Who reports potential fraud claims?

• A. Adjusters
• B. Local District Attorney
• C. Fraud Department of the Department of Insurance
• D. Employers

Answer: (A)

Fraud detection happens through the claims process, and the person closest to the claim is the one who spots and reports it. The adjuster reviews the claim, checks for inconsistencies, unusual billing, or injuries that don’t fit the case, and then follows the insurer’s procedures to escalate any red flags. They’re responsible for filing a report about potential fraud with the insurer’s fraud-control unit or with the Department of Insurance for investigation. The local district attorney is a prosecutor who acts after fraud is identified and referred for legal action, not the initial reporter. The Fraud Department of the Department of Insurance is the regulator that conducts investigations, not the person who first raises the concern. Employers aren’t the primary reporters for individual claims; the responsibility rests with the adjuster handling the claim.