Technology and digitization are revamping businesses across the insurance industry
TPAs have traditionally relied on manual intervention to process claims, which was inefficient, inconsistent, and led to errors. However, the emergence of technology has made processing claims more organized. TPAs and InsureTech startups then started building and deploying Artificial Intelligence (AI), and Machine Learning (ML) based homegrown solutions to process claims efficiently.
While the industry is adapting to the newer ways with a tech-based framework, the InsurTech business is moving towards digitization that includes four elements:
- DigitizationofTariff–TPAs work with the network of hospitals and have their standard operating cost agreed with them. The availability of this information brings transparency to consumers about the rates and how much they will spend and ensures that there will be no surprise expenses to worry about.
- Digitization of Historical medical data – All claims evaluated and settled in the past from specific hospitals are included in historical data. After digitization, this data can assist customers in determining the actual cost of their hospitalization, whether through claim settlement or out-of-pocket.
- Digitizationofhospitalizationbillsanddischargesummaries–There is a good likelihood that the calculations used to determine the claim settlement value will be accurate if AI and ML technology is integrated into the digital forms of existing invoices and discharge summaries. India’s largest TPAs works on human touch for medical adjudication when determining whether or not a claim is permissible under the policy conditions and then use technical methods to ensure that consumers receive the claim amount they deserve.
Claim processing is all about understanding policy conditions and comprehending discharge summaries. In addition, a claim processor must determine which bill items are relevant to the medical condition and should be paid. There are hospital tariffs for each insurance, group, and TPA, which adds to the complexity.
Technology companies and TPAs work together to create components that can be integrated into the claim process. Some are simple digitization tools, while others are machine learning algorithms. But, of course, this success is contingent on the amount of data accessible and feedback going back to the machine for subsequent learning on removing false positives.
For insurers & TPA industry to put their focus on servicing customers digitally
Faster claims processing, lesser human intervention, the ability to evaluate and make data-driven choices, and improved customer experience are all advantages of automating fundamental operations. The technology employs workflows, rule-driven automation, interfaces, and data enrichment to automate processes and offer transparency to the system. In addition to the preceding, fraud detection engines can assist TPAs in detecting and preventing financial losses. In addition, TPAs also use auto-adjudication using Artificial Intelligence to examine and handle incoming claims.
Artificial Intelligence has also aided in improving service and information delivery modes. As more data is added to the systems, the system better understands what might happen in specific claim scenarios. As a result, customers can avoid being overcharged if they receive this information, and it can also help them stay in touch with us during the claim process. From calls and SMS formats to chatbots, Whatsapp, portals, and mobile applications, firms are now surpassing traditional ways of information transmission to customers and meeting the customers where they are present.
Healthcare, unlike any other regular product or service, cannot be marketed to a customer directly. To ensure customer engagement, players in this ecosystem try different channels and services. Whatsapp/Website BOTs and new healthcare products are some ways to stay connected to their customer base.
Deploying chatbots as well as investing in AI/ML to optimize customer servicing digitally
The way TPAs control the customer experience is changing. Previously, communication was limited to phone calls and emails; however, modern communication methods assist clients on the fly. WhatsApp & social media are quickly becoming some of the de facto channels for connecting with TPAs and staying in touch throughout the claims journey.
TPAs connect everyone in the healthcare ecosystem, allowing them to produce better results. TPAs have a customer-centric strategy to ensure that policy data and other critical information are available in digital format to protect policyholders, insurers, and providers. The information provided is secure and meets all security requirements. In addition, the electronic process streamlines the workflow between the insurer and the TPA.
When it comes to providers, technology makes it easier to submit paperless, cashless claims. In addition, the system defines the completeness of documents, eliminating the possibility of falsification and delays due to information shortfalls and allowing hospitals to receive payments faster.
For new business growth and being in the business, the adoption of new technologies should be the focus
Traditionally, the technology and operations departments of insurance businesses have functioned independently. However, the relationship between the two functions is shifting as insurers devote more money to technology while underinvesting operational processes. Incumbents anticipate that this transition would increase profitability and enable them to compete more effectively on the digital landscape, particularly with InsurTechs that operate through technology. Some insurers of all types utilize emerging technologies to serve their clients better. Moreover, these tools will profoundly change how insurers work, including automating some traditional, manual procedures.
Traditionally, insurance companies’ technology and operations teams have operated independently. Technology made the job of the operations personnel easier, but operations—underwriting, claims, and marketing—were the key drivers of corporate performance.
As insurers invest more in technology while underinvesting in operational operations, the relationship between the two functions is evolving. This change is expected to boost profitability and enable incumbents to compete more successfully in the digital ecosystem, particularly with technology-based InsurTechs. In reality, astute insurers of all types are leveraging new technologies to serve their customers better. These tools will significantly impact how insurers operate, including the automation of some human processes.
By better understanding policy conditions and giving them access to how their claims are processed, technology enhances transparency and data-driven decision-making for enterprises, insurers, brokers, and end customers. Every stakeholder in this ecosystem should attempt to push the envelope of technology a step further so that we can solve real-world problems together. For example, India’s largest TPA was the first to offer cashless OPD services and regularly educates its customers about benefit structures through blogs, digital marketing campaigns, and email contacts, among other methods. Furthermore, they made their technological platforms available to their staff as well. As a result, employees can handle their claims, keep track of their policy terms and conditions, and submit claim notifications to their TPA.
TPAs use automation to recognize outliers and the expected output of a data set. Human touch combined with technological advancements can improve the overall experience and lower the proportion of mistakes made during claims processing. InsureTech and HealthTech are expanding rapidly. Each development takes us closer to a better healthcare experience.
The article has been written by:
Himanshu Rastogi, Chief Technology Officer, Medi Assist
And Praveen Samariya, Senior Vice President & Head of Engineering, Medi Assist