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iPMI Magazine Speaks With Marie-Christine Exon-Gallé and Sophie Walker About iPMI Claims and Cost Containment

iPMI Magazine Speaks With Marie-Christine Exon-Gallé and Sophie Walker About iPMI Claims and Cost Containment

Marie-Christine Exon-Gallé ("MC") is a highly motivated bi-lingual, professional, senior Manager and an expert in global private medical insurance as well as the medical assistance sector in particular with exceptional proven experience and success in the Assistance-Claims industry over 30+ years. MC has built up a respected track record in these market sectors.

She possesses an in-depth knowledge of Travel insurance, iPMI and an extensive understanding of its practical and technical aspects, as well as the implications of these areas to providers. MC has a detailed knowledge of the business operating environment including contact centres, project work, global assistance/claims facilities from concept to implementation through to operation.

Sophie Walker is a successful senior Claims Manager with excellent knowledge of the PMI & iPMI market sectors gained over some 15 years experience. She is renowned for her commitment to professional customer service delivery combined with a high quality technical claims management capability to ensure claims leakage is minimised.

Sophie has successfully built and managed a claims team all the way from a single site small department to a global multi-site fully functional claims operation. She has overseen the introduction of new claims systems and has introduced many effective quality practices as well as procedures globally both internally and externally for appointed TPAs.

What is important when processing iPMI claims?

It is essential that an efficient, prompt, fair and a seamless service is provided to customers and product providers combined with robust claims management capabilities to minimise claims leakage. Claims handlers are expected to be knowledgeable, have a good eye for detail and be empowered to make decisions. Customers should be treated fairly and kept updated with the progress of their claims. Advice should be clear and without technical jargon. Where shortfalls apply to a claim, these should be consistent with the policy terms and conditions. Eligible payments and pre-authorisation to claimant's should be prompt and made without delay.

How may an inefficient claims process affect the patient?

The acid test of any insurance policy is when a claim is made. The claims function forms a major component of expenses for the insurance industry, which is why insurers must focus on balancing customer excellence, with reduced claims-related losses. This is a fine balancing act, which is without any doubt one of our strengths. Due to the nature of iPMI claims, it is imperative the claims service is efficient.

The customer needs to be made aware of what their insurance policy offers and have the assurance of support at a time when they are more than likely already in a stressed or vulnerable position. If there are delays in providing coverage terms to a claimant, this can exacerbate the claimant's condition and cause undue stress, lead to a loss of confidence in the policy as well as leading to a customer potentially being out of pocket waiting for reimbursement or having to personally cover costs initially. Effectiveness and efficiency of the claims settlement process are key differences in determining the customer experience.

International claims may be submitted in varied formats and languages. What challenges does this create?

When offering an international claims service to international customers, it is important to be ready to receive claims submitted in various formats, languages and currencies. Providers generally have different invoicing templates and formats, which claims staff need to adapt to. Having claim documents in specific languages can be helpful and it is crucial that the claims departments are set up to deal with these differences.

They also need to have a sound understanding of the various local markets and cultures. Local knowledge is paramount, as well as ensuring translation facilities can be efficiently and promptly utilised by the claims staff when, where and if needed. Claims systems are an important factor in receiving and recording claims information. A flexible system able to adapt to the changes in claims submissions and market needs is also an important element of a successful claims department and management strategy.

How may we define cost containment in 2013?

Claims leakage is very costly and proving to be a continuous challenge to battle against within our industry. It represents many millions of dollars lost every day, week, month and year. It affects everyone in the chain of insurance including the honest policyholders through the premium they have to pay. If we were to give a simple definition of claims leakage, it could be the difference between what was paid, compared to what should have been paid.

This is the reason why EW Claims Consulting considers that one of the main focuses on cost containment in 2013 must be to concentrate on identifying and controlling claims leakage. There is a definite demand to also concentrate on the area of, and remain one step ahead of the fraudsters, in addition to, providing a seamless and efficient case management and claims settlement process.

Without doubt, the element of fraud has become a serious impediment in the International Private Medical Insurance market needing dedicated focus and attention. This continued awareness will further define cost containment and the savings that can be achieved.

What policies and procedures may be streamlined in the iPMI claims process?

Many insurers now have or are moving towards online claims submission and membership management portals, which will assist in streamlining the claims process further. Customers having the ability to access their policy documents, see their benefit utilisation, gain information of their nearest providers, update their details or request pre-authorisation online are all useful tools and with this area expanding it can only continue to enhance the claims process. As far as corporate employers are concerned, such online services make the demand on their HR departments by employees so much easier to manage.

Using various forms of contact mediums such as emails and SMS to customers when a claim has been received or a decision has been made on a claim is a valuable tool, as it allows the customer to be kept updated when they are on the move. Having the ability to upload data from providers directly into a claim system, cuts down on claims staff data inputting time, which provides greater operational efficiency and service.

Another factor in streamlining claims is providing large network coverage where customers can receive treatment on a direct billing/cashless basis through an efficient in-patient and out-patient pre-authorisation process. This allows the patient to receive treatment without having to pay any costs upfront, complete lengthy claim forms, so provides a seamless and user-friendly service.

How can payors and providers maximise their relationships?

Minimise administrative costs, assist with patient's eligibility and maximise cash flow. Reduce claim decision cycle times, offer training, agree procedure tariff and payment terms. Agree mutually beneficial terms, share data, quality and set efficiency targets as well as plans to reduce unnecessary costs &/or complications. They need to establish a clear vision to meet both parties’ expectations and align patient, provider and payer incentives to achieve high quality and efficient care at reasonable cost.

Foster shared vision, trust and accountability and include the providers in customer feedback, carry out regular provider surveys and audits professionally conducted by the payers with outcome shared. We believe in and encourage open relationships. An efficient interaction with external suppliers and third parties helps reduce rising claims settlement.

It was recently suggested on LinkedIn that there is a gap in understanding between underwriting and claims. What do you think?

We think this is a difficult question as it depends on the dynamics of the company you may have been exposed to, the insurance sector and how the different departments work together. In previous roles, we have witnessed close working relationships between underwriting and the claims department within the PMI and iPMI industry.

Claims and Underwriting teams can greatly assist and support each other in assessing new risks, claims reporting data, policy wordings/benefit changes, and decisions concerning non-disclosure cases at point of claim. They both see different sides of the risk and can be an invaluable support to one another as well as the business.

From our own personal dealings, we have not seen such a gap in the understanding between underwriting and claims and it is was part of the culture for the teams to work closely together.

How may a TPA help an insurance company who already has in-house claims and assistance capabilities?

A TPA can assist an insurance company in a number of ways. Here are just a few examples; they can provide capacity overflow during peak business times, an insurer can leverage a TPA’s treatment provider network and negotiated favourable tariffs to provide improved network coverage to their customers, usually at a more competitive price – in addition a TPA can provide local and expert knowledge in a newly entered market where the insurer may have limited experience.

Why are medical case reviews important?

Medical case reviews ensure that claimants are obtaining necessary and customary medical treatment and that this is all effected in line with medical guidelines, standards, accepted and approved practices. Medical reviews also ensure that costs are being monitored and that over-treatment is not taking place or sub-standard treatment is not being provided – all of which could be detrimental to the claimants and impact the costs.

Last but not least, if you could live anywhere in the world, at land or at sea, where would it be?

We both love to see and experience new places, but our hearts lie within the green and pleasant land of Great Britain, even with our weather!

For more information or to contact Marie-Christine Exon-Gallé and Sophie Walker please visit:

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