The Impact of Insurance Fraud Detection Systems

This article analyzes the impact of detection systems in an insurance fraud context. In a noncommitment Costly State Verification setting insurers can only detect fraudulent claims by performing costly audits, and policyholders are overcompensated by the optimal insurance contract. We show that auditing becomes more effective and overcompensation can be reduced, when insurers are able to condition their audits on the information provided by detection systems.     

Credibility in Loss Reserving

This article proposes using credibility theory in the context of stochastic claims reserving. We consider the situation where an insurer has access to the claims experience of its peer competitors and has the potential to improve prediction of outstanding liabilities by incorporating information from other insurers. Based on the framework of Bayesian linear models, we show that the development factor in the classical chain-ladder setting has a credibility expression: a weighted average of the prior mean and the best estimate from the data. In the empirical analysis, we examine loss triangles for the line of commercial auto insurance from a portfolio of insurers in the United States. We employ hierarchical model for the specification of prior and show that prediction could be improved through borrowing strength among insurers based on a hold-out sample validation.     

Principles for Sustainable Insurance: Risk Management and Value

Some of the largest global insurers are actively pursuing the recently enacted Principles for Sustainable Insurance (PSI). While the concept of sustainability is often associated with a governance design that promotes stakeholder value, the PSI do not appear to be a call for stakeholder‐focused insurers. Rather, the PSI appear to be about internalizing tacit claims in the operations of insurers. Conceptual and empirical literature on shareholder value maximization suggests that when an insurer honors its tacit claims the value to shareholders increases. A key insight from practice is that a sincere pursuit of the PSI will expand the scope of corporate risk management.     

Selection Bias and Auditing Policies for Insurance Claims

Selection bias results from a discrepancy between the range of estimation of a statistical model and its range of application. This is the case for fraud risk models, which are estimated on audited claims but applied on incoming claims in the design of auditing strategies. Now audited claims are a minority within the parent sample since they are chosen after a severe selection performed by claims adjusters. This article presents a statistical approach that counteracts selection bias without using a random auditing strategy. A two‐equation model on audit and fraud (a bivariate probit model with censoring) is estimated on a sample of claims where the experts are left free to take the audit decision. The expected overestimation of fraud risk derived from a single‐equation model is corrected. Results are close to those obtained with a random auditing strategy, at the expense of some instability with respect to the regression components set. Then we compare auditing policies derived from the different approaches.     

Insurance Fraud

Insurance fraud is a major problem in the United States at the beginning of the 21st century. It has no doubt existed wherever insurance policies are written, taking different forms to suit the economic time and coverage available. From the advent of “railway spine” in the 19th century to “trip and falls” and “whiplash” in the 20th century, individuals and groups have always been willing and able to file bogus claims. The term fraud carries the connotation that the activity is illegal with prosecution and sanctions as the threatened outcomes. The reality of current discourse is a much more expanded notion of fraud that covers many unnecessary, unwanted, and opportunistic manipulations of the system that fall short of criminal behavior. Those may be better suited to civil adjudicators or legislative reformers. This survey describes the range of these moral hazards arising from asymmetric information, especially in claiming behavior, and the steps taken to model the process and enhance detection and deterrence of fraud in its widest sense. The fundamental problem for insurers coping with both fraud and systemic abuse is to devise a mechanism that efficiently sorts claims into categories that require the acquisition of additional information at a cost. The five articles published in this issue of the Journal of Risk and Insurance advance our knowledge on several fronts. Measurement, detection, and deterrence of fraud are advanced through statistical models, intelligent technologies are applied to informative databases to provide for efficient claim sorts, and strategic analysis is applied to property‐liability and health insurance situations.     

Deterring Fraud: The Role of General Damage Awards in Automobile Insurance Settlements

Awards for pain and suffering and other noneconomic losses account for over half of all damages awarded under third‐party auto insurance bodily injury settlements. This article hypothesizes that third‐party insurers use general damage awards to reduce the incentive to submit exaggerated claims for specific damages for injuries and lost wages. Consistent with this hypothesis, the article finds evidence using data on over 17,000 closed bodily injury claims that special damage claims that exceed their expected value receive proportionally lower general damage awards than claims that do not. Among the implications of this research is the possibility that insurers will be less zealous in challenging fraudulent special damage claims under a third‐party insurance regime than they will be under a first‐party insurance regime in which access to general damages is limited.     

