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Category Archives: SPOT on Issues

  1. How Do You Effectively Manage A TPA? Speak Up And Be Active! May 20, 2010

    Posted in Best Practices.

    Become The Squeaky Wheel To Actively Manage TPA Outcomes As claim practitioners, most of us are familiar with what to look for when we shop for a third-party claim administrator (“TPA”).  One recent discussion on this blog cited such elements as claims systems, data reporting capabilities, and quality control (6 Essential Elements When To Explore […]

    3 comments
  2. 2 Chores that should not be neglected to become a stronger claims organization May 18, 2010

    Posted in Best Practices, Claims Auditing.

    Lets face it – no one really likes to do mundane things. Nonetheless, it’s those very chores that have to be done regularly to ensure a strong organization. Like cutting grass, the longer you let it go the worse it is for your grass, and the harder it will be to fix the mess that has been created. There are certainly enough chores that need to be done in the world of claims that no one likes to do. You know what they are – those things that you would prefer to not have to get to. They can include writing notes on files, keeping a diary and paying bills. But as any good claims handler knows, if you fail to do those tasks regularly not only won’t your grass grow, but you will have quite a clean-up.

    Two chores that can really help claim departments grow nice healthy grass are in the areas of training and managerial assessments. Learn a few chores that have to be done but will help grow your organization.

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  3. 4 Key Areas For Claims Handlers To Review When Dealing With Follow Form Policies April 15, 2010

    Posted in Coverage.

    A follow form excess or umbrella policies is a type of policy were the terms and conditions of an underlying layer of coverage are adopted and incorporated into the “following” layer. While these policies may still have independent provisions and exclusions, they will nonetheless relate back to the underlying, “followed” policy, for most of the terms. In many situations this way of handling excess coverage prevents inconsistencies and ensures there are no gaps in coverage. However, in complex matters involving multiple layers of coverage, or when the language conflicts with the underlying layer, many problems can occur. In claims involving these types of policies, claims handlers must fully analyze all the terms and conditions of all the policy provisions to truly understand the coverage applicable. This weeks post give 4 key areas for claims handlers to consider when dealing with follow form policies.

    1 comment
  4. Saying “I’m Sorry” Can Reduce Exposure to New Claims March 5, 2010

    Posted in Commentary, Medical Malpractice, My SPOT, SPOT on Costs.

    It may seem counter intuitive, but with the right technique a heartfelt apology can help lower claims costs and exposures There is a wave of civility sweeping through the world of risk management as a way to lower exposure and reduce costs: Apologize. Maybe mom was right when she stood there and said “now say you’re sorry.” In fact, there are some very impressive statistics in the area of medical malpractice around the simple use of an apology. Regardless, there is a proper way to apologize while protecting rights and some policy considerations to consider.

    3 comments
  5. 7 Considerations When Drafting Claims Guidelines March 1, 2010

    Posted in Best Practices, Compliance, SPOT on Issues, SPOT on Ops.

    Claims departments employ professionals that want to do a good job for policy holders as well as the company, and claims guidelines should help foster those goals. Before drafting guidelines there are a few things that should be considered and we, along with our fellow blogger Phil Loree, suggest 7 things a company should consider when drafting claims guidelines.

    5 comments
  6. Important Update: Medicare Secondary Payer changes production date to January 1, 2011 February 18, 2010

    Posted in Medicare Secondary Payer, SPOT on Issues, SPOT on Ops.

    The Centers for Medicare/Medicaid Services (CMS) have announced the following: CMS advises all NGHP RREs that the date for first production NGHP Input Files is changed from April 1, 2010 to January 1, 2011, effective immediately. Read the complete announcement at the CMS website in “What’s New.” This is clearly a welcome change and one […]

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  7. Absence of procedures to notify reinsurance is a basis for bad faith February 17, 2010

    Posted in Bad Faith, Best Practices, SPOT on Issues.

    Recently I was discussing bad faith and notice procedures with attorney Phil Loree Jr., an expert on reinsurance and arbitration issues and author of the the Loree Reinsurance and Arbitration Forum blog.  I thought this was a timely conversation as it reinforced the concepts regarding procedures and the potential risks when they are not in […]

    6 comments
  8. 5 Claims issues cited for non-compliance on market conduct exams & 3 tools to avoid them February 15, 2010

    Posted in Best Practices, Compliance, SPOT on Issues, SPOT on Ops.

    Insurance Market Conduct examinations are a regular part of the insurance business. Besides the stress of the exam itself, being cited for violations can result in costly fines. Regardless, many citations can be avoided. Every year, insurance compliance solutions provider Walters Kluwer releases its annual study of top ten reasons insurance companies are found to […]

    3 comments
  9. Improve bottom-line outcomes on claims by thinking outside-the-box! February 9, 2010

    Posted in Best Practices, SPOT on Issues.

    Claim handling is just as much an art as it is a science. Synthesizing facts and investigating losses requires, not only following process and procedures, but also the ability to look at new ways of solving established problems. Following best practices is of course an effective way to achieve consistently good claims results. Regardless, the […]

    1 comment
  10. Med Mal Update: Reasons for decrease in frequency and recent Illinois court decision to strike down damage caps February 5, 2010

    Posted in Medical Malpractice, SPOT on Issues.

    In response to my post, medical malpractice report shows increased severity despite lower frequency, I received a number of LinkedIn comments that I felt offered an interesting perspective on this topic. I have included some of that discussion below. Additionally below, I review the news that the Illinois Supreme Court has struck down that state’s […]

    1 comment
  11. Failing to properly document files can be costly – It cost one insurance agency $5.83 Million February 1, 2010

    Posted in Best Practices, Commentary, SPOT on Ops.

    Files should speak for themselves. A recent California decision is yet another example of what can happen if you don’t document your files and maintain procedures. In this case – it cost $5.83 million.

    No comments
  12. Medical Malpractice report shows increased severity despite lower frequency January 28, 2010

    Posted in Medical Malpractice, SPOT on Issues.

    The Insurance Information Institute has just released a comprehensive look at Medical Malpractice outlining recent developments and industry trends (read more at Medical Malpractice: The Topic). This article breaks down the industry by looking at, among other things, market conditions and national developments. Key highlights include Damage caps can save $54 Billion in medical costs […]

    2 comments