The road to building seamless, hands-off, end-to-end claimsprocessing still is under construction. But with straight-throughcapability as their distant destination, insurers are choosing aroute of deploying solutions bit by bit to drive efficiency intoexisting claims systems.

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By Michael P. Voelker

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The ability of a claims ad-juster to open up a laptop, do aninstant damage ap-praisal, and write a check for payment in onevisit perhaps is one of the more impressive displays of claimstechnology in the eyes of the average policyholder. But as insurersknow, claim payment is only one part of the claims process, andhours of work remain to adjudicate, negotiate, and subrogate afterthe check is cut.

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I am still surprised going into companies, particularlyproperty/casualty companies, by how much of a manual process[claims] still tend to be, says Pat Turocy, principal analyst atresearch firm and consultancy Doculabs.

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In the best dreams of claims managers, claims processing is aseamless, end-to-end activity from first notice of loss to finalrecovery. Consider a theft loss. A policyholder uses the carriersWeb site to report, for instance, his new projection TV has beenstolen. The Web-based first notice of loss system connects with theclaims and policy administration system to populate all the datafields of a new claim. The claim is sent to a claims rules engineto confirm coverage and then to an ERP system to source a new set,which is delivered to the policyholders door. When the stolen setlater is recovered by police (hey, it could happen), a salvageassignment automatically is sent to a vendor.

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That automated straight-through pro- cess doesnt happen inclaims, but it does in underwriting. Sticking with our P&Cexample, carriers have demonstrated the ability to performsuccessfully hands-off, end-to-end processing, particularly inhighly homogeneous lines such as personal auto. Applicationscompleted online are passed through underwriting rules engines, andpolicies automatically are generated.

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So why not claims? First and foremost, claims systems arentdesigned to capture the amount of data needed to fully enablestraight-through processing. You may look at 200 attributes just tohandle a claim [vs.] 30 attributes to underwrite a policy, explainsMichael Costonis, a partner in Accentures Insurance SolutionGroup.

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Take our television example, for instance. A claims systemdoesnt capture make, model, and SKU information [using the types oftheologies commonly utilized by retailers and manufacturers] toprocure automatically an identical TV, Costonis says. Therefore,human intervention, decision-making, and negotiation are involved,and the end-to-end automation effort breaks down.

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Another challenge is, unlike the underwriting process, wheredata requirements are established before the transaction takesplace, in claims, insurers dont know exactly what theyre going toget until a claim occurs. Claims are more fluid, Costonis says.They change their profiles and patterns as they go along. So anytechnology needs to be smart enough to recognize when the patternof the claims changes and then smart enough to change its own paththat its going down.

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Additionally, insurers arguably treat claims with a greaterdegree of suspicion than they do applications, which makes themreluctant to take a truly hands-off approach to claims, whetherthey be property, liability, or medical claims. Therefore, carrierstend to target automating specific segments of the end-to-endclaims process, such as referrals to auto repair shops in propertylines and medical bill review in health and casualty.

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One of the key developments happening today is [carriers] arebringing in more external rules engines in claims, reports BonnyEappen, practice director of insurance for Tata Consul-tancyServices. These systems, though not replacing the decision-makingin claims as they have in underwriting certain lines, have begun toplay a role in supporting the decision processfor example, helpinginsurers to better allocate claims based on skills andspecialization, handle authority referrals and auditing, andidentify fraud signals and patterns.

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A companys ability to improve the cost efficiency of claims alsois affected by line of business. Health insurerswhich havecompleted HIPAA-driven systems projects, use clearinghousesextensively, and have well-established EDI between payers andprovidersare further along in automating the processing and paymentof claims than other verticals, Turocy maintains.

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The beginning piece [of automation] is what causes the mostgrief, which is the capture of information, she says. In the healtharena, insurers are more standardized in providing systems whereclaims information is input and getting that information in anelectronic format earlier in the process.

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Even so, she says, health insurers still are focused primarilyon continuing to drive paper out of the claims process, includingdirecting (or at least encouraging) care providers to useelectronic forms for claims and providing more Web-basedalternatives for claims and benefit inquiries from plan members andindividuals.
In P&C, carriers potentially are hamstrung by the need todeliveror at least offerhigh-touch claims service. In P&C,[high touch] is a nemesis for carriers, because adjusters have togo out and get the information, Turocy explains. Distributed datacapturethat is, relying on thousands of adjusters to collectinformation and transmit it rather than having centralized staffinput itcan be a data-quality nightmare.

