The buck stops with claims

A dose of consumer care

In this unprecedented era of ever-advancing technologies and ever more empowered consumers, the wider world of customer service is having an inevitable influence on healthcare. US consumers expect the same type of simple, personalized experiences they have grown accustomed to in their daily lives, from ordering home goods online for swift delivery, to easy web retail returns and instant refunds. When it comes to healthcare claims processing, the prognosis is good for those insurers willing to embrace transformation by removing legacy barriers that shield inefficiencies and compromise the consumer experience. It could be terminal, however, for those resisting change.

Claims are seldom a differentiator for choosing healthcare coverage, but they are an integral part of consumers’ experience and therefore have significant influence over satisfaction with a healthcare payer. Facilitating fast and accurate claims transac-tions is little more than a baseline expectation of the healthcare purchaser, whether it’s the employer group or the consumer, with no reward to payers for simply getting it right.

An IBM Institute for Business Value bench-marking study of 102 US healthcare payers looked at claims handling through the lens of metrics describing cost, speed and efficiency to help payers see where and why to improve claims handling. Those metrics, coupled with insights from how data, analytics and count-er-fraud capabilities underpin claims handling, highlight three areas of improvement that are transferrable to health insurance models all over the world:

–Payers recognize that consumers expect a more satisfying claims experience. Typically, only 24 percent of consumers are satisfied with their claims experience.

–Payers using more sophisticated analytics have less manual involvement in claims. Thirty-two percent of payers use advanced data analytics in claims processing and therefore typically have a third less manual effort than others.

–Potential for smarter, or intelligence-led, pathways for legitimate claims remains untouched. Seventy-four percent of payers use artificial intelligence (AI) to predict claims risks or detect fraudulent claims, but improvement in claims outcomes is lackluster.

Our analysis reveals that a seamless process between payer, provider and consumer throughout a claim is necessary to improve patient satisfaction and efficiency. If anything breaks in the chain, the claim will sit in pending status and not move forward, creating headaches all around. Payers must move forward from this fractured, transaction-focused model to create a value chain that can lead to more positive consumer experiences.