In the complex realm of insurance, claims processing is crucial in managing risks and providing timely resolutions. However, traditional methods are often plagued by inefficiencies and limited insights. That’s where data analytics comes in.

Data analytics in claims processing revolutionizes the landscape, enabling self-insured entities to prevent and mitigate losses efficiently. Organizations can enhance operational effectiveness, streamline workflows and make informed decisions by harnessing the power of claim processing data analytics.

In this blog, we will explore the transformative role of data analytics in claims management and processing and the benefits it brings to self-insured entities. These data analytics capabilites were only available to large organizations in the past, but new tools make them available to all.

Understanding Data Analytics in Claims Processing

In claims processing, data analytics has emerged as a transformative force. But what exactly is data analytics, and how does it apply to claims management?

Data analytics involves systematically analyzing large volumes of data to extract meaningful insights, patterns and trends. In claims processing, it entails leveraging sophisticated algorithms and tools to process incident-related data, claim-related data, including policy information, loss data and customer details.

Data analytics in claims management plays a crucial role in uncovering valuable insights and optimizing the entire claims process. By analyzing vast amounts of data, self-insured entities can identify trends, patterns and anomalies that help in risk assessment and operational efficiency. This allows these organizations to make informed decisions, enhance customer satisfaction and mitigate losses effectively.

Benefits of Data Analytics in Claims Processing

Data analytics plays a pivotal role in revolutionizing claims processing for self-insured entities. By utilizing data analytics in claims management, significant benefits can be achieved.

1. Enhanced Risk Mitigation

One significant benefit of data analytics in claims management and processing is that it empowers self-insured entities to identify and mitigate risks effectively. Organizations gain valuable insights that enable proactive risk management by analyzing patterns and trends in incident and claims data.

For example, identifying frequent causes of incidents, claims or high-risk areas allows entities to implement targeted risk mitigation strategies that may include training and policy updates. They can also analyze historical data to identify emerging risks and take preemptive measures. Leveraging data analytics in claims management provides a comprehensive understanding of risks, enabling self-insured entities to make informed decisions and allocate resources strategically.

This proactive approach enhances risk mitigation efforts, reduces potential losses and fosters a culture of proactive risk management within the organization.

2. Improved Cost Control

Data analytics in claims processing offers substantial cost-saving potential for self-insured entities. By leveraging data analytics, they can identify cost drivers and optimization opportunities within their claims management process. Analyzing claim data allows for a granular understanding of where costs are incurred and where efficiencies can be gained.

With data-driven insights, entities can make informed decisions for better cost control and financial stability. By optimizing processes, reducing wasteful spending and allocating resources effectively, self-insured entities can maximize cost savings.

Embracing data analytics in claims management empowers organizations to achieve financial efficiency and long-term sustainability.

3. Expedited Claims Processing

Carriers can reduce manual effort and save valuable time by leveraging data analytics tools and technologies. Automation streamlines routine tasks, such as data entry, document verification and claim assessment, allowing faster and more efficient processing.

Expedited claims processing can lead to quicker resolutions and improve customer satisfaction. Policyholders receive prompt responses and settlements, enhancing their overall experience. By leveraging data analytics in claims management, organizations can achieve operational efficiency and deliver swift, hassle-free claim services to their policyholders.

4. Improved Decision-Making

Data analytics in claims processing empowers self-insured entities to make informed and strategic decisions. Organizations can gain a comprehensive understanding of claims management, reserves and risk mitigation strategies.

For instance, analyzing historical data helps identify trends, patterns and correlations that can help inform decision-making. Self-insured entities can accurately assess claim severity, allocate reserves effectively and implement targeted risk mitigation strategies based on data analytics. These insights enable organizations to optimize resource allocation, streamline processes and make proactive decisions that align with their objectives.

By harnessing the power of data analytics in claims management, self-insured entities can enhance decision-making and achieve optimal outcomes.