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P&C carriers therefore tend to focus on getting assignmentsto the field more quickly, making information more available, andautomating routine parts of the workflowsuch as report orderingtofree up adjusters time for other claims tasks.

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An analysis of several insurers success stories found differingstrategies depending upon whether theyre starting from scratch (orare prepared to start over), are willing to renovate substantialsegments of their claims system environment, or feel they alreadyhave a firm foundation on which to add end-to-end automationenhancements.

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Unitrin Direct: Starting From Scratch

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When Unitrin formed its direct-marketing automobile insurancesubsidiary, Unitrin Direct, in 2000, it was literally apen-and-paper process to settle claims, with manual entry into astand-alone reserving and payment system, explains Brian Crumbaker,senior vice president of Unitrin Direct.

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However, this was by design. Having personally gone throughother startup insurance ventures in the past, Crumbaker recommendedUnitrin Direct process claims manually from end to end at theoutset to better evaluate its needs before making a systemcommitment. Armed with knowledge of these needs, Unitrin narrowedvendors to Netrex, PDA Software Services, and Covansys, ultimatelychoosing Covansys ClaimConnect, which was deployed in 2001.

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Today, all losses are reported to Unitrin Direct using a 1-800number. An Avaya telephony system routes the call to theappropriate remote servicing office based on the calls origination.Using selections the caller made in the IVR system, the systemfurther distributes the call to either an adjuster (for new claims)or to the service queue (for existing claims).

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Adjusters key claims information into the Covansys front end,which integrates with Unitrin Directs policy processing system fromDecision Research Corporation to populate policyholder informationand with its reserving system to set statistical reservesautomatically. Claims are sent electronically in batches overnightto ISO for matching against ISOs ClaimSearch database. The systemalso links with CCC Information Services Web-based Autoverse systemfor transmission of claims details to independent and staffappraisers and repair shops.

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ClaimConnect currently also provides rules-based workflow forboth fraud and authority referrals. There is a long list of alertswe established, such as thefts and fires, reserves over a certainamount, and other scenarios where we determine referral to SIU ormanagement is required, Crumbaker explains. Authority templatesthat detail the authority level of new adjusters also help UnitrinDirect add newly hired staff to the system quickly.

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After claims are paid, the system automatically opens a salvageand subrogation reserve. The subrogation process is automated viaan interface Unitrin Direct built with subrogation specialistTrumbull, which sweeps the insurers claims system nightly anddetermines claims that have subrogation potential. Weve takenpotential adjuster error out of the mix, Crumbaker explains.Unitrin also is working on a system with CoPart Salvage AutoAuctions to handle a similar process for salvage.

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Future enhancements in-clude integrating the carriers imagingsystem with ClaimConnect. Because all loss notices currently arecaptured electronically, and since the majority of images receivedare digital, the need to link any ancillary scanned documents isnot crucial, Crumbaker explains. In the interim, log notes inClaimConnect identify images that exist, which can be retrievedfrom a central image server if needed.

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Although Unitrin Direct itself started from scratch, it did haveto contend with integration issues when it acquired Kemper Directin 2002. Unitrin Direct built an integration component between theKemper policy administration system and ClaimConnect but currentlyis handling existing claims on Kempers system. However, Crumbakerreports, remaining runoff claims from Kemper Direct will beconverted to ClaimConnect at the end of 2004.

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Unitrin Directs claims strategy has had a marked impact on itsbusiness, according to Crumbaker. When we started with paper files,our ratio of claims adjuster to clerical staff was 4 to 1. Now its15 to 1, he says. We grew from zero to $165 million in premium inthree years, yet our claims closing ratio is 90 percent. The systemalso has allowed us to grow at a reasonable loss adjustmentexpense.

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NASCO and California Casualty: Leveraging ExistingInvestments
The National Account Service Company (NASCO) is an outsourceprovider of health insurance claims processing for Blue Cross BlueShield plans, with 27 Blues currently using NASCOs processingservices in some form. In business since 1987, NASCOsmainframe-based claims system has evolved over time and representsboth a significant investment and a powerful workhorse, processingmore than 100 million claims annually, about 70 percent of whichwith no human intervention.

