Next Generation of Claims Adjusters Needs Next Generation Claims Handling Technology

Property/casualty insurers need to replenish their claims-adjusting ranks, as age and attrition take their toll. While searching for top candidates, carriers also need to look for processes and technologies that will enable this next generation to come up to speed quickly, ensuring efficient, effective and service-sensitive claims handling.

As insurers set the stage for a new generation of medical injury claims professionals, they should think about technology and the impact of medical costs on the adjusting process.

Insurers face challenges recruiting and training a new generation of adjusters, given the number of professionals leaving the ranks. Yet there’s an opportunity to leverage technology to empower medical injury claims adjusters to process claims more effectively, positively impacting policyholders and insurers.

Inexorably Rising Medical Costs

What really should be on insurers’ minds as they build their claims professional ranks is the unrelenting rise of medical costs. As the key component of injury claim settlement values, medical costs have to be tackled to effectively manage the costs of medical care related to the handling of injury claims. Empowering claims handlers to manage medical costs in an automated and efficient manner is key to surviving and thriving, given the claims environment.

Consider the rise in medical inflation: From January 2002 to January 2012, overall inflation increased 28 percent, while during this same period medical cost inflation increased by 46 percent.

It’s clear adjusters should be tasked with mitigating the impact of continuously rising medical costs, while ensuring the injured party receives prompt, appropriate and high-quality care.

The challenge, therefore, goes beyond just training a new generation of medical injury claims adjusters; it is one of supplying these adjusters with the tools, technologies and techniques for a brave new world of medical cost management.

All claims professionals balance large caseloads of claims with multiple moving parts. Medical injury claims professionals, in particular, encounter compliance requirements, timing considerations, the need to determine exposure and establish timely and accurate reserves, and settlement strategies/negotiations. Automating these components of the claims handling process allows adjusters to apply their people skills where they make the most difference — interacting with the injured party, treating doctors, attorneys, employers and others involved in the medical claim ecosystem — to create settlement outcomes amenable to all.

Captured Benefits

The trend toward core claims management solution replacement is well-established, and most insurers are benefitting from their new claims software solutions. Modern IT infrastructures and programming languages, system flexibility and modification speed capabilities, and ease-of-use provide advantages to claims handling teams, rookies and seasoned adjusters alike.

But have carriers truly captured all the benefits that software can provide their claims handling communities?

There is a breed of system that, when integrated with carriers’ claims solutions, can bring even more value to claims handling accuracy, consistency, efficiency and service levels provided to customers.

Enter the era of the claims expert point solution, specifically envisioned to bring the new generation of claims adjusters into the modern age. Embedded into the claims handling process, these solutions deliver decision support tools that empower claims adjusters to automate and streamline key parts of medical injury claims handling, containing costs wherever possible while ensuring the insured receives the best care possible.

Expert Point Solutions as a Guide

The goal of expert point solutions is to achieve consistency and fair outcomes by putting the best adjusters’ expert guidance at key points in the claims handling processes. The critical areas of claims handling — coverage evaluation, investigation, liability evaluation, recovery evaluation, settlement evaluation and negotiation and settlement — need to be part of a consistent claims evaluation process.

All steps in the claims process can be automated in a consistent claim evaluation framework that empowers effective and productive claim settlement results.

The first step in effectively handling any claim is clearly understanding and evaluating the jurisdictionally appropriate coverage that applies to the occurrence, and then consistently executing key claim investigative activities. Liability determination, recovery evaluation and settlement evaluation require clear and accurate documentation, appropriate detailing, and accounting of special and general damages for negotiations to proceed smoothly in a timely and logical manner. Sharing data and workflow seamlessly among all these steps leads to more appropriate loss and loss adjustment expense, improved claims cycle time and better customer service.

Analytics and Business Intelligence

The application of advanced analytics and business intelligence is another example of using technology to better understand the actual drivers of injury claims handling effectiveness, as well as healthcare delivery efficiencies.

Analytics can be employed to help improve adjuster performance and, therefore, settlement outcomes. Analytics can provide the adjuster with greater insight into the claim context, the claimant and providers, as well as be used to automate certain routine business rules — such as when to forward claims for independent medical exams or to special investigative units — accelerating the claims process.

Predicting which claims would benefit most from early intervention is key to molding the next generation of adjusters. Predictive analytics aids in improved front-line decisions that make the most of scarce resources by triaging high-cost claims before they escalate. Insurers know that a small number of high-cost claims drive the majority of loss dollars. These costs can be better controlled by effectively managing claims from the onset — a better use of adjusters’ time and expertise.

Integrating New Provider Networks

Claims data and analysis also help with the most expensive claims. Once again, medical costs — as well as fraud and abuse — are driving claims analytics usage. Medical management partners, expanded Preferred Provider Organization networks along with new network configurations, such as Voluntary Provider Networks (VPNs), and Out-of-Network (OON) service-providers are starting to hit stride.

Adjuster decision support technologies are being closely integrated with out-of-network provider and payment services.

The benefit to insurers is that they are able to leverage the estimated 70 percent of medical charges generated by providers not part of a provider network. By automating and integrating provider network tiering and out-of-network negotiation services into adjuster technologies, medical costs are addressed at the start of the claims settlement process.

Since time is of the essence in handling the most expensive medical claims, full integration with medical bill adjudication software and the service-provider is essential to success.

Medical bills eligible for out-of-network negotiation services must be seamlessly selected and transmitted to negotiation services partners without any need for intervention from claims professionals or re-keying of information. VPNs and OONs can help make the most of adjuster claims handling expertise by automating and incorporating a cost containment component into the claims workflow.

Adjusters can deploy claims handling technology to become efficient, and with control over decision-making, when they have the systems to guide them through the claims process, and with full access to claim information and medical bills. Rising medical costs will not likely change, but claims adjusters, armed with the best technology, can mitigate them within the adjustment and settlement process.