5. Stakeholder-Centric Approach

Utilizing data analytics in claims processing can empower entities to deliver a stakeholder-centric claims experience, where stakeholder can range from employees, to customers and vendors. Organizations can personalize their claim services and tailor solutions based on stakeholder data.

Analyzing stakeholder behavior, preferences and past interactions allows customized communication, proactive outreach and tailored claims-handling processes. This stakeholder-centric approach enhances the overall claims experience, improves stakeholder satisfaction and fosters loyalty. By leveraging data analytics in claims management, you can understand your stakeholders better, anticipate their needs and provide timely and relevant support.

This focus on the stakeholder strengthens relationships, boosts retention and establishes a reputation for exceptional service.

6. Continuous Improvement

Organizations can identify areas for improvement and drive ongoing operational excellence by tracking key performance indicators (KPIs) and leveraging data insights. Data analytics provides valuable metrics and trends that enable self-insured entities to measure performance, identify bottlenecks and streamline processes.

Organizations can continuously analyze data to implement targeted enhancements, optimize workflows and improve efficiency. This iterative approach to leveraging data analytics in claims management ensures that self-insured entities stay proactive and responsive to changing needs, driving continuous improvement and maximizing their outcomes.

7. Enhanced Reporting and Insights

Data analytics in claims processing can empower self-insured entities to generate comprehensive reports and gain valuable insights. Leveraging advanced tools and techniques allows organizations to transform complex claims data into intuitive visualizations — enabling a better understanding of trends, patterns and outliers.

Enhanced reporting and insights provide a clear overview of claims performance, reserve analysis and risk exposure. These actionable insights support strategic decision-making, enabling organizations to identify areas for improvement, optimize resource allocation and ensure regulatory compliance. With data analytics in claims management software, self-insured entities can harness the power of data visualization to drive informed decisions and achieve operational excellence.

The Future of Claims Processing and Data Analytics

The future of claims processing is closely intertwined with the rapid advancements in data analytics. As self-insured entities strive for more efficient and effective claims management, emerging trends in data analytics are set to revolutionize the industry. One such trend is the integration of artificial intelligence (AI) and machine learning (ML) technologies into claim management systems.

These technologies can automate manual processes, analyze vast amounts of data in real-time and provide accurate predictions and insights. AI-powered algorithms can quickly identify patterns and anomalies, improving fraud detection and risk mitigation.

Additionally, predictive analytics can help anticipate claim outcomes, enabling proactive decision-making. The continuous evolution of data analytics in claims management software ensures that self-insured entities can leverage the power of data to enhance operational efficiency, drive cost savings and deliver exceptional customer experiences.

As the industry evolves, data analytics will remain a vital tool in shaping the future of claims processing, enabling self-insured entities to stay ahead of the curve.

Revolutionize Your Claims Processing With Cloud Claims by APP Tech

To summarize, data analytics in claims processing is the driving force behind the insurance industry’s transformation. By harnessing the power of data, self-insured entities can prevent and mitigate loss, streamline operations and improve customer satisfaction.

To unlock these advantages, we introduce Cloud Claims, an incident-based, claims-focused risk management information system (RMIS) by APP Tech. Experience the benefits of Cloud Claims, including expedited claims processing, time savings, greater oversight, enhanced risk mitigation, complete customization and user-friendly reporting capabilities. With its cloud-based accessibility, all stakeholders can access the platform, receive alerts and ensure regulatory compliance.

Take the next step toward optimizing your claims management process by contacting APP Tech to learn more about Cloud Claims and how it can benefit your organization.

As businesses face growing risks and potential losses, effective claims processing is crucial for managing and mitigating those risks. However, traditional claims processing methods often focus on managing claims after they occur rather than preventing them from happening. An incident-based approach to claims processing can help businesses identify and address potential risks before they escalate into full-blown claims.

