Flag Hidden
High-Risk Claims
Before they damage
customer relationships
America’s Claims Event 2014
2
High-risk claims that are
neglected by insurers
3
High-risk claims will wreak havoc if not
detected quickly, resulting in inaccurate
reserves, increased severity, longer
...
4
Source: JD Power & Associates
Only 50% of
policyholders would
definitely renew if
less than “delighted”
5
Insurance
companies
overlook
valuable
indicators for
high-risk claims
that are hidden
in claims files
6
To proactively find high risk claims,
you must analyze
free-form text and scanned
documents across thousands of
claims f...
7
More than 50% of supervisors spend 2-4 hours and
27% spend 4-6 hours reviewing staff claim files
Sources: Towers Watson ...
8
Claims Adjuster Note – FNOL
Spoke to clmts sister, clmt taken to hsp for tx.
Ankl is sprained, clmt has aircast. Tx and
...
9
Claims Adjuster Note – FNOL
Spoke to clmts sister, clmt taken to hsp for tx.
Ankl is sprained, clmt has aircast. Tx and
...
10
Claims Adjuster Note – 14 Days after FNOL
Clmnt called with update. Ankle pain getting
worse. Went to e/r and now that ...
11
Claims Adjuster Note – 30 Days after FNOL
Clmt called back. Sx has been completed on
ankle. Possible PPD rating will be...
12
Claims Adjuster Note – 30 Days after FNOL
Clmt called back. Sx has been completed on
ankle. Possible PPD rating will be...
13
Case Study #2 – Prescription Abuse
Claims Adjuster Note
Injured worker suffered a soft tissue back injury
and is unable...
14
Case Study #2 – Prescription Abuse
Claims Adjuster Note
Injured worker suffered a soft tissue back injury
and is unable...
15
Case Study #2 – Prescription Abuse
Scanned Document – Prescription Records
16
Case Study #2 – Prescription Abuse
Scanned Document – Prescription Records
17
Case Study #2 – Prescription Abuse
Scanned Document – Prescription Records
Actions:
• Review loss reserve for potential...
18
Dashboard Demonstration
19
Case Study #3 – Fraud
Claims Adjuster Note
Clear liab, insd admits to losing control and hitting
tel. pole. No police, ...
20
Case Study #3 – Fraud
Claims Adjuster Note
Clear liab, insd admits to losing control and hitting
tel. pole. No police, ...
21
Case Study #3 – Fraud
Claims Adjuster Note
Clear liab, insd admits to losing control and hitting
tel. pole. No police, ...
22
Case Study #3 – Fraud
Claims Adjuster Note
Clear liab, insd admits to losing control and hitting
tel. pole. No police, ...
23
Case Study #4 – Underwriting
Claims Adjuster Note
Homeowner has ice dams, stating that ceiling was
leaking for several ...
24
Case Study #4 – Underwriting
Claims Adjuster Note
Homeowner has ice dams, stating that ceiling was
leaking for several ...
25
Case Study #4 – Underwriting
Scanned Document – Appraisal Form
APPRAISER COMMENTS
Upon arrival at the residence, an ang...
26
Case Study #4 – Underwriting
Scanned Document – Appraisal Form
APPRAISER COMMENTS
Upon arrival at the residence, an ang...
27
Source: Aite Group
Approximately 15% of loss costs
and LAE could be saved with the
proper use of technology and
process...
28
Be Proactive with High-Risk Claims
Minimize risk
and costs
Improve
customer
retention
Decrease
cycle time
Maximize
reso...
978-436-8735
www.trilliumsoftware.com/claims
michael_chochrek@trilliumsoftware.com
FOR MORE INFORMATION VISIT BOOTH #210
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Wed1250pm uncoverhiddenhighriskinsuranceclaims

  1. 1. Flag Hidden High-Risk Claims Before they damage customer relationships America’s Claims Event 2014
  2. 2. 2 High-risk claims that are neglected by insurers
  3. 3. 3 High-risk claims will wreak havoc if not detected quickly, resulting in inaccurate reserves, increased severity, longer cycle time and customer service issues
  4. 4. 4 Source: JD Power & Associates Only 50% of policyholders would definitely renew if less than “delighted”
  5. 5. 5 Insurance companies overlook valuable indicators for high-risk claims that are hidden in claims files
  6. 6. 6 To proactively find high risk claims, you must analyze free-form text and scanned documents across thousands of claims files – the 50%+ of information your company cannot reach today.
