Enhance customer claims experience- APAC OPEX Insurance Summit 2017

Enhancing Customer Claims
Experience
Dr (Maj) Mukund Kulkarni
Free lancing Strategic Consultant- Healthcare, Health Insurance, Corporates
Drmukundkulkarni@yahoo.co.in
+91 9833566112

Agenda
• Customer-Insurer ecosystem
• Claims Maturity model
• Customer Claims journey:
• Care coordination concept
• Triggers/Data points
• Customization- Health Risk Assessment
• Claims Decision-Impact
• Customer Engagements- Disease/Case management programs
• Summary
07-08-2017
Dr (Maj) Mukund Kulkarni, OPEX Insurance Summit(APAC)-
2017
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Customer-Insurer Ecosystem
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Customer-Insurer Ecosystem
Customer – Beneficiary for the Policy proceeds
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Claim – Legal right as per Insurance contractual terms
Well connected
Well Informed
Wide choices
Need to customize
Ease of Interaction
Low Discrimination (Banks vs Insurance)
Dynamic
Data lakes
Insight pools
Deep dive-Life cycle
Partner vs Payer approach
Understanding Customers
Insurer approach
TRUST
CUSTOMIZE
DIFFERENTIATE
Business Cycle
Internal ecosystem
External ecosystem
INSURER

KYC- Customer risk classification
Regulatory
Identity, Residence proof
Customer
DD
Financials
Others
Reporting
Suspicious cases
Suspicious customers
DPlaws
Documentation
Records
Attestation
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Pre-
Membership
UW information
Agent information
Industry databases
Others
Membership
Change requests (SA, Nominee,
Member, etc)
Lapsation/Reinstatement behaviour
Others
Claim
History
Intimation mode
Claimed event
Cooperation and followup
Interactions
Complaint
Cust Satisfaction Outcome
Others
CRI
(Customer Risk Index)KYC Index
CURI
(Customer
UW Risk
Index)
CPSRI
(Customer
Policy
servicing Risk
Index)
CCRI
(Customer
Claims Risk
Index)
MANDATORY CUSTOMISED
Regulatory adherence
Risk customization
Reduce Claims leakages
Customer mgt/Satisfaction
Operational Optimization
Reputation
Benefits
Data and technology
Awareness and training
Cross functional integration
Industry collaboration
Dependencies
Holistic Customer segmentation based on
risk parameters

Claims Maturity Model
• Concept
• Department level
• Transaction level
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Claims Maturity model
Set Reference benchmark
Holistic assessment
Identify gaps & Leakages
Identify scope of improvements
Competitive comparison
Management information
Others
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Exercise to evaluate and score Claims and associated functions on their respective
relative maturity to derive a baseline for current and future reference.
Departmental
•Overall benchmark
•Goal
•Management
information
Transactional
•Indl parameters
•Objectives
•Operational
information
Purpose
Types
Reduce leakages/Losses
Best practices
Customer satisfaction
New Business opportunities
Regulatory
Reputation, brand
Competitive advantages
Benefits
Independent assessment
Holistic assessment
Dedicated approach
Map current competencies
Futuristic approach
Key Statements

Claims Maturity model- Dept level
Customer
handling
Claims Registration
Follow-up
Payment process
Regulatory Adherence
SLA
Customer Feedbacks
Grievance redressal
Analytics
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Triage
Investigations
Matrix
Authorities
Verification parameters
Manual/Auto assignment
Fraud triggers
Outcome analyses
Claims
Adjudication
Authority
Case assignment
Expert opinions
Fraud triggers
Documentation
Regulatory adherence
Technology
Claims system
Integration
Data capture
Analytic capability
Reporting capability
Innovations- ML
Qualityreview
Frequency
Prospective/Retrospective
Audit team expertise
Data/Automation
Outcome
Analyses
Others
People
Training
Provider management
Business Intelligence
RCU
Innovations e.g
Drone/Sensors
• Legacy
• Mainstream
• Leading

Claims Maturity model- Transactional level
Walkin Postal Tele Email Online Mobile app
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Intimation
Documents Manual Scanning Indexing DMS OCR ML
Manual Basic system Customised System generated DynamicTriggers
Assignment Manual Basic System Auto-assign Investigator mapped Monitoring
Competency level Training level Authority matrix Non tech Tech ExpertsPeople
System No systems Legacy System validation Automation DSS
No guidelines Basic (Non-Tech) Advanced (Tech) Dynamic ML basedGuidelines
Single level decision Peer review DSS based Technical inputs (EMO) OthersQuality
Manual Electronic SLA Integration Discharge liabilityPayment
SLA STD Communication Dedicated resource
Customized
communication
C Sat surveyCustomer
Registration
Investigation
Assessment
Customer
Mapping current stage of each step in Claims transaction on the scale of Process Improvement scale (based on
market, regulatory and individual best practices) will allow find suggestions to improve for any Insurer.

