Claims Management Research Articles

Association between workers’ compensation claim processing times and work disability duration: Analysis of population level claims data

Delays in workers’ compensation claim processing (CP) times have been associated with reduced recovery and delayed return-to-work. This study aimed to (1) determine the injury, worker, and workplace factors associated with CP delays and (2) investigate whether CP delays are associated with longer disability duration after adjusting for these factors. Retrospective cohort analysis of Australian workers’ compensation claims was conducted from 1st July 2009 to 30th June 2016 for objective (1) and to 30th June 2014 for objective (2). CP times were derived by calculating differences in days between: injury and lodgement dates (lodgement); lodgement and decision dates (decision) and; injury and decision dates (total). All CP times were shorter for younger workers and those with fractures or traumatic injury, and longer for those with neurological or mental health conditions, and other diseases. Claims from self-insured employers had shorter decision times. With increasing lodgement, decision and total time there was significantly higher hazard of longer disability duration. Findings suggest the need for more efficient claims management to ensure fewer barriers to claim lodgement or approval. This in turn should reduce disability duration and ensure improved return-to-work outcomes.

Part II: Psychological Factors In Delayed And Failed Recovery and Unnecessary Disability

Abstract Part two of this two-part article on psychological factors in delayed and failed recovery and resultant unnecessary work disability (DFRUD) considers both conceptual and practical interventions, including specific evaluation and treatment methods. The authors propose five categories of intervention for DERUD: 1) advance and operationalize our knowledge base; 2) make conceptual and practical shifts in our approaches; 3) place greater emphasis on prevention; 4) improve recognition of potentially difficult cases, and 5) apply specific management approaches and tools. Further, the authors propose conceptual and practical changes that should be made: Eliminate the dualistic separation of mind and body and the scientific reductionism that follows; change the focus from disability to capability; reduce improper workers’ compensation claims; improve the administrative and medical management of valid claims; enhance collegiality and communication among all stakeholders; and adopt a cost-utility vs absolute cost approach. The overarching goals of managing DFRUD include optimizing administrative and clinical treatment of the worker; protecting all stakeholders from excess; and overcoming barriers to intervention. To these ends, three activities can optimize the process: Intervene early; avoid iatrogenicity (ie, shorten claim durations and reduce costs); and stratify risk and employ stepped care. Barriers to meaningful intervention in DFRUD include questions of jurisdiction and responsibility for management (eg, does management of DFRUD fall to insurers or clinicians); who will pay; what are the maladaptive health cognitions and/or psychiatric comorbidities; and how can clinician behavior be altered to implement evidence-based practice?

Development of Prediction Models for Claim Cause Analyses in Highway Projects

India has the second largest road network in the world at 4.5 million km, and still, the government plans to develop a further 66,117 km of roads in the near future. Recently, out of 1,263 road infrastructure projects, 297 and 350 reported a time or cost overrun, respectively, and 103 projects faced both time and cost overruns. Thus, the majority of highway construction contracts lead to claims and disputes among stakeholders. It is necessary to understand, assess, and take appropriate actions for increasing the predictability of these claims and disputes in order to control them. This study attempts to analyze the patterns of claim and dispute occurrences between contractors and clients of highway construction projects in India. Data on disputes and claims for 77 contracts containing 573 claims and dispute cases under highway construction projects implemented over a period of 10 years in India were collected. These claim causes are grouped by using principle component analysis. A dispute occurrence index is developed through the analytical hierarchy process (AHP) to examine the relative potential of occurrence of dispute and claim events. Further, prediction models for time overrun and cost overrun for highway projects using multiple linear regression and an artificial neural network are developed to understand and predict the cause-effect impact. This study can enhance knowledge in claims management.

