- • Long Claims Adjudication and Submission.
- • Erroneous, Unnecessary Payouts leading to increase in Net Payment.
- • Lack of identification of outliers billing for Provider/Doctor/Patient.
The claims process is a critical moment of truth for any insurer. It's an opportunity to demonstrate your commitment to your policyholders and build trust by delivering swift and accurate payouts.
However, traditional claims processing is fraught with challenges.
It entails:
Manual tasks and complex procedures can lead to lengthy processing times, causing delays in payouts and frustrating claimants.
Manual processing requires significant human resources and administrative overhead, increasing operational costs.
Manual data entry and subjective assessments can lead to errors and inconsistencies in claims processing.
Detecting fraudulent claims can be challenging with manual methods, leading to unnecessary payouts and financial losses.
Delays, errors, and lack of transparency can negatively impact the customer experience, potentially damaging the insurer's reputation.
If you continue with traditional claims processing, you're inadvertently fueling a cycle of inefficiency, rising costs, and customer dissatisfaction. Each manual step, from data entry to verification to payment processing, introduces the potential for errors, delays, and inconsistencies. This impacts your bottom line and erodes the trust and loyalty you've worked hard to build with your policyholders.
Existing Ancestral Claims Submission and Claims Adjudication Process
Provider submits medical preapprovals or claims.
Policy Adjudication is performed by the adjudicator, manually or via a rule-based system.
Manual Adjudication is performed along with data entry checks
Provider submits medical preapprovals or claims.
Client/Policyholder submits life claims.
Policy Adjudication is performed by the adjudicator, manually or via a rule-based system.
Medical Adjudication is performed for medical claims. Claims authenticity is checked for medical or life claims
Manual Adjudication is performed along with data entry checks
Client/Policyholder submits life claims.
Medical Adjudication is performed for medical claims. Claims authenticity is checked for medical or life claims
90% Reduction in process time. Hence faster claims submission and adjudication. 10-11% Reduction in the Net Payout due to lack of identification of unnecessary billings.
File a claim (as a policyholder or member)
Submit Proofs
Our Al runs intense algorithms to check claim authenticity
If all seems good our Al will make the payment in seconds
Otherwise, our Al allocates your case to Human Intelligence to settle your claims ASAP
Artificial intelligence is transforming the way insurers handle claims, enabling a level of speed, accuracy, and personalization that was previously unimaginable. By automating routine tasks, streamlining workflows, and providing intelligent insights, AI empowers claims adjusters to work smarter, not harder, and deliver exceptional service to policyholders.
The introduction of AI into insurance claims processing has been met with a mix of excitement and apprehension. While many recognize the potential for increased efficiency and accuracy, some fear that AI will replace human jobs and lead to a loss of the personal touch that's so crucial in the claims process.
There's a concern that algorithms, however sophisticated, can't truly understand the nuances of individual circumstances or provide the empathy that claimants need during a difficult time.
However, this fear is often based on misconceptions about AI's role in claims management. The truth is that AI is not meant to replace human adjusters; it's meant to empower them. By automating routine tasks and providing data-driven insights, AI frees up adjusters to focus on the human aspects of claims: providing support, building relationships, and making nuanced decisions that require empathy and understanding.
In fact, embracing AI in claims processing is a move in the right direction for both insurers and policyholders.
For insurers, it means increased efficiency, reduced costs, and improved accuracy. For policyholders, it means faster payouts, greater transparency, and a more personalized experience.
By moving past the fear of AI and embracing its potential, the life and health insurance industry can tap into an entirely new era of customer-centric AI claims management.
Curious about how it all works?
Let's dive in.
MedML's AI-powered claims solution is designed to transform the way health and life insurers handle claims, enabling faster payouts, reducing costs, and enhancing customer satisfaction.
Here's a step-by-step look at how our platform works:
Our streamlined, AI-driven approach to claims processing offers significant advantages over traditional methods:
Our goal is to empower insurers to provide exceptional service to their policyholders while optimizing their operations. By embracing the power of AI, you can transform the claims process from a source of frustration into a moment of truth that strengthens customer relationships and drives business growth.
Here are three scenarios that illustrate how MedML can be used in the health and life insurance industry:
Let's say a major life insurance company receives a claim following the death of a policyholder. Traditionally, processing this claim would involve a lengthy process of verifying the death certificate, reviewing policy details, and manually assessing the claim's validity. This could take days or even weeks, causing delays in payment and adding to the beneficiary's distress.
With MedML, the process is streamlined and expedited. The beneficiary submits the claim and supporting documents through the MedML platform. MedML instantly verifies the information, checks for any red flags, and if all is in order, automatically approves and processes the claim payment within seconds.
This swift and efficient process provides much-needed financial support to the beneficiary during a difficult time, while also reducing the administrative burden on the insurer.
A health insurer experiences a significant increase in claims during peak flu season. Their claims adjusters are overwhelmed with the volume of paperwork, leading to delays in processing and frustrated customers.
MedML steps in to alleviate the pressure. The platform automatically processes a large volume of straightforward claims, e.g., those for doctor's visits and prescription medications. AI verifies policy details, checks for inconsistencies, and approves legitimate claims for instant payment.
This frees up human adjusters to focus on more complex cases, e.g., hospitalizations or claims requiring further investigation. The result is faster processing times, reduced costs, and improved customer satisfaction.
A health insurer notices a suspicious pattern of billing from a particular provider. Manually investigating this pattern would be time-consuming and resource-intensive.
MedML's AI-powered fraud detection capabilities come to the rescue. The platform analyzes the provider's billing history, comparing it against industry benchmarks and historical data. AI identifies anomalies and red flags that suggest potential fraudulent activity, e.g., unusually high billing amounts or excessive claims for certain procedures.
This information is then passed on to the insurer's special investigations unit for further review, helping to prevent fraudulent payouts and protect the insurer's financial integrity.
The insurance industry is on the cusp of a significant transformation, and AI is leading the charge. By embracing AI for insurance claims, health and life insurers can unlock new levels of efficiency, accuracy, and customer satisfaction.
Whether you're looking for group insurance claims solutions or a comprehensive AI insurance claims processing platform, MedML has the tools you need to succeed in the digital age.
Contact us today to schedule a demo and discover how our AI claims management solutions can revolutionize your claims operations.