![Claims Management - Edge through Efficiency Objective The objective of this paper is to talk about the current state of the claims process and how an efficient and ideal claims system should be. This document is most relevant for the Indian insurance industry. Introduction As Insurance companies are becoming more mature in age and volumes, the number of claims arising is also increasing. Claims management is one of the key business processes which have a direct impact on Customer Satisfaction and overall relationship with the carrier. Claims management accounts for approximately 40% of an insurer's administrative overhead. Based on various survey results, average customer satisfaction is ‘Poor’ after going through the claims process. This kind of resource-intensive function will result in such poor customer satisfaction. Requirements for a Claims Management System In claims processing, the main goal of an organization is to decrease claim processing cost. The same can be achieved by reduction in the claims processing TAT (turnaround time) and improvement in their closure rate. This, in turn, will not only help the carriers reduce the operational claims expenses but also result in better customer satisfaction. However, this process is often dampened by several inefficiencies – ,[object Object]](https://image.slidesharecdn.com/claimsmanagement-100117130750-phpapp02/85/claims-management-edge-through-efficiency-1-320.jpg)
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Claims Management - Edge through Efficiency
- 2. Too many handshakes between the stake holders
- 5. Quality checks on the manual claim processing
- 8. Assessment
- 12. Post-Assessment
- 16. Increased revenue and member satisfaction/retention
- 17. Response time on the data entry screens
- 20. FEWS (Frauds and early warning signs)
- 22. Improved claim data accuracy
- 23. External rules
- 24. Maintenance of business workflow
- 25. Customizable data entry screens
- 26. ICD 10 list
- 28. Call center average speed of answer has fallen to two minutes
- 29. 97% of the claims are processed in 30 days
- 30. The application has been instrumental in detecting frauds and non-disclosures
- 31. Benchmarking of tariffs of the hospitals in the network has been achieved by the application
- 32. Reduction in fraudulent claims achieved due to built in fraud rules that help in quickly identifying blacklisted customer and hospitals
- 34. Inclusion of dental and vision LOB by the carriers
- 35. Inclusion of Pharmaceutical expense in the insurance
- 36. Standardization in the format the claim data is exchanged between the TPA, providers and carriers
- 37. Mandatory compliance of ICD-10 diagnosis codes
- 38. Protection of customers’ Personal Health Records and Medical Health Records
- 40. Can the system cater for auto adjudication?
- 41. Are the claims processing rules easily configurable?
- 42. What is the dependency on IT when there are minor changes, like regulatory changes to be made?
- 43. Are there any reusable components?
- 44. Are the modules tightly coupled or loosely coupled?
- 45. How strong is the FEWS module?
- 46. How does the system take care of the futuristic requirements?
- 47. Can the system be scaled up?
- 48. Can additional LOB’s be added?Conclusion Better use of technology, such as better claim solutions, telemedicine, etc. can efficiently provide better customer services, assuming the local infrastructure is in place to take advantage of it.