Fraudulent and abusive claims slipping through weak controls

Even a modest 3–5% fraud and abuse rate on processed claims can translate into $150,000–$500,000 in excess payouts per $5M of annual claims volume routed through these manual processes. • Fraudulent and abusive claims that reach AP stage are often paid in full, adding an avoidable 3–10% to claims and related vendor spend, which can mean $300,000–$1,000,000 per $10M claims disbursement. • Missed early red flags lead to more fraudulent claims entering the pipeline, contributing to the overall 3–10% excess claims cost the firm or its carrier partners absorb, effectively hundreds of thousands annually for moderate claim volumes.

Copy-pasting data between PDF, email, and core systems, tracking edge cases in personal spreadsheets or notebooks, and informally asking colleagues for a 'second pair of eyes' on questionable claims. • Logging calls and walk-ins in basic logs or spreadsheets, scanning and emailing documents to back-office teams, and relying on personal intuition about odd requests. • Manual triage of claims and policy changes using email, shared drives, spreadsheets, and ad‑hoc checklists to decide what to flag for extra review, relying heavily on staff judgment and memory.