Tedious health insurance claims processes during a medical emergency can not only be distressing for the policy holder but also for the TPA companies. In the health insurance sector, the complexities of the insurance claims management cause a significant loophole.
Manual processes that go in the claims management right from checking the policy documents to proof/document verification are lengthy and complex. However, with the emergence of insurance technology these processes can be streamlined.
This case study illustrates the significant technological adoptions that have been implemented by one of our clients who is a leading TPA company. By leveraging our solution, the client has achieved notable improvements in managing claims processes with utmost efficiency and accuracy.
Client Profile at A Glance
Started in 2013, our client is one of the leading TPA companies, based in India. It is a joint venture of public sector non-life insurance companies –National Insurance Co. Ltd, the Oriental Insurance Co. Ltd, The New India Assurance Co. Ltd, United India Insurance Co. Ltd and GIC of India.
They are committed to providing greater efficiency in health insurance claims processing, with an aim to enhance customer experience in health insurance.
Challenges Confronting Our Client
The client faced some of the critical challenges that were roadblocks for them in delivering efficient health claims. Apart from facing a critical challenge of processing large volumes of health claims from 4 of the largest PSUs in the country, here are the additional challenges that our client faced:
- Inefficient claims management
- Customer inconvenience.
- Increased claim-processing TAT
- Customer followed manual processes.
- Claims leakage
Solution We Implemented
iNube’s comprehensive decision powered claims management solution played a pivotal role in addressing the client’s key challenges.
By leveraging advanced technology and streamlining workflows, we not only tackled the inefficiencies in the claims management but also streamlined the entire claims management process.
The thorough and well-coordinated approach has not just solved the clients’ existing issues but enhanced their existing health claims management system.
Here are the implementations that we carried out:
- A decision powered claims management solution:
To handle complex businesses in a multiple PSU driven health insurance setup. This replaced the fragmented and tedious workflows with a streamlined solution to process large volumes of health claims
- FWA prevention in Claims:
Our Health Claims System’s business rule engine capability helped in detecting and flagging fraudulent claims, allowing the client to eliminate in dealing with fraudulent claims and optimizing resources.
- Enhanced communication channels:
Real-time communication eliminated the multiple manual follow-ups leading to faster processing time, effective control and management of health claims.
- Business User Management:
Multiple user interfaces, including Members, Insurers, Providers and Investigators Portal, catering to the different stakeholders across the entire claim cycle. This Robust role-based user management approach helped in streamlining fragmented workflows as it enabled specific functionalities for every stakeholder.
- Monitoring and Dashboards:
The solution helped in providing real-time monitoring of the claims management analytics with the ready-made availability of dash boards and generation of MIS reports.
Transformational Benefits from iNube’s Health Claims System:
Automating and Accelerating Claims Processes
- Operational costs
- Quicker decision making
From Grievances to Enhanced Customer Satisfaction
- Reduced Claim Processing TAT defying the situation earlier
- Smarter Claim assignment and handling
Impact we made:
- 3000+ hospitals are empanelled in the system
- 1500+ claims processed per day
- 1 lakh claims successfully processed till date
The implementation of the decision powered health claims management solution has significantly been a turning point in the health claims management process.
By replacing the manual and time-consuming claims management process, the application is addressing some of the key challenges of controlling fraudulent policy issuance, tedious claims management and inefficient service provider management. The customisation for handling multiple PSU driven claims has helped in addressing large volumes of claims without getting overwhelmed, enhancing efficiency and accuracy.
Overall, the new system represents an improvement in helping TPAs to streamline the tedious health claims management with accuracy and acceleration.
