Claims Quality Assurance and Compliance Framework

Claims Quality Assurance and Compliance Framework

Version 2.4

Version:2.4 Last amendment:15/08/2017 Approved by: Mary Maini Date: 15/08/2017 Owner: Manager, Claims Quality and Compliance

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Claims Quality Assurance and Compliance Framework 2

Version control

Version number Effective date Valid to Details

1.03 April 2016 April 2017 Approved by Mary Maini

2.0 May 2016 May 2017 Approved by Mary Maini

2.1 November 2016 November 2017 Approved by Mary Maini

2.2 February 2017 February 2018 Approved by Mary Maini

2.3 May 2017 May 2018 Approved by Mary Maini

2.4 August 2017 August 2018 Approved by Mary Maini

2.4 August 2018 August 2019 Approved by Tass Calaitzopoulos

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Contents

1. Purpose 4

2. Principles 5

3. Scope 6

4. Definitions 7

5. Quality Assurance and Compliance Matrix 8

5.1 Plan 8 5.2 Internal Review 9 5.3 External Review 11 5.4 Continuous Improvement 11

6. Quality Assurance Review Framework 13

6.1 Framework Review Guide 13

7. Reporting and Tracking 15

7.1 Reporting 15

8. Framework Review 18

9. Annexure 19

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1. Purpose

This framework document has been developed by the TAL Claims Quality Assurance & Compliance function and specifies the TAL Claims Quality Assurance and Compliance Framework including its principles, scope, methodology, operational assurance, continuous improvement program, and reporting.

This framework has been designed to ensure compliance with TAL Limited’s Risk Management Framework.

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2. Principles

To enable TAL to enhance and maintain quality customer outcomes and meet its statutory and regulatory obligations, the TAL Claims Quality Assurance and Compliance function is committed to providing an environment where all staff are equipped and feel empowered to create moments of brilliance for our customers whilst minimising TAL risk.

Guiding principles:

Providing a review and feedback system that mitigates business risk

Provide a compliance framework which balances the business requirement to manage risk with staff

empowerment to step outside of guides where required

Monitor the implementation of changing business processes and practices

Foster a Manager led quality culture where all staff are fully committed to an open culture of quality &

compliance

Identify areas for personal and departmental improvement

Adherence to Regulatory Requirements

The customer is the central focus in all interactions.

Provide clear and easy to use measurement criteria to ensure a continuous improvement culture.

Use analysis of data outputs to provide guidance on risk issues, areas for improvement and

realisation of business positives

All staff have a role to play in delivering the Claims Quality Assurance and Compliance Framework

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3. Scope

This framework applies to all TAL Claims Assessment staff and is managed by the Claims Quality Assurance and Compliance function.

The scope of work includes the following:

Quality of Customer Interactions

The framework reviews the quality of direct customer interactions through the review of telephone calls and relevant documentation, and evaluates with the relevant customer and telephone call assessment tools.

Accuracy of Technical Assessment and Decision making

The framework includes the accuracy of case assessments and decisions through listening to telephone calls and reviews of case management files, and evaluates with the relevant technical assessment tools.

Case Management

The framework considers the quality and effectiveness of case management which will include Case Management Framework, Case Management Model, and Claims Capability Framework), this will also align to the QA Framework and evaluate with the relevant case management assessment tools.

Data completeness and accuracy

The framework evaluates the completeness and accuracy of key data in claims systems.

Compliance with Controls

The framework will review and evaluate compliance of controls within Policies, Processes and Procedures.

Out of Scope:

Factors which may result in a TAL Claims Staff member being outside of scope of the Quality Assurance Framework are:-

- Staff resignations – The framework is designed to provide feedback and create development opportunities for current staff. There is therefore no benefit in conducting this process for staffs who have resigned unless a particular need is identified (i.e. Risk Management).

- Business Requirements – In some instances a claims staff member may be redeployed or seconded to assist in another part of the business or on a project. Subject to the duration of this requirement, the need for a quality review may be out of scope as their role and responsibilities may have changed.

- AustralianSuper – The Quality Assurance framework for Superpartners Assessors is documented and managed under the Insurance Service Agreement between TAL and AustralianSuper.

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4. Definitions

The following definitions are used in this framework:

Audit – Relates to either an Internal, External or Reinsurer Audit

GM - General Manager, Claims

QA - Quality Assurance. In the procedure you will find it referenced with QA Review or QA Framework

Case Management Framework – Optimises return to work and health outcomes for individuals whilst also reducing costs for the business

Case Management Model – Sets out the Case Management Model to be implemented across Claims.

