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INSURANCE

Automation and Expertise Plug the Leaks in Medical Claims Costs

The Challenge

Medical benefits associated with workers’ compensation claims have escalated dramatically, more than tripling since 2003. For one global insurance carrier, excessive or unnecessary treatment associated with these claims resulted in medical claims leakage of a staggering 7% to 9% annually.

The company needed a strategic solution as traditional cost containment strategies, such as bill review, utilization review and nurse case management, were failing to address the leakage. The company partnered with Cognizant to find a solution.

Our Approach

We helped the insurer implement Cognizant Optima MedWise™, a customizable treatment plan engine for automating claim processing, and combined it with trained clinical services staff to review claims requiring intervention. 

This “medical necessity review as a service” capability enables the establishment of injury-specific treatment plans. It also validates clinical activities against those plans, automatically reviews every claim and routes exceptions to trained registered nurses for review.

Routing Reviews to Clinical Experts Optimizes Claims Handling

Integrating medical necessity review into the carrier’s claims process helps facilitate medical care for injured workers, achieve better outcomes and reduce medical costs without increasing claims allocated to loss adjustment expenses.

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$508 million

in excessive or unnecessary claims identified in three years

~$192 million

in savings since going live

40%

of medical bills auto-adjudicated

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