 "ICICI Pru Life Uses Health Claims Mgmt System To Cure Inefficiency")
Insurance industry players face their own set of challenges when dealing with Third Party Administrators (TPAs). According to media reports, there are only a couple of insurance companies in India that have done away with TPAs in the health insurance (viz. non-life insurance) space for servicing customers as far as claims management is concerned. ICICI Prudential, though primarily a life insurance player, also offers health insurance policies to its customers. The company decided to do away with TPAs and have a centralised, unified system for claims management. To take this step and change its functional model, ICICI Pru had to develop a single application for health claims management. How the insurance player went about doing this and what it led to is a story of how technology can change the way business is conducted.
The company has built a robust, scalable, Web-based integrated system that will serve as a single application to be used by a network of 3,000 hospitals, providing cashless service to policyholders across 488 locations spread across the length and breadth of the country. All parties involved will be using this application to co-ordinate the entire claims management process. This is purely a Service Oriented Architecture (SOA)-based health claims solution.
How was claims management handled before?
The designated team for health claims maintained volumes of offline data. For example, under a general health policy, if a person has undergone a surgery that costs Rs 60,000, he is not necessarily compensated with the entire amount. It depends on the type of ward he was admitted to, the policy limit and a number of other factors. The calculation and other ancillary work associated with the processing was carried out manually and data stored offline. All of this data was double-checked and was restricted to a particular employee’s desktop. It was not available online. “This would limit us on the front of data availability,” says Anita Pai, Executive VP-Customer Service, Technology & Marketing, ICICI Pru life. Thus, the calls hitting the customer care centres were left partially unresolved due to the unavailability of data.
“Our existing processes and systems did not support more than two parties (the claimant and the provider in case of a life insurance policy). We wanted to extend the system for third-party integration too,” says Pai. Additionally, the system was unable to include a general health policy that can package the entire family under a single policy. It would only cover a single person under a life insurance policy. Further, there is only a single payout that happens in the life policy upon death, whereas in health insurance, the customer can avail of annual and lifetime limits of multiple people in the same policy. The current system was unable to calculate the multiple payouts on annual and lifetime limits of these people.
How did the integrated system change things?
ICICI Pru Life along with vendors developed the Health Claims Management System (HCMS). The solution was called CAPS and the first phase of the same was implemented by SEEC (now acquired by Polaris) while the second phase was implemented by Value Momentum. This implementation involved the first successful usage of ACORD (an international insurance data model standard) in India for a health insurance claim system that drives integration with third-party systems, which include hospitals, clinics and branches. The HCMS is completely built on a J2EE multi-layered architecture. It provides the flexibility to change the components without touching the core.
The roll-out was done in phases. The first phase included the development of the ‘Calculation of the Benefits’ table having information about the kind of customer benefits based on the policy. It uses a flexible claim benefit calculation engine primarily built on the Actuate engine. In the second phase, the system was equipped with all the customer letters that are delivered to the customer under various scenarios. Earlier, the letters were drafted on Word, however, now they are automatically sent online. The system facilitates real-time integration with SMS, e-mail and the document management engine for customer and hospital communication at various stages of claims processing. All the communication aspects were built in phase two. “We have also been able to build a lot of fraud detection parameters,” says Pai.
The benefits reaped
The company has been able to slash the turnaround time for resolving cashless claims from eight hours to three hours. The seamless availability of information has helped tremendously in doing the required analytics. It has also reduced the amount of fraudulent claims from customers, agents and hospitals. The company has improved the upselling process from the information trend derived via customer claims. Now the customers don’t have to manually calculate benefits, there is an inbuilt functionality available in the Health Claims Management System (HCMS).
The amount is automatically calculated based on the number of days, type of policy etc. This eliminates chances of errors. The information is readily available to call centre employees also. Unlike before, the information is not restricted to a single desktop but a robust workflow facility has been designed to auto allocate the claims cases to respective assessors, which has led to considerable productivity improvements. The customer can access the information online from any location. “After the completion of each phase, we were able to add more and more functionalities as we went live with them,” concludes Pai.