Claims Capability Framework – Enable managers and team members to evaluate a team member’s capabilities against both current role and/or desired future role

Case Management Model – Sets out the Case Management Model to be implemented across Claims.

Medical Opinion Governance Framework – This document sets out the provision of medical opinion provided specifically to the product, underwriting and claims teams by TAL Chief Medical Officer (CMO). Tele - Telephone

VoC - Voice of Customer

OA – Operational Assurance.

Regulatory Requirements – Including but not limited to: ASIC, APRA, FSC, Privacy, ETC

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5. Quality Assurance and Compliance Matrix

The Quality Assurance and Compliance Matrix identifies the controls, frameworks and processes in place to develop and maintain a high performing quality service culture within the T AL Claims area.

• Recruitment · High Performance Service Culture

· Case Management Framework

· Case Management Model · Delegations of Authority ·Processes and Proced • Risk Management Framework

• QA&C feedback loop · Reporting/tracking · Capability development · Training & Development · Process Improvement · Framework/model improvements

· Internal & External Feedback Channels

5.1 Plan

•QA & Compliance · Payment Officer Checking

· Referral Reviews · Call Reviews

· Leakage and Optimisation edical opinion governance

•Capability Framework Assessment

• T AL Internal Audits · Compliance Reviews Data Quality Reviews · Decision Committee

e erra s

· External Audits • Reinsurer Audits

The plan is the foundation of the way in which T AL Claims manages risk and the needs of its customers.

5.1.1 Recruibnent The recruitment of claims people with diverse backgrounds and skills that enable T AL Claims to meet business needs and strengthen the TAL culture. The Claims Capability Framework guides managers in their recruitment by outlining the capabilities required of case managers.

5.1.2 High Performance Service Culture The high performance service culture aims to improve communication and interaction with our customers, ultimately giving customer service equal billing with excellence in technical claims management.

5.1.3 Case Management Framework and Case Management Model The framework and model are outcome driven with a focus on high engagement levels between a Case Manager and the customer. The Case Manager's primary focus is on supporting a customer's return to health and work.



5.1.4 Delegation of Authority

The quality assurance and compliance matrix is circular allowing it to align with the development of a claims Case Manager. As the claims Case Manager develops as per the Claims Capability Framework and becomes more experienced, an increase in their role and responsibilities and delegation of authority may be granted*. In the event that this occurs the cycle of their matrix recommences.

* Note: A minimum number (as agreed with relevant Claims channel) of reviews must be conducted before an increase in delegation of authority can be granted – refer Claims Authority and Delegations Guidelines.

5.1.5 Processes and Procedures

Documented processes and procedures ensure that a consistent and compliant case management approach is adhered to by all claims staff. Claims staff can access these procedures via the TAL Intranet under the claims tab.

5.1.6 Risk Management Framework

TAL’s risk management framework is designed to reduce risk to an acceptable level within its risk appetite by ensuring that all material risks that have the potential to significantly impact business operations, capital or client entitlements are identified and managed appropriately at the correct level within TAL.

5.1.7 Medical Opinion Governance Framework

TAL has recently moved to an internal model for medical opinion with the recent appointment of an internal Chief Medical Officer (CMO). The CMO will be responsible for the provision of medical opinion across underwriting, claims and product areas. The CMO will also have responsibility for providing medical feedback across the three areas and to ensure that medical opinion in these areas is consistent and aligned.

5.2 Internal Review

It is imperative that we factor in TAL’s Claims vision of providing our customers with a High Performance Service Culture. With the shift towards Tele-based claims and case management, it is important that we factor in customer and Tele- based skills into our review process.

The aim of our review process is therefore to: confirm the validity of TAL’s claims assessment process and decision making; case management effectiveness; customer service standards, and compliance with processes and controls.

5.2.1 Quality Assurance and Compliance Technical Reviews

The Quality Assurance and Compliance function conducts a planned number of independent claim reviews on an annual basis, which is documented as per 6.1 of this document “Framework Review Guide” and tracked by regular reporting. . Audit requirements are reviewed quarterly and targeted to life or business risks or more frequently if required to allow for business environmental or risk changes and priorities, for example, staffing numbers, new employees in their probationary period, processes, claims experience etc.

A technical Review can include Full File Audits, Tele-Assessment Reviews (through call review structure) and Referral Reviews by the QA team, where an area of concern has been identified (Targeted) or a combination of these items.

A minimum of 3 claims or activities will constitute a technical review per 6 months.

The Quality Assurance and Compliance function conducts reviews within the scope outlined in this framework document.

