The world of health insurance claims is not simple to deal with. It has multiple stakeholders, complex user journeys, changing regulations, with an evolving technology landscape and changing customer habits that only increase the number of challenges.
The Candela Labs Digital Health Claims Solution focuses on understanding and solving the challenges the customer, the partners and the insurers face, by reimagining each and every user journey.
Based on the user journeys, challenges and key findings, we have designed a health claims solution that is state-of-the-art, scalable, manageable and testable.
Increasing customer satisfaction and experience
Faster claim assessment / processing TAT
Decreasing fraudulent cases
Lower claims leakage
Lower operational and IT costs
Outsource fewer products to TPAs
Simple and easy to use digital channels that allow for a single seamless conversation. It allows customers to initiate and track claims across multiple channels, be it mobile applications, website or a chatbot. It provides ease and simplicity with pre-filled forms and the Document Vault, which saves historical medical records.
Each channel provides value added services, such as emergency services, notification set-up, multiple validation options (via policy number, national ID, phone number, etc.), connecting to external apps to book medicines or a cab, etc.
While the omnichannel engagement channel is primarily for the insured, there also is an abridged version of the engagement platform for loved-ones to file a claim or raise an emergency service.
The Policy Simplifier eases anxiety and frustration for a claimant prior to hospitalisation, by providing essential details of their policy coverage (policy limit, room rent, etc.), empanelled hospitals, benefits and exclusions in simple and easy to understand language.
The OSAW is a single source of information designed to enhance productivity for the case assessor by standardising information that needs to be assessed by consolidating historical information, demographic details, limits, and exceptions.
The OSAW helps an assessor to make decisions easily by providing the following information in one worksheet – details of existing policy; details of past claims; diagnosis and procedure details; ICD 10 codes; exclusions and mismatch based on best-option basis; non-disclosure checks; etc.
The worksheet has built-in smarts to auto calculate final approved amounts, detect deviations in pricing, or detect possible fraud. The worksheet also allows the assessor to automate notifications to all relevant parties as well as request for information or review.
Built to be customised, the Fraud Detection and Exception Handling Engine uses Machine Learning and client data to create customised fraud and exception rules. It comes built in with standard industry learning but has the smarts to be client and geography specific based on the local healthcare nuances.
Get standardised as well as intelligent process reports that provide actionable business insights. These reports are either Process Reports or Real-time Intelligent Reports.
Process Reports: Touch time report; Process level SLA reports; Productivity report; STP count report; etc.
Intelligent Report: Reserve limit report; Usability report; Fraud analysis report; Cost breakdown report; etc.
These are presented in attractive and easy to understand dashboards for faster decision making. The intelligent dashboards also come with pre-built fraud detection engine.