Basics and Components of Risk Management in Claims Processing

Risk management in claims processing involves identifying, assessing and mitigating potential risks that could lead to claims against a business. It is a crucial component of claims processing and helps businesses minimize losses and protect their assets. The basics and components of risk management in claims processing include:

• Risk identification: This involves identifying all the potential risks that could lead to claims against a business. These risks can be internal, such as employee errors, or external, such as non-preventable vehicle accidents or customer injury.
• Risk assessment: After identifying potential risks, the next step is to assess the likelihood and impact of those risks. This helps businesses prioritize risks and determine which ones require the most attention.
• Risk mitigation: When a potential risk has been identified and assessed, businesses can develop strategies to mitigate it. This can include implementing safety procedures, improving employee training or investing in insurance coverage.
• Risk monitoring and review: Risk management is an ongoing process, and it is essential to continuously monitor and review risks to ensure that risk mitigation strategies are effective. This can involve regular audits, employee feedback or reviews of insurance coverage.
• Claims handling procedures: It is essential to have effective claims handling procedures in place, including clear guidelines for reporting and investigating claims, as well as a plan for managing claims once they occur.
• Communication and reporting: Effective communication is critical to successful risk management in claims processing. Businesses should establish clear lines of communication between employees, management and insurance providers and ensure that all stakeholders are informed of any potential risks or claims.

Overview of Risk Management Information Systems

A risk management information system (RMIS) is a software tool that helps businesses manage and analyze risk-related data. It provides a centralized platform for storing, organizing and analyzing risk data, enabling businesses to make informed decisions and reduce the likelihood of losses due to risks.

An RMIS typically includes several components, such as:

• Data collection and storage: An RMIS collects and stores data related to risk management, including incident reports, incident photos, insurance policies, claims data and other relevant information.
• Risk assessment: An RMIS enables businesses to assess and analyze potential risks by analyzing data and identifying patterns and trends.
• Claims management: An RMIS provides tools for managing claims, including claims reporting, tracking and settlement processes.
• Reporting and analytics: An RMIS provides reports and analytics to help businesses understand their risk exposure and make informed decisions about risk management strategies.

Reasons to Have a Fully Integrated Risk and Claims Management System

There are several reasons businesses should consider implementing a fully integrated risk and claims management system. Some of these reasons include:

• Improved efficiency: Integrating risk and claims management systems can help businesses streamline processes and reduce duplication of effort. By having a single system that handles both risk and claims management, businesses can eliminate the need for multiple systems and processes, reducing the time and resources required for managing risk and claims.
• Enhanced data analysis: By integrating risk and claims management systems, businesses can analyze data from both systems together, enabling them to identify patterns and trends that may not be apparent when analyzing each system separately. This can help businesses make more informed decisions about risk management strategies and improve overall risk posture.
• Better risk mitigation: An integrated risk and claims management system can help businesses identify potential risks and implement strategies to mitigate them more effectively. By having a comprehensive view of all the risks faced by the organization, businesses can develop more targeted risk mitigation strategies that address specific areas of concern.
• Improved claims management: By integrating risk and claims management systems, businesses can improve their claims management processes. They can track claims more effectively, automate the claims handling process and reduce the time and resources required for claims management.
• Better communication and collaboration: An integrated risk and claims management system can improve communication and collaboration between different departments and stakeholders involved in risk and claims management. This can help ensure everyone is on the same page and that risks and claims are managed effectively.

Incident-Based Approaches to Claims Processing

An incident-based approach to claims processing rejects the traditional workflow of working with each individual claim. Instead, you track any incident where a claim may or may not arise. This approach offers key benefits:

• Risk mitigation: Incident-based approaches empower self-insured businesses to identify risks and create systems for preventing them. For example, if injuries or near-injuries continue to happen on the same machine, training and operational procedures need to change. Businesses can also use incidents to find opportunities for early intervention and prevent claims from being submitted.
• Reporting consolidation: Streamline claims management by generating multiple claims from a single incident. For example, a multi-car accident may involve several medical and auto claims. Pull all relevant details from the incident to prevent redundancy and ensure consistency across all claims.
• Insight: Collecting incident data informs your business about the most prevalent incidents and drives decision-making. Incident-related decisions may involve changes to policies or instructions for employees to reduce liability. With improved oversight, you can gauge the value of these changes over time and justify the value of investments when required.

