EXL's AI-Powered Claims as a Service for Absence Claims

The Challenge: Group and Voluntary Benefits Carriers dedicate significant human resources to the administration of low margin/ high volume short term disability and leave claims, i.e. Absence Management Services:

• A complex maze of federal, state and municipal regulations coupled with corporate paid leave policies have made absence claims servicing labor intensive
• Additionally, claims processing is highly disjointed, it needs information from multiple parties including the Employer, Employee and Physician
• Highly manual and disjointed processes have produced a poor customer experience for the claimant (employee)

EXL Solution: Claimants (employees) expect their claims journey to be effortless, they want to stay informed and most importantly they want to know quickly if their claim was approved. Claimants expect:

1. Easy claims submission at a time and place of their choice
2. Short wait times for claims decision
3. A single point of contact for disability and absence claims
4. 24x7 live access

While the EXL service is focused on improving the claimant (employee experience), EXL can help insurance carriers reduce 40-50% OPEX in the immediate to medium term. EXL brings together their leading Employee Benefits talent and best of breed platforms further augmented by automation to deliver highest value at the lowest risk to carriers. Their flexible deal structure offers committed productivity gains, variable pricing models and gain sharing for advanced analytics transformation.

EXL’s Claims Payment as a Service offering helps clients deploy new operating models that significantly reduce OPEX while improving claimant experience. The offering addresses the key components of the operating model i.e. people, process, technology and metrics.

People:

• In the immediate-term, drive value by sourcing all roles other than customer facing roles
• Rebadge customer facing and select SME roles
• Revisit multiple roles within claims function e.g. telephonic claim intake by nurses for a differentiated claimant experience
• Align claim teams by book of business
• Staff for customer service, low complexity back office and high complexity claim adjudication and clinician skills
• Additionally, deploy employment law counsels to support American with Disabilities Act claims and compliance with new leave legislations e.g. First Families Coronavirus Response Act

Process:

• Maintain a single point of contact for the claimant for disability and absence claims – end to end claim ownership.

Intake and Eligibility:

• Deploy self-service automation EXL’s Intelligent Virtual Assistant to make claims intake low touch/ effortless experience
• Intake telephonic claims through nurses
• Institute an AI-powered automation for fast/ rapid claims, e.g. simple maternity
• Automate eligibility decisions for all claims through a combination of employer file feeds and validation of claim, policy coverage, employer special handling data

Core case handling:

• Automate claims review processes to support experienced claim specialists
  • Data and analytics driven next best recommendation from analysis of:
  • reason for leave
  • ICD 9/10 codes
  • last working day
  • leave duration
  • attending physician statement
  • employer file feed
  • coverage information, and
  • special handling instructions

Initial Decision:

• Automate fast/ rapid and routine claims e.g. simple surgeries
• Data and analytics driven claims duration determination for most frequent claim reasons
• Deploy experienced claims specialists supported by clinical staff for complex claim

Ongoing Claims Management:

• Continue the claims specialist to maintain single point of contact
• Leverage data to uncover claims propensity to transition from short term to long term disability
• Refocus efforts to proactively manage complex, improve return to work date

Technology:

• EXL is technology platform agnostic and has developed a suite of digital assets for automating the claim process. Additionally, they can bring partners for best of breed technology platforms.
• EXL’s Intelligent Virtual Billing Assistant – NLP/ AI driven self-service automation for claims intake
• EXL’s Intelligent Content Extraction algorithm – NLP/ AI smart content extraction from unstructured documents to review and auto adjudicate fast/ rapid and routine claims
• EXL’s Claims Duration analytics – data and analytics models predicting accurately claims duration
• EXL’s Return to Work analytics - data and analytics models to uncover claims ripe for clinical intervention for improving return to work dates

• Improved customer experience
  • Customized journeys by Claimant personas
  • Single point of contact for the Claimant
  • Shortened customer wait time
  • Proactive outreach
• Low touch/ straight through processing leveraging EXL’s digital assets
• Maintain and continuously improve key metrics
  • Eligibility Notice sent within 24 hours
  • Claims adjudicated within 3 business days
  • Improved CSAT scores
• 40% to 50% reduction in operating expense