Claims

Claim Scoring

We have seen how the use of predictive models for scoring claims has a major impact on claim practices and will deliver significant benefits, with an immediate return on investment. We have developed a computerized claim segmentation mechanism, using predictive modeling tools, called “Claim Scoring” to improve how you assign and manage claims. This offers claim managers an instantly recognizable, objective indicator of the opportunity to resolve the claim.

Claim scoring simplifies the life of the case handler:

  • The score suggests a path and a strategy for the claim.
  • The score may help the handler recognize when non-medical factors are impacting recovery.

Opportunity Reports shine a light on claims with high recovery potential.

With scoring, the case handler goes from having a complex pile of unrelated files to a discrete set of categorized files, with a report highlighting those which show the greatest opportunity.

To ensure a safe and secure process our internet portal delivers customized automated claims reporting to our clients on a regular basis.

Rehabilitation

Claim Analytics predictive modeling tools can analyze the impact of rehab referrals on claim outcomes in both STD and LTD. This identifies where rehab intervention has had a positive, neutral or negative impact on claim outcomes, both overall and by various factors such as diagnosis, spend and timing.  This can be an effective tool to help carriers realize the greatest impact from their rehab investment.    

A key feature of the analysis is the expected recovery rate calculated for each claimant. These expected recovery rates reflect the unique characteristics of each claimant (e.g., age, elimination period, diagnosis, etc.) and are based your own claimant recovery experience. Our analysis compares the actual outcome (recovery or not) to the expected outcome for each claim that had a rehab referral. This allows us to analyze and summarize the impact of rehab intervention by the various claimant characteristics.  

This can be extended to focus on a proactive and automated scoring based approach to identifying claims to refer to rehab.  Based on what is learned from the rehab study, a custom claim scoring mechanism identifies and flags claims likely to have improved outcomes with rehab intervention.  The scoring mechanism would typically run daily or weekly.

Fraud and Abuse  Prevention

Unfortunately fraud is a fact of life for insurance companies. However, fraud patterns can be identified and this does not have to be an after-the-fact exercise, scoring can be built into the administration process to flag potentially fraudulent claims.


What our clients say...

“Predictive modeling helps us optimize our staff resources throughout the department, mainly because it helps us focus staff people on the claims that need them most.”

What our clients say...

“The Opportunity Reports help you to focus your efforts on the files where you can make a difference. After spending the time to review a file in its entirety, you pick up on things that may have been missed before. You start to notice patterns. You see the red flags.”