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June 2011

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Business Innovation Powered By Technology

CAT Response: Surviving The Claims Spike p.4 Cutting Claims Costs With Predictive Modeling p.6 Esurance Builds Trust With Transparent Claims p.8 Narragansett Bay Accelerates Claims p.10 Fraud Prevention Best Practices p.16 4 Claims Areas Ripe for Innovation p.19

The Claims Advantage


Insurance companies finally are looking at claims from the policyholders point of view, moving to improve the customer experience and gain a strategic advantage. p.11

Table of Contents p.2

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June 2011

COVER STORY

11
4 UPDATE Processing Disaster Carriers are tapping mobile and other technologies to speed their responses to a spike in claims following recent catastrophes.
Predicting Claims Success Predictive analytics can help insurers segment claims and lower processing costs, according to a Deloitte report.

Profiting From Claims Distinction


Insurance carriers increasingly are adopting technologies to improve the claims experience for policyholders and distinguish themsleves via exceptional customer service. VIRTUAL ROUNDTABLE 16 Preventing Claims Fraud Our experts weigh in on the best practices insurers can employ to prevent claims fraud. INDUSTRY VOICE 19 Claims Innovation Carriers should focus on four key areas of innovation to improve the claims experience, says Accentures Michael Costonis. This is the third of five all-digital issues that Insurance & Technology will produce in 2011.
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8 ONE ON ONE Transparent Claims By including the customer in the claims process, Esurance is building credibility, says Joe Laurentino, the carriers VP of material damage. 10 CASE STUDY
Accelerating the Claims Pipeline A new web-based claims system from BlueWave helps NBIC gain big-company advantages while remaining agile.

FROM THE EDITOR EDITORIAL AND BUSINESS CONTACTS

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Mobile should
mean more to you than just a customer app

Weathering the Storms

he world may not have come to an end May 21, but Mother Nature definitely has been having her way with the world. If there ever was a time for insurance companies to demonstrate state-of-the-art claims proficiency, it has been the past few months. As I write this column Im watching coverage of the horrific tornadoes that devastated Joplin, Mo., and parts of Minnesota and Kansas. The storms followed recent destructive tornadoes in Alabama and elsewhere that, in turn, followed floods and blizzards in other U.S. regions this past winter that, of course, followed the awful earthquake and tsunami in Japan. As of mid-May the U.S. had experienced 1,076 tornadoes (compared to an average of 1,200 per year), with 875 occurring in April 2011 alone, reports the NOAAs National Weather Service. According to the Insurance Information Institute, severe thunderstorms and accompanying tornadoes in the past three years have caused about $30 billion of the total $97.8 billion in insured losses in the U.S. between 1990 and 2009. With hurricane season just around the corner, the scrutiny on the insurance industry will remain intense. There couldnt be a better time for carriers to embrace the new generation of technology capabilities related to mobility, geographic intelligence and analytics, along with next-generation claims management systems. And many of the reports in this special digital issue on claims best practices illustrate how a growing number of companies are expanding their focus beyond claims efficiency to the claims experience. Inevitably there will be questions about the fairness of insurers claims administration, along with the usual accusations of greed and callousness. Perhaps as companies become as proficient at managing the claims experience as they are with the transaction itself, they will avoid the worst of the reputational storm battering. Katherine Burger, Editorial Director
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June 2011

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2011 Hyland Software, Inc. All rights reserved. 2011 Software, ft reserved.

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Update

CAT MANAGEMENT

Carriers have used a variety of emerging technologies to respond quickly to the spike in claims resulting from recent catastrophes, including the tornados that ripped across North Carolina and Alabama in April.

the losses from the tornadoes in the U.S. could top $5 billion. SHARE Tom Larsen, SVP of product architecture for the Oakland-based CAT modeler, says that while these events occurred close together, there isnt evidence of a trend, and theres no way of knowing for sure what could be coming down the road. We spend a lot of time trying to answer the question: Is this observed increase in the claims climate related, or is it something else? he explains. It seems to be a cluster of events, but at this point it looks like we were relatively inactive beforehand, and it seems to be coincidence, Larsen continues. We havent found any really conclusive evidence that there is more... an increase [in catastrophes]. Catastrophe events, of course, mean an increase in insurance claims. According to the Insurance Information Institute (III), about 700,000 claims have been filed in the southern United States for the storms dating April 22 to April 28. But when disaster strikes, carriers must respond to the sudden spike in distressed customers as quickly as possible with empathy for their losses. Several carriers spoke with Insurance & Technology about the ways they used technology to efficiently and accurately process claims in the wake of the recent disasters.

in

When Disaster Strikes


A STRING OF DISASTERS HAS PUT INSURERS CAT MANAGEMENT CAPABILITIES TO THE TEST. CARRIERS ARE TAPPING MOBILE AND OTHER TECHNOLOGIES TO STREAMLINE CLAIMS RESOLUTION.
By Nathan Golia @NateG_InsTech

I
4

t hasnt been an easy 2011 for insurance companies, with the earthquake and tsunami in Japan headlining a catastrophe-heavy beginning of the year that also included a major winter storm and several devastating tornadoes in the United States. Risk modeler EQECAT says the losses in Japan could reach $39 billion, and
June 2011

