“health Insurance Claims Process Unveiled: From Approval To Reimbursement In Australia” – Michael Cline is the Managing Director and Insurance Sector Claims Leader at Deloitte Consulting LLP. He has over 28 years of experience in claims operations and technology in insurance companies and in the consulting field. He also holds insurance industry professional designations from the Insurance Institute of America; CPCU, AIC, API, AIS and AINS. Michael is licensed as an insurance property & casualty adjuster in the State of Nevada and is an active member of the Insurance Institutes National Claims Interest Group committee.

Kedar Kamalapurkar is the Managing director and a leader in the claims practice in the insurance sector at Deloitte Consulting LLP. He has nearly 15 years of experience in claims operations, including as a claims adjuster. He has led claims transformations from strategy to execution at many of the major insurance carriers in the United States and Europe. Kedar also holds professional designations in the insurance industry from CPCU, AIC, API, and AINS.

“health Insurance Claims Process Unveiled: From Approval To Reimbursement In Australia”

As insurers allow enabling technologies such as artificial intelligence to handle an increasing portion of claims, companies must improve the capabilities and expand the roles of claims professionals to reap the rewards. benefit from advanced tools while maintaining personal engagement in moments that matter.

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Claims are the largest component of property and casualty insurer costs, as compensable losses combined with investigation and settlement costs account for nearly 70% of US premiums collected last year. 2020.

The pressure is always on to increase claims processing using new technologies and data sources that increase efficiency, productivity, and accuracy, because every dollar saved goes straight to the bottom line. This change has been greatly accelerated during the pandemic because necessity has become the mother of reinvention, prompting the implementation of widespread digital and virtual acquisitions that manage almost overnight. (See sidebar, “Pandemic forces faster digital transformation.”)

However, interviews with chief claims officers (CCOs) from a dozen large and midsized personal and commercial lines carriers in the United States, Canada, and the United Kingdom found that most walk a tightrope between in the drive to transfer more claims to automated systems and the overriding. must maintain a human touch at the moment that matters most to policy holders.

It’s not an either/or choice between technology or people. Insurers must continue to strengthen their data sources and technology infrastructure to resolve claims faster, more accurately, and at a lower cost, while also improving their claims professionals. claim. That way, they can maximize the value of all the new integrated technology and data available while still being able to curate a personalized customer experience.

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The challenge facing insurers is how to effectively integrate these two sides seamlessly, so that they can provide the right service at the right price point to the right claimant at the right time, with the goal of satisfying customers in a broad level of expectation.

In fact, customers pay close attention to the claims of an insurer who manages the reputation. A personal line consumer survey by Deloitte found that 44% of U.S. respondents conducted claims research with a particular auto or homeowners insurer before purchasing coverage—while more high percentages do so in China (79%) and Australia. (58%).

The fact that a claim can be the only touchpoint a customer has with an insurer makes this element essential to sustainability and growth.

This report focuses on how CCOs can overcome such challenges in transforming their operations, balancing the benefits of automation and more advanced technologies with customer needs for personalized service. To do this, insurers must look to raise the game of field adjusters, fraud investigators, claim file handlers, customer service representatives, and other key claims department personnel to an exponential level (see sidebar, “ What exactly is an ‘exponential’ claims professional?”).

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Advanced technology and new data sources should supplement and supplement (but not necessarily replace) adjusters, managers, fraud investigators, and other claims professionals. These improvements should free them from many labor-intensive but low-value tasks, while equipping them with tools to speed up case resolutions and payments. This should also improve results and customer satisfaction.

So departments and professionals in exponential claims must have (i) the training and skills to manage and audit the automated results of a case and portfolio level, (ii) the judgment to quickly identify -which tools and data are best applied to a particular acquisition, (iii) the ability to strike a balance between automation and the ongoing need for human interaction, and (iv) ) the opportunity to offer value-added services internally and externally.

The pandemic has significantly accelerated claims renewal plans among the insurers that participated in this research. Several carriers noted that the percentage of claims handled virtually (often with imaging technology in mobile apps) and digitally (with automated straight-through processing) increased last year from a digits to as high as 55% of a personal insurer line interviewed. . Meanwhile, the 2021 US Property claims satisfaction study by JD Power found that carrier acceptance of customer photos and videos for settling claims grew from 61% in early 2020 to 68% during the pandemic.

“We are already on a journey to a digital operating model that will provide more self-service solutions and really simplify the acquisition process for our people and customers, but we have not done everything yet. which is a lot of progress before the pandemic,” admitted in a personal line CCO. “But then the pandemic came and eliminated the adjustment period that we had budgeted (to make the transition), so instead of taking two or three years, we had to finish that trip in a few weeks and months . I didn’t think it was possible before we did it.”

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It also seems unlikely that insurers can or will want to put this digital genie back in the bottle. “We want to keep what we’ve done in place and build it postpandemic. There’s no turning back,” said a major commercial line CCO that launched a virtual appraisal platform in 2020 at a much faster pace. time frame.

However, this same CCO added, “while we were able to digitize half of our claims, how do we manipulate the other half which is more complex and resists a technological solution? Can we simplify is it more than enough to handle digital so we can continue to scale? I think that’s the final frontier for these innovations.”

Today’s tech-savvy customers are increasingly looking for greater convenience, faster turnaround times, and more self-service options—expectations that insurers are trying to meet with mobile apps, virtual viewing, and direct processing of many custom claims, and other innovations.


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