Episode 028: Claims Processing for Insurance – Part 2

Thanks for joining us today. My name is Kevin Ledgister, your host. And this podcast, Better Claims Processing for Insurance, is the second part of a two part series, where we take the best practices of going paperless, to the world of insurance claims. Now if you haven’t listened to the first part of the series, this is going to feel like you’re walking into the middle of a movie. And the reason for that is, is that we took one long conversation and broke it up into two podcast episodes.

For those of you who are returning after listening to the first part, recall that we’re speaking with Jeff Hiegert, who is the senior customer advisor of insurance at Hyland Software. And we’re taking this concept, the business process framework, and applying it to the world of insurance claims, by breaking down each step of the claims process, so that we can look at what technology can be used at each step of the way, to make the process much more efficient. So let’s go ahead and resume this conversation with Jeff.

This evaluate phase, once you get all this information and documentation, and then having to make a whole range of decisions. And sometimes it can be a lot of documents that are involved, and a lot of different bits and pieces. So when you get to this point, when you start to talk about this, what are some things that you talk about? What are some ways that maybe some technology can make that evaluation phase a little bit easier on the person that has to look at that and make those decisions?

If it’s a paper document, maybe it’s in your content management system. If it’s information, maybe it’s just stored in your core claims system. If it’s a phone call, maybe you’ve got an assistant with your phone network that does recordings of your phone interactions with your customers. Or maybe it’s a video file that’s stored in another drive somewhere, that you have to open up with a special program, all that kind of thing.

So as an examiner, when you’re trying to evaluate a claim, a lot of times, in order to get a complete view of, not only the policy itself, but all of the information related to a specific claim, it can be a little cumbersome to get all of that together, and be able to look at it in the context of the loss that you’re evaluating.

So that’s where we look at solutions for case management. Solutions like our WorkView product, where working with our insurance customers, help them build out, for lack of a better word, a claim workbench, that can bring together information, and content, and data, from all these different systems, and present it to the claim’s examiner in a single place, where they can view all of that stuff and get access to information, whether it’s stored in OnBase, if that’s their content management system, or their claims management, their core system, like a Guidewire, or Duck Creek, or wherever that information may reside.

We have tools that can build out, and like I said, a workbench, that allows that claims examiner to get access to all of that stuff. So they know they’re making a better, more informed decision regarding that particular claim, which helps the bottom line of the carriers. If they’re making better decisions in the claims process, that’s going to positively affect their loss ratios, and overall, their combined ratios, and make a carrier more profitable.

Maybe you need to contact a medical facility for more information, because there’s a health claim that comes along with it. What are some ways in terms of what factors we have to consider with respect to, how do we track all these different interactions, as opposed to having 200 sticky notes over a paper file, or all over your desk, that you don’t eventually get recorded? How do we put all this together so that somebody can, from a customer service perspective, and I’m thinking of this, when you call in and someone’s working your claim, they’re working your claim, and that’s great. But next time you call in, you might not get that person, you might get somebody else. How do they see that information, get that history quickly, and be able to document that, so it goes into your file? It doesn’t just stop there, and somebody scratches down a note on their desk, and then nobody ever sees it again. How do you help with that?

So those are things that, while complicated, are things that can be avoided with technology. So when we talk to customers about that interactive step of a claim or any process, we just want to understand who are the stakeholders that you communicate with, and what is the messaging that you need.

We have technology that can range anywhere from ad hoc correspondence to full blown production, print, document composition and packaging as an integrated solution in OnBase, that allows the on demand dynamic creation of a claim packet.

So when the claims examiner is going through the process, and they’re ready to generate, maybe it’s in that initiate and collect phase, where they’re needing to generate that claim packet that says, “Hey, here’s the information that we need, and here are the forms that are part of your claim submission.”

Document composition and packaging can use a lot of business logic to know that, “Oh it’s this policy type, it’s in this state, and it’s this line of business. Therefore I know I need to have these four documents.” And then, basically prepackage those all together, and present them to the examiner, and give them the ability to re-sort the order. It dynamically creates a cover page. It ensures that the logo and the closing is all compliant with that particular product and line of business.

If there’s something where the examiner needs to insert an additional piece of content, they can easily go pull that from OnBase, insert that into the package. And when they’re ready, they can generate that package, and convert it into a PDF, regardless of what the source file types are, generate that PDF, and then share that out to their consumer through a technology, like we talked about before, in ShareBase.

So to really ensure that whatever you’re communicating outbound is put together in a compliant manner. So it’s not just necessarily compliant, but it’s also, “Hey this is an interaction with my consumer customer. I want to make sure that we are putting our brand forward in the most positive light.” And we see a lot of carriers that have outbound correspondence being generated from multiple sources.

The court system is spitting out a monthly bill, and somebody in the claims department is producing out of a word template, and filling in things. Somebody in customer service has their own template, and a customer can get three pieces of correspondence in a month, and they all look different. The logos aren’t the same color, the same font size, and they don’t have the same look and feel about a piece of correspondence.

And that’s where a lot of our CCM technology in Concert Composer can help. So we can pull all of those things in, and make sure that when they go out the door, they have a consistent look and feel from a branding perspective, to make sure that the right logo went on there, that they all have the same opening and closing, and they all have the same font type. And you don’t have address blocks that are in all caps, because that’s how the data got pulled from the core system. You can manipulate that, so that the letter, at least when the consumer gets that, it feels as if it was more tailored and specialized to them, and not just spit out of a data stream.

