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Claims Quality Assurance & Cost Management Service Approach

Claims Quality Assurance & Cost Management Service

Claims Quality Assurance & Cost Management Service Approach

Weighted Case Count Model (monthly benchmarking)

This is an internal staffing report used to manage claim examiner workloads and production. In our industry, it is critical that workloads be adequately maintained to ensure quality claims handling practices.

Often, workloads are not properly managed or tracked and can cause claim file “leakage”, further defined as missed cost mitigation opportunity.

This staffing model not only measures claim counts but also assigns specific incremental weight variables to each claim file, ensuring a more precise measure of each examiner’s respective claims inventory. Aside from the claims count, the weighted case variables include the number of claims in litigation, subrogation and reinsurance reporting status. The total incurred exposure and claim type (lost time v. medical only) are additional factors. This staffing model is considered to be cutting-edge and is not prevalent in the claims risk management industry. Numerous clients and reinsurers of our programs have been impressed by this staffing model.

Again, it should be clarified this is not a claims count but a true, weighted case variable reflective of the degree of difficulty each examiner’s desk is carrying at any given time. This is tracked and measured on a monthly basis to ensure optimal claim results and quality service.

Closing Ratio (monthly benchmarking)

The closing ratio is a tool used for tracking examiner production and is defined as the number of claims closed divided by the number of claims received. This calculation is built into our WTD case count staffing model. 

Often times in our industry, examiners will lack aggressive claims handling and diary control practices, which translates into poor closing opportunities. This can cause a claims inventory to be over inflated and parlay into an out-of-control desk. The result is the unnecessary prolonged life of a claim file that can equate to more unnecessary claims expense. The objective is to achieve a 100% closing ratio. This allows for us to ensure all claim examiner inventories are stable at all times and is another benchmarking tool that we use on a monthly basis.

Diary Tracking (monthly benchmarking)

Claims diaries are a means by which our claims examiners track and handle their claims. It is imperative that claims examiners maintain a current diary at all times.

This translates into proactive claims handling practices, solid control and successful early resolution, all which minimizes the opportunity for claim leakage. A supervisory diary is carried on every adjuster file to ensure proactive claim management is always in order. Monthly diary reports are generated on an as-needed basis. Any diary more than 10 days outstanding is considered late. A diary set more than 60 days by an adjuster warrants supervisory approval.

Litigation Handling Practices (subject to internal audits)

On any litigated claim, defense counsel is required to provide us with a preliminary case assessment within 30 to 45 days of any assignment.

A substantive update is required every 60 to 90 thereafter, with a pre-trial report within 60 days of any final hearing/trial. Interim reports outlining significant developments between the required structural reporting period are also part of our protocol. Counsel is required to keep us posted on all fact development with recommended defense strategy on an on-going basis. A budget is also required (with continuous updated case assessments) as the case progresses. Most of our programs are member owned; therefore, we require counsel to copy in the member on all significant case assessments. A copy of our general litigation handling guidelines can be supplied upon request.

Reserve Philosophy (subject to internal audits)

Our practice is to post a reserve reflective of the reasonable worst case exposure based on all information known at that time.

This should be addressed in solid fashion within 45 to 60 days of any new claim. Reserve “stair stepping” is completely discouraged. Any new significant information warranting a reserve adjustment is to take place on the examiner’s scheduled diary, and no later than 60 days of becoming aware of same.  A reserve worksheet is required on all serious exposure cases.

Internal Audits (quarterly review - adjuster audits)

Audits are completed on a quarterly basis. Highlights of the audit exercise are:  24-hour contact standard, proactive diary practices, early file investigation and recognition of key issues, timely reserving, proactive claims risk management, proper litigation and medical case management, action plan assessment, and early file resolution.

Staffing (Sr. Claims Examiners 10+ years experience)

Proper claims staff experience is a must to ensure a successful claims service program. We are happy to provide current resumes of all related program claim examiners.

Our clients are regularly updated on any staffing change with follow-up credentials of any new examiner we are looking to introduce to the service team. The senior adjusting team currently in place carries a minimum of 10 years experience.

Dedicated Adjuster Client Assignments

We do not believe in an adjuster rotation service approach. At present, every client with IPMG has an adjuster dedicated to their program. This promotes more familiarity and continuity between the adjusters and their respective clients, which ultimately results in a higher level of service and trust.

State-of-the-Art Claims System

Based on our service reputation in the industry, our organization was approached by a reputable software developer to assist with the development of a new cutting-edge claims risk management system.

In the spirit of always looking for ways to bring added value to our clients, we have developed the following additional online technology service features:

  • Electronic claim submission
  • Direct report generation
  • Direct access to key program performance data
  • Direct access to other key claims data denoting the status of any given claim

Client Surveys

Continuing in the spirit of always looking to improve, IPMG issues random surveys to our clients.

While we are confident the aforementioned is and continues to elevate our service to another level, we feel it is necessary to obtain client feedback. We would view this process as a needs assessment. In short, we realize it is more important to ensure that we are delivering exactly what our clients need, as opposed to what we think they need. This survey process is always ongoing (annual) and serves as a “suggestion box” for IPMG; all in the spirit of helping us identify client needs and helping ensure we deliver the best service possible to our clients.

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