THANK YOU FOR SUBSCRIBING
Insurance CIO Outlook | Tuesday, July 16, 2024
Modern insurers need a high-performance claim, as claims are the customer's biggest expense.
FREMONT, CA: It is becoming increasingly difficult for insurance companies to identify new opportunities and define solutions to claims management as it becomes increasingly complex. Insurers can identify customer and provider journey pain points and uncover opportunities for claims management by analyzing a random sample of closed claims pragmatically and in detail.
Stay ahead of the industry with exclusive feature stories on the top companies, expert insights and the latest news delivered straight to your inbox. Subscribe today.
Companies with different goals may revisit inefficient claims handling, but the common objective remains identifying what led to monetary losses in the first place. Inefficient claim processing, lack of business or technical rules, payment errors, fraud, and many other causes can lead to these monetary losses.
Archetype definition: A claim archetype is a set of claims processed similarly that share certain characteristics. A top-down diagnosis of the claims operating model enables us to identify the archetypes with the greatest potential for improvement, which can be prioritized for immediate attention.
Questionnaire elaboration: An assessment process must be structured and standardized, tailored to the specifics of each insurance product. Consequently, the first step is to fully map out the different claims management processes to understand the processes and the people performing each task, inputs, and outputs, and IT support systems, controls, and interdependencies between the processes.
Sample preparation: All archetypes defined in the archetype definition are retrieved for random samples before we start the assessment and then grouped according to archetype and time. Most insurance companies have a detailed claim register in their system, which can be used as a data analytics tool with Tableau or Power BI. After selecting a sample size, set statistical levels that match the sample size as the second step in preparing samples. As a goal for sample size, a common approach is to estimate a confidence level of 90 percent and a margin of error of 10 percent, implying 90 samples per archetype, given the claims population. Generally, it takes 10 minutes to review one claim on average, resulting in around 15 hours for a given archetype to be reviewed.
End-to-end claim revision: As part of the revision process, a team of agents from each step of the claims value chain should be included, in addition to external consultants. The real assessment can begin once the team has been assembled, all systems are up and running, and all supporting documents have been collected. A supporting questionnaire evaluates each closed claim from the sample against the current setup and best practices to identify divergences, highlighting key decisions and actions made throughout the claims processing process. It is documented and quantified every time the claims file deviates from the agreed-upon best practice during the process.
Results extrapolation: An extrapolation of the divergences observed and quantified during the review of the random samples for each claim type is made to the total population of archetypes. We can extrapolate that 2.2 percent of the total claim archetype count will have the same issue if, during the review, two unjustified duplicate payments occurred for a specific archetype over a 90 claims sample size of 2.2 percent. It follows the same logic to calculate excess money paid. This exercise quantifies all opportunities identified to determine their major sources of opportunity. These opportunities are then clustered based on their underlying cause, such as duplication of payments due to a lack of technical rules.
More in News