So it’s one of those things where some of our customers don’t give it the attention that I feel it deserves. But how they interact and communicate with customers and agents, and things like that, is really an opportunity for them to look at technology, to help not only save money, by making it compliant, and generating in a more efficient manner, but also just from a brand awareness type of perspective, where they can ensure that everything goes out the door with the same look and feel.

So I think that this definitely could really, from what I understand what you said, really streamline the process, and so when a customer does get something, it is the right information, the correct information, that addresses their needs and concerns, and also communicates in a way that is also compliant, so the compliance guy can sleep at night.

And I would assume as well too, that there would be technologies, that when you are creating these correspondences, or generating these things, that they can be automatically put inside the customer file and accessed by anybody that has access to that file, as opposed to somebody types up a letter in Word, and mails it out, and then it’s up to that person to mentally say, “Oh, I need to stick this along with the customer file,” or print it off, and put another copy in the file cabinet type of thing.

You may need the interact section, where you’re developing these customer communications. That might be needed at the beginning. That might be needed at the end. It might be needed in the middle. And this is just your approach, in terms of how you break the process down, and then bring technologies and the different aspects that can be used really at any point, in terms of the process, really does, in my mind, it just helps it to make so much more sense of that, and just a much easier way approach it.

So after this is all done, we’ve collected information or communicated with the customer, we’ve made evaluations, at the end, there’s some sort of closing out process, where we execute on the final decisions. And that might be the claim needs to be paid in full, paid partial, because you need to make an adjustment, or a not paid at all, because of some circumstance, whatever, that it’s a non-covered event.

And that usually involves a lot of different steps and pieces too. Not only communicate with the customer, there’s maybe a core system that needs to be looked at. There’s things that happen, maybe accounting, walk us through that. What could this look like in a future world, where maybe they’ve taken down the steps and looked at some of these technological solutions?

And so what we like to do is, we are by no means going to replace a core claims management system. But what we want to do, is wrap functionality around those systems, and fill in whatever gaps they may have. And we have done a lot of work with Guidewire and Duck Creek. They are both technology partners of ours.

We are the only UCM vendor that’s on the Guidewire’s solution partner program. And we’ve worked closely with them, to build out accelerators, that basically contain a lot of prebuilt, pre-tested, pre-validated code, integration code, that allows systems like OnBase to ride right alongside with systems like Guidewire. So for example, when a document is captured in OnBase, and we classify that as a part of this claim, we can have prebuilt rules that kick off a task in Guidewire, so that the claims examiner is made aware of it. Okay, this document was received, and here are the things that you need to do with it.

Or conversely, if the examiner is working in a backend system, like a Guidewire or Duck Creek, and they perform some transaction in that system, whether that’s updating a keyword or updating a status, or something like that. Through that prebuilt integration, that information can also be updated and made available within OnBase.

So from that execute phase, it’s really about how can we reduce and eliminate situations where someone has to take information from one system, and then go update it in another place. And so you have information that may be stored in both places that isn’t in sync. And so from an execute standpoint, where we look at integrating with those core systems, to make it easy, and keep all the data in sync. And then also, we’ve got some reporting capabilities, with our reporting dashboards, and things like that.

Because ultimately, throughout the process, and once you’re done, you’re going to want to look back, and do some measurements, in terms of how long did it take us to get from initiate to execute? And how long did it take in between each of those steps? And how many did Susan do? And how many did John do? And did they do them correctly? And were they done within the SLA’s? And all those types of things. So really, from the execute phase, we also look at, how do we go back and do analytics and reporting on that overall process? So that’s a huge feature functionality, that we see our insurance customers using quite a bit as well.

So Jeff, we’ve run the gamut here, from initiate to collect, to evaluate, to interact, to execute. So now that we’ve got this business process framework, that we just unpacked and wrapped their arms around it, how are we going to adjust the entire claims process with this? Why is it so key for insurers to really take this approach, and solve their claims challenge this way?

So like I said, it’s not necessary that you’ve got to solve all the problems at once. But breaking the process down into those five steps, understand how they are connected, how they feed one another, and how they rely on the previous step to perform certain functions, is really a smart way to go about it. Because then when you do go in and solve issues or challenges that may reside in one of those five steps, you can do it knowing that you’re either going to help support the later steps, and not break anything downstream. So that’s another value of looking at it this way. It helps you focus on the what it is that you’re doing, and not necessarily how, but fixing the what you’re doing, and then building the how around, with technology.

And so that also makes the process longer, as opposed to quicker. And there’s always that challenge of, there’s functionality available, one’s not available in the other. And it just creates all kinds of challenges that way, when you’re patching pieces together, as opposed to something that really can walk you through from the back.

So Jeff, this has been very insightful, Jeff. And I think a discussion maybe on another business process in insurance might be great to have in the future. And for our listeners, if you are interested in insurance solutions, you can go to Imagesoftinc.com/insurance. That’s Imagesoftinc.com/insurance.

Thanks again for joining us on this podcast, and if you haven’t already done so, be sure to subscribe to Paperless Productivity, where we tackle some of the biggest paper-based pain points facing organizations today. We’ll see you next time.