Webinar - Improving claims management
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The Facility, together with its partners FSDA and AFD, organized a webinar on "Improving claims management". In this webinar we offered guidelines on how to manage claims efficiently and improve operations. Claims is the moment of truth in insurance - it is when the promise of insurance becomes a reality. For low-income households, client satisfaction hinges on receiving the insured benefit as the settled claim offers tangible evidence of the value of an insurance policy. The webinar featured insights from two innovation partners on claims process improvements and better claims data management. Presenters: Patrick Kihuria (Britam) and Frida Mwaura (MicroEnsure). Moderator: Aparna Dalal (the ILO's Impact Insurance Facility)
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Webinar - Improving claims management
- 1. The moment of truth: Claims
- 3. 1. Notification 2. Submission 3. Validation 4. Approval 5. Settlement Claims procedures
- 4. Analyse each of the categories of claims procedures: ‒ Consider the impact of product type and program design/structure ‒ Identify any specific tools or strategies that you are using to improve client value, business value, or both ‒ Are there any areas where procedures could be improved? • Why? What change would you make? • Does it fit under one of the guiding principles? Program review – processes
- 5. CLAIMS PROCESS REVIEW PATRICK KIHURIA MANAGER-MICROINSURANCE OPERATIONS
- 6. BRITAM MICROINSURANCE PRODUCTS PRODUCT TARGET MARKET COVERAGE CLAIMS TYPES KINGA YA MKULIMA TEA FARMERS ASSOCIATION INPATIENT & LAST EXPENSE HOSPITAL, REIMBURSEMENT & DEATH CLAIMS AFYA TELE REGISTERED GROUPS (Corporates, clubs, SHGs etc,) INPATIENT, OUTPATIENT & LAST EXPENSE HOSPITAL, REIMBURSEMENT & DEATH CLAIMS SACCO SOLUTION SAVINGS & CREDIT COOPERATIVES INPATIENT, PERSONAL ACCIDENT & LAST EXPENSE HOSPITAL, REIMBURSEMENT & DEATH CLAIMS
- 7. OBJECTIVES • Map claim process & team structure • Calculate average processing time • Identify pain points RATIONALE FOR THE REVIEW • CLIENT SATISFACTION: Ensuring timely claim payments to hospitals and clients • ADAPTING TO NEW MIS: Ensuring challenges from legacy systems are not taken forward
- 8. CLAIMS REVIEW: APPROACH PROCESS MAPPING MEASURE STEP WISE TATs ‘AS-IS’ TO ‘SHOULD-BE’ MAPS LIST TYPES OF CLAIMS IDENTIFY PEOPLE & RECORDS CHECK FOR DOUBLE DATA ENTRY & MULTIPLE APPROVALS ACTIVE/DEAD TIME FROM TIME OF EVENT ALERT FOR OUTLIERS RATIONALIZE STEPS IDEAL TATs DEFINE ROLES
- 9. HOSPITAL QUALITY ASSURANCE CONTROLLER CLAIMASSISTANT ye PRE-AUTHORIZED AMOUNT COVERS THE TREATMENT COST CHECKS IF BENEFIT ARE REMAINING PATIENT PAYS THE BALANCEAMOUNT EXTENSION OF COVERAGEIS APPROVED REQUESTS FOR EXTENSION OF COVERAGE PATIENT IS DISCHARGED CLAIM FORM (ONLY FOR OP) INVOICEDISCHARGE DOCUMENTS SENDS PHYSICAL CLAIM DOCUMENTS THROUGH POST, COURIER OR RUNNERS CLAIMDOCUMENTS ARE RECIEVED & STAMPED PHYSICAL DOCUMENTS ARE SCANNED & UPLOADED TO DMS- FORTIS VETS CLAIMS BY REVIEWING AMOUNT, VALIDITIY OF DIAGNOSIS & EXCLUSIONS SCANNED CLAIMFORMS CONFIRMS CLAIMS ENTRY & CHECKS PAYMENT IN MAJMED UPDATES DATAIN MAJMED BASED ON DISCHARGE VOUCHER PREPARES A HOSPITAL WISE EXCEL SHEET OF CLAIMS PRINTS BATCH TO FORTIS DIRECTLY FROMEXCEL SHEET INDEXES BATCH OF CLAIMS BYPUTTING BATCH NUMBER, AMOUNT, HOSPITAL NAME INDEXED BATCH OF CLAIMS MOVES TO PAYMENT SCHEDULE FOLDER IN DMS PRINTS BATCH OF CLAIMS FROM PAYMENT SCHEDULE ENTERS DETAILS OF PRE- AUTHORIZATIONS INTO MAJMED (KYM) ROW WISEDETAIL IN MAJMED DOCTOR PRESCRIBES INPATIENT ADMISSION VERIFIES TEA GROWER/POLICY NO. IN PREMIUM DATATBASE/AIMS VERIFIES IF THERE ARE ANY PREVIOUS CLAIMS IN EMAIL HISTORY PREPARES THE LETTER FOR UNDERTAKING AND SENDS VIA EMAIL UNDERTAKING LETTER BATCH OF CLAIMS FOR VERIFICATION PRINTED COPY OF BATCHED CLAIMS (See: Documents!B3) VERIFIES INDIVIDUAL CLAIMS FROMBATCH TO CLAIMINVOICES IN CLAIMS ARE MATCHED SENDS PRE- AUTHORIZATION REQUEST LETTER BY EMAIL PRE-AUTH REQUEST LETTER CLAIMS ARE CONSISTENT NOYES NO YES YES NO YESNO YES VERIFIES BENEFIT LEVEL, NUMBER OF MEMBERS COVERED IN FORTIS/AIMS REJECTS PRE- AUTHORIZATION NO NO VERIFIES IF SUM ASSURED IS AVAILABLE YES YES REJECTS PRE- AUTHORIZATION NO PRINTED & RETURNED PRINTED DOCS CORRECTION CLAIMREQUISITON RAISED CLAIM REQUISITION FOR APPROVAL CLAIMS APPROVAL YES NO MOVES TO FINANCE FOR PAYMENT CLAIMS PROCESS MAP
