Why should rising health claim be a surprise?

Some or more of the factors are in play; some affect all insurers and others are insurer specific.

Take your pick:

• Inflation.
• Abuse by providers + Leakage by your claims, risk/ fraud team(s).
• Claims/ legal/ fraud team(s) working in silos!
• Lack of suitable medical talent.
• High Tolerance philosophy of organization.
• Ancient systems, technology and processes/internal guidelines remain unchanged for years.
• Irrational spends on field verification, legal fees.
• No ongoing medical training of claims team(s).
• Periodic clinical review of underwriting and
  claims (both settled and those lost at legal fora) decisions.
• In-depth analytics of historic data to identify medical/ clinical outliers and use them to create future benchmarks based on current misses.
• Focused review based on:
  • Providers.
  • Intermediaries.
  • High ticket size clinical conditions.
  • Specific group clients based on claim ratio.

Ways to tackle inflation?

Insist of Rational & Customary Treatment (as already mentioned in policy documents) by ensuring your teams deploy Standard Treatment Guidelines into EACH claim adjudication (incl OPD claims).

These STGs should work on rules decided upon by core team on claim adjudication.

The Train your claims teams regularly.

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