Does Reinsurance Need Reinsurers?

The reinsurance market is the secondary market for insurance risks. It has a very specific organization. Direct insurers rarely trade risks with each other. Rather, they cede part of their primary risks to specialized professional reinsurers who have no primary business. This article offers a model of equilibrium in reinsurance and capital markets in which professional reinsurers arise endogenously. Their role is to monitor primary insurers credibly, so that insurers can raise capital more easily. In equilibrium, the financial structure of primary insurers consists of a mix of reinsurance and outside capital. The comparative statics yield empirical predictions which are broadly in line with a number of stylized facts from the reinsurance market.     

Efficiency in the international insurance industry: A cross-country comparison

The purpose of this paper is to provide new empirical evidence on frontier efficiency measurement in the international insurance industry, a topic of great interest in the academic literature during the last several years. A broad efficiency comparison of 6462 insurers from 36 countries is conducted. Different methodologies, countries, organizational forms, and company sizes are compared, considering life and non-life insurers. We find a steady technical and cost efficiency growth in international insurance markets from 2002 to 2006, with large differences across countries. Denmark and Japan have the highest average efficiency, whereas the Philippines is the least efficient. Regarding organizational form, the results are not consistent with the expense preference hypothesis, which claims that mutuals should be less efficient than stocks due to higher agency costs. Only minor variations are found when comparing different frontier efficiency methodologies (data envelopment analysis, stochastic frontier analysis).     

Issues and risks in performing SysTrust® engagements: implications for research and practice

This paper identifies issues related to the delivery of SysTrust® services by public accounting firms. We first review the professional and academic literatures relating to trust services, analogizing to the literature on financial statement audits. Our review reveals that there are a number of articles in the professional and academic literatures on trust services relating to user issues, most of which address the nature and extent of the potential demand for these services. However, very little attention has been paid to issues relating to engagement issues for service providers. In contrast, the auditing literature provides a large body of conceptual and empirical research devoted to the management of audit engagement risk. We identify several specific issues relating to trust services engagement risk, including sources of potential expectation gaps and barriers to attestation risk reduction. In order to facilitate further research on providing trust services, we use a case situation to illustrate specific aspects of these issues in a complex client environment.     

What Are the Characteristics That Explain Hospital Quality? A Longitudinal Pridit Approach

Health outcomes vary substantially between high‐ and low‐quality institutions, meaning the difference between life and death in some cases. The prior literature has identified a number of variables that can be used to determine hospital quality, but methodologies for combining variables into an overall measure of hospital quality are not well developed. This analysis builds on the prior investigation of hospital quality by evaluating a method originally developed for the detection of health‐care fraud, Pridit, in the context of determining hospital quality. We developed a theoretical model to justify the application of Pridit to the hospital quality setting and then applied the Pridit method to a national, multiyear data set on U.S. hospital quality variables and outcomes. The results demonstrate how the Pridit method can be used predictively, in order to predict future health outcomes based on currently available quality measures. These results inform the use of Pridit, and other unsupervised learning methods, in fraud detection and other settings where valid and reliable outcomes variables are difficult to obtain. The empirical results obtained in this study may also be of use to health insurers and policymakers who aim to improve quality in the hospital setting.     

Accounting, Truth and Communication: The Case of a Bank Failure

There have been many papers admonishing accounting researchers to abandon traditional approaches to research and to embrace a particular social theory or philosophy, such as those of Braverman, Foucault or Habermas. Few empirical studies, however followed this advice. This paper employs Habermas' theory of communicative action and, more specifically, his notion of the four validity claims implicit in any speech act in an empirical analysis of the financial reporting and auditing of the Canadian Commercial Bank. Any speech act involves a double structure of speech which combines the communication of propositional content with that of interpersonal relations. Consequently, any analysis of financial reporting and auditing must necessarily involve the double structure of speech and, therefore, the perspective of the four validity claims: comprehensibility, truth, truthfulness and rightness. This paper provides an analysis of financial reporting and auditing of the Canadian Commercial Bank. It shows that the four validity claims were violated. This analysis of one case is then used to make observations about public accounting in general.     

