Red Flags

​Case Managers need to be aware of the warning signs called “red flags” that indicate a claim may be fraudulent. Such signs may indicate the need for closer scrutiny and further investigation during the claims handling process. The existence of more than one fraud indicator does not necessarily mean that a claim is fraudulent. Indicators of fraud may exist purely through coincidence in legitimate claims. Claims that raise concerns need to be examined carefully before final conclusions are drawn.

Certain patterns, factors, or indicators have been noted in the industry as being common to fraudulent claims. These possible fraud indicators are outlined below. The Case Manager should become familiar with them, as doing so will assist in identifying fraudulent claims. If a Case Manager identifies specific indicators of fraud and believes that a claim requires further investigation, the Case Manager should discuss the claim with his/her Manager.

Potential Indicators of a Fraudulent Claim