  7. 7. 7 More than 50% of supervisors spend 2-4 hours and 27% spend 4-6 hours reviewing staff claim files Sources: Towers Watson “Insights: Property & Casualty Claim Officer Survey#8, Aite Group analysis Reviewing direct reports’ files Attending claim‐related meetings Attending training Reviewing reports Email / company communications Handling their own data
  8. 8. 8 Claims Adjuster Note – FNOL Spoke to clmts sister, clmt taken to hsp for tx. Ankl is sprained, clmt has aircast. Tx and released. Given crutches, clmt OOW. Neck/back pain and some numbness in hands. Following up with PCP in a couple of weeks. Clmt may retain an attorney. Car totaled, appraiser has seen. Clmnt not in rental due to ankle injury. Case Study #1 – High Exposure
  9. 9. 9 Claims Adjuster Note – FNOL Spoke to clmts sister, clmt taken to hsp for tx. Ankl is sprained, clmt has aircast. Tx and released. Given crutches, clmt OOW. Neck/back pain and some numbness in hands. Following up with PCP in a couple of weeks. Clmt may retain an attorney. Car totaled, appraiser has seen. Clmnt not in rental due to ankle injury. Case Study #1 – High Exposure Analysis must detect abbreviations, misspellings and claims vernacular
  10. 10. 10 Claims Adjuster Note – 14 Days after FNOL Clmnt called with update. Ankle pain getting worse. Went to e/r and now that swelling is down, Xrays show fx’d ankle. Fx is displaced and they are recc sx with ORIF. Clmt will be OOW as construction worker for some time. MRI ordered for spine due to tingling sensation radiating down arms. Possible HNP? Case Study #1 – High Exposure
  11. 11. 11 Claims Adjuster Note – 30 Days after FNOL Clmt called back. Sx has been completed on ankle. Possible PPD rating will be assigned. MRI results are back and are negative for HNP, though DDD is present. Case Study #1 – High Exposure Continuously analyze data, aggregate results from multiple notes, determine context
  12. 12. 12 Claims Adjuster Note – 30 Days after FNOL Clmt called back. Sx has been completed on ankle. Possible PPD rating will be assigned. MRI results are back and are negative for HNP, though DDD is present. Case Study #1 – High Exposure Actions: • Properly segment claim • Complete supervisory review • Develop on-point action plan
  13. 13. 13 Case Study #2 – Prescription Abuse Claims Adjuster Note Injured worker suffered a soft tissue back injury and is unable to RTW. Has been placed on Oxy. Medical records indicate hx of depression and ETOH abuse. Employer indicates on intake sheet that worker was on perf mgt. Plan is to collect medical bills and records, pay meds and wages. Goal is to have clmnt RTW in same capacity.
  14. 14. 14 Case Study #2 – Prescription Abuse Claims Adjuster Note Injured worker suffered a soft tissue back injury and is unable to RTW. Has been placed on Oxy. Medical records indicate hx of depression and ETOH abuse. Employer indicates on intake sheet that worker was on perf mgt. Plan is to collect medical bills and records, pay meds and wages. Goal is to have clmnt RTW in same capacity. Analysis must determine context of flagged indicators
  15. 15. 15 Case Study #2 – Prescription Abuse Scanned Document – Prescription Records
  16. 16. 16 Case Study #2 – Prescription Abuse Scanned Document – Prescription Records
  17. 17. 17 Case Study #2 – Prescription Abuse Scanned Document – Prescription Records Actions: • Review loss reserve for potential adjustment • Refer to nurse case manager for pain medication management • Contact treating physician for collaboration on treatment regimen
  18. 18. 18 Dashboard Demonstration
  19. 19. 19 Case Study #3 – Fraud Claims Adjuster Note Clear liab, insd admits to losing control and hitting tel. pole. No police, no witnesses. 3 passengers in vehicle, all injured. LOR’s rec’d from Atty John Smith on all 3. No E/R visits-clmnts went straight to chiro. TX at Back Aches Chiropractic. No l/w’s as clmnts are all unemployed. Clmnts are looking to resolve claims quickly per atty.
