Claims Solutions

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Claims Solutions

    Claims Solutions

  • We work with insurers, brokers, MGAs, corporates and public entities to deliver great customer service and improved underwriting performance, through efficient management of the claims process.

    We are the leading independently owned providers of outsourced end-to end claims solutions, often operating on a white-label basis for our clients. In addition to our third party administration services, we provide a full range of loss adjusting, surveying, fraud detection, and supply chain solutions.

    We have more than tripled our annual investment in technology and digital transformation, including our CQ claims administration platform, our video and drone claims handling solutions, as well as investing in robotics and machine learning to drive speed and efficiency.

  • Our desktop claims handling solutions teams operate on a white-label basis for our clients and offer a 24/7 365 FNOL service, across all classes of insurance.

    What makes us different is our technical teams of claims handling specialists, and our ability to draw upon our claims technology, that we use in the right places, to streamline process and generate the right outcomes for our clients.

    Through our CQ claims administration platform we import data for customer background checks, which integrate with telephony and online portals providing valuable data and information to assess and manage claims. We use online registration, portals, two-way SMS and web chat to provide customers and clients real time access to ongoing claims.

    • NPS Measurement, Analysis and Reporting

      Using our Voice of the Customer technology we work with businesses to develop customer experience programmes that allow both us and our clients to monitor, track and report on customer service. We use this feedback collaboratively to support continuous improvement across all elements of service and NPS scoring per client and line of business.

    • Claims Tracker

      Our Claims Tracker provides policyholders with claim notification capability as well as real time claim updates via push notifications on their smart devices, allowing policyholders to stay up to date with their claim at their convenience.

  • We draw upon our global network of experienced loss adjusters and combine them with our technology solutions. We pivot between desk adjusting, in-person loss adjuster visits, virtual video adjusting as well as drone surveying meaning that we can respond to individual claims and customers’ needs in a way and a time that is convenient for them.

    • Technical Services

      Our in-house surveying and engineering team provide the following services;

      • Subsidence – full management, diagnosis to remediation and recovery
      • Structural engineering services
      • Project Management including CDM
      • Dispute Resolution including third part wall acts
      • Defect diagnosis and management

    • Fraud Identification and Management

      Our special investigations team is a dedicated Counter-Fraud unit comprised of experienced Field and Desktop Investigators handle investigations across all product classes including Property, Commercial, High Net Worth, Private Client, Motor, Niche and Casualty. We provide a range of investigative solutions to meet the needs of our Clients. This includes Desktop based Cognitive Interviewing, Intel Screening and Field Investigations requiring evidential interviews and statement taking. Our latest technology-led service offering, provides us with the capability to live stream video interview key parties linked to investigations.

  • Through our contents repair and replacement & building contractor network we provide a range of building repair services in a managed and cost controlled way. All repair work is guaranteed and our contractors are subject to regular performance management and audits.

    • Emergency Response and Restoration Services

      We operate a managed response network to include the followings services:

      • Trace and access
      • Building drying services
      • Buildings and Contents restoration
      • Emergency boarding and Glazing
      • Deep cleaning

    • Alternative Accommodation

      Alternative accommodation claims can be expensive and present a disruption to the customer journey. We protect claims spend and the customer journey through in-house management including:

      • Facilitation of emergency accommodation
      • Creative solutions, such as non-standard accommodation, holiday homes etc.
      • Liaison with contracted hotel and estate agents
      • Front funded deposit process
      • Temporary kitchen and bathroom solutions
      • Secure removal and storage solutions
      • Provision of caravan / static homes

  • We help businesses manage legacy and open claims allowing them to focus on existing live business and new opportunities. We work collaboratively with our clients to understand their claims processes and philosophies to deliver a high level of service.

    Claims leakage is a concern for many of our clients, and we work closely with businesses to assess and analyse existing claims processes and deliver actionable insights for new ways of working that improve operational efficiency and deliver the right outcomes.

    Throughout the migration process, our technical experts work alongside in-house teams to create bespoke technology solutions that enable flawless claims data migration into our CQ claims administration platform.

    In addition, our specialist teams are able to provide due diligence, transaction support and consulting services to clients that are considering taking over the management of run-off portfolios.

  • We provide workers’ compensation TPA services for a variety of insurance clients and self-insured entities including public entities and private employers with employees in many states.

    The workers’ compensation TPA claims handling process includes a number of services such as nurse case management, nurse triage, medical bill review, pharmacy benefit management, telemedicine, medical provider options, return-to-work initiatives, peer review, utilisation review and more.  

    As a TPA, we provide a number of flexible client options, such as choice of nurse case management, medical provider access with PPO networks or Alternative Cost Containment, and a choice of surveillance and claims investigation. We also offers telemedicine as a managed care solution. 

    Our US workers’ compensation claim adjusters, have an average of 25 years of industry experience in handling all aspects of workers’ compensation claimsof which eight (8) years of service has been with the company. We have a strong track record of delivering excellent financial outcomes for our clients such as averaging indemnity savings of almost a third through our pharmacy benefit management.