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According to Mark Barnard, NASCOs vice president of operationsand CIO, the company looked for ways to improve the efficiency ofclaims service provided by its own staff and by the 12,000 clericalpersonnel across the network of Blues who access the system. Italso looked to provide real-time claims information, such as claimsstatus, deductible balances, or remaining benefit amounts toemployers and plan members.

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Having chosen IBM as the outsourcer for its data center supportand most of its application development, NASCO teamed with IBMagain to develop a Web-based application that would connect withits processing system and give plan members more control over boththeir claims information and enrollment.

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Supporting the Web application with the mainframe required somework on NASCOs part. It already had created an integration hub,which it named InterAct, to the mainframe, helping enable a Webfront end. It also changed its mainframe processing strategy,moving batch processing back several hours to expand systemavailability during peak demand hours, and interfaced the mainframewith several midrange platforms to deliver real-time information,essential for a 24/7 Web site. We essentially developed a hybridapproach, says Barnard.

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NASCO measures the success of its system both financially andoperationally. First, Barnard reports, optimizing the mainframe hasenabled it to cut a full day off claims processing. DeployingNASCOs midrange platform in 2001 has been essential to support theWeb application, which has grown both in functionality and userbase. When first deployed, the Web tool provided members withclaims eligibility and provider information. Today, it alsoprovides coordination of benefits details, handles ID cardrequests, and gives employers the ability to make plan changesdirectly.

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Additionally, according to Craig Fagin, NASCOs director ofcustomer relations, The user base of the system has grown from 150to more than 2.5 million. He adds by leveraging its InterActintegration platform, NASCO also ensures internal claims serviceapplications, such as its call center system, have access toreal-time plan information that reflects current claims activitiesregardless of their point of origination.

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Like NASCO, insurer California Casual- ty Management Companylooked for a way to improve the efficiency of its claims processingwithout replacing existing systems. A longtime customer of CSC,California Casualty already had created modules that interfacedwith its CSC claims administration system to deliver greater value.For instance, it wrote a first notice of loss front-end applicationin J2EE, de-ployed last year, which cut the time needed to inputnotices from 17 to 8 minutes, according to Beau Brown, CaliforniaCasualtys executive vice president of products and technology.Therefore, the company looked to continue to bolt on more modulesto deliver additional benefits.

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For California Casualty, Brown explains, a component approach toits claims processing systems makes sense. When you look atend-to-end claims systems, there are some companies with some smartpeople trying to develop a claims system that will do everything.However, another approach is to look for best-of-breed componentsthat generally can be integrated quickly using the latesttechnologies, he says.

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A recent deployment in this strategy was a business processmanagement application from ProcessClaims, which hosts theapplication on an ASP basis for California Casualty. Currently, thesystem is used solely for automobile physical damage claims,according to Michael Lloyd, assistant vice president, materialdamage manager at California Casualty.

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When a damage claim is received in the California Casualtyclaims call center, report-takers key the claim into the firstnotice system, which pulls data from the CSC system to prepopulatepolicy information. Currently, claims dispatchers then must invokethe ProcessClaims system to make an assignment of the claim eitherto a staff appraiser, independent appraiser, or preapproved repairshop. However, Brown reports, California Casualty plans to havethis process automated, as well, by press time.

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ProcessClaims sends new- claims alerts by e-mail or fax, and therecipient of the alert logs on to ProcessClaims using a standardWeb browser to retrieve the assignment. The system interfacesdirectly with estimating applications from ADP, CCC, and MitchellInternational for assignment transmission. Brown says since thesethree vendors represent the bulk of systems used by repair shopsCalifornia Casualty deals with, this interface allows the insurerto establish relationships quickly with additional shops withoutcustomizing EDI connections.

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Furthermore, being Web based, it gives us the ability to use andadd independent appraisers to the system and for multiple users toview claims details simultaneously, which is important for claimsreferrals, says Lloyd.

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The system allows California Casualty to monitor workloads, heexplains, and provides rules-based workflow the insurer currentlyuses for audit referrals to claims specialists. This improves theproductivity of our specialists because they can hone in onexceptions rather than hunt for cases, he says. According to Lloyd,ProcessClaims has delivered substantial savings in claimsprocessing. It has definitely paid for itself, he says.

