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The moment of truth:
Claims
Claims analytical framework
1. Notification
2. Submission
3. Validation
4. Approval
5. Settlement
Claims procedures
Analyse each of the categories of claimsprocedures:
‒ Consider the impact of product type and programdesign/structure
‒ Identify any specific tools or strategies that you areusing to improve client value, business value, or both
‒ Are there any areas where procedures could beimproved?
• Why? What change would you make?
• Does it fit under one of the guiding principles?
Program review – processes
CLAIMS PROCESS REVIEW
PATRICK KIHURIA MANAGER-MICROINSURANCE OPERATIONS
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
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
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
HOSPITAL QUALITY ASSURANCE CONTROLLER CLAIM ASSISTANT
ye
PRE-AUTHORIZED AMOUNT COVERS THE
TREATMENT COST
CHECKS IF BENEFIT ARE REMAINING
PATIENT PAYS THE BALANCE AMOUNT
EXTENSION OF COVERAGE IS APPROVED
REQUESTS FOR EXTENSION OF
COVERAGE
PATIENT IS DISCHARGED
CLAIM FORM (ONLY FOR OP)
INVOICE DISCHARGE DOCUMENTS
SENDS PHYSICAL CLAIM DOCUMENTS THROUGH POST,
COURIER OR RUNNERS
CLAIM DOCUMENTSARE RECIEVED &
STAMPED
PHYSICAL DOCUMENTS ARE
SCANNED & UPLOADED TO DMS-
FORTIS
VETS CLAIMS BY REVIEWING AMOUNT, VALIDITIY OF DIAGNOSIS & EXCLUSIONS
SCANNED CLAIM FORMS
CONFIRMS CLAIMS ENTRY & CHECKS PAYMENT IN MAJMED
UPDATES DATA IN MAJMED BASED ON
DISCHARGE VOUCHER
PREPARES A HOSPITAL WISE EXCEL SHEET OF CLAIMS
PRINTS BATCH TO FORTIS DIRECTLY FROM EXCEL SHEET
INDEXES BATCH OF CLAIMS BY PUTTING
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-AUTHORIZATIONSINTO MAJMED (KYM)
ROW WISE DETAIL 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 EMAILUNDERTAKING
LETTER
BATCH OF CLAIMS FOR VERIFICATION
PRINTED COPY OF BATCHED CLAIMS
(See: Documents!B3)
VERIFIES INDIVIDUAL CLAIMS FROM BATCH TO
CLAIM INVOICES IN
CLAIMS ARE MATCHED
SENDS PRE-AUTHORIZATION REQUEST LETTER
BY EMAIL PRE-AUTH REQUEST LETTER
CLAIMS ARE CONSISTENT
NOYES
NO YESYES
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
CLAIM REQUISITON RAISED
CLAIM REQUISITION FOR APPROVAL
CLAIMS APPROVAL
YES
NO
MOVES TO FINANCE FOR
PAYMENT
CLAIMS PROCESS MAP
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
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
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
THANK YOU
With you every step of the way
Immediate requirement is to collect sufficientdate to evaluate and pay the claimCollecting detailed historical claims data can addadditional 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
CLAIMS MANAGEMENT
IMPACT INSURANCE FACILITY WEBINAR
THURSDAY, 2ND MARCH 2017
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
Unprecedented Products
High-Volume Systems
TechnicalStrength
Market Knowledge
Speed, Efficiency,
Agility
Customer Value
Robust Operations
MicroEnsure Business Model
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:
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
Why Delaying Claims is Poor Strategy
Loss incurredFirst claim
report
Claim documents
receivedClaim 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
• 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
• 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
• 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 2.93SCHEME 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
Total settlement time is key for clientsInefficient workflow contributes to higher expense levelsFocus on improving the step that creates the biggestproblem or bottleneck firstTest workflow process before “hard-wiring” it into anautomated systemReporting claims ratios and other performance indicatorscan be used to improve program sustainability, productdesign and pricingCoordinate data requirements and reporting withdepartment(s) responsible for setting premiums andreserves
Key points to remember
1. Claims management needs to be considered in the context ofoverall program design.
‒ Existing social capital and distribution channels can beleveraged to create a one-stop process for clients’insurance needs.
2. The claims notification and submission processes need to besimple and easy to understand
‒ For clients, intermediaries AND claims managers.
3. Claims documentation requirements should not be tooonerous
‒ Requirements should be sufficient to manage fraud, butnot excessive.
Guiding principles
4. Turnaround time is a key factor both for client satisfaction andcost-effectiveness.
‒ From the client’s point of view, the total time from loss topayment is what matters.
5. Efficient and streamlined workflow processes should beimplemented.
‒ 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 providemultiple contact points for communication.
‒ Benefits should be provided in a convenient form.
Guiding principles
7. It is important to maintain control over data and processes,including appropriate fraud control mechanisms.
‒ Use of third party service providers involves additionalcontrols and service standards.
‒ Investments in technology should be well thought outprior to development.
8. Clear management objectives are necessary in order tobalance appropriate trade-offs between business and clientperspectives.
Guiding principles
Microinsurance Paper No. 28: Claims Management inMicroinsurance
‒ http://www.impactinsurance.org/publications/mp28
Le Roy, P., & Holtz, J.; Third Party Payment Mechanisms in HealthInsurance.
‒ http://www.ilo.org/public/english/employment/mifacility/download/mpaper13_payment.pdf
Steinmann, R.; Process mapping for microinsurance operations: Atoolkit for understanding and improving business processes andclient value.
‒ http://www.ifad.org/ruralfinance/pub/toolkit.pdf
References and Resources
Q&A
Join us for our next webinar in early May, focusing on “Change management”
Thank you!