Opaqueness in the Insurance Industry: Why Are Some Insurers Harder to Evaluate than Others?

Many articles have investigated various tools used to evaluate the financial strength of insurers. This is the first study to investigate whether certain insurers are simply inherently more difficult to evaluate than others, regardless of the tool used. The article identifies certain specific insurer characteristics that are associated with greater difficulty in financial strength evaluation, as proxied for by the level of rating disagreement by Moody's and Standard and Poor's. Specifically, the empirical results indicate that insurers that exhibit the following characteristics are more difficult to assess in terms of financial strength: smaller insurers, stock insurers, insurers with a history of reserving errors, insurers that use less reinsurance, insurers with greater levels of investment in stocks and low-grade bonds, and insurers that are more geographically diversified.     

Fraud Classification Using Principal Component Analysis of RIDITs

This article introduces to the statistical and insurance literature a mathematical technique for an a priori classification of objects when no training sample exists for which the exact correct group membership is known. The article also provides an example of the empirical application of the methodology to fraud detection for bodily injury claims in automobile insurance. With this technique, principal component analysis of RIDIT scores (PRIDIT), an insurance fraud detector can reduce uncertainty and increase the chances of targeting the appropriate claims so that an organization will be more likely to allocate investigative resources efficiently to uncover insurance fraud. In addition, other (exogenous) empirical models can be validated relative to the PRIDIT‐derived weights for optimal ranking of fraud/nonfraud claims and/or profiling. The technique at once gives measures of the individual fraud indicator variables’ worth and a measure of individual claim file suspicion level for the entire claim file that can be used to cogently direct further fraud investigation resources. Moreover, the technique does so at a lower cost than utilizing human insurance investigators, or insurance adjusters, but with similar outcomes. More generally, this technique is applicable to other commonly encountered managerial settings in which a large number of assignment decisions are made subjectively based on ‘‘clues,‘’ which may change dramatically over time. This article explores the application of these techniques to injury insurance claims for automobile bodily injury in detail.     

Risk-Based Premiums for Insurance Guaranty Funds

Insurance guaranty funds have been adopted in all states to compensate policyholders for losses resulting from insurance company insolvencies. The guaranty funds charge flat premium rates, usually a percentage of premiums. Flat premiums can induce insurers to adopt high-risk strategies, a problem that can be avoided through the use of risk-based premiums. This article develops risk-based premium formulas for three cases: a) an ongoing insurer with stochastic assets and liabilities, b) an ongoing insurer also subject to jumps in liabilities (catastrophes), and c) a policy cohort, where claims eventually run off to zero. Premium estimates are provided and compared with actual guaranty fund assessment rates.     

Academic auditing research: an exploratory investigation into its usefulness

This paper has been produced in reaction to the publication of the AICPA/AAA monograph entitledAuditing Practice, Research, and Education: A Productive Collaboration . In our view, the monograph relied on a narrow conception of auditing-research usefulness. This paper aims to investigate usefulness of auditing research from a perspective more global than that of the monograph. Our theoretical discussion focuses on who may benefit from auditing research and in what ways. We supplemented our theoretical work with an empirical assessment of auditing-research usefulness from the point of view of auditors. In particular, we content analysed a series of auditing-research articles written by North American academics and published in a set of journals that, collectively, play a large role in validating these academics’ knowledge claims. Our results suggest that auditing research is to a large extent “useful" to auditors, that is to say, auditing papers generally possess a relatively high degree of applicability, and the degree to which auditing papers threaten the legitimacy of the auditing profession is relatively low. We then put forward that this degree of usefulness is the result of auditors’ efforts to control the auditing-research community. In fact, research resources, such as business funding of research, allow auditors to exert influence over academic researchers in their quest to capture the research community.     