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California Casualty plans to integrate ProcessClaims fully withits first notice system to eliminate the need to toggle betweensystems, says Brown. It also is considering several other modulesto bolt on to its administration and processing systems, includinga fraud detection system and a data-mining component.

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Penn National Insurance: Willing to StartOver

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At Penn National, the desire to automate the workflow of claimsprocessing coincided with a major overhaul of its claimsadministration and support systems.

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According to Ken Garcia, the companys vice president of claims,in 2001 Penn National Insurance embarked on a project dubbede-Claims, beginning with installing a centralized imaging systemfrom ImageRight in its Harrisburg headquarters. In late 2003, itdeployed Claims Workstation from Fiserv to manage its claimsprocess and workflow. Currently, it is converting its legacy claimsadministration from CSC to Allenbrooks Phoenix system, a projectthat is scheduled for completion in commercial lines later thisyear and for personal lines in 2005.

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While after-hours emergent claims are handled by a call center,the majority of claims come to Penn National Insurance via fax. Ouragent population is most accustomed to that way of doing business,explains Garcia. All faxes are received by the central ImageRightsystem, which integrates with Claims Workstation. Based on thegeography of the loss, an operator electronically transmits the faxto the appropriate customer service office using ClaimsWorkstation.

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At that office, a team leader receives the fax and assigns itusing the Fiserv system, which sends to the queue of each adjusteran electronic notification of assignment. Adjusters then begininvestigations on property and liability losses, while they referauto damage losses to independent appraisers, Garcia says.
Claims rules in the system provide additional routing andautomation. In property losses, dollar thresholds and losstypesidentified by claims codestransfer claims from field adjustersto general adjusters at headquarters at any point in the life ofthe claim that those rules are matched. Casualty claims currentlyare reviewed manually.

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Perhaps not surprisingly, the number and scope of claimstechnology initiatives under way at Penn National Insurance havestretched its IT resources, Garcia admits. Additionally, theinsurer unexpectedly became a beta customer in the ClaimsWorkstation project when another Fiserv customer changed thescheduling of its installation, a situation the vendor confirms.The difficulty increased exponentially, and the amount of resourcesthat had to be dedicated to it were pretty well tested, Garciasays.

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Nevertheless, the Fiserv installation and the total project haveshown positive results thus far at Penn National Insurance. From apure day-to-day technical management perspective, its been veryproductive, Garcia explains. The ability to answer questions,interact with home-office examiners who have the same accessibilityto the claims, and allow for decision-making to be madeinstantaneously are important. It also provides direct informationto our agents when they inquire about single or multiple losses, hesays.

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From a hard-numbers perspective, we will look at [the project]and evaluate it by the end of the year to determine the ROI and anycost savings aside from that which would be meaningful toreport.
Although each of these companies has taken a different approach tomaking end-to-end claims processes more efficient and effective,all ensured their infrastructures were in order before trying toadd workflow technologies, rules engines, or pro-cess managementapplications.

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You cant reap any big rewards until you tackle the systems thatkeep people in a state of gridlock, says Accentures Costonis, whoreports failures often happened when claims staff members wereforced to be the integrators between different solutions becausethe legacy systems couldnt handle the transactions.

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Its still a question of biting the bullet on the legacy system,he adds, putting in the right technology with the right kind ofdata, details, and access to data to make [other] systemswork.
(For Tech Guide, see p. 24)

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Tech Guide: Claims and Fraud

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Accenture
Murray Hill, N.J., 267-216-1049
www.accenture.com

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Adjustable Software
Markham, Ont., Canada, 905-415-0664
www.adjustablesoftware.com

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ADP Claims Services Group
Elk Grove Village, Ill., 847-718-3381
www.adpclaims.com

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AGO Insurance Software, Inc.
Mt. Arlington, N.J., 973-770-3200
www.agois.com

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Allegient Systems
Wilton, Conn., 203-761-1289
www.allegientsystems.com

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Allegis Communications, Inc.
Seattle, Wash., 800-566-6112
www.allegisteam.com

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American Management Systems
Fairfax, Va., 800-255-8888
www.ams.com

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Apex Data Systems.com
Tucson, Ariz., 520-298-1991
www.apexdatasystems.com

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Attus Technologies, Inc.
Charlotte, N.C., 704-752-6249
www.attustech.com