- 10. FINDINGS: HOSPITAL CLAIMS Claims capture Claims capture Verification & indexing Verification & indexing Requisition Requisition Approval Approval Finance payment Finance payment YTD Sept & Oct STEP WISE BREAKDOWN OF CLAIM PROCESSING TIME
- 11. FINDINGS: FROM THE TIME OF EVENT KYM Death KYM Reimbursement Hospital STEP WISE BREAK DOWN OF TATs Customer document submission Factory document transfer Majani document transfer Hospital submission Internal processing
- 12. TRANSLATING FINDINGS INTO ACTION • ONE STEP AT A TIME • SEPARATE IT AND NON-IT INTERVENTIONS • DATA MANAGEMENT IS KEY – REDUCE DATA FRAGMENTATION – DATA ANALYSIS FOR SMART PROVIDER MANAGEMENT • PROCESS AUTOMATION – AUTHORIZATIONS – CLAIM SUBMISSION AND NOTIFICATIONS (SMSes) • TEAM STRUCTURE – DATA BACKED WORK FLOWS
- 13. THANK YOU With you every step of the way
- 14. Immediate requirement is to collect sufficient date to evaluate and pay the claim Collecting detailed historical claims data can add additional value to a microinsurance program: ‒ Evaluate trends in underlying claims drivers • Utilisation / frequency of claims • Average claim amounts • Primary causes or types of claims • Claim volumes ‒ Analysis by different factors such as • Age and gender • Location / service provider Program review – data management
- 15. CLAIMS MANAGEMENT IMPACT INSURANCE FACILITY WEBINAR THURSDAY, 2ND MARCH 2017
- 16. MicroEnsure is a specialist in designing, delivering, and operating insurance products for the emerging consumer. 50 million registered customers 200 products launched 25 countries 15 years in business Shareholders: MicroEnsure: Who we are
- 18. Our Key Insight: People actually love insurance when it really works. Especially emerging consumers, who frequently face risk. Earn free hospital cash, life and accident cover up to $2,500 when you top up $2 The more you top up, the more you earn Pay $1 per month & double the free cover you earn Earn up to $5,000 in life, accident and hospital insurance Buy additional cover for your family Buy higher-impact health products: telemedicine, info MicroEnsure Freemium Product Lifecycle:
- 19. Claims: The Ultimate Selling Point Claimant TV Ad, Ghana: • “I received my money in 2 hours” • “This is not a fabrication; this product is real” Micro insurance Myth: The more claims I pay, the less money I make. Emerging customers need proof that a product works, and then they will buy it; claims management is essential for growing the market to scale. Watch the ad “Hafiz Baba Testimonial on Airtel Insurance” on https://www.youtube.com/watch?v=vX6TySibSU8
- 20. Why Delaying Claims is Poor Strategy Loss incurred First claim report Claim documents received Claim paid MicroEnsure Typical claims experience 1-2 days 3-5 days 1-2 hours 10-15 days 40-45 days 72 hours Policy terms aren’t clear, report has to be made in person at insurer office Claimants go through many rounds of document review and keeps being asked for additional documents Clock only starts when ALL documents received; claims processed through multiple departments Customer knows exactly what cover she has, with no fine print, and claims are reported easily via phone A proactive customer service process and clear directions on document/s required allows for faster claims submission MicroEnsure performs most claims analysis before final document receipt, earns payment authority from insurer 50-70 days from loss to payment 4-7 days from loss to payment Claimant tells everyone about your product Claimant is tired of your company
- 21. • Start from claim event (customer perspective), not from notification (insurer’s perspective) • Track every step, every sub-step, every contact • Maintain direct contact with claimants through process • Adaptive process and documentation requirements • Follow up pro-actively with claimants until closure Claims Management: Guiding Principles Validate Validate Validate 1 2 3 4 5 6 7 8 9 . . . . . . . . . . . . . . . . . . . . . .. Event Reporting Contact Review Closure
