Risk Management Based Approach
INCHES's Audit Model is a risk management based approach to ensure client's audit resources are focused on the business units with the greatest risks viz
We, at INCHES, focus on auditing issues, not people; on developing solutions, not placing blame. Issues are discussed as identified and we develop action plans in collaboration with management. The draft audit report comes along with the action plans and approach for addressing issues.
This approach is vitally useful and allows us to:
- Share with our clients what we have learnt from handlings claims across insurers
- Help senior management address risk and strengthen internal controls
- Constantly improve our quality because of the insight and wisdom we gain from our partnership with insurers
Types of audit
- Underwriting Audit
- Designing documents pertaining to medical process
- STP cases
- Medical underwriting cases
- UW process audit (Post facto)
- Claims Process Audit
- Communication Audit (Repudiation letters etc)
- Medical audit (Transaction) of claims
- Concurrent claims audit means instant resolution of suspicious claims, as they are done PRIOR to settlement within a short TAT (so as to not cause delay is settlement of admissible claims. This also helps avoid arduous process and time wasted in recovery of amount erroneously paid and in case of internal teams – expensive learning and process refinement.
- Based on trends identified by historic data and prevalent healthcare environment (e.g. monsoons for acute cases and holidays for planned surgeries) the triggers are set in the analytic system to flag outliers, which is then subjected to 2-level medical adjudication and 1 level medicolegal adjudication (if claim to be repudiated).
- Concurrent audit occurs both at pre-auth stage as well as prior to settlement. INCHES team of experienced and specially trained medicos perform concurrent audit by reviewing clinical information among documents available to ensure rationality of the claim w.r.t. policy terms and conditions as well as medical appropriateness. Needless to say all of the above is managed in rigid timelines as loss containment must go hand in hand with customer satisfaction.
- The final report with conclusion and justification on admissibility are supported with periodic trends of clinical conditions +/- providers +/- consumers, adhering to 95-97% decision congruence.
- Practices prevalent in the health insurance market today and its impact on the client.
- Inputs w.r.t. claims which have adversely impacted their expectations and reserves.
- Analysis of the increased ICS attributable to COVID / Non COVID claims
- Helping create benchmarks for future, which can help clients improve Claims cost for both COVID cases and non COVID cases.
- Additionally, INCHES also aids the insurer with:
- Retrospective (based on data available)
- Post Facto Audit is broader in scope with the objective of ensuring that the control framework to mitigate key risks are assessed from an end-to-end perspective to highlight and provide value-added solutions to address issues leading up to leakage and preventable losses through fraud and abuse.
- Herein, settled claims are reviewed to evaluate admissibility.
- This critical mass is sieved through an analytical platform (4Sight) based on several pre-defined clinical and non-clinical outliers, which scores cases with high probability of abuse/fraud. Thus, shortlisted cases are subjected to 2-level manual desk audit by aptly trained and experienced medicos and tagged as Red, Amber & Green.
- The final report with opinion on preciseness of the decision taken by the in-house team/ TPA are supported with trends of clinical conditions +/- providers +/- consumers leading to higher, preventable, ICR. Our recommendations towards curbing losses achieve 95-97% decision congruence.
- Audit of network medical establishments
- Audit of appropriateness of treatment given (picks out under/ over treatment given)
- Audit for billing abuse (of consumables)
- Team INCHES, all medicos, well-versed in medical policy and terminology; with collective clinical expertise of 370+ years; team undergoes regular in-house training
- In-house repository of:
- 3500+ STGs
- Huge knowledge repository
- Ongoing in-house training