Background
As insurance claims and related costs continue to increase, so does the need to further automate the claims process for more efficient customer service and error free workflows. In a recent engagement with a mid-west based insurance company that specializes in disability claims, CrawfordTech along with IBM helped ease the rapidly rising administrative costs with an automated case based claims processing solution.
The Challenge
Virtually all of their customer documents were delivered via the web, and were stored in an enterprise content management system in AFP format and ePresented in HTML and PDF. The insurance company needed a solution that would integrate with their ECM system and that could handle high volumes of complex documents such as explanations of benefits, statements and invoices. They wanted to ensure that the solution architecture and licensing would give them a flexible and scalable foundation to support future business growth and evolution.
When considering the options for accessible formats, the company decided to offer both Accessible PDF and Accessible HTML5 since their customers already relied on ePresentment for their communications. They recognized that although Accessible HTML5 might be a preferred format for documents such as invoices, multi-page communications such as explanations of benefits would be better suited to Accessible PDF. They needed to automate the conversion from their AFP print streams to Accessible PDF and Accessible HTML5 with complete document integrity — ensuring that all information was an exact match to the original, in the proper read order, and could be easily consumed with assistive technology.
Solution
The insurance company selected CrawfordTech’s Riptide to automate the ECM output management function along with IBM’s Case Manager for managing the case process. By using Riptide, they can take groups of different documents from one or multiple IBM ECM repositories and submit them to one or more designated outputs. By automating this process, they are able to reduce the labor-intensive task of assembling documents, minimize errors, and deliver critical information more rapidly.
Documentum Retention Policy Services was chosen to provide lifecycle control over the archived policy documents insuring that documents were held for periods in compliance with the ICOB guidelines.
Use Case
Although disability claims are somewhat unique in the complexity of the cases, and the time it takes to reach a resolution, the underlying process is identical to other insurance claims. When an insured party files a claim, the process begins with the insurer opening a new case. The application is entered into a case management claims processing solution that tracks the claims processes throughout its life span.
At this point, numerous people, such as adjusters, multiple physicians, and others, will review the claim and create supporting documentation. If the insured does not agree with the eventual claims determination, a settlement must be reached – either through mediation or litigation. At any stage of the review process and settlement stages, an normous amount of information needs to be consolidated into a standard format and made available to all concerned parties.
In the instance of this insurance company, case files are in an IBM FileNet P8 repository, typically with dozens of documents in disparate formats: TIFFs, PDFs, Word documents, spreadsheets and XML transmissions. As cases progress, the case managers maintain a case worksheet documenting the claims processing actions and all interactions with the insured.
When these documents need to be made available as a consolidated package for claim settlement or litigation, Riptide is able to automatically assemble a transportable packet that contains:
- A cover sheet
- A table of contents
- All the IBM Filenet P8 case contents sorted in chronological order
- All the case manager worksheets associated with the case
- Original policy information, physician information, and other material
- All other artifacts associated with the case
Riptide distributes this packet to the relevant parties at multiple geographic locations. For tracking and security, each package can have a unique watermark. Delivery methods for Riptide are comprehensive, and include print, fax, email, PDFs on CD/DVD, file folder locations, mobile and ePresentment distribution. With Riptide, each individual and team receives everything they need promptly and securely, and in a consolidated and organized format.
Summary
With the combination of CrawfordTech Riptide and IBM’s Case Manager, the insurance company is now able to automate and manage claims processing process while reducing errors and manual processes, resulting in improved customer service and reduced administrative costs.