Chartis Japan: iPhones, iPads Bring Order to Chaos The March 11 Tohuku earthquake devastated Japan. In addition to the tremors, a resulting tsunami washed away coastal cities and triggered a nuclear emergency that remains tenuous months later. According to the III, nearly 800,000 insurance claims have been filed so far in the country. In This Issue To help expedite claims processing, New Yorkbased Chartis (more than $30 billion in 2009 Bringing Transparency to Claims p.8 direct written premium) ordered 100 Apple iPad A Modern Core Supports Growth p.10 2s and iPhones for its Japanese field force immeProfiting From Claims Distinction p.11 diately following the disaster. The company had Fraud Prevention Best Practices p.16 received 31,000 claims as of April, Jose A. 4 Key Areas of Claims Innovation p.19 Hernandez, president and CEO of Chartis Far East Holdings, told the Wall Street Journal. Table of Contents p.2 Chartis loaded the Apple mobile devices with
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Update

CAT MANAGEMENT

Smart Attack, an app from Tokyo-based Going.com. The use of these devices simplifies the claims adjustment process and enhances efficiency, allowing for a shorter timeframe for payment of insurance claims to the policyholder, Fumiyasu Sato, a spokesman for Chartis Japan unit, writes in an email. With the Smart Attack app, adjusters can conduct assessments and create reporting documents while consulting with specialists in the head office, sending the necessary photos and videos to the head office in real time. This capability mitigated the need to bring forms to the damage sites, Sato adds. Chartis also took advantage of the front-facing cameras equipped on latest-generation iPads and iPhones. That enables us to use Skype for communication, he explains. Adjusters can conduct the assessment while consulting with specialists in the head office. North Carolina Farm Bureau: Trial by Fire North Carolina Farm Bureau (NCFB; $1.6 billion in assets) had just finished deploying a new version of CSCs Exceed claims system when the first wave of U.S. tornadoes slammed North Carolina during a mid-April weekend. The company had been training offices in Exceeds use from east to west in the state, figuring that the first major catastrophe it would face was likely to be a coastal event, relates Pam Hiovich, operations division manager for the Raleigh-based company. But the tornadoes hit the central and western parts of the state. The joke was on us, she says. It was impacting the offices we were training. NCFB didnt have an enterprise claims system previously, Hiovich says, adding that the carriers goals in implementing Exceed were to unite disparate claims systems, take paper out of its process and make it easier for adjusters In This Issue to be more productive on the go by enabling mobile access to the system via the web. Bringing Transparency to Claims p.8 But Exceed also features workflow functionalA Modern Core Supports Growth p.10 ity that aided the company in responding to the Profiting From Claims Distinction p.11 tornadoes. NCFB developed a claims mass reasFraud Prevention Best Practices p.16 signment page, Hiovich explains: When its coun4 Key Areas of Claims Innovation p.19 ty-level offices picked up the loss notices, they were able to sort losses by a number of criteria, Table of Contents p.2 such as location or severity. Then they were able
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June 2011

to drag and drop multiple claims into one adjusters queue. Nearly 7,000 claims came in to NCFB during the first three weeks of April. Information on all of these was more readily available to the many stakeholders in the organization, including agents and county offices, than it had been in the past, Hiovich insists. Agents now got notified of claims in real time, she says. Once the loss notice is submitted, we generate an email with the loss notice in a PDF.

USAA: Mobile Capabilities Pay Off Another wave of tornadoes struck Alabama April 27, devastating parts of the cities of Tuscaloosa and Birmingham. With so many homes and banks damaged, many customers took advantage of the mobile services that San Antoniobased USAA (more than $18 billion in net worth) provided by both its insurance and banking businesses, according to Tom Larsen, EQECAT company spokeswoman Nicole Alley. The difference in this storm is that were really starting to see how smartphones and the tech capabilities can help people cope after a crisis like that, Alley says. We noticed an uptick in people filing claims on their phones and using mobile banking. USAA recorded a 21 percent increase in mobile claims in April compared to January, Alley reports. The numbers that you get arent going to be in the tens of thousands, but they will show the trending pattern upward, she says. SHARE Farmers: Location Information Cuts Response Time Paul Quinn, AVP of claims communications for Los Angeles-based Farmers Insurance ($16 billion in gross premium income), says the Alabama tornadoes are the worst catastrophe event hes seen in 34 years in the business. A couple of things make this very unique, he comments. One tornado went from Tuscaloosa to Birmingham and never left the ground. Others that hit northern Alabama earlier that day spread the organization pretty far and wide. With so many policyholders to reach, Farmers decided to test a new tech-

We havent found any really conclusive evidence that there is an increase [in catastrophes].

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Update
nique to establish the location of losses so that it could best allocate its resources, according to Quinn. Concurrent with a helicopter flyover the usual way the company plotted loss locations Farmers procured a Google Earth image taken after the tornado and laid it over its plotted policy locations. The Google Earth data was just as good as the flyover data, Quinn says, so the carrier is entering into negotiations to get the data automatically and mitigate the need for flyovers at future CAT sites. We paid for it [in Alabama] because it was immediately valuable, he explains. Technology is getting us to the point where our customers can be out of town, have a loss and they dont even have to wait until they get home to turn in a claim. I sulting and advisory firm says in a recent report. Predictive modeling has become table stakes on the underwriting side because its a revenue-generating area, Deloitte principal Pil Chung tells Insurance & Technology. Now carriers are starting to look at the other side of the equation, which is cost management. Its important for insurers to identify potentially complex claims early because 20 percent of claims drive 80 percent Having these of losses, Deloitte reports. If an event such as a catastrophe tools ... helps occurs, Chung notes, analytics can help establish which claims you balance can be automated and determine how limited resources can your workload be most effectively deployed to the toughest cases. better. When you start to realize that the claims are on the rise in total, having models that can detect certain things good Pil Chung, Deloitte or bad you can try to automate those. When youre expecting more claims coming through the door, having these tools to help you helps you balance your workload better, Chung explains. Traditionally, you wait until the claim develops to see a pattern, he adds. But now, with predictive models, were getting that insight way up front. Ongoing Analysis Deloitte contends that effective use of predictive modeling early in the claims process can drive a 4 percent to 8 perIn This Issue cent reduction in annual losses and expenses, a 3 percent to 7 percent improvement in nurseBringing Transparency to Claims p.8 managed claims, a 5 percent to 10 percent A Modern Core Supports Growth p.10 improvement in claims managed by a fraud Profiting From Claims Distinction p.11 investigator, and a 20 percent to 25 percent Fraud Prevention Best Practices p.16 redeployment of supervisory resources. But its 4 Key Areas of Claims Innovation p.19 not as simple as a once-and-done approach, Chung says predictive models should be Table of Contents p.2 applied early and often through the life cycle
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PREDICTIVE MODELING

