The moment of truth:

Claims

Claims analytical framework

1. Notification

2. Submission

3. Validation

4. Approval

5. Settlement

Claims procedures

Analyse each of the categories of claimsprocedures:

‒ Consider the impact of product type and programdesign/structure

‒ Identify any specific tools or strategies that you areusing to improve client value, business value, or both

‒ Are there any areas where procedures could beimproved?

• Why? What change would you make?

• Does it fit under one of the guiding principles?

Program review – processes

CLAIMS PROCESS REVIEW

PATRICK KIHURIA MANAGER-MICROINSURANCE OPERATIONS

BRITAM MICROINSURANCE PRODUCTS

PRODUCT TARGET MARKET COVERAGE CLAIMS TYPES

KINGA YA

MKULIMA

TEA FARMERS

ASSOCIATION

INPATIENT &

LAST EXPENSE

HOSPITAL,

REIMBURSEMENT

& DEATH CLAIMS

AFYA TELE REGISTERED

GROUPS

(Corporates, clubs,

SHGs etc,)

INPATIENT,

OUTPATIENT &

LAST EXPENSE

HOSPITAL,

REIMBURSEMENT

& DEATH CLAIMS

SACCO

SOLUTION

SAVINGS &

CREDIT

COOPERATIVES

INPATIENT,

PERSONAL

ACCIDENT &

LAST EXPENSE

HOSPITAL,

REIMBURSEMENT

& DEATH CLAIMS

OBJECTIVES

• Map claim process & team structure

• Calculate average processing time

• Identify pain points

RATIONALE FOR THE REVIEW

• CLIENT SATISFACTION: Ensuring timely claim payments to hospitals and clients

• ADAPTING TO NEW MIS: Ensuring challenges from legacy systems are not taken

forward

CLAIMS REVIEW: APPROACH

PROCESS MAPPING

MEASURE STEP WISE TATs

‘AS-IS’ TO ‘SHOULD-BE’ MAPS

LIST TYPES OF CLAIMS

IDENTIFY PEOPLE & RECORDS

CHECK FOR DOUBLE DATA

ENTRY & MULTIPLE APPROVALS

ACTIVE/DEAD TIME

FROM TIME OF EVENT

ALERT FOR OUTLIERS

RATIONALIZE STEPS

IDEAL TATs

DEFINE ROLES

HOSPITAL QUALITY ASSURANCE CONTROLLER CLAIM ASSISTANT

ye

PRE-AUTHORIZED AMOUNT COVERS THE

TREATMENT COST

CHECKS IF BENEFIT ARE REMAINING

PATIENT PAYS THE BALANCE AMOUNT

EXTENSION OF COVERAGE IS APPROVED

REQUESTS FOR EXTENSION OF

COVERAGE

PATIENT IS DISCHARGED

CLAIM FORM (ONLY FOR OP)

INVOICE DISCHARGE DOCUMENTS

SENDS PHYSICAL CLAIM DOCUMENTS THROUGH POST,

COURIER OR RUNNERS

CLAIM DOCUMENTSARE RECIEVED &

STAMPED

PHYSICAL DOCUMENTS ARE

SCANNED & UPLOADED TO DMS-

FORTIS

VETS CLAIMS BY REVIEWING AMOUNT, VALIDITIY OF DIAGNOSIS & EXCLUSIONS

SCANNED CLAIM FORMS

CONFIRMS CLAIMS ENTRY & CHECKS PAYMENT IN MAJMED

UPDATES DATA IN MAJMED BASED ON

DISCHARGE VOUCHER

PREPARES A HOSPITAL WISE EXCEL SHEET OF CLAIMS

PRINTS BATCH TO FORTIS DIRECTLY FROM EXCEL SHEET

INDEXES BATCH OF CLAIMS BY PUTTING

BATCH NUMBER, AMOUNT, HOSPITAL

NAME

INDEXED BATCH OF CLAIMS MOVES TO

PAYMENT SCHEDULE FOLDER IN DMS

PRINTS BATCH OF CLAIMS FROM

PAYMENT SCHEDULE

ENTERS DETAILS OF PRE-AUTHORIZATIONSINTO MAJMED (KYM)

ROW WISE DETAIL IN MAJMED

DOCTOR PRESCRIBES INPATIENT ADMISSION

VERIFIES TEA GROWER/POLICY NO. IN

PREMIUM DATATBASE/AIMS

VERIFIES IF THERE ARE ANY PREVIOUS CLAIMS IN EMAIL HISTORY

PREPARES THE LETTER FOR UNDERTAKING AND SENDS

VIA EMAILUNDERTAKING

LETTER

BATCH OF CLAIMS FOR VERIFICATION

PRINTED COPY OF BATCHED CLAIMS

(See: Documents!B3)

