Keep Insurance Claims Processing Compliant with Claims Direct Access

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Jake Wintczak

email: jakew@primeis.com

Insurance Claims Processing

Keep Insurance Claims Processing Compliant with Claims Direct Access

Regulatory compliance in insurance claims processing is vital, but, all too often, a struggle for insurers. That is an important fact backed up by a recent Wolters Kluwer review, which examined the United States insurance industry’s top compliance shortcomings. The study found that claims handling noncompliance is a common issue impacting insurers across the country.

Wolters Kluwer completes this comprehensive public data review every year to help insurers identify where they may need to focus extra attention to stay in regulatory compliance. In the latest report, Wolters Kluwer highlighted the top ten market conduct actions for property and casualty insurers, and life and health insurers.

These actions include problems that are challenging, but ultimately avoidable with due diligence. For example, one highlighted issue is a failure to acknowledge, pay, investigate, or deny claims within specified timeframes. Insurers can avoid this by ensuring claims are acknowledged and investigated as early as practicable. Then the claim can be paid or denied within the appropriate timeframe.

Overcoming Problems with Timely Insurance Claims Processing

Insurance claims processing sets the tone for regulatory compliance. When a claim is acknowledged, investigated, and paid or denied on the appropriate schedule, it stands to reason that other compliance details are under control.

For a lot of insurers, however, getting things done within a timeframe might seem like it is easier said than done. Everyone is aiming to acknowledge, investigate, and determine what to do with a claim as soon as possible. Still, as it is showing up in a top ten list of problems, it is clear that not every insurer has the resources they need to succeed.

Some of it comes down to organization. Some firms are better able to leap into action without having to sort through unorganized paperwork, contact information, and other files. Some insurers find themselves short-staffed or burdened with a heavy caseload that makes it difficult to treat every incoming claim with the urgency it requires. In such situations, partnering with skilled insurance claims processing experts is key.

It is also important to note that an insurance claim that is handled quickly is not necessarily compliant. It may have been rushed through for the sake of a speedy resolution. As Wolters Kluwer’s review goes on to say, there are other conduct actions related to insurance claims processing that is anything less than meticulous. These issues stemming from sloppy work include failure to provide required compliant disclosures, improper or incomplete documentation of claim files, and improper or incomplete documentation of underwriting files.

The question, then, is how insurance producers can ensure that their clients have claims handled quickly and effectively, yet accurately, to stay in compliance with regulations. It might seem tricky to have both speed and accuracy, but it is possible. Read on to find out how we ensure fast resolutions, accuracy, and compliance, while avoiding excess costs.

Claims Direct Access with Prime Insurance Company

Prime Insurance Company has a strong focus on claims processing and claims results, helping insurance producers like you avoid compliance problems. We accomplish this through our claims direct access service (CDA). We do not take a passive approach but get involved early and work hard to ensure that there’s a timely resolution without unneeded costs.

We are committed to accuracy from the start, determining the factual and legal issues that impact claims resolution and claims value. We have a team of insurance, medical, and legal professionals with strong working knowledge and a commitment to keeping up with evolving legal and regulatory changes. With a long history of managing claims, we understand and apply the coverage terms and conditions of all insurance policies.

Our experienced, proactive team handles even complex multi-line claims with ease. We will attend mediations, conferences, and arbitrations in person, reaching into a deep well of case law and legal knowledge. We aim to keep all claims work in-house so that we can control costs and gain the insight we need firsthand. When we need to work with outside resources, we rely on our strong, vetted network of carefully selected partners. We do the same for class actions, cross complaints, and counterclaims.

Find out more about our Claims Direct Access here and download our CDA brochure for even more details and case studies.

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Rick J. Lindsey
Rick Lindsey

President, CEO and Chairman