A (Predictive) Model Approach


BY USING PREDICTIVE ANALYTICS EARLY AND OFTEN IN THE CLAIMS PROCESS, INSURERS CAN IDENTIFY POTENTIALLY SEVERE OR FRAUDULENT CLAIMS AND ADJUST RESOURCE ALLOCATION ACCORDINGLY, DELOITTE SAYS.
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By Nathan Golia @NateG_InsTech

dvances in predictive analytics can help insurance companies lower claims costs, according to a recent report from Deloitte, Driving Operational Excellence in Claims Management. By analyzing data acquired at first notice of loss, carriers can segment claims by severity, the New York-based con-

June 2011

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Update

PREDICTIVE MODELING

4 Steps to Operational Excellence


In addition to incorporating predictive analytics into the claims process, Deloitte recommends four other areas in which insurers can drive operational excellence: 1. A supplier management strategy can help insurers contain costs, while enhancing the customer and agent experience. 2. A performance-based approach to legal cost management helps carriers develop a streamlined, reusable process for firm selection, case governance and traditional cost management. (By combining this with predictive modeling, cases can be assigned to the most appropriate resources.) 3. Developing an overarching approach to technology enablement ensures that infrastructure effectively supports the firms initiatives to enhance operations. 4. Insurers that adopt advanced fraud detection tools and techniques that identify claims with a high propensity for fraud can reduce losses and gain a reputation in the industry for being hard on fraud.

Change is good. Change is hard. We can help.


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of a claim as new data is introduced, he asserts. Fortunately, predictive analytics can be implemented without a teardown of legacy claims systems, according to Chung, who says insurers also should look to add other capabilities that are likewise compatible, such In This Issue as business process management. We have to get away from the notion of Bringing Transparency to Claims p.8 having to gut and replace everything. The tools A Modern Core Supports Growth p.10 allow you to work around those legacy sysProfiting From Claims Distinction p.11 tems, he says. You now have tools and rules Fraud Prevention Best Practices p.16 engines that sit on top allowing you to do rout4 Key Areas of Claims Innovation p.19 ing of work and monitoring of work much easier. Its one of the biggest advancements that Table of Contents p.2 we see claims organizations implement. I
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June 2011

CHANGE IS GOOD.

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2011 Guidewire Software, Inc. All rights reserved. Guidewire, Guidewire Software, Guidewire ClaimCenter, Guidewire PolicyCenter, Guidewire BillingCenter, Guidewire InsuranceSuite, Deliver Insurance Your Way, and the Guidewire logo are trademarks or registered trademarks of Guidewire Software, Inc. in the United States and/or other countries.

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OneOnOne

JOE LAURENTINO, ESURANCE

A Reassuring View
Esurance launched its RepairView program in 2007, allowing customers who use the San Francisco-based online insurers preferred auto repair shops to see pictures of their cars while theyre being repaired. Joe Laurentino, VP of material damage for Esurance ($209 million in Q1 2011 premium), recently spoke with I&T associate editor Nathan Golia (@NateG_InsTech) about how the program has evolved from its browser-only beginnings into a multichannel service. [Ed note: This interview was conducted before Allstate agreed to acquire Esurance for $1 billion. The deal is expected to be finalized in the fall.]

Joe Laurentino, VP, Esurance

RepairView has been around for almost five years. What was the driver behind the services initial introduction? Laurentino: The general public had never been very trusting of the insurance industry, and that stemmed from the fact that there wasnt very much transparency. And theres also a perception that the repair industry is not as trustworthy as some of the other services we buy in the marketplace today. Transparency leads to credibility. By including the customer in the process we began to build that credibility.

In This Issue
CAT Management Put to the Test p.4 Predicting Claims Success p.6 Profiting From Claims Distinction p.11 Fraud Prevention Best Practices p.16 4 Key Areas of Claims Innovation p.19 Table of Contents p.2

Optimize Claims Processing with Pega Claims for Insurance


Pega Claims is transforming the way leading insurers align claims strategy with execution. Pega frees insurers to focus on the claims handling, risk mitigation and retention strategies that drive true competitive differentiation. Insurers can optimize claims operations by combining intelligent and adaptive claims processes with industryleading case management functionality. The result: innovative and agile claims management that accelerates ROI and drives dramatic business improvement.

