I’ve already discussed some of the issues surrounding the optimization of medical claims: the need for structured data and the need for performance indicators. In this interview with Insurance Networking News, I discuss the need for a data-centric approach to medical claims processing.

Survey of US insurers

Accenture surveyed US insurers to find out their thoughts about medical claims processing. Despite the $50 billion paid out every year, 80 percent of insurers say that their processing is not optimized. Optimizing how medical claims are processed could result in significant improvements to productivity and reductions in cycle times.

Generally, carriers are doing a good job of getting information to the person best suited to deal with the claim, but then that person spends a lot of time looking for the information they need. There’s a significant loss of productivity when that person needs to organize and decipher information.

Challenges to medical claims processing

The hurdles to optimizing medical claims processing are both technological and organizational. One major problem is illegible handwriting; in fact, nearly half of respondents to Accenture’s survey cited this as “important” or “very important.” Another primary problem is the adjuster’s lack of medical expertise.

Insurers have made significant technology investments to streamline workflow. Advances in document imaging and management have been solid investments, and now is the time to take a holistic view at how data is acquired and handled. As I discussed last week, structured data is a step in the right direction.

Analytics for fraud detection and segmentation

A lot has been said about the use of structured data for data mining. However, it also has significant potential in fraud detection. By applying predictive modeling techniques with a fraud-detection lens, insurers can flag claims that are more likely to be fraudulent.

Further, predictive modeling can segment claims cases into different levels of complexity, allowing the more complex cases to be funneled directly to more highly trained adjusters.

Developing industry standards

Carriers can benefit from working more closely with medical personnel and health care providers to develop industry standards for how medical information is reported. This reduces the number of errors and the need for repetitive contact as carriers seek information to support a claim.


Insurers must step back and assess how they process medical claims. By implementing an integrated approach, carriers will spend less time wrestling with information and more time analyzing it.

Though seemingly isolated to medical claims processing, this holistic approach to medical claims processing—with a focus on data management—has important implications for business strategy, customer satisfaction and overall profitability.

Submit a Comment

Your email address will not be published. Required fields are marked *