Aligning public financial management system and free healthcare policies: lessons from a free maternal and child healthcare programme in Nigeria

BackgroundRelatively little is known about how public financial management (PFM) systems and health financing policies align in low- and middle-income countries. This study assessed the alignment of PFM systems with health financing functions in the free maternal and child healthcare programme (FMCHP) of Enugu State, Nigeria.MethodsData were collected through quantitative and qualitative document review, and semi-structured, in-depth interview with 16 purposively selected policymakers involved in FMCHP. Data collection and analysis were by guided a framework for assessing alignment of PFM systems and health financing policies. Revenue and expenditure trend analyses were done using descriptive statistics and analysis of variance (ANOVA). Level of significance was set at ρ < 0.05. Qualitative data were analysed using a framework approach.ResultsThe results showed that no more than 50% of FMCHP fund were collected despite that the promised fund remained unchanged since inception. Revenue generation significantly varied between 2010 and 2016 (ρ < 0.05). Level of pooling was limited by non-compliance with contribution rules, recurrent unauthorised expenditure and absence of expenditure caps. The unauthorised expenditure significantly varied between 2010 and 2016 (ρ < 0.05). Misalignment of budget monitoring and purchasing revealed absence of auditing and delays in provider payment. Refunds to providers significantly varied between 2010 and 2016 (ρ < 0.05) due to weak Steering Committee, weak vetting team, paper-based claims management and institutional conflicts between Ministry of Health and district-level officials.ConclusionsThis study identified important lessons to align PFM systems and FMCHP. A realistic and evidence-informed budget and enforcement of contribution rules are critical to adequate and sustainable revenue generation. Clarity of roles for various FMCHP committees and use of clear resource allocation strategy would strengthen pooling and fund management. Enforcement of provider payment standards, regular auditing, and a stronger role for the parliament in budgetary processes are warranted.

The digitization of advice and welfare benefits services: re-imagining the homeless user

Digitization is transforming the way in which people in England access advice and welfare benefits. Face-to-face advice provision is being increasingly replaced by telephone and online services, whilst the online application and management of benefit claims have become mandatory within the introduction of Universal Credit. This paper argues that the current shift to digitization fails to recognize the variation and complexity surrounding homeless people’s use of technology, with homeless people as technology users often placed into homogenizing categories. Based on findings from qualitative interviews and observations carried out with homeless people and voluntary sector organizations, this paper discusses the social and contextual factors affecting homeless people’s use of technology for advice and benefit purposes. The paper highlights the need for a more nuanced understanding of homeless people’s use of technology.

CAUSES OF DEVIATIONS IN PROJECT EXECUTION AND THEIR EFFECTS

Over the past few years the German and Austrian construction industries have been confronted with increasing complexity in projects, a situation, which has resulted in a significantly higher number of construction claims. The lack of an effective documentation system and a standardized claim management system has led to a growing number of disputes and legal cases. To develop a standardized claim management system, it is essential to understand and analyze deviations in the as-planned vs. the as-built occurring during project execution. A standardized system may assist in the quantification of impacts of different deviations and change procedures in future projects. This paper focuses on deviations and their effects occurring during project execution, as well as possible disputes arising from them. Further research is necessary in order to develop an effective standardized claim management system.

A Cross Segment Analysis of Performance Variables of General Insurance Players in India

The general insurance sector has been dynamically changing and upgrading its business operations in the field of product development, product pricing, underwriting, actuary, claims management, risk management, asset and liability management, reinsurance and customer relationship management to be in line with ever changing regulatory and non-regulatory business norms over the years. These changes arise out of increased emphasis on liberalization and open market systems has transformed the orientation of domestic general insurance markets from that of sellers to a buyer's market. In the past two decades of post privatization operations, the sector has witnessed many challenges in terms of performance. The present study attempts to provide an insight into the behavior of the variables, which determines the performance of general insurance business in India. The formulation of econometric models based on the behavior of the variables influencing the performance of general insurance business in India across the segments of fire marine and miscellaneous will facilitate better decision-making and risk management processes of the players in the industry. The findings of the study are likely to help the policy formulators in bringing needed modifications to the existing policy and provisions to give further boost to the industry.

