Insurance claims consume nearly 80% of the insurance company’s premium in the form of payments, fraudulent losses, and processing costs. Therefore, insurance companies are justifiably concerned about optimizing the claims process but are often unsure about the most effective method to accomplish this.
Good thing that there are a few key actions that can be taken to optimize claims performance. From integrating bill review and claims systems, to using a rules engine to promote low-touch processing, improving claims performance across the board helps companies manage costs and improve outcomes.
Here are some solutions for companies to consider.
1. Integrate disparate technology systems
Take a look at your claims process. This might sound all too familiar: your claims management system is over here, your bill review platform is over there and your nurse review recommendations are coming in from a completely different system altogether. This is how many companies find themselves managing claims — separate systems that lack integration. When technology systems don’t work together in unison, companies often miss cost containment opportunities.
By using platforms that are integrated, your company can solve many challenges and better manage costs. For example, when a nurse review system integrates with the bill review platform, a company can be more confident that the nurse’s recommendations are applied during the bill review process. When these two aren’t connected, it’s easy for nurse recommendations to get lost during the process.
When choosing any system to assist in your claims handling, look for platforms that integrate the various software and services your company uses during the process. Using consolidated, robust software systems will streamline the claims handling process, not only making your adjusters’ lives easier, but also helping to ensure the company is consistently paying the most accurate price on bills.
2. Rely on strategic partners
An important step in optimizing claims performance is providing your adjusters with expert resources to help them make expert decisions. You can have a sophisticated technological platform, but if your team doesn’t fully understand the platforms they’re utilizing, then these outside resources are not being used to their fullest potential. Often, industry experts are able to leverage a wide variety of cross-carrier experiences to make recommendations on software technology and service utilization. While adjusters will always be more knowledgeable on individual claim handling, it’s beneficial to have experts take a holistic look at your use of technology within your claims process. Leveraging these experts’ knowledge will help fine tune and customize your company’s claims performance, in addition to enabling your adjusters to make better decisions.
For example, strategic partnerships can help improve efficiency around Preferred Provider Organization networks. When a carrier or TPA is the administrator for its own network solutions, a great deal of extra work is added since the company now has to individually negotiate and reconfigure providers in the stack. However, by choosing a strategic partner with the access and expertise to optimize the networks, companies remove the need to manage this otherwise tedious process. Now the partner will provide the appropriate recommendations while handling the administrative tasks surrounding networks, greatly increasing efficiency and eliminating internal pain points.
3. Utilize embedded analytics and decision support
Embedded analytics refers to visual or logical representation of data analytic content within business process applications that details necessary intelligence to assist users in making optimal decisions. One helpful tool is a visual dashboard that allows adjusters to easily see different parts of a claim. By reviewing the entire history of treatments for a claim, an adjuster can make better-informed decisions.
Embedded analytics are also valuable to the claims process when adjusters are approving provider payments. The best way to improve efficiency in this area is to use a system that leverages clinical data to automatically flag a bill for a listed procedure that isn’t related to an injury or diagnosis. This simplifies the process for adjusters and allows them to focus their time on flagged treatments rather than sifting through them in their entirety to decide which to approve and which to deny. Additionally, this helps to make sure adjusters aren’t inadvertently approving unrelated treatments. By using a system that flags treatments based on data, adjusters can improve their efficiency and spend more time focusing on their most important tasks.
4. Select technological platforms that facilitate automation
Each bill that comes through the system is different, so in order to improve claims performance, it’s necessary to choose programs that allow decision makers to automate certain functions within the claims process. A common way to help facilitate this automation is to use a rules engine that allows for flexibility in deciding which bills adjusters need to pay close attention to. For example, with a capable rules engine, you will be able to automatically approve low-cost hospital bills, while stopping other bills that contain higher amounts or rare or unrelated procedure codes.
Not only is it important to choose a robust rules engine, but it’s also important to customize it so you’re using it to its maximum potential. Time needs to be spent writing rules that help your business improve efficiency and pay the fairest price on bills. A good business and/or a technology partner can assist you in optimizing your rules library.
Another way to automate more of your claims process is to employ technology that automatically applies the industry standard medical treatment guidelines. Systems that enable this process to happen automatically increase efficiency and eliminate a pain point for adjusters when they review bills that fall outside of the recommended treatment guidelines.
Adjusters have a great deal on their plate, so by using technology that facilitates customized automation within the claims process, it’s much easier to make sure they are only spending their time on important tasks instead of tedious paperwork. Appropriate technology also makes it easier to ensure that bills are approved using the company and industry-approved standards, saving money and helping to prevent litigation.
5. Help adjusters make expert decisions
By utilizing the resources available to empower adjusters to make the best decisions, the company will start to see the best outcomes on claims. For example, in third party auto claims, an effective way to do this is to supply adjusters with a liability and injury assessment platform that allows the company to incorporate their best practices knowledge and rules. This makes it easier for adjusters to make and explain key decisions in attorney negotiations, which ultimately helps keep costs down.
Another way is to use technology to help adjusters electronically refer claims to Independent Medical Examiners (IME), nurse reviewers, or other review services. Facilitating this process with a platform that relies on industry data to make intelligent recommendations allows adjusters to make the correct decisions about if and when a claim needs to go through outside steps. This also saves companies time and money by not referring claims too early or too late.
6. Seek new ways to improve consistency
Lastly, building expert knowledge into the company’s claims adjudication systems is a great way to achieve consistency across the board, and a consistent operation is one step closer to functioning at the optimum level. There are a variety of ways to do this, from using enterprise-grade rules engines to building a knowledgebase into your liability and injury assessment systems, all of which seamlessly integrate the claims process.
Company’s compensation claims costs can be greatly reduced once businesses integrate otherwise disparate systems, leverage partner expertise and solutions, and incorporate intelligence and analytics into their process and workflows. These steps not only increase the businesses overall productivity, but they may lead to higher profitability and to empowering better outcomes.
We here at Inmediate provide companies and insurers with peace of mind by effectively optimizing claims management and fraud detection, not only by customers, but also by other parties in the value chain.
Inmediate is an insurtech startup from Singapore that is using the latest technology such as Artificial intelligence, Distributed Ledger, and NLP, making insurance processing and underwriting fast, cheap, and flexible. That gives for better processes, lower costs, improved time to market, and new revenue opportunities.