The most important obligation for an insurer’s policyholders is to pay their claims. For policyholders, this means paying the right claims quickly. In a small number of cases, a claim may be invalid and should be blocked. Blocking invalid claims also benefits policyholders – if a claim is fraudulent or is not covered by the policy terms and the insurer pays these claims, it increases costs for other policyholders. For this reason each claim must be evaluated before payment is made.

Claims triage is important for high volume claims

For insurers with high claim volumes, it isn’t possible for a human to adjudicate all claims. Claims departments need to be able to filter out the clearly valid claims and pay them quickly, as well as identify claims that need further investigation. In addition, complex claims can be identified earlier and pushed to more experienced claim handlers, reducing the cost of claims handling.This improves the customer experience and makes the process more efficient.

The most effective and cost efficient way to filter claims is to use a model that makes an initial triage decision quickly and moves claims into the correct workflow. The model should identify claims that are clearly not fraudulent for payment, identify fraudulent claims for investigation and direct more complex claims for inspection to senior claims assessors. This makes the most efficient use of the claims assessing department, and has been proven to reduce cost of claims significantly as well as reducing the claims expenses.

Use Excel to create a claims triage filter

This type of claims filtering model is challenging to build into claims systems as the developers who understand the code must interpret complex rules set by claims assessors in core claims systems, and then update them as the assessors change their views.

But building the logic in Excel is easy – most claims assessors have a good understanding of Excel, and know what the filtering rules should be. With Optalitix Models, these spreadsheets can become high capacity, super intelligent systems in minutes.

Benefits to insurer

  • Significant claims savings are possible if the correct claims are checked
  • Reduced claims expenses due to improved workflow processes
  • Easier for claims assessors to build claims filtering rules into Excel
  • Easier for developers to connect claims systems via APIs
  • Rapidly update claims rules without needing developers to implement changes.
  • Optalitix Models can process millions of calculations

Example

This example demonstrates  how a life insurer could evaluate a claim for triage to different levels of claims assessor, from junior to more experienced, using a point scoring mechanism. Each feature of the claim is assessed, and allocated points depending on whether it appears suspicious or not.

A death at an older age with a long policy duration is less concerning than a death at a young age for a recently started policy. In addition, the model illustrates how dynamic fields can be created based on the cause of claims, with “terminal illness” requiring additional inputs that aren’t required for a death claim.