INN: With approximately 80% of premium dollars going toward losses and loss adjustment expenses, what should carriers do to reduce expenses associated with claims processing?Tim Helton, ImageNow: Invest in solutions that directly impact the labor-intensive aspects of claims processing. Having to copy, file and route paper burdens even the most efficient claims process. Electronic document imaging and workflow solutions optimize work processes and simultaneously provide an electronic audit trail of all document touch-points. Solutions are available at practical price points that integrate seamlessly into claims applications. Carriers can realize gains in claims expense control and identify processing bottlenecks as they materialize.
Marcus Ryu, GuideWire Software: The great opportunity in claims today is to improve outcomes by instilling flexibility in the claim process. The traditional one-size-fits-all approach, hoping for the best from overburdened adjusters, leads to systematic errors - errors costing the industry over $30 billion every year. Instead, insurers should identify the best practices that reduce claims costs, and use technology to embed those best practices in the claim process. Successful insurers can shave multiple points off their loss ratios and dramatically increase their surpluses.
Susan Macri, Delphi Technology, Inc.: Information availability can streamline the claims processing process. Technology solutions can give claims examiners access to information right at their workstation - simplifying coverage verification, file management, and customer service. When examiners aren't searching through paper files to find relevant information, they can focus on what they do best - managing claims efficiently - which keeps costs low. Also, carriers can keep costs low by intervening early on claims, communicating closely with claimants, and eliminating wait times for benefits, medical transactions, answers to questions, etc.
Jim Dickens, CCC Information Services Inc.: Insurers must first identify where they consistently see issues with expenses. One way to identify estimates that do not comply with insurance guidelines is to review claims using tools such as CCC Accumark' Reinspection, which enables insurers to electronically reinspect estimates, quickly and efficiently. Additionally, because CCC Accumark Reinspection comes with integrated audit functionality, insurers can pinpoint and focus on those claims with the greatest number of exceptions, maximizing their potential for recapturing some of the expense associated with claims processing and creating increased accuracy in their estimates.
Raymond A. Roy, MFXchange Holdings, Inc.: State-of-the-art technology in an application service provider environment brings carriers huge processing advantages and a great ROI. It reduces costs of hardware, software, network and maintenance while gaining the advantages of a web-based comprehensive claims processing system. It comes complete with fax-in FNOL, medical bill review, event driven diary, electronic funds transfer, bulk payment processing, and system-generated state forms and letters. ClaimsAssure by MFX is powerful enough to handle complex, heavy volume claims and frees adjusters to spend more time adjudicating claims and less time "pushing paper."
William Fallon, EasyLink Services Corporation: By automating manual processes companies can free up staff to do some of the tasks that the more skilled adjusters are doing. For example, in many insurance companies, claims staff are "re-keying" information from claims forms, handling lots of paper via mail or fax and storing and maintaining paper files. By automating these tasks a carrier can reduce their claims input costs by 50% or more, and eliminate such clerical responsibilities for key staff members such as adjusters.
John Blake, The SSI Group, Inc.: Based on the nature of specific losses, several tools can be used to help curb occurrences. Assessing whether the issues are created because of lack of rules utilized during the claim submission process or employing tools during the intake process are keys to helping reduce expenses. SSI's Eligibility software provides verification of coverage during the intake process. SSI can also deploy various types of edits to help to alleviate some of these issues.
INN: How can insurance carriers streamline workflow and reduce paperwork in claims processing?
Randy Wheeler, Valley Oak Systems: To truly streamline workflow, organizations must apply appropriate technology and automation to each step of the claims process. On the front end, scanning and document imaging significantly cut back on paperwork and data entry. This allows important information to be electronically stored and available, eliminating the need to store paper files. Since carriers now divide claims management among various "specialists," browser-based technology can easily connect these individuals, improve communication between them using e-mail and real-time notifications, and enable the connectivity to share information and reports.
Johnny E. Mize, Corporate Systems: We partner with our CS ClaimsPro and CS MedBillPro customers to enable them to fully realize cost reductions while improving outcomes. Significant workflow improvements and reductions in administrative costs are now truly feasible through the automation of business rules, exception processing, claim routing, and many other administrative functions. Improved operational benefits are also realized through CS ClaimsPro's automated forms/letter production that includes a library of 1400 Carrier/Employer Claim Adjudication Forms - insuring the right form for jurisdictional compliance and improved workflow.