Trust Cloud Claims for an Incident-Based Approach to Claims Management

Effective claims processing is critical for managing and mitigating risks, but traditional methods may not be enough to prevent future claims. An incident-based approach to claims processing can help businesses identify and address potential risks before they escalate into claims. By encouraging incident reporting, investigating incidents, mitigating risks and continuously improving, businesses can create a safer work environment, save money and enhance their reputation.

Cloud Claims is a powerful and user-friendly cloud-based risk and claims management system, unlike other claims management solutions on the market. By leveraging the modern concept of incident-based reporting, Cloud Claims is a single platform for risk management and claims processing. Key features include:

• Easy incident reporting: Cloud Claims lets businesses report incidents quickly and easily, reducing the time and effort required to submit incident reports. The system provides customizable forms and fields, making it easy to capture all relevant information related to the incident.
• Automated claims management: Cloud Claims automates the claims management process, from initial reporting to final settlement. This can help businesses reduce the time and resources required for claims management and ensure that claims are processed efficiently.
• Comprehensive data analysis: Cloud Claims provides comprehensive data analysis capabilities, allowing businesses to identify trends and patterns related to incidents and claims. Analyze data within the platform or export to your preferred business intelligence engine. This can help businesses make more informed decisions about risk management strategies and improve overall risk posture.
• Real-time collaboration: Cloud Claims provides real-time collaboration capabilities, enabling all stakeholders to work together seamlessly. This collaboration can be particularly valuable for businesses with third-party administrators and large enterprises with several locations.
• Scalability: Cloud Claims is highly scalable, making it suitable for businesses of all sizes. Whether you have a small business or a large enterprise, the system can be customized to meet your specific needs.

With its user-friendly interface, comprehensive data analysis capabilities and real-time collaboration features, Cloud Claims is an excellent choice for incident-based claims management. Contact us to schedule a demo.

Claims management is one of the essential parts of the insurance process. It is a critical part of financial planning and dictates how insurance providers handle customer service. The claims management process involves multiple parties and steps, and obstructions at any of these points can significantly affect the result.

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Every industry has inherent risks, and proactive management is crucial for avoiding the consequences. Those consequences often involve monetary loss, but unmanaged risks can also hurt your organization in areas like agility, efficiency and reputation. Manual risk management usually involves outdated systems like spreadsheets and email attachments, but a risk management platform can streamline the process, and enable you to mitigate risk.

With the ability to capture incident data, identify root-cause, take corrective action and track progress, a digital system can help you revolutionize your approach to risk management and reap the many benefits that come with it.

What Is a Risk Management Information System?

A risk management information system, or RMIS (pronounced “RIM-iss”), organizes and stores a wide range of risk management data — such as claims records, property values and loss control measures — and turns it into actionable resources. A RMIS allows decision-makers to act on all available data and access relevant insights. It can also serve as an incident reporting tool and may have industry-specific features.

Some functions you might find in a RMIS include:

• Cloud-based access for field reporting from any device, in any location.
• Dashboards to visualize risk factors.
• Reporting features, such as loss run generation.
• Business rule modules to automate common actions and workflows.
• Claims and policy management.
• Property and asset management.
• Activity logs to track adjuster notes and actions.
• Notification of open action items, such as court dates, appointments and filing deadlines.
• Medicare Section 111 compliance.
• Financial tracking for reserves, payments, and collections.

The RMIS provides a centralized space for these resources, so users can access the information they need from one convenient program. Centralizing your data can provide more security, too, since users can store information directly in a protected system instead of fragmenting it across different devices and platforms.

What Are Risk Management Information Systems Used For?