The methodology and tools are outlined in this document. Section 6 - Quality Assurance Framework.

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5.2.2 Referral Reviews

A Referral Review is conducted when a Senior Claims Assessor, Claims Technical Consultant or Team Manager Reviews a claim that is above the delegated authority of an individual member of the claims assessment team. Team managers are required ensure that a planned number of reviews on an annual basis. This supports individual and team development and as outlined earlier is a key requirement for obtaining an increase in Delegation of Authority.

The Quality Assurance and Compliance Team will also conduct random Quality Assurance and Compliance reviews on referral reviews focussing on technical, process and authority levels.

5.2.3 Call Reviews

Call Reviews cover the review and feedback around the quality of our telephone interaction with our customers. It includes formal call calibration and call listening.

Call calibrations allow a free exchange of views about claims discussions and through open conversation is an opportunity for learning and developing technical skills and service culture.

These discussions may take place at a team level or in the form of a one-on-one (live listening or process review) with a Manager or Quality Assurance consultant. Keeping results of these reviews is an important part of the framework as it allows tracking of the progress of Case Manager development.

5.2.4 Capability Framework

The Capability Framework is directly aligned with TAL’s core organisational capabilities to ensure that quality case management is sustainably embedded in the operating rhythm of the organisation.

In TAL Claims, the framework is used to support and guide thinking in relation to recruitment (now and in the future); development and learning; superior service delivery to our customers; career pathways and succession planning; and to promote more flexible professional and management practice.

5.2.5 TAL Internal Audits

TAL’s Internal Audit team conduct audits in accordance with an annual plan approved by the TAL Board Audit Committee. The objectives of the internal audits are to assess the adequacy, efficiency and effectiveness of management controls and the annual Internal Audit plan may include coverage of the Quality Assurance and Compliance Framework and more broadly the Claims Operational Excellence Team.

5.2.6 TAL Compliance Reviews

Dedicated TAL Compliance Staff undertake regular reviews and verification testing of business practices against approved policies and procedures to assess and maintain the overall integrity of TAL’s compliance framework. In addition, as part of their regular reviews, Compliance staffs also confirm the existence of the internal controls identified by the business on their respective Risk and Control Templates (RCTs).

The monitoring program is agreed each year. Reports or results of such monitoring are provided to the relevant Board or Compliance Committee.

As part of the Annual Compliance Review Plan, Compliance Staff periodically review the TAL Life Claims area to ensure claims are being processed in accordance to the terms and conditions of the Policy and that the relevant legislation is being followed.

5.2.7 Payment Officer Checking

With the Claims payment function being outsourced, the Quality Assurance and Compliance function will conduct a targeted number of planned reviews of claims paid by the entity. Reviews will be tracked and monitored.

5.2.8 Decision Committee Referrals

Through the operation of the Claims Decision Committee, customers and their representatives should be confident that there is a transparent and equitable decision-making process where these claims are decided openly, objectively and in keeping with TAL’s Claims Philosophy.

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5.2.9 Leakage and optimisation spend

Leakage and optimisation spend will be identified through Claims QA Audits, Referral Reviews and claims staff feedback. This is recorded in a centralized Business Optimisation spreadsheet and reported to senior management on a monthly or quarterly basis.

5.2.10 Bank Account Details Verification

Where Bank Account details are obtained by phone, via the Tele-Claims process, details will be verified via a sampling of Bank Accounts entered into the relevant claims system, by the Team Manager, Senior Case Manager or Senior Service Consultant. These samples will be completed as “Referral Reviews”

Team Managers, Senior Case Manager or Senior Service Consultant to review Bank Acc. Details of 1 claim per person per month in respect of new claims

IP Claims (New & Ongoing where a subsequent change has been made to Bank account details) – min 4 per month across the team

5.3 External Review

External reviews are conducted by independent bodies external to TAL. Their primary focus is to examine and evaluate the internal controls and frameworks put in place to mitigate risk.

5.3.1 External Audits

External audits are conducted to provide clearance that TAL financial statements and accounts are presented in accordance with accounting policies and procedures. The external audit is coordinated through the Finance team who are responsible for the provision of requested information responding to audit reports/findings and implementing and agree actions.

5.3.2 Reinsurer Audits

Reinsurer Audits are conducted on an as-needs basis when identified by the reinsurer or as required by TAL. The audits are coordinated by the Quality and Compliance Team, who are responsible for the provision of requested information, responding to audit reports/findings and implementing any agreed actions.

