Livestream

Brad: Every business faces inflation—whether it is salary inflation, increases in the cost of goods purchased or inflation in service rates. To try to maintain or reduce administration fees to customers, we have had to invest heavily in technology. This has been a combination of customer-facing technology for self-service and back-shop technologies to improve and automate our business processes. The result has been no increases to our overall administration fee structure for the past five years.

Great-West Life offers electronic claims services for our group insurance customers and plan members. Plan members are reimbursed more quickly, minimizing out-of-pocket expenses. In 2012, nearly 75% of the 28 million health and dental claims filed with Great-West Life were filed electronically through one of its e-claims services.

Marilee: Technology has really enabled self-service at the plan member and plan administrator levels. There are many examples of this: making real-time changes to eligibility, straight-through submission and processing of claims, and integrating with payroll feeds. Technology has also enabled better detection and prevention of benefits fraud, benefits abuse and reporting on trends in an employee population or plan’s experience that employers can use to take informed action—for example, to introduce wellness and prevention programs or plan design changes.

Carl: New technology certainly helps us in being more accurate when processing claims. The drugs adjudicated are much more complex now because not only do we need to verify the prescribed drug, but we also need to look at the patient’s condition to see if we are going to reimburse. Technology has allowed us to do that electronically.

At the same time, technology has helped the insured and the plan sponsors in getting rapid information on their claim. Our members on disability now receive an email to inform them of the status of their claim. When the decision is taken, [the member] will receive another email. Better service, and no need to call us.

New technology has also allowed us to offer more flexibility in the plan designs. It is especially useful for clients that want to control the costs of their drug plan.

Jean-François: It’s playing a major role on both counts. Secure websites and online services give plan administrators and plan members more autonomy and easy access to forms, which increase the efficiency of the claims and billing processes. On our side, they reduce transaction fees and take some of the pressure off of our client service centres. They also allow us to give plan administrators and plan members more information and updates on products and services much more quickly and efficiently. Online training means our trainers don’t have to go out on the road, and plan administrators can take the training at their own pace, when it’s most convenient for them.

We’re now starting to introduce mobile applications to expand our client services. We recently introduced a mobile application as part of our travel insurance service offer. Plan members can register their personal health information—allergies or prescription medications, for example—which is then accessible in several languages if they have an accident or fall ill while travelling. It also gives them information about what to do if they lose their passport, a list of emergency contacts and the location of the nearest healthcare facilities in the area they are visiting.

Chris: New technology has resulted in convenience to plan members (e.g., online claims submission, provider submission) and plan sponsors (e.g., online access to better reporting).

With a few exceptions, we have not seen a direct link between efficiencies from new technology and lower costs to plan sponsors. Those exceptions are generally in the realm of customized prescription drug program design and targeted, customized direct-to-employee communication.

Brian: It is easier to comment on how technology has improved service to plan sponsors. Technology has improved immensely in the last several years in the areas of reporting, plan administration and employee self-service. The group insurance business used to be paper-driven, with many manual interventions. This has changed considerably in recent years, and, without a doubt, some aspects of the overall service levels to plan sponsors and plan members have improved. This is not to suggest that there are still no service issues within the industry. A heavy reliance on technology can create a different set of issues if appropriate oversight and/or audit processes are not in place to ensure the technology is doing what it should. And with technology comes the need to streamline processes and create rules—rules that sometimes do not make sense given the unique client situation.

With respect to costs, it is more difficult to assess the impact of technology. We have certainly seen some downward movement in costs in recent years; however, it is difficult to say with absolute certainty that technology has been the driver versus the overall competitive environment. Recently, we have seen some insurers offer variable pricing for claims settlement expenses based on whether claims are submitted online versus on a reimbursement basis. So I think it is safe to say that technology has been a factor in reducing an insurer’s cost of delivery. Whether that cost reduction is being passed along to plan sponsors or being used as a lever to improve profitability, the jury is out. It is probably a bit of both.

Q. What else can be done to advance innovation around claims processing, claims accuracy and fraud?

Marilee: We can use data to act on trends before they become costs. For example, providers have the tools to profile inappropriate trends—among providers or members—and use that information to manage claims abuse and fraud. But we can also use it to monitor behaviour and help ensure that members are in compliance with treatment recommendations and best practices, or be on the lookout for contraindicators. This lets us help plan members in a timely and effective way.

Brad: Today, Great-West Life is processing nearly 75% of our claims electronically in real time. Accuracy of claims continues to meet or exceed rigorous standards, and our technology has built-in, state-of-the-art controls designed to prevent and detect fraud and plan misuse. Now the biggest opportunity around innovation and technology is balancing claims processing with careful cost management and health and wellness programs.

We are all looking to elevate our services and our engagement with plan members beyond the simple transaction of submitting and paying a claim. Each claim interaction provides ways to achieve a deeper level of engagement with plan members and to provide education, whether on health initiatives or tips on actions they can take to help keep their benefits plans sustainable. Mobile health information, mobile tools to assist members in self-monitoring their medication compliance and real-time GPS-based provider locators are a few of the directions these technologies will help us unlock.

Stuart: Mobile e-claims have doubled in the past year and are continuing to build innovation both online and via mobile, which is essential to ensuring innovation keeps up with how members want to make benefits claims. Paperless claim submission, coupled with strong fraud controls, makes both claims processing and payment faster, and ensures that potential fraudulent patterns are easier to detect.

Jean-François: We recently introduced a service that lets healthcare providers submit claims on behalf of plan members, so members don’t have to worry about it. We have also developed anti-fraud campaigns to raise plan members’ awareness on claims fraud and provide plan sponsors with tools to help prevent fraud.

Chris: With the increased uptake of member and provider e-claims, insurers and PBMs [pharmacy benefit managers] need to ensure that their fraud detection audit methodology includes both member and provider profiling to detect anomalies in billing practices. This includes identifying duplicate claims and also more sophisticated algorithms that identify relationships and links between members, providers and combined benefits to identify any potential fraudulent situations.

Also, insurers and PBMs should be using claims history to confirm if the right drug is being taken at the right time. This can ensure that a patient has taken the widely accepted first-line therapy (as per clinical guidelines) before allowing a claim for a likely less cost-effective second-line therapy. This electronic step-therapy adjudication practice is only offered currently by a couple of insurers. This method is far better than the more manual prior authorization process in use by most insurers, as it does not require the physician to complete a form that normally comes at the expense of the member.

Brian: We live in a world where technology shapes so many different aspects of our daily lives that it is hard not to imagine the pace of change accelerating. And the insurance industry needs to keep up. Perhaps the biggest future opportunity is in the area of connectivity—using technology to connect all aspects of employee health with their benefits. How powerful would it be to use technology to track employee health (through claims data), link this with employee demographics and preferences, and then—in a predictive way—design a benefits program that meets the unique needs of the individual given his or her current and expected health needs?

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