It’s Not That Adjusters Don’t See Fraud—It’s That Many Lack the Bandwidth to Fight It

A few days ago, I came across a discussion in a claims adjuster group that stopped me in my tracks. An adjuster asked a simple question:

“Have you ever found fraud in a claim?” The responses were honest… painfully honest.

One adjuster said: “Yes, I found one. I told my manager. She said: ‘Close it. Let the carrier deal with it.’” Another added: “Do you know how hard it is to prove fraud? Carriers don’t want to deal with it unless it’s a slam-dunk case.” And countless others agreed.

Not because they didn’t care. Not because they couldn’t see the red flags. But because the system around them leaves no room to pursue it.

This is the part of insurance people outside the industry never see — the emotional and operational reality of being an adjuster.

The Real Reason Fraud Gets Ignored: It’s Not the Adjuster. It’s the Environment. Most adjusters do spot inconsistencies. They do feel when something is off. They do want to do the right thing. But here’s what the industry doesn’t acknowledge enough:

Adjusters are drowning. High caseloads. End-of-month targets. Diaries. Email backlogs. Provider calls. Policy reviews. Recorded statements. Unrealistic timelines. Fraud review becomes a “luxury task” squeezed into minutes that don’t exist.

Fraud is hard to prove and even harder to pursue. Unless a case screams fraud at first glance, most adjusters know:

• It will take hours to dig into

• They may not get support

• The burden of proof is too high

• Leadership may push to close it instead

• The referral might get returned for “insufficient facts”

That combination kills motivation faster than any training can fix. Many claim departments are built for closure, not investigation. Productivity metrics → Close more. Litigation pressure → Move quicker. Cycle times → Shorter is better.

Fraud review, on the other hand, requires:

• slowing down

• asking questions

• challenging inconsistencies

• thinking critically

• documenting carefully

These are the opposite of what most adjusters are measured on. Adjusters feel the pressure — but also the guilt. Behind the screens, many admit:

• “I didn’t have time to dig deeper.”

• “I knew something wasn’t right.”

• “I wish I could’ve done more.”

• “I don’t want to wrongfully accuse anyone.”

It’s not a lack of skill. It’s a lack of bandwidth. Where Fraud Actually Hides: Not in Bold Lies, But Quiet Inconsistencies. Most fraud is not cinematic. It’s not staged crashes, organized rings, or dramatic schemes. It often starts with:

• A slightly altered receipt

• An invoice that looks templated

• A story that shifts in small ways

• Metadata that doesn’t align

• A claim that grows after documentation is requested

• A detail that “doesn’t sit right”

Adjusters notice these things; they just don’t always have space to pursue them.

So, What’s the Solution? Not more pressure. More support.

Adjusters don’t need:

• More trainings they have no time to attend

• More referrals that get bounced back

• More “reminders” about fraud indicators

• More metrics

• More expectations

What they need is:

• Help

• Time

• Backup

• investigative support

• someone who can slow down when they can’t

• someone who can look deeper without disrupting workflow

That’s the role Claim Analysis Group, LLC was built for. How Claim Analysis Group, LLC Fits into this Reality.

CAG exists for the adjuster who knows something is off but doesn’t have the hours to prove it. For the SIU team that wants cleaner referrals. For the claims department that wants clarity without slowing down.

We provide:

• Structured case review

• Travel insurance fraud screening

• Documentation integrity checks

• Red flag pattern analysis

• Provider behavior review

• Clarity reports that stand on their own

• Support during high-volume periods

• No system access.

• No workflow disruption.

• No pressure on the adjuster.

• Just clarity.

A Final Thought:

Adjusters Are Not the Problem, The Workload Is

When adjusters say:

“It wasn’t worth pursuing.” or “My manager said close it.” Or “It wasn’t a slam dunk.” They aren’t admitting failure. They’re revealing a truth the industry has ignored for too long:

Fraud fighting requires time, space, and support, not just awareness. And sometimes all it takes is someone who can look closer when the adjuster can’t.