Anti-Fraud Checklist

Pull 5-year loss runs from each prior carrier and any in-force endorsements. A claim filed within 30 days of policy inception or right before a non-renewal is a common red flag worth flagging at intake.

Run the claimant's name, address, SSN/TIN, and VIN (if auto) through CLUE and ClaimSearch. Look for prior claims under variant spellings, related addresses, or shared phone numbers — staged-loss rings reuse identifiers.

Check the dec page against the FNOL date. Watch for back-dated coverage requests, mid-term endorsements adding the damaged property the day before the loss, and reinstatements after a lapse.

Disclose recording at the start — most states are one-party consent but FL, CA, MA, and others require two-party. An undisclosed recording is inadmissible and supports a bad-faith argument later.

Apply the carrier's red-flag matrix: late reporting, no police report on a theft, prior bankruptcy, claimant pressure for fast settlement, recent coverage increase. Three or more flags typically triggers SIU referral under most carrier protocols.

Search by claimant, vehicle, property address, and provider NPI. Duplicate medical bills filed with multiple carriers and shared treating providers across unrelated claimants are the two highest-yield patterns.

Plot the loss date, FNOL date, and binding date on a timeline. Losses reported within the first 60 days of a new policy or immediately after a coverage increase warrant deeper review.

Document the rationale either way. Texas Insurance Code Chapter 542 still runs on the underlying claim — referral to SIU does not pause the 15-business-day acknowledgement or 60-day decision clock.

Assign an SIU investigator, set the litigation hold, and freeze the claim file from auto-purge. The investigator is typically separate from the adjuster of record to preserve the integrity of any subsequent denial.

The ROR preserves the carrier's coverage defenses while the investigation continues. Cite the specific policy provisions implicated; a generic ROR is routinely held insufficient in coverage litigation.

Most policies make EUO attendance a condition precedent to coverage. Send the demand by certified mail, allow reasonable time for counsel, and capture document production demands in the same notice.

Memorialize the EUO transcript, surveillance, expert reports, and provider record reviews. The findings memo is what supports either a denial under the concealment-or-fraud condition or a referral to the state fraud bureau.

Screen at every payment, not just at policy issuance — claimants, attorneys, and assignees can be added to the SDN list mid-claim. Screen the medical provider or repair shop separately when they receive direct payment.

Block the disbursement in the claims system and notify the compliance officer. OFAC blocked-property reports are due within 10 business days of the determination; rejected-transaction reports follow the same window.

Mid-claim ACH detail changes are the most common payment-fraud vector. Require independent verification through Plaid or a callback to a known phone number on the policy file — never the number in the most recent email.

Most carriers set the dual-approval line at $25K or $50K. Confirm the second approver is outside the adjuster's reporting line — same-line approvals are a market-conduct exam finding under the NAIC unfair claim settlement model.

Capture reserve, ALAE, and indemnity allocations separately. The carrier's retention schedule typically requires 7+ years for P&C and longer for workers comp given lifetime medical exposure.

NY, CA, FL, NJ, OH, NM, KY, LA, and MN require periodic Anti-Fraud Plan filings with the DOI. Refresh the plan after any acquisition or change in SIU leadership — acquired carriers often inherit a stale plan.

NICB referrals support cross-carrier ring detection. State fraud bureau referrals are separate and follow each state's mandatory-reporting statute — many require referral within 60 days of a reasonable belief of fraud.

Most state Anti-Fraud Plan filings require evidence of recurring training. Use the prior quarter's actual referrals as case studies — abstract red-flag lists do not change adjuster behavior the way reviewing a real ring does.

The compliance officer signs the review attesting to SIU activity, training delivery, and Part 500 access controls on the claims and policy systems. Retain the signed attestation alongside the Anti-Fraud Plan filing.