Page 37 - The Insurance Times October 2025
P. 37
Iterative Nature of Optimization: How are some companies achieving
Claims Processing in Health Insurance by nature is complex. this?
The primary reason for this complexity is the process that
involves digitization, number of line items to be reviewed in Some insurers have started to enjoy substantial savings and
a great ROI and are reducing overpayments and saving
hospital bills, complex medical terminologies, and handling
fraud. money every day. In India, a few health insurers save an
average of Rs. 4,000 per claim and enjoy an ROI of more
The first pass with a new solutions reveals the most obvious than 10X.
opportunities. Deeper, more nuanced efficiencies are typi-
cally identified through ongoing analysis and experience with The main ingredient to achieve this is by using a Data + AI
the new system. What seems optimal on paper might need approach to solving this problem. For an AI solution to make
adjustments based on real-world claims volume and com- meaningful impact it is important to solve the business prob-
plexity. lem and the underlying data problem as well.
The Blueprint for Lasting Efficiency: Digitisation of bills and other hospital documents can be
tricky. Its always challenging to ensure accuracy of the digi-
Most solutions will help reduce claims processing time by
tized output. Accuracy validation of data requires tools and
half and increase Tariff coverage by more than 60%. How-
ever, this does not imply reduction of human capital by the solutions to check various aspects of the data.
same number. To achieve this, companies will need consis-
tent Monitoring and Process Tweaking. It is important to acknowledge that in this whole approach,
data resides in the center around which all other solutions
The key to unlocking sustained operational efficiency lies in revolve. Hence it is imperative that companies understand
a commitment to an iterative cycle of monitoring, analysis, data quality is sacrosanct.
and refinement. This is where technology truly "makes the
invisible, visible". The need for a human-in-the-loop to validate and remediate
digitization is critical. It serves as a great way to validate
Consistent Monitoring with Technology: Modern data and ensure quality for upstream applications to con-
claims processing technologies provide dashboards, analytics, sume. Without human involvement, we risk the authentic-
and reporting capabilities that offer unprecedented insight ity of the data and thus reduced trust.
into every stage of the claims lifecycle. Companies must
leverage these tools to: Track Key Performance Indicators Over a period of time patterns and clarity start to emerge
(KPIs) in real-time (e.g., claim processing time, error rates, on cost reductions. This helps in making bold and informed
first-pass resolution rates, specific task durations). decisions on cost reductions after achieving the optimiza-
tion at satisfactory levels.
Zscore has been helping companies automate claims pro-
cessing and also identify patterns and trends that highlight Consistently monitoring performance and courageously
emerging issues or areas for improvement. Segment data tweaking processes based on data-driven insights is the true
to understand variations in efficiency across different claim path to making the invisible visible and achieving sustain-
types, teams, or individual processors. able operational efficiency in claims processing.
New Online Course Launched : Operational Risk Management
In an increasingly complex and fast-paced business environment, Operational Risksranging from process failures to
cyber threats and human errorscan significantly impact organizational performance and reputation.
SmartOnlineCourse.com, in collaboration with the Risk Management Association of India, introduces a comprehen-
sive 10-hour self-paced eLearning course on Operational Risk Management. This course is designed to help profes-
sionals understand, assess, and manage operational risks using global best practices, frameworks, and case studies.
Enroll Today : www.smartonlinecourse.com
Phone/Whatsapp : 8232083010 Email info@smartonlinecourse.org
34 October 2025 The Insurance Times
