Ideally, claims with identified issues have clear resolution steps and the processing time is kept to a minimum. However, sometimes a claim moves slowly. Those claims that are delayed in processing drive a lot of volume to the call center. The claimant wants to know why their claim is not moving, and the staff person on the phone might not have a satisfactory answer. 

Even when there are documented resolution steps for all possible situations and the system can identify and assign tasks to the right queue, claims can still be delayed if there are many handoffs involved.

Example 

Imagine a process where five work items must be completed, and teams are expected to resolve work items within 48 hours. 

  • Scenario one: All five work items can be completed by a single staff person, and all five are done within 48 hours.  

  • Scenario two: Each of the five work items needs to be completed by a different staff person, and all five are done within ten days (48 hours x 5 = 10 days). 

Both scenarios resolve each work item within 48 hours, but the claimant must wait five times longer for a resolution in the second scenario.

While some handoffs could be unavoidable, minimizing handoffs in your process is critical to expediting claim resolution. No matter how modern your system is, if processes are not well defined, consistent, and efficient, it is impossible to set expectations with claimants for when their payments will be issued.

Recommendations

Identify and resolve issues with slow-moving claims 

When you want to improve your claims process, consider focusing on situations that are most likely to increase inbound calls related to claims status updates. Particularly those that can be resolved without any major technological investments. 

The table below contains some examples of common situations and how to identify and resolve them. 

Claim issue 

How to identify

How to resolve

The claim is not in anyone’s queue, so no one is looking at it or working on it. 

 

This is usually a data issue with how a system’s task or queuing logic is set up. 

 

Find these types of claims by comparing the claims currently in queues with all active claims in your system. 

Work with your operational experts to first determine what criteria are causing these claims to be excluded from existing queues. Then, build new queues to accommodate them.

The claim is in a queue, but no one who is responsible for that queue knows how to resolve the claim.

The claim is in a queue, but the responsible staff has forgotten it or is avoiding the claim.

This could be because the claim is in the wrong queue and needs to be assigned to a different team, or staff may perceive the claim as too difficult or tedious to resolve.

 

The best way to identify this type of claim is to look at two metrics:

1) claims that have been stuck in particular queues for longer than average;

2) claims that have bounced between queues multiple times.

First, analyze the claim to understand why it isn’t moving forward. Then, focus on ensuring that each claim has a clear path forward by developing training materials, providing individual training, and setting up new standard operation procedures (SOPs) and policies.