Medical Audit
Globally, medical analytics of paid out claims are the largest component that gets fed into the
sourcing and underwriting policies. This analysis also forms the part of subsequent year claims
benchmarks with clear quantified reduction targets on payouts based on current misses.
For this to be possible, a thorough medical audit is mandatory. Decisions in approx 50% of
logged in claims are based on technical (medical) inputs/ insights (as shown below)
Claims audit in insurance is largely a Process Audit. There is negligible medical audit being
performed. If audit findings are meant to percolate in process enhancements, this is a clear gap
that needs to be plugged.
Following figures pertaining to three years of data w.r.t. policies sold and claims presented
reveals rear about 100% rise in claims every year (most companies agree to this rise in claims)
| FY | Policies sold | % increase | Claims logged | % increase | Total payout | % increase |
|---|---|---|---|---|---|---|
| 2006-2007 | 79,22,274 | - | 13,139 | - | 155.46 Cr | - |
| 2007-2008 | 1,32,61,558 | 67% | 25,558 | 95% | 316.22 Cr | 103% |
| 2008-2009 | 1,50,10,710 | 13% | 46,525 | 82% | 633.12 Cr | 100% |
With 633 Cr INR worth of claims settled in 2008-2009, approximately 317 Cr INR
worth of claims are settled with verification of medical data.
What? How? When? of Medical Audit
- Audit is proposed as follows
a.initial sample, reflecting total mass - 10% of settled claim cases
b. going ahead (ongoing audit) - 5% of cases - Triggers built into the system for analytics based audit selection
a. value b. medical profile mis-match
c. cases beyond (very close to) TAT, to name a few - Medical Opinion Scoring
a. objective segregation in red, amber, green
- based on action triggered
- based on medical cause of death - Audit results help establish medical trends for future business
a.based on geography
b.based on profession
c.suspected collusion
d.based on policy terms/ forms
INCHES proposes not only to audit companies individually to increase the sanctity of the medical opinions and thereby strengthen the sourcing-underwriting-claims cycle, but also help in creating industry benchmarks through robust analytics that will help each member company peg and enhance its internal strengths.
