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Accelerate Workflows and Improve Productivity with a Purpose-Built Claims System for TPAs

Insurance organizations must perpetually combat inefficiencies in order to remain competitive. On the revenue side, attracting and retaining clients has never been more difficult; on the operations side, firms not leveraging technology to the fullest quickly become victims of it. To this end, purpose-built and automated claims systems are essential for TPAs to offer niche services, increase operational efficiencies, and ensure continual growth.

Insurance claims these days are costly, complex transactions involving multiple parties/systems and require a myriad of legal and regulatory considerations. A purpose-built claims solution for TPAs offers easy configuration of best practices, integrated compliance capabilities, and tools for enhancing productivity and automation capabilities, allowing teams to focus on claims resolution and customer care.

In this article, we’ll explore how a purpose-built, automated claims system for TPAs can help firms combat inefficiencies and focus on costs, outcomes, and service.

Automating the Claims Workflow

Automated or not, today’s claims workflows consist of a tightly integrated orchestration of data, systems, and people; however, the latter adds the most risk to the insurance value chain in non-automated workflows. For example, adjusters must continuously recall deadlines, contract requirements, and other details with custom business rules, to name a few. This myriad of claims-related activities leaves a significant margin of human error. A purpose-built, automated claims management system designed with TPAs in mind can dramatically reduce the risk and costs of manual processing, leading to time savings via routine task automation.

In addition, automated claims management systems can eliminate time-consuming, manual document management processes (e.g., automatic attachment of files directly to claims), resulting in accelerated workflows and improved productivity. These systems can automatically adapt to emerging requirements with a highly configurable system that scales to your organization’s needs without custom programming or development.

Minimizing Complexity and Improving Usability

Despite automation’s benefits, humans are still an essential component of the claims experience; by making the claims workflows more usable and easier to use, insurance carriers can simplify their claims processes—even for complex claims—providing human operators with an intuitive user experience designed to support the unique demands of TPAs. A claims management system handles the intricacies of the insurance claims process, including multi-line claims operations, including disability, liability, auto, property, and workers' compensation, resulting in enhanced performance, improved efficiency, and a reduction in overpayments.

Reducing Jumper Claims

A claims management system can also be instrumental for surfacing and mitigating complex, difficult-to-predict risk scenarios. Jumper claims, or claims that jump at approximately the 90-day mark, ultimately become high-cost cases that require close management, increased reserves, and more resources and attention, despite appearing relatively benign at first notice of loss (FNOL). These “jumper” or “sleeper” claims account for 40% of ultimate losses, or the same proportion of costs as high-cost claims—and 40% of the $60 billion paid each year for workers' compensation benefits. 

To mitigate the risk of jumper claims, a key component of a claims management system should be embedded predictive analytics. With these insights, claims specialists can quickly identify claims that have the potential to "jump" sooner and mitigate costs with preventive action; for example, by taking proactive steps to mitigate costs earlier by allocating the appropriate resources and implementing preventive measures. This allows insurance firms to achieve and maintain visibility across the claims lifecycle.

Improving Compliance

A purpose-built claims management system for TPAs enables tighter adherence to regulatory compliance requirements and mandates from oversight bodies. These systems typically have a fully integrated compliance program that automatically generates alerts reminding claims professionals of upcoming deadlines, cut-off dates, and other events of interest, helping to prevent tardiness penalties and non-compliance fines

With a purpose-built claims platform for TPAs, firms can improve data intake across the insurance claims workflow. From claim notification to safety inspections, audits and assessments, and field inspections, automated claims systems fully integrate these processes into a unified loss control platform, enabling TPAs and insurance professionals to streamline assessments, audits, investigations and corrective actions, incident and near-miss reporting, and OSHA reporting——with features like combined document/policy and loss control program storage, allowing for real-time printing of OSHA logs whenever facilities professionals require them. 

Data-Driven Intelligence for Combating Inefficiencies

Claims management and mitigation is ultimately a game of numbers; subsequently, TPAs and insurance/risk professionals require the right analytics, tools, and dashboards for interpreting these numbers and gleaning actionable insights. A claims management system brings these numbers and data together in a user-friendly, streamlined interface, allowing insurance professionals to interact with data conversationally and identify trends quickly with advanced analytics. When more powerful analytics, data discovery, and reporting tools are required, an optimal claims management solution will provide more under-the-hood power with advanced APIs for connecting, extending, and enriching data.

Chat with an expert today to see how Ventiv’s Claims Solution is right for your organization.

Nov 17, 2023

 | Originally posted on 

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