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2014 ICA Annual Education Conference

By David Schulman

Senior Sales Consultant, FINEOS

I had the honor of attending ICA’s Annual Education conference, this year held in New Orleans, Louisiana. As always, I find the information provided extremely valuable because I become aware of emerging industry topics, gain additional insight and knowledge on insurance topics that I may already cognizant of, and check out any trends in technology.
I was able to attend many breakout sessions and talk to many attendees. Below is the summary of my findings as well as my professional observations and opinions.

Use of the internet, including social media, in claim investigations

This was presented in two sessions, which I’ll summarize in this section. Using the internet, and more specifically social media, to gather data to be used in a claim investigation has been getting more and more attention, starting with a session at last year’s conference. Whether used internally by claim examiners or an investigation unit, or farmed out to third-party investigators, insurance companies are finding that the information found on the internet about a claimant or insured is a very useful tool when investigating claims, especially suspicious ones. Notice I mentioned the word ‘tool” in the previous sentence. This was done on purpose, and will be a common theme throughout this blog.

Information can be used to either confirm what is already known or to identify discrepancies. Whether trying to find out if a claimant in truly disabled, an insured has truly died or even existed, etc., the information found can be very relevant. For example, if a disability claimant is claiming to have lower back pain but posts a video on Facebook of a spectacular athletic feat they accomplished where their back seems perfectly fine. This could be documented by the investigator and eventually could cause anything such as a shortened benefit period, claim denial, and, possible, fraud charges being brought against the claimant.

Likewise, social media can confirm unfortunate circumstances, such as a “tribute” posting in case of the death of a loved one. However, if that death is confirmed that it occurred outside of the United States, then investigators may be needed due to the possible unavailability of documents, such as a certified record of death or coroner’s report.

While the point of this is not to discuss any ethical issues or insurance company policies on investigation or their procedures, FINEOS needs to be aware of the trend and the solution needs to address supporting this, for which we are in great position. How? Some examples:

  • Rules can be used to identify suspicious claim circumstances and a process, task, or follow-up can be automatically generated to investigate. Simple investigation can confirm what is known and save a company investigation fees or warrant time and money spent on further investigation.
  • Investigation items, such as Word documents, PDFs, images, videos, etc. can be saved to the claim record and easily identified for future use.

Using the internet and social media for claim investigation is a merely a “tool” in the box. The recurring theme of the both sessions was that any information should be taken with “a grain of salt” and be corroborated. Even simply verifying names, addresses, or phone numbers should be not be taken at face value.

Metrics and analytics

As I mentioned in the internet/social media section, metrics and analytics is also looked on as a tool to help someone make a decision. The person, though, has to rely on their experience and business savvy ultimately to make the decision.

“Why” metrics are needed is that they are critical in the day-to-day operations of an insurance company. Insurance companies need timely and accurate information to evaluate performance, assess trends, identify training and/or development opportunities, determine staff levels, and assess goals for individuals and teams. Metrics are also needed for internal and external auditors as well as regulatory agencies.

“What” metrics are measured were stated in the following categories:

  • Service delivery (turnaround time)
  • Productivity (for individual and team)
  • Quality
  • Unit cost
  • Inventory
  • Financial Impact

Of the “whats” mentioned above, service delivery and quality were focused upon. When asked what frequency metric reports are run, the answer is that some are monthly, but a lot are needed hourly (yes, hourly). This is where the “how” comes into play. The consensus of session attendees stated that dashboards are really needed and should become more commonplace.

Over the years at ICA sessions, I’ve attended many sessions about analytics. This year was no exception and had a session about return-to-work. However, the overarching theme is that analytics is a tool to help make the decision, in this case, what is the likelihood that a claimant could go back to work. The attendee sitting next to me quoted almost verbatim the same phrase that I heard many years ago – “disability claim processing is an art, not a science.” I think this is true for almost all of claim processing. While rules can automate the triage of claims and figure out which ones are eligible for “jet” approval and payment in the simplest of cases, it is the human element that really brings out the “moment of truth” for the basic principal of insurance – the contractual guarantee to indemnify for an eligible loss. This could mean not only promptly paying a claim, but also identifying early in the claim process (3-6 months) which individuals are eligible to return to work.

“How” can FINEOS Claims support metrics and analytics? FINEOS provides dashboards, which give real time statistics. The charts and graphs in the dashboard give a holistic picture to users while providing drill-down capabilities to see specific information. For example, a claim examiner could see the number of cases they have in different statuses, a calendar view with the number of tasks due (or overdue) on a particular day, and duration of claims. Also, FINEOS provides reporting tools where users, such as supervisors or managers, can get more specific metrics based upon any data within the FINEOS Claims solutions.

Analytical tools embedded in a claims solution can be used to determine the likelihood of many things: fraud, transitioning from STD to LTD, filing a Social Security claim, and returning to work. With return-to-work, for example, FINEOS Claims can identify claimants who have a good probability of returning to work. The solution can then provide case management, workflow processing, and rules to appropriate staff, such as case managers, so they may be involved early and help the claimant in determining their return to work possibilities.

Advanced Life Claim Roundtable

I’ve attended this session in past years, and as well as this year, to see if any new trends were emerging relative to life claim processing. There were about 13 people representing 11 companies, ranging from small to big. Topics could be about anything, and here are some discussion highlights:

  • I asked my favorite question to the session attendees, which is whether their company offers any sort of portal capabilities when it comes to reporting death claims. I got the same answer that I usually get – one company, who works with direct agents, allows their agents to report death claims via their agent portal. The rest of the companies overwhelmingly are still phone or paper-based for the reporting of a death claim. The most advanced is a fillable pdf document that can be printed and sent/faxed to the insurance company.
  • When it comes to automating or gaining efficiencies, there wasn’t much progress. A few items though:

o A gentleman from one large company stated that they have tweaked their Life Claim System over the years to gain big efficiencies. The conversation turned to metrics, similar to the session discussion that I attended. It really showed the need for dashboards so managers and supervisor could have real time data and make necessary adjustments.
o Many companies are still using homegrown claim systems which are “pieced” together and not very efficient. There could be a diary system, a document system, payments systems, etc. which don’t always “talk” to each other. This is very different from FINEOS Claims, which offers workflow, documents, diary, payments, email, etc., all in one solution.
o Interest rate calculation is still a big pain point. Most companies still don’t have a good way of automating the calculation or updating rates and calculations. FINEOS Claims supports this area quite well performing the calculation automatically and providing an interest rate administration facility.

Summary

During the entire conference, I spoke with attendees about both disability and life claim processing. It seems the human element (the “art”) is performing just fine and their jobs are being done, but they wish the tools (e.g., modern claims solution) they are provided (i.e., the “science”) would be better. As far as FINEOS goes, as long as we provide great quality tools for claims personnel to perform their job, we should have a long future.