5.4 Continuous Improvement

Essential in any quality program is the continuous improvement cycle and feedback loop. This ensures that the benefits of the Quality Assurance Framework are utilised to improve the functioning of the team and claims experience, staff capabilities, and the quality of the customer experience.

Element of the continuous improvement program are:

5.4.1 Management Feedback Loop:

Quarterly management meetings between the Quality Assurance and Compliance Manager and Claims Heads Of/Team Managers are held to enable mutual understand of expectations from quality assurance and compliance reporting and findings, team matters, authorities and issues.

5.4.2 Training and Development Feedback

The Quality and Compliance Matrix caters for targeted and ongoing feedback to be provided to the Training and Development team. Whether it is a new Claims Assessor or a change to Process or Procedures the Quality Assurance and Compliance function will track and report observations and trends identified which may result in additional clarity or further training.

Where an issue has been identified as a “Disagreed” by the QA Team that requires rectification by the CM, the QA team will raise a “Mail item” in the appropriate claim system that is to be actioned by the CM within close of following business day.

Where an issue has been identified as a “Major Disagreed” by the QA Team that requires rectification by the CM, the QA team will raise a “Mail item” in the appropriate claim system that is to

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be actioned by the CM. The QA team will conduct a follow-up review within 72 hrs. (from when issue has been identified) to ensure the issue has been rectified.

If the issue has not been rectified the QA Team will escalate the matter to the appropriate Team Mgr.

5.4.3 Capability Assessment Input

The Quality and Assurance Framework provides a means to assess and monitor the capabilities of claims staff through objective data provided to team managers supporting the validation of capabilities assessments with Claims Capability Framework. The Claims Capability Framework sets out the assessment and development process.

5.4.4 KPI or Development Plan Alignment

As part of continuous improvement program, areas that require further development should be aligned with KPI’s or Development Plan for individual Claims Managers with overall accountability with Team Managers to ensure achievement.

5.4.5 Internal and External Feedback Channels

Third parties and other internal business units play an important part in capturing and reporting feedback on areas of improvement. A Bi-annual review of internal and external feedback channels will be conducted as a minimum, to observe whether any comment has been made in relation to the Claims area. Channels where feedback will be sort from are:-

o Complaints, o Internal Dispute Resolution Team, o External Dispute Resolution Team, o Legal, and o Underwriting

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6. Quality Assurance Review Framework

The main Quality Assurance and Compliance function is to review and provide results and comments to Management, Team Managers and Case Managers via the feedback tools (assessment sheet and/or traffic light reports) and through scheduled reporting and meetings. The guideline to this review function is outlines below.

6.1 Fra1nework Review Guide The Quality Review Process Guide outlines what activities are monitored from the Quality Assurance and Compliance matrix. It also highlights the minimum expectations which need to be met for that specific activity.

Activity Type Responsible Purpose Minimum Target How Reported Expectation

Technical Reviews Review individual Review individual

Technical Compliance assessors every 6 assessors every 3 Individual Feedback QA Technical Call Listening (targeted

Quality Assurance and Case Manager months months Team Report Review or routine) Minimum 3 claims per Minimum 3 claims per Business Line Report

Referral Reviews Development Case Manager Case Manager GM Claims Report

Team Managers 2 per person per month 4 per person per month

Review of referred (QA Will endeavour to (QA Will endeavour to Individual Feedback

cases that are outside Senior Case Technical Compliance complete these based complete these based Referral Reviews Manager Team Report and Individuals and Case Manager on the capacity of on the capacity of Delegation Technical Development Claims to complete Claims to complete Business Line Report

Consultants reviews) reviews) GM Claims Report

2 Calls per consultant 1 Call per consultant per per month

Team Managers month 1 Call Calibration

Call Calibration Senior Case 1 Call Calibration Session per consultant Individual Feedback

High Performance Session per consultant per Month Team Report Call Reviews Managers Service Culture Call listening Technical per quarter Business Line Report

Consultants NB: Where Case NB: Where Case GM Claims Report Managers have member Managers have member contact contact


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Activity Type Responsible Purpose Minimum Target How Reported Expectation

Audit Call Review Calibration Quality Assurance High Performance Service Individual Feedback Calibration

QA Full Audit Calibration Consultants Culture 1 Call Calibration Session 1 Call Calibration Session Team Report

per quarter per quarter Business Line Report Referral Review

Ensure consistency in GM Claims Report

Calibration approach to Auditing 1 Full QA Audit Cal bration 1 Full QA Audit Calibration

per quarter per quarter

1 Referral Review Audit per 1 Referral Review Audit per quarter quarter

Ensure claims data is as

Quality Assurance and accurate and up to date as possible and to ensure Business Line Report Data Quality Reviews Data Quality checks Claims Business that claims continue to be Ad-hoc Ad-hoc GM Claims Report

