There’s not a whole lot of attention paid to medical expenses reimbursed as a result of property/casualty claims … but that’s not to say there isn’t a reason to look into it. More than $50 billion is paid annually for medically related claims in the P&C sector, reports consulting firm Accenture, yet challenges in skill and scale prevent insurers from improving claims outcomes.

There are other reasons why P&C insurers are facing limitations with regard to medical claims processing, according to a research report released yesterday by Accenture that is designed to identify key issues related to the processing, adjustment and analysis of medical-related claims.

From lack of key performance indicators (KPIs) that set the stage for improvements, to difficulty in accessing medical information and then applying it to the injury/medical adjudication process, to the challenges associated with a lack of skills among adjusters, insurers are hard-pressed to fully optimize their medical claims processing. Still other challenges plague insurers, including the lack of standard, consistent rules to evaluate claims, and the difficulty of identifying complex and/or high-severity injury claims.

Of the 30 senior claims executives (head of claims or equivalent) in July and August 2009 at U.S. property/casualty insurers interviewed by Accenture as part of their research, only one in five carriers believe they are operating at an optimal level in terms of medical records processing, even though a majority of survey respondents say that improvements would have direct benefits for indemnity accuracy, recovery identification and capture, and fraud detection and prevention.

According to Accenture, analytics tools available to carriers today, including data mining and predictive modeling, coupled with the capabilities to effectively and accurately structure medical information, appear to be setting the stage for breakthroughs in injury and medical data management.

Still, medical records processing may be one of the more public—and inscrutable— challenges faced by both health insurers and P&C insurers, especially in light of the scramble to utilize electronic medical records under the Obama Administration’s push for stimulus funds to support improvements.

And, the technology is highly desired. According to Accenture’s report, 70% of respondents indicate that highly skilled claims resources spend more than 10% of their time on what may be categorized as “non-core activities” (i.e. organizing and interpreting medical information). Absence of medical context, missing documentation and difficulty in accessing medical information were the three most commonly cited challenges after illegible handwriting.

Insurers are investing in a variety of technologies to help adjusters adjudicate claims, notes the survey. Key areas for investment are document imaging/management; workflow; bill review; and valuation.

This article can also be found on InsuranceNetworking.com.

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