Information, please
Consider a claim for a surgical procedure. Typically, the medical specialist who performed the surgery is required to submit to insurers, upon request, a form containing certain specific information about the procedure so that the adjudicator can process the claim.
In this instance, the surgeon’s report was readily available and contained all of the necessary details, including the claimant's medical history leading up to the procedure and the procedure itself. Could this report be accepted as sufficient evidence for claims processing, rather than requiring the surgeon to transcribe the report’s information onto the insurer’s form?
Another issue for claims assessors is determining which of the many available forms to use. Some insurers require specific forms depending on the medical condition or claim scenario.
This generally means forms can only be sent to the medical specialists once the adjudicator can determine which form is required.
This can create several inefficiencies:
- In many instances, the initial claim filing is already accompanied by some documentation of the needed medical evidence. However, the insurance company’s claims department requires the information to be submitted using the applicable information form.
- Most claim information forms sent to medical specialists and care facilities are returned incomplete. In some instances, the questions on the required form may not even be relevant to the specific condition, which often leads to frustration and requires claim adjudicators to spend more time obtaining answers.
- Most claims departments require medical providers to physically print out the information form, fill it out, sign it, and then re-scan it and email it. As medical practices generally set aside specific days during a week or month for administrative work such as report-writing and claim form completion, claims department generally have to wait, which can delay receipt of the information. Medical treatment notes, on the other hand, are generally readily available and can be obtained in a more timely manner. Could these notes also be deemed sufficient evidentiary information for a claim?
Consider another scenario: a claimant has submitted high-level information about their occupational duties on their claim form. The claim, however, needs more granular detail, so the adjudicator has follow-up questions. A phone call with specific targeted questions is generally the most efficient way to obtain the information, but standard procedure at many insurers is to send the claimant a follow-up form in order to get the information in writing. As claimants usually believe they have provided sufficient information and are now having to fill out yet another form, this can cause processing delays.