Improving Insurance Claims Management

Problem

One of our clients, a leading health insurance provider, was struggling to manage a high volume of insurance claims and payments. The data they received from clients was unstructured and inconsistent, coming in various formats such as Excel spreadsheets, PDFs, emails, and free text. This lack of standardisation made it challenging for their small team to efficiently track and validate claims, resulting in financial losses from continued payments on cancelled or no longer valid policies. The team was manually reviewing thousands of claims, making the process both inefficient and prone to human errors.

Pilot Project

During an initial prototyping exercise, our team discovered that out of a pool of 20,000 customers, nearly 900 (about 5%) had expired policies. These customers were still potentially receiving benefits, such as coverage for glasses or dental care, despite no longer being eligible. This revealed the extent of the issue and highlighted the need for a robust solution to manage these claims more effectively.

Solution

To address the client’s challenges, we worked closely with their team to design an automated solution:

Data Automation and Integration: Centralise and structure their data turning fragmented claims data into structured information for processing.
Validation: Identify invalid claims, such as cancelled or expired policies, preventing payments from being made on void plans.
Scalable Automation: The solution is designed with scalability in mind, capable of efficiently processing large volumes of claims from bigger clients while still offering flexibility for smaller clients with fewer claims.

Benefits

Time Efficiency: The automated system speeds up the claims process, enabling faster decision-making and insights.
Improved Accuracy: The solution reduces human error and ensures that only valid claims are processed.
Cost Effectiveness: By eliminating the need for additional manual workers, the client is able to save on operational costs, while also reducing payouts on invalid claims.

Conclusion

With fewer errors and faster claims processing, the company can focus on growing their customer base, improving customer satisfaction, and investing in other areas of the business, all whilst improving their financial performance.

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