Many different businesses use RMISs to avoid and keep track of incidents, claims and risks. Some circumstances that typically call for a dedicated RMIS include:

• High levels of risk: Industries like construction, manufacturing, utility and transportation naturally involve considerable risk with issues like potential injuries and damage to assets. A RMIS helps organizations respond to incidents, avoid them and factor them into business decisions to facilitate prevention.
• Regulatory compliance needs: Risks can also come in the form of violated regulations, so businesses like healthcare and food and beverage companies often use a RMIS to oversee them. They might use it to watch for potential violations and assess their impacts.
• Complex insurance coverage: Some businesses have complex, layered insurance policies and work with multiple carriers. A RMIS can help users navigate the demands and risks associated with each one.
• International concerns: Operating across borders can come with challenging policies and multiple languages and currencies. With a RMIS, businesses can more easily accommodate the risks associated with international operations.
• Large quantities of data: Large businesses or those with a large number of assets benefit from the visibility a RMIS offers. It can keep data in one place and let users access everything in an organized way, avoiding errors or time-consuming navigation demands.

The Benefits of a RMIS

While a RMIS offers the foundation for necessary tasks, a dedicated platform also helps businesses improve their risk management approach overall. A RMIS can offer benefits such as:

1. Fewer Errors and Auditability

When you use scattered apps and manual processes, errors become inevitable. A typo here or an outdated document there can result in costly ramifications for an organization dealing with claims. It could also lead to significant time spent fixing problems, such as chasing down files or repairing a damaged reputation. With robust tools for organization and automated reporting, a RMIS is a powerful resource for reducing human error.

A RMIS can help mitigate human error through detailed audit logs, as well. In highly regulated industries, for instance, these logs might be required, and the RMIS creates them automatically.

2. Business Agility

Modern businesses must be able to pivot their strategies in response to evolving demands. From normal fluctuations to adopting new technologies, agile capabilities let organizations respond to threats and make changes without excessive risk.

Agility is often a primary factor in company growth, and a RMIS supports agile initiatives by providing a clear picture of the company’s risk and a flexible, scalable platform.

3. Centralized Data

The old-fashioned approach typically involves stashing data away in various places, like individual laptops, hard drives and different apps. Files can get lost or destroyed, and users might have to spend precious time collecting information from other people. With a RMIS, your data stays in one place, ideally accessible through the cloud.

All users involved in the claims process can access the information they need from anywhere and on any device. An employee can manage claims from their phone in the field or on a desktop computer in the office. Data centralization also enables robust and customizable dashboards and reports for fast insights into the most important areas of risk management.

Overall, a centralized approach can help improve data quality, collaboration and speed.

4. Efficiency

Unsurprisingly, all that ease of use and flexibility can help employees work much faster. They can eliminate the tedious work associated with manual processes and focus more on the tasks that demand their attention and skill.

Some of the features employees might use to save time with a RMIS include:

• Automated reporting
• Workflows and event triggers
• Streamlined user interface
• Email/document templates
• Reminders
• Search tools
• At-a-glance dashboards

5. Cost Savings

With all of these benefits comes cost savings related to many different processes. For instance, greater efficiency can help save on labor costs and reduce employee frustration, while reduced errors can protect against violations or expensive fixes. Business agility can impact the trajectory of a company and allow for new possibilities that would not be possible if it was too difficult to make changes.

Get More From Your Risk Management With Cloud Claims

Now that you have seen RMIS explained, you can find the right tool for your business and approach risk management in a more effective way. Whether your main priority is speed, accuracy or something else, Cloud Claims can help. This cloud-based RMIS from APP Tech offers a host of features for reducing risk and working more efficiently, including:

• Rich and flexible reporting
• Thorough incident data capture
• Automated notifications
• Reminders and activity logs
• Tag-based organization
• A customizable dashboard
• Global Search
• Claim financials

Cloud Claims is an incident-based platform that is easy to deploy, scalable and tailored to the unique needs of your business. Our clients span diverse industries like transportation, insurance, third-party administration and construction. We push updates automatically and maintain top-tier security standards for all of our products.