Testing for Adverse Selection in Insurance Markets

This article reviews and evaluates the empirical literature on adverse selection in insurance markets. We focus on empirical work that seeks to test the basic coverage–risk prediction of adverse selection theory—that is, that policyholders who purchase more insurance coverage tend to be riskier. The analysis of this body of work, we argue, indicates that whether such a correlation exists varies across insurance markets and pools of insurance policies. We discuss various reasons why a coverage–risk correlation may not be found in some pools of insurance policies. The presence of a coverage–risk correlation can be explained either by moral hazard or adverse selection, and we discuss methods for distinguishing between them. Finally, we review the evidence on learning by policyholders and insurers.     

On the Economics of Postassessments in Insurance Guaranty Funds: A Stakeholders’ Perspective

This article proposes a model that suggests there are contagion effects among members of an insurance guaranty fund when postassessments are charged to all other insurers upon the failure of a member company. Indeed, these extraordinary payments are shown to increase the default rate of other firms in the industry, ultimately lowering the value of corporate claims as well as government tax claims. The model is also used to examine the efficiency of different recoupment mechanisms (both existing and new) used by regulators and insurers to potentially reduce these contagion effects. Analysis allows us to stipulate the conditions under which a “tax carryforward” provision could be more efficient than the usual recoupment mechanisms known as “premium rate surcharge” and “premium tax credit.”     

The nature and determinants of disclosure practices in the insurance industry: Evidence from European insurers

Filling a gap in the existing literature on disclosure practices by insurance companies, this research provides new empirical evidence on the nature and determinants of disclosure practices in the European insurance industry over the 2005–2010 period. The main results show that insurers are more inclined to invest in the quantity of risk information rather than in the disclosure quality of the entire annual report, as risk information is addressed to high-level financially educated people and requires fewer resources than are needed for an investment in quality. Further, the analysis also shows that insurer level characteristics, in terms of size and technical provisions, as well as country level variables, significantly affect the amount of risk information disclosed. In the years affected by the financial crisis, the level of risk disclosure quantity increases as insurers use disclosure as a tool to reassure stakeholders on their independence from the global financial crisis.     

Some Economics of Audit Market Reform

The purpose of audit market reforms since 2001 is to restore public confidence in the institution of auditing based on two considerations: (1) ensuring audit quality; and (2) controlling the ‘adverse effect of competition’ in audit supply. Market reforms for audit quality are delivered through a package of prescribed actions motivated by an analytical relationship between audit quality and its possible determinants: (1) limiting audit tenure through a combination of mandatory firm rotation, partner rotation and re‐tendering; (2) limiting provision of non‐audit services (NAS) by the incumbent auditor; and (3) joint auditing and empowering the audit committee to enhance audit quality. This paper examines the competing independence hypothesis and expertise hypothesis that produce ambiguous theoretical relationships for audit quality–audit tenure and the independence‐provision of NAS. We then review whether the empirical literature resolves these conundrums. We also review the usefulness of joint auditing and empowering the audit committee to improve audit quality in the context of audit market reform.     

Systemic Risk in the Insurance Sector: A Review and Directions for Future Research

This article reviews the extant research on systemic risk in the insurance sector and outlines new areas of research in this field. We summarize and classify 48 theoretical and empirical research papers from both academia and practitioner organizations. The survey reveals that traditional insurance activity in the life, nonlife, and reinsurance sectors neither contributes to systemic risk nor increases insurers’ vulnerability to impairments of the financial system. However, nontraditional activities (e.g., credit default swap underwriting) might increase vulnerability, and life insurers might be more vulnerable than nonlife insurers due to higher leverage. Whether nontraditional activities also contribute to systemic risk is not entirely clear; however, the activities with the potential to contribute to systemic risk include underwriting financial derivatives and providing financial guarantees. This article is not only likely of interest to academics but also highly relevant for the industry, regulators, and policymakers.