P&C Sector Medical Claims Handling Found Lagging

The survey involved telephone interviews in July and August with 30 U.S. claims executives, nearly half of whom have record optimization target lines above $500 million.

Participants in the survey said challenges in skill and scale prevent carriers from achieving improvement in medical claims handling and only one in five carriers believe they are operating at an optimal level in terms of medical records processing.

Most said they were not operating at a high level even though a majority said improvements would have direct benefits for indemnity accuracy, recovery identification and capture, and fraud detection and prevention, Accenture reported.

Survey respondents were found to recognize opportunities for efficiencies in task delegation and removing "non-core" work from a highly skilled claims adjusting workforce.

Over 70 percent agreed that improvements would lead to important benefits in productivity and cycle time.

Accenture noted that analytics tools available to carriers today, including data mining and predictive modeling, coupled with the capabilities to effectively and accurately structure medical information, appear to be setting the stage for breakthroughs in injury and medical data management.

Over three-quarters (79 percent) of insurers surveyed agreed that their medical records processing is not fully optimized and requires further improvement. One-third mentioned difficulty of accessing medical information and the lack of skills among adjusters. Approximately half of insurers surveyed said lack of key performance indicators is the most important challenge faced.

Accenture said respondents, listing what appear to be less pressing challenges, mentioned a lack of standard, consistent rules to evaluate claims and difficulty identifying complex and/or high-severity injury claims.

Seventy percent of respondents indicated that highly skilled claims resources spend over 10 percent of their time on what may be categorized as "non-core activities" (i.e. organizing and interpreting medical information).

Sixty-nine percent of survey participants said casualty and body injury adjusters spent more than 10 percent of their time on organizing and interpreting medical information, and 21 percent spent more than 20 percent of their time on these activities.

Insurers identified illegible handwriting as the most important challenge faced by casualty/bodily injury adjusters, with 47 percent citing it as "important" or "very important."

After illegible handwriting, absence of medical context, missing documentation and difficulty in accessing medical information were the three most commonly cited claims challenges.

Even when records are received, the executives said they are too often not being used in injury / medical adjudication.

Eighteen percent said while they expect medical records to be received in connection with medical claims, they are only received 50 to 75 percent of the time.

Even when medical records are received on claims, 25 percent of respondents indicated that these records are not actually reviewed.

Two-thirds of insurers said they believe their company needs further improvement in terms of data analytics and analysis such as predictive modeling and data mining

The survey indicated that 69 percent of insurers saw the need for improvement in predictive modeling, while 79 percent saw the need for improvement in data mining.

Nineteen percent or executives rated their firms poor for predictive modeling, and 14 percent said their companies were poor at data mining.

Accenture said the majority of insurers have started implementing technologies that lay the foundation for taking advantage of the information in medical records.

Key areas for investment were listed as: document imaging/management, workflow, bill review and valuation.

Specific technology products mentioned repeatedly were Image Write in document imaging/management and Colossus in valuation.