A stochastic model to evaluate pricing distortions in indemnity insurance methods for MTPL insurance

Direct compensation or the direct reimbursement scheme is an indemnity insurance method that many European and American countries use to manage motor liability claims in which the driver that suffers an accident is paid by his/her insurance company that possibly later receives a flat-rate reimbursement (known as forfeit). Using non-life actuarial methodologies, this article analyses the distortion effects due to the direct compensation mechanisms and the effects of different forfeit reimbursement systems on policyholder tariffs in the management of motor liability claims involving vehicles in two different sectors, i.e. automobile and motorcycle. We empirically analyse and formalize the distortion effects resulting from the mechanism that different direct reimbursement systems produce, and explore the correlation between increasing tariffs for motorcycle policyholders and decreasing tariffs for other vehicle policyholders. We propose some alternative methods to overcome these distortion effects, evaluating their pricing impact through a stochastic model applied to a case study.

CLAIM MANAGEMENT FRAMEWORK UNDER FIDIC 2017: CONTRACTOR CLAIM SUBMISSION

Purpose of the study: The objective of this research is to develop a framework for managing the claim document. The contractual and management issues will be considered in this framework to enhance the Claims Management System (CMS). The framework includes the mechanism of claim submission based on the clauses and procedures of Fédération Internationale Des Ingénieurs Conseils (FIDIC, 2017).&#x0D; Methodology: Qualitative methodology has been selected for this paper as the topic requires a collection of sensitive information from an experienced professional. The proposed Claims Management (CM) framework is developed on the basis of a study conducted to rank the feature required for CMS. This study has been conducted among 43 experts in CM field working on contractor firm’s category A. Then, the framework was verified by seven experts who participated in the first study.&#x0D; Main Findings: Eleven features were required for CMS that can enhance contractor claim submission. These factors have different levels of importance. The top three factors are Tracking Claim Status (99.5%), Supporting all types of documents (96.3%), and having a Centralized Database (93.0%). Based on these features, the proposed framework was developed to improve contractor claim submission.&#x0D; Applications of this study: Applying the proposed framework reduces human efforts in getting documents related to claims by its systematic recording, transparency, reminder feature, contractual guide, user-friendliness, and other features of the system. Moreover, it provides the contractual support pursuant to FIDIC 2017 clauses.&#x0D; Novelty/Originality of this study: The framework will improve contractor claim submission and the contractor will be satisfied by claim resolution and engineer determination. Side by side, the framework will save about 50% of time consumed by the claims analysts that are usually spent in collecting, screening, and identifying information related to claim event in the project’s documentation.

Predictors of Return to Work for Occupational Rehabilitation Users in Work-Related Injury Insurance Claims: Insights from Mental Health.

Purpose This study evaluates the Occupational Rehabilitation (OR) initiatives regarding return to work (RTW) and sustaining at work following work-related injuries. This study also identifies the predictors and predicts the likelihoods of RTW and sustainability for OR users. Methods The study is conducted on the compensation claim data for people who are injured at work in the state of Victoria, Australia. The claims which commenced OR services between the first of July 2012 and the end of June 2015 are included. The claims which used original employer services (OES) have been separated from claims which used new employer services (NES). We investigated a range of predictors categorised into four groups as claimant, injury, and employment characteristics and claim management. The RTW and sustaining at work are outcomes of interest. To evaluate the predictors, we use Chi-squared test and logistic regression modelling. Also, we prioritized the predictors using Akaike Information Criterion (AIC) measure and Cross-validation error. Four predictive models are developed using significant predictors for OES and NES users to predict RTW and sustainability. We examined the multicollinearity of the developed models using Variance Inflation Factor (VIF). Results About 75% and 60% of OES users achieved RTW and have been sustained at work respectively, whilst just approximately 30% of NES users have been placed at a new employer and 25% of them have been sustained at work. The predictors which have the most association with OES and NES outcomes are the use of psychiatric services and age groups respectively. We found that having mental conditions is as an important indicator to allocate injured workers into OES or NES initiatives. Our study shows that injured workers with mental issues do not always have lower RTW rate. They just need special consideration. Conclusion Understanding the predictors of RTW and sustainability helps to develop interventions to ensure sustained RTW. This study will assist decision makers to improve design and implementation of OR services and tailor services according to clients' needs.