You recently brought the program to Facebook and mobile devices. How has that affected its use? Laurentino: Our Facebook integration allows customers to share photos of ongoing repairs with their entire networks, and it has skyrocketed the use of RepairView. We track views per claim and IP addresses before, we

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JOE LAURENTINO, ESURANCE

averaged about three IPs and eight to nine views per repair; since the program launched on Facebook, the amount of IP addresses went to 20 and views per claim to 60-plus. How does the extra exposure benefit Esurance? Laurentino: The claims experience is really something we see as a big point of differentiating for us. In car insurance, policyholders really only interact with the carrier when they have a claim. Customers wanted to hear, How are you going to make the claim experience positive for us? How do you track the programs impact on service? Laurentino: We used to measure customer service at the conclusion of a claim, but RepairView lets us actively react to the issues within a claim because we can survey people through the life of the claim. Very early on, we had sub-satisfactory reactions we worked on narrowing that gap and taking action during the course of the claim. Now our quality team has a view into the repairs, and we can keep constant communication with our customers How have the repair shops adjusted to having cameras in their workplaces? Was it difficult to get them to sign on for the idea? Laurentino: In the beginning, it really was difficult. Any time you take a business that operates as it has for many years, change is very difficult. But as we began to force this into the system, the benefits to the repairer were amazing. In This Issue The body shops began to see that they were not being interrupted with phone calls from customers. CAT Management Put to the Test p.4 Instead, customers were leaving messages in their Predicting Claims Success p.6 inbox. So they were able to interact when their Profiting From Claims Distinction p.11 minds were right instead of having to immediately Fraud Prevention Best Practices p.16 react to a phone call. And the shops dont see us 4 Key Areas of Claims Innovation p.19 as often, and they seem to be more receptive to Table of Contents p.2 letting us monitor from a distance than someone walking through their doors suddenly. I
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June 2011

Transparency leads to credibility.

Improved Efciency | Enhanced Customer Service Improved Enhanced Customer Service Consistent Consistent Claims Handling | Faster Claims Resolution Faster

www.insurancetech.com

info@FINEOS.com | www.FINEOS.com info@FINEOS.com www.FINEOS.com


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CaseStudy

CORE TRANSFORMATION

With technology driving subrogation, our recoveries are up.


Bob Khosropur, Narragansett Bay Insurance Co. we gained commitment at the highest levels, he says. By October 2009 a two-phase deployment began, starting with the BlueWave solution and followed by the integration with Exigen. For infrastructure, NBIC invested in separate private clouds for production and disaster recovery. Then NBICs team, drawn from its IT staff of 12 as well as members of the business claims team, worked with BlueWave using an iterative development and testing approach. In June 2010 the first phase hit a speed bump: Microsoft (Redmond, Wash.) SQL performance and Oracle (Redwood Shores, Calif.) licensing issues prevented PipelineClaims from operating on NBICs private cloud. As a workaround, BlueWave offered to host us at their colocation until these issues were resolved, recalls Anselmo. PipelineClaims went live in August 2010, and the fully integrated systems were rolled out less than three months later. With our legacy systems, it took at least a week to become comfortable with the claims systems, Khosropur observes. Today, new internal and external staff hit the ground running such as during storm spikes when additional examiner resources are needed and are fully functional on the [BlueWave] claims technology in half a day. Plus, as a webenabled system, PipelineClaims is accessible from anywhere, even on an [Apple] iPad. Additionally, workflow and task automation allows NBIC to settle claims a week earlier, on average, according to Khosropur. And by designing its system to consider every claim Snapshot as having subrogation potential by default, NBICs Company: Narragansett Bay recoveries have soared. To override, an adjuster Insurance Co. (Pawtucket, R.I.; must provide a reason, explains Khosropur. With $60 million in premium). technology driving subrogation, our recoveries Lines of Business: Homeowners. are up 2 percent to 3 percent. Vendor/Technology: BlueWave Next, NBIC plans to add external services from Technologies (Honolulu) ISO and others, Anselmo says. Our new enterPipelineClaims claims solution. prise architecture allows us to dramatically Challenge: Modernize claims systems to enable growth. reduce costs, provide value, offer flexibility and grow the business, he adds. I
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Accelerating Claims
NARRAGANSETT BAYS MOVE TO BLUEWAVE TECHNOLOGIES WEBBASED PIPELINECLAIMS SYSTEM HAS HELPED THE INSURER SPEED CLAIMS RESOLUTION, BOOST RECOVERIES AND PREPARE FOR GROWTH.
By Anne Rawland Gabriel

s new leadership strived in 2008 to resurrect Narragansett Bay Insurance Co. (NBIC) from the ashes of its predecessor, Pawtucket Mutual Insurance, legacy technologies impeded success, reports Mike Anselmo, NBICs CIO. None of our existing systems could keep up with our growth goals, he says. We wanted new systems that provided big-company advantages while staying agile and nimble. As NBIC researched core vendors in early 2009, two policy admin systems rose to the top. But neither had claims systems we considered ready for prime time, recalls Bob Khosropur, chief claims officer for Pawtucket, R.I.-based NBIC. But research also introduced NBIC ($60 million in premium income) to BlueWave Technologies (Honolulu) PipelineClaims. Because we intended to operate as a lean company by drawing on third parties for services, such as first notice of loss, BlueWaves interface was attractive because it required virtually no training, explains Khosropur. Plus, In This Issue BlueWaves SOA [service-oriented architecture] and web-enabled platform gave us confidence CAT Management Put to the Test p.4 that it could scale up efficiently. Predicting Claims Success p.6 Wary about integration between BlueWave Profiting From Claims Distinction p.11 and its policy admin vendor at the time, SaaSFraud Prevention Best Practices p.16 based Exigen Insurance Solutions (San 4 Key Areas of Claims Innovation p.19 Francisco), NBIC brought the CEOs of both comTable of Contents p.2 panies together over the 2009 Labor Day weekend, according to Anselmo. From that meeting,
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June 2011

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CoverStory

CREATING COMPETITIVE ADVANTAGE

Seizing the Claims Advantage


By Anthony ODonnell @AnthODonnell

Insurers are deploying maturing workforce management, advanced analytics and flexible core technologies, often in new combinations, to achieve competitive distinction in their claims service and operational effectiveness.