  20. 20. 20 Case Study #3 – Fraud Claims Adjuster Note Clear liab, insd admits to losing control and hitting tel. pole. No police, no witnesses. 3 passengers in vehicle, all injured. LOR’s rec’d from Atty John Smith on all 3. No E/R visits-clmnts went straight to chiro. TX at Back Aches Chiropractic. No l/w’s as clmnts are all unemployed. Clmnts are looking to resolve claims quickly per atty. Suspicious relationship detected
  21. 21. 21 Case Study #3 – Fraud Claims Adjuster Note Clear liab, insd admits to losing control and hitting tel. pole. No police, no witnesses. 3 passengers in vehicle, all injured. LOR’s rec’d from Atty John Smith on all 3. No E/R visits-clmnts went straight to chiro. TX at Back Aches Chiropractic. No l/w’s as clmnts are all unemployed. Clmnts are looking to resolve claims quickly per atty. Analysis must include data from multiple sources, including scanned documents
  22. 22. 22 Case Study #3 – Fraud Claims Adjuster Note Clear liab, insd admits to losing control and hitting tel. pole. No police, no witnesses. 3 passengers in vehicle, all injured. LOR’s rec’d from Atty John Smith on all 3. No E/R visits-clmnts went straight to chiro. TX at Back Aches Chiropractic. No l/w’s as clmnts are all unemployed. Clmnts are looking to resolve claims quickly per atty. Actions: • Implement early referral to SIU • Schedule IMEs for all claimants • Begin surveillance of claimants • Schedule statements under oath
  23. 23. 23 Case Study #4 – Underwriting Claims Adjuster Note Homeowner has ice dams, stating that ceiling was leaking for several hours. Visited home to inspect and write scope of damage. PH has an aggressive dog on premise that had to be restrained and put into another room when I entered the residence. Looked to be a pb.
  24. 24. 24 Case Study #4 – Underwriting Claims Adjuster Note Homeowner has ice dams, stating that ceiling was leaking for several hours. Visited home to inspect and write scope of damage. PH has an aggressive dog on premise that had to be restrained and put into another room when I entered the residence. Looked to be a pb. Timely claims information is critical to making better underwriting decisions
  25. 25. 25 Case Study #4 – Underwriting Scanned Document – Appraisal Form APPRAISER COMMENTS Upon arrival at the residence, an angry dog had to be put on a leash by the homeowner and secured outside. Following this incident with the dog, the homeowner was cooperative, provided a view of the damages and answered all questions in a thorough manner.
  26. 26. 26 Case Study #4 – Underwriting Scanned Document – Appraisal Form APPRAISER COMMENTS Upon arrival at the residence, an angry dog had to be put on a leash by the homeowner and secured outside. Following this incident with the dog, the homeowner was cooperative, provided a view of the damages and answered all questions in a thorough manner. Actions: • Identify potential high-risk information in claims files • Automate delivery to underwriting team • Make data-driven decisions about who to underwrite, who not to renew and who to charge a higher premium or deductible
  27. 27. 27 Source: Aite Group Approximately 15% of loss costs and LAE could be saved with the proper use of technology and process improvements.
  28. 28. 28 Be Proactive with High-Risk Claims Minimize risk and costs Improve customer retention Decrease cycle time Maximize resource allocation Develop timely action plans
  29. 29. 978-436-8735 www.trilliumsoftware.com/claims michael_chochrek@trilliumsoftware.com FOR MORE INFORMATION VISIT BOOTH #210
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