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
Fax: +91 124 4088 588
alam.singh@milliman.com