Towards Data Exchange between Health Information System and Insurance Claims Management System

Towards Data Exchange between Health Information System and Insurance Claims Management System

Australian General Practitioners' and Compensable Patients: Factors Affecting Claim Management and Return to Work.

Purpose General Practitioners (GPs) play an important role in personal injury compensation systems yet system processes have been perceived as burdensome. Objectives were to (1) determine attitudes of Australian GPs on health benefits of return to work (RTW) after injury/illness and (2) identify associations between GP characteristics and agreement with issues surrounding treating compensable patients. Methods Cross-sectional postal survey of 423 Australian GPs to determine agreement with issues associated with compensable patients (including patient advocacy, conflicting opinions between GPs and compensation systems, fitness-for-work certification, and refusal to treat). Results The vast majority of GPs agreed there was a health benefit to early RTW. GPs with 16-20 years' experience had significantly higher odds of agreeing that the certificate of work capacity is the primary method of communication between RTW stakeholders (OR 2.36 [1.13-4.92]) than those with greater experience. 49% of GPs agreed they should be able to refuse to treat compensable patients. Female GPs had significantly lower odds (OR 0.60 [0.40-0.90]) of agreeing with right to refuse than male GPs, as did those from remote or regional practices (OR 0.43 [0.20-0.94]; OR 0.60 [0.39-0.92]) than GPs from urban practices. Conclusions Reducing administrative barriers identified by Australian GPs and improving communication with compensation systems will likely have a positive impact on their refusal to treat compensable patients.

Presentation and Discussion Incidents Regarding the Competence of Fiscal Authorities In Code of Fiscal Procedure in Romanian Law

The enactment of the Code of Fiscal Procedure in 2003 represents a major step toward the unification of the Romanian fiscal legislation. Unfortunately, the Romanian Fiscal Law continues to be scattered, by the enactment of a plethora of legislative acts and regulations which intend to complete or modify the Code of Fiscal Procedure. This paper studies chapter I of the Third Title of the Code of Fiscal Procedure entitled “General Procedural Provisions”. This chapter provides for the general jurisdiction of the fiscal bodies. The authors define concepts such as: jurisdiction of the fiscal bodies, general jurisdiction territorial jurisdiction, jurisdiction on the secondary seats, territorial jurisdiction of the fiscal branches of the local public administration (as well as special jurisdiction by inference from the same notions used by the Civil Procedure Law (that is the common law for the interpretation and completion of the Code of Fiscal Procedure). The authors indicate which are the fiscal bodies with jurisdiction on the fiscal claims management as well as the fiscal bodies entitled to regulate the application of the legal fiscal provisions and to exercise the fiscal control. The paper highlights the legal gaps to be found in the provisions of Chapter I, Title III of the Code of Fiscal Procedure and tries to fill these gaps by de lege ferenda proposals.

Causes and Problem Identification in Construction Claim Management

The construction service industry is a sensitive and a complex industry and has a fairly high construction uncertainty, related to the development of processes, methods, construction techniques, and the natural conditions factor in construction activities, and often result to claims. Claims can occur both from users or contractor due to perception differences from the initial agreement that has been stated in a construction contract. Construction claims appear as a result of problems in aspects of organization, planning, and contracts. A claim can be described as an administrative tool to correct failures that occur in the construction process. The application of good claim management will be able to avoid dispute that will have an impact on cost overrun and time overrun. This study aims to identify the factors that cause the occurrence of claims during the construction work and identify the problems in each claim management process. The study was conducted by collecting questionnaire data to respondents, practitioners from the owner, contractor and consultant. Data analysis was performed using qualitative analysis (descriptive analysis) to determine the highest score of respondents’ opinions regarding the causes of claims and problems that occur in each claim submission process so that an effective and efficient claim submission process is produced.