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laims is a natural area to plumb for opportunities for increased operational efficiency, and P&C insurers continue to explore those opportunities. But they also are eyeing claims as a way to differentiate themselves through improved customer service and operational effectiveness enabled by maturing technology. Carriers have adopted configurable core claims systems and business process management technologies, and have begun to embed analytics at various stages of the claims process to support automation, decision support In This Issue and more sophisticated fraud detection. In addition, insurers have shifted their focus from technology CAT Management Put to the Test p.4 improvements intended to enhance the adjuster Predicting Claims Success p.6 experience to enhancements intended to improve Bringing Transparency to Claims p.8 the claimant experience. In claims, just as Fraud Prevention Best Practices p.16 in other areas of the insurance value 4 Key Areas of Claims Innovation p.19 chain, insurers are striving to meet Table of Contents p.2 the anytime/anywhere demands of

consumers who expect instantaneous service delivered via their preferred channels, including their mobile platform of choice and both self-service options and proactive outreach from their insurers. Historically a great deal of technology investment was about adjuster experience, customer retention and loss adjustment expense management, notes John Mullen, VP and North American leader for P&C insurance solutions at Capgemini Financial Services (New York). Now thats just the ticket to the dance. Our call to action today is for insurers to leverage claims as part of their brand platform, not just for customer retention but for acquisition. Insurers have by no means wrung all of the inefficiencies out of their claims organizations, Mullen acknowledges, but they need to redirect efforts to achieve improvements in the effectiveness of claims SHARE decision making and indemnity management rather than simply tightening loss adjustment expense, he asserts. Such improvements require more targeted and refined data strategies, applications and analysis, Mullen emphasizes. Carriers must be able to marry operational data with financial, underwriting and actuarial data to become more predictive in their analysis of what drives total claim outcome, Mullen says. They need more precise foresight into a host of factors, such as developing loss trends, fraud, or even the best repair suppliers or external lawyers. more... These advances need to be pursued as part of an

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CoverStory
7 Claims Best Practices

CREATING COMPETITIVE ADVANTAGE

overall improvement in the value proposition of the brand, Mullen stresses. Its not about reducing indemnity, he says. 1. Focus on the customer experience. We have a commitment its about 2. Implement rules-driven processes to the most efficient fulfillment of the improve workflow. underwriting commitment. 3. Deploy predictive analytics to identify claim severity and gain transparency Maturing technologies provide a variety into staff activity and claim inventory. of ways for insurers to stand out among 4. Extend mobility to the point of claim their peers by providing better service to for both adjuster and customer (enable claimants in their time of need, suggests self-service). Donald Light, a San Francisco-based senior 5. Modernize core systems. analyst with Celent. Many claimants will 6. Adopt enterprise content managebe in emotional distress, and one way to ment capabilities. make the experience better is to give them 7. Implement data warehousing techpersonal support, he says. nology with reporting capabilities. Customers are reassured by knowing that there are individuals at the insurer who are there for them and will reach out proactively as the situation demands, Light elaborates. The claim handler or adjuster has to rely on technology to see the whole process and where the claimant is in that process, and whether he or she might need to push a certain part of the process along, he notes. Light sees the potential for improvements in supply chain management whereby adjusters and even customers can have real-time In This Issue communications about status or costs with contractors. Workflow technology and desktop anaCAT Management Put to the Test p.4 lytics both can smooth the flow of file handling Predicting Claims Success p.6 and enable managers to evaluate the performance Bringing Transparency to Claims p.8 of claims handlers and claims offices, he advises. Fraud Prevention Best Practices p.16 These and other opportunities are informing 4 Key Areas of Claims Innovation p.19 transformational initiatives across the insurance Table of Contents p.2 industry. On the following pages are three carrier case studies that exemplify the trend. >>
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June 2011

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2011 StoneRiver, Inc. Apple and iPad are registered trademarks of Apple Inc.

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CoverStory

CREATING COMPETITIVE ADVANTAGE

We can ... take the guesswork out of daily operations.


Mark Lingren, VSP incoming claim volume has traditionally been a very manual process executed at the unit level and relying on individual experience, he continues. With the Verint tools, instead of every supervisor having to decide every day what staff will handle what tasks, we can automate assignment and take the guesswork out of daily operations. I

Workforce Management: VSP Automates to Meet Demands

s the nations largest vision benefits provider, VSP receives more than 16.5 million claims a year. To handle that volume, the Sacramento, Calif.-based insurer developed its own claims system in the early 2000s, but it retained a variety of manual processes and relied on experience and intuition to ensure the smooth and timely handling of claims, acknowledges Mark Lingren, VSPs claims operations manager. As a result, maintaining demanding service levels for example, the company commits to paying 95 percent of its claims within five days often was achieved at the cost of adding overtime at periods of peak activity, according to Lingren. Seeking to modernize this aspect of its claims organization, in July 2010 VSP began working with Melville, N.Y.-based Verint to streamline processes, align and automate the assignment of claims to processors based on skill set and availability, and measure service levels intraday so the carrier could more effectively make adjustments to workloads to meet service deadlines without incurring unnecessary overtime, Lingren reports. VSP officially kicked off the transformation project in September 2010, working with Verint to observe processes, determine best practices, and establish future forecasting models using the vendors Impact 360 Desktop Process In This Issue Analytics (DPA) and Workforce Optimization (WFO) tools to improve the flow and efficiency of claims CAT Management Put to the Test p.4 processing, according to Lingren. Were making Predicting Claims Success p.6 a transformational change into a more automated Bringing Transparency to Claims p.8 environment for managing our business when it Fraud Prevention Best Practices p.16 comes to managing staff, claims volume and 4 Key Areas of Claims Innovation p.19 inventory, as well as implementing a way of projecting what the future will look like, Lingren says. Table of Contents p.2 Our way of assigning staff and forecasting our
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June 2011

