Wed1250pm uncoverhiddenhighriskinsuranceclaims

transcript

Flag Hidden High-Risk Claims

Before they damage customer relationships

America’s Claims Event 2014

High-risk claims that are neglected by insurers

High-risk claims will wreak havoc if not detected quickly, resulting in inaccurate reserves, increased severity, longer cycle time and customer service issues

4Source: JD Power & Associates

Only 50% of policyholders would definitely renew if less than “delighted”

Insurance companies overlook valuable indicators for high-risk claims that are hidden in claims files

To proactively find high risk claims, you must analyze

free-form text and scanned documents across thousands of

claims files –

the 50%+ of information your company cannot reach today.

More than 50% of supervisors spend 2-4 hours and 27% spend 4-6 hours reviewing staff claim files

Sources: Towers Watson “Insights: Property & Casualty Claim Officer Survey#8, Aite Group analysis

Reviewing direct reports’ files

Attending claim‐related meetings

Attending training

Reviewing reports

Email / company communications

Handling their own data

Claims Adjuster Note – FNOL Spoke to clmts sister, clmt taken to hsp for tx.Ankl is sprained, clmt has aircast. Tx and released. Given crutches, clmt OOW. Neck/back pain and some numbness in hands. Following up with PCP in a couple of weeks. Clmt may retain an attorney. Car totaled, appraiser has seen. Clmnt not in rental due to ankle injury.

Case Study #1 – High Exposure

Claims Adjuster Note – FNOL Spoke to clmts sister, clmt taken to hsp for tx.Ankl is sprained, clmt has aircast. Tx and released. Given crutches, clmt OOW. Neck/back pain and some numbness in hands. Following up with PCP in a couple of weeks. Clmt may retain an attorney. Car totaled, appraiser has seen. Clmnt not in rental due to ankle injury.

Analysis must detect abbreviations,

misspellings and claims vernacular

Claims Adjuster Note – 14 Days after FNOL Clmnt called with update. Ankle pain getting worse. Went to e/r and now that swelling is down, Xrays show fx’d ankle. Fx is displaced and they are recc sx with ORIF. Clmt will be OOW as construction worker for some time. MRI ordered for spine due to tingling sensation radiating down arms. Possible HNP?

Claims Adjuster Note – 30 Days after FNOL Clmt called back. Sx has been completed on ankle. Possible PPD rating will be assigned. MRIresults are back and are negative for HNP, though DDD is present.

Continuously analyze data, aggregate

results from multiple notes, determine

context

Claims Adjuster Note – 30 Days after FNOL Clmt called back. Sx has been completed on ankle. Possible PPD rating will be assigned. MRIresults are back and are negative for HNP, though DDD is present.

Actions:

• Properly segment claim

• Complete supervisory review

• Develop on-point action plan

Case Study #2 – Prescription Abuse

Claims Adjuster NoteInjured worker suffered a soft tissue back injury and is unable to RTW. Has been placed on Oxy. Medical records indicate hx of depression and ETOH abuse. Employer indicates on intake sheet that worker was on perf mgt. Plan is to collect medical bills and records, pay meds and wages. Goal is to have clmnt RTW in same capacity.

Analysis must determine context of

flagged indicators

Scanned Document – Prescription Records

Actions:

• Review loss reserve for potential adjustment

• Refer to nurse case manager for pain medication management

• Contact treating physician for collaboration on treatment regimen

Dashboard Demonstration

Case Study #3 – Fraud

Claims Adjuster NoteClear liab, insd admits to losing control and hitting tel. pole. No police, no witnesses. 3 passengers in vehicle, all injured. LOR’s rec’d from Atty John Smith on all 3. No E/R visits-clmnts went straight to chiro. TX at Back Aches Chiropractic. No l/w’s as clmnts are all unemployed. Clmnts are looking to resolve claims quickly per atty.

Suspicious relationship detected

Analysis must include data from multiple sources, including

scanned documents

Actions:

• Implement early referral to SIU

• Schedule IMEs for all claimants

• Begin surveillance of claimants

• Schedule statements under oath

Case Study #4 – Underwriting

Claims Adjuster NoteHomeowner has ice dams, stating that ceiling was leaking for several hours. Visited home to inspect and write scope of damage. PH has an aggressive dog on premise that had to be restrained and put into another room when I entered the residence. Looked to be a pb.

Timely claims information is critical

to making better underwriting

decisions

Scanned Document – Appraisal Form

APPRAISER COMMENTS

Upon arrival at the residence, an angry dog had to be put on a leash by the homeowner and secured outside.

Following this incident with the dog, the homeowner was cooperative, provided a view of the damages and answered all questions in a thorough manner.

Scanned Document – Appraisal Form

APPRAISER COMMENTS

Upon arrival at the residence, an angry dog had to be put on a leash by the homeowner and secured outside.

Following this incident with the dog, the homeowner was cooperative, provided a view of the damages and answered all questions in a thorough manner.

Actions:

• Identify potential high-risk information in claims files

• Automate delivery to underwriting team

• Make data-driven decisions about who to underwrite, who not to renew and who to charge a higher premium or deductible

27Source: Aite Group

Approximately 15% of loss costs and LAE could be saved with the

proper use of technology and process improvements.

Be Proactive with High-Risk Claims

Minimize risk and costs

Improve customer retention

Decrease cycle time

Maximize resource allocation

Develop timely action

978-436-8735

www.trilliumsoftware.com/claimsmichael_chochrek@trilliumsoftware.com

FOR MORE INFORMATION VISIT BOOTH #210

Wed1250pm uncoverhiddenhighriskinsuranceclaims

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