《工程造价与索赔管理》案例教学法探析

《工程造价与索赔管理》案例教学法探析

从乍得洛贡河油气管道穿越项目探讨变更索赔管理

从乍得洛贡河油气管道穿越项目探讨变更索赔管理

A Stochastic Model to Evaluate Pricing Distortions in Indemnity Insurance Methods for MTPL Insurance

Direct compensation or the direct reimbursement scheme is an indemnity insurance method that many European and American countries use to manage motor liability claims in which the driver that suffers an accident is paid by his/her insurance company that possibly later receives a flat-rate reimbursement (known as forfeit). Using non-life actuarial methodologies, this article analyses the distortion effects due to the direct compensation mechanisms and the effects of different forfeit reimbursement systems on policyholder tariffs in the management of motor liability claims involving vehicles in two different sectors, i.e. automobile and motorcycle. We empirically analyse and formalize the distortion effects resulting from the mechanism that different direct reimbursement systems produce, and explore the correlation between increasing tariffs for motorcycle policyholders and decreasing tariffs for other vehicle policyholders. We propose some alternative methods to overcome these distortion effects, evaluating their pricing impact through a stochastic model applied to a case study.

Digital health and disability claims

Abstract Digital technology is starting to enable new and improved modes of healthcare delivery. The healthcare and disability claims spaces are closely intertwined. Disability claimants certainly have healthcare needs but disability claims management has the added dimension of supporting return to work. In this paper, we explain what is meant by the term “Digital Health.” We then compare the challenges in the healthcare and disability claims management spaces where digital technology may improve outcomes. We touch briefly on how the efficacy of digital technology may be evaluated. The later parts of the paper focus on Digital Health technology providers who have engaged with the insurance industry and we conclude with some learnings around the challenges of implementing these technology-based opportunities. This paper focuses on interventions once a policyholder’s health has failed to the extent that they need to claim. There are many opportunities to improve wellness and prevent claim using digital technology, as noted by the IFoA Wearables and Internet of Things Working Party,1 and we do not discuss these further this paper.

Effects of Claims Management on Profitability of Listed Insurance Companies in Nigeria

The study examines the effects of claims management on the profitability of listed insurance companies in Nigeria. Using descriptive statistics and the multiple regression techniques, the data was analyzed with the aid of the Statistical Package for Social Sciences to analyze the effect of claims payments on the profitability of selected insurance companies in Nigeria, by examining their claim costs ratio to total cost and the associated expenses, as they influence the profit margin. The result reveals that ROA (profitability) has an indirect relationship with LR (loss ratio) and NC (net claims), but a direct relationship with ER (expense ratio). It further reveals that net claims have a significantly positive impact on loss ratio. The study recommends that the Nigerian insurance industry must effectively manage their claims processes, in order to reduce the number of claims for every earned premium.

REINSURANCE UTILISATION AND DEPENDENCE ON THE FINANCIAL PERFORMANCE OF NON-LIFE INSURERS: EVIDENCE FROM NIGERIA

Reinsurance is used by primary insurers as a device to cushion the effect of underwriting and solvency risks. However, an overdependence on reinsurance could cause depletion in the income of the primary insurer. The study examined the effect of reinsurance on the financial performance of non-life insurers in Nigeria. Secondary data used for this research were analysed with descriptive statistics, coefficient of determination (R2), and linear regression. Results showed a significant positive relationship between reinsurance utilisation and premium growth rate. Similarly, a significant positive relationship was found between reinsurance dependence and profitability (loss ratio). It was recommended that non-life insurers should embrace more of reinsurance facilities particularly for risks of high loss potentials in order to stabilise premium growth rate. In addition, Insurance firms in Nigeria should harness their claims management activities in order to minimise cost and exposure to underwriting risks.