Reach out today, and see for yourself why so many companies trust Cloud Claims and APP Tech for their risk management software.

On December 6, 2022, CMS hosted an online webinar addressing NGHP Section 111 reporting issues. The first half of the webinar covered concerns and points of interest from CMS’s point of view and the second half was a Q&A session fielding attendee concerns. 

We heard a varied list of CMS’s concerns with the quality (and capability) of reporting that they are seeing. Angel Pagan, EDI Director at BCRC, pointed out that many of the points and procedures he was explaining in the webinar are outlined in the NGHP User Guide. Nevertheless, industry confusion prompted CMS to cover these topics in a webinar. 

Some Takeaways, Reminders, and Points of Interest 

• Indemnity-only settlements that do not release medicals do not need to be reported under Section 111 as TPOCs (total payment obligation to the claimant).
• Property damage amounts should be included in the TPOC amount if those amounts are part of a single settlement that has the effect of releasing medicals. 
• The Event Table in Section 6.6.4 of Chapter IV of the NGHP User Guide has details on many common TPOC scenarios and is a good reference for RREs. 
• Situations where ORM terminates for one injury but continues for another were covered. To properly report these situations:
  • If there is no settlement, the ICD codes must be updated to reflect the continuing injury only, leaving ORM open until it terminates. 
  • If there is a settlement (TPOC) for one injury that terminates ORM, then the original report is updated with the ICD codes for the continuing injury and the ICD codes for the settlement are moved to a new claim record with the TPOC amount. 
• Section 6.3 in Chapter III of the NGHP User Guide is a helpful guide to ORM reporting. 

CMS Errors 

One interesting segment was a view of the top ten error codes (though, humorously, the chart only showed nine) CMS has seen over the past quarter.

It was no surprise to see the CR12 Rep Phone as the top error because it is a “soft error” that does not prevent successful reporting. It points out that the introduction of soft errors last year has enabled claims to be reported to CMS which were likely previously withheld by RREs.

Another notable pair was the prevalence of CI05 and CI03 on the list. Their presence highlights that it is still common for CMS to receive invalid ICD-9 or ICD-10 codes on their submissions. CMS publishes a list of the acceptable ICD codes, which enables RREs to verify the codes they are submitting are acceptable. Section 111 vendors (like APP Tech) include validation checks to verify the correctness of ICD codes before claims are sent to CMS.

Additional slides in the presentation were dedicated to explaining technical bits about how ICD codes should be reported. It’s surprising that many claims are still reported with invalid ICD codes, given the prevalence of technology to assist with accurate reporting.

TPA Transfers 

Two scenarios for moving claims from one TPA to another were reviewed. Although discussing a routine happening, the second scenario may have been confusing for some in the audience new to Section 111. This slide implied the Policy Number always changes when TPAs change and therefore it was necessary to send DELETE-ADD transactions to CMS for all claims when a new TPA takes over claims from another. It wasn’t quite clear from the slide that this only applies if one of the Section 111 “key fields” is changing (e.g. policy number). Mr. Pagan elaborated on this point during the Q&A segment, but we hope they clarify the slide before releasing the final deck on CMS’s website.

Upcoming Changes to the CP13 No-Fault Error Code

CMS flags a CP13 soft error for claims where the submitted No-Fault Limit is under $1,000. This is to help RREs identify incorrectly submitted no-fault claim limits. However, there are many policies (they noted motorcycle policies as an example) where the limits are less than $1,000 and this is causing many false positives. Therefore, effective January 2023, the threshold for triggering the CP13 error code is dropping to $500. This should be a relief for RREs that are currently reviewing many of these errors.

Here to Help

APP Tech is a leading provider of NGHP Section 111 Reporting Services via its MIR Express™ reporting platform. If you have questions about the CMS webinar or anything related to MMSEA Section 111, let us know. We’re here to help!

Update 12/15/2022: CMS posted the slides for the webinar on their website. You can access the complete slide deck with talking points here.