In July and August of 2009, Accenture conducted interviews with 30 senior claims executives at major property and casual firms in the United States. These executives are either the head of claims or the equivalent. Our objective was to identify key issues related to the processing, adjustment and analysis of medical-related claims.

Results of the study

In March, I discussed the results of these interviews in an article for Claims Magazine titled “Optimizing Medical Claim Processing.”

Our survey revealed wide variations in the number of adjusters employed at each firm, and in the number of claims managed by each adjuster. Generally, more senior adjusters deal with more complex or high-severity injury claims, with these claims also reviewed by a supervisor.

Some interesting statistics emerged from the study. Notably, of the insurers that we interviewed, 43 percent of them have targets above $500 million. However, 79 percent of insurers believe that their medical records processing is not fully optimized.

Challenges in medical claims processing

When asked about specific challenges in their industry, insurance executives cited:

  • Difficult in accessing medical information.
  • Lack of skill among adjusters.
  • Lack of key performance indicators.
  • Lack of standard, consistent rules to evaluate claims.
  • Difficulty of identifying complex and high-severity injury claims.

In fact, half of insurers mentioned that a lack of key performance indicators is the most important challenge they face.

Developing key performance indicators

In developing key performance indicators for medical claim processing, it is important to have a holistic view of all processes. This includes re-aligning technology investment to streamline processes and to take advantage of the extensive information found in medical records. While most carriers see the value in technology investment, many fall short in thinking about how to acquire and handle medical information. By adopting a more holistic view of medical history and available data, insurers can reduce cycle times, improve efficiency and achieve high performance.

Next week, I will discuss the need for structured data in medical claim processing: how it can streamline existing processes and provide valuable analytics for future projections.

Do you have key performance indicators in your organization, and do they present an accurate measurement of performance? Do they account for an end-to-end, holistic view of your process?

One response:

  1. I work for a small broker and I specialize in group benefits customer service, specifically working on claims issues for our clients. Currently there are no measurements or KPIs with which to measure my progress and abilities and the owner of the company, my supervisor, has requested that I come up with KPIs for my position. Though my position requires a lot of problem-solving and managing of clients’ expectations and casework, I am paid hourly and I make about $30,000 a year. The owner states that the quality of work that I put forth is outstanding and that the agents and clients all agree on this, but that the pace is not up to par. He wants me to create KPIs for myself and figure out how to do claims analyzation and resolutions faster. He stated that it is better to get something done quickly with some mistakes than to take too long — I thrive on make sure everything is precise and complete before providing information to clients.

    Is there any way that I could get some advice on this, and some help on how to find KPIs for customer service claims work, precisely? Thank you so much in advance any help will truly be appreciated.

Submit a Comment

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