VERIFIES INDIVIDUAL CLAIMS FROM BATCH TO

CLAIM INVOICES IN

CLAIMS ARE MATCHED

SENDS PRE-AUTHORIZATION REQUEST LETTER

BY EMAIL PRE-AUTH REQUEST LETTER

CLAIMS ARE CONSISTENT

NOYES

NO YESYES

NO

YESNO

YES

VERIFIES BENEFIT LEVEL, NUMBER OF MEMBERS

COVERED IN FORTIS/AIMS

REJECTS PRE-AUTHORIZATION

NO

NO

VERIFIES IF SUM ASSURED IS AVAILABLE

YES

YES

REJECTS PRE-AUTHORIZATION

NO

PRINTED & RETURNED

PRINTED DOCS

CORRECTION

CLAIM REQUISITON RAISED

CLAIM REQUISITION FOR APPROVAL

CLAIMS APPROVAL

YES

NO

MOVES TO FINANCE FOR

PAYMENT

CLAIMS PROCESS MAP

FINDINGS: HOSPITAL CLAIMS

Claims capture

Claims capture

Verification & indexing

Verification & indexing

Requisition

Requisition

Approval

Approval

Finance payment

Finance payment

YTD

Sept & Oct

STEP WISE BREAKDOWN OF CLAIM PROCESSING TIME

FINDINGS: FROM THE TIME OF EVENT

KYM Death

KYM Reimbursement

Hospital

STEP WISE BREAK DOWN OF TATs

Customer document submission Factory document transfer

Majani document transfer Hospital submission

Internal processing

TRANSLATING FINDINGS INTO ACTION

• ONE STEP AT A TIME

• SEPARATE IT AND NON-IT INTERVENTIONS

• DATA MANAGEMENT IS KEY

– REDUCE DATA FRAGMENTATION

– DATA ANALYSIS FOR SMART PROVIDER MANAGEMENT

• PROCESS AUTOMATION

– AUTHORIZATIONS

– CLAIM SUBMISSION AND NOTIFICATIONS (SMSes)

• TEAM STRUCTURE

– DATA BACKED WORK FLOWS

THANK YOU

With you every step of the way

Immediate requirement is to collect sufficientdate to evaluate and pay the claimCollecting detailed historical claims data can addadditional value to a microinsurance program:‒ Evaluate trends in underlying claims drivers

• Utilisation / frequency of claims• Average claim amounts• Primary causes or types of claims• Claim volumes

‒ Analysis by different factors such as• Age and gender• Location / service provider

Program review – data management

CLAIMS MANAGEMENT

IMPACT INSURANCE FACILITY WEBINAR

THURSDAY, 2ND MARCH 2017

MicroEnsure is a specialist in designing,

delivering, and operating insurance

products for the emerging consumer.

50 million registered customers

200 products launched

25 countries

15 years in business

Shareholders:

MicroEnsure: Who we are

Unprecedented Products

High-Volume Systems

TechnicalStrength

Market Knowledge

Speed, Efficiency,

Agility

Customer Value

Robust Operations

MicroEnsure Business Model

Our Key Insight:

People actually love insurance when it really works.

Especially emerging consumers, who frequently face risk.

Earn free hospital cash, life and accident cover up to

$2,500 when you top up $2

The more you top up, the more you earn

Pay $1 per month & double the free cover you earn

Earn up to $5,000 in life, accident and hospital

insurance

Buy additional cover for your family

Buy higher-impact health products: telemedicine, info

MicroEnsure Freemium Product Lifecycle:

Claims: The Ultimate Selling Point

Claimant TV Ad, Ghana:

• “I received my money in 2 hours”

• “This is not a fabrication; this product is real”

Micro insurance Myth: The more claims I pay, the less money I make.

Emerging customers need proof that a product works, and then they will buy it; claims management is essential for growing the market to scale.

Watch the ad “Hafiz Baba Testimonial on Airtel Insurance” on https://www.youtube.com/watch?v=vX6TySibSU8

Why Delaying Claims is Poor Strategy

Loss incurredFirst claim

report

Claim documents

receivedClaim paid

MicroEnsure

Typical claims experience

1-2 days 3-5 days 1-2 hours

10-15 days 40-45 days 72 hours

Policy terms aren’t clear, report has to be made in person at insurer office

Claimants go through many rounds of document review and keeps being asked for

additional documents

Clock only starts when ALL documents received; claims processed through multiple

departments

Customer knows exactly what cover she has, with no

fine print, and claims are reported easily via phone

A proactive customer service process and clear directions on document/s required allows for faster

claims submission

MicroEnsure performs most claims analysis before final

document receipt, earns payment authority from

insurer

50-70 days from loss to payment

4-7 days from loss to payment

Claimant tells everyone

about your product

Claimant is tired of your

company

• Start from claim event (customer perspective), not from notification (insurer’s perspective)

• Track every step, every sub-step, every contact

• Maintain direct contact with claimants through process

• Adaptive process and documentation requirements

• Follow up pro-actively with claimants until closure

Claims Management: Guiding Principles

Validate Validate Validate

1 2 3 4 5 6 7 8 9 . . . . . . . . . . . . . . . . . . . . . ..

