161
9%
Owner Give Up
Paper Accident/Phantom
Accident
Faked Damage
750
745
-5
-1%
745
803
58
8%
1,693
1,965
272
16%
1,965
2,031
66
3%
4,540
5,652
1,112
24%
5,652
5,765
113
2%
Inflated Repairs
1,302
1,660
358
27%
1,660
1,693
33
2%
First 3 Quarters 2011, 2012, 2013 Referral Reason Analysis
10/29/2013
Page 7 of 9
Hail Damage
Suspicious Vehicle
Fire/Arson
Suspect Rental Bills
913
1,339
426
47%
1,339
1,363
24
2%
1,540
1,565
25
2%
1,565
1,589
24
2%
68
77
9
13%
77
77
0
0%
VIN/HIN/PIN Manipulation
Questionable Vehicle
Theft (Auto, Boat,
Heavy Equipment, etc.)
Inflated Tow Bill/Storage
117
96
-21
-18%
96
95
-1
-1%
8,527
9,329
802
9%
9,329
9,210
-119
-1%
302
292
-10
-3%
292
283
-9
-3%
Odometer Fraud
47
53
6
13%
53
44
-9
-17%
Auto Glass Fraud
659
584
-75
-11%
584
299
-285
-49%
Total Vehicle QC
Referral Reasons
26,598
31,297
4,699
18%
31,297
32,698
1,401
4%
Overall, Vehicle QC referral reasons increased 4% when comparing the First 3 Quarters 2012 to the First 3
Quarters 2013. Auto Glass Fraud experienced the largest decrease in terms of volume for Vehicle QC referral
reasons. Questionable Vehicle Theft (Auto, Boat, Heavy Equipment, etc.) referrals are the highest Vehicle
referral reason in terms of volume. Water/Flood Damage topped the above chart in terms of percentage
increase.
First 3 Quarters 2011, 2012, 2013 Miscellaneous QC Referral Reasons
Miscellaneous QC
Referral Reason
Q1-Q3
2011
Q1-Q3
2012
Difference
%
Change
Q1-Q3
2012
Q1-Q3
2013
Difference
%
Change
Medical Provider
5,957
5,727
-230
-4%
5,727
9,230
3,503
61%
2,160
2,270
110
5%
2,270
2,811
541
24%
255
223
-32
-13%
223
276
53
24%
Medical Provider/Attorney
Relationship
Agent/Adjuster Fraud
First 3 Quarters 2011, 2012, 2013 Referral Reason Analysis
10/29/2013
Page 8 of 9
Premium Avoidance
Catastrophe (Hurricane,
Tornado, Hail, Wind, Fire)
Material Misrepresentation
in:
Recorded Interview/
Deposition
/ SUO/ EUO
Vendor Fraud
1,951
2,125
174
9%
2,125
2,595
470
22%
667
716
49
7%
716
862
146
20%
5,996
6,376
380
6%
6,376
7,533
1,157
18%
532
877
345
65%
877
1,036
159
18%
Prior Loss/Damage
Organized Group/Ring
Activity
Fictitious Loss
7,359
9,008
1,649
22%
9,008
10,369
1,361
15%
2,416
2,310
-106
-4%
2,310
2,643
333
14%
7,219
8,058
839
12%
8,058
9,209
1,151
14%
Attorney Activities
2,239
2,532
293
13%
2,532
2,853
321
13%
Questioned Documents
Altered.
Forged, Falsified,
Duplicated
2,969
3,372
403
14%
3,372
3,788
416
12%
Extensive Loss History
4,092
4,477
385
9%
4,477
4,899
422
9%
Informant Tip - Law
Enforcement
Lack of Cooperation from
Insured
Application
Misrepresentation
246
257
11
4%
257
277
20
8%
7,244
7,948
704
10%
7,948
8,398
450
6%
5,544
6,030
486
9%
6,030
6,072
42
1%
Malingering
1,025
1,164
139
14%
1,164
1,119
-45
-4%
Multiple Policies
345
338
-7
-2%
338
324
-14
-4%
Informant Tip - Anonymous
384
478
94
24%
478
447
-31
-6%
Total Miscellaneous QC
Referral Reasons
58,600
64,286
5,686
10%
64,286
74,741
10,455
16%
Overall, Miscellaneous QC referral reasons increased 16% when comparing the First 3 Quarters 2012 to the
First 3 Quarters 2013. Medical Provider referrals topped the above chart with a 61% increase. All the
categories for Miscellaneous, with the exception of Malingering, Multiple Policies and Informant TipAnonymous referrals, displayed increases from the First 3 Quarters 2012 to the First 3 Quarters 2013.
First 3 Quarters 2011, 2012, 2013 Referral Reason Analysis
10/29/2013
Page 9 of 9