Analytics: Accident Fund Builds Through Teamwork

ansing, Mich.-based Accident Funds (about $3 billion in assets) newly appointed chief claims officer, Patrick Walsh, is tasked with consolidating the capabilities of the workers compensation insurers individual operating units while preserving their unique qualities, he reports. In addition to consolidating claims platforms across Accident Funds operating companies, Walsh sees analytics as a key component of a strategy that puts the right tools in the hands of employees with the goal of achieving better results for customers. The claim experience is the closest thing to a tangible product that we have, but the industry has made the mistake of thinking of claims as a cost center rather than a differentiator, Walsh says. Many carriers focus on loss expense, which represents between 7 and 14 cents on the dollar. Thoughtful investment in claims handling and service can improve the total financial picture of claims, which covers between 60 and 70 cents on the dollar. Accident Fund has formed a kind of analytics faculty of actuarial and data-focused professionals who have experience in workers compensation and healthcare to build propietary analytics capabilities, according to Walsh. Within that body, one team is focused on predictive modeling for claims and other areas, including underwriting. A second
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CoverStory

CREATING COMPETITIVE ADVANTAGE

The claim experience is the closest thing to a tangible product that we have.
Patrick Walsh, Accident Fund

team is focused on things that we know to be true, and taking advantage of that data to drive decisions, Walsh adds. Walsh says his analytics team is focusing on the 15 percent of claims that make up 75 percent of total spend. Within that segment are subsets of claims that are particularly expensive and therefore important to target for special processing. We want to get very creative in handling those subsets to minimize exposure and get people back to work as soon as possible and to a higher quality of life, Walsh comments. Analytics will be a major part of identifying what will be the more complex and severe claims that we formerly had to identify through experience alone. I

Launch.

Core Modernization: CNA Upgrades in Search of the Truth

T
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im Shea acknowledges that hes making a big statement, but the VP of worldwide claims strategy at CNA ($9.2 billion in 2010 revenue) insists that the commercial P&C carriers ambition is to have the best claims organization in the industry, without exception. Toward that goal, he reports, Chicago-based CNA has embarked on a multiyear journey at the center of which is the upgrade of its core claims system. We have set out a seven-year process to examine all of our organizational processes to make sure that were doing the right thing, sequencing the stages of each claim, serving our policyholder and agent customers, as well as our internal partners, Shea relates. Thats
June 2011

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Intelligence in Action

TM

CoverStory

CREATING COMPETITIVE ADVANTAGE

who we serve every day giving the information they need to make more nimble decisions on product introduction and add to both top- and bottom-line growth of the organization. The carrier is now in its fourth year of the initiative, during which it has teamed with Capgemini to develop its transformation road map, reevaluate and reengineer processes to maximize efficiency and efficacy and achieve standardization across the enterprise, and perform an upgrade of its Guidewire (San Mateo, Calif.) ClaimCenter system from version 3.0 to 5.0. The carrier also established a new service center in Littleton, We have set out ... Colo., to complement an existing facility in Reading, Pa. CNA began the core system upgrade in January 2010 to to examine all of move toward its vision of a single claims platform across all our organizational lines of business. According to Shea, the upgrade will enable processes to the carrier to more tightly integrate claims with key company make sure that processes, standardize claims processes across the enterprise, were doing capture and analyze claims data more effectively, and docu- the right thing. Tim Shea, CNA ment claims with greater speed and flexibility. ClaimCenter version 5.0 went live at CNA in November 2010 for commercial lines and will be extended to specialty lines and the companys U.K. and Canada operations in the near future, Shea says. The Guidewire application will be the single central repository for CNAs enterprise claims operations going forward, he explains, and in June the carrier will deploy the first generation of operational metrics that measIn This Issue ure the time and efficacy of claims functions. CAT Management Put to the Test p.4 This will be accessible to many more people Predicting Claims Success p.6 than in the past, when we have had to gather Bringing Transparency to Claims p.8 the information in different ways through differFraud Prevention Best Practices p.16 ent channels, notes Becky Nelson, VP of IT. It 4 Key Areas of Claims Innovation p.19 will be propagated throughout the organization so that more people will be able to access this Table of Contents p.2 single source of the truth. I
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June 2011

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VirtualRoundtable

CLAIMS FRAUD PREVENTION

Constant Threat
By Peggy Bresnick Kendler

laims fraud is a perpetual and daunting challenge for insurance companies. While carriers have at their disposal increasingly sophisticated tools, including advanced analytics, to detect and prevent fraud, organized crime rings often seem to be able to stay one step ahead of investigators. What are the top threats insurers face, and which technologies can they leverage in the fight against claims fraud?

Keeping Crime From Paying


There are few laws that stop fraud, and nearly nonexistent enforcement and prosecution. In many states insurance carriers are on their own in the fight against insurance fraud states dont have the resources to combat insurance fraud when there are so many priorities competing for the law In This Issue enforcement dollar. Referrals to the National CAT Management Put to the Test p.4 Insurance Crime Bureau Bob Cline Bringing Transparency to Claims p.8 (NICB) and law enforcement National SIU Claims A Modern Core Supports Growth p.10 Manager, Esurance around the country are up (San Francisco) Profiting From Claims Distinction p.11 significantly. Insurance car4 Key Areas of Claims Innovation p.19 riers pour money into special investigation units Table of Contents p.2 (SIUs) and into technology that makes these units more effective. In addition, highly skilled investi16
June 2011

