The challenge

Effective claims management for larger volumes of policyholders and dependents is critical when providing employee benefits solutions to the workforce of large corporations and groups.

Claims management involves multiple touchpoints across systems and processes - from the point of intake; through the meticulous research into each individual claim; multiple follow-ups with agents, health care providers, employers, legal councils, the claimant and the policyholder itself; right up to claims adjudication and disbursements of payments. It is imperative to deliver an efficient, accurate, and seamless experience to the end customer.

The legacy system did not allow for simple routing rule changes and took almost 3 months to develop even minor changes. The system did not provide intelligent routing and, more importantly, configurable routing rules, changeable by non-IT business managers.

In this extremely complex process, our client wanted to address the following prioritized concerns;

Claims examiner has to toggle between more than 07 different applications and portals
Manager scours over multiple queues to assign claims to examiners
Claims cases are assigned manually
Inability to invoke a simple claim case routing rule
No direct access to reports or productivity matrix
Claims examiners scour through multiple lists, but unable to identify significant or prioritized claims or tasks
Examiners are overwhelmed with claim cases being pushed by managers
Limited search capabilities and visibility to historical data
Multiple applications and inconsistent research methods were used by individual examiners to make claim determinations

Our client’s key focus was to achieve an outcome of:

Ease - Consistency, simplicity to get data, easier to train and learn adjudication process
Accuracy - Standardize claims processing
Speed - Reduction of initial claims processing time by 10% or 2 minutes, from 20 minutes to 18 minutes
Cost - Automation and integration to provide a cost reduction span over 5 years

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