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The Bluebook International
Lake Forest, Calif., 888-425-8326
www.bluebook.net

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Bramerhill Technology Group
Norcross, Ga., 770-368-3255
www.bramerhill.com

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Bridium
Atlanta, Ga., 920-451-9777
www.bridium.com

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Business Software Solutions
Mt. Laurel, N.J., 856-866-5601
www.bssnj.com

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Burkitt Computer Corp.
North York, Ont., Canada, 416-642-6159
www.bccorp.com

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Cardiff Software
Vista, Calif., 760-936-4500
www.cardiff.com

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Castek
Toronto, Ont., Canada, 416-777-2550
www.castek.com

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CCC Information Services
Chicago, Ill., 800-621-8070
www.cccis.com

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CGI
Montreal, Quebec, Canada, 514-841-3200
www.cgi.com

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ChoicePoint
Alpharetta, Ga., 800-342-5339
www.choicepoint.net

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Clear Technology, Inc.
Westminster, Colo., 303-583-4150
www.clear-technology.com

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Corporate Systems
Amarillo, Tex., 800-858-4351
www.csedge.com

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Covansys
Farmington Hills, Mich., 913-469-8700
www.covansys.com

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CSC Financial Services Group
Austin, Tex., 512-275-5000
www.csc-fs.com

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Cunningham Lindsey
Lewisville, Tex., 214-488-5139
www.cunninghamlindsey.com

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Decision Research, Corp.
Honolulu, Hawaii, 808-949-8316
www.decisionresearch.com

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Delphi Technology
New Brunswick, N.J., 732-418-0008
www.delphi-tech.com

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Docucorp International
Dallas, Tex., 800-735-6620
www.docucorp.com

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DWL
Toronto, Ont., Canada, 416-364-2045
www.dwl.com

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E-Claim.com
Gretna, La., 504-433-9599
www.e-claim.com

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EigenSoft
Portsmouth, N.H., 603-430-8032
www.eigensoft.com

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Fair Isaac & Co.
Irvine, Calif., 949-655-3300
www.fairisaac.com

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FARA
Mandeville, La., 800-259-8388
www.fara.com

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FileNet
Costa Mesa, Calif., 714-327-3400
www.filenet.com

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FINEOS
South Portland, Maine, 207-879-0400
www.fineos.com

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First Notice Systems
Boston, Mass., 617-886-2000
www.firstnotice.com

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Fiserv
Brookfield, Wis., 900-322-4220
www.fiserv.com

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GAB Robins
Parsippany, N.J., 973-993-3400
www.gabrobinsna.com

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Genelco Software Solutions
St. Louis, Mo., 800-983-8114
www.genelco.com

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GenSource Corporation
Valencia, Calif., 661-294-1300
www.gensourcecorp.com

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Guidewire Software
Menlo Park, Calif., 650-233-1700
www.guidewire.com

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Hawkins Research
Murray, Ky., 800-736-1246
www.powerclaim.com

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Hyland Software, Inc.
Westlake, Ohio, 919-462-8505
www.onbase.com

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IDMI
Altamonte Springs, Fla., 407-389-0963
www.idmi.com

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ILOG, Inc.Mountain View, Calif., 650-567-8000
www.ilog.com

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Infinity Systems Consulting, Inc.
New York, N.Y., 212-541-7602
www.infinity-consulting.com

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Injury Sciences
San Antonio, Tex., 877-979-7378
www.injurysciences.com

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INFOEL USA, Inc.
Aubrey, Tex., 940-300-4623
www.infoelusa.com

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Infoglide Software
Austin, Tex., 214-357-4636
www.infoglide.com

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Information Builders
New York, N.Y., 212-736-4433
www.informationbuilders.com

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The Innovation Group
Danbury, Conn., 203-743-6000
www.tigplc.com

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Insurance Data Processing
Wyncote, Pa., 800-523-6745
www.idpnet.com

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Insurance Services Office
Jersey City, N.J., 800-888-4476
www.iso.com

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Insurance Solutions & Technology Inc.
Cayce, S.C., 803-796-1112
www.the-ist.com

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ISCS
San Jose, Calif., 888-901-4727
www.iscs.com

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JCRS Inland Marine Solutions
Oakland, Calif., 510-444-4811
www.jcrs.com

