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India InsurTech Thought Leadership

Innovation At Work

Innovation At Work

The world around us has altered within a very short time post Covid19. Economic resilience and corporate BCPs are being tested in new ways. Insurers across the world are facing the tall task of reimagining their core processes to remain agile and customer-centric under the new normal. Health insurers have been at the forefront of this fight against Covid. They have been ensuring their member services are far more prompt than under pre-covid scenarios, as well as their claims policy being upgraded to make member claims experience as smooth and hassle-free as it was before the pandemic.

At my company ManipalCigna (MCHI) we believe in keeping our customers at the center of everything we do. Our constant endeavor is to improve the health, wellbeing, and peace of mind of those we serve through a passionate focus on innovation and integrity.

Earlier this year when the nationwide lockdown was imposed in India, one of the essential verticals to take a massive hit was claimed investigation operations. The crux of the verification process was face-to-face appointments with providers and personal visits by TPA to collect evidence. All of this came to a sudden standstill with a large number of in-process claims in the system. This is when the MCHI leadership came together with the claims department as One Team to figure out a way ahead and fast.

What we ended up doing was no sort of innovation that I would like to share here.

Key challenges that we had to solve:

  1. How would we go forward with routine investigation without affecting the overall claims processing time & efficiency?

  2. What would the evidence collection look like?

  3. How would we ensure the same rigor in catching fraudulent claims as before?

The solution:

The best ideas are sometimes the simplest ones. Simplicity and innovation go hand in hand. We transitioned into a digitally enabled desktop model of verification with a few tweaks to our core claims administration system.

The working prototype development:

The field experiences of our claims investigators turned out to be our biggest asset here. This helped us in collating a series of stakeholder questions that were based on real-time past experience of the process, claims, trends, red flags, etc. Thereafter a design thinking approach was used to develop a successful digital verification process. Evidence collection was moved to a complete digital mode using data input via emails and messenger apps.

Additional documentary evidence, for the erstwhile physical verification type cases, was requested to be collected from the customer. Ample timelines were built in for submissions. However, if customers were unable to provide the required additional documents, investigations were reinitiated via flexible verification when lockdown restrictions were partially lifted. Such cases were put on temporary hold, with an auto status trigger to the member, from the system, explaining the reason for the hold. This model was put under full live testing from the 2nd week of May 2020, as we had a backlog to clear.

A quality team of 3 members, from the customer service department, was set up to ensure proper quality of recordings and evidence collection. Three levels of quality checks were put in place on the system itself.

  1. 1st level of scrutiny was done by the desktop investigator. This person would go through all the scanned documents submitted by the member. Following a predefined logic scanning would be carried out for suspect red flags and raise triggers

  2. 2nd level of scrutiny was by the regional QC team, that reviewed the investigation findings and concluded the investigation with proper remarks.

  3. An extra level of quality check was added for claims where the regional team could not conclude the claim. A core quality team member was responsible for this scrutiny.

We started with 16 investigators during the live testing. However, as the inflow of claims increased, more were brought on board and trained to ensure consistent online investigation quality. By month 2 we had created a standardized checklist for claim documents, in the new environment, to maintain claims operations uniformity.

The closure rate was maintained at above 90% with rigorous monitoring and tracking of cases by the regional claims team in Mumbai, Bangalore, Delhi & Kolkata. The core quality team was active in the provision of triggers and resolution of cases where telecommunication had been unsuccessful.

Some challenges:

The impact on the hit rate was a foreseen risk. The inflow of claims drastically reduced in the months of April and May as a result fraud claims had practically stopped being registered. There was a dip in the rate of fraud proven, but it was held steady at 15-17%. About 60% of the investigations closed successfully and they were good quality investigations.

Some hospitals were short-staffed or completely shut given local restrictions. This affected the closure rates, which dipped slightly by 2-3% of the normal average.

Key result areas:

  1. The hit rate in terms of claims savings continued to hold and rise after reaching “nil value” by mid- April 2020.

  2. High value claims are being verified with same discipline, now, as Pre-Covid levels.

Next Steps:

With the prevailing uncertainty, surrounding us, our motto is to ensure our model is constantly evolving to adapt as the situation demands.

  1. MCHI is mulling a flexible model of investigation even after complete unlocking has been effected in India.

  2. The desktop digital model will slowly transition into a flexible model creating space for both physical and digital verification.

  3. Moving this verification module into a mobile app that completely does away with physical processes.

  4. Physical investigation will be initiated, selectively only.

  5. Addition of an inbuilt document checklist, integrating video calling into the app, auto generation of investigation reports to name a few.

An innovation, to be effective, has to be simple and it has to be focused. Our desktop model ran on two basic principles- Customer first and Simplicity. It will continue to remain our motto as we grow and navigate the new normal.

Author: Nilanjan Roy, Group Business Head, Manipal Cigna Health Insurance Co. Ltd.

(Disclaimer: The opinions expressed within this article are the personal opinions of the author. The facts and opinions appearing in the article do not reflect the views of IIA and IIA does not assume any responsibility or liability for the same.)

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