gators can uncover bogus claims quickly and also confirm meritorious claims, leading to timely and accurate settlements. As a result, suspect claims are quickly referred to the NICB and law enforcement for further investigation. In fact, the NICB recently reported a 119 percent rise in suspicious accidents being reported in Florida since 2008; that means insurance carriers have significantly improved their abilities to recognize and report fraud. Technology plays an increasing role in reducing fraud, as companies bring to market more sophisticated tools to help track fraudulent claims. With the growth of digital recordkeeping, data mining analytics technology has become much more robust and allows us to quickly sift through petabytes of data that would have taken an investigator days or even weeks to go through by hand. We are using specialized software that sifts through claims and flags those that could potentially be fraudulent. But at the end of the day, technology is just another tool we have at our disposal ultimately, it is the detective work of our investigators that gets the job done. The No. 1 threat to preventing claims fraud is the migratory nature and sophistication of organized fraud rings. These rings are moving into areas with little to no enforcement and can fly under the radar of insurance carrier analytics. And more and more criminal groups are getting into the business of insurance fraud because of the low risk and high reward. I

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Fraud By the Numbers


The basic fraud scams really havent changed. While there are only estimates of total fraud, there is a consensus that the greatest amount of fraud is in medical claims. The good news is that a lot of readily available analytic tools are quite effective at spotting medical fraud. The biggest area on the P&C side is still private passenger auto fraud, particularly staged accidents. As always there is a big divide between organized fraud and individual fraud in terms of how it is done and how it can be detected. Incidents of individual fraud have risen recently because of the tough economic times. The insurance industry has made significant progress in fight-

Donald Light Senior Analyst, Celent (Boston)

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VirtualRoundtable
In This Issue

CLAIMS FRAUD PREVENTION

ing fraud, implementing a variety of analytic tools. The business case for deploying these tools is usually pretty strong. Furthermore, as CAT Management Put to the Test p.4 an insurer, if your key competitors have impleBringing Transparency to Claims p.8 mented fraud packages and you havent, you A Modern Core Supports Growth p.10 can start to feel a bit exposed. Profiting From Claims Distinction p.11 The traditional red flag best practice meth4 Key Areas of Claims Innovation p.19 ods for fraud detection do not provide very Table of Contents p.2 good metrics on how effective your detection and countermeasures are. This results in a kind of competitive arms race between insurers with modern fraud mitigation tools and those without. This arms race has made it easier for fraud solution providers to build interest in their technologies. There are three legs on the fraud-mitigation technology stool: Data, analytic tools that can be applied against the data, and scoring/decision-making solutions. All three must be in use in some form for fraud mitigation to be effective. Data sets might be internal or external. Analytic tools may be general statistical packages or focused fraud solutions, including newer ones incorporating pattern recognition and text mining. Scoring and decision making is usually done by business rule management solutions. One additional technology worth noting is case management, which provides a means for organizing data and processes within SIUs. I

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The goal of technology in claims fraud is to automate the fraud-detection process and highlight suspicious claims as quickly and effectively as possible, while also enabling genuine claims to be settled quickly. Technology cannot replace the judgment
17
June 2011

Richard Colven President, Detica (Guildford, Surrey, U.K.)

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Copyright 2011 Epicor Software Corporation or a subsidiary or afliate thereof. All rights reserved.

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VirtualRoundtable

CLAIMS FRAUD PREVENTION

of the investigator, but new techniques can help make sense of the huge amounts of data involved and apply advanced analytical techniques to increase hit rates and productivity. Today, insurers use business rules, data matching and data mining to uncover claims fraud. But as fraud becomes more organized, it also becomes harder to detect effectively using these techniques alone. Organized fraudsters develop an Technology understanding of the systems used by insurers cannot and know how to evade basic detection and fraud- replace the judgment prevention checks. Rules are effective when you know what you are of the looking for but cannot discover new modus operandi investigator. or multiple people operating in collusion. Data mining helps tune rules and discover what you dont know but can only act on one customer at a time. Data-matching techniques help to provide single views but assume the customer is an honest individual who will provide consistent identification information such as names, addresses, dates of birth and Social Security numbers. Fraudsters cover their tracks and bypass data-matching processes. Insurers need a fraud-detection solution that is designed to prevent organized collusive fraud. Social Network Analysis (SNA), which attempts to identify the relationships among members of a network, is proving to be the most effective weapon against this In This Issue threat. SNA enables insurers to understand the full extent of the relationships among their cusCAT Management Put to the Test p.4 tomers and claimants, and typically doubles Bringing Transparency to Claims p.8 fraud-detection rates. By joining data together A Modern Core Supports Growth p.10 into social networks prior to employing busiProfiting From Claims Distinction p.11 ness rules, data mining and data matching 4 Key Areas of Claims Innovation p.19 techniques, fraud can be detected at higher levels, preventing attempts by criminals to Table of Contents p.2 evade the system. I
18
June 2011

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Industry Voice

RETHINKING CLAIMS PROCESSING

Protecting the Crown Jewels


CLAIMS PROCESSING OFFERS INSURERS A MAJOR OPPORTUNITY TO CREATE COMPETITIVE ADVANTAGE. BUT CARRIERS NEED TO THINK OF CLAIMS NOT AS A COST, BUT AS A WAY TO PROVIDE DISTINCTIVE CUSTOMER SERVICE, SAYS ACCENTURES MICHAEL COSTONIS.

