In our recent research report, Customer Experience: The Claim Handler’s Perspective, we asked health and dental insurance claims handlers about their daily challenges, factors delaying processing, and customer needs. 

We found that health and dental insurance claims involve unique challenges such as high levels of customer interaction, complex documentation, and lengthy approval processes. With the right technology, these challenges can be addressed, leading to more efficient operations, improved customer satisfaction, and a happier workforce.

The unique challenges of health and dental claims processing

Customer communication

Health and dental claims require extensive customer interaction. Our survey revealed that 61% of respondents find this tedious, involving complex scenarios and frequent follow-ups, which are time-consuming and frustrating.

Reviewing and processing claims documents

47% of respondents find document review and processing to be a major pain point. The diverse nature of health and dental incidents means handling various documents, from medical reports to treatment receipts. Ensuring the accuracy and authenticity of these documents is time-consuming.

Data entry and updates

44% of respondents expressed frustration with data entry. Managing extensive data associated with health and dental claims, including multiple touchpoints and varied documentation, can lead to errors and delays if done manually.

Factors contributing to delays in health and dental claims

Lengthy approval processes

30% of respondents cited lengthy approval processes as a major delay factor. The complexity of health and dental claims necessitates thorough reviews, leading to slower processing times.

Inadequate information from customers

23% highlighted inadequate information from customers as a significant delay factor. Gathering complete and accurate details can be challenging, especially in stressful health and dental situations.

Time spent on retrieving and reviewing documents

27% of respondents pointed to this as a delay factor. The manual effort involved in retrieving and reviewing diverse documentation significantly contributes to processing times.

Enhancing job satisfaction

More tools for data analysis and insights

55% of claims handlers believe better data analysis tools would greatly enhance their job satisfaction.

Fewer manual and repetitive tasks

39% want fewer manual tasks.

Improving customer satisfaction

Faster resolving of claims

38% of claims handlers say faster claim resolution is key to improving customer satisfaction.

Automating the claims process

26% see automation as a major improvement area. Implementing automated workflows reduces manual effort, resulting in quicker and more accurate outcomes.

Transparency in the claims process

23% of respondents noted that customers frequently request more transparency.

Why health and dental claims are suited for automated claims processing

Health and dental insurance claims come with unique challenges that make them particularly suited for automated processing. Automation can enhance efficiency, accuracy, and customer satisfaction by managing complex data and frequent customer interactions.

Health and dental claims involve a diverse range of documents and data points:

– Claims require the verification of multiple documents like medical reports, treatment receipts, and prescriptions.

– Claims handlers interact with customers, medical facilities, dental clinics, and pharmacies.

The benefits of automating health and dental claims processing

– Efficient data handling: Automated systems quickly scan, verify, and process large volumes of documents.

– Error reduction: Automating data entry and validation minimises the risk of human error.

– Reduce customer communication needs: Faster processing means fewer queries and detailed explanations.

– Clear information from the start: Automation ensures that any missing information is identified and communicated promptly.

– Streamlined workflows: Automated systems streamline approval workflows and track progress in real-time.

– Faster approvals: Automating routine checks and approvals reduces processing time.

– Fewer challenges in information gathering: Incomplete submissions can complicate communication and information gathering.

– Intelligent data extraction: AI can extract and interpret data from documents in various languages.

 How processes health and dental claims uses your claim handling philosophy to deliver the best possible outcome for both insurers and customers, achieving 98% accuracy often within seconds. This allows claims handlers to focus on complex claims that require a human touch and high levels of expertise.

1. Claim classification

The claim is initially classified to understand its nature. For example, in the case of a health or dental insurance claim, it might involve incidents such as medical treatments, surgeries, dental procedures, or prescription medications. This step sets the stage for detailed investigation and flags any missing information that may be crucial for processing.

2. Cause analysis

The cause of the claim is thoroughly analysed. For instance, if the claim is for a medical or dental treatment, the analysis will determine whether the treatment was for an illness, an accident, or another health issue. This helps in establishing liability and understanding the context of the incident.

3. Assessment

The severity of the incident is assessed. This includes evaluating the required treatments for medical and dental claims, the extent of the health issue, and the value of medical expenses. This step ensures that the claim is accurately quantified and that necessary interventions are identified.

4. Inclusion checking

The claim is then checked for coverage under the customer’s specific health or dental insurance policy. This involves verifying policy details to ensure the incident is covered. Verification can be conducted through a digital policy administration system or by using natural language processing (NLP) to interpret the terms directly from the policy document.

5. Exclusion verification

Potential exclusions are reviewed to ascertain if the claim falls under any policy exclusions. This step is crucial to ensure that claims are not wrongfully processed or denied. Like inclusion checking, this can be achieved via a digital system or through an NLP review of the policy document.

6. Special terms

Any special terms related to the policy are examined. These might include unique inclusions or exclusions that are not typically covered in the standard policy language and are often stored in an unstructured format. This examination ensures all conditions and clauses of the policy are considered and can also be facilitated through digital systems or NLP.

7. Settlement calculation

Finally, the appropriate payment is calculated based on the outcomes of the above steps. Advanced deep learning algorithms can be employed to align the settlement with the insurer’s claims handling philosophy, ensuring accuracy and fairness in the compensation provided. This technology allows claims handlers to allocate more time to complex cases that require detailed attention and expert judgement.

Conclusion streamlines health and dental claims processing, ensuring quick, accurate, and fair settlements. By automating routine tasks, allows claims handlers to focus on more intricate aspects of claims, improving efficiency and customer satisfaction. 

Read about the top challenges for pet and travel claims, and how to solve them too.

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