- 22. • Claim volumes per Product, Partner, Country, etc. • Claim incidence rates per Product • Claim ratios • TATs per Month, Product, Partner, Insurer, etc. • Contact (number, mode & frequency to get to closure) • Proportion of payable claims by product & partner • Reasons for rejection • Open vs. closed claims per Product, Partner, Country, etc. • Proportion of Claims paid on time per Product, Partner, Country, Insurer, etc. Claims Management: Data Analytics
- 23. • Reasons for rejection show us potential to enhance product in a way that meets customer demand • Claim incidence rates: low = enhance benefits; high = increase premium, change policy terms • Time taken for notification: being able to demonstrate how quickly claims are processed when we have direct contact with claimants and claim settlement authority vs. when we don’t Claims Management: Insights CLAIM PROCESSING TAT ANALYSIS SCHEME Average of Time - Incident to ME Notification (Days) Average of Time - ME Notification to initial Docs (Days) Average of Time - Initial to Complete Docs (Days) Average of Time - Comp Docs to ME Comp Verification Average of Time - ME Verif to Insurer Average of Time - Insurer to Payment TOTAL TURN- AROUND TIME: Incident to Payment SCHEME 1 (M.E. DIRECT) 1.54 0.50 0.08 0.08 0.09 0.64 2.93 SCHEME 2 (MFI – DIRECT CONTACT, CLAIM SETTLEMENT AUTHORITY) 13.85 0.26 2.73 2.51 0.02 2.87 22.24 SCHEME 3 (MFI – NO CONTACT, NO CLAIM SETTLEMENT AUTHORITY) 29.85 4.88 4.60 3.69 1.23 11.69 55.94
- 24. Total settlement time is key for clients Inefficient workflow contributes to higher expense levels Focus on improving the step that creates the biggest problem or bottleneck first Test workflow process before “hard-wiring” it into an automated system Reporting claims ratios and other performance indicators can be used to improve program sustainability, product design and pricing Coordinate data requirements and reporting with department(s) responsible for setting premiums and reserves Key points to remember
- 25. 1. Claims management needs to be considered in the context of overall program design. ‒ Existing social capital and distribution channels can be leveraged to create a one-stop process for clients’ insurance needs. 2. The claims notification and submission processes need to be simple and easy to understand ‒ For clients, intermediaries AND claims managers. 3. Claims documentation requirements should not be too onerous ‒ Requirements should be sufficient to manage fraud, but not excessive. Guiding principles
- 26. 4. Turnaround time is a key factor both for client satisfaction and cost-effectiveness. ‒ From the client’s point of view, the total time from loss to payment is what matters. 5. Efficient and streamlined workflow processes should be implemented. ‒ And workflow should be evaluated on a regular basis. 6. A loss event is a difficult time for the client: ‒ The process should be fast and simple. ‒ Claims settlement should be transparent and provide multiple contact points for communication. ‒ Benefits should be provided in a convenient form. Guiding principles
- 27. 7. It is important to maintain control over data and processes, including appropriate fraud control mechanisms. ‒ Use of third party service providers involves additional controls and service standards. ‒ Investments in technology should be well thought out prior to development. 8. Clear management objectives are necessary in order to balance appropriate trade-offs between business and client perspectives. Guiding principles
- 28. Microinsurance Paper No. 28: Claims Management in Microinsurance ‒ http://www.impactinsurance.org/publications/mp28 Le Roy, P., & Holtz, J.; Third Party Payment Mechanisms in Health Insurance. ‒ http://www.ilo.org/public/english/employment/mifacility/do wnload/mpaper13_payment.pdf Steinmann, R.; Process mapping for microinsurance operations: A toolkit for understanding and improving business processes and client value. ‒ http://www.ifad.org/ruralfinance/pub/toolkit.pdf References and Resources
- 29. Q&A
- 30. Join us for our next webinar in early May, focusing on “Change management” Thank you!