ith images of Britains royal wedding fresh in their memory, insurers can be forgiven for thinking of claims as the crown jewels of the business. While claims payment is insurers single largest expenditure, it also is their most significant point of vulnerability in terms of customer service. Indeed, according to Accenture research, insurance customers placed speed of problem resolution (that is, fast claims service) as their top criterion for choosing an insurance provider, ahead of price transparency and the availability of products that suit their individual needs. We have seen over and over again that consumers drive innovation in insurance by demanding speed, access and collaboration. Consumers have become sophisticated users of information technology, and this sophistication In This Issue has raised their expectations as to how insurers CAT Management Put to the Test p.4 deal with claims processing and payment. Predicting Claims Success p.6 Claims also represent a high-potential opportunity for insurers to increase operating efficiency. Bringing Transparency to Claims p.8 Many (although not all) insurers have undertaken Profiting From Claims Distinction p.11 basic process improvements, such as making sure Fraud Prevention Best Practices p.16 that difficult or high-exposure claims are routed Table of Contents p.2 immediately to the adjusters with the expertise necessary to handle them. While additional
June 2011

opportunities remain, insurers seeking high performance will need to embrace technology, viewing it not as a support function but as a key enabler of competitive advantage. With improved customer service and greater operating efficiency both hinging on development and maintenance of a high-value-added claims function, insurers should be focusing management resources and capital budgets on four key areas of claims innovation: 1. Mobility. The extraordinarily rapid growth of mobile devices and applications provides insurers with a tremendous opportunity to improve service while lowering fixed costs. Customers with mobile devices have essentially invested in a new sales and service channel, one that they can use at times and places of their choosing. Insurers should accelerate their efforts to push information and service capabilities onto mobile devices. Theoretically, customers should be able to report incidents, obtain updates on claims status, forward photographs and other documentation for investigations, and perform a host of other claims-related activities on mobile platforms. Insurers need to close the gap between what customers know is possible and what they are currently delivering. 2. Collaboration.High-performance claims processing is all about expertise getting the right information to the right people on a timely basis, and providing those people with the resources they need, including data and access to external experts. As is the case with mobile applications, many insurers have taken first steps, such as integrating claims adjuster calendars with those of outside service providers. The most significant improvements, however, are realized when everyone involved in the claims SHARE process has immediate access to all information necessary to service the claim. 3. Analytics. Effective analytics play multiple roles in improving claims processing efficiency and lowering costs. Business rules can help insurers make sound underwriting decisions often heading off difficult and/or costly claims before they occur by analyzing applicant information and comparing this data with the insurers experience with similar applicants. Analytics can help extend the insurers reach to tap into industry, law enforcement and other databases to help prevent so-called application fraud. more... And, when a claim is filed, analytics can perform high-speed sorting oper-

Customers identify fast claims service as their top criterion for choosing an insurance provider.

in

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Industry Voice

RETHINKING CLAIMS PROCESSING

Randall Day, Head of Claims Solutions, FINEOS Corporation

ations, forwarding routine claims for rapid payment while sending more problematic claims to appropriate 4 Key Areas of investigative units (see page 6 for related article). For Claims Innovation claims under investigation, analytics can help identify 1. Mobility. potential fraud by searching vast quantities of data, 2. Collaboration. including links between claims data and known fraud3. Analytics. sters, as well as links formed through communications 4. Core Systems on social media networks, customer call centers and Modernization. elsewhere (see related Virtual Roundtable, page 16). 4. Core Systems Modernization. Insurers are again making the investments necessary to modernize and integrate core claims systems, which often struggle to deal with the barriers imposed by legacy systems. However, insurers need to build a high degree of flexibility into such systems both to deal with the impact of emerging technologies and to minimize the cost of future upgrades. A modular approach can help ensure that changes made to deal with developments in one area do not cause new problems elsewhere in the system. Maintaining the Personal Touch While these elements are vitally important to an effective claims strategy, the claims workforce ultimately determines the success or failure of the claims operation. The industry must address the fact that many of its top claims professionals are nearing retirement age. Claims processing offers insurers numerous opportunities to establish and protect competitive advantage. To achieve consistently In This Issue high performance in claims, however, insurers CAT Management Put to the Test p.4 need to look at these crown jewels in a new Predicting Claims Success p.6 light, thinking of them not so much as a cost but as a way to provide distinctive customer service Bringing Transparency to Claims p.8 in the one area that really matters to insurance Profiting From Claims Distinction p.11 customers: getting claims processed and paid. I Fraud Prevention Best Practices p.16

Using Technology in the Fight Against Fraud

nsurance fraud is not a new problem. But in a period characterized by a global recession, the fraud problem historically worsens, resulting in increased nancial burdens on both insurers and policyholders. The National Insurance Crime Bureau (NICB) reported that in the rst quarter of 2009, 19,967 questionable claims (QCs) were referred from its member insurance companies. And the trend has worsened, with 24,497 referrals received in the rst quarter of 2011 a 23 percent increase. Given the growth in volume of questionable claims, the increasing sophistication of fraudsters, and investigators heavy workloads, insurers are turning to technology as a key in their fraud-ghting efforts, including: Business rules that alert claims handlers to factors that may indicate a questionable claim. For instance, a higher than normal percentage of workers compensation claims reported on a Monday may be the result of a non work-related accident. Predictive analytics, which can be a powerful tool for ghting fraud by tying together multiple strands of data to develop a fraud score. Industry databases that can be utilized to identify individuals with a history of claims activity.

Voice Stress Analysis (VSA) technology also has gained more interest recently. Link analysis is a particularly valuable tool in the ght against organized fraud rings as it is designed to document relationships between multiple parties that participate in a claim. Technology alone isnt a panacea in the ght against fraud. But in combination with social awareness, insurer and law enforcement efforts, and the effectiveness of organizations such as the NICB in the U.S. and The Insurance Fraud Bureau in the U.K., there is reason to hope that progress can be made.

To nd out more about FINEOS, please visit www.FINEOS.com.

Table of Contents p.2

Michael A. Costonis is managing director of Accentures global claims practice.


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June 2011

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