Customer Claims journey
• Care coordination- Concept
• Trigger and data points- OPEX
• Customization- Health Risk assessment(HRA)
• Claims Decision and Impact
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Care coordination- Concept
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TERMINALLY ILL CHRONIC/ACUTE ILLNESS RISK FACTORS HEALTHY
PALLIATIVE THERAPEUTIC PROMOTIVE PREVENTATIVE
Signsand
Symptoms
Diagnosis
Early
Late
Critical
Disabled
Awareness
Screening
Education
Behaviour
Motivation
Fitness
Complication
IDEAL
FITNESS
DEATH
Denied Sub-STD Postponed STANDARD Preferred Super-Preferred
Case Management
Support services (e.g Psychologic ,
Nursing care etc)
Rehabilitation
Domiciliary
Counselling
Provider recommendation
Case Management
Evidence based guidance
Disease management
Counselling
Monitoring
Wellness Programs
Screening
Counselling
Education & Awareness
Monitoring
Wellness program
Incentivization
Education & Awareness
Euthenics?
Data capture
Data analyses capability
Provider management
Vendor management
Cost Benefit analysis
UW Risk Class
Insurer
Interventions
Concept of moving from ‘Payer’ to ‘Partner’ support by assessing Customer
needs at all stages holistically and providing relevant, evidence based and
reasonable solutions.

Customer Journey
Pre-sales/Sales UW/NB Policy Servicing Claim
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Profile
Insurance
need
Purpose
of buying
Lead
generatio
n
Distributi
on choice
Existing
Insurance
Others
Risks Social Financial
Occupatio
nal
Behaviour
al
Type of
product
Risk
coverage
applied
Other
Insurance
Others
Member
change
Residence
change
Coverage
change
Nomination
change
Porting Others
Event
Circumsta
nces
Contribut
ors
Complicat
ion
Outcome
Claim
frequency
Interactio
n triggers
Provider
selection
Beneficiar
y details
Others
Industry data
Market reports
Others
Agent report
Proposal form
UW Questionnaire
Social media
Others
POS Data
Social media
Industry data
Others
Claims history
Event information
Investigation report
Provider reports
Claim form
Others
CUSTOMER SEGMENTATION RISK SELECTION FRAUD TRIGGERS RISK MGT (DISEASE/CASE MGT) PROGRAMS C-SATOPEX QUALITY
TRIGGERS
DATA
SOURCE
OUTCOME
Identifying triggers/Opportunities by mapping Customer journey at all stages to benefit the Insurer in both aspects-
Internally (Risk management/OPEX) and Externally (Customer management)

HRA- Health Risk assessment
‘A systematic approach to collecting information from individuals that identifies risk factors, provides individualized
feedback, and links the person with at least one intervention to promote health, sustain function and/or prevent disease’
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GENERAL
SOCIAL
LIFESTYLE
PSYCHOLO
GICAL
MEDICAL
• Demography
• Geographic risks
• Financial status
• Others
• Interactions
• Participations
• Memberships
• Others
• Fitness initiatives
• Behavioural- Smoking/Alcohol/Drugs
• Nutrition and Dietetics
• Others
• Perception/Insight
• Confidence
• Motivation
• Readiness to change
• Spiritual
• Others
• Biometrics
• Health history
• Inheritance
• Examination findings
• Lab reports
• Others
HRA highlights health risks but does not diagnose disease and should not replace consultation with a medical practitioner
HRA
Identification- Risks
Prediction- Morbidity/Mortality
Measurement- DALY/Productivity
Evaluation- Efficacy of Wellness Programs
Org
Team
Indl
Levels Purpose
CVS predictor
Oncology
Dementia
Diabetes
Others
Specific Calculators