Solutions progresses

To develop a deeper Capability Assessment Assessment of T earn Managers understanding of Annual Assessment Assessment every 6 Business Line Report

Framework Capabilities against Tool assessor capability months GM Claims Report development

Payment Officer Quality Assurance To review and report Review 10% of payments Review 10% of payments GM Claims Report TALs current arrangement and expenses processed to and expenses processed to

Checking with SYKES monitor accuracv monitor accuracv

Business Line Reporting

To ensure accuracy of Individual Feedback Bank Account Details Data Quality checks T earn Managers Bank Account details FP - 1 PIP PNV FP- 1 P/P PNV Team Report

verification entered into Claims IP New and Ongoing 4 PNV IP New and Ongoing 4 PNV Business Line Report systems GM Claims Report

Assess adequacy, Individual Report -

TAL Internal & External Internal Audit efficiency and management actions

Audits External Auditors effectiveness of As per Approved Audit Plan As per Approved Audit Plan tracked and reported on

management controls in Monthly GM Claims Report Individual Report -

Assess and ensure the As per approved Monitoring As per approved Monitoring management actions Compliance Reviews TAL Risk & Compliance overall integrity ofTAL's Program Program tracked and reported on

compliance framework in Monthly GM Claims Report

6.1.1 Feedback The Quality Assurance and Compliance Consultant and Case Manager will engage in a 1-on-1 discussion where feedback is to be provided and any case recommendations agreed and documented. The Team Manager may attend this discussion if they wish or if asked by the Quality Assurance and Compliance Consultant. The Team Manager is to attend all discussions with an overall disagree rating.



7. Reporting and Tracking

7.1 Reporting

Reporting is generated and distributed on a monthly or quarterly basis to the Claims Management Team and other key stakeholders as required. Generally these reports are designed to help compliment the Continuous Improvement stage of the QA Framework by providing visibility around individual and team performance. Audits/Reviews which help highlight these areas are:-

• QA Matrix results

• Referral Review results

• Telephone Review results (Reporting currently under development)

Ad-hoc reporting may also be generated to communicate feedback and findings around:-

• Business Optimisation

CMO Governance Feedback • Reinsurance feedback as appropriate

• Internal & External Audits

• Complaints and Voice of Customer (VoC)

NPS reporting

Meaningful reporting helps identify/highlight areas of improvement at an individual, team, department and organisational level.

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7.1.1 Reporting Frequencies The Quality and Compliance function provides different levels of feedback and results on a monthly and quarterly basis. The results captured and the recipient of this feedback is captured in the table below .

Activity Monthly Reoortina Quarterly Reoortina Individual Consultant Team Managers Team Managers Business Units Quarterly GM Claims Quarterly Report

Reports Monthly Report Report QA Results

~ ~ ~ ~ ~ Referral Results

~· ~· ~· ~· ~· Call Reviews ~~ ~~ ~~ ~· Data Quality

~· ~· ~· Internal Audit ~~ ~· External Audit ~~ ~· Complaints,

~ ~ Compliments and voe

Tracking QA

~ ~ Reviews against plan

Tracking Call

~ ~ ~ Calibration Reviews

Tracking % of ~ ~ ~ ~ Referral Reviews Tracking

~ outstanding Audit I Compliance

actions Payment Officer ~ Checking

Decision

~ ~ Committee Referrals



7.1.1.1 Monthly Reporting

Monthly reporting will provide a high level (at a glance) summary on how each Case Manager and Claims Team is tracking.

7.1.1.2 Quarterly Reporting

The quarterly report is a summary of results and findings over the quarter and comparison to previous quarter by team and by individual.

In both instances the reports will provide communications around results and tracking.

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8. Framework Review

The quality assurance and compliance framework is owned by the Claims Operational Excellence function.

The owner is responsible for monitoring and reviewing the framework and process to ensure it remains current and relevant and aligns with the TAL strategy and its regulatory obligations.

This document is to be reviewed annually ensuring it aligns with internal and external audit feedback and requirements.

Effective Date Next Review Date Approved By

1 May 2016 1 August 2016 Approved by Mary Maini

1 August 2016 1 February 2017 Approved by Mary Maini

1 February 2017 1 May 2017 Approved by Mary Maini

1 May 2017 1 May 2018 Approved by Mary Maini

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9. Annexure

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Documents

Claims Quality Assurance and Compliance Framework