The Future of Technology and Claims Investigations

Wednesday, June 25, 2014

Host:Michael RiversManager, Claims Analytics andConsulting ServicesISO Claims Services, ISO

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Panelists:Marcia HalvorsenClaims Operations ManagerGuideOne Insurance

Ella TayrienManager, Claims DepartmentTraders Insurance

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Why Talk about technology?

“Analytics is defined as the scientific process of transforming data into insight for making better decisions.”

- INFORMS

The Institute for Operations Research and the Management Sciences (INFORMS)

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Does further investment matter?

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What am I hearing?

Manual effort“It is up to the insurer to do its diligence to obtain any information thatwould serve…the third party's claim. Is this time consuming andexpensive? Most definitely.”

“I don’t know how we are doing.” – March 2014

“…if it is not automated, the manual process may get missed.” –June 2013

“A claim is a claim is a claim." “Those who subscribe to this school ofthought are aggravated that someone hasn't yet come up with acomputer algorithm that would replace the need for adjustersaltogether!” 7

What has been done already?

Subrogation/Liability• Structured and consistent investigations• Not new as adjusters expected to do this already

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We are not done!

The insurance company is changing• Office consolidation and work from home models• Adjusters assigned claims from multiple states

The occurrence of fraud is increasing• “Aite Projects Insurance Fraud Will Cost $80 Billion Annually

By 2015” By Christina Bramlet, PropertyCasualty360.com 8/2013

Compliance• For statutes, there are many public sources. Manual effort to

apply to the applicable claim• Case law, manual efforts to manage as well

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MedSentry & Provider Fraud

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http://www.aota.org/DocumentVault/Surveys/LCD‐Outpatient.aspx?FT=.pdf

What makes initiatives fail?

Don’t state goals such as:• “must have 15% of claims with more liability”• “must have 4 referrals to the subro team”• “must have 100% closure rate”

Improve the investigations leads to better outcomes.

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Benefits of Analytic Decision Making:

Benefits of Analytic Decision Making: • Information in – intelligence out• Objective and consistent• Proactive decisions • Considers multiple inter-related factors• Efficient and scalable • Optimizes use of human subject matter experts

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Discussion / Feedback

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