    • Nurse Case Management / Managed Care

      Telephonic nurse case management (TCM), when coordinated with optional field case management, provides a cost-effective managed care solution to provide prompt and concurrent review and management of the medical care of injured employees.  Alternatives to TCM are nurse triage and telemedicine. 

       FAQs

      • TCMs work with the injured worker, client and claim adjuster.   
      • Telephonic nurse case management is authorised by the client and initiated by the claim adjuster.  
      • Nurse case management is considered on a case-by-case basis. 

       

      Nurse Triage offered is one of the best ways to obtain the necessary medical attention for the injured employee, which helps reduce the duration of the claim while keeping overall costs low.  Triage needs are determined by the client. Based on the client’s criteria, the case will be referred to Triage Nurse for evaluation.   

       FAQs:

      • Each case is reviewed to confirm the need for triage and based on the basis of the FROI only. 
      • Cases requiring immediate intervention, such as catastrophic claims, will be reviewed with the claim adjuster and may be referred immediately to Field Case Management.   
      • Initial Assessment and Recommendation (IAR) activities include telephone contact with the injured worker, medical provider and worksite supervisor.

       

      Telemedicine allows an injured worker to be virtually connected at the time of a minor injury on the job. It begins with 24/7 minor work related-injury initial assessments and rechecks. The injured worker speaks with a care coordinator followed by a clinician. Telerehab is also available Monday through Friday’s at work or in the home with a clinician or therapist trained in occupational medicine. 

       FAQs

      • All service is accessible via a downloadable app on a smartphone and can be accessed from a private and quiet worksite location.  
      • Telemedicine can be combined with existing nurse triage programs. 
      • With telemedicine 98% of cases are recommended for return to work. 
      • With telemedicine 4.7% of cases require medical prescriptions (YTD Q2, 2019) 
      • With telemedicine injured workers have the ability to follow-up with a clinician remotely during times of uncertainty.  

       

      Additional managed care services include utilisation reviews, independent medical exams, peer reviews and PPO Networks.

    • Pharmacy Benefit Management (PBM)

      PBM use secures discounts for medication and can make arrangements with pharmacies to fill prescriptions. With a PBM solution, prescriptions are vigilantly monitored to ensure that medication is appropriate for the injury involved. A PBM program can also drastically increase over all savings by an additional 30% to 50% through utilisation of an aggressive mandatory generic substitution program whenever possible.  

      FAQs

      • For long-term medication, a PBM establishes a mail order program specifically for the injured worker, eliminating the need to visit a pharmacy each time they need a refill.  
      • A PBM can help identify physicians and claimants at risk of overutilisation and inappropriately prescribed medications through intervention strategies, outreach, and other clinical recommendations by working directly with primary treating physicians and injured workers to consider weaning programs, drug testing, goal setting and other programs of clinical medical necessity. 

    • Return to Work (RTW)

      The importance of workers satisfaction throughout the treatment and return-to-work process is an important part of developing overall trust. With our client’s direction, we will co-develop an aggressive return-to-work plan resulting in lower overall costs, reduced lost time and happier employees with an end result of earlier claim closureA comprehensive customer care plan, in coordination with the adjuster’s action plan, must be developed for each claim file.  

       FAQs

      • Our ultimate goal is to have the injured worker rehabilitated and back to a productive status faster to reduce costs and claims duration whose absence impacts the client’s productivity.  
      • Pre-injury solutions include identifying jobs by their description followed by post-injury analysis which include modified duty, wage earning capacity assessment, transitional work and more. 

    • Alternative Cost Containment (ACC)

      We offer choice with how you access medical providers. We offer traditional PPO Networks and Alternative Cost Containment. As an alternate to a PPO Network, we also offer Alternative Cost Containment (ACC), a direct choice through provider relationships that improves care.  

      ACC was created for entities with workers’ compensation claim exposures. Alternative Cost Containment offers a direct contractual relationship with proven medical providers to improve provider/employer relationships, drive deeper discounts, and deliver a higher quality of care for employees.   

       FAQs:

      • With ACC an employer benefits from a direct contractual relationship with the medical provider, eliminating the middleman.  
      • Employers receive a pricing model where flat fees-for-service are negotiated proactively (before the service is needed) following a cost-plus model rather than the traditional network, discount-off-retail model.   

    • Medical Bill Review

      Medical bill review service ensures that medical bills are reviewed and adjusted quickly and accurately. Bills are reviewed and all fee schedule or usual and customary discounts are automatically deducted. After all discounts are deducted, a PPO discount is applied if the provider is participating in one of the PPO networks.  

    • Reporting

      We provide CMS reporting options and MSA compliance. Our claims staff is properly trained on CMS reporting requirements and semi-monthly reports are ran to assure compliance for reportable claims.   

    Claims Team

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Matt Button, CEO - Claims Solutions US

Luke Dalgarno, Senior Operations Manager

Darren Martin, IT Director

The Claims Solutions team

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