Raymond A. Roy: ClaimsAssure was designed around an adjuster's real-world needs and the result is a seamless system that fits the work process precisely. Necessary claims documentation is received as a fax or e-mail, captured as an image file, stored, flagged for special handling and sorted to multiple destinations. A Financial Impact window provides detailed financial information, and pop-up menus offer relevant links. Completed tasks trigger automatic updating, color-coded diary entries highlight important items including supervisor notification of outdated entries.
Ellen Myers, XyberNET: Systems can play a significant role in allowing carriers to finally realize their goal to streamline workflow and reduce paperwork in claims processing. Integration of multiple systems, including web applications, is an efficient way to push some processing tasks out to the field and outside the carriers' direct sphere of task responsibility. Integrating systems to enable full automation for claims processing also enables insurers to significantly reduce paperwork and the need to handle claim files multiple times. XyberNET's fully integrated XY-CLAIM System's dynamic online processing capabilities provide a complete claims management solution, from initial notification of a claim through the entire adjudication and final disposition phase of the process. When run in an ASP environment, the carrier receives all the benefits without the additional responsibility of maintaining systems.
Susan Macri: Insurance carriers can streamline workflow and reduce paperwork by taking advantage of the latest technology solutions that have built-in workflow drivers. Business rules can be used to create automated workflow processes for the routine tasks of examiners and underwriters, freeing up your employees for more challenging issues. Automated workflows, with or without imaging systems, also reduce paperwork and increase productivity by enabling all claims employees to work off the same electronic file, rather than making copies and passing paper.
William Fallon: Stop dealing with paper. Just because your customers and agency partners either need, or find it more convenient to transact some of their business with you using fax or paper doesn't mean you have to handle paper. EasyLink helps companies by converting transactions that begin on paper into digital information that can be injected into workflow or claims systems, delivered to employee desktops, or archived. Significant savings can be achieved quickly by automating a form or process at a time.
INN: How can Web-based technologies improve claims processing?
Vincent Cialdella, ISO: Web-based technology helps automate the flow of information among adjusters, customers, and company partners, such as auto repair vendors. Vendors can build and implement cost-effective automated processes that quickly deliver return on investment.
Web-based technology can automate processes without adding to software and consultation costs. And web-based vendors can integrate information from ISO ClaimSearch into their services. That ability brings the benefits of automated claims-handling and fraud-detection services directly to customers.
Johnny E. Mize: Web-based technologies in CS ClaimsPro and CS MedBillPro deliver accurate and timely integration of claim collaboration and seamless integration with applications or third parties (e.g. care management systems), delivering improved claim outcomes. Web-based interfaces facilitate direct feeds from carriers and other sources, reducing costs. ASP model benefits include accelerated implementation and training, simplified business recovery; secure, cost-effective and responsive, profile-driven workflows. Web-based technologies are the basis for virtual claim processing, streamlined and flexible business process improvement, and simplified compliance management.
William Fallon: Companies have invested heavily in downstream workflow or claims processing systems but have done little to address how paper transactions get into them efficiently. While some customers and agency partners will change their transaction process in favor of web-based approaches, history shows that the web should be viewed as only a part of an overall "input management" framework. Being easy to do business with means offering an array of options, not issuing threatening mandates. Broad adoption of automation is ultimately what drives results.
Raymond A. Roy: ClaimsAssure acts as a digital file cabinet for financial data and documents associated with a claim. Based on security access granted, TPAs, independent adjusters or risk managers can access the on-line claim file. Participants in the claim and incident management process can dispense with the paperwork, which for years has taken up significant time and space compounded with retrieval limitations. That liberated time can be used in judgmental work, creating a real benefit to customer service, indemnity and expense cost reduction, and efficiency.
Jim Dickens: Web-based technology offers the ability to connect from anywhere at anytime. Web-based applications, such as CCC Autoverse' Claim Management, allow users to consult all the information relevant to a particular claim in one place, including pictures. This creates a tremendous opportunity for carriers to achieve large productivity and cycle time savings for carriers. However, field reinspectors may need the capacity to process the information off-line. CCC Accumark' Reinspection offers the possibility to download any estimate or appraisal data from the Internet and process it off-line, at any location without connecting.