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Jury Verdict Research
Horsham, Pa., 215-784-0860
www.juryverdictresearch.com

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JW Software, Inc.
St. Louis, Mo., 314-843-5950
www.jwsoftware.com

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Magnify
Chicago, Ill., 312-214-1420
www.magnify.com

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Management Data, Inc.
Birmingham, Ala., 205-991-7511
www.mgtdata.com

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Marshall & Swift/Boeckh
New Berlin, Wis., 800-285-1288
www.msbinfo.com

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Metropolitan Reporting Bureau
Philadelphia, Pa., 800-245-6686
www.metroreporting.com

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MFX
Toronto, Ont., Canada, 416-385-4800
www.mfxfairfax.com

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Mitchell International
San Diego, Calif., 800-854-7030
www.mitchell.com

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MountainView Software
Layton, Utah, 888-533-1122
www.claimzone.com

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Neap Analytics
Westerville, Ohio, 614-523-1067
www.neapanalytics.com

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nsite solutions
Urbandale, Iowa, 888-282-6596
www.nsitesolutions.net

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onClick Corp.
Houston, Tex., 713-784-7600
www.onclickbiometrics.com

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OpenFlex
Los Angeles, Calif., 213-252-2360
www.openflex.com

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PDA Software Services
Overland Park, Kan., 913-469-8700
www.pdainc.com

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ProcessClaims
Manhattan Beach, Calif., 310-937-4040
www.processclaims.com

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QualCorp
Valencia, Calif., 888-367-6775
www.qualcorp.com

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Quest Claims Services
St. Johns, Mich., 800-541-2593
www.questsoftware.com

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Rebus Systems
Secaucus, N.J., 401-247-4925
www.rebusgroup.com

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ReClaim Technologies
Newark, Ohio, 740-344-6956
www.reclaimtech.com

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Recognition Research
Blacksburg, Va., 540-961-6500
www.rrinc.com

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Results International Systems
Dublin, Ohio, 800-875-2126
www.resultscorp.com

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RGL
Englewood, Colo., 303-721-8898
www.rgl.com

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Riskclick
New York, N.Y., 877-747-5254
www.riskclick.com

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Risk Sciences Group, Inc.
Schaumburg, Ill., 800-619-0224
www.risksciencesgroup.com

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SAP America
Newtown Square, Pa., 888-727-8591
www.sap.com

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SceneAccess
Pittsford, N.Y., 585-387-9883
www.sceneaccess.com

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SeaTech Consulting Group, Inc.
Torrance, Calif., 310-328-8119
www.seatech.com

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Sherwood International
Armonk, N.Y., 905-275-2299
www.sherwoodinternational.com

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Simsol Software
Orlando, Fla., 800-447-4676
www.simsol.com

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Sirius Financial Systems, Inc.
Englewood, Colo., 303-209-5914
www.sirius-inc.com

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Stargate Solutions Group
Indianapolis, Ind., 317-469-7512
www.stargatesolutions.com

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StarTech Software Systems
Novi, Mich., 248-344-2266
www.startechsoftware.com

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Synergy 2000
Pasadena, Calif., 626-792-8600
www.synergy2000.com

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Taliant Software Solutions
Denver, Colo., 303-209-4601
www.taliantsoftware.com

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TEKclaims
Cincinnati, Ohio, 513-821-7844
www.tekclaims.com

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Teradata
Dayton, Ohio, 860-537-9055
www.teradata.com

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Tropics Software Technologies, Inc.
Sarasota, Fla., 941-955-1234
www.gotropics.com

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Trumbull
Windsor, Conn., 877-285-2174
www.trumbull-services.com

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Valley Oak Systems
Alamo, Calif., 925-552-1650
www.valleyoak.com

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Visibillity, Inc.
Chicago, Ill., 888-484-7424
www.visibillity.com

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VS Visual Statement Inc.
Kamloops, B.C., Canada, 888-828-0383
www.visualstatement.com

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WildCard Systems
Sunrise, Fla., 954-851-0700
www.wildcardsystems.com

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World Group
Emeryville, Calif., 800-785-4526
www.wgcusa.com

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Worldwide Testing and Security Services
Clifton Park, N.Y., 518-371-8327
www.worldwidetest.com

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Xactware
Orem, Utah, 800-424-9228
www.xactware.com