Simplifying Claims Management - Insurance Institute of India
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Transcript Simplifying Claims Management - Insurance Institute of India
Simplifying Claims Management
Alam Singh
III Workshop, Feb. 24th, 2012
Agenda
Key claims management objectives
Strengthening claim management
Options for simplifying provider contracting & claims management
Additional thoughts
Key claims management objectives
Claims management: key objectives
Detect fraud
Reduce transaction cost
Timely settlement of claims
Reduce unwarranted excess payments & inappropriate billing
Derive information for data driven contracting
Monitor outcomes, promote provider transparency and accountability
Promote customer involvement and awareness in managing claims
Common hurdles
Resource mix availability
Ad-hoc operations / workflow processes
No standardisation in documentation, poor information exchange
No or minimal provider contracting or agreements
Market led packaged contracting rather than information based
contracting
Misaligned incentives in insurer – TPA contract
Lack of common protocols / guidelines
Key success factors in claims management
Full and complete exchange of information, efficiently
Knowing what to do with the information, efficiently
Aligned incentives
Strengthening claim adjudication
Role of IT systems
Desirable features in claims management system
Workflow management / process management
Policy and insurance checks through rules engine
ICD Code specific processing checks
Integrated clinical logic (Example)
Usual & customary charges checks
Provider profiling
Ideally, system should aggregate benefit, beneficiary and claim
information at single source (also referred to as policy, enrolment
and claims data)
Good rules engine with in-built logic key to auto-adjudication
Desirable features of IT systems
Components required to achieve significant automation and reduce
claims processing time.
Work flow management module
Ensure optimum work routing and distribution, in-built escalation and strong
external communication features
Product configurator
Enables the automation of various validation checks on policy,
claimant, benefits and provider
Business process builder
Builds operational workflow compatible with new
products
Rules engine
Interacts with the product configurator
to define product benefits and
exclusions
Reduces claims processing time
and simplifies claims personals
work
Medical
appropriateness check
Fraud
management
Auto adjudication
Objective: Automation of claims processing, partially or fully
Integrated rule engine or in-built logic can assist significantly if
detailed data entry is done.
–
Enrolment checks: verification, eligibility, benefits and coverage
–
Benefit checks: sub-limits, person, policy, condition, procedure, equipment, facility
and amount checks. Restrictions arising from underwriting (Example)
–
Clinical checks: medical appropriateness, excluded services or items, known
patterns of inappropriate billing (Example)
–
Contracting checks: compliance with contracted or package rates. Can be
additionally enhanced to check against usual & customary charges
Pre-conditions: quality & granular data, standardized policy terms,
pre-authorization & claims form. Computerised provider billing at line
item level.
Advantages & disadvantages
Standardizes claims management
Save costs as excessive unwarranted items not missed
Improve efficiency as “clean” claims can be paid quickly
Improves MIS and evidence based contracting with detailed bill entry
Optimizes resource utilization as specialist resources used for
specialist tasks
Requires high quality in-put data, including accurate coding (skill?)
Can detect abuse but cannot easily detect fraud. Well structured fraud
“passes through” auto adjudication engines. Most fraud in India is
manually detected (MS Word printed bills, no lab reports or surgical notes, no
telephone number for hospital , same handwriting on all bills, etc ).
Rules and clinical logic to identify variations
ICD CPT mismatch (indications not met for the diagnosis given at authorization)
Delay in surgery flag
Length of stay mismatch
Duration of ICU stay mismatch
Excessive physician visit flag
Unwarranted specialist visit flag
Unwarranted assistant surgeon fee flag
Procedure not indicated for the age group / gender
Excessive investigations flag
Unwarranted investigation flag
Excessive consumables flag
Unwarranted consumables flag
Unwarranted drug use flag
Drug charged above marked price flag
Non chargeable consumable flag
April 13, 2015
…. and more
Data entry (capturing discharge details & bill)
April 13, 2015
Data Entry - (investigations)
April 13, 2015
Adjudication screen
Thank you
Milliman India Pvt. Ltd.
Plot No. 121, Second Floor,
Institutional Area, Sector 44,
Gurgaon – 122 022
Haryana (India)
Tel: +91 124 4641 503
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