Claims Decision- Impact
Decision Category Customer reaction Reasons Recommendation
PAID Contractual Fraud customers are happy Insurance is a need and not a
choice
• Automate
• Capture more experience and triggers
Ex-Gratia Satisfied Out of the way support • Management approval
• Accounting
• Monitor
DENIED T & C Generally not complaining Clear evidence • Review coverage constraints to improve
Exclusions Dissatisfied - Fine print
- UW exclusions not
communicated
- Others
• Review Sales process
• Review UW process
• Review customer communication
ND/PED Only Fraud customers are
quiet
- Contractual challenge
- Misunderstanding of
clauses
- Fraudulent behaviour
• Expert Opinions mandatory
• Policy voidance
• Legal preparation
• Industry wide action
• Case study
PENDING • Documents
• Information
• Legal aspects
Dissatisfied - Contractual wordings
- Fine print
- Non STD Documentation
• Review wordings
• Review process
• Standardize process
• Communication
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Fraudulent Innocent
Material
Non-
Material
ND

Customer Engagements
Disease/Case management programs
• The Implementation model
• An Illustration
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Disease management programs- Model
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Structure/Governance
Market stats
Guidelines
Team Constitution
Budgeting
Governance
Roles and
Responsibilities
Review framework
Assessment
Portfolio
assessment
HRA
Disease load
Evaluation
parameters
Engagement
intensity
Dependencies
Goals/Objectives
Qualitative/Quanti
tative reference
baseline
Alignment with
existing
strategies/process
es
Selection and
classification of
WP
Outcome
measurements
Project plan with
timeline spread
(ST/MT/LT)
ProgramStrategy
Mapping Vendor
programs
CBA- Self/Vendor
driven
Member
engagement plan
Member
incentivization
Implementationplan
Targets
Timelines and
calenderization
Plans Execution
Record and data
maintenance
(wellness
calendar)
Review&Evaluation
Program Outcome
review
Recommendation
Review guidelines
Outcome
parameters review
Feedbacks and
Surveys

Disease management programs-
Illustration (Obesity)
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Structure/Governance
Market stats
(Obesity stats)
Guidelines (E.g
AACE guidelines)
Team Constitution
(Medical, Health,
HR, PMO
members)
Budgeting (cater
for fitness events,
trackers, data
tools, training
sessions etc)
Governance
Roles and
Responsibilities
Review framework
Assessment
Portfolio
assessment
(High BMI people,
Claims costs,
Complications,
etc)
HRA
(Overall and
specific HRA)
Disease load
(claims costs)
Evaluation
parameters
(BMI, Lipid levels)
Engagement
intensity
Dependencies
Goals/Objectives
Qualitative/Quanti
tative reference
baseline
(Avg BMI)
Alignment with
existing
strategies/process
es
Selection and
classification of
WP
(Fitness events,
trackers,
Consultation, trg
sessions)
Outcome
measurements
(BMI, Lipid levels)
Project plan with
timeline spread
(ST/MT/LT)
ProgramStrategy
Mapping Vendor
programs
CBA- Self/Vendor
driven
Member
engagement plan
(Calendarization)
Member
incentivization
(Gym vouchers,
food vouchers,
premium redn)
Implementationplan
Targets
(BMI reduction
2%)
Timelines and
calenderization
Plans Execution
Record and data
maintenance
(wellness
calendar)
Review&Evaluation
Program Outcome
review
(Avg BMI, Lipid
levels,
Complications)
Recommendation
Review guidelines
Outcome
parameters review
(claims costs,
IP/OP, etc)
Feedbacks and
Surveys

Summary…
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Summary…
• Insurers have to move from ‘Risk carriers’ to ‘Risk managers’ internally and pure ‘payer’ model to
‘partner’ model in dealing with customers
• ‘KYC’ can be more holistic to feed into triggers for better risk management
• Claims Maturity models help in setting benchmark to improve & enhance controls enhancing
customer experience on a long term.
• Transaction level maturity models will help immediate betterment solutions while Dept level
models would be more strategic
• Its imperative to map solutions which contribute value to the customer journey by seamless
alignment
• Customer claims experience need to support holistically than as an individual benefit.
• Risk management solutions need to be based on customer segmentation and the specific
segmental needs.
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THANK YOU…
For further Consulting requirements:
Email- drmukundkulkarni@yahoo.co.in
Tel- +91 9833566112
07-08-2017
2017
20

Enhance customer claims experience- APAC OPEX Insurance Summit 2017

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