Event

Reporting Contact Review Closure

• Claim volumes per Product, Partner, Country, etc.

• Claim incidence rates per Product

• Claim ratios

• TATs per Month, Product, Partner, Insurer, etc.

• Contact (number, mode & frequency to get to closure)

• Proportion of payable claims by product & partner

• Reasons for rejection

• Open vs. closed claims per Product, Partner, Country, etc.

• Proportion of Claims paid on time per Product, Partner, Country, Insurer, etc.

Claims Management: Data Analytics

• Reasons for rejection show us potential to enhance product in a way that meets customer demand

• Claim incidence rates: low = enhance benefits; high = increase premium, change policy terms

• Time taken for notification: being able to demonstrate how quickly claims are processed when we have direct contact with claimants and claim settlement authority vs. when we don’t

Claims Management: Insights

CLAIM PROCESSING TAT ANALYSIS

SCHEME

Average of

Time -

Incident to

ME

Notification

(Days)

Average of

Time - ME

Notification

to initial Docs

(Days)

Average of

Time -

Initial to

Complete

Docs (Days)

Average of

Time - Comp

Docs to ME

Comp

Verification

Average

of Time -

ME Verif

to Insurer

Average of

Time -

Insurer to

Payment

TOTAL

TURN-

AROUND

TIME:

Incident to

Payment

SCHEME 1 (M.E. DIRECT) 1.54 0.50 0.08 0.08 0.09 0.64 2.93SCHEME 2 (MFI – DIRECT CONTACT,

CLAIM SETTLEMENT AUTHORITY)13.85 0.26 2.73 2.51 0.02 2.87 22.24

SCHEME 3 (MFI – NO CONTACT, NO

CLAIM SETTLEMENT AUTHORITY)29.85 4.88 4.60 3.69 1.23 11.69 55.94

Total settlement time is key for clientsInefficient workflow contributes to higher expense levelsFocus on improving the step that creates the biggestproblem or bottleneck firstTest workflow process before “hard-wiring” it into anautomated systemReporting claims ratios and other performance indicatorscan be used to improve program sustainability, productdesign and pricingCoordinate data requirements and reporting withdepartment(s) responsible for setting premiums andreserves

Key points to remember

1. Claims management needs to be considered in the context ofoverall program design.

‒ Existing social capital and distribution channels can beleveraged to create a one-stop process for clients’insurance needs.

2. The claims notification and submission processes need to besimple and easy to understand

‒ For clients, intermediaries AND claims managers.

3. Claims documentation requirements should not be tooonerous

‒ Requirements should be sufficient to manage fraud, butnot excessive.

Guiding principles

4. Turnaround time is a key factor both for client satisfaction andcost-effectiveness.

‒ From the client’s point of view, the total time from loss topayment is what matters.

5. Efficient and streamlined workflow processes should beimplemented.

‒ And workflow should be evaluated on a regular basis.

6. A loss event is a difficult time for the client:

‒ The process should be fast and simple.

‒ Claims settlement should be transparent and providemultiple contact points for communication.

‒ Benefits should be provided in a convenient form.

Guiding principles

7. It is important to maintain control over data and processes,including appropriate fraud control mechanisms.

‒ Use of third party service providers involves additionalcontrols and service standards.

‒ Investments in technology should be well thought outprior to development.

8. Clear management objectives are necessary in order tobalance appropriate trade-offs between business and clientperspectives.

Guiding principles

Microinsurance Paper No. 28: Claims Management inMicroinsurance

‒ http://www.impactinsurance.org/publications/mp28

Le Roy, P., & Holtz, J.; Third Party Payment Mechanisms in HealthInsurance.

‒ http://www.ilo.org/public/english/employment/mifacility/download/mpaper13_payment.pdf

Steinmann, R.; Process mapping for microinsurance operations: Atoolkit for understanding and improving business processes andclient value.

‒ http://www.ifad.org/ruralfinance/pub/toolkit.pdf

References and Resources

Q&A

Join us for our next webinar in early May, focusing on “Change management”

Thank you!