Randy Wheeler: Web-based technology, especially in the form of browser-based technology, delivers five key benefits to the claims process. First, browser-based technology automates key functions, such as reporting and notification. Second, it provides secure access to real-time information anytime, from anywhere. Third, these systems provide cost-effective connectivity with the entities that need to communicate to improve costs and outcomes. Fourth, it provides transparent consolidation of information from a variety of sources. Finally, browser-based systems simplify the technology infrastructure, eliminating the need for middleware.
INN: In what ways can insurers minimize the cost and incidences of claims fraud?
John Blake: While the use of Pre-Certification can help minimize the incidences of fraud, subscribers and providers have fought this process. Competition within the insurers market is quite fierce, thus many have done away with the use of this transaction. SSI's Real-time eligibility software can help in identifying the validity of the person receiving service. Clearinghouses or service providers can also assist in this process by forcing "questionable" claims to paper which can trigger further examination of potentially fraudulent claims.
Vincent Cialdella: Companies can train frontline adjusters to recognize patterns, or indicators, of fraud so they can reduce claims losses. Companies can also provide technology tools to help adjusters identify suspicious claims faster.
Many technology products help improve fraud detection and reduce payments for fraudulent claims. We've developed a fraud-detection tool - ClaimDirectorSM - that automatically scores claims at first notice and throughout the life of the claim. Companies can reduce their claims losses by as much as five to ten percent with effective fraud detection.
Ellen Myers: There are several options available for identifying fraudulent claim activity. Since fraud patterns are dynamic, XyberNET recommends Datarray, our data-warehousing product. Used in conjunction with standard business intelligence tools Datarray provides the means to quickly identify suspicious activity through data mining and analysis. It is vital that insurers be able to utilize their data to recognize trends, identify unusual activity and confirm or refute suspicious transactions. Datarray provides these capabilities.
INN: How do business rules play a role in lowering the costs associated with claims?
Marcus Ryu: The key to reducing claims costs is handling every claim the right way. Business rules can help you tailor your action plan to the requirements of each individual claim, and assign each activity to the most appropriate professional. Rules can also flag the most important claims to ensure follow-up by supervisors or experts. This way you can streamline the process of handling routine claims, reducing adjustment expense, while giving complex claims the attention required to limit loss costs.
Tim Helton: Business rules are effective at reducing costs when they are enforceable, auditable and easily modified as business needs dictate. Rules-based workflow systems allow carriers to identify processing bottlenecks, balance workloads and make decisions that improve processing efficiencies. Systems that offer rule creation and modification - without requiring heavy IT involvement - are ideal in the real world of long IT backlogs. User administration of rules-based workflow makes timely changes possible, a critical factor in lowering costs.
Ellen Myers: Business rules lower costs for a carrier by enabling them to consistently apply corporate guidelines to all claims processed. Carriers with standard procedures and automated rules are able to implement systems that minimize manual efforts and human intervention, all the while applying the guidelines established by the carrier. In addition, whether through attrition, downsizing or mergers, carriers may experience the loss of skilled claims personnel, and with them a valuable claims knowledge base. Implementing automated business rules in claims processing systems preserves this knowledge base and proficiency level. The application of business rules improves productivity and streamlines overall claims processing, contributing to lower costs for the carrier.
John Blake: Business rules play a vital role in the process. In formulating a process, insurers can identify how they can best take advantage of some of the technologies currently available. While there may be some costs associated with the implementation of the tools available, assessing the financial and service impact can show these costs, be it internal infrastructure or external service costs, have a positive impact over the way business is currently structured.
Randy Wheeler: Business rules can reduce claims costs in a number of ways. First, they reduce operational costs. Rules can be configured to streamline workflow and automatically route electronic information. Second, they reduce potential liabilities. For instance, rules can be configured to identify problem areas, such as large payments or changing reserves. Appropriate claims experts are then notified so immediate action can be taken to reduce potential losses. Third, rules enable mandated activities to occur on time, so organizations avoid stiff penalties.
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